School mental health has recently seen an unprecedented surge in interest and investment. This growth is fueled by a youth mental health crisis, exacerbated by the global pandemic, paired with evidence for schools as a critical venue for preventing and treating mental health problems (Hoover & Bostic, 2021a).

As Co-Director of the federally-funded National Center for School Mental Health for over a decade, and as a clinical psychologist working in schools for a decade before that, I have had the privilege of witnessing and supporting expansion of school mental health in the United States. In all of my years in this field, I have never observed the (long overdue) level of interest and investment we are now seeing, and it is essential that we act with intention and focus.

5 Opportunities to Leverage this School Mental Health Moment

Below, I outline five opportunities fundamental to leveraging this unparalleled moment in school mental health to achieve the ultimate goal of promoting mental health and well-being for all youth. Each opportunity aligns with the central theme of “moving upstream,” investing in a public health approach to promote well-being of all students, identify mental health concerns early, and strategically offer early intervention and treatment where youth are – in schools.

Opportunity 1: Nurturing Environments that Foster Prosocial Behaviors and Connectedness

We have incontrovertible evidence that the vast majority of challenges impacting our youth could be prevented or diminished by creating nurturing environments starting early and continuing into middle and high school and beyond.

In his book, “The Nurture Effect: How the Science of Human Behavior Can Improve Our Lives and Our World,” Dr. Anthony Biglan, a Senior Scientist at the Oregon Research Institute, distills decades of scientific research from the fields of psychology and prevention science into tangible, actionable steps that policymakers, families, and institutions like schools can take to reduce youth problems and to produce caring and productive young people (Biglan, 2015).

In a nutshell, the research from years of rigorous randomized trials tells us that all successful interventions make environments more nurturing in at least three of four ways:

• Promoting and reinforcing prosocial behavior
• Minimizing socially and biologically toxic conditions, like poor nutrition and housing insecurity
• Monitoring and setting limits on influences and opportunities to engage in problem behavior
• Promoting the mindful, flexible, and pragmatic pursuit of prosocial values

These interventions can and should be implemented with both families and schools. In the earliest years of children’s development, effective interventions include things like Incredible Years, Nurse-Family Partnerships, and the Triple P Parenting Program. In elementary years and beyond, interventions like Family Check Up are helpful to support parents in handling common problems, using reinforcement to promote positive behavior, monitoring their child’s behavior and setting limits, and improving family communication and problem solving.

Schoolwide systems to minimize coercive and punitive interactions and to teach, promote, and richly reinforce prosocial behaviors have demonstrated long-term positive impacts on adolescent risk behavior and engagement in college and career. When implemented with fidelity, the promise of programs like Good Behavior Game, Positive Action, and Positive Behavioral Interventions and Supports to promote prosocial outcomes in our adolescents and young adults is tremendous.

Further, we must invest in school environments and strategies that increase a sense of student connectedness (Centers for Disease Control, 2022). In their most recent report on youth mental health, the Centers for Disease Control called on the nation’s schools to act with urgency and compassion to promote connectedness and belonging among students (CDC, 2023). Doing so, they argued, has the potential to dramatically improve youth well-being and to tackle the concerning increases in child and adolescent depression, anxiety, and suicide.

The good news is that we have years of evidence for the positive impact of effective programming to promote student connectedness and belonging, including interventions that target positive school climate and positive youth development. There are seemingly simple daily strategies that educators can employ to create a warm environment that fosters connection. For example, welcoming students by name and with a friendly greeting when they board the school bus and enter the school and classroom is a no-cost but powerful tool. Ensuring that each student has at least one positive adult ally in the school and one extracurricular activity in which they are actively engaged also enhances student connectedness.

More comprehensive school climate programming, including assessment and continuous quality improvement of school climate domains (belonging and connection, safety and wellness, environment), is also critical. Several districts across the nation have utilized the school climate assessment platform and accompanying toolkit for school leaders funded by the U.S. Department of Education via the National Center for Safe and Supportive Learning Environments (National Center for Safe Supportive Learning Environments, 2023).

To fully address the current youth crisis and to prevent future mental health challenges, it is essential to foster nurturing environments where youth feel connected and engage in positive, health-promoting behaviors. Schools can also increase connectedness and belonging among students by employing positive youth development programming and strategies that identify and leverage youth assets and protective factors (U.S Government Youth, n.d.).

Opportunity 2: Mental Health Literacy and Life Skills

In addition to fostering positive and nurturing school environments that enhance student and staff well-being, we are increasingly seeing efforts to embed life skills and mental health literacy into the curriculum (Hopeful Futures, 2023).

