Resource Mapping

Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders December 2023

Division of Adolescent and School Health (DASH) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) Centers for Disease Control and Prevention (CDC)

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Contents

Acronyms and Abbreviations 5

Acknowledgments 6

Contributors 6

External Reviewers 6

Introduction 8

Things to Keep in Mind When Implementing Strategies to Promote Mental Health and Well-Being in Schools 11

Multitiered Systems of Support 11

Using Comprehensive Assessment Tools 12

Access to Mental Health Promotion and Treatment 12

Role of All School Staff in Supporting Student Well-Being and Mental Health 13

Diverse Needs of Students 14

Strategies for Promoting Mental Health in Schools 15

1. Increase Students’ Mental Health Literacy 16

What Can Schools Do? 16

Deliver Classroom-Based Mental Health Education Curricula 16

Implement Peer-Led Modeling Programs 17

Focus on Equity 18

Implementation Tips 18

2. Promote Mindfulness 19

What Can Schools Do? 19

Deliver Classroom-Based Mindfulness Education 19

Dedicate Time for Students to Independently Practice Mindfulness 20

Offer Small Group Mindfulness Activities 20

Focus on Equity 21

Implementation Tips 21

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

3. Promote Social, Emotional, and Behavioral Learning 22

What Can Schools Do? 22

Provide Classroom Instruction Focused on Building Social Skills and Emotional Development 22

Offer Targeted Education Focused on Teaching Social Skills and Emotional Development 23

Focus on Equity 23

Implementation Tips 24

4. Enhance Connectedness Among Students, Staff, and Families 25

What Can Schools Do? 25

Provide Relationship-Building Programs 25

Focus on Equity 26

Implementation Tips 26

5. Provide Psychosocial Skills Training and Cognitive Behavioral Interventions 27

What Can Schools Do? 27

Promote Acceptance and Commitment to Change 27

Provide Cognitive Behavioral Interventions 28

Engage Students in Coping Skills Training Groups 28

Focus on Equity 29

Implementation Tips 29

6. Support Staff Well-Being 30

What Can Schools Do? 30

Offer Mindfulness-Based Training Programs 30

Provide Therapeutic Resources 31

Focus on Equity 32

Implementation Tips 32

Promising Practices for Promoting Mental Health and Well-Being in Schools 33

Conclusion 34

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Appendix A 35

Assessing the Evidence 35

Peer-Reviewed Literature Review 35

Gray Literature Review 37

Focus Groups 37

Expert Listening Sessions 37

References R-1

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Acronyms and Abbreviations

ACT acceptance and commitment therapy

CASEL Collaborative for Academic, Social, and Emotional Learning

K–12 kindergarten through 12th grade

LGBTQIA+ lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other sexual minority identities

MTSS multitiered systems of support

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Acknowledgments This action guide is based on research about school-based comprehensive mental health promotion programming and intervention services that contribute to improved student mental health. It was developed by the Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health and RTI International (Contract # GS00F354CA, order number 75D30121F12871).

Contributors Autumn Barnes, RTI International

Adina Cooper, PhD, Centers for Disease Control and Prevention

Marci Hertz, MPH, Centers for Disease Control and Prevention

Kesha Hudson, PhD, RTI International

Sarah Lee, PhD, Centers for Disease Control and Prevention

Sandra Leonard, RN, FNP, DNP, Centers for Disease Control and Prevention

Bailee Peralto, RTI International

Mary Schauer, MSPH, Centers for Disease Control and Prevention

Katy Suellentrop, MPH, RTI International

Jorge Verlenden, PhD, Centers for Disease Control and Prevention

Natalie Wilkins, PhD, Centers for Disease Control and Prevention

Camara Wooten, RTI International

Anna Yaros, PhD, RTI International

External Reviewers We appreciate the hard work of the many individuals and organizations who shared their knowledge and helped inform our understanding of school-based strategies that support mental health. We extend our gratitude to the National Center for School Mental Health, in particular, Sharon Hoover and Nancy Lever, for helpful feedback, support, and encouragement for this resource. We especially thank focus group participants, who provided key evidence for this report, and the following 17 subject matter experts, who participated in the listening sessions and provided feedback during the development of the package:

Olga Acosta Price, The George Washington University

Riana Elyse Anderson, Stanford University

Melinda Baldwin, Substance Abuse and Mental Health Services Administration (SAMHSA)

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Renee Bradley, U.S. Department of Education

Catherine Bradshaw, University of Virginia

Jessie Coffey, Nebraska Department of Education

Sean Darling-Hammond, University of California, Los Angeles

Dorothy Espelage, University of North Carolina at Chapel Hill

Jamie Freeny, Mental Health America of Greater Houston

Anne Gregory, Rutgers University

Jakatae Jessup, Shelby County Public Schools (Tennessee)

Brittani Kindle, Chicago Public Schools

Kurt Michael, The Jed Foundation (JED)

Jason Okonofua, University of California, Berkley

Farzana Tabitha Saleem, Stanford University

Joyce Sebian, Federal/National School Mental Health Partnership

Trish Shaffer, Washoe County Public School System (Nevada)

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Introduction This action guide was designed for school administrators in kindergarten through 12th grade schools (K-12), including principals and leaders of school-based student support teams, to identify evidence-based strategies, approaches, and practices that can positively influence students’ mental health.

Mental health is important for everyone, and includes our emotional, psychological, and social well-being.6, 7 It affects how we think, feel, and act as well as how we handle stress, relate to others, and make choices. For children and youth, mental health also includes reaching developmental and emotional milestones, and learning skills to cope with challenges and function well at home, school, and in their communities. Mental health is a component of behavioral health, which also includes choices or actions that affect overall wellness.

Schools play an important role in promoting the behavioral and mental health and well-being of students through education, prevention, and early intervention efforts.8-10

• Schools have the potential to establish safe and supportive environments that connect students to caring adults and encourage positive peer relationships. Many schools also play an important role in linking students and families to behavioral and mental health services, especially for students living in low-income settings.

• The work schools do to promote student mental health and well-being helps them achieve their educational mission. Poor mental health can interfere with students’ ability to learn and can affect classroom behavior, school engagement, and peer relationships.11

Recent data shows adolescent mental health is getting worse and has brought national attention to the important role schools play in promoting mental health and well-being.

• In 2021, 42% of high school students reported having felt so sad or hopeless for at least two weeks in the past year that they couldn’t engage in their regular activities, and 22% of high school students reported that they had seriously considered suicide.1

• The data for female students, lesbian, gay, bisexual, queer or questioning students, and students who have experienced racism in school shows they are even more likely to experience poor mental health.1, 3

• When youth experience poor mental health, they are also at increased risk of school absence and dropout, risky sexual behavior, and illicit substance use.4, 5

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

This action guide describes six in-school strategies that broadly promote and support mental health and well-being. The strategies in this guide are not intended to replace the individual behavioral and mental health treatment services that are critical to the children and young people who need them. For each strategy in this action guide, approaches or specific ways to use the strategy are provided, and a summary of evidence-based policies, programs, and practices that illustrate each approach is included. Tips to support successful and equitable implementation of strategies are described, with considerations for how to ensure all students are benefitting from mental health promotion and well-being efforts.

