School Behavioral Health: Mark D. Weist Kathleen B. Franke Robert N. Stevens Editors

Mark
D. Weist
Kathleen B. Franke
Robert N. Stevens Editors
School
Behavioral
Health
Interconnecting Comprehensive School
Mental Health and Positive Behavior
Support
School Behavioral Health
Mark D. Weist • Kathleen B. Franke
Robert N. Stevens
Editors
School Behavioral Health

Interconnecting Comprehensive School
Mental Health and Positive Behavior Support
Editors
Mark D. Weist Kathleen B. Franke
Department of Psychology The Unumb Center for Neurodevelopment
University of South Carolina University of South Carolina
Columbia, SC, USA Columbia, SC, USA
Robert N. Stevens
Medical University of South Carolina
Goose Creek, SC, USA
ISBN 978-3-030-56111-6 ISBN 978-3-030-56112-3 (eBook)

https://doi.org/10.1007/978-3-030-56112-3
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Foreword
My work in the disability field began over three decades ago with an early career
position as a paraprofessional. I subsequently have held positions as a special edu-
cation teacher, mental health provider, consultant, and researcher. My commitment
to the particular population of children and adolescents with emotional and behav-
ioral problems began early on, as I was challenged by intervention limits, the exces-
sive use of punitive procedures, and the lack of advocacy for this group of students.
Much has changed over the past 30 years. Highly punitive procedures that were
conventional as recently as a decade ago have become far less standard, in favor of
approaches that endeavor to understand the causes of problem behavior as well as
the role of childhood experiences, such as trauma. Many schools have adopted uni-
versal screening procedures, with efforts to discover all students who might need
behavioral and mental health support. Tiered systems of support in schools are on
the rise, promising efficient and effective intervention matched to student needs.
Preventive and instructional programs are being introduced to children at a young
age, with follow-through efforts as children age. Finally, the education field has
recognized and embraced the importance of research- and evidence-based programs
and practices.
Still, outcome data do not bode well for our efforts. Little change is evident
across many indicators of progress. Students with emotional and behavioral prob-
lems continue to surpass all other disability groups across measures of disciplinary
referrals, suspensions, grade retention, and school dropout. Suicide rates among
adolescents have seen a recent acceleration, according to data from the Centers for
Disease Control and Prevention. And, poor outcomes endure into adulthood, with
unemployment and underemployment, limited enrollment in postsecondary educa-
tion, and high rates of involvement with the criminal justice system.
The presumably favorable shift in the nature of positive intervention approaches,
the earlier onset of preventive efforts, and the adoption of more rigorously researched
intervention strategies and programs does not seem to align with the persistently
poor outcome data for students with social and emotional needs. So, how do we
explain the incongruent data? I believe one explanation is that we have overwhelm-
ingly focused on prevention. We have seen a recent surge in implementation of
v
vi Foreword
interventions targeted at the universal (tier 1) level. Intervention at this level brings
about much contentment, as large decreases in problem behaviors (e.g., disciplinary
referrals) ensue. While these efforts should be applauded, they often occur at the
expense of the population of students with more intensive needs. This lack of atten-
tion to problems of greater concern and severity is exacerbated by the persistent
aversion and stigma toward behaviors (internalizing and externalizing) that leach
the boundaries of conventional school behavior.
So, how do we move forward? Indeed, we must continue (and perhaps expand)
early prevention and intervention efforts. There is ample evidence from rigorous
research studies that tiered and preventive systems of support work. For instance,
school-wide efforts, such as Positive Behavioral Interventions and Supports (PBIS),
have a substantial impact. These efforts need to be further expanded to all school
settings. Most importantly, in spite of PBIS, teachers continue to struggle with stu-
dents who exhibit emotional and behavioral problems in their classrooms, the set-
ting where students spend most of their school day. This is just one area where
attention should be directed. There is an abundance of evidence that pre-service
training and in-service support and induction programs are deficient for preparing
teachers to support students with challenging behaviors. This must be improved.
At the same time, school- and program-wide data cannot obscure the outcome
data for students with the most intensive needs (tier 3). The data must be parceled,
which will compel us to direct attention to also improving intervention for students
with more intensive needs at tier 3. Moreover, there are no data to suggest that men-
tal health problems can be entirely eliminated for a variety of risks and environmen-
tal reasons. This is supported with convincing models of illness and disease that
have been approximated in medicine, public health, and other fields. We must con-
sider intervention a routine practice. At the same time, there is compelling evidence
that emotional and behavioral problems can be greatly reduced.
This brings us back to the topic of school behavioral health. The efforts we have
undertaken over the past several decades are undeniably insufficient. As yet, the
pieces have not come together to forge a meaningful impact. And, as this book
attests, the answer is not simple. What this book offers is a blueprint for moving
forward. The authors spell out the collective effort that is needed to accomplish the
important goal of providing comprehensive and effective school behavioral health
services.
To do so, the authors lay out five themes: (a) building partnerships between edu-
cation, families, mental health, and other youth-serving systems; (b) developing
effective school-wide approaches; (c) promoting cultural responsiveness and humil-
ity; (d) improving the quality of services and increasing the use of evidence-based
practices; and (e) improving implementation support for evidence-based practices.
In addition to these five theme areas, three priority populations – students connect-
ing to child welfare and juvenile justice systems and from military families – are
addressed. The authors take a deep dive, rely on community members with unique
expertise, and explore issues in a way that has not been previously seen.
Three unique features of the book render it of great value to our field. First, the
five themes and three priority populations are jointly addressed. For many years, we
Foreword vii
have seen efforts to tackle a single theme. For instance, researchers and practitioners
have illustrated ways to build partnerships between education, families, mental
health, and other youth-serving systems. More recently, attention has been paid to
school-wide approaches, culturally responsive and humble interventions, and
evidence-based practices. This book brings the themes together within a common
framework, with the underlying premise that all themes are essential for successful
school behavioral health.
Second, diverse stakeholders were convened to contemplate the five themes and
three priority populations and consider ways to move our field forward. While we
often speak to the need to consider opinions from a variety of stakeholders with an
interest in and commitment to children’s behavioral health needs, seldom do we
accomplish this feat. Real (logistics, time) and perhaps perceived (territorial) barri-
ers make this a challenge. In this book, the voices of many stakeholders emerge.
These include sometimes overlooked groups, including youth and their families
involved with juvenile justice, child welfare, and the military. The issues distinctive
to these various groups and the related systems that provide services and supports
demand unique consideration, as offered in this text.
Finally, this book confronts barriers and generates potential solutions in a way
that has not been previously accomplished. The perspectives of multiple stakehold-
ers, particularly direct care providers, are evident. The rich and deep analyses that
transpired from the focus group format heighten our understanding of real obstacles
and propose practical solutions. Each chapter draws in pertinent research and
reflects upon current practice as experienced by those in the field.
This book will be of great value to a range of individuals, including pre-service
personnel, in-service practitioners, program and school administrators, families,
researchers, and others. The authors, innovative thinkers, dedicated practitioners,
and exceptional researchers assembled an equally talented group of collaborators.
The result is thoughtful considerations and recommendations that should serve as a
critical launching point for advancing school behavioral health in a way that will
yield meaningful outcomes.
Lee Kern
Lehigh University
Bethlehem, PA, USA
Acknowledgments
We would like to convey our sincere thanks to the Patient Centered Outcomes
Research Institute (PCORI) for the Eugene Washington Engagement Award
(EAIN-2874, 2015–2017) that enabled the eight focus groups on school behavioral
health (SBH) reviewed in this book and our program officer, Lia Hotchkiss, and
advisor, Marina Broitman, for providing insight and guidance throughout the proj-
ect. We would also like to thank the National Center for School Mental Health
(SMH; see www.schoolmentalhealth.org) and the Center on Positive Behavioral
Interventions and Supports (PBIS; see www.pbis.org), and leaders of a national
workgroup on interconnecting SMH and PBIS: Lucille Eber, Susan Barrett, Kelly
Perales, Robert Putnam, and Joni Splett. We are grateful for the systems integration
and the leadership of state leaders in South Carolina, particularly state Department
of Education (https://ed.sc.gov) and Department of Mental Health (https://scdmh.
net). We also extend our gratitude to the more than 100 diverse stakeholders (teach-
ers, clinicians, families, advocates, healthcare professionals, systems leaders,
researchers) who participated in the forums and shared their ideas for expanding
and strengthening SBH programs. Finally, we express appreciation to chapter
authors, Darien Collins and June Greenlaw, who also provided significant assis-
tance in organizing this book.
ix
Contents

Advancing Effective School Behavioral Health�� 1
Mark D. Weist, Kathleen B. Franke, and Robert N. Stevens

Collaboration: An Essential Ingredient for Effective School
Behavioral Health�� 9
Kathleen B. Franke, John Terry, Tristan Collier, and June Greenlaw

Improving School-wide Approaches in School Behavioral Health�� 21
Tristan Collier and Victoria Rizzardi

Cultural Humility and School Behavioral Health�� 35
Victoria Rizzardi, Sommer C. Blair, Barbara Kumari, and June Greenlaw

Improving School Behavioral Health Quality �� 47
Sommer C. Blair, Darien Collins, and Kathleen B. Franke

Enhancing Implementation Support for Effective School
Behavioral Health�� 59
Samantha N. Hartley and Carissa Orlando

Youth with Connections to the Juvenile Justice System:
A Priority Population for School Behavioral Health�� 75
Linden Atelsek and Alex M. Roberts

Addressing the Unique Needs of Children and Families
Within the Child Welfare System �� 95
Samantha Martinez, Tara Kenworthy, Sommer C. Blair, Lee Fletcher,
Yanfeng Xu, and Robert N. Stevens
xi
xii Contents

Serving Those Who Serve: Increasing Understanding
of Mental Health Needs in Military Families�� 107
Marissa Miller and John Terry

Furthering the Advancement of School Behavioral
Health in Your Community �� 123
Mark D. Weist, Darien Collins, Samantha Martinez, and June Greenlaw
Index�� 129
Contributors
Linden Atelsek University of Virginia School of Law, Charlottesville, VA, USA

Sommer C. Blair South Carolina Department of Social Services, Lexington, SC,
USA
Tristan Collier Psychology Department, University of South Carolina, Columbia,
SC, USA
Darien Collins Department of Psychology, University of South Carolina,
Columbia, SC, USA
Lee Fletcher South Carolina Department of Social Services, Lexington, SC, USA
Kathleen B. Franke The Unumb Center for Neurodevelopment, Columbia, SC,
USA
Psychology Department, University of South Carolina, Columbia, SC, USA
June Greenlaw Psychology Department, University of South Carolina, Columbia,
SC, USA
Samantha N. Hartley Psychology Department, University of South Carolina,
Columbia, SC, USA
Tara Kenworthy Psychology Department, University of South Carolina,
Columbia, SC, USA
Lee Kern Lehigh University, Bethlehem, PA, USA
Barbara Kumari Department of Psychology, Arizona State University, Tempe,
AZ, USA
Samantha Martinez Department of Psychology, University of South Carolina,
Columbia, SC, USA
Marissa Miller University of South Carolina, Columbia, SC, USA
xiii
xiv Contributors
Carissa Orlando Psychology Department, University of South Carolina,

Columbia, SC, USA
Victoria Rizzardi Psychology Department, University of South Carolina,
Columbia, SC, USA
Alex M. Roberts Psychology Department, University of North Carolina, Chapel
Hill, NC, USA
Robert N. Stevens South Carolina Association for Positive Behavior Supports,
Johns Island, SC, USA
John Terry Psychology Department, University of South Carolina, Columbia, SC,
USA
Mark D. Weist Psychology Department, University of South Carolina, Columbia,
SC, USA
Yanfeng Xu University of South Carolina College of Social Work, Columbia, SC,
USA
Glossary of Acronyms
AAPCSH American Academy of Pediatrics Committee on School Heath

ACF Administration for Children and Families
ADHD Attention Deficit Hyperactivity Disorder
APA American Psychological Association
BH Behavioral Health
BHOP Behavioral Heath Optimization Program
CONUS Continental US
CW Child Welfare
DJJ Department of Juvenile Justice
DMH Department of Mental Health
DoD Department of Defense
DSS Department of Social Services
DV Domestic Violence
EB Emotional/Behavioral
EBD Emotional/Behavioral Disorder
EBP Evidence-Based Practice
ED Emotional Disability
EFMP Exceptional Family Member Program
FBA Functional Behavior Assessment
FERPA Family Educational Rights and Privacy Act
FHC Family Health Clinic
HHS U.S. Department of Health and Human Services
HIPAA Health Insurance Portability and Accountability Act
IDEA Individuals with Disabilities Education Act
IEP Individualized Education Plan
IS Implementation Support
ISF Interconnected Systems Framework
JJIY Juvenile Justice-Involved Youth
LbC Leading by Convening
MCE Modular Common Elements
MCY Military-Connected Youth
xv
xvi Glossary of Acronyms
MFLC Military Family Life Counselor

MH Mental Health
MI Motivational Interviewing
MOS Military One Source
MTF Military Treatment Facility
MTSS Multi-Tiered Systems of Support
NLTS National Longitudinal Transition Study
OCONUS Outside the Continental US
OSEP Office of Special Education Programs
PBIS Positive Behavioral Intervention and Supports
PCM Primary Care Managers
PCORI Patient-Centered Outcomes Research Institute
PCS Permanent Change of Station
PTSD Post-Traumatic Stress Disorder
RTI Response to Intervention
SBH School Behavioral Health
SES Socioeconomic Status
SBMI School-Based Motivational Interviewing
SC South Carolina
SES Socioeconomic Status
SMH School Mental Health
SOP Standard Operating Procedure
SSBHC Southeastern School Behavioral Health Community
US United States
USC University of South Carolina
Y-AP Youth-Adult Program
Advancing Effective School Behavioral
Health
Mark D. Weist, Kathleen B. Franke, and Robert N. Stevens
Beginning in 2012, teams from the University of South Carolina (USC), state
Departments of Education and Mental Health, and the South Carolina (SC)
Association of Positive Behavior Supports began to meet to try to expand and
improve, and make school behavioral health programs in the state more coherent
and impactful. Early on, it was agreed the term school behavioral health (SBH)
would be used to convey clinicians from the mental health system joining schools’
multitiered systems of support (MTSS) toward greater depth and quality in pro-
grams/services delivered at Tier 1 – promotion/prevention, Tier 2 – early interven-
tion, and Tier 3 – more intensive intervention.
A decision was made to develop a community of practice (see Wenger, & Snyder,
2000) for SBH in SC, reaching out to diverse stakeholders with a vested interest in
these programs, beginning to convene regularly, and moving from discussion to
dialogue to collaboration and policy change/resource enhancement, toward capacity
building of effective programs throughout the state. The community connected
stakeholders in education, youth-serving systems (e.g., mental health, child welfare,
juvenile justice, disabilities, primary health care, allied healthcare services, family,
and youth advocacy) from every county in SC and its first conference was held in
Columbia, SC, in 2014. Following this meeting, a website and listserv were estab-
lished, and a second conference was held in Charleston, SC, in 2015. During this
conference, the diverse stakeholders, students with emotional/behavioral (EB) con-
cerns, and families participated in a research forum. Together, the participants
M. D. Weist ()
e-mail: weist@sc.edu
K. Franke
The Unumb Center for Neurodevelopment, Columbia, SC, USA
e-mail: Katie.franke@unumbcenter.org
R. Stevens
South Carolina Association for Positive Behavior Supports, Johns Island, SC, USA
© Springer Nature Switzerland AG 2020 1

M. D. Weist et al. (eds.), School Behavioral Health,
https://doi.org/10.1007/978-3-030-56112-3_1
2 M. D. Weist et al.
identified five critical themes for the advancement of SBH in SC: (1) building part-
nerships between education, families, mental health, and other youth-serving sys-
tems, (2) developing effective school-wide approaches, (3) promoting cultural
responsiveness and humility, (4) improving the quality of services and increasing
the use of EBPs (evidence-based practices), and (5) improving implementation sup-
port for EBPs (Weist & Stevens, 2017).
The innovative work of the community was recognized in 2015 by the Patient-
Centered Outcomes Research Institute (PCORI), who provided a Eugene Washington
Engagement Award for the community’s work, specifically to support the third con-
ference held in Myrtle Beach, SC, in the Spring of 2016. In addition, as part of this
application, the core team assembled a diverse panel of stakeholders, including
researchers, leaders, and staff from education, mental health, family and youth
advocacy, juvenile justice, child welfare, and primary care. This group convened as
part of a research preconference prior to the 2016 conference and made recommen-
dations on stakeholder engagement in SBH research, and practice and policy
improvement, including the recommendation to conduct focus groups on each of
the five prioritized themes. In 2016–2017, these five focus groups were conducted
in locations around SC. In addition, during this time, based on a recommendation
from PCORI leaders, the community expanded to become the Southeastern School
Behavioral Health Community (SSBHC) in order to promote regional capacity
building (see www.schoolbehavioralhealth.org).
As a regional collaborative, the SSBHC held its first conference in Myrtle Beach,
SC, in 2017, and through the PCORI Engagement Award, another preconference
meeting was held with the diverse stakeholder panel. During this meeting, prelimi-
nary themes from the five focus groups were presented, panel members reacted to
them, and they offered ideas for research, practice, and policy enhancement. In
addition, participants also recommended that additional forums be held to advance
services for three priority populations: youth in the child welfare system, those with
connections to the juvenile justice system, and youth from military families. These
additional forums were conducted in the remaining 7 months of 2017, again at dif-
ferent locations throughout SC.
An application for exempt research on human subjects was approved by the
University of South Carolina (USC) Institutional Review Board to conduct the
focus groups. Each of the eight focus groups included 11–25 participants, again
representing diverse stakeholder groups with vested interest in SBH, including
researchers, systems leaders and staff, and youth and families. Participants were
anonymous in all focus groups, responding to seven to ten discussion questions. All
focus groups were audiotaped, tapes were transcribed, and the NVIVO program
(https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home)
was used for formal qualitative analysis.
This book includes nine additional chapters following this introduction. Chapters
2 through 9 provide background and stakeholder reactions/recommendations for
each of the eight focus groups and the particular theme being explored (five dimen-
sions of effective SBH, and three priority populations), and Chap. 10 summarizes
themes and presents ideas for advancing this agenda at a community level.
Advancing Effective School Behavioral Health 3
It should be noted that the conceptual framework for our work in advancing SBH
in SC and in the Southeast region of the United States (US) has been the
Interconnected Systems Framework (ISF) for School Mental Health (SMH; see
Weist, Lever, Bradshaw, & Owens, 2014) and Positive Behavioral Interventions and
Supports (PBIS; see Sugai & Horner, 2006). This conceptual framework merges
two national movements – for more comprehensive mental health services in
schools as in SMH, and for PBIS. Prior to around 2008, in general, these initiatives
were operating separately. With support of national centers for PBIS (see www.pbis.
org), and SMH (see www.schoolmentalhealth.org), a meeting was held of leaders
from these fields and an e-book on the ISF (Barrett, Eber, & Weist, 2013) was devel-
oped and since then has been widely disseminated and viewed/downloaded (>
50,000 times). The ISF provides specific guidance for mental health system integra-
tion into schools’ MTSS, including clinician involvement on teams; assuring teams
are operating effectively; using data for decision making, implementing, monitor-
ing, and refining evidence-based practices at tiers 1, 2, and 3; and building effective
strategies at classroom, school building, school district, and state levels. In 2019, a
second edition of the ISF e-book was developed (Eber et al., 2019) and, at the time
of this writing, is being widely disseminated and discussed by school and district
teams for action planning (see www.midwestpbisnetwork.org).
Thus, the current book serves to further illustrate critical themes for effective
school behavioral health as in the ISF, and provides rich qualitative information
reflecting views from diverse stakeholders on strengthening these programs. All
authors have a connection to the University of South Carolina, as faculty, graduate,
or undergraduate students or as close collaborators (e.g., from the SC Association of
Positive Behavior Supports, from a state agency, a close colleague from another
university).
Overview of Book
Following this introductory chapter (Chap. 1), in Chap. 2, Kathleen Franke, John
Terry, Tristan Collier, and June Greenlaw discuss the importance of collaboration in
implementing successful strategies for prevention and interventions related to
SBH. Particular attention is paid to the importance of strong partnerships between
schools, mental health clinicians, families, students, and youth-serving organiza-
tions in multiple dimensions to increase the impact of programs. Prominent themes
include decreasing stigma and increasing awareness of mental health challenges for
students, growing collaborative teams to build program capacity, engaging families
and other stakeholders, and assuring that appropriate services are available to stu-
dents with special needs. Recommendations are suggested for collaborative
approaches to improving coordination of care, empowering students as leaders in
services they receive, eliminating blame, engaging families, and building in empa-
thy and understanding when addressing SBH improvements.
In Chap. 3, Tristan Collier and Victoria Rizzardi discuss the critical importance
of school-wide approaches to programming. These programs build from effective
multitiered systems of support (MTSS), which are best exemplified by PBIS (Sugai
& Horner, 2006, see www.pbis.org). Highlighted themes include the importance of
implementing school-wide approaches with fidelity; obtaining buy-in and ongoing
guidance from diverse stakeholders, especially students and families; providing
ongoing professional development, coaching, and implementation support; and
assuring statewide support. The authors provide guidance for school staff, mental
health clinicians, families, and other stakeholders to implement collaborative strate-
gies across all three tiers of the MTSS.
Chap. 4 reviews issues related to cultural responsiveness and humility. Following
review of the fundamental importance of this construct, Victoria Rizzardi, Sommer
Blair, Barbara Kumari, and June Greenlaw summarize participants’ responses
regarding barriers that may prevent access to SBH for racial, ethnic, and sexual
minority students. Barriers may include lack of trust, stigma regarding mental
health, stereotypes, and disciplinary actions that remove students from school. The
authors also describe the importance of increasing active involvement of important
individuals (e.g., parents, school staff, community leaders) in students’ lives in
order to enhance and increase the positive impact of culturally responsive SBH
programs.
In Chap. 5, Sommer Blair, Darien Collins, and Kathleen Franke review
dimensions of high-quality SBH. Key themes include purposeful attention to strong
collaboration between school service providers, families, students, and other
stakeholders; enabling youth to be in leadership roles; actively using data for deci-
sion making; and prioritizing SBH as a way to remove/reduce barriers to student
learning. In addition, systemic challenges of addressing mental health issues within
school systems and ways to overcome them are presented. Other themes include
empowering parents and students to collaborate with service providers, expanding
funding to strengthen SBH programming, and restructuring aspects of the school
day to improve learning for students who may need additional support.
Chap. 6 by Samantha Hartley and Carissa Orlando reviews the critical importance
of implementation support (IS). Potential barriers and facilitators to successful
implementation are addressed with themes such as staff capacity, community
partnerships, and interdisciplinary collaboration all critical to effective IS. The
authors underscore that without substantial emphasis on IS, SBH programs are
likely to have attenuated impacts. A range of strategies for IS are presented, along
with discussion on enhancing IS for particular staff in schools. For example, sug-
gestions are offered for teachers to become skilled change agents in supporting
school-wide programs and implementing evidence-based classroom interventions.
In Chap. 7, Linden Atelsek and Alex Roberts discuss participants’ perspectives
regarding SBH for juvenile justice-involved youth (JJIY). During this forum, themes
emerged regarding risk factors for this population, the quality of education received
prior to juvenile justice interactions, failure of the behavioral health system to

address students’ needs, and the need for a continuum of care, including supports
for students leaving this system. Short- and long-term effects of youth involvement
in the juvenile justice system are discussed such as increased drop-out rates, adult
unemployment for ex-juvenile offenders, and recidivism. Recommendations for
decreasing rates of JJIY are suggested with education of stakeholders in social-
emotional learning (SEL) strategies being at the top of the list along with early
identification of learning disabilities and co-occurring mental health conditions.
The need for enhanced funding of programs for these youth is emphasized, along
with the need for all involved to be willing to focus on rehabilitation of JJIY rather
than punishment.
In Chap. 8, Samantha Martinez, Tara Kenworthy, Sommer Blair, Lee Fletcher,
Yanfeng Xu, and Robert Stevens underscore critical needs of students connected to
child welfare systems, including students in foster and congregant care such as
group homes. Themes emphasize challenges that affect SBH, including poor com-
munication between service providers, underutilization of family and community
supports, and prevention of juvenile justice involvement. Participants provided sev-
eral recommendations and examples of effective programs for this priority popula-
tion. Recommendations include providing families with opportunities to work with
state agencies to create a system of communication to increase collaboration
between families, schools, and organizations; as well as developing community and
family supports to aid in removing barriers to care.
In Chap. 9, Marissa Miller and John Terry review challenges experienced by
students in military families, and the growing urgency to increase attention to these
needs through tailored SBH programs for military-connected youth (MCY).
Emphasized themes include services that currently exist for MCY, gaps in available
services, and ongoing needs for these students, particularly the lack of programs for
children. Authors describe potential supports for MCY in schools and outline the
benefits of having military-connected parents and community members involved in
the development of SBH programs tailored for this population. Recommendations
for improving current services that are offered include comparing the emotional/
behavioral needs of MCY to non-MCY and developing a theoretical model of the
experiences of these students’ unique experiences, and using insight from military
family members to inform innovations in practice. Other identified recommenda-
tions include enhancing statewide leadership to encourage collaboration and devel-
oping holistic programs for MCY and families.
In Chap. 10, Mark Weist, Darien Collins, Samantha Martinez, and June Greenlaw
distill recommendations from all eight focus groups toward a comprehensive set of
recommendations and action agenda for improving and expanding SBH programs
going forward. These recommendations include suggestions for action at the indi-
vidual, school, district, state, and national levels toward a more coherent and impact-
ful agenda for SBH, which is relevant to all stakeholder groups in a community.
Completing this Book in April 2020
Four years after the research this book was started, we bring it to a close in a very
challenging time for the US and the world, as we are contending with the novel
COVID-19 virus. At the time of this writing, there are around 1.6 million documented
cases and around 97,000 deaths worldwide. Numerous reports are documenting wide-
spread increase in stress, domestic violence, abuse and neglect, anxiety, depression,
and other problems. For example, in recent days, Indiana has seen a 25-fold increase
in calls to a helpline that addresses citizen mental health and other concerns (https://
www.wane.com/top-stories/covid-19-stress-affecting-hoosier-mental-health/).
Currently in the US, almost all school buildings are closed, and educators and
all staff connected to schools, including those involved in SBH, are trying to learn
how to support student learning and be generally helpful to them and their fami-
lies, in the middle of unprecedented challenges. Countless students are experienc-
ing an unexpected change in their access to mental health care and for those
receiving tier 3 supports, may no longer be in contact with someone who was very
important in helping and supporting them (e.g., school counselor, mental health
clinician).
Without question, the mental health impacts of this pandemic will continue for
years to come, underscoring the importance of well-done SBH, integrating more com-
prehensive school mental health and PBIS. As leaders in SBH and our Southeastern
School Behavioral Health Community (www.schoolbehavioralhealth.org), and along
with many groups nationwide, we are scrambling to identify and organize a range of
resources that are helpful to students, families, and schools (see https://drive.google.
com/drive/u/1/folders/1kU12en8023QbdpcPgwN-ziLHe_Z3SAKO).
In this work, it is clear that planning for effective learning and effective SBH in
this new reality will also continue for years to come. For example, as the pandemic
requires school districts across the country to begin using home-based academic
instruction, there is a need for SBH researchers and clinicians to find ways to deliver
evidence-based practices using these new instructional paths, and capitalizing on
technological advances. Indeed, one apparent positive in the middle of this crisis is
the dramatic increase in telecommuting and telehealth technology, along with
breaking down barriers for using these technologies (e.g., HIPAA, FERPA compli-
ance), and broadly increased appreciation for them. A critical challenge being con-
fronted is no or inconsistent access to the Internet for many families, and in other
cases challenges are being encountered in increasing family/student comfort for the
telehealth experience, and addressing issues like finding private spaces in homes for
these sessions. It is highly likely that the distance, online, and telehealth learning
strategies being developed now will continue to be a major instructional system at
later stages of and after the pandemic, and we need to advance our knowledge on
using these technologies to deliver effective SBH in the context of all tiers of
schools’ multitiered systems of support.
Further, an important foundation of SBH is to assure continuity in programming

during extended school breaks, including over the summer, and during holiday
breaks. What we are learning now to support children and families during this
extended physical break from school should build knowledge on year-round pro-
gramming. In addition, this knowledge should better prepare education, mental
health, and other systems leaders for improved responsiveness following inevitable
future population-wide challenges such as natural disasters, significant health chal-
lenges as in the current pandemic, or acts of terrorism/war (see Weist et al., 2002).
A prominent theme in focus groups reviewed in this book was the emphasis by
diverse stakeholders on the essential need for meaningful and consistent communi-
cation between the student/family, education staff, and SBH staff. Moreover, youth
and families expressed the expectation to be equal collaborators in this work and
desire training in PBIS, mental health literacy, effective behavioral management,
and other areas (see Garbacz, Minch, Jordan, Young, & Weist, in press). The
COVID-19 pandemic has shown this to be a glaring weakness, as schools and col-
laborating mental health centers are struggling to consistently communicate with
families, and a large percentage of students are not participating in online learning.
We hope that enhanced family-school-mental health collaboration and other core
themes emphasized in this book assist communities and schools in strengthening
SBH in general, as well as contributing to the refinement and tailoring of efforts to
increase effectiveness and impact in the challenging times we find ourselves in.
References
Barrett, S., Eber, L., & Weist, M. D. (2013). Advancing education effectiveness: An Interconnected
systems framework for Positive Behavioral Interventions and Supports (PBIS) and school
mental health (Center for Positive Behavioral Interventions and Supports (funded by the Office
of Special Education Programs, US Department of Education)). Eugene, OR: University of
Oregon Press.
Eber, L., Barrett, S., Perales, K., Jeffrey-Pearsall, J., Pohlman, K., Putnam, R., et al. (2019).
Advancing education effectiveness: Interconnecting school mental health and school-wide
PBIS, volume 2: An implementation guide (Center for Positive Behavioral Interventions
and Supports (funded by the Office of Special Education Programs, U.S. Department of
Education)). Eugene, OR: University of Oregon Press.
Garbacz, S. A., Minch, D., Jordan, P., Young, K., & Weist, M. D. (in press). Moving towards
meaningful and significant family partnerships in education. Adolescent Psychiatry.
Sugai, G., & Horner, R. (2006). A promising approach for expanding and sustaining school-wide
positive behavior support. School Psychology Review, 35, 249–255.
Weist, M. D., Lever, N., Bradshaw, C., & Owens, J. S. (2014). Further advancing the field of
school mental health. In M. Weist, N. Lever, C. Bradshaw, & J. Owens (Eds.), Handbook of
school mental health: Research, training, practice, and policy (2nd ed., pp. 1–16). New York:
Springer.
Weist, M. D., Sander, M. A., Lever, N. A., Rosner, L. E., Pruitt, D. B., Lowie, J. A., et al.
(2002). School mental health’s response to terrorism and disaster. Journal of School Violence,
1(4), 5–31.
Weist, M. D., & Stevens, R. (2017). Advancing school behavioral health. Report on Emotional &
Behavioral Disorders in Youth, 17, 1–5.
Wenger, E. C., & Snyder W. M. (2000). Communities of practice: Organizational Frontier. Harvard
Business Review, 78(1), 139–145.
Collaboration: An Essential Ingredient
for Effective School Behavioral Health
Kathleen B. Franke, John Terry, Tristan Collier, and June Greenlaw
Strong partnerships increase the ability to provide services to youth with mental
health challenges. School behavioral health (SBH) allows for broad collaboration
on a range of prevention and intervention services across youth-serving systems and
cooperation among various helping agencies. The objective is a true “shared agenda”
between schools, mental health agencies, families, students, and the community to
promote student mental health and school success (Andis et al., 2002; Weist et al.,
2012). Actively partnering to collaborate allows a full continuum of services to stu-
dents in schools among school staff, mental health professionals, families, and com-
munity providers (American Academy of Pediatrics Committee on School Health
[AAPCSH], 2004; Weist, Lowie, Flaherty, & Pruitt, 2001; Zellman & Waterman,
1998). Collaborative approaches improve coordination of care and empower stu-
dents and families as leaders in the services they receive (Rones & Hoagwood,
2000; Weist, Garbacz, Lane, & Kincaid, 2017).
Collaboration within SBH means more than schools referring students to another
agency to receive services and then waiting for resolution of the referral concern.
Commonplace language, such as “Referral,” “Co-located,” “Pull-out Programs,”
“On-site,” and “Outside Clinician,” connotes a passive and hands-off approach to
collaboration. Extensive scholarship indicates that teaming between families,
schools, and community partners is beneficial for student outcomes (Splett et al.,
2017). For example, in the general education setting, the parent-reported level of
involvement in school is associated with increased reading performance and teacher
ratings of lower learning problems for students (Zellman & Waterman, 1998).
During a series of focus groups with school and community-based behavioral health
K. B. Franke (*)

