Whatever the true reality is in terms of the trends in overall prevalence rates, the very simple fact of the matter is that a substantial portion of our youth are in need of mental-health services. Regrettably, many of those children and adolescents never receive any kind of mental-health support. Though as many as 40 % of those with a psychiatric diagnosis and associated impairment may be accessing services across different sectors, only about one in five is receiving care from a specialty mental-health provider (Burns et al., 1995). Less conservative estimates suggest that between two-thirds and three-quarters of those youth in need of help do not have access to appropriate care and are thus left untreated (United States Congress, Office of Technology Assessment, 1991). This issue is especially troublesome for youth suffering with internalizing disorders , as such problems are often less visible to parents and teachers as compared to externalizing conditions. Indeed it has been documented that the majority of youth struggling with anxiety and depression have never received treatment (Chavira, Stein, Bailey, & Stein, 2004; Logan & King, 2002). Perhaps most disturbing of all is that relatively little ground has been gained, as the estimated percentage of those with unmet needs—across all categories of psychopathology—has remained virtually unchanged over a span of nearly three decades (United States Congress, Office of Technology Assessment, 1986).

Moreover, despite strong support in favor of evidence-based practice (EBP) from the American Psychological Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP), fewer still of the individuals receiving services are actually administered the type of empirically supported treatments (ESTs) that research evidence has deemed “efficacious” (U.S. Public Health Service, 2000). Although the emphasized importance of reliance on an evidence base is beginning to lead to a greater focus on ESTs in the training of the newest generations of psychologists (Cukrowicz et al., 2005), a considerable gap remains. McCabe (2004) claims that “practical guidelines for professional psychologists who may be interested in incorporating EBPs into their own work setting are not available” (p. 571). Schoenwald and colleagues (2008) state that “little is known about the nation’s infrastructure for children’s mental health services…the capacity of that infrastructure to support the implementation of (ESTs), and factors affecting that capacity” (p. 85).

The consequence of such a set of circumstances is a host of long-term negative sequelae for youth who are otherwise unable to access quality mental-health services. For instance, youth with attention-deficit/hyperactivity disorder (ADHD) have been found to suffer academic impairments spanning from preschool through adolescence (Daley & Birchwood, 2010), while investigators have found such outcomes to persist into adulthood where ADHD is associated with lower educational attainment as well as lower levels of employment (Kuriyan et al., 2013). The presence of other “disruptive behavior disorders ” (e.g., oppositional defiant disorder and conduct disorder ) has been shown to be a significant predictor of continuing behavior problems that tends to correspond with a higher rate of criminal justice system involvement and represents a significant financial burden to the general public (Fergusson, Horwood, & Ridder, 2005; Scott, Knapp, Henderson, & Maughan, 2001; Van Bokhoven, Matthys, van Goozen, & van Engeland, 2006). Although often perceived as less troublesome than those exhibiting externalizing symptomatology, youth with internalizing difficulties are nevertheless often comparably distressed and impaired. Anxiety disorders in childhood and adolescence can lead to impairments in school functioning (Mychailyszyn, Mendez, & Kendall, 2010) and increased vulnerability to the development of comorbid conditions and, if left untreated, may persist into adulthood. Untreated anxiety disorders are particularly associated with the development of substance abuse problems (Kendall, Safford, Flannery-Schroeder, & Webb, 2004; Woodward & Fergusson, 2001). Depression is similarly associated with a range of negative outcomes (Collins & Dozois, 2008), with episodes of earlier onset having a longer duration and significantly predicting later episodes of adult depression (Wicks-Nelson & Israel, 2009). Of significant concern is evidence indicating that youth with even subclinical levels of depressive symptoms experience a wide range of psychosocial impairments (Georgiades, Lewinsohn, Monroe, & Seeley, 2006; Gotlib, Lewinsohn, & Seeley, 1995).

What all of the above information impresses upon us is that there is a significant need for change with regard to the manner in which quality mental-health services are delivered to children and adolescents. Further, it is imperative for the healthcare community to explore methods for increasing access to mental-health treatment for at-risk children and adolescents. One commonly suggested solution to this problem is to more comprehensively incorporate mental-health services into school systems. Farmer and colleagues (2003) found that the education sector was the most common point of entry as well as the most frequent provider of such services for children and adolescents across all age groups.

Despite—or perhaps more appropriately, because of—its role as the primary access point, the education sector bears considerable responsibility to enhance its ability to be a reliable provider of quality mental healthcare services for youth. Indeed, the need for schools to play a larger role in the establishment and maintenance of emotional and psychological well-being for youth is widely noted (Weist, Evans, & Lever, 2003). In the United States, the Surgeon General’s Report on Children’s Mental Health in 2000 and the President’s New Freedom Commission on Mental Health (2003) have advocated for schools to accept a greater role in promoting mental health care for young people, specifically emphasizing the dynamic interplay between emotional well-being and academic success. These sentiments have been echoed by governments around the world. For instance, in establishing its national action plan for mental health from 2006 to 2011, the Council of Australia Governments (COAG) pledged political and financial support to reforming mental-health services and building partnerships that would allow a more effective institution of school-based prevention and early intervention programs for children and adolescents in need of care.

