School Psychology Quarterly © 2015 American Psychological Association

2015, Vol. 30, No. 2, 159 –165 1045-3830/15/$12.00 http://dx.doi.org/10.1037/spq0000118

Understanding Mental Health Intervention and Assessment Within a

Multi-Tiered Framework: Contemporary Science,
Practice, and Policy

Stephen P. Kilgus and Wendy M. Reinke Shane R. Jimerson

University of Missouri University of California-Santa Barbara
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

This special topic section features research regarding practices that will support mental
This document is copyrighted by the American Psychological Association or one of its allied publishers.

health service delivery within a school-based multitiered framework. The articles

include data and discussions regarding the evaluation of universal, targeted, or inten-
sive intervention addressing mental health concerns and assessment tools intended for
use in screening, progress monitoring, or problem identification. The featured inter-
ventions and assessment practices are suitable for use within a service delivery model
that prioritizes ecological theory, data-based decision making, and problem solving
logic. Each article includes a conceptualization of how the intervention/assessment of
interest fits into a school-based multitiered framework and information about feasibility
and utility of the practice in school-based settings. These articles highlight the use of
mental health intervention and assessment within a multitiered problem-solving frame-
work, and will hopefully stimulate interest in and further scholarship on this important
topic.

Keywords: assessment, intervention, mental health, multitiered framework, prevention

Federal and state legislation (e.g., Individ- idence base supports each intervention and
uals with Disabilities Education Improvement assessment within a prescribed role. Each
Act, 2004), calls from professional organiza- method also possesses characteristics that
tions (National Association of School Psy- permit its application within a prevention-
chologists, 2002), and emerging lines of oriented multitiered systems of support
scholarship have resulted in increasing atten- (MTSS) founded on ecological theory, prob-
tion toward multitiered frameworks of service lem solving logic, and data-based decision
delivery (Jimerson, Burns, & VanDerHeyden, making.
2007, 2015). Research has yielded numerous Decades of research have generated support
strategies and tools that form the foundation for MTSS frameworks as comprehensive mod-
of each service delivery tier, including uni- els of service delivery across two primary do-
versal prevention strategies, targeted and in- mains: academics and social behavior (Barnett,
tensive interventions, and assessment meth- Eber, & Weist, 2013; Bradshaw, Reinke,
ods suitable for use in screening, progress Brown, Bevans, & Leaf, 2008; Fixsen & Blase,
monitoring, or problem identification. An ev- 2008; Jimerson et al., 2007, 2015; VanDerHey-
den, Witt, & Gilbertson, 2007). Though MTSS
frameworks, such as Positive Behavioral Inter-
ventions and Supports (PBIS), have demon-
Stephen P. Kilgus and Wendy M. Reinke, Department of strated relevance to social behavior concerns
Educational, School, and Counseling Psychology, Univer- (e.g., externalizing problems, attention difficul-
sity of Missouri; Shane R. Jimerson, Department of Coun-
seling, Clinical, and School Psychology, University of Cal- ties), research has not yielded recommendations
ifornia-Santa Barbara. for MTSS frameworks targeting internalizing
Correspondence concerning this article should be ad- problems associated with disturbances in emo-
dressed to Stephen P. Kilgus, Department of Educational,
School, and Counseling Psychology, University of Mis-
tion and mood (e.g., depression, anxiety; McIn-
souri, 16 Hill Hall, Columbia, MO 65211. E-mail: tosh, Ty, & Miller, 2014). This is an important
[email protected] area for further emphasis and empirical evi-
159
 160 KILGUS, REINKE, AND JIMERSON

dence, as although treatment of internalizing and cueing of pro-social behavior); teaching

problems, such as depression and anxiety, has strategies intend to promote instruction of im-
historically been considered beyond the portant yet previously unlearned skills (e.g., fol-
school’s purview and the domain of outside lowing the principles of direct instruction); and
professionals (Chafouleas, Kilgus, & Wallach, consequence strategies are implemented to re-
2010), repeated calls have been made for duce the inappropriate responses and increase
schools to participate in their prevention, early appropriate responses (e.g., via performance
identification, and early intervention (National feedback, planned ignoring, positive reinforce-
Research Council and Institute of Medicine, ment). Each strategy targets variables that are
2009; The White House, Office of the Press highly malleable, in that intervention might lead
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Secretary, 2013). to rapid growth (e.g., within academics) or even