The Unumb Center for Neurodevelopment, Columbia, SC, USA
e-mail: Katie.Franke@UnumbCenter.org
J. Terry · T. Collier · J. Greenlaw
e-mail: tcollier@email.sc.edu; jbheadle@mailbox.sc.edu

https://doi.org/10.1007/978-3-030-56112-3_2
10 K. B. Franke et al.
professionals from a large and urban school district, students and families repeat-
edly described collaboration as a critical element of successful SBH programs
(Mellin & Weist, 2011).
Robust collaboration often fails to be realized across systems despite its docu-
mented benefits. Literature in the field of public administration identifies five
required antecedents for collaboration: the need for resources and risk sharing,
resource scarcity, previous history of efforts to collaborate, a situation in which each
partner has resources that other partners need, and complex issues (Thomson &
Perry, 2006). For example, in a qualitative study of school bullying, parents indi-
cated that they felt excluded from schools’ responses to bullying, and some parents
reported that they did not know if administrators received notification of their con-
cerns (Brown, Aalsma, & Ott, 2013). In this sample, several parents reported failing
to receive a callback when reporting bullying to the school, and others reported
experiencing resistance from the school (Brown et al., 2013). Importantly, school
and community collaboration were most likely to be successful when administrators
and other school personnel prioritized SBH services for students and frequent com-
munication with community providers, which prevented both gaps and duplication
in services (AAPCSH, 2004; Mellin & Weist, 2011).
The Leading by Convening (LbC) framework is a blueprint for authentic stake-
holder engagement developed by the IDEA Partnership to address common chal-
lenges in collaboration (Cashman et al., 2014). The “Partnership Way” was
developed by the Council of Special Education Administrators and the National
Association of School Psychologists to describe best practices in collaboration and
the type of partnership needed to impact student outcomes (Cashman et al., 2014).
LbC emphasizes the main principles of coalescing around issues, doing the work
together, and ensuring relevant participation as well as tools and strategies for
increasing collaboration. Coalescing around issues is the practice of organizations
coming together around shared concerns (Cashman et al., 2014). Doing the work
together describes the interactions between and among the participants with an
emphasis on effective teamwork to achieve outcomes across agencies at broad lev-
els (Cashman et al., 2014). Ensuring relevant participation refers to guaranteeing
that the correct combination of stakeholders is recognized and participating
(Cashman et al., 2014).
Here, we review prominent themes relevant to this focus group related to partner-
ships and collaboration in SBH. These themes were: 1) Increasing awareness of
mental health needs of children and youth, 2) capacity of programs to meet needs,
3) stigma, 4) increasing actions that convey empathy and understanding, and 5)
increasing family engagement in care.
Awareness
There is an estimated 1 in 5 children and adolescents that experience a mental health
disorder with anxiety, depression, and behavioral functioning most prevalent (Bitsko
et al., 2018; Ghandour et al., 2019). The onset of mental health concerns first
Collaboration: An Essential Ingredient for Effective School Behavioral Health 11
presents by 14 years of age in approximately half of the children and adolescents

with mental health problems (Kessler et al., 2007). These data demonstrate that
mental health problems in children and adolescents are substantial and are widely
understood to be problematic. The literature calls for a paradigm shift away from
just increasing awareness of mental health concerns faced by children and adoles-
cents toward the implementation of real prevention services. The critical question
is – what are schools, collaborating youth-serving agencies, and communities doing
with these data to raise awareness of unmet needs and to create a sense of urgency
for broadening programs to meet these needs? Awareness in SBH allows for coalesc-
ing around issues and then importantly emphasizing real prevention to address men-
tal health concerns (Cashman et al., 2014).
Limited Capacity
SBH emphasizes doing the work together and active teamwork to achieve outcomes
across broad levels (Cashman et al., 2014). During a series of focus groups examin-
ing SBH collaboration, school personnel and community providers indicated sig-
nificant barriers to effective cooperation (Ouellette, Briscoe, & Tyson, 2004). These
participants described insufficient time for consistent communication, unclear roles
and responsibilities, difficulty navigating external health care systems, challenges
communicating with relevant parties and outside behavioral health providers, and
constraints when scheduling meetings as common barriers (Ouellette et al., 2004).
In a noteworthy survey, 89% of preschool and elementary school teacher respon-
dents indicated that schools should address students’ behavioral health concerns,
and most teachers endorsed teaching students with emotional and behavioral con-
cerns, including disruptive behavior, aggression, and depression. Despite this sig-
nificant support, only 34% of teachers reported possessing the knowledge and skills
necessary to meet students’ behavioral health needs in the classroom. Further, many
teachers indicated they have a keen interest in receiving training to better under-
standing the behavioral health needs of children, as well as strategies for collaborat-
ing with families (Reinke, Stormont, Herman, Puri, & Goel, 2011).
Stigma
There is a broad consensus that stigma is a significant barrier to student access to

mental health services in schools (Bowers, Manion, Papadopoulos, & Gauvreau,
2013; Chandra & Minkovitz, 2007; Huggins et al., 2016). Students will avoid talk-
ing to teachers, guidance counselors, peers, and even parents and about mental
health concerns out of fear of being stigmatized (Bowers et al., 2013; Hartman
et al., 2013). Parents often feel blamed by others as being the cause of their child’s
mental health concern, and this decreases the likelihood of effective collaboration
between parents and school-based mental health providers (Hinshaw, 2005). To

ensure relevant participation, reducing stigma in stakeholders that may feel margin-
alized is crucial for true collaboration.
Increasing Actions that Convey Understanding and Empathy
Seeking to understand and support students and their families in need of services is
at the heart of effective collaboration and providing high-quality SBH services. For
effective collaboration, school personnel must know the families whom they serve,
as well as understand families’ perceptions regarding school and SBH (Knopf &
Swick, 2008; Minke & Vickers, 2014). For example, school personnel and behav-
ioral health providers should seek to understand families’ cultural backgrounds, as
well as whether families view the school as a partner or as working against their
child. They should also try to understand whether families see behavioral health
symptoms and treatment as stigmatizing, or whether they openly seek support for
behavioral health concerns. A non-judgmental understanding of families’ percep-
tions may assist schools in effectively building empathic relationships with them,
which sets the stage for effective programs and services (Minke & Vickers, 2014).
Motivational interviewing (MI) is an increasingly prominent strategy for schools
and SBH staff to develop empathic relationships with students and families while at
the same time promoting improvement in their functioning (Strait et al., 2020).
Motivational Interviewing-based treatments such as the Family Check-up and
Classroom Check-up intend to increase the utilization of evidence-based parenting
and classroom management practices (Dishion, Nelson, & Kavanagh, 2003; Reinke,
Lewis-Palmer, & Merrell, 2008). The Student Check-up, 2019 addresses student
issues that frequently require support (Strait et al., 2017; see https://studentcheckup.
org Strait et al., 2012; Terry, Smith, Strait, & McQuillin, 2013). These interventions
express support for the emotional/behavioral needs of youth, parents, and teachers
in an understanding manner consistent with the Spirit of MI. The developers of MI
describe the Spirit of MI featuring core values of evocation, collaboration, auton-
omy, acceptance, and compassion (Miller & Rollnick, 2012). Evocation refers to
eliciting motivation to change from the individual as opposed to educating them
about the need to change. Collaboration refers to the counselor allowing and sup-
porting the individual to lead the dialogue and direction of the interaction. Autonomy
is the counselor’s acknowledgment and support of the individual’s freedom to
choose his or her goals and behaviors. Foundational to MI and these approaches are
acceptance and compassion, which will increase the likelihood of ensuring partici-
pation and authentic collaboration (Miller & Rollnick, 2012).
Family Engagement
Seeking to understand the perspectives of families and develop genuine rapport will
increase the likelihood of collaborative and engaged partnerships and effective SBH
services (Weist et al., 2017). Family engagement in SBH includes promoting the
involvement of the family as a participant in a student’s behavioral health team, as
well as reducing barriers that may prevent families from participating in the stu-
dent’s team. Common barriers to family engagement include lack of transportation
to meetings, lack of childcare for children who may not participate in the collabora-
tion meetings, and difficulties scheduling meetings outside of parental work hours
(Ouellette et al., 2004). Emotional barriers to family engagement include schools
initiating contact with families only after a behavioral problem or disciplinary
action has occurred, rather than regularly communicating about student behavior,
with an emphasis on communication regarding positive behavior (Ouellette
et al., 2004).
Method
Seventeen diverse participants in SBH partook in a 2017 focus group to explore

awareness of mental health concerns in the classroom, availability of services,
resources and limited capacity, stigma, support for emotional concerns and under-
standing services in schools, family engagement, and collaboration. The stakehold-
ers consisted of five university staff and faculty members, one professional
counselor, three parents, one family advocate, one school liaison officer, and one
neuropsychologist. The following questions guided the conversation.
1. In your experience, how have youth and families, schools, mental health, and
other youth-serving systems collaborated to advance SBH in South Carolina (SC)?
2. What barriers prevent such collaboration?
3. How can these barriers be overcome?
4. Are there examples of middle and high school students helping to lead SBH
efforts? If so, please describe.
5. What has limited student involvement in guiding SBH in SC and how can these
factors be changed?
6. Are there examples of family members helping to lead SBH efforts? If so, please
describe.
7. What has limited family involvement in guiding SBH in SC and how can these
factors be changed?
8. What are the most important strategies for students, families, and youth-serving
systems leaders and staff to truly collaborate in advancing SBH in SC?
9. What other recommendations do you have to move this work forward?
Results
In general, participants reported that stigma regarding SBH utilization was a barrier
to collaboration for students and families. One participant noted, “There’s still a
stigma involved with even getting called to the office for their next appointment;
it’s even more difficult to advocate for them…” Similarly, another participant
identified,
the stigma of just being identified as having a mental health issue in the school environment.
Kids are really driven by their peers, and with their peers not having the education to under-
stand that another peer needs support in this area, it could turn out to be ugly instead of
something helpful.
These participants also stated that stigma regarding behavioral health extends
beyond the school setting, identifying the existence of “stigma in our society in
general and we need to address it outside our schools as well.”
Several participants expressed concerns regarding limited resources and capacity
for SBH that preclude collaboration. One participant noted that, “…they [school-
based clinicians] also have the care of the entire school so sometimes it would get
overwhelming.” Additionally, funding limitations might prevent students without
Medicaid from receiving school-based behavioral health supports. One participant
stated, “…they need the mental health services for the other students that are not on
Medicaid... They need those services as well.”
Awareness of available services also emerged as a barrier to collaboration.
Several participants identified that students and families might be unaware of ben-
eficial services until symptoms have escalated. One participant indicated,
No one tells a parent when they come in the door that this behavior may need mental health
services. The first thing they label the behavior as…this child has a behavioral issue. No one
goes to say that we have services that we can assist him... That connection never occurs
unless the parent is constantly going to the school saying that there is something else going
on here and I need additional support. But there has to be a willingness of the school to say
that we may see these behaviors, we want to help you help him to ensure that his school life
runs much more smoothly as he finishes out with us. No one says that. Parents get this news
from another parent or someone else who works in the mental health field or they stumble
across just having a conversation with someone to say ‘Oh, you’re having that problem?
This is what I did.’ But there’s not an upfront effort to say if your child is having issues that
may be behaviorally related, please come see us. We’ll connect you with the right ser-
vices… Instead of at the back end.
This lack of collaboration and awareness contributes to feelings of isolation and

judgment for students and families. As one participant summarized, “It’s just mak-
ing it aware that you can go get help without feeling there is just something wrong
with me or someone is going to judge me.”
Participants emphasized the need for support and understanding services in
schools. One participant called for “trauma-informed schools and organizations…
sensitivity and… classrooms too that also address social/emotional health.”

Participants also called for increased understanding at an individual level stating,
To me, it’s understanding a behavior and the proper interventions for behaviors, instead of
okay that kid get them out… when you actually sit down with a student, you actually under-
stand what is behind the behavior. But if you’re constantly saying “Well, you constantly do
this,” and not even take a chance to sit down and have a conversation and to see what’s
underlining that behavior, you’ll never know. You’ll just keep putting the student out until
finally they’re disengaged.
Supportive services extend beyond traditional SBH clinicians. Participants called

for the training of all personnel, including resource officers, noting “if a person is
going to be in our schools responding to these kinds of issues, we absolutely have
to make sure we have the right kind of training for them.”
Participants frequently identified both physical and emotional barriers that pre-
vent family collaboration. Several participants noted frequent blaming of caregivers
and parents for behavioral health concerns, expressing, “I have been blamed as a
parent for my child’s behavior and shamed by school personnel. I think that’s a big
barrier to getting parents to come on board and participate.” One participant stated,
“…staff are still blaming parents for the inconsistencies or shortcoming or behavior
of their children.”
Finally, participants noted specific difficulties experienced by twice-exceptional
children, meaning those gifted students who also present emotional/behavioral
challenges (Dole, 2001). A parent of a twice-exceptional student reported,
I think it’s difficult to have your child recognized and served under both. We just sort of pick
and choose one. With my son was in all the honors and gifted, and they’ll say he’s gifted,
but they said he couldn’t be in this program anymore because he was having these issues.
And to me means that’s missing a large part of who he is.
Recommendations
Participants provided several recommendations to improve collaboration between

schools, families, and the community. Five participants stated that education and
training are vital to enhancing collaboration and student outcomes, recommending
“education for parents and students and staff… I also think workshops for all par-
ents for early identification and understanding.” In addition to training on behav-
ioral health symptoms, participants also recommended training for supportive,
understanding environments, stating, “You’ve got to teach patience and… sensitiv-
ity training.”
Participants also discussed strategies to improve barriers to engagement, with
one participant stating,
If you want to engage families, sometimes you need to go where the families are, you need
to go look at their schedules and those kinds of things… I think that school environment…
raises their own issues of whether they were good in school or didn’t do well at math or got
in trouble or whatever. So I think about being creative a lot of times in how do you engage
the families as a whole for the school.
Another participant added,

There are real life obstacles for single parents who are working two jobs, folks that don’t
have transportation, people who have language barriers, all sorts of things; if we aren’t
identifying those real barriers and are just ignoring them and calling them bad parents or
they won’t be involved, we won’t get anywhere.
Participants recommended that a single individual identified as the school-based

point of contact to facilitate collaboration between relevant individuals is best. One
participant noted that “having someone at the school who knew her [child with a
behavioral health concern] and knew how to help her [was beneficial]. When she
needed to go to the high school, we had someone we knew guiding us through the
process.” Additionally, recommendations included “greater funding and infrastruc-
ture” for SBH. According to one participant,
I think we also may want to look at how difficult it may be for teacher in the classroom to
balance all these different needs, all of these different [Individualized Education Plan;
IEPs]… and 504s and hearing what they need to be able to manage. I don’t think most of
them are out to disregard or hurt anyone, but at the same time they have to try to balance the
workload… I’ve always wondered… why in elementary schools there are teacher’s assis-
tant but not in middle and high schools.
Finally, recommendations were made for schools to identify and acknowledge

the complexities of students who are twice-exceptional, or gifted but also contend-
ing with a disability, and to increase their access to relevant services. In the words
of the participant whose child was twice-exceptional, “somehow learning how to
manage both [exceptionalities]” is crucial for appropriately serving the student. For
example, collaboration must occur between general and special education teachers,
school-based behavioral health clinicians, families, and community providers.
Participants’ suggestions are consistent with recommendations from the SBH
literature. It is essential to provide school personnel with information regarding the
importance of family-school collaboration to increase buy-in for it (Symeou,
Roussounidou, & Michaelides, 2012). Crucial components of communication are
also an important area of emphasis, including practical training including modeling
essential skills, using role-plays, providing supportive feedback, addressing parents
by their preferred name, active listening, and asking open-ended questions (Shute,
2016). In addition, schools should communicate positive information (e.g., writing
an email to a caregiver when a child has behaved well) to families to foster a posi-
tive, collaborative relationship (Ouellette et al., 2004; Shute, 2016). Moreover, there
is a significant need to train teachers in promoting positive classroom environments,
creating and maintaining positive relationships with all students (as learning is
mediated through the student-teacher relationship), and identifying students with
more intensive needs so connections to appropriate supports can be suggested
(Kern, George, & Weist, 2016; Reinke et al., 2011).
Collaboration through the creation of teams is commonplace in schools, and
teaming is relied upon heavily to implement frameworks such as Positive Behavior
Intervention and Support, Response to Intervention, and the Interconnected Systems
Framework (Barrett, Eber, & Weist, 2013; Brown-Chidsey & Steege, 2005; Nellis,
2012; Splett et al., 2017). Teaming enhances the capacity to implement innovation,
however, group dynamics created through teaming can lead to additional challenges
(i.e., Forming, Storming, Norming, Performing, Adjourning) that must be managed
to ensure effectiveness (Bonebright, 2010). School staff members can feel dissatis-
fied with team functioning, resulting in the absence of true collaboration and student
outcomes not being achieved (Doll et al., 2005; Lee-Tarver, 2006).
Conclusion
Authentic and strong collaboration is required to serve students appropriately; how-

ever, true collaboration is difficult to achieve. Here, focus group participants and the
literature identified important themes related to successful collaboration in SBH.
Increased awareness of mental health challenges youth face and coalescing
around this issue are the initial steps to enhancing readiness for action. Importantly,
awareness campaigns are only beneficial if they create a sense of urgency to make
meaningful change through collaboration and agencies doing the work together.
The limited capacity of individual organizations to address an issue as significant as
child and adolescent mental health is the foundational rationale for collaboration.
Enhancing collaboration and ensuring relevant participation within SBH teams
should intentionally include individuals from all related areas of students’ lives,
including general and special education teachers, mental health providers (school-
and community-employed), allied health providers (e.g., nursing, speech, and occu-
pational therapy), family members, and students. Improving engagement with
families and students is crucial and highly challenging at the same time. Families’
perceptions of explicit or implicit blame for the mental health challenges faced by a
youth causes increased stigma and results in decreased motivation to work collab-
oratively to address these issues.
In the future, training in collaborative approaches and effective strategies for col-
laboration will lead to effective SBH practices in schools. Utilizing strategies that
convey understanding and empathy are vital to reducing stigma and promoting col-
laboration. LbC and the principles of coalescing around issues, doing the work
together, and ensuring relevant participation increase the likelihood of effective col-
laboration (Cashman et al., 2014). School-based techniques like MI are helpful
strategies; however, more importantly, the foundational Spirit of MI that empha-
sizes actions that convey acceptance and compassion is what truly improves a sense
of understanding and empathy. Importantly, frequent and effective communication
between school personnel, families, and community providers positively contrib-
utes to positive development for twice-exceptional students (Dole, 2001). School
psychologists, special education teachers, and general/gifted educational personnel
must work together to develop enrichment plans to promote growth in areas of a
particular talent, as well as interventions to support areas of need (Reis, Baum, &
Burke, 2014). It will also be helpful for SBH teams to identify supports for the stu-
dent outside of traditional behavioral health services, including connecting the stu-
dent with affirmative community programs, such as sports teams (Weist et al., 2012).
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Improving School-wide Approaches
in School Behavioral Health
Tristan Collier and Victoria Rizzardi
In 1997, the United States Congress approved the Individuals with Disabilities
Education Act (IDEA), which in addition to mandating supports for students with
disabilities in all public schools, called for more research to prevent childhood emo-
tional and behavioral problems before students reached a level of need that could
only be provided by special education services (Sugai & Horner, 2002).
Comprehensive, school-wide systems of prevention called multitiered systems of
support (MTSS) were developed to provide a continuum of supports covering pro-
motion/prevention at Tier 1, early intervention at Tier 2, and more intensive inter-
vention at Tier 3 (Sugai & Horner, 2002). MTSS provide a range of supports across
domains of student social, emotional, behavioral, and academic (SEBA) function-
ing, with specialized supports for students with higher degrees of need (Shogren,
Wehmeyer, Lane, & Quirk, 2017). An earlier form of school-wide academic sup-
ports, Response to Intervention (RTI), reflects similar concepts of MTSS but is
more focused on student academic performance (Shogren et al., 2017).
Perhaps best articulating the concept of MTSS is Positive Behavioral Interventions
and Supports (PBIS), which initially reflected effective applied behavioral analysis
to assist individual students (Carr et al., 2002), but has since undergone dramatic
expansion to reflect all dimensions of effective multitiered assessment, prevention,
and intervention in schools (Shogren et al., 2017). PBIS emphasizes effective use of
data, and installing systems and practices to implement and refine evidence-based
practices across the MTSS (Sugai & Horner, 2006), and is being implemented in
over 26,000 schools in the United States (Center on PBIS, U.S. Office of Special
Education Programs, 2018). PBIS has been demonstrated to significantly reduce
office discipline referrals (Bradshaw, Mitchell, & Leaf, 2010), reduce suspensions
(Bradshaw et al., 2010), increase perceptions of safety (Horner et al., 2009), and
increase academic test scores (Simonsen et al., 2012) in elementary schools with
T. Collier (*) · V. Rizzardi

e-mail: tcollier@email.sc.edu

https://doi.org/10.1007/978-3-030-56112-3_3
22 T. Collier and V. Rizzardi
similar effects found in middle schools (Lassen, Steele, & Sailor, 2006). Although
research into PBIS in high schools has demonstrated similar reductions in office
discipline referrals and suspensions (Bohanon et al., 2006; Morrissey, Bohanon, &
Fenning, 2010; Muscott, Mann, & LeBrun, 2008) and improvements in academic
test scores (Muscott et al., 2008), effective implementation of PBIS is often difficult
because of the complex organizational structure of high schools (Bohanon, Flannery,
Malloy, & Fenning, 2009).
School-wide approaches to school behavioral health, most notably PBIS, have
seen marked success across several studies (Barrett, Bradshaw, & Lewis-Palmer,
2008; Bradshaw et al., 2010; Horner et al., 2009; McIntosh, Bennett, & Price, 2011).
Implementing and maintaining PBIS with fidelity, however, poses a significant chal-
lenge for schools (Bohanon et al., 2009). Although some schools may implement
Tier 1 supports with fidelity, Tier 2 and 3 interventions have been found to be more
difficult to implement (Hoyle, Marshall, & Yell, 2011; Scott, Anderson, Mancil, &
Alter, 2009). Barriers to the successful implementation of PBIS across all Tiers
include those related to implementing evidence-based practices (EBPs; Hoyle et al.,
2011), having enough time to conduct effective trainings for staff (Scott et al.,
2009), limited building-level administrative support (Scott et al., 2009), and resis-
tance from staff to change their student behavior management techniques (Scott
et al., 2009).
Barriers such as these can vary depending on the school’s demographics (e.g.,
rural, urban, suburban, high, or low SES, etc.), warranting different techniques for
successful implementation (Dexter, Hughes, & Farmer, 2008; Putnam, McCart,
Griggs, & Choi, 2009). For instance, PBIS implementers in rural school districts
have found that conducting communication using email and video chats help to
avoid excessive travel times in districts that cover large geographic areas (Steed,
Pomerleau, Muscott, & Rohde, 2013). Additionally, barriers such as a lack of inter-
agency and intraschool collaboration, as well as a lack of family engagement, can
have negative effects on PBIS implementation (Bradshaw, Koth, Bevans, Ialongo, &
Leaf, 2008; Garbacz et al., 2016).
Literature on PBIS and effective MTSS is growing rapidly. In our literature
review, five themes were particularly prominent: (1) Implementing PBIS with fidel-
ity, (2) assuring program buy-in, (3) providing effective training for staff, (4)
increasing family engagement and leadership in programming, and (5) moving to
large-scale implementation. These themes are reviewed in more detail in the follow-
ing, and are also prominently represented in findings from the focus group
reviewed later.
Implementing PBIS with Fidelity
Implementation fidelity is a measure of how well a program is being executed as

intended by the program’s developers and original model (Breitensten et al., 2010).
As programs are implemented in ecologically valid settings such as schools, a
downside is that buy-in and resources may be less than optimal, contributing to
Improving School-wide Approaches in School Behavioral Health 23
challenges in program delivery within the MTSS (Dane & Schneider, 1998).
Programs that are implemented with low fidelity are less likely to produce the
desired results. Further, the effects that are present may be masked by the inconsis-
tencies, lowering buy-in for the program (Dane & Schneider, 1998).
Reduction in students’ office discipline referrals and suspensions is significantly
related to the level of fidelity with which PBIS is implemented, meaning schools
implementing PBIS with high fidelity will see a larger reduction in office discipline
referrals and suspensions than schools implementing with lower levels of fidelity
(Flannery, Fenning, McGrath, & McIntosh, 2014; Simonsen et al., 2012). Similarly,
one study demonstrated that schools that met PBIS implementation criteria had a
higher number of students achieving mastery on state standardized math tests
(Simonsen et al., 2012). There are clear benefits of strong implementation fidelity,
but achieving the recommended benchmark for successful PBIS implementation
requires strong staff buy-in, administrative support, and coaching (see Eber et al.,
2019; Sugai & Horner, 2006).
Assuring Buy-in
School staff buy-in has been identified as a critical component of successful imple-
mentation of PBIS (Kincaid, Childs, Blase, & Wallace, 2007), with a recommenda-
tion of 80% of staff buy-in before implementation (DeStefano, Dailey, Berman, &
McInerney, 2001). Buy-in can encounter several barriers, including school staff sat-
isfaction with the implementation plan, staff willingness to try new approaches, and
staff continued the use of PBIS practices (Hieneman & Dunlap, 2000). Handler
et al. (2007) recommend that staff buy-in be formally assessed by regularly evaluat-
ing staff use of PBIS practices, with data on this helping to inform implementation
processes.
Administrator and senior faculty buy-in is a critical component in the implemen-
tation of PBIS as it can help to both encourage teacher buy-in and facilitate inter-
ventions (Flannery, Sugai, & Anderson, 2009; Hershfeldt, Pell, Sechrest, Pas, &
Bradshaw, 2012; Kam, Greenberg, & Walls, 2003). For instance, Hershfeldt et al.
(2012) found that senior teacher resistance was also associated with negative atti-
tudes about PBIS. Additionally, principal support for a school-wide practice can
impact both the sustainability of the practice (Benz, Lindstrom, Unruh, & Waintrup,
2004) and the effects of the practice on student outcomes (Kam et al., 2003).
Providing Effective Training
For school staff to effectively implement PBIS, they must receive both training in
PBIS practices as well as ongoing coaching on the use of those practices (Bradshaw,
Reinke, Brown, Bevans, & Leaf, 2008). Effective and ongoing staff training in PBIS
practices creates consistent behavioral expectations and discipline practices across
classrooms, which in turn can lead to reductions in office discipline referrals and
suspensions (Barrett et al., 2008; Bradshaw et al., 2010). These benefits, however,
are contingent on teachers’ familiarity with the supports available; Stormont,
Reinke, and Herman (2011) found that, within a sample of general education teach-
ers, 57% were unsure if their school provided functional behavioral assessment and
intervention planning. Initial training in PBIS should include a plan for continued
professional development around PBIS practices as well as thoughtful planning to
maintain buy-in and implementation fidelity.
Family Engagement
Familial involvement with the school experience of children and adolescents is

associated with a variety of positive outcomes, including improved school atten-
dance, academic achievement, and positive student behavior (for a review, see
Garbacz et al., 2016). A major goal of improving family engagement in a MTSS
system such as PBIS is to promote improvements in children’s behavior both in
school and at home. Unfortunately, the typical implementation of PBIS does not
always incorporate a formal system of family engagement (Garbacz et al., 2016).
The Center on PBIS developed a comprehensive guide to increase family and youth
engagement and leadership in schools in 2017 (Weist, Garbacz, Lane, & Kincaid,
2017). This e-book documented the promise of this work, and that relatively little
progress has made. Emanating from the e-book was the creation of the Family-
School-Community Alliance (FSCA, see https://fscalliance.org), an international
organization seeking to elevate planning in research, practice, and policy forums to
significantly increase family and youth leadership in schools.
Large-Scale PBIS Implementation
For school-wide PBIS to be sustained, systemic support must extend beyond the
school to include support from district and state leadership. Organizing and collabo-
rating between several schools establishes a common vision, improving the effi-
ciency of resource allocation and implementation processes (Eber et al., 2019;
OSEP Technical Assistance Center on PBIS, 2017). Fortunately, the three-tiered
approach of PBIS/MTSS maps on to state efforts to implement this programming,
for example, statewide efforts (e.g., web-based support, conferences) corresponding
to Tier 1, targeted support to districts corresponding to Tier 2, and more intensive
work with schools/districts corresponding to Tier 3 (see Barrett et al., 2008).
Statewide PBIS implementation increases the number of schools implementing
with fidelity and improves student outcomes (Barrett et al., 2008; Simonsen et al.,
2012). Nevertheless, Simonsen et al. (2012) and Barrett et al. (2008) assert that the
improved student outcomes are likely due to increased implementation fidelity
rather than simply the scaling up of PBIS at the state level.
Method
Fourteen stakeholders gathered to discuss the strengths and weaknesses associated

with effective school-wide approaches in South Carolina (SC). This group was
comprised of six members from youth and family-serving agencies, three K-12
school staff members, four university staff and faculty members, and one student.
Five of the participants were parents of students who were attending or previously
attended school in SC. The discussion was organized using the following ten
questions:
1. In your experiences at a school, what factors are most important for building
high-quality school behavioral health (SBH) programs? What factors are most
important at the District level?
2. What have your experiences been with PBIS?
3. How should PBIS efforts be strengthened?
4. What should we do to improve school-wide approaches that are for all students
and focus on promotion and prevention?
5. What strategies can be employed to increase advocacy with the SC Departments
of Education, Mental Health, and Health and Human Services for growing PBIS
in schools?
6. What are the key resource needs in SC schools to effectively implement SBH?
How do these needs vary based on school classification (e.g., rural, urban, sub-
urban, higher vs moderate vs lower SES)?
7. What has limited family involvement in guiding SBH in your school/district and
how can these limiting factors be changed?
8. What are the most important strategies for effectively engaging school adminis-
trators as leaders of SBH in schools?
9. What other recommendations do you have to advance SBH in SC schools?
Results
Implementing PBIS with Fidelity
A major concern for participants in this forum was that PBIS is not being practiced
by all individuals within a school. As mentioned, PBIS is intended to be in place
within an entire school (e.g., all classrooms, hallways, the cafeteria, library, etc.)
and practiced by at least 80% of school staff (OSEP Technical Assistance Center on
PBIS, 2017). Concern over too few teachers practicing PBIS was mentioned twice
during the research forum, suggesting that PBIS is not being implemented with
fidelity.
One of the frustrating things for me was to have a group of six kids in a classroom that I’m
working with every week, and then to see them go back to their classroom walking down
the hall. And they don’t get that same support that I can give them… I think the most effec-
tive a system can be is if it’s happening all over, and then the students realize it’s happening
all over, because they know what’s going on, but they know they gotta listen to me.
A similar concern regarding fidelity was also mentioned twice during the research
forum. This concern surrounded the lack of understanding of PBIS, resulting in
poor implementation of PBIS practices. One participant, a PBIS coach, mentioned
that it took several years of working as a coach before she truly understood PBIS:
“A lot of teachers say they are using PBIS but then turning around and doing some
sort of negative response as well, and it’s confusing for children.”
Assuring Buy-in
Participants brought up the issue of buy-in to PBIS as an important aspect of suc-

