NITT SMHRP Toolkit_FINAL

This Toolkit was developed under contract number HHSS283201200030I for the Center for Mental
Health Services (CMHS), SubstanceAbuse and Mental Health ServicesAdministration (SAMHSA).
The views, policies, and opinions expressed are those of the authors and do not
necessarily reflect those of SAMHSA or HHS.

ACKNOWLEDGEMENTS
The following individuals are thanked for their generous contributions to the School Mental Health
Referral Pathways Toolkit.
Danielle Guttman-Lapin, PhD
Adjunct Post Doctoral Research Associate
Department of Counseling, School, and
Educational Psychology
University at Buffalo, The State University of
New York
Amanda Nickerson, PhD
Professor
Department of Counseling, School, and
Educational Psychology
University at Buffalo, The State University of
New York
Meagan O’Malley, PhD
Research Associate
Health and Human Development Program
WestEd
Tyler Renshaw, PhD
Assistant Professor
Department of Psychology
Louisiana State University
Kristi Silva, M.A.
Research Associate
National Latino Behavioral Health Association
Suganya Sockalingam, PhD
Partner
Change Matrix
Donna Burton, PhD
Research Assistant Professor
Department of Child & Family Studies
University of South Florida
Katie Eklund, PhD
Assistant Professor
Department of School Psychology
University of Arizona
Rachele Espiritu, PhD
Partner
Change Matrix
David Klingbeil, PhD
Assistant Professor
Department of Educational Psychology
University of Wisconsin, Milwaukee
Miranda March, PhD
Senior Research Associate
Center for Applied Research Solutions
Tom Massey, PhD
Professor
Department of Child & Family Studies
University of South Florida
Christina Pate, PhD
Research Associate
Health and Human Development Program
WestEd
Jill Sharkey, PhD
Research Faculty
Department of Counseling, Clinical, and School
Psychology
University of California, Santa Barbara
Kris Varjas, PsyD
Professor
The Center for Research on School Safety,
School Climate and Classroom Management
Georgia State University
Lead Contributors
Expert Reviewers

TABLE OF CONTENTS
INTRODUCTION....................................................................................................................................................9
Multitiered System of Supports (MTSS): A Conceptual Framework..................................................................... 11
Organization of the SMHRPT...............................................................................................................................13
Using the SMHRPT..............................................................................................................................................14
Now Is The Time Factsheet: Addressing the Mental Health Needs of School-Aged Youth.................................15
Figure I.1. The Multitiered System of Support Model for Mental Health Supports in Schools.............................12
CHAPTER 1: LAYING THE FOUNDATION: ASSESSING YOUR CURRENT REFERRAL
MANAGEMENT APPROACH..............................................................................................................................17
The Challenge: Building Referral Systems that Work..........................................................................................19
Four Stages of Referral Pathway Self-Assessment.............................................................................................20
Steps for Establishing a Problem Solving Team...................................................................................................21
Figure 1.1. The Multitiered System of Support Model for Mental Health Supports in Schools...........................20
Figure 1.2. Four Stages of Referral Pathway Self-Assessment..........................................................................20
Toolbox 1.1. Questions to Consider When Assessing Problem Solving Team Structure and Functioning.........23
Toolbox 1.2. Community Resource Recruitment Form.......................................................................................26
Toolbox 1.3. Sample List of Resources and Partners within the MTSS Framework...........................................27
Toolbox 1.4. Software Systems for Tracking Intervention Data...........................................................................30
Tool 1.1. Example Referral Forms.......................................................................................................................31
Tool 1.2. Sample Completed Database...............................................................................................................36
Tool 1.3. Additional Resources for Assessing Your Referral Management Approach.........................................37
CHAPTER 2: SCHOOL-BASED PROBLEM-SOLVING TO PROMOTE YOUTHS’ MENTAL HEALTH.............39
A Problem-Solving Approach for Promoting Mental Health..................................................................................41
Establishing a Problem-Solving Team..................................................................................................................43
The Four-Step Problem-Solving Model................................................................................................................45
Using the ABC Theory to Promote Youths’ Mental Health...................................................................................47
Assessment Strategies for Gauging Youths’ Mental Health.................................................................................49
Intervention Strategies for Promoting Youths’ Mental Health...............................................................................52
Using the Problem-Solving Model within MTSS for Promoting Mental Health.....................................................57
Core Problem-Solving Procedures that are Flexibly Applied Across Tiers...........................................................57
Core Problem-Solving Procedures that are Variably Applied Across Tiers..........................................................59
Figure 2.1. Four-Step Problem Solving Model for Promoting Mental Health in Schools.....................................45
Figure 2.2. Key Features of the ABC Theory of Behavior...................................................................................47
Figure 2.3. The Multitiered System of Support Model for Mental Health Supports in Schools...........................57
Table 2.1. Relation of Behavioral Assessment Methods to Assessment Purposes.............................................50
Table 2.2. Example Behavior Rating Scales for Measuring Student Mental Health Problems...........................61
Toolbox 2.1. Core Procedures Checklist for the Four-Step Problem-Solving Model...........................................46
Tool 2.1. Example Event Recording Form...........................................................................................................64
Tool 2.2. Example Time Sampling Form.............................................................................................................64
Tool 2.3. Example ABC Recording Form.............................................................................................................65
Tool 2.4. Example Self-Report Behavior Rating Scale for Internalizing Behavior Problems...............................66
Tool 2.5. Example Self-Report Behavior Rating Scale for Externalizing Behavior Problems..............................67
Tool 2.6. Values Clarification and Public Commitment to Promoting Valued Behavior Exercise.........................68
Tool 2.7. Discrepancy Analysis Exercise.............................................................................................................68
Tool 2.8. Linking Maintaining Factors and Intervention Strategies Exercise.......................................................69
Tool 2.9. Intervention Planning Exercise.............................................................................................................70
Tool 2.10. Additional Resources for School-Based Problem-Solving..................................................................71

CHAPTER 3: BUILDING EFFECTIVE PARTNERSHIPS.................................................................................. 73
Understanding the Need to Partner....................................................................................................................75
Mental Health Partnerships: Leveraging Community Resources for Maximum Impact......................................77
How Can Schools Partner Effectively?................................................................................................................79
The Partnership Process.....................................................................................................................................80
Phase 1: Defining Roles and Responsibilities.....................................................................................................80
Memoranda of Understanding (MOU).................................................................................................................82
Phase 2: Sharing Information and Monitoring Progress Across Sectors............................................................84
Phase 3: Planning for Transitions between Levels of Care.................................................................................87
Conclusion..........................................................................................................................................................88
Figure 3.1. The Multitiered System of Support Model for Mental Health Supports in Schools..........................76
Figure 3.2. Electronic Data Tracking System, User Interface............................................................................85
Toolbox 3.1. Levels, Purpose, Structure, and Process of Partnerships.............................................................81
Toolbox 3.2. MOU Checklist...............................................................................................................................82
Toolbox 3.3. Consent to Release Information Checklist.....................................................................................84
Toolbox 3.4. Resources for Identifying Treatment Monitoring Instruments........................................................84
Tool 3.1. Overview of Privacy Laws...................................................................................................................89
Tool 3.2. Example Parental Consent for LEA to Release Student Information..................................................94
Tool 3.3. Additional Resources for Building Effective Partnerships....................................................................95
CHAPTER 4: CULTURAL AND LINGUISTIC CONSIDERATIONS.................................................................. 99
The Need for Cultural and Linguistic Competence in School Mental Health Referral Systems........................101
Foundational Concepts to Achieve Cultural and Linguistic Competence in the School Setting........................102
Mental Health Disparities in Culturally Diverse Students..................................................................................104
Addressing the Challenges of Diverse Cultural and Language Needs.............................................................106
Culturally and Linguistically Competent Referral Systems: Step-By-Step........................................................107
Figure 4.1. Benefits of Cultural and Linguistic Competence to School Mental Health.....................................102
Figure 4.2. Four Stages of Referral Pathways Development...........................................................................107
Figure 4.3. Four-Step Problem Solving Model for Promoting Mental Health in Schools..................................116
Table 4.1. Elements of the Cultural and Linguistic Competence Framework...................................................104
Table 4.2. Existing Mental Health Disparities Among Racial and Cultural Populations in the
United States...................................................................................................................................104
Toolbox 4.1. Activities and Practices to Build Cultural and Linguistic Competence.........................................108
Toolbox 4.2. Characteristics of Effective Cultural Brokers................................................................................110
Toolbox 4.3. Guiding Questions for Identifying Effective Cultural Brokers.......................................................110
Toolbox 4.4. Using Translators and Interpreters Effectively............................................................................. 111
Toolbox 4.5. Key Characteristics of Cultural Competence Training.................................................................113
Toolbox 4.6. Example Skills Matrix, Community Partner Cultural and Linguistic Supports..............................115
Tool 4.1. Applying National CLAS Standards in Schools.................................................................................119
Tool 4.2. Additional Resources for Cultural and Linguistic Competency (CLC)...............................................121
TABLE OF CONTENTS

School Mental Health Referral Pathways Toolkit10

Introduction 11
INTRODUCTION
The School Mental Health Referral Pathways Toolkit (SMHRPT) was funded by the U.S. Substance Abuse
and Mental Health Services Administration (SAMHSA) to help State and Local Education Agencies and their
partners develop effective referral systems for use within and across child-serving organizations.
The SMHRPT provides best-practice guidance and practical tools
and strategies to improve coordination and collaboration both within
schools and between schools and other youth-serving agencies.
The SMHRPT supports the cultivation of systems that improve
the wellbeing of young people by providing targeted mental health
supports at the earliest sign that a need is present. In particular, the
SMHRPT delves deeply into the topic of referral pathways, which for
the purpose of the toolkit is defined as the series of actions or steps
that begins at the moment a person in the school or local community
identifies a mental health-related concern in a school-aged young person.
Referral pathways vary from community to community based on the resources available, including the public
and private organizations providing services to school-aged youth, and community-specific cultural and
linguistic considerations. School and community-based mental health providers must navigate this natural
variation across communities in order to ensure the seamless provision of mental health supports to school-
aged youth and their families. While mental health referral pathways may be comprised of different partners
from community to community, all effective referral pathways share similar characteristics:
• They define the roles and responsibilities of all partners in a system.
• They have clearly articulated procedures for managing referrals within and between partners.
• They share information across partners in an efficient manner.
• They monitor the effectiveness of evidence-based interventions provided by all partners within a
system.
• They make intervention decisions collaboratively with a priority on what is best for young people and
their families.
The SMHRPT provides guidance to support the critical, albeit challenging work of building effective mental
health referral pathways in diverse communities throughout the United States.
Multitiered System of Supports: A Conceptual Framework
The multitiered system of support (MTSS) framework is employed as a guiding conceptual model throughout
the SMHRPT. The MTSS framework is widely used among educators and mental health practitioners,
thus providing a common language to anchor all SMHRPT topics. Attesting to its broad appeal as a model
for organizing mental health and other student supports, federal agencies, including SAMHSA, have
incorporated the MTSS framework into grant opportunities and related guidance documents for State and
Local Education Agencies.
Mental Health Referral Pathway:
A series of actions or steps that
begins at the moment a person
in the school or local community
identifies a mental health-related
concern in a school-aged young
person.
For detailed information about the status of mental health among young people in the United States; the links
between mental health and key educational and economic outcomes; and new directions in school-community
mental health partnerships, see the Now Is The Time Factsheet located on page 15. In order to engender support
for your work, consider sharing this Factsheet with members of your community, including key leaders and decision
makers, such as members of your school board, city council, and local chamber of commerce.

As applied to mental health-related needs, MTSS supports are best thought of a continuum of supports
defined by (a) the precision and intensity of assessment involved in assigning students to intervention
conditions, (b) the dosage of intervention provided to match the presenting mental health need, and (c) the
number of students targeted by the intervention (Figure I.1). Based on these defining characteristics, the
MTSS framework is typically organized into three levels, or Tiers, of prevention and intervention supports:
• Tier 1 supports are typically implemented for the purpose of prevention, are designed to reach
all students in a school, and are delivered within the scope of the general education curriculum.
For example, delivering an
evidence-based social and
emotional learning program in all
classrooms would be considered
a universal prevention strategy.
• Tier 2 interventions are intended
for students with mild or
emerging mental health-related
needs (i.e., social, emotional,
and/or behavioral). Tier 2
interventions require effective
problem-solving approaches,
including the strategic use of data
to identify targeted students and
match their needs to appropriate,
evidence-based treatments.
Tier 2 interventions are typically
delivered in small group settings
and are typically time-limited in
duration. An example of a Tier
2 intervention is a school-based
mental health clinician delivering
an evidence-based mindfulness
curriculum over the course of
ten weekly half-hour sessions
to a small group of eight to ten
students identified as having
mild to moderate challenges with
anxiety.
• Tier 3 interventions are meant
for students with more advanced
mental health-related needs
(i.e., social, emotional, and/or behavioral) and for whom more intensive intervention is warranted.
Typically, Tier 3 interventions are individualized and delivered by trained mental health clinicians,
often in one-to-one settings. As with Tier 2 interventions, Tier 3 interventions require problem-solving
strategies that accurately match students’ presenting needs to evidence-based treatments. Tier 3
interventions are distinguished from Tier 2 interventions by their intensity and duration. An example
of a Tier 3 intervention is a year-long intervention wherein a mental health clinician meets weekly with
a young person to treat his symptoms of depression using an evidence-based therapeutic approach.
Tier 2
Tier 1
Tier 3
Number of Students Receiving Services
+
+
++
Figure I.1. The Multitiered System of Support Model
for Mental Health Supports in Schools1
1 Renshaw, T. L., & O’Malley, M. D. (2015). A new take on the old triangle: Illustrating the key characteristics of a multitiered system of supports
for efficiently organizing problem-solving in schools. Self-published illustration. doi:10.13140/RG.2.1.4633.5204

Introduction 13
MTSS supports are designed to be cumulative, meaning that a student who receives Tier 3 supports should
also receive the Tier 2 supports that align with their needs as well as the Tier 1 supports provided to all
students.
In addition to the process of mapping what resources are available to address student mental health needs
at each tier of the MTSS framework, school personnel and their partners must consider the process by
which young people are identified for additional Tier 2 and Tier 3 mental health supports and by what metrics
response to targeted and indicated interventions will be gauged. The SMHRPT provides tools meant to assist
users with these tasks.
Organization of the SMHRPT
The SMHRPT is divided into four chapters meant to provide ‘best practice’ guidance to facilitate referrals both
within schools and between schools and their community partners. The SMHRPT describes several strategies
for defining interventions within the MTSS model and matching young people to the interventions that are
most appropriate for their needs. Chapters are meant to be practical and user-friendly; they are divided into
sections by sub-topics and important resources are regularly highlighted in Toolboxes. Each chapter of the
SMHRPT provides several relevant and practical techniques and tools related to the following topics:
Chapter 1, Laying the Foundation: Assessing Your Current Referral Management Approach, provides a
process for determining what mental health-related resources and partnerships currently exist for a school
and how to link students with mental health needs to appropriate school and/or community-based services.
Chapter 1 provides tools and techniques for:
• Establishing referral management systems
• Establishing a problem solving team
• Mapping school- and community-based mental health resources across MTSS tiers
Chapter 2, School-Based Problem-Solving to Promote Youths’ Mental Health, gives an in-depth description of
the problem solving process through which school-based teams can create individualized intervention plans
for young people whose social, emotional, and behavioral needs extend beyond the universal, Tier 1 supports
provided in the general classroom environment. Topics detailed in Chapter 2 include:
• Establishing a problem solving process
• Applying a problem solving model to customize mental health-related interventions for individuals
• Monitoring mental health-related intervention effectiveness for individuals
Chapter 3, Building Effective Partnerships, describes strategies for collaborating with external partners for the
purpose of developing robust prevention and intervention supports at all MTSS Tiers. Chapter 3 addresses:
• Models for effective collaboration across sectors
• Understanding cross-sector roles for supporting the mental health of school-aged youth
• Tracking mental health-related referrals and monitoring intervention progress across youth-serving
systems
• Legal considerations for sharing mental health-related information within and across youth-serving
systems
• Planning for transitions across youth-serving systems
Chapter 4, Cultural and Linguistic Considerations, provides an overview of cultural and linguistic
considerations for building effective referral pathways. Topics detailed in Chapter 4 include:

• Understanding disparities in mental health services for culturally and linguistically diverse students
• Effective strategies for referring culturally and linguistically diverse students to appropriate mental
health supports at school and in the community
• Identifying and supporting culturally and linguistically competent practice among school mental
health personnel and community partners
Using the SMHRPT
Who can use the SMHRPT? A variety of stakeholders are encouraged to use the SMHRPT, including
families, caregivers, and community members; educators, including teachers and school administrators;
mental health providers in school and community settings; and persons affiliated with child-serving
agencies that intersect with school mental health. Because of the anticipated interest from diverse groups,
the SMHRPT incorporates best-practice guidance and related tools intended for all audiences, including
those with varying degrees of background knowledge (i.e., emerging to advanced) related to school and
community-based mental health services for school-aged youth.
While each of these stakeholders will find parts of the SMHRPT useful for informing their own work, the
SMHRPT is designed for use by teams of school personnel and their community-based partners to inform
collaborative efforts to improve mental health supports for school-aged youth.
How should the SMHRPT be used? The SMHRPT can be used as a single, comprehensive resource
to guide all steps involved in building effective mental health referral pathways, or individual chapters can
be referenced in isolation to answer specific, topical questions. In order to provide a common point of
reference, users are encouraged to distribute the SMHRPT to their state and local partners.

Child-Serving
Government
Agencies
• Juvenile Justice
• Law Enforcement
• Child Welfare
Community-
Based Mental
Health Providers
• Public local mental
health providers
• Private local mental
health providers
School Personnel
• School administrators
• Teachers
• School-based mental
health providers
Families
• Family members of
school-aged youth

Introduction 15
Now Is The Time Factsheet
Addressing the Mental Health Needs of School-Aged Youth: A Shared Priority
Embracing the need for effective mental health referral pathways within schools and between schools and community service
providers requires a thorough understanding of the scope of the mental health challenges faced by school-aged young people
in the United States today. This Now Is The Time Factsheet provides up-to-date information about the nature of the mental
health challenge; the links between mental health and key educational and economic outcomes; and key characteristics of
effective school-community mental health partnerships.
The Status of Mental Health Among School-Aged Young People
Many school-aged young people are suffering due to mental health-related challenges that impair their interpersonal and
academic functioning, leading to short- and long-term consequences at home, at school, and in their communities.
• Approximately one in six school-aged children experiences impairments in his or her life functioning due to a
diagnosable mental health disorder1
and an estimated 70% of children have experienced some type of physical or
emotional trauma.2
• The majority of mental illnesses emerge in childhood3
, yet fewer than half of children who suffer from mental illness
receive treatment.4
• Young people with mental illness are frequently absent from school and many experience reductions in academic
achievement.5
• Among students with disabling conditions, young people with mental illness are the most likely to drop out of school.6
• Only one third of young people with mental illness advance to postsecondary education.7
• More than 60% of children in juvenile detention have a diagnosable mental illness.8
These data point to an urgent need for educators and their partners in diverse private and public sectors to dramatically reduce
the impact of mental illness on young people in their communities by prioritizing collaborative prevention and intervention
efforts.
Supports for Mental Health in Schools: The Current Landscape
The prevailing pattern of mental health service delivery to young people suggests a need for communities to invest in school-
based supports. This is due in large part to the fact that schools are easily accessible to most children and youth, and the
reality that several barriers to access exist for community-based settings (e.g., stigma, cultural beliefs, limited availability of
providers, confusion about how to initiate services). What is more, providing prevention and early intervention mental health
supports at school is cost effective. These truths are born out in the data:
• In any given year, 11-12% of school-aged young people access mental health services through the education sector,
whereas only 7% and 4% are served through specialty mental health (community-based) and general medical settings,
respectively.9
• Young people are more likely to seek mental health supports when they are available on their school’s campus.10
• Preliminary evidence suggests that school-based mental health care is less expensive than private and community-
based mental health services.11
• Early intervention in school is critical given that the indirect costs (e.g., lost earnings, emergency medical care) of
treating adult mental illness in the United States are estimated at over $300 billion per year.12
Despite the fact that they are the most accessible context for the provision of mental health services to young people, schools
have not historically been organized for mental health services delivery. There exist both perceived and real structural,
programmatic, and financial barriers that must be overcome to provide quality mental health services in school settings:
• The overall average ratio of students to qualified mental health services staff in schools across the U.S. is 500 to 1.13
• The activities assigned to school staff with mental health-related expertise compete for time that might otherwise be
spent working on prevention and early intervention efforts. For instance, over 50% of school psychologists’ time is
spent conducting psychoeducational assessments for the purpose of identifying students for special education.14
The
assessment process is reserved for students who appear to require intensive, individualized, and resource-intensive
intervention.
• Administrators may struggle with requirements to provide mental health services for students with mental, emotional
and behavioral disorders because the services themselves are perceived as time consuming, costly, and hard to
integrate into the existing school-day schedule.15

Advances in School-Based Mental Health: Partnerships That Work
Despite the fact that schools are not traditionally organized to provide mental health education or service delivery, school-
based mental health innovations are on the rise. The attention to this matter is in no small part propagated by legislation
in support of school mental health (i.e., No Child Left Behind Act of 2001 and Individuals with Disabilities Education
Improvement Act of 2004) that emphasizes the role of schools in supporting childhood cognitive and behavioral development,
particularly for those with identified mental health-related disabilities. Below are key characteristics of effective school mental
health partnerships:
• Integrated mental health services involve the merging of resources across sectors, including combined school and
medical, school and community mental health, and school and home-based services.
• The ideal integrated system represents the full continuum of care from behavioral health promotion and pro-social
development, to prevention, early intervention, treatment, and crisis management.16
• Planning for school mental health should take into account avenues toward promotion of healthy families,
enhancement of childhood resilience and protective factors, strategies to reduce systemic issues in schools that
impact healthy development and learning, and the promotion of school-community partnerships that improve access
to health and mental health services.17
• Selection of services (e.g., psychotherapy, case management, prevention education, medication management)
depends on the needs and preferences of the youth and family, the nature of the mental health needs, the diagnosis,
the severity of the problem and the cultural and linguistic needs of the family. Services provided also depend on the
strengths and natural supports inherent in the child and the context in which he or she lives.
• Providers are able to reduce barriers to access by meeting with youth and their families within community locations,
schools, and in homes. Providers also acknowledge the value that other positive, informal supports have for mental
health and wellbeing, such as faith-based organizations, non-profit agencies, friends and neighbors, and youth
organizations.
Now Is The Time to Support the Mental Health of Young People in Your Community
Communities throughout the United States are called upon to cultivate systems that improve the wellbeing of young people
by providing effective mental health supports at the earliest sign that a need is present. Meeting the highest standards of
mental health care will require coordinated partnerships between schools and other youth-serving organizations as well as
investments by partners in public and private sectors. By using a systematic approach to working together, communities can
make substantial improvements in the lives of young people.
______________________
1 Perou, R., Bitsko, R., Blumberg, S., Pastor, P., Ghandour, R., Gfoerer, J…Huang, L. (2013). Mental health surveillance among children: United States, 2005-2011. CDC
Supplements, 62, 1-35.
2 Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychology, 64, 577-584.
3 Kessler, R., Amminger, P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustun, T. (2007). Age of onset of mental disorders: A review of recent literature. Current Opinion Psychiatry,
20, 359-364. doi: 10.1097/YCO.0b013e32816ebc8c
4 Center for Behavioral Health Statistics & Quality, SAMHSA (2014). Serious mental health challenges among older adolescents and young adults. Retrieved August 25, 2015, from
http://www.samhsa.gov/data/sites/default/files/sr173-mh-challenges-young-adults-2014/sr173-mh-challenges-young-adults-2014/sr173-mh-challenges-young-
adults-2014.htm
5 Breslau, J., Lane, M., Sampson, N., & Kessler, R. (2008). Mental disorders and subsequent educational attainment in a US national sample. Journal of Psychiatric Research, 42,
708-716.
6 Panty, M., Hussar, W., Snyder, T., Provasnik, S., Kena, G., Dinkes, R., KewalRamani, A., & Kemp, J. (2008). The Condition of Education 2008 (NCES 2008-031). National Center
for Education Statistics, Institute of Education Sciences, U.S. Department of Education. Washington, DC.
7 United States Government Accountability Office. (June 2008). Young Adults with Serious Mental Illness; Report to Congressional Requesters. GAO Report Number GAO-08-678.
Washington, D.C.
8 Teplin, L., Abram, K., McClelland, G., Dulcan, M., & Mericle, A. (2002). Psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry. 59, 1133- 1143.
9 Farmer, E., Burns, B., Philips, S., Angold, A. & Costello, E. (2003). Pathways into and through mental health services for children and adolescents. Psychiatric Services, 54, 60-
66.
10 Slade, E. (2002). Effects of school-based mental health programs on mental health service use by adolescents at school and in the community. Mental Health Service Research,
4, 151-166.
11 Nabors, L., Leff, S., Mettrick, J. (2001). Assessing the costs of school-based mental health services. Journal of School Health, 2001, 199– 200.
12 Insel, T. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165, 663-665.
13 Teich, J., Robinson, G. & Weist M. (2007). What kind of mental health services do public schools in the United States provide? Advances in School Mental Health Promotion, 1,
13–22.
14 Bramlett, R., Murphy, J., Johnson, J., Wallingsford, L. & Hall, J. (2002). Contemporary practices in school psychology: A national survey of roles and referral problems.
Psychology In The Schools, 39, 327-335.
15 Powers, J., Bowen, N., & Bowen, G. (2010). Evidence-based programs in school settings: Barriers and recent advances. Journal of Evidence Based Social Work, 7, 313-331.
16 Burton D.L., Hanson A., Levin, B.L., & Massey, O.T. (2013). School mental health. In: Shally-Jensen, M. eds. Mental Health Care Issues in America. Santa Barbara, CA.
17 Center for Mental Health in Schools. (2005). Addressing what’s missing in school improvement planning: Expanding standards and
accountability to encompass an enabling or learning supports component. Retrieved July 28, 2015, from http://smhp.psych.ucla.edu/pdfdocs/enabling/standards.pdf

Chapter 1: Laying the Foundation: Assessing Your Current Referral Management Approach 17

LAYING THE FOUNDATION: ASSESSING YOUR CURRENT REFERRAL
MANAGEMENT APPROACH
Key Questions
1. How can schools build effective systems for matching students referred for social, emotional, or
behavioral concerns with high quality interventions that meet their needs?
2. How can schools build effective problem solving teams?
3. How can problem solving teams self-assess their effectiveness for the purpose of continuous
improvement?
The Challenge: Building Referral Systems that Work
The work of identifying, tracking, and referring young people with social, emotional, or behavioral concerns
involves multiple steps and processes. Because of the complexity of the challenge, it is essential that schools
develop and implement an effective referral pathway and tracking system. This referral system facilitates
gathering and analyzing information in an objective and systematic fashion in order to plan for students’
behavioral, social, emotional, and academic development. Essential to effective referral systems are the
use of multidisciplinary problem solving teams that work to match identified students with evidence-based
supports at appropriate levels of support within a multitiered system of support framework (MTSS, Figure 1.1,
see SMHRPT Introduction for detailed description). The team is tasked with determining whether referred
students’ needs may be best matched by promotion and prevention services, early intervention services, and/
or more intensive and individualized interventions provided by school or community-based personnel.
Systematic and effective referral pathways capitalize on the fact that school personnel (i.e., specific grade
level teachers, content area teachers, administrators, school safety officers, and specialized instructional
support personnel) have separate but complementary roles and functions within the system, and are
collectively organized to achieve the ultimate goal of improving the wellbeing of young people. School
professionals, in collaboration with community partners, work together to function as a ‘net’ that effectively
captures students needing extra support and links them to appropriate services.
The remainder of this SMHRPT chapter describes a process intended to help schools reflect upon and
improve their referral pathways by assessing the infrastructure (i.e., processes, resources, procedures) and
service capacity currently in place to support students at all levels of the MTSS framework. A thorough self-
assessment of infrastructure and service capacity will provide insight into the system improvements that can
be made to optimally serve students’ mental health needs at all MTSS tiers.
CHAPTER 1

Four Stages of Referral Pathway Self-
Assessment
Self-assessment of the quality of your school’s referral
pathway system occurs across four stages (Figure 1.2):
Stage 1 evaluates the system for managing referral
concerns; Stage 2 evaluates the process of managing
referral flow; Stage 3 examines existing resources and
procedures for matching needs to interventions; and
Stage 4 involves evaluating effectiveness of prescribed
interventions. Tools and techniques for each of these
stages are provided throughout the remainder of this
SMHRPT chapter.
Stage 1: Establish a Referral System
The initial stage of a referral pathway self-assessment
process requires an examination of how the school
identifies presenting concerns among its students.
Schools must consider several things when examining
their referral processes:
• Are systems in place to manage all types of
referral concerns? Referral concerns may include
a constellation of presenting problems within one or more of the following domains: academic, emotional,
behavioral, social, or physical. High quality referral systems have the capacity to effectively manage all
types of referral concerns.
• Are referral systems formalized? Formalized referral systems provide structured and clearly defined
channels designed specifically for referral. In formal referral systems, individuals know what procedures
are required to make referrals for individual students. Procedures for accessing formal referral systems
are not so burdensome as to reduce their utility; for referral systems to be effective, school professionals,
caregivers, and young people need to be willing to use them. Universal screening systems may be
considered a part of formalized referral
systems when they are used to accurately
identify young people for whom subsequent
intervention is appropriate.
• Does a collaborative structure exist to
manage referrals? Using a team approach
for identifying and addressing students’
presenting problems is essential (Burns,
Kanive, & Karich, 2015). Effective problem
solving teams (also referred to as student
care teams, student success teams, or
student study teams) are multidisciplinary,
have a set of decision-making protocols that
guide their work, and make data-informed
decisions. The topic of problem solving
team effectiveness is described in detail
later in this chapter.
Tier 2
Tier 1
Tier 3
+
+
++
Adapted from: Renshaw & O’Malley (2015)
Figure 1.1. The Multitiered System of Support
Model for Mental Health Supports in Schools
SMHRPT Chapter 1 3
Figure 2. Referral Pathways Self-Assessment Process
Stage 1:
Establish a Referral
System
Stage 2:
Manage Referral Flow
Stage 3:
Map Resources
Stage 4:
Evaluate Intervention
Effectiveness
Figure 1.2. Four Stages of Referral Pathway
Self-Assessment

• Are all individuals who might make a referral aware of the referral process? Because behaviors that
may lead to a referral are diverse in nature, they may be of concern to different individuals interacting
with a student, including parents/guardians/caregivers; self; peers; teachers; administrators; and/or other
school staff or adults. In order for referral systems to have maximum impact, each of these groups must
understand the referral system and know how to use it.
• Are referral systems sensitive to developmental, cultural, and linguistic diversity? Effective referral
systems take into account special considerations for developmental, cultural, and linguistic diversity across
individuals asked to make referrals, students being referred, and the families and caregivers of students
being referred. Chapter 4 of the SMHRPT describes this topic in detail.
Steps for Establishing a Problem Solving Team
Establishing a problem solving team is fundamental for ensuring that students with social, emotional, and
behavioral needs are matched to interventions that will effectively meet their needs. Below are several steps
to follow if your school does not yet have a problem solving team:
1. Assess Existing Teams. Avoid “team exhaustion” by assessing existing student support teams on
campus. Consider which teams that might be natural fits for the task of managing referrals. Examples of
existing teams include (Iachini, Anderson-Butcher, & Mellin, 2013):
• School climate teams
• Wellness teams
• Transition teams
• Grade-level teams
• Crisis intervention teams
• Wraparound teams
• Multidisciplinary Individualized Educational Plan (IEP) teams
• Positive Behavior Intervention Supports (PBIS) teams
2. Identify Team Members. Multidisciplinary teams should include personnel representing physical health,
general education, special education, law enforcement, and mental and behavioral health. Although it’s
acknowledged that some schools have fewer personnel to participate on a problem solving team than
others, it should never be the case that a single individual is responsible for managing all tasks that would
otherwise be covered by a team. If effective referral systems are considered a priority, then all schools
have the capacity to bring together several people to do this work collaboratively. Consider inviting the
following individuals to become members of your problem solving team:
• Administrators
• School Resource Officer
• School Psychologist
• School Counselor
• School Social Worker
• Teachers
• School Nurse
• Family Representative/PTA representative
• Member of community agency/organization
- Mental health provider
- Healthcare professional
- Police
- Child Protective/Social services
Include Family Members and
Caregivers. When teams are
convened to discuss students who are
struggling, it is best practice to invite
families to participate. Welcoming
families to be a part of the discussion
and to help identify solutions to the
presenting problem is often beneficial
in accessing services and ensuring
follow-through.

