ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ i Bridging the Gap: Implementing a Multi-Stakeholder Approach to Enhance Mental Health and Social Service Initiatives in a Rural School District A Doctoral Capstone Project​ Submitted to the College of Education, Arts and Humanities​ Department of Education​ ​ In Partial Fulfillment of the​ Requirements for the Degree of ​ Doctor of Education​ ​ Denelle R. Diehl​ Pennsylvania Western University​ July 2025 ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ iii Dedication ​ The public education system seeks to nurture one of the extraordinary forces within this universe, the human mind. Careful care and cultivation of curiosity, creativity, and critical thinking by educators have helped cured diseases, advanced society through innovation and ingenuity, and even put a man on the moon. Beyond these complex formulas and mathematical calculations, the essence of the human experience has been captured and replayed in stories, music, screenplays and poetry. The human mind responsible for the creation of it all. While this complex network is powered by impersonal compounds and mere electricity, it is capable of housing the full spectrum of human emotions, from the bounty that love brings to the depths of despair. From the impersonal, comes the idiosyncrasies of each individual and the nuances of a unique personality. Despite its near limitless potential, the human mind is equally as capable of limiting its own possibilities. Without proper care, the human mind can extinguish the very gifts that make this world a better place. This work is dedicated to those who bravely and diligently seek care to protect this asset which is most dear to each of us, particularly students who face mental health challenges in their formative years. Throughout the course of this study, this purpose has not been forgotten, nor has the memory of those gone too soon…. Help is available for those in crisis. If you or someone you know are experiencing feelings of despair or suicidal ideation, please call or text the National Suicide Hotline at 988. ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ iv Acknowledgements I have learned that the simple practice of gratitude has a very profound and positive impact on overall wellbeing. As this project draws to a close, my heart is full when I reflect upon the village who have walked this path with me. In one way or another, you have each taught me how to better lead with a tough skin and a tender heart… To Dr. Mary Wolf, thank you for your careful and considerate guidance that you have provided each step of the way on my leadership and doctoral journey. The care for your students and the betterment of public education as a whole, is evident in all you do! To Dr. Jerry Shoemake, thank you for giving of your time, knowledge and expertise in helping me to realize the completion of this project and for the practical advice in helping me apply the lessons learned each day at Tussey Mountain. To Dr. Maria Scott-Bollman, thank you for, despite being firmly retired, agreeing to be my “teacher” one last time. You continue to model what it means to be not only a caring educator, but what it means to be a woman who leads with grace, confidence and intelligence in this industry. To Bill Denny and Matt Goddissart, thank you for guidance and expertise with editing and formatting and helping me to make this project the best it could be. To Amy, thank you for walking with me from the darkness into light and continuously reminding me that prioritizing self, enables care for others. To Jacque, Robin and Brenda, thank you for the many pep-talks and days when we dared to dream of something bigger for our students. I am lucky to have each of you as co-workers and even more fortunate to count you as friends. To my family, Mom, Dad, Darcee, Kyle, and Tera, thank you for always being my cheerleaders, practical advice-givers, and a source of constant encouragement. And to my JD, thank you for always reminding me to see that in every situation, even perceived problems, flaws and insecurities that there is something to love and there is something to use. You bring me (and Finn) joy, a sense of peace, and laughter each day. We love you dearly! ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ v Table of Contents Signature Page​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ii​ Dedication​ ​ ​ ​ ​ ​ ​ ​ ​ ​ iii​ Acknowledgements​ ​ ​ ​ ​ ​ ​ ​ ​ ​ iv List of Tables​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ix​ List of Figures​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ x​ Abstract​ ​ ​ ​ ​ ​ ​ ​ ​ ​ xi​ CHAPTER I: Introduction​ ​ ​ ​ ​ ​ ​ ​ ​ 1​ Background​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2 New Mental Health Initiatives​ ​ ​ ​ ​ ​ ​ 3 Presentation of Research Questions​ ​ ​ ​ ​ ​ ​ ​ 5 Data Collection & Participants​ ​ ​ ​ ​ ​ ​ ​ 6 Financial Implications​​ ​ ​ ​ ​ ​ ​ ​ ​ 7 Chapter Summary​ ​ ​ ​ ​ ​ ​ ​ ​ 8​ CHAPTER II: Review of Literature​ ​ ​ ​ ​ ​ ​ ​ 10 The Pennsylvania Youth Survey​ ​ ​ ​ ​ ​ ​ 10 Evolution of the Pennsylvania Youth Survey: History & Development​ ​ 12 Pennsylvania Youth Survey: Purpose & Uses​ ​ ​ ​ ​ ​ ​ The Impact of Risk & Protective Factors for Students​ ​ ​ ​ ​ ​ ​ 16 ​ ​ ​ ​ 18 Relationship Between Risk Factors, Protective Factors & Student Outcomes​ 21 Impact of the COVID-19 Pandemic and Social Media on Risk and Protective 24​ Factors​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ vi Student Wellbeing, Challenges and Relationship to School Achievement​ ​ 30 Debate: The School’s Role in Supporting Adolescent Mental Health​ ​ ​ ​ 36 ​ Current Challenges, Opportunities, Barriers and Programming Models​ ​ 39​ ​ Parent Perspectives​ ​ ​ ​ ​ ​ ​ ​ ​ 45​ ​ ​ ​ ​ ​ ​ ​ ​ 47​ CHAPTER III: Methodology​​ ​ ​ ​ ​ ​ ​ ​ 50 Study Purpose​​ ​ ​ ​ ​ ​ ​ ​ ​ 51 Research Setting & Context​ ​ ​ ​ ​ ​ ​ ​ ​ 53 Chapter Summary​ ​ ​ ​ Student Risk & Protective Factors within the Tussey Mountain School District​ Selection of Research Participants​ ​ ​ 54 ​ ​ ​ ​ ​ 62 ​ Research Question One: Student Surveys​ ​ ​ ​ ​ ​ 62 ​ Research Question Two: Student Interviews​ ​ ​ ​ ​ ​ 62 ​ Research Question Three: Parent Surveys​ ​ ​ ​ ​ ​ 63 ​ ​ ​ ​ ​ 63 Research Methods & Data Collection​​ ​ ​ Research Question One: Data Sources & Collection Methods​ ​ ​ 64​ ​ Research Question Two: Data Sources & Collection Methods​ ​ ​ 65 ​ Research Question Three: Data Sources & Collection Methods​ ​ ​ 65 Fiscal Implications​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 66 Validity​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 66​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 67 CHAPTER IV: Data Analysis & Results​ ​ ​ ​ ​ ​ ​ 70​ Use of Data Triangulation​ ​ ​ ​ ​ ​ ​ 70 ​ Chapter Summary​ ​ ​ ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ vii Research Question One: Data Analysis & Results​ ​ ​ ​ ​ ​ 71​ Results: PhenX School & Protective Factors Tool Kit​ ​ ​ ​ 72 Results: Phen X School Social Factors Tool Kit​ ​ ​ ​ ​ 78​ Results: Discipline Data​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 84 ​ ​ ​ ​ ​ ​ 86 Research Question Two: Data Analysis & Results​ ​ ​ ​ ​ ​ 88 Results: Quantitative & Qualitative Summary of Student Interviews​ ​ 89 Results: Chill Room Usage Data​ ​ Research Question Three: Data Analysis & Results​ ​ ​ ​ ​ ​ 92 ​ Results: Parent Pre Surveys​ ​ ​ ​ ​ ​ ​ ​ 93 ​ Results: Parent Post Surveys​ ​ ​ ​ ​ ​ ​ ​ 100 ​ Comparison: Pre & Post Surveys​ ​ ​ ​ ​ ​ ​ 107 ​ ​ ​ ​ ​ ​ 109​ CHAPTER V: Conclusions & Recommendations​ ​ ​ ​ ​ ​ 113 Research Question One: Conclusions ​ ​ ​ ​ ​ ​ ​ 114 ​ Impact on Risk Factors​ ​ ​ ​ ​ ​ ​ ​ 115 ​ Impact on Protective Factors​ ​ ​ ​ ​ ​ ​ ​ 117 ​ Recommendations for Future Research​ ​ ​ ​ ​ ​ 119 Chapter Summary​ ​ ​ ​ Research Question Two: Conclusions​ ​ ​ ​ ​ ​ ​ 120 ​ Student Reports of Awareness​ ​ ​ ​ ​ ​ ​ 121 ​ Student Reports of Access​ ​ ​ ​ ​ ​ ​ ​ 122 ​ Student Reported-Barriers​ ​ ​ ​ ​ ​ ​ ​ 123 ​ Recommendations for Future Research​ ​ ​ ​ ​ ​ 124 ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ viii Research Question Three: Conclusions​ ​ ​ ​ ​ ​ 124​ ​ ​ ​ ​ ​ 127 ​ ​ ​ ​ ​ 128 Recommendations for Future Initiatives at the Tussey Mountain School District​ ​ 129 Financial Implications​​ ​ ​ ​ ​ ​ ​ ​ ​ 130 Closing​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 132 References​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 134 Appendix A: Institutional Review Board Documentation​ ​ ​ ​ ​ 144 Appendix B: Survey Informed Consent Letter​ ​ ​ ​ ​ ​ 145 Appendix C: Student Assent Statement (Surveys)​ ​ ​ ​ ​ ​ 149​ Appendix D: Informed Consent (Interviews & Surveys)​ ​ ​ ​ ​ 151 Appendix E: Student Assent Form (Interviews)​ ​ ​ ​ ​ ​ 154 Appendix F: Student Interview Script​ ​ ​ ​ ​ ​ 156​ Appendix G: Informed Consent (Parent Surveys)​ ​ ​ ​ ​ ​ 158​ Appendix H: Parent Survey Questions​ ​ ​ ​ ​ ​ 161​ Appendix I: Thematic Coding, Research Question Two​ ​ ​ ​ ​ 165​ Appendix J: Thematic Coding, Parent Pre Surveys​ ​ ​ ​ ​ ​ 168​ Appendix K: Thematic Coding, Parent Post Surveys​​ ​ ​ ​ ​ 173​ ​ ​ Recommendations for Future Research​ Limitations​ ​ ​ ​ ​ ​ ​ ​ ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ ix ​ List of Tables Table 1. Depressive & Suicidal Ideation Reports in the Tussey Mountain School​ District, 2021 55 Table 2. Depressive & Suicidal Ideation Reports in the Tussey Mountain School ​ District, 2023 56 Table 3. PhenX Protective Factors Pre and Post Survey Results 73 Table 4. PhenX School Drug Environment Pre and Post Survey Results 75 Table 5. PhenX School Social Factors Pre and Post Results 78 Table 6. Phen X School Social Factors Sub Domains 80 Table 7. Perceived Exclusion and Privilege 84 Table 8. School Disciplinary Data 86 Table 9. Chill Room Usage Data 87 Table 10. Parent Pre-Survey Mental Health Service Perceived Importance & ​ 96 Accessibility Table 11. Barriers Reported in Parent Pre Surveys 100 Table 12. Parent Post-Survey Mental Health Service Perceived Importance & ​ 103 Accessibility Table 13. Barriers Reported in Parent Post Surveys 106 ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ x List of Figures Figure 1. PAYS Risk & Protective Factors 22 Figure 2. CDC Tiered Service Model for Mental Health Services in Schools 41 Figure 3. Tussey Mountain School District, Risk Factors, 2023 Pennsylvania Youth Survey 59 Figure 4. Tussey Mountain School District, Protective Factors, 2023 Pennsylvania ​ Youth Survey 60 Figure 5. Sources of Support for Tussey Mountain Students 61 Figure 6. Emotional Thermometer 86 ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ xi ENHANCING MENTAL HEALTH SERVICES​ ​ ​ ​ ​ ​ xi Abstract This action research project explores the critical issue of student mental health challenges, which have been exacerbated by the COVID-19 pandemic, within the Tussey Mountain School District, in rural Pennsylvania. In this school and on the national scale, rising rates of depression, anxiety, and suicidal ideation reported have negatively impacted student achievement as well as overall wellbeing. This study aimed to investigate stakeholder perceptions regarding the efficacy and accessibility of district-initiated mental health and social service programs (such as the Chill Project), identify barriers to service delivery, and assess the school's role in supporting student mental health. Specifically, this action research project investigated: 1) the impact on self-reported risk and protective factors before and after program implementation; 2) effective strategies and existing barriers for students accessing mental health services; and 3) the impact on parent perceptions regarding program availability. A mixed-methods approach was utilized, using surveys, interviews, discipline data, and Chill Room usage data. This research aimed to inform programming improvements and refine the school's role in addressing adolescent mental health needs in this rural Pennsylvania district. Findings of the study indicated a significant reduction in student-reported risk factors, as well as an increase in positive connection to the school community and other specific protective factors. Among the parent group, there was significant variance in perceptions. Parent surveys indicated general support for mental health services in schools but also highlighted concerns about communication and clarity regarding program specifics. These results will be used to impact district programming recommendations moving forward. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 1 CHAPTER I​ Introduction ​ In the five-year period following the COVID-19 pandemic, most students have returned to school. This transition, however, has not been without some challenges, with many education and mental health professionals noting more prevalent and more pronounced mental health needs and challenges within the student population. The pandemic has exacerbated existing mental health concerns among students, while simultaneously increasing the need for mental health services. In fact, at any given time approximately 20% of school-age youth are actively meeting the criteria for a mental health disorder (Garret et al., 2022). Moreover, by grade 7, up to 40% of students will have experienced a mental health issue at some point in their lives. ​ Schools can play a vital role in addressing these challenges by providing universal supports and targeted interventions. The National Alliance on Mental Illness (2024) has identified schools as being well-positioned to improve student access to mental health services by removing barriers to care such as transportation, scheduling, and stigma. Currently, almost half of all students receiving mental health care are doing so at school. The National Alliance on Mental Illness (NAMI) finds that schools can effectively support mental health with staff and student training to recognize mental illness risk factors; provide direct services with mental health professionals, such as counselors and psychologists; and refer students and families to community-based resources. Obstacles, however, such as limited resources, staff training, and parental concerns hinder effective implementation of these programs. Productive collaboration between schools and parents is crucial for successful mental health support programs, ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 2 requiring open communication, shared decision making, and culturally sensitive approaches. While research highlights the potential of schools to improve student mental health, further research is needed to understand student and parent perspectives on the accessibility and efficacy of these programs. There is also some question regarding the school’s role in the delivery of these services, with some parents, community leaders and even school administrators indicating that there are questions about how involved the school should be when it comes to student mental health. Background Access to much needed mental and behavioral health services is limited for the adolescent population, particularly in rural areas. The Tussey Mountain School District is situated in rural Bedford and Huntingdon Counties in southwestern Pennsylvania. Serving just over one-thousand students presents a unique challenge to school administrators as community resources and partnerships may differ, depending on the student’s county of residence. Furthermore, the school’s comprehensive plan from 2020 identifies limited community resources as a central challenge to student achievement (Tussey Mountain School District, 2020). In reviewing specific district challenges, student responses to the Pennsylvania Youth Survey (PAYS) are of particular interest. During the 2020 administration of the survey, 50-60% of students at the middle/ high school, “felt sad or depressed most days in the past twelve months” (Pennsylvania Commission on Crime and Delinquency et al., n.d.). Even more concerning were the reports of students who considered, planned or attempted suicide. During this administration of the PAYS, over 46% of the senior class “seriously considered suicide”, 33% “planned an attempt”, and 25% “attempted suicide”. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 3 About 33% of sophomores participating in the survey also reported considering and attempting suicide (Pennsylvania Commission on Crime and Delinquency et al., n.d.). Student reports of substance abuse also exceeded the state averages for alcohol, marijuana, abuse of prescription medications, use of over-the-counter medications (to get high), cocaine, methamphetamines, hallucinogens, and other synthetic drugs. During this administration of the PAYS survey, over 70% of seniors reported using alcohol at some point in their lives (Pennsylvania Commission on Crime and Delinquency et al., n.d.). Sadly, during the 2023-2024 school year, two students enrolled at Tussey Mountain High School died by suicide. Since these tragic events, there has been renewed public interest in support available to students through district programming, as well as district initiatives (Watson, 2023). In reviewing these concerns, there is a perception among many stakeholder groups that student needs are not being met through existing social service programming, mental health programming, or behavioral health supports available inside and outside of the school district. ​ New Mental Health Initiatives During the 2024-2025 school year, several new mental and behavioral health initiatives were implemented in the school district. The Tussey Mountain School District used grant funding from the Pennsylvania Department on Crime and Delinquency to partner with Allegheny Health Network (AHN) in order to bring the Chill Project to students who were enrolled at the shared middle/high school. The Chill Project has enabled the school district to provide students and staff with access to additional mental health professionals, beyond those directly employed by the district. “The Chill Project features dedicated professionals, a calming space, and regular instruction to help every ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 4 member of a school’s community better handle pressure and anxiety” (Allegheny Health Network, 2024, para. 1). The district has also begun to implement a teen Mental Health First Aid (tMHFA) program with select staff and all tenth-grade students. tMHFA is an evidence-based program that teaches students in grades 10-12 “how to identify, understand, and respond to the signs of mental health and substance abuse challenges among their friends and peers” (National Council for Mental Wellbeing, n.d., p. 2). Additionally, interest among the Tussey Mountain student body in raising awareness of mental health issues, led to the inception of Students Empowering Mental Health Awareness (SEMHA). In his presentation to the Tussey Mountain School Board of Directors, SEMHA President, Barrett Brode (2024) said that: The Tussey Mountain Student Empowerment of Mental Health Awareness Team was formed by students for the betterment of student mental health by promoting positive interactions and supporting students with opportunities to discuss their mental health with peers and/or individuals that can further assist them in the mental health journey. The Tussey Mountain Student Empowerment of Mental Health Awareness Team works to promote good mental and physical health, as well as good decision making. (slide 2) This group of students hopes to impact their school in the following ways: ●​ “Making the school a brighter and more positive place to learn” ●​ “Educating students about good decision making” ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 5 ●​ “Educating parents, community members, and teachers about mental health” ●​ “Supporting fellow students through their struggles” ●​ “Providing students with the space they need to get through the school day” ●​ “Supporting teachers and school staff” (Brode, 2024, slide 3) Presentation of Research Questions The Chill Project, tMHFA, and SEMHA indicate the school district’s commitment to provide students with quality services, an infrastructure of social support, and mental health services through strategic partnerships with many community agencies. These programs are aimed at connecting students with the resources they need to be successful, academically, and otherwise. During the implementation of these programs, research was and is needed to determine the perceived effectiveness, accessibility, and knowledge of available resources among parent and student stakeholder groups. ​ ​ As the district implemented programs such as Teen Mental Health First Aid and the Chill Project, this research project endeavored to engage student and parent stakeholder groups to study the impact of programming on risk and protective factors, identify strategies for overcoming barriers to services, and the perception of parents on program availability. Specifically, this research sought to answer these questions: Research Question 1: What was the impact on self-reported risk factors and protective factors before and after the implementation of mental and social service programming initiatives? ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ ​ 6 Research Question #2: What strategies, as reported by students, were effective for helping students access mental and behavioral health services through their school, and what barriers existed? ​ Research Question #3: What was the impact on parent perceptions regarding the availability of mental health and social service programming? Ultimately, the project aimed to assess the effectiveness of newly implemented mental health and social service programs in the district. It also explored how these programs can be improved to better meet student needs. Data Collection & Participants For this project a mixed-methods approach was utilized. Because there were various stakeholder groups involved in this study, a mixed-methods approach assisted in gaining a more comprehensive picture of the research topic among the various stakeholder groups to identify common experiences, challenges, and perspectives, as well as potential areas of divergence or disagreement. Use of quantitative data helped validate, as well as challenge, existing perceptions. The collection and analysis of qualitative data in this study also helped establish a more complete context for the research, while providing a lens through which research findings and implications could be interpreted. The use of quantitative data allowed for a straightforward report of the results. For this research, two stakeholder groups of research participants were included: high school students and parents. Parents and guardians were surveyed before and after the implementation of mental and behavioral initiatives to assess their perceptions of student services, as well as any potential change in perceptions over time. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 7 For the student participant group, students completed pre- and post-surveys to assess various risk and protective factors. This methodology was selected to determine whether there was a change in student perceptions of safety, support, and connectedness after the mental health programming was introduced/presented to students. Additionally, students were interviewed to collect more detailed information about student perceptions of program accessibility, needs or short-comings, and barriers. Data specific to barriers and successes of district programming was collected through 1:1 interviews with student participants using a survey instrument developed by the researcher. These student interviews also explored the perception of stigma, usage of services, and program strengths. Both survey data and interview responses were analyzed quantitatively to assess the prevalence of student perception regarding the impact of various barriers and effectiveness of implemented strategies and programming to remove them. Participant responses were also analyzed using the thematic coding process for quantitative analysis and triangulation. Data triangulation was completed using pre- surveys, post surveys, one-to-one interviews, school discipline data, and Chill Room usage data. Financial Implications The costs of administering the current study were minimal. However, the financial implications associated with the studied programming were significant. Philanthropic and other grant funding were applied to cover the cost of the aforementioned new initiatives for the current school year. The availability of grant and philanthropic funding, in conjunction with the proposed capstone research project, provided the district with a ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 8 unique opportunity to learn about various stakeholders’ perceptions of efficacy and barriers before committing local funds to sustain these programs. This capstone project helped the district make informed decisions about the future of programs such as the Chill Project based on their impact. Furthermore, the provision of grant and philanthropic monies to fund the project for one year could help the district assess if savings elsewhere by implementing these preventative initiatives. This offered the school district the unique opportunity to assess the human, as well as the financial impact of programming before committing to spending local tax dollars. Chapter Summary This study investigated the effectiveness of mental health and social service programs within the Tussey Mountain School District, a rural Pennsylvania school district. The COVID-19 pandemic significantly impacted student mental health, with many experiencing increased anxiety, depression, and suicidal ideation. The district faced challenges in providing adequate mental health support, such as limited district resources, a high student-to-clinician ratio, and a lack of community resources. Despite these challenges, the district implemented new programs such as the Chill Project and Mental Health First Aid to enhance mental health support. This study investigated the impact of these programs on student mental health, assessed the accessibility of services, and explored parental perceptions of these programs. A mixed-methods approach was selected using surveys, interviews, and ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 9 analysis of locally collected discipline and Chill Room usage data, to provide insight into the effectiveness of mental health programs in a rural school district. The findings of this study and implication of the research can better inform future efforts to improve student mental health outcomes. Furthermore, the results of this study will be used to inform programming as well as budgeting decisions moving forward. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 10 CHAPTER II Review of Literature​ The Pennsylvania Commission on Crime and Delinquency suggests that by tracking changes in student reports of risk and protective factors, the Pennsylvania Youth Survey (PAYS) helps communities allocate resources to address pressing issues facing today’s youth (Pennsylvania Commission on Crime and Delinquency [PCCD], 2024a). The 2021 administration of the Pennsylvania Youth Survey within the Tussey Mountain School District indicated high rates of depression, suicidal ideation, and substance abuse among the student body (Pennsylvania Commission on Crime and Delinquency [PCCD] et al., n.d.). Two student suicides during the 2023-2024 school year heightened district and community concerns regarding the accessibility of mental health services (Watson, 2023). Due to the school district’s rural location, the studied school district has limited community resources (Tussey Mountain School District, 2020). The school and community face profound challenges in providing adequate support services in the wake of the COVID-19 Pandemic and ensuing mental health crisis. These are not unlike those reported on a national, and even global, scale following the COVID-19 pandemic (Jones et al., 2021). As school leaders look to build programming aimed at building social/emotional skills and building adolescent mental health, debates have emerged regarding the school’s role in the delivery of such programming (Abrams, 2023). The Pennsylvania Youth Survey Various agencies within the Commonwealth of Pennsylvania have been surveying students to gather data on middle and high school students’ attitudes and behaviors related to various risk factors since 1989 (PCCD, 2024a; PCCD, 2024b). These surveys ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 11 have taken place approximately every two years and have aimed to understand trends, identify risk factors, and inform effective prevention strategies (PCCD, 2024a). Generation at Risk surveys were the previous iteration of this. (Pennsylvania Commission on Crime and Delinquency [PCCD], 2024c). When the Pennsylvania Youth Survey (PAYS) replaced Generation at Risk Surveys, the survey measured not only the prevalence of substance abuse but began to more robustly assess risk and protective factors that influence youth behavior (PCCD, 2024c). The PAYS has evolved over time, incorporating questions from existing surveys like the Communities That Care Youth Survey (CTCYS), which was based on the work of Hawkins et al.(1992) (PCCD, 2024c). Hawkins et al.