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ORIGINAL PAPER
The Impact of School Mental Health on Student and School-Level
Academic Outcomes: Current Status of the Research and Future
Directions
Shannon M. Suldo •Matthew J. Gormley •
George J. DuPaul •Dawn Anderson-Butcher
Springer Science+Business Media New York 2013
Abstract This manuscript summarizes areas of school
mental health (SMH) research relevant to the interplay
between students’ academic and social–emotional out-
comes. After advancing a multidimensional conceptuali-
zation of academic success at the levels of individual
students and schools, we summarize observational and
intervention studies that connect students’ mental health to
their academic achievement, with acknowledgment of the
bidirectional relationship. Then, current and future direc-
tions of SMH research are discussed, including (a) the
impact of SMH health initiatives and services on schools’
achievement, (b) the need to address the mental health of
historically neglected subgroups of students, and (c) inter-
disciplinary collaborations necessary to support enhanced
outcomes. Based on the findings from these literature
integrations, we conclude with recommendations and
implications for research and practice.
Keywords Student success Impact of school mental
health prevention and intervention Research directions
Introduction
In this paper, we establish students’ mental health and
academic outcomes as different domains of functioning
that are interrelated. Despite most educators’ primary focus
on academic learning and indicators of achievement,
attention to student mental health is warranted in part
because (a) mental health (particularly externalizing
problems) affects academic outcomes, (b) academic
achievement affects mental health (particularly internaliz-
ing problems), and (c) in so far as the mission of schools
involves developing competent citizens, a dual focus on
mental health and academic outcomes is warranted given
their separability. Summaries of such literature set the
stage for current and future directions in school mental
health (SMH) research, which begin with increasing
attention to school-level indicators of academic success.
Then, we draw attention to student subgroups (e.g., stu-
dents with chronic physical health conditions, high-
achieving students in rigorous curricula) who may not
receive adequate attention from educational and mental
health professionals. Last, we describe the need to docu-
ment how SMH professionals can work collaboratively
with related disciplines, and partner with additional
resources in communities, to optimize access to and posi-
tive outcomes of SMH services.
Historical Focus of School Mental Health Prevention
and Intervention Research
SMH research is differentiated from the larger literature in
child clinical and prevention science by many features
beyond the intervention setting. In relation to the impact of
SMH on academic success (as defined in the next section),
S. M. Suldo (&)
Department of Psychological and Social Foundations, University
of South Florida, 4202 East Fowler Ave., Tampa, FL 33620,
USA
e-mail: suldo@usf.edu
M. J. Gormley G. J. DuPaul
Department of Education and Human Services, Lehigh
University, Bethlehem, PA, USA
D. Anderson-Butcher
College of Social Work, The Ohio State University, Columbus,
OH, USA
123
School Mental Health
DOI 10.1007/s12310-013-9116-2
the mere examination of student academic outcomes as an
indicator of youth functioning differentiates SMH research
from clinic-based research. Most early research examined
the impact of SMH services on individual students’
achievement outcomes in the context of controlled efficacy
trials (Hoagwood & Johnson, 2003). Students were tar-
geted for inclusion in these studies because they were at-
risk on a particular factor, such as disruptive behaviors or
school dropout risk. As such, services were focused on
secondary (selective) prevention. Research followed that
examined the impact of school-wide SMH primary (uni-
versal) prevention programs on groups of students’ aca-
demic outcomes, particularly in terms of schools that are
at-risk (e.g., high poverty, community violence or crime).
For example, the school-wide positive behavior support
(PBS) movement involves a three-tiered approach to pre-
vention and intervention that promotes prosocial behavior
for the school population as a whole (Sailor, Dunlap, Sugai,
& Horner, 2009).
In recent years, there has been increasing emphasis on
the effectiveness research that involves the implementation
of evidence-based interventions by school personnel under
less controlled, ‘‘real-world’’ conditions. In particular,
there is growing acknowledgment of the substantial impact
of organizational variables (e.g., school climate and cul-
ture) on achievement and behavioral outcomes (Doll,
Spies, & Champion, 2012; Hoagwood & Johnson, 2003).
Further, these organizational variables must be incorpo-
rated in any plans to implement prevention and interven-
tion activities in schools (Forman et al., 2013). Last,
schools are faced with growing accountabilities that require
schools to ensure all students demonstrate proficiencies in
key grades and subject areas, paying particular attention to
students representing certain subgroups of the student body
who are historically underperforming. Research on the
contributions of SMH to school-level success is of
increasing importance.
Defining Success
Student success can be defined at the level of individual
students, and at the aggregate level with regard to the
performance of a particular school (or district). The out-
comes, or domains of functioning, that constitute student
success can entail a narrow focus on academic skills and
performance, or be defined broadly to include attention to
students’ social–emotional health. The latter is illustrated
by Roeser, Eccles, and Sameroff’s (2000) seminal defini-
tion of adolescents’ psychosocial functioning in the school
context, which posits the relevance of two interconnected
domains: social–emotional functioning (including mental
health) and school functioning (i.e., academic enablers and
skills). It should be noted that the concepts of social–
emotional and school functioning overlap to a certain
degree, especially in the case of some disorders (e.g.,
attention-deficit/hyperactivity disorder, autism) whose key
features are influenced, at least in part, by learning pro-
cesses. However, as defined in the next sections, we view
these two areas as separate but overlapping concepts.
Student-Level Indicators of Social–Emotional
Functioning
Social–emotional health includes both psychological and
behavioral indicators (Roeser et al., 2000). Most indicators
within the psychological domain have focused on symp-
toms of distress (i.e., psychopathology). Modern definitions
of psychological well-being recognize that although an
absence of symptoms is desirable, the presence of positive
emotions is optimal and constitutes thriving (Howell,
Keyes, & Passmore, 2013). Common indicators of distress
include the frequency or severity of internalizing or
externalizing problems, as reported by students, parents,
and/or teachers. Indicators of well-being include students’
global appraisals of quality of life (i.e., subjective well-
being, often indexed by life satisfaction) or frequency of
specific positive dimensions such as positive affect, pur-
pose, and self-acceptance. Behavioral indicators of social–
emotional functioning assess peer relationships, including
social competence (e.g., social skills, adaptive relation-
ships) and problems (e.g., victimization, affiliation with
deviant peer groups).
