MENTAL HEALTH WITHIN A MULTITIERED SYSTEMS OF SUPPORT FRAMEWORK:

The Practice of School Psychologists

by

Margaret A. Sedor, M.S., NCSP, LEP

San Diego State University and Claremont Graduate University

April 2, 2019

© Margaret A. Sedor, 2019

All rights reserved.





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by

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 APPROVAL OF THE DISSERTATION COMMITTEE

This dissertation has been duly read, reviewed, and critiqued by the Committee listed below,

which hereby approves the manuscript of Margaret A. Sedor as fulfilling the scope and quality

requirements for meriting the degree of Doctor of Philosophy.

Dr. Rafaela M. Santa Cruz, Co-Chair Dr. Carl Cohn, Co-Chair

San Diego State University Claremont Graduate University

Professor Professor

Dr. Colette Ingraham, Committee Member

San Diego State University

Professor

Dr. Kyo Yamashiro, Committee Member

Claremont Graduate University

Professor
 Abstract

MENTAL HEALTH WITHIN A MULTITIERED SYSTEMS OF SUPPORT FRAMEWORK:

The Practice of School Psychologists

by

Margaret A. Sedor, M.S., NCSP, LEP

Doctor of Philosophy in the Graduate School of Education

San Diego State University and Claremont Graduate University: 2019

The prevalence of mental health concerns of youth within the United States is increasing.

Yet, the lack of access to services continues to be a critical issue. Schools are commonly

recognized at an increasing rate as the primary location for the provision of comprehensive

mental health services for students. Recent national- and state-level educational policies have

explicitly identified school psychologists as key school-based mental health professionals to

provide leadership and deliver a continuum of school-based mental health services. There are

few existing studies on the practice of school psychologists as mental health providers, and even

fewer studies on the barriers and supports school psychologists face in the provision of mental

health services within a comprehensive, cohesive, multitiered systems of support (MTSS)

framework.

The purpose of the current study is to advance the research on school psychologists as

mental health leaders and identify the role of school psychologists across a multitiered

continuum of school mental health services. Because existing literature primarily utilizes a

national sample of school psychologists and a narrow definition of mental health services (i.e.,

direct counseling services), this study aimed to understand the practice of school psychologists in

California as providers within a comprehensive continuum that encompasses mental health

wellness, chronic stressors, and serious mental illness. The researcher provides a new lens on the

professional contextual factors of school psychologists that serve as barriers and supports to

engage in mental health services within the MTSS framework. The current study was a mixed-

methods study among California school psychologists. Participants completed an online survey.

Upon completion, some chose to participate in a one-on-one personal interview with the

researcher. The researcher recorded candid responses about participants’ training and

experiences as mental health providers, as well as the professional and demographic factors that

serve as supports or barriers in the provision of mental health services within an MTSS

framework. The researcher discovered school psychologists have transformed their practice

beyond direct services to encompass prevention and wellness promotion services, universal

screening, implementation of evidence-based interventions, progress monitoring, and systematic

decision making about programming and services. Findings also indicated a significant

correlation between professional development and the amount of time school psychologists

engaged in mental health activities, including prevention and wellness promotion, evidence-

based interventions, and systematic data-informed programming and services. Further, the most

frequently mentioned factors supporting the delivery of mental health services included support

from administration, training and professional development, time, and collaboration with other

school-based mental health providers. The barriers school psychologists reported most frequently

to interfere with the provision of mental health services included limited time, lack of

administrator support, and the ratio of school psychologists to students. School psychologists are

interested in providing mental health services, have transformed their practice into prevention

and wellness promotion efforts, and are engaged in systemic mental health frameworks such as

MTSS.
 Dedication

First and foremost, I thank God for providing me with passion, strength, and endurance

throughout this experience. I dedicate this work to my father, Gerald Sedor, and my mother,

Alma Sedor. You both have always believed in me and have been my light along this journey. I

have persevered because of your enduring example of love, persistence, laughter, and generosity.

I am blessed to have you as my parents—I love you.

 Acknowledgements

This journey has been one of strength, fortitude, persistence, and endless support from a

community of so many people along the way. To the members of my dissertation committee,

thank you for your invaluable time, support, and encouragement. Dr. Santa Cruz, thank you for

your insight, analytical expertise, patience, and invaluable feedback. Dr. Cohn, thank you for

your expertise, wisdom, faith, and enduring commitment. Dr. Yamashiro, thank you for your

knowledge, feedback, and guidance throughout this process. Dr. Ingraham, thank you for your

mentorship, coaching, and encouragement across the years. I could not have asked for a better

role model in school psychology, along with Drs. Valerie Cook Morales, Jean Ramage, Carol

Robinson Zanartu, and Brian Leung, who all served collectively as mentors and provided the

foundation for me to become a school psychologist invested in addressing the mental health

needs of our students by transforming the systems within our educational community.

To the SDSU-CGU joint doctoral students and support system: My colleague and

classmate Rachel Stein, thank you for reconnecting me, the long drives to class, and endless

hours of writing. Cecilia Necoechea, Cece Gaddy, Grace Elliott, and Yvonne Tempel, thank you

for your enduring guidance and navigation throughout this journey.

To the school psychologists who engaged in this journey alongside of me and who shared

their stories with me: I am honored that I had the opportunity to learn from each of you about our

profession and the important work we do with our students, families, fellow educators, and

community. Thank you Heidi Holmblad for facilitating the collaboration with CASP and

supporting this important research within our state and profession. To my SANDCASP and

CASP colleagues and friends: Thank you for your positivity, leadership, and faith. To my NASP

and GPR family: Your advocacy, compassion, and continual encouragement has truly been

vii
amazing—thank you. Dr. Robert Dixon, thank you for the endless hours of coaching, guidance,

mentorship, and cheering from the cheap seats; I am forever grateful. Drs. Katie Eklund, Kelly

Vaillancourt-Strobach, Kari Oyen, Anthony Adamowski, John Kelly, Stephen Brock, Ray Easler,

and Steve Fisher, I appreciate your friendship, knowledge, and support along this journey.

To my work family, Clarisa Gomez, Susie Robinson, Kenya Bratton, Nancy Park, Ruben

Sanchez, Elise Matos, Antonia Terrazas, Molly Ravenscroft, Carrie Rea, Dr. Mariana Gomez, Dr.

Jay Marquand, Dr. Joe Fulcher, and Dr. Karen Janney: Thank you for your perpetual

encouragement and faith. To my PENT and SELPA Crisis team: Russell Coronado, Ryan

Estrellado, Marcus Jackson, Chelsea Gould, Elizabeth Fogaren, and Reid Burns, thank you for

your affirmation, kindness, and compassion. To my Immaculata Family: Father Matt Spahr,

Clarisa Gomez, Doreen Matzke, Vida Gruning, Laurie Ruthven, Jim and Pat Spotts, Mary Ellen

McLaughlin, your prayers, guidance, and kindness have been priceless. To my New England

friends that are like family: Laurie Relinkski, Lynn Russ, Jane Durgin, Jean Burbank, Tammy

Melcher, Jay Oswell, Lucille Cassis Rogers, thank you for accompanying me along this journey.

To my family: Gerald Sedor, Alma Sedor, Kathy Sedor, Jim Sedor, Julie Sedor, John

Sedor, Val Sedor, Liz Nordlie, Katie Sedor, Hollie Sedor, Chris Nordlie, Ella Nordlie, Luke

Sedor, and Mia Sedor, thank you for your laughter, love, and positivity. I am blessed that we are

family; I love you all.

To my husband, Jonathan Frye: I am so blessed to have you as a best friend and partner.

Thank you for the love, laughter, support, and encouragement to hang in there during the more

challenging times. I so appreciate having you by my side. Our journey together has taught me so

much and I love you!

viii
 Table of Contents

Chapter 1 Statement of the Problem ............................................................................................... 1

Theoretical Framework ................................................................................................................2

The Public Health Model .............................................................................................................3

MTSS Framework for Mental Health ..........................................................................................4

Mental Health MTSS Components ..............................................................................................6

Research Questions ....................................................................................................................11

Significance of the Study ...........................................................................................................11

Limitations of the Study .............................................................................................................12

Definition of Terms ....................................................................................................................13

Organization of Dissertation ......................................................................................................14

Chapter 2 Literature Review ......................................................................................................... 16

Prevalence of Student Mental Health Needs ..............................................................................16

Mental Illness of Youth ..............................................................................................................18

Mental Health Services in Schools.............................................................................................20

National Policy ...........................................................................................................................23

California State Policy ...............................................................................................................25

The Practice of School Psychologists ........................................................................................30

Application of MTSS as a Prevention Model ............................................................................36

Conclusions ................................................................................................................................37

Chapter 3 Methodology ................................................................................................................ 39

Research Design .........................................................................................................................39

Protection of Human Subjects ....................................................................................................42

ix
 Instrumentation...........................................................................................................................43

Procedures ..................................................................................................................................46

Data Analyses .............................................................................................................................47

Chapter 4 Findings and Discussion............................................................................................... 50

Demographics.............................................................................................................................51

Analyses for Research Question 1 .............................................................................................57

Mental Health Practice of School Psychologists ................................................................... 57

Analyses for Research Question 2 .............................................................................................68

Factors Supporting Provision of Mental Health Services ..................................................... 68

Analyses for Research Question 3 .............................................................................................76

Factors Limiting Provision of Mental Health Services ......................................................... 76

Analyses for Research Question 4 .............................................................................................85

School Setting and Community Professional Workplace...................................................... 85

Analyses for Research Question 5 .............................................................................................92

Years of Experience............................................................................................................... 95

School Psychologist to Student Ratio .................................................................................... 97

Chapter 5 Summary, Conclusions, and Recommendations ........................................................ 100

MTSS Components ..................................................................................................................100

Supportive Factors....................................................................................................................103

Limiting Factors .......................................................................................................................105

Conclusions ..............................................................................................................................115

Recommendations ....................................................................................................................116

Appendix A – School Psychologist Recruitment Letter ............................................................. 138

x
Appendix B – Survey Informed Consent .................................................................................... 139

Appendix C – Survey Questions ................................................................................................. 143

Appendix D – Interview Informed Consent................................................................................ 156

Appendix E – Interview Questions ............................................................................................. 157

Appendix F – Methods Matrix .................................................................................................... 159

Appendix G – Range of Hours Engaged in MTSS Components Frequency & Percentages ...... 161

xi
 List of Tables

Table 1 – Research Design ............................................................................................................41

Table 2 – Demographics of Survey Participants Frequency & Percentages .................................54

Table 3 – Characteristics of Professional Workplace Frequency & Percentages ..........................55

Table 4 – Demographics of Interview Participants-School Setting, Community, Experience ......57

Table 5 – Hours per Week Engaged in Mental Health MTSS Components .................................59

Table 6 – Scope of Mental Health Services within MTSS Components Frequency .....................63

Table 7 – Fixed-Choice Survey Question Identified Degree of Administrator Support for

Provision of a Comprehensive continuum of Mental Health Services Frequency &
Percentages ....................................................................................................................69

Table 8 – Fixed-Choice Survey Question Identified Supports for Provision of Mental Health
Services Frequency & Percentages ...............................................................................70

Table 9 – Open-Ended Survey Identified Supports for Provision of Mental Health Services
Frequency & Percentages ..............................................................................................71

Table 10 – Fixed-Choice Survey Identified Barriers in Provision of Mental Health Services

Frequency & Percentages ............................................................................................78

Table 11 – Open-Ended Question Identified Barriers in the Provision of Mental Health Services
Frequency & Percentages ............................................................................................81

Table 12 – Factors that Influence Mental Health Service Delivery...............................................86

Table 13 – MTSS Component 1 by School Setting and Community Means and Standard
Deviations ...................................................................................................................87

Table 14 – MTSS Component 2 by School Setting and Community Means and Standard
Deviations ....................................................................................................................88

Table 15 – MTSS Component 3 by School Setting and Community Means and Standard
Deviations ...................................................................................................................89

Table 16 – MTSS Component 4 by School Setting and Community Means and Standard
Deviations ....................................................................................................................89

xii
Table 17 – MTSS Component 5 by School Setting and Community Means and Standard
Deviations ....................................................................................................................90

Table 18 – Correlations of MTSS Components, Demographic, and Professional Contextual

Factors ..........................................................................................................................93

Table 19 – Statistics for MTSS Components by Years of Experience ..........................................95

Table 20 – Statistics for MTSS Components by Ratio of School Psychologist to Student ...........98

xiii
 List of Figures

Figure 1 – Mental Health Multitiered System of Support (MTSS) Framework ..............................7

Figure 2 – Range of Hours for MTSS Components ......................................................................61

Figure 3 – School Setting and Community Influence of Mental Health Service Delivery ...........93

xiv
 Chapter 1 Statement of the Problem

The importance of providing mental health services for youth has been well established,

and schools have been recognized as the system in which students most frequently access these

services (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Farmer, Burns, Phillips, Angold,

& Costello, 2003; Flaherty, Weist, & Warner, 1999; Knopf, Park & Mulye, 2008; Merikangas et

al., 2010; Perou et al., 2013). The high prevalence of students’ mental health needs and the

inadequate access to services require that school mental health providers, such as school

psychologists, serve in leadership roles. Recent changes in national educational policy (i.e.,

Every Student Succeeds Act [ESSA], 2015) and California Education Code 49424 explicitly

identified school psychologists as optimal and qualified providers of mental health services

within schools (California Department of Education [CDE], 2010; U.S. Department of

Education, 2016). The CDE (2018) reported the count of school psychologists in the state to be

6,159 during the 2017-18 school year, and the ratio of the school psychologists to students was

1:1,000 (CDE, 2018).

School psychologists are uniquely qualified mental health providers and possess expertise

and experience in mental health and learning (Beam, Brady, & Sopp, 2011; ESSA, 2015; Nastasi

et al., 2000; National Association of School Psychologists [NASP], 2010). School psychologists

have demonstrated the desire to transform their role beyond conducting traditional

psychoeducational assessments to providing a continuum of mental health services to address the

unmet mental health needs of youth and respond to recent educational policy changes (Eklund,

Meyer, Way, & McLean, 2017; Hanchon & Fernald, 2013; Hosp & Reschly, 2002; Larson &

Choi, 2010; Perfect & Morris, 2011; Suldo, Friedrich, & Michalowski, 2010). Research indicates

school psychologists’ expertise is instrumental in providing mental health services and in

1
implementing a school-wide prevention model that reaches the entire student population (Hess,

Pearrow, Hazel, Sander, & Willie, 2017; NASP, 2015; Nastasi, Vargas, Bernstein, & Plymert,

1998). Little evidence exists on the practice of school psychologists as mental health providers

within a continuum of comprehensive services such as multitiered systems of support (MTSS).

Theoretical Framework

According to Garbarino (2001), “Thinking ecologically about health and equally

approaching health as a social-ecological issue is at the crux of new work attempting to address

social, physical, and mental health well-being” (p. 363). Mental health exists on a continuum

comprised of mental wellness, enduring stress, and serious mental illness. Thus, students can

access a variety of support services including prevention, intervention, and intensive mental

health services. The MTSS framework for mental health is based on the public health conceptual

framework of prevention within the U.S. Surgeon General’s report on mental health (U.S.

Department of Health and Human Services, 2000; Walker et al., 1996). The paradigm shifts in

the practice of school psychologists as mental health providers embodies critical components of

the public health approach (Nastasi, Overstreet, & Summerville, 2011) and promotes the

provision of mental health services along a continuum of universal, targeted, and intensive

mental health support services. Services span from system-level prevention approaches within

the environments children and adolescent function in by engaging in health promotion or risk

prevention supports, such as the development of social-emotional competence, coping strategies,

and wellness promotion, to direct therapeutic services among individuals with significant mental

health issues. Nastasi et al. (2011) identified the need for a broad system of care that would

provide a continuum of mental health services for students, as well as support for their parents

and teachers.

2
 Doll and Cummings (2008) asserted the need to shift from the traditional school mental

health services model to an ecological, population-based mental health services framework with

a focus on multiple ecological systems of classrooms, schools, and families. The traditional

model of services is predicated on the deficiencies attributed to the individual student. The

ecological model focuses on strengthening the characteristics of the ecosystem related to

educational success (i.e., classroom and school). An ecological approach to school mental health

can enhance the contributions of school psychologists to routines and practices that support the

success of youth in school (Doll, Spries, & Champion, 2012).

The Public Health Model

The public health model approach, which addresses the mental health of children and

adolescents, is composed of wellness promotion, prevention, and treatment of mental health

problems to optimize the mental health and development of all children and adolescents within

the environmental systems in which they function (Miles, Espiritu, Horen, Sebian, & Waetzig,

2010; Nastasi, 2004; Nastasi et al., 2011; Substance Abuse and Mental Health Services

Administration [SAMHSA], 2014). The public health model also considers the ecological

contexts that influence the well-being of students. This perspective focuses on three population-

level outcomes: (a) creating environments to promote and support optimal mental health and

resilience skill development; (b) creating a balanced-approach for mental health problems and

positive mental health; and (c) working collaboratively across a system that impacts the well-

being of all students (Miles et al., 2010).

The National Association of School Psychologists (2010) established the school

psychology standards of practice aligned with the public health model, The Model for

Comprehensive and Integrated School Psychological Services. MTSS is grounded in the public

3
health model of prevention and seeks to prevent, minimize, and resolve mental health problems

to promote the social, emotional, and academic success of all students within the school system

(Strein, Hoagwood, & Cohn, 2003). The MTSS framework is an important structure for school

psychologists to support their practice as school-based mental health providers for the health,

well-being, and educational success of students.

MTSS Framework for Mental Health

Many researchers, professional organizations, and policymakers have engaged in

advocacy efforts and policy development for the utilization of a comprehensive, coordinated, and

integrated continuum of school mental health services to address the mental health needs of all

students (Cook et al., 2010; Doll & Cummings, 2008; Hess, Short, & Hazel, 2012; Vaillancourt,

Cowen, & Skalski, 2013). MTSS is a comprehensive prevention-oriented service delivery

framework which organizes and delivers a continuum of evidenced-based practices that

encompass mental wellness, chronic stress, and severe mental illness in tiers of intensity to

address the social, emotional, and behavioral needs of all students (Cook, Burns, Browning-

Wright, & Gresham, 2010; Cook et al., 2015; Zhang, 2015).

MTSS is defined as a framework that encompasses prevention and wellness promotion,

as well as universal screening for academic and behavioral barriers to learning. The framework

includes implementing evidence-based interventions that increase in intensity as needed. In

addition, it monitors the ongoing progress of students in response to implemented interventions

and engages teams in systematic decision making about programming and required student

services based upon specific student outcome data (Vaillancourt et al., 2013).

Historically, the MTSS framework was represented as a pyramid of three-layered tiers of

prevention: Primary Prevention/Universal, Secondary Prevention/Targeted, and Tertiary

4
Prevention/Intensive. The MTSS framework optimizes positive mental health to foster a greater

sense of social well-being and provides support for all students (Miles et al., 2010). The primary

prevention and universal supports are mental health promotion services and programs that build

community and resiliency to prevent the development of mental health problems. These services

encompass approximately 80% of the needs of both students and adults within the educational

milieu. The secondary prevention supports the targeted services designed for early intervention

for approximately 15% of students at risk of mental health issues (Miles et al., 2010). The

tertiary prevention (intense services) provides for the 5% of students requiring high levels of

intervention for moderate-to-severe mental health issues.

The theoretical framework for MTSS rises from the research and practice literature in

school-based mental health services which promotes a multitiered approach to services for

students. MTSS is recognized as a significant advancement of comprehensive school reform, to

allocate school resources effectively and efficiently, identify students in need of services and

supports, and enhance the learning of all students (Jimerson, Burn, & Van Der Heyden, 2007;

Sailor, 2015). This multitiered, population-based approach was developed from the public health

model and utilizes tiers of intervention depending on the needs of the population (Kutash,

Duchnowski, & Lynn, 2006). MTSS is a whole school, data-driven, prevention-based framework

for improving learning outcomes for all students through a layered continuum of evidenced-

based practices and systems. MTSS shifts the identification or labeling of mental health

problems from the student as the identified “client,” to identification and implementation of a

continuum of prevention and intervention strategies and services. The MTSS framework aligns

the system of initiatives, supports, and resources as well as implements continuous improvement

5
processes through the system to address the whole child (CDE, 2017). The MTSS framework

consists of five components.

Mental Health MTSS Components

Component 1: Prevention and wellness promotion. Prevention and wellness promotion

mental health activities are universal strategies that are informed by an understanding of

mental health and designed to optimize positive mental health, build resilience, address

barriers to learning, support protective factors, and minimize mental health risk factors in

school. Typical activities include mental health consultation and suicide prevention

efforts, as well as school or classroom wide approaches including restorative practices

and social emotional learning.

Component 2: Universal screening for academic and behavioral barriers to learning. The

universal screening for barriers to learning is a systematic assessment of all children

within a given class, school building, or school district regarding social-emotional or

mental health strengths and early risk indicators. Examples of the universal screening

include the California Health Kid Survey (CHKS), school climate surveys, and strength-

based assessments.

Component 3: Implementing evidenced-based interventions. The implementation of

evidenced-based interventions includes targeted and indicated services for at-risk

students and group level resilience-building and intensive services that address mental

health risk factors. Services include individual and group counseling, social skills

instruction, and conducting risk and threat assessments.

Component 4: Progress monitoring. The progress monitoring consists of measurement and

feedback regarding evidence-based mental health interventions. The activities in this

6
 component include monitoring the progress of social emotional goals and interventions.

Component 5: Systematic decision making about programming and services. The

systematic decision making about programming and services is a process used by a

stakeholder team from multiple settings to analyze and evaluate information related to

planning and implementing effective instructional strategies matched to student mental

health needs. This component involves engagement of leadership teams in collecting,

analyzing, and utilizing data to address student educational needs.

The researcher translated the traditional three-tiered MTSS model consisting of universal,

targeted, and intensive levels of interventions and services into the comprehensive, cohesive, and

integrated five-component MTSS framework (Vaillancourt et al., 2013). The five-component

MTSS framework was utilized as the overarching structure to explore the services provided by

school psychologists in addressing the mental health needs of students. A visual depiction of the

MTSS framework is presented in Figure 1.

The MTSS framework as the foundation of this study explicitly broadens the

conceptualization of mental health services to include five components: (1) prevention and

wellness promotion, (2) universal screening, (3) evidenced-based interventions, (4) progress

monitoring, and (5) systematic decision making for programming and services. MTSS

Component 1 extends the universal tier of the traditional model beyond class and/or school-wide

prevention and wellness promotion services such as self-care, mindfulness, and relationship

building to include universal screening for barriers to learning (MTSS Component 2), which is a

systematic assessment of all students regarding social, emotional, and mental health strengths

and early risk indicators.

The targeted tier of the traditional model is expanded within the five-component MTSS

7
framework to include the universal screening of mental health strengths and early risk indicators

(MTSS Component 2) in addition to the corresponding evidenced-based interventions (MTSS

Component 3). The evidenced-based interventions include targeted group level resilience-

building services and intensive mental health services for at-risk students.

The intensive tier of the traditional model is comprised of evidenced-based interventions

(MTSS Component 3) and is expanded in the five-component MTSS framework to include a

progress monitoring system (MTSS Component 4) to measure and provide outcome feedback

regarding the evidenced-based interventions, programs, and services. A newly identified and

vital component to the MTSS framework is systematic decision-making for programming and

services (MTSS Component 5), which is threaded throughout the comprehensive, cohesive

integrated five-component MTSS framework. It is a process by which stakeholder teams

evaluate and analyze data related to planning and implementing effective strategies matched to

student mental health needs.

Purpose of the Study

There are a limited number of studies on the practice of school psychologists in the

provision of mental health services. It is critical to understand providers’ perspectives regarding

mental health services and the time apportioned, as well as the supports and barriers to

implementing these services. National studies have examined the graduate training and

coursework which prepares school psychologists as qualified providers of mental health services,

the amount of time school psychologists spend providing direct counseling services, the system-

level factors that limit and facilitate involvement in mental health services, the impact of staffing

ratios on service provision, and the influence of legislation and policy changes on the

transformation of the practice of school psychologists (Curtis et al., 2004, 2008;

8
Figure 1. Mental Health Multitiered Systems of Support Framework

Curtis, Hunley, & Grier, 2002; Eklund et al., 2017; Farmer et al., 2003; Hosp & Reschly, 2002;

Larson & Choi, 2010; Massey, Armstrong, Boroughs, & Henson, 2005; Reschly, 2000; Suldo et

al., 2010). To date, there have been no studies based on the MTSS framework among California

school psychologists examining the amount of time and types of mental health services, the

corresponding supports and barriers, or the professional and demographic contextual factors

9
among those implementing mental health services. Additionally, there are no studies conducted

since the recent changes in federal and state educational policies addressing the mental health

needs of students.

The researcher sought to contribute to the limited existing body of knowledge through a

study of school psychologists as mental health providers within a continuum of comprehensive,

cohesive tiered service delivery model. Because the existing literature primarily focuses on

traditional practice of school psychologists at the national level, this research explored: (a) the

percentage of time and the type of mental health services school psychologists provide with five

components of MTSS, (b) demographic contextual factors (i.e., professional development,

experience), and (c) professional contextual factors (i.e., school setting, community, and the ratio

of school psychologist to students). This research focused on how best to capitalize on the

knowledge, expertise, and leadership of school psychologists.

The researcher conducted a mixed-methods study of California school psychologists from

primary and secondary school settings within urban and suburban communities. Participants

provided information about the time and services they provide across the five components of the

MTSS framework: prevention and wellness promotion, universal screening, evidenced-based

interventions, progress monitoring, and systematic decision making about programming and

services. The use of the MTSS framework provided a deeper understanding of the transformation

in the practice of school psychologists from a traditional assessment role to a comprehensive role

as mental health providers.

10
Research Questions

Five overarching research questions guided this research:

1. What is the current practice of school psychologists in the provision of MTSS

components of mental health services?

2. What factors support the practice of school psychologists in the provision of MTSS

components of mental health services?

3. What factors limit the practice of school psychologists in the provision of MTSS

components of mental health services?

4. Are there differences in the practice of school psychologists in the provisions of MTSS

components of mental health services in terms of professional contextual factors

including school setting (i.e., primary, secondary) and community (i.e., urban, suburban)?

5. What is the relationship between demographic contextual factors, professional contextual

factors, and the provision of mental health services for each of the MTSS components?

Significance of the Study

The increasing prevalence of mental health needs of youth is a public health crisis (Doll

et al., 2003; NAMI, 2013; U.S. DHHS, 2000; WHO, 2014). Youth within America continue to

have inadequate access to mental health services (Brock & Reeves, 2017; NAMI, 2013;

SAMHSA, 2014; Weist, Lever, Bradshaw, & Owen, 2014). Public schools serve as the primary

mental health service location (Costello et al., 2003; Farmer et al., 2013; Hanchon & Fernald,

2013; Merikangas et al., 2010; NASP, 2015; Perou et al., 2013). School psychologists are

uniquely qualified and are identified as the key leaders for providing comprehensive mental

health services (Beam et al., 2011; NASP, 2010; Nastasi et al., 2000).

11
 The information gained from this research can assist educational administrators,

policymakers, and professional organizations in capitalizing on the exceptional knowledge and

expertise of school psychologists while utilizing their training, experience, and leadership as

school-based mental health providers to improve student educational engagement and learning

outcomes.

