Scanlan Center for School Mental Health
two students sitting with teacher
Practice Briefs

The purpose of the Practice Briefs on School Mental Health project is to provide free-access research-based summaries on important topics that are relevant to practicing educators and school mental health professionals. Our practice briefs are written by national experts in the field, reflect best practices in education and school mental health, and undergo a peer-review process before publication.

Jonathan M. Platt, Ph.D., Assistant Professor, Department of Epidemiology, University of Iowa College of Public Health
Gerta Bardhoshi, Ph.D., Professor of Counselor Education, University of Iowa College of Education
Bengi Baran, Ph.D., Assistant Professor, Psychological and Brain Sciences, University of Iowa College of Liberal Arts and Sciences
Description
Adolescence is a period of substantial change, occurring across biological, psychological, behavioral, and social systems. Young adolescents (ages ~12-14) experience significant development in personal autonomy, identity formation, and coping skills (Arnett, 2015), while planning and self-control skills (generally referred to as executive functioning) mature in later adolescence (ages ~17-18; Tervo-Clemmens et al., 2023). Adolescents also undergo a realignment of sleep physiology and sleep/wake regulation (Carskadon, 2011). These changes allow teens to learn the skills needed to be good students, friends, and, eventually, healthy adults (Tottenham & Galván, 2016). The social world of young people becomes more complex during adolescence. Peer relationships become increasingly important, family relationships change as teens strive for independence, and social media is introduced (Gerwin et al., 2018; Shifflet-Chila et al., 2016). For some teens, negotiating such rapid change is challenging and can result in stress and conflict with family members, peers, and others. As such, early adolescence is characterized by a marked increase in mental health challenges (McLaughlin & King, 2015; Miech et al., 2020). These challenges have become more common among adolescents in recent years, with rising rates of depression (Keyes et al., 2019), psychological distress, anxiety (Collishaw, 2015), attention-deficit hyperactivity disorder (ADHD; Xu et al., 2018), and suicidal behaviors (Keyes & Platt, 2023). Recent adolescent mental health trends have occurred in parallel with an increased use of social media. Social media refers to interactive websites or applications (i.e., apps) that allow users to generate, share, and view content with others, create personal profiles, and develop online social networks (Obar & Wildman, 2015). Over the past 20 years, it has become a central part of the social environment, and a key part of adolescent development. Nearly all (97%) US adolescents use at least one social media platform, on which they spend an average of three hours per day. A third of teens say that they engage with social media “almost constantly” (Vogels et al., 2022). Social media facilitates the identity exploration, autonomy, friendships, and peer acceptance that are important for social development and mental health of young people (Gerwin et al., 2018). The social media environment is complex and dynamic, with features that are beneficial and harmful for adolescent mental health, both directly and indirectly through sleep disruption. Additionally, the experience of social media use likely differs based on the personal identity of the user, including their age, race, sexual orientation, etc. Understanding these complexities is critical to developing effective policies and practices to reduce high-risk social media use behaviors and reduce adolescent mental health problems. Prevention and Identification Strategies The Effects of Social Media Use on Mental Health Social media use often exposes the user to public social commentary and experiences intended to provide an emotional reward to the user (e.g., when posted content receives ‘likes’ from friends). These rewards can be observed in the brain, through activation of regions involved in reward processing, social cognition, and attention (Sherman et al., 2016). In developing youth, social media features may contribute to negative self-evaluations, maladaptive interpersonal behaviors, such as excessively seeking feedback from others, upward social comparisons, and harmful coping strategies like excessive focus or discussion of problems or negative feelings (Nesi et al., 2018; Nesi & Prinstein, 2015). Over time, these heightened emotional responses may disrupt the development of a positive self-identity and healthy peer relationships, increasing depression and anxiety symptoms, including suicidal thoughts and behaviors, as a result. Social media use may disrupt attention, as content is often highly stimulating and delivered rapidly, making it more difficult to later engage in tasks requiring sustained attention (Thorell et al., 2022). Additionally, users may lose the ability to regulate their attention internally after having gotten used to external regulation through social media (Madore et al., 2020). Despite these negative effects, it is important to note that certain features of social media may facilitate positive mental health. Anonymous use allows the user to control what personal information is shared, in content, format (e.g., text, audio, visual), and timing, which may increase opportunities for approval and social acceptance in turn. Social media may also increase access to mental health-promoting resources, by exposing users to meaningful conversations, normalizing help-seeking, providing informational resources, and reducing the stigma around mental health (Betton et al., 2015; O’Reilly et al., 2018). Adolescents report frequently seeking mental health resources on social media (Vogels et al., 2022). How We Measure Social Media Use is Important Despite substantial attention on the role of social media use as a potential cause of adolescent mental health problems, our understanding of the risk is still unclear. This is primarily due to the limitations of previous research. Most studies use simplistic and self-reported measures, recorded at a single point in time. Self-reported data significantly underestimates how much time teens spend using social media (Wade et al., 2021), especially among those with the riskiest social media use behaviors (Wenz et al., 2024). While it is important to assess how much time adolescents spend on social media, more detailed measures are needed to capture important risk and protective factors from use, including sleep disruption. The Effects of Social Media Use on Sleep Although sleep need does not change throughout adolescence (~ 9h/night) (Ohayon et al., 2004), a combination of biological, psychological and societal changes limits sleep opportunity for teens. Changes in brain circuity makes it easier to resist sleep; the biological clock of adolescents dictates them to go to bed later at night and wake up later in the morning. Numerous psychosocial factors push adolescents towards later bedtimes: academic pressures, extracurricular activities, increased social interaction, and social media. At the same time, earlier school start times compound sleep deficits, increasing negative outcomes, including physical health problems, cognitive deficits, and mental health challenges (Owens, 2014). While smartphones and social media have become widespread only in the last decade, electronic media and screens have been introduced to sleep environments long before. In fact, based on the National Sleep Foundation’s 2006 Sleep in America poll, 97% of US adolescents had at least one electronic media device in their rooms, and those with multiple devices in their bedrooms were more likely to experience profound daytime sleepiness. Strikingly, less than 20% of adolescents get an optimal 9 hours of sleep on school nights, with 60% reporting a sleep duration of 7 hours or less. Bedtime screen behaviors (social media, talking/texting, streaming, video games) or leaving phone alerts on during the night are strongly associated with trouble falling asleep and maintaining sleep (Nagata et al., 2023). Beyond delaying and disrupting sleep, nighttime social media use interferes with the biological clock because of exposure to artificial light from backlit screens. Melatonin is a natural hormone that signals to brain circuitry the optimal time for sleep onset. Its production typically follows a regular rhythm, with highest levels in darkness (immediately before bedtime), and lowest levels during the day, reflecting that melatonin is highly influenced by light exposure. In fact, blue light exposure from screens suppresses melatonin production, with lengthier exposure to blue light delaying sleep onset (Tähkämö et al., 2019; West et al., 2011). Importantly, the negative effects of screen use on sleep disruption are found to be highest for adolescents who are more likely to be considered as “night owls” and are naturally more active during the later parts of the day (Kortesoja et al., 2023). Chronic sleep restriction in adolescents has been shown to increase negative affect, depression and anxiety, and reduce self-esteem (Fredriksen et al., 2004; Kelly & El-Sheikh, 2014; McMakin & Alfano, 2015). Further, night-to-night variability in sleep quality has been linked to day-to-day variability in mood and emotions (Ben Simon et al., 2020; Shen et al., 2022). Disrupted sleep may have effects on the ways adolescents interact with social media. For instance, following a night of disrupted sleep, teens may be more likely to choose exposure to high-arousing negative content or engage in more negative personal interactions (e.g. more argumentativeness). Consequently, these negative interactions may cause mild levels of hyperarousal (irritability, anxiety, hypervigilance, and impulsivity) which have been shown to disrupt sleep by delaying sleep onset, decreasing sleep time, increasing awakenings, and reducing perceived sleep quality. In summary, social media plays an important role in nearly all adolescents’ social lives, however, its risks and benefits remain unclear due to the simplistic ways that it has been studied. Certain aspects of social media have important consequences for adolescent mental health, including excessive use, use that may disrupt sleep, and use that triggers strong negative emotional responses.   Intervention Strategies The American Psychological Association (APA) advisory on social media use in adolescence highlights several indicators that necessitate intervention (APA, 2023). These include excessive use of social media that the teen is unable to curb, consistently losing track of time and neglecting other activities, spending excessive attention to posted photos and the feedback to photos, becoming socially isolated and spending less time personally interacting with peers, failing to keep up with school or family responsibilities, and experiencing more negative emotions like irritability and anger. While parents have the most intimate and direct access to their child, both home and school interventions can be used to promote a healthy relationship with social media. Below, we detail practical solutions for both parents and schools. Despite overwhelming support by US adults (81%) for requiring parental consent for minors to create social media accounts (Anderson & Faverio, 2023), lack of such regulations means that parents need to play a primary role in setting and monitoring social media limits. Setting effective social media boundaries is best done in conversation and collaboration with the teen themselves (Wachs et al., 2021). Discussing the negative effects of unlimited social media use and working with your teen to identify potential harmful content can empower parents and adolescents to identify solutions for some of the unhealthy aspects of social media. When creating boundaries around social media use, considering the maturity level of the teen is important. Children aged 10 to 14 might require additional assistance in safely navigating social media (Magis‐Weinberg et al., 2021) and may need more extensive monitoring. Parents should coach teens on how to identify and navigate social media pitfalls such as cyberhate, health-risk behaviors (e.g. self-harm, disordered eating), cyberbullying, and privacy concerns (APA, 2023). Some parents and teens might benefit from using social media contracts for each family member, to set guidelines and responsibilities with mutual accountability. For some teens, setting a specific time limit for social media platforms might be appropriate, with more autonomy provided as teens mature and gain social media literacy skills. Parents can also install apps that block certain websites, as well as enforce time limits. Establishing specific times during the day (e.g., while eating dinner) that are “social media free” or “technology free” for the entire family also can discourage excessive use. Another important step is curbing social media and phone use around bedtime (see above for more details). Having a phone in the bedroom, even if the teen is not using it, can also affect sleep quality as the mere presence of the phone can create psychological alertness in