Public Health Framework
Public Health Framework
A public health approach to mental health has been advocated by the World Health Organization1 and provides the guiding framework for Every Moment Counts, emphasizing the promotion of mental health as well as the prevention of and intervention for mental illness. National leaders in the field of children's mental health have also promoted the adoption of a multi-tiered public health approach.2,3,4,5,6,7 This continuum of care is also referred to as a Multi-tiered System of Supports (MTSS tiers) and supports a change in thinking from the traditional individually-focused deficit driven model of mental health intervention to a whole-population, strength-based approach.
"Education and mental health integration will be advanced when the goal of mental health includes effective schooling, and the goal of effective schooling includes the healthy functioning of students".2
Mental health is everyone's business!
Because addressing children's mental health is complex, leaders are calling for a shift in practices – to better prepare all school personnel (e.g., teachers, administrators, para-educators, and related service providers) to proactively address the mental health needs of all students.8,9,10
Within this public health model, a range of services are provided and include:
- Promotion: enhancing competencies; helping children be mentally healthy and happy
- Prevention: reducing risks; minimizing mental health problems and promoting positive mental health
- Intensive, individualized: accommodations and interventions provided to reduce the effects of a mental disorder and promote positive mental health
Depicted as a pyramid representing a multi-tiered system of interventions and supports, this approach is designed to meet the mental health needs of all students:
Tier 1: ALL (green area) Universal, whole school strategies for promoting positive mental health in all students with and without mental health challenges. Focus: promotion & prevention.
Tier 2: SOME (blue area) Targeted interventions for students at-risk of developing a mental health challenge. Focus: prevention and promotion using small groups and embedded strategies (e.g. teaching self-regulation strategies for a student experiencing anxiety)
Tier 3: FEW (red area) More intensive, individualized interventions for students experiencing a mental health challenge. School personnel collaborate with mental health providers and families to provide a coordinated system of care. Focus: promotion, prevention and intervention to reduce symptoms.
School Mental Health (SMH) can be thought of as a framework of approaches expanding on traditional methods to promote children's mental health by emphasizing prevention, positive youth development, and school-wide approaches. This SMH framework promotes interdisciplinary collaboration between mental health providers, related service providers, teachers and school administrators in order to meet the mental health needs of all students.11,12
A national movement to develop and expand school mental health (SMH) services has grown during the past several decades as a result of the high prevalence of mental health needs among youth and the awareness that more youth can be reached in schools. Schools must be active partners in the mental health of all children and youth because it is currently accepted that a major barrier to learning is the absence of essential social-emotional skills and not necessarily a lack of sufficient cognitive skills. Approximately one in every five children and adolescents has a diagnosable emotional or behavioral disorder with the most common being anxiety, depression, and behavioral disorders.13,14 Emotional and behavioral disorders can adversely affect a child’s successful participation in a range of school activities including classroom work and social interaction with peers and adults. Children with disabilities are at increased risk for developing mental and/or behavioral challenges. Nearly 1 in 3 children with developmental disabilities is diagnosed with a co-occurring mental health problem.15
Legislative changes have also prompted schools to shift to a multi-tiered model of services committing to the success of all students by providing early identification and intervening services. The Education for All Handicapped Children Act of 1975 (Pub. L. 94–142), later reauthorized as the Individuals With Disabilities Education Improvement Act of 2004 (Pub. L.108–446), was the first federal initiative that required schools to meet the mental health needs of students with emotional challenges. Section 504 of the Rehabilitation Act of 1973, as amended (2008; Pub. L. 93–112; 34 C.F.R. Part 104.4), also provides accommodations for students with mental health diagnoses. The World Health Report (2001) called for schools to prevent suicide and help students develop positive mental health.1 In addition, the health-promoting school model advanced by WHO provides an organizing framework for comprehensive health promotion to create school environments that support students’ mental and physical health and family involvement.16
For more information about School Mental Health, check out the websites listed below.
Once school personnel are oriented to the multi-tiered mental health promotion, prevention, and intervention framework, they can work together to offer universal, targeted, and individualized services.
Refer to the 1-page summary sheet provided in the link below. Examples of services and activities at Tiers 1, 2, and 3 are provided.
Download a pdf of the Summary Pyramid: Tiers 1, 2, & 3 Services
1 WHO (World Health Organization). (2001). Mental health: new understanding, new hope. The world health report. WHO, Geneva. 2 Atkins, M. S., Hoagwood, K. E., Kutash, K., & Seidman, E. (2010). Toward the integration of education and mental health in schools. Administration and Policy in Mental Health, 37, 40–47. 3 Barry, M. M., & Jenkins, R. (2007). Implementing mental health promotion. Edinburgh: Churchill, Livingstone, Elsevier. 4 Bershad, C. & Blaber, C. (2011). Realizing the Promise of the Whole-School Approach to Children's Mental Health: A Practical Guide for Schools. Washington, DC: Education Development Center, Inc. 5 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. 6 Stiffman, A. R., Stelk, W., Horwitz, S. M., Evans, M. E., Outlaw, F. H., & Atkins, M. (2010). A public health approach to children’s mental health services: Possible solutions to current service inadequacies. Administration and Policy in Mental Health, 37, 120-124. 7 Atkins, M. S., & Frazier, S. L. (2011). Expanding the toolkit or changing the paradigm: Are we ready for a public health approach to mental health? Perspectives on Psychological Science, 6, 483-487. 8 Bazyk, S. (Ed.). (2011). Mental health promotion, prevention, and intervention with children and youth: A guiding framework for occupational therapy. Bethesda, MD: AOTA Press. 9 Arbesman, M., Bazyk, S., & Nochajski, S. (2013). Systematic reviews of occupational therapy and mental health promotion, prevention, and intervention for children and youth. American Journal of Occupational Therapy, 67(6),e120-e130. 10 Bazyk, S., & Arbesman, M. (2013). Occupational therapy practice guidelines for mental health promotion, prevention, and intervention for children and youth. Bethesda, MD: AOTA Press. 11 Koller, J. R., & Bertel, J. M. (2006). Responding to today's mental health needs of children, families and schools: Revisiting the preservice training and preparation of school-based personnel. Education and Treatment of Children, 29, 197–217. 12 Masia-Warner, C., Nangle, D. W., Hansen, D. J. (2006). Bringing evidence-based child mental health services to the schools: General issues and specific populations. Education and Treatment of Children, 29, 165–172. 13 Koppelman, J. (2004). Children with mental disorders: Making sense of their needs and systems that help them. NHPF Issue Brief, No. 799, National Health Policy Forum, The George Washington University, Washington DC. 14 National Research Council & Institute of Medicine. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: National Academies Press. 15 Schwartz, C., Garland, O., Waddell, C., & Harrison, E. (2006). Mental health and developmental disabilities in children. Research report prepared for Children and Youth Mental Health. Vancouver: British Columbia Ministry of Children and Family Development, Children's Health Policy Centre. 16Jané-Llopis, E., & Mittelmark, M. B. (2015). No health without mental health. Promotion and Education Supplement, 2, 4–5. https://doi.org/10.1177/10253823050120020101x