Mental Health in Schools: An Overview of Multitiered Systems of Support

Abstract

Mental health–related disabilities are a leading cause of health issues worldwide. Because of this, an argument can be made that schools integrate mental health services for their students to positively impact their mental health outcomes. This article outlines how multitiered systems of support (MTSS) can assist schools in providing all students with mental health services including students with disabilities. The role of school-based mental health professionals (i.e., school counselor, school psychologist, school social worker) within the MTSS framework is discussed to better assist teachers in helping their students access school-based mental health services.

Keywords

emotional and behavioral disorders (EBD)behavior school counseling depression at risk students suicide

Mental health–related disabilities (e.g., depression, anxiety) are a leading cause of health issues worldwide, affecting around 450 million adults and adolescents, two thirds of whom will not access help from a health professional (World Health Organization, 2018). In the United States, one in five adults and one in five adolescents will experience some form of mental health issue (National Alliance on Mental Illness, 2019).

For adolescents, depression is the most common mental health issue, which affects approximately one in eight adolescents (Federal Interagency Forum on Child and Family Statistics, 2017). Diagnosed depression rates among adolescents have risen significantly from 8.7% in 2005 to 11.3% in 2014; however, mental health service access rates did not increase (Mojtabai et al., 2016). Furthermore, for students from ages 10 to 24, the second leading cause of death is suicide (Centers for Disease Control and Prevention [CDC], National Center for Injury Prevention and Control, 2017). More than 90% of students who committed suicide had at least one diagnosable mental health disorder (National Alliance on Mental Illness, 2017). Currently, the Individuals with Disabilities Education Act (IDEA, 2004) categorizes students with mental health–related disabilities under the emotional disturbance category; however, recent research has discovered that many students from a variety of disability categories also experience mental health issues (IDEA, 2004; Pastor & Reuben, 2009). To effectively address the mental health needs of students with disabilities as well as at-risk students, it is important that the identification and service provision discussion includes school-based services (CDC, Division of Adolescent and School Health, 2016; Pastor & Reuben, 2009).

An argument can be made that school-based services that integrate mental health services can positively impact mental health issues in adulthood (Atkins et al., 2010; Marsh, 2016; Mental Health America, 2015). It is estimated that students with disabilities who receive services early for mental health issues have the lowest rates of problematic outcomes and the highest levels of positive school-related outcomes (e.g., increased school connectedness, better decision-making and problem-solving skills, lower rates of suicide ideations and attempts; Cumming et al., 2018; McGorry & Purcell, 2009). However, students with disabilities who experience school-related problems because of mental health issues, who do not receive services are at an increased risk for dropping out of school, being expelled from school, and engaging in health risk behavior (e.g., aggression toward others, substance abuse, self-harm, delinquency; Cumming et al., 2018; Edmonds-Cady & Hock, 2008). This is particularly problematic as social isolation only heightens the risk of developing chronic mental health issues through adulthood (Kauffman & Badar, 2018).

Currently, about 65% of school districts actively review mental health policies with school staff (CDC, Division of Adolescent and School Health, 2016). Most district policy procedures are considered multitiered systems of supports (MTSS; Brown-Chidsey & Bickford, 2016). These tiered levels of supports are prevention-based programs for all students that include foundational support programs (e.g., school-wide positive behavioral interventions and supports [SWPBIS], screening) as well as more targeted support programs for students who require additional services (i.e., referrals to mental health agencies, social services; Brown-Chidsey & Bickford, 2016; CDC, Division of Adolescent and School Health, 2016). However, there are still many schools that struggle with MTSS procedures to address student mental health (Rossen & Cowan, 2015). Despite this, more than 75% of schools employ at least one individual capable of addressing student mental health needs (Brener et al., 2007). The services available, the number of specialized individuals available to help, the overall quality of the programs, and the fidelity of implementation by schools differ from state to state and district to district (Brener et al., 2007; Cook et al., 2015; Kauffman & Badar, 2018).

