Prevention Science in Childrens School Mental Health Beth Doll University of Nebraska Lincoln

What are preventive school mental health services? Services that have been carefully designed to meet the mental health needs of ALL students enrolled in a school (Doll and Cummings, 2008; Chapter 1)

Referral vs. preventive Referral Assessment Planning + Services Assessment Planning + Services

Prevalence of mental disorders in the United States DisorderChildrenAdolescents All Mental Disorders 200 Anxiety Disorders 150 ADHD 7454 Conduct Disorders Depression 1570 OCD 2-44 Autism, schizophrenia 3-4

National Comorbidity Survey Replication (Adults) 12-monthLifetime Any disorder 26.2%46.4% Anxiety Disorders 18.1%28.8% Mood Disorders 9.5%20.8% Impulse Control Disorders 8.9%24.8% Substance Use Disorders 3.8%14.6%

What we have learned from prevalence… Age-of-onset for most mental disorders are concentrated during the first two decades of life 20% of students in the typical school classroom meet the criteria for one or more mental disorder 5% of students are typically receiving mental health services through community or private mental health centers 1% of hundred students are identified with emotional or behavioral disabilities The US must direct a greater part of our thinking about public mental health interventions to the child and adolescent years Schools are the primary providers of mental health services to children and adolescents

Risk = Students are more likely to be unsuccessful adults Risk Poverty Low parent education Marital/family dysfunction Poor parenting student maltreatment Poor health Parental illness Large family Adult outcomes Mental illness Physical illness Educational disability Delinquency Teen parenthood Financial dependence Unemployment Low social competence Doll & Lyon, 1998

Resilience = Vulnerable students who become successful adults Individual Positive social orientation Friendships Internal locus of control Positive self-concept Achievement orientation Community engagement Family & community Close bond with one caretaker Effective parenting Nurturing by other adults Positive adult models Connections with pro-social organizations Effective schools

Broad principles One in five school-age students in the USA has a diagnosable mental disorder Only ¼ of these students receive community mental health services The strongest predictors of students' mental health are characteristics of communities and families Schools are an important protective factor for many students And they are the primary provider of mental health services for many students Students' school success is directly related to their psychological wellness and mental disorders

And a roadmap to preventive school mental health Promote students friendships Foster their self-determination and internal locus of control Strengthen their personal efficacy Build students self-discipline Provide frequent and authentic opportunities for adult nurturing Engage students with prosocial organizations in the community Provide students with opportunities to pass it forward

Goals of preventive school mental health services 1. Promote the psychological well-being of all students so that they can achieve developmental competence 2. Promote caretaking environments that nurture students and allow them to overcome minor risks and challenges 3. Provide protective support to vulnerable students; and 4. Remediate social, emotional or behavioral disturbances so that students can develop competence.

Intentional cycle of planning Carefully collect information about the mental health status of students Construct a plan describing the mental health services that are needed, who provides them, and who receives them Competing needs are reconciled based on the urgency of needs and the anticipated outcomes of services Incorporate school-wide, class-wide, small group, and individual services Incorporate prevention, early intervention, and remedial services Implement the plan Monitor the impact of services and the changing face of the schools mental health needs Refine the plan as needed

Making Classrooms Mentally Healthy STEP ONE Use the ClassMaps Survey as a practical and reliable measure of the complex classroom environment Assess Class Needs Make Sense of the Data Plan & Implement Class Changes Evaluate & Refine

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Making Classrooms Mentally Healthy STEP TWO Information from the CMS is then used in a problem-solving process that identifies classroom strengths and weaknesses Assess Class Needs Plan & Implement Class Changes Evaluate & Refine

Making Classrooms Mentally Healthy STEP THREE The data-based problem solving process identifies intervention strategies to reinstate essential contextual supports in classrooms Assess Class Needs Make Sense of the Data Evaluate & Refine

Making Classrooms Mentally Healthy STEP FOUR Verify the effectiveness of those supports once they are implemented Assess Class Needs Make Sense of the Data Plan & Implement Class Changes

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Continuum of school mental health interventions Infrastructure building activities to anchor preventive services in the community Universal mental health services Selected mental health services Remedial Services Adapted from Doll & Cummings, 2008; Chapter 1; and from Doll (In press) chapter in the Encyclopedia of Public Health, London: Elsevier

Assessing the collective mental health of students Systematic analysis of existing school records attendance or discipline records Epidemiological procedures including multi-tier assessment models in which broad screening is followed by comprehensive mental health assessments (Short & Strein, 2008; Chapter 2) Sampling Technically sound measures Traditional mental health assessments administered and aggregated across the schools enrollment (Baker, 2008; Chapter 3) Assessment of demographic and functional risk and protective factors