cessful implementation. Specifically, the participants discussed the need for top-
down buy-in within a school: “I also feel like the administrators are still a missing
piece, like we don’t have buy-in from the administrators... It doesn’t feel like the
administrators are involved in the treatment as well.” Another participant felt that
part of the problem of low buy-in is how PBIS is presented to school staff: “When
I’m listening to folks, there’s a disconnect, they really haven’t been sold. I think
selling it in a way that teachers, school administrators, school board members, can
consume it is something I think can go a long way.”
Participants continued to discuss ways to bridge the gap in understanding and to
garner stronger buy-in from administrators, district administration, and
school boards:
I think speaking their language in two ways. One is aligning the effects of PBIS with the
outcomes they care about. like … ways that PBIS will improve educational outcomes. Also
from a dollar perspective, the extent to which investing in PBIS will decrease the cost of
other things like alternative education – things that cost a lot of money.
Lastly, participants also noted the need for buy-in at the state level, stating “The
only way to really assure that it is a statewide activity and not district wide activity...
is for the state Department of Education to promote PBIS to the point of providing
staff to support it.”
Providing Effective Training
Participants discussed the need for effective training and professional development
for effective implementation of school-wide systems, such as PBIS. One participant
elaborated on how to best implement and maintain teacher and school staff training:
I think one thing that needs to be happening is [after] training teachers, providing materials
that they need, especially something that’s like a school-wide, like SOPs [standard operat-
ing procedures], or things like that, that’s actually going around in the schools so that every-
one’s on board doing it, and then having monthly meetings.
Additionally, one participant noted the need for training to be at all levels:
Professional development, it has to be at all levels it cannot just be to the teachers or to the
specialized groups like school psychologists and guidance counselors. It needs to be prin-
cipals; it has to start from the top. It has to be the superintendent. It has to be at every level.
Every department has to understand the philosophy and the importance of the initiatives
that we are working on and trying to get students’ support for whatever mental health issues
they have.
Family Engagement
Throughout the forum, Participants discussed their experiences with family/school

interactions, as well as the need for effective family engagement. Several partici-
pants mentioned their feeling excluded and ignored during meetings with school
staff, with one student participant noting, “There have been instances where people
have listened in on my [Individualized Education Plan; IEP] meetings and also have
totally discarded what my parents’ thought.” Another participant noted the difficult
position parents are often put in when meeting with school personnel to discuss
their child’s behavioral health challenges: “There’s a lot of blame game going on,
and for students with disabilities, those disabilities are just kind of ignored as not
[being] a contributing factor, and so they also attribute characteristics to parents that
their children are exhibiting.”
The forum participants also discussed how to improve family and school interac-
tions through youth empowerment:
We really need to empower the students as well and develop opportunities for ways students
can have a voice... we really need to develop a way for students to have opportunities to, in
a safe environment, be able to say what they need.
The participants also talked about positive experiences they have had working
with school staff:
Great things have come out of those meetings though... At the end of that meeting, the
administrator did take two DVDs I had on bipolar disorder. He held a training for his faculty
on Bipolar Disorder and showed the DVDs…Sometimes out of a little bit of conflict then
comes great growth.
Large-Scale PBIS Implementation
The need for universal implementation of PBIS was explicitly mentioned three
times throughout this research forum and several other times in relation to imple-
mentation fidelity. Participants expressed their concern that a lack of statewide
implementation prevents students from receiving the necessary resources due to

attending a non-PBIS school, noting:
There are a lot of kids that I know that are currently in the school that I was at that have
problems, but there’s no way for them to get any kind of help… so I think one of the first
things is we have to make sure it’s integrated across the board in every school, in the entire
state, at all three tiers.
Moving Forward
Our view is the most prominent theme from this focus group focused on assuring
buy-in. When implementing PBIS, it is critical to garner support from administra-
tors to ensure the values and practices of PBIS are supported from the top-down
within a school. Administrators may be resistant to some of the school-wide changes
needed for the effective implementation of PBIS. To help guide administrators
toward PBIS practices, Hershfeldt et al. (2012) recommend that PBIS implementers
spend time learning the overarching school structure (e.g., administrative priorities,
common practices, explicit and implicit goals, etc.) including reviewing the district
or school’s School Improvement Plan. Understanding a school’s culture and goals
can help implementers “sell” the PBIS system to administrators to meet those goals
(e.g., improving behavior can improve academic outcomes; Hershfeldt et al., 2012).
This strategy aligns with qualitative findings from McIntosh, Kelm, and Canizal
Delabra (2016), which indicates that principals are more likely to buy-in to PBIS
when they feel it aligns with their personal values.
In addition to administrative buy-in, teacher buy-in must occur for PBIS to be
implemented with fidelity. Some teachers, however, may be resistant to changing
their teaching strategies and they may vocalize their dissent, which could have a
negative impact on the willingness of other teachers to accept PBIS practices.
Hershfeldt et al. (2012) note that senior teachers can greatly facilitate or hinder the
acceptance of PBIS practices among other teachers; therefore, it may be advanta-
geous for PBIS implementers to have individual conversations with senior teachers
about PBIS practices and how they may help teachers meet their classroom goals.
Following steps to assure buy-in, critical to school-wide PBIS is ongoing and
effective training and coaching. For example, Reinke, Herman, and Stormont (2013)
emphasize that teacher use of evidence-based PBIS practices in the classroom (e.g.,
specific praise to students versus general classroom praise, giving students opportu-
nities to respond) after an initial training will not meet optimal levels without addi-
tional coaching. They recommend the use of data-based performance feedback
when training teachers in new PBIS practices, which can help increase their use of
effective strategies in the classroom.
While standard training models of PBIS for teachers emphasize creating behav-
ioral expectations and effective classroom management (Hershfeldt et al., 2012;
Reinke et al., 2013), training in mental health and crisis response is increasingly
seen as a necessary skill for teachers to possess. Schools interested in promoting
mental health awareness among staff and students could utilize school-wide mental
health literacy programs, such as The Guide (Kutcher, Wei, & Morgan, 2015).
Additionally, there are more intensive crisis response and mental health training
programs designed for professionals who work with youth such as Mental Health
First Aid (Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010).
Also underscored by the literature reviewed and themes brought up in this focus
group, increasing family engagement in SBH programming is essential. For exam-
ple, enhanced family engagement in PBIS can help to bridge behavioral expecta-
tions between the school and home (Garbacz et al., 2016). This consistency in
behavioral expectations can both help improve student behavior in both settings
(Feil et al., 2014) and improve students’ attitudes toward attending school (Allen &
Tracy, 2004). Additionally, the effective use of family engagement within school-
based interventions has also been found to improve social, emotional, behavioral,
and academic (SEBA) outcomes beyond interventions that do not include this
emphasis (Feil et al., 2014; Pearce, 2009; Sénéchal & Young, 2008). Therefore, both
school staff and parents should have a vested interest in creating strong partnerships
to enhance the school experience for children and improve their SEBA outcomes.
To improve family engagement in schools implementing PBIS, Fix et al. (2017)
have made several suggestions across all three Tiers of the MTSS. For example, at
Tier 1, schools should have a range of resources and materials available to families
(at the school, and web and email-based), hold family-focused mental health pro-
motion workshops to provide psychoeducation about a variety of topics including
mental concerns common in students, and empower students to develop training and
awareness-raising programs related to mental health. Families and youth should
also be on school teams, guiding planning for all actions within the MTSS. At Tier
2, students and families can be guiding supportive programs for students presenting
early signs of problems, including mentoring-based programs, and can help connect
families together who are contending with similar SEBA challenges to promote
information sharing and mutual support. At Tier 3, school- and community-
employed mental health staff in schools should work with students and families as
collaborators in care versus taking an expert stance in therapy.
This forum also included consideration of moving school-wide approaches to
larger-scale at district and state levels. Themes underscored that this is a complex
process requiring the district/state to have an initial level of readiness to begin
implementation supported by detailed planning and on-going evaluation. For
detailed support on scaling-up PBIS, there are several articles and manuals support-
ing large-scale implementation; for example, the School-wide Positive Behavior
Support: Implementers’ Blueprint and Self-Assessment (Lewis, Barrett, Sugai, &
Horner, 2010).
The Center on PBIS (2017) has identified four key components for successful
large-scale implementation of PBIS: (1) There is a strong leadership team to coor-
dinate implementation; (2) the leadership team and participants in planning work
from a solid organizational framework that includes emphases on funding, visibil-
ity, and political support; (3) solid plans are in place for ongoing training, coaching,
and evaluation; and (4) a group of exemplar schools are identified and lessons
learns, findings from their experiences are shared with other schools to promote
scaling up of effective practices.
The Association for Positive Behavior Support (n.d.) emphasizes the importance
of leadership teams in statewide implementation. These teams are integral in facili-
tating training and technical assistance planning, evaluation, and interagency col-
laboration. Leadership teams should facilitate interagency coordination, connecting
other human service agencies (e.g., mental health, child welfare, juvenile justice) to
schools to promote collaboration in planning and program a shared agenda of pro-
viding a continuum of interventions and supports for all students within a school.
Implementors of PBIS are more likely to be successful when they are regularly
engaging in meetings around training, troubleshooting, and planning of PBIS imple-
mentation, and these efforts should be more intense in early years (Barrett et al.,
2008). Participants noted an important link between training, school staff buy-in,
and implementation fidelity. For instance, one participant expressed the need to
ensure that PBIS training include all teachers, administrators, and even superinten-
dents to increase unilateral buy-in, which in turn could facilitate implementation
fidelity. Additionally, participants recommended aligning the goals of PBIS with
multiple levels of outcomes that are valued by school personnel. For example, well
done PBIS helps to improve academic outcomes as well as reducing costs for more
intensive placements, which in turn facilitates buy-in from teachers, administrators,
and district leaders, which in turn can strengthen resources for PBIS, in a positive
snowballing growth curve. This process would help reach the goal emphasized by
participants in this forum of universal PBIS across SC, consistent with the goal of
equitable programming for all students in the state.
An area of critical importance the forum participants brought up is the need for
meaningful inclusion of families in SBH planning and implementation. For
instance, several participants reflected on negative experiences at school meetings
where they felt their voice was not heard, that school staff had a lack of understand-
ing of their or their children’s needs, and even felt blamed and stigmatized for hav-
ing identified diagnoses/disabilities. Participants recommended creating
opportunities and spaces for students to voice their concerns and express their
needs to school staff, consistent with recommendations from Fix et al. (2017).
Additionally, one participant reflected on how increasing the mental health literacy
of school staff can reduce stigmatizing attitudes toward students and families with
mental health concerns. Fortunately, there is a growing national movement around
the expansion of mental health literacy to reduce stigma with the proliferation of
evidence-based programs such as Youth Mental Health First Aid (Kelly et al.,
2011), Kognito (Eisenberg, Hunt, & Speer, 2012), and The Guide (Kutcher et al.,
2015). We strongly encourage schools to examine how mental health stigma may
impact the functioning of their MTSS and/or special education processes and fur-
thermore how to meaningfully incorporate student and family voice in ongoing
planning to improve these processes.
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Cultural Humility and School
Behavioral Health
Victoria Rizzardi, Sommer C. Blair, Barbara Kumari, and June Greenlaw
While researchers and practitioners may first think of race and ethnicity when dis-
cussing cultural competency, these variables represent only one form of diversity.
Religious affiliation, sexual orientation, gender, age, language, beliefs, socioeco-
nomic status (SES), occupation, peers, interests, and many other variables are
aspects of cultural diversity (Clauss-Ehlers, Serpell, & Weist, 2013). As a response
to growing diversity, cultural competency has become increasingly emphasized in
health and mental health care (see Sue, 2001; Sue et al., 1982; Sue, Arredondo, &
McDavis, 1992). Due to the unique ways culture can manifest in each individual,
the goal of having mastery or competence of all cultures may not be realized or
feasible. An additional criticism of the concept of cultural competency lies in its
lack of recognition of factors that contribute to an individual’s development that
may be unique to that individual and not reflective of the culture with which they
identify (Fisher-Borne, Cain, & Martin, 2014).
Related to these and other factors, the concept of cultural competence has evolved
to emphasize cultural humility, which focused on self-reflection and empathy and
frankly acknowledges the inherent challenge in becoming “culturally competent.”
Cultural humility is the ability to be open to new ideas and other cultures while still
being true to your own. When practicing cultural humility, the person in the helping
role is cautious to ask others about their culture versus prematurely making conclu-
sions about cultural background and preferences (American Psychological
V. Rizzardi · J. Greenlaw
e-mail: jbheadle@mailbox.sc.edu
S. C. Blair (*)
South Carolina Department of Social Services, Lexington, SC, USA
e-mail: Sommer.Blair@dss.sc.gov
B. Kumari
Department of Psychology, Arizona State University, Tempe, AZ, USA
e-mail: bahall4@asu.edu

https://doi.org/10.1007/978-3-030-56112-3_4
36 V. Rizzardi et al.
Association [APA], 2018). To further elaborate, cultural humility is characterized

by the professional: deliberately reflecting on the aspects of one’s own culture,
being intentional about one’s role as a learner rather than as an expert, searching for
chances to develop partnerships, and adopting a lifelong growth mindset (Mosher
et al., 2017).
Importantly, the limited focus on cultural humility is particularly important for
minority students, where there continue to be inequities for these students in rela-
tion to both their receipt of needed programs and services, and receipt of exclusion-
ary discipline (Carpenter-Song, Schwallie, & Longhofer, 2007; Fisher-Borne et al.,
2014). Further, traditional approaches to address this problem are limited; for exam-
ple, cultural competency training programs that encourage teachers to learn about
different cultures in a standardized process with a focus on a few, simplistic, core
characteristics (Elhoweris, Parameswaran, & Alsheikh, 2004; Tervalon & Murray-
Garcia, 1998) to the neglect of a more nuanced and in-depth analyses of cultural
differences (Guo, Arthur, & Lund, 2009). In this regard, four themes are necessary
to consider, stereotypes, stigma, lack of trust, and school discipline practices.
Stereotypes
Social stereotypes were defined as early as 1922 by journalist Walter Lippmann as

flawed generalizations about certain groups (Judd & Park, 1993), with these gener-
alizations typically accompanied by stigma (Heary, Hennessy, Swords, & Corrigan,
2017). Stereotypes and stigma threaten students’ academic performance and overall
well-being. For example, when asked to look at photos of children that were simi-
larly dressed, a majority of teachers identified black males as the most likely to be
involved with gangs and to drop out of school (DeCastro-Ambrosetti & Cho, 2011).
Stereotypes regarding SES also negatively affect students. In one study, fourth,
sixth, and eighth-grade students were asked to consider the academic performance
of “rich” and “poor” students. All ages indicated that “rich” students are more likely
to perform better academically compared to their “poor” counterparts (Woods,
Kurtz-Costes, & Rowley, 2005). When children’s SES is made salient, this nega-
tively impacts disadvantaged children, as they are then less likely to perform well in
school and more likely to buy into the stereotype that they will always live in pov-
erty (Woods et al., 2005). As young as first grade, children recognize that being
wealthy is desirable while being poor is not (Woods et al., 2005).
Some students are affected by multiple stereotypes. For example, in addition to
ethnic stereotypes, African American and Hispanic students are more likely to be
challenged by poverty and stay impoverished longer (Schmitz, 1995) and thus may
face stereotypes related to SES. Additionally, stereotypes exist past race and
SES. Stigma is associated with minorities related to sexual orientation, religion,
family structure, etc. For example, professional circles often label single-parent
households as a problem, and such households are rarely referred to as a healthy
choice for a family system (Schmitz, 1995). When diversity is demonized, instead
Cultural Humility and School Behavioral Health 37
of normalized or celebrated, there can be adverse effects on anyone who is stereo-

typed or stigmatized.
Mental Health Stigma
Stigma includes a variety of distorted beliefs that involve labeling, stereotyping, and
isolating the group that is not the majority (Knifton, 2012). Public stigma, or stigma
that is accepted by most of society, sets the foundation for all other forms of stigma
because it is the majority’s misguided belief about a specific group (Parcesepe &
Cabassa, 2013). Public stigma has often associated mental health with negative
words such as “weak” or “crazy.” For example, Abdullah and Brown (2011) found
that over 50% of Americans do not want a person with mental illness to marry into
their family, work with them, or socialize with them. Self-stigma differs from public
stigma. For mental health, self-stigma is a person’s internalization of public stigma
regarding mental health concerns (Abdullah & Brown, 2011). In their review,
Clement et al. (2015) identified self-stigma as a barrier to seeking mental health
treatment. If a person is concerned with stigma, they are less likely to accurately
perceive their need for mental health treatment (Miranda, Soffer, Polanco-Roman,
Wheeler, & Moore, 2015). Additionally, one research study reported that 32% of
individuals recognized they had a mental health issue but would not seek treatment
due to stigma (Alvidrez, Snowden, & Kaiser, 2008).
Further, stigma issues may be more significant for minority youth. For example,
within the rural African American community, there is a cultural mistrust of mental
health providers (Haynes et al., 2017). African American parents report more stigma
and less positive attitudes when it comes to receiving mental health services (Turner,
Jensen-Doss, & Heffer, 2015), and some suggest stigma is the largest contributor to
lower help-seeking by African Americans for mental health services (Haynes et al.,
2017; Turner et al., 2015). This conclusion is consistent with findings from a
national survey of over 14,000 students that found that minority students were less
likely to seek mental health counseling than their majority-race peers (Miranda
et al., 2015).
Lack of Trust
Several frameworks consider the interactions between mental health care providers
and consumers as one of the most critical factors in mental health care (Rosenheck,
2001; Tansella & Thornicroft, 1998). Within this relationship, trust is the most
essential variable for promoting healthy, effective interactions (Mechanic, 1998;
Murray & McCrone, 2014). However, as a result of stigma, mental health consum-
ers may distance themselves from those associated with mental health services,
including mental health providers, creating distrust with those associated with the
mental health care field (Verhaeghe & Bracke, 2011). Not only are self-stigma expe-
riences related to distrust in mental health care providers, but distrust is also signifi-
cantly related to mental health consumers’ service satisfaction (Verhaeghe &
Bracke, 2011). Further, consumers’ lack of trust in their providers may reduce treat-
ment adherence and prevent them from seeking care (Thom, Hall, & Pawlson,
2004). Compared to their White counterparts, African American and Latino patients
are less likely to trust their care providers (Berrios-Rivera et al., 2006; Bova et al.,
2012) especially when their care provider is a different race/ethnicity from their
own (Gordon, Street, Sharf, Kelly, & Souchek, 2006).
Discipline Practices
Since the 1990s, school discipline rates for most racial and ethnic groups have
declined (Wallace, Goodkind, Wallace, & Bachman, 2008); however, suspension
and expulsion rates among racial and ethnic minority groups have increased
(American Academy of Pediatrics Committee on School Health, 2003). Despite this
increase, research consistently demonstrates the negative effects of suspension,
including higher rates of academic failure and dropout (Arcia, 2006), failure to
graduate on time (Mendez, 2003), increased risk of drug and alcohol use, and a
greater likelihood of engaging in antisocial behavior (American Academy of
Pediatrics Committee on School Health, 2003; Hemphill et al., 2012). Moreover,
suspension from school does not reduce the likelihood of future discipline referrals
(Tobin & Sugai, 1996). Conversely, Hemphill et al. (2012) found that suspension
predicts future nonviolent antisocial behavior and suspension, as well as poor aca-
demic performance.
Issues associated with suspensions are especially problematic given that the
majority of students who receive suspensions belong to a minority group or are of
low SES (Vavrus & Cole, 2002). It has been consistently shown that African
American youth experience the highest rates of suspension, with Hispanic and
American Indian youth trailing closely behind (Wallace et al., 2008). Even more
concerning is that the racial disproportionality in suspension rates is related to a
similar rate of disproportional referrals to the juvenile justice system (Nicholson-
Crotty, Birchmeier, & Valentine, 2009). While suspension predicts future victimiza-
tion, criminal activity, and incarceration in adulthood for all students, African
American students are significantly more likely to experience these long-lasting
consequences as adults (Wolf & Kupchik, 2017). One explanation for the increased
suspension rate for minority youth is that they participate in antisocial behaviors
that result in suspensions more often than White students. However, Skiba et al.
(2011) found that African American and Hispanic students are more often sus-
pended than White students for similar discipline referrals.
Method
This forum included these participants from different stakeholder groups, with sev-
eral overlaps within individual participants. There were 15 attendees, including par-
ents, teachers, faculty members, a graduate student, and staff members from a
university hospital. The questions below were asked to create a dialogue surround-
ing cultural humility as it relates to improving school behavioral health (SBH):
1. In your experiences in South Carolina (SC) schools, what factors are most
important for building high-quality SBH programs? What factors of SBH pro-
grams are most important for improving cultural humility in the school?
2. What have your experiences been with training on disparities in schools with
SBH programs?
3. How can Positive Behavioral Interventions and Supports (PBIS) and other SBH
initiatives be strengthened to reflect cultural humility and empathy?
4. What should we do to improve school-wide approaches that help all stakeholders
recognize personal factors that affect their views and actions about disparities?
5. What emphases are needed to improve policies and practices that reduce restric-
tive placement and discipline of minority students?
6. How can we improve SBH initiatives to include families and communities that
have been traditionally underserved? How do the family needs of students vary
based on school classification (e.g., rural, urban, suburban, higher vs. moderate
vs. lower SES)?
7. Due to schools’ limited resources, how can the role of other community groups
and members, such as the faith community and businesses, help in eliminating
disparities? How can school-based SBH stakeholders work smarter?
8. Can the SBH initiative stakeholders help in identifying biases? How can the
initiative help change these biases?
9. What other recommendations do you have to advance cultural humility in SC
schools?
Results
Four main themes relating to cultural humility and SBH arose from the discussion
in the forum. The topics of these themes have been defined earlier in this chapter as
a prelude to the discussion of the dialogue with these stakeholders.
The first identified theme in this forum was stereotypes and the problems that
stem from them, especially within some cultures. The second theme surrounded
stigma. Participants believed that parents do not reach out for services due to the
stigma associated with mental health, particularly in minority and low-income com-
munities. The third theme centered around a lack of trust between families and
schools, accompanied by the need to build these relationships. The final theme
regarding discipline practices arose out of dialogue involving students being
removed from the classroom because of their behaviors. Suggestions for handling
this issue included trying to find more of the root causes and, once again, looking
closely at the impact on minority and low-income families. Participants consistently
mentioned involving more people in the students’ lives as another way to combat
these issues. Furthering the conversation, participants identified utilizing interdisci-
plinary meetings, more support staff, and embracing “the village” mentality as ways
to overcome effects of stigma, stereotypes, and building trust. The themes focused
on by these stakeholders are vital to consider when exploring cultural humility and
how it relates to SBH.
Stereotypes
The first problem identified by the participants was stereotypes. One participant
explained that, “The communication is about the most important factor here because
mental health has always been stereotyped.” Another participant recognized that she
struggled with stereotypes when her child was referred to mental health services.
Regarding her child’s referral, the participant shared,
I even struggled with it because of mental health in the black community. That is one thing
we suffer, it is stereotyped, like something is wrong with you if you seek mental health. We
need to really look at these labels.
One participant spoke further on this issue related to stereotypes, as well as cul-
tural humility in general through their lived experience. The participant explained,
A lot of times we throw the word ‘cultural’ and ‘culture’ and ‘cultural competencies’ and
‘cultural humility.’ We throw these words around so lightly but the culture between my
house and her house even though we’re both African American women, it can be com-
pletely different.
Mental Health Stigma
Mental health stigma was also recognized during the forum. The participants
believed that minority and low-income communities were at a greater risk of per-
petuating mental health stigma within their own families and neighborhoods. One
participant said,
We talk a lot about our administration and teachers, but with the parents and many people
who are apprehensive of mental health services, especially in different cultures such as
African American cultures [and] Hispanic cultures, when they hear mental health or behav-
ioral health…it has a stigma to it...
The discussion then shifted to overcoming this barrier. The same participant
went on to say, “We definitely need to go in these communities and educate them
about what we’re doing with their children.” Communicating with parents regarding
their children’s care drew the greatest consensus among the group on how to combat
the stigma.
Parental Lack of Trust
This forum identified a general lack of trust between families and school personnel.
One participant emphasized that, before any further relationships can be built with
the family, the existing relationship with the student(s) must be repaired. The par-
ticipant said, “We have to find a way to undo all of the mistrust and repair some
things to our young people.” After beginning with the students, efforts must be
turned toward the parents. One participant emphasized this plan of action saying,
“We have to bridge a level of respect between school authority and parents.” The
group spoke of how school personnel cannot skip the steps of building trust with all
parties involved. A participant spoke to this process, “When [parents] feel they can
trust you, you get a little bit more from them, but you have to start there.” Other
participants agreed that it would be difficult to continue any other type of service
without a strong initial relationship. One participant indicated that it is important to
show parents support, saying,
when they can see that they’re all working as a team to understand them better and to work
more, I think that will take us to the point that we can really get something done and then
have the expectation that this is the team that’s going to follow me all year and if I’ve got
more than one person I know there’s some significant system concerned about what I’m
going to do. I think that could start to shift to make a significant change on the outcome that
we’re looking for.
Another forum participant spoke to the current, broken state of these relation-
ships stating, “These parents, my heart goes out to them because... they need some-
body to say this is where to start [and] this is how we’re going to help you.”
Discipline Practices
The impact on minority and low-income students was discussed further within the
subtheme of removing students from school due to behavioral issues. Forum partici-
pants were angered by both their personal experiences and those they had witnessed.
One participant described racial inequity, stating, “[Of] twenty-four children that
were expelled from an alternative school, twenty-two were African American chil-
dren.” Parents within the group discussed that, often times, parents are not provided
with alternative options when their child is suspended from school for their behav-
ior. They are instructed to pick their child up from school and take them home as
soon as their behavior becomes unmanageable. A participant who went through
such experiences with her child said, “It wasn’t, ‘How can we help?’ ‘These are the
resources.’ None of that was available...” The forum offered alternatives to simply
sending a child home such as,
Instead of you talking to him as principal, send him [to the school-based counselor], let her
or him talk to him and let them do something about it instead of you just throwing him out
of school, and then he’s not getting the help and he’s going to act out more.
Working harder to find the underlying issues to behavioral problems, as opposed to

utilizing suspensions, was something the forum participants discussed with
great fervor.
Recommendations for Moving Forward
Reducing Punitive Discipline Practices
While overall school discipline rates have declined since the 1990s, those rates have
increased for African American students (Wallace et al., 2008). Skiba et al. (2014)
explored the impact that school-level characteristics, like school climate and empha-
sis on diversity, play on discipline disproportionality. They found that these charac-
teristics may be better predictors of suspension and expulsion than student behavior.
In their work, they found that principals’ orientation toward discipline, school-wide
academic achievement, and percentage of African American enrollment explained
racial and ethnic disproportionality above student behavior or student-level charac-
teristics (Skiba et al., 2014). Given the contribution of school-level variables on
discipline disparities, policy, and practice interventions with a focus on reorienting
administrators’ views toward less punitive practices, developing their capacity to
change practices within their school, and introducing instructional interventions
with an emphasis on reducing implicit bias may be effective at reducing discipline
disparities (Skiba et al., 2014). Additionally, interventions to improve the quality of
academic instruction and develop a positive school climate for all student groups
are likely to lead to improvements in student behavior and academic performance
(Rausch & Skiba, 2005; Scott, Nelson, & Liaupsin, 2001).
In addition to reducing discipline disparities, it is important to ensure that stu-
dents who are suspended or expelled from school are supported upon their return to
school. Absences from school may have negative effects on students’ academic
progress, as well as provide students with the opportunity to associate with other
youth exhibiting antisocial behavior, thus increasing the likelihood of future suspen-
sions (Hemphill et al., 2012). Schools may be able to alleviate negative outcomes
during suspensions by providing students with schoolwork and partnering with par-
ents and the community to provide supervision during suspension (Hemphill
et al., 2012).
Greater Involvement in Students’ Lives
Forum participants agreed that handling the complex issues involved in effective
and culturally humble SBH requires all stakeholder groups to be actively involved,
including leaders and staff from education, mental health, and other youth-serving
systems, along with families and students, and community leaders. Many partici-
pants mentioned that involving different groups in the child’s life could have a more
significant impact on the student. Participants would like to see school systems
embrace how it was, “back in the day,” according to one participant when “the vil-
lage raised the child.” Many participants agreed that “...more support staff in
schools” is essential to this work. The participants hoped that “more school social
workers, school nurses,” would, in turn, “get the people... in the community and
show them how to access services.” Involving everyone in the neighborhood would
ease the burden of individual parents. Additionally, participants felt that the more
people who consistently impact a child’s life, the less likely it would be for the child
to fall through the cracks and not receive the care or services they need.
Developing Trust
The relationship between families and their children’s schools plays an essential
role in children’s social and academic outcomes (Jeynes, 2005; Serpell & Mashburn,
2011). Schools can capitalize on mental health providers who are already connected
to their schools to foster effective school-family partnerships. Mental health provid-
ers can promote the sharing of information and connecting of schools, families, and
other organizations (Talapatra, Miller, & Schumacher-Martinez, 2019). Mental
health providers possess counseling and communication skills to help promote
group functioning and resolve conflicts as they arise, as well as knowledge of
evidence-based practices when designing plans for students (Talapatra et al., 2019).
Further, their connections with school staff and other community providers make
mental health providers well-suited to develop plans for students that generalize to
real-world situations and can be applied at home or in the classroom (Talapatra
et al., 2019).
A critical skill for mental health providers, and one that may encourage effective
teaming, is learning how to facilitate consumers’ trust in the provider (Hall, Dugan,
Zheng, & Mishra, 2001; Thom et al., 2004). In a comprehensive review, Murray and
McCrone (2014) identified several characteristics mental health providers should
possess to gain the trust of those in their care: effort, continuity and time, caring,
personal knowing, and respect; interpersonal skills; competence; and patient-
provider partnering. Facilitating trust with clients requires a conscious effort from
providers (Hem, Heggen, & Ruyter, 2008) and commitment to continuity and time,
or regularly meeting with them (Eriksson & Nilsson, 2008). Equally important is
the provider’s ability to understand the client’s individual experience (Thom &
Campbell, 1997), to be empathetic to their concerns (Sheppard, Zambrana, &
O’Malley, 2004; Thom, 2001), and to show acceptance and encouragement
(McAlearney, Robbins, Kowalczyk, Chisolm, & Song, 2012; Thom, 2001).
Conclusion
The concerns voiced by stakeholders in this forum were all evidence of a need for
increased emphasis on cultural humility in schools and in SBH programs. The real-
ity is that insufficient attention to cultural humility will limit the effectiveness and
relevance of these programs, and work is needed to infuse this emphasis in ongoing
interactions with students and families in planning and implementing all aspects of
programming within the MTSS (Waters & Asbill, 2013). In this work, mutual trust
is foundational, and this can only be achieved through ongoing collaborative inter-
actions between educators, SBH staff, students, and families, seeking understanding
of cultural issues, effective, and respectful ways to communicate about them, and
ways to transparently identify and work to remove barriers to effective program-
ming related to culture.
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Improving School Behavioral Health
Quality
Sommer C. Blair, Darien Collins, and Kathleen B. Franke
Youth spend most of their time either at school or at home, which places schools in
a unique position to identify and address emotional/behavioral (EB) problems in
students. This level of care helps to remove barriers to students’ learning and pro-
mote academic gains (Hess, Pearrow, Hazel, Sander, & Willie, 2017; Kase et al.,
2017). As reflected in the chapters in this book, there is a significant national move-
ment to integrate education and mental health systems to provide high-quality
school behavioral health (SBH) programs (Barrett, Eber, & Weist, 2013; Weist,
Lever, Bradshaw, & Owens, 2014). Quality SBH programs address needs across all
levels of schools’ multitiered systems of supports (MTSS), including universal or
schoolwide approaches (Tier 1), selective or early interventions (Tier 2), and tar-
geted interventions (Tier 3) to address behavioral health needs (Hess et al., 2017).
This chapter reviews qualitative data from a focus group of parents, school princi-
pals, clinicians, and other school personnel who discussed characteristics of high-
quality SBH, roles for key stakeholders, and ways to further improve the quality of
this innovative approach to improving student mental health and school success.
Critical Quality Dimension in SBH
High-quality SBH services include several important factors (see Weist et al., 2007).
Collaboration between school service providers, parents, students, and other stake-
holders promotes responsive, supportive environments and learning for all students
S. C. Blair
Department of Social Services, South Carolina, Columbia, SC, USA
e-mail: Sommer.Blair@dss.sc.gov
D. Collins (*) · K. B. Franke
e-mail: darienc@email.sc.edu; Katie.franke@unumbcenter.org

