Abstract
Schools face an unprecedent demand for mental health services. Student mental health problems can be addressed via a continuum of mental health evidence-based practices (EBPs) integrated within school-wide Positive Behavioral Interventions and Supports (PBIS). However, integrating mental health interventions with PBIS can be challenging. The purpose of this study is to examine the integration of mental health interventions with PBIS in a group of schools in Pennsylvania. We describe the extent to which schools implementing PBIS with fidelity were using mental health EBPs at tiers 2 and 3, examine recommendations about how to achieve further integration, and identify school professional needs for training and support. The study is based on a statewide sample of 48 K-8 schools. Members of the leadership team completed questionnaires and participated in qualitative interviews. Most schools had established advanced tiers of support and offered EBPs for externalizing behavior problems at tier 2. However, few schools reported offering mental health EBPs at tier 3, or interventions for internalizing problems. Qualitative analyses of interview transcripts revealed key recommendations regarding characteristics of interventions students should receive, who should provide the extra supports to students and the type of training that should be made available to school personnel and providers of tier 2 and tier 3 interventions. Participants indicated school mental health personnel did not receive adequate technical assistance to implement EBPs.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
Data for this article can be obtained from the first author upon reasonable requests.
References
Anderson, A. R., Christenson, S. L., Sinclair, F., & Lehr, C. A. (2004). Check & connect: The importance of relationships for promoting engagement with school. Journal of School Psychology, 42(2), 95–113. https://doi.org/10.1016/j.jsp.2004.01.002
Anderson, C., Childs, K., Kincaid, D., Horner, R., George, H., Todd, A., Sampson, N., & Spaulding, S. (2009). Benchmarks for advanced tiers. Unpublished instrument. Educational and community supports.
Anello, V., Weist, M., Eber, L., Barrett, S., Cashman, J., Rosser, M., & Bazyk, S. (2016). Readiness for positive behavioral interventions and supports and school mental health interconnection: Preliminary development of a stakeholder survey. Journal of Emotional and Behavioral Disorders, 25(2), 1–14. https://doi.org/10.1177/1063426616630536
Angus, G., & Nelson, R. B. (2021). School-wide positive behavior interventions and supports and academic achievement. Contemporary School Psychology, 25(4), 443–465. https://doi.org/10.1007/s40688-019-00245-0
Barrett, S., Eber, L., & Weist, M. (2013). Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support. Retrieved from: https://www.pbis.org/resource/advancing-education-effectiveness-interconnecting-school-mental-health-and-school-wide-positive-behavior-support
Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology Science and Practice, 17(1), 1–30. https://doi.org/10.1111/j.1468-2850.2009.01187.x
Bradley, E. H., Curry, L. A., & Devers, K. J. (2007). Qualitative data analysis for health services research: Developing taxonomy, themes, and theory. Health Services Research, 42(4), 1758–1772. https://doi.org/10.1111/j.1475-6773.2006.00684.x
Bradshaw, C. P., Reinke, W. M., Brown, L. D., Bevans, K. B., & Leaf, P. J. (2008). Implementation of school-wide positive behavioral interventions and supports (PBIS) in elementary schools: Observations from a randomized trial. Education & Treatment of Children, 31(1), 1–26. https://doi.org/10.1353/etc.0.0025
Bradshaw, C. P., Mitchell, M. M., & Leaf, P. J. (2010). Examining the effects of schoolwide positive behavioral interventions and supports on student outcomes. Journal of Positive Behavior Interventions, 12(3), 133–148. https://doi.org/10.1177/1098300709334798
Bradshaw, C. P., Pas, E. T., Goldweber, A., Rosenberg, M. S., & Leaf, P. J. (2012a). Integrating school-wide positive behavioral interventions and supports with tier 2 coaching to student support teams: The PBISplus model. Advances in School Mental Health Promotion, 5(3), 177–193. https://doi.org/10.1080/1754730X.2012.707429
Bradshaw, C. P., Waasdorp, T. E., & Leaf, P. J. (2012b). Effects of school-wide positive behavioral interventions and supports on child behavior problems. Pediatrics, 130(5), e1136-1145. https://doi.org/10.1542/peds.2012-0243
Cappella, E., Hamre, B. K., Kim, H. Y., Henry, D. B., Frazier, S. L., Atkins, M. S., & Schoenwald, S. K. (2012). Teacher consultation and coaching within mental health practice: Classroom and child effects in urban elementary schools. Journal of Consulting and Clinical Psychology, 80(4), 597–610. https://doi.org/10.1037/a0027725
Cashman, J., Rosser, M., & Linehan, P. (2013). Policy practice and people: Building shared support for school behavioral health. In S. Barrett, L. Eber, & M. Weist (Eds.), Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support (pp. 96–112). University of Oregon.