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Some have suggested PBIS might be ex- immediate level change (e.g., within social be-
panded to address internalizing problems (Her- havior). Such variables are readily observable
man, Merrell, Reinke, & Tucker, 2004; Lane, within the school context, and might be repeat-
Wehby, Robertson, & Rogers, 2007; McIntosh edly measured over time to allow for documen-
et al., 2014). For instance, the Interconnected tation of an effect on both short- (e.g., days,
Systems Framework (ISF; Barnett et al., 2013) within a day) and long-term scales (e.g., weeks,
has been proposed as a means through which to months).
integrate PBIS and a School Mental Health ap- In contrast, frameworks used to intervene on
proach toward the targeting of a broader array internalizing problems are commonly founded
of mental health concerns, including those re- on a medical model (Sheridan & Gutkin, 2000).
lated to social behavior and internalizing behav- Student problems are equivalent to individual
ior. Whether done through PBIS, ISF, or some pathologies, which represent one’s limited ca-
alternative approach, it is clear that work is pacity to respond appropriately to environmen-
needed to identify how best to meet student
tal stimuli. As recently reviewed by McIntosh et
internalizing problems through a MTSS frame-
al. (2014), the Lonigan and Vasey (2009) model
work.
of internalizing problem development reflects
this medical/pathological approach. The model
Conceptual Discrepancies specifies that a pattern of negative affectivity
Several explanations for limited research re- can lead to an individual’s enhanced focus on
garding MTSS frameworks and internalizing stressful stimuli within the environment. Thus,
problems may be posed. Chief among these is mitigation of this maladaptive pattern is through
the difference in problem conceptualization the individual’s use of effortful control to direct
across MTSS approaches and common service his or her focus away from the stressors and to
delivery frameworks targeting internalizing other more positive stimuli. The Lonigan and
problems. MTSS frameworks, including those Vasey (2009) model, along with others, stresses
targeting either academics or social behavior, the role of the individual in both causing inter-
are founded upon an ecological-behavioral nalizing problems and supporting their amelio-
model (Daly, Witt, Martens, & Dool, 1997; ration. Interventions designed in accordance
Poncy, McCallum, & Schmitt, 2010; Sheridan with such an approach focus less on environ-
& Gutkin, 2000). Within this model, problems mental manipulation and more so on teaching
are defined as discordance between the child’s students the skills required to function within
needs and available environmental supports. their current circumstances. Educators would
Students are supported via removal of this dis- look to affect change through use of group- and
cordance, with educators manipulating the en- individual-level treatments intended to promote
vironment to promote learning and exhibition of coping skills and social-emotional competence
key behaviors and skills. For both academics (Herman et al., 2004). The extent to which such
and social behavior, this environmental manip- treatments are effective is commonly evaluated
ulation takes three forms. Antecedent strategies through measurement of teacher, parent, or stu-
aim to prevent inappropriate responses and oc- dent self-reports of symptomatology. Such re-
casion appropriate ones (e.g., via provision of ports correspond to subjective perceptions of
instructional level academic tasks, prompting attitudes, cognitions, and feelings that are not as
 MENTAL HEALTH WITHIN A MULTI-TIERED FRAMEWORK 161

observable as those variables targeted within versal intervention strategies, early screening
MTSS frameworks. identification methods, targeted intervention,
Despite the historical disparities between the and progress monitoring tools that can benefit
MTSS and traditional approaches to internaliz- students in need of mental health supports, in-
ing problems, some have called for increasing cluding internalizing problems within a multit-
incorporation of ecological elements of MTSS iered framework.
models into traditionally pathologically ori- In the first article, Cook et al. (2015) examine
ented internalizing problem frameworks. Weist the use of evidence-based universal practices to
and Murray (2008) indicated school mental reduce mental health problems in children. Re-
health service delivery should not only look to searchers have made recent calls for research in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

