Abstract
The rising prevalence of mental health challenges among youth has created a pressing need for effective, feasible, equitable, and contextually relevant interventions. Educators and school mental health professionals face critical challenges in helping students overcome such barriers to school success. This makes the need for school-based intervention development research particularly that conducted in the context of collaborative research-practice partnerships, greater than ever. Despite the critical importance of iterative intervention development work, such work often receives less in attention in the published literature compared to studies about the outcomes of interventions. The goal of this special issue is to highlight innovative and rigorous research that describes the process of iteratively developing school mental health services in partnership with educators. Each paper in the special issue describes how education partners (and others including students, families, and other community partners) contributed to the development of an intervention or implementation strategy (i.e., a method or technique to enhance intervention adoption, implementation, or sustainment), how data informed iterations of the intervention or strategy, considerations related to contextual appropriateness, and lessons learned related to community-partnered school-based intervention development. In this introduction paper, we provide a context for this work and highlight innovations across papers in the special issue.
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Mental health challenges represent a key cause of distress and impairment among children and adolescents (Merikangas et al., 2010), and these challenges have exacerbated in recent years (Deng et al., 2023). The COVID-19 pandemic significantly impacted the academic and social well-being of many children (Institute of Education Sciences, 2022; Murthy, 2022) with impacts amplified for students facing barriers to learning (e.g., those receiving special education), students of color, and students with other marginalized identities (Bitler et al., 2023; Fahle et al., 2023). Educators and school mental health professionals (SMHPs) play a critical role in addressing these mental health needs (Hoover & Bostic, 2021), yet they face many challenges in accessing and implementing interventions to support student mental health. For example, many educators and SMHPs have limited training in such interventions (e.g., Weiss et al., 2024) and typical school infrastructure, resources, and schedules often limit the availability of implementation supports (e.g. Connors et al., 2021). Similarly, among existing interventions, many are not accessible to educators, or viewed as feasible, acceptable, or culturally matched to the student body (e.g., Murray et al., 2022). Innovative research focused on intervention development in schools is needed to overcome these challenges. We argue that this research must use iterative development processes in the context of meaningful research-practice partnerships to develop feasible, equitable, contextually relevant interventions to meet the mental health needs of students in schools.
The goal of this special issue is to highlight innovative and rigorous research that describes the process of iteratively developing school mental health services in partnership with educators, school administrators, and intervention recipients. Each paper in the special issue describes how education partners contributed to the development or adaptation of an intervention or implementation strategy (i.e., a method or technique to enhance intervention adoption, implementation, or sustainment) and how data gathered from multiple sources and representing multiple voices informed iterations of the intervention or strategy. Each paper also highlights considerations related to contextual appropriateness (i.e., fit to a particular school, district, or cultural context) and lessons learned related to community-partnered, school-based intervention development. In this introduction paper, we describe the context and need for this work and highlight innovations across papers in this special issue that advance science and practice in the field of school mental health.
School-Based Intervention Development Research
In the early decades of youth psychotherapy research, most interventions were developed and tested in university or laboratory settings and later transported to community settings (Weisz, 2014). However, subsequent research revealed limitations of this approach. For example, interventions with demonstrated efficacy were not adopted or implemented consistently by many community- and school-based mental health providers, in part because the interventions are not viewed as feasible or contextually relevant to the practice setting (Evans et al., 2013; Garland et al., 2010; Owens et al., 2014; Weiss et al., 2024). In addition, evidence suggests (Assenany & McIntosh, 2002; Nilsen et al., 2013) that these interventions have limited effectiveness for a sizable minority of youth, as the samples with which the interventions were initially evaluated often did not generalize to the broader population served (e.g., with regard to economic status, race, immigration status, language, diagnostic status or severity).
In contrast to this linear approach, models such as the deployment-focused model (Weisz et al., 2005) call for interventions to be developed and evaluated in the context in which they will be used and in partnership with the providers and recipients of the interventions, so that fit and contextual relevance can be better considered from the earliest stages of development. Given that schools are a key setting in which youth receive mental health services (Ali et al., 2019; Duong et al., 2021), they represent an opportune context for partnered research in intervention development. Indeed, in the last two decades, the field has witnessed an increase in embedded intervention development research for youth in schools (see Evans et al., 2023).
However, given barriers to delivering effective mental health interventions in schools (Connors et al., 2021; Murray et al., 2022; Weiss et al., 2024), intervention development research-practice teams are tasked with several key challenges. First, they must develop interventions that are effective at improving the desired student outcomes. The development phase provides important opportunities for all partners to inform the goals and design of future efficacy and effectiveness studies, including who is included in the trial and what outcomes are assessed. Second, teams must also develop interventions that are feasible and contextually relevant so they can ultimately be implemented and sustained in school settings without support from a research or evaluation team. Third, teams must operate in a way that supports educators’ capacity to understand, prioritize, implement, and sustain use of interventions that have evidence of effectiveness. Addressing each of these goals at the development phase is critical for narrowing the gap between scientific discovery and uptake and implementation of interventions. Indeed, these goals are prioritized within the requirements of federal agencies that provide much of the funding for intervention development work for youth in schools, including the Institute of Education Sciences (IES) and the National Institute of Health (NIH; see Doolittle & Buckley, 2024; Rooney et al., 2024).