Table 1. Action Guide Strategies and Approaches

Strategy Approach Increase Students’ Mental Health Literacy • Deliver classroom-based mental health education curricula

• Implement peer modeling programs Promote Mindfulness • Deliver classroom-based mindfulness education

• Dedicate time for students to independently practice mindfulness • Offer small group mindfulness activities

Promote Social, Emotional, and Behavioral Learning

• Provide classroom instruction focused on building social skills and emotional development

• Offer targeted education focused on teaching social skills and emotional development

Enhance Connectedness Among Students, Staff, and Families

• Provide relationship-building programs

Provide Psychosocial Skills Training and Cognitive Behavioral Interventions

• Promote acceptance and commitment to change • Provide cognitive behavioral interventions • Engage students in coping skills training groups

Support School Staff Well-Being • Offer mindfulness-based training programs • Provide therapeutic resources

The strategies and approaches included in this action guide are based on findings from a review of peer- reviewed research literature. The equity and implementation considerations were informed by focus groups and listening sessions with students, parents/caregivers, school-based mental health staff (e.g., counselors, social workers, and psychologists), other school staff (e.g., teachers, nurses, administrators), and experts in school-based mental health and well-being from nongovernmental organizations (NGOs), universities, and federal, state, and local educational agencies. For more information on how the evidence in this action guide was assessed see Appendix A.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Strategies included in this action guide do not represent all school-based strategies that are important for promoting student well-being, such as school nutrition and physical activity programming. For more information about additional school-based health promotion strategies, see Healthy Schools | CDC.

There are also additional strategies, approaches, policies, programs, and practices that have an impact on bullying, externalizing behaviors (e.g., aggression, disruptive behavior, attention problems), substance use, chronic absenteeism, and physical health promotion, which are not included in this action guide. Additional evidence-based resources for addressing these other important aspects to student well-being may be found in the following program registries and resources:

• Blueprints for Healthy Youth Development

• The California Evidence-Based Clearinghouse for Child Welfare

• CDC Division of Violence Prevention’s Resources for Action

• Collaborative for Academic, Social, and Emotional Learning (CASEL)

• Programs That Work, from the Promising Practices Network on Children, Families and Communities

• What Works Clearinghouse

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

programs are often delivered in a small group setting by professionals with specialized training such as school counselors or other school behavioral or mental health professionals.

• Tier 3 programs are generally individualized and are often described as “indicated” or “tertiary” prevention programs. Tier 3 programs might involve frequent sessions of longer duration, and often address specific and sometimes more severe behavioral and mental health concerns that a student may be experiencing. Student involvement in Tier 3 programs typically requires parental consent and student assent and is sometimes described in individualized education programs (IEPs). Tier 3 programs are generally provided by certified or licensed professionals qualified to conduct the specific program or intervention.

The strategies in this action guide can align with schools’ existing MTSS to enhance the student support efforts schools have already established.

Figure 1. Multitiered Systems of Support

Note: A variety of MTSS models are available to schools. This resource uses the MTSS to describe the general framework, not a specific model.

Things to Keep in Mind When Implementing Strategies to Promote Mental Health and Well- Being in Schools When implementing strategies related to school- based promotion of mental health and well-being, it is important to consider existing educational practices that may guide decision-making in the school district. It is also important to consider the school and community context, including availability of resources, needs of students, and capacity of staff. This section outlines several of the things to keep in mind when planning and implementing the school-based mental health and well-being approaches outlined in this action guide.

Multitiered Systems of Support Multitiered systems of support (MTSS) is a framework used by many schools and districts to coordinate systems and services to address students’ academic, behavioral, mental health, and social and emotional needs. The MTSS framework uses a public health approach to promote student well-being by identifying three “Tiers” of prevention to support the needs of the entire school population.

• Tier 1 programs, practices, and policies are often called “universal” or “primary” prevention programs. These are typically implemented schoolwide and meant to benefit the entire student body. Programs implemented by classroom teachers are frequently Tier 1 (universal, primary prevention).

• Tier 2 programs are described as “targeted” or “secondary” prevention programs. These programs are typically appropriate for students who might benefit from additional supports, skill development, or early intervention to address concerns. Tier 2 (targeted, secondary prevention)

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

| School Mental Health Quality Guide— Screening: https://www.schoolmentalhealth. org/media/som/microsites/ncsmh/documents/ quality-guides/Screening.pdf

| The School Counselor and Universal Screening: https://www.schoolcounselor.org/Standards- Positions/Position-Statements/ASCA-Position- Statements/The-School-Counselor-and- Universal-Screening

| Guidance for Trauma Screening in Schools: https://www.ksdetasn.org/resources/1270

| Best Practices in Universal Screening: https://smhcollaborative.org/wp-content/ uploads/2019/11/universalscreening.pdf

Access to Mental Health Promotion and Treatment Students may have difficulty accessing mental health services in their communities because of barriers such as provider shortages, insufficient or no insurance, and transportation. Schools can help their students overcome these barriers by doing the following:

• Helping link students and families to providers offering mental health services via telehealth. This is one way schools can help address students’ transportation challenges, saving time and costs.14 In rural communities, telehealth can bridge long distances between providers and those who need services. Schools can also provide access to reliable broadband internet that can support video conferencing for telehealth.

• Using multiple funding streams and different payment structures for Tier 3 mental health services based in schools.

• Embedding mental health supports in school-based health centers (SBHCs)—SBHCs can partner with community providers to help students meet their mental health needs without having to travel to an additional location.15

Using Comprehensive Assessment Tools Using data to understand and improve both students’ and adults’ competencies, behaviors, performance, and accountability12 is critical for assessing need, understanding how students and staff are implementing new programs, policies, and practices, and assessing what effect these practices are having on mental health and well-being. Using student data to make decisions about supports that students need is a central component of MTSS, and school-based screening of students to learn about their social, emotional, behavioral, and mental health concerns is a way to better understand student needs. Screening can also help with linking students to needed services.

• Social skills and emotional development assessment tools, for example, might be used to help schools understand their climate and opportunities for improving curricula over time. These assessments can also be helpful to teachers as they support skill development in students and tailor curricula to classroom needs.13

• Other screening tools specifically ask about students’ mental health needs. Before implementing screening initiatives in a school or district, it is important to decide how students’ answers will be used to benefit them. Ethical responsibilities include protecting students’ privacy and linking them to mental health supports. For example, if screening uncovers a high need for mental health treatment (which falls into “tertiary” or Tier 3 services), administrators should determine if those services are available through the school or in the local community. Professional organizations such as the National Association of School Psychologists offer guidance for schools as they consider the adoption of screening in schools. For a more detailed discussion of mental health screening, see the following resources:

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

• Partnerships with families, community organizations, and behavioral health providers which can help ensure mental health and well-being activities meet the most pressing needs of the school community and support program effectiveness and sustainability.

• Awareness of local, state, and federal policies which often inform on-the-ground implementation of any program or practice related to mental health and well-being among students.

Role of All School Staff in Supporting Student Well-Being and Mental Health School administrators, teachers, school nurses, and school-based mental health staff all play important roles in supporting the mental health and well-being of students. Implementing new programs or making changes to existing programs requires coordination and collaboration across the school. Consider the responsibilities of staff and how they will work together and with families and other community partners to support implementation. Some key things that can help with staff coordination and collaboration include the following:

• School-based leaders or champions who can communicate the purpose of a new mental health and well-being program or practice and may lead plans to integrate it into existing school programs (including academic programming).

• Consistent administrator buy-in and support at the district and state level which can send a message of support to teachers and other staff.16

• Adequate school-based mental health staffing (i.e., no more than 500 students per one psychologist; 250 students per one counselor) which is important to consider when selecting new mental health and well-being programs and making changes to established practices and policies.17

• Effective and sustained training for staff aligned with requirements of the programs they will be asked to implement. For example, the Collaborative for Academic, Social, and Emotional Learning (CASEL’s) School Guide implementation model for supporting social and emotional learning uses leadership teams and ongoing coaching to support implementation.18, 19 To address training needs and expand the capacity of school personnel, schools might partner with community-based organizations and providers as well as collaborate with local universities and colleges to increase access to resources and training opportunities.20

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

attitudes about mental health and help seeking. Promoting inclusive, nondiscriminatory practices that reduce judgment, blame, stereotypes, and prejudice and that raise awareness of mental health and school-based mental health promotion activities may foster engagement, bolster connections, and reduce barriers to help seeking.17

• Review school practices and policies to identify whether they might disadvantage specific groups of students. For example, consider how a dress code could negatively affect student mental well-being for some students more than others. Items often called out in a dress code, such as hats or hoodies, may have different meaning or value that should be explored with students before the items are banned. Anti- bullying and harassment policies can also better serve the diverse needs of students when sexual orientation, gender identity, and gender expression are specifically listed as protected characteristics in addition to race, ethnicity, national origin, sex, disability, and religion.24

Diverse Needs of Students To effectively and equitably promote mental health and well-being for all students, schools can do the following:

• Match programs to students’ developmental needs. Many programs are designed for elementary, middle, or high schools and adapted for or tested in other grade ranges. Consider the grades identified by the developer of a program when determining whether it is appropriate to implement.