The findings of this research contribute to recommendations on how best to support

school psychologists in transforming their practice as school-employed mental health providers

and effectively meeting the complex mental health needs of students. In addition, the findings

inform stakeholders and policymakers of future policy and legislative needs regarding school

psychologists and the delivery of mental health services to students in the California K-12

education system. This research contributes to the body of knowledge that examines the factors

that support and limit school psychologists in the provision of a comprehensive, integrated

continuum of mental health services. The research provides insight for professional development

opportunities for school psychologists and stimulates support from the school districts, county

offices of education, and the state professional organization, the California Association of School

Psychologists (CASP).

Limitations of the Study

A significant limitation of this research was the small number of school psychologists

participating in the study. The invitation to participate in the research was disseminated by CASP

to a membership of 1800. A total of 200 responded to the survey. The survey in this study is a

self-response questionnaire and assumes honesty in the responses provided.

12
Definition of Terms

The following concepts related to student mental health and the practice of school

psychologists are defined for both clarity and brevity:

Mental health: The successful performance of mental function, resulting in productive

activities, fulfilling relationships with other people, and the ability to adapt, change, and cope

with adversity (U.S. DHHS, 2000).

Mental health problems: The spectrum of signs or symptoms ranging from problematic

behavior to a severe mental illness that do not meet the intensity or duration necessary in the

diagnosis of a mental health disorder. The signs and symptoms may warrant interventions

regarding health promotion, prevention, and treatment (U.S. DHHS, 2000).

Positive mental health: High levels of life satisfaction and positive affect (emotional

well-being) as well as psychosocial functioning (psychological and social welfare) (Miles et al.,

2010).

Mental illness: Refers collectively to all diagnosable mental disorders (U.S.

DHHS, 2000).

Mental disorders: Health conditions that are characterized by alterations in thinking,

mood, or behavior (or some combination thereof) associated with distress and/or impaired

functioning (U.S. DHHS, 2000).

Multitiered Systems of Support (MTSS): Framework that encompasses prevention and

wellness promotion, universal screening for academic and behavioral barriers to learning,

implementing evidence-based interventions that increase in intensity as needed, monitoring the

ongoing progress of students in response to implemented interventions, and engaging in

systematic decision making about programming and services need for students based upon

13
specific student outcome data (Vaillancourt et al., 2013). For purposes of this research, the

mental health component of the MTSS framework will be the focus.

School psychologist: a school staff member whose role is formally defined by the

National Association of School Psychologists (NASP, 2010):

School psychologists are uniquely qualified members of school teams that support

students’ ability to learn and teachers’ ability to teach. They apply expertise in mental

health, learning, and behavior to help children and youth succeed academically, socially,

behaviorally, and emotionally. School psychologists partner with families, teachers,

school administrators, and other professionals to create safe, healthy, and supportive

learning environments that strengthen connections between home, school, and the

community. (p. 1)

Suicide: Defined as a death caused by self-directed injurious behavior with any intent to

die as a result of the behavior (Stone et al., 2017).

Organization of Dissertation

This dissertation is organized into five chapters. The first chapter introduces the

preponderance of mental health issues of students within the K-12 educational system.

Furthermore, it discusses the importance of schools and the practice of school psychologists in

addressing these needs within a comprehensive, coordinated, and integrated continuum of

services. This chapter includes a statement of the problem, an introduction to the unique

knowledge and expertise of school psychologists as mental health providers, the purpose of the

study, significance and limitations of the study, research questions, and definition of terms and

the organization of the dissertation. Furthermore, this chapter also discusses the theoretical

underpinning of the mental health MTSS framework.

14
 Chapter two provides a thorough review of the literature encompassing the pervasiveness

of the mental illness of youth and mental health services in schools. Additionally, this chapter

provides the context of educational policy reforms at the national- and state-level related to

student mental health, the practice of school psychologists, and the application of MTSS as a

preventative model.

Chapter three presents a detailed description of the study’s research methodology,

including the research design and statistical procedures employed. Chapter three further reviews

the sample utilized, procedures employed to protect the human subjects, instrumentation,

proposed data analyses, and limitations of the study.

Chapter four provides the quantitative and qualitative findings which include detailed

analyses of the surveys and interviews, participants’ demographics, professional workplace

characteristics, the percentage of time and types of mental health services provided, professional

and demographic contextual factors related to participants in the provision of mental health

services, and additional overall findings.

Chapter five provides a discussion of the findings identified by the researcher. This

chapter also provides implications for policymakers, school administrators, professional

organizations, and future research.

15
 Chapter 2 Literature Review

The literature review is intended to provide a better understanding of the mental health

needs and services for students within the K-12 educational setting and the practice of school

psychologists in the state of California as mental health providers across a comprehensive,

cohesive, continuum of mental health services.

The literature review is divided into seven sections. The first section explores the

prevalence of student mental health needs and disorders of school-aged youth. The second

section explores mental illness of youth. The third section discusses mental health services in

schools. The fourth section explores national educational and mental health policies. The fifth

section reviews the California state educational and mental health policies. The sixth section

examines the practice of school psychologists. The seventh section expands on the application of

mental health MTSS as a prevention model. Conclusions about the existing literature are

discussed, and recommendations for additional research regarding the provision of mental health

services by school psychologists are presented.

Prevalence of Student Mental Health Needs

A substantial amount of research exists regarding the high prevalence of mental health

needs of the nation’s youth and the inadequacies in the provision of mental health services within

the K-12 educational setting (Flaherty et al., 1999; Nastasi, 2000). In 2014, approximately 2.8

million U.S. youth ages 12 to 17 and 9.8 million adults were identified with a serious mental

illness (SAMHSA, 2014). By the year 2020, mental and substance use disorders throughout the

world will surpass any physical disease as a major cause of disability (NAMI, 2013). An

estimated 247 billion dollars were spent in 2012 to address these mental needs (Perou et al.,

16
2013). Beyond the annual cost, early-onset of mental health issues disproportionately impact

students’ academic performance, social relationships, and educational engagement (Perou et al.,

2013).

The mental health needs of U.S. school-aged youth are a growing concern for families,

educators, policymakers, and society. Mental health is a component of the social fabric of the

educational environment in which children and adolescents develop their academic and social

skills as they acquire new knowledge and form relationships with peers and adults (Nastasi et al.,

2011; Zeng et al., 2013). Mental health is an essential element for healthy development, learning

outcomes, and life-long success. Mental health, like physical health, may be viewed as existing

on a continuum from wellness to chronic illness. In 2000, the U.S. Surgeon General defined

mental health as a successful performance of mental function, resulting in productive activities,

having fulfilling relationships, and the ability to adapt, change, and cope with challenges

(SAMHSA, 2014; U.S. DHHS, 2000). A person with positive mental health uses interpersonal

assets and skills to function successfully in his or her daily life. The mental health issues of youth

emerge when these assets and skills begin to deteriorate or are not fully developed, resulting in a

struggle to cope with life’s challenges and responsibilities. The continued deterioration of these

skills signals the onset of mental illness as significant distortions to thinking, coping, and

responding dominate personal functioning and impair a person’s ability to perform the activities

of daily life. All people fall somewhere on this continuum on any given day.

Understanding the prevalence of mental health disorders is essential for identifying and

providing the necessary supports and services. More than half of the U.S. population experiences

some level of mental health challenges throughout their lifespan resulting in significant costs to

families, employers, and publicly funded health systems (SAMHSA, 2014). Youth in the United

17
States face a plethora of life challenges that impact their mental health. Approximately 20% of

youth between the ages of 13 and 18 experience a serious mental disorder (NAMI, 2013). The

data regarding youth mental illness and the profound impact on their lives are overwhelming.

Most mental health disorders begin before the age of 14; there is typically a decade between

initial onset of symptoms and treatment, and only 50% of youth receive mental health services

(NAMI, 2013; Weist, Lever, Bradshaw, & Owens, 2014). NAMI (2013) noted that 26% of

homeless and 70% of youth in the juvenile justice system have at least one mental health

condition, and 20% of those youths have a serious mental health illness.

Mental health problems are the spectrum of signs or symptoms ranging from problematic

behavior to severe mental illness that do not meet the intensity or duration necessary in the

diagnosis of a mental health disorder. The signs and symptoms may warrant interventions

regarding health promotion, prevention, and treatment (U.S. DHHS, 2000). The terms mental

illness and mental disorder are used interchangeably. Mental illness is the term that refers

collectively to all diagnosable mental disorders (U.S. DHHS, 2000). Mental disorders are

described as health conditions that are characterized by alterations in thinking, mood, or behavior

(or some combination thereof) associated with distress and/or impaired functioning (U.S. DHHS,

2000).

Mental Illness of Youth

Historically, there has been lack of empirical data on the prevalence and distribution of

mental health disorders among youth in the United States. The first data on the prevalence of

mental illness were provided by Merikangas et al. (2010). The research found 32% of youth were

identified with anxiety disorders, the most common condition. The second most common

condition was behavior disorders (19%) followed by substance use disorders (11%), with

18
approximately 40% meeting the criteria for a lifelong disorder. The average onset of anxiety

disorders is by the age of 6, age 11 for behavior disorders, age 13 for mood disorders, and age 15

for substance use disorders (Merikangas et al., 2010).

In 2018, the Centers for Disease Control and Prevention (CDC) published an updated

report regarding the wellness of youth ages 10 to 24. The data collected between September 2016

and December 2017 provide staggering results regarding youth in the United States: 32% of

youth felt sad or hopeless, 19% reported being bullied at school, 17% seriously considered

suicide, 14% reported having a suicide plan, and 7% engaged in a suicide attempt (CDC, 2018).

From 2000 to 2016, suicide rates increased 30% from 10.4 to 13.5 per 100,000 population.

Currently, suicide is one of the leading causes of death, second to motor vehicle accidents

(Collins, 2018; Hedegaard, Curtin, & Warner, 2018).

Research indicates many students may be at risk of developing a mental illness and often

do not display signs or symptoms (Costello et al., 2003; Merikangas et al., 2010). The onset of

mental illness may occur as early as 7 to 11 years old. Symptoms are typically observed by the

age of 14, yet many students do not receive services for at least a decade (Kessler et al., 2005)

and most never receive the services they need (Kataoka, Zhang, & Wells, 2002). According to

Costello and colleagues (2003), the presence of mental health issues in children and adolescents

could lead to continued mental health illness and impaired functioning in adulthood, thus

impacting their school success, decreasing their quality of life, and increasing the cost to society.

A total of 13 to 20% of children and youth within the United States experience a mental

disorder. Surveillance data from 1994 to 2011 have demonstrated an increase in the prevalence of

Attention-Deficit/Hyperactivity Disorder (7% increase), which was the most prevalent, followed

by conduct problems (4%), anxiety (4%), and depression (2%) (Perou et al., 2013). Recent data

19
reflect youth mental health is declining (Center for Behavioral Health Statistics and Quality,

2015). In 2012, 6% of youth in the United States were diagnosed with a major depressive

disorder; in 2015, the prevalence increased to 8% (CDE, 2018; United Health Foundation, 2017).

Given the increase in prevalence, 1.7 million youth continue to receive no treatment or services

(Brock & Reeves, 2017). In the state of California, the prevalence is 17%, slightly below the

national rate. Overall, 11.9% of youth ages 12 to 17 reported suffering at least one major

depressive episode in the past year.

According to Brock and Reeves (2017), there has been a 24% increase between 2007 and

2010 of residential care placement for individuals with mental illness and an 80% increase in

psychiatric hospitalizations. Approximately 11% of youth ages 12 to 17 (2.8 million adolescents)

had a major depressive episode in the past year. This is higher than the percentage between 2004

and 2012 as determined by the Center for Behavioral Health Statistics and Quality (2014). In

2014, adolescents demonstrated an 8% rate of severe mental health impairment (Center for

Behavioral Health Statistics and Quality, 2015) with 28% having a co-occurring major

depressive episode and substance use disorder. Although schizophrenia is typically identified

around the age of 25, there is current evidence of early onset in high schools (Brock & Reeves,

2017), and early identified disorders are more easily treated. Early identification may expedite

access to services and treatment and thus has potential to mitigate negative impacts of

schizophrenia.

Mental Health Services in Schools

A significant increase in the need for mental health services has been well documented

for students within the K-12 educational system (Costello et al., 2003; Doll et al., 2012; U.S.

DHHS, 2000). Approximately 70% of children and adolescents with a mental health diagnosis do

20
not receive needed services due to an array of factors: cost, stigma, or lack of access (Hanchon &

Fernald, 2013; Kataoka et al., 2002; U.S. DHHS, 2000). The majority of children and

adolescents who do have access to mental health services do so within the school setting (Farmer

et al., 2013; Hanchon & Fernald, 2013). Research reveals that schools are a vital setting for

students to receive these services (NASP, 2015; U.S. DHHS, 2000). Often, schools that do

provide mental health services are criticized for diverting academic funding to allocate resources

into school programs to support students’ social, emotional, and psychological wellness (Doll et

al., 2012). It is evident from the review of research that the provision of comprehensive,

preventative, and responsive mental health services is warranted to improve the educational

outcomes for students (NASP, 2015). Mental health challenges can affect classroom learning and

social interactions, both of which are critical to the success of students (Kessler et al., 2005).

However, if appropriate services are put in place to support a young person’s mental health

needs, we can often maximize success and minimize negative impacts for students.

The positive influence of prevention and early intervention services provided by schools,

including academic achievement, school climate, high school graduation rates, and the

prevention of high-risk behaviors are well documented in research (Center for Healthcare in

Schools, 2011; Doll et al., 2012; Farmer et al., 2003; Greenberg et al., 2003; Tolan & Dodge,

2005; Welsh, Parke, Widaman, & O’Neil, 2001; Zins, Bloodworth, Weissberg, & Walberg,

2004). Prevention services are an essential ingredient for healthy development, overall success in

life, and the welfare of society (Fantuzzo, McWayne, & Bulotsky, 2003; Power, Eiraldi, Clarke,

& Mazzuca, 2005).

Nationally, children and adolescents arrive at school daily carrying much more than just

their lunch and homework; they arrive with a host of factors (e.g., violence, family discourse,

21
poverty) which impact their wellness. The U.S. Surgeon General identified schools as a primary

setting for the possible recognition of mental health disorders in children and adolescents (U.S.

DHHS, 2000), as schools are a natural access point and a significant provider of mental health

services to children (Doll, 2008; Rones & Hoagwood, 2000). Although the importance of

providing prevention and intervention services for children and adolescents is well documented,

few resources for the services, beyond the instructional needs of children and adolescents, are

allocated within schools (Adelman & Taylor, 1998; Doll et al., 2012).

According to Zins et al. (2004), improved mental health functioning (including social-

emotional competencies) leads to improvements in an array of areas: academic performance and

subject mastery, school engagement, study habits, motivation, and commitment to learning.

Children and adolescents who are provided with early mental health supports at school

demonstrate improvements in academic performance, school engagement, and commitment to

learning (Catalano et al., 2003; Nelson, Martella, & Marchand-Martella, 2002). Positive

adjustment to school, including academic engagement and achievement, serves as a protective

factor against negative mental health outcomes (Cicchetti & Toth, 1998). Strengthening the

mental health of children can reduce the burden on an overtaxed mental health care system while

simultaneously improving society’s potential for academic success, economic well-being,

productivity, competitiveness in the global market, ability to protect the nation’s security, and

quality of life (Miles et al., 2010).

Adelman and Taylor (2008) contend schools must incorporate mental health resources

into the educational setting by creating a cohesive and integrated continuum of interventions that

promote healthy development, prevent problems, and intervene with individuals with severe and

chronic mental health problems. The Center for Mental Health in Schools (2011) reported there

22
is a lack of alignment between academic goals, mental health services, and monitoring outcomes.

When students have access to school-based mental health, they are substantially more likely to

seek out services (Slade, 2002) and achieve better academic outcomes (Greenberg et al., 2003).

The provision of mental health services within an evidenced-based multitiered systems of

support provides students with access to highly qualified school-based mental health

professionals and results in positive educational outcomes (Luiselli, Putnam, Handler, &

Feinberg, 2005). Given the documented need in the research for a comprehensive, integrated

continuum of school-based mental health services to address student needs, it is critical for

policymakers to establish policies at the national level.

National Policy

Throughout history, policymakers have attempted to establish the conditions to address

the mental health needs of the nation’s youth. The changes in mental health policy have

traditionally been narrowly focused on individuals with a significant mental health disorder and

have resulted in minimal measurable outcome changes. The World Mental Health Survey

Initiative (WHO, 2010) highlighted that well-formulated mental health policy can result in

optimal positive outcomes when the social and physical environments are considered. The

current research stipulates that to address new mental health policy effectively, we must cultivate

a full continuum of coordinated and integrated systems of services to unify the ongoing

fragmented efforts and discuss limited school resources (Adelman & Taylor, 1998, 2001, 2002;

Knitzer, 1993, 2003; WHO, 2010; World Mental Health Survey Initiative, 2010).

In the past few years, the United States has experienced significant laws and policy

reforms at both the national and state level, demonstrating efforts on the part of policymakers

committed to address the mental health needs of children and adolescents. The increased focus

23
on children’s mental health services has significant implications for the practice of school

psychology (Hess et al., 2017). In 2010, Public Law 111-148, also known as the Patient

Protection and Affordable Care Act (ACA), provided the most significant overhaul to the U.S.

Healthcare system since the creation of Medicare and Medicaid in 1965 (NASP, 2013). The ACA

increased funds and expanded the availability for school health and mental health prevention and

intervention services (NASP, 2013). The passage of ACA also renewed the Children’s Health

Insurance Program. School psychologists are explicitly identified within the ACA as school-

based mental health services providers for children and adolescent mental and behavioral health

services (NASP, 2013). Moreover, the Mental Health in Schools Act (MHSA) introduced by

Senator Alan Franken served to amend the public health service act and provide access to school-

based comprehensive mental health programs that are culturally and linguistically sensitive,

trauma-informed, and developmentally appropriate (Franken, 2013). A grant program was

established with the passage of MHSA in an attempt to bridge community agencies and school

districts to collaborate and provide training for school personnel, families, and members of the

community to recognize signs of mental health problems (Civic Impulse, 2017; Franken, 2013).

In December 2015, the new national education law was passed, ESSA (U.S. DOE, 2016). ESSA

addressed equity for all students, including measures to address mental health needs. The

transformation of the practice of school psychologists as mental health providers has been

significantly influenced by the passage of national legislation and policy. The literature cites a

major factor perpetuating the traditional role of school psychologists is the implementation and

reauthorization of Public Law 94-142, the Individuals with Disabilities Education Act (IDEA)

(Larsen & Choi, 2010). The law mandated school psychologists conduct psychoeducational

assessments and potentially place students within special education programs. During the 1960s

24
through the 1990s, school psychologists devoted more than half of their time within a traditional

role (Curtis et al., 1999; Reschly & Wilson, 1995), which involved conducting

psychoeducational assessments for special education determination.

National policies have influenced the practice of school psychologists as mental health

providers and afford opportunities for school psychologists to promote comprehensive service

delivery to assist the learning of all students (Hughes, Minke, & Sansosti, 2017). Yet, to address

the unique needs of youth in California, it is critical that California policymakers institute

educational and mental health policy changes.

California State Policy

Recently, the state of California has experienced significant educational policy changes

including: (1) Assembly Bill (AB) 114 which delineates the delivery of mental health services

for children and adolescents with special needs, (2) the new state educational finance system, the

Local Control Funding Formula (LCFF), and (3) the suicide prevention policy, AB 2246 (CDE,

2016). These policy changes have significant implications for the role of school psychologists in

the provision of mental health services in the California K-12 educational system.

The school system is recognized as the ideal location for the provision of comprehensive

mental and behavioral health services (Nastasi, 2011). School psychologists are recognized as

the best equipped to provide these services and play a critical role in the provision of mental

health services within schools (Beam et al., 2011; NASP, 2010, 2015; Sailor, 2015). There are

significant recent changes to the California state education finance system and the delivery of

mental health services for children and adolescents which requires educators, researchers, and

policymakers to work collaboratively to address these vital needs.

25
 The current changes in California policy acknowledge the critical mental health needs of

students and the pivotal role the actual school environment plays in addressing those needs. As a

result, these changes have initiated a more intensive focus to address these needs within local

educational agencies (LEA) (i.e., school districts). In 2013-14, the state of California initiated a

new finance system for education (LCFF) for the K-12 education system (CDE, 2013). This

requires local school districts to create a plan to identify, intervene, and monitor the progress of

all students, known as the Local Control Accountability Plan (LCAP). This new policy requires

school districts to work in tandem with parents, school psychologists, educators, and the

community to create and identify a plan to meet annual goals for all students with specific

activities to address state and local priorities (CDE, 2013).

An additional policy change in California was AB 114, which altered the responsibility of

the provision of mental health needs of students with special needs. Under AB 114, the

responsibility for providing mental health services for students with special needs shifted from

the Department of Mental Health to LEAs. California school districts are now solely responsible

for ensuring students with special needs (e.g., emotional disturbance), as designated by the

Individual Educational Plan (IEP), receive the necessary mental health services required to

benefit from a special education program (Beam et al., 2011). Although this policy provides

mental health services for students with disabilities, it does not address the myriad of mental

health services needed by all students within schools.

Over the past decade, there have been significant policy changes in the state of

California. These changes reflect increased advocacy for local control of educational decisions

and accountability, which altered the landscape of mental health services for children and

adolescents. In 2011, the responsibility for mental health services transferred from the county

26
department of mental health and child welfare to local school districts. In 2013, Governor Jerry

Brown and the California legislature recognized the importance of student wellness with the

creation of a statewide accountability system for local educational agencies. This change in

educational funding and accountability shifted the responsibility to local school districts. The

LCFF accountability system requires local school districts and charter schools to develop and

evaluate a plan (LCAP) in partnership with parents and the community. The plan is required to

include efforts to address student engagement and positive school climate. In 2018, a youth

suicide prevention bill was passed in the state of California, AB 2246 (CDE, 2016). AB 2246

requires local educational agencies (grades 7 to 12) to adopt a policy on suicide prevention by

addressing the mental health needs of at-risk youth. The policymakers in the state of California

have acknowledged the critical mental health needs of youth and have taken vital steps to enact

policy to address the needs.

On June 30, 2011, the California State Legislatures signed into law AB 114, Chapter 43,

Statues of 2011 (CDE, 2011), which was amended to eliminate the longtime statutes and

regulations related to AB 3632—the authority to provide mental health services to students with

special needs who required mental health services to benefit from the free and appropriate public

education (FAPE). AB 114 transferred the responsibility and funding for mental and behavioral

services, now identified as educationally related mental health services (ERMHS), from county

mental health and child welfare departments to the department of education. The “related

services” or mental health services include outpatient therapy, day treatment services, and

residential care services to be provided by local educational agencies. The law did not identify

specific mental health providers for the mental health services for students with special needs.

27
Districts were required to provide mental health services immediately with little to no time to

create and implement a plan of service provision nor identify the mental health service provider.

Beam et al. (2011) reported California school district administrators were uncertain about

the personnel qualified to provide the mental health services for students with special needs. The

questions regarded the school personnel who possessed the professional training and credentials

to evaluate and provide psychological services directly related to educational benefits. Beam et

al. (2011) reported specific language in the law which “clearly identifies school psychologists as

those credentialed to provide and coordinate the [mental health] related services in schools”

(p.3). Further, the California Education Code 49424 defines school psychologists’ services to

include consultation, psychological counseling, and other therapeutic techniques with children

and parents (CDE, 2010). School psychologists are uniquely qualified as mental health providers

in the schools and possess expertise and experience in mental health and learning (NASP, 2010;

Nastasi et al., 2000).

On June 24, 2015, California Governor Brown signed AB 104, Chapter 13, the state

legislation which allocated funding for the development, alignment, and improvement system of

academic and behavioral supports (ISABS), the California state MTSS framework (CDE, 2018).

This bill was intended as a unification effort to address barriers to learning and engage students

by creating a culture of collaboration among marginalized and fragmented support for students.

The state provided funding for school districts to institute a scalable and sustainable multifaceted

approach to address student needs by alignment of schoolwide and data-driven systems. It

provided the groundwork for a statewide transformation that enhanced equitable access to

opportunity, addressed the development of the whole child, and intended to close the

achievement gap for all students.

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 ESSA and the Local Control Accountability Plan (LCAP) provided the foundational

infrastructure for building a statewide system of support, and the California MTSS framework

was the driver for implementation. AB 104 provided the capacity for advancement with

implementation of MTSS through braiding key supports and resources into a comprehensive

multitiered systems of support framework in order to improve the learning outcomes for all

students. The state awarded a $30 million grant to the Orange County Department of Education

(OCDE) to assist schools and district throughout California with the implementation of a proven

framework of supports to address students’ academic, behavioral, and social needs. OCDE was

positioned by CDE as the lead agency on the California Scale-Up MTSS Statewide Initiative, or

SUMS Initiative, which was designed to promote and expand the use of MTSS (CDE, 2018).

On September 26, 2016, the Pupil Suicide Prevention Policy (AB 2246) was passed in the

state of California. This new policy evolved from the alarming data the CDE gleaned from the

CHKS in which students were asked to describe how they felt about school and the school

environment (CDE, 2016). The survey reflected nearly one-fourth of seventh graders, and

approximately one-third of ninth and eleventh graders reported feelings of chronic sadness or

hopelessness. In addition, 20% of high school students had seriously contemplated suicide.

Further, there were close to 2,300 suicide attempts in 2014 within the state of California by

students 15 to 19 years of age (CDE, 2016). AB 2246 requires all California County Offices of

Education, school districts, state special schools, and charter schools serving pupils in grades 7 to

12 to adopt pupil suicide prevention policies. The policies must address, at a minimum,

guidelines for suicide prevention, intervention, and postvention (CDE, 2016). The current

California state policy changes along with the new national education law, ESSA, provide a

29
promise for a comprehensive, integrated approach of education at the local level across policy,

practice, and research to address the mental health needs of adolescents and youth.

Grassroots advocacy efforts have also responded to the growing identified mental health

needs of students by creating professional practice policies for school psychologists. The

professional standards of practice by both the state association (CASP, 2007) and national

association (NASP, 2010) distinctly define school psychologists as “qualified school-based

mental health providers within a continuum of mental health services” (p. 3). School

psychologists are highly trained and provide direct psychological counseling for individual

students, indirect consultation, and system-level prevention and wellness promotion services

(NASP, 2015). The national professional organization delineated a clear role of school

psychologists in the provision of mental health services within the schools (NASP, 2010).

Through ESSA, new California state policies and new national education law provided a

promise for a comprehensive, integrated approach of education at the local level across policy,

practice, and research to accurately address the mental health needs of all youth. School

psychologists are explicitly identified in education code to be credentialed, and are uniquely

qualified as mental health providers in the schools and possess expertise and experience in

mental health and learning (NASP, 2010; Nastasi et al., 2000). New policies explicitly identify

school psychologists as the most competent to address youth’s mental health needs; thus, it is

essential to examine the current practice of school psychologists.

The Practice of School Psychologists

One of the most influential advocates for addressing the mental health needs of school-

aged children is the National Association of School Psychologists (NASP), who was the first

national organization to provide a voice for school psychologist practitioners working within the

30
nation’s schools (Fagan & Wise, 2007). NASP advocates for the critical role of school

psychologists in the provision of mental health services within a comprehensive continuum of

mental health services in the schools (Larson & Choi, 2010; NASP, 2010), and has established

and influenced the standards of practice of school psychology and educational policy reforms for

over 50 years. According to NASP (2015), “School psychologists are uniquely trained to deliver

high quality mental health services in the school setting to ensure all students have the support

they need to be successful in school, at home, and throughout life” (p. 3). School psychologists

are increasingly dedicated to serve all children prior to referral for special education assessment

eligibility. One of the major recent strengths of school psychology practice is its embrace of the

public health model (Flanagan & Miller, 2010).