Most students who experience mental health issues are educated in the general education environment with teachers, who have not been trained to recognize the subtle signs of their issues or to address their needs (Kauffman & Badar, 2018). This also is the case for students with disabilities (Kauffman & Badar, 2018). Teachers are in the unique position of being able to identify possible externalized or internalized issues of behavior and refer students to support services, so it is important that they are trained to recognize early warning signs as well as understand their school’s MTSS support structure for addressing student mental health issues. Once they are trained in identifying the soft signs, they can improve their school’s level of support and be a valuable resource for other school professionals (i.e., counselor, school social worker, school psychologist) responsible for providing students with mental health services (Kang-Yi et al., 2018). Because of this, teachers are valuable and integral in addressing the mental health issue of many students with disabilities. This article outlines the MTSS process and describes the roles of additional school personnel who may be on school campuses to support students with disabilities as well as at-risk students who may require additional mental health supports or evaluation.

Mr. Stewart has been teaching resource level English at the middle school level for about 4 years. During those 4 years, he has experienced his fair share of students who have behavioral challenges. Last year, Mr. Stewart attended a SWPBIS professional development session provided through the school district to improve his classroom management skills, but his current school does not have a SWPBIS system in place. Despite the lack of SWPBIS at his school, he was able to develop a classroom management system in order to address classroom behavior issues. However, this year, Mr. Stewart has a new student, Braden, who is struggling in his class. Braden started off the year coming to school daily, arriving to class on time, participating in class discussions, and completing work both in groups and independently. However, over the past few weeks, Braden has been missing school more often, arrives to class late, when he arrives to class he puts his head down, he loses his homework, doesn’t complete much class work, and asks to leave class to go to the bathroom three or four times during class. Mr. Stewart has grown concerned with the behavior he has observed, but when he talks to Braden, Braden says he’s fine and that he’s just tired. When, Mr. Stewart gives Braden positive verbal feedback, greets him as he arrives, or gives him some general words of encouragement and some help starting his work, he will begin to engage in the class but not to the same level as before. Also, these problem behaviors will continue the following day or he may miss one or more days of school. Mr. Stewart knows that Braden requires additional support beyond classroom interventions but is unsure of his next steps in coordinating additional services for Braden (see Note 1).

Multitiered Systems of Support

Screening and referral protocols for identifying students for school-based mental health services vary among schools and districts with no specific model for referral deemed a best practice (Paternite, 2005). Despite the lack of cohesion in policy, many teachers and administrators consider addressing student mental health as imperative for learning (Moon et al., 2017). For many schools, mental health service provision exists at the school level as a part of the MTSS process, such as SWPBIS, which includes school-wide practices that address mental health and mental health assessment screening (Brown-Chidsey & Bickford, 2016; Kauffman & Badar, 2018). Also, as a part of the MTSS process, additional levels of support can be provided to students by a school counselor, social worker, or school psychologist (Atkins et al., 2010; Demissie & Brener, 2017).

The first step for Mr. Stewart is to locate his school’s MTSS coordinator regarding the provision of mental health services and supports on his school campus.

Fundamentally, MTSS is the application of prevention systems in the school environment (Brown-Chidsey & Bickford, 2016). The most common iterations of MTSS in schools are (a) the response to intervention (RTI) process, designed to identify students who are academically struggling as well as students at risk of learning disabilities; (b) SWPBIS, which is designed to address problem behaviors; and (c) social and emotional learning (SEL) programs designed to address student’s social and emotional development (Brown-Chidsey & Bickford, 2016; Kauffman & Badar, 2018). An MTSS incorporates three tiers of intervention.

The first tier is universal intervention or intervention that is provided to all students, which can consist of academic instructional practices, SEL inititatives, or SWPBIS (Gargiulo & Metcalf, 2017). The first tier of MTSS serves as a universal screening process to assess student academic skills and behavior, as well as social and emotional well-being (Brown-Chidsey & Bickford, 2016). Screening consists of academic progress-monitoring assessments, behavior referral data, school climate and safety assessments, and additional social and emotional screening instruments (Brown-Chidsey & Bickford, 2016; Desrochers, 2015). Tier 1 interventions can address most students’ needs, but a small number of students may not repond to this level of intervention, as identified by the screening procedures, and can become eligibile for Tier 2.

The second tier of MTSS is a targetted level of intervention designed to address the needs of a small number of students who may be at risk for certain academic, behavioral, or social and emotional issues (Gargiulo & Metcalf, 2017; Rossen & Cowan, 2015). Tier 2 interventions can include targeted academic instruction, the “check-in check-out” strategy, social skills groups, mentoring, and counselor small group sessions (Gargiulo & Metcalf, 2017; Rossen & Cowan, 2015). While there is evidence that these second-tier interventions are effective for most students, a small number of students may require additional individualized intervention.