3. Articulate Team Purpose and Clarify Roles. All members of the team should be able to articulate the
common purpose for the group as well as the roles and responsibilities of individual team members for
meeting that common purpose. Problem solving teams work best when:
• A single individual is identified as a team leader. Team leaders are responsible for the critical tasks
that keep the team running, including delegating housekeeping tasks (e.g., sending meeting notices,
obtaining meeting space, keeping notes) and management tasks (e.g., setting agenda, ensuring
participation of key team members, ensuring team objectives get met).
• They clearly articulate the types of student concerns they manage (e.g., academic, behavioral, social,
emotional, physical), as well as the environments from which these concerns are expected to arise
(e.g., school, home, community).
• Team members bring specialized skills to bear on the team. Team members adequately represent the
following domains of school functioning:
- Student assessment
- Individual support services
- School discipline and behavior management
- Family engagement
- Academic instruction
- Community collaboration
- School policy and governance
4. Establish Routines. Establishing a routine for team meetings will help reduce the burden on team
members by allowing them to focus their time on triaging student concerns. Teams should utilize an
agenda, meet at regular intervals, and act within a specific time frame. Agendas do not need to be lengthy,
but should include opportunities to discuss the following topics, each of which is described in more detail
later in this chapter:
• Progress review of previously referred students
• Examination of new referrals
• Review of team members’ responsibilities for next steps
5. Reassess Team Structure and Functioning. After a problem solving team is established and has met for
several months, it will almost always be the case that the team’s structure and functioning will need to be
revaluated and perhaps modified to better meet its aims. Toolbox 1.1 provides key questions to consider
when assessing the structure and functioning of a problem solving team.
Stage 2: Manage Referral Flow
Once the problem solving team is in place, their first order of business is to
determine how to manage referral flow. For the purpose of this topic, referral
flow refers to the series of steps that occur between the point that the young
person comes to the problem solving team’s attention and the point that the
team matches his/her needs with an appropriate intervention. Below are four steps for effectively assessing
referral flow:
1. Does the problem solving team effectively collect initial referrals? First, problem-solving teams
need to establish a procedure for receiving referrals. Referral forms are often used for this purpose and
it is the first task of the problem solving team to adopt a referral form or set of referral forms that suit their
needs. In addition to the types of referral forms the team wishes to use, they will need to determine what
languages the referrals forms need to be translated to in order to ensure that linguistically diverse students,
family members, and community members can make referrals as needed. Tool 1.1 provides three
examples of referral forms: school adult, parent, and self or peer.

After creating referral forms, the problem solving
team must determine procedures for using the
referral forms. Key considerations for referral form
procedures include:
• Will blank referral forms be available in paper or
electronic format, or both?
• Where can referral forms be found by individuals
seeking to use them?
• Where can referral forms be submitted? Will
electronic submissions be accepted?
• Who will review referral forms? Will the problem
solving team review all submitted forms, or will
a delegated individual review form and submit
them to the problem solving team?
• How will procedures for submitting referral forms
be communicated with school professionals,
parents, and community members?
2. Does the problem solving team effectively
expand on initial referrals? Once the initial referral
has been received, the problem solving team should
gather additional information in order to better
understand the scope of the problem. The process
of understanding the referral concern using school-
based problem solving methods is discussed at
length in Chapter 2 of the SMHRPT. For the purpose
of this chapter, however, a few key methods for
expanding the problem solving team’s understanding
of the referral concern are offered below:
• Collect Background Information. Collecting
background information is paramount to
understanding the context of the student’s
presenting referral concern(s). In order to
understand the history of the child in order
to provide context for the current presenting
problem, the problem solving team may wish
to conduct a review of records and/or interview
the student’s caregiver(s). Teams may
consider tasking a single team member, such
as the school psychologist, with obtaining and
summarizing any psychological or educational history (e.g., previous evaluations or reports) relevant
to the presenting problem. Teachers or learning specialists may also be able to collect and report on
relevant academic or instructional information relevant to learning concerns. Information gleaned from
this thorough examination of background information should be organized, summarized, and presented
to the team in order to inform intervention decisions.
Schools may consider formalizing the collection of background information by requiring that reports and/or
forms to be completed by designated members of the problem solving team. These reports or forms may be
comprised by the following questions:
• Is this the first time this concern has been brought to the school’s attention? If not, what initiated
previous referrals?
Toolbox 1.1. Questions to Consider
When Assessing Problem Solving Team
Structure and Functioning
Communication, Collaboration, and
Leadership
• Are there regularly scheduled meetings, or
only as needed?
• Is sufficient time provided for team meetings?
• Are all people who have a role to play invited
to participate on the team?
• Do team members communicate regularly
outside of planned meeting dates?
• Do team members know what skills they and
others bring to the team?
• Is there a clear team leader?
• Does the leader use an effective leadership
style?
• Does the team engage in ongoing self-
reflection and improvement efforts?
Relationships with School Staff, Families, and
Community Partners
• Do school personnel know who members of
the team are?
• Do members of the team enjoy positive
relationships with school personnel?
• Has the team met with community partners
to introduce the team’s purpose and to invite
community partners to participate?
• Have family members been asked to inform
the team’s processes?
• Do family members play a meaningful role on
the team?
• Do school personnel, community members,
and families know when the team meets and
how to get in touch with team members if
needed?
Adapted from: Wisconsin Department of Public Instruction’s
Collaborative and Comprehensive Pupil Services’ Self-
Assessment (2008)

• Is there background information that may influence the problem behavior, such as a medical diagnosis
or history of trauma experiences?
• What has been done to address the current problem (pre-referral interventions)?
• Is the student seeing a professional about this problem within or outside of the school?
• What interventions have been implemented in the past for similar problems?
- Have past interventions been partially effective, fully effective, or not effective at all?
- Are there explanations for why interventions have or have not been effective?
Of course, confidentiality needs to be maintained and information (e.g., parental report of infidelity) that is not
relevant to the presenting concern should not be shared or introduced for discussion by the team.
• Conduct Observations. Observation of the student can provide valuable insight into the context for
the referral concern(s). The problem solving team will need to consider:
- Is there a formal observation protocol adopted by the problem solving team?
- Is parental consent considered when conducting observations?
- Are there specific problem solving team members who are most qualified to conduct
observations?
- How are observation records incorporated into other sources of data related to the
referral?
• Interview Teacher(s) and Other School Adults. Problem solving teams may also choose to interview
school adults who frequently interact with the student in order to address specific questions about the
presenting problem and the student’s functioning in a variety of school settings. The problem solving
team will need to consider:
- Is there a formal interview protocol that is adopted by the team?
- Are there specific problem solving team members who are most qualified to conduct
interviews?
- How are interview records incorporated into other sources of data related to the
referral?
• Interview Community Partners. In addition to interviewing school personnel, the problem solving
team may learn that the student frequently interacts with partners in the community, such as afterschool
youth development staff, law enforcement, or a mental health provider. These individuals, if they do not
sit on the problem solving team themselves, may need to be interviewed to obtain their insights into the
student’s presenting concern. In addition to interview considerations for school personnel, the problem
solving team will need to consider whether the child’s parent or guardian has given signed consent for
information about the child to be shared across agencies.
3. Does the problem solving team have defined decision rules? Once the team has conducted a
thorough assessment of the referral concern, a meeting should be held to review the collected information,
synthesize it, and discuss next steps. Advancing all students to Tier 2 or Tier 3 intervention may not be
necessary; in some cases, an informal plan to monitor the child’s progress may be sufficient. Before
moving forward in the referral pathway, it is important to examine the rules by which the team makes
recommendations for interventions. The team must consider:
• How do we know when a student needs a Tier 2 intervention?
• How do we know when a student needs a Tier 3 intervention?
• How do we know when we can begin to fade an intervention?
• How do we know when an intervention should be discontinued because it is not working?
4. Does the problem solving team have a record management system? The process of managing
referrals will generate several documents, including referral forms, record reviews, and observation and
interview reports. The problem solving team must have a system for retaining these materials. Teams
must consider:

• Are paper records generated by the problem solving team stored in a secure location?
• Does the problem solving team use a secure electronic filing system?
• Should all members of the problem solving team have access to the team’s documents, or are different
levels of permission appropriate?

Stage 3: Map Resources
If the problem solving team decides to move forward with intervention after
thoroughly reviewing the referral concern, then they will need to ensure that
there exists a clear link between the presenting problem and the type of
intervention selected. Matched interventions may include social, emotional,
and/or behavioral consultation between the student’s teacher(s) and member(s) of the problem solving team; a
targeted evidence-based intervention delivered in a small group or individually; and/or a referral for additional
services to outside agencies. In order to match students to the intervention that will best meet their needs, the
problem solving team will need to (a) establish an up-to-date map of available resources and (b) engage in a
vetting procedure to ensure that all resources are evidence-based and of high quality. Below are three self-
assessment topics that should be addressed when mapping resources:
1. Has the team identified all school and community resources available to them? The problem solving
team will need to create a database of all existing and potential resources, interventions, and partnerships
both within the school or district, and in the community. To obtain information for the database, the team
may wish to ask community partners to submit information about their organization (Toolbox 1.2) that will
then be used to populate a resource database for ongoing use by the team (For example, see Tool 1.2).
To optimize utility of the resource database, the team will wish to describe the MTSS tiers each resource
fits into. Toolbox 1.3 displays a sample database of resources and partners (e.g., providers, services,
programs, etc.) both within and outside of school, categorized by tier.

Toolbox 1.2. Community Resource Recruitment Form
Name of Organization and Website
Date Updated
Responsible School-Based Team
Member
Services Provided ☐ Individual Counseling
☐ Substance Abuse Counseling
☐ Group Counseling
☐ Family Sessions
☐ Behavioral Approaches
☐ In-Office
☐ Home Visits
☐ Other_________________
Organization Type
Vetting and Licensure Names of agencies that have approved the service:
Licensure of service providers:
Operating Days/Hours
Contact Person at Community
Resource
Specific Providers
Telephone/Email
Location/Transportation Concerns

Cost: Insurance, Sliding Fee Scale, etc.

How is progress monitored at the
community site?
☐ Checklists
☐ Clinical Judgment
☐ Progress Monitoring forms
☐ Other_________________
Languages ☐ Spanish
☐ Chinese
☐ Korean
☐ Other_________________
Age Population ☐ Early childhood
☐ Elementary
☐ Adolescents
☐ Adults
Other Notes
Toolbox 1.3. Sample List of Resources and Partners within the MTSS Framework
NAME WITHIN/
OUTSIDE
TIER(S) TYPE SUMMARY
Social Emotional Learning
(SEL) Curriculum
W 1 Program School counselor facilitates in
classrooms
After School Clubs W 1 Program Variety of club opportunities
focused on academics or social
activities
Parent Teacher
Association
W 1, 2 Volunteers Utilizing families to provide
connections, volunteers for
reading interventions, or career
day
Positive Behavioral
Interventions Supports
W 1, 2, 3 Program Tiered Approach to rewarding
positive behaviors
Group Counseling W 2 Service
Provider
Group counseling, short term,
focusing on at-risk students,
developing specific skills
Check and Connect W 2 Service/
Program
Home-school liaison facilitates
Functional Behavioral
Assessment and Behavior
Intervention Plan
W 2, 3 Service School psychologists and
multidisciplinary team
implement
Individual Mental Health
Services
W 3 Licensed
mental health
clinicians,
school based
School-based individualized
mental health services

Individual Mental Health
Services
O 3 Licensed
mental health
clinicians,
community
based
Community-based
individualized mental health
services
Chamber of Commerce O 1 Private
partnerships
Grant opportunities
Boys and Girls Club O 1, 2 Program Private organization
Faith-based Organization O 1, 2 Non-profit
organization
After school programs, faith-
based supports
Child Protective Services O/W 2, 3 Government
Agency
Provides support for safety of
children
Person in Need of
Supervision (PINS)
Diversion Program
O 3 Government
Agency
Family specialists work with
families to address non-violent
offenses
Hospitals O 3 Medical Mental health crisis response
Note: The first column represents an example type of resource. The next column labeled, “Within/Out”
indicates if the resource is located within (W) the school or outside (O) of the school. The third column
indicates type of organization, such as a formal program or an individual service provider. The last column
is a short description of each resource/partner.
2. Has the team examined the breadth and quality of interventions provided at school? After
thoroughly mapping resources available within the school, the problem solving team will need to judge the
quality and breadth of resources in order to answer the following questions:
• Are any interventions not supported by research and therefore appropriate for disqualification?
• Are there sufficient types of Tier 2 and Tier 3 interventions to match diverse student needs?
• Are there enough spaces in Tier 2 and Tier 3 interventions to adequately serve all students who may
need them?
3. Has the team examined issues related to access to community-based resources? Below are several
questions that could be used to guide the problem solving team’s relationship with community partners.
Additional strategies for building effective partnerships are covered at length in Chapter 3 of the SMHRPT.
• Whose responsibility is it to facilitate contact between the student’s family and the community partner?
• Is there a structured relationship between the school and the community partner?
• Is there a written agreement between the community partner and school?
• Are data shared between the partner agency and the school? Is there a memorandum of understanding
(MOU) in place to codify data sharing?
• Whose role is it to track a referral after it has gone from the school to the community partner?
• Is the student’s family experiencing any barriers to accessing services offered by the community
partner? (e.g., transportation, concerns about confidentiality, cultural or linguistic barriers)
• Are there any barriers to accessing services by community partners that the school may be able to
address, such as school policies that prevent collaboration?

Stage 4: Evaluate Intervention Effectiveness
The final set of procedures that the problem solving team must self-assess
are the ones they use to monitor the effectiveness of the interventions
they’ve prescribed. This stage is critical for ensuring that the problem
solving team can speak with confidence when they say they are improving
the social, emotional, and behavioral wellbeing of young people. In addition
to the detailed steps articulate in Chapter 2 of the SMHRPT, the problem solving team will need to answer the
following questions:
1. Does the problem solving team define what response to intervention will look like? The team must
answer the question, “What will it look like when this student no longer experiences the problem for which
he/she was referred?” The team must answer this question in as observable and quantifiable a way as
possible so that students’ response to intervention can be measured.
2. Does the problem solving team collect process data? Process data help the team monitor whether the
intervention is happening as planned. Process data include things like the number of sessions provided
and the duration of sessions.
3. Does the problem solving team collect outcome data? Outcome data help the team determine if
the interventions they selected are working for reducing the problem for which the student was referred.
Outcome data might include improved school attendance, improved grades, or fewer fights with peers.
4. Does the problem solving team monitor intervention progress? The team will want to know before an
intervention concludes whether or not the intervention is working for the purpose it was selected. For this
reason, the team may request to monitor progress by asking for reports on process and outcome indicators
at regular intervals during the course of the intervention. For example, if a student is assigned to a Tier 3
intervention meant to occur once per week for fifteen weeks, the team might request reports on progress
indicators at weeks five and ten.
5. Does the problem solving team request intervention effectiveness information from community
partners? It is sometimes the case that problem solving teams request different information from school-
based practitioners than they do for community partners. Typically this is due to the fact that community
partners are not employees of the school district and cannot therefore be required to provide data. Most
community partners will gladly provide requested information if provided an efficient and lawful route to do
so. See Chapter 3 of the SMHRPT for more information about sharing data across agencies.
6. Does the problem solving team request feedback from the student and/or his/her family about the
intervention experience? A valuable source of process data can be obtained by asking the student and
his or her family how they felt about the intervention. Did the student feel the experience was useful? Did
he/she feel connected to the person providing the intervention? Did the student’s family perceive any
positive changes as a result of the intervention?
7. Has the problem solving team adopted student information systems for tracking response to
intervention? Problem solving teams should consider adopting software systems to electronically track
intervention process and evaluation data. Toolbox 1.4 displays several software systems that may be used
for tracking intervention data.

Toolbox 1.4. Software Systems for Tracking Intervention Data
Name of Data System Developer Description
Early Warning System
betterhighschools.org/ews.asp
The National
High School
Center
A downloadable electronic tool that “helps schools and districts
systematically: 1) identify students who are showing signs that
they are at risk of dropping out of high school; 2) match these
students to interventions to get them back on track for graduation;
and 3) monitor students’ progress in those interventions.”
Source: The National High School Center, American Institutes for
Research
Hero
herok12.com
Hero K12, LLC
“An in–browser web app and a mobile app to allow K–12 schools
to capture a record of anything that happens on their campus.”
Source: HeroK12
Maxient
Maxient.com
Maxient
A web-based information system designed to coordinate “student
discipline, academic integrity, care and concern records, Title IX
matters, or just an “FYI”...an integral component of many schools
overall early alert efforts, helping to identify students in distress
and coordinate the efforts of various departments to provide
follow-up.”
Source: Maxient
SWIS Suite
pbisapps.org
PBISApps
“A reliable, confidential, web-based information system to collect,
summarize, and use student behavior data for decision making.”
Source: PBISApps
8. Does the problem solving team report intervention effectiveness information to stakeholders?
There are several stakeholder groups that would benefit from knowing about the problem solving
team’s work. For instance, in individual cases, both family members and school adults that have daily
interactions with a referred student may be interested in understanding intervention assignment and
progress. Although he or she may not be interested in individual-level data, the school superintendent may
be interested in understanding how the team makes intervention decisions and how those interventions
correspond to student outcomes at the aggregate. Due to the sensitive nature of the work, the problem
solving team will want to ensure that stakeholder(s) receiving the data have the appropriate permissions
to receive the level of data shared, especially with regard to whether the data have the student’s name or
other identifying information attached to them.
This chapter of the SMPRT outlined four self-assessment stages, each characterized by several assessment
questions, that schools—problem solving teams, specifically—can use to gauge the quality of their referral
systems. By reflecting on their answers to these questions, problem solving teams can identify the strengths
of their referral systems as well as the weaknesses and gaps that need to be addressed in order to optimally
address students’ social, emotional, and behavioral needs at all MTSS tiers.

SMHRPT Chapter 1 19
Tool 1: Example Referral Forms
Example Referral Form: School Adult
Name of student: _____________________________________________________________
Your name: _________________________________________________________________
Relationship to student:___________________________________________________
The school’s problem-solving team may wish to contact you to discuss your referral concerns.
Please provide your contact information and the best time to reach you.
Phone:_________________________ Best time to contact:_________________________
Area of concern (please mark all boxes and describe):
 Academic concerns:
 Behavioral Concerns:
 Social Concerns:
 Emotional Concerns:
 Physical Health Concerns:
 Family Concerns:
 Other: _____________________
Behavioral concerns (please mark all boxes that apply):
 Exposed to community violence, other
trauma
 Nightmares, intrusive thoughts
 Anxious, fearful or irritable mood
 Jumpy or easily startled
 Avoids reminders of trauma
 Aggressive
 Sexualized play or behaviors
 Difficulty concentrating
 Talks excessively
 Gets out of seat and moves constantly
 Interrupts and blurts out responses
 Inattentive, distractible, forgetful
 Disorganized, makes careless mistakes
 Angry towards others, blames others
 Fights and is aggressive
 Argumentative and defiant
 Sad, depressed or irritable mood
 Hopelessness, negative view of future
 Low self-esteem, negative self-statements
 Diminished interest in activities
 Low or decreased motivation
 Anxious and fearful
 Worries excessively
 Difficulty sleeping
 Restless and on edge
 Specific fears or phobias
 Clingy behavior
 Appears distracted
Tool 1.1. Example Referral Forms

SMHRPT Chapter 1 20
How often is this behavior occurring? (e.g., several times per day; 1-2 times per week)
How long has this behavior been occurring? (e.g., several weeks, several months)
To your knowledge, what interventions have previously been tried?
 In school supports:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
 Outside of school supports:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
To your knowledge, what interventions, if any, are currently in place?
 In school supports:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
 Outside of school supports:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
What do you think will help the student to experience success?
Adapted from: Los Angeles Unified School District School Mental Health Referral Form, available at:
http://achieve.lausd.net/Page/7249

SMHRPT Chapter 1 21
Example Referral Form: Parent or Guardian
Date:__________________________________________________________________________
Name of child:___________________________________________________________________
Your name:_____________________________________________________________________
Relationship to child:______________________________________________________________
The school’s care team may wish to contact you to discuss your referral concerns. Please provide
your contact information and the best time to reach you.
Phone: _____________________________ Best time to contact: _______________________
Who does your child live with?
 Biological parents
 Adoptive parents
 Foster parents
 Relative care
 Group home
 Other: ____________________
Desired language of service?
 English
 Spanish
 Other: ____________________
Does your child have an Individualized Education Plan (IEP)?
 Yes
 No
 I don’t know
Area of concern (please describe):
 Academic concerns:
 Behavioral Concerns:
 Social Concerns:
 Emotional Concerns:
 Physical Health Concerns:
 Family Concerns:
 Other: _____________________
Please mark all boxes that apply:
 Exposed to community violence,
other trauma
 Aggressive
 Gets out of seat and moves
constantly
 Disorganized, makes careless
mistakes

SMHRPT Chapter 1 22
 Hopelessness, negative view of
future
 Low self-esteem, negative self-
statements
 Clingy behavior
How often is this behavior occurring? (e.g., several times per day; 1-2 times per week)
How long have you had this concern about your child?
To your knowledge, has your child ever received any supports or interventions for this behavior
in the past?
To your knowledge, is your child receiving any supports or interventions for this behavior
currently?
What do you think will help your child experience success?

SMHRPT Chapter 1 23
Example Referral Form: Self or Peer
Date: _______________________________________________________________________
Your name: _________________________________________________________________
Who are you looking for support for?
 Myself
 Another student at my school
The school’s care team may wish to contact you to understand your concerns better.
 Yes, it’s ok to contact me
 No, please don’t contact me
Please share the reason you are seeking support for yourself or another student:
Please mark all boxes that apply:
 Exposed to community violence,
other trauma
 Aggressive
 Gets out of seat and moves
constantly
 Disorganized, makes careless
mistakes
 Hopelessness, negative view of
future
 Low self-esteem, negative self-
statements
 Clingy behavior
Please share any additional information you would like the care team to know:

Tool1.2.SampleCompletedDatabase
ApprovedServiceProvidersforLEADistrictSchools
ContactInformation
Description
ofService
Populations
Served
Family/School
Involvement
Effectivenessor
Results
Vetting
Licensure
Organization
Capacityand
Cost
Example:
XYZProgramwww.
xyz.exp
YouthMentalHealth
Services(YMHS)
www.ymhs.exp
JaneDoe
555-555-5555jane.
doe@ymhs.exp
Example:
XYZisan
8week,
45minute,
smallgroup
intervention
forupto6
studentstohelp
youthdevelop
stressreduction
skills.
Example:
Grades6through
12,forlowself-
concept,social
isolation,familial
stress,anger
issues,hasbeen
implemented
withfree/
reducedlunch
studentsfrom
white,African-
American,
Latino,andAsian
backgrounds
Example:
YMHSstaff
implements
servicesto
studentsand
providestraining
toteachersand
counselors.
YMHSstaffreach
outtofamilies
throughhome
visits,family
groupsessions,
andone-on-one
counseling
Example:
Pre/Poststress
physiologytest
showedlower
stresslevels.
Pre/Poststudent
surveysshowed
increasedempathy,
emotionalcontrol,
optimism,self-
concept.Teacher
interviewsrevealed
morepro-social
behaviorand
peeracceptance.
Studentreferrals
forphysicaland
socialaggression
decreased.
Example:
SAMSHA
UCLA
AllYMHSstaff
haveterminal
degreesofMSW
orPhD,thestaff
arelicensedby
thestateboard
Example:
YMHShasthe
capacitytolead
10XYZgroups
atatimeover
atypicalschool
year.Programis
grantfunded.Cost
toparticipantsis
basedonasliding
scaledetermined
byfree/reduced
lunchapplications
and/orteacher/
counselor
recommendation

Tool 1.3. Additional Resources for Assessing Your Referral Management Approach
Name of Resource
Name of Resource
Developer
URL Resource Short Description
Addressing The Unmet
Mental Health Needs Of
School Age Children:
Guidelines For School-
Community Partnerships
Illinois Children’s
Mental Health
Partnership
http://www.icmhp.org/
icmhppublications/files/
ICMHP-SchoolGuidelin
esFinalWEB11-19-10_
ICMHP-.pdf
Steps to establish partnerships and
finance strategies; provides specific
tools such as grant writing, creating
effective strategic plans, appropriate
oversight, etc.
Using Coordinated School
Health to Promote Mental
Health for All Students
National Assembly
on School-Based
Healthcare
http://www.nasbhc.org/
atf/cf/%7Bcd9949f2-
2761-42fb-bc7a-
cee165c701d9%7D/
white%20paper%20
csh%20and%20mh%20
final.pdf
Provides resources and a framework
for providing this care within the school
context.
Strategic Planning Toolkit
for Communities: 2012
National Forum
on Youth Violence
Prevention
http://ojp.gov/fbnp/pdfs/
forum_toolkit.pdf
Toolkit for communities addressing
prevention of youth violence. Includes
data-driven strategies for: prevention,
Intervention, Enforcement, and Reentry.
Contains references and referrals for
other relevant resources.
Community Conversations
About Mental Health
Planning Guide
SAMHSA
http://store.samhsa.gov/
shin/content//SMA13-
4765/SMA13-4765.pdf
Facilitating community Discussions
around mental health.
School-Community
Partnerships: A Guide School Mental Health
Project, Dept. of
Psychology, UCLA
http://smhp.psych.ucla.
edu/pdfdocs/guides/
schoolcomm.pdf
Guide to building partnerships, focusing
on relationships and families.
Collaborative and
Comprehensive Pupil
Services
Wisconsin
Department of Public
Instruction
http://sspw.dpi.wi.gov/
sites/default/files/imce/
sspw/pdf/pscandc.pdf
Self-assessment tools for professionals
evaluating systems-wide approaches for
prevention and referrals.
School Mental Health
Capacity Instrument
Feigenberg & Watts
Boston Children’s
Hospital
Contact Author: luba.
feigenberg@childrens.
harvard.edu
Quantitative assessment tool for school
approaches to the prevention of mental
health concerns.
NJ State Board of
Education
Resource Manual
http://www.state.nj.us/
education/students/irs/
A practical manual for school-based
intervention and referral services from
the NJ DOE with useful flow charts and
examples of referral procedures and
forms.
GUCCHD TA Center
Putting the Pieces
Together: A Toolkit
on Developing Early
Childhood Systems of
Care
http://gucchdtacenter.
georgetown.edu/
resources/ECMHC/
ECSOC%20Toolkit/
PPT_Toolkit.pdf
Several examples of referral processes
and pathways including: Family
Navigators - as part of their Screening,
Assessment, Referral & Treatment
(SART). Their goal is to create a “warm
hand off” between Family Navigators
in the prevention end of the service
continuum and Family Partners in the
treatment end of the continuum of care
for young children.
Office of Juvenile
Justice and Delinquency
Prevention (OJJDP)
Strategic Planning Tool
National Gang Center
http://www.
nationalgangcenter.
gov/About/Strategic-
Planning-Tool
Sign up for a free account to develop a
program matrix and online community
resource inventory.