Between 1984 and 2000, NASP advocated for the expanded role of school psychologists

and published a progression of three versions of professional standards: School Psychology: A

Blueprint for Training and Practice I, II & III (Blueprint I; Ysseldyke et al., 2008). The

Blueprint I standards identified six areas of practice: psychological foundations, educational

foundations, assessment, interventions, statistics and research, and professional school

psychology (Larson & Choi, 2010). Blueprint II expanded the standards to include data-based

decision making, collecting data, and collaboration (Blueprint II; Ysseldyke et al., 2008). The

Blueprint III standards created a broader focus on a systems-oriented framework, marking the

most fundamental shift from the traditional practice of school psychology.

In 2010, NASP approved and published their first policy on the practice of school

psychologists, the NASP Model for Comprehensive and Integrated School Psychological

Services. This is commonly referred to as the NASP Practice Model. The NASP Practice Model

identifies competencies of school psychologists within ten domains of knowledge and skills with

31
the goal to provide a comprehensive range of services for students, families, and schools (NASP,

2010). The ten domains include:

Domain 1: Data-Based Decision Making and Accountability

Domain 2: Consultation and Collaboration

Domain 3: Interventions and Instructional Support to Develop Academic Skills

Domain 4: Interventions and Mental Health Services to Develop Social and Life Skills

Domain 5: School-Wide Practices to Promote Learning

Domain 6: Prevention and Responsive Services

Domain 7: Family-School Collaboration Services

Domain 8: Diversity in Development and Learning

Domain 9: Research and Program Evaluation

Domain 10: Legal, Ethical, and Professional Practice

The NASP Practice Model is aligned with the public health framework to address student

mental health in three specific domains: (1) an emphasis on prevention and early intervention,

(2) consultation and collaboration, and (3) systems-level services in addition to the use of data-

informed decision making (Hess et al., 2017). School psychologists provide a full continuum of

services to support students, families, and communities. School psychologists are uniquely

qualified as mental health providers in the schools and possess expertise and experience in

mental health and learning (NASP, 2010; Nastasi, 2000). Additionally, school psychological

services promote students’ mental health (NASP, 2010).

Over the past 50 years, the literature demonstrates the desire of school psychologists to

broaden their role beyond traditional psychoeducational assessments; yet, school psychologists

continue to spend more than half of their time conducting assessments (Larson & Choi, 2010;

32
Reschly, 2000). School psychologists’ roles are traditionally defined as assessing individual

students with psychoeducational tools to identify remediation strategies to address student

weaknesses and placement in specialized programs (Larson & Choi, 2010; Tindall, 1964). The

origin of the title “school psychologist” is traced back to 1915 with Arnold Gesell, hired by the

state of Connecticut (Tindall, 1964). The importance of shifting from a traditional special

education assessment role has been endorsed by researchers, policymakers, and practitioners

over the past four decades (Bardon, 1972; Bennett, 1970; Bradley-Johnson & Dean; 2000; Close-

Conoley & Gutkin, 1995; Larson & Choi, 2010; Swerdlik & French, 2000; Tindall, 1964).

Fagan and Wise (2007) acknowledged the role of school psychologists is narrow; they

traditionally engage in the role of an assessor. More than 25% of school psychologists’ time is

spent in counseling and remediation (Fagan & Wise, 2007; Reschly, 2000). It is important to note

the assessment activities of school psychologists have changed from a focus on cognitive

functioning to include behavioral assessments to target behavioral interventions, monitor

progress, and program evaluations (Reschly, 2000).

A study conducted by Hosp and Reschly (2002) examined the influence of state mandates

and administrative codes on the practice of school psychology across the United States. The

study indicated school psychologists spend 50% or more of their time conducting assessments

and very few hours conducting direct intervention services within the mid-Atlantic region.

Providing approximately 10 hours a week of direct services was the highest in the nation (Hosp

& Reschly, 2002). The majority of the participants strongly agreed the role of school

psychologists should be to assist in the regular education intervention and resources while

shifting away from the traditional eligibility determination, to support teachers with interventions

before conducting a psychoeducational assessment.

33
 The role and function of school psychologists were studied by Curtis et al. (2002)

through an examination of how their time was spent during the 1999-2000 school year. School

psychologists responded the majority of their time (79%) was allocated to special education

evaluations. Approximately 30% of the school psychologists completed 25 or less initial

evaluations, a decreasing trend from the previous years in conducting psychoeducational

evaluations.

The effects of educational legislation on the role and function of school psychologists

were investigated by Larson and Choi (2010) upon the passage of IDEA 2004 in which RTI was

introduced as an alternative method to identify students with disabilities and the need for special

education placement. The research was conducted with a stratified random national sample of

500 school psychologists from NASP. Larson and Choi (2010) found a significant decrease in the

percentage of time school psychologists devoted to the transitional assessor role. According to

the literature, after the passage of IDEA 2004, for the first time, less than half of school

psychologists’ time was spent conducting psychoeducational assessments (47%). There was a

significant decrease in time spent on traditional role activities and an increase in time devoted to

intervention, preventive services, and team collaboration. The researchers also noted a

correlation between the time participants engaged in a direct counseling services role and the

NASP training standards in place at the time of the participants’ graduation. Participants who

graduated when the 2000 NASP standards were in place, reported more time engaged in direct

counseling services.

Massey et al. (2005) conducted focus groups to examine school-based mental health

providers’ experiences, challenges, and supports in the implementation and sustainability of

school-based mental health services. Participants identified numerous challenges within the

34
system—access to resources, administrative support, focus of services (e.g., prevention versus

intervention), program visibility, communication among providers, and role and responsibility of

internal and external service providers.

Suldo et al. (2010) examined the range of mental health services school psychologists

provided, in addition to the systemic and personal factors that facilitated or limited the provision

of mental health services. A total of 39 school psychologists participated in 11 focus groups. The

researchers reported 11 mental health services themes including group counseling, individual

counseling, crisis intervention services, consultation, behavior interventions, case management,

social-emotional-behavioral assessment, in-service training, counseling school personnel,

prevention, and family services. Nine barriers to the provision of school-based mental health

services were identified: physical space and location, lack of administrative support, role strain,

caseload, problems with school personnel, insufficient training, challenging student factors,

personal characteristics, and insufficient time and integration into the school site. Eight themes

were identified that facilitated the provision of mental health services: sufficient time, training,

administrative support, relationships with school staff, personal characteristics, site-based service

delivery, caseload, and community support. The findings suggested that recommended levels of

prevention are not yet being provided.

Eklund et al. (2017) surveyed 192 school psychologists located within a western state in

the United States to examine the range of mental health services provided by school

psychologists and how service delivery was related to school psychologist to student ratio,

current practice, barriers to service provision, and state Medicaid policies. Overall, 57% of

school psychologists indicated providing mental health services across six areas: individual

counseling (63%), crisis intervention (38%), group counseling (32%), teacher consultation

35
(30%), family support (9%), and school/class-wide supports (5%). The researchers found 43% of

the participants indicated they were not providing mental health services at the time of the

survey. Seventy-three percent of participants identified a range of barriers in providing mental

health services: provided by another school personnel (69%), lack of time (51%), services not

supported by district and/or school (38%), not trained to provide services (6%), and lack of

interest in providing services (3%). The findings indicated that as the school psychologist to

student ratio increased, the availability and provision of school-based mental health services

decreased. The study also found that state Medicaid policies influenced the provision of mental

health services at school. There was an association between the state-level Medicaid policies and

the number of school psychologists qualified to bill for Medicaid reimbursable services.

Numerous studies have been conducted on the role and practice of school psychologists

as mental health providers. Recent studies have examined the range of mental health services to

include prevention and early intervention. Policymakers, educators, and professional

organizations have advocated for the expansion of the practice of school psychologists as mental

health providers and for the implementation of a comprehensive continuum of mental health

services in schools, such as MTSS.

Application of MTSS as a Prevention Model

A public health approach, such as MTSS, can address the mental health needs of students

across a continuum of prevention and wellness. MTSS takes a preventative approach by

embracing students’ social capital prior to displaying risk factors and implementing interventions

aimed at mitigating mental health issues that are interfering with students’ educational

attainment. The practice of school psychology should be explored to create a preventative model

36
which implements mental health services for students at the broadest level (Sheridan & Gutkins,

2000).

MTSS is recognized as a significant advancement of inclusive school reform, allocating

school resources effectively and efficiently, identifying students in need of services, and supports

and enhances the learning of all students (Jimerson et al., 2007; Sailor, 2015). This is also

identified as a population-based approach developed from the public health model and utilizes

different tiers of intervention depending on the needs of the population (Kutash et al., 2006).

MTSS is a prevention-based framework for improving learning outcomes for all students through

a layered continuum of evidenced-based practices and systems. Prevention efforts address the

mental and behavioral needs of students by addressing problem behaviors and promoting pro-

social behaviors.

The MTSS framework aligns the system of initiatives, supports, and resources, as well as

implements continuous improvement processes through the system to address the whole child

(CDE, 2017). The expanded practice of school psychology aligns with the preventative

continuum of mental health services framework.

Conclusions

The mental health needs of students continue to grow in the United States. A review of

the research exemplifies the disproportionate number of students who require mental health

support services but do not receive the services. School psychologists are uniquely trained to

provide mental health services within the educational setting. Their role is crucial to providing

these services, but there are a multitude of demands and responsibilities that preempt school

psychologists from adjusting their role beyond special education. Although research reflects

37
school psychologists expressed an interest in expanding their role as mental health providers, a

shift in professional daily practice continues to be a challenge.

Over the past decade, a plethora of legislative initiatives have emerged at the state and

national level to address the mental health needs of students. These initiatives have implications

for the practice of school psychology. The state and national changes in the professional

standards of school psychology are influenced by the changing needs of students along with the

legislative initiatives. Although legislative initiatives and professional practice policies have

evolved concerning the provision of mental health services for students, the research has not

explored the current practice of school psychologists across the continuum of mental health

services within a multitiered systems of supports framework.

In response to the unique national regions and states, this study is designed to identify

factors that support and/or limit the practice of California school psychologists in the provision

of mental health and behavioral services across the continuum of the MTSS. Specifically, the

results from this study aim to inform researchers, practitioners, and policymakers on the current

condition of school psychologists’ services and needs to foster their practice as mental health

providers and foundational knowledge for future research.

38
 Chapter 3 Methodology

This chapter is an overview of the current study’s research design. This chapter includes a

discussion of the sample, protection of human subjects, instrumentation, analytical procedures,

and the data analysis plan for the study.

Research Design

The researcher utilized a mixed-methods, two-phase approach to conduct an in-depth

exploration of the practice of school psychologists. As suggested by Creswell (2009), a mixed-

methods approach was most appropriate in this study as the study goal was to gather data to

explore the mental health practice and services provided by school psychologists within the

MTSS framework, in addition to learning of the barriers and supports within the California K-12

educational milieu. The initial phase was a Qualtrics survey that included 32 fixed-choice items

and four open-ended items. The second phase involved follow-up, individual semi-structured

interviews with eight school psychologists. The interview data provided rich context for

understanding the participants’ perspectives in the provision of mental health services within a

coordinated, comprehensive, and multitiered system. The alignment of content data from the

interviews, with data from the online survey research platform, provided a more holistic

understanding of school psychologists’ demographic and professional contextual factors that

influenced the delivery of mental health services. Moreover, the combination of quantitative data

with qualitative data allowed for aggregation and comparison of responses, and further

exploration of the research questions (Patton, 2002). A table delineating the research questions,

instrumentation, and variables can be found in Appendix F.

39
Table 1

Research Design
Phase Procedure Product
1 Survey Data Collection -Descriptive survey (n = 117) -Quantitative survey data

Survey Data Analyses

-Survey fixed-choice questions -Descriptive statistics

data screening

-Survey open-ended questions -Response transcripts

coding and thematic analyses -Codes and themes

2 Interview Data Collection -Individual interview protocol -Interview transcripts

(n = 8)

Interview Data Analyses

-Coding and thematic analyses -Codes and themes

Integration of Survey and

Interview Results -Interpretation and explanation of -Discussion and Implications

survey and interview results

Table 1 shows the research design. The first phase of the research consisted of gathering

data using an online survey. The survey consisted of 36 items, including 32 fixed-choice

questions and four open-ended questions. The first phase of statistical analyses calculated

descriptive statistics. Next, thematic analyses of participants’ responses to the four open-ended

questions were conducted. The questions included: “What supports you in the provision of

40
mental health services?”, “What barriers impede you in the provision of mental health

services?”, “What can CASP do in the future to help in the provision of mental health services?”,

and “What other information/input would you like to provide that has not been asked?” For

purposes of this study, the data related to CASP are not included, but it will be directly shared

with the professional organization. The open-ended survey questions were used to gather

information to explore the supports and barriers school psychologists face in their practice as

mental health providers.

During the second phase, a group of eight school psychologists were selected from the

larger survey sample of the study for one-on-one interviews with the researcher. The interviews

were used to gather information specific to the supports and barriers they experienced as mental

health providers. Theme analyses were conducted on the interviews.

Sample

Survey participants. A total of 117 school psychologists were recruited using a

convenience sample from California K-12 schools. According to Mertens (2005), a sample of at

least 100 participants should be used to obtain statistically significant results. The school

psychologists who are current members of CASP received an email invitation to participate in

the research.

The membership of CASP is reported as 1800 total members, with 1100 self-identified as

school psychologists employed as practitioners within the K-12 educational setting (CASP,

2018). The remaining CASP membership included school psychology graduate students,

administrators, retired school psychologists, and related professionals. Each of the school

psychologist participants in this study completed the online survey between February 2018 and

May 2018. The sample was restricted to school psychologists whom self-identified as

41
practitioners within the K-12 educational system. School psychologists who self-identified as

students, university faculty trainers, retired, or from related professions were excluded from this

study.

Interview participants. The 117 school psychologists who participated in the Qualtrics

survey were provided an opportunity to participate in the interview phase of the research and

were asked to provide their contact information to the researcher. A total of twelve participants

indicated interest in being interviewed, and eight were available to participate in the interview.

The school psychologists who were interviewed were asked a series of six semi-structured, open-

ended questions. The interview was meant to be highly focused with open-ended, neutral,

singular, and clear questions so that interviewee time was used efficiently. One-on-one

interviews were conducted by phone via Zoom, a web-based telecommunication conferencing

system. Interviews were later transcribed by the researcher. All interviews were completed in

one sitting. The average time was 13 minutes from beginning to end, with the shortest interview

being approximately 8 minutes and the longest being approximately 27 minutes. The majority of

the participants expanded on their answers, giving examples of their experience in providing

mental health services within the school setting along with the supports and barriers they

experience as a school psychologist. The researcher allowed for some flexibility within the one-

on-one interview sessions; yet, strived to remain within the protocol parameters at all times.

Protection of Human Subjects

The researcher followed appropriate procedures to collect data, and ethical issues were

considered in compliance with the Institutional Review Board (IRB) at San Diego State

University as dictated by the Joint Doctoral Program Guidelines prior to commencing the

research study. The anonymous survey instrument was distributed electronically using Qualtrics.

42
Qualtrics is an online survey tool to conduct survey research, and it is a convenient research tool

for the distribution of survey instruments as well as gathering, formatting, and managing data.

Additionally, the Qualtrics platform affords participant anonymity. The survey contained an

electronic consent form that required participants’ acknowledgment prior to accessing the survey,

demonstrating that school psychologists were voluntarily participating in the research and had

guaranteed rights. Participants interested in participating in the interview portion of the research

were directed to a separate survey link in which they completed an interest form, requiring them

to provide their email address, and they granted the researcher permission to contact them. All

data are secured in a locked file cabinet and will be destroyed one year after the research is

completed. Online surveys will remain anonymous and are password protected.

Instrumentation

Survey instrument. The survey instrument used in this study included a 36-item self-

report questionnaire including four open-ended questions specifically to collect data that related

to the practice of school psychologists in the provision of mental health services within the

MTSS framework. A copy of the survey can be found in Appendix C. A survey facilitates the

ability to obtain information about a large number of school psychologists in a non-threatening

manner (Mertens, 2005). The theoretical basis for this instrument was extrapolated from the

existing school-based mental health literature and adapted from a recently developed survey with

permission. This primary survey, School Based Mental Health Services and Advocacy Survey

(SBMHS) was designed by Eklund, Meyer, Way, and McLean (2017). The SBMHS “is a three-

part 27-item self-report survey designed by the authors to identify patterns in the delivery of

SBMH services” (Eklund et al., 2017, p. 282). The SBMHS survey items inquired about the

background and experiences of school psychologists across three areas: (1) demographic

43
information (n = 10), (2) mental health service delivery (n = 8), and (3) Medicaid billing

procedures (n = 9).

The SBMHS survey was adapted by the current researcher to incorporate the five

components of MTSS (Vaillancourt et al., 2013): prevention and wellness promotion, universal

screening, evidence-based intervention, progress monitoring, and systematic decision making

about programming and services need for students based upon specific student outcome data.

Sixteen of the 27-items of the SBMHS survey were utilized in their original or revised form in

the current study (i.e., items 2-11, 13-14, 17-18, 24, 26-28, 30-31). The 11 items of the SBMHS

that were excluded from the current study related to employer, credential and/or license, and

medical billing which were not related to the focus of the current study. Sixteen additional fixed-

choice questions and four open-ended questions were created for this study. The modifications of

the SBMHS for purposes of this current research study included the addition of: (1) the mental

health MTSS components (e.g., average number of hours per week, types of services), (2)

supports and barriers in the provision of mental health services, (3) professional development,

and (4) advocacy efforts.

The aforementioned authors of the SBMHS self-report survey worked in conjunction

with the NASP Government and Public Relations (GPR) Committee to conduct a pilot study

with five state professional organizations of school psychologists to elicit data regarding the

current role of school psychologists as mental health providers. The NASP GPR Committee

reviewed the initial survey data and provided the information to the state organizations. The

initial results were presented at the annual NASP Convention in February 2017. Currently, there

are no published instruments that could be identified to evaluate the role of school psychologists

44
in the provision of mental health services within the MTSS framework. Consequently, data

pertaining to the validity and reliability of the instrument are not available.

Interview instrument. The interview protocol consisted six semi-structured open-ended

interview questions which satisfy the norms of qualitative inquiry by ensuring questions are

“open-ended, neutral, singular and clear” (Patton, 2002, p. 353). The demographic questions

within the interview served as a procedure in selecting participants for the interview: “What

setting do you primarily serve (i.e., primary, secondary)?”, “What community do you primarily

serve (i.e., urban, suburban)?”, and “How would you describe your level of experience as a

school psychologist (i.e., early career, late career)?”

The six semi-structured open-ended interview questions ensured each interviewee was

asked the same question, in the same way, and order, including standard probes. The questions

that guided the school psychologist interviews can be found in Appendix E and are:

1. Tell me about the skills and experience you have in the provision of mental health

services within the MTSS framework.

2. What professional development opportunities have prepared you to practice within a

continuum of mental health services?

3. Please describe the supports within your practice for providing mental health services.

4. Can you provide examples of barriers you experience in providing mental health

services?

5. How can CASP best support your practice as a mental health provider?

6. Is there anything else you would like to share?

45
Procedures

The study was approved by the San Diego State University Institutional Review Board.

The instrument was anonymously administered online using the Qualtrics survey platform. The

survey was embedded within the Qualtrics data system and disseminated electronically to active

members of CASP. The CASP Executive Director facilitated the distribution of the survey to all

active CASP members by sending the School Psychologist Recruitment Letter, which can be

found in Appendix A, with access to an active link to participate in the online survey. The CASP

members were emailed the recruitment letter and access to the online survey multiple times to

ensure access and encouragement for participation. A copy of the informed consent form and

survey are presented in Appendix B and D, respectively. Participation was voluntary and school

psychologists had the option not to participate in the survey. Additionally, school psychologists

were asked if they were interested in taking part in an individual interview (phase 2 of the

research). Those that were interested clicked a link at the end of the survey and provided

demographic and contact information. This information was used to identify the participants for

phase two.

In addition, an invitation with a live link to participate in the survey was posted on the

CASP web-page for approximately four months. This provided access to school psychologists in

the state of California to participate regardless of their affiliation and/or membership with CASP.

The data collection phase lasted four months. The volunteers for the semi-structured

interview were emailed a copy of the interview protocol and an invitation with a date and time

for an online meeting. A copy of the interview protocol is presented in Appendix E. Once the

interviews began, the researcher reminded participants of the importance of the study, the

procedures employed to safeguard confidentiality, and ensured participants were comfortable

46
answering each question. The interview was audio recorded; participants were assigned a subject

number and the audio file was exported to Dedoose (version 8), a qualitative data analyses

program.

Data Analyses

Phase one. The researcher conducted analyses using the Statistical Package for the Social

Sciences (SPSS IBM, version 25.0, 2017) to ensure the study was statistically valid and reliable.

Descriptive statistics were calculated for research question 1, to examine the current practice of

school psychologists in providing mental health services within the MTSS components in order

to find means, standard deviations, and frequencies for the instruments utilized in the research.

Means were calculated to determine the average amount of time school psychologists engaged in

mental health services within each of the five MTSS components. Standard deviations were

calculated to determine the variability of responses. The frequencies of the types of mental health

services within each of the five MTSS components were calculated to determine the most

common services provided by school psychologists. For research questions 2 and 3, descriptive

statistics were calculated to find the frequencies and percentages related to the supports and

barriers experienced by school psychologists in providing mental health services.

The data gathered for research question 4 were analyzed using a 2 by 2 analyses of

variance (ANOVA). The two factors were school setting and community. The ANOVA

procedure compared the means of the MTSS components for each group to determine if there

was a significant statistical difference between them. To further explore research question 4,

descriptive statistics were calculated for each of the five MTSS components to examine the

means and standard deviations for the instruments utilized in the research.

47
 Correlational measures showing how changes in one variable are associated with changes

in a second variable were utilized for exploring research question 5. Both the demographic (i.e.,

years of experience, education) and professional contextual factors (i.e., school psychologist to

student ratio, advocacy, professional development) of participants in relation to each of the five

mental health components of MTSS were used. The methodology matrix can be found in

Appendix F and delineates the data analyses conducted for each of the research questions.

Phase two. Theme analyses were conducted for the data obtained from the semi-

structured interview questions. The data from semi-structured interviews were transcribed into

word processing files and imported for analyses into Dedoose (version 8), a cross-platform

application for analyzing qualitative data. The transcripts of participant responses to interview

questions were analyzed by generating a list of themes and codes that provided evidence

reflective of broader perspectives (Mertens, 2005). There was an emphasis placed on the practice

of school psychologists in the provision of mental health services within the MTSS framework

along with the related barriers and supports. The themes and categories were utilized to further

discuss school psychologists’ provision of mental health services. Additionally, the themes and

categories were utilized in the analyses to discuss the relationship with the survey data collected

in the first phase of the research.

Coding and Analyses

The researcher used Dedoose, a system of qualitative coding to assist in the data analyses.

The qualitative coding focused on themes, which emerged from separating common

terminology, experiences, and references into distinct categories to allow the researcher to seek

out commonalities and distinctions among participants’ answers. The coding was conducted in

48
each of the two study phases: (1) the open-ended survey questions and (2) the six interview

questions.

In phase one, the coding and analyses were conducted on the responses to three of the

four open-ended survey questions: (1) supportive factors for the provision of mental health

services provided within the MTSS framework (n = 73), (2) the barriers school psychologists’

experience in providing mental health services (n = 85), and (3) other information respondents

wish to share (n = 5). An examination of the data and initial coding of the perceptions of

participants was conducted. Emergent themes were identified from the initial coding and were

consistent with the themes identified within related literature.

In phase two, the coding and analyses were conducted on the responses to the six

questions from the semi-structured interviews. After much consideration and examination of the

recorded quotes, analyses were conducted of the most salient shared terms and themes among the

collection. Following the creation of the initial list of codes and excerpts, the researcher studied

the quotes from the semi-structured interviews and focused solely on determining common

themes and expressions put forth by the participants.

49
 Chapter 4 Findings and Discussion

The current study investigated the mental health practices of California school

psychologists within the K-12 school setting. Specifically, the researcher examined the

experiences, skills, and scope of mental health services within an MTSS framework. Phase one

of data analyses included descriptive analyses with the fixed-choice survey questions and theme

analyses for the open-ended survey questions. The means, standard deviations, frequencies, and

percentages were calculated for fixed-choice survey items to estimate the scope of services

within each of the five MTSS components. This included the average hours per week engaged in

mental health MTSS components, the types of services provided within each of the MTSS

components, supportive factors and limiting factors in providing services, years of experience,

the student enrollment served by each school psychologist, the school setting, and community of

school psychologists. Frequencies, percentages, and theme analyses were conducted for the

open-ended survey questions to investigate the supportive and limiting factors in providing

mental health services.

A 2 by 2 ANOVA examined how differences in school psychologist professional

workplace factors, setting, and community (independent categorical variables) were related to

the number of hours school psychologists provided mental health services within each MTSS

component (dependent variables). Correlation analyses were conducted to examine the

relationship between the MTSS mental health components and the demographic and professional

contextual factors of school psychologists. This included the five MTSS components: (1)

prevention and wellness promotion, (2) universal screening, (3) evidenced-based interventions,

(4) progress monitoring, and (5) systemic decision making about programming and services. It

50
also included the demographic and professional contextual factors including years of experience,

ratio of school psychologist to student, education, engagement in advocacy efforts, and

professional development.

Phase two of data analyses used theme analyses to understand the perspectives, feelings,

and experiences of school psychologists in the provision of mental health services. The theme

analyses were conducted on the semi-structured interview responses to access information

relative to the supports and barriers with providing mental health services.

This chapter begins with the demographics of the survey participants within the first

phase of the study and the eight semi-structured interview participants within the second phase of

the study. The findings of this study are presented in the order of the research questions.

Demographics

Previous studies have typically surveyed school psychologists across the United States

and are comprised predominately of female participants who identify their race/ethnicity as

Caucasian (Hanchon & Fernald, 2013). The representation of California school psychologists

within national surveys is often minimal. For example, one study only included two participants

(Hancon & Fernald, 2013). The present study intentionally examined the statewide practices of

California school psychologists.

In California, there are approximately 6,000 school psychologists currently employed

within the K-12 educational system (CDE, 2018). Given school psychologists are employed in a

variety of roles in the school system (e.g., program specialist, MTSS coordinator, principal,

special education director), it is unclear if this number represents the current number of

practicing school psychologists engaged in the role of a school psychologist. An overall total of

1,800 school psychologists comprise the membership of the state professional organization

51
(CASP, 2018), 1,100 who identify themselves as practitioners within the schools. A manual

count of the CASP membership directory database was conducted by the researcher (CASP,

2018).

The current study focused specifically on school psychologists’ provision of mental

health services within the state of California. Two hundred participants volunteered to participate

in the survey. Of the 200 volunteers, 81 participants did not finish the survey; they were removed

from the analytic sample. A further review of the data resulted in two additional participants

being removed from the sample as they primarily worked within the university or college setting,

which is outside of the scope of this research. The final analytic sample included 117

participants. Table 2 presents a summary of the demographics of the analytic sample.