• Incorporate culturally and linguistically responsive information in mental health programming, including input from communities.21

• Educate staff on the social, historical, and environmental inequalities that certain student groups face. For example, inequalities based on race, ethnicity, gender and/or sexual identity.12

• Support and welcome students, especially those who are at higher risk for marginalization, such as students who recently immigrated to the United States, who are living with a disability, or who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex, or asexual (LGBTQIA+). This can include acknowledging and promoting cultural events, providing multilingual programming, and supporting the creation of student clubs that promote inclusion, such as genders and sexualities alliances (GSAs).21, 22

• Support school attendance by addressing factors that can contribute to absenteeism, including mental health concerns, exclusionary discipline practices (e.g., suspension), and social or economic factors.23 Understanding how mental health knowledge and awareness, previous experiences with stigmatizing or discriminatory situations, and cultural norms can contribute to

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Strategies for Promoting Mental Health in Schools This section includes six evidence-based strategies for promoting mental health and well-being in schools. For each strategy, specific approaches that schools can implement are described, and the evidence of their impact on mental health and well- being is summarized. A list of example programs and links to additional resources, considerations for focusing on equity, and additional tips for implementing the approaches in real-world settings are also provided.

Some general principles around centering equity apply across all six strategies. These principles are designed to help schools think about how approaches can result in equitable outcomes for all types of students. Across strategies and approaches, consider the following:

• Use data to understand your students and staff. Be aware of the unique groups of students and staff that make up your school—diverse races; ethnicities; gender identities; sexual orientations, mental and physical abilities; income levels; urban, suburban, and rural neighborhoods; religions; household structures; and education levels.

• Adapt programs and practices to address the different backgrounds of students in school settings. For example, school-based mental health staff could consider how mental health challenges such as stress might manifest differently for students based on culture or context.

• Recruit staff who reflect the unique backgrounds of the students in your school community.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

can be delivered in core classes or integrated into comprehensive school health education curricula. Mental health curricula can increase mental health literacy in schools by doing the following:

• Providing information about causes and symptoms of mental illnesses.

• Exploring stigma as it applies to mental illness and explaining how to reduce stigma.

• Emphasizing that mental illnesses are treatable and addressing barriers to seeking treatment.

• Encouraging students to talk with trusted adults and seek treatment.

Evidence Summary: Classroom-based mental health education curricula are associated with the following student mental health outcomes:

�Mental health knowledge and attitudes27-32

� Stigma related to mental health30, 32

�Help-seeking behaviors (i.e., reaching out for mental health support)29, 31, 32

1. Increase Students’ Mental Health Literacy

Mental health literacy includes having knowledge and understanding of mental health as well as skills that support help-seeking (i.e. reaching out for mental health support when needed). Increasing students’ mental health literacy promotes mental health and well-being by helping identify mental health concerns and facilitate access to timely and effective intervention.

Mental health literacy includes increasing knowledge in the following areas:25, 26

• How to develop and maintain positive mental health.

• How to reduce stigma around expressing distress or having a mental illness.

• How to effectively engage in help-seeking behaviors (e.g., when and where to obtain help).

• How to identify specific mental health disorders and treatment options.

What Can Schools Do? Schools can increase students’ mental health literacy by delivering classroom- based mental health education curricula and implementing peer-led modeling programs.

Deliver Classroom-Based Mental Health Education Curricula

Description of Approach: Classroom- based mental health education curricula offer a way to increase mental health literacy in schools. Curricula often include interactive, skill-based lessons that incorporate personal testimony from young adults about their mental health journeys, in-class group activities, and homework assignments. Mental health curricula

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

learn about the importance of engaging in healthy activities, having friends who engage in behaviors that benefit or help others, accessing medical and mental health resources, and engaging trusted adults. Through interactive presentations, peer leaders emphasize the importance of identifying resources and strategies for coping with adversity and they share personal narratives about their own experiences. They might also share the names of adults whom they engaged with when experiencing distress and encourage students to identify adults they would trust if they were concerned about the well-being of themselves or a friend.33

Evidence Summary: Peer-led modeling programs are associated with the following student mental health outcomes:

�Coping attitudes33

�Acceptability of seeking help33

� Perception of adult support33

Evidence Description: Peer modeling of healthy coping strategies improved high school students’ coping attitudes and perceptions of help-seeking behaviors. Improvements were observed in the following things for students:

• Attitudes toward overcoming barriers to engage adults for suicidal youth.

• Attitudes toward seeking help from adults.

• Perceptions about the availability of adult help and peer and family support for seeking help.

• Naming trusted adults.

Importantly, students who reported experiencing suicidal ideation in the past 12 months benefited the most from peer-led presentations that modeled healthy and effective coping behaviors.33

Learn more about the peer-led modeling program that we reviewed:

• Sources of Strength (Tier 1).

Evidence Description: Studies have shown that classroom-based mental health education curricula lead to improvements in knowledge, attitudes, and help-seeking behaviors and reductions in stigma among students.27-32 Middle school and high school students who participated in mental health curricula reported the following:

• Less-negative emotional responses toward people who have a mental illness32 and were more likely to interact with people, including their peers, who have a mental illness.30, 32

• Improvements in knowledge27-32 and attitudes toward mental illness that lasted over time.27, 28, 30, 32

• More help-seeking behaviors (e.g. reaching out for mental health support) and greater optimism about treatment effectiveness.31

• Fewer worries about sharing personal information with a counselor.32

One study reported that middle school students who had high levels of mental health symptoms were more likely to seek treatment over the course of the next two years if they had been taught from a mental health curriculum.31

Learn more about the classroom-based mental health education programs30, 31 that we reviewed:

• NAMI Ending the Silence (Tier 1).

• Adolescent Depression Awareness Program (Tier 1).

• A School-Based Intervention for Mental Illness Stigma (Tier 1).30

Implement Peer-Led Modeling Programs

Description of Approach: Peer-led modeling programs train adolescent peer leaders to model positive attitudes, skills, and behaviors to promote change among students. Programs focused on mental health and well-being teach peer leaders how to promote the development of healthy coping strategies for themselves and their peers. Peer leaders

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

• Create consistent guidelines and practices to support any type of mental health training, including mental health literacy training. For example, make sure that school staff know how to support students in distress, how to get help when a student has an immediate need for support, and how to communicate concerns to families.

“I feel like the teachers at my school are generally good and aim to promote student well-being, but they don’t have the support of the administration behind them, so it can be hard for them to take any real action.”

– Student

Use CDC’s Health Education Analysis Tool (HECAT) to examine health education curricula, compare strengths and weaknesses of multiple curricula, and develop a scope and sequence for health education that supports mental, emotional, and behavioral health across grade levels. It may also be valuable to consider integrating mental health content into state or district health education standards. The District of Columbia’s Health Education Standards provide an example of how this can be accomplished. The National Institute of Mental Health’s Resources for Students and Educators also offer a variety of learning resources for students and teachers about mental health and the brain.