What are the impediments to progress that hinder achievement of the goal of enhancing school-based mental-health service provision? Such a question is multifaceted and involves research that cuts across various domains of investigational inquiry. The remainder of this chapter will review and discuss the topics pertinent to answering this question, in hopes that such consideration may aid the field’s advancement toward the realization of such a critical objective.

Based on the accumulation of outcome studies and conclusions reached by literature reviews (e.g., Collins & Dozois, 2008; Eyberg, Nelson, & Boggs, 2008; Horowitz & Garber, 2006; Ollendick, King, & Chorpita, 2006), cognitive-behavioral therapy (CBT) meets established standards to be considered an evidence-based treatment for internalizing disorders and disruptive behavior disorders in youth. Best practice parameters indicate that CBT should be endorsed as the first-line treatment of choice for youth struggling with these problems (American Psychological Association Task Force on the Promotion and Dissemination of Psychological Procedures, 1995; Chambless & Hollon, 1998; Compton et al., 2004). The importance of adhering to evidence-based treatment recommendations is underscored by conclusions drawn from a review conducted by Evans and Weist (2004) who determined that providing interventions that do not have empirical support is likely to provide little to no benefit to students and schools. Even with such knowledge, however, questions remain regarding the potential for empirically supported interventions to be successful when implemented in schools, where they are typically delivered by a variety of professionals and to diverse populations (Owens & Murphy, 2004). For instance, in educational settings, mental-health services may be delivered by teachers, guidance counselors, school social workers, or school psychologists, among others. And although the findings are somewhat mixed in the literature, at least some evidence points to a reduction in outcome effects when programs are conducted by individuals with less training in the intervention (e.g., Brunwasser, Gillham, & Kim, 2009). It is therefore imperative that school-based personnel responsible for such service delivery—most particularly school psychologists, whose focused mental-health training makes them the most well equipped—continue to extend their skills and training in order to deliver interventions with fidelity and comparable effect.

Answers to these questions revolve primarily around features of “transportability ”―the degree to which evidence-based treatments work when implemented in community contexts (Schoenwald & Hoagwood, 2001). Issues revolving around this topic are not new. Nearly 20 years ago, the Journal of Consulting and Clinical Psychology devoted a special issue to an examination of “how findings from carefully controlled studies of efficacious psychosocial interventions for children can be transported into naturalistic studies of the effectiveness of services” (Hoagwood, Hibbs, Brent, & Jensen, 1995, p. 683). The notion of transportability has continually been discussed at multiple levels, surfacing in the Surgeon General’s Conference on Children’s Mental Health which promoted increased reliance on the use of “scientifically proven” mental-health services implemented as “cost-effective, proactive systems of behavior support at the school level” as well as a strengthening of schools’ capacity to be “a key link to a comprehensive, seamless system of school- and community-based identification, assessment and treatment services” (U.S. Public Health Service, 2000). Ginsburg and colleagues (2008) accurately point out that one challenge which continues to confront psychology is successful dissemination of empirically supported intervention strategies to community treatment settings—especially settings serving youth from diverse racial and ethnic backgrounds. The difficulty is found in the gap between research and service clinics such that results derived from the lab may be difficult to replicate in the community (Weisz, Donenberg, Han, & Weiss, 1995).

Achieving transportability requires a “bridging of the gap,” which has also been referred to as “translating science into practice” (Chorpita, 2003). What this entails is essentially a move from “efficacy ” to “effectiveness ” (Mufson, Dorta, Olfson, Weissman, & Hoagwood, 2004; Schoenwald & Hoagwood, 2001) or from “research therapy” to “clinic therapy” (Weisz et al., 1995). In each case, the former term reflects scenarios characterized by homogeneously comprised samples and therapists with in-depth training in the use of manual-based treatments. The goal of these studies is to specifically test and evaluate the intervention. Conversely, the latter term describes efforts to evaluate applications of these efficacious treatments in community settings, which often lack resources such as research funding, an available team of clinicians in training, and a variety of treatment-related materials, among other things. Thus, an unfortunate consequence of a shift to community settings is often lower adherence to treatment fidelity and a drop-off in treatment effects compared to randomized controlled trials (e.g., RCTs; Henggeler, Melton, Brondino, Scherer, & Hanley, 1997).

One solution to the problem of transportability may lie in what Schoenwald and Hoagwood (2001) refer to as “street-ready” interventions—ones that can be applied in representative settings and systems. Following empirical validation of efficacy , treatments can be adapted in logical and user-friendly ways for application in broader community settings.