train and promote emotional resilience and cop- the area of developing and evaluating integrated
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ing skills, but also enhance environments to models of school-based mental health preven-
support student display of these skills. Herman tion that target various risk and protective fac-
et al. (2004) formalized such an approach, de- tors into a single program that has the potential
scribing a multitiered social-ecological model to produce better outcomes than a single pro-
of depression prevention, focusing on the role gram in isolation (Domitrovich et al., 2010;
of not just the individual, but also sociocultural Herman et al., 2004; Reinke, Herman, & Ia-
structures and psychosocial environmental fac- longo, 2012). Cook and colleagues take on this
tors in contributing to depressive symptoms. call by examining the independent and com-
The model further emphasizes the role of the bined effects of two widely adopted universal
school context in fostering emotional health of prevention oriented approaches, Positive Be-
students, suggesting the school environment is havior Interventions and Supports (PBIS) and
an important target of intervention. A cogni- Social Emotional Learning (SEL), on student
tive– behavioral approach is used in teaching mental health outcomes. This study was an ini-
students coping skills, while educators also in-
tial evaluation of the impact, acceptability, and
corporate antecedent and consequence strate-
integrity of integrating the Strong Kids (Merrell
gies intended to support the display of such
et al., 2007) universal SEL curriculum and a
skills. Herman and colleagues further suggested
class-wide version of PBIS in eight 4th and 5th
ecologically oriented assessment for internaliz-
ing problems ought to target observable and grade classrooms on students’ mental health
measurable outcomes, including (a) attendance, outcomes. A quasi-randomized control research
trips to the nurse, and universal screening scores design was implemented to examine the iso-
at the systems level, and (b) social participation, lated and combined effects of PBIS and SEL.
academic engagement, and productivity at the The findings were promising as the combined
individual level. intervention produced significant change in
teacher reports of student externalizing and in-
Articles Featured in This Special ternalizing problems in comparison with either
Topic Section approach in isolation. In addition, the added
value of combining PBIS and SEL was evi-
Herman and colleagues’ (2004) multitiered denced by significantly greater change from pre
social-ecological model provides a promising to post in teacher-reported externalizing prob-
approach to increasing the capacity of schools lems for students in the combined condition in
to support students with mental health problems comparison with SEL and PBIS only condi-
crossing both externalizing and internalizing tions. Further, the combined approach was im-
domains. However, further research is needed to plemented with acceptable levels of treatment
identify the specific systems and practices that integrity and teachers reported that it was fea-
will allow schools to build capacity for appro- sible to implement and mutually beneficial for
priate identification and support related to men- both teacher and students, demonstrating the
tal health challenges among youth. Articles practical possibility of using this combined ap-
within this special topic section reflect contem- proach to universal prevention in schools.
porary science with regard to innovation in in- The second group of articles examines the
tervention and assessment with an emphasis on use of universal screening to accurately identify
systematically developing and evaluating uni- students who would benefit from additional
 162 KILGUS, REINKE, AND JIMERSON

supports. Accurate and early identification of no student is overlooked who might benefit
student with mental health concerns within a from emotional and behavioral supports.
tiered model of support could greatly decrease Stormont et al. (2015) offer an innovative
the number of youth who currently receive no perspective on universal screening in which
services for their mental health problems. Fur- they examine the accuracy of a single-item
thermore, early identification of risk allows for school readiness screener in Kindergarten
schools to intervene and prevent or ameliorate among a diverse low-income sample. Given the
risks, altering potential negative life trajectories association between early academic and social
of youth (Coie & Jacobs, 1993; Kellam & Re- problems and later school failure, externalizing
bok, 1992). The article by Miller and colleagues problems, and depressive symptoms, identify-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

(2015) reports the results of a comparison of ing students at risk early can be beneficial in
This document is copyrighted by the American Psychological Association or one of its allied publishers.