Focus on Equity Consider ways to expand the availability of mental health services through partnerships with local, state, and regional organizations as well as community-based groups. For example, in schools with a large population of Spanish- speaking students, schools can identify clinicians and community organizations who offer supports and services in Spanish. It is also helpful to identify organizations that support students with LGBTQ+ identities as well as organizations experienced with supporting the needs of diverse student populations and with providers who reflect the demographics of the students in the school.

Consider parent, caregiver, and community perceptions of mental health and how these might affect students’ ability and decisions to seek mental health support. If communicating with parents and caregivers, be mindful of the language being used and offer information in a variety of formats. Some parents and caregivers might be comfortable reading materials, whereas others would prefer a conversation with school staff. Consider integrating information about mental health services into other information provided by the school to connect mental health and academics and to normalize information about mental health.

Implementation Tips Administration-level support is critical for implementing programs, practices, and policies to address mental health literacy. To better support implementation of approaches that increase students’ mental health literacy, school administrators can take these actions:

• Identify ways to convey to teachers and staff that administrators understand and support the need for programs, practices, and policies to increase mental health literacy.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Evidence Summary: Classroom-based mindfulness education has been associated with the following:

�Anxiety34, 35

�Depressive symptoms36

�Negative coping behaviors36

� Positive coping behaviors37

Evidence Description: Research shows that practicing mindfulness has positive impacts on students’ mental health and well-being, including the following:

• Lower ratings of anxiety (by teachers) among elementary-aged girls34 and fewer self-reported symptoms of anxiety among high school students.35

• Lower levels of self-reported depressive symptoms and negative coping behaviors (e.g., disengagement, denial, substance abuse, self- blame) among middle school students.36

2. Promote Mindfulness Mindfulness is a skill that involves intentionally bringing one’s attention to the present moment by noticing thoughts and sensations in a nonjudgmental and nonreactive way. Practicing mindfulness can help students manage stress in their everyday lives and regulate their emotions and behaviors.

What Can Schools Do? Schools can promote mindfulness among all students by providing mindfulness education in the classroom and dedicating daily time for independent mindfulness practices. Small-group mindfulness interventions can be provided to students who are experiencing elevated mental health symptoms.

Deliver Classroom-Based Mindfulness Education

Description of Approach: Classroom-based mindfulness education supports students’ awareness of the mind-body connection through the following:34-37

• Instruction about stress, including the effects of stress on the body and ways to manage stress, develop self-regulation, and build healthy relationships;

• Experiential practice of mindful breathing, meditation, and mindful movement, such as yoga; and

• Group discussion about how to practice mindfulness in everyday situations.

Mindfulness education may take the form of longer lessons in health or wellness education classes35 or brief sessions that can be incorporated into transitions that occur throughout the school day, such as during morning meetings or advisory periods, after recess, or before the start of a class lesson.34

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

• Greater engagement in positive coping behaviors (such as problem-solving, emotion regulation and expression, positive thinking, cognitive restructuring, and acceptance) among middle school students.37

Learn more about the classroom-based mindfulness education programs that we reviewed:35, 36

• Master Mind (Tier 1).

• Transformative Life Skills (Tier 1).

• MindUp (Tier 1).

Dedicate Time for Students to Independently Practice Mindfulness

Description of Approach: Making time for students to independently practice mindfulness daily may also support students’ mental health and well-being. Providing students with a few minutes to meditate each day is sufficient for establishing a consistent mindfulness practice.

Evidence Summary: Allowing students to independently practice mindfulness has been associated with the following effects:

� Anxiety38

� Resilience38

Evidence Description: In one study, after learning how to practice meditation, high school students were offered 15 minutes at the beginning and end of the school day to meditate.38 At the end of the school year, students who were given the opportunity to meditate in the morning and afternoon each school day reported lower anxiety and increased resilience.

Learn more about the independent mindfulness practice that we reviewed:

• Quiet Time (Tier 1).

Offer Small Group Mindfulness Activities

Description of Approach: Small groups of students, often led by counselors, learn about and practice mindfulness activities. These interventions aim to promote emotional regulation skills among students experiencing Tier 2 or Tier 3 risk for mental health symptoms. Students learn to understand their thoughts and feelings and develop and practice skills to help them reflect on and manage their emotions in a positive way.

Evidence Summary: Students who participated in small-group mindfulness interventions experienced the following changes in self-reported symptoms:39-41

� Stress39

� Internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms)39

�Depressive symptoms40

Evidence Description: Middle and high school students experiencing mild to moderate depression benefit from small-group mindfulness interventions. Among Latine/Latinx and Asian American middle and high school students experiencing mild to moderate depression, students who participated in small-group mindfulness interventions experienced greater reductions in self-reported stress and internalizing behaviors, including feelings of anxiety, withdrawal, and depressive symptoms compared to students who received no treatment or Interpersonal Therapy - Adolescent Skills Training.39-41 In one study, researchers reported that the intervention was most beneficial for students who experienced more severe mental health symptoms.39

Learn more about the small-group mindfulness intervention that we reviewed:

• Learning to BREATHE (Tier 2)

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

It is important to remember that mindfulness interventions may not be useful for everyone. Teachers, staff, and students should be invited, but not pressured, to incorporate mindfulness strategies into their classrooms or develop an independent mindfulness practice.

Focus on Equity Explore mindfulness practice as a way to advance equity. Mindfulness approaches can help teachers and students develop a more open and inclusive classroom environment.42 Because mindfulness encourages nonjudgmental observation, it can help individuals in the school reflect on and manage feelings of stress that can result from a disconnect between their identities and that of others in their school or classroom. It can also help teachers reflect on their assumptions and behaviors in ways that are helpful for identifying and reducing bias.43

Incorporate student voice in the development of mindfulness activities, such as by asking students what visualization strategies they like best. Offer students the opportunity to lead mindfulness exercises throughout the school year.42 It is important to remember that developing a mindfulness practice can help students learn how to cope with stress, but it does not address the factors that cause distress or disruption in students’ lives. Some students may experience events that lead to persistent or highly traumatic distress that may also require additional intervention.

Implementation Tips To better support the implementation of mindfulness strategies, school administrators can consider doing the following:

• Training teachers and staff throughout the school on the importance of mindfulness, as well as strategies for incorporating it throughout the day.

• Offering mindfulness opportunities for staff and teachers. For example, administrators could give a mindfulness minute for staff at the beginning of each day, or offer mindfulness projects at the district level. These projects could include student-led opportunities to advance mindfulness practice in their schools (e.g., a gratitude wall or wellness conference).

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Programs focused on building social skills and emotional development vary. For example, some programs consist of a single, computer-based session, whereas others include several lessons delivered by a guidance counselor outdoors,47 or a scripted curriculum delivered by classroom teachers twice a week throughout the school year.47-49

Evidence Summary: Programs implemented for all students in either a grade or a classroom (i.e., universal social skill and emotional development programs) were found to have the following effects:

�Depressive symptoms49

� Internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms)48, 50, 51

�Anxiety47, 48

�Mental health and well-being52

� Resilience53

Evidence Description: Researchers have explored the impact of single-session interventions focused on one skill area, such as growth mindset, as well as longer programs addressing multiple skill areas.47, 51, 53 For example, a single-session intervention delivered in a rural school with high school students was

3. Promote Social, Emotional, and Behavioral Learning

School-based programs can promote social skills and emotional development by focusing on the following: self-management, responsible decision- making, relationship skills, social awareness, and self-awareness.44 These programs have been linked to school climate and positive interpersonal relationships between peers and with teachers. They have also been found to improve specific mental health outcomes such as depressive symptoms and anxiety.45, 46 Nationally, surveys have observed that there is strong support among school administrators for programs that improve students’ social skills and emotional development, as they recognize its significant impact on students’ academic performance and mental health outcomes, and its value for promoting positive school climates.12

What Can Schools Do? K–12 schools can provide classroom-based programming that includes instruction on social skills and self-regulation for all students. For students at elevated risk of negative mental health outcomes, small-group support might benefit students by providing an opportunity to enhance and practice skills related to social, emotional, and behavioral learning.