References
Burns, M. K., Kanive, R., Karich, A. C. (2014). Best practices in implementing school-based teams within a
multitiered system of support In P. L. Harrison & A. Thomas (Eds.), Best Practices in School Psychology
Data-Based And Collaborative Decision Making (pp. 569–582). Bethesda, MD: National Association of
School Psychologists.
Iachini, A . L. Anderson-Butcher, D., & Mellin, E. A. (2013). Exploring best practice teaming strategies among
school-based teams: implications for school mental health practice and research. Advances in School
Mental Health Promotion, 6(2), 139-154, doi:10.1080/1754730X.2013.784618
Wisconsin Department of Public Instruction. (2008). Collaborative and comprehensive pupil services:
Student services/prevention & wellness team division for learning support: equity and advocacy.
Retrieved from: http://sspw.dpi.wi.gov/sites/default/files/imce/sspw/pdf/pscandc.pdf

Chapter 2: School-Based Problem-Solving to Promote Youths’ Mental Health 39

SCHOOL-BASED PROBLEM-SOLVING TO PROMOTE YOUTHS’ MENTAL HEALTH
Key Questions
1. What is a problem-solving approach and how can the four-step problem-solving model be used
to promote youths’ mental health in schools?
2. What roles do school personnel and community partners play on problem-solving teams
dedicated to promoting mental health?
3. How can problem-solving teams use the antecedent–behavior–consequence theory of behavior
to effectively solve youths’ mental health problems?
4. What evidence-based assessment and intervention practices are available for problem-solving
teams to use to promote mental health within multitiered systems of supports?
A Problem-Solving Approach for Promoting Mental Health
A problem-solving approach is a practical and scientific approach for effectively solving mental health
problems experienced by youth in schools. This approach is practical because it provides school personnel
and community partners with an organized way of thinking about and working with youths’ mental health
problems so they can be changed for the better. It is scientific because it uses a systematic hypothesis-testing
approach that is driven by evidence-based theory and current data.
Within a problem-solving approach, the word “problem” is defined as:
An unacceptable discrepancy between desired levels of valued behavior and observed levels of
that behavior (Deno, 2013).
In other words, a “problem” arises when school personnel care about the way students behave (i.e.,
valued behavior) and a particular student (or group of students) is unable to meet the school’s behavioral
expectations (i.e., unacceptable discrepancy between desired levels and observed levels of that behavior).
An important implication of this definition is that “problems” are not viewed as concrete things existing solely
inside of youth, but rather as situational things that arise as the result of youth interacting with their school
environments. As Deno (2013, p. 11) plainly put it: “problems exist in the eye of the ‘beholder’ [i.e., school
personnel] rather than in the behavior or performance of the student.”
As with academic problems, many students also experience mental health problems that make school and
life more challenging. Just as a problem-solving approach is useful for resolving academic concerns (Deno,
2013), it is also useful for solving mental health problems (Barrett, Eber, & Weist, 2015). Although students
can experience lots of different kinds of mental health problems, a useful way of classifying these problems is
to divide them up into two general categories: internalizing problems and externalizing problems (Form, Abad,
& Kirchner, 2014).
CHAPTER 2

• Internalizing problems occur when students experience an excess of unwanted, aversive thoughts
and feelings that are directed inwards toward the self. The most common kinds of internalizing
problems are depression and anxiety. Because students’ thoughts and feelings are only observable
to themselves, these kinds of problems can sometimes be difficult for school personnel to detect.
However, these excesses of unwanted, aversive thoughts and feelings are usually associated with
deficits in adaptive behavior, such as withdrawing from social interaction or avoiding school tasks,
which school personnel are likely to notice over time.
• Externalizing problems occur when students exhibit an excess of behaviors that are disruptive to
social harmony or that threaten others’ physical or psychological wellbeing. The most common kinds
of externalizing problems are non-compliance, defiance, hyperactivity–impulsivity, and aggression.
Although these problems are often associated with unwanted internal experiences, such as anger or
impulsive feelings, it is the outward behavior that usually is concerning to school personnel, because of
its negative effects on other students and staff.
Whether used for addressing internalizing or externalizing problems, or any other kind of problem, a school-
based problem-solving approach is characterized by five core features: it is (1) values-based, (2) outcome-
focused, (3) data-driven, (4) school-led, (5) collaborative, and (6) process-oriented (Deno, 2013; Pluymert,
2014).
• Values-based. As mentioned above, a “problem” is a discrepancy between valued behavior and actual
behavior. From this perspective, values can be defined as desired qualities of behavior that are intentionally
chosen and used to guide goal setting. Goals can then be defined as behavioral expectations that can be
quantified and achieved, while values are the “things people care about” that motivate them to set and achieve
goals in the first place. Probably the most common value for school personnel is that youth be academically
successful. This value guides the setting of various academic goals, including benchmark and test scores
that indicate mastery of skills and subject areas. Working toward goals is a way to realize values—to support
students in behaving in desirable ways—but achieving goals doesn’t finalize values, as there is always more to
do to be a “successful student.” When school personnel choose to value youths’ mental health in a similar way
that they value academic success, then they empower themselves to set and achieve goals toward this end.
• Outcome-focused. The ultimate aim of a problem-solving approach is to improve youth outcomes that are
linked to goals that are derived from school personnel’s values regarding student behavior. The practical
implication of this is quite simple: if outcomes are improving and goals are being met, then school personnel’s
problem-solving efforts are working. And if outcomes aren’t improving and goals aren’t being met, then problem-
solving efforts are ineffective and need revising. To that end, the important principle underlying an outcome-
focus is to set realistic goals that are tightly linked with values, and which can be feasibly evaluated to determine
success.
• Data-driven. A problem-solving approach relies on data-based decision making as the primary means for
identifying problems, generating hypotheses for how to best solve problems, selecting specific strategies to
intervene with problems, and for evaluating the effectiveness of problem-solving efforts. Such data are collected
and interpreted systematically and repeatedly, using pre-established decision rules. From a problem-solving
perspective, the only way to judge if mental health outcomes are improving, if goals are being met, and if values
are being realized is by collecting and using data regarding student behavior.
• School-led. When a problem-solving approach is initiated by school personnel, they take responsibility for
leading all aspects of the process—from establishing values to determining outcomes to collecting data to
testing solutions. This means that the responsibility for achieving desired student outcomes rests squarely on
school personnel’s shoulders. If problem-solving efforts are ineffective for promoting students’ mental health,
the onus is on the school personnel, not the student or the student’s family. If school personnel do not have the
time, resources, or expertise to lead a particular aspect of the problem solving process or to provide students
with needed mental health services, it is their responsibility to contact and collaborate with community partners
to ensure that such services are made available.

When initiating a problem-solving approach in schools for the purposes of promoting youths’ mental health,
school personnel can begin by taking two key steps: establishing a problem-solving team and selecting a
problem-solving model.
Establishing a Problem-Solving Team
Problem-solving teams can take different shapes in schools, depending on the number and type of personnel
who are available and dedicated to promoting youths’ mental health. There are several different types of school
personnel that are commonly involved in problem-solving teams: school mental health professionals, teachers,
support staff, and administrators.
• School mental health professionals are practitioners who have graduate-level training in promoting
mental health, and who provide support services to youth in school settings. These individuals may be
employed part-time or full-time by the school and may come from a variety of training backgrounds.
Common school mental health professionals include: school psychologists, child clinical psychologists,
counseling psychologists, school social workers, marriage and family therapists, and behavior analysts
or behavior specialists. The role of school mental health professionals on the problem-solving team is
to share their specialized knowledge related to assessing and intervening with youths’ internalizing and
externalizing behaviors and to apply that knowledge by providing indirect (e.g., consultation) and direct
(e.g., counseling/therapy or skill-training) mental health services to youth at school.
• Teachers are those educators employed by the school, either part-time or full-time, to teach core
content area courses or elective courses. The role of teachers on the problem-solving team is to share
their specialized knowledge regarding students’ educational functioning, to offer observations regarding
how youths’ mental health problems are interfering with school success, and to assist school mental
health professionals in providing support services to students by collecting data and implementing
classroom or schoolwide interventions.
• Support staff refers to those educators employed by the school to assist teachers in their duties.
These individuals may also be present at the school part-time or full-time and they may be employed to
support academic instruction (e.g., “reading specialist”) or to support youth with challenging behaviors
(e.g., “one-on-one aid”). Similar to teachers, the role of support staff on the problem-solving team is to
offer observations regarding how youths’ mental health problems are interfering with school success,
and to assist school mental health professionals in providing support services to students by collecting
data and implementing classroom or schoolwide interventions.
• Collaborative. Although school personnel initiate and take responsibility in leading the problem-solving process,
they must also actively collaborate with students, families, and community partners to efficiently and effectively
accomplish their purposes. Depending on the scope of the problem, it can be helpful to invite students and
families into the problem-solving process to clarify and establish shared values, develop culturally sensitive
outcome goals, and design socially feasible intervention procedures. And when mental health problems become
severe or require time and resources beyond those available in the local school setting, community partners
with advanced expertise should be engaged in the problem-solving process to provide necessary or specialized
support services.
• Process-oriented. Instead of being a “quick fix,” a problem-solving approach is a process-oriented method
that involves following specified steps of a logic model (described below), which requires a significant time and
resource investment from school personnel. The payoff of this investment is that staff members’ efforts are
likely to be more effective for achieving valued student outcomes. Also, when efforts to promote mental health
in schools are ineffective, the logic model underlying the problem-solving process provides a self-correcting
mechanism for moving forward to act more effectively in the future. All of the phases or the logic model guiding
the problem-solving process are consistently characterized by the five previous key features: (1) values-based,
(2) outcome-focused, (3) data-driven, (4) school-led, and (5) collaborative.

• Administrators are those educators who are responsible for supervising teachers and school staff,
managing student concerns, and establishing and enforcing schoolwide policies and practices.
Common administrative positions include: principal, vice principal, dean of students, and school
counselor. The role of administrators on the problem-solving team is to share their specialized
knowledge regarding schoolwide policies and practices, to offer observations regarding how youths’
mental health problems are interfering with school success, to function as the liaison with families and
community partners when necessary, and to generally oversee the provision of mental health services
within the local school setting.
Although it is desirable for a problem-solving team to have members from each of these key categories of
school personnel, sometimes this may not be possible. At the very least, then, it is recommended that problem-
solving teams devoted to promoting youths’ mental health consist of at least two school personnel: a school
mental health professional and an administrator. Although problem-solving teams consisting only of educators
can function effectively to solve academic problems, it is not recommended that they target mental health
problems without the expertise of a school mental health professional, as this is likely to result in unethical
practice.
That said, given that school mental health professionals have such varied training backgrounds, it is important
to recognize up front the limits of their expertise and then to contact and collaborate with other school or
community mental health practitioners who are capable of providing necessary services that cannot be
provided by the local school-based practitioner. This point is described in mental health professionals’
codes of ethics as “practicing within the bounds of one’s competence” (e.g., National Association of School
Psychologists, 2010) and must be a major consideration when forming a problem-solving team. Common
examples of school mental health professional’s limited expertise and their need for collaboration include:
• Some school mental health professionals may only have expertise in solving externalizing problems
and may therefore not be capable of providing support to students with internalizing problems,
necessitating referrals to other mental health providers.
• Many school mental health professionals are only competent to provide mental health services to
students with mild to moderate problems, and will therefore need to refer out to specialized community
practitioners, such as child clinical psychologists and psychiatrists, when youth present with severe
mental health problems (e.g., bipolar disorder or early onset childhood schizophrenia).
• Some school mental health professionals may have substantial knowledge and skills regarding small-
group and individual supports, but lack expertise in schoolwide assessment and prevention strategies,
necessitating supervision or consultation from other school-based practitioners with expertise in this
area.
After a core group of school personnel and community partners have been established as a problem-solving
team, the next major step is to select a problem-solving model that will guide all future steps the team will take
in promoting youths’ mental health.
Several different logic models have been recommended for helping school-based problem-solving teams
accomplish their purposes. Some problem-solving models have been specific to academic skill problems
(Deno, 2013), some oriented toward externalizing problems (Erchul & Schulte, 2009), others to internalizing
problems (Huberty, 2009), and still others have been intended for application to any kind of problem (Pluymert,
2014). Although these models have some differences, they are more similar than not. This section presents a
synthesis of what can simply be called the four-step problem-solving model for promoting mental health in
schools (see Figure 2.1).

Step 1: Problem Identification
• Formative questions
o “What does the problem-solving team
value?”
o “Is there a problem?”
o “If so, what exactly is the problem?”
• Analytic aims
o Identify school personnel’s values regarding student behavior.
o Determine the presence of student problem behavior.
o Define student problem behavior in a way that is useful for guiding the remaining problem-solving
steps.
• Core procedures
o Clarify values and make a public commitment to promoting valued behavior.
o State the problem behavior in measurable and understandable terms.
o Obtain a baseline measure of the problem behavior.
o Conduct a discrepancy analysis to identify differences between desired and observed levels of
behavior.
Step 2: Problem Analysis
o “What factors are maintaining the problem?”
o “How can maintaining factors be changed to positively influence the problem?”
• Analytic aims
o Identify the factors maintaining the problem behavior.
o Identify an intervention strategy for the problem behavior that is logically connected to the
maintaining factors.
• Core procedures
o Assess potential factors maintaining the problem behavior.
o Determine the factors maintaining the problem behavior and link them with an intervention strategy
to positively influence problem behavior.
Step 3: Intervention Development
o “How can we implement the intervention strategy to positively influence the problem?”
o “How can we ensure the intervention is implemented with fidelity?”
o “How can we know if the intervention is working?”
• Analytic aims
o Develop an intervention plan for intervening with the problem behavior.
o Determine a method for gauging and improving implementation fidelity.
o Determine the valued behavioral outcome and an associated evaluation procedure.
The Four-Step Problem-Solving Model
The four steps within this particular problem-solving
model are: (1) problem identification, (2) problem
analysis, (3) intervention development, and (4)
intervention evaluation. Each of these steps is
outlined below according to its (a) formative questions,
(b) analytic aims, and (c) core procedures. When
followed closely, these three elements form a tight
logical sequence that functions to guide school
personnel in effectively resolving youths’ mental health
problems.
1. Problem
Identification
2. Problem
Analysis
3. Intervention
Development
4. Intervention
Evaluation
Figure 2.1. Four-Step Problem Solving Model
for Promoting Mental Health in Schools

• Core procedures
o Select an evidence-based intervention that operationalizes the intervention strategy.
o Develop the specific procedures and schedule for the intervention.
o Develop an implementation fidelity measure and establish a schedule and procedures for evaluating and
enhancing intervention integrity.
o Develop an outcome goal, select a progress-monitoring method, and establish a schedule and procedures
for evaluating intervention effectiveness.
Step 4: Intervention Evaluation
o “Is the intervention being implemented as planned?”
o “Is the intervention positively influencing the problem behavior?
o “If not, what can be done to improve intervention effectiveness?”
• Analytic aims
o Determine the level of implementation fidelity.
o Determine the effect of the intervention on the problem behavior.
o If needed, identify potential improvements to the problem-solving process.
• Core procedures
o Calculate the proportion of intervention components implemented with fidelity and, if needed, provide
support to enhance implementation fidelity.
o Graph progress-monitoring data.
o Use pre-established decision rules to determine intervention effectiveness.
o If needed, revisit the problem analysis step and the intervention development step and then re-implement
the intervention.
Toolbox 2.1. Core Procedures Checklist for the Four-Step Problem-Solving Model
Completed Problem-Solving Step / Core Procedure
_____ Step 1: Problem Identification
_____ Clarify values and make public commitment
_____ State the problem behavior is measureable terms
_____ Obtain a baseline measure of the problem behavior
_____ Conduct a discrepancy analysis
_____ Step 2: Problem Analysis
_____ Assess factors maintaining the problem behavior
_____ Link factors maintaining the problem behavior with an intervention strategy
_____ Step 3: Intervention Development
_____ Develop an intervention plan for intervening with the problem behavior
_____ Determine a method for gauging and improving implementation fidelity
_____ Determine the valued behavioral outcome and associated evaluation procedure
_____ Step 4: Intervention Implementation
_____ Calculate implementation fidelity and provide implementation support
_____ Graph progress-monitoring data
_____ Use decision rules to determine intervention effectiveness
_____ If needed, revisit the problem analysis and intervention development steps

A B C
Antecedent Behavior Consequence
What happens before
the behavior occurs?
What is the
person doing?
What happens after the
Behavior occurs?
The four-step problem-solving model provides school personnel with a straightforward method for effectively
solving youths’ mental health problems that are within their scope of influence. However, nothing in the
formative questions, analytic aims, or core procedures of each step tells problem-solving teams how to use this
logic model efficiently to serve an entire school population.
One way to apply this model efficiently is to adopt a common theoretical perspective on what mental health
problems are, how they are maintained, and how they can be influenced for the better. Although some
presentations of the problem-solving model have advocated for a specific theoretical viewpoint (e.g., Erchul
& Schulte, 2009), others have allowed for diverse theoretical perspectives, as long as they are grounded in
empirical evidence (e.g., Gimpel Peacock, Ervin, Daly, & Merrell, 2010).
When a problem-solving team chooses a unified, common theoretical perspective then team members are able
to communicate with each other more clearly and to make decisions regarding how to accomplish problem-
solving steps with greater ease. Although there are several theories explaining youths’ mental health problems
(see Mash & Barkley, 2014), the most straightforward, feasible, and proven theory for school personnel to use
in the problem-solving process is the Antecedent–Behavior–Consequence (ABC) theory of behavior (see
Ramnerö & Törneke, 2008; see Figure 2.2).
Using the ABC Theory to Promote Youths’ Mental Health
The ABC theory of behavior is useful within the four-step problem-solving model for a few reasons:
• First, it provides problem-solving teams with a way of understanding how all behavior can be changed
for the better using basic principles. This means the ABC theory is useful for resolving internalizing
and externalizing problems as well as for promoting valued behaviors that mental health problems
commonly interfere with.
• Second, it focuses problem-solving teams on observable factors that are under their control to change.
Research shows that there are many factors involved in youths’ mental health problems that are not
accessible for problem-solving teams to change (e.g., genetics and history), but that there are also
many factors that are accessible for them to change (e.g., current school and home environments). The
ABC theory focuses squarely on those things that are workable for promoting youths’ mental health in
the present moment.
• Third, it provides opportunities for students and their families to engage and participate meaningfully
in the problem-solving process. Because the ABC theory centers on changeable factors in youths’
environments, and because students and caregivers are key players in shaping those environments,
they can often play important roles in promoting mental health in schools.
At the core of the ABC theory is the idea that three defining features characterize everything people do:
antecedents, behaviors, and consequences (Ramnerö & Törneke, 2008).
Figure 2.2. Key Features of the ABC Theory of Behavior

• Antecedents are the environmental events that happen right before a behavior occurs. For example, a
common antecedent for a student’s aggressive behavior is being teased by his peers, while a common
antecedent for a student’s test-anxiety is being told by the teacher that there will be a test tomorrow.
Antecedents can be seen as the environmental “triggers” or “sparks” for mental health problems, as they set
the stage for them to occur. The important thing to remember is that antecedents are not important in and
of themselves, but rather because they signal the availability of a consequence that is somehow beneficial
to a student. Because of this tight relationship, mental health problems can sometimes be changed for
the better by simply altering the antecedents that are reliably associated with problem behaviors and their
consequences.
• Behaviors are the actual actions of the student—the things the student is doing or, in some situations,
not doing. Mental health problems usually consist of combinations of public behaviors (observable by
other people around the student) and private behaviors (only observable by students themselves). For
externalizing problems, common examples of public behaviors include hitting or yelling at other students
and disrupting the teacher during instruction. Private behaviors associated with these kinds of externalizing
problems are angry thoughts and impulsive feelings. For internalizing problems, common examples of
private behaviors include fear about things happening in the future or negative thoughts about one’s
self-worth, while public behaviors associated with these private behaviors include avoiding school tasks
or escaping social interactions with peers. Although private problem behaviors are often aversive and
unwanted, it is important to remember that it is the public problem behaviors associated with them that
produce the consequences that are seen as maintaining mental health problems.
• Consequences are the external or internal changes that take place following behavior. For instance, a
common environmental consequence for a student’s aggressive behavior is that his peers will stop teasing
him, while a common internal consequence of a student’s test-avoidance is that her negative thoughts and
feelings regarding how poorly she would have performed will cease. When something happens following
the problem behavior that is likely to make that behavior more likely to occur in the future, this is called a
reinforcing consequence. From the perspective of the ABC theory, mental health problems are maintained
because of the reinforcing consequences that the problem behavior brings about. So although the behavior
is a “problem” to caregivers, it continues to occur because it is actually functional in some way for students.
How behaviors that are viewed as “problems” can actually be useful to students is better understood by
considering the two types of reinforcing consequences: positive reinforcement and negative reinforcement.
o Positive reinforcement occurs when a behavior helps a student increase or obtain a desirable
consequence. This kind of reinforcement is called “positive” because it “adds” something to the
situation that benefits the student in some way, making the behavior more likely to occur in the
future. Both externalizing and internalizing behaviors can be positively reinforced.
 Externalizing problem example #1. Disrupting a teacher’s classroom instruction might help a
student get attention from peers.
 Externalizing problem example #2. Bullying other youth can be a means for a student to get
money, food, clothing, or other desired things.
 Internalizing example #1. Withdrawing from one’s peers can lead to increased attention from
concerned adults at school.
 Internalizing example #2. Telling caregivers that they feel “depressed” or “anxious” might
result in a student receiving privileges or gifts that he or she wouldn’t have had otherwise.
o Negative reinforcement happens when a behavior helps a student reduce or avoid an unwanted
consequence. This kind of reinforcement is called “negative” because it “subtracts” something from
the situation that benefits the student in some way, making the behavior more likely to occur in the
future.
 Externalizing problem example #1. Verbally threatening a peer might stop the current
teasing or harassment from that peer.
 Externalizing problem example #2. Talking to other students during classroom instruction
can allow a student to escape from the demands of academic tasks.
 Internalizing problem example #1. Not attending school on the day of a major test may
substantially reduce a student’s feelings of anxiety associated with that test.
 Internalizing problem example #2. Avoiding social interaction with peers can lead to reduced
negative thoughts about one’s self-worth in comparison to those peers.

When applied to mental health problems, the ABC theory shows that “problem” behaviors are actually
functional for youth in some way, and that they are maintained by logical connections between antecedents
and consequences. Problem behaviors work for students in the short-term, but they often become problematic
over time because they produce poor long-term outcomes.
• For example, a young student who spends his independent seatwork time disrupting and talking to
other students may obtain peer attention and escape academic tasks that he finds undesirable in the
short-term, but he will also fail to acquire key academic skills and knowledge in the long-term.
• As another example, a adolescent student who refuses to come to school because of test anxiety may
successfully achieve temporary reductions in aversive thoughts and feelings related to test-taking, but
she will also fail courses as a result and may put herself at-risk for failing to graduate high school.
These examples demonstrate an important point about consequences: it is the immediate consequences
that maintain problem behavior, not the distant ones. It is also important to mention that although problem
behaviors are somehow functional for youth in the short-term, they can also be very distressing for youth.
This observation can lead some school personnel to think that an internalizing or externalizing behavior is “not
working” for a student because it brings about obvious negative consequences (e.g., apparent unhappiness
or school discipline). However, the fact is that most problem behaviors bring about multiple short-term
consequences yet only select consequences maintain that behavior. The same could also be said about
antecedents: most problem behaviors are preceded by multiple antecedents yet only select antecedents trigger
that behavior.
The major task of the problem-solving team during the first two steps of the model—problem identification and
problem analysis—is not to understand all possible ABCs of student mental health problems, but rather to
identify the ABCs that are the most relevant and changeable by the team. Decades of applying the ABC theory
in practice have given rise to several assessment strategies that are useful in school settings for gauging
youths’ mental health.
Assessment Strategies for Gauging Youths’ Mental Health
All assessment strategies serve one of three purposes that inform intervention: describing behavioral
topography, measuring behavioral dimensions, or determining behavioral function (Cooper, Heron, & Heward,
2007).
• Describing behavioral topography refers to strategies for detailing what the mental health problem
“looks like” in behavioral terms. The purpose of this type of assessment is to replace the common
language used to talk about mental health problems (e.g., “disrespectful” or “anxious”) with more
specific descriptions that detail what the student is actually doing that is problematic for school
personnel (e.g., “shouts out in class and talks back to teachers” or “cries upon arriving at school and
refuses to enter the classroom without parents”). Clarifying the topography of mental health problems
is a helpful first step for focusing future assessment efforts on the behaviors that matter most. It also
facilitates communication among school personnel, students, families, and community partners,
who may misunderstand or overgeneralize vague descriptors often used to described mental health
problems (e.g., “impulsive” or “depressed”).
• Measuring behavioral dimensions refers to strategies for quantifying how often (frequency) the
problem behavior occurs as well as how long it lasts (duration) when it happens. Although all problem
behaviors have a frequency and duration, it is only necessary to measure the dimension that allows
the problem-solving team to gauge how well the behavior is responding to intervention. If a problem
behavior occurs fairly often and has a brief duration (e.g., shouting out in class or pushing other
students), then frequency is the most useful dimension to measure. If a problem behavior occurs
less often but has a longer duration (e.g., crying or putting head down on desk), then duration is
the most useful dimension to measure. However, some problem behaviors can occur often and for

extended periods of time (e.g., arguing or tantruming) and may therefore benefit from measuring both
dimensions. Ultimately, it is important to assess behavioral dimensions because they function as the
baseline measures and progress-monitoring measures in the problem-solving process.
o Baseline measures are the “starting points” of a problem behavior prior to intervention.
Intervention effectiveness is judged by comparing measures of the problem behavior obtained
after intervention to baseline measures.
o Progress-monitoring measures are the “follow-up points” of a problem behavior at different
times during the intervention process. If progress-monitoring measures show improvement in
relation to baseline measures as well as earlier progress-monitoring points, then the intervention
is “working” or judged to be effective.
• Determining behavioral function refers to strategies for mapping the logical connections between
problem behaviors, the antecedents that trigger them, and the consequences that maintain them.
This aspect of behavioral assessment helps the problem-solving team identify the factors that are
maintaining the problem behavior so that an appropriate intervention strategy can be selected. Prior to
determining the function of any problem behavior, school personnel must first describe its topography.
But it makes little difference if the dimensions of the problem behavior are measured prior to, in
conjunction with, or following this process.
The three purposes of assessment can be accomplished using five different assessment methods: direct
behavior observations, self-monitoring, direct behavior ratings, behavior rating scales, interviews, and surveys.
Although some of these methods are useful for accomplishing only one assessment purpose, others are useful
for accomplishing multiple purposes (see Table 2.1).
Table 2.1. Relation of Behavioral Assessment Methods to Assessment Purposes
Behavioral Assessment Method
Behavioral Assessment Purpose
Describing behavioral
topography
Measuring behavioral
dimensions
Determining
behavioral function
Direct behavior observations X X X
Direct behavior ratings X
Behavior rating scales X
Interviews X X X
Surveys X X X
• Direct behavior observation refers to assessment methods that have an observer watch and record
student behavior as it occurs in real time. There are several different direct observation methods that
can be used to accomplish each of the three assessment purposes. Probably the most common direct
observation methods are: event recording, timing, time sampling, and ABC recording.
o Event recording involves measuring each occurrence of the target behavior by simply
marking a tally each time it occurs during the observation window. Because observations can
have varying durations (e.g., 10, 20, or 30 minutes), which makes them difficult to compare,
results from event recordings are usually represented as a rate of the number of behavioral
events observed per minute (e.g., two talk-outs per minute during classwide instruction). Event

recording is most useful for target behaviors that are brief, have a clear beginning and end,
and that are likely to occur often during the observation period. This method is feasible for
use by school mental health professionals, teachers, support staff, students (self-monitoring),
and peers (peer-monitoring). However, it can be challenging because it requires continuous
observation of behavior, which is difficult for teachers, students, and peers to perform amidst
their other activities. (See Tool 2.1 for an example of event recording form.)
o Time sampling involves measuring the occurrence of the target behavior during specified times
throughout the observation period. Results from this method are presented as the percentage of
intervals for which the target behavior was observed (e.g., disruptive behavior was observed for
80% of samples), and the length of the interval is standardized but adjustable depending on the
capability of the observer—ranging from 10 seconds to 10 minutes. There are three common
time-sampling methods: whole interval, partial interval, and momentary. (See Tool 2.2 for an
example time sampling form.)
 Whole interval time sampling is useful for target behaviors that are expected to occur
frequently, consist of several different sub-behaviors, and have long durations (e.g.,
academic engagement or on-task behavior). When using this method, the target
behavior is marked as occurring during the interval only if it persists for the entire interval
(e.g., all 30 seconds).
 Partial interval time sampling is useful for target behaviors that are expected to occur
frequently, consist of several different sub-behaviors, but have brief or variable durations
(e.g., disruptive or off-task behavior). When using this method, the target behavior is
marked as occurring during the interval if it happens at any time, no matter for how long,
during the interval (e.g., once for ten seconds or twice for five seconds).
 Momentary time sampling is useful for the same purposes as either whole interval
or partial interval methods, but it is usually a more feasible method for use by
teachers, students, and peers, who are likely to be engaged in other tasks during the
observation period and cannot spend as much time observing as a school mental health
professional. When using this method, the target behavior is only observed at a specified
moment during the interval (e.g., at the end of every minute or every five minutes) and is
marked as occurring only if it is observed at that time.
o Timing involves measuring the duration of the target behavior, typically in minutes and
seconds. Timing is best for target behaviors that have moderate to long durations, have a clear
beginning and end, and that are likely to occur seldom during the observation period (e.g.,
tantrums or social withdrawal). This method is usually feasible for use by school mental health
professionals, teachers, and support staff, but not by students or peers.
o ABC recording involves select observation of the target behavior (“B”) that is accompanied
by a brief written narrative of the antecedent events preceding the behavior (“A”) and the
consequential events following the behavior (“C”). Although ABC recording is not always
necessary, it can often be helpful when there is ambiguity regarding the environmental events
that are maintaining the problem behavior. (See Tool 2.3 for an example ABC recording form.)
o Narrative observation involves continuous observation of all behavior occurring within a
sampling period (e.g., 15 or 30 minutes) that is accompanied by a written narrative of what is
observed. The purpose of this method is to generate an adequate description of a students’
observed behavioral repertoire so that problem behavior can be discriminated from valued
behavior. Although narrative observation is not always necessary, it can often be a helpful first
step when there is ambiguity surrounding the nature of the problem behavior.