It is acknowledged that the dissemination and implementation of empirically supported treatments within school systems would mark a considerable change from the way in which mental-health services are traditionally provided to youth (Evans & Weist, 2004). Challenges exist with regard to schools’ acceptance of a greater role in children’s mental health (Owens & Murphy, 2004; Pincus & Friedman, 2004; Weisz et al., 1995) and questions about the logistics and feasibility of applying EFT protocols in schools abound. For instance, Schoenwald and Hoagwood (2001) inquire: What is the [best] intervention? Who can implement it, under what circumstances, and to what effect? Owens and Murphy (2004) ask: How effective are these treatments when delivered to diverse populations by mental-health professionals in community settings who struggle with the added burdens of higher caseloads and fewer resources? Such questions reflect a procedural challenge for school-based interventions.

While the link between children’s mental health and academic success would seemingly provide a natural avenue for collaborative efforts between professionals in psychology and education (Mufson et al., 2004), developing and sustaining such relationships can be difficult, and significant barriers to effective implementation exist.

A particularly problematic obstacle for school-based mental-health interventions can be getting teachers “on board” (Pincus & Friedman, 2004). Teachers are often asked to play an active part in the delivery of such services, with tasks including identification of at-risk students, completion of questionnaires, and even program implementation in some cases. However, these tasks may require training, reflecting a time commitment that competes with an already demanding academic schedule (Owens & Murphy, 2004). Combined with the possibility that children may need to spend time out of the classroom to participate in the intervention, it is understandable that teachers may not be enthusiastic about also adopting a central role in the delivery of mental-health services.

In terms of barriers to transportability /dissemination of ESTs in educational settings, important findings were obtained in a study conducted by Beidas, Mychailyszyn, and colleagues, (2012). While some of the challenges identified by school mental-health providers mirrored those often faced in standard clinic-based service provision, others were specific to the particular school context. Organizational and systemic constraints were cited including the limited time to conduct individual sessions, the resources available for each child (e.g., clinicians reported an average of 5 sessions over a period of 3 months as contrasted with typical clinic-based treatment which likely comprising 12 sessions over the same span of time), and the support from some principals and members of the school’s administration. Qualitative accounts offered by school mental-health providers underscored how difficult implementation of ESTs can be in an educational setting. For instance, one participant was unable to remove students from the class for an hour each week due to the academic instructional time that would be lost. Feedback from those charged with the duty of providing services in schools underscores the significant nature of the obstacles that are present; it may be that such barriers exist to the extent that perfect adherence to the well-validated procedures of ESTs may not be feasible in an educational setting. What then may be done in order to ensure that youth are being delivered services that are consistent with best practice parameters? Beidas and colleagues (2012) have likely stated it best when they assert, “Collaborating with providers to adapt ESTs to be more amenable to the school context is paramount” (p. 204).

Despite the pitfalls, numerous advantages make schools a preferred setting for addressing the mental-health needs of youth. Schools are the most youth-accessible location because this is where they spend the most concentrated amount of time each day (New Freedom Commission on Mental Health, 2003). The school setting provides the opportunity to maximize access, affording an increased ability to reach youth by offering interventions “where they are” (Weist et al., 2003). When schools provide mental-health services, they become centers of care that are located within the community. This change can help to eliminate common obstacles that prevent youth from receiving care (Flaherty, Weist, & Warner, 1996), including transportation needs which must often be coordinated around busy and chaotic parental schedules (Storch & Crisp, 2004).

From an ecological contextual perspective considering the varied role of environmental influences (Bronfenbrenner, 1979), schools are a significant part of a child’s microsystem, serving as one of the most proximal influences in a youth’s development. Schools are also a primary setting in which youth display impairment (Ginsburg, Becker, Kingery, & Nichols, 2008). As the problematic nature of disruptive behavior disorders is essentially grounded in an interpersonal context, the school environment poses extraordinary challenges for such youth who struggle to balance appropriate interactions in a complex social structure that involves both peers and authority figures. For youth fraught with anxiety and depression, many of the situations that cause disorder-related interference are interwoven within the school experience. Anxious youth may be apprehensive about separating from parents to attend school, concerned about social interactions among a network of peers, and worried about evaluation of academic performance (McLoone, Hudson, & Rapee, 2006). For depressed youth, the school setting may force them to confront on a daily basis the aspects of life they are depressed about (e.g., absence of meaningful peer relationships or academic underachievement). School-based interventions are uniquely poised to enhance generalizability , fostering growth in the very situations that lead to difficulty. As such, school demonstrates the type of “ecological validity” (Owens & Murphy, 2004) allowing treatment benefits to be realized in a context that is both clinically and practically meaningful to the everyday lives of children and adolescents. Schools also offer an ideal setting for treatment evaluation by multiple informants (e.g., students, school-based mental-health practitioners, teachers, parents, administrators, etc.), with ongoing adaptations made based on the lessons learned from implementation.