Provide Classroom Instruction Focused on Building Social Skills and Emotional Development

Description of Approach: Classroom instruction focused on building social skills and emotional development might cover such topics as the following:

• Recognizing thoughts.

• Understanding feelings.

• Decision-making and problem-solving.

• Healthy relationships.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

to more positive mental health outcomes for these students. When offered as a supplement to universal instruction on social skills and emotional development and integrated into academic subjects, targeted education reduced internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms) among elementary school students.55 Similarly, a program focused on processing and responding to interpersonal trauma in relationships decreased anxiety and depression among students.54

Learn more about the targeted interventions that we reviewed:

• SEL Foundations Curriculum (Tier 2).

• Forgiveness within the Family (Tier 2).

Focus on Equity Consider using transformative social and emotional learning to advance equity. Although promoting equity is not an explicit component of all social, emotional, and behavioral learning, these interventions do offer opportunities to address issues related to equity (e.g., skills for interpersonal relationships).56 Transformative social and emotional learning focuses specifically on advancing equity among all students. It incorporates exploration of individual and contextual factors that contribute to inequity (e.g., how issues of race, class, and culture influence society) and focuses on identity, agency, belonging, collaborative problem-solving, and curiosity. Transformative social and emotional learning intentionally addresses structural inequities that students experience in their schools and communities.57 For example, a transformative social and emotional learning program could provide an opportunity for youth to identify inequities in their communities and develop solutions.

Consider using screening tools to support students, but examine the tools for potential bias and misuse. Screening is discussed more specifically in the “Screening to Support MTSS Implementation” section, but it is important to note that in addition to school-based screening for social,

found to reduce depressive symptoms.49 A 12 session program implemented in middle schools increased resilience among students. Programs implemented for all students in either a grade or a classroom (i.e., universal social skills and emotional development programs) were found to reduce depressive symptoms, internalizing behaviors, and anxiety and to increase resilience and mental health and well-being among students.

Learn more about the classroom-based skill building programs that we reviewed:

• The PATHs program (Tier 1).

• Project Growing Minds (Tier 1).

• Second Step (Tier 1).

• Speaking to the Potential, Ability, & Resilience Inside Every Kid (SPARK; Tier 1).

• Strong Kids (Tier 1).

Offer Targeted Education Focused on Teaching Social Skills and Emotional Development

Description of Approach: Targeted education that focuses on social skills and emotional development provides students with small-group or individualized instruction on skills and is tailored to their identified needs. Specific strategies to identify students who might benefit from more specific, small-group instruction might vary depending on age level and rely on teachers’ observations along with self- reported feelings and experiences.

Evidence Summary: Research has found that targeted education focused on social skills and emotional development had the following effects:

� Depressive symptoms54

� Internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms)55

� Anxiety54

Evidence Description: Targeted approaches designed specifically for students at risk for emotional and behavioral disorders were linked

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

curriculum or strategies that the school is using, observing practices and lessons in the classroom, and reviewing data that schools are already collecting, e.g., school climate data.12 Monitoring and assessment can support continuous quality improvement efforts in implementation.

• Incorporating social and emotional skills-based instruction into academic subjects. For example, one program was implemented as part of a literacy course.55 Implementation can also take place outside of the classroom. Additional benefits have been observed when social, emotional, and behavioral learning is implemented in an outdoor, natural space.47

• Integrating programs throughout the school setting. This has been used as a strategy for supporting students and schools as they transition back to in-person instruction after COVID-19- related school building closures. Teachers noted that incorporating social skill and emotional development strategies into classrooms can help support students, but that teachers need appropriate implementation support and professional development to be certain they are implementing strategies with fidelity and in a way that responds to the different needs in their classrooms.

“They [the school staff] have a system where the teachers almost incorporate it [mental health] in the curriculum. One of my anatomy classes would have us do a self-awareness journal, where we would talk about where we are in the moment.… It was a nice break to have. They would give us resources about ways to handle stress and find people to talk to as well.… That was a new thing they started post-COVID because they realized that it was becoming more of an issue and something that was never talked about previously.”

– Student

emotional, behavioral, and mental health concerns, there are also assessment tools that can be used to identify areas of focus for social and emotional programming. Such screening is a strategy that some schools and districts have used to provide universal and targeted programming for students. However, these tools should be used with care. From an equity perspective, it is critical to look for biases that might be present in screening tools and ask whether these biases influence expectations for different students. It is also important to create a clear plan for using the data, ensure that schools can follow up as needed based on the screening responses, and ensure that the follow-up plan is shared with staff.

Implementation Tips School administrators can support the implementation of social, emotional, and behavioral learning in schools by doing the following:

• Integrating social skill and emotional development competencies into strategic planning and budgeting, human resources, professional development, and operations, in addition to standard academic programming and initiatives.12 This includes ensuring that teachers have tools for integrating practices or lessons into their classroom and receive ongoing support during implementation. For example, there are tools to support integration into existing lesson plans and a coaching toolkit that can support implementation efforts.

• Integrating programs at the district level. Outcomes at the district level (e.g., positive climate; buy-in for and commitment to social, emotional, and behavioral learning; clear roles and responsibilities) directly relate to student outcomes (e.g., increased academic performance, increased mental health wellness, fewer disciplinary actions).12

• Monitoring implementation and assessing opportunities for improvement. This could include gathering teacher feedback on the specific

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Evidence Summary: Relationship-building interventions have been associated with the following:

� Internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms)60, 61

Evidence Description: Research conducted in elementary schools suggests that relationship- building interventions that are tailored to address the unique experiences and challenges facing military- connected children61 and children with or at risk for disruptive behavior problems60 lead to reductions in teacher- and parent-reported internalizing behaviors.

Learn about the school connectedness programs that we reviewed:

• Staying Strong with Schools (Tier 1).

• Starting Strong (Tier 3).

4. Enhance Connectedness Among Students, Staff, and Families

School connectedness refers to each student’s belief that adults and peers in school care about their learning and about them as individuals. This feeling includes a sense of being cared for, being supported, and belonging at school.58 Some students, including students of color, students living with disabilities, and students who identify as LGBTQIA+, are at increased risk for experiencing feelings of social isolation or alienation at school.59 School connectedness can protect and promote students’ mental health and well-being.

What Can Schools Do? Schools can enhance students’ feeling of connection to their peers, teachers, and the school community through relationship-building interventions.

Provide Relationship-Building Programs

Description of Approach: Relationship-building interventions aim to strengthen connections between students, families, and school communities. These interventions promote positive family–school relationships through frequent two- way communication between parents or caregivers and school staff (e.g., teachers, guidance counselors). The interventions accomplish this by offering (1) group sessions for teachers that focus on how to build strong student-teacher relations and how to collaborate with parents and (2) group or individual sessions for parents that focus on the importance of parental involvement in school and ways to develop collaborative relationships with teachers. Additional supports may include classroom activities to strengthen peer relationships or schoolwide events that raise awareness about various student experiences and needs. Relationship-building interventions can be tailored to meet the unique needs of different student populations.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

• Enacting trauma-informed policies and practices, especially related to disciplinary practices (e.g., restorative practices).

For more information on these policies and practices, see the “Promising Practices” section.

Implementation Tips School administrators can support implementation of connectedness interventions by doing the following:

• Engaging parents and students in the process of identifying and prioritizing relationship-building efforts.

• Supporting professional development for teachers on classroom management approaches that help build relationships with students (for more information about classroom management, see https://www.cdc.gov/healthyyouth/classroom- management/index.htm).

• Making sure that parent engagement activities are being offered at times, locations, and in ways that fit the needs of families.