(1992) examined risk and protective factors, to evaluate various prevention strategies for high-risk groups, and proposed recommendations for future research and practical applications. They found that the best way to prevent adolescent drug abuse is to focus on risk factors. This involves identifying these factors and then finding effective ways to address them. Applying this methodology to both high-risk and general populations was beneficial in their controlled studies. As indicated, the present version of the PAYS incorporates the work of various researchers to provide school and community leaders with student-reported data to address areas of need in the school community and at large (PCCD, 2024a). Further review of the historical development of this survey provides context for understanding the literature base of the survey, as well as a conceptual framework for analyzing survey results according to risk and protective factors. This also may provide some historical context for school leaders within the Commonwealth of Pennsylvania who seek to better ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 12 define the role of the school in supporting the aforementioned mental health concerns, post COVID. Evolution of the Pennsylvania Youth Survey: History and Development In 1989, Pennsylvania launched a statewide survey of public and nonpublic school students to assess their attitudes and behaviors towards alcohol and other drugs (Pennsylvania Commission on Crime and Delinquency [PCCD], 2024d). Funded by the federal Drug-Free Schools and Communities Act of 1986, the Generation at Risk Survey was part of the PENNFREE initiative, Governor Robert P. Casey's plan for a drug-free Pennsylvania. The Drug Policy Council initially administered this survey. The first survey was administered, anonymously, to students in grades 6, 7, 9, and 12, using the Primary Prevention Awareness, Attitude, and Usage Scale (PPAAUS) (PCCD, 2024d). During this administration of the survey, the goal was to gather data on drug use patterns among Pennsylvania youth and inform the development of effective prevention programs. The Pennsylvania Commission on Crime and Delinquency (n.d) reports that, at the time, the survey filled a critical information gap, as federal youth surveys at the time were limited to high school seniors with outdated data. By providing a comprehensive and statistically valid assessment of drug use among Pennsylvania youth, the survey helped policymakers and educators tailor prevention efforts to address specific needs and challenges of Pennsylvania students (PCCD, 2024d). The Generation at Risk Survey was repeated in 1991, with some minor revisions (Pennsylvania Commission on Crime and Delinquency [PCCD], 2024e). The Pennsylvania Department on Crime and Delinquency states that “the 1991 survey basically used the same survey instrument as the 1989 survey with some modifications” ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 13 (PCCD, 2024e, para. 1). The most notable changes were the inclusion of three substances: crack cocaine, anabolic steroids, and over-the-counter medications “specifically taken to get high” (PCCD, 2024e, para 1). The Pennsylvania Commission on Crime and Delinquency (2024e) notes that the 1991 A Generation at Risk survey instrument maintained “excellent statistical reliability and validity” (para 1). Administration of the survey continued in 1993, with the Pennsylvania Commission on Crime and Delinquency (2024f) reporting that the survey had been “continuously refined” (para. 1) since its inception, but the basic elements and structure of the survey still remained. In 1993, however, the survey also included items from the Youth Risk Behaviors Survey which was developed by the Centers for Disease Control (PCCD, 2024f). Administration of the survey continued in 1995, with additional questions assessing violence added (Pennsylvania Commission on Crime and Delinquency [PCCD], 2024g). In 1997, the Pennsylvania Commission on Crime and Delinquency began administering the survey under its current name, Pennsylvania Youth Survey, with the Pennsylvania Commission on Crime and Delinquency (PCCD) administering all surveys since this time (PCCD, 2024b). However, in 1999, they did not administer the Pennsylvania Youth Survey as scheduled, as the instrument underwent significant, comprehensive revision (PCCD, 2024c). In 1999, an advisory group representing the Pennsylvania Departments of Health, Education, and Public Welfare and other state agencies including the Governor’s Policy Office, the Children’s Partnership, Juvenile Court Judges’ Commission, and the PCCD, identified the need for a new statewide survey. This new survey ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 14 would measure the prevalence of the use of alcohol, tobacco, and other drugs, while also assessing additional risk and protective factors that help shape youth behavior. The risk and protective data could then be used to guide prevention efforts, to help address existing problems, and to promote healthy and positive youth development (PCCD, 2024c, para. 1). For the purposes of the present study, these changes are notable as they provide a historical context, as well as a research-based practice framework, for further examining risk and protective factors when developing targeted prevention programming for adolescents. It should also be noted that the advisory group substantially moved the survey beyond the assessment of alcohol, tobacco, and other drugs (ATOD) to include a more thorough examination of other risk and protective factors impacting Pennsylvania youth. The Pennsylvania Commission on Crime and Delinquency reports that these changes had two objectives: first, to “estimate the prevalence of ATOD use and other delinquent behaviors among middle school and high school students” and, second, to “identify risk and protective factors that correlate with ATOD use and other delinquent behaviors in order to inform prevention planning” (PCCD, 2024c, para. 7). Administration of the PAYS continued in 2003, with some additional changes. The 2003 youth survey was similar to the one conducted in 2001; however, to make the survey shorter and provide more options, they offered two different versions (PCCD, 2024g). One version focused on family factors through the use of 40 questions, while the other included only one question about families. Schools could choose which version to give to their students. For the purposes of the current study, the inclusion of survey ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 15 questions related to families is notable, as this study explores parent perceptions, in addition to the impact of extenuating external risk and protective factors beyond the school community It should also be noted that, for the first time, the 2003 survey included questions about feelings of sadness, hopelessness, and worthlessness (PCCD, 2024g). They did not include the results for these questions in the 2003 summary report. Questions regarding students’ emotional state were again included in the 2005 administration of the PAYS with the results being reported at the conclusion of the survey (Pennsylvania Commission on Crime and Delinquency [PCCD], 2024h). Other notable changes in the 2005 survey were the inclusion of questions about gambling and the use of prescription drugs for non-medicinal purposes. Schools could also choose to administer the survey on paper or online, with about 10% of the surveys completed online that year. Administration of the PAYS continued in 2007; while minimal changes were noted to the content of the survey, significant changes to the scoring process enabled better analysis of risk and protective factors according to demographics and grade level (PCCD, n.d.). The Pennsylvania Commission on Crime and Delinquency (n.d.) reported that these updates included changes to several risk and protective factor scales, including, “the introduction of a new normative database, and changes to grade-level scoring” (para. 3 ). PAYS reports issued that year (and in subsequent years) recalculated historical data related to risk and protective factors, so that schools and communities could compare results over time (PCCD, n.d.). These were the last notable changes to the scoring of the PAYS survey, with regular bi-annual administrations occurring in 2009, 2011, 2013, 2015, 2017, 2019, 2020, 2021, and 2023 (PCCD, 2024a). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 16 In 2013, however, they made permanent changes to the structure of the study to address differences in response rates at the beginning versus end of the survey (PCCD et al., n.d). These changes have facilitated greater participation and collection of dataThis was the last major structural change to the survey however over time, they added or reworded some questions for clarity,to obtain more specific data. Throughout its thirty-five-year history, the PAYS (and the Generation at Risk Surveys) has evolved from assessing emerging trends related to alcohol, tobacco, and other drug usage to providing a comprehensive assessment of youth behavior and risk factors, as well as the protective factors surrounding them in their schools, homes and communities. Upon completion of the PAYS, school leaders are provided with a detailed report of the results, specific to their school and student population (PCCD et al., n.d.). Pennsylvania Youth Survey: Purpose and Uses ​ The Pennsylvania Commission on Crime and Delinquency (2024) reports that: Thirty years of Prevention Research has shown that current problems have precursors–signs that point to what is likely to happen. PCCD uses programs that, supported by evidence, impact these precursors either by limiting risk factors or strengthening protective factors as identified in local communities. (para. 3) In addition to providing each participating school and community with a detailed report and analysis of PAYS surveys results in their community, the Pennsylvania Commission on Crime and Delinquency, partners with several other public and private agencies, including the Pennsylvania Department of Human Services, the Pennsylvania Department of Education, the Pennsylvania Department of Drug and Alcohol Programs and the Edna Bennet Pierce Prevention Research Center, through PennState University’s ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 17 College of Health and Human Development. This facilitates the identification and implementation of evidence-based programming in response to identified areas of need through its PAYS Guide (PennState College of Health and Human Development, 2020). ​ This guide provides structured discussion points to review and analyze student data for school and community leaders and a framework for implementing evidence-based action plans in identified areas (Penn State College of Health and Human Development [HHD], 2020). By pairing an individual school or community’s PAYS results with this guide, leaders can identify areas of need, develop targeted interventions, evaluate the effectiveness of these interventions over time, and track trends in the data (PCCD et al., n.d.; Penn State College HHD, 2020). Beyond programming decisions, PAYS data could be used to advocate for additional resources, support existing school-based prevention programs and provide data to inform policy decisions at local and state levels. ​ The PAYS Guide provides school and community leaders a framework for accomplishing these objectives through the completion of detailed steps identified within six modules (PennState College HHD, 2020): ●​ Module 1- Form Your Team and Analyze Data ●​ Module 2- Determine Targets and Priorities ●​ Module 3- Conduct Resource Assessment ●​ Module 4- Explore Evidence Based Programs ●​ Module 5- Create an Action Plan ●​ Module 6- It PAYS to Know…It PAYS to Share (Resources for community engagement and sharing of data) ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ ​ 18 This framework provides school and community leaders with actionable and evidence-based resources to be responsive to identified risk and protective factors in their schools and communities, and engage other stakeholder groups, in response to the PAYS (PennState College of Health and Human Development, 2020). Understanding the development of the PAYS, its implications, and practical uses are salient to the current research as it provides context to the studied school district as well as the evolution of programming within the Commonwealth as a whole. It also provides historical context as school leaders seek to define their role in supporting at-risk youth for better outcomes, academic and otherwise. Both PAYS reports and the PAYS Guide appear to be valuable tools for schools and communities to address mental health and social service needs, improve student outcomes, and promote positive, adolescent development. This is largely done by providing leaders with self-reported student data related to risk and protective factors. The Impact of Risk and Protective Factors for Students As summarized in the previous section of this literature review, much of the evolution of the PAYS has centered around the addition and more detailed analysis of risk and protective factors in Pennsylvania youth. By understanding what risk and protective factors are and how they have the potential to impact student outcomes (positively or negatively), educators, parents, community members, and school and community leaders can work together to create supportive environments that promote positive outcomes for students (PCCD, 2024i). Risk factors are conditions or experiences that increase the likelihood of negative outcomes in students, such as academic difficulties, behavioral problems, or substance ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 19 abuse (Fraser, 1997; Substance Abuse and Mental Health Services Administration [SAMHSA], n.d.). Fraser (1997) notes that: Risk factors that occur or exist at one moment in time, such as a stressful life event, may be useful in determining the risk status in children, but provide little information about how or why a child came to be at risk. (p. 13) Examples of common individual risk factors for students may include learning disabilities, substance abuse, mental health problems, and negative self-esteem (Fraser, 1997). Common family risk factors may include family dysfunction, parental substance abuse, and lack of parental involvement. School risk factors include poor academic performance, negative school climate, and lack of support services. Community factors which place students at higher risk for negative outcomes include limited employment, limited access to education, poverty, and discrimination. Fraser (1997) also contends that identified risk factors can have a compounding impact and makes the distinction between risk factors and risk processes. “Risk processes refer to the mechanisms whereby a risk factor contributes overtime to heightened vulnerability” (Fraser, 1997, p. 13). For risk processes, Fraser provides the example that poor parenting practices or an inadequate supervision/response to a child’s behavior at home may contribute to noncompliance or behavior issues in other settings. Several studies have shown that the presence of a risk factor does not necessarily mean a negative outcome for the student. In fact, supportive adults, both at home and within the school system, can serve as protective factors which mitigate risk for students (Masten et al., 2008; Vanderbuilt-Adriance & Shaw, 2008). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 20 Fraser (1997) identifies that some conditions or experiences can buffer the potential impact of risk factors and increase the likelihood of positive outcomes. While some scholars make a distinction between protective (external) and resilience (internal to the child) factors, Fraser (1997) defines protective factors as “both the internal and external factors that help children resist or ameliorate risk” (p. 16). Individual protective factors for students include high intelligence, positive self-esteem, resilience, and strong coping skills (Fraser, 1997). SAMHSA (n.d.) identifies protective factors as “characteristics associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact. Protective factors may be seen as positive countering events” (SAMHSA, n.d., para. 4). The impact of protective factors is the subject of much research. Vanderbuilt-Adriance and Shaw (2008) found that supportive family relationships, particularly in early childhood, in addition to parental involvement and positive role models, improve the likelihood of positive outcomes for students. Their study aimed to investigate the protective factors that help children from low-income urban families overcome adversity and develop positive social adjustment. Specifically, their study examined the impact of child IQ, parenting quality, parent-child relationship, and parental relationship quality on children's social skills and antisocial behavior from early childhood to early adolescence. Intelligence of the child, nurturant parenting, and parent-child relationship quality were consistently associated with positive social adjustment, even in the context of high neighborhood disadvantage (Vanderbuilt-Adriance & Shaw, 2008). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ ​ 21 School systems may also offer protective factors to at-risk students. Masten et al. (2008) found that schools with strong protective factors are characterized by positive school climate, effective systems, and supportive teachers, and that these protective factors can help students meet academic, physical and emotional needs. Masten et al., (2008) also noted that protective factors may also be found within the community. Communities with robust proactive factors for children include strong social connections and opportunities for community involvement. ​ These research studies provide specific examples of the interplay between risk and protective factors. It is important to note that risk and protective factors interact in complex ways and influence an individual's susceptibility to substance use and mental health disorders (SAMHSA, n.d.). The presence of multiple risk factors can increase the likelihood of developing these issues, while protective factors can mitigate their impact. Each of these factors could influence one another (SAMHSA, n.d.). Relationship Between Risk Factors, Protective Factors and Student Outcomes By their very definition and as illustrated in the research reviewed in the previous section, risk and protective factors are linked to student outcomes, academic and otherwise. Fraser (1997), states that “no single event produces a negative outcome. Rather, interactional processes shape behaviors and problems over time” (p. 13). ​ The Pennsylvania Commission on Crime and Delinquency also identifies the relationship between risk factors to negative student outcomes and protective factors to positive student outcomes (PCCD et al., n.d.). Figure 1, from PCCD illustrates these relationships: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 22 Figure 1 PAYS Risk and Protective Factors Note. This figure helps visualize the relationships between risk and protective factors to various student outcomes, as illustrated by Pennsylvania Commission on Crime and Delinquency, Pennsylvania Department of Drug and Alcohol Programs, & Pennsylvania Department of Education. (n.d.) At the federal level, government agencies have also sought to improve public literacy and knowledge regarding the role and impact of risk and protective factors in adolescents, as well as conceptualize the relationship between risk and protective factors and the emergence of certain mental health conditions (youth.gov, n.d.). Youth.gov is a U.S. government website created to support the development and well-being of adolescents, by providing information from various government agencies and up-to-date ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 23 research. When speaking of risk and protective factors and the relationship to positive outcomes for adolescents, this resources identifies: There are contextual variables that promote or hinder the process. These are frequently referred to as protective and risk factors. The presence or absence and various combinations of protective and risk factors contribute to the mental health of youth. Identifying protective and risk factors in youth may guide the prevention and intervention strategies to pursue with them. Protective and risk factors may also influence the course mental health disorders might take if present. (youth.gov, n.d., para. 1-2) Youth.gov also provides a visual guide which identifies how various risk factors (within the domains of the individual child; parent; or school, neighborhood, and community) correlate to certain mental health conditions. For instance, risk factors such as low self-esteem, family conflict, or school failure have been linked to anxiety disorders; while poor social skills, parental depression, negative family environment, and school violence have been linked to depression. A more comprehensive list of the relationship of over sixty risk factors to the conditions of depression, anxiety, substance abuse, schizophrenia, and conduct disorder can be found on the website (youth.gov, n.d.). These resources provide a comprehensive review of various studies by various government agencies and researchers of multiple risk and protective factors; however, there are also numerous individual research studies which provide further insight into how risk and protective factors relate to more specific student outcomes. In a study exploring the relationship between risk and protective factors, researchers analyzed data from 11,875 children aged 9 to 11 years and found that higher ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 24 levels of mental health concerns in parents were strongly linked to increased mental health concerns within their children (Zhang et al., 2020). Additionally, within this study, higher socio-economic status was associated with better general cognition, executive function, and lower behavioral inhibition in children. The study also noted that a positive social environment and strong interactions were linked to better behavioral regulation skills in children. By understanding the interplay between risk and protective factors, school leaders can develop more effective interventions to promote healthy child development, good mental health and prevent substance use disorders (SAMHSA, n.d.). This is important, especially in light of substantial changes to risk and protective factors for students in the wake of the COVID-19 Pandemic. Impact of the COVID-19 Pandemic and Social Media on Risk and Protective Factors The impact of risk and protective factors became even more apparent in the aftermath of the COVID-19 Pandemic. Changes associated with the pandemic significantly impacted the lives of students worldwide, exacerbating existing risk factors, and challenging the effectiveness of existing protective factors (Shah et al., 2020). Prior to the pandemic, many students were already facing challenges such as poverty, family dysfunction, and limited access to resources. When the pandemic introduced students to new risk factors, such as isolation, economic hardship, and disruptions to education, Shah et al. (2020) found that these factors appear to have exacerbated existing challenges, impacted the social development of students, and led to negative mental health outcomes. Furthermore, the pandemic strained existing protective factors, as families faced financial difficulties, schools closed, and social connections were limited (Shah et al., 2020). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 25 When these risk and protective factors are considered within the greater context of the COVID-19 Pandemic, there is evidence to suggest a profound impact on adolescent mental health with increased rates of adolescent mental health disorder reported around the globe as one of the most common changes to overall student well-being following the pandemic (Chavira et al., 2022). Jones et al. (2021) conducted a systematic review of sixteen peer-reviewed research studies and found that the COVID-19 pandemic had pronounced, negative impacts on adolescent mental health. The research team found that pandemic-related stressors, such as social distancing and uncertainty, have been difficult for adolescents to process, leading to increased rates of anxiety and depression. It was also noted that pandemic limited social interactions, which led to decreased social support and exacerbated feelings of loneliness and isolation. Moreover, the pandemic has placed certain vulnerable groups at further risk for mental health challenges faced by adolescents. The literature review also indicated a more pronounced impact for those from historically marginalized demographics, such as LGBTQ+ youth and those with pre-existing mental health conditions (Jones et al., 2021). Since the start of the pandemic, these individuals have experienced additional stressors related to discrimination, isolation, and uncertainty about their future. Moving forward, the research suggests that increasing access to mental health services, promoting social support networks, and teaching effective coping strategies can help students face these increased challenges and increase the likelihood of positive outcomes in the future (Jones et al., 2021). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 26 Additional studies suggest that other vulnerable populations may be at greater risk for the emergence of mental health concerns, such as anxiety and depression, which impact academic opportunities (Totsika et al., 2024). Totsika et al. (2024) investigated school absence among children with neurodevelopmental conditions (intellectual disability and/or autism) in the UK following the initial COVID-19 outbreak. A significant portion of these children, 32%, missed 10% or more of school days. School refusal and illness were the primary reasons for absence, with COVID-19-related absences being less common. The study found that child anxiety was a significant factor contributing to both overall absenteeism and school refusal, while hyperactivity was associated with lower levels of school refusal but higher levels of school exclusion. A positive relationship between parents and teachers was found to be protective against various types of absence, indicating that adults in the school, home, and community can help students through these challenges. As the study concluded, the authors identified a path forward with these research considerations in mind, “as we enter the post-pandemic recovery era, findings from the present study would indicate a need to focus on child mental health, in particular anxiety, and perceived level of unmet need as potentially substantial barriers to regular school attendance. At the same time, findings highlight the potentially protective role of parent-teacher relationships” (Totsika et al., 2024, p. 3006). In addition to further exacerbating student risk factors, while simultaneously disrupting the social safety networks which offer protective factors, the pandemic’s impact on social media usage and habits has also had a pronounced impact on adolescent mental health. The COVID-19 pandemic significantly increased social media usage, with ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 27 a 61% rise in engagement during the initial wave (Fullerton & Anderson, 2021). During the pandemic, many used social media to restore a sense of connection to others; however, experts say that its usage had the opposite effect, contributing to depression and anxiety. Fullerton and Anderson (2021) report that frequent social media usage can exacerbate a negative self-image by fostering comparison and perfectionism due to the curated nature of social media, where users often present idealized versions of themselves. This can lead to feelings of inadequacy and low self-esteem. Additionally, the constant exposure to perfectly edited photos and seemingly flawless lives can contribute to unrealistic expectations and negative body image (Fullerton & Anderson, 2021). Beyond concerns with negative self-image, Fullerton and Anderson (2021) also noted that misinformation propagated on social media increased stress and anxiety, as users were faced with a near constant barrage of conflicting news and opinions, making it difficult to discern fact from fiction, which led to confusion and fear. Young et al. (2024) reported similar findings when analyzing recent data published within the Centers for Disease Control’s 2023 Youth Risk Behavior Survey (YRBS). With the inclusion of a question about social media usage, results of the survey were able to provide the first national prevalence estimate of social media use among US high school students (Young et al., 2024). Using additional data collected on the YRBS, researchers were able to extrapolate additional data regarding the impact of social media usage on student mental health. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 28 The survey data indicated that 77% of US high school students access social media accounts multiple times a day (Young et al., 2024). Furthermore, frequent social media use was linked to increased bullying victimization, mental health issues, and suicide risk. These associations were particularly strong for female students and heterosexual students. It was, however, noted that, for some marginalized groups, especially LGBTQ+ students, social media can provide a sense of community and support, potentially mitigating negative impacts (Young et al., 2024). This analysis of the impact of social media usage is also consistent with research which investigated longitudinal impact of the COVID‑19 pandemic on adolescents' mental health/social emotional status, substance use, and digital media use (Shoshani & Kor, 2024; Young et al., 2024). Shoshani and Kor (2024) found that over the course of the pandemic, daily video game usage increased from 1.72 to 2.81 hours; total daily screen time increased from 7 hours 25 minutes to 8 hours 32 minutes; and a large proportion of participants (75%) were spending more than 5 hours a day on social media. As the pandemic progressed and media usage increased, they observed significant increases in reports of depression, anxiety, somatization (presentation of perceived physical symptoms in response to psychological symptoms), and general distress (Shoshani & Kor, 2024). The study also showed there were significant increases in the prevalence of tobacco, alcohol, and cannabis use among the participants. Overall, this research indicates that the pandemic seems to have had a negative impact on the mental health and digital media habits of the study participants, which showed a strong correlation to ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 29 increased rates of substance use and problematic digital media consumption (Shoshani & Kor, 2024). Research surrounding the relationships between adolescent social media usage and mental health is also drawing the attention of government officials (Arkin, 2024). In 2023, Surgeon General Vivek Murthy issued a warning about the link between social media and mental health issues like depression and anxiety, advocating for a warning label on social media platforms similar to those on tobacco products. In 2024, the United States Senate Judiciary Committee held hearings regarding the safety of social media usage and potential mental health harm to children. Further public concern was noted earlier this year, when fourteen attorney generals (representing California, Illinois, Kentucky, Louisiana, Massachusetts, Mississippi, New Jersey, New York, North Carolina, Oregon, South Carolina, Vermont, Washington state and Washington, D.C.) filed suit against TikTok, citing concerns that the company harms adolescent mental health, collects data without appropriate consent, and uses such to build “addictive features” into their platform. (Arkin, 2024, para. 4) From the reviewed literature thus far, it is evident that pandemic and changes in social media habits that followed have exacerbated mental health challenges among students, increasing rates of depression, anxiety, and stress. Garret et al. (2022) reviewed recent incidence and prevalence data and reported that between 2016-2020, the rate of depression increased by 27% for students aged 13-17, while the rate of anxiety grew by 29% for students of the same age. Additionally, from 2019-2020, behavior and conduct problems increased by 21%. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 30 The National Alliance on Mental Illness [NAMI] (2024) reports similar statistics while also raising concerns about critical challenges for adolescents accessing care. They report that one in six American teens experience a mental health disorder, with half of all mental health conditions beginning by the age of 14. Root causes of these increases are likely multi-faceted, such as increased risk factors, diminishment of established protective factors, and ongoing changes in student habits which do not promote mental health, such as social media usage. The reviewed research indicates that there is some evidence to suggest that promoting positive school-home connections, implementing programming that facilitates the development of social-emotional skills, and increased access to mental health services in the school system may each be a means of addressing these growing needs (Jones et al., 2021; Totsika et al., 2024). Student Wellbeing, Challenges and the Relationship to School Achievement As schools look to address changing needs within their student populations following the COVID-19 Pandemic, understanding the relationships between student well-being, mental health challenges and student achievement/school performance is important. Understanding these relationships can help school leaders provide focus to educational programming initiatives and better define the school’s role and purpose in supporting adolescent mental health. Researchers have found links between student mental health and emotional well-being to their overall academic success. A meta-analysis, which included fifty-one existing studies was conducted to better understand the relationship between emotional intelligence skills and academic performance (Somaa et al., 2021). The study specifically ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 31 investigated three hypotheses: “ H1: There is a positive association of emotional intelligence with academic performance” (p. 4); “H2: Academic performance is strongly predicted by ability-based emotional intelligence” (p. 5); and “H3: There is a strong association of emotional intelligence with academic performance at a younger age” (p. 5). At the conclusion of this meta-analysis, a significant positive correlation was found, indicating that higher emotional intelligence is associated with better academic performance. Statistical analysis indicates support for all three hypotheses, with the strongest effect size noted for hypothesis one. While there is much evidence to suggest that emotional intelligence is just one factor impacting academic achievement, at the conclusion of the study the authors stated, “to date, there is ample evidence suggesting that academic performance and emotional intelligence are intimately connected” (Somaa et al., 2021, p. 13) The Chicago Longitudinal Study (CLS) also found strong evidence that early social-emotional skills, such as self-regulation, are powerful predictors of later academic achievement, even after controlling for socioeconomic status and cognitive abilities, over the course of a child’s entire educational experience (Reynolds, 1999). The CLS followed a cohort of 1,539 students presenting with various risk factors such as neighborhood poverty, low family socioeconomics, and other educational hardships from early childhood into adulthood. Within this study, researchers collected data on a variety of factors, including cognitive development, social-emotional skills, academic achievement, and family characteristics. The longitudinal design of the study allowed researchers to track changes in children's development over time and to identify the factors that contribute to positive ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 32 or negative outcomes. At the conclusion of the study, researchers found that social-emotional skills are strong predictors of academic achievement (Reynolds, 1999). Children who were able to regulate their emotions, pay attention, and get along with others were more likely to succeed in school during the multi-year study (Reynolds, 1999). During this study, Reynolds (1999) also identified that high-quality early childhood programs can have a significant positive impact on children's academic and social-emotional development. These programs can help children develop important skills like self-regulation, problem-solving, and social competence, which are crucial for success in school and beyond. In a separate longitudinal study, over 750 participants were studied using data from a non-intervention group of high-risk children and a normative group of low-risk children starting when the children were in kindergarten, with outcomes being assessed over the next thirteen to nineteen years (Jones et al., 2015). Upon entry into the study, kindergarten teachers were provided with ratings scales for each participant, measuring the student’s social and self-regulation skills using an eight-item Likert scale. The findings of this study indicated that there is a statistically significant positive correlation between social emotional skills observed in kindergarten and outcomes in young adulthood across all domains that were measured in the study, including, educational attainment and success, employment, criminal activity, substance abuse and overall mental health. In this study, Jones et al. (2015) found that students who presented with better prosocial skills in kindergarten were approximately 50% more likely to graduate on time and 100% more likely to complete a college degree. The research team also found that ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 33 the ratings scales completed by the teachers provided more significant predictive value of future outcomes, compared to other metrics included in the study (Jones et al., 2015). Furthermore, in a two-wave longitudinal study, aimed at understanding how subjective well-being (life satisfaction, positive emotions, and low negative emotions) affects academic engagement in high school students, researchers noted a connection between higher life satisfaction and lower negative emotions with increased academic engagement over time (Datu & King, 2018). Datu and King (2018) also found that initial academic engagement was found to positively influence subsequent well-being. This suggests a mutual relationship between student well-being and academic performance. These longitudinal studies allowed researchers to observe and understand the development of risk factors and impact of protective factors over time. However, it is also valuable to review research which provides targeted and in-depth investigation into the various stages of student development in a more focused manner. A review of data collected in Baltimore City Schools, indicates that students in kindergarten who presented with social or behavior deficits were significantly more likely to be suspended or expelled, retained in a grade, or receive support through an Individualized Education Program or 504 plan (Bettencourt et al., 2016). In this data review, Bettencourt et al. (2016) reported concern that social or behavioral deficits were far more likely to impact boys than girls and stated concern about possible inequities. While most of the reviewed research thus far has studied the relationship between social skills, emotional regulation, behavior, or student overall well-being on academic performance, there is also a growing body of research to suggest that school-based interventions, aimed at developing social emotional and coping skills may be effective in ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 34 facilitating improvements in academic areas as well. In a meta-analysis of school-based social and emotional learning programs reviewing data from 213 studies (which researched over 270,000 students), researchers indicated that students who participated in social-emotional learning programs improved standardized test scores by 11 percentile points compared to those who did not (Durlak et al., 2011). The researchers in this program stated that several programs or studies were excluded from the meta-analysis, as they did not have systematic monitoring of program fidelity or student check-ins built into their programming, suggesting a need for improvement in these areas Furthermore, in a longitudinal study aimed at exploring program efficacy and the relationship between social and emotional risk factors and academic performance during the transition to secondary school, researchers specifically examined the relationships between conduct problems and academic performance, the impact of depressive symptoms versus the impact of anxiety symptoms on academic performance, and how these factors may impact a student’s attitude toward school (Riglin et al., 2013). The study also sought to identify specific actionable areas for improvement in the established school-based programming. Riglin et al. (2013) selected research participants in their first year of secondary school for inclusion in this study, as they identified that this is often a significant period of adjustment for students, which can be accompanied by increased psychological difficulties and a decline in academic performance. Data was collected regarding identified emotional problems (such as depression, general anxiety, and school anxiety); student affect towards school (school liking and school concerns); and conduct problems ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 35 or concerns. These data points were selected to better factors that could be targeted in school interventions to optimize student academic potential. The researchers found that, while existing interventions focused on bridging the gap between primary and secondary education or supporting vulnerable students, research data suggested the need to address additional risk factors (Riglin et al., 2013). In this study, conduct problems, school liking, and school concerns emerged as key areas for intervention. Conduct problems, particularly at the beginning of secondary school, were strongly linked to later deficits in academic achievement. The study also found that depressive symptoms, though not directly predictive of poor academic performance, may be an early indicator of a downward trajectory, especially for boys. At the conclusion of the study, Riglin et al. (2013) suggested that in addition to universal support provided to all students may hold some benefit, there is a need to also review student needs and offer tailored programming. The research team identified that, while conduct problems and school liking may be universal targets, depressive symptoms and school concerns could be more specific to boys, requiring tailored support for better outcomes (Riglin et al., 2013). Similarly, Hudesman et al. (2013) conducted a three-year longitudinal study with students to learn more about the role of self-regulated learning and formative assessment in student achievement.. At the conclusion of the study, there was a marked improvement in student achievement for research participants who received interventions to improve metacognition and self-regulation (Hudesman et al., 2013). When the results of each of these studies are considered in relation to one another, it is evident that strong social-emotional skills are a critical factor in academic success. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 36 The summarized research suggests that identifying and addressing mental health challenges early on may hinder the development of more serious problems or mental health, while improving academic outcomes. These skills may help students manage stress, build positive relationships, and stay focused on their studies, even in the presence of other challenges and risk factors. On the other hand, mental health issues, such as depression and anxiety, can significantly hinder academic performance. School-based interventions that promote social-emotional learning are effective in improving both mental health and academic performance. Debate: The School’s Role in Supporting Adolescent Mental Health Despite overwhelming evidence of the impact of risk and protective factors (inside the school system), as well as a robust body of data suggesting more prevalent and complex mental health needs in the adolescent population today, there is still considerable debate among stakeholder groups regarding the school’s role in facilitating access to mental/behavioral health and social services (Abrams, 2023). Therefore, it is important to explore the perceptions of some stakeholder groups in supporting adolescent mental health as well as the school’s responsibilities to students to ensure accessible education services, according to historical precedents and current practices. The relationships between risk and protective factors and academic outcomes raises societal questions regarding how a school should respond to factors directly impacting the accessibility and effectiveness of a child’s education, their chief role. After studying the impact of social emotional learning programs and the relationship to student achievement and exploring the school system at large, Durlak et al. (2011) stated: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 37 There is broad agreement among educators, policy makers, and the public that education systems should graduate students who are proficient in core academic subjects, able to work well with others from diverse backgrounds in socially and emotionally skilled ways, practice healthy behaviors, and behave responsibly and respectfully. (para. 3) Current policies and practices within Pennsylvania, as well as on the national scale suggest some expectation that schools are to be responsive to student mental health concerns in their program design, which is consistent with Durlak et al. 's characterization of “broad agreement among educators, policy makers, and the public”. Within the Commonwealth, the Pennsylvania Department of Education has released the Pennsylvania Career Readiness Skills and Continuum. This is a framework designed to help students develop the social and emotional career skills they need to be successful in the 21st-century workforce (Pennsylvania Department of Education, 2024a). Specific skills are identified on the continuum according to three broad areas: self-awareness and self-management (skills related to understanding and managing emotions, setting goals, and responding effectively to challenges; social awareness and interpersonal skills (skills related to building and maintaining positive relationships, communicating effectively, and resolving conflicts; and responsible decision-making (skills related to making informed choices, problem-solving, and critical thinking). ​ This framework indicates that schools in Pennsylvania have a responsibility to their students to provide instructional services and programming to develop skills in these areas to promote social-emotional skills which lead to employment following graduation. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 38 Beyond direct instruction and programming to help students meet the standards listed on the continuum, there is a historical precedent for working collaboratively with community and government agencies to bolster protective factors to mitigate risk through collaboration and supportive programs. The evolution of the PAYS survey in Pennsylvania and the school’s continuous role in administering it, strongly suggests that schools play a crucial role in supporting adolescent mental health, wellbeing, and healthy development and has for nearly forty-years (PCCD, 2024a). As discussed earlier, the PAYS Guide provides evidence-based identifying trends and patterns school-specific data to tailor support services to address the specific needs of their students (PennState College of Health and Human Development, 2020). Administration of similar surveys and resources, at the federal level also suggest some precedent for the school system playing a valuable role in supporting adolescent mental health on the national scale as well (Young, 2024; youth.gov, n.d.). Considering this, it should be noted that during the 2021-2022 school year, 49% of public schools reported providing some form of assessment or diagnostic service for mental health to their students and 38% reported offering some form of mental health treatment (National Center for Education Statistics [NCES], 2022). Schools report offering more services at the secondary level, compared to the elementary level. Additionally, higher numbers of urban and suburban schools were able to provide assessments or diagnostic services to their students, compared to rural schools (NCES, 2024). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 39 Current Challenges, Opportunities, Barriers and Programming Models Early intervention is key to effectively treating mental health conditions in young people (NAMI, 2024). The sooner a young person receives treatment, the better the long-term outcomes and the lower the overall costs (NAMI, 2024). However, there is a critical shortage of mental health professionals available to address a growing mental health crisis. Even before the start of the pandemic, just half of the 77 million children with treatable mental health conditions were receiving treatment. (Whitley & Peterson, 2019). Currently 70% of counties in the United States do not have any child psychologists, with urban and rural counties being disproportionately impacted by this shortage (McBain et al., 2018). Quite often these critical shortages cause significant delays in accessing care, with many young people waiting months or even years to receive help (NAMI, 2024). Individuals aged 15-40 experiencing psychosis wait as long as a year and half before receiving treatment. These delays can lead to worsening symptoms, making treatment more challenging and expensive. Schools can be exceptionally effective in providing more expedient delivery of mental health services. NAMI (2024) identifies that “by removing barriers such as transportation, scheduling conflicts and stigma, school-based mental health services can help students access needed services during the school-day” (para. 3). Currently nearly half of all students who are receiving mental health care do so in their school (NAMI, 2024). The National Alliance on Mental Illness (2024) indicates that there are several ways through which schools can support the mental health of their student population. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 40 Schools can support screening and early intervention efforts by training staff and students to recognize risk factors, warning signs and symptoms of mental illness (NAMI, 2024). Some schools may also opt to provide direct mental health services to their students by hiring school counselors, school social workers, school psychologists, and school nurses. Alternatively, or in conjunction with direct services provided by school staff, the school district may refer students and families to community resources. The National Alliance on Mental Illness (2024) reports that this collaborative approach between schools and mental health providers can significantly improve access to care and ultimately, enhance the mental well-being of young people. The recommendations by the National Alliance on Mental Illness represent various levels of intervention, as well as skill level to implement them, as they range from screening efforts by teachers and peers to direct services provided by credentialed mental health professionals (NAMI, 2024). Riglin et al. (2013) identifies universal measures such as SEL instruction may not be enough to meet the needs of all students. While studying psychological functioning and academic attainment, their research team found that “there is great potential for schools to deliver interventions to support pupils with psychological problems. Nevertheless, universal programs based in schools that aim to prevent the development of psychological problems have had only limited success” (Riglin et al., 2013, p. 41). In fact, interventions are most effective when they are tailored to the specific needs of the target population (SAMHSA, n.d.). The Substance Abuse and Mental Health Services Administration (n.d.), identifies various types of prevention interventions that may address various levels of need within the student population, including universal ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 41 prevention interventions,which are designed for the general population to prevent problems before they occur; selective prevention interventions, which target specific groups at increased risk; and indicated prevention interventions which focus on individuals already showing signs of a problem by providing counseling or therapy. The Centers for Disease Control [CDC], 2024.) has identified a similar model, based on tiered services of which school leaders and educators may have some level of familiarity. Figure 2 from the CDC illustrates a tiered service model for mental health supports in schools: Figure 2 CDC Tiered Service Model for Mental Health Services in Schools Note. In their action guide, (https://www.cdc.gov/healthyyouth/mental-health-action-guide/​ index.html) aimed at assisting schools with developing programming to promote student ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 42 mental health and wellbeing, the CDC identifies programs such as these that can be embedded with existing MTSS framework that a school may already have implemented. The Chill Project offers a tiered approach to providing social/emotional support services, much like those described, to be implemented in schools (Allegheny Health Network, 2024). Allegheny Health Network (2024) indicates that by providing a shared language and practical skills, this program helps individuals identify, discuss, and respond positively to stress, to reduce negative reactions which hinder learning and growth. Dedicated mental health professionals, calming spaces, and regular instruction are key components of this initiative. Schools participating in The Chill Project have reported decreased behavioral health incidents among students, improved well-being for educators and parents, and enhanced mindful awareness and resilience across the entire school community (Allegheny Health Network, 2024) The program offers a range of services, including one-on-one counseling, support groups, medication management, school-based outpatient services, school-wide preventive services, professional development opportunities, social-emotional curriculum, classroom consultations, and specialized support for student athletes (Allegheny Health Network, 2024). In an action-research study conducted at Northgate Middle/High School in Pennsylvania, the Chill Project was identified as one of the primary interventions during the study (Smith, 2022). This action-research project assessed the impact of implementing social-emotional learning programs. The study aimed to determine if these ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 43 interventions could improve the school's ability to address the needs of the whole child and reduce the negative effects of childhood trauma and adversity (Smith, 2022). The study involved administering surveys to teachers before and after the implementation of the interventions. The surveys measured teachers' perceptions of the school's implementation of whole-child design principles, their own ability to use trauma-informed practices, and their overall satisfaction with the school climate (Smith, 2022). Additionally, data from Allegheny Health Network's CHILL Project was analyzed to assess changes in faculty attitudes and practices related to student mental health. In this study, the researchers hypothesized that the interventions would lead to increased faculty capacity to implement trauma-informed practices, improved ability to meet the needs of the whole child, and a more positive school climate. At the conclusion of the study, it was determined that the interventions administered within AHN’s Chill Project, could be effective in creating a positive school climate and addressing the mental health needs of students. The study found that the implementation of Whole-Child Design principles, an advisory program, and the Chill Project led to increased alignment with Whole-Child Design practices. Additionally, teachers perceived an increase in their ability to use trauma-informed practices, as well as an improvement in the school's ability to meet the needs of the whole child (Smith, 2022). While initiatives such as the Chill Project increase access to licensed professionals and evidence-based programming, other intervention techniques aim to build student capacity at a universal (or tier one) levelTeenage Mental Health First Aid ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 44 (tMHFA) is an evidence-based program that teaches students in grades 10-12 “how to identify, understand, and respond to the signs of mental health and substance abuse challenges among their friends and peers” (National Council for Mental Wellbeing, n.d., p. 2). This program is based on the notion that adolescents more often reach out to peers than adults for support (National Council for Mental Wellbeing, n.d.). In a randomized controlled trial of nearly two-thousand students, across four schools, which evaluated the effectiveness of tMHFA compared to traditional Physical First Aid (PFA) training, it was found that tMHFA was significantly more effective in improving students' intentions to help peers with mental health issues, increasing their confidence in providing support and reducing stigmatizing beliefs. These findings suggest that tMHFA is a valuable tool for promoting mental health literacy and encouraging help-seeking behavior among adolescents (Hart et al., 2018). While evidence suggests that schools serving as an access point for varying levels of mental health services or social/emotional interventions may help many students overcome the barriers to care, school leaders report challenges associated with providing mental health services within the school settingIn a 2021-2022 survey, half of public school officials cited lack of access to licensed professionals or inadequate funding as barriers to providing mental health services to their students (NCES, 2024). These appear to be the most common barriers from the perspective of school officials. Policy and legal disputes, concerns about parent reactions, lack of community support, and reluctance to label students (for fear of stigmatization) were also reported as concerns (NCES, 2024). These concerns and barriers may impact the extent to which a school is able or willing to provide mental health services to its students. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 45 Parent Perspectives ​ While school leaders reported that inadequate access to mental health professionals and funding concerns were their biggest barriers to offering mental health programming to students, nearly ten percent of public schools surveyed cited concerns about the reactions of parents as a factor that limited their ability to provide programming to students in a more impactful way (NCES, 2024). In an article published to members of the American Psychological Association, Abrams (2023), discusses the controversy surrounding Social-Emotional Learning (SEL) programs in schools. ​ Lawmakers have proposed bills in at least eight states seeking to limit social-emotional programming in schools, with many parents supporting this movement (Abrams, 2023). Abrams (2023) identifies that, while SEL programs aim to teach students interpersonal skills and emotional regulation, they have been targeted by conservative groups who falsely associate social emotional programs with political issues, such as critical race theory and gender diversity initiatives. To address the concerns raised by critics, Abrams (2023) suggests several strategies such as using clear, jargon-free communication and familiar terms when communicating with parents about initiatives. Offering explanations of what SEL programs are and how they benefit students can help resolve misunderstandings. Abrams (2023) also identifies that focusing on practical outcomes, such as the long-term benefits of social emotional programming (i.e. improved academic performance and better social relationships) and including parents in the conversation, by providing opportunities for dialogue and feedback could also be helpful in facilitating productive school-parent relationships. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ ​ 46 There are several research studies which also suggest that when parents have a clear picture of what social emotional programming or mental health services looks like in their child’s school, oftentimes there is overwhelming support for these types of initiatives (Searcy van Vupen et al., 2018). Searcy van Vupen et al. (2018) studied over 600 parents to investigate their perceptions on mental health services in rural schools in counties along the Eastern shore of Maryland, noting that in their study, over 78% of parents agreed that schools should address student mental health issuesIn this study, parents cited anxiety, depression, and bullying were the top concerns for their children's mental health. Parents reported that a lack of support for them along with a lack of mental health awareness, and programs were key obstacles to delivering effective mental health support to students in schools. It is important to note that this research study was prior to the COVID-19 pandemic. Additional studies have indicated similar support for programs that support adolescent mental health and social/emotional skills, while also underscoring the need for dialogue between the school and parents (Longhurst et al., 2021). In a research study exploring the perceptions of parents and caregivers of students who participated in a school-based counseling program in the UK, several central themes emerged from the interviews with parents and caregivers. Longhurst et al. (2021) found that parents and caregivers generally appreciated the school-based setting for counseling as it was convenient and familiar for their child. However, many parents said that they wished for better communication from the school regarding the program and their child’s progress. Confidentiality was also very important ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 47 to parents whose children participated in the program. At the conclusion of the program, many parents reported positive outcomes for their students. When considering parent perceptions in the context of the school’s role in supporting adolescent mental health, it is also important to consider the impact of culture (Roy & Giraldo-García, 2018). Carefully and thoughtfully navigating these considerations may help school officials and parents achieve better outcomes for students. Roy and Giraldo-García (2018) found that parents who are involved in their children's education and social-emotional learning tend to have children who do better in school, especially when schools actively work to include parents in a culturally informed way. Despite these findings, there is limited empirical research available regarding parent perceptions of social emotional learning and school-based mental health initiatives post-Covid, as well as research centering on best practices to engage school-parent teams that support adolescent mental health. Chapter Summary Many researchers have documented the correlation between certain internal and external (or environmental) factors and their potential relationship to positive or negative student outcomes. These are frequently referred to as risk and protective factors. Understanding the interplay between risk and protective factors and processes may help schools, families and communities partner together to build a network of protective and resilience factors for better outcomes. Tools such as the Pennsylvania Youth Survey and accompanying resources provide a framework for assessing and understanding risk and ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 48 protective factors, within the context of a given school or community and equip schools to more comprehensively understand the challenges faced by youth in their communities. Following the COVID 19 pandemic, many students have continued to face challenges related to academic loss, mental health issues, and economic hardship. Furthermore, adolescent mental health concerns have increased since the COVID-19 pandemic for a variety of reasons. This has been coupled with a critical shortage of mental health providers and services available to students. Students face additional barriers in accessing mental health services such as stigmatization, transportation concerns, lack of awareness of services, scheduling issues, and financial complications. In the presence of these challenges, protective factors, such as resilience, strong social supports, and access to mental health services can play a crucial role in helping students recover from the pandemic's effects. Research also found that schools can play a critical role in removing some of these barriers by not only providing universal support to students, but by serving as an access point for more intensive programming for students who are exceptionally at-risk. There is evidence to suggest that more schools are offering some level of assessment or even intervention to students to support their mental well-being. As the needs of student populations are evolving and more schools implement such programming, this has left many stakeholder groups such as school leaders, parents, and students questioning the extent of the schools’ role in supporting adolescent mental health. School leaders have cited insufficient access to trained professionals, funding, outdated policies, parental reactions, community support and stigmatization as frequent concerns. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 49 Currently, there is a limited body of literature regarding parent and student perceptions of social-emotional learning and mental health program initiatives in schools post-Covid. There are some reports that suggest that some parents may have misconceptions about social/emotional learning or mental health services in schools, associating these programs with other controversial topics. Parents may worry that social/emotional learning programs are designed to indoctrinate students with specific beliefs or values. However, research clearly indicates better outcomes for students when parents and schools work collaboratively to meet student needs. To achieve a healthy working-relationship schools should provide clear and accurate information programming to parents, involve them in decision-making processes, provide regular communication about district initiatives and opportunities for parents to elicit feedback. Being mindful of cultural differences can ensure that programs are culturally sensitive and inclusive. Although experts have recognized the potential of the school system to act as an access point for students to access needed mental health services, there is limited data available regarding student and parent perspectives of program accessibility and efficacy. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 50 CHAPTER III Methodology From the review of literature, it is evident that various researchers have identified well-established correlations between certain internal and external (or environmental) factors and their potential relationship regarding positive or negative student outcomes. These are frequently referred to as risk and protective factors (Fraser, 1997). Understanding the interplay between risk and protective factors and their associated processes may help communities and school leaders build a network of protective factors to achieve better outcomes for students. In Pennsylvania, tools such as the PAYS and accompanying resources provide a framework for assessing and understanding risk and protective factors, within the context of a given school or community and equip schools to more comprehensively understand the challenges faced by youth in their communities within the state of Pennsylvania (PennState College of Health and Human Development, 2020). These tools are particularly useful in addressing challenges following the COVID-19 pandemic. Many students have continued to face challenges related to academic loss, mental health issues, and economic hardship (Shah et al., 2020). Increased instances of mental health concerns have emerged since the pandemic. This has been coupled with a critical shortage of mental health providers and services available to students (Whitley & Peterson, 2019). Students may face additional barriers in accessing mental health services such as stigmatization, transportation concerns, lack of awareness of services, scheduling issues, and financial complications (NCES, 2022). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 51 As indicated, protective factors (such as resilience, strong social supports, and access to mental health services) play a crucial role in helping students recover from the pandemic's effects. Research has determined that schools can play a critical role in removing some of these barriers through not only providing universal support to students, but by serving as an access point for more intensive programming for students who are exceptionally at-risk (CDC, 2024). Furthermore, there is evidence to suggest that more schools are offering some level of assessment or even intervention to students to support their mental well-being. As the needs of student populations evolve and more schools implement such programming, many stakeholder groups such as school leaders, parents, and students have begun to question the school’s role in supporting adolescent mental health. School leaders have cited limited access to trained professionals, funding, outdated policies, parental reactions, community support and stigmatization as frequent concerns. These research findings reported within currently available literature are consistent with contextual factors also observed and noted within the Tussey Mountain School District in rural Pennsylvania. Study Purpose Currently, there is a limited body of literature regarding parent and student perceptions of social-emotional learning and mental health program initiatives in schools post-Covid. Some reports suggest that some parents may have misconceptions about social/emotional learning or mental health services in schools, associating these programs with other controversial topics. Parents may worry that SEL programs are designed to indoctrinate students with specific beliefs or values (Abrams, 2023). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 52 This research project sought to investigate stakeholder perceptions regarding perceived efficacy and accessibility of district-initiated programming and community partnerships, to address limited access to mental healthcare and social services within the Tussey Mountain School District. Furthermore, this action-research project sought to identify barriers to service delivery among various stakeholder groups (parents and students) in order to implement solutions, ultimately helping them achieve better outcomes. This research also sought to investigate parent perceptions regarding the role of the school district in assisting students with accessing these services. The Institutional Review Board at PennWest University approved this study in October 2024 (Appendix A). The following research questions were developed for this capstone project to serve as a lens through which data would be critically examined, provide a focus for interpretation of this data, and serve as a metric for which results would be measured: Research Question 1: What was the impact on self-reported risk factors and protective factors before and after the implementation of mental and social service programming initiatives? ​ Research Question #2: What strategies, as reported by students, were effective for helping students access mental and behavioral health services through their school and what barriers existed? ​ Research Question #3: What was the impact on parent perceptions regarding the availability of mental health and social service programming? ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 53 Answering these research questions provided a benchmark within this study to evaluate the success of the research, as well as district-initiated mental and behavioral-health programming to draw meaningful conclusions. Findings of this research can help equip school leaders to improve programming initiatives as well as better define the school’s role in helping students overcome risk factors for better overall well-being, as they seek to meet a seemingly changing set of needs regarding adolescent mental health. Research Setting & Context A review of enrollment data indicates that in recent years, the Tussey Mountain School District typically serves just over 900 students in grades K-12, with 18-20% receiving special education services (Pennsylvania Department of Education, Bureau of Special Education, 2024). Over sixty percent of students are identified as economically disadvantaged (Pennsylvania Department of Education, 2024b). Demographic data from the Pennsylvania Department of Education also identifies that there is little diversity in terms of race or ethnicity, with over 97% of students being identified as white. The Tussey Mountain School District currently employs several mental health professionals of various credential levels. Included on the district’s mental health team are: three school counselors serving at each building level (elementary, middle and high), one school psychologist (who serves all students K-12, hired in 2020) and one school social worker (who also serves all students K-12; hired in 2021). In 2024, the National Association of School Psychologists recommended a student-to-school psychologist ratio of 500:1, indicating that the current school psychologist at the Tussey Mountain School District is serving a caseload that is ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 54 significantly higher than the national recommendation (National Association of School Psychologists, 2024). Additionally, the School Social Work Association of America recommended a student-to-social worker ratio of no more than 250:1. However, the Association also identified that this ratio should be lower for populations with higher needs (School Social Work Association of America, n.d.). Given the rate of economic disadvantage and self-reported risk factors by students on the PAYS, the student population should be considered “high need”, also indicating a much higher student-to-clinician ratio than recommended. Student Risk & Protective Factors within the Tussey Mountain School District Within the Tussey Mountain School District various stakeholder groups have noted concerns and challenges which mirror those noted in the peer-reviewed literature. Following the COVID-19 Pandemic, data sources have indicated an increase in the prevalence of various risk factors impacting students in the district. Table 1 summarizes data related to self- reports of depression, suicidal ideation, and other risk factors such as self-harm during the 2021 Pennsylvania Youth Survey among middle and high school students in the Tussey Mountain School District (Pennsylvania Commission on Crime and Delinquency et al., n.d.): ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 55 Table 1​ Depressive & Suicidal Ideation Reports in the Tussey Mountain School District, 2021 2021 Pennsylvania Youth Survey Survey Item: Felt depressed or sad most days in the past 12 GR 6 GR 8 GR 10 GR 12 50% 42.2% 59.6% 47.8% 11.8% 3.3% 32.4% 16.7% Agree with the statement “Sometimes I think that 19.4% 25% 39.6% 35.6% 23.5% 13.3% 35.8% 35.6% 57.1% 24.4% 50% 37.8% GR 8 GR 10 GR 12 Students who “seriously considered suicide” 10% 33.3% 46.2% Students who planned suicide 6.7% 27.5% 33.3% months Engaged in self-harm in the past 12 months life is not worth it” Agree with the statement “All in all, I am inclined to think I am a failure” Agree with the statement “At times I think I am no good at all” Student Reports - Suicide Survey Item: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ Students who attempted suicide ​ 6.7% ​ 56 33.3% 25% Note. This table summarizes data collected by the Pennsylvania Commission on Crime and Delinquency et al. (n.d.). The 2023 administration of the PAYS indicated improvement in some of these areas but also indicated that many students continue to struggle with depressive symptoms, among other concerns. This data is summarized in Table 2: Table 2​ Depressive & Suicidal Ideation Reports in the Tussey Mountain School District, 2023 2023 Pennsylvania Youth Survey Survey Item: GR 6 GR 8 GR GR 12 10 Felt depressed or sad most days in the past 12 46.2% 41.2% 38.6% 47.2% Engaged in self-harm in the past 12 months 4.0% 24.5% 15.5% 18.5% Agree with the statement “Sometimes I think 18.4% 32.0% 26.8% 22.6% 23.5% 13.3% 35.8% 35.6% months that life is not worth it” Agree with the statement “All in all, I am inclined to think I am a failure” ENHANCING MENTAL HEALTH PROGRAMMING​ Agree with the statement “At times I think I am 35.4% ​ ​ 35% ​ 57 34.9% 37% no good at all” Student Reports - Suicide Survey Item: GR 8 GR GR 12 10 Students who “seriously considered suicide” 15.7% 22.8% 23.1% Students who planned suicide 12.2% 12.3% 17.3% Students who attempted suicide 8.2% 7.0% 7.7% Note. This table summarizes PAYS risk factor data reported by PCCD et al., n.d. In addition to these reported values, during the most recent administration of the PAYS, students in the Tussey Mountain School District reported engaging in the following risky behaviors at rates which exceeded the state average in the following areas (PCCD et al. ,n.d.): ●​ Vaping/use of e-cigarettes ●​ Lifetime AND 30-day use of marijuana ●​ Lifetime use of over-the-counter drugs to get high ●​ Required medical care after a suicide attempt ●​ Made a suicide plan in the past year ●​ Felt sad or hopeless almost every day to the point that they stopped doing regular activities ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 58 ●​ Gambling (lifetime, past 30 days, and lying about gambling habits) ●​ Bullying Tussey Mountain Middle and High School Students were also at higher risk for negative outcomes based on their reports of social acceptance and interaction with their peers and their community (PCCD et al., n.d.). Tussey Mountain students reported higher levels of acceptance by their peers of risky behaviors than other students in the Commonwealth. Students also reported higher levels of acceptance among adults in the community of illegal behaviors. Furthermore, students also reported that they were more likely (or willing) to experiment with drugs and other substances than other students in Pennsylvania if presented by someone else. Students also reported that community members were willing to provide alcohol at rates which were noted to be far higher than the state average. Tussey Mountain students were also far more likely to take alcohol from adults without permission (PCCD et al., n.d.). When the PAYS results are considered holistically, low school commitment (58.7%), parental attitudes favorable towards antisocial behavior (51.2%), and perceived low risk in drug use (46.4%) emerge as some of the most significant risk factors impacting the student population within the Tussey Mountain School District. Figure 3​ illustrates the prevalence of various risk factors within the Tussey Mountain School District and is organized by community, family, school, and individual/peer domains: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 59 Figure 3​ Tussey Mountain School District, Risk Factors, 2023 Pennsylvania Youth Survey Note. Figure 3 summarizes student self-reported risk factor data from PCCD et al. (n.d.). There is limited data available regarding parent perspectives on programming needs, perceived effectiveness, or the school’s role in implementing services to support adolescent mental health. However, student-reported data on the PAYS provides some information regarding student attitudes toward protective factors in their school and community for students in the Tussey Mountain School District. Student reports on the PAYS provide insight into their perspectives regarding protective factors in their school and community (Pennsylvania Commission on Crime and Delinquency et al., n.d.). A significant portion of students report having strong family attachments, opportunities for prosocial involvement within their families, and a belief in ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 60 a moral order. However, lower levels of religiosity, community rewards for prosocial behavior, and school opportunities for prosocial involvement are areas of concern (PCCD et al., n.d.). This is illustrated in Figure 4. This figure reflects the percentage of students in grades 6, 8, 10 and 12 who reported having at least three protective factors in each of the identified domains (community, family, school and individual/ peer). Figure 4​ Tussey Mountain School District, Protective Factors, 2023 Pennsylvania Youth Survey ​ Note. Data was collected and reported by PPCD et. al (n.d.) during the 2023 PAYS. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 61 During the 2023 administration of the PAYS, students in the Tussey Mountain School District viewed one another as one of the most common means of support. This data provided school stakeholders with an important consideration when selecting and designing supports such Teen Mental Health First Aid (tMHFA), as students reported they were more likely to reach out to a peer when they were sad or upset than any other group of people. This is important contextual data to consider with regard to the current study when investigating the student perception of program efficacy. Figure 5 further illustrates this by comparing student reports of sources of support:​ Figure 5 Sources of Support for Tussey Mountain Students Note. Figure 5 from PCCD et al. (n.d.) illustrates where students in the Tussey Mountain ​ School District are turning for support. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 62 Selection of Research Participants High school students represent a critical population for understanding the effectiveness and perception of mental health services, within the Tussey Mountain School District. Their direct experiences with, and perspectives on, available mental health resources are invaluable when considering programming needs in a school. Therefore, Tussey Mountain High School students represented a critical population for inclusion in this capstone project. Additionally, due to the research gap regarding parent perception of mental and behavioral health programming, parents and guardians of middle and high school students were also selected to participate to achieve more in-depth understanding. Research Question One: Student Surveys Research question one studied subjects enrolled in grades 9-12 at Tussey Mountain High School. Student enrollment at Tussey Mountain High School (grades 9-12) was just over three hundred students during this capstone project. An informed consent letter (Appendix B) describing the research study was sent home with all students in grades 9-12. Interested students/families returned the letter to a secure drop box located in the district office to indicate their interest. Once the consent form was returned, students were read the assent to research statement (Appendix C) and then completed the pre and post surveys. Research Question Two: Student Interviews At the high school, there is a voluntary club called Student Empowerment of Mental Health Awareness (SEMHA). The inception of this club was student-driven, and its members have an interest in learning about and promoting mental health awareness at ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 63 Tussey Mountain High School. There are currently twenty-two student members in this organization. ​ ​ Student members of SEMHA were recruited for this part of the study, as this group possessed a distinct understanding of their school environment, peer relationships, and the challenges they faced. Student participants were recruited with parent consent from fall 2024 through spring 2025, using announcements at SEMHA meetings. The informed consent document (Appendix D) was provided for students to take home to their parents to review and sign. Interested students/families returned the informed consent to a secure drop box in the district office. Once the consent form was returned, students were read the assent to research statement (Appendix E) prior to completing the interview. During the interviews, the researcher used an interview script (Appendix F). Insights from research participants in this group provided crucial information about the acceptability, accessibility, and effectiveness of mental health services from a student's viewpoint. Research Question Three: Parent Surveys The survey and all informed consent information (Appendix G) and survey questions (Appendix H) were available electronically. Participants were recruited via district social media. To be eligible to participate in this part of the study, the participants had to have had a child enrolled in the middle/high school and be at least 18 years of age. Research Methods & Data Collection ​ When designing this research study, the researcher relied heavily on data from The Pennsylvania Youth Survey (PAYS) due to its comprehensive collection of risk and protective factor data. The two most recent administrations (in 2021 and 2023) of the ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 64 PAYS provided a robust understanding of the contextual factors surrounding the research questions within the Tussey Mountain School District. Historic PAYS data also established a baseline for comparison when assessing the efficacy of district-initiated programming on risk and protective factors. Like its predecessors, the next administration of the PAYS in fall 2025 will undoubtedly help paint an inclusive picture of how risk and protective factors are changing over time in the Tussey Mountain School District. Due to the timing of the current study and the bi-annual administration of the Pennsylvania Youth Survey, use of this data to study the research questions was not feasible. Therefore, to study the impact of district-initiated programming on student risk and protective factors, to learn more about barriers to student support and explore parent perceptions, the researcher utilized a mixed-methods to answer the three research questions. This mixed methods study used student survey data, student interview responses, parent survey data, student discipline data Chill Room usage to answer the three research questions. Research Question One: Data Sources & Collection Methods This research question focused on the impact on self-reported risk factors and protective factors before and after the implementation of mental and social service programming initiatives. To explore this research question, quantitative data was collected using the PhenX: School & Protective Factors ToolKit and School Social Environment ToolKit, which were administered to students at the beginning and end of the study. Pre-surveys were administered in February-March 2025, with post-surveys occurring in May 2025. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 65 Disciplinary data from the previous and current school year was also used to assess the impact of district programming on student risk factors. Chill Room usage data was also analyzed to assess the efficacy of district programming. Research Question Two: Data Sources & Collection Methods The second research question explored what strategies, as reported by students, were effective for helping students access mental and behavioral health services through their school and what barriers existed. Both quantitative and qualitative data were collected through student interviews. The interviews assessed student perceptions of access to mental health services, effective strategies for accessing services, and barriers to accessing services. The interview questions were designed by the researcher. Participants were recruited in February-March 2025, and interviews were conducted in March-April 2025, with analysis following the interviews. Research Question Three: Data Sources & Collection Methods The third research question examined the impact on parent perceptions regarding the availability of mental health and social service programming. Quantitative and qualitative data were collected using a researcher-designed survey instrument. The survey assessed parent/guardian perceptions of adolescent mental health, the school's role in service delivery, efficacy of existing programming, barriers to accessing programming, referral processes, and other related information. This survey instrument was designed by the researcher. The survey was administered at the start and close of the study, and preand post-surveys were compared. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 66 Participants for the pre-survey were recruited with consent, and the survey was administered in December 2024-January 2025. Recruitment for the post-survey, as well as the administration occurred in May-June 2025. Fiscal Implications The implementation of this research study presents minimal direct costs to the Tussey Mountain School District, a factor largely attributed to the strategic utilization of existing resources and external funding. The core data collection tools (PhenX toolkits, disciplinary records, Chill Room usage reports, student interviews, and parent survey) do not result in any additional financial costs to the district. The PhenX toolkits were available online at no cost and disciplinary records were already maintained by the district within the student information system, a necessary budget expense. Student interviews were conducted by the researcher, minimizing labor costs. The parent surveys were distributed electronically, to eliminate printing and mailing expenses. The district's existing infrastructure, including meeting spaces, was used for data collection. The primary financial consideration involves the researcher's time, which can be viewed as an indirect cost. Indirect costs, such as staff time allocated to the project, are those that are necessary for the study. In this case, the researcher's time is factored into the overall operational expenses of the district. Validity​ ​ It is important for researchers to take measures to ensure high-quality data collection for several reasons. First and foremost, taking quality data can help ensure that the data which has been collected is valid. Validity is a critical component to any quality ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 67 research. Ensuring that the data is accurate, unbiased, reliable, and well-aligned to answer the research question can increase validity of any given study. Furthermore, taking measures to ensure high quality data will provide credibility to the research. When data is collected with fidelity and the study is well-designed, other professionals in the field can take confidence in the results. In qualitative research, Mertler (2022) states that generally, the inductive analysis process is used. Inductive analysis usually follows three steps: organization, description, and interpretation. This framework was used for analyzing qualitative data collected in the present study. Mertler (2022) notes that qualitative research can provide more descriptive information than quantitative studies. By providing narrative accounts of observation, researchers are able to identify characteristics important to the research that are not easily expressed by data sets or numbers. Additionally, qualitative research lends itself to answering “how” and “why” questions by studying the process itself. While correlation may be easily identified by qualitative studies, quantitative studies may provide some insight into causation, etc. For these reasons, qualitative data sources were selected for collection and review when seeking to learn more about student and parent perceptions regarding the school’s role in supporting adolescent mental health, as well as the successes and barriers of programming specific to the Tussey Mountain School District. Chapter Summary​ ​ In the aftermath of the COVID-19 pandemic, schools nationwide have faced a concerning surge in student mental health challenges, with a significant portion of the ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 68 student population experiencing mental health challenges. Recognizing their pivotal role in addressing these needs, schools are striving to provide accessible mental health services. However, obstacles such as limited resources, insufficient staff training, and parental concerns often hinder the effective implementation of such programs. This study focused on the Tussey Mountain School District, a rural district located in southwestern Pennsylvania, where the challenges cited elsewhere in the literature are particularly evident.​ ​ The district is faced with alarmingly high rates of student depression, suicidal ideation, and substance abuse, as evidenced by concerning data from the Pennsylvania Youth Survey. Recent tragic student suicides have underscored the urgent need for effective mental health interventions. In response to this crisis, the district is implementing several new initiatives, including the Chill Project, a partnership with Allegheny Health Network designed to provide students and staff with access to mental health professionals and calming spaces; teen Mental Health First Aid (tMHFA), an evidence-based program aimed at equipping students and staff to identify and respond to mental health and substance abuse challenges; and Students Empowering Mental Health Awareness (SEMHA), a student-led initiative focused on raising mental health awareness and providing peer support. The core purpose of this study was to evaluate the effectiveness, accessibility, and perceived impact of newly implemented mental health and social service programs within the Tussey Mountain School District. Specifically, the research aimed to understand how these programs impacted student risk and protective factors, identify strategies for ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 69 overcoming barriers to service access, and assess parental perceptions of program availability and efficacy. Student and parent research participants were crucial stakeholders, and their selection as research participants was paramount to the present study. The students, as the primary recipients of the mental and social service programs, held unique insights into the effectiveness and accessibility of these initiatives. Gathering their perspectives through surveys and interviews allowed the research to capture firsthand experiences, perceived barriers, and suggestions for improvement. Similarly, parents played a pivotal role in their children's well-being and school involvement. Their perceptions of the existing programming, referral processes, and overall state of adolescent mental health provided essential context. By including both students and parents, the research aimed to obtain a holistic understanding of the program's impact, address potential discrepancies in viewpoints, and ultimately, tailor the initiatives to better meet the needs of the entire school community. Their inclusion ensured that the study reflected the realities of those most affected by the programs, making the findings more relevant and actionable for the school district. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 70 CHAPTER IV Data Analysis & Results To gain an in-depth and comprehensive understanding of each research question, a mixed-methods approach was used, combining quantitative and qualitative data collection and analysis to ensure a comprehensive understanding of the contextual issues surrounding the research. By using multiple data sources (student surveys, parent surveys, interviews, discipline data, and Chill Room usage records), the study benefited from data triangulation. This strengthened internal validity by providing multiple perspectives on the research questions and reduced the risk of bias from any single data source. To enhance the validity and credibility of this study, data triangulation was used. Triangulation allowed for a more nuanced and detailed understanding of the research questions. This is a technique that involves using multiple data sources, methods, or perspectives to examine a research question (Mertler, 2022). Use of Data Triangulation Within the present study, data triangulation was used across all three research questions. For research question one, data triangulation was achieved by combining student survey data (PhenX toolkits) with disciplinary data and Chill Room usage data. This allowed for a multi-faceted view of changes in risk and protective factors. Methodological triangulation was also achieved by using both pre and post surveys (within the same group of research participants), along with disciplinary data, and Chill Room usage reports. Data triangulation was achieved in research question two, by combining quantitative data (frequency tables from survey elements within the interviews) with ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 71 qualitative data (thematic coding of interview responses). This allowed for a deeper understanding of student experiences regarding access and barriers. For research questions three, a methodological triangulation was achieved through the use of pre and post surveys. This allowed the researcher to measure changes in parent perception over time. Within the present study, use of data triangulation helped the researcher capture subtle details and complexities, providing a nuanced and detailed picture of each research question in this study. The subsequent subsections of this chapter describe the data analysis methods, as well as the specific results in more depth. In addition to triangulating data within each research question, the results were compared to one another using coding practices as well as comparing quantitative and qualitative data between stakeholder groups. Triangulating the data across research questions helped achieve a stronger and more reliable evidence base by cross-referencing information from various sources and perspectives. This helped ensure a well-rounded and comprehensive understanding of various stakeholder perspectives and how they may interact. Research Question One: Data Analysis & Results Research question one aimed to determine the impact on self-reported risk factors and protective factors before and after the implementation of mental and social service programming initiatives. To analyze this, quantitative data was collected using the PhenX School & Protective Factors ToolKit and the School Social Environment ToolKit, which were administered to students at the beginning and end of the study. The School Protective Factors ToolKit provided a detailed analysis protocol for assessing school ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 72 environment, risk and protective factors according to the domains of School Opportunities for ProSocial Involvement, School Rewards for ProSocial Involvement, Academic Performance, Commitment to School, School Alcohol Environment, School Tobacco Environment, School Marijuana Environment, General Protective School Environment (a general summary scale), and General School Drug Environment (a general summary scale). The researcher then used an average of domain scores to report results. In addition to the established test protocols, the student responses from these surveys were analyzed using descriptive statistics to summarize the data and provide an overview of the findings, including calculating the prevalence of students reporting various risk and protective factors. Frequency tables (reported as percentages) were created to analyze how often different categories of responses occurred. Trend analysis was then employed to examine if and how the data changed throughout the project's duration. ​ Disciplinary data from the previous school year (as a control year) was also reviewed and compared to the current year to determine the impact on risk and protective factors. Additionally, Chill Room usage data was reviewed to learn more about the potential impact of this intervention.