Childs, K. E., Kincaid, D., George, H. P., & Gage, N. A. (2016). The relationship between school-wide implementation of positive behavior intervention and supports and student discipline outcomes. Journal of Positive Behavior Interventions, 18(2), 89–99. https://doi.org/10.1177/1098300715590398
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. Guilford Press.
Copeland, W. E., Shanahann, L., Costello, E. J., & Angold, A. (2009). Childhood and adolescent psychiatric disorders as predictors of young adult disorders (2009). Archives of General Psychiatry, 66(7), 764–772. https://doi.org/10.1001/archgenpsychiatry.2009.85
Crone, D. A., Hawken, L. S., & Horner, R. H. (2010). Responding to problem behavior in schools: The behavior education program (2nd ed.). The Guilford Press.
Dray, J., Bowman, J., Campbell, E., Freund, M., Wolfenden, L., Hodder, R. K., McElwaine, K., Tremain, D., Bartlem, K., Bailey, J., Small, T., Palazzi, K., Oldmeadow, C., & Wiggers, J. (2017). Systematic review of universal resilience-focused interventions targeting child and adolescent mental health in the school setting. Journal of the American Academy of Child & Adolescent Psychiatry, 56(10), 813–824. https://doi.org/10.1016/j.jaac.2017.07.780
Duchnowski, A. J., & Kutash, K. (2009). Integrating PBS, mental health services, and family driven care. In W. Sailor, G. Dunlap, G. Sugai, & R. Horner (Eds.), Handbook of positive behavior support (pp. 203–231). Springer.
Duong, M. T., Bruns, E. J., Lee, K., Cox, S., Coifman, J., Mayworm, A., & Lyon, A. R. (2020). Rates of mental health service utilization by children and adolescents in schools and other common service settings: A systematic review and meta-analysis. Administration and Policy in Mental Health. https://doi.org/10.1007/s10488-020-01080-9
Eber, L., Weist, M., & Barrett, S. (2013). An introduction to the interconnected systems framework. In S. Barrett, L. Eber, & M. Weist (Eds.), Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support (pp. 3–17) Retrieved from: https://www.pbis.org/resource/advancing-education-effectiveness-interconnecting-school-mental-health-and-school-wide-positive-behavior-support
Eiraldi, R., Benjamin Wolk, C., Locke, J., & Beidas, R. (2015). Clearing hurdles: The challenges of implementation of mental health evidence-based practices in under-resourced schools. Advances in School Mental Health Promotion, 8(3), 124–140. https://doi.org/10.1080/1754730X.2015.1037848
Evans, S. W., Simonsen, B., & Dolan, G. (2013). School level practices. In S. Barrett, L. Eber, & M. Weist (Eds.), Advancing education effectiveness: Interconnecting school mental health and schoolwide positive behavior support (pp. 58–72). Retrieved from: https://www.pbis.org/resource/advancing-education-effectiveness-interconnecting-school-mental-health-and-school-wide-positive-behavior-support
Flegge, L. G. (2022). Examining facilitators and barriers to evidence-based professional practice by mental health providers in schools. Psychology in Schools, 60(3), 566–591. https://doi.org/10.1002/pits.22783
Forman, S. G., Shapiro, E. S., Codding, R. S., Gonzales, J. E., Reddy, L. A., Rosenfield, S. A., Sanetti, L. M. H., & Stoiber, K. C. (2013). Implementation science and school psychology. School Psychology Quarterly, 28(2), 77–100. https://doi.org/10.1037/spq0000019
Foster, S., Rollefson, M., Doksum, T., Noonan, D., & Robinson, G. (2005). School mental health services in the United States, 2002–2003 (DHSS Publication No. SMA 05–4068). https://doi.org/10.1037/e571812009-001
Gage, N. A., Whitford, D. K., & Katsiyannis, A. (2018). A review of schoolwide positive behavior interventions and supports as a framework for reducing disciplinary exclusions. The Journal of Special Education, 52(3), 142–151. https://doi.org/10.1177/0022466918767847
George, H. P., Kincaid, D., & Pollard-Sage, J. (2011). Primary-tier interventions and supports. In W. Sailor, G. Dunlap, G. Sugai, & R. Horner (Eds.), Handbook of positive behavior suppor (pp. 375–394). Springer.