The majority of the 117 California school psychologists identified as female (n = 92,

79%) and White (n = 69, 60%), consistent with previous research and state organization data

(CASP, 2018; Hanchon & Fernald, 2013; Suldo et al., 2010). In terms of education, participants

most commonly reported having earned a master’s/specialist degree (n = 102, 87%) and only a

few indicated they received a doctorate degree (n = 12, 10%), in line with previous research

findings (Hanchon & Fernald, 2013). The findings of one study indicated a fairly balanced

representation of the level of education between master’s and doctoral degrees (Suldo et al.,

2010). The participants in the current study reported the average number of years of experience

in the field of school psychology was 12 years, and seven years in their current position. These

findings align with previous research and the CASP membership database (CASP, 2018; Eklund

et al., 2017; Hanchon & Fernald, 2013; Suldo et al., 2010).

The professional association membership at the local, state, and national level was a

demographic factor introduced in the current study. Approximately three-quarters of participants

52
indicated they were members of CASP (n = 85, 73%) and over half reported to be a member of

NASP (n = 60, 51%).

Table 2

Demographics of Survey Participants Frequency & Percentages

Demographics Frequency %
Total Sample 117 100
Gender
Male 23 20
Female 93 79
Not Reported 1 1
Ethnicity
Caucasian/White 69 60
Hispanic or Latino 30 25
American Indian, Native American, or Alaska Native 0 0
Asian 7 6
Native Hawaiian or Pacific Islander 2 1
Black or African American 1 1
Middle Eastern 1 1
Other 6 5
Not reported 1 1
Education
Doctorate 12 10
Master’s/Specialist Degree 102 87
Not Reported 3 3
Experience
Early Career (> 10 years) 63 54
Late Career (10+ years) 54 46
Professional Association Membership
No Association Membership 9 8
Local Association 13 11
State Association CASP 16 14
National Association NASP 9 8
Local and State Association 19 16
Local and National Association 1 1
State and National Association 26 22
Local, State, and National Association 24 20
Note. Professional organization participants were able to select multiple items.

53
 School setting. In terms of school setting, the low number of participants in each school

setting of the current study necessitated the merging of groups into primary school setting (i.e.,

preschool, elementary school) and secondary school setting (i.e., middle school, high school) to

create more balanced grouping for purposes of data analyses. One participant reported preschool

as the school setting and was merged with the group of participants who reported the elementary

school setting as their workplace. School psychologists in the primary school setting yielded the

highest number of respondents, nearly half of the participants (49%) and consistent with previous

research (Eklund et al., 2017). Sixteen participants reported they worked in the middle school

setting (14%) and twenty-five (21%) worked in the high school setting. The group of participants

working within the secondary school setting comprised 38% of the participants. The remaining

16% of participants were grouped into the “other” category of school setting; nearly all indicated

their workplace to span across all school settings (i.e., primary and secondary), with one

participant identifying the school setting as juvenile hall. All results are presented in Table 3.

Table 3

Characteristics of Professional Workplace Frequency & Percentages

Characteristics of Professional Workplace Frequency %
School Setting
Primary School 57 49
Secondary School 41 35
Other 19 16
Community
Urban (50,000 or more) 46 40
Suburban (3,000 < 50,000) 60 51
Rural 11 9
Ratio of School Psychologist to Student
0-999 43 37
1000-1999 42 36
> 2000 32 27

54
 Community. The professional workplace factor of community was examined in the

current study (i.e., urban, suburban; see Table 3). Analyses of data denoted a relatively balanced

number of participants between the two community groups: urban (n = 46, 40%) and suburban

(n = 60, 51%). Suburban was selected as the most common workplace community, similar to

previous research findings (Hanchon & Fernald, 2013). The state organization membership data

in terms of workplace community indicated school psychologists more commonly worked within

an urban community (CASP, 2018). Less than 10% of the participants in the current study (n =

11, 9%) identified their professional workplace community as rural. Due to the low number of

rural participants, they were not included in the data analyses conducted for professional

workplace community.

School psychologist to student ratio. The caseload, or more commonly known as school

psychologist to student ratio, has been identified by researchers as an influential factor related to

the practice of school psychologists (Eklund et al., 2017; Hanchon & Fernald, 2013). As shown

in Table 3, 37% of participants reported a ratio between 0 and 999, 36% reported a ratio between

1000 and 2000, and 27% report a ration above 2000 students per psychologist. In previous

research, the ratio of school psychologist to student was significantly related to the provision of

mental health services (Eklund et al., 2017). The national recommended ratio is 500 students per

school psychologist (NASP, 2010). The current CDE data system indicated there were a total of

6,159 school psychologists during the 2017-18 school year and 6,220,413 students. Given these

numbers, the California school psychologist to student ratio is identified as 1:1,000 (CDE, 2018).

It is unclear what the CDE statewide personnel data reflects, the total number of school

psychologists whom are credentialed within the state and/or the number whom work within the

role of a school psychologist. Additionally, it was difficult to ascertain the demographic and

55
professional contextual data related to school psychologists. At this time, school psychologists

reported to work in a variety of jobs within the schools (e.g., mental health specialist, MTSS

coordinator, program manager, ERMS coordinator). Thus, it is unclear what the state ratio data

truly represent in terms of the practice and role of school psychologists within California.

However, the 1:1,000 ratio approximated the findings in previous research (Hanchon & Fernald,

2013). These results are reflective of Suldo and colleagues (2010) findings in which almost 80%

of school psychologists reported a ratio above the California statewide ratio (1:1,000) and the

national recommended ratio (1:500).

In phase two of the study, survey participants were invited to volunteer in a one-on-one

semi-structured interview to elicit rich data on the perspectives of school psychologists. A total

of twelve school psychologists volunteered for the interview and eight were available to

participate. Table 4 presents the number of interview participants across the demographic and

professional contextual factors of school setting (i.e., primary, secondary), community (i.e.,

urban, suburban), and years of experience (i.e., early career, late career). Interviewees were

balanced across these identified factors; no additional demographic or professional contextual

factors of the interview participants were examined (e.g., gender, rural community). Thus, the

findings may not be representative of the entire group of school psychologist working as

practitioners within the K-12 educational milieu.

56
Table 4

Demographics of Interview Participants-School Setting, Experience, Community

Interview Participant School Setting Experience Community
Ella Primary School Early Career Suburban

Mia Primary School Early Career Urban

Hollie Primary School Late Career Suburban

Elizabeth Primary School Late Career Urban

Alma Secondary School Early Career Suburban

Max Secondary School Early Career Urban

Katie Secondary School Late Career Suburban

Judy Secondary School Late Career Urban

Note. Interview participants were assigned a pseudonym.

Analyses for Research Question 1

The first research question inquired about the current practice of school psychologists in

the provision of MTSS components of mental health services.

Mental Health Practice of School Psychologists

The practice of school psychologists as mental health providers has been identified as an

answer to addressing the continued unmet mental health needs of students (Eklund et al., 2017;

Hess et al., 2017; Perfect & Morris, 2011). School psychologists are uniquely qualified as mental

health providers. Yet, research has found the role expansion beyond the traditional special

education role assessment has been minimal (NASP, 2010; Nastasi et al., 2000; Perfect &

Morris, 2011). The impetus for the transformation of the practice of school psychologists from a

traditional assessment role to a more diversified role has been advocated for decades by

practitioners, scholars, and policymakers (Bardon, 1972; Bennett, 1970; Bradley-Johnson &

57
Dean, 2000; Close-Conoley & Gutkin, 1995; Cummings et al., 2004; Larson & Choi, 2010;

Swerdlik & French, 2000; Tindall, 1964).

Historically, researchers explored the practice of school psychologists as mental health

providers in reference to the amount of time they engaged within the traditional role as special

education assessors and with special education programs and services. Previous studies have

found that an estimated 50 to 80% of the school psychologist’s role was engaged in conducting

special education eligibility assessments and working with students within the context of special

education. Yet, only 9 to 25% of their time was spent providing mental health supports such as

individual and/or group counseling services (Castillo, Curtis, & Geller, 2012; Curtis et al., 2002;

Fagan & Wise, 2007; Hosp & Reschly, 2002; Massey et al., 2005; Reschly, 2000).

More recently, researchers have examined the mental health practices of school

psychologists and found that more than half provide mental health services, with approximately

10% spending five hours of their time engaged in mental health services on a weekly basis

(Eklund et al., 2017; Hanchon & Fernald, 2013; Larson & Choi, 2010; Suldo et al., 2010).

Current study. The current study explored the frequency, average amount of time, and

scope of mental health services within an expanded innovative framework, the five MTSS

components. Data were collected from two sources, survey questions and semi-structured one-

on-one interview questions. The researcher analyzed data in two phases; phase one included

responses to the survey, and phase two encompassed the responses from the interviews.

In phase one, school psychologists were asked to respond to survey questions in regard to

the average number of hours per week (0 to 40 hours per week) they engaged in mental health

services within the five components of MTSS: (1) prevention and wellness promotion services,

(2) universal screening, (3) implementation of evidence-based intervention, (4) progress

58
monitoring, and (5) systematic data-decision making for programming and services. The results

are displayed in Table 5.

Table 5

Hours per Week Engaged in Mental Health MTSS Components

MTSS Component n Mean SD Min Max

1. Prevention and Wellness Promotion 110 5.65 5.99 0.00 29.00

2. Universal Screening 84 4.07 5.75 0.00 31.00

3. Evidenced-Based Interventions 104 7.21 6.27 0.00 28.00

4. Progress Monitoring 94 4.01 3.91 0.00 21.00

5. Systematic Decision Making 89 2.92 3.31 0.00 22.00

In phase one, the researcher examined the average amount of hours per week school

psychologists engaged in each of the MTSS components. The data are presented in Table 5. The

participants indicated they engaged in mental health services within each of the mental health

components, which ranged from a minimum of zero hours to a maximum of 40 hours per MTSS

component. Overall, there were large variations in responses; some school psychologists

reported no hours engaged in mental health services and some reported a maximum range of 21-

31 hours per week across the components.

On average, participants reported to spend approximately three to seven hours a week

engaged some type of mental health services, similar to the finding of more recent research

(Eklund et al., 2017). They reported to spend most of their time, seven hours per week,

implementing evidenced-based interventions (M = 7.21, SD = 6.27). School psychologists

indicated they spent the least amount of time engaged in systematic decision making about

programming and services (M = 2.92, SD = 3.31). It is interesting to note the participants spent

59
nearly six hours per week providing prevention and wellness promotion services (M = 5.65, SD =

5.99), approaching the average of seven hours a week they reported to spend with evidenced

based interventions. School psychologists reported to spend slightly less time, four hours a week,

with universal screening (M = 4.07, SD = 5.75) and progress monitoring (M = 4.01, SD = 3.91).

Figure 2. Range of Hours for MTSS Components

Given the wide variability in terms of time engaged within the five MTSS components,

further examination was conducted with the amount of time school psychologists spent within

each of the MTSS components. The researcher apportioned the hours into four ranges: zero

hours, 1 to 5 hours, 6 to 10 hours, and 11 or more hours, as displayed in Figure 2. The more in-

depth investigation revealed the majority of school psychologists spent one to five hours per

week engaged within each of the MTSS components. They identified spending the most amount

of time within prevention and wellness (MTSS Component 1), progress monitoring (MTSS

Component 4), and systematic decision making for programming and services (MTSS

Component 5). Interestingly, a substantial number of school psychologists, 18 to 25% reported to

spend no time engaged in systematic decision making for programming and services (MTSS

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Component 5) or with universal screening (MTSS Component 2), respectively. A table

corresponding to this figure can be found in Appendix G.

In order to conceptualize the type of services and activities school psychologists provided

within each of the five MTSS components, the participants were asked to identify the mental

health services they have provided. A comprehensive list of mental health services within each

component was provided and participants were asked to select from a list of multiple items. The

researcher calculated frequencies of the scope of mental health services for each of the five

MTSS components and these are shown in Table 6.

In phase two, the researcher further examined the mental health practices of school

psychologists through interviews. Thematic data analyses of the eight semi-structured interviews

were conducted to answer the first research question regarding school psychologists’ skills and

experiences in providing mental health services within the MTSS framework. The interview

responses indicated school psychologists regard the role as mental health providers as an

important element of their practice. Similar to the findings from the survey analyses, interview

participants also indicated they had provided services beyond direct counseling to include

system-wide prevention services such MTSS, restorative practices, mindfulness, and social

emotional learning. Several of the interview participants reported the importance of a

comprehensive framework and working at the system level to address the needs of all students.

Scope of Mental Health Services within each MTSS Component

MTSS Component 1: Prevention and Wellness Promotion Services. In phase one, 110

survey participants responded to the survey item regarding MTSS Component 1: prevention and

wellness promotion services. On average, they spent roughly five hours a week engaged in

prevention and wellness promotion services (see Table 5). The responses ranged from no hours

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to a maximum of 29 hours per week. Almost 60% (n = 75) reported to spend one to five hours

and almost 20% (n = 21) spent six to ten hours on average per week. Fifteen percent spent more

than 11 hours providing prevention and wellness promotion services. The most commonly

reported types of services included mental health consultation (n = 97), self-regulation strategies

(n = 76), school crisis team services (n = 73), and suicide prevention (n = 61). Other types of

prevention services mentioned were novel mental health services which included participation in

the school leadership team, social emotional learning (SEL) programs, restorative practices,

trauma informed practices, recognizing mental health needs, mindfulness, and wellness self-care

plan development, as displayed in Table 6.

In phase two, similar to the findings of the survey analyses, the interview participants also

indicated their practice as mental health providers had expanded to incorporate prevention and

wellness promotion services. Seven of the eight participants indicated that they provided services

beyond direct counseling such as participation as a member of the student study team (SST),

system-wide interventions most commonly referred to as Tier 1 supports, restorative circles,

mindfulness, and social skills. In fact, during an interview, Mia shared the recent training she

received prepared her to expand her role to provide preventative services, stating, “I have been

through a lot of different trainings on different counseling techniques and just how to work

within an educational system, on how to work with the whole school beginning with preventative

measures.” Judy endorsed the importance of a systemwide approach: “ecological perspective and

looking at the whole child, within the context in which they came from has informed the

practitioner I became. I am frontline in terms of consultation in regard to behavioral

interventions.” Max shared the universal services he provides to all students: “We do universal

supports in the PE block. We implement things like mindfulness and social skills.”

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Table 6

Scope of Mental Health Services within MTSS Components Frequency

Mental Health Services (n = 117) Frequency
MTSS Component 1: Prevention and Wellness Promotion
Mental Health Consultation 97
Self-Regulation Strategies 76
School Crisis Team 73
Suicide Prevention 61
School Leadership Team 40
Social Emotional Learning (SEL) Programs 38
Restorative Practices 35
Trauma Informed Practices 34
Recognizing Mental Health Needs 31
Brain Based/Mindfulness Strategies 29
Wellness/Self-Care Plan Development 25
MTSS Component 2: Universal Screening
School Climate Assessment 27
California Healthy Kids Survey 18
Universal Assets/Strengths Based Assessments 10
Universal Screening of Mental Health Needs 9
Adverse Childhood Experience Study 6
MTSS Component 3: Evidenced-Based Interventions
Suicide Risk or Threat Assessment 81
Individual Counseling 80
Social Skill Instruction 59
Group Counseling 54
Educationally Related Mental Health Services 51
Trauma Informed Practices 35
MTSS Component 3: Evidenced-Based Interventions
Mental Health Intervention Coaching 41
Restorative Practices 41
Brain Based/Mindfulness Instruction 26
Wraparound Plan Coordination 18
MTSS Component 4: Progress Monitoring
Progress Monitor Social Emotional Literacy/Mental Health Goals 71
Student Self-Monitoring Plans 60
Direct Treatment Protocol 30
Pre/Post Assessment of Mental Health Interventions 28
MTSS Component 5: Systematic Decision Making for Services
Provision of Professional Development 42
School Equity, Climate, Culture Leadership Team 29
Positive School Climate Survey/Strategy Data Analyses 25
Online Software Analyses of Schoolwide Data 18
Note. Participants were able to select multiple items within each component.

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 MTSS Component 2: Universal Screening for Mental Health Strengths and

Barriers. The school or district wide prevention assessment of mental health strengths,

resiliency factors, and mental health needs is identified as universal screening. Eighty-four

school psychologists responded to the survey question related to MTSS Component 2: universal

screening for mental health strengths and barriers. They reported spending on average four hours

per week engaged in this mental health service as presented in Table 5. The maximum number of

hours per week reported was 31 hours per week. More than half of the participants (n = 46) spent

one to five hours, and an additional 12% (n = 10) spent somewhere between six and ten hours

per week. It is interesting to note, 25% (n = 21) of the survey participants indicated they did not

spend any time engaged in universal screening (see Figure 2). The most common universal

screening services provided by school psychologists included school climate assessments (n =

27), CHKS (n = 18), and universal assets/strength-based assessments (n = 10) as displayed in

Table 6. Two survey participants indicated they provided no mental health services related to

universal screening. The interview participants did not discuss their involvement with universal

screening practices and/or services.

MTSS Component 3: Implementation of Evidenced-Based Interventions.

Historically, evidenced-based interventions have included direct service provision of individual

or group counseling and typically are the type of services that come to mind when mental health

services are discussed. In phase one, 104 of the survey participants responded to the question

related to MTSS Component 3: implementation of evidenced-based interventions. They reported

to spend most of their time engaged in this component as compared to the other four MTSS

components. The participants spent approximately seven hours per week on average

implementing evidenced-based interventions (M = 7.21, SD = 6.27), as reported in Table 5. A

64
wide range of hours engaged in these services was evident in the data, presented in Figure 2. A

few of the participants reported to spend zero hours, with others reporting to spend as much as 28

hours per week. An examination of Figure 2 shows 44% of the school psychologists (n = 46)

spent a range of one to five hours a week engaged in evidenced-based interventions. An

additional 28% (n = 29) spent six to ten hours per week and 24% spent more than 11 hours per

week providing mental health interventions. Only 4% (n = 5) indicated they provided no services

in this MTSS component.

The engagement of school psychologists in the various types of mental health services

within MTSS Component 3: implementation of evidenced-based interventions (Tier 2 and 3) is

presented in Table 6. The participants have extended these types of services beyond individual

and group counseling. The most frequent evidenced-based mental health service reported was

suicide risk and/or threat assessments (n = 81). The next most commonly identified intervention

included individual counseling (n = 80) and social skills instruction (n =60).

Similar to the findings from the survey analyses, interview participants (n = 8) also

indicated they provided evidenced-based intervention services such as individual and group

counseling. All interview participants (n = 8) also indicated they provided evidenced-based

intervention services such as individual and group counseling, threat and risk assessment,

mindfulness and social emotional learning supports. Max shared, “We teach through the second

step curriculum. All of the students are introduced to bullying, and self-awareness. Every day we

do check in and check out.” Ella reported, “I provide Tier 3 mental health services (i.e., direct

individual counseling through an IEP (i.e., individual education program) and I also supervise

Tier 2 inventions. I also work on Tier 1, coaching and implementing class-wide support.” Mia

stated she provides “different social skills and play therapy, and different solution focused brief

65
counseling.” Katie also shared information about the work she does with her team to provide

prevention and wellness promotion mental health services for students. She reported, “We meet

weekly for a year with a group of students identified and not identified for special services with

sustaining attention over time, focusing, deep breathing, and increasing the sustained attention.”

MTSS Component 4: Progress Monitoring of Mental Health Interventions and

Services. The evaluation of the effectiveness of mental health interventions and services, or

commonly referred to as progress monitoring, has been a growing interest of mental health

service within the field of school psychology. A total of 94 of the survey participants responded

to the question about providing progress monitoring services. Participant responses indicated a

wide range of hours engaged in these mental health services, illustrated in Figure 2. On average,

the participants reported to spend four hours per week engaged in this mental health service (see

Table 5). Similar to the other MTSS components, some participants reported to spend no hours

within this area and some reported to spend as many as 21 hours on average per week engaged in

progress monitoring. Nearly 70% indicated they spent one to five hours per week. Sixteen

percent stated they spend six to ten hours on average and 6% spent more than 11 hours per week.

Notably, 10% spent no time monitoring progress on mental health interventions and services.

The most common types of mental health services school psychologists reported included

progress monitoring of social, emotional literacy, and mental health goals (n = 71), student self-

monitoring plans (n = 60), and direct treatment protocol (n = 60) as presented in Table 6.

Ella reported progress monitoring services to be a mental health service she provides; she

stated, “I am assigned to supervise the rainbow room. They utilize second step curriculum and

other social emotional curriculums and I collect data.” Similar to the findings related to universal

66
screening, the other interview participants did not explicitly discuss their engagement with

progress monitoring services.

MTSS Component 5: Systematic Decision Making about Programming and

Services. The convening of a school or district team to review student assessment data has been

a common practice for educators in terms of academic growth indicators. It has only been

recently that this practice has expanded to include the examination and decision making with

social, emotional, and behavioral data.

Eighty-nine of the survey participants responded to items for MTSS Component 5.

Participant responses indicated school psychologists have participated in systematic decision

making about program and services and spent almost three hours on average per week engaged

in this work (see Table 5). The maximum number of hours per week was 22 hours. Close to 70%

of the participants (n = 59) spent one to five hours and 14% (n = 12) spent somewhere between

six and ten hours per week (see Figure 2). To date, some school psychologists have yet to

include systematic decision making into their practice as mental health providers. Eighteen

percent (n = 16) of the survey participants indicated they do not spend any time engaged in this

component of mental health services. The most frequently reported mental health services

provided within MTSS Component 5 included professional development (n = 42), participating

in a school equity, climate, and culture leadership teams (n = 29), and analyses of positive school

climate survey data (n = 25; see Table 6).

During the semi-structured interviews, participants shared they are involved with the

psychological triage team and/or student study team to review data. Hollie shared she

participated within a school leadership team to review data to inform the programs and services

provided within the school site. She stated, “We do the Hanover survey in our district, the top

67
three needs that came up from teachers, parents, and everyone is social emotional learning,

safety, and behavior.” Alma shared, “I am part of a school team, like a pre-referral triage team.

We would meet to review all the data and make recommendations.”

Analyses for Research Question 2

The second research question examined the factors which serve to support the practice of

school psychologists in the provision of MTSS components of mental health services.

Factors Supporting Provision of Mental Health Services

The factors which facilitate the role expansion of school psychologists have been studied

by numerous researchers (Eklund et al., 2017; Perfect & Morris, 2011; Suldo et al., 2010; Wnek,

Klein, & Bracken, 2008). Until recently, most of the research involved a national sample of

school psychologists and/or explored mental health within a narrow definition. Two state-level

studies were conducted to examine the supportive factors school psychologists experienced in

the provision of mental health services (Eklund et al., 2017; Suldo et al., 2010). No studies have

been conducted with the broad definition of mental health within a MTSS framework nor with

school psychologists within the state of California.

Current study. The researcher answered the second research question regarding the

supportive factors in the provision of mental health services by examining data from two

sources: the survey items and the semi-structured interviews. In phase one of the study, 117

participants responded to two fixed-choice survey questions and one open-ended question related

to factors enabling their role as mental health providers and their experience with the degree of

administrator support. In phase two, eight participants engaged in a semi-structured interview

and described the factors supporting their practice as mental health providers. Overall, the survey

and interview participants identified a continuum of overarching supportive factors which

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influenced their ability to deliver mental health services: school psychologist to student ratio,

time, administrator support, professional development, and collaboration with other school based

mental health (SBMH) providers.

Table 7

Fixed-Choice Survey Question Identified Degree of Administrator Support for Provision of a

Comprehensive continuum of Mental Health Services Frequency & Percentages
Administrator Degree of Support n = 117 %
Strong Support for Provision of Mental Health Services 30 26

Some Support for Provision of Mental Health Services 58 50

Indifference for Provision of Mental Health Services 17 14

No Support for the Provision of Mental Health Services 12 10

.

The initial fixed-choice survey question (Survey Question 1) specifically inquired about

the degree of administrator support related to the role of school psychologists in providing a

comprehensive continuum of mental health services. The participants were asked to select from

five responses ranging from strong administrator support to the administrator being strongly

opposed to or against school psychologists in providing a comprehensive continuum of mental

health services. Twenty-six percent of the respondents indicated their administrator provided a

strong level of support to them in providing mental health services. Fifty percent indicated they

received some support from their administrator. Interesting to note, 10% of school psychologists

indicated they received no support from their administrator to provide a comprehensive

continuum of mental health services as displayed in Table 7.

The second fixed-choice survey question (Survey Question 19) asked participants to select

from a list of five supportive factors: more training or professional development, school and/or

district administrator support, improved ratios (school psychologist to student), collaboration

69
with school counselors and school social workers, and an option to indicate no interest in

providing the services.

Table 8

Fixed-Choice Survey Question Identified Supports for Provision of Mental Health Services
Frequency & Percentages
Supportive Factors n = 117 %
School Psychologist to Student Ratio 97 83

Administrator Support 75 64

Training/Professional Development 69 60

Collaboration with Other SBMH Providers 68 58

Note. Survey participants were able to select multiple items.

The majority of the school psychologists (n = 97, 83%) identified the ratio of school

psychologist to student as the predominate supportive factor for their ability to provide mental

health services as presented in Table 8. Administrator support and professional development

were indicated as the second and third supportive factors, respectively. A novel supportive factor

which emerged from the data was the collaboration with other SBMH providers, endorsed by

58% of school psychologists. Typically, school psychologists work in isolation as the only

school psychologist at a specific school site and/or assigned to multiple school sites. Thus, the

findings suggests school psychologists appreciate the ability to access and to collaborate with

other SBMH providers such as fellow school psychologists, school counselors, and/or school

social workers within the context of mental health service delivery.

Additionally, the survey participants responded to an open-ended question (Survey

Question 33) regarding the supports they experienced as mental health providers. Their

responses resulted in seven identified supportive factors as displayed in Table 9. Similar to the

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fixed-choice questions, school psychologists identified key supportive factors in their provision

of mental health services: collaboration with other SBMH providers (n = 73, 29%), administrator

support (n = 18, 25%), and professional development (n = 16, 22%). Some of the participants

indicated the mental health services provided by other SBMH providers to be a supportive factor.

Table 9

Open-Ended Survey Identified Supports for Provision of Mental Health Services Frequency &
Percentages
Supportive Factors n = 73 %
Collaboration with Other SBMH Providers 21 29

Administrator Support 18 25

Professional Development 16 22

Others Provide the SBMH Services 12 16

Sufficient Time 9 12

Receive No Support 5 7

Access to Resources 4 5

Note. Survey participants could select multiple items.

The second phase of the study further explored the perspective of California school

psychologists through individual interviews to elicit data from personal stories and experiences

related to the supportive factors in providing mental health services. A review of the semi-

structured interview transcripts provided enriching personal experiences of school psychologists

regarding the elements in their practice as mental health providers. Many of the identified factors

are consistent with the survey participant responses. The interview participants were asked to

describe the supports within their practice in delivering mental health services, resulting in nine

identified supportive factors: administrator support, school psychologist to student ratio, time,

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professional development, collaboration with other SBMH providers, teacher support, parent

and/or family support, access to resources, and others provide the mental health services. Two

interview participants indicated they received no support.