Several states and districts have adopted standards of social emotional learning (SEL), sometimes referred to as “skills for life,” and aligned them with curricular requirements. Despite the ongoing debate about the role of SEL in schools, educators and families universally agree that schools must foster life skills that promote academic success, employability, and citizenship. In partnership with families, schools are an essential venue for teaching and reinforcing skills like problem-solving, empathy, communication skills, and emotion regulation, all critical to daily and life success. Whether states and communities choose to call them “social emotional competencies,” “skills for life,” or even “employability skills,” there is a long and robust research base documenting the evidence of these skills as predictors of better school performance, well-being, and college and career readiness (Greenberg, 2023).

Recently, several states have also passed legislation that requires the integration of mental health literacy into K-12 education (Mission Square Research Institute, 2021). Typically, mental health literacy involves teaching students how to obtain and sustain positive mental health, understand and identify mental health challenges, decrease stigma about mental illness, and seek help for mental health concerns. Dr. Stan Kutcher and colleagues from Canada developed, studied, and widely disseminated mental health literacy programming throughout schools in Canada and several other countries.

Implementation studies of their mental health literacy intervention demonstrated increased educator and student knowledge about mental illness and health and greater help-seeking behaviors among students (see www.mentalhealthliteracy.org). This intervention has since been adapted for and studied in the United States by the Mental Health Collaborative with versions for educators, students, families, and coaches. I anticipate Mental Health Essentials and other mental health literacy programs like Born this Way and Teen Mental Health First Aid will be increasingly adopted by state and district leaders as an upstream approach to managing the youth mental health crisis.

Other states will develop “homegrown” life skills curricula, as we saw mandated by Utah’s legislature, in which the state department of education partnered with a local mental health institute to embed mental health literacy during the school day and to engage parents in its implementation (State of Utah, 2022). Both life skills and mental health literacy offer an opportunity to build more resilient and emotionally healthy generation of students, better equipped to navigate life stressors and mental health challenges.

Opportunity 3: Well-Being Check Ins

Almost two decades ago we saw a burgeoning interest in school mental health screening when states were increasingly funded to deliver suicide prevention activities in schools. This trend was not without challenges or controversy, and many states and districts opted not to implement comprehensive screening programs, often due to concerns about privacy or liability if concerns were identified without the capacity to address them in the school. While these concerns remain, COVID and a greater recognition of the vital role of schools in early identification of mental health challenges have contributed to a renewed interest in school mental health screening (Hoover et al., 2020).

As interest and implementation of mental health screening in schools grows, we have observed some best practices to safeguard against some of the challenges encountered with previous efforts. For example, to address concerns about privacy and parent/student rights, many school communities have intentionally engaged families and students during the planning stages of screening. Students and families provide input on consent and assent processes, instrument selection, privacy considerations, and family notification procedures to ensure that efforts are feasible, culturally sound, and well-received by the community (Hoover & Bostic, 2021b). Our National Center for School Mental Health developed a School Mental Health Quality Guide on Screening, laying out the nuts and bolts of best practices in school mental health screening (National Center for School Mental Health, 2020).

I am also heartened by the movement away from annual screenings rooted in traditional medical models of psychopathology toward more frequent “well-being check-ins” that assess constructs like subjective well-being, belonging, and connectedness. Furlong and Dowdy, colleagues at UCSB, have led the Covitality project to support schools in measuring these factors as opposed to simply assessing for anxiety, depression, or trauma alone. In doing so, they have demonstrated that when we inquire about how connected students feel to their home, school, and community and about their general well-being, we are more able to predict who is doing well and who could benefit from intervention.

Schools are also increasingly assessing for social determinants of health that influence mental health, shifting the focus of intervention to systems that contribute to poor mental health, like housing and food stability, and away from “fixing” individuals responding to poor conditions.

We have also seen a movement toward more frequent check-ins that allow teachers and other school staff to quickly assess the emotional status of their students and connect them to coping skills or staff support when needed. Programs like CloseGap, a rapid, technology-supported app that students can report on daily as they begin school, offers teachers and school mental health staff a “pulse check” of the daily well-being of students. This type of relatively low-burden check-in prevents students who may be suffering from falling through the cracks and allows teachers to route students to support.

Opportunity 4: Filling in Tier 2

School mental health has long been described as best implemented as a multi-tiered system of supports, or MTSS (Hoover et al., 2019). Usually, this involves three tiers, from Tier 1 (Universal) supports that promote mental health of all students in the school system to Tier 3 (Indicated) services for students with identified mental health challenges that interfere with daily functioning.

While most schools offer something at each tier, I am increasingly hearing concerns about a “missing tier 2” within the MTSS. That is, schools often have at least some programming that reflects universal approaches to mental health such as school climate efforts, positive behavior interventions and supports, mental health literacy, or social emotional learning.

Similarly, schools typically offer some level of Tier 3 services to struggling students, sometimes as part of special education supports or via partnerships with school-based community behavioral health providers. However, there is considerably less consistency in the delivery of Tier 2 supports for students with mild mental health concerns or for those who may be at greater risk for experiencing mental health challenges.