teens (Elsheikh et al., 2023). Consider establishing a screen downtime at least two hours before bedtime and setting up an overnight device zone away from bedrooms to store all family devices. If screen use must occur in the evening, restricting blue light exposure with the use of amber-lens glasses may improve sleep onset delay (Knufinke et al., 2019). Additional strategies to curb the disruptive effects of screen use on sleep and biological rhythms include maximizing natural bright light exposure during the day, establishing daily activity and bedtime routines, and avoiding the use of the bed for anything other than sleep. Finally, parents and educators may also wish to discuss potentially positive aspects of social media, to emphasize that any social media boundaries come from a complete, thoughtful, and well-meaning standpoint. Social media can be a powerful tool for fostering opportunities for social support and connection, especially during times of isolation (Charmaraman et al., 2022) and steering teens toward those functions can be helpful. Self-disclosure is an important part of adolescent development and is shown to increase help-seeking behavior (Valkenburg & Peter, 2011). Online communities can be used to enhance opportunities for social support (Wang et al., 2021; Wang et al., 2019), increase access to mental health-promoting resources, and encourage open conversations around mental health that reduce stigma (Betton et al., 2015; O’Reilly et al., 2018). Key Implications for Practice Beyond interventions implemented by parents, schools can also play an important role in establishing healthy social media boundaries. Below are some key implications for practice in schools. Integrate Social Media Literacy instruction into curricula. Whether selecting to incorporate specific lesson plans or an entire curriculum, these opportunities typically address knowledge and skills to access and create purposeful content, critically evaluate the quality of information, and participate online in socially responsible and safe ways. Encourage shared decision making and student voice in developing social media policies. Incorporating student perspectives in proposed solutions and providing a clear rationale for establishing access and use policies is important for building a climate of transparency and shared agency. Consider policies that address social media access in school to limit unfettered social media use during school hours. For example, schools may: restrict access to some social media platforms on school wi-fi networks, use secure classroom-specific social media platforms, implement content filters to screen harmful or inappropriate content, or can require students to hand over their phones during class time to limit distractions. Create a cyberbullying plan, along with instruction and information provided to students, staff, and caregivers on how to identify and report cyberbullying. Provide clear guidelines for teachers and staff regarding their own social media use and maintaining professional conduct in their interactions with students on social media. Provide access to resources to enhance social media literacy for parents and caregivers and introduce practical tools for addressing their teen social media use. Provide information for parents and caregivers on school and community resources and activities accessible after school and during school breaks to help create schedules that encourage physical movement and in-person social interaction. Regularly review and update policies to address changing social media trends. Incorporate sleep hygiene education into curricula. Adolescents who are better informed about negative mental health consequences of insufficient sleep will be more likely to keep regular sleep hours. Related Resources To Understand the Risks of Social Media Use Social Media and Self-Doubt (Child Mind Institute) Social Media and Body Image (The Jed Foundation) Understanding Social Comparison on Social Media (The Jed Foundation) Screen Time and Technology (Child Mind Institute) To Develop Practical Interventions How to create a screen time contract Selfies, Social, & Screens: 2023 Back-to-School Toolkit (Mental Health America) I Don’t Know How To Navigate My Child’s Technology Use (Mental Health America) How to Make a Family Social Media Plan (On Our Sleeves) Am I a Cyberbully? Examples of Cyberbullying and How to Stop (The Jed Foundation) Help Teens Avoid Online Mistakes (Center for Parent & Teen Communication) To Promote Healthy Use Behaviors Conversation starters to talk to kids about social media use Safe Spaces – How Digital Environments Can Serve Youth (Mental Health America) How to Know if Your Child Has a Social Media Problem (On Our Sleeves) Mindful Consumption of Social Media Can Support Our Mental Health (Active Minds) How to Protect Your Space and Well-Being on Instagram (The Trevor Project) To Understand and Improve Sleep Hygiene Healthy Sleep in Teens Winding Down Worksheet (Boston Children’s Hospital) How to Sleep Well (Teen Sleep Guide)   https://doi.org/10.17077/rep.006664 
Kids on cell phones
Laura Gallo, Ph.D., Assistant Professor of School Counseling, University of Iowa College of Education
Description
Suicide is the 3rd leading cause of death for youth ages 10-24 (CDC, WISQARS 2022). Rates of suicide for youth continue to rise each year. Just in 2020 alone, 6,663 young people (age 5-24) died by suicide (CDC, WISQARS 2022). Additionally, 18.8% of high school students in the US reported considering suicide, 15.7% reported creating a suicide plan, and 8.9% reported trying to take their own life during 2019 (Ivey-Stepheson et al., 2019). https://youtu.be/2vCVScivgQk?si=8Vqs2lvlMJwsPTx6   There are notable differences within minoritized populations as well. For example, when examining the breakdown of suicide for youth from different racial or ethnic groups, the highest suicide rates can be found among those identifying as American Indian/Alaska Native (CDC, 2019). There is also a significant difference in adolescents seriously considering suicide based on their sexual identity (heterosexual: 14.5%; LGB: 46.8%; not sure: 30.4%; Ivey-Stepheson et al., 2019). Suicide affects many of our youth and can have serious consequences, including a range of negative mental health outcomes, increased risk of subsequent attempts, and death. Educators, and specifically school counselors, are well positioned within the school system to identify and intervene when children and adolescents are struggling with suicidal thoughts and behaviors. This practice brief provides educators with information and resources on suicide prevention, intervention, and postvention that is evidence-based and applicable to the K-12 school setting. Subsequently, suicide prevention, intervention, and postvention efforts are essential as educators continue to meet their students' needs and require the collaboration of the entire school community. Prevention and Identification Strategies Suicide prevention work relies on creating a culture where educators have positive attitudes regarding help-seeking behaviors at the school level. A school climate that supports mental health and advocacy efforts is more likely to result in students recognizing that depression, anxiety, and stressors that lead to suicidal ideation are significant enough to talk about with someone they trust (Erbacher et al., 2014). Schools may adopt prevention programs which embrace an attitude that students are resilient and can learn to rely on positive coping skills before becoming susceptible to suicide risk (Suicide Prevention Resource Center, 2012). Classroom lessons that focus on mindfulness, emotional regulation, and social skill development have all been effective in reducing risky behaviors and helped prevent suicide (Broderick & Jennings, 2013; Rudd, 2017). Schools can use a specialized curriculum that fosters school connectedness and includes factors such as: school belonging, positive social relationships, feeling cared about by adults at school, and supportive learning environments (Miller, 2018). In addition, gatekeeper training programs, which provide information about warning signs and help educators become more comfortable talking with students about suicide, are also highly effective. Some well-known gatekeeper trainings used in schools include: Question, Persuade, Refer (QPR), Applied Suicide Intervention Skills Training (ASIST), and Signs of Suicide (SOS). Signs of Suicide is one common program that includes both a gatekeeper training curriculum and a suicide risk screener. The Suicide Prevention Resource Center provides a list registry of evidence-based programs at: https://sprc.org/keys-to-success-2/evidence-based-prevention/. Although best practice would be for a school district to bring in an evidence-based program annually to train all staff, providing supplemental trainings or reminders regarding warning signs and risk factors would also be beneficial. Warning signs are indications that an individual may be at risk of suicide and are widely endorsed within the field of suicide prevention. The following list provides some of the most noted indicators in students: Withdrawal from activities Social isolation Perception of being a burden Risk-taking, recklessness (e.g., self-harm, substance use) Sleep problems Agitation Anxiety (Joiner, 2005; Rudd, 2017) All schools should have a protocol in place for how they will address suicide. Protocols provide step-by-step instructions for how to respond when a student is suicidal, who is responsible for responding, resources, strategies for responding, and how to document the process. The Substance Abuse and Mental Health Services Administration’s toolkit has examples of protocols that can be easily adapted to a district’s needs (2012). The toolkit can be found at https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669. Schools can also work with families and the community to increase suicide prevention efforts. For example, school counselors can provide education on identifying behaviors that may indicate more serious signs of a student who may be struggling with suicidal ideation and help family members become more comfortable initiating conversations with their children. Schools can also work with community partners (local chapters of National Association of Mental Illness, American Foundation for Suicide Prevention, or the Red Cross) to gather a list of resources, provide recommendations, and increase outreach.   Intervention Strategies Suicide prevention/intervention can be structured within (a) Tier 1 (universal approaches), (b) Tier 2 (selective interventions targeted towards groups of students who demonstrate risk factors), and (c) Tier 3 (intensive interventions targeted at students who screened positive for a risk factor). Universal Approaches (Tier 1) All adults in the school are part of Tier 1. Universal approaches target ALL students and promote a schoolwide culture that is proactive and focused on healthy behaviors and positive social, emotional, and behavioral skills. These skills can be taught through classroom lessons, small group instruction, or peer support programs. Sources of Strength (2020) and Hope Squad (n.d.) are two examples of peer programs that incorporate upstream prevention strategies and utilize protective factors to create a help-seeking culture within the school environment. They emphasize relationship building, forming connections, and identifying supports. Both programs are evidence-based and offer schools a format to train students and staff in suicide prevention. Through classroom and small group instruction, students can be taught about common warning signs of suicide, myths of suicide, and how to seek out trusted adults when confronted with challenges. It is important to educate teachers and other staff through gatekeeper trainings about how to appropriately respond to students. These trainings help adults learn to respond to students without judgment and with more empathy, increasing the likelihood that the student will be open to support. Universal screeners are also utilized as part of Tier 1 interventions when approved by the school district. Universal screeners can assist with identifying students who may need more individualized support. Targeted Interventions (Tier 2) Targeted interventions support students at risk for suicide who have demonstrated warning signs such as changes in behavior (e.g., social isolation, poor sleep habits, substance use). Programs such as Reconnecting Youth (Eggert et al., 2009) and Coping and Support Training (CAST) are two evidence-based programs that work on skill development to help students build resiliency and are specifically designed as Tier 2 interventions. School counselors may schedule regular check-ins with these students to build a relationship and to provide ongoing support. Teachers who work with these students may also offer extra help or encouragement in the form of extra time, positive notes, or phone calls home. An important aspect of suicide prevention work is that a student finds a trusted adult in their life they can connect with on a regular basis. Intensive Interventions (Tier 3) Students who have reported or been identified as individuals with suicidal ideation