Study participants identified critical factors that were perceived to support their practice

of providing mental health services as well as the underpinning ideology of these supportive

factors. Several of the overarching supportive themes from the current study were consistent with

the literature and included the following: administrator support, lower school psychologist to

student ratio, training and professional development, other personnel provided the services, and

sufficient time. Six additional supportive themes were identified in this study: collaborating with

other school-based mental health providers, development of a comprehensive system, access to

resources, the need for role definition, and both teacher and parent/family support. Three primary

supportive factors emerged from the data and will be shared thematically: school psychologist to

student ratio, administrator support, and professional development.

School psychologist to student ratio. The survey participants identified the most

predominant supportive factor for providing mental health services was the school psychologist

to student ratio. Over 80% of survey participants (n = 97) reported lower school psychologist to

student ratio as a critical supportive factor in their ability to provide mental health services (see

Table 8). Sixty-three percent (n = 74) stated the current school psychologist to student ratio is at

or above the state ratio average in their workplace (see Table 3).

Interview participants also endorsed the importance of school psychologist to student

ratio in the delivery of mental health services. During his interview, Max shared extensive

school-wide prevention services he provided and endorsed the importance of a low school

psychologist to student ratio on his ability to provide a comprehensive continuum of mental

72
health services. He stated, “We have a ratio of school psychologist to student of 1:150 being at a

site full time is important.”

Administrator support. School psychologists are interested in providing mental health

services and they have identified conditions that support their practice in providing these

services. The primary supportive factor identified by interview participants and the second most

frequently endorsed facilitative factor by survey participants within this study was administrator

support. Slightly more than 60% of survey participants (n = 75, 64%) and interview participants

(n = 5, 63%) identified administrator support as a critical factor to support their practice as

mental health providers. In fact, 75% (n = 88) of school psychologists in the current study

reported their administrators provided some to strong levels of support in the provision of a

comprehensive continuum of mental health services. Participants indicated administrator support

demonstrated an understanding of the importance for: (1) system change, (2) building

relationship, (3) a focus on the whole child, and (4) the necessity to expand the role of school

psychologists to incorporate preventative services.

The findings of the interviews supported the survey data and indicated administrator

support was perceived to foster the broadening of the school psychologist role to encompass

more prevention and wellness promotion services. The district administrator support was

described as the understanding of the importance of children’s mental health and the value of

relationships in the schools. Max stated, “I think first and foremost in regards to providing

mental health services I have complete support from admin and freedom that goes along with

that.” Mia shared in the interview the importance of administrator support, resulting in more time

to provide mental health services: “The support of our district level, they have allowed us more

time at our school site, so there is one school psychologist at each school site which has helped a

73
lot in being able to actually provide these services.” Mia further expressed that the support from

administrators enabled the expansion of the role as a mental health provider to include

collaboration with others and the provision of prevention services such as professional

development by sharing, “The administration at the school, our Principal is interested in

identifying the needs of our students and referring students to me and providing more time to

reach out to teachers and provide professional development and collaborate with staff members.”

Katie shared the continual conversations, monitoring of workload, and providing professional

development opportunities by an administrator have been helpful: “Our director does support us,

she provides training opportunities and encourages us to find things to grow, she encourages us

to participate, she listens to our needs, she checks into how many students we are seeing and if

we need relief.”

The support for mental health services identified by the interview data extends

administration support to be inclusive of all stakeholders including the superintendent. Hollie

stated, “We have stakeholders waking up and seeing there is a huge need for these things.” She

further indicated, “we need to focus on more than just academics for growing people…we need

to make sure we grow the whole child; that is finally starting to click in our district.” A paradigm

shift within the educational system was identified in which mental health and relationships were

embraced as priorities. Judy shared, “It was a system change at the district-level, district

superintendent who valued relationships in the schools, set the stage for us to do this work…

valued relationships between students and staff, students and students, staff and staff, parents.”

Professional development. Sixty percent of survey participants (n = 69) indicated

professional development as a supportive factor, less than the ratio of school psychologist to

student (n = 97, 83%) or administrator support (n = 75, 64%). Similar to the survey analyses,

74
interview data theme analyses also identified continuing professional development as a

supportive factor for the practice of school psychologists as mental health providers.

Six interview participants identified professional development and training in specific

mental health areas such as cognitive behavioral therapy, risk and threat assessment,

collaboration with other team members, student study team, and NASP PREPaRE crisis response

and prevention (NASP crisis prevention curriculum for school-based mental health providers) as

contributing influential factors as mental health providers. Additionally, it is interesting to glean

from the data that interview participants described professional development to include

workshops and trainings as well as engagement within their daily practice within the schools.

The interview participants consistently identified their work within the schools and on-the-job

training and experience as a critical opportunity to practice and enhance their skill set as mental

health providers. School psychologists indicated they attended workshops and presentations

within their school districts, local special education local planning areas (SELPA), the regional

county office of education, the California Diagnostic Center and/or the cadre of trainers via

Positive Network of Trainers (PENT), and/or the local, state or national association of school

psychologists (i.e., CASP and NASP).

One interview participant, Mia, shared during an interview, “we’ve had training focused

on MTSS and it has helped me to identify behavior of students and their social emotional needs.

It went over supports at each level and whole school trainings on restorative practices.” Ella

indicated she has “received training on how to work within a comprehensive mental health

framework.” Hollie said the training she has received supported her ability to address the needs

of all students school wide; she stated, “current professional development opportunities in

implementing MTSS systems specifically related to behavior and social emotional learning.”

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Yet, Hollie also expressed during an interview the feeling she is “missing the skills and need

more professional development on MTSS and mental health services.” Elizabeth expressed

during the interview the need for more focused training on mental health. However, many of the

trainings continue to have a focus on assessment. She stated, “professional development money

is used to become better measurement people, data interpreters, there isn’t a lot of around mental

health but, I do think there should be a focus on it.”

Additional supportive factors. A new supportive factor identified in this study was the

collaboration with other SBMH professionals (i.e., other school psychologists, school

counselors, school social workers), identified by 58% of survey fixed-choice item responses and

29% of responses to the open-ended survey question. In addition, access to resources (50% of

interview responses, 5% open-ended responses) was identified as supporting school

psychologists’ mental health practice. Interesting to note, 16% of the school psychologists

responded to the open-ended survey question regarding supportive factors in providing mental

health services and indicated having another mental health professional to provide the services

was supportive. In addition, five of the respondents to the open-ended question (7%) indicated no

supportive factors in providing mental health services.

Analyses for Research Question 3

The third research question examined the factors which limit the practice of school

psychologists in the provision of MTSS components of mental health services.

Factors Limiting Provision of Mental Health Services

The factors which impede the practice of school psychologists as mental health providers

has been studied by numerous researchers (Curtis et al., 2002; Eklund et al., 2017; Hanchon &

Fernald, 2013; Massey et al., 2005; Suldo et al., 2010). Similar to the research of supportive

factors, research has typically been conducted with a national sample of school psychologists
76
and/or within a narrowly defined scope of mental health services. Two state-level studies

examined the barriers school psychologists with providing mental health services (Eklund et al.,

2017; Suldo et al., 2010). No studies have been conducted in this area with school psychologists

in the state of California.

Current study. In the current study, school psychologists identified factors that were

perceived to limit their practice in providing mental health services. In phase one, survey

participants responded to two questions regarding the limiting factors or barriers faced in

providing mental health services, a fixed-choice item (Survey Question 18) and an open-ended

item (Survey Question 34). One hundred and seventeen participants responded to the fixed-

choice survey question by selecting from a list of five predetermined items: (1) time, (2) another

professional provided the service, (3) not enough training, (4) no school/district administrator

support, and (5) not interested. The initial data analyses were descriptive statistics to provide

frequencies and percentages of identified limiting factors endorsed by school psychologists (see

Table 10). The same number of participants responded to the open-ended question regarding

limiting factors, resulting in eight overarching factors and are presented in Table 11.

In phase two, eight participants engaged in a semi-structured interview and provided

descriptions of seven factors which limited their mental health service delivery. Overall, the

survey and interview participants identified common overarching limiting factors which

influenced their ability to deliver mental health services: insufficient time, school psychologist to

student ratio, training and professional development, and the lack of administrator support.

Almost 90% (n = 105, 88%) of the school psychologists who responded to the fixed-choice

survey question identified insufficient time as the primary barrier in their engagement as mental

health providers within the schools (see Table 10).

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Table 10

Fixed-Choice Survey Identified Barriers in Provision of Mental Health Services Frequency &
Percentages
Barrier Factors n = 117 %
Insufficient Time 105 88

Another Professional Provides the Services 43 37

Insufficient Training 39 33

Lack of Administrator Support 35 30

Not Interested 2 2

Note. Survey participants were able to select multiple items.

Interesting to glean from the data analyses, 30% of the respondents indicated the second most

common limiting factor in providing mental health services was the fact that someone else was

providing the services (e.g., school counselor, school social worker). Approximately 30% of

school psychologists identified insufficient training (n = 39, 33%) and lack administrator support

(n = 35, 30%) as interfering with their ability to provide mental health services. Only two

participants indicated they were not interested in providing services. Thus, the vast majority of

school psychologists are interested in assuming the role as mental health providers and

addressing the unmet needs of students.

The survey participants also responded to an open-ended question (Survey Question 34)

regarding their perceptions of the limits which impede their ability to provide mental health

services. Eighty-five survey participants responded; theme analyses were conducted, resulting in

a total of eight collective themes, presented in Table 11. Comparable to the responses to the

fixed-choice survey question, school psychologists identified fundamental limiting factors which

intrude in their role as school-based mental health providers. Forty-nine percent reported

78
insufficient time, the most prevalent factor identified. A novel limiting factor was identified by

25% of the respondents, lack of a comprehensive intervention system. Additional limiting factors

included the expectation to engage in the traditional assessment role (n = 19, 22%), lack of

administrator support (n = 11, 13%), insufficient training (n = 11, 13%), school psychologist to

student ratio (n = 12, 12%), as well as fiscal constraints and another professional providing the

mental health services.

The second phase of the study explored the perspective of California school

psychologists beyond responses to survey items to elicit data from personal stories and

experiences in providing mental health services. Eight survey participants were available for an

individual, semi-structured interview and were asked to describe the limitations within their

practice in providing mental health services. A review of the eight interview transcripts provided

personal experiences of school psychologists regarding the limiting elements in their practice as

mental health providers. Their responses endorsed many of the aforementioned limiting factors

congruent with the survey responses. In addition, interview participants also described access to

resources and the ineffective prevention efforts such as the student study team process.

Insufficient time. Time was the most commonly endorsed factor by survey and interview

participants which limited mental health service delivery, as presented in Tables 10 and 11.

Nearly 90% of the respondents to the fixed-choice and 49% of the open-ended survey questions

respondents identified time as the critical barrier they experienced as mental health providers.

The element of time was the most frequently endorsed factor serving as a barrier by interview

participants in terms of school psychologists providing mental health services (n = 6, 75%).

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Table 11

Open-Ended Question Identified Barriers in the Provision of Mental Health Services Frequency
& Percentages
Barrier Factors n = 85 %
Insufficient Time 42 49

Lack of a Comprehensive Intervention System 21 25

Traditional Assessment Role Expectations 19 22

Lack of Administrator Support 11 13

Insufficient Training 11 13

School Psychologist to Student Ratio 10 12

Fiscal Constraints 7 8

Another Professional Provides the Services 3 3

Note. Survey participants were able to select multiple items.

The interview participants expressed concerns regarding time allocation for engaging in

mental health practices related to competing demands of the traditional assessment role, legal

requirements of the job, and the ratio of school psychologists to students which interfere with

their ability for mental health service delivery. For example, several of the interview participants

addressed this issue. Mia stated, “the number one thing is not having enough time, although I am

at one school, the ratio is 500, there is a high need for mental health services, I am called upon

for other duties which are great.” Mia further stated, “I don’t have enough time to dig deeper to

get to the root of what’s going on.” Elizabeth stated, “Time, I am a school psychologist, I have to

meet legal requirements of the job, pressure to write legally defensible reports, no time left

over.” Hollie identified the time allocated to address the mental health needs of students is often

overlooked until a crisis occurs: “Give us time to implement interventions that help support the

social emotional and behavioral needs of kids.” She further conveyed, “things happen after a

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school shooting or terrible mass tragedy, people’s emotions run high and you’ll see different

things on Facebook lighting up, then a couple months after, so Parkland has been a couple of

months not seeing those.” Hollie suggested school psychologists should engage in preventative

efforts, “instead of waiting for the next one to happen to pump our energies and start looking for

those things and how do we become proactive and hopefully not have to wait.”

Traditional role expectations. The impeding factor of time seems related to the

expectations for school psychologists to maintain the traditional assessment role. Thirteen

percent of the survey participants responded to the open-ended survey question by reporting the

traditional assessment role expectation as a barrier in their practice as a mental health provider

(see Table 11). A school psychologist responded to the open-ended survey question by indicating

the time constraints of the role limits the practice of school psychologists to a traditional practice

of conducting assessments: “too many assessments and little time left for counseling.”

During her interview, Alma stated that “there is an unspoken expectation that school

psychologists do not provide mental health services.” Katie echoed this during her interview by

asserting, “I was told it was not our role even in the context of education, we attempted to use the

NASP Model and show the needs of staff, we couldn’t get them to budge, it wasn’t from a lack

of trying.” Given the impediment invoked within a district, Katie shared this has impacted the

retention of school psychologists: “We have lost several professionals over the past 8 years

because we haven’t been asked, we were told not to do it, required or use our skill sets to provide

mental health services.” The barrier of the expectation to conduct assessments was also endorsed

by Alma: “High caseload of assessments…clear they expect me to do assessments” and speaks to

the issue of school psychologist to student ratio. Ella reported time as a barrier; yet, indicated she

81
has been allocated time to supervise tier 2 evidenced based interventions. She shared concerns

that no time was allocated for her to engage with the prevention and wellness promotion services

Lack of a comprehensive intervention system. A newly emerging theme from the

semi-structured interviews spoke to the overarching need for a comprehensive cohesive

framework such as MTSS that explicitly identified school psychologists as mental health

providers. During the interview, Alma clearly identified the initial barrier to providing mental

health services was the need for a comprehensive structure within the educational system: “Well,

there is no framework for it first of all to do counseling and consulting about social emotional

support.” Max further endorsed the lack of a comprehensive intervention system and identified

the definition of MTSS and mental health serviced as a barrier. He stated, “when you say mental

health, many aren’t familiar with the term and may confuse it will mental illness which is like a

taboo or cultural obstacle with the Hispanic culture and the catholic faith.”

Other professional provides the service. Thirty-seven percent (n = 43) of survey

participants in the present study identified a predominant barrier to providing mental health

services was the fact that other professionals provide the mental health services. Interestingly,

16% of participants (n = 12) noted it was also a supportive factor. One survey participant

composed a lengthy response to the open-ended survey question regarding factors that serve as a

barrier in the provision of mental health services. The participant identified the concern of the

school district replacing school psychologists with other mental health providers as a cost-saving

measure: “Our school district is contemplating replacing our mental health itinerant school

psychologist who delivers the ERMHS (educationally related mental health services) with MFT

(marriage, family therapists) agency interns to save money in the budgeting of salaries.” This

participant further shared administrator support also served as a barrier along with the

82
undervaluing of the role of school psychologists as mental health providers: “The district

administrators lack the understanding and the importance placed on understanding school-based

services that the experience and expertise school psychologists possess when delivering ERMHS

that an MFT does not possess.”

During the interview, Elizabeth shared that her “district does contract with an outside

agency to provide interns to do counseling but, there is a rotation of them who have little

experience.” Katie reported, “I haven’t been required to [provide mental health services], and

actually it was discouraged for using time for providing mental health support services and they

outsourced it to a variety of agencies.” Alma reported that other professionals are being assigned

the mental health role: “…no one said that I cannot provide mental health counseling but, the

expectation is that all students who have DIS counseling services are referred to the school

counselors that are on contract.” She further added, “the DIS counselors we contract to provide

mental health counseling are protective of their role” and “I was told I was not the expert and my

services disrupt programs.”

Lack of administrator support. School psychologists are interested in providing mental

health services and they have identified conditions that interfere with their practice in providing

these services. Although administrator support was identified in this study to serve as a

supportive factor for the provision of mental health services, it was also identified as a barrier in

accessing services. The lack of administrator support was identified by 30% (n = 35) of survey

participants, substantially less than the 82% of responses in previous research (Suldo et al.,

2010). The interview participants also mentioned lack of administrator support served as a

barrier in their ability to employ mental health services. Hollie indicated, “getting admin support

to give us the time, a lot of times they want to fast track to special education rather than giving us

83
time to implement interventions that help support the social emotional and behavioral needs of

kids.” She additionally indicated, “they know there is need for it, they aren’t willing to put the

resources behind it, the money, the training to make these things a reality.”

In the current study, participants identified several factors which limited their practice as

mental health providers. A review of the data found several of the overarching themes within the

current study that were recognized as limitations were previously identified by survey

participants as supportive factors: school psychologist to student ratio (12%), the administrator

(30%), time (88%), training and professional development (33%), and another professional

provides the mental health services (37%).

Factors that influence mental health service delivery. In the current study, participants

identified a total of seven primary factors which served as supports and seven primary factors

that served to limit their practice as mental health providers. It was interesting that not all factors

were only identified as either a support or limit—some factors served to be both. Some of the

school psychologists identified a factor as a support; yet, some of their colleagues identified the

same factor as a limiting factor influencing mental health service delivery, as presented in Table

12.

The participants in the current study identified two primary factors that influence mental

health service delivery: school psychologist to student ratio and time. The school psychologist to

student ratio was identified by 83% of participants as a supportive factor and 88% identified time

as a limiting factor, both seem to be a different side of the same coin. Interestingly,

administrators and professional development were identified by approximately 60% of

participants as a supportive factor. Yet, roughly 30% identified both factors as limiting their

mental health service delivery. In addition, 37% indicated a limiting factor involved the fact that

84
other personnel provided the mental health services. However, 16% viewed this factor as a

support in mental health service delivery

Table 12

Factors that Influence Mental Health Service Delivery

Factors Limit Support
School Psychologist to Student Ratio 83% 12%

Administrator 64% 30%

Professional Development 60% 33%

Collaborate with Other SBMH Providers 58%

Time 12% 88%

Other Provides the Services 16% 37%

Comprehensive System 25%

Traditional Role 22%

Access to Resources 5%

Note. Survey participants were able to select multiple items.

Analyses for Research Question 4

The fourth research question examined potential differences in the practice of school

psychologists in the provisions of MTSS components of mental health services in terms of

professional contextual factors including school setting (i.e., primary, secondary) and community

(i.e., urban, suburban).

School Setting and Community Professional Workplace

Current study. A new contribution to the research of school psychologists as mental

health providers was provided by the current study, the exploration of the professional contextual

factors such as school setting and community. The researcher answered the fourth research

85
question regarding the differences in the mental health practice within the MTSS components

among school psychologists in terms of professional contextual factors.

The survey participants were divided into two groups for comparison: those working

within the primary school setting and those within the secondary school setting. The two groups

had a relatively equal number of assigned participants. The primary school setting yielded

slightly more participants (n = 57, 49%) than the secondary school setting (i.e., middle school,

high school; n = 41, 35%). The survey participants were also divided into groups based on the

community of their workplace: urban and suburban. An approximately even number of

participants work within an urban community (n = 46, 40%) and suburban community (n = 60,

51%).

Overall, mental health service delivery was found to vary among school psychologists in

terms of the school setting and/or community of their workplace within MTSS Component 1:

prevention and wellness promotion, MTSS Component 2: universal screening, MTSS

Component 4: progress monitoring, and MTSS Component 5: systematic decision making for

programming and services (see Figure 2). Data analyses were conducted for each of the MTSS

components in terms of setting and community variables, and the results are presented in Tables

13 through 17. Each of the aforementioned tables provide the descriptive statistics for each

MTSS components.

Table 13 shows the means and standard deviations for the dependent variable MTSS

Component 1: prevention and wellness promotion, across the independent variables (i.e., school

setting, community). A statistically significant difference was not found in the prevention and

wellness promotion services provided by school psychologist in terms of their school setting or

community. There were no differences between primary and secondary school psychologists nor

86
urban or suburban school psychologists. Regardless of the school setting or community in which

school psychologists worked, participants spent about six hours providing MTSS Component 1.

Yet, analyses of both setting and community revealed that urban secondary school psychologists

spent the most amount of time in this area. On average, urban secondary school psychologists

spent almost eight hours on average per week engaged in prevention and wellness promotion,

about one and a half more hours than the other groups.

Table 13

MTSS Component 1 by School Setting and Community Means & Standard Deviations
Source n Mean SD F p
Main Effect School Setting .08 .76
Primary 50 5.88 6.48
Secondary 35 6.00 6.47
Main Effect Community .78 .38
Urban 37 6.60 6.76
Suburban 48 5.54 6.28
Interaction Effect .93 .34
Urban Primary 21 5.81 5.70
Urban Secondary 16 7.63 8.02
Suburban Primary 29 5.93 7.09
Suburban Secondary 19 4.95 4.90

The theme analyses of the interview data reflected that urban school psychologists

identified training within graduate school and within their workplace provided the groundwork in

the provision of prevention and wellness promotion services. They described mental health

services provided within MTSS Component 1included mindfulness, positive behavior

interventions and supports, peace patrol, and facilitating universal restorative practice circles.

Mia stated she works from a school-wide perspective: “at the whole school level I have had

trainings on restorative practices.” Max stated, “universally we provide for all of our students is

facilitating restorative circles.”

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Table 14

MTSS Component 2 by School Setting and Community Means & Standard Deviations
Source n Mean SD F p
Main Effect School Setting .03 .87
Primary 37 4.03 6.06
Secondary 27 4.44 5.08
Main Effect Community 3.60 .06
Urban 25 6.00 7.71
Suburban 39 3.05 4.11
Interaction Effect .07 .79
Urban Primary 14 6.07 8.73
Urban Secondary 11 5.91 6.59
Suburban Primary 23 2.78 3.29
Suburban Secondary 16 3.44 5.16

Table 14 shows the means and standard deviations for the dependent variable MTSS

Component 2: universal screening across the independent variables (i.e., setting, community). No

significant differences were found between school psychologists in terms of those who worked

within a primary or secondary school setting. Interesting to note, the difference between urban

and suburban school psychologists approached significance (p = .06). The urban school

psychologists (M = 6.00, SD = 7.71) spent an average of six hours engaged in universal

screening services, twice as much time as their suburban counterparts (M = 3.05, SD = 4.11).

Interview participants did not explicitly identify universal screening as a mental health service in

their discussion of their practices.

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Table 15

MTSS Component 3 by School Setting and Community Means & Standard Deviations
Source n Mean SD F p
Main Effect Setting .03 .86
Primary 47 6.85 6.51
Secondary 33 7.15 5.08
Main Effect Community .13 .72
Urban 37 7.30 5.54
Suburban 43 6.70 6.29
Interaction Effect .16 .69
Urban Primary 21 7.43 6.10
Urban Secondary 16 7.13 4.91
Suburban Primary 26 6.38 6.91
Suburban Secondary 17 7.18 5.38

The means and standard deviations are presented in Table 15 for the dependent variable

MTSS Component 3: implementing evidenced-based interventions across the independent

variables (i.e., setting, community). No significant differences were found in the time school

psychologists spent providing evidenced-based interventions between those working in a primary

or secondary school setting or those working in an urban or suburban community. All interview

participants reported to provide evidenced-based interventions.

Table 16

MTSS Component 4 by School Setting and Community Means & Standard Deviations
Source n Mean SD F p
Main Effect Setting 2.44 .12
Primary 42 3.29 2.75
Secondary 31 4.52 4.46
Main Effect Community 3.00 .09
Urban 32 4.53 4.31
Suburban 41 3.22 2.86
Interaction Effect 1.37 .25
Urban Primary 18 3.56 2.71
Urban Secondary 14 5.86 5.61
Suburban Primary 24 3.08 2.83
Suburban Secondary 17 3.41 2.98
.

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 Table 16 shows the means and standard deviations for the dependent variable MTSS

Component 4: progress monitoring across the independent variables (i.e., setting, community).

No significant differences were found between primary and secondary school psychologists.

However, the difference between urban and suburban school psychologists approached

significance (p = .09). The suburban school psychologists spent approximately five hours per

week engaged in progress monitoring, almost two hours more time per week than urban school

psychologists who spent a little more than three hours per week. A review the interview data

indicated participants did not explicitly discuss progress monitoring services.

Table 17

MTSS Component 5 by School Setting and Community Means & Standard Deviations
Source n Mean SD F p
Main Effect Setting 5.84 .02
Primary 38 2.13 1.79
Secondary 29 4.03 4.61
Main Effect Community .19 .66
Urban 29 3.07 4.05
Suburban 38 2.87 2.91
Interaction Effect .73 .40
Urban Primary 17 1.94 1.48
Urban Secondary 12 4.67 5.82
Suburban Primary 21 2.29 2.03
Suburban Secondary 17 3.59 3.66

A significant difference was found in relation to the school setting (independent variable)

of the participants workplace (p = .02) and their engagement in MTSS Component 5 (dependent

variable). The secondary school psychologists spent on average four hours per week in

systematic decision making about programming and services (MTSS Component 5), twice as

much time than the primary school psychologists who spent an average of two hours per week

(see Table 17). The interview participants indicated they coordinated and/or participated as a

90
member of a student study team yet, it is unclear if the team utilized data for systematic

databased decision making about programming and services.

Figure 3. School Setting and Community Influence of Mental Health Services.

Overall, the school setting and/or community in which school psychologists worked was

found to influence their practice as mental health providers within each of the MTSS components

as presented in Figure 3. A review of the survey findings reveals a significant difference in one

of the MTSS components (MTSS Component 5), nearly significant differences within three of

the five MTSS components (MTSS Component 1, MTSS Component 2, MTSS Component 4),

and no difference in one of the MTSS components (MTSS Component 3).

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 A significant difference was found between secondary and primary school practitioners

in the area of MTSS Component 5: systematic decision making for programming and services.

The secondary school psychologists spent on average four hours per week in this area, twice the

amount of their counterparts working within a primary school setting which spent an average of

two hours per week. No significant differences were found across the remaining MTSS

components in terms of school setting and community. However, the differences between groups

of school psychologists approached significance within three additional MTSS components,

MTSS Component 1: prevention and wellness promotion, MTSS Component 2: universal

screening, and MTSS Component 4: progress monitoring. Urban secondary school psychologists

spent almost eight hours per week engaged in prevention and wellness services, one and a half

more hours than any other group. Urban school psychologists spent about six hours weekly

conducting universal screening, double the time of their suburban colleagues whom spent an

average of three hours per week. Suburban school psychologists spent almost five hours per

week engaged in progress monitoring (MTSS Component 4), one and a half more time than

urban school psychologists whom spent about three hours per week.

Analyses for Research Question 5

The fifth research question investigated the relationship between demographic contextual

factors, professional contextual factors, and the provision of mental health services for each of

the MTSS components.

Survey item data analyses. The relationship among demographic and professional

factors such as school setting and community on the mental health practices of school

psychologists has not been examined by previous researchers. The sources of data for analyses in

the current study were the responses to the survey items and semi-structured interview questions.

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Correlations were calculated to examine the relationships between the demographic contextual

factors, professional contextual factors, and the MTSS components.

