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 Topic Brief, April, 2015

Tier 1 Procedure Natalie Hoff, Reece L. Peterson, Jenna Strawhen & Scott Fluke, University of Nebraska-Lincoln. Both into oth an ethical and a scientific argument exist for improving access for all children, irrespective of their income, to high quality mental health services. (Fazel, Hoagwood, et al., 2014, p. 1). Both mental health and education professionals have begun to recognize the potential positive impact schools can have on addressing mental health needs of students across the globe, both in high income countries such as the United States, and in low or moderate income countries. They are recommending glob- al effort to screen and deliver behavior and mental health ser- vices through schools (Fazel, Patel, Thomas, & Tol, 2014). To do so they recommend using a tiered prevention model. This would include universal positive and preventative interventions for all students delivered in school, as well as screening for students with mental health and behavior problems in order to implement a variety of targeted academic and mental health services: O Identifying At- Risk Students for Tier 2 & 3 Intervention Mental health services embedded within school systems can create a continuum of inte- grative care that improves both mental health and educational attainment for children. To strengthen this continuum, and for optimum child development, a reconfiguration of education and mental health systems to aid implementation of evidence-based practice might be needed. Integrative strategies that combine classroom-level and student-level interventions have much potential. Both ethical and scientific justifications exist for integration of mental health and edu- cation: integration democratizes access to services and, if coupled with use of evidence-based practices, can promote the healthy development of children. (Fazel, Hoagwood, et al., 2014, p.377.) A population-based approach, which covers a wide variety of potential mental health, be- havioral, and academic needs of students will ensure that young people can access preventive and treatment services whenever they are needed. Needs for Behavioral and Mental Health Screening in School About 10-20% of children and young people worldwide would benefit from some form of mental health intervention, but in high-income countries, estimates show that only 25% of children who require a mental health intervention are identified or treated (Fazel, Hoagwood, et al, 2014). "Peer relationships, social interactions, academic attainment, cognitive process, emotional control, behavioral expectations, physical development and moral development are all mediated through school, and all of these areas are affected by mental health" (McNamee, 2014, writing about the Fazel, Hoagwood, et al., 2014 study). The U.S. Department of Education reported in 2002 that upwards of 20 percent of students experience emotional and behavioral disorders (EBD), while less than 1 percent of students receive special education support for such disorders. Further, the majority of those children who are identified as Emotionally Disturbed and thus eligible for special education services externalize their behaviors (e.g., verbal and physical aggression, noncompliance, and delinquent acts), with teachers tending to overlook referral of those students with internalizing behavior problems (e.g., anxiety, depression, and social withdrawal; Lane, Kalberg, Lambert, Crnobori, & Bruhn, 2010; Lane, Menzies, Oakes, Lambert, et al., 2012). This is problematic because 6-18 percent of youth have anxiety disorders, 3-6 percent of students under 18 have depression, and about 16 percent of students experience comorbidity (i.e., experience multiple mental health disorders; Lane, Menzies, et al., 2012). Internal emotional disorders as a whole are reportedly present in 46.6 percent of the population, with over half of those diagnosed showing signs by the age of 14 (Lane, Oakes, et al., 2012). As a result, many students with behavioral or mental health needs are not provided any services to address these needs while in school. At the same time, it is not clear that students with emerging behavioral or mental health disorders who are identified for special education services are being served effectively. Community services for children and youth with mental health needs are scant, and sometimes difficult to access. Presently, both externalizing and internalizing behaviors of students impact relationships between those students, their teachers, and the students' peers. They negatively impact the effectiveness of the teacher as a result of distractions and misbehaviors in the classroom (Kal- berg et al., 2011). Obviously these behavioral and mental health needs also impact the aca- demic achievement of both the students with mental health needs, as well as other students. Furthermore, students who go without treatment have been linked to later academic problems, dropout from school, as well as unemployment and continued mental health concerns (Mental Health America, 2013). Identifying Students With Behavioral and Mental Health Needs One of the first steps to address the behavioral and mental health needs of students is to implement a population based, school wide method to identify students who are showing signs of behavior or men- tal health problems, or who are at elevated risk for developing those problems. What Is Screening? "Screening is the process of collecting data to decide whether more intensive assessment [or inter- vention] is necessary. Implicit in screening is the notion that the student's difficulties may go unnoticed" (Salvia, Ysseldyke & Bolt, 2007). Screening generally refers to a brief procedure that attempt to differen- tiate those who might have a signs of minor problems which might grow worse through time, or those who have a high risk of developing problems later. The students identified are then provided services that are intended to avoid or diminish the problems of concern. Screening in schools can be used to identify a multitude of possible problem areas, including academic problems, disabilities, or health con- cerns. For example, students with small vision or hearing