Collaborating with Schools to Support Youth Mental Health

The Benefits and Barriers of School Collaboration

Since the onset of the COVID-19 pandemic, youth anxiety and depression rates have doubled, placing substantial strain on systems supporting  children’s mental health. While schools are a critical access point for youth to receive ongoing mental health service and support, it is critical that school-based mental health professionals and community health providers (CHP) pool resources, share perspective and expertise to work together in support of children’s mental health^1,2,8.

Collaboration between school mental health teams and CHPs enhances access to care while supporting more effective assessment and intervention services for students with psychological conditions¹. Recently, school professionals have identified some positive collaborations with CHPs, however, many concerns have also been raised. School teams identified various barriers to effective collaboration including:

• lengthy reports lined with too much medical and psychological jargon
• difficulty initiating and maintaining communication
• a limited understanding of the school culture instigating frequent inappropriate or ill-feasible recommendations^1,2.

A recent CHCO survey completed by Colorado school districts identified similar barriers to collaboration -- primarily citing time constraints and CHPs’ misconceptions of schools supports and processes. Importantly, district professionals also conveyed common themes in what collaborative efforts and expertise they need most from CHPs. Most respondents endorsed wanting feedback around safety concerns and safety planning, information relating to diagnosis, medications and recommendations related to social and emotional functioning⁵. 

School Consultation Best Practices

When student advocacy is conducted collaboratively in lieu of more coercive approaches, it prompts school administration to be more empathetic and understanding with families, and positively influences special education team members perceptions of working with the student^1,8. Therefore, it is critical community providers’ contact with schools is initiated thoughtfully and with cooperative spirit. There are many important considerations to support collaborative relationships with a patient’s school. The following are a good place to start: 

Who to contact?

Colorado school districts indicated preferences for school psychologists and school counselors⁵, however, this may vary by district and school. Consequently, it is recommended community providers clarify the preferred contact person(s) and obtain a release of information. 

How to connect?

Although it is feasible for CHPs to share information in a written report or letter, verbal collaboration and open communication with the school has been found to lead to more effective assessment and intervention services for students^1,8.

What to recommend?

Before giving educational recommendations, it is important CHPs first connect with the child’s school to gather information. School teams continue to report CHPs inappropriate and ill-feasible educational recommendations to be a top barrier to effective school-community partnerships^1,5,8. CHPs should seek understanding of recommendations that may have already been tried within the school setting, the feasibility of the support within the school context and the child’s response to intervention. Other ways CHPs can support and advocate for a patient’s support in school include: 

• Provide families with relevant documentation of the child’s diagnosis, symptoms, difficulties applicable to the school setting, strengths and challenges in school functioning and areas of needed support at school.
• Letter for the educational team that outlines diagnosis and best practice recommendations for the school to consider adding to support plan.
• In collaboration with the school and family, support family in referring to early intervention or special education for an evaluation. 

*See additional resources section for links to specific verbiage, school letter templates, parent handouts and other useful information to support school/family collaboration. 

School districts consider information from a variety of sources when interpreting evaluation data and making placement decisions. CHPs feedback is another source that makes up the universe of information about the student. School teams often recognize the qualified position CHPs are in to recommend specific interventions to target academic and/or socio-emotional/behavioral domains based on their expertise about the child’s condition⁹. However, before weighing in on school-based recommendations, it is important for CHPs to know the breadth and complexity of academic and behavioral health systems of supports in schools.

Know School Systems of Support  

Community health providers must have some awareness of the educational setting itself and perceptions school teams may have if recommendations are not carefully considered within their context. While many pediatric patients have already been identified to receive intensive intervention at school, other students may not have accessed any supplementary support in this setting. Thus, when advocating for patients and families, community providers should first consider recommendations that are not necessarily part of special education programming, but rather fit under the larger umbrella of schools’ multi-tiered systems of support (MTSS)⁹. 

MTSS is a comprehensive tiered model of support that seeks to meet both academic and social-emotional needs of all children, providing intervention for students at varying levels or “tiers”. At each tier, different types of services and supports are available and they increase in intensity from Tier 1 to Tier 3. Movement between tiers is a fluid, data-driven process that is supported by information gathered from universal screeners, progress monitoring and response to intervention. These tiers exist for academic subjects as well as for socio-emotional/behavioral areas.