broad methods used by teachers in social, emo- providing needed supports to prevent these
tional, and behavioral screening to elucidate problems (Herman, Lambert, Reinke, & Ialongo,
information about the appropriateness, technical 2008; Reinke, Herman, Petras, & Ialongo, 2008).
adequacy, and usability of these measures in This study evaluated the predictive utility of sin-
identifying students with mental health con- gle-item measures of school readiness adminis-
cerns. This study compared a number of screen- tered at school entry on academic and mental
ing measures, including teacher ratings, teacher health indicators at the end of the school year.
nomination, and office discipline referrals to Findings indicated that the single-item mea-
determine differences in classification accuracy sures of academic readiness and behavior read-
between measures. Disparate findings were iness were predictive of end of year standard-
found across measures, indicating the impor- ized academic achievement, teacher report of
tance for schools to consider the aims of assess- internalizing problems and disruptive behavior,
ment, domains of interest, and the feasibility of and observed levels of disruptive behavior.
Having brief feasible screening options within a
the measure within a multitiered model. There-
tiered model of support that teachers can use
fore, schools planning to initiate universal
with all students, particularly at salient devel-
screening should determine the key indicators
opmental periods such as school entry, could be
of risk for the domains they intend to provide
useful in early identification and intervention to
targeted and intensive supports and map valid, ameliorate risk and prevent later negative aca-
accurate, feasible measures onto the domains. demic, social behavioral, and emotional out-
In ongoing efforts to identify students who comes.
may be underserved, the Eklund, Tanner, Stole, Once students are identified as at-risk for social
and Anway (2015) study examined differences behavioral or emotional problems, effective tar-
in the identification of mental health concerns geted and intensive intervention are necessary
between gifted and general education students to provide the needed supports to these students.
utilizing a multiinformant, multigate ap- In their reviews of the literature, both Mitchell,
proach to universal screening. Findings indi- Stormont, and Gage (2012) and Bruhn, Lane,
cated fewer students identified as gifted dem- and Hirsch (2014) noted the lack of evidence
onstrate emotional and behavioral risk, regarding supports for internalizing problems
relative to peers who were not identified as within a multitiered framework. Given this
gifted. Although not significant, parents re- void, Dart and colleagues (2015) evaluated a
ported higher levels of internalizing problems modification of Check-In/Check-Out (CICO), a
among gifted youth. Further, both parents and targeted evidence-based intervention within the
teachers reported higher levels of problems PBIS literature, to incorporate cognitive–
for male students regardless of giftedness. behavioral elements and peer-mediation in the
The researchers note the need for using mul- interest of affecting internalizing behavior.
tiinformant assessment as the data provides Three lower elementary students identified with
important information toward identifying elevated internalizing problems were adminis-
those students in need of additional supports. tered the intervention by 5th grade student in-
A percentage of gifted students were found to terventionists. Findings indicated that two of the
be at risk and therefore, having universal three target students demonstrated positive
screening procedures in place will ensure that change following the intervention resulting in
 MENTAL HEALTH WITHIN A MULTI-TIERED FRAMEWORK 163

all three participants no longer scoring above Conclusions

the “at-risk” criterion at the end of the interven-
tion phase. Results suggest that peer-mediated The articles in this special topic section ad-
CICO may be a useful and resource-efficient vance contemporary knowledge and under-
targeted intervention to address internalizing standing of interventions within a multitiered
problems among elementary students. The framework addressing mental health concerns
study provides a template for considering how and assessment tools intended for use in screen-
theory and research can be utilized to adapt and ing, progress monitoring, or problem identifica-
innovate current effective and feasible school- tion. In particular, three themes emerged. First,
based practices to fill voids in areas of student a gap remains between the supports utilized by
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

support, such as targeted interventions for stu- schools targeting mental health concerns related
This document is copyrighted by the American Psychological Association or one of its allied publishers.

dents with internalizing problems. to internalizing problems versus social behav-

