February 11, 2025 Read Time:
Mental Health
Read Craig's first blog in the series here and the second blog here.
As we continue to investigate how to find the students who most urgently need support, we have to talk about universal mental health screening. Universal mental health screening is the practice of looking at all students and using some sort of tool to figure out which students show signs or symptoms associated with mental health concerns. It turns out that the best way to figure out if a student is struggling is, in fact, just to ask them. No mental gymnastics, complicated procedures, or expensive tests needed!
Unfortunately, the practice of mental health screening is not as widespread as it should be. A review of mental health services in schools in 2022 summarized:
“Only one-third (34%) of schools provide outreach services, which includes mental health screenings for all students. These universal behavioral health screenings are considered a best practice and allow for schools to better identify all students with needs and tailor services to their specific student population. However, many schools do not offer these screenings often due to a lack of resources or difficulty accessing providers to conduct screenings, burden of collecting and maintaining data, and/or a lack of buy-in from school administrators.”
This is as good a time as any to refer back to the previous article around how to work smarter, not harder to begin the mental health outreach process by leveraging existing school systems. In order to do mental health screening, many of the same barriers are in place. Questions like these often pop up:
- If we ask the questions, do we become responsible for fixing all these things?
- Why are schools involved in identifying mental health concerns? Isn’t our job to educate, not try and fix mental health?
- How could we possibly have the personnel to do this? It sounds like a massive undertaking!
To which, I’d start by stating that we have screened for scoliosis, hearing, and vision concerns for years in schools. I have not yet heard of schools being bankrupted by needing to provide glasses or back braces. Nor have I heard of school nurses being sued for disclosing these conditions to parents. Now, while I’m sure there’s a first for everything, I think it’s safe to say that mental health screening is not just best practice, but is an imperative. Research has demonstrated that reducing availability of lethal means (e.g. firearms, medications) can decrease rates of suicide from 30-50%. Even if all we did was screen for suicidality and inform parents so they could take protective measures without providing any additional services, we can save lives.
With that being said, I do understand that this is a shift in thinking for schools, from the reactive model of waiting for students to drop by the counseling offices to proactively identifying students. With that in mind, I’m going to give two and a half different levels of possible mental health screening that could serve as prototypes for any school. I am going to keep my discussion at a broader level to discuss each approach as there are very good resources out there to discuss more granular and technical issues with mental health screening.
The Casual Screener
The most unobtrusive and least taxing form of screening is to take a step back from directly asking about specific mental health conditions (such as depression or anxiety) and instead look at the foundational things related to mental health. I know, it’s a bit confusing–let me explain.
As discussed above, a lot of people get nervous about directly confronting mental health in schools. But, when we’re talking about the basics of mental health, we’re not necessarily talking about clinical issues. Instead we’re focusing on daily living–do our students feel connected to others? Do they have things they enjoy doing? Are they engaged with their lives?
Asking these questions can be a good entry way to screening for staff and students alike. It builds trust for students to show that school staff are listening and are responsive. It also empowers school staff–no one needs a clinical license to help a lonely student. Doing it this way is still a bit limited; it won’t allow for a direct identification of students with anxiety or depression. However, it may open the door for a lot of foundational work to be done.
If we know that major symptoms of depression are feelings of sadness or hopelessness and loss of pleasure or interest in normal activities, we can either ask directly about these feelings (like a standardized depression symptom checklist which we’ll talk about later) OR we can ask about things one step removed, but still connected. For example, we could ask students if they feel like they have friends at school or if there’s an adult at school they feel connected to. Both of these things are correlated with student wellbeing and academic success. A lack of these things may be a sign of depression, and so this can be a way to identify a struggling student, instead of asking them directly “Are you feeling hopeless?” which they might not feel comfortable answering. Being this one step removed–i.e. Asking about the things that can impact a student’s wellbeing rather than asking about their mental health symptoms directly can make it easier for students and staff to openly discuss how the student is actually doing and feeling.
An additional benefit of a more casual approach is that there can be information gathered that is useful for creating relationships with students. One approach I used was to try and build up what students were interested in–what’s that song that is stuck in their head right now? What is something that they’re proud of in school? What is their favorite movie or sport or celebrity? What’s the biggest challenge that they’re working to figure out? Favorite class? What’s their biggest strength? You can even tap into a student advisory committee to help make the questions authentic and relevant.
All of this can be easily compiled using electronic questionnaires and provided to all school staff. Schools or support areas could set up a spreadsheet so that each homeroom teacher could see the answers their students gave. Students who lacked an adult connection might be highlighted in red. Make it searchable, so any staff member who had trouble connecting with a student could try and see if there were any points of interest they could leverage in building a relationship. It helps to reach that super shy kid when you suddenly play their favorite song during independent work time, or when you drop that super nerdy niche reference to something they thought they were alone in loving. It’s useful to bring it up during School Support Team (SST) meetings, so you can incorporate student strengths and passions into the conversation, rather than just discussing problems and negatives. Similarly, students with no connections to other students and staff can be identified. Even better, this information can be cross referenced with the other points of data I talked about last time to see if there are either other concerns or strengths coming into play.
I like and used this approach a lot as a start to screening. While it lacks diagnostic rigor, in my experience it works, and tends to make a lot of sense to all stakeholders involved. I actually advocated doing this sort of screening alongside other more formal measures, as everyone got something out of this process. Teachers felt like they got a secret weapon to connect with kids. Students seemed to enjoy the surveys, giving surprisingly thoughtful answers on their hopes and what they were proud of. They articulately spoke about their challenges and what they wished their teachers knew about them. We even got a few great suggestions when we asked what students would do if they were in charge of the school, as well as some deeply funny ones.