Focus on Equity Approaches to build connection within schools should intentionally include and center students who are at a disproportionate risk for being marginalized and disconnected in school. Girls, youth who report experiencing racism, youth from racial and ethnic minority groups, and youth who identify as LGBTQIA+ often feel less connected at school and experience poor mental health.3, 62

While racial/ethnic minority students make up over half of the population of students in the U.S. public education system, fewer than two in ten teachers have racial/ethnic minority identities.63 This is a notable gap since research has found that having school staff who are representative of the racial/ethnic backgrounds of students in the school can increase connectedness within the school and between staff and students.64

“What does it mean for a student to be connected and even in the smallest things… like… if a student walks into your classroom, do they see themselves? In the school, do they see themselves? What does that look like? And [you have to be] really being intentional about understanding that intersectionality aspect.”

– Focus Group Participant

Other examples of policies and practices that can support connection at school for all students, including students at higher risk for being disconnected include the following:

• Establishing affinity groups for students of color and LGBTQIA+ students (e.g., genders and sexualities alliances).

• Enacting anti-bullying and anti-harassment policies that specifically protect staff and students against gender and sexual identity-based harassment.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Evidence Summary: Approaches using acceptance and commitment to change show an association with the following effects:

� Coping65

� Depression66

� Somatic symptoms66

Evidence Description: One study explored dialectical behavior therapy in a group of students attending an alternative education program and found improvements in somatic symptoms and symptoms of depression.66 Another study using acceptance-based behavioral therapy in middle schools showed that students increased their use of problem-solving coping strategies.65

Learn more about the acceptance and commitment program we reviewed:

• Teen Talk (Tier 3)

5. Provide Psychosocial Skills Training and Cognitive Behavioral Interventions

Schools can teach specific skills to students to help them cope with their thoughts and behaviors. Cognitive behavioral interventions teach students to identify their own unhelpful thoughts and replace them with alternative thinking strategies. These interventions also often try to get students to engage in positive activities and coping behaviors in their lives, which can improve their moods and other symptoms of mental distress.

Districts and schools can use programs that help students with their thoughts and behaviors (and also improve their well-being and resilience) in one-on- one settings, small groups, and in the classroom. Some of these interventions focus on concepts that are also taught in social skill and emotional development programs, such as self-regulation and decision-making.

What Can Schools Do?

Promote Acceptance and Commitment to Change

Description of Approach: A new category of psychosocial skills training interventions asks students to explore whether their behaviors align with their personal values and, if not, prepares them to make behavior changes. These interventions also promote acceptance of one’s current circumstances in ways that are similar to mindfulness. A specific type of therapy, dialectical behavior therapy, incorporates both mindfulness and acceptance and commitment principles.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Small-group and one-on-one cognitive behavioral interventions also have been shown to improve students’ ability to cope with trauma and specific anxieties. Several studies of a small-group intervention for elementary and middle school students experiencing anxiety, posttraumatic stress disorder, or both showed improvements in anxiety and posttraumatic stress.69, 73, 75, 76, 79 Another study tested a cognitive behavioral intervention addressing social anxiety delivered to high schoolers and showed reductions in students’ social anxiety.70

Learn more about the cognitive behavioral interventions we reviewed:

• LARS & LISA (Tier 1).

• Tools for Getting Along Curriculum—Behavior Management Resource Guide (Tier 1).

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS) (Tier 2).

• Footprints (Tier 2).

• Brief Intervention for School Clinicians (Tier 2/3).

• Bounce Back (Tier 3).

• Skills for Academic and Social Success (Tier 3).

• Building Confidence (Tier 3).

Engage Students in Coping Skills Training Groups

Description of Approach: Coping skills training groups use principles of cognitive behavioral intervention to teach students skills to help them handle specific struggles and periods of adjustment. Similar to social, emotional, and behavioral learning programs, coping skills training often emphasizes strengthening resilience and learning to practice skills outside of the small group.

Provide Cognitive Behavioral Interventions

Description of Approach: Cognitive behavioral interventions teach students how to manage their thoughts and behaviors. Cognitive behavioral interventions in schools often include multiple small-group or individual sessions that follow a standardized manual of activities that help students examine their own thoughts and behaviors. Cognitive behavioral interventions sometimes encourage sharing what students learn about their thoughts and behaviors with others, including parents. Modular cognitive behavioral intervention is one example of this type of intervention in which counselors or therapists focus on a specific topic particularly relevant for a small group of students or one student. Other cognitive behavioral interventions specifically target symptoms of depression, anxiety, or posttraumatic stress.

Evidence Summary: Research into cognitive behavioral interventions has shown significant improvements in a range of mental health outcomes in students, including the following:

� Internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms)67-69

�Anxiety, including social anxiety70-73

�Depression73-75

� Posttraumatic stress69, 73, 75, 76

Evidence Description: Research shows that teachers can effectively deliver cognitive behavioral interventions during classroom activities in K–12 schools. In one study, researchers showed that internalizing behaviors (e.g., feelings of anxiety, withdrawal, and depressive symptoms) decreased among elementary and middle school students.68 High school students who received a cognitive behavioral intervention during a wellness class showed lower levels of depression than students who did not receive the intervention.74 Modular cognitive behavioral interventions have been shown to help K–12 school students with anxiety and other internalizing behaviors.67, 71, 77, 78

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

behavior caused by extreme emotions (emotional dysregulation). For this reason, some schools have begun implementing whole-school approaches to create trauma-sensitive school climates.

Implementation Tips Cognitive behavioral interventions and psychosocial skills training occur across a range of tiers of student needs and grade levels. School administrators may do the following:

• Work with school-based mental health staff to find ways for students to practice their new behaviors and coping skills.

• Use the MTSS framework described earlier in this action guide to ensure that students are appropriately screened and matched with classroom, small-group, or individualized interventions depending on their needs.

Evidence Summary: Coping skills training groups have been shown to have the following effects:

�Anxiety80

�Depression80

�Coping81

Evidence Description: Coping skills training groups use principles of cognitive behavioral intervention by teaching specific skills for specific struggles and periods of adjustment. Like social skill and emotional development programs, coping skills training often emphasizes strengthening resilience and learning to practice a growth mindset. For example, one study evaluated a coping skills training program for middle schoolers transitioning into high school and showed improvements in both anxiety and depression.80 Another intervention paired coping skills training with social, emotional, and behavioral learning to help students after a natural disaster and showed improvements in measures of coping with stress.81

Learn more about the coping skills training group program we reviewed:

• Journey of Hope (Tier 1).

• High School Transition Program (Tier 3).

Focus on Equity Children who have been exposed to adverse childhood experiences and trauma often receive cognitive behavioral interventions in schools because of their unique mental health needs. It is critical that students who have been exposed to trauma have the opportunity to receive trauma- focused or trauma-informed interventions. These interventions address the unique needs of students who have been exposed to trauma by being sensitive to potential triggers of re-experiencing trauma, being aware of students’ fight-or-flight emotional response, and preventing potential outbursts or disruptive

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Evidence Summary: Mindfulness-based training programs have been associated with the following mental health outcomes among teachers and school staff:

� Stress84-86, 88, 90

�Depressive symptoms85, 86, 88, 90

�Anxiety85, 86, 88, 90

�Well-being90

Evidence Description: Positive effects on stress and feelings of depression and anxiety were consistently observed after participation in mindfulness-based professional development programs:

• High school teachers and staff perceived work to be less stressful and reported decreased stress levels overall.84

• Teachers, including educators of children with special needs, experienced reductions in stress, feelings of anxiety, and depressive symptoms.85, 86