problems may go unnoticed, and, without early and effective intervention these students may show diminished academic achievement and develop behavior problems. As they fall further and further behind and become more frustrated, these problems grow and these students may become disengaged from school, particularly as they fall behind their peers. The result may be academic or behavior problems, leading to the student dropping out of school. As a result almost all schools require vision and hearing screening intended to identify students who have even minor vision or hearing problems so that those problems can be corrected before students show these negative outcomes. A similar approach should be taken to screen for behavior problems. Currently, several screen- ing tools are available to identify students who are at heightened risk to later develop severe behavior problems or mental disorders. It is anticipated that implementing screening for risks of mental health and behavior problems will permit early intervention which will prevent the negative outcomes in a way similar to that described for vision screening and intervention. What is Behavior Screening? Behavior screening procedures, or screeners, are used across a student population to identify stu- dents who are at risk of developing serous behavior problems or mental disorders. (Lane et al., 2009). These assessment tools often consist of questionnaires completed by the student, teacher, parents, or any combination. Behavioral screeners are particularly helpful for identifying students who exhibit in- ternalizing behaviors that are less overtly observable but are just as detrimental as externalizing behav- iors (Lane et al., 2010); however, both internalizing and externalizing behaviors are identified through screening. These screeners are designed for implementation at multiple points within the school year to identify and monitor progress for those students who are either at risk for, or who are already displaying signs of emotional and behavioral conduct problems. High-quality screeners are those that have under- gone rigorous scientific testing to determine the reliability and validity with which the screener identifies students who are at risk. Several screeners have been scientifically validated for identifying students with emotional and behavioral concerns. Who Should Be Screened? Screening procedures in schools are designed for use with an entire population of students. Typically all students within a school or school district would be subject to a screening procedure. In the case of behavior screening, the focus is on catching behavior problems at an early age, or when they first emerge before those problems become severe or chronic. When that happens it is then easier to provide effec- tive intervention. As a result the focus is typically on elementary schools. However, some mental health disorders emerge during adolescence, and as a result screening may be valuable at any level of schooling. Why Is Behavioral Screening Important? Behavior screening is crucial to schools identifying students who are at-risk due to their behavioral needs. When students have behavioral needs or problems, including mental health issues, such screen- ing can result in an intervention that prevents or lessens the negative outcomes for those students. Early intervention for these needs may also improve relationships, diminish disruptions to classroom instruc- tion, and enhance outcomes for all students. This type of screening is imperative in order to ensure health and wellness for the child, and prevent future inappropriate behaviors from occurring or wors- ening. Just as students are screened for physical health issues during mandatory school physicals, they should also be screened for any behavioral "red flags" at key times throughout their school careers. School-wide behavior screeners also facilitate more accurate decision making, and involve carefully monitoring risk and progress in the school as a whole. More specifically, school-wide screeners also en- gage teachers in identifying at-risk students who may require additional academic, behavioral, or social support (Lane, 2012b). Thus, screening provides more direct access to Student Assistance Team, and pos- sibly to special education services, as well as community services where available. Therefore, all schools should be conducting some form of systematic screening for social, emotional, and behavior problems in order to promote positive school mental health and early intervention What Are the Problems With Traditional Behavioral Screening Methods? Traditionally, teachers were asked to simply identify students with behavior problems for interven- tion and refer these students to counselors or student assistance teams. Sometimes other school data such as office discipline referrals or attendance data were also used. Unfortunately, these approaches are not evidence-based and are not a reliable method by themselves for identifying behavior problems with accuracy (Kalberg et al., 2011; Lane et al., 2011; Lane, Menzies, Oakes, Lambert, et al., 2012; Lane, Oakes, et al., 2012; Marchant et al., 2009). How Often Should Behavior Screening Occur? The frequency of behavior screening will of course depend in part on the cost in time and resources involved in such screening. However, several behavior screeners can be completed quickly and with little such costs. Because of this, and the valuable data it provides, experts currently ad- vise that both academic and behavioral screening measures be implemented at three points throughout the school year: fall (six weeks into the semester), winter (just before winter break), and spring (six weeks prior to the beginning of summer break; Kalberg, Lane, & Menzies, 2010; Lane et al., 2010; Lane, Menzies, Oakes, Lambert, et al., 2012). When conducted in early elemen- tary school, this permits the earliest identification of new be- havior or mental health problems among students, and permits better monitoring of treatments outcomes for students identified as being at high risk (Walker, Cheney, Stage & Blum 2005). Of course screening can occur less frequently, and is always valuable so long as interventions occur based on the