would qualify for a Tier 3 intervention. Students may express suicidal ideation in various ways such as verbally or behaviorally. Some signs are overt, for example a student saying they want to die, while other times it is implied, “I wish I would go to sleep and not wake up.” Students may write in an assignment or draw something that alarms the teacher. Some educators have also received training on asking directly about possible suicidal thoughts or plans and may directly broach the topic with students. Educating the school community (students, staff, families) to seek out the support of a qualified mental health professional (school counselor, social worker, school psychologist) to further talk with the student of concern is critical. This includes how to conduct a referral that utilizes a warm handoff, which involves the educator personally connecting the student with the school mental health provider, such as the school counselor. Spending some face-to-face contact during the referral is different than simply asking the student to go see the provider. Conducting a warm handoff increases the likelihood the student will earnestly engage in counseling and get the help they need. Thus, educators can play a pivotal role in supporting students through the suicide intervention process. Once students have been identified as needing support for possible suicidal thoughts or behaviors, school counselors have an ethical obligation to intervene (ASCA, 2022; A.9). School counselors should conduct a suicide risk assessment, a process that includes asking a student about their suicidality and taking precautions to keep them safe. An important aspect of interviewing the student about their suicidal thoughts or behaviors includes spending an adequate amount of time listening. Collaborating with the student, validating their feelings, and attempting to build a relationship is more likely to create a therapeutic experience (Sommers-Flanagan & Sommers-Flanagan, 2021). Conducting a risk assessment should be viewed as an opportunity to engage with the student in a manner they would find helpful. Some recommendations for intervening with students who are experiencing suicidal ideation include asking directly about possible suicidal thoughts or plans, asking about their current mood or level of agitation, gathering information about their level of suicide intent, and inquiring about any past attempts. Sometimes educators or parents will provide critical information in these areas, and this knowledge is incorporated into the formal suicide risk assessment. School counselors can also talk with students about what they list as their reasons to live and reasons to die- it can be helpful to understand their current level of functioning and to incorporate it into safety planning. Other recommendations include consulting with one or more professionals, developing a safety plan, ensuring detailed documentation of the assessment and decision-making process and notifying parents/guardians, and offering support for the next steps (Sommers-Flanagan & Sommers-Flanagan, 2021). School counselors need to be mindful when using a risk assessment tool. They should have proper training in using the tool and never minimize risk when sharing the results with parents/guardians. Safety planning is an important step in the suicide intervention process. Suicide experts no longer advocate using no-suicide contracts (Rudd, 2017; Sommers-Flanagan & Sommers-Flanagan, 2021). Stanley and Brown (2008) have created a popular safety planning tool for suicide risk. However, schools should work to develop a tool appropriate for the developmental level and population of the students they serve. Safety plans generally include identification of warning signs, coping strategies, substitute activities, individuals/agencies to contact for support, and efforts to reduce their access to the method to carry out their suicide plan. It is best if safety planning is a collaborative process between the school counselor and the student, but it may depend on the age of the child. Parents or guardians may also need to be a collaborator in this process, especially in reducing access to the method of their suicide plan. Unless child abuse is suspected, parents/guardians would be notified of a student’s thoughts of suicide. School counselors should check with their school district on all suicide intervention procedures, including specific forms related to safety planning. When creating a safety plan, school counselors should emphasize protective factors over risk factors and wellness over diagnosis. Protective factors are defined as characteristics associated with positive outcomes or outcomes that counter risk factors. Common protective factors include family support (and acceptance of identities), a sense of safety at school, close friends, emotional regulation, and a sense of hope and life satisfaction (SAMHSA, 2012). Risk factors are characteristics associated with a higher likelihood of negative outcomes. Young people are resilient, and focusing on their strengths and supports can help build their coping and problem-solving skills (Sommers-Flanagan & Sommers-Flanagan, 2021). Recognizing the student’s reasons for living can help in the safety planning process and become an important factor in helping a child recognize their ambivalence about suicide. Schools can also share resources such as the Suicide Prevention Lifeline, 988, with students and their families. Educators can serve an important role after a student has been referred to a school mental health professional. While they might not be privy to the confidential information the student has shared with the mental health professional, it is important to follow up with the student post-referral. Educators can work with the counselor to identify strategies for checking in with the student, supporting them through their journey, and monitoring for any additional signs of concern. Educators can be enlisted as supportive adults to further enhance protective factors.   Postvention Strategies Postvention is an intervention conducted after a suicide occurs. Schools will benefit greatly from creating a postvention plan BEFORE a tragedy happens. In the unfortunate event a student dies by suicide, staff may be overwhelmed with the fallout and have difficulty coming up with a plan in the moment. The postvention plan conducted after a student death from suicide can help reduce suicide contagion among those students most vulnerable. Suicide contagion is the increased risk of others resorting to suicide after one suicide occurs. Therefore, schools should view and treat all student deaths in the same way. For example, losing a student to illness or accident should be approached in the same way as losing a student to suicide to avoid inadvertently simplifying, glamorizing, or romanticizing the decedent (Suicide Prevention Resource Center; SPRC, 2018). Other postvention recommendations include consulting reputable organizations that promote best practices and evidence-based tools when creating planning documents and working with multiple entities within the school and community to develop and respond to the postvention plan. Engaging in these efforts is important to support the staff, students, and family members in identifying and gathering all the resources needed to carry out the plan. SPRC offers a toolkit to help school districts with postvention efforts, this can be found at https://tinyurl.com/ynx5t4ck. Finally, documenting and evaluating the crisis response and reviewing and revising the crisis plan annually is essential for ensuring an effective and applicable plan. Key Implications for Practice Invest in a suicide prevention curriculum for students and gatekeeper training for all staff Have suicide/crisis protocols in place (includes postvention) Ensure informed use of risk assessment tools (proper training, validated instruments, developmentally and culturally appropriate) Have community resources list available (updated regularly) Make sure all school mental health professionals receive up-to-date suicide assessment training Consider parent education on identifying suicide warning signs Create school climates that promote belonging and help-seeking Related Resources Suicide & Crisis Lifeline: call or text 988 or 1-800-273-TALK I’m Alive National Suicide Hotline and Chat: 1-800-SUICIDE Preventing Suicide: A Toolkit for High Schools (SAMHSA) Model school district policy on suicide prevention After a suicide: a toolkit for schools The Trevor Project *for LGBTQ youth American Association of Suicidology School Resources https://doi.org/10.17077/rep.006644 
holding hands
Sarah Ketchen Lipson, Ph.D., EdM, Associate Professor in the Department of Health Law Policy and Management, Boston University School of Public Health + Principal Investigator, Healthy Minds Network
Description
As a prospective college student, or a parent of a prospective college student, there are numerous, nearly universal challenges that new college students experience, including adjusting to a new environment (often having left home for the first time), dealing with homesickness, making friends and building new support networks, establishing routines (often with less structure than in high school), and being responsible for things like healthcare use, sleep, and personal finances, all on top of heightened academic standards and mounting concerns over debt and the cost of higher education. This is far from an exhaustive list of the challenges new students encounter, and of course, there are distinct stressors based on students’ backgrounds and identities (e.g., for international students, there is immersion into new cultures). College is also a time when mental health problems often begin or intensify. For depression, the average “age of onset” (or time when symptoms first appear) is in the mid-20s, which coincides with the traditional college years. In fact, 75% of lifetime mental health problems will onset by about age 25. With roughly half of all adolescents and young adults in the U.S. enrolled in postsecondary education, mental health in college student populations is increasingly recognized as a public health priority. As such, the topic of mental health at colleges and universities has received a significant amount of media attention in recent years. National data reveal high and rising prevalence of mental health concerns among students. My colleagues and I lead the Healthy Minds Study, a mental health survey conducted at hundreds of colleges and universities annually. In our 2022-2023 data, 41% of students screened positive for symptoms of depression and 36% for symptoms of anxiety, nearly doubling in symptom prevalence over the past decade. Though less frequently discussed in the media, many students are also thriving in college; in the most recent Healthy Minds data, 36% of students met criteria for ‘flourishing’ (or positive mental health). Of note, the prevalence of depression, anxiety, flourishing, and other mental health outcomes varies significantly across both student and institutional characteristics; the patterns are complex and point not only to urgent opportunities for system-level change but also to the importance of college “fit,” as discussed below. My career’s work studying and reporting on the mental health needs of college students was originally motivated by my time working in residence life, where I served as a live-in advisor to first-year undergraduates (most fresh out of high school). Drawing from both the national data my colleagues and I have collected through Healthy Minds as well as my lived experiences in residence life and now as a faculty member, I see many opportunities for high school students (prospective college students) to prepare for holistic success in college by prioritizing their mental health and wellbeing at each stage of the process. What follows are recommendations and considerations primarily aimed at prospective students and their families.   