Ghanem, N. (2021). The effect of violence in childhood on school success factors in US children. Child Abuse & Neglect, 120. https://doi.org/10.1016/j.chiabu.2021.105217
Green, J. G., McLaughlin, K. A., Alegria, M., Costello, E. J., Gruber, M. J., Hoagwood, K., Leaf, P. J., Olin, S., Sampson, N. A., & Kessler, R. C. (2013). School mental health resources and adolescent mental health service use. Journal of the American Academy of Child and Adolescent Psychiatry, 52(5), 501–510. https://doi.org/10.1016/j.jaac.2013.03.002
Hawken, L. S., Vincent, C. G., & Schumann, J. (2008). Response to intervention for social behavior: Challenges and opportunities. Journal of Emotional and Behavioral Disorders, 16(4), 213–225. https://doi.org/10.1177/1063426608316018
Hawken, L. S., Adolphson, S. L., McLeod, K. S., & Schumann, J. (2009). Secondary-tier interventions and supports. In W. Saylor, G. Dunlap, G. Sugai, & R. Horner (Eds.), Handbook of positive behavior support (pp. 395–420). Springer. https://doi.org/10.1007/978-0-387-09632-2
Hawken, L. S., Bundock, K., Kladis, K., O’Keeffe, B., & Barrett, C. A. (2014). Systematic review of the check-in, check-out intervention for students at risk for emotional and behavioral disorders. Education & Treatment of Children, 37(4), 635–658. https://doi.org/10.1353/etc.2014.0030
Herschell, A. D., Kolko, D. J., Baumann, B. L., & Davis, A. C. (2010). The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review, 30(4), 448–466. https://doi.org/10.1016/j.cpr.2010.02.005
Higgins, E., & O’Sullivan, S. (2015). “What works”: Systematic review of the “FRIENDS for life” programme as a universal school-based intervention programme for the prevention of child and youth anxiety. Educational Psychology in Practice, 31(4), 424–438. https://doi.org/10.1080/02667363.2015.1086977
Jaycox, L. H., Langley, A. K., & Hoover, S. H. (2018). CBITS: Cognitive behavioral intervention for trauma in schools. Rand Corporation. https://doi.org/10.7249/TL272
Kendall, P. C., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual. Workbook Publishing.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. https://doi.org/10.1001/archpsyc.62.6.593
Kincaid, D., & Romer, N. (2020). Implementing positive behavior interventions and supports: A framework for mental health promotion. In P. J. Lazarus, S. M. Suldo, & B. Doll (Eds.), Fostering the emotional well-being of our youth: A school-based approach (pp. 79–91). Oxford University Press. https://doi.org/10.1093/med-psych/9780190918873.001.0001
Layne, A. E., Bernstein, G. A., & March, J. S. (2006). Teacher awareness of anxiety symptoms in children. Child Psychiaty & Human Development, 36, 383–392. https://doi.org/10.1007/s10578-006-0009-6
Lochman, J. E., & Wells, K. C. (2004). The coping power program for preadolescent aggressive boys and their parents: Outcome effects at the 1-year follow-up. Journal of Consulting and Clinical Psychology, 72(4), 571–578. https://doi.org/10.1037/0022-006X.72.4.571
Lochman, J. E., Wells, K. C., & Lenhart, L. (2008). Coping power child group program: Facilitator guide. Oxford University Press. https://doi.org/10.1093/med:psych/9780195327878.001.0001
Macklem, G. L. (2011). Evidence-based school mental health services: Affect education, emotion regulation training, and cognitive behavioral therapy. Springer. https://doi.org/10.1007/978-1-4419-7907-0
Maggin, D., & Mills, C. (2013). Interconnecting school and mental health data to improve student outcomes. In S. Barrett, L. Eber, & M. Weist (Eds.), Advancing education effectiveness: Interconnecting school mental health and school-wide positive behavior support (pp. 58–72). University of Oregon. Retrieved from: https://www.pbis.org/resource/advancing-education-effectiveness-interconnecting-school-mental-health-and-school-wide-positive-behavior-support