6. Support Staff Well-Being In a 2022 survey, 73% of K–12 teachers and 85% of principals reported experiencing frequent job-related stress—about twice as high as the average across all work sectors.82 Compared to other working adults, teachers and principals were also more likely to report burnout and symptoms of depression, and less likely to report feeling resilient. Educators of color, especially Hispanic and Latine/Latinx teachers, were more likely than their White peers to experience symptoms of depression.82 Poor teacher well-being and mental health is also associated with lower- quality learning environments and poorer academic achievement among students.83

What Can Schools Do? Districts and schools may consider incorporating opportunities for teachers and school staff to learn about how supportive practices, such as mindfulness, can be incorporated into daily routines.84-88 Schools may also make therapeutic resources available to teachers and staff.89

Offer Mindfulness-Based Training Programs

Description of Approach: Mindfulness-based training programs can help teachers develop skills to effectively manage the demands of teaching and mitigate the physical and psychological impacts of stress. Mindfulness-based programs for teachers and staff are typically group-based and can be delivered over the course of several weeks during planning periods, before or after school,84 or during longer evening or full-day sessions.85, 86 Across modes of delivery, programs focus on recognizing and understanding one’s own emotions and emotional patterns and using mindfulness, meditation, yoga, and breathing exercises to regulate emotions.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Evidence Description: In one study, researchers partnered with a school district to evaluate the effectiveness of a self-help version of ACT that involved reading an ACT workbook and completing exercises. Researchers reported two key findings:

• Reading the workbook and engaging in the exercises prevented the onset of psychological distress for teachers and school district staff who were not experiencing elevated symptoms of anxiety or depression at the start of the intervention. Teachers and staff who were not experiencing elevated symptoms of anxiety and did not receive the self-help workbook were more likely to meet clinical criteria for anxiety and depression at follow-up than were their peers who read the workbook and engaged in the exercises.

• Reading the workbook and engaging in the exercises reduced symptoms of psychological distress among teachers and school district staff experiencing elevated symptoms of stress, anxiety, or depression at the start of the intervention. Teachers and staff who met clinical cutoffs for stress, anxiety, or depression and who read the self-help workbook and engaged in the exercises experienced a greater reduction in symptoms than their peers who did not receive the self-help workbook.

Learn more about the therapeutic resource that we reviewed:

• ACT Bibliotherapy.

• School district employees and teachers reported less psychological distress, which included indicators of stress, anxiety, and depression88, 90 as well as improved overall well-being.90 One study reported that the program was equally beneficial for school district employees who reported higher anxiety or depressive symptoms before participating in the program and that benefits lasted for 3 months after program participation.90

Learn about the mindfulness training programs for teachers that we reviewed:

• Healthy Minds Program .

• Cultivating Awareness and Resilience in Education .

• Stress Management and Relaxation Techniques in Education .

• Relaxation Therapy .

• Contemplative/Emotion Training.

Provide Therapeutic Resources

Examples include self-help workbooks as a cost-effective option for supporting K–12 teachers’ and staff members’ mental health.

Evidence Summary: Research found therapeutic resources for acceptance and commitment therapy (ACT) had the following effects among teachers and school staff:89

� Stress

�Depressive symptoms

�Anxiety

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

• Coordinating teacher and administrator needs with parent–teacher associations or parent–teacher organizations; this provides an opportunity for engaging the community in these efforts. For example, parent–teacher associations could coordinate teacher appreciation activities.

• Depending on the level of support available through school districts, consider allowing school or district mental health and wellness teams to offer some level of support to teachers as well. This might include providing training or support during in-service or professional development days or compiling a robust referral list of mental health providers in the community.

“School climate is awesome and I’m like, ‘Woohoo,’ but part of… the reason why is because we’re providing psychological supports for the staff.”

— School staff member

Organizational changes can help reduce stress and create consistent opportunities for school staff to engage in positive coping.

• Learn more about how to develop comprehensive plans for teacher and staff well-being using an MTSS approach .

• Organizational changes can help reduce stress and create consistent opportunities for school staff to engage in positive coping. For additional information and resources, see Tips for Promoting School Employee Wellness .

Focus on Equity In a recent survey,82 teachers and principals of color were more likely to experience racial discrimination than their White peers. Teachers of color were most often racially discriminated against by other staff, but principals of color were most often racially discriminated against by students’ family members. Subsequent analysis then linked that racial discrimination with worse mental health outcomes. This suggests that addressing racial discrimination and promoting inclusivity in schools could have a positive impact on the mental health of teachers and principals of color.

Strategies for reducing racial discrimination and promoting inclusivity include the following:

• Offering culturally relevant mental health and well-being supports that are accessible to staff.

• Building supportive environments within schools by ensuring that efforts to build supportive environments for students include safe spaces for staff (e.g., affinity groups) and activities that provide social support and promote resilience.

Implementation Tips School administrators can support staff well-being approaches by doing the following:

• Asking staff how school practices and policies could be improved to reduce stress.

• Incorporating opportunities to practice mindfulness skills within existing routines. For example, adding a mindfulness minute to start meetings, the school day, or professional development opportunities.

• Engaging school staff in discussions about how to overcome barriers to accessing mental health supports.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

• Responsive circles, which are designed to address peer conflict in a school and include the students involved in a specific conflict along with an adult facilitator.

• Restorative conferences, which are held to negotiate a repair after a student’s behavior harmed a relationship with another student or staff member.

Restorative practices are most successful when they are used throughout a school building to set expectations for positive relationships and accountability. See the International Institute for Restorative Practices (IIRP) for more information and training on restorative practices in schools.

Many high schools across the United States have implemented restorative practices with promising results, including declines in out-of-school suspension and disproportional exclusionary discipline.91, 92 In one study in Denver, district suspension rates declined by nearly 47%, with the largest reductions among African American students.92 Restorative practices are often implemented instead of suspensions or expulsions, which have been shown to affect racial and ethnic minority groups of students at higher rates than ethnic majority groups.93 Discipline disparities are associated with negative outcomes for Black boys and young men, including lower levels of school connectedness, school engagement, and academic achievement.94 Restorative practices have shown positive results in reducing exclusionary discipline (e.g., out-of-school suspension95), although results from experimentally controlled studies are mixed as to whether or not disparities in discipline for Black students were reduced.96,97

Promising Practices for Promoting Mental Health and Well-Being in Schools While the six foundational strategies presented above were supported by a collection of evidence found in rigorous peer-reviewed literature, emerging evidence suggests that approaches for promoting nurturing and welcoming school environments may have a positive effect on the mental health and well-being of students and staff but did not have the level of evidence needed to meet criteria for inclusion as a strategy in this Action Guide. These approaches were mentioned by both focus group participants and subject matter experts, and they were found in either the gray literature or peer- reviewed literature that was not rigorous enough to meet criteria for inclusion (e.g., a study without a comparison group; a study that showed impact on outcomes related to mental health, but not mental health directly, etc.). As such, additional research is needed on the effectiveness of the strategies described in this section, but they offer promise for promoting student mental health and well-being. School administrators can consider two primary approaches for promoting welcoming school environments—with the caveat that additional research is needed on their impact on mental health outcomes.

Restorative practices can be implemented in schools and are characterized as promoting high levels of warmth and positive relationships between staff and students and high levels of structure and accountability for one’s behaviors. Restorative practices often include the following:

• Proactive circles, or community circles, where students are brought together, typically with facilitation by an adult, to set expectations and build relationships among students in a classroom.

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Conclusion This action guide provides K–12 schools, districts, and administrators with strategies and approaches to promote mental health and well-being in schools based on the most current research evidence, lived experience of students and school staff, and subject matter expert opinions. As mental health concerns for young people have increased in recent years, schools need approaches that are evidence based and feasible. The strategies and approaches presented in this package are best centered in the MTSS that many schools already use to assess and address students’ needs. Centering equity in implementation of these strategies and approaches is also critical for prioritizing the unique experiences of students and staff who are disproportionally affected by poor mental health outcomes. School leaders can use this resource to reflect on current practices in their district and schools and explore opportunities for improvement and expansion of strategies to effectively and equitably support student mental health.