• Direct behavior ratings refer to assessment methods that have observers watch behavior and
then rate that behavior immediately following its occurrence. Direct behavior ratings only function to
measure relative behavioral frequency and are comparable to the purposes of event recording and
time sampling. Because recording of observations is not required continuously or regularly throughout
the monitoring period, direct behavior ratings are a more feasible measurement procedure for
teachers, support staff, students, and peers. Examples of direct behavior ratings can be found at www.
directbehaviorratings.org.
• Behavior rating scales refer to assessment methods that have observers rate behavior based on
previous experiences over the past several weeks to several months. These methods are contrasted
with direct behavior ratings because they are not immediately preceded by an actual observation, but
rely on knowledge obtained from historical observations, which may be more or less recent. Similar
to direct behavior ratings, however, behavior rating scales also only function to measure relative
behavioral frequency and are comparable to the purposes of event recording and time sampling.
Because immediate observation is not required, behavior rating scales are feasible methods for all
informants, including students, teachers, and caregivers. (See Tool 2.4 and Tool 2.5 for examples of
self-report behavior rating scales for internalizing and externalizing problem behaviors.)
• Interviews refer to assessment methods that have one observer meeting with another observation
to ask them about their previous observations of the target behavior. Interviews can be useful for all
assessment purposes, and they can be conducted with target students, caregivers, and teachers/
support staff who work closely with the target student. There are several resources available to school
personnel that provide examples of interviews that can be used at various steps within the problem-
solving process (see Sheridan & Kratochwill, 2007).
• Surveys refer to assessment methods that function similar to interviews, but which are accomplished
without one observer meeting with another observer. Instead, observers are provided with a survey,
which asks them to answer several questions that might be related to any of the purposes of behavioral
assessment and then to return it when completed. The advantage of surveys is that they can be used
to reach more informants and that there content is flexible, but their disadvantage is that they do not
allow for in-depth or follow-up questions that are common in interviews.
Once assessment strategies have been used within the problem-solving model to describe the topography
of problem behavior, measure the dimensions of that behavior, and determine the functions of that behavior,
the next step is to use this assessment data to select and then monitor the effectiveness of appropriate
intervention strategies.
Intervention Strategies for Promoting Youths’ Mental Health
The ABCs theory of behavior indicates three basic intervention strategies: altering antecedents, altering
consequences, and teaching skills (Noell & Gansle, 2009). Although these strategies are described separately
below, it is important for problem-solving teams to remember that these strategies can also be used in
combination to effectively address both simple and complex mental health problems.
• Altering antecedents refers to intentionally changing the environmental events that precede behavior.
Of the three intervention approaches, this is probably the most underused and overlooked, yet it can
be very effective. There are two main approaches to altering antecedents: removing antecedents and
adding antecedents.
o Removing antecedents refers to taking away environmental events that “trigger” the problem
behavior, so that the problem behavior occurs less often because the desired consequence
is now unavailable. It is important for problem-solving teams to remember that just because
an antecedent triggers problem behavior does not mean it should always be removed (e.g.,
taking a test at school, playing at recess, or group-work in class). However, there are some

antecedents that are quite easy to change and others, although difficult to change, which are
very important to remove to improve student wellbeing.
 Externalizing problem example. If sitting next to a friend during independent seatwork
(antecedent) results in a student being off-task during instruction (problem behavior) in
order to get his friend’s attention (consequence), then changing the student’s seating
assignment so that he is no longer seated next to a friend (removing a antecedent) may
reduce the likelihood of off-task behavior.
 Internalizing problem example. If being bullied by her peers (antecedent) results in a
student experiencing depression-related thoughts and feelings and withdrawing from
participating in class (problem behavior) to avoid further contact with those same peers
(consequence), then her depression-related problems may be alleviated by intervening
with her peers and preventing them from bullying her in the first place (removing the
antecedent).
o Adding antecedents refers to putting in new environmental events so that there’s either a
reduced need to use the problem behavior or so that prosocial or healthy behavior is more likely
to be exhibited instead. This strategy is always applicable and is helpful to use in combination
with all the other strategies to enhance student success. Teachers, other students, and families
can all participate in adding small antecedents to the environment that are likely to improve
youths’ mental health.
 Externalizing problem example. If during classwide instruction (antecedent) a student
calls out and disrupts the teacher (problem behavior) in order to get the teacher’s
attention (consequence), then either providing the student with more teacher attention
earlier in the day or intentionally calling on the student to answer questions during
classwide instruction (adding antecedents) may reduce the likelihood of the disruptive
behavior later in the day.
 Internalizing problem example. If whenever a student feels anxious doing schoolwork
(antecedent) he tells the teacher he “feels sick” and is sent to the school nurse and
misses instruction (problem behavior), which then relieves his anxiety (consequence),
then scheduling frequent breaks during classwork or establishing a signal the student
can use to tell the teacher he needs a break from his work (adding antecedents) may
reduce the likelihood of the student leaving class and missing instruction.
• Altering consequences refers to intentionally changing the external events that follow behavior.
Although consequences in the ABC theory can also refer to internal events, the only consequences
that problem-solving teams have direct influence over are the external kind. There are three main
approaches to altering consequences: differentially reinforcing lower rates of problem behavior,
differentially reinforcing valued behavior, and withholding reinforcement from problem behavior.
o Differentially reinforcing lower rates of problem behavior refers to providing students with
desirable consequences when they exhibit successively lower rates of the target behavior.
When using this strategy, it is important to explicitly communicate to students that they are
receiving desirable consequences because their problem behavior is decreasing. It’s also
helpful to let older children and adolescents know the expectation they must meet to access
these consequences.
 Externalizing problem example. If when standing in line (antecedent) a student
constantly touches and pokes those around him (problem behavior) to get their attention
(consequence), then allowing the student to select a toy from the “prize box” every time
he touches others less often than he did the previous time (differentially reinforcing lower
rates of the problem behavior) may result in less problem behavior in the future.

 Internalizing problem example. If upon arriving at school each day (antecedent) a young
student cries and refuses to enter the classroom for several minutes (problem behavior)
so that she can prolong her contact with her parent (consequence), then allowing the
student to engage in a preferred play activity immediately when entering the classroom
if she cries for less time than she did the previous time (differentially reinforcing lower
rates of the problem behavior) may reduce the refusal behavior over time.
o Differentially reinforcing valued behavior refers to providing youth with desirable
consequences when they exhibit valued behaviors that either replace or are incompatible with
the problem behavior. This approach is very effective by itself but is also useful when used in
combination with the other two approaches. When using this strategy it’s important to explicitly
tell students why they are receiving a desirable consequence, so that they do not mistakenly
attribute the reinforcement to an unrelated or non-valued behavior.
 Externalizing problem example. If while standing with friends in the hallway during
passing periods (antecedent) a student makes rude comments to those walking by
(problem behavior) to make her friends laugh and get their attention (consequence),
then specifically praising the student when she talks kindly or is helpful to other students
in class who are not her friends (differentially reinforcing valued behavior) may increase
her likelihood of being respectful towards similar students in other situations in the future.
 Internalizing problem example. If during unstructured times in class (antecedent) a
student puts his head down on his desk (problem behavior) to avoid interacting with
peers that he says “don’t like him” (consequence), then specifically praising the student
when he interacts positively with others during structured class activities (differentially
reinforcing valued behavior) may increase the likelihood of more prosocial behavior
occurring in the future.
o Withholding reinforcement from problem behavior refers to not providing youth with the
desirable consequences that usually follow their problem behavior. This strategy is best used in
combination with one of the previous two strategies, not as a stand-alone strategy.
 Externalizing problem example. If during recess on the playground (antecedent) a
student yells at and hits her peers (problem behavior) to get immediate access to the
play equipment she wants (consequence), then having a supervising adult prevent her
from accessing the equipment when she is aggressive (withholding reinforcement from
the problem behavior) until she waits her turn (differentially reinforcing valued behavior)
may reduce the likelihood of the aggressive behavior continuing in the future.
 Internalizing problem example. If during in-class testing (antecedent) a student often
complains of “feeling depressed” (problem behavior) and as a result is allowed to stop
taking the test (consequence), then having the teacher encourage the student to persist
in the test following the complaint (withholding reinforcement from the problem behavior)
and providing him with verbal praise for finishing the exam (differentially reinforcing
valued behavior) is likely to reduce the likelihood of this problem behavior in the future.
• Teaching skills refers to explicitly instructing students in new behaviors that help them act in valued,
prosocial, and healthy ways when they encounter antecedents that have historically triggered problem
behaviors. The important thing for problem-solving teams to remember is that new skills must be
functional for helping students contact similar or more preferred consequences than the problem
behavior did, otherwise these skills will not be maintained. Although there is an infinite number of skills
that can be taught to students, a useful way of talking about them is to divide them into two general
categories: teaching replacement behaviors and teaching self-regulation behaviors.

o Teaching replacement behaviors refers to explicitly teaching students skills that serve
the same function as problem behaviors, but which do so in a way that is considered to be
appropriate and valued by the problem-solving team. Although school personnel often assume
that students “don’t know the right thing to do” and need to be taught replacement behaviors, it
is often the case that students already possess the necessary skills and that they will engage in
valued behaviors when antecedents and consequences are altered. However, this is not always
the case, and young children and students with developmental disabilities are especially likely to
benefit from teaching replacement behaviors.
 Externalizing problem example. If during small-group activities (antecedent) a young
child takes toys and materials from other children in his group without asking (problem
behavior) so that he can use them himself (consequence), then instructing the student in
strategies for appropriately “getting what he wants”—such as asking politely, trading, and
waiting his turn (teaching replacement behaviors)—may allow him to contact desirable
consequences without frustrating peers and teachers.
 Internalizing problem example. If when working with a one-on-one aid on a new
academic task (antecedent) a student with a development disability covers her face and
cries (problem behavior) to escape from the demands of the aid (consequence), then
instructing the student in strategies for appropriately requesting short breaks when she
feels overwhelmed (teaching replacement behaviors) may allow her to briefly escape the
academic demands while facilitating greater overall work completion.
o Teaching self-regulation behaviors refers to teaching students skills that help them manage
their problem behavior more effectively by disrupting the tight connection that has been formed
between its ABCs. Specifically, this approach consists of three core strategies: making students
aware of the antecedents that trigger their problem behavior, teaching them skills that calm their
aversive thoughts and feelings (private behaviors) that automatically follow those triggers, and
training them to use a problem-solving skills to guide their actions in difficult situations (public
behaviors).
 Externalizing problem example. If during most cooperative social interactions with peers
(antecedent) a student soon becomes frustrated or angry with them (problem behavior)
and this results in him getting his way (consequence), then being instructed to use deep
breathing techniques accompanied by positive self-talk in response to feeling angry
(teaching self-regulation behaviors) may enable him to interact more prosocially with his
peers in the future.
 Internalizing problem example. If when engaged in a challenging academic task
(antecedent) a student experiences negative self-talk (e.g., “I’m a complete failure—I’ll
never be good at anything and nobody likes me”) that is followed by giving up on the
task (problem behavior), which temporarily stops the negative self-talk (consequence),
then being instructed to be mindful and accepting of her negative self-talk while
persisting in challenging tasks (teaching self-regulation behaviors) may allow her to be
more academically successful in the long run.

Direct instruction is widely considered the most effective method available for conducting skill
training with youth with problem behaviors (Forness, Kavale, Blum, & Lloyd, 1997), and its core
components can be applied to effectively train both replacement behaviors and self-regulation
behaviors related to internalizing and externalizing concerns. A helpful heuristic for representing the
general sequence of direct instruction components is: Tell–Show–Do–Review–Repeat.
• Tell. Skill training begins by explicitly telling students what skill they will be learning and
providing them with a rationale for why it is important to learn this skill. Following, the
interventionist describes in detail the parts of the skill and how they are enacted.
• Show. Next, the interventionist models the skill for the students so they can see what it looks
like in practice. If the skill has several parts, each should be modeled in turn, accompanied by
behavioral narration. It is helpful to model several examples of the skill as well as to model non-
examples of the skill and then ask students to identify why the non-examples were incorrect.
• Do. After “Tell” and “Show,” the next step is for students to “Do” or role-play the skill. This can
be done one-on-one with the interventionist, in pairs with other students, or in small groups.
Students should be provided with ample response opportunities to practice the skill in different
hypothetical contexts.
• Review. Throughout the role-playing process, the interventionist should immediately provide
performance feedback to students. This feedback should clearly identify and reinforce
successful demonstrations of the skill as well as successive approximations of the skill (“getting
closer and closer”), and it should also clearly correct errors exhibited by students along the way.
• Repeat. Following the “Review” step, the skill training process is repeated—starting at
“Show” and going all the way through “Review”—as many times as necessary until students
demonstrate they have mastered the skill. For complex skills that are made up of several sub-
skills (e.g., “anger management skills”), it is often useful to train one sub-skill at a time and to
progressively combine them until students can successfully demonstrate the entire skillset.
When teaching replacement behaviors and self-regulation behaviors, it is important for
interventionists to remember that it is almost always easier for students to successfully demonstrate
skills in teaching situations than it is for them to actually use the skill when they need it in “real life”
situations. Therefore interventionists should make efforts to help students generalize their skills
outside of teaching situations by identifying opportunities when students might, did, or could have
used the target skill in natural settings. The “Tell” step can be used in natural settings to remind
students how to use the skill prior to actually using it and to coach them in using the skill in the
moment, while the “Review” step is useful to reinforce and correct students’ actual use of the skill or
missed opportunities to apply the skill.
Although all of the examples above suggest school personnel as the interventionists, it is important to
remember that the same intervention strategies can be implemented in similar ways by peers and parents,
who should be encouraged to be involved as active members of the problem-solving team. Also, although all of
the examples provided above for intervention strategies are related to individual students, the same strategies
can be scaled up to small groups of students, classrooms, and whole schools (see Simonsen & Sugai, 2009;
Skinner, Skinner, & Burton, 2009; Wehby & Lane, 2009; Little, Akin-Little, & Cook, 2009). That said, the ABC
theory of behavior does not provide guidance regarding how to efficiently address youths’ mental health
problems at different scopes of service delivery. Problem-solving teams are therefore encouraged to apply the
four-step problem-solving model and the ABC theory within a multitiered system of supports (MTSS) for
promoting mental health in schools, which has been developed for just this purpose.

Using the Problem-Solving Model within MTSS for Promoting Mental Health
Whereas the purpose of the four-step problem-solving
model is to ensure that problem solving team members’
efforts to promote mental health in schools are effective,
the purpose of MTSS is to ensure that those efforts are
structured in a way that serves all students and conserves
school resources (see SMHRPT Introduction for a detailed
overview of MTSS; Stoiber, 2014). The formative questions,
analytic aims, and core procedures that guide school
personnel through each step in the problem-solving model
remain the same in each of the three tiers of MTSS. Most
of the practices used to accomplish the core procedures
of the four-step problem-solving model do not vary much
from tier to tier, because they are characterized by general
techniques that can be flexibly applied to variations in
the number of students, severity of the problem behavior,
and intensity of assessment and intervention practices.
However, the specific practices used to operationalize some
core procedures tend to vary more among the three tiers,
because some assessment and intervention techniques are
more feasible and useful for targeting different scopes of
students and problems than others.
Core Problem-Solving Procedures that are Flexibly
Applied Across Tiers
• Step 1: Problem Identification
o Clarify values and make a public commitment to promoting valued behavior. This
procedure is accomplished by having the problem-solving team clarify what they value for youth
and why, and then to publicly commit to each other to work together to promote these values for
the betterment of youth. The intent of this is to make explicit values that are often implicit in the
problem-solving process, so that the problem-solving process can proceed with shared purpose
among the team members. This procedure should be carried out each time the problem-solving
team begins the problem-solving process anew, whether for the entire school, for a classroom or
small group, or for an individual student. An example exercise for accomplishing this procedure
is provided in Tool 2.6.
o State the problem behavior in measurable terms. This procedure is accomplished by
defining the problem behavior in a way that makes it amenable to baseline measurement while
also making it understandable to the members of the problem-solving team. For example, what
is initially described as “naughty” or “disrespectful” may be stated as “disruptive behavior during
classwide instruction—including shouting-out and throwing objects.” Although this process is
similar across tiers, it is important for problem-solving teams to remember that more specific
problem statements are more useful in Tier 2 and Tier 3, and that more general problem
statements (e.g., “disruptive behavior” or “social withdrawal”) are often useful enough in Tier
1, as the specific measurement procedures used across tiers vary in specificity (see below for
more on this point).
Tier 2
Tier 1
Tier 3
+
+
++
Figure 2.3 The Multitiered System of
Support Model for Mental Health Supports

o Conduct a discrepancy analysis to identify differences between desired and observed levels
of behavior. This procedure involves using baseline data obtained for the problem behavior to
determine how exactly it is discrepant from the values and expectations of the problem-solving
team. The intent of this is to clarify exactly how much change is desired for the problem-solving
process to be considered successful. An example exercise for accomplishing this procedure is
provided in Tool 2.7.
• Step 2: Problem Analysis
o Determine the factors maintaining the problem behavior and link them with an intervention
strategy to positively influence problem behavior. This procedures involves summarizing the
data obtained from assessment of the potential maintaining factors of the problem behavior by
directly stating the factors that appear to be maintaining the problem behavior, and then directly
linking intervention strategies to these factors that are likely to positively influence the problem
behavior. The intent of this exercise is not to fully develop an intervention, but rather to clearly lay
out the logic underlying why a particular approach to intervention is selected as opposed to other
approaches. An example exercise for accomplishing this procedure is provided in Tool 2.8.
• Step 3: Intervention Development
o Plan the procedures and schedule of the intervention. This procedure explicitly plans out all
aspects of the evidence-based intervention to ensure it is capable of being feasible and effectively
implemented to resolve the problem behavior. An example exercise for accomplishing this
procedure is provided in Tool 2.9.
o Develop an implementation fidelity measure and establish a schedule and procedures for
evaluating and enhancing intervention integrity. This procedure requires the problem-solving
team to create a measure that can be used to track implementation of the core procedures of the
intervention plan, for the purposes of gauging if it is being implemented appropriately. Although
some intervention plans have various procedures and are quite complex, the point here is not to
track all possible intervention components, but rather to track those that appear to be the most
important.
o Develop an outcome goal, select a progress-monitoring method, and establish a schedule
and procedures for evaluating intervention effectiveness. This procedure is accomplished by
establishing a goal that is derived from the discrepancy analysis from Step 1, and then determining
how often progress-monitoring will occur and what decision rules will be used to determine how
well the intervention is “working.” Although evaluating intervention effectiveness should occur
on a schedule that is feasible for school personnel, the following schedules are most commonly
recommended:
 Tier 1. Three or four times per school year
 Tier 2. One or two time per month
 Tier 3. One or two times per week
• Step 4: Intervention Evaluation
o Determine the level of implementation fidelity. This procedure involves calculating the level
of implementation fidelity to determine how effectively the intervention is being applied. All that is
required is that the measure, schedule, and procedures that were established for this purpose in
Step 3 be followed according to plan.
o Determine the effect of the intervention on the problem behavior. This procedure likewise
involves following the plan that was developed for this purpose in Step 3.

o If needed, identify potential improvements to the problem-solving process. If the intervention
evaluation process indicates that the intervention is not effective, and it has already been
determined that it is being implemented with fidelity, then the first option in this procedure is to
systematically revisit Step 3 (intervention development) and look for potential improvements
that can be made to the intervention plan to increase its effectiveness. If it is determined that no
improvements can be made to the plan, then the second option is to systematically revisit the Step
2 (problem analysis) to investigate other maintaining factors that may have been missed during the
first analysis, which may then be linked with a new intervention strategy. If it is determined that no
maintaining factors were missed but that the problem-solving team does not possess the expertise
or resources necessary to implement an appropriate intervention, then the third and final option is
to refer the student to an outside service agency that is equipped to support the problem behavior.
Core Problem-Solving Procedures that are Variably Applied Across Tiers
• Step 1: Problem Identification
o Obtain a baseline measure of problem behavior. The types of measures used to obtain baseline
measures of problem behavior typically differ across tiers. A key point for problem-solving teams to
remember is that measures used with greater numbers of students typically have less specificity
and therefore require that the problem behavior be understood and intervened with in more general
terms. On the other hand, measures used with individual students and small groups of students
have greater specificity and therefore result in more targeted intervention plans.
 Tier 1. Brief behavior rating scales called “universal screeners” are most useful because
they provide an efficient way to measure the mental health of every student in a school
(see Table 2.2 for a listing of common behavior rating scales and their key characteristics).
Brief behavior rating scales are available that measure overall mental health problems
as well as general internalizing and externalizing problems. Teacher-report screeners are
most efficient for primary students, while youth self-report screeners are most efficient for
secondary students.
 Tier 2. Brief rating scales can be useful, but lengthier behavior rating scales called
“narrowband” (targeting a single problem) or “broadband” (targeting multiple problems)
measures are recommended because they provide a more in depth assessment of mental
health problems. Teachers and/or students can complete these lengthier rating scales.
Additionally, direct behavior ratings and direct behavior observations of groups or individual
students data can be used to obtain measures of problem behavior that are easily seen by
school personnel, such as aggression or social withdrawal.
 Tier 3. Although narrowband and broadband measures may be useful, it is recommended
direct behavior ratings and direct behavior observations be used as the primary methods.
Although using a single measurement method is most efficient in the previous tiers, it is
often helpful to use multiple methods to measure the problem behavior in this tier.
• Step 2: Problem Analysis
o Identify the factors maintaining the problem behavior. The types of assessment techniques
useful for understanding the factors maintaining the problem behavior are also likely to vary
across tiers, as more targeted methods are deemed more useful for understanding more specific
problems, while more general methods are useful for understanding less specified problems.
 Tier 1. Brief surveys asking teachers or students to report on the context of problem
behaviors are the most useful. Survey items should directly state the mental health
concerns and should ask specific questions about the relation of problem behaviors to
antecedents and consequences so that the most appropriate approach to intervention can
be determined. Both multiple-choice and free-response questions may be helpful.

 Tier 2. Brief interviews with caregivers and students can provide information regarding
the relation of mental health problems to antecedents and consequences. Similar to
surveys, interviews should be directly linked to the identified problem behavior and focus
on factors that help inform intervention. The primary benefit of interviews as opposed to
surveys is that they allow respondents the opportunity to provide detailed information or
to offer important information that was overlooked on surveys.
 Tier 3. Although interviews are also recommended in this tier, the distinguishing
feature is the use of ABC recordings to systematically observe the relation of problem
behaviors to antecedents and consequences across different contexts within the school
environment. It is imperative that ABC recordings be conducted not only in contexts
where the problem behavior occurs, but also in contexts where the problem behavior
does not occur, so that differences in maintaining factors can be compared across
different environments.
• Step 3: Intervention Development
o Select a specific evidence-based intervention to operationalize the intervention strategy.
The three general approaches to intervention—altering antecedents, altering consequences,
and teaching skills—are often packaged, combined, and presented differently across the three
tiers of service delivery, yet the strategies themselves remain the same. It is therefore important
for problem-solving teams not only to select an intervention that has evidence supporting it,
but also to examine the contents of the intervention to determine if it contains the appropriate
strategies to target the present problem behavior. Given that mental health problems are often
complex, it is also appropriate to select multiple evidence-based interventions or to supplement
interventions when needed.
 Tier 1. Social–emotional learning (SEL) and social-skills curricula provide guides for
helping students learn common replacement behaviors as well as self-regulation
behaviors. These skill-building curricula can vary widely in the number and nature of
skills included, so the important principle is to ensure that a curriculum is selected based
on its ability to target the identified mental health concerns. Many of these curricula also
contain strategies for teachers and caregivers to adjust antecedents and consequences.
Additionally, alterations to antecedents and consequences can be made without
these curricula by simply employing schoolwide and classroom practices to change
problem behavior for the better, such as those commonly recommended by Positive
Behavioral Interventions and Supports (www.pbis.org). The important characteristic
of any intervention selected at this level is that it be feasibly implemented by teachers
amidst typical school duties. The Collaborative for Academic, Social, and Emotional
Learning (CASEL) offers two guides to help school personnel identify effective social and
emotional learning programs, one for preschool and elementary schools and another for
secondary schools. Both guides can be found at casel.org/guide.
 Tier 2. Skill-building curricula are also common at this level, as are alterations to
antecedents and consequences in the classroom or other settings. These interventions
are more intensive and usually benefit from using a school mental health professional—
such as a school psychologist, school counselor, or behavior specialist—to provide
direct services to targeted students (e.g., lead skill-building groups) or indirect services
to assist teachers in providing more focused and effective interventions in the classroom
(e.g., behavioral consultation to reduce disruptive behavior). Typically one intervention
approach is selected and implemented at a time in order to determine its effects on
improving students’ mental health problems.

 Tier 3. Intervention approaches in this tier are similar to those used in the previous tiers,
yet the implementation of these interventions is characterized by collaborations across
personnel within the school as well as with parents. Unlike previous tiers, this tier is
typically characterized by a treatment package that consists of multiple intervention
approaches that are both time and resource intensive. However, if the time and
resources needed to provide a comprehensive intervention are not available within the
school, then referrals are recommended to community mental health professionals.
Table 2.2. Example Behavior Rating Scales for Measuring Student Mental Health Problems
Name Type
MTSS
Tiers
URL
Youth Internalizing Problems
Screener
Screener 1, 2
https://www.researchgate.net/
publication/279295613_Youth_Internalizing_
Problems_Screener
Youth Externalizing Problems
Screener
Screener 1, 2
https://www.researchgate.net/
publication/279295611_Youth_Externalizing_
Problems_Screener
Strengths and Difficulties
Questionnaire
Screener 1, 2 http://www.sdqinfo.com/
Behavioral and Emotional
Screening System
Screener 1, 2
https://www.pearsonclinical.com.au/products/
view/250
Pediatric Symptoms Checklist Screener 1, 2
http://www.massgeneral.org/psychiatry/
services/psc_home.aspx
Student Risk Screening Scale Screener 1, 2
http://www.sai-iowa.org/10_%20Behavior%20
Screeners.pdf
Achenbach System of
Empirically Based Assessment
Broadband 2, 3 http://store.aseba.org/
Conners Comprehensive
Behavior Rating Scales
Broadband 2, 3
http://www.mhs.com/product.
aspx?gr=edu&id=overview&prod=cbrs
Burks Behavior Rating Scales
(2nd
ed.)
Broadband 2, 3
aspx?gr=cli&prod=bbrs2&id=overview
Behavior Assessment System
for Children (2nd
ed.)
Broadband 2, 3
http://www.pearsonclinical.com/education/
products/100000658/behavior-assessment-
system-for-children-second-edition-basc-2.
html
Beck Youth Inventories
(2nd
ed.)
Narrowband 2, 3
http://www.pearsonclinical.com/psychology/
products/100000153/beck-youth-inventories-
second-edition-byi-ii.html
Revised Children’s Manifest
Anxiety Scale
Narrowband 2, 3
aspx?gr=edu&prod=rcmas2&id=overview

Overall, it is imperative for problem-solving teams to remember that there is no “perfect” or “best” way to use
the problem-solving model to promote students’ mental health. Rather, there are more or less useful ways,
depending on the number of students being served, the severity of the problem behavior, and the availability
of school personnel’s expertise and resources. Using the four-step problem solving model, the ABC theory
of behavior, and MTSS, school personnel will be empowered to make substantial contributions to promoting
the mental health and wellbeing of the youth they serve. However, as mentioned above, it is imperative that
school personnel recognize the limits of their expertise and resources, and that they arrange relationships with
community partners who are capable of providing mental health services that they cannot provide.
Although the information provided in this chapter is intended to guide problem-solving teams toward effectively
and efficiently promoting youths’ mental health, it is recommended that teams seek out further practical
resources to guide them in these efforts. For a list of high quality resources that are relevant to problem-
solving for promoting youths’ mental health in schools, see Tool 2.10.
References
Barrett, S., Eber, L., & Weist, M. (2015). Advancing education effectiveness: Interconnecting school mental
health and school-wide positive behavior support. Retrieved from www.pbis.org
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Measuring behavior. In J. O. Cooper, T. E. Heron, & W. L.
Heward, Applied behavior analysis (2nd ed., pp. 72–101). Upper Saddle River, NJ: Pearson.  
Deno, S. L. (2013). Problem-solving assessment. In R. Brown-Chidsey & K. J. Andren (Eds.), Assessment for
intervention: A problem-solving approach (2nd ed., pp. 10–36). New York, NY: Guilford.
Erchul, W. P., & Schulte, A. C. (2009). Behavioral consultation. In A. Akin-Little, S. G. Little, M. A. Bray, & T. J.
Kehle (Eds.), Behavioral interventions in schools: Evidence-based positive strategies (pp. 13–25).
Washington, DC: American Psychological Association.
Forms, M., Abad, J., & Kirchner, T. (2011). Internalizing and externalizing problems. In R. J. R. Levesque (Ed.),
Encyclopedia of adolescence (pp. 1464–1489). New York, NY: Springer.
Forness, S. R., Kavale, K. A., Blum, I. M., & Lloyd, J. W. (1997). Mega-analysis of meta-analyses: What works
in special education and related services. Teaching Exceptional Children, 29, 4–9.
Friman, P. C., Volz, J. L., & Haugen, K. A. (2010). Parents and school psychologists as child behavior problem-
solving partners: Helpful concepts and applications. In G. Gimpel Peacock, R. A. Ervin, E. J. Daly, & K.
W. Merrell (Eds.) (2010). Practical handbook of school psychology: Effective practices for the
21st century (pp. 390–407). New York, NY: Guilford.
Gimpel Peacock, G., Ervin, R. A., Daly, E. J., & Merrell, K. W. (Eds.) (2010). Practical handbook of school
psychology: Effective practices for the 21st century. New York, NY: Guilford.
Huberty, T. J. (2009). Interventions for internalizing disorders. In A. Akin-Little, S. G. Little, M. A. Bray, &
T. J. Kehle (Eds.), Behavioral interventions in schools: Evidence-based positive strategies (pp.
281–296). Washington, DC: American Psychological Association.
Little, S. G., Akin-Little, A., & Cook, C. R. (2009). Classroom application of reductive procedures: A positive
approach. In A. Akin-Little, S. G. Little, M. A. Bray, & T. J. Kehle (Eds.), Behavioral interventions
in schools: Evidence-based positive strategies (pp. 171–188). Washington, DC: American
Psychological Association.
Mash, E. J., & Barkley, R. A. (Eds.) (2014). Child psychopathology (3rd ed.). New York, NY: Guilford.
MacKay, L., Andreou, T., & Ervin, R. A. (2010). Peer-mediated intervention strategies. In G. Gimpel Peacock,
R. A. Ervin, E. J. Daly, & K. W. Merrell (Eds.) (2010). Practical handbook of school psychology:
Effective practices for the 21st century (pp. 319–336). New York, NY: Guilford.
National Association of School Psychologists (2010). Principles for professional ethics. Bethesda, MD: Author.
Noell, G. H., & Gansle, K. A. (2009). Functional behavioral assessment. In A. Akin-Little, S. G. Little, M. A.
Bray, & T. J. Kehle (Eds.), Behavioral interventions in schools: Evidence-based positive strategies (pp.
43–55). Washington, DC: American Psychological Association.

