When I (Emily) was in elementary school, I vividly remember being screened for scoliosis. One day, all the students in my fifth-grade class marched down to the school library, and one by one, we were each briefly and privately evaluated by the school nurse. This was a form of universal screening: systematically screening every student for given criteria.
Universal screening continues to be commonplace today in our pre-K-12 schools. In education, we screen all students for academics: Are they reading on grade level? We screen all students for key health-related factors: Could their hearing or vision be impeding their academics? We provide universal screening for a variety of factors that can affect students’ school success … but what about screening for mental health?
Mental health concerns are prevalent in society, with approximately 80% of chronic mental health disorders beginning in childhood. The National Academy of Sciences estimates that 14% to 20% of youths each year are diagnosed with mental, emotional or behavioral mental health disorders. In addition, we are seeing substantial stress in childhood and adolescence. According to Dr. Sandra Hassink, a former president of the American Academy of Pediatrics, approximately one-third of children display signs of stress, while more than half of college students report overwhelming anxiety. Hassink categorizes stress as the “top health problem facing kids today.”
In addition to stress and anxiety, we remain concerned about the rates of suicide, self-harm, depression and school violence among pre-K-12 students. Despite the prevalence of mental health concerns, only 45% of youths with a diagnosis receive treatment. And less than 25% of those youths receive any form of treatment in the schools, despite the overwhelming evidence supporting early prevention and intervention.
In schools, it is often easier to identify externalizing behaviors such as aggression and rule breaking rather than internalizing behaviors such as depression, anxiety, isolation, suicidal ideation and so forth. In fact, in a 2008 study, Catherine Bradshaw, Jacquelyn Buckley and Nicholas Ialongo found that students with internalizing behaviors were substantially underserved in pre-K-12 schools compared with their peers with externalizing behaviors. This suggests that students with internalizing behaviors may fly under the radar of school staff, making them less likely to be identified and, thus, less likely to receive services.
Given the prevalence of mental health and behavioral concerns in students and the gaps in adequately identifying and serving students with elevated needs, there has been a call for change in pre-K-12 schools. After the devastating school violence and loss of life at Sandy Hook Elementary School in 2012, the Connecticut Office of the Child Advocate conducted a thorough investigation and made recommendations, the first of which was screening every student in a particular class, grade, school or district for criteria related to mental health or social/emotional indicators. Universal screening, also known as universal mental health screening (UMHS), has been recommended by a plethora of organizations, including the 2002 President’s Commission on Excellence in Special Education, the National Association of School Psychologists, the Institute of Medicine, the American Academy of Pediatrics, and A Framework for Safe and Successful Schools, which was authored or co-signed by a wealth of educational and mental health organizations.
Furthermore, burgeoning research supports the implementation of school-based UMHS, suggesting that it can increase the likelihood of identifying students with internalizing behaviors. Many of the schools we have talked to have echoed this sentiment, saying that after implementing UMHS, they identified students struggling with internalizing concerns who previously had not been identified by either the school or the family and thus were not receiving services. UMHS can help pinpoint student needs that are beyond the awareness of school staff and parents or guardians, thus ensuring that fewer students fall through the proverbial cracks.
Schools and school districts nationwide are considering UMHS, with more and more schools beginning implementation. At the same time, successfully facilitating this practice requires significant planning and time initially and having a system of resources readily available to serve the students, once identified. In 2018, the National Center for School Mental Health at the University of Maryland created a guide for operationalizing the steps to UMHS. We’ll describe those steps.
Step one: Create a multidisciplinary team and secure buy-in from key stakeholders. The UMHS team is responsible for designing and coordinating UMHS implementation. Because of the systemic nature of the process and the plethora of responsibilities, implementation should truly be a team effort rather than falling on one or two staff members. Team members could include school-based mental health providers such as school counselors and licensed mental health counselors, as well as school psychologists and school social workers. It is also important to include school-based and district-level administrators on the team, both for their expertise in school leadership and resource availability and to gain their buy-in. Some teams might have other stakeholders such as family members, school nurses, teachers, resource officers, and related community partners join the team to offer their unique perspectives. It might be helpful to develop district-level teams to discuss districtwide protocol and resources.