​ Results: PhenX School & Protective Factors ToolKit ​ ​ Eight students completed pre and post surveys, using the PhenX School & Protective Factors ToolKit. Individual student results were tabulated for each sub domain, as well as the General School Protective Environment. Results in each of the subdomains ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 73 were then averaged to obtain aggregate scores in each domain, for the research participants as whole. Table 3 summarizes an aggregate view of these results: Table 3 PhenX Protective Factors Pre and Post Survey Results Domain: Pre: Post: School Opportunities for ProSocial Involvement 2.91 2.86 School Rewards for ProSocial Involvement 2.64 2.86 Academic Performance 3.08 2.56 General School Protective Environment 2.79 2.97 Note. Results reported represent an average of participant responses for questions in the respective subdomains. In each sub domain a range of scores from 1-4 could be reported, with scores closer to 4 indicating a more protective environment for students. Before the intervention or period of observation (“pre" results), the students' perceptions of School Opportunities for ProSocial Involvement averaged 2.91, suggesting a moderate but improvable sense of available pro-social avenues. Their feeling of School Rewards for ProSocial Involvement was slightly lower at 2.64, indicating room for growth in how positive behaviors are acknowledged. Academic Performance registered an average of 3.08, suggesting a relatively positive perception in this area. Overall, the General School Protective Environment stood at an average of 2.79. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 74 After the administration of the post survey, some notable shifts occurred. School Opportunities for ProSocial Involvement saw a slight decrease to 2.86, suggesting a minor dip in perceived opportunities. However, the students' perception of School Rewards for ProSocial Involvement improved to 2.86, indicating a positive change in how they felt their pro-social actions were recognized. In the subdomain of Academic Performance, a more significant positive shift was noted, improving to 2.56. This suggests a more protective academic environment was perceived. Most encouragingly, the General School Protective Environment showed a positive upward trend, increasing to 2.97. In summary, while there was a minor decrease in perceived opportunities for pro-social involvement, the research suggests an overall positive movement towards a more protective school environment for these eight students, particularly in how they felt rewarded for pro-social behavior and in the general sense of a protective atmosphere. This indicates that efforts to enhance the school environment may be having a beneficial impact on students' perceptions of safety and support. ​ The PhenX School and Protective Factors Toolkit also provided a framework for assessing the impact of district initiated programming on risk factors such as alcohol, tobacco and drug use in the student population. Research participants answered questions related to their perceptions of student acceptance and prevalence of alcohol, tobacco and drug use within their school. Once again, individual student results were tabulated for each sub domain (School Alcohol Environment, School Tobacco Environment, and School Marijuana Environment) and the General School Drug Environment. Results in each of ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 75 the subdomains were then averaged to obtain aggregate scores in each domain, for the research participants as whole. Table 4 summarizes an aggregate view of these results: Table 4 PhenX School Drug Environment Pre and Post Survey Results Domain: Pre: Post: School Alcohol Environment 2.81 2.38 School Tobacco Environment 2.15 2.23 School Marijuana Environment General School Drug Environment 3.04 2.97 2.52 2.79 Note. For this portion of the survey instrument, a range of scores from 1-5 could be reported, with scores closer to 5 indicating more prevalent use or risky behaviors associated with alcohol, tobacco and drug use reported. These results suggest a generally positive shift in students' perceptions of the school's drug environment following the intervention or observation period. While there was a minor uptick in perceived tobacco risk, significant improvements were seen in the perceived alcohol and, particularly, marijuana environments. The overall decrease in the General School Drug Environment score indicates that students perceive a less prevalent or risky drug environment within their school, suggesting that efforts aimed at addressing drug use and associated behaviors may be yielding positive results. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 76 Specifically, prior to the intervention or observation period ("pre" results), the students' average score for the School Alcohol Environment was 2.81. This suggests a moderate perception of alcohol prevalence or associated risk behaviors within the school setting. The School Tobacco Environment registered a lower average of 2.15, indicating a comparatively less perceived presence of tobacco use or risk behaviors. The School Marijuana Environment had the highest pre-score at 3.04, suggesting a relatively higher perceived prevalence of marijuana use or associated risks among the students. Overall, the General School Drug Environment stood at an average of 2.97. Following the observation period or intervention ("post" results), significant and largely positive shifts were observed. The School Alcohol Environment score decreased to 2.38, indicating a perceived reduction in alcohol prevalence or risk behaviors. The School Tobacco Environment saw a slight increase to 2.23, suggesting a marginal rise in perceived tobacco use or risk behaviors, though still remaining relatively low. Most notably, the School Marijuana Environment experienced a substantial decrease to 2.52, suggesting a significant improvement in students' perceptions of marijuana prevalence or associated risks. Consequently, the General School Drug Environment also showed a positive trend, decreasing to 2.79. Results: PhenX School Social Factors ToolKit ​ The PhenX School Social Factors ToolKit was also used as a pre and post survey instrument to assess the impact on student perception of protective factors. Eight students participated in these surveys. The survey instrument contained 39 questions to assess students’ feelings related to their sense of connectedness and pride of their school and school community. Students were able to select from five multiple choices (“Strongly ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 77 Disagree,” “Disagree,” “Neither Agree nor Disagree,” “Agree,” or “Strongly Agree”). The survey asked questions within the following subsections: ●​ Teacher Relationships ●​ School Connectedness ●​ Academic Support ●​ Order and Discipline ●​ School Physical Environment ●​ School Social Environment ●​ Academic Satisfaction ●​ Perceived Exclusion and Privilege Within the subdomains of Teacher Relationships, School Connectedness, Academic Support, Order and Discipline, School Physical Environment, School Social Environment, and Academic Satisfaction student responses indicating “agreement” or “strong agreement” with the survey item indicated student agreement or strong agreement with feelings of connectedness or pride to the school or school community. Table 5 utilizes a stacked bar graph to illustrate the change in student perceptions related to school social factors, over time, during the course of this research: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 78 Table 5 PhenX School Social Factors Pre and Post Results ​ Note. This table illustrates the number of times participants selected each response during each administration of the Phen School Social Factors Survey for the indicated sub-sections. Figures reported are reflected as percentages. ​ As illustrated by Table 5, at the start of this research project, students' responses indicated a varied perception of protective factors within their school environment. A significant portion of responses fell into the "Agree" category at 40.50%, suggesting a baseline level of positive feelings. However, a combined 23.97% (7.44% Strongly Disagree + 16.53% Disagree) expressed negative sentiments, while a substantial 28.93% remained neutral ("Neither Agree nor Disagree"). ​ At the end of this project, there was a noticeable shift towards more positive perceptions among the students. The percentage of responses indicating "Agree" increased substantially to 50.64%, and "Strongly Agree" also saw a rise to 8.58%. This ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 79 means that the combined positive sentiment (Agree + Strongly Agree) increased from 47.11% pre-survey to 59.22% post-survey. Conversely, negative sentiments decreased, with "Strongly Disagree" falling to 3.43% and "Disagree" to 11.16%. The neutral "Neither Agree nor Disagree" responses also saw a slight decrease to 26.18%. ​ When the survey data is considered according to sub sections, there is a clear trend towards improved student perceptions of protective factors, particularly in Teacher Relationships, School Connectedness, Academic Support, Order and Discipline, and School Social Environment subsections of the survey. These areas show a decrease in negative sentiments and a noticeable increase in agreement or strong agreement. The most significant positive shifts were observed in Teacher Relationships and the School Social Environment, where previously high levels of dissatisfaction or neutrality transitioned into predominantly positive views. However, the School Physical Environment remained relatively stable with no significant increase in positive perception. More notably, Academic Satisfaction indicated that students held decreased positive feelings about their academic experiences as the project progressed. Table 6 disaggregates these results according to survey sections: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 80 Table 6 ​ Phen X School Social Factors Sub Domains This data indicates that, initially, perceptions of teacher relationships were mixed. While a significant portion of students (44.1%) agreed, indicating positive sentiments, a considerable number also disagreed (33.9%) or remained neutral (33.9%). Notably, no students strongly agreed, and a small percentage (3.4%) strongly disagreed. At the end of the survey, there was a marked improvement in student perceptions of teacher relationships. The percentage of students who agreed or strongly agreed significantly increased to a combined 75.0% (64.3% Agree, 10.7% Strongly Agree). Disagreement plummeted to a mere 5.4%, and strong disagreement was no longer reported (0.0%). The neutral category also saw a substantial reduction to 19.6%. This suggests a strong positive shift towards more supportive and positive teacher-student interactions. Students' sense of school connectedness at the start of the study showed room for improvement, with only 23.7% (15.8% Agree, 7.9% Strongly Agree) expressing positive feelings. A notable 39.5% remained neutral, and a combined 36.8% (10.5% Strongly ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 81 Disagree, 26.3% Disagree) held negative views. At the conclusion of this project, perceptions of school connectedness generally improved. The percentage of students agreeing or strongly agreeing increased to 43.9% (36.6% Agree, 7.3% Strongly Agree). While there was still a substantial neutral segment (29.3%), both strong disagreement (7.3%) and disagreement (19.5%) saw decreases. This indicates a moderate but positive trend towards a stronger sense of belonging among students. Students largely perceived high levels of academic support at the beginning of the project, with a combined 81.0% (52.4% Agree, 28.6% Strongly Agree) indicating positive feelings. Only 14.3% disagreed with survey questions related to a positive academic support environment, and none strongly disagreed. As this project progressed, positive perceptions of academic support further solidified. The combined percentage of students agreeing or strongly agreeing rose to 86.5% (62.2% Agree, 24.3% Strongly Agree). Disagreement decreased to 5.4%, and the neutral category slightly increased to 8.1%. This suggests that students continued to feel well-supported academically, with an even greater proportion expressing positive sentiments. In terms of order and discipline, students had a generally positive view of order and discipline, even at the start of this project, with 52.4% agreeing and no one strongly agreeing. However, a significant 33.3% remained neutral, and 25.0% (8.3% Strongly Disagree, 16.7% Disagree) expressed negative views. Despite this generally positive view at the start of the study, perceptions of order and discipline, there was notable improvement in student responses in these areas. The percentage of students agreeing or strongly agreeing increased to 64.2% (62.2% Agree, 2.0% Strongly Agree). Strong disagreement significantly dropped to 2.0%, and disagreement also decreased to 10.2%. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 82 The neutral category slightly increased to 38.8%. This indicates a more positive and secure feeling regarding the school's structure and enforcement of rules. Throughout the course of this project, students generally felt positive about the school's physical environment, with 50.0% agreeing to positive statements about the school’s physical environment. A substantial 35.7% reported neutral feelings, and 14.3% (3.6% Strongly Disagree, 10.7% Disagree) held negative views. Perceptions of the school physical environment remained largely stable with some minor shifts. The percentage of students agreeing or strongly agreeing slightly decreased to 46.2% (46.2% Agree, 0.0% Strongly Agree). There was a slight decrease in disagreement (7.7%) but a noticeable increase in the neutral category (42.3%). Strong disagreement remained similar (3.8%). This suggests that while dissatisfaction slightly decreased, there wasn't a significant increase in strong positive feelings. In terms of the school social environment, the pre-survey revealed a challenging perception of the school social environment, with a high percentage of students strongly disagreeing (30.8%) or disagreeing (7.7%), totaling 38.5% negative sentiment. A large 42.6% remained neutral, and only 15.4% agreed. This sub-section of the survey ultimately indicated a significant positive turnaround. The combined percentage of students agreeing or strongly agreeing surged to 46.7% (40.0% Agree, 6.7% Strongly Agree). Strong disagreement dramatically decreased to 13.3%, and the overall negative sentiment (Strongly Disagree + Disagree) was reduced to 40.0%. The neutral category saw a sharp decline to 13.3%. This suggests substantial improvement in students' perceptions of the social interactions and atmosphere within the school. Academic satisfaction was relatively high at the beginning of this project, with a ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 83 combined 64.2% (57.1% Agree, 7.1% Strongly Agree) of students expressing positive feelings. However, a notable 21.4% strongly disagreed, and 7.1% disagreed. During the course of this study, perceptions of academic satisfaction experienced a decline. The combined percentage of students agreeing or strongly agreeing fell to 33.3% (33.3% Agree, 0.0% Strongly Agree). Conversely, disagreement significantly increased to 22.2%, and the neutral category rose to 33.3%. Strong disagreement also decreased to 11.1%. This suggests a decrease in the overall satisfaction students felt with their academic experiences, possibly indicating a shift in their perceptions of curriculum, workload, or learning outcomes. For the Perceived Exclusion/ Privilege of the PhenX School Social Factors Toolkit, “strong disagreement” or “disagreement” indicated a belief among students that they are being treated equally and fairly. For these reasons, this subsection of the toolkit was analyzed separately. At the start of this research project a combined 28.57% of students expressed a positive perception of fairness and equality, with 9.52% strongly disagreeing and 19.05% disagreeing with statements of exclusion or privilege. A substantial 47.62% of students held a neutral stance, indicating neither strong agreement nor disagreement with feelings of exclusion or privilege. Meanwhile, a combined 23.81% of students (19.05% Agree, 4.76% Strongly Agree) perceived some level of exclusion or privilege. At the conclusion of this action research project, there was a noticeable positive shift in students' perceptions of fairness. The percentage of students who disagreed or strongly disagreed with statements of exclusion/privilege significantly increased to a combined 47.62% (9.52% Strongly Disagree, 38.10% Disagree). This indicates a stronger belief among students that they are being treated equally and fairly. The neutral category ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 84 also saw a decrease to 33.33%. Additionally, the percentage of students who agreed or strongly agreed with perceptions of exclusion/privilege slightly decreased to a combined 19.05% (14.29% Agree, 4.76% Strongly Agree). Table 7 illustrates these results using a stacked bar-graph: Table 7 Perceived Exclusion and Privilege Note. The results for the "Perceived Exclusion/Privilege" sub-section demonstrate a positive trend from the pre- to the post-survey. The increase in "disagree" and "strongly disagree" responses suggests that students' perceptions of being treated equally and fairly within the school environment have improved. While nearly half of the students still hold a neutral or positive (perceiving exclusion) stance in the post-survey, there is a significant shift away from neutrality and towards the positive perception of fairness. Results: Discipline Data During the study, the file "Action Code Usage Report" was used. This report from the student information system provides a breakdown of disciplinary actions within the Tussey Mountain School District during the 2023-2024 school year. The report focuses ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 85 on high school students (grades 9-12) and categorizes disciplinary actions using specific codes. Below a summary has been provided for each of the following discipline codes: ●​ Warnings: When student behavior was escalated to the office-level, there was little change from the previous to current school year, in terms of warnings issued by the principal (57 to 62). This represents a slight increase in less severe, verbal/minor interventions. ●​ Referral to SAP, Counseling, Other Agency: There was a moderate decrease in the number of principal-initiated referrals to outside programming outside of the discipline process (from 11 to 6). ●​ Detention: Increased significantly (from 121 to 149). This is a substantial rise in a mid-level disciplinary action. ●​ In-School Suspension (ISS): In school-suspensions increased from (7 to 16). This is a notable increase in more severe disciplinary measures. ●​ Out-of-School Suspension (OSS): Out-of school suspensions) decreased significantly (from 9 to 4). This is the only clear positive trend, indicating fewer instances of the most severe disciplinary action. Table 8 provides a visual representation of this data, frequency counts and a frame of reference for comparing disciplinary data from the previous to current school year: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 86 Table 8​ School Disciplinary Data Results: Chill Room Usage Data Chill Room usage data was also used to assess the impact of district initiated programming on student risk and protective factors. Upon checking in and out of the Chill Room, students are asked to rate their mood and ability to engage in school tasks in a healthy way, using an emotional thermometer. This visual tool helps students visualize their feelings, as well as their strength. Figure 6 provides an example of an emotional thermometer, similar to the one used in the Chill Room: Figure 6 Emotional Thermometer Note. The emotional thermometer also provides a data point to determine the efficacy of Chill Room interactions, according to student perception. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 87 Table 9 summarizes data collected related to Chill Room usage by students and its impact: Table 9​ Chill Room Usage Data December 2024 January 2025 February 2025 ●​ Drop ins: 10 ●​ Drop ins: 29 ●​ Drop ins: 34 ●​ Average Rating In: ●​ Average Rating In: ●​ Average Rating In: 3.5 3.3 ●​ Average Rating ●​ Average Rating Out: 2.2 March 2025 3 ●​ Average Rating Out: 1.6 April Out: 1.2 May ●​ Drop ins: 35 ●​ Drop ins: 38 ●​ Drop ins: 11 ●​ Average Rating In: ●​ Average Rating In: ●​ Average Rating In: 2.9 ●​ Average Rating Out: 1.6 3.5 ●​ Average Rating Out: 1.8 3.2 ●​ Average Rating Out: 1.8 When this data is reviewed to determine trends, it is notable that the number of student "drop-ins" to the Chill Room showed a consistent and significant increase from December 2024 (10 drop-ins) to April 2025 (38 drop-ins). This could suggest a growing awareness and utilization of the Chill Room as a resource among students over these months. May 2025 saw a sharp decrease to 11 drop-ins, likely correlating with the end of the school year or reduced student presence.​ ​ Additionally, the "Average Rating In" generally hovered in the moderate to ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 88 somewhat intense range (between 2.9 and 3.5). This rating showed a slight downward trend (indicating calmer entry moods) from December (3.5) to March (2.9), suggesting that students might have been seeking the Chill Room for slightly less intense emotional states as the months progressed, or perhaps for proactive regulation. However, during the month of April, an increase (back to 3.5), was noted, indicating students entering with higher intensity, before dropping to 3.2 in May. Even with the fluctuation between “Average Rating In,” the "Average Rating Out" was significantly lower than the "Average Rating In", consistently for each month during this action research project. The " Average Rating Out" consistently fell into the calm to mostly calm range (between 1.2 and 2.2). The lowest "Rating Out" was observed in February (1.2), indicating students were leaving the Chill Room feeling very calm and ready to learn after their visit. The average reduction in intensity (difference between "Rating In" and "Rating Out") ranged from 1.3 points (December) to 1.9 points (February), consistently demonstrating a substantial positive shift in student mood and readiness for school tasks. Research Question Two: Data Analysis & Results Research question two explored the strategies students reported as effective for accessing mental and behavioral health services through their school as well as the barriers to accessing services. For this research question, both quantitative and qualitative data were collected. Participants were recruited through the student mental health team for interviews. The interviews aimed to assess student perceptions of access to mental health services, effective methods for accessing these services, and the barriers that existed. Once consent and assent were obtained, student interviews were conducted. Student responses were recorded in written format for further analysis. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 89 The analysis of student interview responses involved both qualitative and quantitative methods. Frequency counts (reported as percentages) were used to quantify how often different categories of responses occurred. For the qualitative portion, thematic coding was employed to identify specific aspects of the discussion that were most relevant to the research question. The researcher’s notes have been included as Appendix H. By assigning and reassigning codes, the research aimed to help the Tussey Mountain School District gain a greater understanding of the perceived efficacy of district-initiated programming, identify barriers to accessing said programming, and determine effective strategies to improve accessibility. Through the coding process, eight central themes emerged in student responses. These included: ●​ The prevalence of mental health challenges within the Tussey Mountain School District ●​ Awareness and utilization of resources ●​ Perception of the sufficiency of resources ●​ Channels of information about services ●​ Effective strategies for accessing mental health services ●​ Barriers to accessing services ●​ Opportunities for improvement Results: Quantitative and Qualitative Summary of Student Interviews A total of eight students participated in interviews with the researcher. Upon completion and analysis of student responses, it was notable that 100% of those interviewed indicated that they have felt “stressed, anxious, or depressed while at ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 90 school.” Of these students, 87.5% of respondents reported that they were aware of resources to help them cope with these feelings while at school. Of the students who reported being aware of district resources to help them 67% of respondents noted the Chill Room being a helpful resources, 33% noted access to the school-based therapist through Allegheny health network being helpful, and 33% of students noted the school counseling/ guidance office being a place they would turn for help when needed. ​ Through the interviews, the researcher also sought to learn if students perceived whether or not there were enough resources at school. When answering this question, 75% of students felt that there were adequate mental health resources at the school while 12.5% of respondents did not feel there were enough resources. One responder did not provide a “yes” or “no” response to the question, but felt that things were “moving in the right direction, but that more students needed to take it (the opportunities) up.” ​ Participants were also asked questions related to how they learned of district resources. From these responses, 55.5% of student interview responses seeking information about how students learned about services indicated that students most frequently learn about services from talking with their teachers. Other means by which students report being made aware of district services (though far less common) include: ●​ From conversations with the school/ guidance counseling office ●​ From SEMHA Team publications ●​ From school announcements ●​ Word of mouth (other classmates) ●​ Through school announcements ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 91 These student interviews also sought to identify what strategies have been helpful in assisting students with accessing mental health services. Seventy-five percent of students who completed the interview reported that having an adult explain and walk them through options was helpful to them. In subsequent interview questions, 33% of participant responses indicated that Allegheny Health Network staff were particularly helpful in walking them through this process. Interview participants equally identified their teachers as helpful in this process (also 33% of responses). District paraprofessionals were also identified as helpful to helping students access services (22%), along with school counselors (11%). Students in grades 10-12 also answered questions about how programming has changed over time, since they started high school. During this interview question, many students elaborated on the programs and strategies where they have observed positive change during their high school careers. Eighty-eight percent of participants surveyed indicated that they have observed much positive change since starting high school in terms of the resources which are available to students. Participants most commonly cited the Chill Room being on-sight as an effective strategy to help students access services. Students reported that they liked the flexibility of this space and that it was effective in helping them to find what worked for them. Less commonly, but still emerging as a theme, participants also referenced SEMHA raising awareness to mental health concerns and reducing stigma. Students were also asked about the barriers to accessing services and support within their school. When these student responses were analyzed 75% of students reported that accessing services was “easy” and 25% of students reported that it was ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 92 difficult. Students most frequently cited teachers not allowing them to access guidance/ school counselors or the Chill Room as one of the biggest barriers to accessing services. Students also cited the Chill Room’s operating hours presented a barrier to accessibility. (The Chill Room is currently only open to students Tuesday-Thursday). This lack of availability creates a barrier to consistent service delivery. Students were also asked a series of questions related to opportunities for improvement. On these questions, students most frequently identified training for staff (to help teachers better recognize the signs of a mental health problem) as one of the best ways to improve district programming moving forward. Other suggestions included: more advertisement of district programs and more consistency/ intentionality in the schedule to help students access services. Research Question Three: Data Analysis & Results Research question three focused on the impact on parent perceptions regarding the availability of mental health and social service programming, a survey instrument was designed and used to gather data. This survey aimed to assess parent/guardian perceptions of the overall state of adolescent mental health, the school’s role in service delivery, the efficacy of existing programming, barriers to accessing programming, referral processes, and other relevant information. The survey was administered at the start and close of the study to determine if there was any change in parent perceptions of programming before and after the implementation of new school initiatives. Descriptive statistics were used to analyze participant responses and determine the community's perception of the most prevalent barriers and most successful programming. Frequency tables were created to show how often different categories of responses occurred within ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 93 the community. Trend analysis was also employed to examine whether and how the data changed during the six-month project period, comparing pre and post survey results. Results: Parent Pre Surveys During the pre-survey, parents within the Tussey Mountain Community community overwhelmingly recognized the critical need for mental health and social service. The first question in the survey asked parents to rate their agreement with the statement, "mental health services are important for the overall well-being of students in our school district.” Almost 90% of parents surveyed indicated some level of agreement with this statement, with 77.8% selecting "Strongly Agree;” another 11.1% chose "Agree;" and the remaining 11.1% responded "Neither agree nor disagree." This indicates a very high consensus among parents regarding the critical importance of mental health support for students in the district. The second question on the parent survey asked parents to indicate their level of agreement with the statement, "social service programs are essential in supporting students facing challenges outside of school." A significant proportion of parents reported that they, 66.7%, "Strongly Agree." Additionally, 11.1% selected "Agree," and 22.2% chose "Neither agree nor disagree." This also demonstrates strong parental recognition of the necessity of social service programs in addressing challenges students face outside the school environment. In response to the third question, "there is a growing need for mental health and social service support in our rural community," parents again showed strong agreement, with 77.8% selecting "Strongly Agreed." Another 11.1% chose "Agree," and 11.1% opted for "Neither agree nor disagree." This consistent strong agreement across the first three ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 94 questions underscores a widely perceived and increasing need for both mental health and social service support within their rural community. Despite these positive results, participating parents reported significant gaps in the accessibility, awareness, and effectiveness of programming available during the pre-survey, particularly those offered by or in collaboration with the school district. A notable shift in sentiment occurred with the fourth question, "students in our school district have easy access to mental health services when needed." A clear majority of parents, 66.7%, "Disagreed" with this statement. Only 11.1% "Strongly Agreed," and 22.2% selected "Neither agree nor disagree." This indicated a strong perception among parents that access to mental health services were not readily available for students in the district, pointing to a significant accessibility barrier at the start of this project. For the fifth question, "I am aware of the different types of social service and mental health programs available to students and families in our community," responses were quite varied. While 11.1% "Strongly Agreed" and 11.1% "Agreed," a combined 77.7% either chose "Neither agree nor disagree" (44.4%) or "Disagree" (33.3%). These mixed responses indicated a discrepancy in awareness among parents regarding the various support programs available in their community, at the start of this action research project. Regarding the sixth question, "the mental health services offered by the school district are effective in addressing student needs," opinions leaned towards skepticism or neutrality. 