https://doi.org/10.1007/978-3-030-56112-3_5
48 S. C. Blair et al.
(Hess et al., 2017). Including youth in services improves overall knowledge of men-
tal health and increases the likelihood that students will become actively involved in
promoting their mental health and receiving effective mental health services
(Salerno, 2016). With universal screening and effective data-based decision-making,
schools support students who may not seek services, with problems flagged by
screening data followed by proactive actions by school staff (Dowdy et al., 2015).
Prioritization of mental health at the school level can contribute to enhanced school
climate, which may result in fewer barriers to service delivery (Townsend et al.,
2017; DeFosset, Gase, Ijadi-Maghsood, & Kuo, 2017).
Collaboration The Individuals with Disabilities Education Act (IDEA) empha-
sizes parental involvement in their children’s education, as parents provide unique
knowledge about their child (Jung, 2011; Yell, Katsiyannis, & Losinski, 2015).
Parental/familial involvement is thus legally mandated in Individualized Education
Plan (IEP) meetings, which are designed to develop a curriculum road map for spe-
cial education services (Jung, 2011; Lo, 2012; Yell et al., 2015; Wilson, 2015,
Dilberto & Brewer, 2014). The IEP is an individually designed educational plan
designed to meet the needs of a student with a disability (Galemore & Sheetz, 2015).
Sect. 504 plans are similar, in that they protect all people with disabilities from dis-
crimination in educational settings (Galemore & Sheetz, 2015). An IEP is unsuc-
cessful without open communication between the school and family (Diliberto &
Brewer, 2014). Even when the legal requirements for participation are satisfied,
collaboration between parents, educators, mental health clinicians, and other parties
in attendance of the meetings can be poor or missing altogether. A 2005 National
Longitudinal Transition Study found that one-third of parents with children who
have a disability desire greater involvement in the IEP decision-making process
(Wilson, 2015). Approaching this plan of intervention holistically (i.e., involving all
important individuals in a child’s life) rather than individually (e.g., involving teach-
ers and parents separately) can improve children’s behavior and reduce the proba-
bility that behavior problems will escalate (Dilberto & Brewer, 2014).
Parents often feel a power imbalance and are treated as recipients, instead of
participants, in their children’s educational plans (Jung, 2011; Scanlon, Saenz, &
Kelly, 2018; Wilson, 2015). This imbalance can occur if professionals within the
school setting blame the parent, choose not to acknowledge the parent’s expertise,
are insensitive to certain cultural differences – whether religious or otherwise, and/
or use educational jargon with which only they are familiar (Jung, 2011). Clinicians
walking parents through initial diagnostic and special education eligibility pro-
cesses need to take time to communicate unknown acronyms and technical terms to
both the parents and the teachers (Dunn et al., 2016). Parents and school personnel
must view each other as allies throughout the entire IEP collaboration process
(Carlson et al., in press; Scanlon et al., 2018). Clinicians should approach meetings
with a mindset of emphasizing students’ strengths, discussing challenges, and pro-
gram directions based on data, rather than prescribing families an explicit sequence
of steps they must follow (Dunn, Constable, Martins, & Cammuso, 2016).
Improving School Behavioral Health Quality 49
Youth Involvement/Training Youth are often considered “half-members” when it

comes to interacting with mental health practitioners, their parents, and other adults
regarding their care, and they are often considered to not have full interaction rights
in their own care (O’Reilly, Lester, & Muskett, 2016). Little research describes how
professionals should communicate with youth regarding their mental health
(Wasserman et al., 2018). Yet, various interventions and frameworks have been
shown to improve knowledge of mental health, attitudes toward mental health, and
help-seeking behaviors when school-based mental awareness programs are imple-
mented (Salerno, 2016). For example, the Youth-Adult Program (Y-AP) is an
American program that generates a forum for adults and youth to discuss youths’
health care concerns (Heffernan et al., 2017). Although this program is designed for
more general areas of health, it provides a framework that could be tailored to men-
tal health, allowing youth to be decision-makers rather than solely consumers of
information or services. Y-AP views neither the youth nor the adults as experts, but
it operates under the assumption that everyone has something to learn (Heffernan
et al., 2017). Entering meetings with the mentality that everyone has a voice could
encourage youth to become more involved in mental health services.
Relatedly, giving youth a voice in their own care and allowing them the opportu-
nity to communicate with their peers openly in the school setting about their issues
may prove beneficial. Peer support provides a buffer from loneliness (Rasalingam,
Raanaas, & Clench-Aas, 2017), and most students reach out to their peers for this
support, including support regarding mental health, before they reach out to a pro-
fessional (Byrom, 2018). Peer support has been shown to have a greater effect than
even parental support on mental health and victimization issues, as these problems
often occur in school settings where parental response is not accessible (Rasalingam
et al., 2017). Furthermore, mental health interventions delivered by peers are shown
to decrease stigma (Gopalan, Jung Lee, Harris, & Acri, 2017), as well as promote
positive outcomes. For example, in one study on treatment for depression, a peer-
facilitated program performed just as well as an intervention led by professionals
(Byrom, 2018). Providing students with connections to peers for support may facili-
tate discussion of mental health issues and promote mental health awareness in
schools.
Data-Based Decision-Making Students often only receive mental health services
after significant symptoms of distress are present (Dowdy et al., 2015). Universal
screening for mental health issues increases emphasis on prevention, early interven-
tion, and promotion of mental health (Dowdy et al., 2015). There are often structural
barriers between education and mental health services, however, with no joint data
system for service coordination between schools and community agencies
(Heflinger, Shaw, Higa-McMillan, Lunn, & Brannan, 2015). Coordinated use of
screening data can be used to refine and expand mental health service delivery in
schools (Dowdy et al., 2015). Performance measurement of existing service sys-
tems is an integral piece to ensure that service systems are implementing these
principles (Heflinger et al., 2015). A solution to lack of coordinated data utilization
in schools would be partnering with local community agencies. Partnerships
between schools and mental health agencies can assist in closing the research-to-
practice gap, improving uptake, and implementing evidence-based practices (EBPs;
Connors et al., 2018). Community-partnered school behavioral health is a model in
which clinicians are trained in modular “common elements” (MCE) practices and
deliver services in schools (Connors et al., 2018). The MCE approach utilizes data-
driven selection and sequencing of interventions (Connors et al., 2018). Clinicians
report that standardized evidence-based practices can be incompatible with some
aspects of school behavioral health, requiring adaptation of EBPs to fit the student’s
needs (Connors et al., 2018). Students who require extensive crisis management and
those who lack basic needs or family structure, for example, may not benefit wholly
from standardized practices (Connors et al., 2018). Providing training and support
for SBH clinicians and school staff in data-based decision-making, as in functional
behavioral assessment (FBA), can help to address some of these issues (Pence & St.
Peter, 2018).
Prioritize Mental Health Some schools may not address the mental health needs
of their students for fear of reflecting negatively on the school. However, school-
level variables, such as school climate, can inform whole-school improvement
efforts (Hopson, Schiller, & Lawson, 2014). For example, students who reported a
more supportive school climate were three times as likely to report average or better
behavior mental health, and less perceived stigma about mental health concerns
(Hopson et al., 2014; Townsend et al., 2017). Further, regular assessment of school
climate can help school staff and students to recognize and understand mental health
concerns (Townsend et al., 2017). Even then, referrals from teachers or other profes-
sionals may not lead to services (DeFosset et al., 2017). Instead, mental health
needs are often addressed when there is disciplinary action involved or when needs
have reached higher levels of severity (DeFosset et al., 2017; Merikangas et al.,
2010); in many schools, there is a need for a more proactive stance about addressing
student mental health issues (DeFosset et al., 2017). Routine measurement of school
climate from the perspectives of key stakeholders, including students, parents,
teachers, and administrators, is a critical strategy for prioritizing student mental
health issues (Townsend et al., 2017).
Despite these recommendations, a reality is that a focus on fiscal issues may
constrain schools’ focus on student social, emotional, and behavioral functioning
(Hardin, 2016). For example, some states only require districts to report summary
information on budgets and expenditures versus more detailed reports on how these
funds are allocated (Hardin, 2016). Incomplete policy guidance at the national level
has produced a patchwork of fragmented services provided by federal, state, and
local agencies that may be highly variable from community to community. Further,
there may be competition between communities to obtain funding (Eiraldi, Wolk,
Locke, & Beidas, 2015). Funding constraints in school districts also affect training,
continuing education, and licensure status of mental health professionals in schools
and the quality of services they provide (Demissie & Brener, 2017). These findings
also underscore the critical role of school principals in advocating for sufficient
funding for high-quality SBH professionals (Iachini, Pitner, Morgan, &
Rhodes, 2015).
Overcoming Inertia in Systems In some instances, data are not utilized to support
improved student functioning. For example, a number of studies support delayed
starts to school to enable more sleep for students (Au et al., 2014, Wahlstrom,
Berger, & Winome, 2017); yet, many school districts have failed to make this change
(Wheaton, Chapman, & Croft, 2016). Similarly, smaller class sizes and increased
individualized and supportive interactions with students have been shown to
improve student performance, but related to fiscal constraints, many schools are
unable to make these critically needed changes (Weeden, Wills, Kottowitz, &
Kamps, 2016). A final example is integrating of students with significant EB chal-
lenges into general education classrooms, with differentiated instruction strategies
to enable their learning. Despite evidence of the effectiveness of this approach,
many schools continue to teach these students in segregated environments
(Conderman & Hedin, 2015).
Method
A focus group on improving quality in SBH was held with 13 diverse stakeholders,
including four parents, five mental health providers (from disciplines of counseling,
school psychology, and social work), one researcher, one research coordinator, and
two community agency leaders. The method for the forum and strategy for analysis
is reviewed in the introductory chapter. Forum participants were presented with all
questions below, followed by a discussion on each of them.
1. What are the characteristics of high-quality SBH programs at Tier 1? At Tier 2?
At Tier 3?
2. Thinking about your experiences in our schools, what factors are most important
for building high-quality SBH programs? Which of these factors are frequently
missing in our schools? Why?
3. What is the top priority for quality improvement in SBH programs at Tier 1? At
Tier 2? At Tier 3?
4. How have schools used data to help make decisions about or improve the quality
of SBH services? Provide examples of schools doing this well at Tier 1, 2,
and/or 3.
5. There are many research-based EBPs available for schools at Tier 1, Tier 2, and
Tier 3. What challenges exist for adopting and implementing these programs in
schools? What recommendations do you have for overcoming these challenges?
6. How can students and families be more involved in collaboratively guiding and
implementing EBPs in schools?
7. What other recommendations do you have to advance SBH in SC schools?
Results
The results of the forum were collected and categorized into five different sub-
themes related to improving SBH quality. A number of these subthemes map onto
critical dimensions of quality reviewed in the introduction to this chapter. First,
many of the participants voiced the need for stronger collaboration between school
personnel and parents, particularly concerning behavioral plans such as IEPs and
Sect. 504 plans. A forum participant who works within a school noted, “Everyone
is in crisis mode…,” when mental health issues are being addressed, stating, “We
struggle; staff, admin, psychologists, and social workers of putting fires out. [We]
put a band aid on something that clearly needs some stitches.” The group discussed
ways to facilitate communication between all parties involved in the decision-
making process, including students. Participants suggested avenues, such as educa-
tion or peer groups, as possible ways to engage students in mental health services.
Again, mapping onto the literature review, subthemes of data-based decision-
making, training, and prioritizing mental health were discussed. Reflecting a cogent
summary, one participant stated, “I think that people don’t see [students’ mental
health] as a priority unless they are experiencing it personally within themselves.”
Collaboration
Participants emphasized the need for greater collaboration between school person-
nel and parents. One participant stated, “Family education will be very important,
meaning schools modeling to the parents how to interact with the schools and
explain what services are actually available at the schools.” The same participant
went on to say, “A lot of times parents don’t approach the schools because they
don’t think they can help and think that DSS (The Department of Social Services)
is going to come after them.” Fears, as well as other thoughts and feelings, “can be
overwhelming for them [parents],” and another participant empathized, “because
we don’t know what a parent is going through.” Instead of being bombarded with
disheartening outlooks, parents should be empowered to collaborate with their
child’s education and SBH personnel. As one participant put it, parents should feel
they can take on a, “nothing about us, without us,” mentality when it comes to the
decisions regarding their students’ well-being. A collaborative partnership between
schools and families can decrease caregivers’ fears and allow them to have an active
voice in their child’s care.
Youth Involvement/Training
A participant noticed that mental health service providers “don’t take input from the
youth very often, if at all.” The forum participants noted that youth, like their care-
givers, need to be active contributors in the discussion and planning of any type of
services provided. One participant mentioned the importance of giving youth a
voice so that they can “be vocal about what they need instead of [professionals] tell-
ing them what they need.” Participants also emphasized the need for peer support
among students. One participant suggested helping “the youth be more engaged
with other students, because a lot of times they are completely isolated… and don’t
really interact.” Such interactions would provide a space for the youth to engage
with one another about mental health and promote healthy social skills.
Data-Based Decision-Making
Many participants emphasized the importance of data-based decision-making

throughout the forum. One participant said:
I always go back to the data; the data helps us make decisions and get past personalities, and
that’s important. So, anything that we can do to get better, more consistent, and more accu-
rate data in the hands of the right people… is what we need to do.
Utilizing data to prevent bias and to present clear, measurable goals was repeated
throughout the meeting. One participant noted that one characteristic of high-quality
SBH programs was “some way to collect baseline data on everyone as to their men-
tal health issues.” However, another participant brought up another issue concerning
data, stating, “Our dilemma with school people is that they are wonderful at admir-
ing data, but they do not know how to problem solve with data.” Incorporating train-
ing to help school personnel use data more effectively and efficiently was proposed
as a solution by participants. One participant stated, “They have to have a team
that’s responsible, and those people are trained in collecting data and understanding
and knowing what to do with it.”
Prioritize Mental Health
Participants agreed that no steps can or will be taken by schools until mental health
is prioritized. The participants gave several reasons regarding why they believed
schools were not addressing their students’ mental health. One explanation was,
“Some of the schools seem like they do what is best for them, like their image… or
how they are perceived by others, not what is in the best interest of their students or
what their students actually want.” This was quite concerning for forum group
members who also mentioned that schools prioritize fiscal needs and disregard
students’ social, emotional, and behavioral needs. Simply put by one participant,
“The social-emotional piece tends to fall aside in favor of the immediate fiscal
needs.” Another participant added, “There should be a balance. The social-emotional
needs should be just as important as the other needs.” Schools must be a place for
learning, but also a place where students are taken care of, both physically and
mentally.
System Failures
A final concern that was discussed in the forum was the overall failure of the school
system, specifically dealing with traditional school structure, including class size
and environment. Although many of the participants agreed on the problem, they
offered various solutions. One participant believed a simple solution is smaller class
sizes, explaining, “Smaller class sizes would allow teachers to build individualized
instruction and provide needs for students who may need a smaller class environ-
ment to better learn. That would allow the teacher to better address the needs of
students.” Another participant thought the size of the class was not the problem, but
instead thought the setting to be the biggest issue. This participant’s solution was to
create an alternate learning environment:
If we could do a setting … like Apex online learning [program]… where they come to the
school, so they have the social setting but cut down the area where they feel the anxiety of
being forced to move 4-5 times a day with 30 kids in a classroom. We could see graduation
rates go up and dropout rates decrease…
Similarly, another participant recommended a “… program for kids that tradi-

tional settings do not meet their needs, so they are allowed to go to a different site…
instead of a traditional school setting…” Taking students’ needs into account when
structuring the school day may be a way to improve learning for students who may
have difficulties in a traditional school setting.
Here, we summarize recommendations for improving the quality of

SBH. Recommendations follow from those of participants in the focus group, and
research/literature that was reviewed.
Recommendations by the Participants Among focus group participants, next
steps focused on proper training of individuals who are delivering services and com-
munication between key stakeholders involved in SBH. One participant described
one of the most important factors for building high-quality SBH:
Coming out of schools that I worked in, the factor of the ability of the folks who have been
to school and all these different groups to get out of their silo and to communicate with each
other. If they are not able to do that, I don’t care how high quality a program is, it will not
be as effective as it could be until there is communication across different groups within
a school.
Another participant highlighted the need for use of data to improve the quality of
SBH services: “Training. They have to have a team that’s responsible and those
people are trained in collecting data and understanding and knowing what do with
it when they see it.”
Recommendations from Previous Research Research documents that well-done
SBH improves access to care, reduces stigma regarding seeking treatment, and
increases training opportunities due to targeted responsibilities of clinicians work-
ing in schools (Connors et al., 2018). However, organizational factors and attitudes
toward SBH services can present complex challenges to implementation (Connors
et al., 2018). There are several recommendations in the literature to promote high-
quality SBH services through the use of EBPs. Examples of these recommendations
include assessing clinicians’ attitudes regarding the use EBPs, effectively using
interdisciplinary teams, and finding cost-effective strategies for building capacity
for mental health services (Eiraldi et al., 2015). Inexperienced clinicians may lack
therapeutic competencies, while more experienced providers may not be willing to
change their existing practices (Eiraldi et al., 2015). This suggests that assessing
attitudes to EBPs, promoting a culture of lifelong learning, and providing ongoing
training and technical support for clinicians implementing EBPs are important strat-
egies to combat this barrier.
Considering interdisciplinary teams, under-resourced schools may experience
barriers related to staff allocation, level of expertise, and turnover (Eiraldi et al.,
2015). All of these factors affect the cost of services, which could be decreased by
providing periodic booster training to sustain implementation efforts and reduce
turnover (Eiraldi et al. 2015). Improvements in cost-effectiveness could be facili-
tated by requiring fiscal transparency from public school districts, with states mak-
ing budgets easier to locate and understand (Hardin, 2016). Additionally, findings
suggest that school administrators’ knowledge of mental health services should be
enhanced (Iachini et al., 2015; O’Malley, Wendt, & Pate, 2018). Administrator
knowledge of collaborative decision-making structures, partnership development,
and resource allocation can maximize the role of mental health professionals in the
school and reduce barriers to their effective provision of services (Iachini et al., 2015).
A simple solution for facilitating collaboration between all parties would be to
provide parents with the agenda of the meeting beforehand to allow the opportunity
for them to prepare (Wilson, 2015). Parents often go into school meetings unaware
of the agenda, so a provisional itinerary or having the parents complete a pre-
meeting questionnaire could increase the effectiveness and efficiency of the meeting
(Wilson, 2015). Research has demonstrated that parental involvement leads to better
student outcomes and, therefore, healthy communication with parents is essential
for collaboration success (Wilson, 2015). Support for this parental involvement in
SBH programming should be a part of the larger infrastructure in schools and dis-
tricts focused on effective training, coaching, and ongoing support for SBH clini-
cians and educators to help to assure the highest quality programming within the
multitiered system of support (Eiraldi et al., 2015; Weist et al., 2007).
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Enhancing Implementation Support
for Effective School Behavioral Health
Samantha N. Hartley and Carissa Orlando
Studies have shown that one in five youth will experience a mental health disorder;
however, many will not receive treatment (Merikangas et al., 2010). A variety of
barriers contribute to treatment engagement and retention including personal barri-
ers to seeking help. These include perceived stigma and embarrassment, poor men-
tal health literacy, and a preference for self-reliance (Gulliver, Griffiths, &
Christensen, 2010), situational barriers that complicate treatment engagement (e.g.,
lack of resources, logistical barriers; Prinz & Miller, 1994), and structural barriers
to receiving quality care (e.g., lack of coordination between youth-serving systems,
lack of reimbursement for prevention; Baker-Ericzén, Jenkins, & Haine-Schlagel,
2013; Bringewatt & Gershoff, 2010). These barriers should be considered and
addressed to assure the effectiveness of school behavioral health (SBH) programs.
Providing youth with mental health services within schools can be challenging
(Anderson & Lowen, 2010). While school mental health programs yield evidence of
positive outcomes for youth and schools alike (e.g., Atkins et al., 2006; Catron,
Harris, & Weiss, 1998; Center for School Mental Health, 2013), an essential first
step to providing these services is to successfully integrate the programs into the
school setting. Researchers, mental health professionals, and school staff are often
faced with the challenge of successful implementation. High-quality implementa-
tion of a program is often just as important as the evidence base surrounding the
program (Durlak & DuPre, 2008).
Reviews of SBH programs have found that implementation is consistently one of
the most critical factors affecting program outcomes with quality implementation
linked to more significant program benefits for the individuals served (Durlak &
DuPre, 2008). Before schools can expect students to benefit from evidence-based
programs, high-quality implementation of the program must be achieved. Frequently,
barriers exist in school systems that impede quality implementation (Langley,
S. N. Hartley (*) · C. Orlando

e-mail: Snh1@email.sc.edu

https://doi.org/10.1007/978-3-030-56112-3_6
60 S. N. Hartley and C. Orlando
Nadeem, Kataoka, Stein, & Jaycox, 2010) (Atkins, Frazier, Adil, & Talbott, 2003).
Exploring and understanding these barriers and developing support for successful
implementation is crucial to improving outcomes for students. Staff capacity, com-
munity partnerships, interdisciplinary collaboration, and data sharing between
child-serving entities have been identified as critical themes for successful SBH
implementation, with these themes reviewed in the following.
Staff Capacity
Staff capacity reflects both general and intervention-specific abilities (Flaspohler,

Duffy, Wandersman, Stillman, & Maras, 2008). Individual-level staff capacity may
be understood as the skills, education, and expertise required for an individual to
successfully function in their professional role. Intervention-specific capacities may
include possessing an adequate understanding and knowledge of the intervention,
motivation/buy-in for implementing the intervention, and perceiving oneself as
capable of delivering the intervention successfully (Flaspohler et al., 2008; Scaccia
et al., 2015). Promoting school staff capacity to implement evidence-based mental
health interventions requires both training and organizational support for delivering
the intervention as intended. Schools interested in delivering a new intervention
should seek high-quality training and ongoing coaching to build a sufficient under-
standing of the intervention, troubleshoot implementation challenges as they occur,
and promote fidelity (Forman, Olin, Hoagwood, Crowe, & Saka, 2009).
Interventions delivered by teachers or other non-specialist school staff may
require additional training and support, as many teachers feel that they lack suffi-
cient education and experience to support their students’ mental health needs
(Reinke, Stormont, Herman, Puri, & Goel, 2011). Even when delivered well, train-
ing alone does not guarantee staff capacity to implement an intervention. Contrary
to the belief that implementation will succeed with enough staff training, one of the
more prominent barriers cited by clinicians in school settings is competing respon-
sibilities. For example, in a study of a trauma-focused group protocol delivered in
schools, insufficient time to deliver the intervention was identified as the strongest
impediment to program implementation by unsuccessful implementers. Even those
experiencing success named competing responsibilities as the second most frequent
challenge (Langley et al., 2010). Limited time for the intervention in the school day
and competing priorities are also cited as barriers to implementation in schools by
developers of evidence-based interventions (Forman et al., 2009). It is essential for
administrators striving to make SBH a priority to address these issues and poten-
tially realign staff responsibilities to allow quality delivery of interventions by
teachers and other non-clinical staff. (Fixsen, Naoom, Blasé, Friedman, &
Wallace, 2005).
Enhancing Implementation Support for Effective School Behavioral Health 61
Community Partnerships
Community partnerships improve the effectiveness of SBH (see Lehman, Clark,

Bullis, Rinkin, & Castellanos, 2002). These partnerships also have the potential to
improve a school’s capacity to inform, monitor, and address student mental health
concerns, both individually and at a population-level (Dowdy, Ritchey, & Kamphaus,
2010). Partnering with community-based agencies enhances schools’ abilities to
provide their students with access to mental health services (Weist, Grady Ambrose,
& Lewis, 2006). Frameworks for mental health service delivery, such as systems-of-
care, can help schools and community agencies develop the infrastructure needed to
support students with a wide variety of mental health needs (Powers, Webber, &
Bower, 2011). Under a systems-of-care model, schools and community partners
coordinate care for students in a manner that is strength-based, family-driven, cul-
turally competent, and individualized (Smith, Anderson, & Abell, 2008). Investing
in developing strong collaborative relationships between schools and community
resources can help overcome barriers to quality implementation of evidence-based
practices in schools.
Partnerships between schools and community resources, including universities,
can promote quality implementation. Conducting research relevant to schools, sup-
porting the development of school district organizational capacity, creating plat-
forms for ongoing knowledge exchange, and promoting the use of local data and
evaluation to support evidence-based decision-making about SBH are just a few of
the ways these collaborations can enhance success in delivery of interventions
(Short, Weist, Manion, & Evans, 2012). Although sustaining community–school
partnerships requires strong leadership and a commitment to consistent communi-
cation, collaboration, and coordination (Anderson-Butcher, Stetler, & Midle, 2006),
these partnerships are an important tool for increasing school and community abili-
ties to promote the mental health and well-being of their students.
Interdisciplinary Collaboration
Collaboration between SBH personnel, school faculty/staff, other youth-serving

professionals, and families is foundational to effective implementation (Weist et al.,
2005). Collaborative processes, such as shared decision-making between relevant
parties, coordination and partnerships across agencies, and communication between
all partners are factors that positively impact successful implementation (Durlak &
DuPre, 2008). These interdisciplinary collaborations have the potential to increase
productivity, improve outcomes for students receiving services, decrease the risk of
duplicative or disjointed services (which may, in turn, decrease the financial burden
of services), and raise satisfaction with mental health services (Anderson-Butcher
& Ashton, 2004; Lever et al., 2003; Rappaport, Osher, Greenberg Garrison,
Anderson-Ketchmark, & Dwyer, 2003; Weist, Proescher, Prodente, Ambrose, &

Waxman, 2001).
Forming interdisciplinary teams can be an excellent way to facilitate collabora-
tion and effective provision of school-based services. These teams should include
not only school mental health personnel, but also school staff members (e.g., school
counselors, social workers, nurses, resources officers, etc.), school administration,
community partners and providers, as well as representative family members
(Anderson-Butcher & Ashton, 2004; Barrett, Eber, & Weist, 2013; Waxman, Weist,
& Benson, 1999). These school teams can work together to ensure that school-based
interventions are implemented appropriately through activities such as goal-setting,
determining intervention delivery methods, coordinating on the identification of
additional resources, progress-monitoring, and coordinating responses to any issues
that arise (Anderson-Butcher & Ashton, 2004; Waxman et al., 1999).
Information/Data Sharing
A natural benefit of collaboration is the ease of information and data sharing

between youth-serving entities (e.g., between school-based clinicians and commu-
nity care, such as physicians or psychiatrists). It can often be difficult to share infor-
mation across agencies due to client protection laws, such as the Health Insurance
Portability and Accountability Act (HIPAA) and Family Educational Rights and
Privacy Act (FERPA), as well as the ethical boundaries of client confidentiality to
which licensed mental health providers must adhere. However, with proper permis-
sion obtained from parents/caregivers, as well as the student when appropriate,
regular communication and sharing of pertinent information related to students’
needs and treatment can facilitate them receiving quality care across systems
(Waxman et al., 1999; Weist et al., 2001). Although some mental health profession-
als may adopt an “expert” model when sharing or obtaining information, this hier-
archical perspective may hinder assessment and treatment processes. Rather,
information-sharing is best conducted through an egalitarian perspective, where
each partner is recognized for the unique and helpful knowledge they possess
(Rappaport et al., 2003; Weist et al., 2001). Regular information gathering and shar-
ing with a student’s parent/caregiver can also be a helpful component of treatment,
as parents can serve as helpful collaborators and possess vital information regarding
their child’s symptoms and behavior (Becker, Buckingham, & Brand, 2015).
Method
Eleven stakeholders, including three parents, three researchers, two university staff,
two teachers, and one family advocate, assembled to discuss barriers to and ways to
improve implementation support for evidence-based SBH. The following questions
were presented to participants to guide the discussion on implementation support:
(1) What school behavioral health (SBH) initiatives are your schools currently
implementing?
(2) In your mind, what is the quality of implementation of these programs; for
example, are programs implemented as intended, with consistency, with strong
involvement of school staff and students?
(3) What are the factors that help these programs to be implemented well?
(4) What are the challenges encountered in implementing these programs well?
(5) What recommendations do you have for overcoming these challenges?
(6) How can school, family, mental health, and partnerships with other community
systems help improve the implementation of high quality, evidence-based pro-
grams across the three tiers toward effective and high impact SBH?
(7) What other recommendations do you have?
Results
During the discussion, participants identified a number of themes that either served
as barriers to or facilitators of quality SBH implementation. The questions above
were selected to reflect prominent themes in the literature and helped to serve as a
foundation for this discussion. In this portion of the chapter, we will review the
comments and recommendations of forum participants on these themes.
Staff Capacity
Participants identified insufficient staff capacity as a barrier to quality implementa-

tion of SBH. Insufficient capacity was conceptualized both as a lack of training and
knowledge for existing staff and the inadequate availability of specialized staff to
provide essential services to students. Not having the capacity to address mental
health concerns in schools may disrupt a child’s education. One participant
expressed frustration at being able to identify a child’s mental health needs and the
associated recommended treatment approach but ending up “losing that student for
a year” to residential or home-based services because their school was unable to
provide indicated services.
Addressing insufficient staff capacity may include hiring additional specialized

staff to provide mental health services to students. Existing school staff, such as
school counselors, are often unable to provide those services on top of their other
job responsibilities. Having enough mental health support “available for the kids
when they need it” was identified as being “key” by another participant. To address
the needs of students who require support beyond what a teacher provides in the
classroom, but whose needs do not yet rise to the level of requiring resource-
intensive individualized intervention, some schools have chosen to use their Title I
funds (related to having relatively high levels of disadvantaged students) to hire
behavioral interventionists. When a child is exhibiting behavior-based difficulties in
the classroom, behavioral interventionists intervene early, conduct classroom obser-
vations, and consult with teachers to provide individual strategies for successfully
managing that student’s behavior. Leveraging specialist knowledge at an earlier
stage (i.e., “before it gets to the district support level”) is responsive to the present-
ing need, builds teacher capacity, and demonstrates an effort to keep students within
the least restrictive learning environment.
Participants also emphasized the importance of providing staff with appropriate
training to support student mental health at all levels of need. Participants noted that
recent shifts to a more inclusive mindset promoting the inclusion of children with
disabilities in general education classroom settings have increased requests for
staff-wide training and professional development. Whereas schools in the past may
have “always kind of assumed that the special education teacher was the only one
who needed to have those bag of tricks, that toolbox,” one district-level behavioral
specialist indicated that “schools as a whole – elementary, middle, and high – have
really stepped up to the game in asking for training.” Another participant noted that,
although many teachers, “especially special content teachers at the secondary level,”
may not have a background in behavior, professional development “providing them
with the knowledge to feel confident in understanding behavior and how to inter-
vene” is ‘huge.’” Trainings that allow specialists to consult with teachers through
classroom observation, modeling, and supervised practice of behavioral interven-
tion strategies were viewed as especially meaningful in supporting teachers’ class-
room behavior management capacity. As one group member noted, “you can’t just
hold a meeting and say what you can and can’t do.”
Although the group was generally optimistic about district efforts to provide
training and support to teachers, they expressed frustration with the apparent lack of
quality training demonstrated by mental health clinicians tasked with treating indi-
vidual students. One participant lamented the lack of specialized knowledge evi-
denced in their approach to care, saying, “there’s not requirements for them to have
any training in any particular area, and they are dealing with some of our most dif-
ficult children and it’s not working.”
Community Partnerships
Participants recognized that creating connections between schools and community

mental health resources was an essential step for facilitating appropriate referrals
and ensuring that students receive appropriate specialist care. However, the strength
and nature of school-community partnerships varied extensively across sites.
Although some schools had a general awareness of the existence of community-
based resources, specific knowledge necessary for making student referrals was
often unavailable. As one participant reflected, “We knew there were a lot of differ-
ent agencies out in the community, but to know who did what and the scope of their
expertise was lacking.”
Other districts demonstrated stronger partnerships with community mental
health agencies, including contracts with them to provide school- and home-based
clinical services to students. These partnerships have allowed them not only to pro-
vide access to care “as crises arrive,” but to offer proactive services such as a
monthly preschool parenting class “to help…our parents to work with early onsite
behaviors that we are seeing and that the parents are seeing in the homes.” When
student mental health needs cannot be met with school-based services, strong part-
nerships between school districts and residential treatment programs can help
decrease the time students spend out of school and facilitate a smoother transition
back into the school community that empowers students and their parents. One
participant described the success of this partnership despite obstacles, stating
A lot of families are having to drive to us from an hour or more away… but we have 100%
participation of family in our action, they come in once a week for family therapy… they
are going out with their families on the weekends, it is hard but they do it anyways.
Interdisciplinary Collaboration
One of the themes discussed by forum participants was the importance of interdis-
ciplinary collaboration in effectively meeting the needs of youth. Participants dis-
cussed the benefits of multiple professionals (e.g., mental health professionals,
teachers, behavior specialists, physicians) caring for the child, sharing information,
and working together to treat the child. One participant noted,
The cases in which we’ve made the biggest difference in students are the cases in which the
district support, behavioral specialist, and instructional support specialist and other support
people have actually gone to doctors’ appointments and gone with them to a therapist and
gone with the parents and have had that open round table discussion.
This participant also stressed that this collaboration should begin as early as pos-
sible rather than
“waiting ‘till we are all in crisis, because first we need to get through the crisis before we
can start working with the child.” It was discussed that collaboration should entail a partner-
ship between agencies, with an assumption of equal status between members and a
r ecognition of each member as an expert in their own domain, with one participant explain-
ing, “We need to understand each other’s worlds and have mutual respect.”
Participants also stressed the importance of conceptualizing the parent as the