Another benefit of the educational setting is that for school-based mental-health practitioners, their presence in schools allows them to intervene with youth and process problematic situations on a real-time basis. Of particular importance to school systems located in less economically advantaged areas, school-based clinicians can offer programs that are free and much more accessible as compared to traditional private-practice outpatient or hospital-based services which may not be affordable.

Finally, to the extent that parents see schools as familiar or trustworthy, this may also facilitate treatment. Parents who have good relationships with their children’s schools may view mental-health services provided in this setting as more acceptable. The naturalistic setting of schools may have the capacity to reduce the stigma that often accompanies mental-health treatment in the greater community (Storch & Crisp, 2004). Such a benefit may translate into important differences regarding access to care, as research suggests that youth are more likely to utilize school-based services than those that are offered through traditional mental-health clinics (Anglin, Naylor, & Kaplan, 1996; Earls, Robins, Stiffman, & Powell, 1989).

Given the discussion above, a major goal in the mental-health field is to disseminate and implement (DI) ESTs for youth psychosocial difficulties in school settings. Dissemination includes the purposeful distribution of relevant information and materials to school mental-health providers, whereas implementation refers to the adoption and integration of ESTs into practice in the school setting (Lomas, 1993). A critical step that is fundamental for effective DI is to train school mental-health providers in the provision of ESTs. Recent literature reviews demonstrate the importance of incorporating training and ongoing consultation into DI efforts across a variety of settings (Beidas & Kendall, 2010; Rakovshik & McManus, 2010).

From an ecological perspective, an important step in the implementation of ESTs in educational settings is examining whether contextual variables , such as individual therapist and organizational-level variables, predict the implementation of ESTs or the treatment outcomes (Beidas & Kendall, 2010). Findings are mixed in the broader training literature pertaining to evidence of an association between therapist variables and training outcomes. While one study found that therapist variables, such as interpersonal style, influenced therapist adherence and skill (Henry, Schacht, Strupp, Butler, & Binder, 1993), another study found no effect of therapist interpersonal styles, personality variables, or prior experience on adherence and skill (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). Attitudes toward ESTs as predictors of training outcomes and implementation should also be examined (Aarons, 2005), given findings that therapists who held more positive views toward treatment manuals had higher ratings of adherence (Henggeler, Sheidow, Cunningham, Donohue, & Ford, 2008).

Recent research suggests that organizational factors may influence implementation of ESTs. A number of models consistent with an organizational perspective have been applied to implementation of mental-health services in community settings (Glisson et al., 2010; Weiner, Lewis, & Linnan, 2009). Constructs of particular interest include organizational culture and organizational climate, with the former defined as shared beliefs and expectations of a work environment and the latter defined as shared perceptions about the work environment’s impact on worker well-being (Glisson & James, 2002). Notably, organizational climate has been associated with youth outcomes in child welfare systems, such that youth served by agencies with higher rated organizational climates demonstrate better outcomes (Glisson & Green, 2011).

Unfortunately, much of the DI literature to date on organizational predictors of training outcomes and implementation of ESTs has focused on child welfare and community mental-health settings, not educational contexts. Research in schools has lagged, despite the acknowledgment that schools are a ripe environment for dissemination of ESTs (Storch & Crisp, 2004). Qualitative research has identified a number of organizational factors as pertinent to the implementation process for school staff, specifically principal/administrator support, teacher support, financial resources, high-quality training and consultation, alignment of the intervention with school philosophy, ensuring that outcomes are visible to stakeholders, and developing ways to address turnover in staff (Forman, Olin, Hoagwood, Crowe, & Saka, 2009).

One recent preliminary study completed in the school setting found that pretraining therapist attitudes toward evidence-based practice did not influence training outcomes in school mental-health providers, whereas organizational-level constructs such as organizational climate were important for school mental-health provider engagement (Lyon, Charlesworth-Attie, Vander Stoep, & McCauley, 2011). Advancing the work in this area, Beidas, Edmunds, Marcus, and Kendall (2012) conducted a randomized trial evaluating the efficacy of three training modalities and the impact of ongoing consultation after training on the delivery of CBT. An examination of a subsample of school mental-health providers (Beidas, Edmunds et al., 2012) suggests “that there is a positive relationship between school mental health provider attitudes and improvement in adherence to an EST. Providers with higher attitudes regarding the appeal of evidence-based practice, openness to using evidence-based practice, and endorsement that evidence-based practices do not diverge from their current practice also demonstrated improvement in adherence following training in an EST” (p. 203). Despite such encouraging emerging work, more research on individual- and organizational-level predictors of training outcomes and implementation is needed, due to the unique context of schools which is distinct from that of community mental-health clinics.