Once the team is assembled, it should collaborate with key stakeholders to gain momentum, support and resources. This buy-in can be developed by educating key stakeholders on the purpose and research behind UMHS and how UMHS can meet the specific needs of the school or district. The team can analyze the current concerns of the school or district by gathering corresponding data: Are students’ mental health needs being adequately identified and met? What are the most pressing issues in the school or district? For instance, has there been an increase in student suicide attempts or drug-related suspensions and use in the school and community? Is the team interested in prevention efforts to better identify students with internalizing concerns such as anxiety or depression?
Many of the schools and districts with which we have corresponded have reported that UMHS was supported and even driven by influential district-level stakeholders, such as a superintendent. It is important for counselors to understand that gaining buy-in for UMHS can take years and that it requires purposeful advocacy and education. When attempting to gain stakeholder buy-in, team members may find it fruitful to present UMHS as a tool to meet existing district priorities such as improving students’ social/emotional learning, enhancing college and career readiness, and removing barriers to learning.
Also, rather than presenting UMHS as “one more initiative,” team members can ask how this practice might tie into other programs that already exist in the school or district. UMHS is often implemented as part of multitiered systems of support (MTSS) such as response to intervention and positive behavioral interventions and supports. MTSS is widely implemented in all states nationwide, and its tiered focus on prevention for all students and identification and intervention for those with elevated needs is a natural fit with UMHS. Thus, teams could discuss UMHS within their school’s or district’s existing MTSS practices. Furthermore, in an effort to work smarter, not harder, consider whether an existing student support team is in place that could oversee UMHS, rather than creating a new team to do this.
This first step of garnering key stakeholder support may take some time. We’ve seen that using data to highlight school needs and connecting UMHS to district priorities and current programs generally assist with stakeholder buy-in.
Step two: Clarify the goals and purpose. Once the UMHS team is developed and has gained buy-in from instrumental stakeholders, the next step is confirming the goals and purpose of UMHS. During this step, the team can work with key stakeholders to continue reviewing school/district data and confirming the goals for UMHS. What is important to the stakeholders and the district? What are the most pressing needs for the school or district? It may take some time to reach consensus on the greatest need in the school or district.
Step three: Discuss resources and logistics. UMHS takes considerable planning as the team maps out its processes and procedures. Thus, much of the work for UMHS is done on the front end. Each school or district has unique needs and resources, so there is no one-size-fits-all approach for implementing UMHS. One question the team might ask during this step is which students are currently being screened or should be screened moving forward. We’ve seen some schools that screen for suicide and depression in high school health classes across all students, whereas other schools screen more broadly for strengths and difficulties at multiple grade levels, such as third, seventh and 10th grades. Still other schools may have the resources and desire to screen across every grade K-12. The answer to which students to screen may be based on a school’s or district’s resources and its driving purpose behind implementing UMHS.
Another consideration is garnering the support and consent of parents and guardians. First, the team might consider the overall readiness of parents and guardians for UMHS. Some schools recommend holding educational sessions for parents and guardians in which de-identified school-level data on student needs is provided, along with the rationale for using UMHS to meet those student needs. This may be a helpful time for the team to normalize mental health and UMHS by making comparisons to other school-based screenings for reading level, hearing, vision and so forth.
We also recommend demystifying UMHS by describing the procedures and perhaps showing examples of successful UMHS processes in other schools or districts. These information sessions can also describe how parents and guardians will be notified of their child’s results, especially for children identified with elevated needs. We have witnessed that parents and guardians are often supportive of UMHS when provided with ample and appropriate education and awareness, and when consideration is given to the unique culture of each school community.
Once schools have gained buy-in from parents and guardians, UMHS teams should engage in the consent process. Many schools have found success with a passive consent, notifying parents and guardians about UMHS through several means (email, automated phone calls, letters home, social media, etc.) and communicating that students will be included in the UMHS process unless the parent or guardian completes an opt-out form by a specified date.