“expert” on their child and forming a partnership with the parent, regardless of the
students’ walk of life. One participant noted, “There is nothing like sitting at a table
with everyone and having that open conversation with the parents there about the
child’s whole plan… I wish we were able to do more of that.” A parent participant
shared an appreciation for an inclusion in the team-based collaboration of transi-
tioning their child back into the public school system, stating that
Their therapist from the children’s program actually came to a meeting with [school admin-
istrator] … and told the teachers and his school what worked for him and what they could
do to make the transition more successful….They didn’t leave me to go into the school to
say this is what they say and this is what works.
Data Sharing
This collaboration between interdisciplinary professionals also facilitates informa-

tion sharing regarding care for the child, which was another theme discussed by
forum participants. One medical professional discussed the benefits of being able to
receive information about a child’s school functioning, stating, “There’s a flow [of
information] that happens, so if I am starting a kid on a stimulant, I’m able to get
feedback very quickly on what is working in the classroom and what is not.” Another
participant stressed the importance of this ease of information sharing, noting, “you
want schools to feel comfortable and to get a response from the psychologist, psy-
chiatrist as quickly as possible so that they don’t do anything that would undermine
treatment.” This ease of sharing of information can allow professionals to commu-
nicate directly to each other rather than relying on the parent to act as a “mediator”
between different systems, which one participant pointed out can be “so overwhelm-
ing for them.”
While participants agreed that this collaboration and sharing of information is
essential, it was noted that it can be difficult to achieve due to a variety of barriers.
Indeed, from the perspective of an individual working outside of the school, profes-
sionals working with children often operate in silos, making it very difficult to
access information about the child’s functioning in school. This participant
explained,
I can look at anything, pediatrician records…therapy records from a mental health center,
but I have no clue what goes on in school, because getting that data back is next to impos-
sible, because you never have a conversation with a teacher, never have a conversation with
a counselor from the school. So there has to be some way to figure out how to connect what
is happening in the school settings to what is actually happening in the medical settings or
any other settings in general.
This participant noted that this lack of collaboration results in “two incomplete
sets of plans that sit on each side of the kid.” Several other participants noted that
currently, it can be difficult to access records from various professionals. As pre-
sented earlier, some of these difficulties with information sharing come from legal
parameters surrounding sharing of information, such as HIPAA and FERPA. A par-
ticipant noted that “with teachers sometimes…it is like, ‘how much do I share, how
much do I not share?’” and “‘what is my liability, if I say it?”
Additionally, participants pointed out that parameters surrounding information
sharing vary by school; one participant noted, “some schools are forthcoming and
others are, ‘We can’t send that over the Internet.’” Parameters surrounding informa-
tion sharing also may vary by type of school (e.g., public schools versus charter
schools). Another participant stated that when working in a charter school, “I’m
able to access whatever I need to access, I’m able to look at it and share the informa-
tion back and forth,” noting that charter schools “are smaller and there are different
rules, but you are really able to be in a partnership, whereas with a public school it
is much more difficult to develop that partnership.” This participant suggested that
this difficulty may be due to “a much larger bureaucracy and you are not sure who
you are interacting with and so there is not a built-in information flow that is going
back and forth at any level.”
For individuals working within the school, time constraints were noted as a bar-
rier to interdisciplinary collaboration, as well as sustainability of collaboration. For
example, one participant noted the benefits of mental health staff and teachers work-
ing together to implement indicated behavioral interventions, but noted “these kinds
of things don’t happen on a 30-minute schedule.” Lack of awareness was also noted
as an additional barrier; another participant explained that, “we knew there were a
lot of different agencies out in the community but to know who did what and the
scope of their expertise was lacking.” This participant went on to explain that their
position was created to address this lack of collaboration.
Participants had a few suggestions for improving the implementation of quality

SBH practices. For schools implementing a multitiered system of support (MTSS)
and instituting more inclusive educational practices, participants felt it necessary for
administrators to support training for teachers to be skilled agents at prevention and
promotion-oriented universal classroom interventions. By conducting intensive all-
staff training, working on specific behavior management strategies with individual
teachers, and consistently setting and teaching positive expectations to students, one
behavior specialist was optimistic that many of the behaviors that may have once led
to more resource-intensive intervention referrals could be prevented. This individ-
ual noted,
We’re really starting to see a change in mindset there; opening the doors for us to do inten-
sive trainings with teachers as a whole and with individual teachers really working on
behavior management at the very front, and setting positive expectations and teaching those
expectations to prevent behaviors from reaching tier 2 or tier 3.
Quality implementation of SBH interventions takes time. Without hiring addi-

tional staff, reallocation of existing staff time and responsibilities is imperative to
allow for meaningful engagement in delivery and coordination of quality SBH. One
participant spoke to the importance of school leadership in facilitating this realloca-
tion, saying that her school’s Director of Counseling “has actually done a huge push
for our counselors to not be in charge of testing and other things, so our school-
based counselors are now part of our tiered level of support.” Facilitating the mean-
ingful and significant involvement of school counselors in MTSS “starts at the top.
The top-down needs to say that this is a priority.” As a result of this prioritization,
these school-based counselors were able to overcome barriers to mental health ser-
vice access (e.g., part-time, itinerant staff, insurance challenges) and provide stu-
dents with a continuum of mental health supports (see Owens et al., 2002). At this
participant’s school, this included creating a role for school counselors in teaching
coping skills and mental health literacy in the classroom (Tier I), conducting small
groups for anger management (Tier 2), and providing counseling to students who
have been identified as needing individualized services but do not qualify for special
education services (Tier 3).
To address the issue of a lack of awareness of community-based mental health
resources, one school-sponsored an “agency fair” for all teachers to attend.
Reflecting on the experience, this participant felt that “it opened up the door to all
the different agencies and supports within our community that are offered and that
our teachers weren’t aware of…and equipping our teachers with that knowledge.”
Although parents were not invited to attend last year’s agency fair, the district is
considering coordinating a similar resource fair for parents who “are saying that
they need help, to be pointed in the right direction.”
After addressing the initial step of increasing awareness of what resources exist
in their community, schools, and community agencies are coming together through
memorandums of agreement to improve access by allowing services to be provided
in schools. Although the initial establishment of district-community partnerships
through these documents may require the involvement of the entities’ legal depart-
ments, access after this point “is not an issue because of the written legal document
between the two,” according to one participant.
The Importance of Partnerships
A major theme discussed by participants was creating partnerships with community

and state organizations, which has been found to improve the implementation of
effective services for children and youth (Nastasi, 2000; Power, 2003). One partici-
pant discussed the partnerships formed between several school districts and the
local mental health centers, which enabled clinicians from the mental health centers
to work with students in the schools.
The participants agreed that although there are a few outstanding examples, there
is no wide-scale adoption of effective partnerships between families, schools, and
other youth-serving systems. While some of the programs that participants dis-
cussed seemed to be helpful, a number of barriers (e.g., stigma, transportation prob-
lems, insurance issues) hinder the reach of these programs (see Cummings, Lucas,
& Druss, 2013; Ouellette, Briscoe, & Tyson, 2004). One participant brought up that
some families must drive up to an hour to access programs for their children.
Additionally, the participants said that teachers and school administrators are not
aware of the programs available to schools or families, which precludes any poten-
tial partnership from forming. According to one participant, a district has attempted
to solve this problem by hiring an individual to connect and coordinate all available
services with the schools.
Need to Enhance Communication
Participants identified a lack of communication between schools, caregivers, and

youth behavioral and physical health care providers as a significant major challenge
to effective early intervention and treatment. Specifically, the participants thought
that being able to share information across caregivers and providers would improve
the coordination of services and, in turn, the support students receive. In addition to
enhancing support, this collaborative method of support could foster a greater sense
of collaboration and mutual respect among school and community members
involved in the child’s life. This method of treatment coordination would then keep
the responsibility of communicating a child’s needs and treatment between doctor,
clinician, and school from resting solely on the parents’ shoulders. Although there
are legal hurdles to a system of collaborative care (such as communication restric-
tions associated with FERPA), one of the participants cited a charter school that has
partnered with a local hospital system to establish a flow of information between the
school, the hospital, and clinicians involved in SBH services.
Addressing Insurance Challenges
Participants recognized insurance problems as another major barrier to students

accessing appropriate services. One district that has addressed a structural barrier by
having mental health clinicians deliver services in the schools still deals with the
challenge of costs as uninsured students cannot receive services. In an extreme case,
one participant noted that an uninsured student with more severe emotional/behav-
ioral concerns was sent to a residential treatment center because it was the only way
of receiving affordable treatment. One school was able to address the cost barrier by
acquiring social and fiscal support from the director of counseling at the local
Department of Mental Health, who was able to allocate some funding for treatment
for uninsured students.
Helping Families Find Help
Participants also discussed that parents want help to understand their children’s
behavioral health issues, but they often do not know where they can go to receive
that help. One school has created a parent academy that focuses on helping parents
understand their role in the treatment process and as an advocate for their child.
Another school held an agency fair for parents to learn about programs and services
available for their families. Some of the participants felt that general education
teachers are not receiving enough training in integrating special education students
into standard classrooms, as many schools are moving toward more inclusive class-
rooms. This lack of training is of particular importance as some evidence suggests
that without some training on interacting with students with disabilities, teachers
can focus on the disability rather than the student (Carroll, Forlin, & Jobling, 2003).
Increasing Implementation Supports
Participants had a few suggestions for moving forward with implementation support
in schools. First, schools should make resources about programs and services read-
ily available to families and teachers. Second, partnerships between behavioral
health care providers and schools should be emphasized to coordinate services for
students. Third, more teachers should be trained in understanding adverse child-
hood experiences, with this helping to increase empathy for student situations, and
enthusiasm for implementing effective programs to help them. Finally, team meet-
ings should be interdisciplinary when developing treatment plans for students as
participants have noticed the greatest impacts for students needing intensive inter-
ventions occur when all individuals involved in the student’s treatment come
together to discuss a comprehensive treatment plan.
Conclusion
The perspectives of the stakeholders present for this forum were unique and valu-
able, underscoring the consequences of insufficient capacity and coordination for
high-quality implementation of SBH. Based on findings from this forum, an impor-
tant direction going forward would be to solicit feedback from school-based inter-
disciplinary teams responsible for implementing MTSS on their recommendations
for improving implementation. Speaking with individuals who have direct experi-
ence with implementation will allow us to better understand the current level of
implementation at each tier as well as challenges and facilitators to quality imple-
mentation, and ideas for improved implementation support, training, and technical
assistance. These conversations would have the potential to inform implementation
support that is ideally connected from the school building to district and state levels,
ultimately improving the quality, reach, and impact of school behavioral health.
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Youth with Connections to the Juvenile
Justice System: A Priority Population
for School Behavioral Health
Linden Atelsek and Alex M. Roberts
More than 50,000 juveniles were incarcerated in the United States in 2014, making
juvenile justice involvement disproportionately likely for youth in the United States
compared to other countries (Petteruti & Fenster, 2011; Puzzanchera, Hockenberry,
Sladky, & Kang, 2018). The juvenile justice system originally separated from the
rest of the justice system due to the notion that children are more “redeemable” than
adults and should thus be treated with rehabilitation in mind (American Bar
Association, 2007). However, the past 40 years have seen a return to a retributive
form of justice (Advancement Project, 2010; American Bar Association, 2007). The
juvenile justice system is regarded as having a more punitive mindset, compared to
education and mental health professionals working with juvenile offenders, who
typically view delinquency as a treatable condition (Kapp, Petr, Robbins, &
Choi, 2013).
Juvenile justice involvement is inextricably linked to behavioral health (BH).
Studies show that the majority of juvenile justice-involved youth (JJIY) experience
mental health challenges, often depression and anxiety (Abram, Teplin, McClelland,
& Dulcan, 2003; Burke, Mulvey, & Schubert, 2015; Skowyra & Cocozza, 2006;
Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). Despite this, JJIY rarely
access mental health services (Burke et al., 2015). This is important given the find-
ing that mental health support in childhood (e.g., school- or community-based ser-
vices, inpatient and/or outpatient treatment) may protect against juvenile
incarceration in at-risk youth (Burke et al., 2015; Liebenberg & Ungar, 2014).
Additionally, youth’s ability to access mental health services decreases after they
become involved with the justice system: only one-fourth of juvenile justice facili-
ties screen for suicide risk, and fewer than half screen for general mental health
L. Atelsek (*)
University of Virginia School of Law, Charlottesville, VA, USA
A. M. Roberts
Psychology Department, University of North Carolina, Chapel Hill, NC, USA
e-mail: alexmr@email.sc.edu

https://doi.org/10.1007/978-3-030-56112-3_7
76 L. Atelsek and A. M. Roberts
needs. Further, 90% of JJIY reside in facilities with no mental health professionals
(McPherson & Sedlak, 2010).
Justice involvement has profound short- and long-term effects on youth. Short-
term effects include decreases in overall educational attainment, partially due to
reduced rates of high school graduation (Sweeten, 2006; Tanner, Davies, & O’Grady,
1999). Even juveniles who are motivated to return to school after their incarceration
may face unexpected barriers. For example, school administrators are often sys-
temically motivated to block the reentry of juvenile offenders into the mainstream
school system, as these youth tend to display problem behavior and may decrease
the school’s average level of academic achievement (Mayer, 2005). Additionally,
JJIY are often primed to re-offend because of negative peer influences during incar-
ceration (Mathys, Hyde, Shaw, & Born, 2013; Shapiro, Smith, Malone, &
Collaro, 2010).
Recent evidence suggests that juvenile justice involvement also has long-term
effects on youth in multiple domains. Early incarceration is linked with poor mental
and physical health later in life (Barnert et al., 2017), and arrest before age 18 pre-
dicts felony conviction by 26 (Ou & Reynolds, 2010). Even those JJIY who manage
to escape the cycle of recidivism face significant life challenges throughout adult-
hood, as justice involvement in childhood predicts greater difficulty gaining and
maintaining employment in adulthood (van der Geest, Bijleveld, Blokland, &
Nagin, 2016). Research suggests the existence of a vicious cycle: early arrest leads
to school dropout, which leads to lower occupational attainment, ultimately result-
ing in higher rates of arrest in adulthood (Kirk & Sampson, 2013).
All JJIY do not experience these negative effects equally. Poor and non-White
students bear the brunt of punitive school policies, likely contributing to the finding
that non-White students report feeling less safe in school than do White students
(Lacoe, 2015; Mallett, 2016). Regarding sentencing for juvenile offenses, White
youth are more likely to be assigned to therapeutic programs, while Black youth are
more likely to be assigned to physical labor programs (Cochran & Mears, 2015;
Fader, Kurlychek, & Morgan, 2014; Lehmann, Chiricos, & Bales, 2017).
Additionally, Black youth receive fewer resources while in the juvenile justice sys-
tem and are more likely to be placed in high-security facilities (Cochran & Mears,
2015). Black ex-juvenile offenders are more likely to be unemployed than other
adults who were not justice-involved in their youth; they also receive lower wages
if they are employed—a trend that does not exist for White or Hispanic ex-juvenile
offenders (Taylor, 2016; van der Geest et al., 2016).
Gender and sexual orientation also play a role in juvenile justice involvement.
Although females are less likely to be sentenced to prison than males, they are sig-
nificantly more likely to be held in an alternative residential facility than to be put
on probation or in other “outpatient” programs (Tam, Abrams, Freisthler, & Ryan,
2016). Females who are imprisoned are typically sentenced to longer periods of
confinement, particularly for status offenses (i.e., truancy, curfew violations;
Espinosa & Sorensen, 2016). Nearly 40% of incarcerated female JJIY identify as
lesbian or bisexual (Wilson et al., 2017). This is in addition to the overrepresenta-
tion of sexual minority youth in the entire JJIY population, with approximately 12%
Youth with Connections to the Juvenile Justice System: A Priority Population for School… 77
of juvenile offenders identifying as sexual minorities (Wilson et al., 2017). Youth

who identify as sexual minorities are disproportionately subject to punishment in
schools compared to non-sexual minority peers; they are also more vulnerable to
exclusionary discipline like suspension and expulsion, which may increase overall
dropout rate and lead to initial offense and re-offense (Fabelo et al., 2011; Poteat,
Scheer, & Chong, 2016).
Schools play an integral part in the “school-to-prison pipeline,” which refers to
the connection between school discipline, education policy, and juvenile justice
involvement. Rates of in-school arrests are rising (in Pennsylvania, they recently
tripled over a seven-year period), along with a 300% increase in police presence in
schools (Advancement Project, 2010; Mallett, 2016). Despite this, students do not
report feeling safer when police are present (Advancement Project, 2010). In fact,
police presence may result in educational disruption, as students are temporarily or
permanently removed from the classroom for minor misbehavior (Mallett, 2016).
Students who are given in-school suspension are nearly five times more likely to
drop out of school than other students (Cholewa, Hull, Babcock, & Smith, 2017);
school suspension of any kind is directly related to dropout, grade retention, and
failure to graduate and inversely related to academic achievement (Fabelo et al.,
2011; Noltemeyer, Ward, & Mcloughlin, 2015). A relationship also exists between
school suspension and juvenile justice involvement, as students who receive sus-
pensions are up to three times more likely to engage with the juvenile justice system
in the year following their suspension (Fabelo et al., 2011).
Method
A guided panel discussion on JJIY was conducted to assess a range of stakeholder

opinions with the following objectives: (1) to better understand youth paths to and
through the juvenile justice system and (2) to identify interventions effective in
mitigating the negative effects of youth incarceration. The panel consisted of 16
people: 7 representatives from state agencies (two from juvenile justice), 5 individu-
als from a mental health center, 2 individuals involved with foster care (one a foster
parent), 1 university staff member, and 1 school district leader. The discussion
included the unique needs of JJIY, weaknesses in the juvenile justice and education
systems, and how to better serve the students who interact with each system. The
following questions were used to help guide the discussion:
1. What are the unique emotional and behavioral needs of youth with connections
to juvenile justice?
2. How well are those needs being met?
3. Are you aware of school-based programs or initiatives focused on improving
emotional and behavioral functioning for youth with juvenile justice connec-
tions? Please describe these programs. Would any be considered exemplary?
How could we share innovative practices from these sites?
4. What are the existing infrastructure or organizational supports for this work?
How can this be strengthened?
5. What has limited family involvement in guiding school-based programs for
youth with juvenile justice connections, and how can these limiting factors be
changed?
6. Do you think it would be worthwhile to establish a statewide leadership team
that would help to guide and coordinate training and implementation support for
school BH programs for youth with juvenile justice connections?
7. How can we increase outreach and involvement with policy leaders from cor-
rectional systems to explore mechanisms to advance school BH programs for
incarcerated youth?
8. How can departments of juvenile justice, mental health, social services, educa-
tion, and other youth-serving systems work better to develop and improve school
BH programs for youth with juvenile justice connections?
9. What other recommendations do you have?
Per methods described in the introductory chapter, the forum was recorded and
transcribed. Following transcription of the forum, the discussion was analyzed qual-
itatively. Six major themes emerged, which are described below.
Results
Risk Factors
Problems
Participants noted several risk factors that might predict justice involvement or mis-
behavior in classrooms that may lead to suspension. The two most frequently cited
risk factors were mental health issues and difficulty learning. One participant said,
“We also see a lot of kids with some depression that manifests itself in aggressive
behaviors without a form of treatment… those are the top ones we get. The trauma,
the depression, the ADHD (attention deficit/hyperactivity disorder).”
Research indicates that untreated mental health issues are one major factor pre-
dicting juvenile justice interaction, even when oppositional behavior is not consid-
ered. Specifically, 41.7% of JJIY meet diagnostic criteria for ADHD, and between
10 and 20% meet diagnostic criteria for major depression (Abram et al., 2003;
Teplin et al., 2002). However, participants demonstrated particular concern about
student trauma, with one participant stating, “So many of these youth do have
trauma in their history. A history of adversity that is somewhat unique, maybe not
so much in what they encounter, but in the intensity or frequency of those traumas.”
As many as 93% of JJIY experience some form of trauma before entering the
juvenile justice system, which can lead to increased aggression via a learned inabil-
ity to self-regulate the threat response (Ford, Chapman, Connor, & Cruise, 2012;
Rosenberg et al., 2014). Specifically, JJIY average 14.6 separate traumas per youth,
three-quarters of which are violent trauma, such as being physically assaulted by a

family member or forced into a sexual situation (Rosenberg et al., 2014). Seventy
percent of JJIY report at least one type of family dysfunction in their past (Logan-
Greene, Tennyson, Nurius, & Borja, 2017). This unique history of adversity may
contribute to the development of maladaptive coping mechanisms in these youth.
This may contribute to risky behavior, as one participant stated:
Another thing is, many of them self-medicate. So, when you think about drugs, whether it’s
alcohol or marijuana, cocaine… many times those are the students who really need mental
health assistance. Many of those students should be taking medication for ADHD… but
somewhere from the social point of things, from the parental standpoint, the society stand-
point, they’re not getting what they need… Sometimes they’ll say, ‘Well, I took marijuana,
I smoke before school. I know I shouldn’t, but that calms me down; I can do my work; I can
take my test.’
Indeed, around half of JJIY meet the diagnostic criteria for a substance use dis-
order, and between 11 and 14% of incarcerated juveniles meet criteria for a BH
disorder (major depressive, dysthymic, manic, psychotic, panic, anxiety, attention
deficit-hyperactivity, conduct, or oppositional defiant disorder) and a substance use
disorder (Abram et al., 2003; Teplin et al., 2002). The odds of meeting criteria for a
substance use disorder were much higher for youth who did have BH disorders,
compared to those with no BH diagnosis (Abram et al., 2003).
Participants also named a variety of learning difficulties as risk factors for juve-
nile justice involvement, specifically referencing Greene’s (2013) lagging skills
model, which postulates that “kids are challenging because they lack the skills to
not be challenging.” This is a valid concern, as a sample of JJIY with a mean age of
16 was only reading at an eighth-grade level (Baltodano, Harris, & Rutherford, 2005):
Kids who have difficulty reading are going to struggle wherever they are, because so much
of what we do in school is reading-based… If you think about the fact that you can’t read…
what’s being presented, it’s like us being in this room and speaking in French and trying to
figure that out. Like maybe one person had a year’s worth of French and they’re trying to
figure this out and they get exhausted.
Participants noted that this exhaustion often results in mutual frustration between
the student and the teacher. The student is frustrated because they are asked to per-
form tasks they are incapable of; the teacher is frustrated because their students
consistently fall short of expectations. When discussing this issue, participants indi-
cated that this frustration could lead to students acting out in class, potentially
resulting in their removal from the classroom and subsequent placement in either a
special education classroom or, depending on the severity of the behavior, an alter-
native school. Indeed, while youth with disabilities are overrepresented in the juve-
nile justice system, and nearly 40% of those disabilities are learning disabilities
(Quinn, Rutherford, Leone, Osher, & Poirier, 2005), it is important to note that
behavioral problems, and not just academic skills, also hold JJIY back in the class-
room. Regardless, an examination of whether schools are effectively serving youth
with special learning needs is warranted (Quinn et al., 2005). These findings would
contribute to both a better understanding of how learning disabilities in JJIY
contribute to behavioral difficulties (and vice versa) and possible avenues of inter-
vention for these youth.
Participant Recommendations
While it is impossible to eliminate risk factors entirely, there is potential in reducing
their impact on juveniles. For example, educating stakeholders and other profes-
sionals about the identification of untreated mental health conditions may help facil-
itate their treatment in schools via school behavioral health services and ultimately
prevent a student from being removed from the general education environment
(Mallett, 2016). Similarly, in regard to academic difficulties, screening for specific
learning disabilities could increase early and ongoing identification and thus help
ensure students’ academic needs are met. Further, increasing mental health screen-
ings during entry to the juvenile justice system may increase the accessibility and
efficacy of treatment (McPherson & Sedlak, 2010). Lastly, trauma-informed care is
an integral component in effectively addressing the mental health needs of JJIY and
should be considered at all stages of justice involvement (Branson, Baetz, Horwitz,
& Hoagwood, 2017).
Educational Quality
Problems
Participants discussed the quality of education JJIY had received before their inter-
action with the justice system and how that might contribute to their involvement
with the Department of Juvenile Justice (DJJ), with one participant stating, “We are
not servicing them appropriately—we don’t have resources and programming avail-
able to meet their basic needs academically, so I know their emotional needs are not
being met because their academic needs are not being met.” Participants were par-
ticularly concerned about how social skills deficits may contribute to special educa-
tion referrals, as well as how schools meet students’ needs in this domain. One
participant noted that under-resourced school personnel may contribute to poor
social skills development:
I think we don’t have anyone with expertise in the schools around social [skills] – we have
lots of people who are really good at behavior intervention but we don’t have anybody there
with expertise just on the social skills training.
A lack of social skills may manifest as aggression, sometimes resulting in youth

qualifying for special education services for emotional disability (ED; Mallett,
2016). There is a greater likelihood of at-risk youth being suspended or expelled
after they are transferred to a special education classroom (Espelage, Low, Polanin,
& Brown, 2013; Wagner et al., 2006). In many schools, there is no structure in place
to broadly teach social skills; after-school programs, where social skills are often
acquired via increased opportunities for positive peer interactions, often prohibit
enrollment of children with even a history of moderate behavioral problems and are
ultimately inaccessible to families without ample resources (i.e., money, time, trans-
portation; Mahoney, Parente, & Lord, 2007).
Deficits in social skills are not the only thing that may lead to a disturbance in
students’ mainstream education. As one participant noted, school transitions can be
difficult for students:
In elementary school you have pretty much one teacher who is with the kids five hours a
day, five days a week, 180 days a year, for years, and oftentimes that teacher is a second
mom. And then those kids move onto middle school, where they do not have the perma-
nency of the one adult who cares for them, and so they have lost a caring relationship with
an adult who makes a difference in their lives — and the key of having that caring adult, that
one turnaround teacher, that one person who is showing caring, high expectations, and just
coaching all the time, is not there.
Furthermore, participants said that positive and efficacious teaching practices, as

well as effective behavior management strategies, have a profound effect on stu-
dents’ educational experience. As one participant expressed:
Teacher training on behavior is a big missing component. Because the way that students are
referred for special education … if they were with a stronger teacher who had better class-
room management skills, they probably wouldn’t even be in that situation.
This underscores the importance of educating and providing ongoing training to

teachers on the psychological and behavioral needs of youth.
Whether children remain in their mainstream classrooms can significantly influ-
ence their overall school experience. The quality of education provided in non-
mainstream classrooms is not equal to that provided in mainstream classrooms,
which means improper removal from the general education environment can have
negative effects on academic progress (Morgan, Frisco, Farkas, & Hibel, 2010;
Peetsma, Vergeer, Roeleveld, & Karsten, 2001). For example, students in special
education classrooms showed lagging cognitive development compared to peers
with similar special education needs who remained in mainstream classrooms
(Peetsma et al., 2001). Students in non-mainstream classrooms also perform worse
in math and reading than their mainstream counterparts (Morgan et al., 2010).
Research also suggests that social skills development in special education class-
rooms may vary greatly depending on the individual classroom environment and
quality of instruction (Morgan et al., 2010; Peetsma et al., 2001). Regardless, the
academic delay alone is sufficient to make mainstream reentry difficult. One partici-
pant expressed this concern:
Even if a student goes into special ed[ucation] for emotional and behavioral disorders with-
out an academic problem, often after having been removed from general education for so
long, they are very behind academically… As a former special ed[ucation] teacher, they
really weren’t where they needed to be when I got them, maybe even behaviorally, really,
they couldn’t handle going into a general ed[ucation] classroom, because they just didn’t
have the skills.
The importance of reentry into mainstream classrooms is one of academic attain-