However, addressing these goals also likely requires an evolution from historical approaches to the development of mental health interventions, such as those that prioritize the perspectives of the researchers. Namely, it requires the science community to better incorporate the voices, perspectives, and challenges of educators and youth, and it requires the practice community to be accountable for prioritizing science-based interventions. The work featured in this special issue highlights ways in which this evolution has started to emerge in recent years. We believe that work using iterative and partner-engaged approaches, such as the approaches described here, can contribute to the development of interventions and implementation strategies that will more effectively address youth mental health problems in schools.
Benefits of Meaningful Partnerships in School-Based Research
The development of school mental health interventions for use in K-12 schools is an opportune context for research-practice partnerships. In recent years, there has been a growing emphasis on ensuring that these partnerships are meaningful; built upon the values of equality, mutuality, respect, and reciprocity; and that research projects incorporate educators’ perspectives across all stages of planning and execution (Pellecchia et al., 2018; Price et al., 2020). There are a number of models to guide community-partnered research, including community-based participatory research (Israel et al., 2001), participatory action research (Baum et al., 2006), co-creation science (Craig et al., 2021; Greenhalgh et al., 2019), community-partnered participatory research (Jones & Wells, 2007), and community-academic partnerships (Drahota et al., 2016). These models share common values of (a) collaboration and power sharing between researchers and community members across all research phases (e.g., selecting research questions and outcome measures, study design and execution, interpreting data, disseminating results), and (b) working toward shared goals that benefit all partners. If these goals are realized, it creates a critical context for work that bridges expertise and perspectives from science and practice. We use the term research-practice partnerships in this article, although we note that articles in this special issue use a range of terms for such partnerships.
When done well, such partnerships have the potential to produce science-informed and practice-informed interventions of high feasibility, utility, and impact. When educators, students and/or families are involved at the early stages of research projects (e.g., collaboratively deciding about the goals of the intervention to be developed and the research design) researchers derive benefit because those who deliver and receive interventions are in the best position to offer feedback and recommendations regarding intervention usability, acceptability, and contextual appropriateness (Lyon & Koerner, 2016; Schleider, 2023). Such information, when integrated, enhances the likelihood that the developed interventions address an important need and are relevant and valuable to all partners, as evidenced by the work of Bottiani and colleagues (2024). Such partnerships also enhance the likelihood that the research designs are acceptable and feasible, which sustains educator and student participation so that short- and long-term impacts can be assessed. Although meaningful partnered research may represent a more complex process than that which occurs in more superficial partnerships, it offers unparalleled advantages for science. Indeed, we argue that it is imperative for researchers to meaningfully involve educators, students, and families, particularly those whose voices have been historically under-represented in research, if we are going to adequately serve the increasingly diverse needs of educators and students in the United States. Several papers in this special issue describe processes for meaningfully involving groups who have been historically under-represented in research. For example, Bartuska and colleagues (2024) engaged ethnically and racially diverse high school students in a paid summer internship program to support intervention re-design. Other teams used focus groups to gather perspectives from Black youth experiencing social anxiety (Masia Warner et al., 2024) and autistic youth and their caregivers (Locke et al., 2024; Pugliese et al., 2024).
Research-practice partnerships also have the potential to benefit educators, students, and families as well. First, when given opportunity to provide input and share decision-making power during the early stages of intervention development, such partners can shape the intervention, research questions, and project deliverables to ensure they align with their priorities (Pellecchia et al., 2018). Second, active participation on research projects may offer unique access to trainings or interventions that would not otherwise be available, and meaningful partnerships help ensure that these trainings and interventions meet the needs of their staff and students. Lastly, school partner participation in research is thought to help create local expertise and build internal capacity that can support sustainment (Wallerstein et al., 2020). Partnered research involves an investment of time and resources and new ways of thinking for both research teams and school personnel. However, we argue that making this investment from the earliest stages of research projects can offer short and long-term dividends for both science and practice.