Finally, once students are identified and ap- ioral problems. Partly, this may be attributable
propriate supports are implemented, measures to conceptual discrepancies between how inter-
are needed to determine whether the intervention nalizing problems in youth are conceptualized
is in fact efficacious or if additional supports are and the typical focus of academic and social
needed. The National Center for Intensive Inter- behavior issues within MTSS frameworks. In
vention (NCII) has identified a limited number of fact, many effective practices currently being
progress monitoring measures possessing con- implemented in schools can be impactful to
vincing evidence of psychometric defensibility students experiencing internalizing problems.
Using a multitiered social– ecological model of
(www.intensiveintervention.org). According to
prevention that focuses on sociocultural struc-
the NCII, the sole instrument exhibiting convinc-
tures and psychosocial environmental influ-
ing evidence is Direct Behavior Ratings (DBR),
ences in addition to individual student factors,
with evidence corresponding to reliability, valid-
schools can expand the scope and impact of
ity, and sensitivity to change. However, DBR
practices to meet the needs of all students. For
forms have only corresponded to social behavior instance, innovative methods for combining ef-
targets of disruptive behavior and academic en- ficacious interventions or making modifications
gagement, and a shortage of brief internalizing to currently available and widely used interven-
assessment tools to be used for progress monitor- tions when guided by theory and systematically
ing purposes has been noted. Therefore, to expand evaluated can help fill the gap of available sup-
the scope of progress monitoring tools available to ports to students with internalizing problems.
schools, von der Embse, Scott, and Kilgus (2015) Second, as interventions are developed or
examine the DBR scales for internalizing con- adapted to fill the need of supporting students
cerns, with items specifically targeting academic with internalizing problems, assessment tools
anxiety. The study examined the sensitivity to are necessary to accurately identify students in
change and concurrent validity of DBR of anx- need of these supports. Currently, many stu-
iety and traditional rating scales in measuring dents have unmet mental health needs. Provid-
academic anxiety directly before, during, and ing universal screening methods within a mul-
after anxiety provoking stimulus. Results indi- titiered framework will help to determine the
cated significant relationships between DBRs prevalence of problems while identifying stu-
and pre and post measures of anxiety. The re- dents who may have otherwise gone untreated.
sults from this study provide preliminary evi- Finally, evidence-based assessment and inter-
dence of the repeatability, flexibility, and effi- vention go hand-in-hand; this has previously
ciency of the DBR for anxiety, an area of need been identified as a hallmark of effective mul-
for progress monitoring measures. As interven- titiered systems of support (Jimerson et al.,
tions are developed and used within the school 2007, 2015). As targeted and more intensive
setting for internalizing problems among chil- interventions are developed and implemented,
dren, it is imperative that the field simultane- progress monitoring tools must be simultane-
ously develop and evaluate brief and responsive ously developed and evaluated to support data-
progress monitoring measures to examine the based decision making within a multitiered
outcomes associated with the supports student problem solving framework. As school psychol-
receive. ogists and allied education professionals move
 164 KILGUS, REINKE, AND JIMERSON

toward building comprehensive models of ser- Dart, E. H., Furlow, C. M., Collins, T. A., Brewer, E.,
vice delivery within our school settings, the Gresham, F. M., & Chenier, K. H. (2015). Peer-
field would benefit from ongoing reflection on mediated Check-In/Check-Out for students at-risk
what schools are doing well, how to build upon for internalizing disorders, School Psychology
Quarterly, 30, 229 –243. http://dx.doi.org/10.1037/
the strengths of current practices, and how to spq0000092
innovate to meet the mental health needs of all Domitrovich, C. E., Bradshaw, C. P., Greenberg,
students. Systematic inquiry of adaptations and M. T., Embry, D., Poduska, J. M., & Ialongo, N. S.
newly developed tools and interventions will (2010). Integrated models of school-based preven-
lead to improved outcomes and reductions of tion: Logic and theory. Psychology in the Schools,
the mental health burden among students, fam- 47, 71– 88.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ilies, schools, and society. Hence the impor- Eklund, K., Tanner, N., Stole, K., & Anway, L.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

tance of and intersect of contemporary science, (2015). Identifying emotional and behavioral risk
practice, and policy in advancing understanding among gifted and nongifted children: A multi-gate,
multi-informant approach, School Psychology
and implementation of mental health interven-
Quarterly, 30, 197–211. http://dx.doi.org/10.1037/
tion and assessment within a multitiered frame- spq0000080
work. Fixsen, D. L., & Blase, K. A. (2008, March). Imple-
mentation: The secret to using science in human
service settings. Paper presented at the 5th Inter-
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pits.20514 Accepted February 4, 2015 䡲