ment. Students with emotional disturbances in special education classrooms are
significantly more likely to be retained in a grade than other students, leading to
significant declines in graduation rates (Wagner et al., 2006). This may have long-
term effects, as a participant noted, “We’re looking at the employability… for the
students who have special needs; less than 50% are graduating.”
Schools often do not adequately prepare students to handle their emotions and con-
trol their behavior, and being removed from mainstream classrooms for behavioral
problems is potentially the first step on a child’s path to justice involvement (Mallett,
2016). Participants suggested that one way to improve children’s social-emotional
competence was to implement a social-emotional learning curriculum as a broad
preventative measure, with one participant stating, “I think that’s a major concern,
that the social-emotional learning aspect is not a part of the curriculum here. We
have all these graduation requirements but that’s not in place, for students who need
that social-emotional learning curriculum.” Curricula such as You Can Do It! Early
Childhood Education Program and Second Step: Student Success Through
Prevention have shown promise in reducing children’s aggression and increasing
social skills (Ashdown & Bernard, 2012; Espelage et al., 2013). However, partici-
pants emphasized that these curricula should not be viewed as a panacea.
Extracurricular programs should be made more accessible to youth who may not
have access to transportation or the money to purchase equipment. Particularly for
at-risk youth, attendance in after-school programs can act as a protective factor
(Eisman, Stoddard, Bauermeister, Caldwell, & Zimmerman, 2016). However, youth
who need it most may be least able to participate, so it is important to consider indi-
vidual factors when implementing after-school programs intended to promote social
competency.
While improving social competency and emotional control is one solution to the
problem of students being removed from mainstream classrooms for behavioral
problems, it is also important to educate teachers about how to identify BH prob-
lems. According to teacher interviews, teachers take their responsibilities to identify
and deal with BH needs seriously, but they lack the knowledge and training to do so
(Rothì, Leavey, & Best, 2008). To try to eliminate the possibility that poor class-
room management may cause classroom misbehavior, participants also suggested
that teachers should receive additional training to increase their skills at preventing
disruptive behavior. Classroom management training has been shown to be an effec-
tive behavioral intervention, particularly when the training is intended to increase
the skills of both teachers and students (Korpershoek, Harms, de Boer, van Kuijk, &
Doolaard, 2016).
System Failure
Problems
Some children are simply caught up in an institutional confusion of priorities, noted
one participant:
There’s a fine line between the thinking process of discipline and corrections and education
and the mental aspect. And sometimes there’s some confusion and different people’s phi-
losophies can be different. … Your philosophy has to be the same. If you’re the kind of
person who’s looking at it from more of a discipline, a behavioral, a punishment phase, it’s
going to be different to move to a ‘there’s something else going on here,’ a more mental
health, a social standpoint.
Despite the fact that the juvenile justice system was initially formed to rehabili-
tate children, it is typically viewed as disciplinary, rather than focused on mental
health and/or rehabilitation (American Bar Association, 2007; Kapp et al., 2013).
Participants worried that the higher administration of juvenile justice institutions,
alternative schools, or even mainstream schools dealing with emotional distur-
bances in their students were not sufficiently educated about the mental health needs
of children under their care. One participant stated, “They don’t feel the need is that
important, and they cut in that area before they cut anywhere else … we need to
acknowledge that these needs need to be fulfilled.”
While many administrators rarely, if ever, directly work with juveniles, they are
in charge of a critical piece of the machinery for providing BH care: funding. If
administrators are not properly educated on the BH needs of their students or do not
advocate for BH resources, support for these services diminishes and students with
BH needs suffer:
One of the things is definitely funding… We’ve tried several times, and it took us a couple
of years, to just get a social worker or a psychologist because we didn’t have the funding.
We had the idea of what we wanted the program to look like, we had the idea of what we
wanted them to do for our students, but we didn’t have the funds to do it… we had to cut
teachers and support staff… there’s another need now, because you cut in one area to bring
someone to assist in a different area.
This de-prioritization of mental health and corresponding lack of funds to sup-

port such services leads to another problem: a lack of staff with behavioral training.
Interviews with teachers indicate that they believe behavioral support is necessary
and take their responsibility in this domain seriously; yet, they admit that they do
not have the knowledge to deliver such services and require supplemental education
to do so (Rothì et al., 2008). Forum participants who were teachers said that they
were not equipped to identify behavioral needs and did not know how to provide
students with the resources they needed. Regardless, the major underlying theme of
these problems centers around lack of funding; as one participant shared, this pre-
cludes hiring of trained clinical practitioners:
I think we don’t have anyone with expertise in the schools… we have lots of people who are
really good at behavior intervention, but we don’t have anybody there with expertise on just
the social skills training… I think it’s just that we don’t have the expertise to know what
people who have the skills in counseling would notice and would know what to do… our
fishbowl is limited by not having people there with specialized expertise.
Even when experts are present, they are often overloaded with work (Kapp et al.,
2013). Consequently, burnout and attrition are high (Kapp et al., 2013). One partici-
pant noted that practitioners’ workloads may not even be related to their counseling
expertise: “The counselors are inundated with lots of other things besides
counseling… doing schedules and testing and other things. I think that’s the big-
gest issue.”
It is important that administration and staff who serve JJIY agree on the purpose of
their services. According to participants, a disconnect on whether the juvenile jus-
tice system ought to be punitive or rehabilitative creates confusion and muddies
priorities. They recommended that there be an open discussion to create cohesive
administrative philosophy. One participant suggested that another potential solution
would be sharing leadership between administration, clinical professionals, and
educators: “Oftentimes people at the very top are in their own bubble… if you’re
going to do a leadership team, you need people who are actually on the ground
providing services.”
However, at present, there are certain matters (i.e., funding) that these adminis-
tration members control, and these must be addressed:
Another issue is that, from being on both sides, the administrators – the principals, assistant
principals, superintendents – need to be more educated, more aware of mental health needs.
Because a lot of times they don’t feel the need is that important, and they cut in that area
before they cut anywhere else, so I think that education is important, and we need to
acknowledge that these needs need to be fulfilled so we can be preventive with kids in
the system.
However, because educating administrators on the necessity of BH services is a

daunting and time-consuming task, participants advised that simply seeking out
administrators sympathetic to the need could be a possible stopgap measure. Indeed,
case studies of organizational change in juvenile justice systems have found that a
cooperative administration is vital to successful reform (Elwyn, Esaki, & Smith,
2017; Rocque, Welsh, Greenwood, & King, 2014). As such, it is possible and some-
times necessary to bypass administration and educate legislators and other govern-
ment officials who are in a position to provide funding (Rocque et al., 2014).
Continuum of Care
Problems
Participants identified several ways JJIY fall through the cracks of the system and
end up removed from mainstream classrooms or involved in delinquency, stating
“We have to always think of the whole trajectory of… what happened with each
child, from the beginning of their career in school to where they are now, and where
did the breakdowns occur.” There are several transitional points in a student’s life
where they may be without consistent adult monitoring, including when students
are out of school for summer break. Significant changes in behavior or underlying
mental health symptomatology may either increase or go unnoticed during these
periods.
Additionally, participants were concerned that even when a BH issue was identi-
fied, teachers and other staff might be intimidated by the responsibility of address-
ing BH issues and ignore them, leaving the student to struggle without help:
No one person can handle everything, because those are your most complex kids, and those
are the kids who are ultimately probably moving into the DJJ system as they age… they’re
hard, and we don’t know what to do… and it goes back to that… thing of, ‘Oh, it’s a guid-
ance counselor problem,’ or ‘Oh, the special ed[ucation] teacher needs to work with them,’
but no, it’s everybody, because they are so complex…We need to have teams that work well
together, because I’m not sure we know how to do that yet.
Another potential point where care can become inconsistent is during the transi-
tion into special education. Students who have behavioral disorders and other dis-
abilities are often shuffled between classrooms, despite the benefits of classroom
stability (Wagner et al., 2006). Many students in special education classrooms are
not there because of any special educational need, but instead because of a behav-
ioral need that may not necessarily warrant special education services (Mallett,
2016). As one participant pointed out, there may be disparities in mental health care
between mainstream and special education environments:
What happens is that there’s a lot of focus on kids in the regular education environment,
making sure they get counseling… but all these children who have been labeled special
education—and oftentimes only because of some behavioral issue—are not able to access
that. Because we haven’t figured out how to make sure that we’re merging special education
and the services that are provided through Response to Intervention.
Participants identified two steps to improve the continuum of care for JJIY. First,
examine the breakdowns that occur in the continuum, with emphasis on where
agencies fail to collaborate and youth slip through the cracks. Second, find ways to
close those gaps. To detect points in the continuum where youth are inadequately
served, participants suggested a series of open forums for stakeholders to discuss
how to best integrate the juvenile justice, education, and mental health systems.
They noted one particular group, JJIY themselves, whose feedback is rarely solic-
ited in the overall aim of improving continuum of care: “You need the youth who
are… involved in the system, too. They know their challenges and what kind of
support they need.”
Participants also noted that a continuum-wide team of professionals might be
helpful in connecting schools, the juvenile justice system, and mental health ser-
vices to each other: “I think that would be a good team to put in place and… meet
continually and help us work with the schools, and the probation officers, and the
mental health people in the community, because right now it’s not happening.”
After identifying where breakdowns occur between a community’s service agen-
cies, participants suggested that one of the best ways to bridge the gaps might be to
identify community partners. In fact, research has found that forming community
partnerships was significantly related to the use of best practices in juvenile justice
settings (Farrell, Young, & Taxman, 2011). For example, if agencies that serve chil-
dren outside of school were to provide information to schools regarding a child’s
home life, educational personnel might be better able to address that child’s specific
needs. If schools and mental health professionals partner with local businesses,
those businesses might be able to provide resources to youth that neither schools nor
families are able to afford. One participant shared a story from her agency’s
experience:
We built partnerships with not just the mental health agencies, we built partnerships with
drugstores and facilities, exercise programs… We knew if we were having a student with a
particular problem, we could contact specific agencies and they would send someone to us
free of charge to assist us as a group… I’ll give you a specific example. One of the problems
we would have is that the parents would not fulfill Medicaid requirements. And even if they
did, we had problems getting medical assistance for the kids, getting medication. So we
actually partnered with the pharmacy. The pharmacy would actually deliver the medications
to the school … We had partnership with a gym—they gave us exercise equipment, so after
those students took their meds, they exercised, they did sports a little bit faster, and they
were able to be successful during the day.
Environmental Considerations
Problems
Due to the number of risk factors and social influences that may affect the trajectory
of youth in the justice system, it is important to consider each as an individual case
in both intervention development and individual treatment. Understanding environ-
mental influences on JJIY involves working closely with their families. The juvenile
justice system has a checkered history with involving parents, as previous attempts
to collaborate have often placed a substantial amount of blame on caregivers for
children’s deviant behavior. Due to this, many caregivers still experience stress and
guilt when involved, often resulting in them disconnecting from their children’s
experiences (Walker, Bishop, Pullmann, & Bauer, 2015). As one participant pointed
out, this sometimes perpetuates the underlying problem:
We call them to tell them there’s a problem with their child and we’re suspending them, or
we’re doing whatever, and then they don’t know what to do with them or how to respond…
we encourage a sense of helplessness on their part, because they don’t know what to do. If
they knew what to do, they would do it.
Even when caregivers do not experience helplessness and desire to be informed

about their children, there is often a breakdown in communication, resulting in lim-
ited information exchange between parties (Walker et al., 2015). Therefore, even
though parent involvement is generally regarded as a positive influence in children’s
overall mental health, parents are often not consulted with about possible interven-
tions for their child (Walker et al., 2015). Participants believed this could be due to
a lack of common language between parents, teachers, and students. For example,
while teachers and other school personnel are sometimes trained in how to address
behavioral problems, parents likely do not have similar training and experience sig-
nificant barriers to effective communication because of this lack of education.
Additionally, parents or caregivers may not always be the appropriate person

from whom children should seek support, which should be considered when identi-
fying current and possible future family support for juveniles:
In the system we have a lot of grandparents, and they don’t know what to do. I always get
on teachers about talking their language to them, because they don’t know some of the basic
terms, sometimes, what the juveniles are saying, what they’re talking about. So we need to
provide a lot of support because we have a lot of grandparents — because the parents are
young, or incarcerated themselves, or not involved with the juveniles’ lives, so a lot of the
grandparents are taking over the roles of being a parent.
This is important to consider when attempting to address mental health needs in

juvenile justice populations, as youth in grandparent-headed homes are up to three
times more likely to have mental health needs than youth in their parents’ homes
(Campbell, Hu, & Oberle, 2006). Regardless of who the family support system
consists of, however, accessibility is a concern:
We only allow them the time that we’re available, not the time that they’re available, and
then we say they’re not involved. How do you be involved when you have to work or when
you have childcare issues or other issues that need support?
When working with JJIY, it is important to consider individual differences and the
uniqueness of each youth’s history. Interventions for these children should embrace
trauma-informed care and consider their current family supports. Participants
emphasized the importance of involving parents and caregivers in interventions, and
research shows that family-centered interventions for children are more effective
than interventions involving only the child (Dowell & Ogles, 2010). Special con-
cern should be given to involving parents of JJIY, as they are likely to have problems
accessing services and may have unique service needs. The programs that are most
effective at keeping youth out of residential facilities share at least one trait—a spe-
cific effort to increase service accessibility (Lee et al., 2014).
Transition from the Juvenile Justice System
Problems
The main goal of many interventions targeted at JJIY is to reduce recidivism.
Participants named a number of contributing factors to high recidivism rates, includ-
ing deviancy training, lack of adequate support when exiting the system, and a
vicious cycle of social influences. While there is some conflicting data on the long-
term effect of deviancy training, research indicates that the majority of interventions
that harm rather than help JJIY are group interventions (Welsh & Rocque, 2014).
When grouped together, delinquent youth engage in more antisocial talk; when
housed together in residential juvenile justice facilities, they have higher recidivism
rates (Mathys et al., 2013; Shapiro et al., 2010). Moreover, as one participant noted,
youth may also grow accustomed to the environment itself:
What I’ve experienced is a unique fear. I service the kids that have just come into the system
and the kids that have been there long-term. So, for the students and juveniles that have
been there long-term, there’s a fear. A lot of times I’ll have to do board reports and have to
do recommendations, and when they know they’re up for parole, a lot of them will act out,
because they don’t want to go up, because they’ve been there so long—I have a juvenile
who’s been there two and a half years over his max, and he’s just got that fear because he
doesn’t know what to expect. A lot has changed.
Given this acclimatization to the prison environment, participants were con-

cerned by the dearth of transition support that juveniles receive when exiting the
system. There is little follow-through with juveniles after they complete their sen-
tences; their records may not be transferred to schools for months after their release,
and there may be no behavior, learning, or transition plans in place (Goldkind,
2011). Although it is particularly important to continue monitoring the mental
health of juveniles after their release to prevent recidivism and improve their future
mental health outcomes (Underwood & Washington, 2016), participants were con-
cerned that such support was not always in place. With no support, juveniles may
have little incentive to continue working toward goals to keep them from returning
to the system or little ability to maintain a healthy emotional and behavioral state.
This lack of transition support may exacerbate an already-existing cycle of recidi-
vism. One participant described the pattern of re-offense: “You see a lot of the
crimes are petty… to gain things like cell phones, gym shoes, things out of a store,
to get access to the funding.”
After being incarcerated for a crime, youth experience significant difficulty gain-
ing access to and maintaining employment due to their past incarceration (van der
Geest et al., 2016). This could lead to re-offense out of necessity, and this cycle
often repeats after their next release. Additionally, even a single arrest is related to
higher rates of school dropout, which limits educational attainment (Kirk &
Sampson, 2013). Downstream effects of this include reduced ability to find employ-
ment later in life and the perpetuation of a life-course cycle of negative outcomes
originating with their involvement with DJJ.
Participants suggested several possible steps that could be taken toward reducing
the high recidivism rates that characterize our juvenile justice system. The first was
mindfulness-based social-emotional training for institutionalized juveniles, which
one participant anecdotally said had reduced recidivism at her workplace. Indeed,
there is evidence that mindfulness-based programs do reduce violence, substance
use, and recidivism in JJIY (Himelstein, Saul, Garcia-Romeu, & Pinedo, 2014;
Hoogsteder et al., 2014). But, as another participant pointed out, that is not the only
training youth needed in order to help JJIY succeed in their transition back into the
general population: “Job training and skills that can promote independence — fis-
cal, financial means for them — I think that’s the biggest issue to stop them from
re-entering DJJ.”
While outcomes from vocational training vary depending on the training, its
positive effects are more consistent when this training includes vocational experi-
ence (Altschuler & Brash, 2004). In addition to vocational training, youth benefit
from increased educational opportunity while in custody, particularly since they

often exit detention at an academic disadvantage in comparison to their never-
detained peers, making their transition back into a mainstream school setting diffi-
cult (Baltodano et al., 2005). However, skill building does not solve all transitional
problems. One participant proposed a way to assist youth during periods of inade-
quate support during the transition from DJJ:
I was talking to my superintendent about transition specialists… having those people set up,
because I think that’s where we lose them… For the past two months, we were just having
juveniles coming back, I mean, within two weeks … more often because I think they’re not
getting those supportive services once they leave, so we have someone who’s kind of check-
ing in with them, making sure that they’re staying on track, you know they’ve established
all those goals and that they’re working towards those goals.
Conclusion
Several major themes regarding JJIY emerged throughout this forum—some regard-
ing prevention, some regarding intervention, and some regarding the process as a
whole. First, the reoccurring concern from participants regarding the lack of transi-
tion support services for JJIY exposes a potential area to target for future prevention
and intervention efforts. Fully supporting transitions between grades or teachers
could prevent entry to the justice system, or supporting youth entering and exiting
the justice system could prevent reentry. Participants suggested transition support
could come in several forms, though they stressed the importance of having a con-
sistent adult (i.e., social worker, transition specialist) responsible for guiding youth
through these transitions.
Second, communication is necessary to the success of all intervention and pre-
ventative measures. Direct, accessible lines of communication between the staff of
juvenile justice facilities, educational facilities, and mental health facilities are
essential to providing comprehensive, continuous care for JJIY. Furthermore, fami-
lies are a vital piece of the puzzle when crafting effective interventions for JJIY;
helping parents/caregivers overcome feelings of blame and guilt, as well as ensuring
that DJJ personnel do not perpetuate those feelings in their interactions, is essential
to encouraging family involvement. This may require educating caregivers to ensure
that all involved parties are familiar with the basic ideas of school BH. Additionally,
youth themselves appear to be an untapped resource in identifying and selecting
interventions, and mental health professionals should solicit JJIY feedback.
Third, because schools play such an important role in the school-to-prison pipe-
line, it is critical we educate policy makers and administration who control funding
opportunities used to improve teachers’ identification of students’ behavioral health
difficulties. One of the major problems reported by teachers, and supported by
research, is undiagnosed mental health issues in students. Integrating courses into
educational degree programs that specifically address identification of mental and
behavioral health issues in students may help ensure new teachers are effectively
equipped to handle these challenges. Providing funds for continuing education for
current teachers, specifically to facilitate acquisition of these skills, could signifi-
cantly impact their students’ outcomes. Providing more education to all stakehold-
ers in schools could help make sure students are referred for appropriate mental
health services in order to safeguard them from the negative effects of potentially
avoidable involvement in the juvenile justice system.
Lastly, it is important to establish a cohesive vision of mental health for both the
juvenile justice system as a whole and its interactions with mental health and edu-
cational systems. Producing favorable outcomes for JJIY when each component of
the care system functions in isolation is unlikely. Overall, this vision must address
how the current system fails to properly serve youth. One participant advocated for
examining those youth who avoided the pitfalls addressed in this chapter: “Let’s
take a look at what worked for those kids who haven’t returned to the system. What
was done on those kids, not just looking at the kids who are always coming back.
Those are the kids who get our attention all the time, but what about the kids who
have done well? What was the key?”
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Addressing the Unique Needs of Children
and Families Within the Child Welfare
System
Samantha Martinez, Tara Kenworthy, Sommer C. Blair, Lee Fletcher,

Yanfeng Xu, and Robert N. Stevens
Child welfare (CW) systems are systems that are funded by both state and federal
entities to ensure children have safe and permanent living environments. CW agen-
cies offer child protective services, foster care, kinship care, adoptive services, and
family preservation and reunification services to achieve children’s safety, perma-
nence, and well-being outcomes (Pecora, Whittaker, Maluccio, Barth, & Plotnick,
2017). Voluntary kinship care occurs when a child is living with a family member
and has the support of a CW agency, but the legal court system is not involved.
Formal kinship care is when the child resides with a family member but is legally
placed in the custody of the state or a CW agency (Office of the Assistant Secretary
for Planning and Evaluation, 2000). The CW system is also involved in cases that
involve family reunification after the child has been temporarily removed from the
home. A child enters foster care when they are temporarily placed into legal custody
of the state, which could include living with caregivers in a foster family or in a
group home. In addition to foster and kinship placements, the CW system is also
involved with adoption services. Adoption is the result of the permanent and legal
placement of a child with a family different from their birth parents. In 2016, nearly
500,000 children were adopted out of foster care, highlighting the substantial num-
ber of persons affected by the CW system (U.S. Department of Health and Human
S. Martinez (*) · T. Kenworthy

e-mail: stm1@email.sc.edu; tlk@email.sc.edu
S. C. Blair · L. Fletcher
South Carolina Department of Social Services, Lexington, SC, USA
e-mail: Sommer.Blair@dss.sc.gov; lee.fletcher@scdmh.org
Y. Xu
University of South Carolina College of Social Work, Columbia, SC, USA
e-mail: Yanfeng@mailbox.sc.edu
R. N. Stevens
South Carolina Association for Positive Behavior Supports, Johns Island, SC, USA

https://doi.org/10.1007/978-3-030-56112-3_8
96 S. Martinez et al.
Services (HHS), Administration for Children and Families (ACF), Children’s

Bureau, 2016). These well-known services of the CW system have been essential to
establishing safe environments for children.
ental Health Needs of Youth within the Child Welfare

M
System
Children in the CW system experience greater difficulties with mental health than
the general population (Burns et al., 2004). Specifically, youth in the CW system
experience this heightened risk due to the increased levels of abuse, neglect, domes-
tic violence, and parental substance abuse (Burns et al., 2004). Between 50% and
80% of children who are involved with CW agencies experience difficulties with
emotional, developmental, or behavioral disorders (Burns et al., 2004; Farmer et al.,
2001; Landsverk, Garland, & Leslie, 2002; Taussig, 2002). For example, approxi-
mately 25% of children in foster care will be diagnosed with post-traumatic stress
disorder, a rate twice as frequent as that of United States war veterans (Pecora et al.,
2005) and more than 4 times (6.3%) as frequent as youth from the general popula-
tion (Giaconia et al., 1995). Additionally, youth in foster care are prescribed psycho-
tropic drugs at a higher rate than their non-foster counterparts, and many are
prescribed dosages that exceed guidelines (U. S. Government Accountability Office,
2011). The suicidal ideation rate for youth within the CW system is 27%, compared
to 16% for children in the general population (Anderson, 2011). There is a critical
need for effective mental health treatment for youth in this system, as mental health
challenges increase the number of placements, and threaten academic performance
and long-term functioning if effective treatment is not provided (Garcia, Circo,
DeNard, & Hernandez, 2015; Morton, 2018; Newton, Litrownik, & Landsverk,
2000; Zlotnick, Tam, & Soman, 2012).
By definition, the families and children served by CW agencies have significant
challenges with mental health service needs (Pecora et al., 2017). As stated above
about half of these children require interventions to assist with emotional, develop-
mental, or behavioral disorders (Burns et al., 2004). One of the critical needs for
children and families in CW is a demonstrated need for mental health services.
Unfortunately, barriers exist that prevent youth in the welfare system from access-
ing necessary mental health treatment. Youth are often unable to connect to resources
due to bureaucratic difficulties within most CW agencies (Yoo, Brooks, & Patti,
2007). CW personnel have reported feeling unsupported by the overall system due
to ineffective training, which affects their ability to address the mental health needs
of youth (Van der Geest, Bijleveld, Blokland, & Nagin, 2016). CW organizations
should be more intentional about providing personnel with professional develop-
ment and supervision as it relates to complex cases (Mundy, Neufeld, & Wells, 2016).
Children who enter foster care face a compounded set of challenges in the edu-
cational system. The average reading level of 17- to 18-year-old youth in foster care
Addressing the Unique Needs of Children and Families Within the Child Welfare System 97
is the seventh grade (Breslau, Lane, Sampson, & Kessler, 2008). They are less than
half as likely as their non-foster care peers to enroll in college and 3–11% of former
foster youth attain a bachelor’s degree (Breslau et al., 2008). CW-involved youth
will continue to lag behind their noninvolved peers educationally without improved
mental health care service.
Additionally, research shows a link between child abuse and delinquency
(Ireland, Smith, & Thornberry, 2002). From 2001 to 2005, 14% of youth who were
in CW placement due to physical abuse, neglect, emotional abuse, or sexual abuse
were arrested (Ryan, Marshall, Herz, & Hernandez, 2008), while only 6% of the
general population was arrested over the same timeframe (Office of Juvenile Justice
and Delinquency Prevention, 2019). Further complicating the issue is the high num-
ber of youth in the juvenile justice system with mental health issues (Vincent,
Grisso, Terry, & Banks, 2008) underscoring the amplified needs of youth in CW,
and the potential of school behavioral health (SBH) to better address these needs.
hallenges to Addressing Mental Health Needs for Students

C
in Child Welfare Systems
There are many challenges for youth in CW to receive effective mental health ser-
vices. Four prominent challenges are: (1) Lack of collaboration between schools,
parents, caregivers, clinicians, and other organizations in students’ lives; (2) increas-
ing family and community support; and (3) concern about increased involvement of
CW students in the juvenile justice system.
Collaboration
Lack of collaboration between schools and other organizations (e.g., Department of

Mental Health, Department of Social Services, and Department of Juvenile Justice)
has been a long-standing challenge for children accessing the child welfare system
and using Temporary Assistance for Needy Families, and the Supplemental Nutrition
Assistance Program (Altshuler, 2003). Collaboration between these organizations
and programs is often limited by administrative policies or funding (Garcia et al.,
2015). A lack of communication between different service providers can lead to
confusion about what services a child is receiving, resulting in duplication of ser-
vices, or provide a systemic barrier for a child’s receipt of services (Anderson-
Butcher & Asher, 2004). Thus, it is important that collaborative efforts between the
CW, education, mental health, and other systems be strengthened. Examples
include, collaborative SBH that supports these children, education about abuse and
neglect, life skills enhancements, and school fairs of various emphases (e.g., career,
health, and wellness; Anderson-Butcher & Asher, 2004).
Knowledge of available resources is a critical component of a school’s ability to

collaborate with CW agencies. Teachers and other school personnel report feeling
as though they do not have sufficient education on how to address child abuse and
neglect among their students (Abrahams, Casey, & Daro, 1992). Practices such as
educating teachers on current literature about domestic violence (DV) or conduct-
ing evaluations after DV training have shown to be effective in improving their
response to children exposed to DV (Turner et al., 2017). In addition, some research
has examined organizational factors, such as incorporating community members
when making decisions, and collaboration within and between CW organizations as
a way to better understand access to services (He, 2017; Herlihy, 2016; Lee, Benson,
Klein, & Franke, 2015; Yoo et al., 2007). Collaborating across agencies may include
working with community stakeholders to schedule workshops and opportunities to
visit the organizations as a way for community agencies to increase awareness of
each other’s services provided in other agencies (Anderson-Butcher & Asher, 2004).
Determining ways for schools, community organizations, caregivers, and CW agen-
cies to stay connected will better ensure that youth are connected with the multifac-
eted services they are likely to need.
Increasing Family and Community Support
Unfortunately, family unity is not always possible while ensuring the safety of a
child; in many cases, children benefit from out-of-home foster placements (Conn,
Szilagyi, Jee, Blimkin, & Szilagyi, 2015), but almost two-thirds of these children
experience multiple placements (Office of the Administration of Children and
Families, 2017). Multiple placements are related to increased emotional/behavioral
challenges in these students and the need for more intensive mental health services
(Jones & Wells, 2008; Rubin, O’Reilly, Luan, & Localio, 2007). To promote stabil-
ity in a child’s placement and to promote better child adjustment, it is important to
include the child’s family as well as important community members, such as teach-
ers, school support staff, and faith leaders in their care (see Owens et al., 2004).
Family-centered and driven care helps to ensure that families are actively involved
in their child’s treatment, along with active exploration of strategies for reunifica-
tion and the child’s return home (Anderson-Butcher & Asher, 2004). School person-
nel, such as school-employed mental health staff (counselors, psychologists, social
workers) could play an active role in this family-centered care, but too often are not
involved, pointing to a critical gap and potentially enhanced role for SBH
(Austin, 2004).
Preventing Juvenile Justice Involvement
Children who have experienced maltreatment enter the juvenile justice system at
much higher rates than the general population, due to the association of maltreat-
ment with antisocial behaviors and criminal activity (Van Wert, Mishna, & Malti,
2016). Further, schools may inadvertently increase the likelihood of students enter-
ing the juvenile justice system through ineffective and punitive disciplinary poli-
cies. For example, a study of schools in Texas showed that suspended or expelled
students were three times more likely to have contact with the juvenile justice sys-
tem in the following year (Fabelo et al., 2011). Punitive disciplinary policies do not
consider previous trauma such as physical abuse or neglect that is currently affect-
ing the child. Knowing the complexities that contribute to a child’s behavior and
considering these factors, that are often out of the child’s control may lead to more
empathic and compassionate decision-making, such as avoiding exclusionary disci-
pline and the attendant risk of increased juvenile justice involvement (Van Wert
et al., 2016).
Method
The information collected for this chapter came from an open forum held with CW
stakeholders in the community. The forum consisted of a diverse group of twenty
individuals, including one parent, ten mental health clinicians, one school staff
member, one lawmaker, one social worker, one community member, and five mem-
bers of the research team. The forum was conducted using the guiding questions
presented below. Please see the introduction for the method used in the forum.
Responses presented in the forum (reviewed below) also helped to inform the litera-
ture review presented above. The following questions guided discussion:
1. What barriers prevent collaboration between CW and SBH staff? How can they
be overcome?
2. What CW organizations (either governmental or non-profit) have you worked
with or are you aware of that support behavioral health initiatives?
3. What are the existing infrastructure supports for working with CW agencies?
How should the infrastructure and efforts be strengthened?
4. Are there examples of SBH and CW staff working effectively together? What are
the characteristics of these relationships? Are there SBH programs that could be
considered exemplary in this area (name them)?
5. With the identification of exemplary sites, how can we publicize their experi-
ences and promote generalization of successful programming strategies to other
CW sites and agencies?
6. What recommendations do you have for collaborative training of SBH and CW
staff?
7. What can be done to improve family involvement in guiding CW activities? Can