Despite their demonstrated effectiveness in schools, Tier 2 interventions are often limited due to lack of staffing or funding to support training and implementation. Whereas Tier 1 supports are typically delivered by educators and other school staff and Tier 3 services are regularly funded and delivered by specialty providers like psychologists, social workers, and counselors, it is often unclear who is best equipped to deliver Tier 2 services and how those services can be funded.

From a public health perspective, a “missing Tier 2” is a major limitation in fully supporting the mental health needs of all youth in a school and community. It is well established that a longer duration of untreated mental illness is associated with poorer outcomes and that early identification and intervention can positively adjust the trajectory of psychosocial, academic, and life outcomes for youth.

Fortunately, intervention developers and funders are gaining momentum filling in Tier 2 by offering feasible approaches for Tier 2 implementation. Tier 2 services may include brief individual interventions, like Screening, Brief Intervention, and Referral to Treatment (SBIRT), an early intervention for substance use concerns, or Brief Intervention for School Clinicians, a 4-session intervention based on cognitive behavioral and motivational enhancement techniques. Group modalities are also sometimes used to deliver Tier 2 interventions, including programs like Supporting Transition Resilience of Newcomer Groups,  a school-based intervention to facilitate the transition of refugee and immigrant students to a new school and community.

Some schools also utilize Tier 2 interventions like Check In Check Out (Maggin et al., 2015) or Check and Connect as a way to monitor and support students through checking in throughout the school day with a designated adult and employing coping skills if challenges like mild anxiety or low mood are identified. To fully realize the potential of effective Tier 2 interventions, we must leverage a broader workforce, including health educators and peers, and require reimbursement for these upstream interventions via education funding, Medicaid, and other insurers.

Opportunity 5: School Staff Well-Being

The pandemic shed new light on educator stress and burnout and their impact on quality of teaching performance, retention, and student academic and well-being outcomes (Mission Square Research Institute, 2021). The constant shifting demands, added burden, and perceptions of lack of transparency by administrators left educators feeling even more overworked and undervalued than before COVID.

Given research that stressed teachers are more likely to leave the profession, researchers, policymakers, and education leaders have increasingly focused on promoting educator well-being and reducing their stress. Efforts have targeted both individual and organizational factors that contribute to educator well-being. Live and asynchronous online training opportunities have been adopted by states and school districts to enhance teachers’ personal well-being. For example, Wisconsin’s educators utilize the Compassion Resilience Toolkit  to understand, recognize, and prevent/reverse compassion fatigue. The Georgetown Well-being in School Environments (WISE) Center also developed an online course, TeacherWISE, for educators and school staff to engage in personal well-being planning and support.

Beyond relying on educators to simply care better for themselves, districts and schools must be accountable for creating conditions that foster educator well-being. Our National Center for School Mental Health partnered with the SAMHSA-funded Central East Mental Health Technology Transfer Center to develop a free online system, the Organizational Well-Being Inventory for Schools for districts and schools to assess the organizational factors that contribute to educator well-being and to engage in continuous quality improvement in eight domains: Work Climate and Environment; Input, Flexibility, and Autonomy; Professional Development and Recognition; Organizational and Supervisory Support; Self-Care; Diversity, Equity, Inclusion, and Access; Purpose and Meaningfulness; and, Professional Quality of Life. Be attending to organizational factors that contribute to educator well-being, districts and schools can better support school staff so that they are best able to fully engage in their professional responsibilities and flourish as human beings.

Conclusion

As a nation, we are primed to fully recognize schools as critical to promoting mental health and well-being for all youth and identifying and intervening early when mental health challenges arise. The need is clear and urgent, there are many best practice frameworks and programs to support implementation, and educators and families universally recognize that schools must be part of the solution to our youth mental health crisis. To realize the potential of the school mental health opportunities discussed above, there must be an intentional shift in policy and funding, supported by federal, state, and local partners.

The Hopeful Futures Campaign, a national coalition of health, education, family, and youth leaders, have united around state policy levers that can advance comprehensive school mental health (see www.hopefulfutures.us for the National School Mental Health Report Card and the National School Mental Health Legislative Guide). They have assessed each state’s progress on drivers of school mental health like mental health professional-to-student ratios, well-being check-ins, healthy school climate, and skills for life, and offered legislative examples and guidance to state policymakers.

Table 1 outlines policies aligned with the five opportunities laid out above.

All of us should approach this moment in human history with a combined sense of urgency and hope. For school mental health, we are equipped to position schools as a true partner to families and communities in their quest to foster youth that are well and flourishing. Let us together strategically capitalize on the interest and investment in school mental health by advocating for policy and funding shifts that align with opportunities in the field.

https://doi.org/10.17077/rep.006642