• Tier 1 encompasses the universal, evidence-based core practices and instruction that all students within a school receive. Most students (80-90%) should receive adequate support within Tier 1. When students are identified as needing additional support beyond the scope of Tier 1, they may be transitioned to a Tier 2 level of support.
• Tier 2 is supplemental support serving 10-15% of the student population and may include additional intervention for students not meeting benchmarks under Tier 1. Tier 2 services may be implemented by general education or specially trained school professionals in small group settings. Progress monitoring should be utilized for 6-10 weeks to assess their response to Tier 2 intervention and whether this level of support is appropriate. If students do not make progress, they may be transitioned to a Tier 3 level of support.
• Tier 3 is the most intensive general education support available for students. Transition to Tier 3 requires data indicating that Tier 1 and 2 supports have not been effective. Tier 3 may also initiate a referral for evaluation for special education services. The supports provided under Tier 3 are individualized to the student, targeting academic, socio-emotional, and behavioral needs. These supports often last considerably longer than supplemental instruction provided in Tier 2. 

How to request an evaluation for special services

Parents can request that a public school assess their child for special services at any time. Parents should be encouraged to communicate their requests with the school administrator, both verbally and in writing. Key details should include a description of concerns about their child, what supports have been trialed (i.e. other tiered supports) and the date they are making this request.

*See additional resources for links to specific academic and social-emotional recommendations across tiers, including navigating the 504/IEP process. 

Common school issues for youth and families 

Bullying

Nationwide, about 20% of students ages 12-18 have experienced bullying on school property in the last 12 months³. Bullying affects all youth, including those who are bullied, those who bully others and those who witness bullying. Targets and perpetrators of bullying are more likely to experience depression, suicidality and externalizing symptoms^3,5. The stopbullying.gov website hosted by the U.S. Department of Health and Human Services’ recommends CMPs take three steps to help prevent and protect children from bullying:

1. Recognize: CHPs can be important allies in determining if a child is being bullied. Bullying occurs most often during school transitions (elementary to middle school) and effects students with emotional disabilities at much higher rates³. CHPs can alert parents to signs that bullying is continuing and if it is affecting mood or other aspects of life.
2. Screen: If bullying is suspected, a CHP may ask the child about how school is going, their friends and what activities they do together, if bullying occurs at school and what adult would be safe to talk with if there is a problem. These questions can open deeper discussion to determine what might be most helpful. Many symptom checklist assessments now include items related to bullying.
3. Refer: CHPs may make additional mental health support and advocacy referrals. Parents may have additional questions about how to best support their child or how to talk with school. CHPs can connect families with effective and available resources from self-advocacy strategies to requesting a school’s bullying intervention policy. 

School Refusal/Avoidance

School attendance problems are a significant challenge for many families. Students may refuse to attend school to escape from a situation that causes anxiety (separation from parents, social anxiety or anxiety related to academic difficulties) or to gain attention from a parent or other caregiver. Some students may feel that the school environment is unwelcoming, unsafe or a place where they experience failure. Consequently, it becomes reinforcing to stay home and avoid distress or perceived distress at school. 

The complexity of attendance problems is manifested by multiple risk factors at student, caregiver, family, peer, school, and community levels^4,7. While collaboration with a child’s school team should be first priority, integrated outpatient support can be extremely helpful when evidenced-based and well-coordinated⁷. What CHPs can do: 

1. Assessment: Warning signs of a pattern of school avoidance include associated physical symptoms (headache, stomachache) that improve if allowed to stay home; the absence occurring more often after a break (holiday, illness, weekend, or summer); isolated events prompting school avoidance (loss of a loved one, prolonged illness, changing schools and grade transitions).
2. School Support: Consult with the school about resources they can provide for school attendance and potential mental health concerns contributing to school avoidance.
3. Outpatient Mental Health Support: Seek a mental health professional with experience in treating young people with school refusal problems. Currently, cognitive behavioral therapy and exposure therapy are treatments with the best evidence for supporting children experiencing school refusal. If school refusal behavior is significantly impacting a child’s ability to function at school, considerations for more intensive levels of care may be appropriate.
4. Limit Medical Assessment: While it is important to rule out likely medical causes, the longer the child is out of school, the more difficult it is to return. Beware the “Home Instruction Letter” request. Consult school team, other specialty providers (including psychiatry) prior to making home health/hospital schooling letter of support^4,7.