the factors that prevent or reduce family involvement be changed?
8. Do you think it would be worthwhile to establish a state-wide leadership team
that would help to guide and coordinate training and implementation support for
effective behavioral health in CW organizations?
9. What other recommendations do you have to move this work forward in our CW
systems and agencies?
Results
The results of the forum were collected and divided into four challenges or sub-
themes, many of which were derived from participants’ personal experiences and
interactions with the CW system; these themes are consistent with those reviewed
in the introduction.
Themes Related to Collaboration
The participants felt that increased collaboration between schools, parents, clini-
cians, and other organizations involved in students’ lives would reduce duplication
of services and ensure that clients receive appropriate services. One participant
identified the difficulties with sharing information across agencies: “[We] want to
share information with agencies, but it’s hard to share outside of mental health.”
Some of the participants indicated that collaboration between these organizations is
limited by policies or funding, which results in multiple organizations providing the
same services to the child, rather than pooling their resources. Simply put by a par-
ticipant, “No communication equals duplicating services.” Collaboration is also
important to ensure students are complying with the rules and regulations of all
organizations (e.g., collaboration with Department of Juvenile Justice (DJJ) would
be important if a student is on probation). One forum participant discussed a pro-
gram in the community that helps students facing truancy: “[this] program works
with [the] solicitor’s office to hold pre-judicial truancy court. Students come in front
of representatives from a bunch of different agencies.” Due to the collaboration
within this program, students often do not have to go to truancy or family court as a
result of truancy. Instead, students are able to discuss their individual experience
with stakeholders in the community.
According to participants, the collaboration between organizations is critically
hampered by poor communication. One participant stated, “[The Department of
Social Services; DSS] may have a plan for the child and family but the school has a
different plan and the two are not communicating.” Furthermore, if a student is
receiving services from multiple organizations (e.g., school, the Department of
Mental Health [DMH], DSS), each organization is often unaware of the other ser-
vices the student is receiving, unless the caregiver explicitly communicates this
information. For example, if a student is receiving services from DSS and DMH, the
DSS worker not only does not know if the student is receiving other services, but
also does not have a direct route to finding out which services (and from which
organizations) the child is receiving them. One participant suggested:
Try to establish a home-school link. Help [the] caregiver take accountability for the young
person, because a lot of the times families feel the school is working against them, so they
don’t want to try. Try to model how to approach the school because a lot of parents had bad
experiences when they were in school.
This suggestion could be the direct route for agencies to collaborate with one
another. Another participant stated, “Schools don’t understand children in foster
care and that some behaviors are a result of traumas. More trauma-informed train-
ing would help with out-of-school placement. Instead of suspending, find another
solution.” Providing training for school personnel would act as an additional sup-
port for those in the CW systems.
Themes Related to Family and Community Support
The participants also emphasized the importance of utilizing family and community
support when working with children. A participant stated, “Try to harness family
and community support first.” Another participant built on this comment, mention-
ing a program that works with local places of worship to provide mentors to stu-
dents who had been referred by DJJ for nonviolent offenses. This participant stated,
“[this] faith-based program [was beneficial] for non-violent offenders… Most peo-
ple and youth were in the church, and we met every month with different representa-
tives from the mental health agencies.” A participant noted another program that
used a car dealership as a catalyst to prepare foster children for life outside of the
foster care system by teaching them about the consequences of impulsivity.
The participants recognized that, despite the importance of collaborating with
the family, it can be difficult to involve families, particularly those in the CW sys-
tem, in their child’s mental health care. Participants noted that caregivers may feel
intimidated by the school environment and may even be worried that the school will
criticize their parenting without offering collaborative solutions. Thus, schools and
other CW agencies must work to be more inclusive with families. This way, schools
and agencies can work with the community members rather than separately from
them. Multiple participants suggested, “they [schools] work towards having the
family play a more active role in the child’s treatment and leaning away from indi-
vidualized treatment.” Overall, participants supported the utilization of both com-
munity and family supports to better work with children in the child welfare system.
Themes Related to Prevention of Juvenile Justice Involvement
Participants also agreed that it is important to provide support to students and take
preventative measures to keep them out of the juvenile justice system. A partici-
pant shared:
As a foster parent… I try to keep them out of DJJ and the alternative school, but it’s a
struggle when dealing with DSS. I dropped charges on the child, and they wanted the child
to suffer consequences… if I dropped charges then she couldn’t suffer consequences. My
thing is to keep them out of the system if we can.
It appears that the current system emphasizes punishing children rather than
working with them to find other solutions. One caregiver stated that someone must
Make sure the school knows the kid is in foster care and therapy. [The foster parent] tries to
keep kids out of DJJ, but it’s hard working with DSS. [DSS] wants kids to suffer conse-
quences, but [the] foster parent doesn’t want them to go to DJJ.
Participants’ concerns regarding children in the juvenile justice system extended

beyond merely keeping them out of the system, but also included possible conse-
quences for employment opportunities in the future. One participant voiced that it is
often difficult for young adults to obtain jobs when they have a record with the
justice system. Such concerns led many participants to search for positive outlets to
help children in the CW system. One participant mentioned a community program
that uses positive support as a preventative measure to keep children out of DJJ. With
a large emphasis on the need for support, one participant stated, “the positive sup-
port earlier in the child’s welfare process could potentially work to prevent negative
outcomes, such as DJJ involvement.”
After discussing the implications of SBH for children in the CW system, partici-
pants provided recommendations for the CW community. Many of the proposed
recommendations are supported by existing research. This section will highlight
responses from participants, paired with supporting evidence.
First, the forum participants suggested several strategies to improve the CW sys-
tem’s interaction with schools. The focus group participants indicated that families
may resist engaging with the school system. They reported that previous negative
interactions with the school system, as well as fear of judgment about their parent-
ing may impact families’ willingness to participate. The participants provided rec-
ommendations on how to interact with the school system and community members.
One participant stated, “I’m wondering if… we have a memorandum of agreement
[between] DSS, DJJ, Education, MH [mental health], family advocacy - and we get
the state leaders together” to create a system of communication between various
youth organizations and increase collaboration. Furthermore, a signed HIPAA
[Health Insurance Portability and Accountability Act] release form as outlined in 45
CFR §164.506 (HIPAA Journal, 2017) would allow MH clinicians to disclose treat-
ment progress and share protected health information. If parents have the opportu-
nity to work with state leaders and community organizations in an effort to advocate
for their child, it provides opportunities for more positive interactions with the
school system as well (Swanson, 2002). Participants also recommended using social
media to enhance communication with students and families. It is critical for stake-
holders and representatives of child-serving organizations to create social media
platforms that allow for more engagement with youth participants (Brandtzaeg,
Folstad, & Mainsah, 2012).
Second, participants believed that a collaborative system between CW institu-
tions and other agencies would allow for more effective treatment. One participant
suggested a collaboration with the Children’s Law Center to advocate for legislation
that supports behavioral health initiatives. The Children’s Law Center in Columbia,
South Carolina advocates for the well-being of children in the community and could
help provide both legal assistance and political advocacy. The initiative to have bet-
ter communication between mental health institutions and the CW community has
shown positive outcomes for the children’s mental health (Kerns et al., 2014).
Stronger and more effective communication between programs may help to bridge
the gap between the mental health and CW communities.
Third, the participants suggested that a state leadership committee identify the
points of contact for organizations. This committee could also create an informa-
tion-sharing agreement template. A similar council was implemented in Maryland,
where an advisory board was created that included members from various disci-
plines who were all involved in CW. The initiative created an open forum of com-
munication between providers (Vulin-Reynolds, Lever, Stephan, & Ghunney, 2008).
If expanded to other states, this template could greatly impact collaboration between
organizations within the CW system. Each state has a responsibility to ensure that
children in the CW system receive proper services (Stoltzfus, 2017). Thus, state
legislators should be encouraged to support efforts, such as sharing a template, to
ensure effective services for children.
The fourth suggestion was to encourage more community outreach on behalf of
youth-serving organizations. Such outreach would inform the public of the services
that are available for families within the community. Additionally, agencies who
specifically work with children and families should advance their efforts to connect
with the community (Pecora et al., 2017). Relationships between organizations and
the community are important to implement any initiative, such as improving school
services (Aarons, Sommerfeld, & Willging, 2011; Powell, Son, File, & Froiland,
2012). Communities of practice have been shown to be effective methods to bring
organizations together to work on similar goals (Wenger, 2011). It is critical that
schools help close communication gaps between the community and agencies by
learning about the resources within the community to help enhance community col-
laboration (e.g., He, Lim, Lecklitner, Olson, & Traube, 2015). Engaging family and
community support ensure the continuity or early onset of services, regardless of
whether the services are interrupted at any point in time, which can benefit the
child’s mental health needs (Austin, 2004).
Finally, participants insisted on effective, trauma-informed training for teachers

and school personnel, since so many children in the CW system have experienced
trauma. They also suggested that teachers and staff be taught the signs of trauma, so
they are more aware of what to look for. Research also supports a trauma-informed
approach when working with children in the CW system (Donisch, Bray, & Gewirtz,
2015). Changes to statewide and district-level policies could be made that focus on
the child’s basic needs to feel safe and develop their social and emotional skills
(Harper & Temkin, 2019). The Compassionate Schools Initiative helps educators
understand the impact of trauma on the children they serve and how it can affect
those who care for them. It also provides strategies for instruction and discipline
that move the classroom from being trauma-informed to being trauma-responsive
(Wolpow, Johnson, Hertel, & Kincaid, 2009). Psychoeducation through the dis-
semination of guides such as the Child Trauma Toolkit for Educators provided by
the National Child Traumatic Stress Network would help teachers and staff better
understand how to help children who have been traumatized (National Child
Traumatic Stress Network Schools Committee, 2008), not just those who are
involved in the CW system. Ultimately, a system-wide approach is necessary to
provide the benefits of a trauma-informed learning environment that children
involved in CW need (Harper & Temkin, 2019).
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Serving Those Who Serve: Increasing
Understanding of Mental Health Needs
in Military Families
Marissa Miller and John Terry
There are approximately 3.5 million US military personnel including active duty

military personnel and coast guard members, reserve members, and civilian person-
nel (Department of Defense [DoD], 2017). There are more than 2.5 million spouses,
adult dependents, and children (i.e., military-connected youth [MCY]) in the imme-
diate families of active duty and Selected Reserve personnel alone (DoD, 2017);
these are military families, and they serve in conjunction with the military member.
Despite their often robust resilience (Easterbrooks, Ginsburg, & Lerner, 2013;
Masten, 2013), military families, including MCY, experience stressors generated by
the unique characteristics of the military lifestyle, as well as stressors secondary to
those of their family member or members (Trail et al., 2018). Current research
efforts are aimed at increasing positive development and minimizing stressors, bar-
riers, and adverse outcomes for MCY and their families. In this chapter, a literature
review and themes in qualitative data from a focus group of military family mem-
bers and military mental health providers describe existing services, ongoing needs,
and recommendations for future directions that military families may access or
experience in prevention and intervention. These efforts aim to increase positive
development and minimize stressors, barriers, and negative outcomes for MCY and
their families.
Background and Demographics
Military family members exceed the number of active duty and Selected Reserve
members (i.e., approximately 2,100,000 military members versus approximately
2,700,000 military family members), with nearly 40% of families including depen-
dent children under age 22 (DoD, 2017). Southeastern states have a particularly
M. Miller (*) · J. Terry

University of South Carolina, Columbia, SC, USA

https://doi.org/10.1007/978-3-030-56112-3_9
108 M. Miller and J. Terry
high concentration of military families: Virginia, Texas, North Carolina, Georgia,

Florida, and South Carolina rank among the ten states with the highest number of
active duty military populations. In Virginia, North Carolina, Georgia, and Florida,
the number of military-connected dependents exceeds the number of military per-
sonnel (DoD, 2017). Military families are dispersed across the world, with distinc-
tions often made between families stationed inside the Continental United States
(CONUS), within US Territories (e.g., United States, Puerto Rico, Gaum, Virgin
Islands, American Samoa, Wake Island), and outside CONUS (OCONUS). For
example, roughly 80,000 dependents reside in Europe, 76,000 in Asia, and 12,000 in
Africa/the Middle East (DoD, 2017).
Mental Health in Military Members and Families
Between the September 2001 terror attacks and September 2015, 2.77 million indi-
vidual military service members deployed to various military operations (Wenger,
O’Connell, & Cottrell, 2018). Importantly, military service members often deploy
multiple times; recent data indicate that there were 5.4 million unique deployments
across this period of time (Wenger et al., 2018). Operation Enduring Freedom and
Operation Iraqi Freedom veterans are distinctive, as these military personnel repeat-
edly deployed on tours of duty that lasted longer than previous tours, with shorter
breaks between deployments. Signature injuries of these military operations are
traumatic brain injury, post-traumatic stress disorder (PTSD), military sexual
trauma, and combat-related physical injuries (Hoge et al., 2004; Hoge, Terhakopian,
Castro, Messer, & Engel, 2007).
In addition to the same mental health challenges experienced by civilian fami-
lies, military families face unique stressors of military life such as deployment,
impacts of war-related trauma or physical disability, fear of a military family mem-
ber being killed or injured, reintegration, frequent moves/transitions, and changing
household dynamics. In addition, these families transition frequently between mul-
tiple systems of care. One study suggested that military families may transition up
to nine times across a service member’s career, with an average of 2.9 years at each
duty location (Esqueda, Astor, & De Pedro, 2012). Frequent transitions increase the
possibility of families experiencing difficulty accessing care, disrupt care, and may
result in the family transitioning to an area without resources to address family
members’ needs. Military families must then attempt to access services in new
schools, community supports, and helping agencies, with new clinical providers,
including both military-connected and civilian providers. At the same time, few
civilian medical personnel, who may be the providers of these community-based
services, report feeling confident in their knowledge of military-connected families’
needs or gifts (Esqueda et al., 2012; Harrison & Vannest, 2008).
Needs of Military-Connected Youth
As noted previously, approximately 40% of military families include dependent
children under age 22 (DoD, 2017). MCY are typically young, with most children
aged under 11 years old (DoD, 2017). Their young age alone makes it more likely
for MCY to experience the onset of a mental health disorder during their parent’s
service (Chandra et al., 2011).
Serving Those Who Serve: Increasing Understanding of Mental Health Needs… 109
Depressive and psychiatric symptoms among military adolescents occur signifi-

cantly more frequently than they do in civilian adolescents (Cederbaum et al., 2014;
Chartrand & Siegel, 2007; Gorman, Eide, & Hisle-Gorman, 2010; Hoshmand &
Hoshmand, 2007; Huebner, Mancini, Bowen, & Orthner, 2009). Additionally,
deployment-related stressors, such as prolonged or repeated separation, financial
stress, parent anxiety, and exposure to the veteran’s war trauma, are associated with
poorer mental health outcomes in MCY (Chandra, Martin, Hawkins, & Richardson,
2010; Chartrand & Siegel, 2007; Hoshmand & Hoshmand, 2007; Huebner et al.,
2009; Lester & Flake, 2013).
Gaps in Available Services
Given the gaps in the available services, it is important to turn to the stakeholders,
including parents, caregivers, and children, who note both the strengths and needs
of military families, as well as recommendations for working with military-
connected individuals. Review of the existing literature suggests several driving
themes (with specific sub-themes italicized within): (1) existing services and ser-
vice providers (e.g., Military Family Life Counselors [MFLC], installation-based
supports); (2) ongoing needs related to programming and support for MCY (e.g.,
lack of programs for children); and (3) future directions in research, policy, and
practice (e.g., research ideas, goals for a state-wide leadership team, and community
supports).
Existing Services
Military installation-based helping agencies exist to meet a variety of needs of mili-
tary families. These agencies offer a range of services, and each agency has its own
area of focus and strengths; however, military families often experience barriers and
gaps in services. Military treatment facilities (MTFs) provide medical services to
military members and beneficiaries as well as retirees, National Guard, and Reserve
members. Within MTFs, primary care managers (PCMs) are medical providers,
usually in the Family Health Clinic (FHC), and are the main point of contact for
patient care. The Behavioral Health Optimization Program (BHOP) exists within
the FHC and is designed to increase access to mental health care by having a cre-
dentialed mental health provider embedded in the FHC and available to all military
beneficiaries and dependents. The Exceptional Family Member Program (EFMP)
aims to address the needs of military family members with special needs, especially
on the issue of frequent transitions due to permanent change of station (PCS) or
deployment. EFMP identifies military families with a child or spouse who needs
special health-care services, experiences elevated mental health concerns, or
requires special education services. Military families are then supported with infor-
mation, non-medical case management, and referral services (Aronson, Kyler,
Moeller, & Perkins, 2016). An estimated 128,500 families are enrolled in EFMP;
nearly two-thirds of participants are children and youth (DoD, 2016; Johnson,
Knauss, Faran, & Ban, 2014), though availability of specific services may vary
across settings.
Non-medical counselors such as those connected with Military OneSource
(MOS) are short-term and solution-focused forms of mental health support for sub-
clinical issues (Trail et al., 2018). MOS services are offered in person or via technol-
ogy such as through telephone or the Internet to improve access. MFLCs are part of
a DoD program that provides mental health services to military members and mili-
tary families. MFLC services are short-term and solution-focused forms of mental
health support for subclinical symptoms (Trail et al., 2018). MFLCs also provide
assistance for conventional problems for which individuals commonly seek mental
health support (Trail et al., 2018). MFLCs are licensed mental health providers who
serve military families for 12 free sessions per each presenting problem for each
person (Trail et al., 2018). Confidentiality, no requirement of medical record keep-
ing, and accessibility are key features of MFLC. MFLCs meet with individuals in
convenient locations (e.g., embedded in military units, study rooms in base librar-
ies) and are often located in schools. Importantly, a recent program evaluation of
MFLC found that military members and military families reported decreases in
problem severity, stress, and interference with work/daily routines after engaging in
MFLC services (Trail et al., 2018). Participants in this evaluation also reported high
satisfaction with their connection to the MFLC counselors as well as high satisfac-
tion with the level of confidentiality/privacy of their personal information (Trail
et al., 2018). Additional personnel noted to provide care across domains of health
(e.g., physical, emotional) include military chaplains, who provide services that
may consist of spiritual support and counseling (Besterman-Dahan, Gibbons,
Barnett, & Hickling, 2012).
Regarding services for MCY specifically, prevention programs for youth across
stages of the deployment cycle include school-based services, summer camps (e.g.,
Operation: Military Kids, Operation Purple), and family-based supports (e.g.,
Families OverComing Under Stress; Esposito-Smythers et al., 2011). Resources
range from less formalized supports such as readings and videos to more formalized
treatment approaches (e.g., psychotherapy); however, services for MCY vary
depending on the installation. For example, pediatric clinics may not be available at
all MTFs, and dependents may not be able to receive services in some mental health
clinics (Esposito-Smythers et al., 2011).
Ongoing Needs Few qualitative studies have examined the perspectives of military
families, particularly youth. Much of the existing literature references the stress of
the deployment cycle for families of active duty military members. The deployment
cycle includes at least four phases (i.e., pre-deployment, deployment, reunion, and
post-deployment) throughout which the military member receives the notification
of their departure, leaves for service, returns, and reunites with their community
(Johnson et al., 2007). MCY also report stressors across broader domains of their
lives, including school, family, and peer relationships, with older children facing
more difficulties during both deployment and the post-deployment process of reuni-
fication, according to caregiver reports (Chandra, Martin, et al., 2010). Limitations
also extend to a variety of barriers for military-connected families seeking services,

including confidentiality, stigma, and external barriers such as financial and logisti-
cal concerns.
Lack of Programs for Children While MCY face many stressors, programming
may be limited or inconsistent as they transition from one location to another. In
addition to a lack of programs for children, Esposito-Smythers et al. (2011) note
that many of the available programs have not been rigorously evaluated, with a need
for more empirically supported prevention and treatment programs, to include
cognitive-behavioral therapy and skills training for both youth and parents. Moore,
Fairchild, Wooten, and Ng (2017) completed a systematic review of research on
behavioral health programs for MCY and found poor to fair methodological rigor in
the evaluation of MCY programs. The initial search results for the authors’ review
produced 3324 articles; only 14 studies met inclusion criteria (Moore et al., 2017).
It is important to point out that evidence-based treatment is available to MCY (see
the Penn State Military Family Clearinghouse; https://militaryfamilies.psu.edu);
however, there is a dearth of high-quality research on this population in the litera-
ture (Moore et al., 2017).
Research, Policy, and Practice With this knowledge, previous literature has iden-
tified a variety of next steps in the realms of research, government-based support,
and community support, commensurate with the sub-themes referenced previously.
Research Ideas Esposito-Smythers et al. (2011) offer nine recommendations for
continued growth in supports for MCY: empirically supported treatment, skills
training for youth, skills training for the non-deployed parent, stress management
technique instruction for parents, preparing the non-deployed parent for re-
integration, using group-based delivery formats, ensuring intervention is sensitive
to military culture, using techniques that address multiple behavioral and emotional
problems simultaneously, and taking sustainability and accessibility of services into
consideration. Limitations and future directions noted in other studies have addi-
tionally noted similar needs, as well as goals for conducting research to provide
more clarity in these areas (Chandra et al., 2011; Moore et al., 2017; etc.).
State-Wide Leadership Team Given that military service occurs at a federal level,
many supports initially arise at the federal level and are implemented through instal-
lations or more local resources. However, states provide individual supports and
climates for military families, as noted in the adoption of the interstate compact by
each state. State-based supports have also been utilized in services for veterans and
in some interventions. One such example is HomeFront Strong (Kees, Nerenberg,
Bachrach, & Sommer, 2015; Kees & Rosenblum, 2015), a resiliency intervention
for military and veteran partners delivered through collaboration across community
providers, college campuses, the Department of Health and Human Services, and
others. A 2011 Presidential Report noted the potential of the DoD’s Inter-service
Family Assistance Committee model to generate a state-wide effort to address
military family issues (Obama, 2011). The literature notes few other state-level
efforts that specifically engage or address the needs of children in military families
in addition to military members and partners. In the southeastern United

States, the South Carolina Education Oversight Committee publishes the Annual
Report on Educational Performance of Military-Connected Students which
describes MCY academic performance and activities and resources available to sup-
port MCY (SC Education Oversight Committee, 2017).
Community Supports A 2011 report from the Center for Military Health Policy
Research includes specific recommendations for promoting the emotional and
behavioral health of military families, including the provision of support services
for both MCY-particularly those experiencing emotional difficulties and long
deployments and caregivers, with family communication integrated into these ser-
vices. Esposito-Smythers et al. (2011) also suggested screening for family emo-
tional health and improved empirical support for programs focused on military
families.
Focus groups with military families indicate that MCY and military-connected
parents with stronger social connections (e.g., to other family members, peers, and
local community) were reported to better adjust to the challenges of military life
(Mmari, Bradshaw, Sudhinaraset, & Blum, 2010). Similarly, research with children
and families observed fewer deployment challenges for families who live on mili-
tary installations (Chandra, Martin, et al., 2010). Contributors to more challenges
have included caregivers’ employment status (e.g., more challenges for those who
are employed) and experience of mental health difficulties.
The present focus group sought to further develop knowledge in each of these
areas: strengths (i.e., existing school-based supports for MCY), needs (i.e., those
unique to MCY and families and perceived barriers to receiving supports), and rec-
ommendations for future directions (i.e., strategies for building up and learning
from current supports and overcoming barriers in areas of need).
Method
Thirteen diverse stakeholders in military family behavioral health participated in a

2017 focus group to explore perceptions related to existing behavioral health sup-
ports, ongoing needs, and potential approaches to maximizing services available to
military families, particularly in the Southeastern United States (e.g., South
Carolina). The stakeholders consisted of 14 people: 5 university staff and faculty
members, 2 active duty service members, 3 military spouses, 2 school liaisons, 1
school-based clinician, and 1 military clinician. Five of these participants were also
parents of MCY. The following questions were used to guide the conversation:
1. What organizations (either governmental or non-profit) have you worked with
or are aware of that support behavioral health (BH) initiatives with military
families?
2. What are some of the unique needs for military families in this work? In what
ways should the infrastructure and efforts be strengthened?
3. What has limited family involvement in guiding BH for military families
in local schools? How can these limiting factors be changed?
4. Do you think it would be worthwhile to establish a state-wide leadership team
that would help to guide and coordinate training and Implementation Support
(IS) for effective school behavioral health (SBH) for military families?
5. How can we increase outreach and involvement with policy leaders from our
military systems to explore mechanisms to build the SBH workforce?
6. Are you aware of any schools that are effectively implementing true system-
wide SBH for military families? Is it being done at all tiers? Can these facilities
be named “exemplar”?
7. With the identification of exemplary sites, how can we publicize their experi-
ences and promote generalization of successful programming strategies to
other sites with large military populations?
8. What strategies can be employed to increase advocacy within military
communities?
9. If resources are limited, how can military SBH stakeholders work “smarter”?
10. What other recommendations do you have to move this work forward in schools
that serve military families?
Results
Existing Services
Consistent with the growing movement to provide behavioral and mental health
supports in schools (see “Advancing Effective School Behavioral Health”), the
focus group noted schools as an avenue for receiving services. Participants’ expo-
sure to school behavioral health (SBH) services varied widely depending on several
factors, such as whether the school was DoD-based, a public school with few
military-connected persons, or another academic setting. Some families also noted
that they informed and helped to create the supports at each school their child
attended (e.g., creating clubs or advocating with school leadership). This was par-
ticularly necessary when school personnel were unfamiliar with commonalities of
life on an installation or as an MCY, either due to inexperience in a military-focused
school or being in a non-DoD school setting. As one of the participants stated:
I really think that you can spend all the time that you want to going in and educating the
counselors, the guidance counselors, and school psychologists, etc. that work in the schools
[so that they] know about what these children might be facing, but unless they’ve had some
experience with it, unless they’ve experienced it with themselves, it’s going to take a long
time for them to acclimate and see enough of it, to really get a feel and understanding for it.
Group participants also described a variety of informal supports, such as events

organized by installation-based churches or schools; however, these varied by
installation/location. Further, few of these supports directly engaged children as
well as spouses. This quote illustrates these themes:
It is really a base-to-base difference. Every base that you go to is different; they have differ-
ent things, and that comes down to letting people know what’s there. We never really hear
anything from our family readiness center or anything like that. When people are deployed,
the only thing we ever hear about is spouse dinners, which they’ll do like once a quarter.
Participants indicated familiarity with several more structured programs designed

to provide support to military members and their families. Some examples included
Strong Bonds (see www.strongbonds.org), Families OverComing Under Stress (see
www.focusproject.org), and Smooth Move workshops available through some
installations. However, when describing these programs during the session, partici-
pants reported that most available programs lacked therapeutic supports specific to
children, with an exception found in the MFLC Program, discussed in more
detail below.
MFLC Participants often discussed the MFLC program in conjunction with other
services, such as school supports or additional mental health services. The group
discussed the limited scope of the program, praising the benefits of having someone
to check in with their children or assist with the transition process, but noting the
need for sufficient funds for MFLCs in various settings or for supplemental ser-
vices. As a participant stated:
We’ve used the MFLC on base for personal use, and we’ve also had the luxury of having
[provider’s name] at our school, which has really helped my kids get through. My kids have
been through four deployments in four years since we’ve been here in [city], and it’s been
rough. Having that MFLC in the school has made a huge difference in their lives. She
knows them, not just as who they are in an office setting, but she knows them in the lunch-
room, down the hall, how they’re doing in school… I think that plays a really big part in
how they handle the military life part of things.
Often, discussion of existing services turned to ongoing needs, with participants

raising questions or describing gaps. One contributor described turning to the inter-
net for resources addressing problems beyond the scope of MFLCs:
A lot of clinics… won’t see children because we don’t have the manning or we don’t have
pediatric specialists. So, what happens is, when problems go beyond the scope of MFLC or
guidance counselors, military families – who are often times new to the area – end up going
out into the community to try to find mental health assets for themselves… [People ask me],
‘If my kid is having problems with anxiety or whatever, and it’s beyond the scope of what
MFLCs can do, who should they go to?’ And then I’m Googling clinics or different thera-
pists. So, I think there is a gap there.
Ongoing Needs
While participants demonstrated some knowledge of existing services for military

families, several participants described resources they were able to access only
through strong self-advocacy (e.g., making requests of the school, identifying other
families in the community with a similar experience, etc.). Focus group participants
and the literature describe stressors created by the deployment and reintegration
processes, when family structure shifts and a parent may return with very different
behaviors, needs, and role in the family post-deployment (Chandra, Lara-Cinisomo,
et al., 2010). It is these periods, the greatest times of whole-family need, that demand
the most resources from the families themselves. These difficulties, in combination
with a lack of programming, resulted in participants in this sample engaging in self-
advocacy to meet their needs. With a lack of programs for service members, spouses/
partners, and youth, families may be left to their self-advocacy for supports or what
one participant described as “people that approach them” outside of a program
already in place or lack of information about available services and programs:
There’s counselors and things like that on base…, but there is nothing in place that teaches
[MCY]: this is how it all works, this is what to expect, things like that… Especially if it’s
your first deployment, or the parent hasn’t left in a really long time, and so when you’re five
and your parent leaves, it’s a lot different than when you’re nine and your parent leaves, and
the issues that you go through. There’s nothing there in place for kids, not a real curriculum
anyway, that teaches them how to deal with that. Other than people that approach them, like
our MFLC that will talk them through it, but nothing in place.
Some of the participants felt that another substantial barrier to accessing behav-
ioral health services for their children was the lack of information about the differ-
ent services or resources at each base. One participant noted that the only
family-oriented service they were informed of was spouse dinners hosted by the
on-base church. Another participant added that when their partner deployed, there
was no outreach from base personnel to provide resources to their family. Although
the participants agreed that resources and outreach efforts vary base to base, they
suggested a more unified effort to inform military families of the services available,
regardless of the branch or base.
Lack of Programs for Children Needs among families were noted to fall broadly
into two categories: (1) awareness in the family’s community, which in turn pro-
vides indirect support to MCY, and (2) more direct support to children seeking to
build coping strategies and resilience. One participant described a program they had
led that addressed both needs:
I went to the principal and asked for permission to run a deployment group during lunch,
because I identified that we had many children that were going through the same thing… In
fact, at one point, I had to split it up [kindergarten through second grade] and [third through
fifth grade], because the needs were a little different. It was a great opportunity to kind of
coach them through some of those transitions, and then also allow them to be creative and
artistic, because they would create things to send to their parents or think of ways, like role
play of how to communicate to their friends why they may be sad one day… For example,
[the school] had a family lunch, and this child just broke down in tears because her dad was
deployed and her mom was at work, so she didn’t have anyone to come sit with her. I think
general population children don’t quite understand some of those same issues.
In this program, the leader noted a lack of understanding among the classmates of
a group member handling an experience that was uncommon in her setting. The strat-
egy for building awareness in this case was a form of self-advocacy: teaching chil-
dren how to communicate aspects of their experience to others. The primary focus of
the group, however, was to support elementary-aged children in going through transi-
tions and to provide opportunities to express themselves creatively and facilitating
communication with parents and friends. While this provides a foundation for sup-
ports for MCY, further support was needed in this situation and in many others.
Future Directions
Research Ideas Because some participants were connected directly or indirectly

to research institutions, research questions arose as part of the discussion. Research
was frequently referenced as part of a mechanism to move practical application
forward (e.g., starting a service under the momentum and funding of a research
study). Some examples of research ideas included:
• Assessing “the differences in BH issues in military kids versus non-military kids
in schools [and] in the various grade levels.”
• Developing “a theoretical model of the unique experience of a MCY.”
• Identifying “a military parent willing to volunteer in the schools [and evaluating
effectiveness]. We could start it off as research project and say that we’re going
to identify some moms to go into these various schools, and then we’re going to
evaluate whether the BH… incidents go down in those schools where there is a
military mom in place to provide the education and any kind of help that might
be needed.”
Group members also noted some concerns for research used to initiate practice,
such as the potential lack of sustainability after the departure of involved parties and
the stigma of the required “paper trail” in research, when confidentiality and limited
documentation are sometimes preferred by military-connected individuals:
One thing that makes a program successful [in military populations], is the confidentiality
and the lack of consistent documentation. I think if you were to go and do research or push
more documented mental health services, that could be something that might shy some
military family members away. There’s always been that stigma of, ‘If I have a paper trail,
it’s going to hurt me long term,’ so I don’t know how we could get around that.
State-Wide Leadership Team Participants expanded on the identified needs for

future research and discussed potential opportunities for immediate application
through a “resource mapping” of supports that were available within the state or
could feasibly be brought into local areas. More specifically, recommendations for
next steps for a state-wide leadership team relied on continuing the momentum of
existing gatherings (e.g., the focus group, annual meetings in the state), encouraging
collaboration amongst universities and government agencies such as state depart-
ments of education and mental health, and utilizing existing collections of resources
(e.g., the Penn State Military Family Clearinghouse; see https://militaryfamilies.
psu.edu).
Participants also acknowledged that creating movement at the state level and
engaging across organizations and resources would require training or education for
members of leadership relatively new to military family-focused supports:
I think the biggest thing is educating non-military folks on what the issues are. I think we
should invite [specific personnel] to be on this state-wide committee so that [they] also can
be educated by parents who have these issues and other professionals who have seen the
issues. And if we could get the people at the top to understand what the issues are, they can
mandate going down what needs to happen… [If we could] develop a curriculum for a new
program, a training program, I think that would be great.
Community Supports As mentioned previously, some participants referenced

engaging with their communities through their schools, such as in calling a school
counselor or principal to make them aware of their needs. Participants spoke posi-
tively of times that school personnel or others had responded to their expressed need
and similarly requested more of these community supports across settings:
It would be nice if… they could meet other kids that are going through the same [experi-
ences]. One of our chaplains on base… just deployed for the first time and they have four
kids, and she homeschools. So her kids at church this week were like, ‘I wish we knew
somebody that was going through this,’ and I’m like, ‘Well, we have [provider’s name]…’
she can get them together like, ‘Oh, you’re new here; here are three other kids that have only
been here a year, so they’re kind of new, too.’ There needs to be a program on base that gets
the kids together and helps them learn how to cope with everything that goes on.
Notably, several of the supports that participants referenced as being particularly

helpful were those that they did not need to initiate themselves upon their arrival
(e.g., an ongoing group with other “new” children, a system of welcoming new
families to a base with a packet, etc.). However, many participants also noted that
they felt there was much they needed to advocate for on their own, as referenced
previously.
Given the prominence and service of military-connected individuals in the United