Student-Level Indicators of Academic Functioning
Doll et al. (2012) assert that the definition of student suc-
cess in school has evolved from a focus on dropout, to
actual completion of school, to indicators of engagement
that predict eventual school completion. As such, defining
academic success may include behaviors and attitudes that
serve as academic enablers, in addition to skills assessed by
tests and course grades. The latter dimension has been
prioritized in SMH research (Becker, Brandt, Shephan, &
Chorpita, 2013), and standardized achievement tests are
currently ‘‘clearly viewed as the gold standard’’ within the
field of education (Kutash, Duchnowski, & Green, 2011,
p. 206). However, improvements in behavioral and affec-
tive forms of engagement reflect removal of barriers to
learning, including negative student behaviors (e.g., vio-
lating school rules) and attitudes (e.g., dislike of school).
Improved student engagement, which increases access to
instruction, enhances students’ ability to acquire the aca-
demic skills by which schools are ultimately evaluated.
Academic competence thus entails knowledge and skills,
School Mental Health
123
behavior conducive to learning, and positive attitudes and
values.
Student-level indicators of academic competence can be
further conceptualized as proximal versus distal. Proximal
measures reflect performance of specific skills and class-
room behaviors typically over a short time period (e.g., day
or week) or student attitudes that reflect perceptions of
one’s current abilities, motivation, or attachment at school.
Alternatively, distal indicators measure global performance
over longer periods of time, as reflected in end-of-course
grades, skills demonstrated on state-wide accountability
tests, or school records of accumulated attendance or office
discipline referrals (ODRs). Other distal behavioral indi-
cators include global ratings of academic enablers (Di-
Perna, Volpe, & Elliott, 2002), which include sustained
attention to tasks or instruction, compliance with classroom
rules and expectations, and active participation in instruc-
tional interactions or activities. In contrast to proximal
attitudes pertinent to self-oriented constructs (i.e., aca-
demic self-efficacy; sense of belonging, attachment, or
connectedness to one’s school; motivation for learning or
other aspects of achievement orientation), which may
fluctuate with personal experiences, attitudes classified as
distal may reflect other-oriented attitudes (e.g., school
climate perceptions) that may be slower to change in
accordance with systemic interventions. However, a given
attitude may be classified as either proximal or distal as a
function of how assessed in a particular study, and depend
specifically on the time frame over which students are
prompted to reflect when providing responses.
As summarized in Table 1, academic indicators at the
individual student level may be categorized into one of six
cells: (a) proximal skill (e.g., curriculum-based measure-
ment of reading fluency), (b) proximal behavior (e.g.,
direct observation of student on-task behavior during
classroom instruction), (c) proximal attitude (e.g., self-
efficacy perceptions), (d) distal skill (e.g., standardized
achievement test focused on broad reading or math skills),
(e) distal behavior (e.g., teacher rating of academic ena-
blers), and (f) distal attitude (e.g., perceptions of school
safety). The specific academic indicator that is most rele-
vant for an individual student may vary as a function of
grade level as well as the type and focus of SMH pre-
vention or intervention activity. For example, proximal
skill indicators may be most relevant for students in early
elementary school grades who are struggling with basic
reading and math skills. Alternatively, distal behavior
measures may be preferred for older students who have
Table 1 Indicators of academic success
Skill (knowledge in specific areas) Behavior (behavioral engagement) Attitudes (affective engagement)
Individual student-level outcomes
Proximal Curriculum-based measurement,
e.g., of reading fluency
Direct observation of student on-
task behavior during instruction
Current perceptions of:
Academic self-efficacy
Achievement orientation
Belonging/connectedness
Distal Norm-referenced tests of broad
skills in math, reading, etc.
Course grades, including GPA
Informants’ global ratings of
academic competence
School attendance and truancy
ODRs and suspensions
Global ratings of academic
enablers, such as attention to task
and active class participation
General or global perceptions of:
School climate/safety
Support from teachers,
administrators, peers
School satisfaction
School-level outcomes
Annual performance
indicators
Performance on state-wide tests,
including % proficient overall
and across subgroups
Learning growth among all
students, subgroups, and in
specific classrooms
Post-secondary preparation,
including performance on
examinations relevant to college
admission, and credits earned in
accelerated courses (e.g., AP, IB,
dual enrollment)
Graduation and school completion
rates
Total ODRs, suspensions, fights,
and firearm incidences for school
overall and across subgroups
School attendance and truancy
rates
Participation rates in accelerated
courses, such as AP and IB
Aggregate perceptions of school
climate (safety, caring)
Aggregate perceptions of school
effectiveness
GPA grade point average, ODR office discipline referral, AP Advanced Placement, IB International Baccalaureate
School Mental Health
123
difficulties demonstrating their knowledge and under-
standing on a consistent basis presumably due to mental
health or behavioral challenges. In many cases, combina-
tions of measures across cells may be warranted to assess
intervention impact on multiple indicators of academic
functioning.
School-Level Indicators of Academic Success
New school accountability systems and requirements asso-
ciated with the enactment of The No Child Left Behind Act
of 2001 (NCLB; Pub. L. 107-110) have increased the focus
on school-level, as well as district-level, outcomes. Hence,
schools, districts, and in turn SMH are increasingly held
accountable for contributing to broader outcomes as cap-
tured by a number of school-level performance indicators
that mostly emphasize skills. Every public school and district
in the USA is assessed for adequate yearly progress (AYP).
The ultimate AYP accountability measure of school-level
success is the proportion of students who meet a certain
standard on predetermined state or province year-end diag-
nostic tests (Ross & Scott, 2012). School success, as such, is
defined as the proportion of students in the school who
achieved a certain level of the standard. For exampl e, schools
in Ohio need 80 % of students to reach ‘‘proficient’’ in key
areas such as third-grade reading level.
Other school-level performance indicators involve the
assessment of proficiency levels across identified subgroups
of the student population, including those defined by race/
ethnicity, limited English proficiency, economic status, gen-
der, and disability. Significant gaps and disproportionalities in
group-level performance on achievement tests serve as addi-
tional performance indicators for which schools and districts
are held accountable, and help ensure ‘‘no child is left
behind.’’ Schools are also increasingly accountable for dem-
onstrating learning growth among all students, especially
among those who are gifted and/or talented, or at-risk due to
disability status or low achievement. Teachers in some states
are assessed (and rewarded) based on the demonstrated
learning growth among students in their individual
classrooms.