Strategies to Prepare When and Where to Go College We’ll start with the decisions of when and where to go to college. These are, of course, some of the most important decisions a young person will make in their life. As such, the college application and decision-making processes are riddled with anxiety and uncertainty; naming the anxiety and uncertainty is an important first step. There are resources for handling this stress, including recommendations offered in Set to Go, a program from the Jed Foundation; these include the need to be realistic in where one applies and the importance of avoiding peer comparisons to the extent possible (see Related Resources below). Of course, the prioritization of one’s mental health in deciding when and where to go to college will look different for each individual, but here are some overarching considerations for prospective college students. In deciding when to go to college, be open to the idea of a gap year. For a number of reasons, starting college immediately after high school may not be the right timing for you. Generally speaking, a gap year can be thought of as taking the year after high school to work, volunteer, travel, etc. before starting college. Think of the possibility of a gap year as a potentially empowering decision; after 13+ consecutive years of mandatory schooling, you don’t necessarily need to start college immediately after completing your K-12 education. There may be compelling reasons to take a gap year, and these reasons should be taken seriously. Ideally, you will begin college fueled by curiosity. This may not be possible if you are ‘burned out’ from high school; your academic brain may need a well-deserved break. You may want to get ‘real world’ professional experience; working full-time and saving money during a gap year may alleviate some financial stress, lessening angst about costs when you do begin college. You may simply feel like you need another year to mature. Parents should be reminded that a gap year is not an indication that your child has lost or will lose momentum. Empirical research has demonstrated that gap year participation positively predicts academic motivation in college (Martin, 2010). The Child Mind Institute offers recommendations for picking a gap year program, and the aforementioned Set to Go program lists pros and cons when considering a gap year (see Related Resources below). Whether logistical, emotional, financial, or otherwise, your reasons to take a gap year should be thought of as signs of self-awareness. A gap year may be the best decision for achieving the longer-term goal of having a positive, enriching college experience. In deciding where to go for college, prioritize “fit” (and de-prioritize the rankings). When choosing where to apply and eventually which college or university to attend, prospective students should be focusing on “fit.” “Fit” is related to other terms that are commonly used and measured in survey studies, such as students’ “sense of belonging” in school. But what does it mean to find a school that is a good “fit”? The somewhat nebulous concept is really about the relationship between the person (prospective student) and the environment (college/university). The person-environment fit is not accounted for in the rankings, which some prospective students and their families allow to supersede individual preferences; this rarely works out well in my experience. Early in my career, as an advisor at arguably the most prestigious university in the world, I once sat with a first-year student who tearfully admitted that they knew this was not the right place for them, but they’d felt they had to apply and then attend because of the institutional reputation. The student was filled with regret, which they recognized as avoidable. The “fit” was not right. It is important to think about “fit” along several dimensions. In addition to financial fit (the means to attend a school), there are several, concrete things to consider with fit, including: Institutional size: Do you want to go to a big school or a small school? Location: Do you want to be a car or plane ride from home?; In a city or on a less urban campus? Social life: Do you want to be at a school with Greek life (i.e., fraternities/sororities)? Academics: How well do courses/majors and internship opportunities align with your interests/goals? If you have the ability to visit schools as a prospective student (to tour the campus and potentially spend time with current students), “fit” should be top of mind. Ask yourself versions of: Do I see myself as part of this college community? Why or why not? Virtual tours and admissions open houses are also valuable opportunities to assess fit if visiting a campus is not feasible. On top of some of the more straightforward considerations listed above about location, size, etc., there may be other dimensions of fit that are important based on your goals (e.g., for student-athletes), your identities, and your needs and preferences. Some lesser-emphasized dimensions that warrant attention are: the institutional policies that govern student life and the resources available to support students at a college or university. For example, in the U.S. there is significant variation across colleges and universities in terms of policies that may uniquely affect LGBTQ+ prospective students; the Campus Pride Index allows prospective students and families to search a database of LGBTQ-friendly campuses based on such factors as the school’s anti-discrimination and housing policies. Unfortunately, many schools have systems, forms, and facilities that reinforce a gender binary. Until more institutions adopt protective policies such as allowing students to change their names and pronouns in campus records (a practice that helps prevent against deadnaming and misgendering), it is sadly far from guaranteed that transgender and nonbinary students will be safe and supported on all campuses (even those that may espouse inclusivity in broad terms). As prospective students, you should educate yourself about a school’s policies and systems and consider these to be indications of a school’s underlying values. Prioritize selecting a school with values that align with your own. This can enhance belonging and prevent future discomfort and potential experiences of systemic discrimination. Prospective students should also ask about or look into a college or university’s policies and resources pertaining to mental health and well-being. Much of this information is likely to be available online at institutional websites, but can also be asked about on-campus tours, admissions open houses, etc. Understanding a school’s mental health policies and resources is particularly important for the growing number of prospective students who begin college with a history of mental health treatment (more on continuity of care in the next section). Prospective students and their families should educate themselves about the mental health resources available at a school, including counseling/therapy and psychiatry services on campus and in the local community as well as prevention efforts. Regarding prevention efforts, prospective students and their families should be looking for a school to have a ‘public health ’ (or population-level) approach to mental health on campus, which means that mental health is prioritized not just when it is a problem/crisis, but more holistically and among all students. Because there is no one-size-fits-all approach to prioritizing population-level mental health, prospective students and their families may find it useful to see examples of colleges and universities that received the Healthy Campus Award from the nonprofit organization, Active Minds for their efforts to “champion student health;” importantly, many past recipients of this award have been schools with fewer resources, including community colleges, underscoring that a school’s prioritization of mental health is in no way contingent on endowment. Indications that a school prioritizes mental health at a population level may be evident in the promotion of and attention to wellbeing in academics, through extracurriculars, and within residence life as well as changes to the ‘built environment’ to promote social connectedness and reduce means of self-harm. Relatedly, another discernible signal of a college or university’s approach to student mental health is the institution’s leave of absence policy, which includes their return from absence policy. These policies should be readily available on the college’s website and should be specific but easy to understand. Leave policies should be nonpunitive and should demonstrate parity, meaning that mental health should be held to the same standards as any other medical reason. The Bazelon Center for Mental Health Law provides more detailed information about leave of absence policies, including involuntary leaves, along with a guide to students’ rights under the Americans with Disabilities Act. Additionally, a 2021 guide listed in Related Resources below, details best practices for college and university leave of absence policies. For prospective students, particularly those with no history of mental health problems, it may seem like an irrelevant policy to consider in the application process, but I argue that leave policies can provide clues as to the degree to which a school supports student well-being and mental health needs. Before Starting College We’ve covered some considerations for the decisions of when and where to attend college. Now let’s fast forward to the spring/summer before starting college. Importantly, the strategies offered here will be more effective if built on a foundation of good health behaviors, including healthy sleep, diet, exercise, and use of technology. Preparing to start college will look different for everyone, but what follows are some overarching recommendations. In my experience working in residence life and now as a faculty member, I can tell you that rejection and “failure ” are inevitable in college. The truth is that there will be setbacks and challenges. I don’t know anyone for whom this is not true. Relative to high school, the stakes may feel higher in college, due in part to factors mentioned earlier, including more rigorous academic standards. For many new college students, failures (subjectively defined) can seem catastrophic. Perspective is important. Remember that everyone around you, including your professors, has failed and been rejected. Myself, I have received far more rejections (from journals, organizations, funders, you name it) than acceptances throughout my career. In my experience, rejections and failures have become easier to deal with over time. But as a first-year undergraduate, I did not have the same resilience or perspective I do now. A strategy that can be helpful for new college students is ‘coping ahead, ’ an anxiety management technique borrowed from dialectical behavioral therapy. Briefly, ‘coping ahead’ means thinking about and preparing for the inevitable setbacks, challenges, and failures that one will experience. Not getting into a first-year seminar course. Getting passed over for a spot in a club or on a sports team. Not connecting with your roommate. All of these normal experiences can feel all-consuming and devastating. Being prepared for these scenarios can prevent being “blindsided” by the challenges that will definitely (not maybe) come with college. This is of course made easier by building autonomy and self-efficacy before getting to college. For most students, particularly those who move away, beginning college represents a big leap in independence; just how big a leap depends in part on maturity and life skills. These include executive functioning, time management, and problem-solving skills, all of which can be honed with practice and experience. The Child Mind Institute points to questions that prospective college students can ask themselves, such as: “What would you do if you got a bad grade?” and “Who would you call if you were distressed?”. While many parents may want to help their high school students navigate challenges, doing so may stifle skill development. Importantly, a lack of problem-solving skills has been linked to mental health problems such as depression. The final recommendation before beginning college applies specifically to prospective students with pre-existing mental health needs. Students need to be comfortable self-administering any mental health medications as prescribed, and students should be educated about how alcohol and other substances may interact with medications. Relatedly, continuity of mental health care is extremely important to plan for in the transition to college, which may involve establishing care networks in a new location. Starting College My main advice for the first year of college is to set goals that focus less on grades and academic performance and more on skill-building. Think of the start of college not as a time to achieve, but as a time to grow and set goals accordingly. Take advantage of resources to help you navigate the transition to college; this includes many human resources in the form of peer advisors, faculty mentors, coaches, and student affairs professionals. Ask questions, ask for help, let people support you (and reciprocate when you are in a position to do so). Despite what social media may portray, loneliness is very common among college students. As with the challenges described above, I don’t know anyone for whom loneliness did not at least creep in during college. In our Healthy Minds data, 20-25% of students report “often” feeling “left out,” “isolated from others” or that they “lack companionship.” Particularly for first-year students, remember that some degree of loneliness is to be expected. You are in a new environment and that can feel isolating, even if you are physically surrounded by other people. It will take time for most new students to build relationships with peers and faculty. Be patient but proactive. Don’t expect loneliness to resolve on its own (or linearly). Make time to engage in social and extracurricular activities, the offerings for which are often far more extensive than in high school. Get involved in something (but not too many things). The Set to Go program also offers a guide to making connections on campus. Lastly, students and families need to enhance what is known as ‘mental health literacy.’ Schools should be a setting where this is fostered. Prospective students should look into whether the college/university offers first-year seminars about mental health and wellness. As noted earlier, the traditional college years (~ages 18-25) are a vulnerable time for the onset of mental health problems. Unfortunately, in the U.S., the delay from symptom onset to first treatment contact is, on average, about a decade. Part of mental health literacy is understanding that treatment is most effective when received early. Students and their families should know the mental health resources available at a school as well as the signs and symptoms to look out for; parents are especially well-positioned to observe any changes in the mental or emotional state of students at the start of college (when peer networks are being established). It is also important to be knowledgeable about other supportive resources such as academic tutoring, peer coaching, and resources specific to certain student groups (e.g., for first-generation college students).   Key Implications for Practice In deciding when to go to college, be open to the idea of a gap year. This may be the best decision for having a positive, enriching college experience. In deciding where to go for college, prioritize “fit” along several dimensions, including institutional policies that govern student life and available resources. Expect challenges in college and be prepared by ‘coping ahead.’ Build autonomy and problem-solving skills before coming to college, including the skills and knowledge to manage pre-existing mental health conditions. In starting college, set goals that focus less on grades and more on skill-building. Take advantage of resources to help navigate the transition to college. Students and their families should know the mental health resources available at a school as well as the signs and symptoms to look out for. Engage in social/extracurricular activities and get involved in something (but not too many things). Conclusion The advice and recommendations offered here are rooted in evidence-based risk and protective factors—that is, reducing factors known to negatively affect mental health and fostering factors known to positively support well-being and flourishing in college populations. I hope that these recommendations help prospective college students and their families prepare for higher education in ways that prioritize mental health and well-being. Related Resources Child Mind Institute When to Consider a Gap Year Program: support for students who aren’t ready for college (https://childmind.org/article/when-to-consider-a-gap-year-program/) Preparing for College Emotionally, Not Just Academically (https://childmind.org/article/preparing-for-college-emotionally-not-just-academically/) Medication Management in College: it takes practice, so high school is the time to start (https://childmind.org/article/managing-medication-in-college/) Jed Foundation Deciding Whether You Should Take a Gap Year (https://jedfoundation.org/resource/deciding-whether-you-should-take-a-gap-year/) Tips for Handling College Application Stress (https://jedfoundation.org/resource/tips-for-handling-college-application-stress/) College Relationships 101: Building Connections (https://jedfoundation.org/resource/college-relationships-101-building-connections/) How to Deal with Homesickness in College (https://jedfoundation.org/resource/how-to-deal-with-homesickness-in-college/) Exploring Financial Aid and Loan Options for College (https://jedfoundation.org/resource/exploring-financial-aid-and-loan-options-for-college/) Leaves of absence and other campus policies Taking a Leave of Absence: A Guide for College Students (https://rudermanfoundation.org/white_papers/leave-of-absence/) Bazelon Center for Mental Health Law (https://www.bazelon.org/) The Campus Pride Index (https://campusprideindex.org/) Active Minds Healthy Campus Award (https://www.activeminds.org/programs/healthy-campus-award/)   https://doi.org/10.17077/rep.006643 
Three students walking down hall
Yanchen Zhang, Ph.D., LP, NCSP, Assistant Professor of Psychological & Quantitative Foundations, University of Iowa
Description
A significant proportion of students in the US struggle with social, emotional, and behavioral (SEB) needs (Ghandour et al., 2019). If untreated or treated inadequately, SEB problems can cause various short- and long-term negative outcomes, such as academic failure, disruption to peers' and their own learning, poor relationships with peers and educators, and increased exposure to exclusionary disciplines (e.g., suspension). Unmet SEB needs also contribute to longstanding disparities for students from historically disadvantaged backgrounds. As a result, educators worldwide consistently rank SEB problems among their top concerns. Often, evidence-based practices (EBPs) are used infrequently or not adopted at all in schools. Even if adopted, about 50-75% of EPBs were implemented with low fidelity or quality. Implementation science focuses on the factors, strategies, and processes to translate EBP research effectively and efficiently into routine practices in schools (Williams & Beidas, 2019). In schools, the implementation of EBPs is never an event but an iterative process that requires deliberate attention to factors and strategies that either obstruct or enable the implementation of EBPs (Lyon & Bruns, 2019).   https://youtu.be/B59bybNmo7M   This practice brief focuses on the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2022), to support the implementation of EBPs. The CFIR emphasizes the social-ecological system by using "contextual domains" to categorize factors based on their level of influence on the implementation of EBPs (Figure 1). Specifically, the CFIR contextual domains include (a) outer setting (e.g., policy, finance), (b) inner setting (e.g., leadership, climate), (c) characteristics of individuals (e.g., attitudes, intentions), (d) EBPs (e.g., fidelity, flexibility, acceptability), and (e) implementation process (e.g., implementation stages, implementation strategies). We will base our discussion on three domains (i.e., inner setting, individuals, and EBPs) because they are more relevant and actionable for most school personnel. Prevention/Identification Strategies As a fast-growing field, numerous assessments of implementation factors based on the CFIR domains were developed and validated in many child-serving settings (e.g., child welfare, schools). These assessments can help professionals identify important and malleable implementation factors that either facilitate or impede their current efforts to adopt and implement evidence-based practices (EBPs). Based on the assessment results, schools can select preventive or interventive implementation strategies to improve the identified implementation factors. Below we summarized several widely used, validated, and pragmatic (i.e., cost-effective, free, and easy to use) assessments of selective key factors related to the successful implementation of EBPs for student SEB needs. (For more assessments, see Related Resources). Implementer-Related Factors mplementers' (e.g., teachers, social workers, school psychologists) attitudes about a given EBP and their intentions to implement can predict their subsequent implementation behaviors (e.g., actual use of EBPs in work, intervention fidelity), which are crucial for achieving expected student outcomes. Evidence-Based Practice Attitudes Scale (Aarons et al., 2007) assesses implementers' attitudes toward a specific or generic EBP. It contains 15 items rated on a 5-point Likert scale, which fall into four subscales: (1) Appeal of EBP, (2) Requirements (to use EBP), (3) Openness (to new EBPs), and (4) Divergence (e.g., one believes EBP are not useful). Intentions to Use Scale assesses one's intention to implement a new EBP (Kortteisto et al., 2010). It consists of five items on a 7-point Likert scale ranging from "greatly disagree" to "greatly agree". EBP-Related Factors Some common characteristics of an EBP as perceived by school personnel can either promote or jeopardize their adoption and use of an EBP: (1) feasibility, (2) acceptability, (3) appropriateness, and (4) intervention fidelity. Feasibility is the degree to which a new EBP can be properly adopted and delivered by school-based implementers. Acceptability refers to the degree to which an EBP is agreeable or satisfactory for school-based implementers. Appropriateness refers to the perceived fit, relevance, and/or compatibility of an EBP for school mental health. The Suite of Feasibility, Acceptability, and Appropriateness Scales (Weiner et al., 2017) is a widely used and brief measure, which contains 12 items (four for each factor). Educators can use the suite of measures to assess these three factors together or separately based on their needs. Adequate intervention fidelity (also known as intervention/treatment integrity, or implementation fidelity) is crucial to expected student outcomes. The most important and relevant dimension of intervention fidelity is implementers' adherence (i.e., deliver all core components of an EBP as intended by the original protocol/manual). Many EBPs offer accompanying measures of intervention fidelity that are specific to each EBP. Educators can also customize their own fidelity measures by (a) counting the number of core components they have delivered, and then (b) dividing it by the total number of core components of an EBP. School Inner Setting Factors School-level leadership and climate that are specific to EBP implementation are critical to fostering a "pro-EBP" working environment for all staff and educators, which can in turn reward and motivate their use of EBPs (Zhang et al., 2022b). School-Implementation Leadership Scale (Lyon et al., 2022) assesses educators’ perceptions of their school leaders' behaviors relevant to the delivery of EBPs. The scale has 12 items that fall into four subscales: (1) Proactive, (2) Knowledgeable, (3) Supportive, and (4) Perseverant. All items are scored on a 5-point Likert-Scale ranging from 0 (not at all) to 4 (very great extent). School-Implementation Climate Scale (Lyon et al., 2018) assesses educators' perceptions of the climate in their schools that strategically support the implementation of EBPs. The scale has 29 items that fall into nine subscales: (1) focus on EBP, (2) educational support for EBP, (3) recognition for EBP, (4) rewards for EBP, (5) selection for EBP, (6) selection for openness, (7) use of data, (8) existing supports to deliver EBP, and (9) EBP integration. Implementation Strategies School-based implementation of evidence-based practices (EBPs) often yields lower than desired student social-emotional, and behavioral (SEB) outcomes due to deficits in certain implementation factors (e.g., fidelity, acceptability, leadership). Hence, the main targets of implementation science are implementation factors (or implementation outcomes), which are prerequisites to effective interventions and expected student SEB outcomes. School-based implementation researchers have adapted a compilation of 75 evidence-based implementation strategies to the school settings that map onto nine categories: (1) use evaluative/iterative strategies, (2) provision of interactive assistance, (3) adapt and tailor to context, (4) develop stakeholder relationships, (5) train and educate stakeholders, (6) support educators, (7) engage consumers, (8) financial strategies, and (9) change infrastructure (School Implementation Strategies, Translating ERIC Resources (SISTER); interested readers please see Cook et al., 2019; Waltz et al., 2015; Gaias et al., 2022). In this brief, we introduce best practices for decision-making in the selection and delivery of appropriate implementation strategies based on CFIR (Consolidated Framework for Implementation Research) and SISTER to address common needs or implementation factors related to educators' implementation of EBPs. #1 Preparation School-based implementation of EBPs relies on collaboration among all stakeholders (e.g., school leaders, mental health professionals, educators, consultants/coaches, students, and family representatives). A school needs to make team-based decisions about which implementation strategy to adopt to enhance their existing implementation efforts for a given EBP. Actively engaging stakeholders can ensure that the identified implementation needs/issues and corresponding strategies align with the actual needs and priorities of the school community, which can ensure wrap-around support. #2 Identify the delivery format of the target EBP Different types of EBPs require different levels of implementation strategies. For instance, school-wide positive behavior interventions and supports (SW-PBIS) and universal social-emotional learning curricula require system-wide implementation efforts. So, school teams need to select implementation strategies that target school-level factors (e.g., leadership, climate). Conversely, school-home notes rely on individual participation. Hence, one should use strategies that promote individual-level implementation factors (e.g., teacher buy-in, teacher-family relationship). #3 Identify the current implementation stage The school team needs to match implementation strategies to their current implementation stage. Generally, implementation efforts