When it comes to discussing resources and logistics for UMHS, two questions usually take precedence: How much will UMHS cost, and how much time will UMHS require? The UMHS team should work hand-in-hand with stakeholders, especially administrators who oversee the school or district budget and schedule, to address these concerns. School staff with whom we’ve spoken have reported that UMHS does take time and can have associated costs, especially in the beginning. However, these staff members have also expressed that the cost and time were absolutely worth it.
One cost associated with UMHS is the assessment or screener being used (we will discuss this in greater depth later in the article). Regarding time, the UMHS team should discuss how the school staff will be involved and the training required for their involvement. For example, who will administer and score the assessments/screeners? Who will communicate the results? Who will notify parents and guardians of elevated scores?
When considering time and costs, the UMHS team should also evaluate available resources for providing services to students identified with elevated needs. What school-based services will be offered? What referrals will be made for outside services? Teams typically map out the existing resources available within the school or district, as well as current and possible external partnerships. In anticipation of an increase in identified students and, thus, needed services, these partnerships and referral sources should be explored and confirmed prior to screening. In addition, teams need to create a plan for services based on student need and the level of immediacy (e.g., same-day supports for immediate/critical needs versus same-week supports for moderate needs). Relatedly, some schools secure grants and Medicaid funding to finance provision of services in the schools by community-based mental health professionals.
Other questions that come up frequently center on the issue of liability. For example, schools often ask us:
- “What if we identify students with elevated needs, such as suicidal ideation, and the parents or guardians refuse services?”
- “What if we have more students eligible than we have available services?”
- “Legally, how do we document these results?”
- “Regarding confidentiality: which school staff members should be aware of the results?”
- “Do the results become part of a student’s permanent file?”
These are important questions to consider and talk through with the UMHS team, especially administrators and the school district’s legal experts. By establishing clear district policies and defining protocols proactively, the UMHS team can get ahead of many of these concerns. Furthermore, small-scale pilot screening can help teams predict schoolwide prevalence of students who will need intervention. Collecting and sharing de-identified screening data can also be an essential step in advocating for additional services and resources.
Another important logistic to consider is time. As mentioned, teams usually spend considerable time planning for UMHS implementation, including designing a timeline. Within this timeline, teams often consider conducting a pilot screening, testing UMHS with a small sample of the school, such as a class in each participating grade. After this pilot, schools can collect feedback on the screening to guide changes to the process and procedures before rolling out UMHS throughout the school or district.
The team might also consider the time of year, week and day that UMHS will be implemented. It is often recommended to begin UMHS toward the start of the school year but to allow enough time for students to settle into their new routines and for students and teachers to have built rapport. This also provides time for follow-up screening to occur after the initial baseline. In addition, screening could take place early in the day, such as during an advisory or home room period, and early in the week. This allows time for immediate follow-up, particularly for students identified as having high needs. It also allows time to reach out to the student, parents or guardians, and school-based and community-based resources. In fact, some schools align their UMHS schedules with the availability of internal and external referral sources to ensure that mental health providers are on standby to assist immediately if needed.
Step four: Select a screening tool. Selecting an appropriate screening tool is a crucial aspect of UMHS. Because no two schools are alike, each team should consider its school’s specific needs, culture and resources. The National Center for School Mental Health recommends asking the following questions when considering screening tools:
- Is the tool reliable, valid and evidence-based? In other words, has the tool been empirically tested and backed by research? Similarly, was this tool normed on a population that is similar to the school or district population? We want a tool that is culturally appropriate, valid and reliable, and, thus, as accurate as possible.
- Is the tool free, or can it be purchased for a reasonable cost? Tools have a range of costs, which is important to consider based on the school’s or district’s budget and the number of students completing the tool.
- How long will it take to administer and score the tool? Time is a precious commodity in education. Thus, the UMHS team should investigate the possible options for administering and scoring tools. Although paper-and-pencil tools exist, schools often prefer administering screening tools through online means (e.g., Google forms) or Scantrons. Electronic administering and scoring can lead to fewer errors and faster results.