As is exemplified by the studies contained in this special issue, a number of approaches can be used to develop meaningful research-practice partnerships and to obtain partner input across research project phases. For example, many teams use advisory boards or other workgroups to engage and elicit input from education partners (e.g., Kuriyan et al., 2024; Lawson et al., 2024; Nguyen et al., 2024; Owens et al., 2014; Sharkey et al., 2024). Other projects use regular meeting structures for shared decision-making across key partners (e.g., Albright et al., 2024; Bottiani et al., 2024; Goodman et al. 2024, May et al., 2024). Several studies in this special issue describe specific processes, such as cognitive walkthroughs (Collins et al. 2024) or concept mapping (Okamura et al., 2024) used to gather systematic input from educators. Regardless of the specific approaches used, activities should be guided by principles of shared decision-making power across all project stages, reciprocal resource sharing, and transparent communication, roles, and processes for evaluation (see Jones & Wells, 2007).
A recent scoping review identified characteristics and processes indicative of partnership success, which included strong and shared leadership, flexibility, effective communication strategies, shared allocation of resources, and structures to support partnership processes (Brush et al., 2020). Papers within this special issue highlight specific lessons learned about navigating these processes, such as the importance of intentional decisions about which activities and meetings are best led by research partners versus education partners, and which should be co-lead together (Albright et al., 2024; Pas et al., 2024), so that expertise of each partner is given equal attention and respect. Owens et al. (2024) also discuss how greater power is often ascribed to research partners relative to practice partners, as well ways to elevate the comfort, confidence, and voice of practice partners within this context. Lastly, May et al. (2024) discuss how to navigate the competing priorities and time constraints of all partners in a way that respects the realities of different work demands across partners and allows all partners to contribute meaningfully. Other key lessons highlighted within special issue papers include the importance of researchers spending informal time in community spaces (Goodman et al., 2024) and aligning the intervention development process with district-level initiatives and priorities (Bottiani et al., 2024); the utility of using motivational interviewing approaches to build trust and address partner needs and priorities (Pas et al., 2024); and the value of shifting the sense of ownership to key partners outside of the traditional research team (Bartuska et al, 2024).
Use of Data to Inform Iterative Development Process
It is recommended that iterative intervention development processes use data from multiple sources using multiple methodologies to guide revisions to the intervention in development (e.g., Institute of Education Sciences, 2023). The development process typically begins with developing a theory of change or logic model regarding the intended malleable factors, mechanisms of change, and outcomes targeted by the intervention. Gaining consensus within the research-practice partnership on the critical constructs within these models is important, as they guide what should be prioritized in the preliminary assessment of proximal and distal outcomes (e.g., reduction of problems, disproportionality in outcomes, enhancement of skills, goal achievements). Along with specifying student-level outcomes, it is also important to specify key constructs related to implementation. In particular, constructs such as acceptability (i.e., the perception that a given practice is satisfactory; Proctor et al., 2011), feasibility (i.e., the extent to which an innovation can be used in a given setting; Proctor et al., 2011), and usability (i.e., the extent to which a product can be used by the intended users to achieve the specified goals with effectiveness and satisfaction; Lyon & Bruns, 2019), are necessary precursors for interventions to be implemented and sustained.
These implementation constructs can be measured using quantitative, qualitative, or mixed-method approaches. Quantitative measurement approaches used in studies in this special include documenting the number of sessions or trainings completed to assess feasibility (e.g.,Albright et al., 2024; Masia Warner et al., 2024), employing observational measures of fidelity (Capps et al., 2024; Smith et al., 2024), and using rating scales to assess constructs such as acceptability (nearly all studies in this issue). Qualitative measurement approaches used include semi-structured interviews (e.g., Lawson et al., 2024) or focus groups (e.g., Pugliese et al., 2024), as well coding of field notes (e.g., Nguyen et al., 2024) and descriptive analysis of open-ended feedback responses (e.g., Sharkey et al., 2024). In addition, several author teams highlight the ways in which qualitative or mixed methods approaches can enable a deeper understanding of the constructs of interest compared to quantitative measurement alone (e.g., Capps et al., 2024; Lawson et al., 2024; Owens et al., 2024; Smith et al., 2024) and how measuring these constructs from the perspective of multiple participant groups (such as those who deliver and receive an intervention) with each iteration of the intervention can lead to a richer understanding of these constructs (e.g., Pugliese et al., 2024, Masia Warner et al., 2024).
The research-practice partnership may also choose to assess the most relevant contextual factors (e.g., inner and outer setting characteristics) and implementer characteristics (Aarons et al., 2011; Moullin et al., 2019), as such factors are related to intervention adoption, implementation, and sustainability. The measurement and consideration of contextual factors across these levels is critical for developing interventions that are acceptable, feasible, and contextually appropriate. Studies in this special issue highlight the importance of constructs at the individual level, such as implementers’ knowledge, skills, attitudes, motivations and comfort (e.g., Pas et al., 2024; Sharkey et al., 2024). They also highlight the role of school leaders, champions, school climate and culture, and the organizational structure within schools needed to support interventions (Locke et al., 2024; Okamura et al., 2024; Ouellette et al., 2024). Other studies highlight important lessons learned about outer setting factors such as funding sources, partnering community agencies, policies and sociopolitical contexts (May et al., 2024; Owens et al., 2024).