Aside from documentation of growth in skills, important
behavioral indicators of school-level success include
school completion, or the earning of a degree and the
mastery of skills necessary for employability. Measures
might include four (and sometimes five)-year graduation
rates (Doll et al., 2012). Other school-level academic
behaviors include the assessment of active engagement in
school, as reflected by time spent in engaged learning
activities as measured by daily attendance and/or truancy
rates.
Regarding academic attitudes relevant at the school
level, systems are increasingly measuring indicators related
to a caring school climate, such as perceived school sup-
port, bullying incidences, and overall emotional and
physical safety (see Guerra-Lopez & Toker, 2012). Some
of these trends are tied to policy language in NCLB
requiring the identification of Persistently Dangerous
Schools (PDS). States are required to label unsafe schools
PDS based on the data such as the number of fights at the
school or the times firearms are brought to school.
Other school-level performance indicators of skills and
behaviors have emerged within different states to docu-
ment students’ preparation for post-secondary education.
Such indicators include performance on college admission
tests, involvement in dual enrollment courses which earn
high school and college credits simultaneously, participa-
tion and performance in Advanced Placement (AP) cour-
ses, and the number of honors diplomas awarded.
In the end, school performance on these indicators (sum-
marized in Table 1) is continuously assessed and monitored,
and schools are given annual report cards that reflect the
number of indicators ‘‘met’’ in a given period of time. In turn,
schools and districts are rewarded and punished (often with
more or less funding) based on their progress toward meeting
goals on various performance indicators and their state- or
province-appointed grades (Guerra-Lopez & Toker, 2012).
Schools also may be permanently closed or restructured if
performance on these indicators is lagging. Given the pres-
sures and consequences associated with these school-level
success indicators, SMH initiatives are increasingly held
accountable for supporting schools in achieving state-specific
goals, in addition to documenting progress on student-level
indicators among specific individual and groups of students
served through SMH.
Connections Between Student Mental Health
and Academic Success
A growing literature establishes links between academic
success (in individual students and in a given school) and
students’ social–emotional functioning. Evidence for the
inter-relatedness of students’ adjustment in these two
domains comes from observational studies of naturally
existing relationships between constructs, and intervention
studies that show changes in one area, such as academic
outcomes, follow changes in another, such as social–
emotional functioning. Both bodies of literature illustrate
the relevance of student mental health to schools.
Correlations Between Student Mental Health
and Academic Achievement
Abundant evidence supports the co-occurrence of risk
across psychological, social, and academic domains, such
School Mental Health
123
that students with problems in one area tend to simulta-
neously show problems in the other areas, whereas well-
adjusted children are defined by positive social and aca-
demic competence and minimal problems in terms of
externalizing or internalizing symptoms (Valdez, Lambert,
& Ialongo, 2011). Beyond such person-centered approa-
ches to understanding associations between these domains,
in the last decade, advances in developmental psychopa-
thology have illustrated the across-time associations
between student functioning in the academic, psychologi-
cal, and social domains. In these variable-centered
approaches, researchers have analyzed multiple waves of
data using nested structural models that control for baseline
levels of functioning and concurrent associations between
domains, and isolate cross-domain paths from one time
point to the next. Such cross-lagged panel models have
demonstrated developmental cascades, in which early dif-
ficulties in one domain (typically externalizing forms of
psychopathology) have far-reaching and large effects in
undermining another domain, such as academic
competence.
For example, Masten et al. (2005) illustrated that exter-
nalizing symptoms in the upper elementary school years
predicted worse distal academic skills in high school, which
persisted into late adolescence and, in turn, predicted more
internalizing symptoms in early adulthood. Such adjustment
erosion was replicated in a younger sample assessed at five
time points from ages 6–12, with academic competence
defined as distal behaviors (Moilanen, Shaw, & Maxwell,
2010). Moilanen et al. found that early externalizing
behavior (e.g., at age 6) predicted worse academic compe-
tence (i.e., less on-task, attentive, and diligent classroom
behavior) which, in turn, predicted more internalizing
behavior (age 10) as well as externalizing symptoms (ages 11
and 12). Both studies found these pathways were robust after
controlling for shared risk factors, namely student cognitive
ability, family SES, and parenting quality.
Subsequent research on developmental cascades inclu-
ded social adjustment. In addition to worse academic out-
comes, early externalizing problems also predicted worse
social functioning in terms of diminished competence (i.e.,
social skills; Burt & Roisman, 2010) and additional social
problems (i.e., peer victimization; van Lier, Vitaro, Barker,
Brendgen, Tremblay, & Boivin, 2012). The cascading
effect of initial externalizing symptoms to internalizing
problems later in youth occurred via reduced academic and
social competence at time points in between (Burt & Ro-
isman, 2010; Obradovic, Burt, & Masten, 2010). The
consistent finding that early behavior problems set the
stage for later challenges in both academic and social
competence is often referred to as a dual failure model of
consequences. Early symptoms and forms of externalizing
behaviors also predict more frequent and severe forms later
in youth, in part due to spiraling negative effects on
intermediary social (van Lier et al., 2012) and academic
(Defoe, Farrington, & Loeber, 2013) functioning.
This body of longitudinal research does not indicate a
causal effect of dimensionally assessed internalizing
symptoms on academic outcomes, after baseline levels of
social–emotional functioning are considered. Contradictory
findings have been limited to studies that did not control for
initial levels of academic performance. Instead, internal-
izing problems appear, in part, to be a direct (Defoe et al.,
2013) and indirect result of externalizing problems via the
cascading effect of the latter on social and academic
competence (van Lier et al., 2012). Although anxious and
depressive symptoms have appeared unlikely to exert a
unique influence on academic skills in general samples,
students with clinical levels of internalizing problems in
elementary school (Duchesne, Vitaro, Larose, & Tremblay,
2008) or high school (Fergusson & Woodward, 2002) have
been less likely to complete high school or seek post-sec-
ondary education.
Relative to the literature on the influence of psychopa-
thology on students’ achievement, less is known about the
predictive role of psychological well-being. One exception
involves a two-wave longitudinal study in which middle
school students’ mental health was examined using indi-
cators of both psychopathology (internalizing and exter-
nalizing symptoms) and subjective well-being (Suldo,
Thalji, & Ferron, 2011). Controlling for initial levels of
academic skills, higher subjective well-being predicted
better distal academic skills (GPA) the following year,
above and beyond the negative effect of externalizing
symptoms. Further, the students most at-risk for deterio-
ration in GPA were those with the combination of low
subjective well-being and elevated psychopathology,
underscoring the need to attend to both wellness and
problems.