can be divided into four stages: Exploration, Preparation, Implementation, and Sustainment (Moullin et al., 2019). Different stages require different implementation strategies (Zhang et al., 2022a). For instance, if a school plans to test-drive SW-PBIS, they should select pre-implementation strategies that build up the school-wide readiness for SW-PBIS (e.g., training, change commitment, professional learning communities). On the other hand, if a school is already implementing SW-PBIS but lacks fidelity, they should select strategies to improve fidelity (e.g., hiring coaches, performance-based feedback, motivational interviews). #4 Review school needs and lacking implementation factors The school team will conduct a needs assessment with implementers and then use validated assessments of implementation factors to identify the gaps in their implementation efforts. The assessment process should follow the CFIR model to cover critical domains based on the school team and implementers' consensus (e.g., implementer-related or inner-setting factors). The school team can then refer to the SISTER, ERIC, or other compilation of strategies (Powell et al., 2015; Cook et al., 2019) to select implementation strategies that pinpoint the identified lacking factors. #5 Identify implementation-related contextual factors Consider the contextual factors that may influence the use of the implementation strategy, such as school leadership, climate, policies, existing practices, and the availability of resources required for certain strategies. The school team should assess how feasible each implementation strategy is given their existing infrastructure and resources (e.g., staffing, time, money, material). Then, the school team should work on solutions to identified barriers (e.g., allocate time and incentives for a school team to carry out the identified strategy) (Zhang et al., 2022c). #6 Determine implementation strategies, corresponding goals, and action plan (a) Based on the results of previous steps, the school team will select an ideal implementation strategy and specify their implementation goals (i.e., implementation factors to improve with the selected strategy). (b) Then the school team will set a schedule to monitor their goals for future data-based decision-making. For instance, if the goal is to increase intervention fidelity of behavioral contracting, the school team can have the counselor conduct monthly structured observations of a teacher's intervention fidelity and provide performance-based feedback. (c) Last, the school team needs to decide who, when, and where to deliver the selected strategies to achieve their implementation goals. Accountability measures should be taken by the school team to ensure the strategies were carried out with adequate fidelity (i.e., good fidelity of implementation strategy in addition to good fidelity of intervention). #7 Monitor and make data-based decisions about selected implementation strategies The school team must use validated and pragmatic measures to continuously monitor the target implementation factors. Periodically, the team will convene to review the progress data to make data-based decisions about whether the selected implementation strategies effectively improved the effectiveness of the EBP and student outcomes. Key Implications for Practice In the context of school mental health, implementation science has several implications for how to effectively implement evidence-based practices (EBPs) as part of routine practices in schools. Without adequate implementation factors and strategies in place, even the most established EBP may not yield expected student social-emotional, and behavioral (SEB) outcomes. Common factors that either promote or impede the implementation of EBPs in schools can be categorized into five contextual domains (a) outer setting (e.g., policy), (b) inner setting (leadership), (c) characteristics of individuals (e.g., attitudes), (d) EBPs (e.g., fidelity, acceptability), and (e) implementation process (e.g., implementation stages). There are many validated and pragmatic measures of key implementation factors. School teams can use them to identify the gaps and needs of existing implementation efforts for a given EBP in schools. The results can also be used to inform data-based decision-making about the selection, delivery, and evaluation of implementation strategies for identified gaps or needs in existing implementation efforts. Schools can use implementation strategies to change implementation factors at individual and/or school levels, which will in turn improve the outcomes of their existing interventions (i.e., student SEB needs and/or academic performance). To select appropriate implementation strategies, the school team needs to be mindful of (a) their current stage of implementation, (b) the delivery level of their target EBP, and (c) existing implementation factors that are lacking or barriers in their school context. Related Resources UW School Mental Health Assessment, Research, and Training (SMART) Center (Specific to school-based implementation resource) Evidence-based Prevention and Implementation Support Center Measures for Implementation Research (contains many free and validated measures) Consolidated Framework for Implementation Research (details all CFIR domains) California Evidence-Based Clearinghouse for Child Welfare Evidence-Based Behavioral Practice Active Implementation Hub   https://doi.org/10.17077/rep.006662 
two students with laptops
Jared T. Izumi, Ph.D., Assistant Professor of School Psychology in the Attallah College of Educational Studies at Chapman University
Description
Social-emotional-behavioral health (SEBH) includes a spectrum of protective and risk factors that are associated with positive and negative life outcomes, including a future diagnosis of a mental health disorder. Screening for SEBH is a foundational component of comprehensive multi-tiered systems of support (MTSS) as it provides quick and efficient information to educators that informs instruction and intervention. Taking into consideration resource availability, the implementation of universal screening requires systems to meet the needs of schools and students. This brief provides an overview of considerations when conducting universal SEBH screening. Universal screening of SEBH in children and adolescents has been promoted as a proactive solution to identify and intervene before SEBH problems become resistant to change. Universal screening is a preventative practice to address an estimated 50% of youths with unmet mental health needs (Whitney & Peterson, 2019). Screening data provides the necessary information to recognize the SEBH needs of students and to facilitate systems-level continuous improvement (Mahoney et al., 2021; Romer et al., 2020). Universal screening offers several advantages over targeted methods of identification by: (1) identifying students before problems become resistant to change, (2) identifying students that would have been previously unnoticed, (3) providing data at the system-level, and (4) monitoring progress over time (Romer et al., 2020).   https://youtu.be/V0yJ3iqiKzc What is Social-Emotional and Behavioral Health? SEBH includes both symptoms associated with psychological problems (e.g., internalizing and externalizing problems) and the presence of psychological well-being (e.g., prosocial and adaptive skills; Kamphaus, 2012). SEBH screeners that are conducted in schools should also contain items that promote academic success (e.g., work completion and attention; Kamphaus, 2012). As such, the state of Iowa defines SEBH as “social, emotional, behavioral, and mental well-being that…contribute to resilience and to how one relates to others, responds to stress and emotions and makes choices…that support positive wellbeing and academic success” (IAC §281—14.7).   Identification/Assessment Strategies The first step before conducting universal SEBH screening is to identify a broader mission or vision of SEBH screening and its relationship to a comprehensive MTSS framework. The broader mission or vision should identify the goals/objectives of the school or district and its relation to how the data will be used. For example, SEBH screening data may be used to identify students in need of additional supports or to monitor the functioning of system-wide interventions. The goals/objectives and the SEBH screening tool must be aligned with instructional and intervention practices. When and How Often Should Universal SEBH Screening Be Conducted? When teachers are completing screeners about their student, ample time is needed for the teacher to get to know the students (e.g., one month for most screening tools). Allowing for teachers to have sufficient time to observe their students should be balanced with early identification before problems become resistant to intervention. If the goal/objective is to identify students in need of SEBH intervention, then screening should be conducted in the fall after at least one month has passed, but not long after that time. While there is no definitive number of times SEBH screening should be conducted (Romer et al., 2020), it typically occurs three times per school year. Research indicates SEBH risk status remains relatively stable; however, additional students would be identified during subsequent screening periods (Miller et al., 2019). Screening multiple times per year also allows for systems-level progress monitoring and decision-making such as resource allocation. Who Will Provide the SEBH Information? Teachers, parents, and students may provide information on student SEBH functioning. School and district teams should consider the costs and benefits of each source of data (Glovers & Albers, 2007). Teachers can provide reliable information for universal SEBH screening data, especially when identifying externalizing behaviors and academic enablers (Dowdy & Kim, 2012). School teams may elect for students to provide self-reports on SEBH skills starting in adolescence when rates of internalizing problems increase (Romer et al., 2020). Lastly, parents offer a unique perspective by being able to provide information based on the years of development in multiple contexts. They can also provide information before key transitions (e.g., start of kindergarten; Glovers & Albers, 2007). School and district leadership should also consider how students, parents, and teachers will be informed and consent to SEBH screening. The Individuals with Disabilities Education Improvement Act (IDEA) and the Protection of Pupil Rights Amendment (PPRA) are two federal laws related to SEBH screening. The IDEA (2004) indicates that screening for the purposes of identifying instructional strategies is not considered an evaluation requiring parental consent (34 CFR § 300.302) or evaluations administered to all students do not require parental consent (34 CFR § 300.300[d][ii]). The PPRA (2002) states that schools cannot require students to complete surveys related to “mental or psychological problems” without prior written consent (34 CFR Part 98). In general, universal SEBH screening that has opt-out procedures would not require prior written consent; however, schools and districts should consult with their legal team. In addition, schools and districts should consider how state laws may impact SEBH screening (e.g., prior written consent is required in the state of Iowa if the school is contracting with an outside agency to conduct SEBH screening; IAC §280A.2). How Will Data Be Collected and Stored? Districts and schools must consider how universal SEBH screening data will be collected and stored to ensure student privacy and appropriate access to the data. District and school personnel should consult with their legal counsel to ensure appropriate data storage and access practices are in place. Prior to decision-making, schools should inspect the data to ensure it was properly collected (e.g., missing and duplicate data). Individuals with access to the data should be able to analyze the results quickly and easily. This can be facilitated by being integrated with other data systems (e.g., office discipline referrals [ODRs], grades, and other screening data) and viewed at different levels of specificity (i.e., student-, class-, grade-, school-, and district-level). Lastly, the school or district should consider how data will be shared with key stakeholders, specifically parents. Particular care should be taken when individual student data are shared to ensure proper interpretation of SEBH risk rather than mental health diagnosis, as screeners are NOT used to diagnose students. How Should Screening Data Be Used to Inform Intervention Selection? First, before conducting SEBH screening, schools should determine their capacity for providing intervention. Determining the capacity for intervention allows schools to identify the range and types of students that can be served in a meaningful manner (Romer et al., 2020). This includes creating a problem-solving team (PST) that will examine and make data-based decisions on the data. Members of the PST will depend on each school, but should include administrators, teachers, and individuals with expertise in SEBH at a minimum (Romer et al., 2020). After screening, PST