- Does the tool come with ready access to training and technological support for staff? As mentioned earlier, staff need to be trained on UMHS procedures, including administering and scoring screening tools. Furthermore, most tools have educational requirements, such as a master’s degree in specific fields, associated with administering and scoring them. Hence, some schools and districts have determined that school psychologists or school counselors are responsible for administering and scoring the tools because of their training and expertise.
- Does the tool screen for what the school or district wants to know (e.g., type of mental health or behavioral concern)? Specifically, do the goals and purpose of the UMHS process align with the aim of the screening tool? If a school’s goal is to screen for internalizing mental health concerns (e.g., depression, anxiety, self-harm, suicidal ideation), does the selected tool actually screen for those concerns?
It is important to note that the developmental age of students should be considered when selecting a screening tool, as should the type of administration. Some tools are self-reports completed by the students, whereas other tools are completed by teachers or parents and guardians (this is especially the case when screening younger students). It is also important to discuss the meaning of specific scores for each tool in advance of data collection and analysis. For instance, what score constitutes a high risk in need of immediate follow-up? What score constitutes a moderate risk, and when should follow-up occur? What score constitutes little or no risk?
The following list includes common UMHS tools:
- Systematic Screening for Behavior Disorders: Screens for internalizing and externalizing concerns (K-9)
- Student Risk Screening Scale: Screens for seven externalizing behavioral criteria (lies, cheats, sneaks; steals; behavior problems; peer rejection; low academic achievement; negative attitude; and aggressive behavior) three times per year (K-12)
- Behavior Assessment System for Children, Third Edition: Behavioral and Emotional Screening System: Identifies students with needs in both academic and social domains, including internalizing problems, externalizing problems, school problems and adaptive skills (pre-K-12)
- Strengths and Difficulties Questionnaire: Screens broad behavioral domains, including emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behavior (K-12)
- Resiliency Scales for Children and Adolescents: Profiles personal strengths and vulnerability (ages 9-18)
Step five: Collect data, analyze and follow up. After implementation of the screening tool, UMHS teams will engage in data collection, analysis and follow-up according to their individualized plans. Follow-up may include further evaluation and services for students with elevated needs. It may also include monitoring students with elevated needs and providing additional screening at different points during the school year and subsequent school years. As emphasized by the National Center for School Mental Health, it is imperative that students with high risk to themselves or others receive follow-up the same day.
UMHS and counselors
Both school counselors and licensed mental health counselors (LMHCs) can play active roles in UMHS in several ways. First, school counselors run comprehensive school counseling programs that provide a range of student services, including direct counseling services. School counselors also provide consultation and collaborate as members of student support teams and schoolwide leadership teams. Thus, school counselors should be active members of their respective UMHS multidisciplinary teams, helping to design and implement the screening process, and sharing their expertise on mental health, equity, data-driven practices and culturally responsive systemic change. As part of a UMHS team, school counselors may also assist with analyzing the screening data, referring students to mental health services, and engaging in progress monitoring and continued evaluation. School counselors may also provide counseling services, although their counseling should be short term and time bound.
LMHCs can also be involved in UMHS screening in a variety of ways. School-based or community-based LMHCs may be invited to be members of a UMHS team because they can provide expertise on mental health needs and the services available in the school and community. In addition to consulting and collaborating on screening procedures and data analysis, LMHCs can provide further evaluation and long-term and crisis counseling to those students identified with elevated needs.
Again, we emphasize that counselors’ roles, and the corresponding procedures and services, may be different based on each school’s or district’s culture, resources and needs.
Challenges and benefits
There are both challenges and benefits to implementing UMHS. Among the challenges, there is no denying that screening takes time, resources, stakeholder support and substantial planning. The stigma surrounding mental health issues can also test stakeholders’ willingness to implement UMHS in schools. In addition, some educators and legislators have voiced concerns that UMHS could lead to the overdiagnosis and unnecessary stigmatizing of students, giving them labels that could last a lifetime.