What SSTs Can Do:
- Create the Questionnaire
- What do you want to know from your students?
- What pieces of information do you think you will be able to put to use?
- What would be most helpful for teachers to know?
- What would be fun and interesting for students to answer?
- Decide on a time and place to conduct the screener
- When’s the time and place that would make the most sense to administer it?
- Write a script for people to give the survey to students (see a possible script in this handy guide)
- Distribute the information
- Decide how to put the data in the right hands–is there an advisory system in place? Should it go out to homeroom teachers? Can you make the data searchable so any teacher can find students they want to reach out to?
- Integrate data into support processes–this can make Student Support Team processes about student strengths and interests and not just problems!
Just the Screener and Nothing But the Screener
The second level of screening is incorporating some sort of validated tool to identify students with mental health concerns. For choosing screeners, I highly recommend perusing the SHAPE system’s library of screeners and tools. To make it even easier, I recommend screening for anxiety and depression using the GAD7 (for anxiety) and the PHQ9 (for depression). The GAD7 can be used for students age 11 and older, while the PHQ9 modified for Teens can be used for students age 12 and older.
It turns out that the best way to see if students are experiencing symptoms of mental illness is, surprisingly, to ask them if they are experiencing symptoms of mental illness. While the indirect approach can be useful in fleshing out student experiences and giving a bigger view, being specific and scientific with questions gives more precise and actionable data. These screeners are commonly used in pediatrician’s offices as well, and are currently state of the art in identifying anxiety and depression. They’re simple and easy to administer, are available in many different languages, and are easy to score and understand. What’s not to like?
This approach does take some organizing, primarily by SSTs. Parents must be informed about the screeners as well as what the information is going to be used for and how it is going to be securely stored. They must also be given the opportunity to opt their child out. Additionally, students must be given the information necessary to make an informed decision before disclosing possibly sensitive data. (We always told students that results may be shared with counselors and parents if there was a significant concern.) The counseling team must be ready to respond to concerns, especially since the PHQ9 includes one question about suicidality. This means that there must be a follow-up plan to meet and screen students for self-harm the same school day that the screener is given. Logistics and space to do all this work must be figured out and plans made to understand the results. (I would urge teams who are motivated to immediately dive into the nitty-gritty to check out the Universal Mental Health Screening Implementation Guide released by the MA School Mental Health Consortium (MASMHC). MASMHC has a wealth of information around mental health screening including consent forms, FAQs for parents and students and are actively involved in helping schools get screening up and running as part of their comprehensive school mental health systems.)
Here again, I would argue that just the act of screening, even if it is only followed up with a one time conversation with students at risk of suicide and students scoring high on the screeners, makes the entire thing worth it. It shows students and families that we take mental health seriously and that it is not something to be scared of or hide under the rug. It makes the hidden visible and in the words of Mr. Rogers, makes it clear that “feelings are mentionable and manageable.” Of course, we should also do more.
What SSTs Can Do:
- Review the Tools
- Examine the GAD7 and PHQ9 so everyone understands the screeners
- Decide if one or both are right for your school
- Review the Mental Health Implementation Guide as a team
- Assess existing protocols for risk assessments
- If students need to be assessed for harm to self or others, what are the existing protocols? Does there need to be modifications made for the screening process?
Screening Plus: Fully Integrated Services
The 2.5 version of mental health screening is to have it fully integrated into a system of services, such as Multi-Tiered Systems of Support (MTSS). Fleshing out a full MTSS system will be covered in more detail in future articles, but for now I’ll talk about it in the context of mental health screening.That means using the data gathered from mental health screening to determine which students need what level of services and offering the services based on the results. The beautiful thing about using more formal measures is that they can be repeated over time to measure progress with individual students–so you already have your baseline set up with the initial screening, ready for follow up after intervening.
Imagine this–you use a screener like the GAD7 and identify 10 students with a moderate level of anxiety. Instead of meeting with each student individually to offer 1:1 counseling followed by three to five 30 minute sessions to get an understanding of what is happening (and another three to five sessions to maybe see a benefit), you could instead invite all 10 students to an anxiety skill building group. In the time it would take to see a change in one student, a counselor can support 10 students, as well as all the other students in the time freed up. The students get the benefits of counseling, alongside with the added benefit of peer support (which adolescents in particular crave more than anything). And, while we think individual counseling is automatically more effective, study after study has shown similar rates of efficacy between individual and group counseling approaches. Your system gets to serve 10 students by giving them what they need, while saving hundreds of hours you otherwise would spend on individual counseling. It also gives an opportunity to see who among those ten might benefit from more intensive 1:1 follow up as part of the MTSS process. And the kids who show up on the screener and participate in a group session might never have come down to the counseling office for a 1:1 visit in the first place!
MASMHC Universal Mental Health Screening Implementation GuideBringing it All Together
Universal mental health screening seems like a no-brainer to me. It helps students, staff, and families for very little cost, other than some planning and maybe some tech support to get the questionnaires up and running. I hope this article showed that there can also be different levels of screening for systems at different points. Informal screening can start the process and provide an entry point for students and staff. It can give you an idea about what systems might need to be put in place before a more formal screening can be rolled out, such as how many students may need support. In order to do ‘the whole shebang’ though, there needs to already be a deep understanding of what supports are available in your school. This means having an updated and ‘living’ resource map, a detailed method of how referrals to services are made and processed, as well as an understanding of the staffing involved. Good thing that’s next on our agenda to discuss!
Discussion Tool for your team:
- What are the barriers involved in doing mental health screening at your school?
- What benefits can you think of for doing mental health screening at your school?
- How can you ‘start slow to go fast’ with mental health screening? What are some first steps you might be able to take?