Evidence SMH Interventions Improve Academic
Outcomes
Despite the primary academic goals of the intervention set-
ting, most SMH interventions are examined only in relation
to impact on social–emotional outcomes. Case in point, a
review of the 64 evaluations of school-based mental health
interventions published between 1990 and 2006 that used
strong designs found that only 24 studies (37.5 %) examined
intervention impact on any academic outcome, most com-
monly distal indicators of skills or behavior, such as atten-
dance (Hoagwood, Olin, Kerker, Kratochwill, Crowe, &
Saka, 2007). Most of these studies were universal programs
designed to prevent externalizing behaviors in young chil-
dren. Fifteen of the 24 interventions (62.5 %) evidenced
positive, but modest, effects on academic outcomes; most of
School Mental Health
123
these interventions were complex, intensive, and had mul-
tiple components (i.e., involved students, teachers, and par-
ents). This review revealed a dearth of interventions
targeting either adolescents or youth with internalizing
mental health problems.
More recently published evaluations of SMH services
ranging from preventive to therapeutic further illustrate that
improvements in social–emotional functioning are often
linked to student-level academic gains. Supporting the effi-
cacy of traditional student-focused SMH services, a meta-
analysis of 83 studies that examined the effectiveness of
psychotherapeutic interventions in relation to control groups
(using random assignment) found positive effects that were
significantly different from 0 across a range of academic
outcomes (Baskin, Slaten, Sorenson, Glover-Russell, &
Merson, 2010). Effects were small on distal indicators of
behavior (d=0.26) and skills (d=0.36), whereas the
medium effect on proximal attitudes (e.g., academic self-
efficacy, d=0.59) was similar to effects on mental health
(d=0.50). Similarly, Vidair et al. (2014) reviewed 23
studies of SMH intervention (published 2006–2012) that
targeted both mental health and academic outcomes and
found 91 % demonstrated some significant between-group
differences in academic outcome. Finally, Becker et al.’s
(2013) examination of the clinical treatment literature found
that only 14.5 % of the 592 youth mental health intervention
studies (conducted in schools and community settings)
published between 1966 and 2011 included at least one
educational outcome measure. In those studies, 83.3 % of
intervention groups outperformed a comparison group on an
academic outcome. When effectiveness was defined as sta-
tistically significant superior performance, this high success
rate was observed similarly across indicators of academic
skills and behavior.
Secondary preventative interventions with strong sup-
port for improving academic outcomes include those that
improve externalizing behavior, which is fortunate given
the developmental cascades phenomena which underscore
the importance of reducing behavior problems. For exam-
ple, First Steps to Success is associated with gains in distal
skills (i.e., teacher-rated academic competence) and prox-
imal behavior (i.e., academic engaged time; Sumi et al.,
2013; Walker et al., 2009) and sometimes even proximal
skills (i.e., Walker et al., 2009), but not in distal skills as
indicated by norm-referenced achievement tests (Sumi
et al., 2013). Other multicomponent interventions that
target behavioral improvements in students with attention-
deficit/hyperactivity disorder (ADHD) through combining
SMH with home-based services have yielded positive
effects on distal skills and proximal behavior (Pfiffner,
Villodas, Kaiser, Rooney, & McBurnett, 2013) and some
indicators of proximal skills (DuPaul, Kern, Gormley, &
Volpe, 2011).
The body of literature on the effectiveness of universal
prevention programs, specifically social–emotional learn-
ing (SEL) curricula, contains examples of positive effects
in academic domains in addition to the anticipated effects
on social–emotional competencies, positive social behav-
ior, and psychological functioning. A meta-analysis of 213
studies that examined outcomes of universal SEL programs
in multiple domains including academic performance
found that the 35 studies that assessed distal skills yielded a
significant, positive effect of SEL interventions on both
standardized tests of reading and math skills (ES =0.27)
and course grades (ES =0.33), effect sizes similar in
magnitude to the average effect sizes of educational
interventions (Durlak, Weissberg, Dymnicki, Taylor, &
Schellinger, 2011). The eight studies that examined the
long-term academic outcomes found the positive effects
persisted (ES =0.32) an average of 150 weeks later. Some
SEL programs also improve later academic outcomes by
interrupting the developmental cascade associated with
early externalizing problems. For example, the 4Rs Pro-
gram (Reading, Writing, Respect, and Resolution) has
found that elementary school students with elevated
aggressive behavior at baseline were particularly likely to
manifest gains in distal skills and behavior (Jones, Brown,
Hoglund, & Aber, 2010), and later improvements in the
social domain as well as in attention problems (Jones,
Brown, & Aber, 2011). Findings from such studies provide
promising evidence for the ability of universal mental
health interventions to disrupt the deleterious develop-
mental trajectory of students with externalizing problems,
and illustrate how positive changes in one domain can
impact other outcomes. It is also notable that the classroom
climate target of many SEL programs (e.g., RULER; Ha-
gelskamp, Brackett, Rivers, & Salovey, 2013) is consistent
with calls to proactively promote student mental health at
the universal level through improving the emotional quality
of the learning ecology (Doll et al., 2012).
Less is known about SMH in relation to its contribution
to school-level performance indicators. Most of the rele-
vant research has focused on the impact of school-wide
PBS. For instance, Simonsen et al. (2012) conducted a
longitudinal analysis of data from over 1,000 Illinois
schools implementing PBS, with significant variation in
implementation among schools. Over a 7-year period, PBS
schools evidenced improvements in levels of achievement
in reading, as well as reductions in ODRs. Schools
implementing PBS with fidelity also incurred increased
levels of proficiency in math, in addition to the anticipated
reductions in distal behavior indicators, namely ODRs and
out-of-school suspensions. Likewise, Horner et al. (2009)
documented positive effects on state-wide tests, including
improvements over time in the proportion of third-grade
students deemed proficient on the state reading standard
School Mental Health
123
among schools implementing PBS, and higher proficiency
rates among treatment schools compared to control
schools. Findings also indicated improvements in school-
level mean levels of distal attitudes (i.e., students’ sense of
safety) and behavior (i.e., reduced ODRs).