Table 18

Correlations of MTSS Components, Demographic, & Professional Contextual Factors

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

1. MTSS .49** .45** .45** .38** -.02 -.12 -.07 .05 .19*
-
Component 1 (81) (101) (91) (88) (110) (108) (108) (110) (110)

2. MTSS .37** .55** .47** -.10 -.12 -.10 -.04 -.07

-
Component 2 (76) (73) (70) (84) (82) (82) (84) (84)

3. MTSS .53** .31** -.08 .14 .16 .14 .33**

-
Component 3 (89) (84) (104) (102) (101) (104) (104)

4. MTSS .71** -.02 .20 -.06 -.04 .14

-
Component 4 (82) (94) (93) (92) (94) (94)

5. MTSS -.27* .04 -.06 .09 .22*

-
Component 5 (89) (87) (87) (89) (89)

6. Years of .17 -.22* .16 .18*

-
Experience (115) (114) (117) (117)

7. Ratio School .09 .23* .26**

Psychologist - (112) (115) (115)
to Student

- .10 -.04
8. Education
(127) (127)

- .45**
9. Advocacy
(117)

10. Professional
-
Development

Note. ** Correlation is significant at the .01 level (2-tailed). * Correlation is significant at the .05
level (1-tailed). The number of participants in each correlation is indicated with parenthesis for
each correlation.

Overall, several of the MTSS components, demographic, and professional contextual

factors were correlated and are presented in Table 18. The MTSS components were found to be

93
moderately, positively correlated with each other (all ps < .004). This signifies all MTSS

components tend to be different measures of mental health. Few of the demographic and

professional contextual factors were found to be strongly related to the MTSS components.

The professional contextual factor of professional development was found to be weakly

correlated to MTSS Component 1: prevention and wellness (p = .047), MTSS Component 3:

evidenced-based interventions (p = .001), and MTSS Component 5: systematic decision making

(p = .042). The analyses reported a positive relationship between professional development and

the hours engaged in mental health services: prevention and wellness promotion services,

implementation of evidence-based interventions, and systematic decision making for program

and services. A significant, moderate correlation was found between professional development

and advocacy (p < .001). Professional development was also found to be related to other

professional contextual factors such as years of experience (p = .047) and school psychologist to

student ratio (p = .006). The positive correlation suggests the more years of experience as a

school psychologist, the more time engaged in professional development, the more likely they

engaged in advocacy efforts, and the higher the ratio of school psychologist to student.

The professional contextual factor of experience was found to be related to educational

level and professional development. The factor of experience was found to be negatively related

to education (p = .021). The more years of experience as a school psychologist, the less graduate

education the participant completed. Thus, the findings suggest the early career school

psychologists have a higher propensity to earn a doctorate degree than the late career school

psychologists. Additionally, a positive, significant correlation, although weak, was found

between the number of hours of professional development and years of experience (p = .047).

This suggests that the more experience a school psychologist has, the more professional

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development hours they complete. The findings imply late career school psychologists recognize

the changes within the field of practice of school psychologist, identifying the need to further

develop their knowledge and skills as mental health providers.

Years of Experience

Additional exploration was conducted in terms of years of experience in the profession, a

demographic contextual factor. Specifically, the researcher sought to examine the difference

between early and late career school psychologists in relation to their engagement within each of

the mental health MTSS components. The survey participants were assigned to one of two

groups for comparison: early career (less than 10 years of experience) and late career (10 or more

years of experience). A median split of the frequencies was used to comprise approximately

equal groups: early career (n = 63, 54%) and late career (n = 54, 46%).

Table 19

Statistics for MTSS Components by Years of Experience

Source n Mean SD t df p
MTSS Component 1 0.60 107 .549
Early Career 62 5.94 6.57
Late Career 47 5.21 5.21
MTSS Component 2 1.13 81 .260
Early Career 46 4.71 6.73
Late Career 37 3.27 4.30
MTSS Component 3 1.28 101 .205
Early Career 57 7.92 6.22
Late Career 46 6.33 6.35
MTSS Component 4 0.73 91 .469
Early Career 55 4.24 4.02
Late Career 38 3.63 3.82
MTSS Component 5 2.86 86 .005
Early Career 50 3.76 3.99
Late Career 38 1.79 1.65

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 The data analyses of survey participants in terms of the years of experience and provision

of mental health services are displayed in Table 19. A t test was conducted across the five MTSS

components, and the means and standard deviations are displayed in Table 19. The t test analyses

indicated a significant difference for MTSS Component 5 in terms of experience. The early

career school psychologists reported to spend more time engaged within systematic decision

making about programming and services than their late career colleagues. Early career school

psychologists spent nearly four hours per week in this area, almost twice the time of late career

school psychologists who spent almost two hours on a weekly basis. A possible explanation to

understand this difference may be related to the recency of early career school psychologists in

terms of graduate training. Given the changes in the practice of school psychology and the

national standards for graduate training programs, early career school psychologists may use

their more advanced conceptualization of data-based decision-making given the emergence of

increased systemic, data-based decision making within a collaborative problem-solving

leadership team within the field of school psychology.

Additional information regarding the implications of years of experience on the practice

of school psychologists in providing mental health was gleaned from individual interviews. Max,

an early career school psychologist, shared during his interview that he participates in the student

study team reviewing data prior to engaging in the traditional assessment role. He stated, “The

last thing, if we need to do assessments, we will do that, before that we document concerns

through an SST process.” Additionally, the site team monitored vulnerable youth in terms of

self-injury or self-directed violence. Max reported, “There was a suicide at our school this year,

he had some cutting behavior in middle school last year and it was never brought to someone’s

attention.” He further reported the team now monitors students as they transition from the middle

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school to high school. He shared, “If there was something passed along between schools we

could keep a close eye on this.” Conversely, Ella, who is also an early career school

psychologist, indicated, “this is the area [mental health services] when I first started in this field I

felt least competent.” Judy, a late career school psychologist, was asked about her skills and

experience in mental health. She reported, “With regards to MTSS specifically, I’m not sure I

received it. I did receive a lot of training for crisis prevention, intervention, and postvention.”

Thus, she may have received training in mental health services, exclusive of systematic decision

making for programs and services.

School Psychologist to Student Ratio

The professional contextual factor of the ratio of school psychologist to students within

each of the mental health MTSS components was examined and is presented in Table 20. As

previously discussed, the California state data of school psychologist to student ratio may not

fully provide an understanding of the practice and role of school psychologists. It is unclear if the

number of school psychologists reflected in the state data represents those working within the

school setting and/or those who are credentialed as a school psychologist and employed in an

array of other positions within the schools (e.g., MTSS coordinator, behavior analyst, program

manager, ERMHS therapist). Thus, further information is warranted to fully capture an accurate

picture of the landscape of school psychologist to student ratio.

The survey participants were assigned to one of three groups for comparison: Group 1:

Average, ratio under 1,000 students per school psychologist, Group 2: Exceeds average, ratio of

1,000 to 1999 students per school psychologist, and Group 3: Far exceeds average, ratio of 2,000

or more students per school psychologist. Additionally, school psychologists who participated in

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the semi-structured interviews described the influence of school psychologist to student ratio in

mental health service delivery.

Table 20

Statistics for MTSS Components by Ratio of School Psychologist to Student

Source n Mean SD df F p
MTSS Component 1 2 1.88 .16
Average 42 6.90 6.52
Exceeds Average 39 4.33 5.45
Extremely High Average 27 5.73 5.79
MTSS Component 2 2 1.86 .31
Average 30 5.20 6.71
Exceeds Average 28 2.86 4.99
Far Exceeds Average 24 4.21 5.44
MTSS Component 3 2 2.25 .11
Average 40 7.43 5.78
Exceeds Average 36 5.69 5.59
Far Exceeds Average 26 9.08 7.64
MTSS Component 4 2 3.82 .07
Average 35 3.57 2.77
Exceeds Average 33 3.09 2.83
Far Exceeds Average 25 5.76 5.75
MTSS Component 5 2 1.56 .22
Average 32 2.56 2.17
Exceeds Average 30 2.50 2.89
Far Exceeds Average 25 3.92 4.74

In each of the MTSS components, nearly 50% of the survey participants reported a ratio

of school psychologist to student that exceeded the California state average (i.e., 1,000 students

per school psychologist): MTSS Component 1 (n = 66, 57%) , MTSS Component 2 (n = 52,

45%), MTSS Component 3 (n = 62, 53%), MTSS Component 4 (n = 58, 50%), and MTSS

Component 5 (n = 55, 47%). These findings are fairly aligned with those reported by Suldo et al.

(2010) in which 60% of participants were reported to have a school psychologist to student ratio

in excess of 1:999.

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 An ANOVA was conducted across the five MTSS components and the subsequent means

and standard deviations are displayed in Table 20. An examination of the data indicated MTSS

Component 4: progress monitoring approached significance (p = .07). A difference exists in the

amount of time school psychologists engaged in progress monitoring in relation to the school

psychologist to student ratio. The participants with the largest school psychologist to student

ratio (Group 3) spent the most time engaged in progress monitoring, an average of over five

hours per week compared to less than three hours for the other two categories (i.e., Group 1,

Group 2).

Several of the interview participants discussed the influential factors on their practice,

school psychologist to student ratio, and time. During her interview, Hollie reported, “Of course

things like our ratios of students to school psychologists are insane, the amount of assessments,

meetings and the busy work we do takes away our ability to work directly with kids, planning

interventions, and provide those supports.” Judy also discussed the relationship between time and

school psychologist to student ratio. She stated, “Time, as much as I hate to say that, it’s a really

big factor, time is a super big factor when you have one school psychologists and 2-3,000 kids.

Ratio…. I have 2200 kids, I was the only school psychologist.” Ella also indicated the ratio of

school psychologist to student served as a barrier. She reported, “the data they collect for our

assignments was just the number of assessments you did and the number of counseling kids you

had, for me with my six SDCs and being a new school, what about behavior.”

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 Chapter 5 Summary, Conclusions, and Recommendations

The current study examined the landscape of school psychologists’ practice as mental

health providers by average number of hours per week school psychologists spent across the five

MTSS components, the factors which supported or limited their practice, and relation of

demographic and professional contextual factors which may influence the transformation of their

practice. The research introduced novel components unique to the MTSS framework of mental

health services beyond intervention services to include prevention, systematic decision making

through universal screening, progress monitoring, and databased decision-making by a team to

inform programs and services. This chapter is organized by the five research questions and

discusses the findings in regard to the continuum of mental health practice of school

psychologists across the five components of MTSS. In addition, recommendations are provided

for policy, school administrators, professional organizations, and future research.

An examination of the time engaged in mental health services across the five MTSS

components, found school psychologists spent a range of 7 to 18% of their time, approximately

three to seven hours per week, engaged in providing MTSS-related services. The findings of

previous research are similar; school psychologists reported to spend 10% of their time each

week providing prevention and intervention mental health services (Eklund et al., 2017; Hanchon

& Fernald, 2013; Suldo et al., 2010).

MTSS Components

MTSS Component 1: Prevention and wellness promotion. Overall, the researcher

found 95% of school psychologists were engaged in prevention and wellness promotion services,

second most frequently to evidenced-based interventions. On average, school psychologists spent

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five hours a week involved in mental health prevention services. Sixty percent of participants

spent one to five hours a week engaged in prevention services and 35% spent on average more

than five hours. Results align with previous research with regards to the most common

prevention services: mental health consultation, risk and threat assessment, self-regulation

strategies, school crisis team, and suicide prevention (Eklund et al., 2017). Graduate training,

professional development, and training within the workplace were identified by school

psychologists as influential in their engagement in prevention efforts. The findings reflect school

psychologists are indeed engaged in mental health prevention and wellness efforts.

MTSS Component 2: Universal screening. The use of universal screening within the

schools for mental health functioning is relatively new to school psychologists. An average of

almost four hours per week were spent conducting universal screening. Fifty-five percent of the

school psychologists spent less than one to five hours a week engaged in universal screening.

Twenty-five percent spent no time in this area. School climate assessments, the CHKS, and

universal asset/strengths-based assessments were reported as mental health services provided.

The findings indicate the emergence of school psychologist involvement was shifting from

assessment of individual student needs to collecting data schoolwide to inform the delivery of

mental health services, supports, and programs.

MTSS Component 3: Implementing evidenced-based interventions. The researcher

found school psychologists spent an average of seven hours a week engaged in evidenced-based

interventions, the most amount of time indicated within the MTSS components. Forty-four

percent of the participants spent one to five hours per week implementing these mental health

services and an additional 52% engaged in evidenced interventions for more than five hours per

week on average. The evidenced-based services included suicide risk or threat assessment and

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direct services such as individual counseling. In fact, individual counseling was the most

frequently identified intervention. These findings align with research conducted more recently

(Eklund et al., 2017). Yet, the findings differ from earlier research in which school psychologists

reported spending most of their time engaged in individual and group counseling (Hanchon &

Fernald, 2013; Suldo et al., 2010). The findings suggest school psychologists continue to engage

in direct services and are expanding their repertoire of mental health service delivery to include

prevention.

MTSS Component 4: Progress monitoring. The researcher found approximately 70%

of school psychologists spent one to five hours on average per week engaged in progress

monitoring. The types of mental health services included progress monitoring social-emotional

literacy goals, student self-monitoring plans, and direct treatment protocol. The results are

commensurate with those in terms of universal screening. The initial phase of data-based

decision making related to mental health services typically involves universal screening. The

data revealed current practices of school psychologists have incorporated a comprehensive data

system to identify mental health needs and measure the outcomes of the corresponding services.

MTSS Component 5: Systematic decision making about programming and services.

The researcher found school psychologists spent nearly three hours a week engaged in

systematic decision making about programs and services. Almost 20% of school psychologists

reported they spent no time engaged in this mental health service. The types of services included

the provision of staff development, school equity, climate, culture leadership team, and positive

school climate survey data analyses. The findings suggest there is an opportunity for school

psychologists to employ their knowledge, expertise, and leadership skills in mental health by

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facilitating a team of stakeholders to engage in a systematic data-based decision making process

to identify, monitor, and make informed decisions to address student mental health needs.

Supportive Factors

California school psychologists identified factors that supported their capacity to provide

mental health services, and these align with previous research results (Eklund et al., 2017; Suldo

et al., 2010). These factors included: (1) school psychologist to student ratio, (2) receiving

support from administrators, (3) training and professional development, and (4) collaboration

with other school-based mental health providers.

School psychologist to student ratio. The ratio of school psychologist to student was

identified by 83% of the participants as the most prominent factor supporting the transformation

of their role as mental health providers within a MTSS framework. Yet, in a recent study,

participants identified the ratio of school psychologist to student as a limiting factor (Eklund et

al., 2017). The delivery of mental health service in the previous study included prevention and

intervention services, and findings indicated an elevated school psychologist to student ratio

decreased the availability and provision of services. In the present study, the definition of mental

health services was expanded to encompass the use of data, universal screening, progress

monitoring, and systematic decision making for programs and services, necessitating the need for

school psychologists to function at the system-level.

The current study data analyses showed that 74% of California school psychologists were

working in public K-12 schools with a workload that exceeded the statewide average of 1:1,00

and the national policy of 1:500. In fact, it was not uncommon for a single California school

psychologist to be assigned a student population in excess of 2,000-3,000 students. The second

leading factor identified by California school psychologists to advance their role in providing

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comprehensive prevention-based mental health services was the support of an administrator

(64%). A review of the data analyses showed that school psychologists received support from

their administrators to provide mental health services. In fact, 75% of participants indicated they

received at least some to strong levels of support from their administration.

Professional development. School psychologists recognized the importance of the

training and professional development in their mental health practice in order to meet the

dramatically increasing mental health needs of students. Sixty percent of participants identified

training and professional development as a factor supporting their delivery of comprehensive

prevention-oriented continuum of mental health services. Two core themes emerged with regards

to professional development: enhancing capacity to engage at the system-level and at the

personal level. School psychologists identified the need to receive training in order to understand

and provide leadership in transforming the current mental health systems and/or framework

within the schools. Simultaneously, school psychologists expressed it was essential to

continually build their own personal expertise and mental health skill set by accessing

professional development. Specifically, professional development in the areas of identifying and

assessing mental health need, providing corresponding prevention and intervention strategies,

and utilizing data to measure progress and outcomes of individual and system-wide interventions

employed. Participants identified training from their district, county office of education, and both

state and national professional organizations (i.e., CASP and NASP) as supports. School

psychologists indicated interest in professional development opportunities to learn how best to

address the mental health needs across the framework from the individual to the system-wide

level. These development opportunities included: cognitive behavioral therapy, solution focused

therapy, conducting risk and threat assessments to evaluate self and other-directed violence,

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evidenced-based social emotional learning curriculum, crisis prevention, intervention and

psychological triage, trauma-informed care, and restorative practices.

Collaboration with other SBMH providers. In addition, 58% of the participants

endorsed a novel supportive factor, the collaboration with other SBMH providers, as an element

which empowers their mental health work. These findings suggest California school

psychologists have expanded their perspective of mental health services from a direct service

delivery model to a systemwide prevention framework, while understanding the enormity of the

demand for mental health services and the necessity to collaborate and work in concert with

other SBMH professionals to address the demands.

Limiting Factors

Although many school psychologists prefer to increase their time providing mental health

services than staying within the traditional assessment role, a number of barriers have been

documented that prevent them from doing so (Curtis et al., 2002; Eklund et al., 2017; Hanchon &

Fernald, 2013). A plethora of limiting factors experienced by school psychologists in the

provision of mental health services has been identified in previous research. In analyses of the

data in the current study, several factors were found to impede the practice transformation of

California school psychologists. Many of these factors identified as barriers mirrored those

identified as supportive factors, such as ratio of school psychologist to student, administrator

support, and professional development. In fact, recent research found school psychologist to

student ratio and lack of administrator support served as significant barriers to mental health

services (Eklund et al., 2017). Other researchers found administrator support and insufficient

training to serve as barriers (Suldo et al., 2010). Since ratio, administrator support, and

professional development were more frequently endorsed by participants as supportive factors,

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the data were presented as factors supporting the practice of school psychologists as mental

health providers.

Low interest in providing mental health services. Previous research found a

predominate barrier for school psychologists to provide mental health services was their own

lack of interest in providing these services (Curtis et al., 2002; Hanchon & Fernald, 2013). A

recent study conducted in a western state found 42% of school psychologists indicated no

involvement as a service provider and 3% were not interested in providing mental health services

(Eklund et al., 2017). Conversely, the findings of the current study indicate otherwise, 98% the

participants indicated they provide mental health services across the MTSS components. Only

2% of school psychologists were not interested in providing mental health services which is

similar to a previous study (Eklund et al., 2017). These findings further substantiate the fact that

California school psychologists are interested and engaged in transforming their role in order to

provide mental health services. Yet, there are elements within the current educational system

which serve as impediments. In the current study, four critical factors were identified by

participants to interfere with their capacity to deliver mental health services: insufficient time,

others provide the school-based mental health services, lack of a comprehensive intervention

system, and the expectations to maintain a traditional assessment role.

Insufficient time. The most frequently identified limiting factor in provision of mental

health services in the current study was insufficient time, endorsed by nearly 90% of California

school psychologist participants. Participants identified a myriad of competing demands on their

time. They understand the gravity of the mental health needs of youth and possess the desire to

address these needs. However, the legal mandates which surround their traditional assessment

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role continue to take precedence. In fact, 22% of the participants endorsed the traditional

assessment role of school psychologists as a barrier.

Other provides mental health services. A growing concern identified by California

school psychologists involves other professionals (i.e. interns, itinerant mental health

professionals) providing the mental health services, endorsed by 37% of participants as a barrier.

Participants clearly recognize the increasing mental health needs of students. However,

employing other professionals is perceived to diminish the value of the school psychologist role

and expertise by limiting their practice as mental health providers. Participants further shared the

propensity for school districts to employ itinerant community mental health professionals as a

cost-saving measure. Yet, there is often high turnover rates and therapeutic approaches often

perpetuate the medical model of direct services versus the population prevention systemic

framework.

Need for comprehensive mental health system. A novel factor serving as a barrier

identified by participants was the need for a comprehensive cohesive framework such as MTSS,

reflective of the finding of the supportive factor of working within a comprehensive mental

health system. The state of California has recently acknowledged the importance of a

comprehensive mental health system, safe and positive school climate, and systematic outcome

measures. This is evident in the policy and legislative acts such as LCAP and the California

MTSS initiative.

School setting and community. The researcher provided a fresh lens to school based

mental health service and investigated the professional contextual factors of school

psychologists. The study examined the influence of the work setting (i.e., primary, secondary)

and the community (i.e., urban, suburban) in the mental health practices of school psychologists

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within the five components of MTSS. The researcher found a significant difference related to

school setting. Findings indicated the practice of primary and secondary school psychologists

was different within MTSS Component 5: systematic decision making for programs and services

and the school setting. Secondary school psychologists reported to spend twice as much time

engaged in this area than their colleagues working within the primary school setting. The

findings suggest the conditions within the secondary school environment necessitates the

practice of school psychologists shift from working with individual students to a systemwide

effort by utilizing data to inform the development of programs and services for all students.

Three additional MTSS components were found to approach significance: prevention and

wellness promotion (MTSS Component 1), universal screening (MTSS Component 2), and

progress monitoring (MTSS Component 4). The findings for MTSS Component 1 indicated a

difference related to school setting and community. Urban school psychologists spent one and a

half more hours than other groups providing prevention and wellness promotion services for

students. In the area of universal screening, MTSS Component 2, findings indicated a difference

in the practice of school psychologists related to the school setting. Urban school psychologists

spent twice as much time with universal screening services than those working in a suburban

community. Conversely, suburban school psychologists were found to spend more time engaged

in progress monitoring of mental health interventions and services (MTSS Component 4). No

difference was found related to school setting or community in terms of MTSS Component 3.

Demographic and professional factors. The researcher investigated the relationship

among demographic and professional factors and the five MTSS mental health components. The

demographic and professional factors included years of experience, ratio of school psychologist

to student, educational level, advocacy efforts, and professional development. The analyses of

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the data indicated the MTSS components were weakly related to each other. Each of the

components measured different elements of mental health services.

Professional development. In the analyses of data, three contextual factors emerged:

professional development, years of experience, and school psychologist to student ratio.

Professional development was found to be weakly related, though significant, with three of the

MTSS components: prevention (MTSS Component 1), evidence-based interventions (MTSS

Component 3), and systematic decision making for program and services (MTSS Component 5).

These positive relationships are representative of the importance of professional development

with the practice of school psychologists as mental health providers. This finding suggests that

the more time school psychologists were engaged in professional development, the more likely

they were to provide these mental health services, and vice versa. Conversely, the researcher

found a significant relationship does not exist between professional development and universal

screening (MTSS Component 2) and progress monitoring (MTSS Component 4). A moderate

relationship was found between professional development and both advocacy and ratio. A

negative relationship was found between professional development and years of experience.

Years of experience. A significant relationship was identified between the years of

experience as a school psychologist and time engaged in MTSS Component 5. Early career

school psychologists were found to spend more time than late career school psychologists

conducting systematic decision making for programming and services. This may be attributed to

the changes in the field of school psychology, mental health research, graduate training

programs, and continued professional development. The findings also have implications for the

necessity for creating accountability systems related to mental health programs and services

similar to established systems for academic and behavior. The findings are consistent with the

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recent development of accountability systems and the increased number of students which

necessitates a shift in the school structure for monitoring students to extend beyond the

classroom teacher to a system-wide approach such as progress monitoring. This development of

systems and shift in structure will rely upon the leadership and expertise of school psychologists.

The transformation of the practice of school psychologists as mental health providers has

been identified as an answer to addressing the continued unmet mental health needs of students

(Eklund et al., 2017; Hess et al., 2017; Perfect & Morris, 2011). School psychologists are

uniquely qualified as mental health providers. Yet, researchers have found the role expansion

beyond the traditional special education assessment role has been minimal (NASP, 2010; Nastasi

et al., 2000; Perfect & Morris, 2011). The impetus for the transformation of the practice of

school psychologists from a traditional assessment role to a more diversified role has been

advocated for decades by practitioners, scholars, and policymakers (Bardon, 1972; Bennett,

1970; Bradley-Johnson & Dean, 2000; Close-Conoley & Gutkin, 1995; Cummings et al., 2004;

Larson & Choi, 2010; Swerdlik & French, 2000; Tindall, 1964).

Historically, researchers explored the practice of school psychologists as mental health

providers in reference to the amount of time they engaged within the traditional role as special

education assessors and with special education programs and services. Previous studies have

found that an estimated 50 to 80% of the school psychologist role was engaged in conducting

special education eligibility assessments and working with students within the context of special

education. Yet, only 9 to 25% of their time was spent providing direct mental health supports

such as individual and/or group counseling services (Castillo, Curtis, & Geller, 2012; Curtis et

al., 2002; Fagan & Wise, 2007; Hosp & Reschly, 2002; Larson & Choi, 2010; Massey et al.,

2005; Reschly, 2000).

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 More recently, researchers have examined the mental health practices of school

psychologists and found that more than half provide mental health services, with approximately

10% spending five hours of their time engaged in mental health services on a weekly basis

(Eklund et al., 2017; Hanchon & Fernald, 2013; Larson & Choi, 2010; Suldo et al., 2010). In

addition, contemporary researchers have examined the scope of prevention and intervention

services provided by school psychologists and six mental health service areas were identified:

individual counseling (63-81%), crisis intervention (18-45%), group counseling (32-66%),

teacher consultation (30%), family support (9-12%), and school/class-wide supports (5-43%)

(Eklund et al., 2017; Hanchon & Fernald, 2013).

Current research contributions. Many of the findings provide new contributions to the

literature and the field of school psychology. The findings of the present study found more than

90% of school psychologists desired to provide mental health services. The types of mental

health services were found to have extended beyond direct counseling services to include

systemic prevention-based services consisting of the five components of MTSS, including

prevention and wellness promotion, universal screening, implementing evidence-based

interventions, progress monitoring, and systematic decision making about programs and services.

In the current study, school psychologists spent more time providing mental health services

within the MTSS components involving prevention and wellness promotion and evidenced-based

interventions. Yet, they spent less time with universal screening, progress monitoring, and

systematic decision making for program and services. The most commonly endorsed scope of

mental health services within the current study included mental health consultation, risk and

threat assessment, individual counseling, and self-regulation strategies—which is closely aligned

with the findings of Eklund et al. (2017).

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 The majority of school psychologists have expressed an increase in the demand on their

time and aspire to expand their role as mental health providers (Agresta, 2004; Cummings et al.,

2004; Dickinson, Prater, Health, & Young, 2009; Hosp & Reschly, 2002; Suldo et al., 2010).

Researchers have examined the facilitating factors that support school psychologists with

delivering mental health services which include sufficient time, graduate training, continued

professional development and supervision, administrative support, relationships with school

staff, personal characteristics, site-based service delivery system, caseload, and community

support to provide mental health services (Eklund et al., 2017; Perfect & Morris, 2011; Suldo et

al., 2010; Wnek, Klein, & Bracken, 2008).

Supportive factors. School psychologists in the current study identified factors that

support their capacity to provide mental health services: ratios, administrator support,

professional development, and collaborating with other SBMH providers. All of these factors

exemplify that school psychologists have the desire, expertise, and knowledge to provide mental

health services systemically and recognize key factors that support their practice. The findings

suggest the support of an administrator may be associated with the ratio of school psychologist to

student and having enough time to provide mental health services. A supportive factor identified

in the present study, not identified by previous studies, was the development of a comprehensive

mental health system. These findings suggest school psychologists have expanded their scope of

mental health services to be more broad-based within a systemic framework.