Finding effective preventive assessment measures Center for Academic, Social, and Emotional Learning ( an annotated bibliography of measures to monitor childrens social and emotional well-being; CASEL-developed tools The Annenberg Institute for School Reform ( a bibliography describing measures of childrens developmental health that can be used school-wide or district-wide The World Health Organization ( describes the Global school-based student health survey that measures behavioral risk factors of adolescents. Adapted from Cummings & Doll, Chapter 12; and Doll (In press) chapter in the Encyclopedia of Public Health, London: Elsevier

Creating a preventive plan for school mental health services To match the mental health needs against services provided in the school and community – Resource mapping (Adelman & Taylor, Chapter 11) UCLA Center for Mental Health in the Schools ( A packet including instructions and tools for mapping community resources onto school mental health needsHttp://smhp.psych.ucla.edu Collaborative for Academic, Social and Emotional Learning ( a practice rubric for implementing and sustaining social emotional learning interventions in schools. The World Health Organization ( Rapid Assessment and Response Guide for strategies to improve health-promotion in schools.

Options for interventions Partnering with families to enhance students mental health (Christenson, Whitehouse, & VanGetson, 2008; Chapter 4) School-wide approaches to behavior problems (Bear, 2008; Chapter 5) Response to intervention: A school-wide approach for promoting academic wellness for all students (Martinez & Nellis, 2008; Chapter 6) Social and emotional learning: A school-wide approach to intervention for socialization, friendship problems, and more (Merrell, Gueldner, & Tran, 2008; Chapter 7) School-wide approaches to intervention for school aggression and bullying (Swearer, Espelage, Love, & Kingsbury, 2008; Chapter 8) School-wide approaches to prevention of and intervention for depression and suicidal behaviors (Mazza & Reynolds, 2008; Chapter 9)

Evaluation of prevention services 1. Were the services effective in reducing the frequency or severity of childrens psychiatric disorders? 2. Were the services effective in increasing childrens psychological wellness and developmental competence? 3. What were the unintended positive or negative consequences of the services? 4. What factors increased or decreased the services effectiveness? 5. Were the preventive mental health services implemented with fidelity? 6. Were the preventive mental health services acceptable to children? To families? To mental health service providers? 7. How can the evaluation data be used for refining and enhancing the communitys mental health services for children?

Evaluation resources Center for Academic, Social, and Emotional Learning provides an Implementation Toolkit (available at no cost from that includes publicly available measures and suggestions for evaluation practices the Evaluation Center at Western Michigan University ( includes annotated bibliographies describing major evaluation models, measures, and tools for self-checking an evaluation plan. UCLA Center for Mental Health in the Schools ( provides a technical aid packet on evaluation and accountability Adapted from Cummings & Doll, 2008; Chapter 12 and from Doll (In press) chapter in the Encyclopedia of Public Health, London: Elsevier

Ten essential preventive mental health services 1. Monitor students mental health status including their academic, social-emotional and relational competence 2. Diagnose and investigate psychological disturbance in students 3. Inform, educate and empower students and their families about mental health issues 4. Mobilize school-family-community partnerships to identify and solve psychological disturbances 5. Develop policies and plans that support student, family, school and community mental health efforts

Ten essential preventive mental health services 6. Implement policies and practices that protect students mental health and ensure developmental competence 7. Link students and their families to universal, selected and intensive interventions as needed 8. Provide appropriate staff training and monitor throughout intervention 9. Evaluate effectiveness, accessibility, and quality of school mental health services 10. Research new insights and innovative approaches to promoting mental health Cummings & Doll, 2008; Chapter 12

Mental health is essential to schooling School mental healths goal of promoting psychological wellness is not ancillary to students academic success, but is integral to it

Possibilities of preventive services Reconcile school mental health services with students mental health needs Strengthen the planfulness of mental health services Leverage existing resources so that more students receive mental health services earlier and with more impact Integrate and coordinate school and community mental health services around common goals Highly compatible with the mission of public schools To provide students with the knowledge and skills necessary for productive and successful lives A mission that is shared with other important societal entities such as families, churches, the legal system, and social services

Limitations of preventive services Principally implemented in a small scale in practice Only possible within institutions that are already population- focused (e.g., schools, military bases, public health services) Demand for services is much greater than anticipated Payoff of preventive services may be several budget-cycles removed from their initial implementation Incompatible with many funding mechanisms

Doll, B., & Cummings, J. (2008). Transforming School Mental Health Services: preventive approaches to promoting the competency and wellness of children. Thousand Oaks, CA: Corwin Press / NASP.

CONTACT INFORMATION Beth Doll, PhD. University of Nebraska Lincoln