A Comprehensive School-Based Mental Health Model: A Decade in the Making

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript is well written, has a clear purpose, and adds a novel tool to the literature. The EIS - universal screening - has the potential to improve child mental health and academic outcomes among youth. The paper describes the process of building and then intregrating the EIS into several school districts. This article will be very helpful for schools/communities to learn about and implement in their own districts. 

Author Response

Comment:  This manuscript is well written, has a clear purpose, and adds a novel tool to the literature. The EIS - universal screening - has the potential to improve child mental health and academic outcomes among youth. The paper describes the process of building and then intregrating the EIS into several school districts. This article will be very helpful for schools/communities to learn about and implement in their own districts. 

Response:  We appreciate this comment. Thank you.

Reviewer 2 Report

Comments and Suggestions for Authors

In this article, the authors briefly describe a tool for screening mental health issues in youth. The Early Identification System (EIS). The text presents several aspects: a description of the mental health model and the development of the tool, its use over time, and the work with school practitioners.

The article has a number of qualities: it is well written, the authors consistently follow the basic idea, respectively the presentation of the development and use of EIS over the last decade, the theoretical foundation is adequate, and the ideas expressed are well argued.

However, although the article has undeniable merits, its content does not correspond to the profile of this scientific journal, which focuses on research results. The article is not based on empirical data and does not have a scientific format generally accepted by journals of this type (systematic review, meta-analysis, scale validation, experimental study, correlational study, etc.). Unfortunately, I cannot identify any contribution to scientific knowledge; rather, the text represents information addressed to potential users of this screening tool. For this purpose, it is not necessary to publish in such scientific journal, but other ways of disseminating the information contained in the article can be identified.

Author Response

Comment: The article has a number of qualities: it is well written, the authors consistently follow the basic idea, respectively the presentation of the development and use of EIS over the last decade, the theoretical foundation is adequate, and the ideas expressed are well argued.

Response:  Thank you for this comment.

Comment: However, although the article has undeniable merits, its content does not correspond to the profile of this scientific journal, which focuses on research results. The article is not based on empirical data and does not have a scientific format generally accepted by journals of this type (systematic review, meta-analysis, scale validation, experimental study, correlational study, etc.). Unfortunately, I cannot identify any contribution to scientific knowledge; rather, the text represents information addressed to potential users of this screening tool. For this purpose, it is not necessary to publish in such scientific journal, but other ways of disseminating the information contained in the article can be identified.

Response:  We appreciate that the article does not provide new original data.  However, we were invited to submit a summary of the work of the EIS over the past decade.  This article provided evidence and work across a decade in one place.  We feel fortunate to have the opportunity to compile and submit this article.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this interesting and innovative work. Overall, the manuscript is strong and makes a significant contribution. However, throughout, there were a couple of questions that came to mind that should be clarified: 

1. Were parent reports considered? If so, why were they not included?
2. Were instructions given to the teachers regarding how frequently a behavior should occur to report it on the scale? For example, many students argue or lie occationally. Is it enough for a teacher to check the box for that student if they do this only once? 

Author Response

Comment 1:  Were parent reports considered? If so, why were they not included?

Response 1: The EIS does not currently have a parent report measure, but we are working on one for the near future.

Comment 2: Were instructions given to the teachers regarding how frequently a behavior should occur to report it on the scale? For example, many students argue or lie occationally. Is it enough for a teacher to check the box for that student if they do this only once? 

Response 2: Teachers are asked to reflect on students they have had in class and rate each behavior accordingly.  Teachers have many comparisons of student behaviors.  We have found teacher report to be valid in that they predict expected other data (e.g., high externalizing behavior predicts suspensions).  In one study we found that teacher report that a student is not behaviorally ready in the fall of Kindergarten predicts a host of negative outcomes in third grade (see Reinke, et al., 2025 https://doi.org/10.1080/18387357.2025.2516425).

Reviewer 4 Report

Comments and Suggestions for Authors

Review of “A Comprehensive School-Based Mental Health Model: A 2 Decade in the Making”

 

This is a timely report of exemplary school-based mental health screening.  At a time when some Federal government officials are questioning school-based screening for mental health, this study provides important empirical information on this screening system.  This is a very thoroughly researched system, documenting acceptability and feasibility, good psychometric properties, and evidence that the program is effective, which is bolstered by showing the relationship between fidelity and outcomes. It seems this program has met the criteria outlined by Gottfredsen et al (2015) “Standards of Evidence for Efficacy, Effectiveness, and Scale-up Research in Prevention Science: Next Generation” for effectiveness. 

 

A few points for the authors to consider. 

 

• In the introduction, the authors introduce the concepts of universal, selective, and indicated interventions. Attached to those descriptions is the commonly used breakdown of 80%, 15%, and 5% breakdown of these groups, respectively. This does not match the data, where 15% of youth in US schools qualify for special education, and over 40% are screening positive for sadness or depression.  Rather than trying to force students into the 80, 15, 5 breakdown for care, I think schools need to recognize the actual level of clinical need and work with that. The system described by the authors seems to be able to identify the levels of need, such as if more than 20% of the students exhibit a problem, then they suggest implementing a universal intervention.   However, that consideration is potentially lost with the outdated and misleading reference to the 80,15, 5 proportions.
• The authors describe using two standard deviations above the mean to identify high-risk children. This could be misleading. Rather than using arbitrary statistical standards, cutoffs for identifying students in need should be identified using specificity, sensitivity, and ROC curves for predicting critical outcomes (e.g., mental health diagnosis, academic failure, or behavior problems).
• It is not clear to me from this manuscript how the system allocates students to selective or indicated levels of intervention.
• In the final comments, consistent with Gottfredsen et al 2015, it would be helpful if the authors made some comments on what needs to be done to make this program ready for widespread dissemination. They mention websites and free access; however, going through the recommendations of Gottfredsen would improve the section on implications for practice and policy.