States, questions arise about methods and avenues for service provision not only for
members of the military but also for their families. Participants in the focus group
and previous literature evaluating the current state of services/supports provide rec-
ommendations for next steps.
Among focus group participants, next steps focused on increased child-specific ser-
vices and having more services in place for families to prevent the need for develop-
ing and seeking out new supports at each stage of the deployment cycle. As noted
above, several themes arose in the participants’ discussion of strategies for reaching
these goals, such as maximizing use of MFLCs, developing services aimed specifi-
cally at children’s unique and developing needs, mobilizing community support and
state-wide leadership, and continuing research. One participant indicated that an
ideal circumstance should incorporate these components together consistently:
It would make a huge difference to the kids to have, ‘Dad’s gone but there is this Air Force
guy who can come and eat lunch with you just to see how you’re doing,’ just little things
like that make a big difference. At other bases… we got there, and we got a packet and we
had lunch with some people that had been there for a few years. My husband’s shop set it
up, and we got to meet these people. I was able to immediately ask questions. My kids
immediately met new people and made friends, and it made a big difference to them.
Recommendations from Previous Literature
Similarly, the literature notes the positive aspects of military-connectedness (e.g.,

resiliency, being part of an essential community) as well as the difficulties (e.g., risk
for behavioral and mental health concerns, being misunderstood). Results of previ-
ous research suggest that military-connected individuals with strong social connec-
tions may better adjust to challenges (Mmari et al., 2010). Looking forward, authors
have called for programs with more empirical support and services targeting needs
across the family system and stages of the deployment cycle (Chandra et al., 2011;
Esposito-Smythers et al., 2011).
Limitations
The group in the current study considered the existing services, ongoing needs, and
future directions for services for military-connected families, and they brought to
light strong suggestions for forward movement. Despite this contribution, many
needs still remain.
First, MCY were noted to be frequently overlooked in programming, and their
voices and opinions are also lacking here. Focus groups with MCY, considering
their views of existing services and ongoing needs, will be a significantly valuable
contribution to the literature. Further, MCY’s preferred future directions may
include strategies for engaging their same-aged peers as well as adults and systems
to promote community and successful development across children and settings.
Second, this group focused primarily on mobilizing services in South Carolina,

though several other steps to provide stronger and more consistent services to
military-connected families have been taken in other states both within and outside
of the southeastern United States. Future research might consider existing models of
service in other states or territories and military-connected families’ responses to
them, as well as evaluate and discuss the process of developing new services and
collaborations.
Existing developmental theories are comprehensive and robust; however, given
the unique developmental experiences of MCY, additional research is needed to
determine if existing developmental theories adequately describe, predict, and
explain developmental outcomes for MCY. The research recommendation of the
focus group participant proposing “a theoretical model of the unique experience of
a MCY” is highly relevant. While MCY do access evidence-based treatments, there
is an alarming dearth of quality research published evaluating behavioral health
programs specifically for MCY (Moore et al., 2017). There appears to be an assump-
tion that evidence-based programs will generalize to this population and their con-
texts; however, research and program evaluation is a significant need in this area.
References
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Furthering the Advancement of School
Behavioral Health in Your Community
Mark D. Weist, Darien Collins, Samantha Martinez, and June Greenlaw
The above chapters reflect a deep analysis on strategies to improve school behav-
ioral health (SBH) across five content dimensions, collaboration, schoolwide
approaches, cultural responsiveness, quality of services, and implementation sup-
port, and three populations, students connecting to juvenile justice, child welfare, or
the military, with these themes and populations prioritized through our research
funded by the Patient-Centered Outcomes Research Institute (PCORI). In synthe-
sizing the contents of this focused book, the diverse team of individuals involved in
developing it reviewed findings from all the focus groups and brain-stormed ideas
in relation to our collective experiences in advancing the SBH agenda in South
Carolina and the Southeast region of the United States (US). Collaborators on this
book include disciplines of family members (of youth with emotional/behavioral
challenges), veterans, school and clinical psychologists, mental health consultants,
social workers, teachers, advocates, and undergraduate students, graduate students,
research staff, program evaluators, post-doctoral fellows, and faculty members.
Collectively, this group has over 100 years of experience in SBH. Ideas presented in
the following amplify and add to themes/recommendations emanating from focus
groups, are consistent with research and literature on effective SBH, and can be
viewed as a menu of options for strengthening programs at both school and district
levels. Here, we distill from all chapters critical themes, with 34 identified and
reviewed here:
1. Expand the voices of family and diverse community members in driving the
SBH agenda, and build relationships among school and mental health staff,
students, and families.
2. Attend to “siloing” among systems and groups of people and pursue cross-
system collaboration.
M. D. Weist (*) · D. Collins · S. Martinez · J. Greenlaw

Department of Psychology, University of South Carolina, Columbia, SC, USA
e-mail: weist@sc.edu; darienc@email.sc.edu; stm1@email.sc.edu; june.headley@sc.edu

https://doi.org/10.1007/978-3-030-56112-3_10
3. Improve family-school-community partnerships in developing resources for

guiding and expanding SBH programs.
4. Maintain user-friendly directories of school and community resources, to help
students, families, and school staff connect to these resources and provide
ongoing staff support to assure they are up to date.
5. Conduct community fairs, planned by school staff, families, and students to
involve other community agencies and resources to help build connections
with them.
6. Stigma is a significant issue limiting the use and impact of SBH, and there is a
compelling need to train teachers and students together in mental health liter-
acy, which reduces stigma and is associated with improved help seeking and
functioning.
7. Build wellness-focused training (e.g., coping, exercise, nutrition, stress man-
agement, mindfulness) programming for students, families, teachers, and
school staff including SBH staff from community agencies.
8. Train staff, families, and students on trauma and trauma-sensitive approaches in
schools.
9. Improve training and classroom support for teachers on promoting positive
behavior, effective classroom management, and assuring positive relationships
with students.
10. Improve communication to assure all schools/districts have teams and points of
contact for advancing the SBH agenda.
11. Guided by district level leadership teams, implement effective memoranda of
agreement (MOAs) between schools and community mental health (and other)
agencies, and assure confidentiality and breakdown confidentiality-related bar-
riers (e.g., pertaining to HIPAA, FERPA).
12. Build paraprofessional staff in schools to provide support to educators and
increase staff support especially for Tier 1 and Tier 2 programming.
13. Implement mentoring-based programs at Tier 2 (e.g., Check In- Check Out;
Crone, Hawken, & Horner, 2010), augmented with training in social emotional
learning (SEL) and skills-training programs.
14. Expand teams to ensure they are inclusive of all disciplines, include families
and students, and assure clarity of roles for all team members and effective
team meetings.
15. Empower students and families as decision-makers in schools and support them
in roles to co-create the education environment with school staff and mental
health system collaborators.
16. Embrace technology to improve communication among all professionals and
stakeholder groups.
17. Evaluate all programs delivered across Tiers 1, 2, and 3, to assure they are
evidence-based and consider input from multiple sources within the community.
18. Align programs to eliminate those lacking evidence and/or satisfaction.
19. Make data easier to use and involve diverse school staff, families, and students
in reviewing and making data-driven recommendations for SBH interventions.
Furthering the Advancement of School Behavioral Health in Your Community 125
20. Focus on equity of services and in discipline practices to escalate actions to

reduce disproportionality for negatively affected groups such as males and
youth of color.
21. Increase compassionate and effective approaches for students receiving exclu-
sionary discipline (e.g., suspension/expulsion) to move toward reducing blame
and building supportive programs to help reintegrate them into their schools.
22. Reduce use of alternative school programming for at-risk students, and when
these programs are used, assure appropriate and supportive transitions to the
program and then back to their home school.
23. Assure all programs and services within the multi-tiered system of support
(MTSS) including Tier 3 treatment services are available to all students/fami-
lies regardless of health insurance status, and significantly involve private
insurers more in funding SBH.
24. Make mental health in schools a funding priority through cohesive policies at
the local and state levels, and capitalize on federal funding opportunities.
25. In SBH initiatives, include experts on policy and funding to explore tradition-
ally used (e.g., Title 1, special education funding to schools, Medicaid) and less
commonly used (e.g., funds from juvenile justice and child welfare) funding
mechanisms, to expand programming across schools within districts.
26. Move beyond ad hoc involvement of clinicians from the mental health system
toward their more consistent and meaningful involvement in schools (e.g., no
assignments less than half-time at one school building).
27. Develop strategies to be able to identify students involved in juvenile justice
and/or child welfare systems and provide supportive services in school to them
and their caregivers.
28. Provide training to school staff on common problems encountered by students
in juvenile justice and child welfare systems (e.g., abuse, neglect, domestic
violence, substance abuse) and transition support strategies.
29. Provide supportive liaison/case management services to families/caregivers
with connections to juvenile justice and child welfare to assist them and their
students to stay connected to the school, its curriculum, and supportive
programs.
30. Include caregivers with experience in juvenile justice and child welfare in
developing and implementing district- and state-wide policies to improve pro-
grams and supports for students encountering these systems.
31. Develop a state-wide advisory group that includes older youth and families to
coordinate cross-system collaboration between education, mental health, child
welfare, and juvenile justice in developing SBH programs accessible to the
range of students who are impacted by these additional systems.
32. In communities that have higher percentages of military families, provide sup-
ports within the MTSS for the unique stressors these families and students
encounter (e.g., frequent moves, changes in school systems, family member
deployments, and reintegration).
33. In communities including more military stakeholders, assure that soldiers, offi-
cers, and other family members have a role in decision-making at the district
and school levels.
34. Devote time to data infrastructure, considering use of non-proprietary mea-
sures, strong information technology support, and aligning data systems to
assure that all data collected are actually used for SBH program improvement
and expansion.
Powerful arguments can be made that growing and improving SBH is an agenda
relevant to any community in the United States, since these programs, when done
well, reduce/remove barriers to student learning and help to assure students’ posi-
tive social, emotional, behavioral, and academic functioning (see Eber et al., 2019;
Weist, Lever, Bradshaw, & Owens, 2014). Thus, this agenda is relevant to the
diverse stakeholder groups mentioned throughout the book including families and
youth, leaders and staff of youth-serving systems (e.g., education, mental health,
child welfare, juvenile justice, primary care, disabilities, military involved), govern-
ment officials, researchers, and members of faith and business communities (see
Andis et al., 2002; Lever et al., 2003). Further, as presented in the introductory
chapter, the current COVID-19 pandemic is leading to significantly increased men-
tal health challenges for all people, including children and adolescents, underscor-
ing the importance of SBH as an accessible, ecologically valid, and effective
framework for delivering mental health services in the years to come.
As diverse people meet within school districts and the communities served by
them, embracing a community of practice approach (Cashman et al., 2014; Wenger,
McDermott, & Snyder, 2002) and planning systematically to build capacity for
SBH programs would be a critical strategy for improving the positive adjustment
and wellness of students and families. The above menu of 34 strategies could be
used to help guide these discussions.
To support progress in advancing the SBH agenda in your community, the fol-
lowing resources would likely be of assistance. National centers for Positive
Behavioral Interventions and Supports (PBIS; see www.pbis.org) and school mental
health (see www.schoolmentalhealth.org) provide a range of relevant resources for
improving SBH practice and for building policy support for these programs, includ-
ing many free, public domain materials and resources regarding effective assess-
ment and programming in all levels of schools’ multi-tiered systems of support. The
Midwest PBIS Network (see www.midwestpbis.org) is a partner with the National
Center for PBIS and also works to develop the capacity of schools to support the
success of all students, including those with elevated needs, with a particular empha-
sis on resources from the increasingly prominent Interconnected Systems Framework
(ISF) for PBIS and SMH (also see Barrett, Eber, & Weist, 2013; Eber et al., 2019).
Similarly, the Family-School-Community Alliance (see https://fscalliance.org) sup-
ports outreach, empowerment, and engagement of family, youth, and community
partnerships in research, practice, and policy. The Southeastern School Behavioral
Health Community (SSBHC; see www.schoolbehavioralhealth.org) represents one
of a range of regional collaboratives also focusing on the advancement of SBH. We
Furthering the Advancement of School Behavioral Health in Your Community 127
hope that themes and recommendations in this focused book, including voices from
diverse stakeholders, especially youth and families, helps to inform the develop-
ment and expansions of achievable strategies to build capacity for effective SBH in
diverse communities.
References
Andis, P., Cashman, J., Praschil, R., Oglesby, D., Adelman, H., Taylor, L., et al. (2002). A strategic
and shared agenda to advance mental health in schools through family and system partnerships.
International Journal of Mental Health Promotion, 4, 28–35.
Barrett, S., Eber, L., & Weist, M. D. (2013). Advancing education effectiveness: An interconnected
systems framework for Positive Behavioral Interventions and Supports (PBIS) and school men-
tal health. Center for Positive Behavioral Interventions and Supports (funded by the Office
of Special Education Programs, U.S. Department of Education). University of Oregon Press.
Cashman, J., Linehan, P., Purcell, L., Rosser, M., Schultz, S., & Skalski, S. (2014). Leading by
convening: A blueprint for authentic engagement. Alexandria, VA: National Association of
State Directors of Special Education.
Crone, D. A., Hawken, L. S., & Horner, R. H. (2010). Responding to problem behavior in schools,
second edition: The behavior education program. New York: Guilford Publications.
Eber, L., Barrett, S., Perales, K., Jeffrey-Pearsall, J., Pohlman, K., Putnam, R., Splett, J., &
Weist, M. D. (2019). Advancing education effectiveness: Interconnecting school men-
tal health and school-wide PBIS, Volume 2: An implementation guide. Center for Positive
Behavioral Interventions and Supports (funded by the Office of Special Education Programs,
U.S. Department of Education). University of Oregon Press.
Lever, N. A., Adelsheim, S., Prodente, C., Christodulu, K. V., Ambrose, M. G., Schlitt, J., et al.
(2003). System, agency and stakeholder collaboration to advance mental health programs in
schools. In M. D. Weist, S. W. Evans, & N. A. Lever (Eds.), Handbook of school mental health:
Advancing practice and research (pp. 149–162). Springer.
Weist, M. D., Lever, N., Bradshaw, C., & Owens, J. S. (2014). Further advancing the field of school
mental health. In M. Weist, N. Lever, C. Bradshaw, & J. Owens (Eds.), Handbook of school
mental health: Research, training, practice, and policy (2nd ed., pp. 1–16). Springer.
Wenger, E., McDermott, R.A., & Snyder, W. (2002). Cultivating communities of practice: A guide
to managing knowledge. Harvard Business Press.
Index
A method, 99, 100

Association for Positive Behavior Support, 30 recommendations, 102–104
Attention deficit/hyperactivity disorder voluntary kinship care, 95
(ADHD), 78, 79 Civilian families, 108
Autonomy, 12 Classroom check-up, 12
Classroom management training, 82
Collaboration
B approaches, 9
Behavioral health (BH) and autonomy, 12
educating administrators, services, 84 and awareness, 14
juvenile justice involvement, 75 commonplace language, 9
programs, 78 family engagement, 13
Behavioral Health Optimization Program LbC framework, 10
(BHOP), 109 and partnerships, 10
Buy-in recommendations, improvement,
administrator and senior faculty, 23 15, 16
barriers, 23 required antecedents, 10
interventions, 23 school and community, 10
participants, 26 stigma, 12
PBIS, 23, 26, 28 teaming, 16
recommendation, 23 Collaborative approaches, 9, 17
school staff, 30 Commonplace language, 9
school-wide PBIS, 28 Communication, 11, 13, 16, 17
Community-employed mental health, 29
Community of practice, 1, 126
C Community partnerships, 61, 65
Child abuse, 97, 98 Community support, 97, 103
Child welfare (CW) systems, 2, 5 Continuum of care, 85
adoption services, 95 COVID-19, 6, 7, 126
collaboration, 97, 98, 100, 101 Cultural competency
family and community support, 98, 101 criticism, 35
formal kinship care, 95 health and mental health care, 35
juvenile justice involvement, 99 humanity (see Cultural humility)
juvenile justice system, 102 race and ethnicity, 35
mental health, 96, 97 training programs, 36

https://doi.org/10.1007/978-3-030-56112-3
130 Index
Cultural humility Family-School-Community Alliance

characterization, 36 (FSCA), 24, 126
definition, 35 Family-school-community partnerships, 124
discipline practices, 38, 41, 42 Foster care, 95–97, 102
lack of trust, 37, 38, 41 Functional behavioral assessment (FBA), 50
minority students, 36 Funding, 83
SBH methods, 39
SBH programs, 44
stereotypes, 36, 40 G
stigma, 37, 39, 40 Gender and sexual orientation, 76
themes, 39 General education environment, 81
Culturally competent, 35
Culturally humble SBH, 42
Curricula, 82 H
Health Insurance Portability and
Accountability Act (HIPAA), 62
D HomeFront Strong, 111
Data sharing, 66, 67 Human service agencies, 30
Department of Juvenile Justice (DJJ), 80,
85, 88, 89
Depression, 78 I
Discipline disproportionality, 77 Implementation fidelity, 22, 24, 27, 30
Discipline practices Implementation support
antisocial behavior and suspension, 38 child-serving entities, 60
behavioral problems, 42 community partnerships, 61, 65
drug and alcohol use, 38 data sharing, 66, 67
forum participants, 41 information/data sharing, 62
long-lasting consequences, 38 interdisciplinary collaboration, 61,
racial and ethnic groups, 38 62, 65, 66
Diversity, 123, 124, 126, 127 mental health disorder, 59
Domestic violence (DV), 98 method, 63
quality, 59
recommendations
E addressing insurance challenges, 69
Educational disruption, 77 behavior management strategies, 67
Emotional/behavioral (EB) problems, 47 communication, 69
Emotional control, 82 district-community partnerships, 68
Emotional disability (ED), 80 helping families, 70
Evidence-based PBIS practices, 28 lack of awareness, 68
Evidence-based practices (EBPs), mental health literacy, 68
22, 50 mental health supports, 68
Exceptional Family Member Program partnerships, 68, 69
(EFMP), 109 quality, 68
Exclusionary discipline, 36 resource-intensive intervention, 67
school leadership, 68
supports, 70
F teaching coping skills, 68
Family-centered interventions, 87 school setting, 59
Family check-up, 12 staff capacity, 60, 63, 64
Family Educational Rights and Privacy Act treatment engagement and retention, 59
(FERPA), 62 Implementation support (IS), 4
Family engagement, 10, 13, 15, 17 Individualized Education Plan (IEP), 27, 48
Family-focused mental health promotion Individuals with Disabilities Education Act
workshops, 29 (IDEA), 21, 48
Index 131
Information/data sharing, 62 Mental health services, 75, 85, 90

Information sharing, 66, 67 MI-based treatments, 12
Interconnected Systems Framework Midwest PBIS Network, 126
(ISF), 3 Military-connected youth (MCY), 5
Interdisciplinary collaboration, 61, 62, community supports, 112, 117, 118
65, 66 deployment cycle, 110
deployment-related stressors, 109
EFMP, 109
J existing services, 109
Juvenile incarceration, 75 future directions, 118, 119
Juvenile justice-involved youth (JJIY), 4 gaps in available services, 109
black ex-juvenile offenders, 76 indirect support, 115
continuum of care, 84–86 lack of programs, 111
depression and anxiety, 75 MFLC program, 114
early incarceration, 76 MFLC services, 110
educational quality, 80–82 military-focused/non-DoD school
environmental influences, 86–87 setting, 113
gender and sexual orientation, 76 prevention programs, 110
mental health support in childhood, 75 recommendations, 111
non-White students, 76 research institutions, 116
risk factors SBH services, 113
ADHD, 78, 79 Smooth Move workshops, 114
depression, 78 state-based supports, 111
learning difficulties, 79 state-wide leadership team, 117, 118
learning disabilities, 79 Strong Bonds, 114
mutual frustration, 79 young age, 108
participant recommendations, 80 Military families
student trauma, 78 active duty and Selected Reserve
violent trauma, 79 members, 107
school administrators, 76 EFMP, 109
school-based programs, 77 emotional and behavioral health, 112
school-to-prison pipeline, 77, 89 existing services, 109, 114, 115
short-term effects, 76 MCY, 107 (see also Military-connected
stakeholder opinions, 77 youth (MCY))
system failure, 82–84 MCY and military-connected
transition from DJJ, 87–89 parents, 112
Juvenile justice involvement, 75 mental health
Juvenile justice system, 38, 75 challenges by civilian families, 108
need of MCY, 108
signature injuries, 108
L MFLCs, 110
Lack of trust, 37, 38, 41 MTFs, 109
Large-scale PBIS implementation, 29 stakeholder involvement, 112
Leadership teams, 30 state-wide effort, 111
Leading by Convening (LbC) stressors, military life, 108
framework, 10, 17 supports, 117
Learning disabilities, 79, 80 in Virginia, 108
Military family life counselors (MFLCs), 110,
114, 115, 118
M Military OneSource (MOS), 110
Mental health disorder, 10, 59 Military stakeholders, 126
Mental Health First Aid, 29 Military treatment facilities (MTFs), 109
Mental health literacy, 59, 68 Modular “common elements” (MCE), 50
Mental health providers, 43 Motivational interviewing (MI), 12, 17
132 Index
Multitiered systems of supports (MTSS), 1, 3, scaling-up, 29

4, 47, 67 school-wide approaches, 22
buy-in, 23, 26 SEBA, 29
familial involvement, 24, 27 standard training models, 28
implementation fidelity, 26 Priority populations, 2, 5
large-scale PBIS implementation, Punitive discipline practices reduction
24, 27, 28 absences, 42
methods, 25 academic instruction, 42
PBIS (see Positive Behavioral discipline disproportionality, 42
Interventions and Supports (PBIS)) disparities, 42
providing effective training, 23, 26, 27 school discipline rates, 42
RTI, 21 student-level characteristics, 42
school-wide systems, 21 suspensions, 42
supports across domains, 21
themes, 22
Mutual trust, 44 Q
Quality of services, 51
N
Neglect, 96, 97, 99 R
Non-medical counselors, 110 Response to Intervention (RTI), 21
NVIVO program, 2
S
O SBH planning and implementation, 30
Outpatient programs, 76 SBH programming, 29
School-based programs, 77
School behavioral health (SBH)
P awareness, 11
Partnership, 10, 13 behavioral plans, 52
PBIS implementation with fidelity collaboration, 12, 47, 48, 52
barriers, 22 collaborative approaches, 9, 10, 14
EBPs, 22 (see also Collaboration)
ecologically valid settings, 22 community connected stakeholders, 1
measures, 22 community of practice, 1
negative response, 26 content dimensions, 123
office discipline referrals reduction, 23 COVID-19 virus, 6
research forum, 25, 26 critical themes for advancement
rural school districts, 22 in SC, 2
school challenges, 22 cultural responsiveness and humility, 4
PBIS/MTSS maps, 24 data-based decision-making, 49, 50, 53
Positive Behavioral Interventions and Supports education, 47
(PBIS), 126 family engagement, 13
academic outcomes, 30 IS, 4
administrators, 28 for JJIY, 4, 5
emphasizes, 21 leadership roles, 4
enhanced family engagement, 29 mental health services, 48
family engagement, 29 mentoring-based programs, 124
implementation fidelity (see PBIS method, 51
implementation with fidelity) MI, 12
implementers, 28 MTSS, 1, 3, 4
implementors, 30 for MCY, 5
office discipline referrals reduction, 21 national centers, 3
practices, 28 national movements, 3
Index 133
NVIVO program, 2 Stereotypes

overcoming inertia, 51 definition, 36
participants, 52 mental health services, 40
partnerships and collaboration, 10 participants, 40
practice and policy improvement, 2 SES, 36
prevention and interventions, 3, 9 single-parent households, 36
prioritize mental health, 50, 51, 53, 54 threaten students’ academic
qualitative data, 47 performance, 36
quality, 52 Stigma, 10–14, 17, 124
recommendations, 54, 55 associated mental health, 37
services for priority populations, 2 barriers, 40
Spirit of MI, 12 distorted beliefs, 37
stigma, 11, 12, 14 forum, 40
strengthening programs, 123 lower help-seeking, 37
system failures, 54 mental health treatment, 37
understanding and empathy, 12 self-stigma, 37
wellness-focused training, 124 society, 37
youth involvement/training, 49, 53 Student check-up, 12
School bullying, 10 Substance use disorder, 79
School Improvement Plan, 28 Supportive services, 15
School systems, 43 Systems partnerships, 2, 3
School-to-prison pipeline, 77, 89
School-wide mental health literacy
programs, 29 T
School-wide practice, 23 Teacher training on behavior, 81
Self-advocacy, 115, 116 Teaching practices, 81
Self-stigma, 37, 38 Teaming, 9, 16
Social competency, 82 Therapeutic programs, 76
Social skills deficits, 80, 81 Trauma-informed care, 101
Social, emotional, behavioral, and academic Trust development
(SEBA), 21, 29 clients, 43
Social-emotional learning (SEL), individual experience, 43
5, 82 mental health providers, 43
Socioeconomic status (SES), 35 relationship, 43
Southeastern School Behavioral Health
Community (SSBHC), 2, 126
Special education environments, 85 W
Special education services, 21 Wellness-focused training, 124
Spirit of MI, 12, 17
Staff capacity, 60, 63, 64
Stakeholder involvement, 109 Y
State-wide leadership team, 117, 118 Youth and families, 125, 127
Statewide PBIS implementation, 24 Youth Mental Health First Aid, 30

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School Behavioral Health: Mark D. Weist Kathleen B. Franke Robert N. Stevens Editors

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Mark

School Behavioral Health

ISBN 978-3-030-56111-6 ISBN 978-3-030-56112-3 (eBook)

Linden Atelsek University of Virginia School of Law, Charlottesville, VA, USA

Carissa Orlando Psychology Department, University of South Carolina,

AAPCSH American Academy of Pediatrics Committee on School Heath

MFLC Military Family Life Counselor

Mark D. Weist, Kathleen B. Franke, and Robert N. Stevens

© Springer Nature Switzerland AG 2020 1

prior to juvenile justice interactions, failure of the behavioral health system to

Completing this Book in April 2020

Further, an important foundation of SBH is to assure continuity in programming

Kathleen B. Franke, John Terry, Tristan Collier, and June Greenlaw

K. B. Franke (*)

© Springer Nature Switzerland AG 2020 9

presents by 14 years of age in approximately half of the children and adolescents

There is a broad consensus that stigma is a significant barrier to student access to

between parents and school-based mental health providers (Hinshaw, 2005). To

Increasing Actions that Convey Understanding and Empathy

Seventeen diverse participants in SBH partook in a 2017 focus group to explore

This lack of collaboration and awareness contributes to feelings of isolation and

sensitivity and… classrooms too that also address social/emotional health.”

Supportive services extend beyond traditional SBH clinicians. Participants called

Participants provided several recommendations to improve collaboration between

Another participant added,

Participants recommended that a single individual identified as the school-based

Finally, recommendations were made for schools to identify and acknowledge

Authentic and strong collaboration is required to serve students appropriately; how-

T. Collier (*) · V. Rizzardi

© Springer Nature Switzerland AG 2020 21

Implementing PBIS with Fidelity

Implementation fidelity is a measure of how well a program is being executed as

Providing Effective Training

Familial involvement with the school experience of children and adolescents is

Large-Scale PBIS Implementation

Fourteen stakeholders gathered to discuss the strengths and weaknesses associated

Implementing PBIS with Fidelity

Participants brought up the issue of buy-in to PBIS as an important aspect of suc-

Providing Effective Training

Throughout the forum, Participants discussed their experiences with family/school

Large-Scale PBIS Implementation

implementation prevents students from receiving the necessary resources due to

Victoria Rizzardi, Sommer C. Blair, Barbara Kumari, and June Greenlaw

© Springer Nature Switzerland AG 2020 35

Association [APA], 2018). To further elaborate, cultural humility is characterized

Social stereotypes were defined as early as 1922 by journalist Walter Lippmann as

of normalized or celebrated, there can be adverse effects on anyone who is stereo-

Mental Health Stigma

Mental Health Stigma

Parental Lack of Trust

Working harder to find the underlying issues to behavioral problems, as opposed to

Recommendations for Moving Forward

Reducing Punitive Discipline Practices

Greater Involvement in Students’ Lives

Sommer C. Blair, Darien Collins, and Kathleen B. Franke

Critical Quality Dimension in SBH

© Springer Nature Switzerland AG 2020 47

Youth Involvement/Training Youth are often considered “half-members” when it

Many participants emphasized the importance of data-based decision-making

Prioritize Mental Health

Similarly, another participant recommended a “… program for kids that tradi-

Recommendations for Moving Forward

Here, we summarize recommendations for improving the quality of

Completing this Book in April 2020

Increasing Actions that Convey Understanding and Empathy

Implementing PBIS with Fidelity

Providing Effective Training

Large-Scale PBIS Implementation

Implementing PBIS with Fidelity

Providing Effective Training

Large-Scale PBIS Implementation

Mental Health Stigma

Mental Health Stigma

Parental Lack of Trust

Recommendations for Moving Forward

Reducing Punitive Discipline Practices

Greater Involvement in Students’ Lives

Critical Quality Dimension in SBH

Prioritize Mental Health

Recommendations for Moving Forward

Recommendations for Moving Forward

The Importance of Partnerships

Need to Enhance Communication

Addressing Insurance Challenges

Helping Families Find Help

Increasing Implementation Supports

Transition from the Juvenile Justice System

ental Health Needs of Youth within the Child Welfare

hallenges to Addressing Mental Health Needs for Students

Increasing Family and Community Support

Preventing Juvenile Justice Involvement

Themes Related to Collaboration

Themes Related to Family and Community Support

Themes Related to Prevention of Juvenile Justice Involvement

Recommendations for Moving Forward

Gaps in Available Services