Additionally, some research points to the impact of PBS
and related SMH approaches on improving organizational
structure, as well as influencing teacher-related outcomes
such as teacher stress and efficacy (Ball & Anderson-
Butcher, in press; Bradshaw, Koth, Bevans, Ialongo, &
Leaf, 2008). Few studies, however, have assessed broader
school-level indicators, such as those related to achieve-
ment of students in certain subgroups for whom schools are
held accountable. In an exception, Duchnowski and Kutash
(2011) examined school reform activities and their impact
on students with emotional disturbances involved in special
education programs at schools. Secondary schools who
were highly engaged in school reform activities inclusive
of school-community partnership agendas had students
with emotional disabilities who obtained significantly
higher math achievement scores, were engaged in more
inclusive learning environments, and were more likely to
access mental health services offered by community prac-
titioners. Duchnowski and Kutash (2011) called for more
rigorous, intentional SMH designs and research that can
demonstrate contributions to broader school-level perfor-
mance indicators.
Bidirectional Relationship Between Academic
and Social–Emotional Outcomes
Although findings from the aforementioned studies docu-
ment that students’ mental health has a direct impact on
academic outcomes, this relationship is not unidirectional.
For example, Schwartz, Gorman, Duong and Nakamoto
(2008) reported that elementary school students’ GPA was
negatively correlated with depressive symptoms concur-
rently and 1 year later. Academic achievement also mod-
erated the relationship between social and psychological
outcomes such that as GPA at baseline increased, the
relationship between number of friends at baseline and
depressive symptoms a year later decreased and was non-
significant for those students with the highest GPAs. Evi-
dence that early academic ability predicts facets of mental
health includes Welsh, Nix, Blair, Bierman and Nelson’s
(2010) finding that emergent numeracy skills predicted
end-of-year executive functioning (i.e., attentional control)
among 164 Head Start students. As such, early academic
functioning may impact social and psychological domains
in a manner similar to the developmental cascades
described by Masten et al. (2005).
Academic failure can be a critical initiation point for
both proximal and distal deviant pathways. Proximally,
academic failure has been demonstrated to interact with
negative cognitions to predict depressive symptomatology
(Hilsman & Garber, 1995). Distally, academic difficulties
have been shown to predict poorer mental health, lower
SES, greater deviant behavior, and incarceration (Chen &
Kaplan, 2003; Sum, Khatiwada, & McLaughlin, 2009).
Taken together, the literature base indicates that the
relationship between academic and mental health func-
tioning is bidirectional, and changes in one domain can
predict changes in the other. Such data indicate the
importance of the continual monitoring of mental health
amidst the ever-evolving academic demands placed on
students, as such changes may have mental health conse-
quences for students. Similarly, interventions targeting
both academic and mental health goals may be more
effective and efficient relative to stand-alone programs.
Current and Future Directions of SMH Research Foci
The growing empirical support for the positive academic
outcomes associated with SMH prevention and interven-
tion programs provides SMH professionals with data to
reference when advocating for the value of relevant
resource expenditures. Researchers can further strengthen
the rationale for SMH services by attending to (a) school-
level indicators of academic success, (b) subgroups of
students in need of additional SMH supports, and (c) how
SMH professionals can work collaboratively to optimize
access to and positive outcomes of SMH services.
Assess, Demonstrate, and Communicate Impact
of SMH Services on School-Level Success
The preceding literature emphasizes positive effects of
SMH on student-level outcomes, because those indicators
have been included more often in research studies. We
expect that SMH services also help ensure (a) school
success with meeting AYP, (b) growth among all students
and reductions in disparities and disproportionalities
among at-risk subgroups, (c) completion of high school and
increased engagement along the way, (d) preparation for
post-secondary education, and (e) school-level safety, cli-
mate, and affect. However, evidence of such positive out-
comes is lacking because potential indicators of school-
level success are rarely examined.
Evidence of positive student-level academic outcomes
also contributes to the accountability provisions of NCLB,
which are considered across all students within the school.
As such, each student’s academic proficiency should also
School Mental Health
123
be viewed as a contribution to the school community as a
whole. The aforementioned literature established that stu-
dents with mental health problems underperform academ-
ically (Burt & Roisman, 2010; Moilanen et al., 2010).
Approximately half of the students meeting diagnostic
criteria for a mental health disorder will not receive treat-
ment for such (Merikangas et al., 2010). Mental health
services are vital to helping students gain access to
instructional opportunities; removal of barriers to learning
serves to improve students’ academic proficiency and aid
the school in making AYP. Later, we discuss specific
subgroups of at-risk students whose mental health warrants
particular attention. Beyond these groups with elevated risk
for social and emotional challenges, subgroups of students
who have fallen behind academically in core subject areas
are also highly relevant. The supplemental supports put in
place for students identified as a grade level or more behind
in reading, math, etc., are predominantly academic in
nature. But given the bidirectional relationship between
academic and social–emotional functioning, SMH strate-
gies may also be beneficial. Research is needed on the
specific impact of SMH on the students that schools are not
serving well academically but for whom they are
accountable (e.g., value added). Educators may be more
supportive of SMH initiatives in their building pending
evidence that such services help schools with their
accountability standards under NCLB.
In sum, in the effort to meet school-wide annual per-
formance indicators, SMH interventions become important
tools that can be implemented by schools. Key findings
from the intervention literature reviewed earlier demon-
strate the utility of SMH interventions at improving aca-
demic outcomes. Those studies whose outcome indicators
include state-wide accountability tests facilitate translation
of findings into terms more easily grasped by administra-
tive stakeholders. For example, Fleming, Haggerty, Cata-
lano, Harachi, Mazza, and Gruman (2005) found that
students with higher scores on social and behavioral
characteristics targeted by SEL programs (e.g., social and
problem-solving skills and positive school environment)
scored higher on the Washington Assessment of Student
Learning (WASL). Conversely, higher levels of substance
use, attention problems, depression, and antisocial behavior
were associated with lower WASL scores. The aforemen-
tioned meta-analysis of school-based universal interven-
tions found that students who have participated in an SEL
program experienced an 11-percentile-point advantage in
achievement scores relative to students who did not receive
such programming (Durlak et al., 2011). Similarly, in a
2008 report on the academic and social impact of SEL
programs for school-aged children based on 317 studies
(N=324,303), Payton and colleagues reported that uni-
versal programs benefited students of different ages, across
different school settings (i.e., urban, suburban, and rural)
and for schools with diverse student bodies. Targeted
interventions were also successful at increasing academic
outcomes with a 17-percentile-point gain in achievement
test scores representing an effect size of approximately
0.50 (Payton et al., 2008).