Research-practice partnerships also must determine the process by which they will use the data to refine the intervention in a way that meets a stated need while ensuring that the core elements or mechanisms of change are retained. For example, with quantitative measures, a team might determine that a given score will indicate adequate acceptability, feasibility or usability, whereas scores below this threshold would indicate a need for refinement (e.g., Collins et al., 2024). With qualitative data (e.g., from interviews or focus groups), research teams might identify themes and use a structured process for these themes to guide the next iteration of the intervention (e.g., Kuriyan et al., 2024; Lawson et al., 2024; Nguyen et al., 2024). Several of the studies featured in this special issue highlight the potential utility of using frameworks from the field of implementation science to organize data or guide modification processes. For example, some author teams organized data according to the Framework for Reporting Adaptations and Modifications (FRAME; Albright et al. 2024, Kuriyan et al. 2024) or the Consolidated Framework for Implementation Research (CFIR; Bartuska et al. 2024, Kuriyan et al. 2024). Others used the Exploration Preparation Implementation Sustainment (EPIS) framework to guide study activities (Albright et al., 2024, Locke et al., 2024; Ouellette et al., 2024). Regardless of the specific processes used, rigorous measurement of implementation and/or effectiveness outcomes at the intervention development stage provides opportunities to detect and address challenges with implementation and/or measurement of outcomes prior to expending resources on large-scale efficacy or effectiveness evaluation.
Purpose of the Special Issue
Given the significant mental health needs of youth in schools and the challenges faced by educators in meeting these needs, continued evolution in school mental health intervention development research is warranted. With this special issue, our goal is to advance the literature by providing examples of rigorous, systematic processes for the development or adaptation of interventions or implementation strategies informed by meaning partnerships with educators, youth, and family. The papers in this issue highlight ways to form meaningful partnerships as well as lessons learned about partnership development, balancing power differentials, elevating marginalized voices, and ensuring that developed interventions are contextually appropriate. We hope the lessons highlighted in these papers will contribute to the field’s continued evolution to using more collaborative and iterative approaches to intervention development. These studies reveal multiple methods for gathering data about feasibility, acceptability, utility and preliminary effectiveness, as well as strategies for how to use data to inform modifications. The interventions and implementation strategies described in these papers focus on a range of mental health concerns, including internalizing concerns (e.g., Masia Warner et al., 2024), externalizing concerns (e.g., Albright et al., 2024), and substance use prevention (Okamura et al., 2024). They are designed for a range of student age groups, from elementary (e.g., Ouellette et al., 2024) to secondary (e.g., Bartuska et al., 2024) and across multiple tiers of support. Moreover, the interventions and implementation strategies described in this special issue were developed or adapted with input from a range of educators and intervention recipients, including teachers (e.g., Smith et al., 2024), SMHPs (e.g., Kuriyan et al., 2024); care extender providers (e.g., Goodman et al., 2024); principals (e.g., Collins et al., 2024); school district leaders (e.g., May et al., 2024); students (e.g., Capps et al., 2024); and caregivers (e.g., Locke et al., 2024). The special issue also includes perspectives from scientists at IES (Doolittle et al., 2024) and NIMH (Rooney et al., 2024) describing their respective priorities related to school-based intervention development and optimization research. Lastly we are grateful for the commentaries provided by from leaders in the field (Evans & Bakhtiari, 2024; Lyon, 2024).
Conclusion
The development of contextually appropriate, usable, and effective interventions and implementation strategies to support children’s mental health within the school setting is more important than ever, given the role of schools in responding to the current pediatric mental health crisis. Given the sociopolitical climate related to mental health issues and socioemotional learning in schools, this work is also more challenging than ever. The papers in this special issue highlight key themes regarding community and school partnerships, data-based iterative development, and addressing contextual appropriateness in the unique school context. We hope that they will be a valuable resource for school-based intervention development research projects and stimulate innovations that narrow the research-practice gap.
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Funding
While writing this article, Dr. Lawson’s research was funded by the National Institute of Mental Health under Grant K23MH122577 and Dr. Owens’ research was funded by the Institute of Education Sciences, U.S. Department of Education, through Grants R350A210224, R305A200423, R324A190154 to Ohio University. The opinions expressed are those of the authors and do not represent views of the National Institute of Mental Health or the U.S. Department of Education.
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Julie S. Owens is an Associate Editor for School Mental Health. Gwendolyn Lawson serves on the Editorial Board of School Mental Health.
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Lawson, G.M., Owens, J.S. Research-Practice Partnerships for the Development of School Mental Health Interventions: An Introduction to the Special Issue. School Mental Health (2024). https://doi.org/10.1007/s12310-024-09707-0
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DOI: https://doi.org/10.1007/s12310-024-09707-0