The third tier of MTSS is individualized intervention and may consist of (a) conducting a functional behavior assessment and developing an individualized behavior plan; (b) direct student-level mental health services provided by a counselor, school psychologist, or school social worker; (c) additional coordinated mental health services with community agencies; or (d) possible identification for special education (Gargiulo & Metcalf, 2017; Rossen & Cowan, 2015). It is important to note that enrollment in Tier 2 or Tier 3 levels of intervention does not exlucde students from the other tiers of support. Each tier is an added level of intervention that is supported by the previous tier providing students with the level of support suitable for their needs (Brown-Chidsey & Bickford, 2016). For students with disabilities who are struggling with mental health issues, there are strategies avaliable for them at each level of MTSS; it is not a pathway to special education.

One of the most popular preventive frameworks for addressing mental health in school is SWPBIS; however, only about 18% of all schools employ SWPBIS in their campus (Freeman et al., 2016; Molloy et al., 2013). Despite this, teachers can use the principles of SWPBIS to develop a classroom management system consisting of positive behavior support interventions, which can include strategies such as creating positively stated classroom expectations, positive verbal praise, and specific positive praise to support the mental health needs of their students with disabilities (Cumming et al., 2018; Kauffman & Badar, 2018). These are Tier 1 strategies in regard to the MTSS framework that support all students (Kauffman & Badar, 2018). Utilizing Tier 1 strategies as a preventive intervention can allow educators to identify students who may require additional levels of support (Kauffman & Badar, 2018).

To refer to students for Tier 2 intervention, teachers should be aware of the person on their campus who is responsible for coordinating the mental health program. This person may be a counselor, school psychologist, school social worker, another teacher, or an administrator. Once a teacher is aware of whom that person is on campus, it is important to provide that person with data to assist the MTSS team to determine the appropriate supports. Data could consist of observational behavior data (e.g., frequency of yelling at students, frequency and duration of sleeping in class), attendance, student-disclosed information (e.g., telling the teacher about difficult incidents at home), or other observations that indicate possible issues (e.g., student not eating at lunch, student quitting clubs or activities they used to enjoy). These data can help the MTSS team determine whether Tier 2 intervention is appropriate and which intervention could best meet the student’s needs (e.g., group counseling session, SEL groups, check-in check-out, mentoring). As a part of this process, the MTSS team may decide to involve other school staff who have training in addressing mental health issues as a part of the intervention team.

Referral to the MTSS team may not seem like an option for special education teachers as their students are currently receiving Tier 3 intervention be it academic or behavior related. However, the MTSS framework does not exclude students based on the tier, all Tier 3 students also should be receiving Tier 1 and Tier 2 levels of support. Furthermore, there are a variety of MTSS programs in place on school campuses (e.g., SWPBIS, RTI, SEL, mental health), where a student may be receiving Tier 3 services under one type of program but not another (Rossen & Cowan, 2015). A student with a learning disability who is receiving Tier 3 academic interventions can still be a candidate to receive Tier 2–level mental health supports on a school campus. Integrating students with disabilities in the mental health MTSS programs on school campuses, rather than excluding them, has the potential to not only improve their mental health outcomes but also assist them in developing better connections to adults on their school campuses (Cumming et al., 2018; Sinclair et al., 2005).

Other School Staff

Mr. Stewart discovered that the MTSS coordinator for mental health services was the school counselor. He decided to contact the counselor in order to discuss possible development of coordinated school supports for Braden.

Nationwide approximately 76.8% of schools employ a person at least part-time at the school level in charge of assisting in the provision of mental health services and coordinating mental health services and referrals (Brener et al., 2007; Marsh et al., 2017). Typically, these employees are school counselors, but also can be social service workers or school psychologists (Brener et al., 2007). These individuals can be a valuable addition to the MTSS team as they are able to provide additional services for students including individualized counseling, screening and assessment, referral to community resources, peer counseling and mediation, or social and emotional skills instruction (Demissie & Brener, 2017).

School counselors

School counselors are qualified individuals on school campuses who are able to develop programs to support student success in academics and social and emotional development (American School Counselor Association [ASCA], 2019). These programs may consist of social and emotional curriculum development for classes or individual students, short-term counseling for students, referrals to community agencies for more long-term counseling support, and advocacy and participation in individualized education program (IEP) meetings (ASCA, 2019). School counselors also are responsible for coordinating depression screening and suicide awareness programs (Erickson & Abel, 2013). The use of counseling services at school reduces student engagement in externalized behaviors, improves student social and emotional skills, improves attendance rates and access to services, and develops levels of school connectedness (Amatea et al., 2010; Dimmitt & Wilkerson, 2012; Lemberger et al., 2018).