Pluymert, K. (2014). Problem-solving foundations for school psychological services. In P. L Harrison & A.
Thomas (Eds.), Best practices in school psychology: Data-based and collaborative decision making
(pp. 25–39). Bethesda, MD: National Association of School Psychologists.
Ramnerö, J., & Törneke, N. (2008). The ABCs of human behavior: Behavioral principles for the practicing
clinician. Oakland, CA: New Harbinger.
Renshaw, T. L., & O’Malley, M. D. (2015). A new take on the old triangle: Illustrating the key characteristics of a
multitiered system of supports for efficiently organizing problem-solving in schools. Self-published
illustration. doi:10.13140/RG.2.1.4633.5204
Skinner, C. H., Skinner, A. L., & Burton, B. (2009). Applying group-oriented contingencies in the classroom. In
A. Akin-Little, S. G. Little, M. A. Bray, & T. J. Kehle (Eds.), Behavioral interventions in schools:
Evidence-based positive strategies (pp. 157–170). Washington, DC: American Psychological
Association.
Simonsen, B., & Sugai, G. (2009). School-wide positive behavior support: A systems-level application of
behavioral principles. In A. Akin-Little, S. G. Little, M. A. Bray, & T. J. Kehle (Eds.), Behavioral
interventions in schools: Evidence-based positive strategies (pp. 125–140). Washington, DC: American
Psychological Association.
Stoiber, K. C. (2014). A comprehensive framework for multitiered systems of support in school psychology. In
P. Harrison & A. Thomas (Eds.), Best practices in school psychology: Data-based and collaborative
decision making (pp. 41–70). Bethesda, MD: National Association of School Psychologists.
Wheby, J. H., & Lane, K. L. (2009). Proactive instructional strategies for classroom management. In A. Akin-
Little, S. G. Little, M. A. Bray, & T. J. Kehle (Eds.), Behavioral interventions in schools: Evidence-based
positive strategies (pp. 141–156). Washington, DC: American Psychological Association.

Tool 2.1. Example Event Recording Form
Tool 2.2. Example Time Sampling Form
Tool 2.1
Example Event Recording Form
Sampling Record Sheet
10-Minute Intervals
Student: _____________________________________ Date: ________________________
Behavior: __________________________________________________________________
(Circle 1, 2, or 3)
TYPE: 1. Whole Interval
+ = behavior is continuous
in interval
TYPE: 2. Partial Interval
+ = single instance is
observed in interval
TYPE: 3. Momentary
+ = record only if
behavior present at end of
interval
Record + or –
+ or – Comments + or – Comments + or – Comments
8:00-8:09 11:10-11:19 2:20-2:29
8:10-8:19 11:20-11:29 2:30-2:39
8:20-8:29 11:30-11:39 2:40-2:49
8:30-8:39 11:40-11:49 2:50-2:59
8:40-8:49 11:50-11:59 3:00-3:09
8:50-8:59 12:00-12:09 3:10-3:19
9:00-9:09 12:10-12:19 3:20-3:29
9:10-9:19 12:20-12:29 3:30-3:39
9:20-9:29 12:30-12:39 3:40-3:49
9:30-9:39 12:40-12:49 3:50-3:59

Tool 2.3. Example ABC Recording Form
ABC Observation Form
Student Name:
Observer:
Activity:
Observation Date:
Time:
Class Period:
ANTECEDENT BEHAVIOR CONSEQUENCE
/ /

Tool 2.4. Example Self-Report Behavior Rating Scale for Internalizing Behavior Problems
Source: Renshaw, T. (2015). Youth internalizing problems screener. Available for download at: https://www.researchgate.net/publication/279295613_
Youth_Internalizing_Problems_Screener
Tool 2.4
Example Self-Report Behavior Rating Scale for Internalizing Behavior Problems
Source: Renshaw, T. (2015). Youth internalizing problems screener. Available for download at:
https://www.researchgate.net/publication/279295613_Youth_Internalizing_Problems_Screener
6.29.15
Youth Internalizing Problems Screener (YIPS)
 Student Name: _____________________
 Date: ____________________
 How OLD are you? __________
 Are you MALE or FEMALE? __________
 What is your RACE or ETHNICITY? __________
Here are some questions about what you think, feel, and do. Read each sentence and circle the one best answer.
Almost
Never
Some-
times
Often
Almost
Always
1. I feel nervous or afraid. 1 2 3 4
2. I feel very tired and drained of energy. 1 2 3 4
3. I find it hard to relax and settle down. 1 2 3 4
4. I get bothered by things that didn’t bother me before. 1 2 3 4
5. I have uncomfortable and tense feelings in my body. 1 2 3 4
6. I feel moody or grumpy. 1 2 3 4
7. I feel like I’m going to panic or think I might lose control. 1 2 3 4
8. I do not really enjoy doing anything anymore. 1 2 3 4
9. I feel worthless or lonely when I’m around other people. 1 2 3 4
10. I have headaches, stomachaches, or other pains. 1 2 3 4
!
THANK YOU for completing the survey!

Tool 2.5. Example Self-Report Behavior Rating Scale for Externalizing Behavior Problems
Source: Renshaw, T. (2015). Youth externalizing problems screener. Available for download at: https://www.researchgate.net/publication/279295611_
Youth_Externalizing_Problems_Screener
Tool 2.5
Example Self-Report Behavior Rating Scale for Externalizing Behavior Problems
Source: Renshaw, T. (2015). Youth externalizing problems screener. Available for download at:
https://www.researchgate.net/publication/279295611_Youth_Externalizing_Problems_Screener
6.29.15
Youth Externalizing Problems Screener (YEPS)
 Student Name: _____________________
 Date: ____________________
 How OLD are you? __________
 Are you MALE or FEMALE? __________
 What is your RACE or ETHNICITY? __________
Here are some questions about what you think, feel, and do. Read each sentence and circle the one best answer.
Almost
Never
Some-
times
Often
Almost
Always
1. I forget things and make mistakes. 1 2 3 4
2. I lose my temper and get angry with other people. 1 2 3 4
3. I have a hard time sitting still when other people want me to. 1 2 3 4
4. I fight and argue with other people. 1 2 3 4
5. I have trouble staying organized and finishing assignments. 1 2 3 4
6. I break rules whenever I feel like it. 1 2 3 4
7. I talk a lot and interrupt others when they are talking. 1 2 3 4
8. I say or do mean things to hurt other people. 1 2 3 4
9. I have hard time focusing on things that are important. 1 2 3 4
10. I like to annoy people or make them upset. 1 2 3 4
!
THANK YOU for completing the survey!

Tool 2.6. Values Clarification and Public Commitment to Promoting Valued Behavior Exercise
Date:
Young person receiving services:
Problem-solving team members:
Step 1. As a problem-solving team, discuss the following questions:
• What do we value for her/him/them?
• What skills and knowledge are in her/his/their best interest to acquire?
• What would “being successful” and “living well” look like for her/him/them?
Step 2. As a problem-solving team, complete the following statements using a written response:
• The things we value for her/him/them are . . .
• We value these things because . . .
Step 3. As a problem-solving team, make a verbal commitment to each other to work together to promote
these values for this/these youth.
Tool 2.7. Discrepancy Analysis Exercise
Date:
Step 1. Describe observed levels of problem behavior obtained from baseline measures:
Step 2. Describe how the observed levels of problem behavior are discrepant with the desired levels of
behavior (values and expectations of the problem-solving team):
Step 3. Describe exactly how much the current observed levels of problem behavior would need to change to
meet the desired levels of behavior.

Tool 2.8. Linking Maintaining Factors and Intervention Strategies Exercise
Date:
Step 1. List the factors that appear to be maintaining the problem behavior.
Step 2. Link each maintaining factor with an appropriate intervention strategy that would positively influence
the problem behavior by addressing the maintaining factor.
Maintaining Factors Intervention Strategies

Tool 2.9. Intervention Planning Exercise
Date:
Step 1. Describe the procedures for implementing the intervention strategy:
• How will it be implemented?
Step 2. Describe the schedule for implementing of the intervention:
• Where will it take place?
• When will it take place?
• How often or for how long will it take place?
Step 3. Describe the personnel, materials, and resources needed to carry out the above procedures on
the above schedule:
• Who will implement it?
• What materials are needed?
• What other resources are needed?

Tool 2.10. Available Resources for School-Based Problem-Solving
Topic: Behavior Assessment and Consultation
Chafouleas, S. M., Riley-Tillman, T. C., & Sugai, G. (2007). School-based behavioral assessment:
Informing intervention and instruction. New York, NY: Guilford.
Sheridan, S. M., & Kratochwill, T. R. (2007). Conjoint behavioral consultation: Promoting family–school
connections and interventions. New York, NY: Springer.
Simonsen, B., & Myers, D. (2015). Classwide positive behavior interventions and supports: A guide to
proactive classroom management. New York, NY: Guilford.
Steege, M. W., & Watson, T. S. (2009). Conducting school-based functional behavioral assessments: A
practitioner’s guide (2nd ed.). New York, NY: Guilford.
Stormont, M., Reinke, W. M., Herman, K. C., & Lembke, E. S. (2012). Academic and behavior supports
for at-risk students: Tier 2 interventions. New York, NY: Guilford.
Young, E. L., Caldarella, P., Richardson, M. J., & Young, K. R. (2011). Positive behavior support in
secondary schools: A practical guide. New York, NY: Guilford.
Topic: Interventions for Specific Mental Health Needs
Burrow-Sanchez, J. J., & Hawken, L. S. (2007). Helping students overcome substance abuse: Effective
practices for prevention and intervention. New York, NY: Guilford.
Gimpel Peacock, G., & Collett, B. R. (2009). Collaborative home/school interventions: Evidence-based
solutions for emotional, behavioral, and academic problems. New York, NY: Guilford.
McCabe, P. C., & Shaw, S. R. (Eds.) (2014). Psychiatric disorders: Current topics and interventions for
educators. Bethesda, MD: National Association of School Psychologists.
Merrell, K. W. (2008). Helping students overcome depression and anxiety: A practical guide (2nd ed.).
New York, NY: Guilford.
Merrell, K. W., & Gueldner, B. A. (2010). Social and emotional learning in the classroom: Promoting
mental health and academic success. New York, NY: Guilford.
Miller, D. N. (2010). Child and adolescent suicidal behavior: School-based prevention, assessment, and
intervention. New York, NY: Guilford.

Chapter 3: Building Effective Partnerships 73

BUILDING EFFECTIVE PARTNERSHIPS
Key Questions
1. How can schools best build effective partnerships with other youth-serving organizations to
support the mental health of young people?
2. What are the primary considerations for sharing information about a young person’s functioning
across providers?
3. How can schools and their partners plan for transition of young people across youth-serving
agencies?
Understanding the Need to Partner
Educators and their community partners share an interest in cultivating the mental health of young people,
which means encouraging youth to realize their own potential, cope with stress, work and learn productively,
and contribute to the community (World Health Organization, 2014). The status of mental health among young
people in the United States is thoroughly discussed in the Introduction section of the SMHRPT; however, for
the purpose of grounding the discussion of partnerships, some of the statistics bear repeating. Approximately
20% of school-aged youths have a mental disorder (Centers for Disease Control and Prevention, 2013), yet
only about 1 in 3 of these young people receive services (Merikangas et al., 2011). The situation is even more
serious for young people of color, with Black and Hispanic young people being less likely than their White
peers to receive mental health services, especially for internalizing disorders (Merikangas et al., 2011).
Schools are often the place where mental health concerns
are first noticed. In fact, more than half of young people
who receive mental health services at some point in their
lives enter through the education system (Burns et al.,
1995; Farmer, Burns, Philips, Angold, & Costello, 2003).
This may be due, at least partially, to the fact that school
professionals have both the sustained contact with young
people and the expertise to detect problems at early
stages, before the impact of mental health problems on
academic and social functioning becomes more severe.
Education may also be a more common access point
due to the Individuals with Disabilities Education Act (1990), reauthorized as the Individuals with Disabilities
Education Improvement Act (IDEIA; 2004), the federal law mandating that students whose mental health-
related disabilities impact their ability to benefit from public education receive individualized education and
related services in the least restrictive environment. That is, instead of enrolling a student with a mental
health-related disability in a residential treatment school, hospital, or institutional setting, he or she must have
the opportunity to receive the supports he or she needs within the public school, alongside typical peers.
CHAPTER 3
Why Partner?
• Reduces barriers to access.
• Allows for intervention to occur in natural
settings.
• Provides schools with a more diverse
range of resources and supports to meet
mental health needs within an MTSS
framework.
• Improves outcomes for young people.

A study of young people enrolled in the Substance Abuse and Mental Health Services Administration’s
(SAMHSA) Children’s Mental Health Initiative, Systems of Care, found that young people referred for services
from schools had significantly lower levels of global impairment than young people referred from mental health
settings (Green, Xuang, Kwong, Hoagwood, & Leaf, 2015). What is more, young people referred through the
education sector often do not receive services from other agencies (Farmer et al., 2003). The implication is that
the education system is a central entry point for young people whose needs are identified, and regardless of
intensity of treatment needs, it may be the only setting in which services are provided.
Because schools are one of few places where families interface with local resources, there are many
advantages of providing multitiered mental health services in schools.
• It improves access to services by reducing barriers such as transportation, child care, cost (e.g.,
reduced “no shows”), and stigma (Freeman, Grabill, Rider, & Wells, 2014; Hoover, Stephan, Weist,
Kataoka, Adelsheim, & Mills, 2007). Providing services in schools within a multitiered framework also
allows for more prevention efforts that promote mental wellness.
• Because a local school is a known environment for a young people and their families, mental health
interventions can be more ecologically grounded (Hoover Stephan et al., 2007). Clinicians working in
the schools are more able to influence aspects of the school environment (e.g., classroom structure,
teacher-student interactions) that will positively impact mental health-related outcomes for the young
people they serve. Indeed, multidisciplinary collaboration leads to increased coping and problem-
solving skills, reduced emotional and behavioral problems, improved school climate, fewer special
education referrals, and decreased disciplinary referrals (Ballard, Sander, & Klimes-Dougan, 2014;
Hoover Stephan et al., 2007).
• It reduces the likelihood that young people will experience exclusionary discipline practices (e.g.,
suspension), academic difficulties, school disengagement, school drop out, and incarceration (Brown,
2007; Gregory, Skiba, & Noguera, 2010; Lee, Cornell, Gregory, & Fan, 2011).
Despite the myriad advantages of providing mental health services in schools, serving mental health needs
has not historically been central to the mission of schools and, therefore, schools often do not have the
resources to identify and treat all young people with mental health needs. In addition, pressure to meet federal
and state mandates to show academic gains (Bancroft,
2010) may preclude educators from focusing on mental
health needs. Given the impact and severity of mental
health challenges on academic, behavioral, and social
functioning of young people in school settings, as well
as the limits on school resources, it behooves schools
to partner with other agencies to best meet the needs of
young people and their families.
Partnerships may span across the tiers of prevention
within the MTSS framework (Figure 3.1, see SMHRPT
Introduction for review). Examples include:
• At Tier 1, a non-profit community-based youth
development agency may partner with the school
to provide universal, classroom-based skill building
prevention efforts (e.g., social and emotional skill
development).
• At Tier 2, a private mental health clinician may be
contracted to provide targeted skill training to small
groups of young people with emerging internalizing
or externalizing problems during the school day.
This type of early intervention would be provided
to help reduce the likelihood that mental health
problems will interfere with school functioning.
Tier 2
Tier 1
Tier 3
+
+
++
Figure 3.1. The Multitiered System of
Support Model for Mental Health Supports
in Schools

• At Tier 3, students who do not respond to less intensive interventions may need more individualized
treatment, which may be addressed on or off school campus through effective partnerships with other
sectors (e.g., health/medical, mental health). For instance, a mental health clinician from the local
public mental health agency may be engaged to provide evidence-based individualized treatments on
the school campus before, during, and after school hours.
Mental Health Partnerships: Leveraging Community Resources for Maximum Impact
To effectively meet the mental health needs of young people, schools must partner with a variety of sectors,
including mental health, health/medical, child welfare, and juvenile justice (Burns et al., 1995). Examples of
creative partnerships between schools and each of these sectors are described below.
Mental Health. In the mental health sector, services are provided by a wide variety of organizations,
including hospitals and medical clinics, public and private mental health agencies, and private mental health
clinicians. State Departments of Mental Health are responsible for delivering public mental health services in
a variety of settings, including: psychiatric inpatient, residential treatment, partial hospitalization, community-
based mental health centers, and outpatient drug/alcohol clinics or rehabilitation centers. Through their
state office of mental health, schools can also locate mental health programs in their vicinity. Despite the
comprehensive services available, only one-quarter of young people receiving mental health services enter
through the mental health sector (Farmer et al., 2003). Many of these individuals are only receiving care at
the Tier 3 level of intervention once a mental health concern has developed into a serious condition. These
data underscore the fact that, in order to better realize their mission to reduce the impact of mental illness in
the community, the mental health sector has a stake in partnering with schools for the purpose of prevention
and early intervention. Examples of effective education-mental health partnerships include:
• At Tier 1, school and community mental health agency partnerships may provide social-emotional
learning programs (see www.casel.org) or participate as team members in whole-school model
programs, such as Positive Behavioral Interventions and Supports (PBIS). School and community
partners can provide cross-training for staff and co-lead classroom groups on prevention topics such
as drug and alcohol use, problem-solving, and suicide prevention (Freeman et al., 2014).
• At Tier 2, small groups to target specific areas of need (e.g., bereavement, anger management) may
be facilitated on school campus by a clinician from the local community mental health agency.
• At Tier 3, students in greatest need may be provided with more intensive and coordinated services
such as Multisystemic Therapy (MST; Henggeler, Schoenwald, Rowland, & Cunningham, 2002) by
local, private licensed mental health clinicians on school campus.
• Schools in some districts have partnered with mental health clinicians to create family resource
centers that provide individualized, family, or group interventions for youth and their families at
no cost. These centers are housed within the district, and referrals may come from school-based
providers, but the centers function as separate entities in order to maintain confidentiality and allow
for clinicians to address non-school related concerns.
Health and Medical. The health and medical sector (e.g., medical inpatient unity, community health
center, physician, hospital emergency room) has an increasingly important role in mental health. A study
of national trends found young people’s visits to physicians resulting in mental disorder diagnoses (for
example, ADHD; other disruptive behavior disorders; anxiety and mood disorders, developmental disorders,
psychotic disorders) have doubled over the past two decades (Olfson, Blanco, Wang, Laje, & Correll, 2014).
In addition, the number of visits to physicians for psychotropic medication has increased for young people
(Olfson et al., 2014). The medical sector also becomes involved once a young person is in a mental health
crisis and needs more intensive services and treatment. However, physician diagnoses are often based
on limited information provided by parents and gained during a relatively short office visit. This can lead to
differences between medical diagnosis and educational placement, causing stress for the young clients and
their parents. Often physicians and educators are unable to collaborate regarding individual students due to
time constraints inherent to both professions.

Examples of partnerships between schools and the health and medical sector include:
• School-based health clinics, where medical professionals, such as physicians, dentists, nurse
practitioners, as well as mental health professionals (psychologists, social workers) are placed in
targeted schools to provide additional supports to meet the needs of young people (Glaser & Shaw,
2014). The Center for Health and Health Care in Schools lists several such model programs at http://
www.healthinschools.org/model-programs.aspx.
• Medical professionals may also serve on collaborative teams (e.g., problem solving team meant
to facilitate young people’s transition from hospitals back to school by providing education and
coordination; crisis intervention team) and provide information on issues of importance to schools (e.g.,
accident prevention, substance abuse, violence).
Child Welfare. The primary purpose of the child welfare sector, or social services, is to provide maximum
protection for young people who are physically, sexually, or emotionally abused, neglected, or exploited.
Educators are mandated reporters, so they must make reports if abuse or neglect is suspected. Often this
means that child welfare agencies are involved when providing a Tier 3 level of intervention. Research has
shown that once young people have contact with the child welfare system, their use of mental health services
increases (Leslie, Hurlburt, James, Landsverk, Slymen, & Zhang, 2005). In fact, federal law requires state child
welfare agencies to provide mental health services for children in foster care (Administration for Children and
Families, 2012). However, over time, it is only young people in out-of-home placements that enter the mental
health system at a higher rate than before contact (Leslie et al., 2005); about two-thirds of young people with
mental health problems who remain in their homes after contact with social welfare do not receive services
(Leslie et al., 2005), leaving them without access to necessary mental health supports. Therefore, it benefits
young people for schools and child welfare services to collaborate to prevent incidents of abuse and neglect
that increase youths’ mental health needs. Ideas for innovative education-child welfare partnerships include:
• Child welfare services often have the capacity to offer schools staff training, as well as facilitating
parenting workshops within the school. Services that can be provided to families include: case
management and planning, day care, housekeeping, parent aide, parent training, transportation,
emergency cash or goods, housing, crisis respite care, and clinical services (Erie County Child
Protective Services Agency, n.d.).
• In some counties, the child welfare agency partners with local school districts to have a caseworker
housed within the school one to two days per week to offer families who need support receive the help
they need (i.e., mental health, substance abuse, etc.) and prevent reports of abuse or neglect that
typically result in an investigation (Erie County Child Protective Services Agency, n.d.).
• Another example is child welfare agencies and schools partnering to support homeless youth. Moore
(2005) describes an example in Lancaster, Pennsylvania where a child welfare agency took the lead in
addressing homelessness among youth by creating a Homeless Student Project Task Force. Issues
such as enrollment, medical needs, mental health and other services were coordinated by social
workers from the child welfare agency, in collaboration with the school.
Juvenile Justice. Many young people living with mental illness are also involved in the juvenile justice sector
(i.e., detention center, family court, law enforcement, probation). Young people in the juvenile justice sector
are about three times more likely to have a mental health diagnosis than their peers, with girls in the juvenile
justice sector being even more likely than boys to have mental health diagnoses (Anoshiravani et al., 2015).
Serious concerns exist about the “school-to-prison pipeline,” where some of the most severely affected young
people, many of whom have been exposed to violence and other forms of trauma, are subject to suspension,
expulsion, and other forms of exclusionary discipline that deprive them of educational benefits and push them
toward involvement in the juvenile justice sector. Instead of viewing juvenile justice as a partner of last resort,
schools can partner with juvenile justice to engage in more prevention efforts, such as:
• School Resource Officers (SROs) are police officers whose responsibilities may include those of law
enforcer (e.g., provide supervision, investigate crime, serve as liaison between school and police),
educator (for young people, parents, and school staff about law-related issues), and informal counselor
or role models (Canady, James, & Nease, 2012; James, Logan & Davis, 2011; Quinn, 2014). Properly
trained SROs can form strong relationships with young people and work collaboratively as members of
a school’s student assistance and crisis response teams (James et al., 2011).

• Law enforcement is also an important part of the threat assessment process, which is the
recommended standard approach for schools to take determine the extent to which a student poses a
serious threat to the safety of others (Fein et al., 2002). This process seeks to understand the meaning
and context of a student’s threatening behavior, and uses this information to address the underlying
context of the problem rather than relying on uniform discipline alone (Cornell & Allen, 2011; Cornell &
Sheras, 2006).
Business and Philanthropic Organizations. Members of local business and philanthropic sectors can
be important partners for schools, oftentimes by providing funding for initiatives to improve mental health.
For example, local businesses may provide incentives for schools to use as part of positive behavioral
interventions and supports (Eagle & Dowd-Eagle, 2014). Businesses may also provide grant funding for
specific initiatives regarding positive youth development and other preventive programs to promote mental
health. Local businesses and health foundations created as part of the business sector may also fund a portion
of school mental health positions and services (Freeman et al., 2014). Philanthropic organizations often have
funding opportunities for schools that may be used to improve mental health. These initiatives often involve
developing proposals to meet an unmet need. Many such organizations and foundations require schools to
identify their expected measurable objectives, evaluation data, and capacity to sustain initiatives after the
funding period ends.
Community-Based Organizations. Community-based organizations (CBOs), especially those whose mission
it is to promote youth development, can be engaged in a variety of ways. For example, the Big Brothers Big
Sisters Program links with school to provide mentoring within the community or at school for students identified
in need. Organizations like the Boys and Girls Club, YMCA, and YWCA can collaborate with school to provide
a safe transition from school to after-school care and provide opportunities to develop social skills and
character education (Eagle & Dowd-Eagle, 2014).
How Can Schools Partner Effectively?
Historically, mental health services have been fragmented and uncoordinated across sectors, and most young
people with identified mental health needs do not receive services (Hoagwood, Bruns, Kiser, Ringeisen, &
Schoenwald, 2001). To address these issues and better meet the needs of young people with serious mental
health challenges, the system of care concept was developed to guide the field in reforming child-serving
systems, services, and supports (e.g., education, juvenile justice, child welfare, and mental health; Pires,
2002). The concept and philosophy were the result of a participatory process in the early to mid-1980s that
initiated the National Institute of Mental Health’s Child and Adolescent Service System Program (CASSP)
to provide funding and technical assistance nationwide to improve coordination (Pires, 2002; Stroul, Blau, &
Friedman, 2010).
In the 30 years since its introduction, the system of care
concept has shaped the work of nearly every community
nationwide, and it serves as the foundation of the Federal
Comprehensive Community Mental Health Services for
Children and their Families (Stroul et al., 2010). The
framework is not a proposed “model” of services, agencies,
and organization of the systems, but rather a vision for
transformation to meet the needs of the local community
(Stroul et al., 2010). The wraparound service delivery model
is consistent with this vision; it is a team-based, collaborative
process that identifies, implements, and coordinates a
number of services and supports to meet the needs of young
people and their families with an emphasis on natural and community-based supports, resulting in improved
academic, mental health, living situation, and overall outcomes for young people (Suter & Bruns, 2009).
Defining features of the system of care
philosophy and approach:
• Coordinated network of effective,
community-based services and supports
for young people with mental health
challenges and their families.
• Family driven and youth guided.
• Infrastructure of structures, processes,
and relationships at community level.
• Cultural and linguistic competence.
Source: Pires, 2002; Stroul et al., 2010

The Partnership Process
The process of building effective partnerships involves three phases: (1) defining roles and responsibilities, (2)
sharing information and monitoring progress across systems, and (3) planning for transitions between levels of
care. Each phase of the partnership process is described below.
Phase 1: Defining Roles and Responsibilities
Before establishing a formal partnership process, key stakeholders need to be
invested in the partnership. Initial meetings about the partnership might involve
surveying existing efforts in the community that focus on mental health needs of young people, documenting
the need for the partnership, ensuring buy-in by getting a commitment to attend meetings and provide
resources (e.g., space) needed for, and developing a clear vision (Illinois Children’s Mental Health Partnership,
n. d.). Developing a stakeholder group is also important. This may begin initially by engaging groups with
preexisting relationships. Although there is flexibility in terms of the composition of the group, it may include:
• Someone with decision-making power from each group
• Educators (teachers, administrators, school support staff)
• Family members
• Youth
• Someone with expertise in evaluation
• Community stakeholders (elected officials)
• Juvenile justice providers
• Representatives from parks and recreation
• Social service providers (Illinois Children’s Mental Health Partnership, n. d.)
The group should also be culturally diverse and represent a range of perspectives reflecting the community.
Some of the skills that are valuable for stakeholders in collaborative groups include:
• Commitment to collaboration
• Training and skills
• Dependability
• Collegiality
• Flexibility
• Effective communication
• Knowledge of community
• Positive working relationships with potential partners (Illinois Children’s Mental Health Partnership, n. d.)
Because collaborative efforts have different purposes, there are various structures and processes for
collaboration, ranging from simple sharing of information to complex relations including sharing data, financial
resources, and integrated decision-making. Once potential collaborators are identified, it is important to identify
the type of relationship that will exist between the school and outside organization. Toolbox 3.1 provides a
breakdown of the varying levels of partnership development, with information about the purpose, structure, and
process of each.