should examine system-wide data to determine if Tier 1 supports are functioning adequately (i.e., less than 20% of students have SEBH risk). If screening data identifies significantly more students than the maximum capacity for intervention or greater than about 20% of students are at risk, then Tier 1 interventions must be considered or changed. Next, PST may examine information available to identify individual students in need of intervention. Multiple pieces of information from different perspectives should be used when identifying students in need of intervention (e.g., ODRs, attendance, and grades; Romer et al., 2020). What Universal SEBH Screening Measures Should I Use? A comprehensive evaluation of available SEBH screening measures is beyond the scope of this brief; however, a list of some assessment tools is provided. For a more comprehensive list of SEBH assessment tools readers are forwarded to the RAND Education Assessment Finder. Screening measures should be selected based on the match between domains evaluated and domains of interest, appropriateness for the students of interest, accuracy of information, feasibility of administration, and utility of outcomes (Glover & Albers, 2007). Caution should be taken by schools against selecting SEBH screening methods based primarily on feasibility (i.e., teacher nominations and ODRs). Limitations to teacher nominations and ODRs as a universal screener for SEBH risk preclude recommending their use in isolation. Teacher nominations and ODRs are more likely to be biased toward historically marginalized students, misidentify or underidentify students with internalizing problems, wait for significant SEBH problems to occur, and misalign with the goals of SEBH screening (Eklund & Dowdy, 2014; Gregory et al., 2021; McIntosh et al., 2010; Raines et al., 2012). Using brief behavioral rating scales (BBRS) as a method of universal SEBH screening can help increase the feasibility of collecting screening data from multiple sources. Brief Behavioral Rating Scales (BBRS) BBRS are short surveys that are completed for all students. Each student is rated on the same criteria, leading to more objective identification practices (Raines et al., 2012). School teams should consider the goals/objectives of SEBH screening based off their unique needs to identify the appropriate SEBH screening tool. For example, a high school may be more interested in identifying students with internalizing problems; therefore, they should select a BBRS that measures internalizing problems via self-report. Alternatively, an elementary school may be interested in identifying relationship skills in their students through teachers as informants. BASC-3 Behavioral and Emotional Screening System (BESS) The BESS can be completed by teachers, parents, or student self-report, and is available for students in grades K through 12. The teacher and parent versions include a total Behavioral and Emotional Risk Index, Externalizing Risk Index, Internalizing Risk Index, and Adaptive Skills Risk Index. The student index has an Internalizing Risk Index, Self-Regulation Risk Index, and Personal Adjustment Risk Index. Students are categorized into Normal Risk, Elevated Risk, and Extremely Elevated Risk. The BESS is available in Spanish for parents and students. The BESS may be purchased from Pearson for $1.50 per student (as of June 2023) and may be used with Peason’s QGlobal or aimswebPlus. Devereux Student Strengths Assessment (DESSA)-Mini The DESSA-mini is a teacher, parent, or other child-serving agency survey that takes about 1 minute per student to complete. There is a K through 8 version and a high school version. The DESSA-mini provides a Social and Emotional Total score. Students are categorized into Need for Instruction, Typical, and Strength. The full DESSA can be administered as a follow up, which is a comprehensive assessment that provides more detailed information, which may be helpful to learn about some students that score as Need for Instruction. The DESSA-mini is also available in Spanish. The DESSA-mini may be purchased through Aperture Education for $8.50 per student (as of June 2023 with lower prices for more students) and comes with the full DESSA for schools that prefer to collect additional data on some students. The DESSA-mini also comes with recommended interventions. Social, Academic, and Emotional Behavior Risk Screener (SAEBRS) The SAEBRS is a teacher and student self-report form that takes about 2 minutes per student to complete. The teacher version can be used for students in grades K through 12 and the self-report can be used for students in second grade and above. The SAEBRS provides scores on Total Behavior, Social Behavior, Academic Behavior, and Emotional Behavior. Students are placed into one of three risk categories on each of the scales: Low, Some, and High Risk. The self-report version is available in Spanish. The SAEBRS may be purchased for $3 per student through Illuminate Education or Renaissance Learning (as of June 2023). The SAEBRS requires additional onboarding costs of about $2,000, which include system management and teacher professional development. Strengths and Difficulties Questionnaire (SDQ) The SDQ is a teacher, parent, or student self-report survey that takes about 5 minutes to complete per student. The teacher and parent versions can be completed for children ages 2 to 17 and the self-report version can be completed for ages 11 to 18 or older. The SDQ provides a Total Difficulties scale, Emotional Symptoms subscale, Conduct Problems subscale, Hyperactivity/Inattention subscale, Peer Relationship Problems subscale, and Prosocial Behavior subscale. There is a three and four-category scoring method for identifying risk. The three-category method groups students into Normal, Borderline, and Abnormal categories and the four-category method groups students into Close to Average, Slightly Low/Raised, Low/High, and Very Low/High categories. The SDQ has been translated into over 75 languages. SDQ is offered for free for noncommercial purposes or may be purchased for $1.00 per student (as of June 2023) at SDQplus.org for online administration. Student Risk Screening Scale-Internalizing Externalizing (SRSS-IE) The SRSS-IE is a teacher-completed rating scale that takes about one minute per student to complete. The SRSS-IE has an elementary version and middle/high school version. The SRSS-IE identifies students at-risk for antisocial behavior and internalizing behavior. Students are placed into one of three categories: Low, Moderate, and High Risk. The SRSS-IE is only available in English. The SRSS-IE is provided free of charge and the developers provide a Microsoft Excel template to score the measure. However, additional data management may be required to aggregate data across classrooms to conduct data-based decision-making.   Key Implications for Practice District/school team leaders and key stakeholders (e.g., parents and community members) identify the goals/objectives for conducting universal SEBH screening Select a screening tool that aligns with the identified goals/objectives, has adequate accuracy, and will be feasible to implement Identify other pieces of information to support screening data Use screening data to inform individual and system-wide interventions Related Resources Supporting Child and Student Social, Emotional, Behavioral, and Mental Needs - U.S. Department of Education National Center for School Mental Health RAND Education Assessment Finder School Mental Health Collaborative https://doi.org/10.17077/rep.006638 
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Isaac T. Petersen, Ph.D, Assistant Professor, Department of Psychological and Brain Sciences, University of Iowa
Description
Externalizing behavior problems encompass a wide range of acting out behavior difficulties with the (external) environment, including behaviors such as aggression, bullying, conduct problems, callousness, inattention, hyperactivity, oppositionality, rule breaking, defiance, substance use, and disruptive behavior. Externalizing problems are prevalent in school-aged children and are costly and burdensome to individuals, families, schools, and society. Externalizing problems are disruptive to classrooms and make it challenging for educators to focus on teaching and for the child and classroom to learn. Moreover, early externalizing problems can predict later, more severe problems like violence if left untreated, so accurate assessment of externalizing problems is crucial to ensure children and adolescents receive the services they need. The goal of this practice brief is to help clinicians and school psychologists conduct accurate assessments of externalizing behavior in school-aged children to support effective intervention and prevention. Identification/Assessment Strategies Conduct a Multi-Stage Approach to Assessment Effective assessment of externalizing behaviors uses a multi-stage approach including screening, using multiple assessment methods, interpreting results, designing the treatment plan, and evaluating treatment progress (Volpe & Chafouleas, 2011; Youngstrom & Van Meter, 2016). Consider the Goals of the Assessment When selecting assessment tools to use, it is important to consider the goals of the assessment process. Various goals of assessment include (a) screening, (b) diagnosis, (c) monitoring progress, (d) and characterizing the full range of strengths and difficulties. Different assessments should be selected depending on the goal(s). Another consideration is whether to assess behavior problems at a more general, broad-band level (e.g., externalizing problems), or in more specific, narrow-band ways—e.g., callous-unemotional behaviors, inattention/impulsivity/hyperactivity, oppositionality, aggression, conduct problems, or substance use. Assessments that focus on broad-band problems tend to provide limited depth in any specific concern (Collett et al., 2003). If time allows, it can be helpful to include both the assessment of general, broad-band problems as well as more focused assessment of narrow-band problem dimensions in the areas of greatest potential concern (Achenbach et al., 2016). Screening devices tend to be brief, broad-band, and aim to identify children who are at risk of showing clinically significant problems in their current or future behavior. Schools often implement school-wide screening. Because screening devices aim to identify children who are at risk, screening devices focus on differentiating the top half of the distribution (i.e., the 50th percentile of misbehavior and above) as briefly (i.e., with as few items) as possible. Another purpose of assessment may be to monitor a child’s progress, such as their response to treatment. Instruments designed to monitor progress tend to be brief, so they can be completed regularly (e.g., daily or weekly). A consideration for such measures is whether it is sensitive to change to detect improvement in a child’s behavior over a short timeframe. A fourth purpose of assessment may be to characterize the full range of a child’s strengths and difficulties. Here, the goal is to determine where in the distribution (e.g., what percentile) the child is relative to their peers on dimension(s) of interest (e.g., aggression). Such instruments are longer because they aim to differentiate children across the full distribution (i.e., 1st to 99th percentile), which requires items that differ in severity and requires more items. Other Considerations When Selecting Assessment Tools Other important considerations when selecting assessments include psychometrics: reliability and validity. That is, scores from a given measure should be precise and accurate for the intended construct (i.e., externalizing problems), population, and purpose. The psychometric properties of measures are reviewed by Sattler (2022) and the Buros Mental Measurements Yearbook. It is important to consider whether the measure’s content and items are developmentally appropriate for the child’s age and developmental level (Wakschlag & Danis, 2004). In addition, it is important to consider whether the measures’ scores and norms are appropriate for special populations, including those with intellectual disabilities, those in the child welfare system (Keil & Price, 2006), and those who may not be proficient in English (Paalman et al., 2013). If the instruments used do not have established validity or norms with respect to the particular population of interest (e.g., 13-year-olds), it is important to note potential interpretive concerns in any reports. Use Multiple Methods and Perspectives at Multiple Time Points It is best to conduct the assessment with at least two assessment methods and at least two perspectives, at multiple points in time (Lochman et al., 2001). Assessment methods include questionnaires, interviews, observations, behavior tracking, and school records (e.g., Walker et al., 1991). It is preferable for the perspectives represented to span the home and school contexts. Perspectives could include, for instance, parents, teachers, other caregivers, the child, siblings, and peers. Easily observable misbehavior may be best reported by informants, whereas more hidden or covert misbehavior may require