School-Based Mental Health Interventions: Recommendations for Selecting and Reporting Implementation Strategies*

A key component of student health and well-being is mental health. The rates of diagnosable mental health concerns among students are high—the lifetime prevalence for at least 1 mental health disorder was nearly 50% in a large, nationally representative sample of adolescents from 2010,¹ and prevalence has increased among school-age children and adolescents in recent years.² Notably, only about half of youth with mental health concerns receive treatment,^{3, 4} and rates of treatment receipt are lower among marginalized or low-income youth.^{3, 5} When children and adolescents do receive mental health treatment, they frequently access these services through their preK-12 schools.^6-8 Compared to clinic-based settings, schools offer many advantages for mental health service provision, including promoting access to care and reducing stigma⁹ particularly within under-resourced settings.¹⁰

Unfortunately, there are significant implementation challenges to the uptake and delivery, as well as the study, of mental health services within schools. The primary mission of schools is academic education, and many schools, particularly those serving marginalized or low-income students, frequently lack the resources to achieve their academic mission. As a result, there are often limited resources left to deliver mental health services, especially if they are not directly aligned with the schools' academic mission.⁹ Furthermore, school-based mental health practitioners face multilevel barriers when implementing interventions, including characteristics about the intervention itself (eg, usability, contextual fit), the individual (eg, stress and burnout), the team (eg, turnover), and the school (eg, funding for sustainability), as well as factors related to the macro-level community (eg, service fragmentation).^{11, 12}

Applying concepts from the field of implementation science, the scientific study of strategies to facilitate the uptake of evidence-based practices into real-world service delivery,¹³ has the potential to benefit school mental health research and practice. One way to support successful uptake is to develop and test implementation strategies (ie, the techniques used to enhance the adoption, implementation, or sustainment of interventions), which are key to ensure that school mental health interventions are implemented as intended within schools. The School Implementation Strategies Translating ERIC (ie, Expert Recommendations for Implementing Change) Resources (SISTER) is a compilation of 75 implementation strategies¹⁴ for the school context. SISTER provides a taxonomy of strategies (eg, provide consultation/coaching; monitor the implementation effort) to help researchers and school partners select strategies to support evidence-based practices in schools.

In implementation science, over 140 theories, models, and frameworks have been developed,¹⁵ including those that specify implementation barriers and facilitators, evaluation outcomes, or steps in the implementation process, among other purposes.¹⁶ The EPIS framework¹⁷ may be particularly relevant for school-based researchers and practitioners because it addresses the key phases (ie, explore, prepare, implement, sustain) that guide the implementation process (ie, steps in translating research to practice).

In the Exploration phase, researchers and practitioners use implementation strategies to consider the emerging or existing needs of the school (eg, students', teachers' or other personnel needs), as well as evaluate the potential fit between the intervention and school. During the Preparation phase, it is important to plan for implementation by capitalizing on implementation facilitators and addressing potential barriers to implementation. During the Implementation phase, researchers and practitioners apply implementation strategies and monitor the implementation process. During the Sustainment phase, the structures and processes in schools are considered that would support ongoing implementation.¹⁷ The EPIS framework is particularly well-suited for school mental health research and practice because it highlights constructs at the level of the intervention itself (eg, usability, adaptability), the level of the inner context (ie, individual factors such as attitudes about the intervention, and organizational factors such as culture and climate), the level of the outer context (ie, factors such as policies, legislation, and funding), as well as factors that span the inner and outer context (ie, “bridging factors,” such as community-academic partnerships).

In this commentary, we draw on the EPIS framework¹⁷ to argue that the school mental health field would benefit from explicit consideration of implementation strategies across EPIS phases. Implementation strategies (eg, professional development trainings, coaching) are frequently used in schools to support the delivery of mental health interventions, and therefore, there is growing interest in applying implementation science concepts to school mental health.^{12, 18, 19} We respond to this call to systematically infuse school mental health service research with critical concepts from implementation science. We make 3 specific recommendations for selecting and reporting implementation strategies to advance school mental health research and practice.

In this commentary, we draw on the EPIS framework to argue for the importance of considering and reporting implementation strategies that support school mental health prevention and intervention programs. Specifically, we argue for the need to consider the Exploration and Preparation phases; the importance of Implementation strategies in addition to intensive training and consultation; and the need to focus on Sustainment. We suggest that applying concepts from the field of implementation science, such as the EPIS framework and the SISTER compilation of implementation strategies, has the potential to advance school mental health research and practice, at a time when this is sorely needed to enhance student health. Future work on the implementation of school health programs may also benefit from explicitly considering EPIS constructs, such as the inner context, outer context, and bridging factors. Our recommendations also highlight the critical role of authentic community partnerships and participatory research (ie, shared decision-making, iterative nature of intervention development and implementation, and including partner priorities).³⁶ Indeed, the practice-based expertise of school practitioners are critical in developing and selecting interventions and implementation strategies that are appropriate and feasible across EPIS phases. Moreover, engagement between schools and community organizations, including researchers, is a critical component of overall school health promotion efforts, such as the Whole School, Whole Community, Whole Child model.^{37, 38}