Defining roles
and
responsibilities
Sharing
information and
monitoring
progress across
systems
Planning for
transitions
between levels of
care

Toolbox 3.1. Levels, Purpose, Structure, and Process of Partnerships
Level Purpose Structure Process
Networking
Information clearinghouse
Create base of support
Increase community action
Roles loosely defined
Participation is variable
Low leadership
Minimal decision-making
Little conflict
Informal communication
Cooperation
or Alliance
Match needs
Coordinate and limit
duplication of services
Ensure task completion
Roles somewhat defined
Central body of people as hub
of communication
Facilitative leadership
Complex decision-making
Some conflict
Formal communications within
central group
Coordination
or Partnership
Share resources
Merge resource base to
create something new
Central body of people as
decision makers
Roles defined
Links formalized
Development of new resources
and joint budget
Autonomous leadership (focus on
issue)
Group decision-making (central and
subgroups)
Frequent and clear communication
Coalition
Share ideas
Pull resources from existing
systems
Commit for at least 3 years
Decision-making involves all
Roles and time defined
Written agreement to formalize
links (e.g., MOU)
Development of new resources
and joint budget
Shared leadership
Formal decision-making (all
members)
Common and prioritized
communication
Collaboration
Accomplish shared mission
Build independent system
to address issues and
opportunities (e.g., school-
based mental health
services)
Decision making by
consensus/shared
Roles, time, and evaluation
formalized (e.g., grant
proposal)
Written work assignments and
formal links
High leadership, trust, and
productivity
Equally shared decision-making
Highly developed communication
Adapted from Bridging Refugee Youth and Children’s Services “Refugee Children in U. S. Schools: A Toolkit for Teachers and School Personnel”
Stakeholders should discuss the resources, structures, and processes that will need to be in place to maintain
a successful partnership. When making decisions about what types of partnership to enter into, it is critical
that schools have information about the partners and a process for vetting service providers (for examples,
see Chapter 1: Toolbox 1.2, Toolbox 1.3). This is important for any level of partnership, but may be particularly
important for coalitions or collaborations where there are joint services provided.
Partnerships between schools and other agencies also need to consider the differences in their terminology,
issues of confidentiality and information sharing, perceptions about the role in the school, diagnostic process,
service provision, licensure and continuing education requirements, and funding (Freeman et al., 2014). For
example, school-based mental health professionals adhere to educational laws (e.g., IDEA, FERPA), which
guides their scope of work, diagnostic, information sharing, and intervention procedures. Professionals in
partner agencies may be governed by health care laws and regulations (e.g., HIPAA), and may focus on
specific areas or populations (e.g., intensive treatment needs for young people experiencing trauma; diversion
programs to prevent involvement in juvenile justice system). Access and funding issues also differ, as families

do not pay directly for education and related services provided within public schools, whereas in other
agencies services may be reimbursed from health insurance, Medicaid, or self-pay. State departments of
education also have School Medicaid Claiming guides that allow for reimbursement of particular services.
Many of the partnership levels detailed in Toolbox 3.1 allow for shared funding through school, community,
business, state and county, and foundation support.
Memoranda of Understanding (MOU)
Once stakeholders have agreed upon the nature of the collaboration, it is important to further detail and clarify
the roles of each agency, a process that is typically codified by a Memorandum of Understanding (MOU). An
MOU should include the purpose of the program or partnership, the roles and responsibilities, requirements
for information sharing, and relevant procedures (U.S. Department of Justice, Office of Community Oriented
Policing Services, 2015). MOUs are commonly required when partners receive grant funding. An MOU can
also be considered a policy instrument within the context of applicable state and federal laws; all partners
should sign and abide by the MOU (U.S. Department of Justice, Office of Community Oriented Policing
Services, 2015). Toolbox 3.2 displays a checklist of topics that should be discussed when defining the
parameters of the collaboration with mental health partners, specifically, and included in an MOU.
Toolbox 3.2. MOU Checklist
1. Parties to the Collaboration
 Education Partner Name
 Community Partner Name (Police Department, Mental Health Services, Counseling Services,
etc.)
2. Purpose for the Collaboration
 Include goals and objectives
3. Collaborative Functions
 Assessment (initial screening; diagnosis and intervention planning)
 Referral, triage, and/or monitoring/management of care
 Direct service and instruction (e.g., primary prevention programs/activities; early intervention;
individual, family, and group counseling; and/or crisis intervention and planning)
 Indirect services (consultation, supervision, in-service instruction)
4. Roles and Responsibilities of Mental Health Clinician
 Provide prevention, early intervention, treatment, and assessment services to young people in
the school
 Individual/group therapy
 Social skill training and/or coaching
 Family therapy
 Substance abuse counseling
 Psychosocial evaluations
 Provide consultation, training, and support to teachers, administrators, and other school staff
 Collect data/notes on students to monitor progress
 Complies with a request to share any other information related to a student’s treatment
(requires an appropriate release of information signed by the student’s parents)
 Visits students’ homes or community agencies (permission not needed from the school)

5. Supervision Responsibility of the Community Agency Partner
 Provides supervision and support for mental health clinicians
 Hires and supervises one or more clinicians who will be placed in participating schools
 Holds weekly supervisory and training meetings for clinicians
 Reports to school principal any unusual incidents and work with school to resolve disputes
 Provides monthly reports to school principal with aggregate information such as the number
of students seen, the number and theme of therapeutic groups, and general concerns raised
6. Roles and Responsibilities of the School
 Provide a private space, a locking filing cabinet, and a dedicated phone line for each clinician
assigned to a school
 Provide supplies, materials, and use of office equipment
 Convene a team of relevant individuals to meet regularly to review and assign requests for
services
 Use the referral format specified by the community agency for all referrals, whether from staff,
student, or parent
 All referrals, whether self-referral by the student or by the staff, contain confidential
information and cannot be shared or copied without appropriate authorization
 Work to resolve dilemmas that arise from the legal confidentiality requirements so that all staff
involved with a student can work together in the student’s best interest while adhering to
mandatory mental health laws
7. Miscellaneous Procedures
 Mental health clinicians can/cannot be financially compensated by the school for work
completed as part of their normal duties
 Mental health clinicians are responsible for reporting their hours; clinicians should sign in and
out of the school if the school requires such a procedure
 Clinicians will report their schedules to the school on a monthly basis, and each carries a cell
phone provided by the program to assure that they can be reached when out of the building
 Requests for leave time will be approved by supervisors at the community agency
 Principals will be informed of this leave in writing
 School staff (administrators and teachers), families, and students will be asked to participate
on a regular basis in the evaluations
 Schools will be asked to share school-level data (e.g., attendance records, disciplinary
actions, grades)
8. Legal Considerations
 Mandatory Reporting Laws
 Mental Health Records Are Confidential and Not Part of The School Record
 Disclosure of Mental Health Information
 Release of Mental Health Records Can Be Pursuant To a Court Order

Phase 2: Sharing Information and Monitoring Progress Across
Sectors
In a partnership that includes authentic connection and collaboration, there
needs to be a communication mechanism that allows for timely dissemination of
information to all agencies and stakeholders (SAMHSA, 2000). Although protecting privacy and maintaining
confidentiality are essential, these are challenges that can be navigated through careful planning and
engagement of families, staff, and providers across agencies committed to a common goal (Pires, 2002).
Family Education Rights and Privacy Act (FERPA). Under federal law, if a local or state education agency
receives funds under the Elementary and Secondary Education Act, it must adhere to the Family Education
Rights and Privacy Act (FERPA). FERPA is the primary federal law protecting the privacy and confidentiality of
students’ personally identifiable information (address, social security number, grades, behavioral referrals).
Health Information Portability and Accountability Act
of 1996 (HIPAA). Medical records, including those kept
by a school nurse employed by the health department,
are subject to the Health Information Portability and
Accountability Act of 1996 (HIPAA). More detailed
information about each of these laws is provided in Tool 3.1.
An essential take-home point from all of these privacy laws
is that the parent or legal guardian for young people under
the age of 18 must give consent by signing a release of
information sharing form in order for schools and other agencies to share any information about young people
(for example, see Tool 3.2).
Considerations in Crisis Situations. In relation to privacy regulations, there are exceptions when it comes
to imminent danger. For example, HIPAA permits a provider to notify a patient’s family members of a serious
and imminent threat to the health or safety of self or others if the family members are in a position to lessen or
avert the threat (U.S. Department of Health and Human Services, 2014). Schools must know which hospitals
are equipped to work with young people in crisis. A school-based mental health professional can facilitate the
Information sharing between partner
agencies is critical to meeting the needs
of young people. The signed consent of a
parent or legal guardian to obtain and release
information is essential to comply with privacy
laws.
Toolbox 3.3. Consent to Release Information Checklist
A form indicating guardian consent to release information should include the following key elements (see
Tool 3 for an example):
 The purpose of the disclosure
 The identity of the party or class of parties to whom the disclosure may be made
 Agency requesting the information, name and contact information
 Agency releasing the information, name and contact information
 For young person under 18 years of age: guardian name and contact information
 For young person 18 years of age or older: name and contact information
 Types of records or other information to be received (e.g., education, substance abuse, medical, and/
or mental health records)
 Process by which information will be released (e.g., U.S. mail, fax, electronic mail)
 Signature of individual(s) providing consent, guardian or young person 18 years of age or older
 Contact information for individual(s) providing consent
 Expiration of Consent

19
Figure 2. Electronic Data Tracking System, User Interface
Source: ABC Unified School District
Referral Source is
Trained in MHFA
admittance to a hospital in a crisis situation, or if the young person is already under the care of a psychiatrist,
that doctor can often assist with a direct admittance. Some community mental health centers and mobile crisis
teams also provide emergency assessments to help determine level of risk and the corresponding level of care
required. Schools should have arrangements with agencies and practitioners that can assist them prior to a
crisis.
Tracking Referrals Across Partners. Technology has advanced several tools for improving collaboration
and data sharing between schools and their community partners. Some pioneering education agencies have
developed student information systems wherein mental health professionals enter data and keep track of their
caseload as part of the monitoring and tracking that happens at the end of the referral cycle for students who
have been identified as in need of services (see Chapters 1 and 2 for additional details). In addition to basic
student information (e.g., student identification number, demographics), logged data may include: the referral
source, whether the referral source was trained in Mental Health First Aid, the range of concerns that provided
cause for the referral, and the type and number of interventions provided. Figure 3.2 displays the user
interface for this type of student information system.
When tracking referrals in this way, it is essential that confidentiality and data security be considered and that
systems comply with HIPAA’s Security Rule in terms of the safeguards for electronic records. Such Security
precautions might include (U.S. Department of Health and Human Services, Office of Civil Rights, n.d.):
• Access controls (information only accessed by passwords, PINs)
• Encryption codes (information only accessed by those with a key)
• Audit trail to record who accessed information and what changes were made
• Notification of any breaches to privacy
Figure 3.2. Electronic Data Tracking System, User Interface
Source: ABC Unified School District

Monitoring Treatment Progress within Partnerships. It is now widely acknowledged that evidence-based
practices, or interventions that have been shown to be effective through rigorous research, are the gold
standard for treatments. However, resources for establishing evidence-based practices are still not widely
available in community settings, as treatments shown to be effective in carefully controlled studies cannot be
assumed to be effective when implemented under routine practice conditions (Beidas et al., 2015; Hoagwood
et al, 2001; President’s New Freedom Commission on Mental Health, 2003). Therefore, schools and other
agencies need to examine their own processes and outcomes to ensure that services are being delivered and
making an impact (Garland et al., 2010). Some considerations for partners wishing to establish shared metrics
include:
• Partners must define progress monitoring measures that are used to produce clinical data for
feedback about progress and to inform intervention and outcome measures that are used to assess
the amount/type of change young people experiences from the start to end of an intervention (Meier,
2015).
• Partners can use a practice-based evidence approach that includes systematic and frequent
measurement of both the treatment process and progress within a continuous quality improvement
framework (Bickman, 2008). An example is the Contextualized Feedback and Intervention Treatment
(CFIT), an outcome-driven continuous quality improvement system based on theory of change model
and grounded in psychological and organizational research with four major components: organizational
assessment, treatment progress measurement, feedback, and training (Bickman, 2008).
• Partners should engage in continuous partnership quality improvement, wherein intervention
effectiveness data are used to inform decisions that fortify the quality of the partnership (e.g., improved
personnel training, coordination of services).
Assessing outcomes is a very important way to ensure that schools and their partners are meeting their
shared goals. Schools must determine the shared outcomes of interest to ensure that data are gathered
on shared metrics, when possible. Schools should consider following these steps for measuring intervention
effectiveness:
1. Decide what to measure based on the young person’s presenting needs. There are many reasons
that a young person may be referred for mental health-related support, including internalizing problems
and/or externalizing problems. Chapter 2 of the SMHRPT provides a detailed procedure for evaluating
the specific presenting needs that should be measured before, during, and after treatment. Partners
must reach agreement about what exactly the presenting need is and how response to treatment will be
measured.
2. Decide how to measure intervention effectiveness. Partners must select measures that are sensitive
to change and specify levels of performance to be attained. Toolbox 3.4 provides several resources for
identifying treatment monitoring and behavioral progress monitoring tools.
Toolbox 3.4. Resources for Identifying Treatment Monitoring Instruments
• PROMIS: Dynamic Tools to Measure Health Outcomes from the Patient Perspective (National Institutes
of Health).
A set of freely available, validated, computerized measures of self-report (ages 8-17) and parent proxy report
(ages 5-17) for measuring patient related outcomes (PROs), including physical health, mental health, and social
well-being outcomes.
URL: nihpromise.org
• Contextualized Feedback Intervention and Training (CFIT).
A treatment progress battery, including 10 measures of clinical processes and mental health outcomes for young
people ages 11-18.
URL: peabody.vanderbilt.edu/docs/pdf/ptpb/PTPB_Chapter1.pdf
• National Center on Intensive Intervention.
Provides information on behavior progress monitoring tools for young people
URL: intensiveintervention.org/chart/behavioral-progress-monitoring-tools

3. Determine the level of change expected. Partners need to discuss what level of change is needed to
confidently say that the young person has responded to intervention. Because measuring meaningful
change can be a complex statistical issue, partners should consider referring to the user guidebooks
associated with any measures they select. User guidebooks will provide information that can inform
decisions about meaningful change.
4. Determine how often to measure intervention effectiveness. An important part of monitoring progress
is feeding back the information to the person(s) providing the intervention so that it can be used to improve
services and quality of care. Young people whose mental health clinicians receive session-by-session
feedback improve more quickly than those where feedback is more delayed (Bickman and colleagues,
2011).
5. Determine how to share effectiveness information across partners. The use of technology is an
important consideration as most educators and clinicians do not have the time to be hand entering
and calculating data. Toolbox 3.5 provides examples of software systems that can be used to measure
treatment progress. Also refer to Toolbox 1.4 in Chapter 1 for software systems that may apply to your
partnership needs.
Phase 3: Planning for Transitions between Levels of Care
The intensity of mental health needs can vary at different points in a
young person’s life, making it critical that partnerships support coordinated
and seamless transitions across organizations providing mental health services. In the most severe of
circumstances, the mental health needs a young person has may require intensive treatment in restricted
settings, such as hospitalizations in emergency situations, that must occur quickly and without time for
prolonged planning. Transitions out of hospital placements can be equally abrupt; psychiatric hospital lengths
of stay are typically only a few days (Balkin & Roland, 2007; Clemens, Welfare, & Williams, 2011). Young
people released from detention centers and residential placements often do not return to school after release
(Holman & Zidenberg, 2006; Mears & Aron, 2003), and less than 15% of incarcerated ninth graders go on to
complete their high school education (Holman & Ziedenberg, 2006).
For partnerships to effectively support young people returning to school after receiving intensive mental health
services in more restrictive settings such as juvenile detention centers, hospitals, day treatment centers,
or residential treatment centers, several considerations should be addressed. Paramount in reintegration
planning is the need to maintain required levels of support while placing the young person in the least
restrictive educational environment. The responsibility to coordinate reintegration is often placed on schools
(Glaser & Shaw, 2014), although communication and collaboration between school personnel and partner
Toolbox 3.5. Sample Software Systems for Monitoring Progress
• YouthServices.net
Customizable software for registering participants, tracking attendance and measuring outcomes. Service
providers use the software for data collection, service management and program evaluation needs of the youth
services sector.
URL: youthservices.net
• Wisconsin Department of Public Instruction Student Intervention Monitoring System
Created by the Madison Metropolitan School District with support from the Department of Public Instruction, the
Student Intervention Monitoring System (SIMS) is a software program designed to monitor interventions and
help educators provide additional support for children who are not learning. SIMS is a systematic way to share
information between teachers and to monitor student progress over time.
URL: rti.dpi.wi.gov/rti_sims2

agencies is needed. In addition to ongoing collaboration for building systems of support, partner agencies
should consider engaging in the following practices for transition planning:
• Reentry planning where a multidisciplinary team (problem solving team, IEP team, transition team)
engages in systematic decision-making to plan for the appropriate transitional services, supports, and
goals based on the needs of the family, educators, and student.
• Monitoring and follow-up related to a transition plan in order to continuously evaluate the transition
process.
• Education of school community, including preparing school staff and/or students about the issues
under consideration for the student returning. School reentry teams may consider preparing the school
community by meeting with school faculty and/or students in the young person’s classroom (e.g., Stony
Brook Children’s School Intervention and Re-entry Program http://www.stonybrookchildrens.org/school-
reentry).
Examples of specific considerations to take into account in transition and reentry plans include (Clemens et al.,
2002; Cook-Cottone, 2004; Kaffenberger, 2006; Vermeire, 2008):
• Meet with the young person and family to find out what information will be shared and how they want
information shared.
• Ensure that appropriate release of information documents are signed to share information among
providers for intervention planning.
• Designate a “go to” person who will meet and greet student upon return.
• Provide support and understanding to the student, including assessing the students’ perceptions of his
or her functioning, as well as his or her preferences regarding the type of support wanted (e.g., check-in
with staff at end of day, role-play how to respond to questions from classmates).
• Make up list of missed work for each class; review it with parent and student and assist in contacting
teachers to compile this information.
• Implement appropriate modifications (reduced workload, half-day attendance for a period of time,
alternative assignments, extended time on tests, peer tutoring or mentoring if desired).
• Inform student of supportive resources available (consider special support systems such as personal
phone contact, assigned counselor, school-based continuity of care support group).
• Adhere to recommendations from outpatient providers.
• Provide specific plans and guidance about issues that contribute to students’ problems (e.g., people,
places, and things that may trigger a response).
• Ensure staff are trained in signs of relapse and appropriate interventions and strategies.
• Keeping in mind privacy considerations and constraints, provide information and direction to staff who
will interact with the student.
• Monitor systematically and adjust educational plan as needed.
Conclusion
Meeting the mental health needs of young people can best be accomplished through strong partnerships
between schools and their youth-serving counterparts in a variety of sectors. Building on the strengths
and resources in each setting, a coordinated system of care model allows young people and their families
to receive multidimensional care that is tailored to their needs. This SMHRPT chapter detailed specific
considerations and provided several related tools and techniques to assist educators in their partnership-
building efforts.

Tool 3.1. Overview of Privacy Laws
The Family Educational Rights and Privacy Act (FERPA)
see http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferparegs.pdf
In general, personally identifiable information and education records cannot be disclosed without written con-
sent, even for case management. For aggregated data, system level data are sharable (Partnership for Chil-
dren and Youth).
Personally Identifiable Information (PII):
Includes Does NOT Include
1. Student’s name
2. Names of student’s family members
3. Address of student or student’s family
4. Personal identifier (e.g., student’s social
security number)
5. Indirect identifiers are not unique to the
student or family but can be used in
combination with other information to identify
the student
1. Records kept in the sole possession of the
maker (e.g., personal notes)
2. Records of the law enforcement unit of an
educational agency or institution
3. Records relating to an individual who is
employed by an educational agency or
institution, except when the records are of a
student employee
4. Records created or received by an educational
agency or institution after an individual is no
longer a student in attendance and that are not
directly related to the individual’s attendance
5. Classwork not graded by a teacher

Circumstances or Individuals to Whom Educational Agency Can Disclose PII
(Partnership for Children and Youth; Privacy Technical Assistance Center):
1. To other school officials (e.g., teachers) within the agency/institution or to authorized
representative (e.g., contractor, consultant, volunteer) of a contracted education program
that have legitimate educational interests
2. For school transfers to officials of another school, school system, or institution of postsecondary
education where the student seeks or intends to enroll, or where the student is already enrolled for
enrollment or transfer purposes
3. To an authorized representatives of certain government agencies who are performing an audit,
evaluation, or enforcement or compliance activity
4. If information is in connection with financial aid for which student has applied
5. To state and local officials or authorities if disclosure concerns the juvenile justice system and
the system’s ability to effectively serve the student whose records being requested
6. To organizations conducting research for, or on behalf of schools, school districts, or
postsecondary institutions for developing, validating, or administering predictive tests;
administering student aid programs; or improving instruction
7. To accrediting organizations to carry out their accrediting functions
8. To parents of a dependent (minor) student or to the student
9. A student’s violation of any Federal, State, or local law, or of any rule or policy of the
institution regarding the use or possession of alcohol or a controlled substance to a parent
of child under 21
10. To comply with a court order or subpoena
11. In a health or safety emergency.
12. Information not considered harmful or an invasion of privacy (i.e., “directory information”)
13. Final results of the institution’s disciplinary proceeding to a victim of an alleged perpetrator
of a crime of violence or a non-forcible sex offense (regardless of whether the institution concluded
a violation was committed)
14. Information related to a disciplinary proceeding (i.e., an investigation, adjudication, or
imposition of sanctions by an educational agency or institution with respect to an infraction or
violation of the internal rules of conduct applicable to students of the agency or institution) at an
institution of postsecondary education to alleged perpetrator.
15. Concerns of sex offenders and other individuals required to register under section 170101
of the Violent Crime Control and Law

Health Insurance Portability and Accountability Act of 1996 (HIPPA)
This law covers protected health information: individually identifiable health information is information that
identifies the individual (OCR Privacy Brief). HIPPA applies to a school only when it acts as a health care
provider (provides health care to students through its health clinic) and/or communicates with a health care
provider. If the school provided treatment, billed an agency for payment, or other health care operations
maintains health information only in student health records that are “education records.” For example, if a
public high school employs a health care provider that bills Medicaid electronically for mandated services
provided to a student with an individual education plan, HIPAA applies to all transactions. However, if the
school’s provider maintains health information in education records, only FERPA privacy regulations apply, not
HIPPA. The school would have to comply with FERPA’s privacy requirements by obtaining parental consent in
order to disclose to Medicaid billing information about a service provided to a student.
The HIPPA Privacy Rule applies special protections to psychotherapy notes outside the scope of a school
(i.e., notes recorded by a mental health care provider/professional documenting or analyzing the contents of
a conversation during a private counseling session or a group, joint, or family counseling session and that
are separate from the rest of the patient’s medical record). This is relevant for private providers or outside
agencies not for school-based professionals.
Psychotherapy notes can be disclosed without an individual’s authorization for:
• treatment of the individual
• training
• to defend itself in legal proceedings brought by the individual
• to avoid serious and imminent threat to public health or safety
• to a health oversight agency for lawful oversight of the originator of the psychotherapy notes
• to a coroner or medical examiner or as required by law

The Security Rule of HIPPA
This allows protected health information to be shared without written consent for the following purposes
or situations:
(1) To the individual
(2) Treatment, payment, and health care operations
(3) After direct or indirect (creating an opportunity to agree, acquiesce, or object) verbal permission is
given
(4) If the individual is incapacitated, in an emergency situation, or not available information may be
shared if use or disclosure is in the best interests of the individual
(5) Additional information may be shared as a consequence of another permitted use and disclosure
(6) Information may be release if it is the in public’s best interest and/or benefit and relating to the
following examples:
• preventing or controlling disease, injury, or disability;
• individuals contracted or exposed to communicable diseases;
• information on victims of abuse, neglect, or domestic violence to government employees;
• audits;
• judicial and administrative proceedings/subpoena/court orders;
• law enforcement related to serious criminal activity;
• research;
• to prevent or lessen serious threat to health or safety;
• essential government functions (e.g., determining eligibility for or conducting enrollment in
certain government benefit programs); and
• limited data set for the purposes of research, public health, or health care operations (certain
specified direct identifiers of individuals have been removed.)

FERPA or HIPPA?
FERPA HIPPA
Records covered
Education records include information
directly related to a student maintained
by an educational agency or a party
acting on behalf of the educational
agency recorded in any way (e.g.,
handwritten):
• Grades.
• Behavior referrals.
• Information relating to young
people with disabilities who receive
evaluations, services or other
benefits under Individuals with
Disabilities Education Act.
Records relating to:
• Past, present or future physical or
mental health or condition.
• Providing health care to the individual.
• Past, present, or future payment for the
use of health care.
Students’ immunization and other health
records that are maintained by a school
district or individual school, including a
school-operated health clinic.
Levels of protection
• Personally identifiable information
and education records cannot be
disclosed without written consent,
even for case management.
whereas aggregated data, system
level data sharing is sharable.
• Need written consent from guardian
in order to share records.
It may only be shared with:
• The individual (or his/her personal
representatives) when they request
access to or to share their protected
health information;
• The Department of Health and Human
Services when an investigation.
• Need written consent from guardian in
order to share records
Exceptions to
confidentiality/
procedural safeguards
Confidentiality may not be broken
except in certain circumstances.
Security Rule: specifies a series of
administrative, physical, and technical
safeguards for covered service providers
and their associates to use to assure the
confidentiality, integrity, and availability of
electronic protected health information.

Tool 3.2. Example Parental Consent for LEA to Release Student Information
Name of Student:_____________________________________ Date of Birth: ___/___/____
Name of Parent/Guardian:___________________________________________________________________
Address: ________________________________________________________________________________
City: _______________________________ State: __________________ Zip: ________________________
Phone:_________________________ Email:____________________________________________________
I [Name of Parent/Guardian]:__________________________hereby authorize information from
[Name of LEA] _________________________ to be released to [Name of Agency] ______________________
_____________ for the purpose of coordination of services.
In addition, hereby authorize the following institutions and practitioners ________________________________
to release information concerning the above named student to [Name of LEA]__________________________
The types of information that I allow to be released are (check all that apply):
Education Juvenile Justice Health/mental health
☐ School grades ☐ Probation history ☐ Human service records
☐ School attendance records ☐ Court records ☐ Child welfare history
☐ School discipline reports ☐ Detention record ☐ Mental health intake
☐ IEP/504 ☐ Programs attended ☐ Mental health screen
☐ Psychoeducational evaluation ☐ Pre-trial services ☐ Summary of alcohol/drug and mental health
assessment
☐ Other: ________________ ☐ Other: ___________ ☐ Summary of mental health services plan,
progress, and compliance
☐ Discharge summary
This authorization will automatically terminate on __________ unless previously revoked or extended by me,
the undersigned.
_________________________________________________ ___________________________
Signature of Parent/Guardian Date

Tool 3.3 Additional Resources for Building Effective Partnerships
Name of
Resource
Name of Resource
Developer
URL Resource Short Description
School-Community
Partnerships: A
Guide
Center for Mental
Health in Schools,
School Mental Health
Project, Dept of
Psychology, UCLA
http://smhp.psych.ucla.
edu/pdfdocs/guides/
schoolcomm.pdf
Guide to building school-family-community
partnerships; contains recommendations,
steps, and tools.
Mental Health
Toolkit
Elkhart and St.
Joseph County
Educators (supported
by Office of Safe and
Drug Free Schools,
U.S. Department of
Education)
http://www.
thefamilygateway.net/
home/special-note-to-
schools/mental-health-
tool-kit/
A toolkit to guide educators in making
linkages to support mental health services
within a systems of care model.
Data sharing:
Federal rules and
best practices
to Improve Out-
of- School-Time
Programs and
Student Outcomes
Partnership for
Children and Youth
http://www.expanding-
learning.org/sites/default/
files/ost_data-sharing_
and_ferpa.pdf
Provides examples of sharing data
between schools and partners to improve
outcomes and opportunities for young
people.
Resource Manual
for Intervention
and Referral
Services
Vermeire, G. L. (New
Jersey Department of
Education)
http://www.state.nj.us/
education/students/irs/
Provides guidance for schools’ program
of intervention and referral services to
meet needs of at-risk and high-risk young
people.
Addressing the
Unmet Mental
Health Needs
of School Aged
Youth: Guidelines
for School-
Community
Partnerships
Illinois Children’s
Mental Health
Partnership
http://icmhp.org/
icmhpproducts/files/
ICMHP-SchoolGuidelin
esFinalWEB11-19-10_
ICMHP-.pdf
Resource for developing local and
statewide cross system collaborations to
coordinate prevention, early intervention,
and treatment for young people’s mental
health.
Using Coordinated
School Health to
Promote Mental
Health for All
Students
National Assembly
on School-Based
Healthcare
http://www.nasbhc.org/
atf/cf/%7Bcd9949f2-
2761-42fb-bc7a-
cee165c701d9%7D/
white%20paper%20
csh%20and%20mh%20
final.pdf
Provides resources and gives framework
for providing this care within the school
context.
The Role of
System of Care
Communities in
Developing and
Sustaining School
Mental Health
Services
American Institutes
for Research
http://www.air.org/
resource/role-system-care-
communities-developing-
and-sustaining-school-
mental-health-services
Focused on the school and community
connection and the role of systems of
care, this brief addresses developing
and sustaining effective and coordinated
networks of supports and services.
Collaborations
of Schools and
Social Service
Agencies
National Center for
Homeless Education
http://center.serve.org/
nche/downloads/collab_
school_social.pdf
Addresses how social service/welfare
agencies and schools can collaborate
to assist students in need. Specific
examples of collaboration and
implementation across the country are
detailed.