identification of high risk students. Three-Tier Models of Prevention and Intervention School-wide behavior screening procedures are often incorporated as a part of a Multi-tiered System of Supports (MTSS), such as the three tiered Positive Behavior Interventions and Supports (PBIS) frame- work or the Response to Intervention (RtI) framework. When employed, this universal screening proce- dure identifies those students at risk for, or suffering from, behavioral or academic issues. This permits implementation of additional tier-two or tier-three interventions for those students who require more intensive or individualized support (Lane, Oakes, et al., 2012). The integration of academic, behavioral, and social supports under the three-tier model has been termed the Comprehensive, Integrated Three- Tier Model of Prevention (C13T) by Lane and Colleagues (Lane, Menzies, Oakes, Lambert, et al. 2012). Under this model, schools implement the behavioral screeners as a tier-one, or universal strategy, which identifies students who might need additional services to prevent potential learning problems and mis-behavior from occurring or becoming worse. Those students then receive tier two behavioral supports. If students at the tier two levels are still not showing improvements in behavior, they might need the most intensive, tier three, supports. When appropriate screeners are implemented properly, three tiered intervention systems can have a significant influence on student behavior. A study by Lane and colleagues (2010) found that the imple- mentation of PBIS and a behavior screening instrument increased the percentage of students falling within the normal pro-social behavior range over the course of the school year while also decreasing the number of students falling in the borderline and abnormal range. A later study by Lane, Menzies, Oakes, and Kalberg (2012) yielded similar results when implementing systematic screening in an elementary school. Externalizing and internalizing behavior problems both decreased significantly over the course of three years of the study. In other words these procedures focus schools on prevention and early inter- vention for behavior problems, diminishing the occurrence or intensity of these behavior problems. Concurrent Academic and Behavioral Issues Ennis, Lane, and Oakes (2012) suggest that the most effective screening tools are those that address both academic and behavioral issues since often students who are at risk for mental health problems also have academic problems. They found moderate negative correlations between behavior problems and academic performance, indicating that the higher a child rates on behavior problem scales, the lower their academic performance will be (Ennis et al., 2012). Because of this relationship, it is necessary to analyze behavioral data in conjunction with academic measures to determine which students are hav- ing academic difficulties with interfering behavioral issues (Lane et al., 2010). Although it is beyond our scope to review academic screening tools, many schools have begun an- nual measures of academic abilities through the use of curriculum-based measures for reading, writing, math, and spelling (Kalberg et al., 2010). Examples of curriculum-based measures include dynamic indi- cators of basic early literacy (DIBELS) or AIMSweb for reading. Achievement tests such as the Woodcock Reading Mastery Test-Revised/Normative Update (WRMT-R/NU) have also been used to assess the read- ing ability of children (Nelson et al., 2009). In general, schools are may choose any preferred measure to assess academic achievement, so long as it is a reliable and valid measure. Choosing an Appropriate Behavior Screener As with academic screening, there are a number of tools available for school-wide behavior screen- ing. This allows schools to choose the method that is right for their student population, financial re- sources, and faculty time expended (Harrison, Vannest & Reynolds, 2013; Kalberg et al., 2010; Lane et al., 2011; Lane, Oakes, et al., 2012). As with academic screening it is also important to consider are the psychometric properties of the screening tool. Crucial are the reliability (ability of the test to yield simi- lar results over time) and validity (ability of the test to measure what is intended) of the screener (Lane et al., 2010). While finding a screening tool that is reliable and valid is important, it is also important to ensure that it is implemented carefully and correctly. What Behavioral Screeners are Available? A variety of behavioral screening tools are available, but they differ in their reliability, validity, pur- chase cost, student and staff time required to complete, as well as time to analyze results. Five well- known and commonly used screening tools are described briefly here. See the resource document on behavior screening for more detailed information. Systematic Screening for Behavior Disorders. The SSBD (Walker & Severson, 1992) is a classroom- level screener that takes approximately 45-60 minutes to administer for stages one and two per class- room (these are generally the only two stages completed). The scale requires teachers to rate each student in their class on their externalizing and internalizing behaviors. Once these teacher ratings are gathered, the students with high internalizing and externalizing behaviors are directly observed and the results combined with further individualized data from a variety of sources. These teacher ratings ultimately identify the students in the class most at-risk for developing emotional and behavioral disor- ders. The scale has demonstrated adequate reliability and validity at the elementary level (grades 1-6; New Hampshire Center for Effective Behavioral Interventions and Supports, 2014). This screener was also adapted for students ages 3-5 years and called the Early Screening project (ESP; Oakes, Lane, Cox, & Messenger; 2014). Student Risk Screening Scale. The Student Risk Screening Scale (Drummond, 1994) is administered by teachers roughly three times per year for students K-12. Teachers rate all students in their classroom on seven domains that they observe throughout the year (e.g., behavior problems, peer rejection, nega- tive