*See additional resources for links to targeted prevention and intervention content for bullying and school refusal behaviors including tangible best practices for practitioners, patients and families.

Additional Resources:

Navigating Special Supports in Schools 

Understood.org
Digital resources and community help families of children with disabilities. Easy to use tools, information, templates, and more to help families navigate various systems of support. When parents have questions about special supports in school, understood.org has an answer, with many helpful handouts and templates.   

The Center for Parent Information and Resources 
Over 1,200 family-friendly materials on key topics for Parent Centers. This includes fact sheets, IDEA training materials, parent guides, explanations of early intervention and special education, the IEP process, transition planning, and open webinars on priority topics. 

CDE IEP Procedural Guidance
A Colorado Department of Education resource to help special education teams and families of children with disabilities navigate the special education process. Helpful figures, timelines, and common Q&As for families. 

Learning Services at CHCO 
The Learning Services Department provides diagnostic learning evaluations with a learning specialist for children and adolescents suspected of having a learning disability or having overall difficulty in school.  Results will inform what kinds of help a child should receive to support learning.

MTSS School Evidenced-Based Interventions

An extensive collection of resources, descriptions of organizations, and free academic guides for parents and educators. Resources to help identify, prevent, and intervene in mental health concerns among students. Available interventions for Tiers 1-3. Provides teachers and parents free resources to help struggling learners. 

What Works Clearinghouse 

Intervention Central 

Reading Rockets 

National Center for Rural School Mental Health Intervention Hub 

Educational Advocates for Children with Disabilities

The Colorado Department of Education partners with the following organizations to connect families with educational advocacy and consultation for children with disabilities. 

PEAK Parent Center - 719.531.9400 

THRIVE Center - 303.632.6840 

Bullying Prevention and Intervention

National and state organizations and initiatives providing resources for students, parents, educators, and others. From tips about how to talk with children about bullying to incident reporting templates for parents, these resources are easy for anyone to navigate. Additional state policy and prevention efforts and resources are included. 

PACER National Bully Prevention Center

StopBullying.gov

Human Growth Foundation's Say NO Bullying Resource Booklet

State of Colorado: Bullying Prevention and Education

Colorado Model Bullying Prevention and Education Policy

School Refusal

Evidenced-based, practical tips and resources for CHPs, school team members, and families

National Association of School Psychologists (NASP) School Refusal Best Practices

Anxiety Disorder Association of America, School Refusal or Avoidance  

Childrens Hospital Colorado, Pediatric Mental Health Institute

References:

1. Bradley-Klug, K. L., Jeffries-DeLoatche, K. L., St. John Walsh, A, Bateman, L. P, Nadeau, J., Powers, D. J., & Cunningham, J. (2013). School psychologists’ perceptions of primary care partnerships: Implications for building the collaborative bridge. Advances in School Mental Health Promotion, 6, 51–67.
2. Bradley-Klug, K. L., Sundman, A., Nadeau, J., Cunningham, J., & Ogg, J. (2010) Communication and collaboration with schools:  Pediatricians’ perspectives. Journal of Applied School Psychology, 26
3. Centers for Disease Control and Prevention (CDC).The 2019 Youth Risk Behavior Surveillance System
4. Elliott, J. & Place, M. (2019). Practitioner Review: School refusal: developments in conceptualization and treatment since 2000. Journal of Child Psychology and Psychiatry, 60(1), 4-15.
5. Goldweber, Asha, Waasdorp, Tracy Evian, & Bradshaw, Catherine P. (2013). Examining the link between forms of bullying behaviors and perceptions of safety and belonging among secondary school students. - PubMed - NCBI. Journal of School Psychology.
6. Henry, L., Khindria, N., Hall, C. (in prep, 2023). Collaborating with Schools to Support Youth Mental Health.
7. Kearney, C. A., and Benoit, L. (2022). Child and adolescent psychiatry and underrepresented youth with school attendance problems: Integration with systems of care, advocacy, and future directions. J. Amer. Acad. Child Adolesc. Psychiatry.
8. Mellin EA, Weist MD. Exploring school mental health collaboration in an urban community: A social capital perspective. School Mental Health. 2011;3(2):81–92.
9. Wexler, D. (2018) School-based multi-tiered systems of support (MTSS): An introduction to MTSS for neuropsychologists, Applied Neuropsychology: Child, 7:4, 306-316