self-report. To ensure validity, the assessments should be administered and interpreted by licensed professionals who are trained to use them. Questionnaires Questionnaires can be a quick, easy way to collect information from multiple informants. However, questionnaires have limitations, including (a) they require respondents to be able to read proficiently in the language, (b) they involve informant bias, (c) they often have subjective response formats (e.g., “sometimes”, “often”) that lead to bias and imprecision, and (d) they do not provide systematic opportunities for respondents to ask clarifying questions or for examiners to ask follow-up questions, making it more likely that a respondent will misinterpret a question. One of the most widely used assessments of externalizing problems is the Achenbach System of Empirically Based Assessment (ASEBA). The ASEBA includes assessment of broad-band problems as well as more narrow-band problems, and it includes varying items for different informants and ages to maintain developmental and contextual relevance. For instance, parents provide reports on the Child Behavior Checklist, which has different versions based on the child’s age. Teachers provide reports on the Teacher’s Report Form, which also has different versions based on the child’s age. The ASEBA also includes an optional Multicultural Supplement with multicultural norms. Moreover, the ASEBA includes a brief form, the Brief Problem Monitor that is more sensitive to change for the purposes of monitoring progress. The Peer-report Measure of Internalizing and Externalizing Behavior uses peer nomination to identify externalizing problems. Another widely used questionnaire of externalizing problems is the Strengths and Difficulties Questionnaire*. It assesses functional impairment, has different forms for various ages and informants, and has translated versions in many languages. A questionnaire that is well-suited to study the full range of strengths and weaknesses is the Extended Strengths and Weaknesses of Normal Behavior*. In addition to broad-band questionnaires, there are also questionnaires designed to assess more narrow-band problems, including for callous-unemotional behaviors (Inventory of Callous-Unemotional Traits*), inattention/impulsivity/hyperactivity (Conners 4), oppositionality (Disruptive Behavior Disorder Rating Scale*), aggression (Children’s Aggression Scale), conduct problems (Conduct Disorder Rating Scale), or substance use (Problem-Oriented Screening Instrument for Teenagers*). The Conners 4 is also available in Spanish and French. Interviews Interviews are another common form of assessment. Interviews do not require respondents to be able to read, and they allow examiners to ask follow-up questions. However, interviews take more time to conduct than questionnaires and can be subject to confirmatory bias on the part of the interviewer. For instance, interviewers tend to assess only the behavior problems that fit their hypotheses of the child’s difficulties (Sharp et al., 2013). To prevent confirmatory bias, it is important to use structured or semi-structured interview approaches and to supplement the approach with assessments that span a wider array of potential difficulties than the clinician’s hypotheses might suggest. Some interviews assess broad-band problems, whereas others focus on more narrow-band problems. General interviews include the Schedule for Affective Disorder and Schizophrenia for School-Age Children*, Child and Adolescent Psychiatric Assessment (CAPA)*, and Development and Well-Being Assessment* (DAWBA). CAPA has a child interview and a parent interview. The DAWBA has translations in many languages. Interviews that are focused on externalizing behavior include the Disruptive Behavior Disorders Parent Interview*, Kiddie Disruptive Behavior Disorders Schedule, and Clinical Parent Interview for Externalizing Disorders in Children and Adolescents. An interview focused on callous-unemotional behavior is the Clinical Assessment of Prosocial Emotions*. Observation Observational assessment is a valuable assessment process for externalizing behaviors. Observations are less influenced by informant bias. However, observations can be time consuming to conduct. Moreover, during a brief observation period, it may be unclear how representative a child’s behavior is of their behavior in other situations or contexts, especially if the child acts differently because they are being observed (i.e., reactivity). In addition, if the target behavior is infrequent or covert, it can be more difficult to observe. A widely used approach to observational assessment is functional behavior assessment (FBA). FBA involves observing patterned sequences of antecedents and consequences of the target problem behavior to generate and test potential hypotheses regarding the function(s) of the behavior, which can be useful in intervention (Broussard & Northup, 1995; Gresham, 2015). The same behavior can occur for different reasons, and it is important to know why the child engaged in the problem behavior, because each function might be targeted differently in intervention. Common hypotheses regarding the functions of problem behavior include approach- (e.g., access to attention or access to tangibles, such as toys or preferred activities) and avoidance-related functions (e.g., escape from undesirable situations). When conducting observational assessments, it is helpful to observe the child in different situations (e.g., lunch time, recess, math work), times of day (e.g., morning, afternoon, evening), and contexts (e.g., home, school). Rating specific behaviors close to when they are exhibited is helpful for monitoring progress (Daniels et al., 2021). Schools may also have FBA processes and tools developed by their district, intermediate service agencies, or state departments of education that they are required to use as part of processes like multi-tiered systems of support (MTSS) and special education identification. In addition to FBA, several observational assessments have been developed for externalizing behavior, including the ADHD School Observation Code, ADHD Behavior Coding System, Disruptive Behavior Diagnostic Observation Schedule, Direct Observation Form, Adjustment Scales for Children and Adolescents, Overt Aggression Scale, Revised Edition of the School Observation Coding System, and Classroom Observation Code. There are also playground-based observational systems (Leff & Lakin, 2005). Behavior Tracking  Behavior tracking is a form of observational assessment that aims to assess children prospectively in a less time-consuming way. For instance, it may involve the parent or teacher making a tally for each instance of various behaviors, including compliance, noncompliance, and aggression. Behavior tracking is sensitive to change and is therefore particularly useful for progress monitoring. For instance, behavior tracking may allow practitioners to evaluate whether the frequency of the target problem behaviors change on a day-to-day or week-to-week basis. Handling Informant Discrepancies Informants (e.g., parent, teacher) often disagree about the extent to which a given child shows behavior problems. Informant discrepancies likely occur for many reasons, including (a) the child may behave differently in different contexts and/or with different people, (b) informants may have differing knowledge and perspectives of what is developmentally typical versus atypical; for instance, teachers may generally have a wider range of comparisons than parents and may thus be uniquely positioned to rate the child, (c) there may be cultural differences in what is considered developmentally appropriate behavior, (d) informants have biases to respond in particular ways, and (e) measurement error. To handle informant discrepancies when there is not a clear primary informant who is best positioned to rate the child most accurately, one can count a symptom as present if it is endorsed by any of the informants (Hinshaw & Nigg, 1999). What to Assess It is important to assess many facets of the problem behavior, including its frequency, intensity/severity, onset, and duration; that is, how long it has been occurring, how frequently it occurs, and how intense or severe the behavior is when it occurs. It is also important to consider potential function(s) of the misbehavior (Reitman et al., 1998). Functional impairment should also be considered. For instance, it is important to consider whether the behavior impedes the child’s ability to perform well in school, to hold a job, or to develop meaningful relationships with peers, teachers, and family members. In addition, it is important to consider cultural and contextual factors, including the family and social context (Knapp et al., 2012). It is also important to consider co-occurring issues and conditions. Many cognitive, academic, emotional, behavioral, and medical difficulties commonly co-occur with externalizing problems and are important to assess. Commonly co-occurring issues include internalizing problems (e.g. mood and anxiety-related problems; Achenbach et al., 2016; Cunningham et al., 2013), intellectual disabilities, learning disorders, academic difficulties, neurodevelopmental conditions such as autism, and problems related to sleep, feeding (e.g., picky eating), and voiding (e.g., enuresis, encopresis; McKinney & Morse, 2012) . Data Privacy and Sharing Federal laws protect the privacy of protected health information (HIPAA) and of educational records (FERPA). It can be helpful for clinicians, schools, and families to work together to address a child’s needs. To achieve this, it is important to obtain informed consent and two-way releases of information to ensure that the clinician can share information with the school, and that the school can share information with the clinician. For instance, a parent and teacher might rate the child’s behavior for a clinician conducting an assessment. The clinician then might share their assessment results and a suggested treatment plan with the family and might work with the teacher and family to help them enact the treatment plan. The school may then share the child’s treatment progress with the family and clinician. Putting It Altogether With the assessment information collected, the clinician can develop a case formulation that considers predisposing factors, precipitating factors, perpetuating factors, and protective factors for the given child’s misbehavior. Such a case formulation is helpful when developing a treatment plan. Intervention often aims to address a child’s perpetuating/maintaining factors (e.g., low frustration tolerance; ineffectual caregiver responses) and minimize how frequently the triggering situations occur, while building on the child’s strengths and considering predisposing factors (e.g., family history, temperament). To maximize the usefulness of assessment results for schools, it is important to write a concise and clear report and be timely and attentive to requests for data sharing. In sum, externalizing behavior problems in school-aged children are prevalent, burdensome, and important to assess and address. Key Implications for Practice Conduct a multi-stage approach that includes screening, multi-method assessment, interpreting results, designing the treatment plan, and evaluating treatment progress. Select measures based on their psychometrics, their intended depth and breadth, and the goals of the assessment: screening, diagnosis, monitoring progress, or patterns of strengths and weaknesses. Consider cultural and contextual factors and co-occurring issues. Incorporate multiple perspectives (e.g., parents and teachers) and methods, including observational assessment, across multiple time points. Consider frequency, intensity, duration, functions, and impairment of problem behaviors. Develop a case formulation based on predisposing, precipitating, perpetuating, and protective factors for the child’s problem behaviors. Ensure information sharing forms are completed and reports are shared with families and schools, so that schools can use the information in their planning and delivery of services. Related Resources Supporting Child and Student Social, Emotional, Behavioral, and Mental Needs - U.S. Department of Education Brochures and Facts Sheets - National Institute of Mental Health Attention-Deficit/Hyperactivity Disorder in Children and Teens: What You Need to Know - National Institute of Mental Health Disruptive Mood Dysregulation Disorder: The Basics - National Institute of Mental Health Resources Centers - American Academy of Child & Adolescent Psychiatry Child, Youth and Family (CYF) Database - Centre for Effective Services as part of the Prevention and Early Intervention Research Initiative Mental Measurements Yearbook - Buros Center for Testing Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Institute on Violence and Destructive Behavior (IVDB) Systematic Screening - Comprehensive Integrated Three-Tier Model of Prevention Conduct Disorder - Mental Health America Externalizing Academic Educational - youth.gov * indicates an assessment instrument that is freely and publicly available https://doi.org/10.17077/rep.006639
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