Masia-Warner, C., Klein, R. G., Dent, H. C., Fisher, P. H., Alvir, A., Marie Albano, A., & Guardino, M. (2005). School-based intervention for adolescents with social anxiety disorder: Results of a controlled study. Journal of Abnormal Child Psychology, 33(6), 707–722. https://doi.org/10.1007/s10802-005-7649-z
McIntosh, K., Ty, S. V., & Miller, L. D. (2014). Effects of school-wide positive behavioral interventions and supports on internalizing problems: Current evidence and future directions. Journal of Positive Behavior Interventions, 16(4), 209–218. https://doi.org/10.1177/1098300713491980
McIntosh, K., Mercer, S. H., Nese, R. N. T., Strickland-Cohen, M., Kittelman, A., Hoselton, R., & Horner, R. H. (2018). Factors predicting sustained implementation of a universal behavior support framework. Educational Researcher, 47(5), 307–316. https://doi.org/10.3102/0013189X18776975
Mellin, E. A., Bronstein, L., Anderson-Butcher, D., Amorose, A. J., Ball, A., & Green, J. (2010). Measuring interprofessional team collaboration in expanded school mental health: Model refinement and scale development. Journal of Interprofessional Care, 24(5), 514–523. https://doi.org/10.3109/13561821003624622
National Research Council and Institute of Medicine. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. The National Academies Press. https://doi.org/10.17226/12480
Owens, J. S., & Pastrana Rivera, F. A. (2023). Helping school-based professionals make a difference. In S. W. Evans, J. S. Owens, C. P. Bradshaw, & M. D. Weist (Eds.), Handbook of school mental health. Issues in clinical child psychology (pp. 285–298). Springer. https://doi.org/10.1007/978-3-031-20006-9_19
Palinkas, L. A., Horwitz, S. M., Chamberlain, P., Hurlburt, M. S., & Landsverk, J. (2011). Mixed-methods designs in mental health services research: A review. Psychiatric Services, 62(3), 255–263. https://doi.org/10.1176/appi.ps.62.3.255
Pas, E. T., & Bradshaw, C. P. (2012). Examining the association between implementation and outcomes. Journal of Behavioral Health and Services Research, 39, 417–433. https://doi.org/10.1007/s11414-012-9290-2
Pas, Waasdorp, & Bradshaw. (2015). Examining contextual influences on classroom-based implementation of positive behavior support strategies: Findings from a randomized controlled effectiveness trial. Prevention Science, 16, 1096–1106. https://doi.org/10.1007/s11121-014-0492-0
Poynton, T. A., DeFouw, E. R., & Morizio, L. J. (2019). A systematic review of online response rates in four counseling journals. Journal of Counseling & Development, 97, 33–42. https://doi.org/10.1002/jcad.12233
Reinke, W. M., Stormont, M., Webster-Stratton, C., Newcomer, L. L., & Herman, K. C. (2012). The Incredible Years teacher classroom management program: Using coaching to support generalization to real-world classroom settings. Psychology in the Schools, 49(5), 416–428. https://doi.org/10.1002/pits.21608
Riehm, K. E., Mojtabai, R., Adams, L. B., Krueger, E. A., Mattingly, D. T., Nestadt, P. S., & Leventhal, A. M. (2021). Adolescents’ concerns about school violence or shootings and association with depressive, anxiety, and panic symptoms. JAMA Network Open, 4, e2132131. https://doi.org/10.1001/jamanetworkopen.2021.32131
Rones, M., & Hoagwood, K. (2000). School-based mental health services: A research review. Clinical Child Family and Psychology Review, 3(4), 223–241. https://doi.org/10.1023/A:1026425104386
Saldaña, J. (2013). The coding manual for qualitative researchers (2nd ed.). SAGE.