The results of this literature highlight the role of SMH
interventions, specifically school-wide programs, as
mechanisms for improving student academic outcomes and
subsequently helping schools meet their federal and state
accountability standards. There are numerous effective
SMH programs available that have a relatively high return-
on-investment and have demonstrated improvement on
academic achievement (for review see Greenberg, Domi-
trovich, & Bumbarger, 2000; Vidair et al., 2014). When
applied within a comprehensive system of support
[American Academy of Pediatrics (AAP), 2004] in line
with a public health model of service delivery, such pre-
vention and intervention programs should improve the
social–emotional functioning of all students in a given
school. In turn, the school should see improved engage-
ment and ultimately higher proficiency on high-stakes tests
and increased graduation rates.
Address the Mental Health Needs of Subgroups
of Students Historically Neglected
Beyond a school’s average performance, individual stu-
dents’ outcomes still matter, and schools can be repri-
manded for not serving all students in an effective manner
with minimal disparities between groups. Further, out-
comes valuable to a student or family may differ from the
accountability focus of administrators and legislators.
Thus, it is important to address the specific needs of sub-
groups of students who are at higher than average risk for
compromised mental health functioning and/or whose
emotional needs may be underserved in schools.
Students with Pediatric Health Issues
Approximately 1 in 6 children and adolescents have a chronic
physical health condition such as asthma, diabetes, or epilepsy
(van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa,
2007). These students may be at elevated risk for emotional/
behavioral difficulties (Pinquart & Shen, 2011a)aswellasfor
compromised academic achievement and social functioning
(Pinquart & Teubert, 2012). For each outcome type, risk level
varies as a function of health condition and student demo-
graphic feature (e.g., age, gender). For example, Pinquart and
Teubert’s meta-analysis of 954 studies (N=104,867) found
children with cerebral palsy, spina bifida, and sickle cell dis-
ease demonstrated the greatest academic impairment. Pinqu-
art and Shen (2011a) found internalizing disorder symptoms
School Mental Health
123
were most prominent for students with chronic fatigue syn-
drome, whereas elevated risk for externalizing disorder
problems was found for youth (particularly boys) with epi-
lepsy, migraine/tension headache, visual impairment, hearing
impairment, and spina bifida.Due to the elevatedrisk for, and
negative outcomes associated with, depression (Pinquart &
Shen, 2011b), systematic screening for depression and sui-
cidal ideation may be warranted for adolescents with chronic
physical illness (Greydanus,Patel, & Pratt, 2010). On the basis
of their meta-analytic findings, Pinquart and Shen (2011a)
recommended that all students with chronic physical health
conditions should be regularly screened for psychological
distress throughout development.
Students with Internalizing Disorders
A nationally representative study of 10,000 adolescents (ages
13–18) found that approximately 14 and 32 % had a mood or
anxiety disorder, respectively, at some point during youth
(Merikangas et al., 2010). Whereas 45–60 % of youth with
behavior disorders received clinical services, only 18 and
38 % of youth with an anxiety disorder or any mood disorder,
respectively, received any mental health treatment for their
diagnosis (Merikangas, et al., 2011). Merikangas et al. (2011)
found that youth with internalizing disorders are even
underrepresented in SMH care, which is particularly unfor-
tunate given that a recent meta-analysis of 63 studies
(N=15,211) supports that both depression and anxiety dis-
orders can be treated in schools effectively using cognitive–
behavioral interventions traditionally delivered in clinical or
research settings (Mychailyszyn, Brodman, Read, & Kendall,
2012). Future research should target the classroom (e.g., Doll
et al., 2012) or school (e.g., Herman, Reinke, Parkin, Traylor,
&Agarwal,2009) as a primary intervention setting, and dis-
cern effective strategies to identify those students who would
benefit for more intensive, student-focused intervention.
Asking teachers to nominate which of their students demon-
strate the most symptoms of anxiety or depression has indi-
cated low to moderate sensitivity (Auger, 2004). Although
school-wide screening may catch more symptomatic students,
feasibility is compromised by concerns related to cost, pri-
vacy, stigma, and adequate resources for further assessment
and treatment (Center for Mental Health in Schools, 2005).
Sexual Minority Students
Lesbian, gay, bisexual, and transgender (LGBT) students
are at increased risk for school-based verbal and physical
victimization, lack of school support, peer rejection, low
self-esteem, depression, suicide, substance use, and school
dropout relative to heterosexual peers (Robinson & Espe-
lage, 2011). Many studies have treated LGBT students as a
homogeneous population when such characterization may
not be warranted. For instance, Russell, Seif, and Truong’s
(2001) analysis of the National Longitudinal Study of
Adolescent Health (N[11,000 adolescents in the USA)
indicated differential academic and social impacts on LGB
students based on the student gender and sexual orientation
(e.g., relative to heterosexual students, lower GPAs among
bisexual but not homosexual students; homosexual
females, but not males, perceived less social support from
peers and adults). Supports for LGBT students that have
been found effective at improving outcomes include the
implementation of a gay-straight alliance (GSA) within the
school, supportive faculty members, inclusive curriculums,
and a comprehensive anti-bullying program within the
school (Kosciw, Palmer, Kull & Greytak, 2013; Murphy,
2012). In line with Kosciw et al.’s finding that supportive
faculty members emerged as the strongest predictor of
positive outcomes for LGBT students, future research to
develop interventions targeting teachers’ support of LGBT
students may be of primary importance,
Students who are Racial and Ethnic Minorities
The increased risk for mental health disorders faced by
racial and ethnic minority children has been attributed to
environmental stressors, overt and covert discrimination,
social risk factors, parental expectations, and problem
perception and issues surrounding cultural identity
(Anderson & Mayes, 2010). Although children who are
racial or ethnic minorities are less likely to receive clinic-
based services relative to their Caucasian peers (Cook,
Barry & Busch, 2012), Cummings, Ponce, and Mays
(2010) found no differences between racial and ethnic
groups in school-based mental health services over a 1-year
period. The equal utilization of mental health services is
likely due to the removal of many treatment barriers
including transportation, stigma, and fee (AAP, 2004).