Genders and Sexualities Alliances. Schools should consider implementing internal structures of social support, such as Genders and Sexualities Alliances, for students who face discrimination. States with policies that support nondiscrimination of LGBTQIA+ students also have more Gay Straight Alliances (more recently referred to as Genders and Sexualities Alliances) in schools.98 In addition, emerging research suggests Genders and Sexualities Alliances may be associated with more social support, which buffers against depression and anxiety in LGBTQIA+ youth.99

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Appendix A

Assessing the Evidence

Peer-Reviewed Literature Review Empirical evidence about programs, policies, and practices was obtained through a review of school mental health-related literature and was included if the following criteria were met:

• Research was peer reviewed.

• Research was conducted in K–12 school settings in the United States with students, teachers, or staff between 2011 and 2021.

• The study was a randomized controlled trial or quasi-experimental study with a statistically controlled comparison group.

• Outcomes related to K–12 students’, teachers’, or school staff’s mental health and well-being were reported (e.g., resilience, coping, depression, anxiety, internalizing problems [often measured as a mix of symptoms including feelings of anxiety, depression, withdrawal, and anhedonia], trauma, stress, suicide).

A search strategy was developed for the peer-reviewed literature that included search terms and a list of the databases to be searched. The final search was completed in April 2022. The search strategy is summarized in Table A.1.

Table A.1 Search Strategy

Population (kindergarten* OR “elementary school*” OR “middle school*” OR “high school*” OR “K-12” OR (student* AND (child* OR youth* OR adolescent* OR teen* OR “teacher” OR “staff” OR “personnel” OR “nurse” OR “administrator” or “paraprofessional”)) OR “school based”)

AND Mental Health (“mental health” OR “social emotional learning” OR “behavioral problem*” OR “behavior problem*” OR “social problem*” OR “emotional problem*” OR “depression” OR “anxiety” OR “trauma” OR “stress” OR “bullying” OR “verbal aggression” OR “physical aggression” OR “victimization” OR “well-being” OR “coping” OR “emotion*”)

AND Supports (“comprehensive school mental health” OR “school mental health service*” OR “school mental health support*” OR “access to care” OR “school psychologist*” OR “school counselor*” OR “school social worker*” OR “family school relationship” OR “school community relationship” OR “school environment” OR “school climate” OR “school infrastructure” OR “multi-tiered systems of support” OR “interconnected system*” OR “framework” OR “Tier 1” OR “Tier 2” OR “Tier 3” OR “cultural responsiveness” OR “culturally responsive” OR “equity” OR “inclusive” OR “inclusion” OR “resilience” OR “training” OR “professional development” OR “employee assistance program/EAP” OR “response to intervention” OR “positive behavioral interventions and support”)

OR

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Population Promotion (“mental health promotion” OR “mental health prevention” OR “mental health intervention*” OR “mental health screening” OR “mental health risk assessment*” OR “teaming” OR “needs assessment” OR “resource mapping” OR “mental health program*” OR “mental health policy” OR “mental health policies” OR “mental health literacy” OR “mental health education” OR “psychoeducation” OR “prevention” OR “policy” OR “intervention”) Years 2011–April 12, 2022 Language English Geographic Area U.S. only Population K–12 students or staff Databases PubMed; Web of Science; PsycInfo; ERIC; Embase; CINAHL

Inclusion and exclusion criteria related to population, intervention type, comparison group, outcomes, study design, setting, timing, publication, and language were also developed. Whereas some criteria are consistent (i.e., population, setting), others (e.g., comparisons, study design) varied across policies, programs, and practices due to fundamental differences in implementing and evaluating different types of intervention strategies. For example, articles evaluating programs or practices were required to have a statistically controlled comparison group whereas articles evaluating policies were not. Table A.2 lists inclusion and exclusion criteria.

Table A.2 Inclusion and Exclusion Criteria

Criterion Include Exclude Populations K–12 students, teachers, or staff Populations other than K–12 students, teachers,

or staff (e.g., parents, college students) Interventions Programs; policies; practices implemented in

K–12 school settings during the typical school day

Medicine

Policies, programs, practices that are implemented outside of K–12 typical school day (e.g., after school) or outside of a school setting

Comparisons Statistically controlled comparison group (e.g., active control condition, usual care, waitlist control). Note: for policies include single group pretest-posttest comparisons

No statistically controlled comparison group (e.g., single group pretest-posttest), except in the case of policies

Outcomes Outcomes that are related to K–12 students’ or teachers’/school staff mental health and well-being (e.g., psychosocial outcomes, social-emotional learning, access to care) • mental health/well-being/coping • social-emotional learning • behavioral/social/emotional problem • depression/anxiety • trauma/stress • suicide

Outcomes that are not directly tied to staff or students’ social, emotional, and mental well- being (e.g., physical health promotion, academic problems/learning disabilities, substance use, sexual risk behaviors, truancy, homelessness, bullying/verbal aggression/physical aggression/ victimization etc.)*

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

Criterion Include Exclude Study designs Randomized controlled trials; quasi-

experimental designs; systematic reviews; meta-analyses

Case reports, case series; studies that are only descriptive or qualitative; feasibility studies; psychometric studies; cost-only studies (except in the case of policies)

Setting K–12 school settings in the United States Research conducted in settings other than K–12 schools in countries other than the U.S.

Timing Publications between 2011 and 2021 Publications before 2011; publications after 2011 based on data collected before 2011

Publication type Original research Commentaries, editorials, conference abstracts, study protocols, presentations, dissertations/ theses

Language English Non-English studies

* Publications that include both mental health outcomes and non–mental health outcomes (e.g., substance use) were included.

Gray Literature Review A review of the gray literature (e.g., publications from academic institutions, national organizations and foundations, and federal government resources) was also conducted using the same outcomes and time frame as the peer-reviewed literature search. An online search engine was used to identify sources including government websites and professional organizations’ publications. In addition to a key word search, additional searches were conducted to identify gray literature that described the mental health impact of school-based policies, trauma-informed schools, and mental health education.

Focus Groups Contextual evidence was gathered through focus groups conducted with students, parents/caregivers, school- based mental health staff (e.g., counselors, social workers, and psychologists), other school staff (e.g., teachers, nurses, and administrators), and nongovernmental organization (NGO) representatives. Respondents provided feedback on the availability of programs, policies, and practices to support mental health and well-being in schools, and their perceptions of and suggestions for improved implementation.

Expert Listening Sessions Listening sessions were also conducted with experts in school-based mental health and well-being from NGOs, academia, educational agencies, and federal agencies. They provided additional critical insight around how to frame recommendations, center equity in the recommended approaches, and support implementation of the six strategies described in this action guide.

The example policies, programs, and practices included in this action guide are not intended to be a comprehensive list for each approach but rather to serve as examples that have shown impact on the mental

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Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders

health and well-being of K-12 students and staff based on peer-reviewed literature. It is important to note that programs, policies, and practices that have an impact on outcomes related to mental health and well-being, such as bullying, externalizing behaviors, substance use, chronic absenteeism, physical health promotion, are not included in this action guide. Additional evidence-based resources may be found in existing program registries, such as the following:

The strategies included in this action guide also do not represent all school-based strategies that benefit student well-being, such as school nutrition and physical activity programs, which provide important contributions to students’ health and well-being. For more information about additional school-based health promotion strategies, see Healthy Schools | CDC.

• Blueprints for Healthy Youth Development

• The California Evidence-Based Clearinghouse for Child Welfare

• CDC Division of Violence Prevention’s Resources for Action

• Collaborative for Academic, Social, and Emotional Learning (CASEL)

• Programs That Work, from the Promising Practices Network on Children, Families and Communities

• What Works Clearinghouse

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