attitude). Screening for an entire classroom with the SRSS generally takes 10-15 minutes of teacher time, resulting in a placement for students in either a low-risk, medium-risk, or high-risk category (Oakes et al., 2014). There has been initial evidence to support a revised version of the SRSS, incorporating 5 internalizing behaviors to make the assessment more comprehensive (Lane, Menzies, Oakes, Lambert, Cox, & Hankins, 2012); this new measure is termed the SRSS-IE12. Strengths and Difficulties Questionnaire. Another commonly used screening tool is the Strengths and Difficulties Questionnaire (Goodman, 1997). Two of its advantages are that it is inexpensive and easy to implement. It includes 25 items assessing both positive and negative behavioral attributes. Par- ent and teacher versions are also available, which is especially helpful for screening younger students (Youth in Mind, 2012). Overall, the SDQ has been found to be a reliable and valid screener to detect emotional and behavioral problems in school-aged youth K-12 (Essau et al., 2012). Emotional and Behavioral Screener. The Emotional and Behavioral Screener (EBS; Cullinan & Epstein, 2013) is another universal screener used for students ages 5 to18 years old. Additionally, the EBS consists of only 10 questions and takes 1-2 minutes to complete per student. EBS relies on teacher ratings of emotional and behavioral functioning and has been identified by the authors as a reliable and valid measure (Cullinan & Epstein, 2013). However it is more costly to purchase than some of the other screening instruments. Behavioral and Emotional Screening System. The Behavior Assessment System for Children Behav- ioral and Emotional Screening System (BASC-2 BESS; Kamphaus & Reynolds, 2007) is used to identify strengths and weaknesses in students of all ages (pre-K through grade 12) in the domains of behavior and emotion. The BASC-2 BESS takes relatively little time to administer per class, however its financial demands and intricate scoring process can make it a less appealing option for continual use in some schools. Serving Students at High Risk Once students are identified by a behavior screener as being at elevated risk of behavioral or mental health problems on a screener, some further individualized assessment or data gathering may be useful, and an individually prescribed intervention based on all available information is recommended. Assessment of Social and Emotional Skills. There are two commonly used scales to assess emotion- al and behavioral skills, the Achenbach System of Empirically Based Assessment (Achenbach, 2009), and the Social Skills Rating System (SSRS), now referred to as the Social Skills Improvement System - Rating Scale (Gresham & Elliott, 2008). Many other individual psychological assessment tools and rating scales may also be of value in determining strategies and interventions, particularly for students with chronic or severe behavioral needs. Behavioral Interventions. There are a number of secondary and tertiary (Tier 2 and Tier 3) treat- ment strategies for students who are identified as being at relatively high risk by behavior screening. It is important to note that when moving students from universal (Tier 1) to secondary (Tier 2) or tertiary (Tier 3) supports, parental consent must be obtained (Lane et al., 2010). Some examples include social skills instruction, peer tutoring, one-on-one meetings with the school psychologist or school counselor for specific "packaged" treatments, study skills groups, behavior contracts, behavior monitoring, check in/check out, and conflict resolution skills groups. While this list is not exhaustive, it generates a picture of the types of additional school interventions or programs for students who struggle socially or behav- iorally. Many times these students would be referred for special education services requiring a multidis- ciplinary assessment, as well as the creation of an Individual education plan (IEP) or individual behavior intervention plan. Of course parents of these students may also be referred to community mental health services as well. Summary and Conclusion Several conclusions can be drawn regarding behavioral screening: • Behavior screening is an important and feasible task. • Several empirically supported tools have been developed for behavior screening. Many of these tools have good reliability and validity but differ in terms of costs and time required for implementation. These are all considerations when choosing a screener. Behavior screening can be done at efficiently at relatively low cost in both dollars and staff time. By implementing screening procedures, schools can prevent further/future behavior problems from growing and becoming more complicated, as well as providing support for students experiencing dif- ficulties in this area. The long term value of effective intervention based on screening will be a savings in school resources which would otherwise have been used in dealing with more difficult and complex behavior prob- lems later in students' school careers. Once these programs are firmly in place, teachers, students, and administrators will become more comfortable with the process and it will become a natural part of every school year. Behavior screening appears important, desirable, practical,technically feasible, and needed to benefit students as well as the school itself. Lane, Menzies, Oakes, and Kalberg (2012) suggest that the question should not be "Should we imple- ment school-wide behavior screening?" but rather it should be, "What school-wide behavioral screening tool should we use?" The ability to provide students with early access to needed school based behavior and mental health services outweighs any potential links to stigma or labeling, or loss of time or costs. By developing a universal screening plan, with additional secondary and tertiary supports to students who may need them, many behavior and mental health problems will be prevented or significantly dimin- ished with concomitant increases in academic achievement. A logical conclusion is that all schools should be employing a plan to implement behavior screening, and to provide tiered support based on results of that screening.