Sanchez, A. L., Cornacchio, D., Poznanski, B., Golik, A. M., Chou, T., & Comer, J. S. (2018). The effectiveness of school-based mental health services for elementary-aged children: A meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 57(3), 153–165. https://doi.org/10.1016/j.jaac.2017.11.022
Slade, E. P. (2003). The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States. Journal of Behavioral Health Services Research, 30(4), 382–392. https://doi.org/10.1007/BF02287426
Splett, J. W., Perales, K., Al-Khatib, A. M., Raborn, A., & Weist, M. D. (2020). Preliminary development and validation of the Interconnected Systems Framework-Implementation Inventory (ISF-II). School Psychology, 35(4), 255–266. https://doi.org/10.1037/spq0000369
Stark, K. D., Schnoebelen, S., Simpson, J. P., Hargrave, J. L., Molnar, J. M., & Glenn, E. R. (2007). Treating depressed youth: Therapist manual for ACTION. Workbook Publishing Inc.
Sugai, G., & Horner, R. (2009). Defining and describing school wide positive behavior support. In W. Sailor, G. Dunlap, G. Sugai, & R. Horner (Eds.), Handbook of positive behavior support (pp. 307–326). Springer.
Sugai, G., & Horner, R. H. (2020). Sustaining and scaling positive behavioral interventions and supports: Implementation drivers, outcomes, and considerations. Exceptional Children, 86, 120–136. https://doi.org/10.1177/0014402919855331
Sugai, G., Lewis-Palmer, T., Todd, A., & Horner, R. H. (2004). The school-wide evaluation tool (SET): A research instrument for assessing school-wide positive behavior support. Journal of Positive Behavior Interventions, 6(1), 3–12. https://doi.org/10.1177/10983007040060010201
Swain-Bradway, J., Johnson, J., Eber, L., Barrett, S., & Weist, M. (2015). Interconnecting school mental health and school-wide positive behavior support. In S. Kutcher, Y. Wei, & M. D. Weist (Eds.), School mental health: Global challenges and opportunities (pp. 282–298). Cambridge University Press.
U.S. Department of Health & Human Services. (2021). U.S. surgeon general issues advisory on youth mental health crisis further exposed by COVID-19 pandemic. MentalHealth.gov. Retrieved from: https://www.hhs.gov/surgeongeneral/index.html
Webster-Stratton, C., & Reid, M. J. (2010). The Incredible Years parents, teachers, and children training series: A multifaceted treatment approach for young children with conduct disorders. In J. R. Weisz, & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 194–210). The Guilford Press.
Weisbrot, D. M., & Ryst, E. (2020). Debate: Student mental health matters - The heightened need for school-based mental health in the era of COVID-19. Child and Adolescent Mental Health., 25(4), 258–259. https://doi.org/10.1111/camh.12427
Weist, M. D., Youngstrom, E. A., Stephan, S., Lever, N., Fowler, J., Taylor, L., McDaniel, H., Chappelle, L., Paggeot, S., & Hoagwood, K. (2014). Challenges and ideas from a research program on high quality, evidence-based practice in school mental health. Journal of Child and Adolescent Psychology, 43(2), 244–255. https://doi.org/10.1080/15374416.2013.833097
Funding
The writing of this paper was supported in part by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) award number 5R01HD073430, and the National Institute of Mental Health (NIMH) award number R01MH108555, and K23MH122577.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Eiraldi, R., Lawson, G.M., Patel, A. et al. Integration of Mental Health Interventions Within PBIS: a Mixed-Methods Analysis. Contemp School Psychol (2023). https://doi.org/10.1007/s40688-023-00472-6
Accepted:
Published:
DOI: https://doi.org/10.1007/s40688-023-00472-6