Research regarding SMH interventions for racial and eth-
nic minority students indicates a gap in the literature on
effective treatments. Huey and Polo’s (2008) review of
evidence-based treatments found a lack of well-established
interventions for minority youth, but several probably
efficacious and possibly efficacious treatments for a range
of mental health difficulties (e.g., ADHD, depression,
substance use). Notable given the higher poverty rates
among many minority groups, Farahmand, Grant, Polo,
Duffy, and Dubois’ (2011) review of research with low-
income, urban youth found promising effects of SMH
programs that focused on internalizing symptoms or
social–emotional competence, but uncovered a much
smaller overall positive effect size of SMH interventions
than had been suggested previously (i.e., Rones & Hoag-
wood, 2000), and negative effects of programs for exter-
nalizing problems. Future research should investigate the
School Mental Health
123
academic outcomes of ethnic minority students participat-
ing in universal or targeted SMH interventions, and
develop efficacious targeted interventions for economically
disadvantaged students.
High-Achieving Populations in Accelerated and Rigorous
Curricula
Little attention has been directed toward the social–emo-
tional experiences of students with acceptable or high
levels of achievement, following an assumption that the
absence of distress is sufficient. This disease model is
contrasted with the goals of positive psychology, which
include fostering excellence, including intellectual ability
and exceptional academic performance, as well as institu-
tions (e.g., educational contexts) associated with optimal
outcomes (Seligman & Csikszentmihalyi, 2000). One rel-
evant (and growing) population is high school students
pursuing accelerated coursework, such as AP and Interna-
tional Baccalaureate (IB) courses. Supporting the mental
health of high-achieving students is consistent with build-
ing the intellectual capital vital to our society and also
warranted by consistent findings that students in AP and IB
have significantly higher level of general stress than their
peers in general education (Suldo & Shaunessy-Dedrick,
2013). The effect of stress in high-achieving students is
understudied. Suldo et al.’s (2009) preliminary research
identified inverse links between IB students’ mental health
and academic stressors and found that IB students appeared
particularly sensitive to manifesting adverse psychological
and academic outcomes as stressors increased. Despite the
elevated stress, AP and IB students, on average, report
similar or better psychological outcomes compared with
their peers in general education, and attain exceptionally
high academic outcomes across indicators of skills,
behavior, and attitudes (Suldo & Shaunessy-Dedrick,
2013). Further study of this group affords a unique
opportunity to discover protective and promotive factors,
such as adaptive strategies for coping with academic
stressors (Suldo, Shaunessy, Michalowski, & Shaffer,
2008) that may inform the development of mental health
supports and further foster academic excellence.
Interdisciplinary Investments in Supporting Student
and School-Level Outcomes
The impact of SMH initiatives on student- and school-level
outcomes is often dependent upon the partnerships among
the various stakeholders. More research is needed to
explore the collective contributions of interprofessional
collaboration and school–family–community partnerships
on student outcomes. More specifically, the extent to which
the dual outcomes of academic learning and mental health
occur is dependent upon the involvement of multiple
stakeholders and entities. Professionals from various dis-
ciplines (e.g., psychology, social work, education, and
nursing) are involved in SMH implementation efforts, and
ultimately work together on behalf of students and schools.
There is a common belief that these partnerships among
organizations and relationships among people involved in
SMH ultimately contribute to improved student- and
school-level outcomes. Little research, however, exists to
demonstrate this case (Mellin & Weist, 2011).
Some research has documented initial outcomes related
to partnership agendas. For instance, Ellis et al. (2012) used
growth curve models to estimate improvements among
1,165 schools involved in the national Safe Schools/Heal-
thy Students Initiative (SS/HS), a federal grantee program
focused on promoting school safety, student health and
well-being, and academic achievement. Indicators of
partnership functioning were among the significant pre-
dictors of stakeholders’ perceptions of initiative impact on
school-wide substance use prevention. Derzon et al.’s
(2012) study of student-level outcomes associated with SS/
HS implementation by 57 grantees suggested that student
perceptions of violence risk were in part affected by vari-
ability between grantees in partnership variables, such as
number of partners involved in the initiative and valuing of
partners’ contributions.
There is also some support for the value of coordination
of mental health services in schools. For instance, Puddy,
Roberts, Vernberg, and Hambrick (2012) retrospectively
examined 1 year of case records for students with serious
emotional disturbances who received comprehensive
school-based interventions. They systematically coded
service coordination activities by type (e.g., status update
and sharing of information) and frequency, and level of
overall progress updates/communications. Findings indi-
cated that the frequency and quality of service coordination
predicted improved adaptive functioning and reduced dis-
ruptive behaviors.
In general, there has been an increased prioritization of
comprehensive SMH and school reform strategies to sup-
port student outcomes. Some of these approaches include
Comer School Development Program (Cook, Murphy, &
Hunt, 2000), Coordinated School Health Programs pro-
moted by the Centers for Disease Control and Prevention,
Adelman and Taylor’s (1999) interconnected system
framework, full service and community schools (Dryfoos,
1994), and the Community Collaboration Model (Ander-
son-Butcher et al., 2008). All approaches embed some
element of school–family–community partnership and
system engineering that includes a focused pathway on
SMH.
SMH research has begun to detail challenges related to
school–family–community partnerships and interdisciplinary
School Mental Health
123
practice in support of student- and school-level outcomes.
Challenges such as turf, different theoretical approaches
and language discourse, working in teams, and relation-
ships have been found (Mellin & Weist, 2011; Rones &
Hoagwood, 2000). Despite these barriers, findings from
focus groups suggest that collaboration results in improved
social capital and professional support, improved access
and service delivery consistency, and the addition of
resources for schools. More research is needed to fully
ascertain the added value of partnerships and levels of
collaboration on student- and school-level outcomes.
Implications for Research and Practice
One of the most pressing issues in connecting SMH
research to what is valued by schools pertains to the basic
issue of determining how to define student success. We
advanced a framework for defining academic success
broadly in order to encourage researchers to consider atti-
tudes, behaviors, and skills that may reflect success within
a given student and at the school level. The potential
impact of SMH prevention/intervention strategies on stu-
dent success can and should be assessed in multiple ways.