To refer a student to a school counselor, there are a few steps to follow. First, speak with the counselor directly and express your concerns, some of the behaviors or changes in behavior you’ve noticed from student, and the approximate amount of time you’ve been noticing these behaviors (ASCA, 2019). If you don’t know who the school counselor is, ask an administrator, as they may be part-time and not on campus every day (Brener et al., 2007). The counselor may request that you talk to the student directly about setting up an initial counselor referral, which would help to retain a positive teacher–student relationship and build a new positive relationship between the counselor and student (Cumming et al., 2018). From this point, the counselor may begin to (a) assess the level of student need, (b) work with both student and family, (c) bring services on campus, or (d) develop a referral to a community agency (ASCA, 2019). It is important to note that counselors are bound by ASCA ethical guidelines to protect student privacy and may only report updates and relevant information to teachers (ASCA, 2019).

School psychologists

School psychologists also are qualified individuals on school campuses who apply their expertise in mental health, assessment, and behavioral health to support student and teacher’s needs (National Association of School Psychologists [NASP], 2019). This support may consist of direct intervention for students, consulting with teachers to develop interventions, work with families, collaborate with school-level and community-level mental health professionals, and assist school administrators in the development of school-wide policies and practices (NASP, 2019). School psychologists have been effective in the development and delivery of SWPBIS, as well as instrumental in assessing and developing individualized and classroom-based behavior interventions (Atkins et al., 2010).

Referring students to the school psychologist is dependent on the school system and may vary from district to district; however, the teacher may contact the school MTSS coordinator regarding their concerns for a student and also provide data of incidences of externalized or internalized behavior or changes in behavior that they have observed (NASP, 2019). This is the best course of action, as similar to school counselors, school psychologists may not be on campus every day of the week (Brener et al., 2007). Most special educators should be familiar with the school psychologist as they are typically involved in disability assessment protocols, attend evaluation and reevaluation meetings, and may attend IEP meetings. However, teachers may not be aware of the role of the school psychologist beyond these contexts (Brener et al., 2007). Once the school psychologist is involved, they may work with the school teams to develop classroom-level interventions, supports, and data collection procedures; recommend the incorporation of other school services (i.e., counseling, social work); conduct further assessment to better understand the scope of the social or emotional issue; and work with the teacher(s) to support the incorporation of discussed strategies within their classroom (NASP, 2019).

School social workers

School social workers also are qualified to provide either direct or indirect mental health services on school campus (School Social Work Association of America [SSWAA], 2019). School social workers may participate in direct services including assisting in the design of behavior intervention plans, school safety plans, preventive mental health support plans, group or individual counseling, family counseling and may work as a home to school liaison (SSWAA, 2019). In terms of indirect services, school social workers are a valuable support creating important relationships between the home, school, and community agencies to establish a continuum of mental health services for students (SSWAA, 2019).

Referring students to the school social worker is dependent on the school system and may vary from district to district. To best address their student’s needs, teachers should get in contact with their school counselor or MTSS coordinator and complete a referral. Typically, the school counselor and the school social worker work collaboratively to address student needs (ASCA, 2019; SSWAA, 2019). Once the counselor has completed an assessment, they are able to get in contact with the school social worker, as they may not always be attached to a single campus, and refer them for services, which may include on-campus as well as home and community service and support (ASCA, 2019; Brener et al., 2007; SSWAA, 2019).

It is important to note that while many school districts employ school counselors, school psychologists, and school social workers, the likelihood of having all three dedicated to a single campus is unlikely (Demissie & Brener, 2017). However, each school may have at least one of these individuals working on campus full-time or part-time and that person is likely to be a school counselor (Demissie & Brener, 2017). Once teachers are able to locate the mental health MTSS resource person on their campus, they can provide a referral for services and that person can coordinate services for the student and contact the necessary support systems within the school district or in the community to provide those services (Brener et al., 2007; Demissie & Brener, 2017).