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Suter, J. C., & Bruns, E. J. (2009). Effectiveness of the wraparound process for children with emotional and
behavioral disorders: A meta-analysis. Clinical Child and Family Psychology Review, 12, 336-351.
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http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferparegs.pdf.
U.S. Department of Health and Human Services. (2003). Office for Civil Rights Privacy Brief: Summary
of the HIPPA privacy rule. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/
summary/privacysummary.pdf
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U.S. Department of Health and Human Services (2014). HIPAA Privacy Rule and sharing information related
to mental health. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/
mhguidancepdf.pdf
U.S. Department of Health and Human Services, Office of Civil Rights (n.d.). Privacy, security, and electronic
health records. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/privacy-
security-electronic-records.pdf
U.S. Department of Health and Human Services & U.S. Department of Education (2008). Joint guidance
on the application of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) to student health records. Retrieved from http://
www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hippa-guidance.pdf
U.S. Department of Justice, Office of Community Oriented Policing Services (2015, May). Memorandum of
understanding fact sheet. Retrieved from http://www.cops.usdoj.gov/pdf/2015AwardDocs/chp/CHP_
MOU_Fact_Sheet.pdf
Vermeire, G. L. (2008). Resource manual for intervention and referral services. Trenton, NJ: New Jersey
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features/factfiles/mental_health/en/

Chapter 4: Cultural and Linguistic Considerations 99

CULTURAL AND LINGUISTIC CONSIDERATIONS
Key Questions
1. Why do we need to consider culture and language when addressing school mental health referrals?
2. How do mental health disparities manifest in culturally and linguistically diverse students?
3. How do we address the diverse cultural and language needs of students being referred to mental
health services?
4. What can teachers and members of school-based problem solving teams do to ensure that the
referrals are culturally and linguistically competent?
The Need for Cultural and Linguistic Competence in School Mental Health Referral Systems
There are numerous ethical and practical reasons why school-based mental health referral systems need
to be culturally and linguistically competent. Three critical reasons for providing culturally and linguistically
competent services were initially enumerated by the National Center for Cultural Competence (Goode &
Dunne, 2003) and recently reiterated in the Enhanced National CLAS Standards (2013). These reasons
continue to apply as we consider school mental health:
1. To respond to current and projected demographic changes in the school population within the United
States.
2. To eliminate long-standing disparities in the health status of students of diverse racial, ethnic, and cultural
backgrounds.
3. To improve the quality of mental health services and mental health and educational outcomes in schools.
The work of addressing long-standing disparities has been occurring in health care for the last forty years.
During the same period of time, systemic bias and the disproportionate outcomes that result from it have
been reported in the education sector. As early as 1975, the Children’s Defense Fund studied national data
provided by the Office for Civil Rights (OCR) on school discipline, and reported rates of school suspension
for black students that were 2-3 times more than white students on a variety of measures (Drackford, 2006).
A preponderance of research evidence has shown that punitive, reactionary discipline approaches are often
unfairly applied to students who are learning English, and Black, Hispanic, and American Indian youth (Gregory,
Skiba, & Noguera, 2010; Sullivan, Van Norman, & Klingbeil, 2014). This pattern of bias has continued, and, in
some instances, worsened significantly. According to the Kirwan Institute for the Study of Race and Ethnicity,
“racialized disproportionality in the administration of school discipline is now a national crisis.” What is more,
this systemic bias in school discipline practices contributes to the disproportionate number of minority youth,
English Language Learners, and youth with disabilities who become disconnected from school over time.
In response to this crisis, the U.S. Department of Justice, Civil Rights Division and the U.S. Department of
Education, Office for Civil Rights issued a national “guidance” package to assist public schools in administering
student discipline without discriminating on the basis of race, color, or national origin (http://www2.ed.gov/
policy/gen/guid/school-discipline/index.html). The guidance emphasized the impact of discipline bias, provided
a national overview of racial disparities in the administration of school discipline, and included a list of remedies
to be implemented in cases where a school is in violation of Title IV or Title VI in the administration of discipline.
CHAPTER 4

Schools can work to reduce punitive, exclusionary discipline by providing all students the social, emotional,
and behavioral supports they need to be successful at school. Universal Tier 1 programs that are culturally
and linguistically appropriate can help reduce disparities by supporting the mental health and wellness of
all students. Tier 2 and Tier 3 interventions can also reduce disparities when mental health referrals are
responsive to cultural and linguistic differences and designed to ensure that students are neither over- nor
under-referred based on minority group status. To achieve this, the school-based problem solving team must
see it as their charge to make their mental health referral system free from bias. To this end, schools can learn
from the work of several organizations in the health sector that have, over the course of decades, developed
and refined frameworks for providing culturally and linguistically competent services to their leadership, staff,
and stakeholders.
Recently the American Health Association (AHA, 2013) identified three major arenas—social, health, and
business—in which cultural and linguistic competence extends benefits. The AHA framework has been adapted
here to show the benefits of cultural and linguistic competence to schools. Figure 4.1 shows how culturally
responsive strategies helps engage other sectors and stakeholders.
Figure 4.1. Benefits of Cultural and Linguistic Competence to School Mental Health
Foundational Concepts to Achieve Cultural and Linguistic Competence in the School Setting
In order to provide culturally and linguistically competent services in the school, it is critical to ensure that there
is a shared understanding and a common language to engage in this work. Below is a working list of definitions
that will assist school personnel as they begin the process of integrating cultural and linguistic competence into
school referral processes.
Culture. At its most basic definition, culture is a powerful social system based on a group’s values, norms,
and expectations. It is a communication and interaction guide for a group’s way of thinking, feeling, and acting.
Culture informs how a group perceives health, wellness, disease, health care, and prevention. Hence, health
values, beliefs, practices and behaviors are culturally bound. Given the diverse cultures within the U.S., it
is critical to understand how intimately these two concepts intersect. Much of the conflict and challenges
encountered when integrating cultural and linguistic competence into the United States health care system
comes from the dilemma regarding the role of culture in defining health.
Education
• Incorporates different perspectives, ideas and strategies into
the decision-making process
• Decreases barriers that slow progress
• Decreases use of exclusionary discipline practices
• Increases the potential of higher academic attainment and
graduation
Community
• Increases mutual respect and understanding between school
and community
• Increases trust
• Promotes inclusion of all
• Increases community participation and involvement in school
• Assists students and families in their care
• Promotes student and family involvement in school
Health
• Improves student data collection
• Increases access to early and responsive care by
students
• Reduces care disparities in the student population
• Reduces the number of missed medical or mental health
visits

Elements of Culture
Most people assume that when we speak of culture, we mean race and ethnicity. In fact, culture is much more than
race and ethnicity. It involves myriad other factors, including:
• Country of origin or tribal affiliation
• Number of generations living in the U.S.
• Level of acculturation or assimilation
• Communication, including languages spoken, written, or signed; dialects or regional variants; literacy levels;
verbal and non-verbal cues
• Family household and composition
• Socioeconomic status
• Educational attainment
• Employment
• Health and mental health beliefs and practices
• Religious and spiritual beliefs and practices
• Military affiliation
• Racial and ethnic groups
• Sexual orientation
• Gender identity
It is important to keep the meaning of culture in mind as schools consider ways to integrate cultural and
linguistic competence into their mental health referral management systems. There are many cultural
influences to help-seeking behaviors and attitudes among diverse communities. Many cultural groups use
traditional healers, practices, and medicines, and may have a limited understanding of western medical
systems based on their culture and levels of acculturation. Additionally, they may have had experiences
of racism, discrimination, and bias in general and within the health and educational environment, and/or a
mistrust of health care professionals and institutions outside of their culture. Finally, first generation immigrants,
refugees, and asylees can also have communication and language barriers that may hinder interactions with
schools.
Cultural Competence. The concept of cultural competence initially evolved through work conducted
by the Child and Adolescent Service System Program, a comprehensive system of care for children and
adolescents with behavioral health needs and their families. Since the time of its origin, the work of defining
and developing cultural competence has abounded in various disciplines of human services such as primary
care, public health, education, and social services. The term was first defined as a set of congruent behaviors,
attitudes, and policies that enable systems, agencies, and individual professionals to work effectively in cross-
cultural situations (Cross, Bazron, Dennis, & Isaacs, 1989). Cultural competence requires the integration
and transformation of knowledge about individuals and groups of people into specific standards, policies,
practices, and attitudes as well as the subsequent application of these standards, policies, practices, and
attitudes in appropriate cultural settings to increase the quality of service, thereby producing better outcomes
(Davis & Donald, 1997). Cultural competence is a developmental process in which individuals or institutions
achieve increasing levels of awareness, knowledge, and skills over time and along a continuum (Ponterotto &
Alexander, 1996).
Linguistic Competence. Linguistic Competence is less debated and is more universally understood as the
capacity of an organization and its personnel to communicate effectively and to convey information in a manner
easily understood by diverse audiences, including persons of limited English proficiency, those who have low
literacy skills or are not literate, and individuals with disabilities (Goode & Jones, 2004). In practice, however,
the focus has been more narrow than delineated by this definition. Most organizations recognize the need to
provide translated materials and interpreters to individuals with limited English proficiency as well as individuals
with disabilities. Rarely, however, do they recognize that providing materials for individuals who have low
literacy skills is part of the framework of providing linguistically competent services.

Table 4.1. Elements of the Cultural and Linguistic Competence Framework
Individual Level Organizational Level
Acknowledge cultural differences among school personnel,
students and their families, and the communities being
served
Value and adapt to diversity and cultural contexts of
students and their families and communities being served
Engage in self-assessment Conduct cultural self-assessment
Understand own culture and values and beliefs that inform
perspectives and world view
Manage the dynamics of difference among culturally
diverse school personnel
Acquire cultural knowledge and skills through building
awareness, and through cultural encounters in diverse
communities
Institutionalize cultural knowledge through professional
development activities
View all behavior within a cultural context Adapt policies, structures, practices, and services
Manage personnel behaviors such as negative
assumptions, stereotyping, and micro-aggressions
Eliminate systemic racism and bias within school policies,
infrastructure, and standard operating procedures
Mental Health Disparities in Culturally Diverse Students
Exposure to adversity at a young age is a risk factor for mental disorders. Structural factors that
disproportionately affect people of color such as poverty, racism, attendance at under resourced schools, and
lack of access to health care place non-white students at statistically greater risk for mental health disorders.
Other vulnerable children may live in poverty, have parents with chronic health and mental health conditions,
be exposed to maltreatment and neglect, be exposed to substance use, or experience bias and discrimination
due to factors including sexual orientation, gender identity, physical or mental ability, religion, national origin, or
other cultural markers. Table 4.2 illustrates several mental health disparities across several racial and cultural
populations in the United States.
Table 4.2. Existing Mental Health Disparities Among Racial and Cultural Populations in the United
States
Populations Disparities
American
Indian/
Alaskan
Native
Elevated substance use disorders. In Federal surveys of more than 72,000 youth between ages 12
and 17, thirty-seven percent (37%) said they had used alcohol or drugs in the past year, and about 8%
misused substances to the extent that they had a “substance use disorder.” http://californiawatch.org/
dailyreport/drug-use-highest-among-american-indian-teens-lower-among-blacks-13463
Higher suicide rates. Suicide rates are more than double those for non-native populations, and Native
teens experience the highest rate of suicide of any population group in the United States. http://www.
aspeninstitute.org/sites/default/files/content/images/Fast%20Facts.pdf
Hispanic/
Latino
Highest suicide attempt rates. The percentage of high school students who seriously considered
attempting suicide is 26% amongst Hispanic girls, 21.1% among white girls, and 18.6% among Black
girls. http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf
Elevated rates of depression. The percentage of high school students who felt sad or hopeless as
self-described through the Youth Risk Behavior Surveillance systems is at 47.8% for Hispanic females,
compared to the 35.8% rate for Black and 35.7% for white females. http://www.cdc.gov/mmwr/preview/
mmwrhtml/ss6304a1.htm
Limited access to mental health services. The percentage of Black and Latino youth who use mental
health care services is less than half that of white children (4¬–5% and 10%, respectively). An
estimated 88% of Latino children with mental health issues have unmet needs. http://archive.ahrq.gov/
research/findings/nhqrdr/nhdr11/nhdr11.pdf, http://nccp.org/publications/pub_687.html
Native
Hawaiian/
Pacific
Islander
Highest rates of illicit drug use and underage drinking. 46% of Hawaiian youth reported using alcohol
within the past 30 days compared to 19–29% for Asian American youth. (Wong, Klingle, & Price, 2004)
36% of Hawaiian high school students engaged in binge drinking behavior compared to 31% of
Caucasian students and 19% of other Asian Pacific Islander youth. (Nishimura, Goebert, Ramisetty-
Mikler, & Caetano, 2005)

Populations Disparities
Asian
American
Increasing risk of suicide. In the Asian American youth population, suicide ideation and suicide
rates continue to increase. http://www2.nami.org/Template.cfm?Section=Fact_Sheets1&Template=/
ContentManagement/ContentDisplay.cfm&ContentID=123211
African
American
Increasing risk of suicide. The suicide rate for blacks between ages 10 and 19 increased from 2.1 to 4.5
per 100,000 (114%) between 1980 and 1995 and continues to rise. http://www.cdc.gov/mmwr/preview/
mwrhtml/00051591.htm
Lack of access to mental health services. Black youth are much less likely to enter traditional forms of
mental health treatment than their white counterparts, even when presenting problems are similar. (Wu,
Hoven, Cohen, et al. 2001)
Unmet mental health needs. More than 25% of African American youth exposed to violence have been
shown to be at high risk for post-traumatic stress disorder. http://www.apa.org/about/gr/issues/minority/
access.aspx
Lesbian, Gay,
Bisexual,
Transgender
(LGBT)
Elevated risk of suicide. LGBT youth (35%) experience higher levels of suicide than the heterosexual
population (10%).
Risk of bullying and violence. LGBT youth (19%) are more likely to be threatened or injured with a
weapon in school than the heterosexual population (5%). LGBT youth (13%) are more likely to be in
physical fights that require medical treatment than the heterosexual population (4%).
https://www.americanprogress.org/issues/lgbt/report/2009/12/21/7048/how-to-close-the-lgbt-health-
disparities-gap/
High rates of unmet need exist across all racial/ethnic and cultural groups, with only about 20% of children
(one in five children) with mental health problems receiving care. Yet youth from minority racial/ethnic groups
only receive one-third to one-half as much mental health care as white youth. This is true of both private and
public mental health services (Holm-Hansen, 2006).
Despite all the data that suggest they are at disproportionate risk, access to mental health care is a major
challenge for young people of color. In comparison to the white, non-Hispanic population, Hispanic and
American Indian/Alaskan Native children and African American children are less likely (62% and 32%,
respectively) to have access to care. Asian children are 17% less likely than white, non-Hispanic children to
receive care. In a California Study, children from families below the Federal poverty level and children with
parents who are not proficient in English also has less access to care (Padilla-Frausto, Grant, Aydin, & Aguilar-
Gaxiola, 2014).
Disproportionalities in Child Welfare
Within the U.S. all states have a disproportionate representation of African American children in foster care. As of
2000, the child welfare system in 16 states had extreme rates of disproportionality that were more than three and
one-half times the proportion of children of color in the state’s total child population (Hill, 2005). In the child welfare
system, in states where there is a large population of Native Americans, this group can constitute between 15% to
65% of children in foster care (Casey Family Programs, 2005). Hispanic/Latino children may be significantly over-
represented based on locality; e.g., in Santa Clara County, CA, Latino children represent 30% of child population,
but 52% of child welfare cases (Congressional Research Service, 2005). Besides the adversity of losing parents
and becoming part of the child welfare system, children from underserved populations may also experience
personal trauma such as exposure to violence at home or in the community, either as victims or witnesses.
Schools must be sensitive to the needs of these youth and recognize that some students with unmet
behavioral health needs and youth with disabilities, particularly those with emotional disturbances, are more
likely to experience high suspension rates and lower academic achievement (Skiba et al., 2002). For many of
the reasons highlighted above, racially/ethnically diverse children and adolescents with mental disorders face
major challenges with isolation and discrimination. This type of trauma can impact individual attributes such as
the ability to manage one’s thoughts, emotions, behaviors, and interactions with others. That is why addressing
their needs through a culturally and linguistically competent referral pathway is critical.

Addressing the Challenges of Diverse Cultural and Language Needs
Cultural competence has faced its share of skeptics and non-believers. The challenge has been around the
use of the term “competence,” because needing it alludes to incompetence on the part of the professional
and the school system. Additionally, there is confusion about how we learn about culture given the incredible
diversity in the U.S. population. The section that follows highlights the major outcomes of work on cultural
competence in the healthcare system; it provides practical linkages to the education system generally, and the
development of referral pathways more narrowly.
Culturally and Linguistically Appropriate Services
Cultural competence can serve as a tool to reduce disparities and disproportionalities when tackled on
multiple levels: student, family/community, provider, organizational, and systems. Schools that maintain strong
partnerships with community stakeholders, including healthcare providers, families, community- and faith-
based organizations, and local mental health service providers, are positioned to be culturally responsive to
the specific needs of their students and families. These partnerships should be represented on the school-
based problem solving team, and guide the consideration of language and culture in planning, implementing,
and evaluating referral pathways. This process needs to recognize that children and families from diverse
cultural backgrounds may have differing values, beliefs, and practices as they relate to mental health than
the school personnel with whom they interact. These differences include: the definition of mental health,
including emotional and spiritual health; the perception of illnesses and diseases and their causes; healing
and well-being; help-seeking behaviors and attitudes towards the U.S. health care system and its providers;
and personal experiences of bias and discrimination when accessing and utilizing services. An understanding
of these different belief systems and how they affect the families of the children in our schools is critically
important for school-based problem solving teams.
National CLAS Standards. Culturally and linguistically appropriate services (CLAS) are services that are
respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health
literacy levels, and communication needs, and are employed by all members of an organization (regardless of
size) at every point of contact.
The enhanced National CLAS Standards, released in 2013, are intended to advance health equity, improve
quality, and help eliminate health care disparities by establishing a blueprint for individuals as well as health
care organizations to implement culturally and linguistically appropriate services. The enhanced Standards
are a comprehensive series of guidelines that inform, guide, and facilitate practices related to culturally and
linguistically appropriate health services. By providing a structure to implement culturally and linguistically
appropriate services, the enhanced National CLAS Standards will improve an organization’s ability to address
health care disparities.
The enhanced CLAS standards were intended to provide guidance to health care organizations and systems
around the development of culturally and linguistically appropriate services. The principles that undergird the
standards can apply within the educational context as well. (Tool 4.1 indicates ways each CLAS standard can
be integrated into schools.) There are three overarching areas of focus:
1. Governance, leadership, and workforce – administrators and school leaders need to take on the
adaptive work of leadership and assist the school in shifting values and beliefs to integrate culturally and
linguistically appropriate practices. They need to promote policies and practices that support cultural
responsiveness, and allocate resource to promote educational equity. The school board should promote
and support a culturally and linguistically diverse school leadership, personnel, and teachers. School
leaders should provide ongoing education and training to school personnel on cultural and linguistic
competence in the school environment.
2. Communication and language assistance – school leaders need to ensure that language assistance is
offered at no cost to students/families to facilitate effective communication around the referral process.
They need to inform students/families of the availability of language assistance services either verbally

and/or in writing in their preferred language. School leaders need to ensure that interpreters are either
certified or trained appropriately, and they also need to provide printed/multimedia materials in appropriate
languages.
3. Engagement, continuous improvement and accountability – there should be goals, policies, standard
operating procedures, and accountability infused in the planning, implementation, and evaluation of the
mental health referral pathways to ensure the provision of appropriate services to students needing mental
health services. This includes meaningful engagement with representative stakeholders from the school
and community; collection and use of disaggregated data to continuously reflect on the effect of policies on
disparities; and the designation of responsibility for analyzing and sharing data findings.
Culturally and Linguistically Competent Referral Systems: Step-By-Step
Addressing the needs of culturally and linguistically diverse students in schools is a critically important
undertaking that requires the will of leadership and the resources of all stakeholder groups. (Tool 4.2 provides
several resources to build awareness, knowledge, and skills in educators and their community partners.) Key
aspects of this work include:
• Educating all stakeholders about the disproportionalities that exist, including local government, school
personnel, families and communities, and diverse stakeholders within the community;
• Working to change the school experience for families and communities from diverse cultures to one that is
welcoming and inclusive;
• Collecting, analyzing, and utilizing data on disproportionalities and disparities to continuously inform school
practices; and
• Ensuring that the academic, social, emotional, and behavioral referral pathways are culturally and
linguistically competent.
The last bullet in the list above is the primary focus of the remainder of this SMHRPT chapter. Figure 4.2,
introduced originally in Chapter 1, anchors the remainder of the chapter discussion; cultural and linguistic
considerations for each stage of the referral system are thoroughly explored.
Stage 1: Cultural and Linguistic
Considerations when Establishing a Referral
System
In order to ensure that the referral system
established by your school reflects the essential
cultural and linguistic competencies of your
community, your school’s problem solving team
will need to establish a baseline of knowledge
about both their own and the school’s degree
of cultural and linguistic competence. Individual
self-assessment tools can help school-based
problem solving team members recognize
their own unconscious biases, and create both
space for dialogue and an impetus to pursue
additional training. An organizational self-
assessment measures program components
associated with cultural competence, such
as: administration and policies, services
and supports, quality of environment, and
communication and language capacity. A variety of individual and organizational self-assessment tools
are available to help establish this baseline, and can be found in Tool 4.2. This baseline knowledge should
inform the capacity building strategies pursued by the school problem solving team. A multitude of possible
strategies for increasing the capacity of schools to promote cultural and linguistic through both school-wide and
classroom approaches is detailed in Toolbox 4.1.
SMHRPT Chapter 1 3
Figure 2. Referral Pathways Self-Assessment Process
Stage 1:
Establish a Referral
System
Stage 2:
Manage Referral Flow
Stage 3:
Map Resources
Stage 4:
Evaluate Intervention
Effectiveness
Figure 4.2. Four Stages of Referral Pathways
Development

1. What cultural and linguistic competencies should problem solving team members demonstrate?
A key first step is to help the school problem solving team establish both self-knowledge and knowledge of
the school community. First and foremost, the school problem solving team members will need to develop
knowledge and awareness about:
• Their own cultural identities
• Their own biases and assumptions
• How culture and language influences the behavior of young people in the classroom
• Cultural factors that influence the expression of mental health-related issues
• Social determinants that influence the health of the community.
Toolbox 4.1. Activities and Practices to Build Cultural and Linguistic Competence
School Leadership (e.g. principle, school board, and district level administrators)
• Develop and adopt a school “Diversity Statement” to ensure an inclusive work environment and service
delivery system.
• Create and support a cultural and linguistic competency committee within the school.
• Populate or link your website with comprehensive cultural and linguistic competency resources, publications,
tools, and news.
• Partner with cultural leaders and brokers to learn about the needs of diverse communities.
• Recruit employees in key leadership and direct service positions who reflect the populations of focus.
• Post welcoming and cultural images, art, photographs, posters and other media materials to reflect diverse
communities throughout the school.
• Post student rights in highly visible, easy to see and read locations in English and other threshold languages
at locations where health services are provided.
• Recruit youth and family members of diverse communities to serve as co-trainers, facilitators, speakers,
advisors, content experts, or consultants.
• Engage youth and families in developing language, content, logos, and images for anti-stigma social
marketing materials.
• Sponsor youth and teen events to focus on positive, youth-driven and non-tobacco/alcohol events.
• Commemorate Heritage Months (Native American, Asian/Pacific Islander, Hispanic, African American, etc.)
and Awareness Months (Children’s Mental Health, Disability, Mental Health, Minority Mental Health).
• Sponsor intercultural dialogue events to develop understanding of the needs of local community needs and
issues of diverse communities.
• Identify translators (for written communications) and interpreters (for oral communications) available to assist
with language access in your community.
• Sponsor diversity presentations by local partners such as LGBTQ advocates, deaf/hard of hearing and
disability organizations, and ethnically and culturally diverse groups.
• Organize, sponsor, or partner with annual Health Fair events.
• Partner with faith-based organizations, local churches, and traditional or holistic healing groups on wellness
campaigns.
• Partner with minority-serving and tribal organizations and groups.
• Identify community resources about what services, care, and support are available, accessible, and
affordable, and which organizations offer services to meet the diverse needs of students.
• Conduct Anti-Stigma campaigns that involve and provide leadership opportunities for members of diverse
communities in developing culturally appropriate messages; include images and individuals of diverse
backgrounds.
Teachers/School Personnel
• Sign up for cultural and linguistic competency training.
• Take a cultural self-assessment.
• Learn about community defined, evidence-based and best practices effective in serving diverse
communities.
• Partner with cultural leaders and brokers to learn about the needs of diverse communities.
• Post welcoming and cultural images, art, photographs, posters and other media materials to reflect diverse
communities in your classroom and/or work space.

• Commemorate Heritage Months (Native American, Asian/Pacific Islander, Hispanic, etc.) and Awareness
Months (Children’s Mental Health, Disability, Mental Health, Minority Mental Health).
• Attend language courses to increase your bilingual language capacity.
• Maintain and follow protocols and customs established in tribal communities and governments to ensure
sovereignty, and that program practices are acceptable.
• Identify community resources about what services, care, and support are available, accessible, and
affordable, and which organizations offer services to meet the diverse needs of students.
• Become a member of a minority affiliate association that advocates for the behavioral health needs of
diverse communities (For example, National Leadership Council on African American Behavioral Health,
National Latino Behavioral Health Association, First Nations Behavioral Health Association, National Asian
American Pacific Islander Mental Health Association).
2. What elements can the problem solving team build into the referral system to maximize the team’s
ability to make culturally and linguistically competent decisions? Ensuring that your school-based
problem solving team includes representation from diverse groups in your community is a good first step.
Beyond group membership, however, the most effective team members will have specific skill sets that
enable them to act as cultural brokers between the school and the community. Cultural brokers need not
be mental health professionals, but may be caregivers or family members with lived experience navigating
the school or community mental health system. These stakeholders can be identified through parent
advocacy groups in your area; through community mental health providers in your area; or by health or
other personnel on your campus. Building relationships with cultural brokers in your community is unlikely
to occur all at once, but a commitment to ongoing and continuous outreach can help build your network
over time.
a. Identify the right members to participate on the problem solving team. Look for team members who:
• Have a true understanding of their own cultural identity
• Are aware of the fact that others have diverse identities
• Understand that culture is a part of all behavioral contexts
• Represent diverse lived experiences, so that those lived experiences help bring their diverse
perspectives to this work
• Are committed to ongoing personal assessment
b. As a practice, recruit diverse team members who can serve as natural networks of support.
c. Identify cultural brokers to participate on the school-based problem solving team. Cultural brokers are
individuals from the community who can serve as a bridge between an organization and people of
different cultural backgrounds. Cultural brokers should be familiar with educational institutions and
mental health services within the community in which they live and/or from where they originated. They
can become a valuable source of cultural information and serve as mediators in conflicts and as agents
for change.
Cultural brokers may come from various stakeholder groups (e.g., parent groups, faith-based
organizations) who will be helpful in working with diverse communities and school personnel towards
increasing access to mental health services and eliminating mental health disparities for culturally and
linguistically diverse students and their families.
Toolbox 4.1. Continued

Toolbox 4.2. Characteristics of Effective Cultural Brokers
Cultural brokers are aware of:
• Their own cultural identity
• The cultural identities of the members of diverse communities
• The social, political, and economic factors affecting diverse communities within a cultural context
Cultural brokers are knowledgeable of:
• The values, beliefs, and practices regarding health, wellness, and well-being of their cultural groups, and
well as natural variance from individual to individual and family to family
• Traditional/indigenous health care networks within diverse communities
• Medical, health care, and mental health care systems (e.g., health history/assessment, diagnostic protocols,
treatment and interventions)
• Multiple factors impacting community diversity
• Social services provided in the community
• School climate and culture
Cultural brokers have a range of skills that enable them to:
• Communicate in a cross-cultural context
• Communicate in two or more languages
• Interpret and/or translate information from one language to another
• Manage the dynamics of differences among people
• Self-care and sustain their role
Toolbox 4.3. Guiding Questions for Identifying Effective Cultural Brokers
When working to identify the cultural brokers within the school community, work with stakeholders to answer the
following questions:
• Is the person knowledgeable about cultural beliefs, attitudes, values, and practices of the target community?
• Is the person recognized and/or respected by the target community members?
• Is the person knowledgeable about resources within the community?
• Is the person able to make connections within the community that school personnel would not be able to on
their own?
• Is the person fluent in the primary language of the target population?
• Is the person knowledgeable of the educational needs of the target community?
• Is the person knowledgeable of cultural beliefs regarding the educational needs in the target community?
• Is the person knowledgeable of cultural barriers to education in the target community?
• Is the person knowledgeable of the mental health needs of the target community?
• Is the person knowledgeable of cultural beliefs regarding mental health in the target community?
• Is the person knowledgeable of cultural barriers to mental health service utilization in the target community?
d. Use trained and certified translators (for written communications) and interpreters (for oral
communications) effectively when working with young people and family members with limited English
proficiency. Translate referral-related materials (e.g., referral forms, interview protocols) as much as
possible. If translation is required, it is imperative that the resulting translations are discussed by a
team including translators, members of the local ethnic community, and mental health professionals.
Translators and consultants from the local community can help ensure that the translated referral-
related documents are meaningful, appropriate, and acceptable to the community. However, translators
who have also been trained in mental health are rarely available. Therefore involvement of mental
health professionals on the team is essential to help ensure that the translated and adapted referral

documents continue to be valid and capture the construct of interest. Refer to “Guides for Effective Use
of Resources” (Tool 4.2) for tips on how to effectively use translators and interpreters, and resources for
mental health interpreter training services.
Toolbox 4.4. Using Translators and Interpreters Effectively
The following recommendations apply to using translators (for written communications) and interpreters (for oral
communications) within all stages of referral systems.
Pre-Work:
• Determine whether the translator/interpreter is certified to translate in the language being requested and has
adequate training and background knowledge to work in schools.
• Allow the translator/interpreter to review the school-based problem solving team’s agenda prior to the team’s
meeting regarding a student referral.
• Discuss expectations about what will be translated/interpreted and for whom.
• Schedule frequent breaks for the translator/interpreter to deliver messages with fewer translation errors.
• Describe the boundaries of confidentiality with the translator/interpreter.
• Provide the translator with the opportunity to examine and translate any documents that may need
translation during the session (e.g. referral forms, academic records).
• Discuss technical terms that will be used during the session (e.g., mental health diagnoses).
• Discuss cultural expectations regarding communication and behaviors (e.g., appropriate greetings).
• Provide information that the interpreter needs to understand the unique context of the referral(s) being
discussed (e.g., child trauma history).
• Ask the interpreter where he/she prefers to be seated to ensure effective interpretation.
During Problem Solving Team Meetings:
• Have the interpreter introduce him- or herself, and translate the names and titles of all present.
• Ask all present to speak in short sentences and allow time for the interpreter to communicate between
languages.
• Avoid idioms, slang, and metaphors because they are difficult to translate.
• Take notes relevant to any issues that need to be discussed during debriefing. The interpreter should
also take notes. For example, terms that were difficult to interpret or cross-cultural issues relevant to
communication can be noted and discussed during debriefing sessions.
• If necessary, ask clarifying questions to prevent information loss as a result of translation/interpretation.
During Debriefing Conversations:
• Discuss with the interpreter the outcomes of the meeting, as well as any problems that may have surfaced.
• Discuss any cultural issues that may have surfaced during the meeting.
• Encourage the interpreter to discuss his or her perceptions of the meeting, with specific attention to the
cultural and linguistic competency expressed by the team.
Adapted from Dept. of Health, Queensland, Australia, https://www.health.qld.gov.au/multicultural/interpreters/interp-tips.pdf; and Lopez,
E. (2002), Recommended Practices for Working with Interpreters, available for download at http://www.nasponline.org/resources/
culturalcompetence/recommend.pdf.
Do:
• repeat and summarize the major points
• be specific (e.g., “daily” rather than
“frequent”)
• use diagrams, pictures, and translated
• written materials to increase understanding
• clarify that you have been understood or
that you have understood the person.
Don’t:
• use metaphors (e.g., like a maze),
colloquialisms (e.g., pull yourself up by
your bootstraps), and idioms (e.g., kick the
bucket), because such phrases are unlikely
to have a direct translation
• use medical terminology unless the
interpreter and person are familiar with the
equivalent term.

e. Create a friendly and inviting space for team meetings.
• When it is in the best interest of culturally and linguistically diverse families, consider hosting
problem solving meetings in a neutral environment, such as a community library or community
center.
• Providing food and drink (even water and simple snacks) is an indication of good intentions
• Consider whether the duration of time dedicated to the meeting is sufficient to appropriately
address all the issues, particularly if a cultural broker or interpreter is part of the team.
• Consider whether your team has arranged a meeting time that’s accessible for the family.
f. Create routines that incorporate regular self-assessment of the team’s cultural and linguistic
competence.
g. Communicate to family members and diverse stakeholders within the community how the referral
system works and make modifications as feedback is collected.
h. Use referral tools that have built-in cultural and linguistic considerations. (Refer to Tool 4.2 at the end
of this chapter for guidance in building a culturally competent referral system.)
i. Add cultural and linguistic identifiers to referral forms and/or team protocols. These identifiers will assist
the team in constructing a deeper understanding of the young person’s context, and will be useful later
when examining data for persistent disparities in referral and intervention. Consider adding the
following identifiers:
1. Country of origin
2. Generation
3. Acculturation (may need to collect data from student and families)
4. Linguistic characteristics including languages spoken, written or signed; dialects or regional
variants; literacy levels
5. Family household and composition
6. Socioeconomic status
7. Educational attainment
8. Employment
9. Health and mental health practices
10. Religious and spiritual practices
11. Military affiliation
12. Racial and ethnic groups
13. Sex
14. Sexual orientation
15. Gender identity
16. Disability
Stage 2: Cultural and Linguistic Considerations when Managing Referral
Flow
1. What sensitivities should the problem solving team be working to
build in people who will use the referral system (e.g., parents/family
members, school personnel, peers)?
a. All school personnel asked to use the referral system must be trained to be culturally and linguistically
competent as they complete referrals.