Limiting factors. Although many school psychologists prefer to spend more time

providing mental health services, a number of barriers have been documented that prevent them

from doing so (Curtis et al., 2002; Eklund et al., 2017; Hanchon & Fernald, 2013). A plethora of

limiting factors experienced by school psychologists in the provision of mental health services

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have been identified in previous research and include lack of administrator support, insufficient

time, role definition, services provided by another professional at school, limited access to

resources, communication among providers, physical space and location, problems with school

personnel, inadequate training, challenging student factors, personal characteristics, and lack of

integration into the school site (Eklund et al., 2017; Hanchon & Fernald, 2013; Massey et al.,

2005; Suldo et al., 2010). Recently, the research findings of Eklund et al. (2017) further

accentuated ratios as a limiting factor. Results demonstrated the elevated school psychologist to

student ratio decreased the availability and provision of school-based mental health services.

Professional development. Insufficient training and lack of interest in providing school-

based mental health services have been found by previous studies to impede the practice of

school psychologists (Hanchon & Fernald, 2013; Suldo et al., 2010). The current study suggests

otherwise. Ninety-eight percent of the survey participants in the current study indicated they

want to provide mental health services. In fact, 85% spent at least a quarter of their time each

week engaged in services. Participants identified a multitude of barriers which minimized their

involvement with mental health services, and aligned with previous research (Eklund et al.,

2017, Hanchon & Fernald, 2013; Suldo et al., 2010). Overall, participants in the current study

most frequently endorsed insufficient time as a barrier, along with two other novel factors: other

professionals provide the service and lack of a comprehensive structured framework for mental

health services such as MTSS.

School setting and community. The examination of the professional contextual factors

such as school setting and community of school psychologists as mental health providers was not

evident in the prior literature. In the current study, the researcher explored differences among

school psychologists working within a primary and secondary setting as well as those working

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within an urban and suburban community. Differences were found in prevention, universal

screening, and progress monitoring components of MTSS. The urban secondary school

psychologists were found to invest more time in prevention and wellness promotion efforts.

Urban school psychologist spent more time with universal screening, and suburban school

psychologists spent more time progress monitoring. Further research is warranted to further

explore the conditions within the school setting and community that account for these

differences. One consideration is the ownness of monitoring and supporting the academic and

mental health needs within the primary setting are bestowed upon the classroom by the teacher

versus the school psychologist. Within the primary school setting, students are traditionally

assigned to a single teacher within one classroom environment. Given that primary teachers work

with an average of 30 to 40 students throughout a school day compared to their secondary

counterpart that work with over 100 students per day, they have more time to teach, monitor

progress, and support their students. The primary teacher is more readily able to create a safe,

positive, and supportive classroom environment and collective sense of community. Conversely,

within the secondary school setting, the sheer size of the student population (i.e., 2,000-3,000

students) would necessitate the role of school psychologists to be broad-based and systemic

school-wide (i.e., student study team, leadership team) focused to address student mental health

needs. The secondary students have a multitude of teachers, and the classroom teachers have

contact with upward to 180 students per day. Additionally, the developmental nature of

adolescents is a time in which mental health risk factors and/or diagnosable mental health

illnesses (e.g., depression, anxiety) manifest in various ways and in the decision-making skills of

students.

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 Demographic and professional factors. One novel contribution provided by the

findings of the current study was the exploration of the relationship between demographic factors

and professional factors with the five mental health components of MTSS. The findings from the

survey data identified a correlation between the MTSS components, demographic, and

professional contextual factors. Professional development and ratio of school psychologist to

student ratio were two of the demographic and professional contextual factors that were

significantly related to MTSS components. The positive relationship was found with professional

development and the mental health services in the areas of prevention and wellness promotion,

progress monitoring, and systematic decision-making for programming and services. These areas

are relatively new to the practice of school psychologists and the demand for these mental health

services has increased more recently (Flaherty et al., 1999; Nastasi, 2000, NAMI, 2013,

SAMHSA, 2014; U.S. DHHS, 2000). The ratio of school psychologist to student approached

significance with progress monitoring. Previous research found a relationship between the ratio

of school psychologist to student and the provision of mental health services. An increase in

school psychologist to student ratio resulted in a decrease in providing mental health services

(Eklund et al., 2017). In the current study, a broader definition of mental health services was

introduced to include progress monitoring. Thus, participants with larger ratios engaged in the

mental health practice of progress monitoring to shift to a system-level prevention framework.

Conclusions

School psychologist to student ratio. Many of the participants in the current study

identified the school psychologist to student ratio as a supportive factor in the transformation of

their practice as mental health providers. Conversely, few of the participants perceived the ratios

as a barrier to providing mental health services. Overall, most California school psychologists

115
have a ratio that exceeds the state average and the policy recommendations of both the state and

national organizations. In order to expand the practice of school psychologists as mental health

providers, it is necessary to decrease the ratio of school psychologist to students.

Professional development. The most frequently identified supportive factor by the study

participants involved training and professional development. Participants perceived professional

development to extend their knowledge base and capacity to work not only with individual

students, but also engaging in mental health services from a prevention-based systemwide model.

As a matter of fact, participants who reported to spend time in professional development were

found to spend more time with MTSS components involving prevention and wellness promotion,

evidenced-based interventions, and systematic decision making for program and services. Thus,

it is necessary to provide professional development opportunities for school psychologists in

MTSS which may enhance their involvement in other MTSS components such as universal

screening and progress monitoring.

Administrator support. The support of administers was perceived by participants as a

crucial factor that enabled them to transform their practice as mental health providers. Most

California school psychologists indicated they received high levels of administrator support; yet,

some indicated they did not receive any administrator support. Given this was an element

perceived by school psychologists as a supportive factor, it is necessary for administrators to

demonstrate their value of school psychologist as leaders in MTSS mental health frameworks by

engaging them within the site leadership team.

Recommendations

Recommendations for policymakers, administrators, professional organizations, and

future research are outlined below.

116
 Recommendations for policy. The mental health needs of students continue to be unmet

regardless of the significant changes in legislation and policy related to education and student

mental health over the past decade. In the wake of increased mental health needs, as well as

other- and self-directed school violence, parents and guardians are concerned about the safety of

their children at school. While the practice of school psychologists as mental health providers is

expanding from direct services to include prevention and wellness promotion services, critical

factors continue to impede these practices.

The current research suggests three steps for California policymakers: (1) review the

current statewide personnel data system, (2) address the state ratio of school psychologist to

student, (3) reinstate the continuing professional development requirement for the school

psychologist state credential, and (4) review the implementation and outcome measures of the

MTSS initiatives (i.e., SUMS Initiative).

The current study identified supportive factors that have implications for policymakers,

including school psychologist to student ratio and professional development. As highlighted in

previous research (Eklund et al., 2017), a lower ratio of school psychologist to student resulted in

an increase in the provision of mental health services. The current ratio policy passed by both

state and national professional organizations (CASP and NASP) is 500 students to a school

psychologist (NASP, 2010). The CDE data report the current number of school psychologists to

be 1,124. School psychologists are employed within the educational system in an array of roles

(e.g., MTSS coordinator, mental health/ERMHS coordinator, behavior specialist, program

manager); thus, it is unclear if the number identified within CDE data represent the number of

credentialed school psychologists and/or the number engaged in the role of a school

psychologist. CDE could provide additional support to identify the number of school

117
psychologist practitioners, and the demographic and professional contextual factors to further

understand the practice and role of school psychologists.

Second, it is suggested that state policy makers further examine the ratio of school

psychologist to student ratio. The state ratio, 1:1,124 appears to be approximately double the

policy recommendations of CASP and NASP (CDE, 2018). The current findings reflect nearly

75% of school psychologists in the state of California have ratios far beyond the state average.

The passage of state legislative acts which align with the national policy of 1:500 ratio of school

psychologist to students could have a profound impact on the capacity of school psychologists to

transform their practice and enhance the comprehensive service delivery of mental health

services to all students. The activation of California policymakers is crucial to address the

continued unmet mental health needs of students and to expand the access to school-based

services. School psychologists are explicitly identified as SBMH providers and recognized as

“mental health service providers” in the ACA. Thus, related to the ratio conversation, it is

recommended policymakers explore the state Medicaid plans which may result in a funding

source for mental health services (Eklund et al., 2017).

The participants in the current study endorsed professional development as an important

supportive factor in their capacity to engage as mental health providers within an MTSS

framework. Given the transformation of the practice of school psychologists, it is important for

policymakers to consider reinstituting the professional development requirement for state

credentialing and renewal. The requirement for school psychologists to engage in continued

professional development to maintain state credentialing had been discontinued by the state

department. Given school psychologists identified professional development as a supportive

factor in transforming their practice as mental health providers and the shift to a comprehensive

118
preventive model such as MTSS, consideration should be made by policymakers to require

professional development for credential renewal.

The state of California has invested 30 million dollars into the educational system to

establish a comprehensive MTSS framework to meet California student needs. The funding was

explicitly allocated to unify efforts to address barriers to learning and create a collaborative

culture among marginalized and fragmented support systems, with LCAP serving as the

foundation. The OCDOE was awarded the funds to lead the SUMS Initiative and provide

statewide technical assistance and resources resulting in a multi-faceted approach which is

scalable and sustainable. Teams have been engaged within these efforts for several years. It

would be timely to review the implementation fidelity and outcome accountability measures to

understand the statewide progress with the MTSS initiative. It would be important to convene a

meeting of stakeholders, including parents, educators, students, community members, and

policymakers, to review the data and solicit perspectives in terms of the state of affairs of the

educational system and student outcomes.

Recommendations for administrators. The findings of the current study indicated the

support of California school administrators was perceived to have a positive influence on the

practice of California school psychologists as mental health providers. Based on these results,

school administrators have highly qualified mental health providers within their team—school

psychologists who can provide leadership in creating a comprehensive cohesive mental health

framework such as MTSS. It is recommended that school administrators examine the roles and

responsibilities delineated in the district job description of school psychologists to ensure they

are consistent with the NASP model of practice (NASP, 2010), shift responsibilities from direct

services, and engage their expertise and leadership in creating an MTSS framework within the

119
schools. Additionally, it is recommended that school administrators examine the system-level

barriers school psychologists experience as mental health providers such as insufficient time and

the designation of other personnel to provide the services.

Recommendations for professional organizations. The study underscores the

importance of professional development. The data showed a correlation between the engagement

of school psychologists with providing mental health services and the amount of professional

development they participate in. CASP and NASP have been identified as key sources of mental

health professional development opportunities for school psychologists. A continued focus on

state and national conferences on the mental health prevention and wellness promotion of

students and in terms of all of the facets of MTSS is recommended. School psychologists’

expertise and knowledge of mental health needs and systemic prevention implementation efforts

could be leveraged by facilitating local- and state-level professional development opportunities

for school administrators, educators, students, parents, and community members.

Additionally, the rising mental health demands call upon professional organizations to

engage in advocacy efforts to support policymakers and school administrators in addressing the

shortage of school psychologists and the ratios within the K-12 educational system. Two initial

advocacy efforts are recommended, advocating for a comprehensive state personnel system and

engaging school psychologists as leaders within mental MTSS initiative. Given the need for a

comprehensive state-level data system to better understand the demographic and professional

contextual factors of school psychologists, CASP could be an invaluable voice to guide the

development of the data system. In the state of California, the new educational accountability

system (i.e., LCAP) and the MTSS framework affords the opportunity and potential funding for

school psychologists to assume leadership and advocacy roles to inform and facilitate

120
implementation of system-wide prevention frameworks to address the equity in accessing mental

health services. A partnership among CDE, OCDOE, CASP, and other stakeholder groups could

further the discussion, explore the implementation, and examine the outcome data for the

California MTSS and/or SUMS Initiative.

Recommendations for future research. The current research of school psychologists as

mental health providers is critical given the prevalence of mental health challenges and the

continuance of vulnerable youth to be unserved. The researcher recommends that future research

provides explicit definitions of mental health MTSS to participants. While participants were

provided an explicit definition of MTSS prior to engaging in the survey portion of the study, the

MTSS definition was not reviewed with interviewees prior to their responses to the interview

questions. It is unclear if the interview participants fully understood the MTSS definition as

delineated within the present study. Another recommendation for future research is to engage

school psychologists from rural communities, as a low number of rural school psychologists

participated in the study and little information was obtained. To further the exploration of the

practice of school psychologists within a mental health MTSS framework, it would be important

to examine one or two of the MTSS components more in-depth, such as the data components,

universal screening, progress monitoring, and systematic decision making for programming and

services. It would also be helpful to learn more about the supports and limits connected directly

to the MTSS components. For example, to identify the specific professional development

opportunities school psychologists need in order to increase their engagement with universal

screening. Lastly, it is recommended that future research explore the role of school

administrators and their knowledge and perception of mental health and the practice of school

psychologists as providers of mental health services within an MTSS framework.

121
 References

Adelman, H., & Taylor, L. (1998). New direction in enhancing educational results:

Policymakers’ guide to restructuring student support resources to address barriers to

learning. School Mental Health Project, Department of Psychology, UCLA, Los Angeles,

CA.

Adelman, H., & Taylor, L. (2001). School reform is failing to address barriers to learning.

Retrieved from: http://smho.psych.ucla.edu.comments.htm.

Adelman, H., & Taylor, L. (2002). About mental health in schools: A policy and practice brief.

Los Angeles, CA: UCLA School Mental Health Project.

Adelman, H., & Taylor, L. (2008, July) Center for mental health in schools. Retrieved July 5,

2008, from: http://smho.psych.ucla.edu/comments.htm

Agresta, J. (2004). Professional role perceptions of school social workers, psychologists, and

counselors. Children and Schools, 26, 151-163.

America’s Heath Rankings Annual Report: A Call to action for individuals and their

communities. (2017). United Health Foundation. Retrieved from:

https://www.americashealthrankings.org

Baron, J. I. (1972). Overview of issue-implications for future trends in school psychology.

Journal of School Psychology, 10, 207-211.

Beam, E., Brady, J., & Sopp, T. J. (2011). School psychologists are best equipped to deliver

mental health services in the schools. California Association of School Psychologists,

Sacramento, CA.

Bennett, V. D. (1970). Who is a school psychologist? (And what does he do?). Journal of School

Psychology, 8, 166-171.

122
Bradley-Johnson, S., & Dean, V. J. (2000). Role change for school psychology: The realize its

promise? Journal of School Psychology, 33, 209-217.

Brock, S., & Reeves, M. (2017, March). DSM V and IDEA. Presentation at the meeting of the

San Diego County Association of School Psychologists. San Diego, CA.

California Association of School Psychologists. (2007). Professional Practice. Retrieved from:

http://www.casponline.org

California Association of School Psychologist. (2018). Membership Directory Database.

Retrieved from:

https://services.casponline.org/eweb/DynamicPage.aspx?Site=CASP&WebCode=IndSear

ch

California Department of Education. (2011). AB 114 Special Education Transition: Transition of

Special Education and Related Services Formerly Provided by County Mental Health

Agencies (Assembly Bill 114, Chapter 43, Statues of 2011). Retrieved from:

http://www.cde.ca.gov/sp/se/ac/ab114twg.asp

California Department of Education. (2017). California Department of Education Definition of

MTSS. Retrieved from: https://www.cde.ca.gov/ci/cr/ri/mtsscomprti2.asp

California Department of Education. (2018). DataQuest Staffing Report. Retrieved from:

https://dq.cde.ca.gov/dataquest/

California Department of Education. (2018). Multi-Tiered System of Supports: A framework

that aligns Response to Instruction and Intervention with the California State standards

and the systems necessary to ensure academic, behavior, and social success. Retrieved

from: https://www.cde.ca.gov/ci/cr/ri/

123
California Department of Education. (2010). School Psychologist: Qualifications and definition.

Retrieved from https://www.cde.ca.gov/ls/cg/pr/psychec.asp

California Department of Education. (2015). Conceptual framework for special education task

force successful educational evidenced based practices. California Statewide Special

Education Task Force. Sacramento, CA.

California Department of Education. (2013). Local Control Funding Formula Overview.

Retrieved from: https://www.cde.ca.gov/fg/aa/lc/lcffoverview.asp

Catalano, R. F., Mazza, J. J., Harachi, T. W., Abbott, R. D., Haggerty, K. P., & Fleming, C. B.

(2003). Raising healthy children through enhancing social development in elementary

schools: Results after 1.5 years. Journal of School Psychology, 4, 143-164.

Ceci, S. J. (2006). Urie Bronfenbrenner (1917-2005). American Psychologist, 61(2), 173-174.

Center for Behavioral Health Statistics and Quality (2015). Behavioral health trends in the

United States: Results from the 2014 National Survey on Drug Use and Health (HHS

Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from:

http://www.samhsa.gov/data/

Center for Mental Health in Schools (2011). Moving beyond the Three Tier Intervention Pyramid

Toward a Comprehensive Framework for Student and Learning Supports. Los Angeles,

CA. Retrieved from: http://smhp.psych.ucla.edu/pdfdocs/briefs/threetier.pdf

Cicchetti, D., & Toth, S. L. (1998). The development of depression in children and adolescents.

American Psychologist, 53(2), 221-241.

Civic Impulse. (2017). S. 195-113th Congress: Mental Health in Schools Act of 2013. Retrieved

from: https://www.govtrack.us/congress/bills/113/s195

124
Close-Conoley, J., & Gutkin, T. B. (1995). Why didn’t-why doesn’t school psychology realize its

Promise? Journal of School Psychology, 33, 209-217.

Collins, S. (2018). The hero in each of us: Finding your role in suicide prevention. Suicide

Prevention Symposium 2018. Rady Children’s Hospital, San Diego, CA.

Cook, C. R., Burns, M., Browning-Wright, D., & Gresham, F. M. (2010). Transforming school

psychology in the RTI era: A guide for administrators and school psychologists. Palm

Beach: LRP Publications.

Cook, C. R., Lyon, A. R., Kubergovic, D., Browning-Wright, D., & Zhang, Y. (2015). A

supportive beliefs intervention to facilitate the implementation of evidence-based

practices within a multi-tiered system of supports. School Mental Health, 7, 49-60.

Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and

development of psychiatric disorders in childhood and adolescents. Archives of General

Psychiatry, 60, 837-844.

Cummings, J. A., Harrison, P. L., Dawson, M. M., Short, R. J., Gorin, S., & Palomares, R. S.

(2004). The 2002 conference on the future of school psychology: Implications for

consultation, intervention, and prevention services. Journal of Educational and

Psychological Consultation, 15, 239-256

Curtis, M. J., Grier, J. E., & Hunley, S. A. (2004). The changing face of school psychology:

Trends in data and projections for the future. School Psychology Review, 33, 49-66.

Curtis, M. J., Hunley, S. A., & Grier, J. E. (2002). Relationships among the professional

practices and demographic characteristics of school psychologists. School Psychology

Review, 31, 30-42.

125
Curtis, M. J., Hunley, S. A., Walker, K. L., & Baker, A. C. (1999). Demographic characteristics

and professional practices in school psychology. School Psychology Review, 28(1), 104-

116.

Curtis, M. J., Lopez, A. D., Castillo, J. M., Batsche, G. M., Minch, D., & Smith, J. C. (2008).

The status of school psychology: Demographic characteristics, employment conditions,

professional practices and continuing professional development. Communique, 36(5), 27-

29.

Dickinson, L. A., Prater, M., Heath, M. A., & Young, E. L. (2009). School psychologists’ job

satisfaction and reasons for retention. School Psychologist, 63, 16-22.

Doll, B., & Cummings, J. A. (2008). Transforming school mental health services: Population-

based approaches to promoting the competency and wellness of children. Thousand

Oaks, CA: Corwin Press.

Doll, B., Nastasi, B. K., Cornell, L., & Song, S. Y. (2017). School-based mental health services.

Definitions and models of effective practice. Journal of Applied School Psychology, 33,

179-194.

Doll, B., Spies, R., & Champion, A. (2012). Contributions of ecological school mental health

services to students’ academic success. Journal of Educational and Psychological

Consultation, 22(1-2), 44-61.

Eklund, K., Meyer, L., Way, S., & McLean, D. (2017). School psychologist as mental health

Providers: The impact of staffing ratios and Medicaid on service provision. Psychology in

the Schools, 54(3), 279-293.

Every Student Succeeds Act. (2015). Pub. L. No 114-95. In 114th Congress.

126
Fagan, T. K., & Wise, P. S. (2007). School Psychology: Past, Present, and Future. National

Association of School Psychologists, Bethesda, MD. Author.

Fantuzzo, J., McWayne, C., & Bulotsky, R. (2003). Forging strategic partnerships to advance

mental health science and practice for vulnerable children. School Psychology Review,

32, 17-37.

Farmer, E. M. Z., Burns, B.J., Phillips, S.D., Angold, A., & Costello, E. J. (2003). Pathways into

and through mental health services for children and adolescents. Psychiatric Services,

54(1). 60-66.

Flaherty, L. T., Weist, M. D., & Warner, B. S. (1999). School-based mental health services in the

United States: History, current models, and needs. Community Mental Health Journal, 3,

341-352.

Flanagan, R., & Miller, J. A. (2010). Specialty competencies in school psychology. New York,

NY: Oxford University Press.

Foster, S., Rollefson, M., Doksum, T., Noonan, D., Robinson, G., & Teisch, J. (2005). School

mental health services in the United States, 2002-2003. DHHS Pub no. (SMA) 05-4068.

Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health

Administration.

Franken, A. (2013). Mental Health in Schools Act. §195 2013

Garbarino, J. (2011). An ecological perspective on the effects of violence on children. Journal of

Community Psychology, 29(3), 361-378.

127
Greenberg, M. T., Weissberg, R. P., Utne O’Brien, M., Zins, J. E., Fredericks, L., Resnik, H., &

Elias, M. J. (2003). Enhancing school-based prevention and youth development through

coordinated social, emotional, and academic learning. American Psychologist, 58, 466-

474.

Hedegaard H., Curtin S. C., & Warner, M. (2018). Suicide rates in the United States continue to

increase. NCHS Data Brief, no 309. Hyattsville, MD: National Center for Health

Statistics.

Hess, R. S., Pearrow, M., Hazel, C. E., Sander, J. B., & Willie, A. M. (2017). Enhancing the

behavioral and mental health services within school-based contexts. Journal of Applied

School Psychology, 33(3), 214-232.

Hess, R. S., Short, R. J., & Hazel, C. E. (2012). Children’s comprehensive mental health

services in the schools. New York, NY: Routledge.

Hosp, J. L. & Reschly, D. J. (2002). Regional differences in school psychology practice. School

Psychology Review, 31(1), 11-29.

Hughes, T. L., Minke, K. M., & Sansosti, F. J. (2017). Expanding the school psychology delivery

within the context of national health and mental health reform. Journal of Applied

School Psychology, 33(3), 171-178.

Jimerson, S. R., Burns, M. K., & VanDerHeyden, A. M. (2007). Handbook of response to

intervention: The science and practice of assessment and intervention. Boston, MA:

Springer.

Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., Lowry, R.

Chyen, D., Whittle, L., Thorton, J., Lim, C., Bradford, D., Yamakawa, Y., Leon, M.,

Brener, N.,…Ethier, K. A. (2018). Youth Risk Behavior Surveillance-United States, 2017

128
 Morbidity and Mortality Weekly Report, Surveillance Summaries (Washington, D. C.:

2002) 67(8), 1-114.

Kataoka, S., Zhang, L. & Wells, K. (2002). Unmet need for mental health care among U.S.

children: Variation by ethnicity and insurance status. American Journal of Psychiatry,

159(9), 1548-1555.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K., & Walters, E. (2005). Life-

time prevalence and age-of-onset distribution of DSM-IV disorders in the national co-

morbidity survey replication. Archives of General Psychiatry 62 (6), 593-602.

Knitzer, J. (1993). Children’s mental health: Challenging the future. Journal of Emotional and

Behavioral Disorders, 1(1), 8-16.

Knitzer, J. (1982). Unclaimed Children: The failure of public responsibility of children and

adolescents in need of mental health services. Washington, DC: Children’s Defense

Fund.

Knopf, D., Park, M. J., & Mulye, T. P. (2008). The Mental Health of Adolescents: A National

Profile. San Francisco, CA: National Adolescent Information Center, University of

California, SF.

Kutash, K., Duchnowski, A. J. & Lynn, N. (2006). School-based mental health: An empirical

guide for decision-makers. Tampa: The Research and Training Center for Children’s

Mental Health: Louis de la Parte Florida Mental Health Institute. University of South

Florida.

Larson, J. P., & Choi, H. (2010). The effects of university training and educational legislation on

the role and function of school psychologists. Journal of Applied School Psychology,

26(2), 97-114.

129
Lendrum, A., Humphrey, N., & Wigelsworth, M. (2013). Social and emotional aspects of learning

(SEAL) for secondary schools: Implementation difficulties and their implications for

school based mental health promotion. Child and Adolescent Mental Health, 18, 158-164.

Luiselli, J. K., Putnam, R. F., Handler, M. W., & Feinberg, A. B. (2005). Whole-school positive

behavior support: Effects on student discipline problems and academic performance.

Educational Psychology, 25, 183-198.

Massey, O. T., Armstrong, K., Boroughs, M., & Henson, K. (2005). Mental health services in

schools: A qualitative analyses of challenges to implementation, operation, and

sustainability. Psychology in the Schools, 42(4), 361-372.

Merikangas, K. R., He, J. P., Brody, D., Fisher, P. W., Bourdon, K., & Koretz, D. S. (2010).

Prevalence and treatment of Mental Disorders Among U.S. Children 2001-2004

NHANES. Pediatrics, 1(125), 75-81.

Mertens, D. (2005). Research and Evaluation in Education and Psychology (2nd Ed). Thousand

Oaks, CA. Sage Publications.

Miles, J., Espiritu, R. C., Horen, N., Sebian, J., & Waetzig, E. (2010). A Public Health Approach

to Children's Mental Health: A Conceptual Framework. Washington, DC: Georgetown

University Center for Child and Human Development, National Technical Assistance

Center for Children’s Mental Health.

Morrisey, J. P., & Goldman, H. H. (1986). Care and treatment of the mentally ill in the United

States: Historical developments and reforms. The Annals of the American Academy of Political

and Social Science, 484(1), 12-27.

130
Nastasi, B. K. (2000). School psychologists as health-care providers in the 21st century:

Conceptual framework, professional identity, and professional practice. School

Psychology Review, 29, 540-554.

Nastasi, B. K. (2004). Meeting the challenges of the future: Integrating public health and public

education for mental health promotion. Journal of Educational and Psychological

Consultation, 15, 259-312.

Nastasi, B. K., Overstreet, S., & Summerville, M. (2011). School-based mental health services in

post-disaster contexts: A public health framework. School Psychology International,

32(5), 533-552.

Nastasi, B. K., Varjas, K., Berstein, R., & Plymert, K. (1998). Mental health programming and

the role of school psychologists. The School Psychology Review, 27, 217-232.

National Alliance on Mental Illness. (2013). Mental Health by the Numbers. Retrieved from:

https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers.aspx

National Association of School Psychologists. (2007). What is a school psychologist? Bethesda,

MD. Author.

National Association of School Psychologists. (2008). School psychologists: Providing mental

health services to improve lives and learning of children and youth. Bethesda, MD.

Author.