Mr. Stewart provided the school counselor, Mrs. Ringo, with Braden’s attendance data, tardy data, and some frequency data of Braden putting his head down in class. Mrs. Ringo set up a meeting with Mr. Stewart to develop a plan to support Braden. Following that meeting, Mrs. Ringo reached out to Braden’s parents to let them know about his behavior at school, that the school wanted to put a plan into place to help Braden get the supports he needed, and asked some questions about his behavior at home. Mrs. Ringo discovered that Braden’s dad had lost his job a few months previous and because of this, he was currently out of work, his mother was forced to take a job working mornings, and they had to move out of their house to an apartment. Also, Mr. Stewart met with Braden briefly after class one day, and expressed his concerns about his behavior and suggested that he introduce him to the school counselor to give him an added resource on campus who he could talk with outside of the class. Based on this meeting and the information from Braden’s parents, Braden was enrolled in school counseling services as well as a free lunch plan, which was a tremendous help for the family’s financial situation. Initially to address how often Braden missed school, Braden would check in with Mrs. Ringo each morning, they would go over how he was feeling, set goals for the day, and get him something to eat. If Braden attempted to miss school and his morning check in, Mrs. Ringo would contact his mother, who would contact a neighbor who would help him get to school. After 2 months, Braden’s attendance increased, his tardiness decreased, and he was able to begin to catch up on his missing work and re-engage in class. However, he struggled for the rest of the year to make up for all of the instruction he missed, but he did pass his classes, including Mr. Stewart’s class. During teacher appreciation week, Mr. Stewart received a wonderful thank you note from Braden about all of the help and support he provided to him and let him know that he helped to get him through a very tough time in his life.

Conclusion

While there are many different options in the form of services provided for students with disabilities in need of mental health services, it is important that teachers locate the person or staff responsible for coordinating these services. Professionals on campus such as the school counselor, school psychologist, or the school social worker can incorporate data collected from the classroom teacher to build a rationale for the student requiring mental health or behavioral services at the school level or in collaboration with a community agency (Brener et al., 2007). Although these professionals are responsible for referring students for mental health services, they may not always recognize the signs of mental health issues in students, as they are not working consistently within the classroom (Johnson et al., 2011). In addition to school-wide screening procedures, teachers are able to notice dramatic differences in behavior and possible symptoms of mental health issues in the classroom and can assist other school staff in connecting students with disabilities in need of mental health services with the service providers who can help them (Johnson et al., 2011).

Based on his experience with Braden, Mr. Stewart recommended to his principal that the school should contact the district about implementing SWPBIS at their school. Additionally, Mr. Stewart joined the MTSS team to help them develop Tier 2 intervention options to help students, like Braden, who display signs of mental health issues, but are not highly disruptive in class.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

References

Amatea

E. S.

Thompson

I. A.

Rankin-Clemons

Ettinger

M. L.

(2010). Becoming partners: A school-based group intervention for families of young children who are disruptive. Journal of School Counseling, 8, 1–31.

American School Counselor Association. (2019). The role of the school counselor. https://www.schoolcounselor.org/asca/media/asca/Careers-Roles/RoleStatement.pdf

Atkins

M. S.

Hoagwood

K. E.

Kutash

Seidman

(2010). Toward the integration of education and mental health in schools. Administration and Policy in Mental Health and Mental Health Services Research, 37, 40–47.

Brener

N. D.

Weist

Adelman

Taylor

Vernon-Smiley

(2007). Mental health and social services: Results from the school health policies and programs study 2006. Journal of School Health, 77, 486–499.

Brown-Chidsey

Bickford

(2016). Practical handbook of multi-tiered systems of support: Building academic and behavioral success in schools. Guilford Press.

Centers for Disease Control and Prevention, Division of Adolescent and School Health. (2016). Results for the school health policies and practices study (SHPPS). https://www.cdc.gov/healthyyouth/data/shpps/index.htm

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2017). Preventing suicide: A technical package of policy, programs, and practices. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf

Cook

C. R.

Frye

Slemrod

Lyon

A. R.

Renshaw

T. L.

Zhang

(2015). An integrated approach to universal prevention: Independent and combined effects of PBIS and SEL on youths’ mental health. School Psychology Quarterly, 30, 166–183.

Cumming

T. M.

Marsh

R. J.

Higgins

(2018). School connectedness for students with disabilities: From theory to evidence-based practice. Routledge.

10.

Demissie

Brener

(2017). Mental health and social services in schools: Variations by school characteristics, United States, 2014. Mental Health and Prevention, 5, 5–11.

11.

Desrochers

J. E.

(2015). The best mental health programs start with all students. Phi Delta Kappan, 96(4), 34–39.