Toolbox 4.5. Key Characteristics of Cultural Competence Training
An effective educational or training program for cultural competence correlates with a lasting awareness and
understanding by school personnel. Although there are several approaches to educate staff, all successful
educational programs include (1) cultural assessment, (2) multiple training methods, (3) ongoing professional
development, and (4) tracking participant outcomes. (See Tool 4.2 for training tools.) Common topics included in
cultural competence trainings for educators are:
• Exploration of school personnel members’ own cultural backgrounds and the cultural backgrounds of the
students, families, and communities served;
• Effects of differences between the cultures of school personnel and students;
• Effects of cultural differences among staff, families, and the community on: access to mental health care;
service utilization; quality of mental health care; mental health outcomes; and satisfaction with services;
• Effects of health and mental health beliefs and practices within community groups represented in the school
system;
• Effect of factors such as socio-economic status, race, ethnicity, disability status, sexual orientation, gender
identity, diverse religious and spiritual backgrounds, and other factors on perceptions of health, wellness,
and well-being;
• Challenges in accessing available mental health services for individuals with limited English proficiency, low
mental health literacy, and disabilities or special needs;
• Impact of discrimination based on race, ethnicity, sex, national origin, socioeconomic status, disability status,
religion, sexual orientation, and gender identity on students and families;
• Prevalence of mental health disparities and disproportionalities in school age children;
• Discipline beliefs and practices within the local community and how those beliefs and practices fit (or do not
fit) within a MTSS framework;
• Strategies for collecting race, ethnicity, sex, language, sexual orientation, gender identity and disability
status data in a culturally appropriate manner;
• Strategies to help families and students overcome individual and institutional barriers that exasperate mental
health disparities;
• When and how to access language services for individuals with limited English proficiency;
• Application of laws and provisions that pertain to the delivery of culturally and linguistically appropriate
mental health care and services.
2. After receiving referrals, what cultural and linguistic considerations should the problem solving
team make?
When a school-based problem solving team receives a referral and begins the process of expanding on
the referral by conducting interviews, observations, and records reviews, several key considerations are
warranted:
Considerations for Interviews with Parents and Caregivers: Parents and caregivers of students being
requested for an interview are already in a state of stress by the time they come into the interview. They
are often unclear of the purpose for the interview, and their presence in the meeting, even though a letter
discussing the interview and other relevant documentation may have been sent to them. This situation
is further exacerbated if the family has cultural differences such as language, low level of acculturation/
assimilation, and/or beliefs regarding education or teacher vs. parent roles in education that may impede
communication. It is critical that the problem solving team identify areas of potential conflict and plan
accordingly. Here are some considerations:
• If the family (parent or caregiver) is not fluent in English then the school should use a certified or
trained interpreter (Toolbox 4.4 provides guidance on the use of interpreters)
• Use effective cross-cultural communication strategies such as:
- Using open-ended, clarifying, and/or restating questions
- Carefully reframing and restating if it appears that there is miscommunication
- Summarizing information and confirming understanding
• Make sure that the parent or caregiver has clearly understood the reason for the referral, and their
next steps.

Considerations for Observations: Observation is a process of registering, interpreting, and recording.
Both the process and the data collected are influenced by the problem solving team member’s interactions
with the student. While an objective standpoint is impossible to achieve in situations in which the observed
are known to the observer, recognizing the cultural lens that the observer brings is critical to ensuring
that observations are not distorted by factors outside the arena of inquiry. What is observed and how it is
interpreted are partially based on the team member’s lived experience, cultural lens, and personality traits.
Anxiety and bias can influence the observation, and should be effectively managed. Things to consider:
• Individual perspectives and assumptions will color the observer lens and should be acknowledged and
taken into consideration when making interpretations;
• The student being observed may also be affected by the observation and this may skew behavior and
the subsequent interpretations of student mental health status.
Considerations for Reviews of Records: The cultural identity of the problem solving team member may
also influence the information reviewed and the way it is interpreted. Culturally specific perspectives may
affect how data is collected, how it has been interpreted, and what has been written down in the student
records. Things to consider:
• Review the record, taking into consideration that there might be cultural assumptions and biases
inherent in the record;
• If possible, check statements and observations with the school personnel or teacher who may have
initiated the record to check the team member’s assumptions regarding the data in the record.
Considerations for Writing Summary Reports: Communicating in writing is much like oral communication
in that there are two parties with varying levels of education and literacy skills, varying cultural values
and beliefs, and different life experiences. The written summary reports will be shared with the family or
caregiver. So, some things to consider:
• Know your audience—such as age, sex, race, cultural background, level of education, religion, social
class, etc.—and tailor your writing accordingly;
• If the report is to be shared with the parent-caregiver, you should consider their expectations. You
might put yourself in your reader’s place and imagine what you would be helpful and informative to
them;
• Remember the purpose of the report and communicate information that will be most useful and
meaningful to the family and to service providers;
• If the information is to be translated for the family or caregiver, review considerations for the use of
translators (Toolbox 4.4).
Considerations for How Records are Held: Most schools have policies and protocols for how the
records are stored. This information should be shared with the family or caregiver. Things to consider when
imparting this information to the family or caregiver:
• Describe why the information developed by the school-based problem solving team is critical to support
the health and well-being of the student;
• Explain that this record will be stored in the school but will remain confidential.
Stage 3: Cultural and Linguistic Considerations When Mapping Resources
1. What should the problem solving team do to make sure they have
identified community partners that are culturally and linguistically
competent? (That is, partners to whom referrals can be made?)
The school-based problem solving team must identify those resources in the community that can provide
supports to the diverse populations served by the school. A cultural and linguistic competency skills
matrix is a helpful tool to construct when identifying resources in the community. Skills matrices show
community resources (e.g., advocacy organizations, mental health care providers, businesses, faith-based
organizations) by cultural and linguistic competencies (e.g., translation services, interpretation services,
cultural brokers, communication and broadcasting for specific cultural groups, specialized mental health
services). An example of a skills matrix is provided in Toolbox 4.6.

Toolbox 4.6. Example Skills Matrix, Community Partner Cultural and Linguistic Supports
Translation
Services:
Language
1 (e.g.,
Spanish)
Translation
Services:
Language
2 (e.g.,
Korean)
Interpretation
Services:
Language
1 (e.g.,
Spanish)
Interpretation
Services:
Language
2 (e.g.,
Korean)
Cultural
Broker:
Population
1 (e.g.,
asylee)
Cultural
Broker:
Population
2 (e.g.,
Latino/a)
Communication
& Broadcasting:
Population 1
(e.g., Afghani)
Family &
child mental
health
services,
specialized:
Population
2 (e.g.,
refugee)
Mental
Health
Agency A
X
Non-profit
Organization
A
X
Faith Based
Organization
A
X X X
Business A X
2. What C&L considerations should be made for selecting interventions at all three MTSS tiers and for
matching young people to appropriate interventions?
In theory, most of the interventions in MTSS are evidence-based and most organizations are encouraged
to identify programs and practices that will work for their environment. All evidence-based programs,
however, have not been developed for specific cultural groups. Many have not tested effectiveness for
specific cultural groups, and those that have been developed and tested for cultural groups often do not
have materials (e.g., training manuals) that reflect the breadth of cultures served (Samuels & Schudrich,
2009).
While many organizations are mandated to implement specific interventions or choose from a catalogue
of options, there is a move toward determining the cultural fit of programs and practices (Samuels &
Schudrich, 2009; Bernal, Chafey, & Rodriquez, 2009; Cardemil, Moreno, & Sanchez, 2010). The team will
need to take into consideration whether the program is appropriate for diverse populations.
Below are considerations for the team when selecting an evidence-based program for a young person:
Structure of the intervention
• Modality – is the intervention delivered in individual or group format?
• Number and frequency of sessions
• People involved in services – should services include individuals, families, and/or natural supports?
Delivery of the interventions
• Location of intervention – is the location or setting comfortable for the young person and/or their
caregivers? Might a nonclinical setting (e.g., community center, faith-based setting) be more
appropriate?
• Provider behavior – does the provider attend to relevant cultural values and other social determinants
of health?
• Persons – is a mental or behavioral health provider, peer, spiritual leader, elder, cultural broker, or
someone else providing services?

Program content
• Language – do young people and their families understand language, idioms, and words used?
• Can fidelity be maintained while incorporating issues that address culturally relevant themes?
• Use of culturally relevant metaphors and sayings – are sayings common to the group who is part of
the intervention?

Step 1: Problem Identification
o “What does the problem-solving team
value?”
o “Is there a problem?”
o “If so, what exactly is the problem?”
• Analytic aims
o Identify school personnel’s values
regarding student behavior.
o Determine the presence of student
problem behavior.
o Define student problem behavior in a way
that is useful for guiding the remaining
problem-solving steps.
• Core procedures
o Clarify values and make a public commitment to promoting valued behavior.
o State the problem behavior in measurable and understandable terms.
o Obtain a baseline measure of the problem behavior.
o Conduct a discrepancy analysis to identify differences between desired and observed levels of
behavior.
Cultural considerations: The collective values of the team are informed by the cultural identities of individual
members. These values will shape team members’ perceptions and assumptions and this should be taken into
consideration when:
- determining the existence of the problem
- identifying the type and source of the problem
- assessing a student’s behavior and the level of deviation from what is considered the norm
- determining problem-solving steps
Step 2: Problem Analysis
o “What factors are maintaining the problem?”
o “How can maintaining factors be changed to positively influence the problem?”
• Analytic aims
o Identify the factors maintaining the problem behavior.
o Identify an intervention strategy for the problem behavior that is logically connected to the maintaining
factors.

Stage 4: Cultural and Linguistic Considerations When Evaluating
Intervention Effectiveness
This section revisits the four-step problem solving model introduced in
Chapter 2. In this chapter, cultural considerations for problem solving
under each step have been added. When used in conjunction with the
Toolboxes provided in this chapter and the Chapter Tools provided at the
end of the chapter, these cultural considerations can help school-based problem solving teams infuse cultural
competence into the referral process.
1. When using the four-step problem-solving
model for individual referrals, what cultural
and linguistic considerations should be made
at each stage?
1. Problem
Identification
2. Problem
Analysis
3. Intervention
Development
4. Intervention
Evaluation
Figure 4.3. Four-Step Problem Solving Model
for Promoting Mental Health in Schools

• Core procedures
o Assess potential factors maintaining the problem behavior.
o Determine the factors maintaining the problem behavior and link them with an intervention strategy to
positively influence problem behavior.
Cultural considerations: When analyzing the factors that are creating or maintaining the problem, it will be important
for the team to understand the cultural factors that inform the student’s cultural identity and the social determinants
within the student’s community that influence both the student and his/her family.
Social determinants are conditions in the environments in which people are born, live, learn, work, play, worship,
and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g.,
social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and
neighborhood) have been referred to as “place.” In addition to the more material attributes of “place,” the patterns
of social engagement and sense of security and well-being are also affected by where people live. Resources that
enhance quality of life can have a significant influence on health and education outcomes. Examples of these resources
include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/
health services, and environments free of life-threatening toxins.
Step 3: Intervention Development
o “How can we implement the intervention strategy to positively influence the problem?”
o “How can we ensure the intervention is implemented with fidelity?”
o “How can we know if the intervention is working?”
• Analytic aims
o Develop an intervention plan for intervening with the problem behavior.
o Determine a method for gauging and improving implementation fidelity.
o Determine the valued behavioral outcome and an associated evaluation procedure.
• Core procedures
o Select an evidence-based intervention that operationalizes the intervention strategy.
o Develop the specific procedures and schedule for the intervention.
o Develop an implementation fidelity measure and establish a schedule and procedures for evaluating and
enhancing intervention integrity.
o Develop an outcome goal, select a progress-monitoring method, and establish a schedule and procedures
for evaluating intervention effectiveness.
Cultural considerations: Identifying and developing effective interventions will require an understanding of the different
cultural values that are placed on education, academic attainment, discipline, elder respect, familial and community
beliefs, and practices related to mental health. This is a critical juncture when working with a cultural broker, and other
gatekeepers of culture in the community are critical to identify what could serve as culturally appropriate interventions.
It is not always possible to identify evidence-based interventions that have been normed for the culture of the student.
It is appropriate to look into community informed practices or even promising practices acceptable to the family and
the community. The referral team may want to consider the following elements when identifying evidence-informed,
community-informed practices rather than evidence-based intervention. Does the intervention:
- Consider the culture and lived experience of the student?
- Consider the cultural and social characteristics of the student’s family and community?
- Negotiate the intervention with the student and his/her family to ensure that both the student’s and the school’s
interests are addressed?
- Have the capacity to fulfill the intended outcomes?
Step 4: Intervention Evaluation
o “Is the intervention being implemented as planned?”
o “Is the intervention positively influencing the problem behavior?
o “If not, what can be done to improve intervention effectiveness?”

• Analytic aims
o Determine the level of implementation fidelity.
o Determine the effect of the intervention on the problem behavior.
o If needed, identify potential improvements to the problem-solving process.
• Core procedures
o Calculate the proportion of intervention components implemented with fidelity and, if needed, provide
support to enhance implementation fidelity.
o Graph progress-monitoring data.
o Use pre-established decision rules to determine intervention effectiveness.
o If needed, revisit the problem analysis step and the intervention development step and then re-
implement the intervention.
Cultural considerations: In evaluating the intervention the team needs to clearly identify whether the outcome that
is sought fits the culture and customs of the family and community. It is important to communicate to both the student
and his/her family the purpose of the intervention and the hoped-for outcomes.
2. Why should problem solving teams disaggregate intervention effectiveness data by subgroups?
In order to track disproportionalities and disparities, the problem solving team will need to occasionally take
a step back from problem solving for individual students to look at whether their decisions are improving the
well-being of their schools’ culturally diverse young people in aggregate. Consider disaggregating referral
and intervention effectiveness data by:
1. Country of origin
2. Generation
3. Acculturation (may need to collect data from student and families)
4. Linguistic characteristics including languages spoken, written or signed; dialects or regional
variants; literacy levels
5. Family household and composition
6. Socioeconomic status
7. Educational attainment
8. Employment
9. Health and mental health practices
10. Religious and spiritual practices
11. Military affiliation
12. Racial and ethnic groups
13. Sex
14. Sexual orientation
15. Gender identity
16. Disability

Tool 4.1. Applying National CLAS Standards in Schools
National CLAS Standards School Application
Standard 1: Provide effective,
equitable, understandable, and
respectful quality [mental health]
care and services
Overarching goal of schools providing mental health services to
students and families. This will be accomplished through strategies
provided in Standards 2-15.
Standard 2: Advance and sustain
governance and leadership that
promotes CLAS and [mental]
health equity
Provide CLAS training and cultural competence training on a regular
and on-going basis.
Commit to building a district wide capacity for cultural competence
trainings.
Ensure necessary financial resources are allocated to provide CLAS.
Review school policies (e.g., mental health referrals, Student Support
Teams) and discipline practices.
Standard 3: Recruit, promote, and
support a diverse governance,
leadership, and workforce
Conduct regular assessments of hiring and retention data (workforce
demographics, promotion demographics, community demographics).
Advertise job opportunities in targeted languages, publications, and
other media.
Hire school personnel who reflect the characteristics of the students and
families in your school.
Create a work environment that respects and accommodates the
cultural diversity of the local workforce.
Standard 4: Educate and train
governance, leadership, and
workforce in CLAS
Engage administration in dialogues about the needs of
underrepresented communities.
Administration/management attend CLAS trainings and cultural
competence trainings; possibly become trainers themselves.
Engage with the community—through volunteer work, focus groups, or
learning a new skill.
Standard 5: Offer communication
and language assistance
All staff understand how to acquire interpretation services, and are
capable of doing so, for both face-to-face encounters and over-the-
phone encounters.
Staff understand that the use of interpretation services is necessary for
all encounters (e.g., parent-teacher conference, IEP and 504 meetings).
Standard 6: Inform individuals
about the availability of language
assistance
Utilize an “I speak” card/poster to help you identify what language you
need to acquire through interpretation and/or translation.
Post signs in common areas (e.g., office, guidance department, nurse’s
office).
Be sure your phone system is set up for multiple languages.
Standard 7: Ensure the
competence of individuals
providing language assistance
Hire well-trained, certified interpreters and translators.
Be sure that you check bilingual/multilingual staff for proficiency; testing
programs are available online.

Standard 8: Provide easy-to-
understand materials and signage
Provide signage in languages represented in your school system.
Be sure signage is posted in easy-to-understand wording and utilize
American Sign Language if necessary.
Signs should be posted in common areas.
Standard 9: Infuse CLAS goals,
policies, and management
accountability throughout the
organization’s planning and
operations
All programs and departments are infusing CLAS into their policies and
procedures.
All staff are aware of the impact of culture on conflict resolution and the
evaluation process.
Staff are aware of cultural differences in communication styles and
behaviors.
Standard 10: Conduct
organizational assessments
Schools will evaluate their progress in implementing the CLAS
standards.
Conduct individual assessments for school personnel.
Conduct an organizational assessment for schools (see VA Arlington
Public Schools Cultural Competence Curriculum).
Standard 11: Collect and maintain
demographic data
Collect REaL (Race, Ethnicity, and Language) data using collection
standards put forth in the Affordable Care Act section 4302a.
Keep this data easily accessible so staff can utilize it to schedule
interpreters when needed.
Analyze this data and use it to improve mental health referral system,
services, and programs.
Standard 12: Conduct
assessments of community
[mental] health assets and needs
Identify all services available to all populations in your community (e.g.,
Mapping Resources Activity).
Collaborate with other community organizations to ensure cultural and
linguistic services are planned and implemented within the community
setting.
Standard 13: Partner with the
community
Collaborate with staff, families, and local stakeholders to develop and
review policies, services, and programs to reflect and respond to a
variety of community groups and perspectives.
Engage cultural brokers as a bridge between schools and people of
different cultural backgrounds.
Standard 14: Create conflict and
resolution processes
Conflict and grievance process should be easily understood and
accessible (e.g., multiple languages) by all members of the school
community.
All materials should be developed at a 6th
grade reading level.
Standard 15: Communicate
the organization’s progress in
implementing and sustaining CLAS
Progress regarding the CLAS standards is shared with the community
via school and district websites and other social media outlets (e.g.,
Facebook, Twitter), school and district newsletters, and brochures.
Engage all communities in on-going discussions of progress and self-
assessment.

Tool 4.2. Additional Resources for Cultural and Linguistic Competency (CLC)
Name of Resource Organization Source Summary Audience
Cultural and Linguistic Competence Knowledge and Awareness Building Tools
How is Cultural
Competence
Integrated in
Education?
Center for Effective
Collaboration and
Practice
http://cecp.air.org/
cultural/Q_integrated.
htm
A brief conceptual
background for
cultural competence,
and elements of
cultural competence
in programs serving
children with or at
risk of developing
serious emotional
disturbance.
Child-Serving
Government Agencies
School Personnel
Diversity Toolkit:
Cultural Competence
for Educators
National Education
Association
http://www.nea.org/
tools/30402.htm
Describes main
issues, skill areas,
and strategies for
addressing cultural
competence.
School Personnel
Project Implicit Project Implicit is a
non-profit organization
and international
collaboration between
researchers
https://implicit.harvard.
edu/implicit/
Project Implicit
provides training
services on implicit
bias, diversity and
inclusion, and
leadership.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel
Cultural and Linguistic Competence Training Resources
E-Learning Continuing
Education Programs
The Office of Minority
Health
https://www.
thinkculturalhealth.
hhs.gov/Content/
ContinuingEd.asp
Continuing education
programs designed
to help individuals at
all levels and in all
disciplines promote
health and health
equity.
Mental Health
Providers
Curricula
Enhancement Module
Series
National Center for
Cultural Competence,
Georgetown
University
http://nccccurricula.info The goal of the series
is to incorporate
principles and
practices of cultural
and linguistic
competence into all
aspects of leadership
training.
Child-Serving
Government Agencies
School Personnel
Mental Health
Providers
Infusing Cultural
and Linguistic
Competence into
Health Promotion
Training (Video)
National Center for
Georgetown
University
http://nccc.georgetown.
edu/projects/sids/dvd/
index.html
A training video
designed to guide
development of
outreach materials for
diverse populations in
a CLC manner.
Child-Serving
Government Agencies
School Personnel
Mental Health
Providers

Culture, Language
and Health Literacy
Health Resources
and Services
Administration, U.S.
Department of Health
and Human Services
http://www.hrsa.gov/
culturalcompetence/
index.html
A compilation of
resources for general
CLC and health
literacy.
Child-Serving
Government Agencies
School Personnel
Mental Health
Providers
Closing the Gap:
Cultural Competency
in Health and Human
Services
Cross Cultural Health
Care Program
http://xculture.org/
cultural-competency-
programs/cultural-
competency-training/
A training series to
build awareness,
knowledge, and
skills through a
variety of teaching
methods including
direct instruction, role
playing, case studies,
facilitated group
discussions, and
technology/media.
Mental Health
Providers
Cultural and Linguistic
Competence
Icebreakers,
Exercises, Videos &
Movies
Technical Assistance
Partnership for Child
and Family Mental
Health
http://www.
tapartnership.org/COP/
CLC/default.php
Tools and resources
to implement and
improve their cultural
and linguistic
competence.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel
Cultural and Linguistic Competence Self-Assessment Tools (Group)
Program-Level
Cultural Competency
Assessment Scale
Center of Excellence
in Culturally
Competent Mental
Health
http://nned.net/docs-
general/NKICulturalCo
mpetencyAssessment
Scale-Program_Level-
June2012.pdf
The Cultural
Competency
Assessment scale
is applicable to
behavioral health
care programs
serving multicultural
populations.
Child-Serving
Government Agencies
School Personnel
Mental Health
Providers
Cultural Competency
in Mental Health Peer-
run Programs and
Self-help Groups
National Alliance
on Mental Illness
(NAMI) STAR Center,
University of Illinois at
Chicago
http://www.
consumerstar.org/
pubs/SC-Cultural_
Competency_in_
Mental_Health_Tool.
pdf
Tool for self-
assessment and
development of action
plans to enhance
cultural competency.
Child-Serving
Government Agencies
Mental Health
Providers
Culturally Competent
Care: Some Examples
of What Works
Commission on
the Public’s Health
System
http://www.cphsnyc.
org/cphs/reports/
august_2010-_
culturally_competen/
http__cphsnyc_org_
pdf_childhealth.pdf
Evidence-based
cultural and language
components in
different provider
health care settings.
Child-Serving
Government Agencies
School Personnel
Mental Health
Providers
Planning and
Implementing
Cultural Competence
Organizational Self-
Assessment
National Center for
Georgetown
University Center for
Child
and Human
Development
edu/documents/
ncccorgselfassess.pdf
A guide to conducting
an organizational self-
assessment.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel

Promoting Cultural
Diversity and Cultural
Competency: Self-
Assessment Checklist
for Personnel
Providing Behavioral
Health Services
National Center for
Georgetown
Child
and Human
Development
edu/documents/
A self-assessment
checklist.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel
Multicultural Health
Care: A Quality
Improvement Guide
National Committee
for Quality Assurance
http://www.ncqa.org/
Portals/0/HEDISQM/
CLAS/CLAS_toolkit.
pdf
A guide and toolkit
to apply CLAS
standards to
assessment, planning,
implementation, and
evaluation.
Child-Serving
Government Agencies
Mental Health
Providers
Program-Level
Cultural Competency
Assessment Scale
Nathan S. Kline
Institute for
Psychiatric Research
and the Center
of Excellence in
Mental Health
http://nned.net/docs-
general/NKICulturalCo
mpetencyAssessment
Scale-Program_Level-
June2012.pdf
The Program-Level
Cultural Competency
Assessment scale
measures 14 program
components of
cultural competence
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel
Competence Family
Organization
Assessment
Instrument
National Center for
Georgetown
Child
and Human
Development
http://
gucchdgeorgetown.
net/NCCC/
CLCFOA/NCCC_
CLCFOAAssessment.
pdf
An assessment tool
developed to address
the unique functions
of family organizations
concerned with
children and youth
with behavioral-
emotional disorders,
special health
care needs, and
disabilities.
Mental Health
Providers
Competence Policy
Assessment (CLCPA)
National Center for
Georgetown
Child
and Human
Development
http://clcpa.info A self-assessment tool
to assist community
health centers to
advance and sustain
cultural and linguistic
competence.
Child-Serving
Government Agencies
School Personnel
Foreign Language Assessment Resources
Language Proficiency
Assessments
American Council
on The Teaching of
Foreign Languages
http://www.actfl.
org/professional-
development/
proficiency-
assessments-the-actfl-
testing-office
Certified speaking,
reading and listening,
and writing skill
assessments to
determine functional
language ability.
Mental Health
Providers

Intercultural Communication Tools
Toward Culturally
Competent Care: A
Toolbox for Teaching
Communication
Strategies
Center for Health
Professions,
University of
California, San
Francisco
http://futurehealth.
ucsf.edu/LinkClick.
aspx?fileticket=d5X/
OqyqeuY=
The curriculum
teaches providers
to recognize when
cultural differences
exist in patient
encounters and
to utilize specific
communication skills
to elicit their patients'
cultural perspectives
about health and
illness.
Mental Health
Providers
Worlds Apart: A Four-
Part Series on Cross-
Cultural Healthcare
Fanlight Productions http://www.fanlight.
com/catalog/films/912_
wa.php
A tool for raising
awareness about
the role sociocultural
barriers play in
patient-provider
communication.
Mental Health
Providers
Best and Promising Practices
Evidence-Based
Practices and
Multicultural Mental
Health
National Alliance
on Mental Illness
Multicultural Action
Center
https://www2.nami.
org/Template.
cfm?Section=Fact_
Sheets1&Template=/
ContentManagement/
ContentDisplay.
cfm&ContentID=63974
Discusses the
challenges of using
evidence-based
practices (EBPs) with
diverse populations,
describes promising
cultural adaptations
to EBPs that are
being made, explains
practice-based
evidence (PBE),
and offers policy
recommendations.
Child-Serving
Government Agencies
School Personnel
Mental Health
Services in the
Schools: Tips for
Teachers
National Association
of School
Psychologists
http://www.nasponline.
org/resources/
culturalcompetence/
cultcompmhservices.
pdf
Best practices
for teachers and
school personnel in
navigating Culturally
Competent Mental
Health Services in the
Schools.
School Personnel
Advancing Effective
Communication,
and Patient- and
Family-Centered
Care for the Lesbian,
Gay, Bisexual, and
Transgender (LGBT)
Community
The Joint Commission http://www.
jointcommission.
org/assets/1/18/
LGBTFieldGuide_
WEB_LINKED_VER.
pdf
A compilation of
strategies, best
practice examples,
resources, and
testimonials designed
to help hospitals in
their efforts to improve
communication and
provide more patient-
centered care to their
LGBT patients.
Mental Health
Providers

A Pastoral Education
Guide: Responding
to the Mental Health
Needs of Multicultural
Faith Communities
New York State Office
of Mental Health, The
Nathan Kline Institute
for Psychiatric
Research, Center
of Excellence in
Mental Health
http://ssrdqst.rfmh.
org/cecc/sites/
ssrdqst.rfmh.org.
cecc/UserFiles/
This guide describes
four pathways to
respond to the
different mental
health care needs
in multicultural faith
communities.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel
Keeping the Faith National Center for
Georgetown
Child and Human
Development,
Georgetown
University Medical
Center
edu/documents/SIDS_
california.pdf
This promising
practice program
exemplifies key values
of culturally competent
health promotion that
can inform the referral
process.
Mental Health
Providers
Innovative Self-
Assessment and
Strategic Planning:
Addressing Health
Disparities in Contra
Costa County
National Center for
Georgetown
Child and Human
Development
edu/documents/
Contra%20Costa.pdf
These promising
practices and
procedures are
congruent with
frameworks and
models of cultural and
linguistic competence
and can inform the
referral process.
Mental Health
Providers
Latino Network:
A Natural Fit in a
Community-Driven
Model Westchester
County Community
Network
National Center for
Georgetown
Child and Human
Development
edu/documents/
Westchester.pdf
This promising
practice demonstrates
guiding values
and principles
of community
engagement and
family involvement in
the Latino community
to inform the referral
process.
Mental Health
Providers
Guides for Effective Use of Resources (Interpreters, Translators, Cultural Brokers, etc.)
INTERPRET Tool:
Working with
Interpreters in Clinical
Settings
Think Cultural
Health, Office of
Minority Health, US
Department of Health
and Human Services
https://www.
thinkculturalhealth.
hhs.gov/Content/
communication_tools.
asp
A concise guide for
health providers
working with
interpreters.
Mental Health
Providers
Bridging the Cultural
Divide in Health
Care Settings: The
Essential Role of
Cultural Broker
Programs
National Center for
Georgetown
Child
and Human
Development,
Georgetown
University Medical
Center
http://culturalbroker.
info
A guide to cultural
brokering as a key
approach to increase
access to and
enhance delivery of
culturally competent
care.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel

Provider Training National Latino
Behavioral Health
Association, National
Asian American
Pacific Islander
Mental Health
Association
http://www.nlbha.
org/index.php/
programs/mental-
health-interpreter-
training/19-programs-
and-initiatives/
mhit/32-provider-
training
In-person training on
fundamental principles
of using interpreters
for providers in mental
health settings.
Mental Health
Providers
Mental Health
Interpreter Training
National Latino
Behavioral Health
Association, National
Asian American
Pacific Islander
Mental Health
Association
http://www.nlbha.org/
index.php/programs/
mental-health-
interpreter-training
Training services for
interpreters in mental
health settings.
Mental Health
Providers
Multicultural Health
Care: A Quality
Improvement Guide
National Committee
for Quality Assurance
http://www.ncqa.org/
Portals/0/HEDISQM/
CLAS/CLAS_toolkit.
pdf
Best practices for
implementing CLAS
standards.
Child-Serving
Government Agencies
Mental Health
Providers
Cultural And Linguistic Competence Tools for Serving Specific Populations
Screening and
Assessing Immigrant
and Refugee Youth in
School-Based Mental
Health Programs
Center for Health
and Health Care in
Schools
http://www.rwjf.
org/en/library/
research/2008/05/
screening-and-
assessing-immigrant-
and-refugee-youth-in-
school-ba.html
An overview
of screening,
identification, and
assessment tools and
processes that can be
used by practitioners
who care for
immigrant and refugee
youth.
Child-Serving
Government Agencies
Mental Health
Providers
School Personnel
References
Wong MM, Klingle RS, Price RK. Alcohol, tobacco, and other drug use among Asian American and Pacific
Islander adolescents in California and Hawaii. Addictive Behaviors. 2004;29:127–141. [PubMed]
Nishimura ST, Goebert DA, Ramisetty-Mikler S, Caetano R. Adolescent alcohol use and suicide indicators
among adolescents in Hawaii. Culturally Diversity and Ethnic Minority Psychology. 2005;11:309–320.
Wu P, Hoven CW, Cohen P, et al. Factors associated with use of mental health services for depression by
children and adolescents. Psychiatr Serv. 2001;52(2):189–195. [PubMed]

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