Author Response

Comment 1: This is a timely report of exemplary school-based mental health screening.  At a time when some Federal government officials are questioning school-based screening for mental health, this study provides important empirical information on this screening system.  This is a very thoroughly researched system, documenting acceptability and feasibility, good psychometric properties, and evidence that the program is effective, which is bolstered by showing the relationship between fidelity and outcomes. It seems this program has met the criteria outlined by Gottfredsen et al (2015) “Standards of Evidence for Efficacy, Effectiveness, and Scale-up Research in Prevention Science: Next Generation” for effectiveness. 

Response 1:  Thank you for this comment.

Comment 2: In the introduction, the authors introduce the concepts of universal, selective, and indicated interventions. Attached to those descriptions is the commonly used breakdown of 80%, 15%, and 5% breakdown of these groups, respectively. This does not match the data, where 15% of youth in US schools qualify for special education, and over 40% are screening positive for sadness or depression.  Rather than trying to force students into the 80, 15, 5 breakdown for care, I think schools need to recognize the actual level of clinical need and work with that. The system described by the authors seems to be able to identify the levels of need, such as if more than 20% of the students exhibit a problem, then they suggest implementing a universal intervention.   However, that consideration is potentially lost with the outdated and misleading reference to the 80,15, 5 proportions.

Response 2:  The 80, 15, 5 proportion is referencing a public health approach that indicates optimal levels for intervening across each tier.  Importantly, schools often neglect the resources to intervene one student at a time when more a large number of student indicate need (e.g., 40% student report sadness or hopelessness).  To avoid overwhelming the system, we advise schools to implement a universal intervention that can potentially reduce the number of students with the issue to allow for those most in need to be identified and for interventions to occur.  We have added the following sentence to the manuscript.  

"The 80-15-5 ratio is a generalization that helps illustrate the public health pyramid, a tiered framework for organizing and prioritizing prevention efforts, and provides a way to allocate resources effectively across different levels of risk."

Comment 3: The authors describe using two standard deviations above the mean to identify high-risk children. This could be misleading. Rather than using arbitrary statistical standards, cutoffs for identifying students in need should be identified using specificity, sensitivity, and ROC curves for predicting critical outcomes (e.g., mental health diagnosis, academic failure, or behavior problems).

Response 3:  We use local norms within each school building by identifying those student in that building who are 2 standard deviations above their peers.  Because the EIS is a screener, other data are then used to determine if the identified areas for potential risk is indeed an area the student would benefit from intervention.  The use of local norms is a novel and innovative aspect of the EIS because this does not identify a large portion of students overwhelming the schools (e.g., 40% of student in need of services based on data), but only identifies those student in that building with the highest needs.

Comment 4: It is not clear to me from this manuscript how the system allocates students to selective or indicated levels of intervention.

Response 4: The system is a tool for schools to determine this based on the EIS data.  Also, in the system the red, yellow, green system helps schools identify student who may benefit from selective (yellow) or indicated (red) levels of intervention.  We have edited the manuscript to make this more clear.

Comment 5: In the final comments, consistent with Gottfredsen et al 2015, it would be helpful if the authors made some comments on what needs to be done to make this program ready for widespread dissemination. They mention websites and free access; however, going through the recommendations of Gottfredsen would improve the section on implications for practice and policy.

Response 5:  Thank you.  We have added additional information in the discussion that outlines what is currently in progress or needs to occur for the program to be widely disseminated.

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Unfortunately, I must uphold the decision to reject the article made in the first round of review. I reiterate here the arguments already presented:
(1) The article is not based on empirical data and does not have a scientific format generally accepted by journals of this type (systematic review, meta-analysis, scale validation, experimental study, correlational study, etc.).
(2) No contribution to scientific knowledge can be identified; rather, the text represents information addressed to potential users of a tool called The Early Identification System (EIS).

Author Response

Unfortunately, I must uphold the decision to reject the article made in the first round of review. I reiterate here the arguments already presented:
Comment 1. The article is not based on empirical data and does not have a scientific format generally accepted by journals of this type (systematic review, meta-analysis, scale validation, experimental study, correlational study, etc.).

Response 1.  The intent of the manuscript is to provide a full review of the research conducted over the past decade on a comprehensive school-based mental health model.  The Aims and Scope of Behavioral Sciences does state that a goal of the journal is to rapidly disseminate original articles to behavior scientists, including reviews; it does not stipulate that papers need to provide new empirical data. Further, the original idea of submitting a review of research was vetted prior to being submitted by the researchers organizing the special issue.

  
Comment 2. No contribution to scientific knowledge can be identified; rather, the text represents information addressed to potential users of a tool called The Early Identification System (EIS).

Response 2.  The manuscript does make an scientific contribution in that it highlights a comprehensive school mental health model which has a series of studies that demonstrate the promise of using this model or similar models in schools has on youth outcomes. We are not aware of any other school mental health model that has similar levels of evidence to support it. The intent is to summarize and inform behavioral and social scientists, as well as to clinical practitioners, educationalists, and the general public about this innovative model.