12.

Dimmitt

Wilkerson

(2012). Comprehensive school counseling in Rhode Island: Access to services and student outcomes. Professional School Counseling, 16, 125–135.

13.

Edmonds-Cady

Hock

(2008). Children in crisis: Special education status and other stressors in the lives of children removed from school by expulsion. School Social Work Journal, 32, 72–86.

14.

Erickson

Abel

N. R.

(2013). A high school counselor’s leadership in providing school-wide screenings for depression and enhancing suicide awareness. Professional School Counseling, 16, 283–289.

15.

Federal Interagency Forum on Child and Family Statistics. (2017). America’s children: Key national indicators of well-being, 2017: Adolescent depression. https://www.childstats.gov/americaschildren/

16.

Freeman

Wilkinson

Vanlone

(2016). Status of high school PBIS implementation in the United States. https://www.pbis.org/resource/status-of-high-school-pbis-implementation-in-the-u-s

17.

Gargiulo

R. M.

Metcalf

(2017). Teaching in today’s inclusive classrooms: A universal design for learning approach (3rd ed.). Cengage Learning.

18.

Individuals with Disabilities Education Act, 20 U.S.C. § 1400 (2004).

19.

Johnson

Eva

A. L.

Johnson

Walker

(2011). Don’t turn away: Empowering teachers to support students’ mental health. The Clearing House, 84, 9–14.

20.

Kang-Yi

Wolk

C. B.

Locke

Beidas

R. S.

Lareef

Pisciella

A. E.

Lim

Evans

A. C.

Mandell

D. S.

(2018). Impact of school-based and out-of-school mental health services on reducing school absence and school suspension among children with psychiatric disorders. Evaluation and Program Planning, 67, 105–112.

21.

Kauffman

J. M.

Badar

(2018). The scandalous neglect of children’s mental health: What schools can do. Routledge.

22.

Lemberger

Carbonneau

Selig

Bowers

(2018). The role of social–emotional mediators on middle school students’ academic growth as fostered by an evidence-based intervention. Journal of Counseling & Development, 96, 27–40.

23.

Marsh

R. J.

(2016). Identifying students with mental health issues: A guide for classroom teachers. Intervention in School and Clinic, 51, 318–322.

24.

Marsh

R. J.

Morgan

J. J.

Higgins

Lark

Watts

J. T.

(2017). Provision of mental health services to students with emotional and behavioral disorders. Journal of Disability Policy Studies, 28, 90–98.

25.

McGorry

Purcell

(2009). Youth mental health reform and early intervention: Encouraging early signs. Early Intervention in Psychiatry, 3, 161–162.

26.

Mental Health America. (2015). Parity or disparity: The state of mental health in America.

27.

Mojtabai

Olfson

Han

(2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138, e20161878.

28.

Molloy

L. E.

Moore

J. E.

Trail

Van Epps

J. J.

Hopfer

(2013). Understanding real-world implementation quality and “active ingredients” of PBIS. Prevention Science, 14, 593–605.

29.

Moon

Williford

Mendenhall

(2017). Educators’ perceptions of youth mental health: Implications for training and the promotion of mental health services in schools. Children and Youth Services Review, 73, 384–391.

30.

National Alliance on Mental Illness. (2017). Mental health by the numbers. https://www.nami.org/learn-more/mental-health-by-the-numbers

31.

National Association of School Psychologists. (2019). Who are school psychologists. https://www.nasponline.org/about-school-psychology/who-are-school-psychologists

32.

Pastor

P. N.

Reuben

C. A.

(2009). Emotional behavioral difficulties and mental health service contacts of students in special education for non-mental health problems. Journal of School Health, 79, 82–89.

33.

Paternite

C. E.

(2005). School-based mental health programs and services: Overview and introduction to the special issue. Journal of Abnormal Child Psychology, 33, 657–663.

34.

Rossen

Cowan

K. C.

(2015). Improving mental health in schools. Phi Delta Kappan, 96(4), 8–13.

35.

School Social Work Association of America. (2019). Role of school social worker. https://www.sswaa.org/school-social-work

36.

Sinclair

M. F.

Christenson

S. L.

Thurlow

M. L.

(2005). Promoting school completion of urban secondary youth with emotional or behavioral disabilities. Exceptional Children, 71, 465–482.

37.

World Health Organization. (2018). Mental health atlas 2017. https://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/