National Association of School Psychologists. (2010). Model for comprehensive and integrated

school psychological services, NASP practice model overview. Retrieved from

https://www.nasponline.org/standards/practicemodel/

131
National Association of School Psychologists. (2013). The Patient Protection & Affordable Care

Act (ACA). Retrieved from: https://www.nasponline.org/research-and-policy/policy

matters/the-patient-protection-and-affordable-care-act-(aca)

National Association of School Psychologists. (2015). School psychologists: Qualified health

professionals providing child and adolescent mental health services [White paper].

Bethesda, MD: Author.

National Center for Education Statistics. (2014). Fast facts. Washington, DC: Author. Retrieved

from https://nces.ed.gov/fastfacts/display.asp?id=372

Nelson, J. R., Martella, R. M., & Marchand-Martell, N. (2002). Maximizing student learning:

The effects of a comprehensive school-based program for preventing problem behaviors.

Journal of Emotional and Behavior Disorders, 10, 136-148.

Patient Protection and Affordable Care Act. (2010). Public Law 111-148 111th United States

Congress. Washington, DC: U.S. Government Printing Office.

Patton, M. Q. (2002). Qualitative Research & Evaluation Methods (3rd ed.). Thousand Oaks, CA:

Sage Publications.

Perfect, M. M., & Morris, R. J. (2011). Delivering school-based mental health services by school

psychologists, education, training, and ethical issues. Psychology in the Schools, 48(10),

1049-1063.

Perou, R., Bitsko, R. H., Blumberg, S. J., Pastor, R., Ghandour, R. M., Gfroerer, J. C., & Huang,

L. N. (2013) Mental health surveillance among children–United States, 2005-2011.

MMWR.

Policy Leadership Cadre for Mental Health in Schools. (2001). Mental Health in Schools:

Guidelines, models, resources, and policy considerations. Los Angeles, CA: Author.

132
Power, T. J., Eiraldi, R. B., Clarke, A., & Mazzuca, L. B. (2005). Improving mental health

service utilization for children and adolescents. School Psychology Quarterly, 20(2), 187-

205.

Presidents New Freedom Commission on Mental Health. (2003). Achieving the promise:

Transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-

3832. Rockville, MD. 62(02), 1-35. Retrieved from:

https://www.cdc.gov/mmwr/pdf/other/su6202.pdf

Pumariega, A. J., & Vance, H. R. (1999). School-based mental health services: The foundation of

systems of care for children’s mental health. Psychology in the Schools, 36(5), 371-378.

Reschly, D. J. (2000). The present and future status of school psychology in the United States.

School Psychology Review, 29(4), 507-522.

Reschly, D. J., & Wilson, M. S. (1981). School psychology practitioners and faculty: 1986 to

1991-1992 trends in demographics, roles, satisfaction and system reform. School

Psychology Review, 24, 62-80.

Rones, M., & Hoagwood, K. (2000). School-based mental health services: A research review

Clinical Child and Family Psychology Review, 3, 223-2421.

Rossen, E., & Cowan, K. (2015). Improving mental health in schools. Phi Delta Kappan, 43(4),

8-13.

Sailor, W. (2015). Advances in schoolwide inclusive school reform. Remedial and Special

Education, 36(2), 94-99.

Sheridan, S. M., & Gutkin, T. G. (2000). The ecology of school psychology: Examining and

changing our paradigm for the 21st century. School Psychology Review, 29, 485-502.

133
Shern, D. L., Blanch, A. K., & Steverman, S. M. (2016). Toxic stress, behavioral health, and the

next era in public health. The American Journal of Orthopsychiatry, 86(2), 109-123.

Stone, D. M., Holland, K. M., Bartholow, B., Crosby, A. E., Davis, S., and Wilkins, N. (2017).

Preventing Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta,

GA: National Center for Injury Prevention and Control, Centers for Disease Control and

Prevention. Retrieved from:

https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf

Strein, W., Hoagwood, K., & Cohn, A. (2003). School psychology: A public health perspective:

Prevention, populations, and systems change. Journal of School Psychology, 41, 23-38.

Substance Abuse and Mental Health Services Administration. (2014). Prevention of Substance

Abuse and Mental Illness. Retrieved from: https://www.samhsa.gov/prevention

Suldo, S. M., Friedrich, A., & Michalowski, J. (2010). Personal and systems-level factors that

limit and facilitate school psychologists’ involvement in school-based mental health

services. Psychology in the Schools, 47(4), 354-373.

Swerdlik, M. F., & French, J. L. (2000). School psychology training for the 21st century:

Challenges and opportunities. School Psychology Review, 29, 577-588.

Taylor, L. & Adelman, H. S. (2006). Toward ending the marginalization and fragmentation of

mental health in schools. Journal of School Health, 70(5), 201-215.

Tindall, R. H. (1964). Trends in development of psychological services in the school. Journal of

School Psychology, 3, 1-12.

Tolan, P. H., & Dodge, K. A. (2005). Children’s mental health as a primary care and concern: A

system for comprehensive support and service. The American Psychologist, 60(6), 601-

614.

134
United Health Foundation. (2017). America’s Health Rankings: A call to action for individuals

and their communities. Retried from:

https://assets.americashealthrankings.org/app/uploads/ahrannual17_complete-121817.pdf

U. S. Department of Education. (2016). Every Student Succeeds Act (ESSA). Retrieved from:

https://www.ed.gov/essa

U.S. Department of Health and Human Services. (2000). Report of the Surgeon General’s

conference on children‘s mental health: A national action agenda. 2000. Retrieved from:

http://www.surgeongeneral.gov/cmh/childreport.htm

U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services

Administration. (2010). Mental health United States, 2010 (HHS Publication No.

(SMA)124681). Retrieved from:

http://www.samhsa.gov/data/2k12/MHUS2010/MHUS2010

Vaillancourt, K., Cowan, K. C., & Skalski, A. K. (2013). Providing mental health services within

a multitiered system of supports. In Desrochers, J. and Houck, G. Depression in children

and adolescents: Guidelines for school practice. Bethesda, MD: NASP & NASN.

Retrieved from:

http://www.nasponline.org/resources/handouts/depression/handout_MTSS_key_points.

Villarreal, V. (2018). Mental health collaboration: A survey of practicing school psychologists.

Journal of Applied School Psychology, 34, 1-7.

Walker, H., Horner, R., Sugai, G., Bullis, M., Sprague, J., Bricker, D., & Kaufman, M. (1996).

Integrated approaches to preventing antisocial behavior patterns among school-age

children and youth. Journal of Emotional and Behavioral Disorders, 4, 194-209.

135
Weist, M. D., Eber, L., Horner, R., Splett, J., Putnam, R., Barrett, S., … Hoover, S. (2018).

Improving multitiered systems of support for students with “internalizing”

emotional/behavioral problems. Journal of Positive Behavior Interventions, 20(3), 172-

184.

Weist, M. D., Lever, N. A., Bradshaw, C. P., & Owens, J. S. (2014). Handbook of School Mental

Health: Research, Training, Practices, and Policy. New York, NY. Springer.

Welsh, M., Parke, R. D., Widaman, K., & O’Neil, R. (2001). Linkages between children’s social

and academic competence: A longitudinal analyses. Journal of School Psychology, 39,

463-482.

Wnek, A. C., Klein, G., & Bracken, B. A. (2008). Professional development issues for school

psychologists: What’s hot, what’s not in the United States. School Psychology

International, 29, 145-160.

World Health Organization. (2014). World health statistics 2014. Geneva. Switzerland: WHO

Press. Retrieved from:

http://apps.who.int/iris/bitstream/handle/10665/112738/9789240692671_eng.pdf;jsession

id=2DD69AC58221F78628FBB629E1A7A199?sequence=1

World Mental Health Survey Initiative. (2010). World mental health survey. Geneva,

Switzerland: World Health Organization. Retrieved from

http://www.hcp.med.hard.edu/wmh

Ysseldyke, J. E., Burns, M., Dawson, P., Kelly, B., Morrison, D., Ortiz, S., … Telzrow, C.

(2008). The Blueprint for Training and Practice as the basis for best practices. In A.

Thomas & J. Grimes (Eds.), Best practices in school psychology V: Vol 1. (p.37-69).

Bethesda, MD: National Association of School Psychologists.

136
Zeng, G., Boe, E. E., Bulutsky-Shearer, R. J., Garrett, S. D., Slaughter-Defoe, D., Brown, E. D.,

& Lopez, B. (2013). Integrating U.S. federal efforts to address the multifaceted problems

of children: A historical perspective on national education and child mental health

policies. School Mental Health, 5(1), 119-131.

Zins, J. E., Bloodworth, M. R., Weissberg, R. P., & Walberg, H. J. (2004). The scientific base

linking social and emotional learning to school success. In J. Zins, R. Weissberg, M.

Wang, & H. J. Walberg (Eds.), Building academic success on social and emotional

learning: What does the research say? pp. 3-22. NY: Teachers College Press.

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Appendix A – School Psychologist Recruitment Letter

You are invited to volunteer to participate in a research study exploring the current practices of

school psychologists in the provision of school mental health services within a multitiered

system of supports (MTSS) framework. Participating in this study is voluntary and confidential.

You will be asked to complete a 10-15-minute survey which consists of questions pertaining to

your involvement in the provision of school mental health services with youth. Upon completing

the survey, you may volunteer to participate in a 15-30 minute interview. Your responses and

personal contact information will be confidential, anonymous, and private.

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Appendix B – Survey Informed Consent

School Psychologist Consent to Participate in Research

INFORMED CONSENT PURPOSE OF STUDY

You are invited to participate in a research study being conducted by Margaret A. Sedor, a

doctoral candidate in the joint Ph.D. program in Education with San Diego State University and

Claremont Graduate University. The purpose of this research is to gain information about current

practices of school psychologists in the provision of school mental health services within an

MTSS Framework in the state of California.

PROCEDURES

You are being asked to participate in this study because you are a school psychologist.

Participation in this study involves completing an online survey 10-15 minutes. The survey

includes questions about your involvement in the provision of school mental health with youth.

There are no foreseeable risks to participation in this study. Once completing the survey, you

will have the opportunity to further support this research by participating in a 15 to 30 minute

interview regarding your perspective of school psychologists as mental health providers within a

Multitiered Systems of Support (MTSS) Framework.

POTENTIAL BENEFITS

The benefits of taking part in this study are contributing to the knowledge about practice of

school psychologists’ in working with youth with these presenting issues.

PAYMENT FOR PARTICIPATION

None.

RIGHTS OF RESEARCH PARTICIPANTS

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There are no potential or know risks associated with participation in this research. Participation

in this study is voluntary. You may choose not to participate, and you may withdraw at any time

during the study procedures without any penalty to you. In addition, you may choose not to

answer any questions with which you are not comfortable.

CONFIDENTIALITY

This research is anonymous. Anonymous means that I will record no information about you that

could identify you. There will be no linkage between your identity and your response in the

research. This means that I will not record your name, address, phone number, date of birth, etc.

Therefore, data collection is anonymous. You will be assigned a participant number and only the

participant number will appear with your survey responses. Please note that I will keep all

information confidential by limiting access to the research data and storing it in a password

protected electronic format.

The research team and the Institutional Review Board at San Diego State University are the only

parties that will be allowed to see the data, except as may be required by law. When the research

study is published as a dissertation, or if the results are presented at a professional conference,

only group results will be stated. All study data will be kept for three years.

CONTACT

If you have any questions about the study or study procedures, you may contact Margaret A.

Sedor, M.S., NCSP, at [email protected], or you may contact my advisor Dr. Rafaela

M. Santa Cruz at [email protected]. If you have any questions about your rights as a

research subject, you may contact the IRB Administrator at San Diego State University at:

140
 Division of Research Affairs
Human Research Protection Program
Gateway Center, Room 3505
5250 Campanile Drive, MC 1933
San Diego, CA 92182
619-594-6622
[email protected]

The survey was adopted with permission from the authors: Eklund, K., Meyer, L., Way, S., &

McLean, D. (2017). The SBMH Services and Advocacy Survey (SBMHS).

CONSENT TO PARTICIPATE RIGHTS OF PARTICIPANTS

By beginning this survey, you acknowledge that you have read this information, and agree to

participate in this research, with the knowledge that you are free to withdraw your participation

at any time without penalty. If you choose not to participate, you may close the link to this

survey.

Please retain a copy of this form for your records. By participating in the above stated

procedures, then you agree to participation in this study. If you are 18 years of age and older, you

understand the statements above, and will consent to participate in the study, click on the “I

agree” button to begin the survey. If not, click on the “I do not agree” button which will exit you

from the program.

Yes, I agree (Please proceed to take this survey)

No, I do not agree (Please do not proceed to take the survey)

By beginning the interview portion of this research, you exited the survey portion of the research

and have expressed interest in participating in a personal phone interview. The personal

interview portion of the study will last about 15 t0 30 minutes. Interview questions will focus

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specifically on the practice of school psychologist in the provision of mental health services

across a continuum comprehensive system. The interview will take place by phone at a time

convenient for the participant. You will be assigned a participant number to ensure

confidentiality of all personal identifying information. The personal interviews will be audio-

recorded, transcribed, and reviewed. If you choose not to be audio-recorded, you will not be

asked to participate in the study.

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Appendix C – Survey Questions

School Psychologists are increasingly called upon to work with youth with an array of school

mental health needs. Work with these students sometimes poses unique challenges and requires

specific training. The following survey is designed to collect data about the mental health

practice of school psychologists within a continuum of care, commonly known as the multitiered

system of supports (MTSS). It also seeks to understand the supports or barriers that school

psychologists may experience in that process.

For purposes of this research, the NASP definition will be use in terms of mental health

services within the MTSS Framework. In this survey, you will be asked to identify the average

number of hours per week you spend across these five (5) components of MTSS.

(1) Prevention and wellness promotion

(2) Universal screening for barriers to learning

(3) Implementing evidence-based interventions that increase in intensity as needed

(4) Monitoring the ongoing progress of students in response to implemented interventions

(5) Engaging in systematic decision making about programming and services needed for

students based upon specific student outcome data.

1. To what degree does your district or site administrator(s) support you in providing a

comprehensive continuum of mental health services?

a. Strong support for these services

b. Some support for these services

c. Indifference

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 d. No support for these services

e. Strongly against providing these services

2. MTSS Component 1: Prevention and Wellness Promotion (TIER 1) Services

Universal, prevention-based, school mental health services. These services are provided

school-wide to all students within the school milieu. These services are informed by an

understanding of mental health and designed to optimize positive mental health, build

resilience, address barriers to learning, support protective factors & minimize mental health

risk factors in school. This includes universal screening, positive behavioral interventions

and supports (PBIS), social emotional learning programs, etc.…

In the past year, what is the average number of hours per week you have engaged in MTSS

Component 1: Prevention and Wellness Promotion (Tier 1) Services: (Range 0 to 40).

3. What types of mental health services are you currently providing related to MTSS Component

1: Prevention and Wellness Promotion. (Check all that apply)

a. Mental Consultation

b. Wellness/Self-Care Plan development

c. Self-Regulation Strategies

d. School Leadership Team

e. School Crisis Team

f. Social Emotional Learning (SEL) Programs

g. Restorative Practices (e.g. affective language, relationship building, circles)

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 h. Brain-based/Mindfulness Strategies (e.g. MindUp, Empty the Cup)

i. Suicide Prevention (e.g. recognizing risk factors/warning signs, ASIST, PQR)

j. Recognizing Mental health needs (e.g. Kognito, MH First Aid, Emotional Barriers to Learning)

k. Trauma Informed Practices

l. Other: (please specify)

4. MTSS Component 2: Universal Screening for Mental Health Strengths and Barriers.

The universal screening of mental health strengths and barriers are activities which involve

the systematic assessment of all children within a given class, grade, school building, or

school district, in terms of social-emotional or mental health strengths and early risk

indicators. Indicate the number of hours per week you engage in the specific activities

related to prevention and wellness promotion mental health.

In the past year, what is the average number of hours per week involved in MTSS

Component 2: Universal Screening for Mental Health Strengths and Barriers services:

(Range 0 to 40).

5. What types of mental health services are you currently providing related to MTSS

Component 2: Universal Screening for Mental Health Strengths and Barriers? (Check all

that apply)

a. School Climate Assessment

b. Universal Assets/Strengths Based Assessment

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 c. Universal Screening Mental Health Needs (e.g. SABERS, BESS, SDQ)

d. California Health Kids Survey (CHKS)

e. Adverse Childhood Experiences (ACE) Survey

f. Other: (please specify):

6. MTSS Component 3: Implementation of evidence-based interventions. (Tier 2 & 3) mental

health services.

The implementation of evidenced-based intervention are activities which involve targeted

(Tier 2) and indicated (Tier 3) services for students at-risk for further impact; individual &

group level resilience-building and for intensive services that address mental health risk

factors. Indicate the number of hours per week you engage in the specific activities related

to implementation targeted and indicated of evidenced-based interventions.

In the past year, what is the average number of hours per week you have engaged in MTSS

Component 3: Implementation of evidence-based interventions. (Tier 2 & 3) mental health

services. (Range 0 to 40).

7. What types of mental health services are you currently providing related to MTSS

Component 3: Implementation of evidence-based interventions (Tier 2 & 3) mental health

services (Check all that apply).

a. Mental Health Intervention Coaching

b. Restorative Practices (e.g. Circles, Formal/Reintegration Conference)

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 c. Trauma Informed Practices

d. Social Skills Instruction (e.g. Second Step, ACHIEVE)

e. Brain Based/Mindfulness Instruction (e.g. MindUP)

f. Individual Counseling (e.g. CBITS, Solution Focused)

g. Educationally Related Mental Health Services (ERMHS)

h. Group Counseling

i. Suicide or Threat Assessment

j. Wraparound Plan coordination

k. Other: (please specify)

8. MTSS Component 4: Progress Monitoring of mental health interventions and services.

A process of measurement and feedback of mental health evidenced-based interventions.

Indicate the number of hours per week you engage in specific activities related to

progress monitoring of mental health interventions and services.

In the past year, what is the average number of hours per week you engaged in MTSS

Component 4: Progress Monitoring of mental health interventions and services (Range 0 to

40).

9. What types of mental health services are you currently providing related to MTSS

Component 4: Progress Monitoring of mental health interventions and services (Check all that

apply).

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 a. Student self-monitoring plans (check in/check out)

b. Direct (Mental Health/Wellness) Treatment Protocol

c. Pre/Post Assessment of Interventions

d. Progress Monitoring of social emotional mental health goals

e. Other: (please specify)

10. MTSS Component 5: Systematic data informed programming & services.

A process used by stakeholder teams from multiple settings to analyze and evaluate

information related to planning and implementing effective instructional strategies matched

to student mental health needs. Indicate the number of hours per week you engage in the

specific activities related to systematic data informed programming and services.

In the past year, what is the average number of hours per week you have engaged in MTSS

Component 5: Systematic data informed programming & services (Range 0 to 40).

11. What types of mental health services are you currently providing related to MTSS Component

5: Systematic data informed programming & services (Check all that apply).

a. Online software analyses of school data (SWIS, Review 360)

b. Online software analyses of student data (SWIS, CICO, ISIS)

c. Positive School Climate Survey/Strategy Data Analyses

d. Other: (please specify)

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12. In the past year, how many hours have you attended trainings, workshops, professional

development, and/or self-study on mental health services.

a. 0 hours

b. 1-4 hours

c. 5-9 hours

d. 10-15 hours

e. 16-20 hours

f. 20+ hours

13. In the past year, what areas of mental health services have you attended trainings,

workshops, professional development, and/or self-study in your school district, community,

or state? (Check all that apply)

a. Universal Screening

b. School Climate

c. Suicide Prevention, Intervention, Postvention

d. Brain Based/Mindfulness Strategy Instruction

e. Social Skills Training

f. Trauma-related Interventions

g. Restorative Practices

h. Cognitive Behavioral Therapy (CBT) Oriented Interventions

i. Educationally Related Mental Health Services/Counseling Services

j. Classroom Strategies

k. Systematic Data Progress Monitoring

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 l. Other: (Please Specify)

14. What types of training/professional development opportunities would you be interested in

attending? (Check all that apply)

a. Universal Screening

b. School Climate

c. Suicide Prevention, Intervention, Postvention

d. Brain Based/Mindfulness Strategy Instruction

e. Social Skills Training

f. Trauma-related Interventions

g. Restorative Practices

h. Cognitive Behavioral Therapy (CBT) Oriented Interventions

i. Educationally Related Mental Health Services/Counseling Services

j. Classroom Strategies

k. Systematic Data Progress Monitoring

l. Other: (Please Specify)

15. In the past year, how often have you contacted/engaged in advocacy efforts related to

educational policy, mental health, and/or school psychology? This can include an email,

phone call and/or personal conversation.

a. 0 times

b. 1-2 times

c. 3-4 times

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 d. 5 or more times

16. In the past year, at what level have you contacted/engaged in advocacy efforts related to

educational policy, mental health, and/or school psychologist? This can include an email,

phone call and/or personal conversations. (Check all that apply)

a. District Level (School/District Administrator, Board Member/Superintendent)

b. Local Level (County Office of Education/SELPA, Mayor, Board of Supervisors)

c. State Level (California Department of Education, Legislators)

d. National Level (Senator, Representative)

e. Other: (please specify)

17. The following services allow for Medicaid reimbursement when provided by school

psychologists in the school setting. Which of these services have you/your district billed for

within the last school year? Select all that apply:

a. Psychological testing and evaluation

b. Psychological, individual treatment

c. Psychological, group treatment

d. Family counseling with student present

e. Psychological consultation

f. Behavior management

g. Crisis intervention

h. I do not bill Medicaid for services provided by school psychologists

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18. What challenges or barriers have you faced in providing mental and behavioral health

services? (Check all that apply)

a. Limited time

b. Another professional (counselor, social worker) provides these services

c. Not enough training

d. Not supported by my school or district to provide these services

e. Not interested

Other (please specify)

19. What factors do you feel are important to enabling you to provide mental health services in

schools? (Check all that apply)

a. More training or professional development

b. School and/or district administrator support

c. Improved ratios (student to school psychologist)

d. Collaboration between school counselor and school social worker in providing these

services

e. I am not interested in providing these services

f. Other: (Please Specify)

20. What is your gender?

a. Female

b. Male

152
21. What is your ethnicity/culture:

a. White

b. Hispanic or Latino

c. Black or African American

d. Native American or American Indian

e. Asian/Pacific Islander

f. Middle Eastern

g. Other: (Please Specify)

22. What is the highest degree that you have earned?

a. Doctorate

b. Masters/Specialist Degree

c. Other (please specify)

23. What graduate training program did you attend (Name, City, State)?

24. Years of experience working in the field of school psychology?

25. Years of experience working in your current position?

26. What professional associations are you a member? (Check all that apply):

a. Local school psychologist association member

b. CASP member

c. NASP member

d. APA member

e. Other: (please specify)

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27. What is your primary role?

a. School psychologist/school psychologist-specialist practitioner

b. Private/contracted practice as a school psychologist/school psychologist-specialist

c. School/district administrator

d. University faculty/instructor

e. Other (please specify)

28. What is your current Full-time Equivalent (FTE) you are contracted in your current role?

a. Work .5 - 2 days/week (0.1 - 0.4 FTE)

b. Work 3-4 days/week (0.5 to 0.9 FTE)

c. Full-time (1.0 FTE or more)

29. Which population have you primarily served in your role as school psychologist?

a. Preschool

b. Elementary

c. Middle

d. High School

e. Post-Secondary (College, University, Trade School, etc.…)

f. Other: (Please Specify)

30. Which best characterizes the local population of the schools you serve?

a. Urban (50,000 or more)

b. Suburban/Urban Cluster (3,000 - <50,000)

154
 c. Rural (<3,000)

31. How many schools are you assigned to work at?

32. What is the total student enrollment of the school(s) that you serve:

a. 0-499

b. 500-999

c. 1,000-1,499

d. 1,500-1,999

e. 2,000- 2,499

f. 3,000 – 3,499

g. 3,500 – 3,999

h. 4,000 – 4,499

i. 4,500 – 4,999

j. 5,000+

k. Other: (please describe)

Open-ended Questions:

33. What supports you in the provision of mental health services?

34. What barriers impede you in the provision of mental health services?

35. What can CASP do in the future to help you in the provision of mental health services?

36. What other information/input would you like to provide that we have not asked?

Thank you for participating in the survey.

Please click the following link to volunteer to participate in a 15-30 minute personal interview.

155
Appendix D – Interview Informed Consent

I am interested in your practice of mental health within the MTSS Framework and how it is

implemented in your district. If you are a practitioner in the schools and would like to volunteer

to be considered to participate in a 15-30 minute interview, please click the link below to provide

your demographic and contact information.

Thank you,

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Appendix E – Interview Questions

Demographic Identification:

1. What setting do you primarily serve?

a. Preschool

b. Elementary

c. Middle School

d. High School

e. Other

2. What community do you primarily serve?

a. Urban (50,000 or more)

b. Suburban (3,000- <5,000)

c. Rural (< 3,000)

3. How would you describe your level of experience as a school psychologist?

a. Early Career (> 10 years of service)

b. Late Career (10+ years of service)

4. Tell me about the skills and experience you have in the provision of mental health

services within an MTSS framework.

5. What professional development opportunities have prepared you to practice within a

continuum of mental health services?

157
6. Please describe the supports within your practice for providing mental health services?

7. Can you provide examples of the barriers you experience in providing mental health

services?

8. How can CASP best support your practice as a mental health provider?

9. Is there anything else you would like to share?

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Appendix F – Methods Matrix

Research Question Quantitative Analyses Qualitative Analyses

1. What is the current practice of Survey Item Frequency Interview Item Theme
school psychologists in the 4
provision of MTSS 2, 3, 4, 5, 6, Descriptive Analyses
components of mental health
services? 7, 8, 10, 11,

2. What factors support the Survey Item Frequency Survey Item Theme
practice of school Open-ended
psychologists in the provision 1, 19 Descriptive 33 Analyses
of MTSS components of
mental health services? Interview Item
6

3. What factors limit the practice Survey Item Frequency Survey Item Theme
of school psychologists in the Open-ended
provision of mental health 18 Descriptive 34 Analyses
services?
Interview Item
7
4. Are there differences in the Survey Item ANOVA Interview Item Theme
practice of school
psychologists in the provisions 29,30 1, 2 Analyses
of MTSS components of
mental health services in terms
of professional contextual
factors including school setting
(i.e., primary, secondary) and
community (i.e., urban,
suburban)?

159
5. What is the relationship Survey Item Correlation Interview Theme
between (a) demographic
contextual factors, (b) 12, 13, 15, 3, 5 Analyses
professional contextual factors, 16, 22, 24,
and (c) the provision of mental 32
health services for each of the
MTSS components?

160
 Range of Hours Engaged in MTSS Components Frequency & Percentages

MTSS
Hours
Component

0 1-5 6-10 11-15 16-20 21+

n % n % n % n % n % n %

1. Prevention
8 7 65 59 21 19 4 4 9 8 3 3
(n = 110)

2. Universal

161
Screening 21 25 46 55 10 12 0 0 6 7 1 1
(n = 84)

3. Evidence-
Based
5 4 46 44 29 28 14 14 4 4 6 6
Interventions
(n = 104)

4. Progress
Monitoring 9 10 64 68 15 16 3 3 2 2 1 1
(n = 94)

5. Systematic
Appendix G – Range of Hours Engaged in MTSS Components Frequency & Percentages

Decision Making 13 18 59 66 12 14 1 1 0 0 1 1
(n = 89)