Findings from intervention outcome studies and meta-
analyses indicate that there may be a continuum of effects
with the strongest impact on academic attitudes and
behaviors (proximal followed by distal), then for proximal
skill indices (although assessed in very few studies), and
weakest for distal skill measures. For example, the greatest
impact of the First Steps to Success program was found for
proximal (i.e., academic engaged time) and distal (i.e.,
teacher ratings of behavior and social skills) measures of
academic-related behaviors (Walker et al., 2009). In the
subsequent effectiveness trial of First Steps to Success
(Sumi et al., 2013), small but statistically significant
improvements were found for CBM oral reading fluency
(i.e., proximal skill measure) but not for performance on a
norm-referenced standardized achievement test (i.e., distal
skill measure). As another example, Baskin et al.’s (2010)
meta-analysis on the impact of psychotherapy on academic
outcomes yielded the strongest effects on proximal atti-
tudes, while smaller effect sizes were obtained for most
indicators of distal skills and behavior (e.g., ODRs,
achievement tests).
There are several reasons why SMH prevention/inter-
vention primarily impacts academic attitudes and behaviors
that are most proximal to the learning (and intervention)
environment. First, one of the major objectives of SMH
services is to reduce barriers to learning and increase
opportunities for academic engagement. Thus, it is not
surprising that the most immediate intervention impact will
be seen for proximal and distal behavior measures given
that the most prominent barriers to learning will be
behavioral for the majority of students. For example, the
clear association between student externalizing problems
and academic adjustment is more evident for adaptive
classroom behaviors (e.g., Moilanen et al., 2010) than for
skill assessments (e.g., Burt & Roisman, 2010). This
implies that SMH prevention/intervention impact on aca-
demic success is mediated by improvements in academic-
related behaviors. It is also possible that SMH prevention
and intervention effects on distal skill performance could
take more time (i.e., to promote skill development) and
would require longer-term intervention and/or follow-up
assessment (Sumi et al., 2013). Finally, variation in psy-
chometric properties across measures could account for
differential intervention impact. For example, norm-refer-
enced achievement test scores are typically more stable
over time than are proximal skill assessments like CBM
probes or even grades earned in different courses (e.g.,
Suldo, Thalji, & Ferron, 2011).
Student success also involves a balance of student- and
school-level considerations. To date, most of the research
in SMH has focused primarily on student-level outcomes at
the individual and/or small group level. Research on the
impact of SMH to school-level performance indicators is
less clear, and in turn, the contributions of SMH to school
functioning and overall success are not well understood. As
previously described, schools are held increasingly
accountable for their performance on key indicators such as
proficiency, growth, school completion, performance of
targeted groups of students, and disparities and dispropor-
tionalities among subgroups. Implications of this reality
and other literature reviewed in this paper include
•Continue to examine the impact of SMH on proximal
and distal indicators, particularly student-level atti-
tudes, behaviors, and skills. Document importance of
different SMH approaches on these student-level aca-
demic outcomes. Continue to identify evidence-based
practices that contribute to academic outcomes, partic-
ularly among subgroups of students historically
neglected in such research but who may benefit from
SMH supports due to their risk for compromised mental
health.
•Keep in mind the student-level outcomes valuable to
the ultimate consumers of successful education: fam-
ilies and communities. Collect data and report out-
comes of SMH interventions in relation to students’
social–emotional success, i.e., qualities of productive
citizens. SMH researchers should include brief indica-
tors of well-being that assess quality of life (e.g., life
satisfaction) and social competence. More research is
needed on the academic outcomes associated with
School Mental Health
123
interventions intended to foster well-being, such as life
satisfaction and positive emotions.
•Examine the contributions of SMH to broader school-
level outcomes, performance indicators that administra-
tive stakeholders may ultimately be most focused on in
relation to results. Future research should document the
contributions of SMH to broader school-level perfor-
mance indicators such as proficiency on state-wide tests;
student growth and learning; significant gaps and
disparities across subgroups; school completion and
engagement; post-secondary education preparation; and
school-level safety, climate, and affect. Also, consider
the possible secondary benefits of successful SMH
initiatives on other desirable school targets, such as
increased teacher efficacy and decreased teacher stress
(Ball & Anderson-Butcher, in press).
•In examining the impact of SMH prevention and
intervention programs on student and/or school-level
academic outcomes, explicitly examine path models
that test the potential role of academic attitudes and
behaviors (e.g., engagement) in mediating intervention
effects on longer-term educational knowledge and
skills.
•Researchers developing and testing SMH interventions
should align their intervention components and designs
with school reform strategies, such as focus on
subgroups, site-based management, use of scientifically
based curriculum, parent involvement, focus on inclu-
sion, school-wide planning, scripted lessons, instruc-
tion, use of data to guide teaching and instruction,
parent involvement, and service utilization of commu-
nity mental health (Duchnowski & Kutash, 2011).
•SMH services at a particular school should align with a
public health model to mental health promotion,
targeting systems most likely to have the broadest
impact (e.g., class-wide and school-wide interventions),
at the critical developmental periods (e.g., early child-
hood), and provide additional supports targeting the
most critical problems that undermine future function-
ing (e.g., externalizing behavior problems, anxiety).
•Multiple stakeholders, academic disciplines, and orga-
nizations contribute to SMH research and practice.
Consideration should be placed on the interdisciplinary
nature of the work, and on the importance of school–
family–community partnerships in promoting SMH and
its value in schools. Ball, Anderson-Butcher, Mellin,
and Green (2010) identified a common set of SMH
competencies in areas such as key policies and laws;
interdisciplinary and cross-system collaboration; the
provision of academic, social–emotional, and behav-
ioral learning supports; and data-driven decision mak-
ing. More research is needed to demonstrate the value
of this interdisciplinary work.
•The collaborative work of applied disciplines should be
informed by the ongoing research findings from
psychology, social work, school counseling, teaching
and learning, and educational policy and leadership,
which shed light on the domains, social settings, and
developmental stages to be targeted in order to
maximize likely benefits as a consequence of resource
allocation.
•Researcher–school partnerships should incorporate an
implementation science approach as essential to the
process of translating evidence-based interventions into
school context (Forman et al., 2013), and understand the
fit between these interventions and the organizational
structure of schools (Hoagwood & Johnson, 2003).
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