School leaders are often hesitant to initiate a UMHS program if they lack the resources to meet identified needs without collaborating with outside agencies. Some school administrators in rural areas indicate that school-based mental health services are the only such services available for most families. Teams working to implement UMHS must be prepared to address resistance to universal screening in their communities as part of the implementation process. Hence the importance of seeking early education and buy-in.
At the same time, UMHS is associated with a wealth of benefits, including:
- Prevention and early identification and treatment of mental health and behavioral concerns
- The use of data to guide mental health interventions
- A comprehensive approach that encourages systemic thinking and breaks down school/community/family silos
- Collaboration across school-based mental health providers and between school-based and community-based mental health providers
- Greater normalization and awareness of mental health issues within the schools
Schools and school districts have told us that implementing UMHS is worth the associated challenges. Many school-age youths struggle with mental health and behavioral concerns, yet their struggles are not always identified or treated, leading to larger long-term concerns. Because of the climbing rates of school violence, anxiety, depression, self-harm and suicide among our youths, we need a better system. We need a system in which fewer youths fall through the cracks. We need a system in which more youths are identified earlier and more accurately. We need a system that is comprehensive and that works.
For more information, we suggest the following resources:
- The School Counselor’s Guide to Multi-tiered Systems of Support edited by Emily Goodman-Scott, Jennifer Betters-Bubon and Peg Donohue (2019, Routledge). This book discusses aligning comprehensive school counseling with MTSS, devoting a chapter to UMHS.
- The SHAPE System (theshapesystem.com): The School Health Assessment and Performance Evaluation System is a free, private, web-based portal that offers a virtual workspace for school mental health teams to document, track and advance quality and sustainability improvement goals and to assess trauma responsiveness.
- National Center for School Mental Health (csmh.umaryland.edu): The center is committed to enhancing understanding and supporting implementation of comprehensive school mental health policies and programs that are innovative, effective, and culturally and linguistically competent across the developmental spectrum (preschool to postsecondary) and three tiers of mental health programming (promotion, prevention, intervention).
- Systematic Screenings of Behavior to Support Instruction: From Preschool to High School by Kathleen Lane, Holly Menzies, Wendy Oakes & Jemma Kalberg (2012): The authors show how systematic screenings of behavior, used in conjunction with academic data, can enhance teachers’ ability to teach and support all students within a response-to-intervention framework.
- School-Wide Universal Screening for Behavioral and Mental Health Issues: Implementation Guidance (tinyurl.com/OhioPBISGuide): This document provides a general overview of considerations in implementing UMHS for behavioral and mental health issues.
Emily Goodman-Scott is an associate professor, graduate program director and school counseling coordinator in the counseling program at Old Dominion University in Virginia. Prior to that, she was a school counselor and special education teacher. She is passionate about advocating for lower caseloads and greater resources for school counselors and schools. Her research interests include a range of school counseling topics such as multitiered systems of support (MTSS), counselor education, and counseling exceptional students. Contact her at email@example.com or on Twitter: @e_goodmanscott.
Jennifer Betters-Bubon is an associate professor of counselor education at the University of Wisconsin-Whitewater. Previously, she was an elementary school counselor for 11 years and a special education teacher. In addition to teaching future counselors, her work focuses on data-driven practice, advocacy and leadership in transforming the role of the school counselor within culturally responsive MTSS. Contact her at firstname.lastname@example.org.
Peg Donohue is an assistant professor of counseling at Central Connecticut State University (CCSU) in the Department of Counseling and Family Therapy. Before joining the CCSU faculty, she spent 16 years working as a school counselor in Connecticut and California. Her primary research interests include fostering social and emotional learning, aligning school counselor preparation with MTSS, and universal screening for mental health concerns in schools. Contact her at email@example.com.
For more resources and conversations on UMHS, follow the authors on Twitter:
@SchCouns4MTSS and Facebook: School Counselors for MTSS.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.