44.4% of parents "Disagree," and an equal 44.4% selected "Neither agree nor disagree." Only 11.1% "Agreed," and no parents "Strongly Agreed." This indicates a ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 95 prevailing sentiment that the school district's mental health services were either ineffective or their efficacy was unclear to parents during the first administration of this survey. The seventh question, "The social service programs offered in collaboration with the school district are helpful for students facing challenges," also presented mixed responses. While 22.2% "Agreed," a combined 77.7% either chose "Neither agree nor disagree" (33.3%), "Disagree" (33.3%), or "Strongly Disagree" (11.1%). Suggesting that collaborative social service programs were not consistently perceived as beneficial or helpful by parents during the pre-survey. Concerning the eighth question, "School staff effectively communicate mental health resources available to students to students and families, when needed," a significant majority of parents expressed disagreement (55.6% "Disagree," and 11.1% "Strongly Disagree," totaling 66.7%). Only 11.1% "Agreed," and 22.2% chose "Neither agree nor disagree." This clearly indicates a perceived deficiency in how school staff communicate mental health resources to families. Finally, for the ninth question, "The school environment is supportive of students seeking mental health help," a substantial proportion of parents expressed a lack of support. 44.4% "Disagree," and 22.2% "Strongly Disagree," resulting in 66.6% expressing negative perceptions. The remaining 33.3% chose "Neither agree nor disagree," and no parents "Agreed" or "Strongly Agreed." This suggests that parents generally do not perceive the school environment as conducive to students seeking mental health assistance. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 96 Table 10 illustrates parental attitudes, toward mental health services, as well as their perceived accessibility in a series of pie charts: Table 10​ Parent Pre-Survey Mental Health Service Perceived Importance & Accessibility ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 97 To further explore parent concerns related to existing programming and barriers, thematic coding was completed. The researcher’s coding notes have been included in Appendix J, to summarize prevailing themes which emerged as a result of the coding process. Commonly, the biggest barriers to success from the perception of parents to successful mental health programming were stigma and/ or confidentiality concerns, a lack of awareness about available programs, and systemic issues within the school related to communication, follow-through, and staff responsiveness. Parent responses also indicated strong desire for more integrated, school-based mental health services, improved staff training, and better communication to destigmatize and facilitate access to care. Concerns about school practices contributing to student stress also emerged as a significant point. During the pre survey, parents expressed a clear desire for the school to be more actively involved and to have more in-house resources rather than relying solely on external referrals. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ ​ 98 In addition to the qualitative data obtained regarding parent reports of barriers, a quantitative analysis was also completed for survey questions, 19-25 which asked specific questions related to parent perception of commonly identified barriers within the review of literature. Parents who completed this portion of the survey, reported seeking mental health services for their child within the past calendar year from the date they completed the pre-survey. Regarding the cost of mental health programming or services, 20% of respondents identified it as a "Major Barrier," while 40% found it "Somewhat of a Barrier," and another 40% indicated it was "Not a Barrier." This suggested that while cost was a significant impediment for a minority, it was a moderate concern for a larger group, and not an issue for others. Transportation to outside agency appointments was largely not a barrier, with 60% of participants reporting it as "Not a Barrier." However, 40% did experience it as "Somewhat of a Barrier," indicating that while not a universal issue, it still posed difficulties for a notable segment of families. Similarly, scheduling with outside agency providers was also predominantly "Not a Barrier" for 60% of respondents, with 40% finding it "Somewhat of a Barrier." A more pronounced challenge emerged concerning awareness about available mental health or social service programs in the community. Here, 20% of respondents identified this as a "Major Barrier," and 60% as "Somewhat of a Barrier," with only 20% reporting it as "Not a Barrier." This highlighted a significant need for improved communication and outreach regarding existing resources within the community. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 99 Concerns about confidentiality or stigma proved to be a substantial deterrent. While 40% of respondents indicated this was "Not a Barrier," 20% found it "Somewhat of a Barrier," 20% a "Significant Barrier," and another 20% a "Major Barrier." This broad distribution underscored the varying, but often impactful, role of stigma in preventing families from seeking help. Difficulties navigating the process of getting help, such as referrals and paperwork, were also a notable obstacle. Forty percent of participants described this as a "Significant Barrier," 20% as "Somewhat of a Barrier," and 40% as "Not a Barrier." This suggested that administrative complexities created considerable hurdles for a notable portion of families. Finally, long wait times for appointments were identified as a critical barrier. A significant 40% of respondents categorized this as a "Major Barrier," while 20% found it "Somewhat of a Barrier," and 40% reported it as "Not a Barrier." This indicated that delays in accessing timely appointments were a primary concern for a substantial number of families seeking mental health support. Table 11 illustrates these figures and parental attitudes surrounding each barrier: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 100 Table 11 Barriers Reported in Parent Pre Surveys Results: Parent Post Surveys​ ​ A total of eleven parents participated in the post survey, which took place approximately six months from the date of the pre-survey. It should be noted that due to anonymity in the survey design, there is no way of knowing if this group of participants participated in the pre-survey or not. The terms “pre” and “post” reflect a snap-shot in time, at the beginning and end of this project, with near-identical questions being asked. These terms are not necessarily indicative that a change in perspective occurred over time within the same survey participant. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 101 During this administration of the survey, ​survey participants overwhelmingly recognized the importance of mental health and social services for students, with 91% of respondents either agreeing or strongly agreeing that mental health services were important for overall well-being, and 91% similarly agreeing or strongly agreeing about the essential nature of social service programs. A strong consensus once again emerged regarding the increasing need for these services in the rural community, as 91% of parents agreed or strongly agreed with this statement. Once again, a notable divergence in opinion appeared when addressing the accessibility of mental health services. Only 27% of participants agreed that students had easy access to mental health services, while 45% disagreed or strongly disagreed, with 27% remaining neutral. Awareness of available programs was also a point of concern, with 45% of parents disagreeing or strongly disagreeing that they were aware of different program types, compared to 27% who agreed or strongly agreed and 27% who were neutral. Regarding the effectiveness of school district-offered services, only 27% believed mental health services were effective, while 45% disagreed or strongly disagreed and 27% remained neutral. Social service programs offered in collaboration with the school district fared slightly better, with 36% finding them helpful, 36% disagreeing, and 27% remaining neutral. Communication was once again reported as a concern by survey participants during this administration of the survey. Seventy-three percent of respondents disagreed or strongly disagreed that school staff effectively communicated these resources, with ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 102 only 9% agreeing and 18% reporting neutral feelings about the issue. Opinions were also mixed on the school environment's supportiveness of students seeking mental health help. Only 27% of parents agreed that the environment was supportive, while 36% disagreed or strongly disagreed, and 36% were neutral, indicating a lack of consistent positive perception in this area. Table 12 appears on the next page and to illustrate the proportionate responses to these survey questions. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ Table 12​ Parent Post-Survey Mental Health Service Perceived Importance & Accessibility 103 ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 104 As with the first administration of this survey, parent concerns related to existing programming and barriers were analyzed using thematic coding. The researcher’s coding notes have been included in Appendix K to summarize prevailing themes which emerged as a result of the coding process. Parents reported strong support with district initiatives which support the growing need for mental health and social services for students. However, from the parent’s perspective, the district faces significant challenges in terms of accessibility, awareness, and perceived effectiveness. The most critical barriers identified are stigma, coupled with perceived shortcomings in staff understanding, communication, and accountability. Parents communicated a desire for improved communication, comprehensive staff training with an emphasis on empathy and accountability, and initiatives to increase awareness. Once again, quantitative analysis was completed for survey questions, 19-25 which asked specific questions related to parent perception of commonly identified barriers within the review of literature. This portion of the post survey was only completed by parents who had sought mental health services for their student. Many of these results are similar to those reported in the qualitative analysis. In terms of financial accessibility, the cost of mental health programming or ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 105 services was primarily perceived as either not a barrier or only somewhat of a barrier. Specifically, 60% of parents indicated that cost was "Not a Barrier," while 40% considered it "Somewhat of a Barrier." Regarding logistical challenges, transportation to outside agency appointments was largely not seen as a significant hurdle, with 80% of parents reporting it was "Not a Barrier," and 20% perceiving it as "Somewhat of a Barrier." Similarly, scheduling appointments with outside agency providers posed a barrier for a minority of parents, with 60% stating it was "Not a Barrier" and 40% finding it "Somewhat of a Barrier." However, awareness about available mental health or social service programs in the community emerged as a more notable obstacle. While 60% of parents reported it was "Not a Barrier," a substantial 20% identified it as a "Significant Barrier," and another 20% considered it "Somewhat of a Barrier." Concerns about confidentiality or the stigma associated with seeking mental health help represented the most pronounced barrier among these categories. For 60% of parents, these concerns were "Not a Barrier." However, 20% indicated they were a "Major Barrier," and another 20% viewed them as a "Significant Barrier." Difficulties navigating the process of getting help, such as referrals and paperwork, also presented a barrier for some parents. While 40% found this "Not a Barrier," an equal 40% considered it a "Significant Barrier," and 20% identified it as "Somewhat of a Barrier." Long wait times for appointments were also a notable concern, with 20% of parents reporting them as a "Major Barrier," and 60% as "Somewhat of a Barrier," while 20% found them "Not a Barrier." ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ Table 13 illustrates these parent responses in proportionate pie charts: Table 13 Barriers Reported in Parent Post Surveys 106 ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 107 Comparison: Pre and Post Surveys As indicated, due to the anonymous nature of the surveys and their submissions, there is no way of knowing if participants who completed the pre survey, at the beginning of this action research project repeated the survey during the post administration. When reviewing results, it is important to read the results as a snapshot of parental attitudes at the time of the survey, rather than interpreting them as a change in perceptions over time within the same research group. With this in mind, it is valuable to compare both the qualitative and quantitative survey data during both administrations to gain a comprehensive understanding of the parent perception district programming and initiatives. Parents in the Tussey Mountain community consistently recognized the vital importance of mental health and social services for students, both at the start and end of the project. In the initial pre-survey, an overwhelming 90% of parents agreed or strongly agreed that mental health services were crucial for student well-being. This sentiment remained strong in the post-survey, with 91% of respondents expressing similar agreement. Similarly, the essential nature of social service programs in supporting students facing challenges outside of school was a point of widespread agreement. In the pre-survey, 77.8% of parents agreed or strongly agreed that these programs were essential. This consensus was maintained in the post-survey, with 91% of parents agreeing or strongly agreeing. The perception of a growing need for both mental health and social service support within the rural community was also a consistent theme, with ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 108 77.8% of parents agreeing or strongly agreeing in the pre-survey, and 91% in the post-survey. Despite the strong recognition of need, both survey administrations highlighted significant and persistent gaps in the accessibility, awareness, and effectiveness of available programming, particularly those offered by or in collaboration with the school district. A notable area of continued concern was the accessibility of mental health services. In the pre-survey, a clear majority of parents (66.7%) disagreed with the statement that students had easy access to mental health services. This perception remained largely unchanged in the post-survey, where only 27% of participants agreed that students had easy access, while 45% disagreed or strongly disagreed. Awareness of available programs also remained a significant issue. In the pre-survey, a combined 77.7% of parents either chose "Neither agree nor disagree" or "Disagree" when asked about their awareness of different program types. This lack of awareness persisted in the post-survey, with 45% of parents disagreeing or strongly disagreeing that they were aware of various program types. Regarding the effectiveness of school-district offered mental health services, opinions consistently leaned towards skepticism or neutrality across both surveys. In the pre-survey, 88.8% of parents either disagreed or remained neutral about the effectiveness of these services. The post-survey showed a similar trend, with 45% disagreeing or strongly disagreeing, and 27% remaining neutral. Social service programs offered in collaboration with the school district also presented mixed responses in both ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 109 administrations, suggesting they were not consistently perceived as beneficial or helpful. Finally, communication from school staff regarding available mental health resources was a consistent area of concern. In the pre-survey, a significant majority of parents (66.7%) expressed disagreement that school staff effectively communicated these resources. This negative sentiment was even more pronounced in the post-survey, with 73% of respondents disagreeing or strongly disagree. The perception of the school environment's supportiveness of students seeking mental health help also remained a challenge. In the pre-survey, 66.6% of parents expressed negative perceptions in this area, and in the post-survey, only 27% of parents agreed that the environment was supportive. Chapter Summary To thoroughly address each research question, a mixed-methods approach was employed, integrating both quantitative and qualitative data collection and analysis. This strategy ensured a comprehensive understanding of the contextual issues. The action-research project leveraged data triangulation by utilizing multiple sources, including student surveys, parent surveys, interviews, discipline data, and Chill Room usage records. This approach enhanced the internal validity of the study by offering diverse perspectives on the research questions and mitigating potential biases from any single data source. The use of data triangulation allowed for a more nuanced and detailed understanding of the research questions, a technique that involved examining research questions through various data sources, methods, or perspectives. Pre and post student survey data revealed a more protective school environment, showing improvements in how pro-social behaviors were rewarded and in the general ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 110 sense of safety and support. Perceptions of the school's drug environment also improved, particularly regarding alcohol and marijuana. Furthermore, there was a noticeable positive shift in students' perceptions of school social factors, especially concerning teacher relationships, school connectedness, academic support, order and discipline, and the school social environment. However, academic satisfaction showed a decline, while the physical environment remained stable. Discipline data revealed mixed trends, with slight increases in warnings, detentions, and in-school suspensions, but a positive decrease in out-of-school suspensions. Chill Room usage consistently increased, and data showed a significant positive shift in student mood and readiness for school tasks after visits. Student interviews revealed key strategies and challenges in accessing mental and behavioral health services at Tussey Mountain Middle/High School. All interviewed students reported experiencing stress, anxiety, or depression at school, with most (87.5%) aware of available resources like the Chill Room (67%), the school-based therapist (33%), and the counseling office (33%). Most students (75%) felt resources were adequate, primarily learning about them from teachers (55.5%). The most effective strategy reported was an adult explaining and guiding students through options (75%), often by Allegheny Health Network staff and teachers. Students noted significant positive changes since starting high school, especially praising the Chill Room's onsite availability and flexibility. However, barriers persisted, with 25% finding access difficult, largely due to teachers not allowing access to resources and the Chill Room's limited operating hours. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 111 Students suggested staff training to better recognize mental health needs, increased program advertisement, and greater scheduling consistency as crucial improvements. Parents also completed surveys at two points during this action research project. Parents overwhelmingly recognized the critical need for mental health and social services for students, with over 90% consistently agreeing that these services were important for well-being and that there was a growing community need. Despite this consensus, significant and persistent gaps in accessibility, awareness, and effectiveness were reported across both surveys. A majority of parents (66.7% pre, 45% post) disagreed that students had easy access to mental health services. Awareness of available programs remained a concern, with 77.7% of parents pre-survey and 45% post-survey indicating mixed awareness or disagreement about program knowledge. The effectiveness of school-district mental health services was consistently met with skepticism or neutrality (88.8% pre, 72% post). Communication from school staff about resources and the school environment was also reported as a common concern among parents in both qualitative and quantitative responses. Qualitative data also identified stigma, lack of awareness, and systemic issues as major barriers. While cost, transportation, and scheduling were less frequently major barriers, they remained "somewhat of a barrier" for many. Parents expressed a strong desire for more integrated, school-based services, improved staff training, and better communication to destigmatize and facilitate access. While this chapter focused on detailing these results, the subsequent chapter will ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 112 transition to a deeper analytical discussion, interpreting these findings in relation to the existing literature and addressing the overarching research questions. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 113 CHAPTER V​ Conclusions & Recommendations This action research project undertook a comprehensive investigation into the effectiveness of interventions designed to enhance mental and behavioral health services at Tussey Mountain Middle/High School. Using a robust mixed-methods approach, this study triangulated quantitative data from student and parent surveys, discipline records, and Chill Room usage logs with rich qualitative insights gleaned from student interviews to obtain a comprehensive understanding into district programming. This multifaceted strategy allowed for a nuanced understanding of the prevailing contextual issues. The findings revealed significant positive shifts in student perceptions, particularly concerning school safety, the supportive environment, and the school's approach to drug-related concerns. Furthermore, improvements in social factors, such as teacher relationships and a greater sense of school connectedness, were evident, alongside the demonstrable value of the Chill Room, marked by its increased utilization and positive impact on student well-being. Despite these encouraging developments, the investigation also brought to light persistent challenges. While a decrease in out-of-school suspensions was observed, an increase in warnings, detentions, and in-school suspensions suggests areas warranting further attention. Crucially, student perspectives highlighted barriers to accessing mental and behavioral health resources, including limited operating hours for the Chill Room and instances where access was restricted by staff. Parents, in parallel, consistently reported significant gaps in the accessibility, awareness, and perceived effectiveness of ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 114 existing services, coupled with concerns about communication from school personnel. Qualitative data from parents further emphasized the role of stigma, lack of awareness, and systemic issues as major impediments. Moving forward, it is important to explore these results further to draw meaningful connections to the established research questions. It is also important to explore the limitations of this action research study, exploring how the research design, methodology, or external factors may have influenced the interpretation of the findings. Exploration in these areas will provide a context to provide recommendations for future research, to identify areas that warrant closer examination to potentially. This discussion will also facilitate actionable steps for further improvements to the programming within the Tussey Mountain School District. Research Question One: Conclusions When studying the research question, “what was the impact on self-reported risk factors and protective factors before and after the implementation of mental and social service programming initiatives” many tangible improvements to district programming, services and culture were realized. The action research project demonstrated several tangible improvements. First and foremost, there were increased student perceptions of a protective school environment. Students reported feeling a greater sense of overall safety, support, and recognition for prosocial behaviors. Students also perceived a less prevalent and risky drug environment within the school, particularly concerning alcohol and marijuana. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 115 There is also much evidence of an enhanced school social climate. There was a clear and measurable improvement in students' perceptions of teacher relationships, their sense of school connectedness, the level of academic support, the effectiveness of order and discipline, and the overall school social environment. Students also increasingly felt they were being treated equally and fairly within the school.This was coupled with a notable decrease in serious discipline infractions. The Chill Room proved to be a highly effective and increasingly utilized resource for students to manage their emotions and improve their readiness for learning. The consistent and significant reduction in students' self-reported distress levels after using the Chill Room is another clear and tangible outcome of this project. Impact on Risk Factors A reduction in self-reported risk factors was realized during this study. Data from the PhenX School Drug Environment ToolKit reveals a generally positive shift in students' perceptions of the school's drug environment, indicating a reduction in perceived risk. Improvements were noted in these areas: ●​ General School Drug Environment: This overall summary scale decreased from 2.97 pre-intervention to 2.79 post-intervention (with scores closer to 5 indicating more prevalent use or risk behaviors). This is a positive indicator that students perceive a less prevalent or risky drug environment. ●​ School Alcohol Environment: A significant perceived reduction in alcohol prevalence or risk behaviors was observed, with scores decreasing from 2.81 to 2.38. ●​ School Marijuana Environment: This saw the most substantial decrease, dropping from 3.04 to 2.52, suggesting a significant improvement in students' perceptions of ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 116 marijuana prevalence or associated risks. ●​ School Tobacco Environment: While overall positive, there was a minor uptick in perceived tobacco risk (from 2.15 to 2.23), suggesting that tobacco use or risk perceptions may not have responded as favorably to the interventions as alcohol and marijuana. School discipline data also provided some insight into the impact of district initiated programming on student risk factors. Discipline data presents mixed trends, indicating that while some severe risk behaviors decreased, others saw an increase. Out-of-School Suspensions (OSS) saw a significant decrease from last school year to this school year. This is a clear positive trend, suggesting that the most severe disciplinary actions were less frequently necessary. While there was a decrease in more severe disciplinary actions, low and mid-level disciplinary actions remained relatively stable or increased, with warnings increasing slightly, detentions increasing significantly, and in-school suspensions rising sharply. Additionally, referrals to SAP, Counseling, or Other Agencies decreased. When considered in context, these could indicate more minor behavioral issues but also a shift in how less severe behaviors are being managed by the principal's office. Coupled with fewer principal-initiated external referrals, there is some evidence that proactive approaches such as use of district-initiated mental health programs are being used to address behaviors before they escalate to more serious disciplinary infractions, such as those which require out-of-school suspension. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 117 Impact on Protective Factors Based on the quantitative data collected from the PhenX School & Protective Factors ToolKit, the PhenX School Drug Environment surveys, the PhenX School Social Factors ToolKit, disciplinary data, and Chill Room usage records, the implementation of mental and social service programming initiatives at Tussey Mountain Middle/High School demonstrated a mixed but generally positive impact on self-reported risk and protective factors among students. The aggregate data from the PhenX School & Protective Factors ToolKit indicates an overall positive movement towards a more protective school environment for the eight participating students. Specifically, improvements were noted in these areas: ●​ General School Protective Environment: This key summary scale showed a positive upward trend, increasing from an average of 2.79 pre-intervention to 2.97 post-intervention (with scores closer to 4 indicating a more protective environment). This suggests that students perceived a greater sense of overall safety and support within the school following the initiatives. ●​ School Rewards for ProSocial Involvement: Perceptions significantly improved, moving from 2.64 pre-intervention to 2.86 post-intervention. This indicates that students felt their positive behaviors were better recognized and acknowledged after the programming initiatives. ●​ Academic Performance: This subdomain also showed a positive shift, improving from 3.08 pre-intervention to 2.56 post-intervention (where lower scores indicated a more protective environment). This suggests a more supportive academic environment was perceived. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 118 ●​ School Opportunities for ProSocial Involvement: While the overall trend was positive, there was a minor, albeit slight, decrease in perceived opportunities for prosocial involvement (from 2.91 to 2.86). This suggests that while other protective aspects improved, the perceived avenues for pro-social engagement may require further attention. Analysis of student responses reported using the PhenX School Social Factors ToolKit also demonstrates a noticeable positive shift in students' perceptions of school social factors, indicating an increase in protective elements related to their sense of connectedness and pride. The combined percentage of responses indicating overall positive sentiments increased from 47.11% at the start of the study to 59.22% at the end of the study. Similarly, negative sentiments decreased from 23.97% to 14.59%. This indicates a general improvement in students' perceptions of the school's social environment. The most notable improvements were observed in Teacher Relationships (which improved from 44.1% reporting positive responses to 75.0% reporting positive responses). Improvement was also noted in other sub domains. School Connectedness (increased from 23.7% to 43.9%), Academic Support (further solidified from 81.0% to 86.5%), Order and Discipline (increased from 52.4% to 64.2%). Furthermore, School Social Environment (combined positive sentiment surged from 15.4% to 46.7%). There was also a positive shift in students' perceptions of fairness, with the percentage of students disagreeing or strongly disagreeing with statements of exclusion/privilege increasing from 28.57% to 47.62%. This indicates a stronger belief among students that they are being treated equally and fairly. These shifts suggest that the ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 119 programming initiatives fostered stronger relationships, a greater sense of belonging, and a more positive and secure social atmosphere within the school. While many areas improved, School Physical Environment remained relatively stable with no significant increase in positive perception. More notably, Academic Satisfaction indicated a decline in positive feelings (from 64.2% to 33.3%), suggesting students felt less satisfied with their academic experiences as the project progressed. This could be a critical area for future attention. Additionally, data from the Chill Room strongly supports its role as a valuable protective factor. This was evident through continued, increased utilization. "Drop-ins" consistently and significantly increased from December to April, indicating growing student awareness and willingness to utilize this resource for emotional regulation. Additionally, the "Average Rating Out" was consistently and significantly lower than the "Average Rating In" across all months (e.g., in February, the average reduction was 1.9 points from 3 to 1.2). This consistently demonstrates a substantial positive shift in student mood and readiness for school tasks after visits, highlighting the Chill Room's effectiveness in de-escalation and promoting well-being. Recommendations for Future Research ​ While study of this research question yielded very positive results for the students and school at large, during this action research project, several areas of further inquiry have emerged which may assist in continuing to improve programming within the Tussey Mountain School District and other schools. ​ Further study may be beneficial to determine why survey participants reported a ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 120 decline in academic satisfaction during the course of this study and how this could be addressed through targeted interventions. This could be achieved through conducting qualitative interviews with students to delve deeper into their perceptions of curriculum, workload, grading, instructional methods, and relevance of learning. Supplementing this with teacher and parent focus groups could help gain a more comprehensive understanding of this issue. This was identified as an important area for study, as a limited number of parent respondents (in research question three) reported homework stressors as a concern for their student. Additionally, as indicated it is currently unclear why warnings, detentions, and in-school suspensions increased and the number of external referrals decreased. As discussed this could be evidence that addition of programming available within the school has led to a more proactive approach but more research is needed at this time to better describe and understand the relationship between mental health initiatives and student discipline. Interviewing teachers and administrators to understand their perceptions of behavioral trends and changes in disciplinary practices could help school leaders better understand this relationship. Within the Tussey Mountain School District, this data could also provide greater context to parent concerns reported in research question three regarding staff misunderstandings of mental health disorders. Research Question Two: Conclusions ​ Research question two sought to determine what strategies, as reported by students, were effective for helping students access mental and behavioral health services at Tussey Mountain Middle/High School and determine what barriers existed. Based on the self-reported data from student interviews, the most effective strategy for helping ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 121 students access mental and behavioral health services at Tussey Mountain Middle/High School was direct, personalized guidance from a trusted adult, particularly teachers and Allegheny Health Network staff, combined with the readily available and flexible Chill Room. The tangible benefits of this and other district initiatives was evident in student interview responses as well as the specific identification of successful strategies which improved access and awareness of mental health resources in the school district. Student Reports of Awareness ​ The overwhelming consensus among interviewed students (100%) that they have experienced stress, anxiety, or depression at school underscores the critical need for accessible mental and behavioral health services. A significant majority of students (87.5%) are aware of available mental health resources. The high level of student awareness of available resources indicates that initial efforts to inform students have been largely successful. The most frequently reported effective strategy (75% of students) was having an adult explain and walk them through options. This highlights the crucial role of human connection and personalized support over passive information dissemination. Students benefit significantly when an adult not only informs them but actively assists them in navigating the process of accessing help. Teachers (33% of responses) and Allegheny Health Network staff (33% of responses) were equally identified as particularly helpful in this "walking through" process. This suggests that these groups are perceived by students as approachable and instrumental in facilitating access. The role of paraprofessionals (22%) and school counselors (11%) also indicates a multi-faceted network of support. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 122 Furthermore, the finding that 55.5% of students learned about services from teachers reinforces their critical role not just as facilitators of access, but also as primary disseminators of information. This underscores their direct and consistent contact with students. Additionally, when triangulated with findings from research question one which indicated marked improvement in the area of teacher relationships, there is strong evidence to suggest that levering teacher relationships as part of the referral process and providing additional systems of support for both teachers and students can continue to be an impactful practice. Student Reports of Access ​ The provision of the Chill Room and the on-sight therapist through Allegheny Health Network proved to be an effective strategy at increasing student access to mental health services. Throughout student interviews, students consistently identified the Chill Room as a highly valued and effective resource. Students praised its flexibility and effectiveness in helping them "find what worked for them," indicating it serves as a low-barrier, self-directed support mechanism. During the student interviews, nearly ninety percent of participants noted positive change in available resources since starting high school, most commonly citing the Chill Room being on-site as an effective strategy. The Chill Room was highly recognized (67% of aware students) and appreciated by students for its flexibility and effectiveness in supporting their well-being. One-third of students recognized the school-based therapist (Allegheny Health Network) as a helpful resource. As indicated, an overwhelming percentage of older participants (88%) noted much positive change in available resources since they started high school. These ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 123 students mentioned the Chill Room and SEMHA's efforts to reduce stigma, This a successful cultural shift within the school regarding mental health openness and support among the student body. While 75% of students felt resources were adequate, the qualitative response indicating "things were moving in the right direction, but that more students needed to take it up" suggests that perceived adequacy is tied to actual utilization and awareness among the broader student body, not just those interviewed. Student-Reported Barriers ​ Two barriers to accessing services emerged among students who stated they found accessing services difficult, making them the most salient and actionable findings from the student perspective, with regard to service access. While teachers were reported as a valuable resource to helping initially connect students with resources, teachers not allowing students access to the Chill Room was perceived as a barrier. A small number of students who reported that accessing services was “difficult,” specifically mentioned teachers preventing them from going to the guidance/school counselors or the Chill Room. This barrier raises legitimate concerns regarding the balance between student well being and the daily realities of classroom management, the school’s instructional purpose and established procedures for accessing the Chill Room. Students also explicitly cited that the Chill Room's operating hours (currently Tuesday-Thursday) created a barrier to accessibility and consistent service delivery. Due to staffing issues, similar to those noted in other settings in the review of literature, the Chill Room is currently only staffed part time (Tuesday, Wednesday, and Thursday). While the Chill Room is highly valued, its restricted availability means students experiencing distress on Mondays or Fridays, or outside of those specific hours, do not ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 124 have immediate access to this preferred resource. This inconsistency can make it challenging for students to rely on the Chill Room. Recommendations for Future Research Investigation into this research question, further solidifies the benefits of schools serving as access points for student mental health services, as also identified in the literature review. As schools adapt to this changing role, more research may be needed to determine the needs of teaching professionals. Further study may help school leaders and researchers better understand teachers' perspectives on student mental health needs, service access, and the challenges of allowing students to leave class. Additionally, as more schools implement point-of-access models, similar to the one in this study, future research may be needed to determine the long-term educational impact of programs such as this. Research Question Three: Conclusions Research question three investigated the impact on community perceptions of district-initiated mental health and social service programming. Two surveys (a pre and post survey), with near-identical questions provided via district social media. Due to the anonymous nature of the surveys and the online means of submission, there is no way to determine if the same or different participants completed these surveys. Results should be interpreted as collective parent perceptions at a particular point in time, rather than a change in perception within the same group of research participants. Both pre- and post-surveys demonstrated an overwhelming consensus among parents regarding the critical importance of mental health and social services for student ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 125 well-being, with approximately 90% of parents supporting or identifying a need for mental health and social service programming within the school system. Survey results indicated a disconnect between parents who had sought mental health services for their students since the implementation of studied programming and those who did not. Parents who had sought mental health treatment for their student, reported modest improvements in logistical barriers. When the survey results were also compared to student survey and interview results, there was also discrepancy between student and parent perceptions of program efficacy, communication and the supportiveness of staff and the school environment. Among parents who reported that their child has received mental health services during the study period, the cost of services appears to be perceived as less of a barrier. Prior to the survey, 20% of parents considered cost a major barrier, 40% a somewhat barrier, and 40% not a barrier. Post-survey, the perception of cost as a major barrier dropped to 0%, with 40% still seeing it as somewhat of a barrier and 60% reporting it as not a barrier. This suggests that while cost remains a concern for some, it is no longer considered a major obstacle by any surveyed parents. The provision of free-access to the Chill classroom educator may have helped improve parent perceptions in this area. The provision of on-sight programming also seems to have impacted parent perception with regard to transportation to and from appointments. In this area, there was a positive shift, with 80% of parents reporting that transportation was "Not a Barrier" in the post-survey, compared to 60% pre-survey. When viewed in the context of other parent responses, citing the lack of resources in the rural area, there is further evidence to suggest that the school as an access point for services offers other positive benefits for parents. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 126 Among the parent survey group as a whole, significant and persistent gaps in perceived accessibility, awareness, effectiveness, communication from school staff, and the supportive nature of the school environment remained largely unchanged and revealed some areas for continued improvement and engagement within the parent stakeholder group moving forward. Regarding stigma and confidentiality, the results suggest a polarization in parents' views. Pre-survey, 20% saw it as a major barrier, 20% as significant, 20% as somewhat, and 40% as not a barrier. Post-survey, while the "somewhat" category disappeared (0%), the percentage of parents identifying it as a major barrier (20%) and significant (20%) remained the same. This means 40% of parents still viewed stigma/confidentiality as a significant or major hurdle, while 60% considered it not a barrier. This shift implies that for a subset of parents, stigma and confidentiality continue to be substantial concerns, even as others no longer perceive it as an issue. Awareness of services also continued to be a significant issue. Before the survey, 20% of parents viewed awareness as a major barrier, 60% as somewhat of a barrier, and 20% as not a barrier. The post-survey data for awareness is less clear and presents some inconsistencies. While 0% of parents considered awareness a major barrier post-survey, 20% reported it as somewhat and 20% as significant, totaling 40% who still saw it as a barrier to some degree. The remaining 60% considered it not a barrier. The noted discrepancy where 45% disagreed about awareness in another survey question further highlights that, despite some improvements in the "major barrier" category, overall awareness still remained a problem for a substantial portion of parents. Qualitative analysis of parent responses indicates consistent concerns about a lack ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 127 of easy access to mental health services and ability of school staff to communicate opportunities. This finding would suggest that some parents remain unaware of on-sight district programming. Within the pre-survey, a combined 77.7% of parents expressed mixed awareness or disagreement about program knowledge. This persisted in the post, with 45% disagreeing or strongly disagreeing that they were aware of different program types. This would imply that the initiatives did not effectively bridge the awareness gap for parents. While students reported learning about services from teachers, this information did not consistently reach the parent community, indicating a disconnect in communication strategies. Communication concerns also emerged as primary parent concern in qualitative responses. Recommendations for Future Research These results are very similar to those noted by Longhurst et al. (2021) who found that parents and caregivers generally supported mental health services in the school system, as they are convenient to access and provide a familiar environment for their child. Similarly, in this study, many parents said that they wished for better communication from the school regarding the program and their child’s progress. Abrams (2023) also communicates concerns about ineffective parent communication. Based on each of these findings, it is recommended that more specific research be conducted on how parents wish to receive information about programming. Within the Tussey Mountain School District, it would also be beneficial to explore the divergence in perceptions among parents who have sought treatment for their student and those who have not, as well as the divergence from the perceptions noted in ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 128 student surveys and interviews. Future research should also explore if differing perceptions occur in other settings among these stakeholder groups and the potential root causes for such divergence. Limitations When considering the limitations of this study, it is important to acknowledge that a change in research methodology (PAYS data used to establish the context vs identified data sources in the research methodology) limits the researcher’s ability to make direct comparisons from the baseline data to the data collected. The shift away from relying solely on PAYS data means that direct comparisons to broader state trends or historical PAYS data within the district will be limited. This could affect the study's external validity, or generalizability, as it may be harder to place the findings within a larger context. While broader comparisons to PAYS data are limited, the researcher has chosen methods to allow for a more focused evaluation of the specific district-initiated programs, through use of both quantitative and qualitative data. Another limitation of qualitative research identified by Mertler (2022) is that this form of research, historically, has less participants. This was noted in the present study, as limited sample sizes were noted for stakeholder surveys and interviews. A total of eight students participated in the student surveys and interviews. In total, twenty parents submitted survey data for analysis. While thematic saturation might have been achieved for key themes, the small number of participants potentially limits the generalizability of the findings to the entire student population at Tussey Mountain Middle/High School. Perceptions might differ ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 129 among a larger, more diverse group of students or parents Additionally, much of the data in this survey relies on student and parent reports, which can be subject to recall bias, social desirability bias, or a limited understanding of all available services. Recommendations for Future Initiatives at the Tussey Mountain School District The positive shifts in student connection to the school, indicate that the current mental and social service programming initiatives are having a beneficial impact, particularly, the Chill Room. The increased Chill Room usage and its demonstrated effectiveness in mood regulation are highly encouraging. Future improvements should focus on ensuring consistent and optimal operating hours for the Chill Room, addressing any barriers to access (e.g., teacher permission and staffing) and continuing to effectively advertise its availability and benefits to all students and staff. The slight increase in perceived tobacco risk and the decline in Academic Satisfaction, reported on the student surveys highlight areas needing targeted interventions. This could involve revised prevention programs for tobacco or a review of academic support structures, curriculum, or instructional practices to enhance student engagement and satisfaction. The district can use existing infrastructure within the contracted programming through Allegheny Health Network to implement targeted intervention and prevention programs in these areas. Additionally, the positive impact on teacher relationships, reported by students and parents, suggests that professional development focused on further building positive student-teacher interactions and recognizing mental health needs is valuable and should ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 130 be continued or expanded. Furthermore, the increase in warnings, detentions, and ISS, while OSS decreased, warrants a deeper dive. This could lead to a review of disciplinary policies to understand if this reflects increased vigilance, a lower threshold for intervention, or if students are needing more low-level support. Professional development for staff on de-escalation and positive behavior interventions could be beneficial. The continued parent concerns regarding accessibility, awareness, and effectiveness, as well as communication from school staff, suggest a need for more proactive and clear communication strategies regarding available mental health and social services. This includes consistent outreach to parents and ensuring all staff are well-informed and able to guide students and families to appropriate resources. Conducting dedicated parent focus groups and surveys could help identify specific communication preferences and barriers, as well as piloting new communication strategies and assess their impact on parent awareness and engagement, based on these results. Financial Implications This project, itself, was inexpensive to conduct, but the programs it evaluated carried significant costs. These new initiatives for the current school year were entirely funded by grants and philanthropic donations. This influx of external funding, combined with the proposed capstone research project, gave the district a valuable chance to understand how different groups viewed the effectiveness and challenges of these programs. This capstone project has enabled the district to make data-driven decisions ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 131 about the future of programs like the Chill Project, basing their choices on proven impact. The Chill Project was consistently reported as one of the most impactful initiatives by students. Furthermore, significant positive changes to reported risk and protective factors indicate a significant, positive impact on the student body. During this project, the researcher also evaluated options to sustain programming for future years, in the absence of grant funding. These efforts have yielded an additional year of services for the district for the upcoming school year (2025-2026), as the district continues to seek means through which this program can be financially sustainable and fiscally-responsible. This was achieved through a variety of means. First and foremost, additional philanthropic funding has been obtained through the partnership with Allegheny Health Network. The district’s rural setting and unique challenges provides an environment where program efficacy of the Chill Project can be evaluated in a new setting. Organizational interest and the potential to meet needs in a rural, rather than suburban or urban setting helped facilitate the provision of continued philanthropic donations, as educators and mental health providers, alike, seek to respond to the adolescent mental health crisis in rural America. Additionally, although staffing concerns created barriers to program access, as a Chill classroom educator was only available part time, this reduction in cost did enable the programing to continue for a longer period of time, due to grant funds not being exhausted in one year. In addition to the Chill classroom educator, the current cost of services from Allegheny Health Network also includes an on-sight school-based counselor. The on-sight counselor for Allegheny Health Network currently carries a caseload that is currently 64% funded through insurance billing. As the program grows ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 132 and more students receive this service, the cost of services billed to the district through Allegheny Health Network will decrease, making the program more sustainable. Finally, school leaders, including the researcher, discussed additional available funding streams. Through these discussions, it was discovered that, in some circumstances, some of the services offered to students receiving special education services from the Chill Room can be paid using funding from the Individuals with Disabilities Education Act (IDEA) in very specific situations. Use of this additional funding stream was instrumental in funding the programming for one additional year. The provision of an additional year of program funding provides more opportunities for the school district to pursue additional funding streams which could lead to improved financial sustainability. Closing Amidst these very important fiscal conversations, it is essential not to overlook a critical dimension, the profound human impact. Budgets for those in the public sector, such as schools are not merely a ledger of expenses and revenues; they are a declaration of values and a blueprint for the future of a community's children. Future school years will provide the Tussey Mountain School District time to build on the successes and tangible improvements realized within this action research project, as well as build financial sustainability of programming to meet the challenging and evolving set of needs which necessitated the need for this project and programming. Ultimately, this project demonstrated significant strides in fostering a more supportive and protective environment for students' mental and behavioral well-being ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 133 within the Tussey Mountain School District. The consistent and enthusiastic utilization of the Chill Room, paired with a notable positive shift in student mood and readiness for learning, underscores the direct and beneficial impact of accessible in-school resources. Furthermore, the overall improvement in student perceptions of school safety, prosocial behavior recognition, and critical social factors like teacher relationships and school connectedness, paint a compelling picture of a school community better equipped to meet the holistic needs of its students. These positive outcomes reported by the student stakeholder group, as well as the strong support for mental health programming reported by parents, lay a strong foundation for continued growth and refinement of mental and behavioral health initiatives within the district. The findings of this action research project helped identify a path forward to better meeting student needs and the challenges reported within the parent stakeholder group. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 134 References Abrams, Z. (2023, September 1). Teaching social-emotional learning is under attack. 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Developmental Neuropsychology, 46(8), 537-554. https://doi.org/10.1080/87565641.2021.1999455 Substance Abuse and Mental Health Services Administration [SAMHSA]. (n.d.). Risk and protective factors. https://www.samhsa.gov/sites/default/files/​ 20190718-samhsa-risk-protective-factors.pdf Totsika, V., Kouroupa, A., Timmerman, A., Allard, A., Gray, K., Hastings, R., Heyne, D., Mervin, G., & Tonge, B. (2024, August). School attendance problems among children with neurodevelopmental conditions one year following the start of the COVID-19 pandemic. Journal of Autism and Developmental Disorders, 54(8), 2998-3007. https://doi.org/10.1007/s10803-023-06025-3 Tussey Mountain School District. (2020). Tussey Mountain SD district level plan.:07/01/2020-06/30/2023. https://core-docs.s3.amazonaws.com/​ documents/asset/uploaded_file/474298/CompPlan20-23.pdf Vanderbuilt-Adriance, E., & Shaw, D. (2008, August). Protective factors and the development of resilience in the context of neighborhood disadvantage. Journal ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 142 of Abnormal Psychology, 36(6), 887-901. https://doi.org/10.1007/s10802-008-9220-1 Watson, A. (2023, December 2). Tussey taking steps to combat recent crisis. Bedford Gazette, 1, 3. Whitley, D., & Peterson, M. (2019). US national and state level prevalence of mental health disorders and disparities of mental health care use in children. JAMA Pediatrics, 173(4), 389-391. https://doi:10.1001/jamapediatrics.2018.5399 Young, E., McCain, J. L., Mercado, M.C., Ballestros, M. F., Moore, S., Lactis, L., Stinson, J., Jones, S. E., & Wilkins, N. J. (2024, October 10). Frequent social media use and experiences with bullying victimization, persistent feelings of sadness or hopelessness, and suicide risk among high school students :Youth risk behavior survey, United States, 2023. CDC Morbidity and Mortality Weekly Report. https://www.cdc.gov/mmwr/volumes/73/su/su7304a3.htm youth.gov. (n.d.). Risk and protective factors for youth. https://youth.gov/youth-topics/youth-mental-health/risk-and-protective-factors-yo uth Zhang, H., Lee, Z. X., White, T., & Qiu, A. (2020). Parental and social factors in relation to child psychopathy, behavior, and cognitive function. Translational Psychology, 10(80). https://doi.org/10.1038/s41398-020-0761-6 ENHANCING MENTAL HEALTH PROGRAMMING​ APPENDICES ​ ​ ​ 143 ENHANCING MENTAL HEALTH PROGRAMMING​ ​ Appendix A​ Institutional Review Board Documentation ​ ​ 144 ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 145 Appendix B Survey Informed Consent Letter Dear Parent/Guardian, A research study, Bridging the Gap: Implementing a Multi-Stakeholder Approach to Enhance Mental Health and Social Service Initiatives in a Rural School District, an Action-Research Project, is being conducted at our school to better understand students’ experiences and factors that contribute to their well-being and success in school. This project has received approval from PennWest University Institutional Review Board effective from 10/18/2024 through 10/17/2025. This research will help us develop programs and supports to improve the school environment for all students. Your child is being invited to participate in a survey about student risk factor and school connectedness among students in the Tussey Mountain School District. The purpose of this survey is to gather information about students’ perspectives on the importance, accessibility, and effectiveness of school services, as well as their potential impact on student behaviors. Your student is also being invited to participate in an interview about access to mental health services. The purpose of this survey is to gather information about students’ perspectives on the importance, accessibility, and effectiveness of school services, as well as their potential impact on student behaviors. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 146 Your student’s input will help inform the district’s programming to better meet the needs of our student body, as a whole. Participation- Surveys Students in grades 9-12 are eligible to participate in this survey with parental consent. Participation in this survey is entirely voluntary. The decision to participate or decline to participate will not affect your or your child’s relationship with the school district in any way. If you consent to your child’s participation in this survey, your child will meet with the researcher at the time of your choosing. During this time, your student will be provided with two surveys to complete. Your child will repeat these surveys again in the spring. Each administration of the survey will take approximately 30 minutes. You or your child may choose to stop participating in this study at any time without penalty. Just because your child has started the survey does not mean he or she has to complete it. Confidentiality Your child’s responses to this survey will be completely anonymous. No identifying information will be collected during the actual survey or interview. After your student has completed the survey or interview, their responses will be stored in a locked file. There will be no way of identifying your child’s survey once it has been completed and stored with the remainder of the surveys. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 147 Potential Risks While the risks associated with participation in this survey are minimal, some questions may ask about sensitive topics such as their relationships with school staff members, thoughts on discipline practices, and alcohol/ drug usage among teens in the community which may cause emotional discomfort. If your child feels uncomfortable answering any question, he or she may skip it or stop the survey altogether. We advise you to thoughtfully consider these potential risks before consenting to your child’s participation in this research study. Contact information for mental health agencies in our area is also available for any participant or family who would like information on these resources. Benefits Select participants will be awarded a nominal gift card. Outside of this benefit, there is no direct benefit to research participants. However, information collected will help the school district better understand the needs of students when designing future programs. The information collected will help our school district better understand risk factors impacting our students and assess their overall connectedness to our school. Questions If you have any questions about the research, or a research-related injury, please contact Denelle Diehl at die33397@pennwest.edu. If you have questions about your child’s rights as a research participant that you need to discuss with someone, you can contact the PennWest University Institutional Review Board at InstReviewBoard@Pennwest.edu. Consent ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 148 By completing this form, you are providing consent for your student to participate in the surveys or interviews. Student Name:__________________________________________________________ Parent Signature:________________________________________________________ ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 149 Appendix C Student Assent Statement (Surveys) You are being asked to participate in a research study. Your participation is voluntary and you may stop at any time. This research study is taking a look at how our students feel about our school and student risk factors. We want to use this information to better meet the needs of our students. Your part in this study will be to complete two surveys. These will take approximately fifteen minutes each to complete. You will be provided with a private space to complete the survey. Once you are finished you will place the surveys in the locked box you have been shown. Because your name is not on either survey, no one will know how you have responded. The survey responses will only be seen by the researcher, Ms. Diehl. Your parents, teachers and other school staff will not be shown the surveys. Your parents or guardians have consented for you to participate in this interview, however, you do not have to do this, and you can stop at any time and nothing bad will happen to you. If you choose to not answer a question or stop the interview, no one will be upset with you. If you want to stop taking part in the study, you just need to tell Ms. Diehl that you want to stop. If you have any questions about the study, you may ask now or at any point during the survey. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 150 After the study if something is upsetting to you, you should speak with your parent(s) or guardian(s). I agree to be in this study, have had all my questions answered, and know I can stop at any time. ____________________________​ ​ ​ ​ ​ _________________ Student Participant Signature​​ ​ ​ ​ ​ ​ Date ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 151 Appendix D Informed Consent (Interviews & Surveys) Dear Parent/Guardian, A research study, Bridging the Gap: Implementing a Multi-Stakeholder Approach to Enhance Mental Health and Social Service Initiatives in a Rural School District, an Action-Research Project, is being conducted at our school to better understand students’ experiences and factors that contribute to their well-being and success in school. This project has received approval from PennWest University Institutional Review Board effective from 10/18/2024 through 10/17/2025. This research will help us develop programs and supports to improve the school environment for all students. Your child is being invited to participate in a survey about student risk factor and school connectedness among students in the Tussey Mountain School District. The purpose of this survey is to gather information about students’ perspectives on the importance, accessibility, and effectiveness of school services, as well as their potential impact on student behaviors. Your student’s input will help inform the district’s programming to better meet the needs of our student body, as a whole. Participation- Surveys Students in grades 9-12 are eligible to participate in this survey with parental consent. Participation in this survey is entirely voluntary. The decision to participate or decline to participate will not affect your or your child’s relationship with the school district in any way. If you consent to your child’s participation in this survey, your child will meet with the researcher at the time of your choosing. During this time, your student will be provided with two surveys to ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 152 complete. Your child will repeat these surveys again in the spring. Each administration of the survey will take approximately 30 minutes. You or your child may choose to stop participating in this study at any time without penalty. Just because your child has started the survey does not mean he or she has to complete it. Participation- Interviews Students in grades 9-12 are eligible to participate in this survey with parental consent. Participation in this survey is entirely voluntary. The decision to participate or decline to participate will not affect your or your child’s relationship with the school district in any way. If you consent to your child’s participation in this survey, your child will meet with the researcher at the time of your choosing. During this time, your student will meet with the researcher individually, and complete an oral interview. You or your child may choose to stop participating in this study at any time without penalty. Just because your child has started the interview does not mean he or she has to complete it. Confidentiality Your child’s responses to this survey will be completely anonymous. No identifying information will be collected during the actual survey or interview. After your student has completed the survey or interview, their responses will be stored in a locked file. There will be no way of identifying your child’s survey once it has been completed and stored with the remainder of the surveys. Potential Risks While the risks associated with participation in this survey are minimal, some questions may ask ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 153 about sensitive topics such as their relationships with school staff members, thoughts on discipline practices, and alcohol/ drug usage among teens in the community which may cause emotional discomfort. If your child feels uncomfortable answering any question, he or she may skip it or stop the survey altogether. We advise you to thoughtfully consider these potential risks before consenting to your child’s participation in this research study. Contact information for mental health agencies in our area is also available for any participant or family who would like information on these resources. Benefits There is no direct benefit to your child for participating in this survey. However, information collected will help the school district better understand the needs of students when designing future programs. The information collected will help our school district better understand risk factors impacting our students and assess their overall connectedness to our school. Questions If you have any questions about the research, or a research-related injury, please contact Denelle Diehl at die33397@pennwest.edu. If you have questions about your child’s rights as a research participant that you need to discuss with someone, you can contact the PennWest University Institutional Review Board at InstReviewBoard@Pennwest.edu. Consent By completing this form online, you are providing consent for your student to participate in the surveys or interviews. Your consent will be verified via phone. You may also sign below: Parent Signature: ​ ​ ​ ​ ​ ​ ​ ​ Date: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 154 Appendix E​ Student Assent Form (Interviews) You are being asked to participate in a research study. Your participation is voluntary and you may stop at any time. This research study is taking a look at mental health services available in our school and what our students’ needs are. Your part in this study will be to answer some interview questions about your experiences at our school. This interview will take approximately 30 minutes. During the interview, the researcher, Miss Diehl will be recording written notes about your responses. Your name will not be placed on this note sheet. After you have finished, this note sheet will be stored in a locked drawer with other interview note sheets. This will help protect your privacy, as no one will know which note sheet records your answers. These note sheets will not be seen by anyone but the researcher, Miss Diehl. Additionally, your answers will not be shared with anyone else. Your parents or guardians have consented for you to participate in this interview, however, you do not have to do this, and you can stop at any time and nothing bad will happen to you. If you choose to not answer a question or stop the interview, no one will be upset with you. If you want to stop taking part in the study, you just need to tell Ms. Diehl that you want to stop. If you have any questions about the study, you may ask now or at any point during the interview. After the study if something is upsetting to you, you should speak with your parent(s) or guardian (s). ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 155 I agree to be in this study, have had all my questions answered, and know I can stop at any time. ____________________________​ ​ ​ ​ ​ _________________ Student Participant Signature​ ​ ​ ​ ​ ​ ​ Date ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 156 Appendix F​ Student Interview Script Access to Mental Health Services ●​ Have you ever felt stressed, anxious, or depressed while at school? If so, what did you do about it? ●​ Do you know of resources at our school that help students when they are experiencing these feelings? ●​ How did you find out about the mental health resources available at our school? ●​ Was it easy or difficult to access these services? Why? ●​ (FOR STUDENTS IN GRADES 10, 11, 12) What grade are you in? _____ Think about the services that were offered at the time you started high school in grade 9. Have the services changed? How? If yes, how do you feel about these changes? ●​ Do you think there are enough mental health resources available at our school? ●​ Is there anything else you would suggest to improve student programs? Effective Strategies ●​ If you or a friend did seek help, what was that experience like? What worked well? ●​ Were there any school programs or activities that helped you or a friend with mental health? ●​ Who at the school has been helpful to you when you were struggling? ●​ What kind of support would have been most helpful to you? Barriers to Access ●​ What prevented you or your friends from seeking help when you needed it? ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 157 ●​ Were there any stereotypes or stigmas about mental health that made it hard to ask for help? ●​ What would make it easier for students to seek help? ●​ What would you change about the way mental health services are offered at our school? Follow-up Questions ●​ Can you tell me more about that? ●​ How did that make you feel? ●​ What do you mean by [specific answer]? ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 158 Appendix G ​ Informed Consent (Parent Surveys) Welcome! You are invited to participate in a research study about mental health and social services for students in the Tussey Mountain School District. The purpose of this survey is to gather information about parents’ perspectives on the importance, accessibility, and effectiveness of these services. Your input will help inform the district’s programming to better meet the needs of our students. This study is being conducted by Denelle Diehl, who currently serves as the Director of Education for the school district, in conjunction with coursework at PennWest University. The title of this study is: Bridging the Gap: Implementing a Multi-Stakeholder Approach to Enhance Mental Health and Social Service Initiatives in a Rural School District, an Action-Research Project. This study has received approval from the Institutional Review Board at PennWest University. The effective date of approval is 10/18/2024. This approval expires 10/17/2025. Participation & Withdrawal From The Study All parents and guardians eighteen years of age and older with at least one student enrolled in Tussey Mountain Middle or High School are eligible to participate in this survey. Participation in this survey is entirely voluntary. You may choose to stop ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 159 participating at any time without penalty. Your decision to participate or not will not affect your or your child’s relationship with the school district. This survey will take approximately forty minutes to complete. Potential Risks The risks anticipated with participating in this survey have been deemed to be minimal. However, some questions may ask about sensitive topics such as mental health, which may cause emotional discomfort. If you feel uncomfortable answering any question, you may skip it or stop the survey altogether. Benefits There is no direct benefit to you for participating in this survey. However, your input will help the researcher and the school district better understand the needs of students and families regarding mental health and social services. This information will be used to improve programs and support systems for students. Confidentiality & Data Security Your responses to this survey will be completely anonymous. You will not be asked to provide any information that could be identify you (eg. name). The survey is NOT linked to IP addresses. Individual responses will not be reported, just the aggregated data. All information reported in this survey will be confidential within local, state, and federal laws. The PennWest University Institutional Review Board (IRB) may review the research records. The study's results may be shared in aggregate form at meeting or in a ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 160 journal but your individual responses will not be revealed. Records from this study will be kept by Denelle Diehl for at least (3) years after the study is complete. Non-identifiable information collected as part of this research could be used for future studies or distributed to another investigator with informed consent. Questions If you have any questions about the research, or a research-related injury, please contact Denelle Diehl at die33397@pennwest.edu. If you have questions about your rights as a research participant that you need to discuss with someone, you can contact the PennWest University Institutional Review Board at InstReviewBoard@Pennwest.edu. By clicking on the "I agree" box and continuing with the survey, you have acknowledged that you have read the entire informed consent and are at least 18 years of age. You also acknowledge that you agree to participate in the survey and have the right to not to answer any or all of the questions in the survey. Finally, you understand that your participation is completely voluntary and you may quit the study at any time without penalty. Thank you for your consideration! ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 161 Appendix H​ Parent Survey Questions Part 1: Importance of Mental Health & Social Services Instructions: Please rate your level of agreement with the following statements using the scale provided. ●​ Strongly Disagree (1) Disagree Somewhat (2) Agree Somewhat (3) Strongly Agree (4) 1.​ Mental health services are important for the overall well-being of students in our school district. 2.​ Social service programs are essential in supporting students facing challenges outside of school. 3.​ There is a growing need for mental health and social service support in our rural community. Part 2: Accessibility and Effectiveness Instructions: Please rate your level of agreement with the following statements about the current mental health and social service programs in the school district. 1.​ Students in our school district have easy access to mental health services when needed. 2.​ I am aware of the different types of social service and mental health programs available to students and families in our community. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 162 3.​ The mental health services offered by the school district are effective in addressing student needs. 4.​ The social service programs offered in collaboration with the school district are helpful for students facing challenges. Part 3: Barriers and Suggestions 1.​ (Open Ended) In your opinion, what are the biggest barriers preventing students from accessing mental health and social service programs in our school district? 2.​ (Open Ended) What suggestions do you have for improving the accessibility and effectiveness of mental health and social service programs in our schools? Part 4: Additional Information (Open Ended) Please share any additional comments or suggestions you have regarding mental health and social service support for students in our school district. 1.​ In the past year, has your student sought any mental health treatment or services? (Yes/No) ○​ If yes, please continue to question 2. ○​ If no, please skip to question 5. 2.​ How did your student access mental health support? (Please select all that apply) ○​ Private therapist or counselor ○​ School counselor ○​ School psychologist ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 163 ○​ School social worker ○​ Telehealth services ○​ Hospital emergency room/inpatient program ○​ Other (Please specify) 3.​ During your search for mental health services, did the school provide any of the following resources or assistance? (Please select all that apply) ○​ Information on available mental health providers in the community ○​ Support navigating the referral process ○​ School-based mental health screening or assessment ○​ Collaboration with outside providers ○​ Assistance with scheduling (if needed) ○​ Use of school facilities and technology to participate in teletherapy programs ○​ Other (Please specify) 4.​ (Open ended) How helpful was the school in assisting you in finding mental health services for your student? Please elaborate on your experience. 5.​ (Strongly Disagree - Somewhat Disagree - Somewhat Agree - Strongly Agree) The School staff effectively communicate mental health resources available to students to students and families. 6.​ (Strongly Disagree - Somewhat Disagree - Somewhat Agree - Strongly Agree) The school environment is supportive of students seeking mental health help. 7.​ (Open ended) What improvements could the school make to better support students and families seeking mental health services? ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 164 Part 2: Barriers to Access Instructions: Please rate the extent to which the following factors would prevent you from seeking mental health or social services for your child. Scale: (Not a Barrier / Somewhat of a Barrier / Significant Barrier / Major Barrier) 1.​ Cost of mental health services or programs. 2.​ Availability of mental health services or programs after school hours or on weekends. 3.​ Transportation difficulties in getting to appointments. 4.​ Lack of awareness about available mental health or social service programs in the community. 5.​ Concerns about confidentiality or stigma associated with seeking mental health help. 6.​ School not adequately informing parents about available resources. 7.​ Difficulties navigating the process of getting help (e.g., referrals, paperwork). 8.​ Long wait times for appointments. 9.​ Other (Please specify) (Open Ended) Please share any additional thoughts or experiences you have had regarding barriers to accessing mental health and social services for your student. (Open Ended) If you found the efforts of the school helpful in coordinating care for your student, please share what strategies or programs were successful and why: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 165 Appendix I​ Thematic Coding, Research Question Two Theme 1: Prevalence of Mental Health Challenges ●​ Universal Experience of Stress/Anxiety/Depression: 100% of students reported feeling "stressed, anxious, or depressed while at school." Theme 2: Awareness and Utilization of Resources ●​ High Awareness of Resources: 87.5% of respondents were aware of resources. ●​ Most Frequently Utilized/Noted Resources: ○​ Chill Room (67% of aware students) ○​ School-based therapist through Allegheny Health Network (33% of aware students) ○​ School counseling/guidance office (33% of aware students) Theme 3: Perceptions of Resource Sufficiency ●​ General Adequacy of Resources: 75% of students felt there were adequate mental health resources ●​ Perceived Insufficiency: 12.5% of respondents felt there were not enough resources ●​ Engagement Gap: One respondent noted things were "moving in the right direction," but emphasized the need for more students to "take it (the opportunities) up."/ Also advertisement & awareness ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 166 Theme 4: Channels of Information about Services ●​ Primary Information Source: Teachers: 55.5% of students learned about services from talking with their teachers. ●​ Other Information Sources (less common): ○​ Conversations with school/guidance counseling office ○​ SEMHA Team publications ○​ School announcements ○​ Word of mouth (other classmates) Theme 5: Effective Strategies for Accessing Mental Health Services ●​ Adult Guidance: 75% of students found it helpful to have an adult explain and walk them through options. ○​ Key Personnel Facilitating Access: ■​ Allegheny Health Network staff (33% of responses) ■​ Teachers (33% of responses) ■​ District paraprofessionals (22% of responses) ■​ School counselors (11% of responses) Theme 6: Perceived Changes in Programming Over Time (Grades 10-12) ●​ Significant Positive Change: 88% of participants observed "much positive change" in available resources since starting high school ●​ Most Common Positive Change: Chill Room: Participants most commonly cited the Chill Room's on-site presence, flexibility, and effectiveness ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 167 ●​ Other Positive Changes: SEMHA raising awareness and reducing stigma Theme 7: Barriers to Accessing Services ●​ Perceived Ease of Access: 75% of students reported accessing services was "easy" ●​ Perceived Difficulty of Access: 25% of students reported accessing services was "difficult" ●​ Primary Barrier: Teacher Discretion/Denial: Most frequently cited barrier was teachers not allowing access to guidance/school counselors or the Chill Room ●​ Operational Barrier/ Limited Operating Hours: The Chill Room's limited operating hours (Tuesday-Thursday) presented a barrier to consistent service delivery Theme 8: Opportunities for Improvement ●​ Top Suggestion/ Staff Training: Most frequent suggestion was training for staff to help teachers better recognize signs of mental health problems. ●​ Other Suggestions: ○​ More advertisements of district programs ○​ More consistency/intentionality in scheduling to help students access services ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 168 Appendix J​ Thematic Coding, Pre Parent Surveys Theme 1: Perceived Importance vs. Actual Accessibility & Effectiveness of Services ●​ Strong Agreement on Importance: There was a near-universal consensus that mental health services and social service programs are important and essential for student well-being, especially in a rural community with a growing need. This was evident in the repeated "Strongly Agree" responses to the opening survey questions. ●​ Disagreement/Neutrality on Accessibility and Effectiveness: In stark contrast to the perceived importance, there was significant disagreement or neutrality regarding the ease of access, awareness of programs, and effectiveness of existing mental health and social service provisions. ○​ Many parents "Disagree" that students have easy access to services. ○​ Several parents "Disagree" or "Neither agree nor disagree" with being aware of available programs. ○​ Similarly, effectiveness of school district-offered mental health and social service programs receives mixed to negative responses ("Disagree," "Neither agree nor disagree," "Strongly Disagree"). ○​ Communication of resources by school staff and the supportive nature of the school environment for seeking help also lean towards disagreement or neutrality. Theme 2: Key Barriers to Accessing Services This theme emerges strongly from the open-ended questions and the scaled barrier ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 169 questions. ●​ Stigma and Confidentiality Concerns: ○​ "It is not confidential for where or when you’re going somewhere and therefore they are further embarrassed and not seeking help." ○​ "Concerns about confidentiality or stigma associated with seeking mental health help" is frequently rated as a "Significant Barrier" or "Major Barrier." ○​ One parent mentioned: "It's embarrassing and makes them not want to go to their mental health appointments." ●​ Lack of Awareness and Communication: ○​ Parents explicitly state "Lack of resources," "Lack of diversity," and "Lack of support due to rural community." ○​ "Awareness about available mental health or social service programs in the community" is often cited as a "Somewhat of a Barrier" or "Major Barrier." ○​ Repeated calls for "More awareness of services and availability with confidential meetings" and "Better communication." ○​ "School staff effectively communicate mental health resources available to students to students and families, when needed" received significant disagreement. ●​ Systemic and School-Specific Issues: ○​ Lack of School Support/Trust: Several parents relayed negative experiences they have had in the past ○​ Follow-through and Effectiveness: Repeated responses regarding follow through and communication were noted ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 170 ○​ Cost/Financial Barriers: "Their ability to pay / with or without insurance" is mentioned, and "cost of mental health programming or services" is rated as a "Major Barrier" by some. ○​ Navigation Difficulties: "Difficulties navigating the process of getting help (e.g., referrals, paperwork)" is a recurring barrier. ○​ Long Wait Times: "Long wait times for appointments" is also noted as a barrier. ○​ Attendance Policies: "For those who go to counseling once a week and to a psychiatrist on a regular basis it is a pain to have to have student attendance improvement meetings, especially when they have only had an absence or two otherwise due to illness. It's embarrassing and makes them not want to go to their mental health appointments." Theme 3: Suggestions for Improvement This theme synthesizes parents' recommendations for enhancing mental health and social service support. ●​ Increased Communication and Awareness: ○​ "More awareness of services and availability with confidential meetings." ○​ "Talk about opportunities by making students aware and flyers/notifications to parents." ○​ "Provide more resources and education to parents in the rural community." ○​ "Better communication." ●​ School-Based and Integrated Services: ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 171 ○​ "School-based program incorporated," "incorporate more mental health awareness into the school district," "incorporate more mental health lessons in the school district for students." ○​ "Have more mental health services available in the district, not just from outside agencies." ○​ Suggestions for hiring dedicated staff: "Social worker for elementary, middle and high school. If funds are available, possibly look into hiring a mental health worker as well for each school or work with contracting a school-based program..." ●​ Improved School Staff Training and Responsiveness: ○​ "More mental health training for staff members." ○​ "Listen to what parents are saying. Parents know the children and what they hear better." ○​ "Re-educating staff on mental health. (Parents relayed negative experiences with certain staff members) ●​ Addressing Systemic Issues (Stigma, Cost, Policy): ○​ "I think students should have the ability to get services no matter if they can pay for it or not." ○​ Addressing the attendance policy for mental health appointments. ○​ "Rule out mental health needs vs behavioral." ●​ Community Involvement: ○​ "Involvement in more mental health community activities such as Out of Darkness Walk (suicide)." ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 172 Theme 4: School's Role in Supporting Students Seeking Help (Mixed Experiences) ●​ Limited Direct Assistance: When students did seek help, the school's direct assistance in finding services was often "Not at all" or "Somewhat helpful not fully." ●​ Common School Resources Provided (When Available): "Information on available mental health providers in the community" and "School counselor" were the most common ways the school provided access or support. ●​ Desire for More Proactive and Integrated Support: Parents expressed a clear desire for the school to be more actively involved and to have more in-house resources rather than relying solely on external referrals. ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 173 Appendix K​ Thematic Coding, Parent Post Surveys Theme 1: Perceived Importance and Growing Need for Services ●​ High Agreement on Importance: The vast majority of respondents strongly agreed or agreed that "Mental health services are important for the overall well-being of students" and "Social service programs are essential in supporting students facing challenges outside of school." There was near-unanimous agreement that "There is a growing need for mental health and social service support in our rural community." This indicates a strong consensus among stakeholders about the critical role of these services. Theme 2: Gaps in Accessibility, Awareness, and Effectiveness ●​ Mixed Perceptions of Easy Access: Agreement was highly divided on the statement "Students in our school district have easy access to mental health services when needed." Many respondents disagreed or neither agreed nor disagreed, suggesting that easy access is not consistently perceived across the district. ●​ Varying Awareness of Programs: Awareness of "different types of social service and mental health programs" was also mixed, with responses ranging from "Strongly Agree" to "Strongly Disagree," indicating inconsistent knowledge among the community. ●​ Concerns about Effectiveness: A significant number of respondents disagreed with the statement that "The mental health services offered by the school district are effective in addressing student needs" and "The social service programs offered in ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 174 collaboration with the school district are helpful for students facing challenges." This points to a perceived lack of efficacy in current offerings. ●​ Communication Deficiencies: There was a strong tendency to disagree with the statement that "School staff effectively communicate mental health resources available to students and families, when needed," highlighting a critical communication gap. ●​ Supportive Environment Doubts: The perception of the "school environment as supportive of students seeking mental health help" also garnered mixed to negative responses, with several disagreements and "neither agree nor disagree," suggesting a less than fully supportive atmosphere. Theme 3: Identified Barriers to Accessing Services ●​ Stigma and Bullying (Major Barrier): This emerged as a paramount concern. Respondents explicitly mentioned "being bullied for seeking services," "fear of being judged," and "being found out and bullied or harassed." The data on specific barriers also showed that "concerns about confidentiality or stigma" were identified as a "Major Barrier" by 20% of those who answered this question, and a "Significant Barrier" by another 20%. ●​ Communication and Awareness (Significant Barrier): A lack of knowledge about services ("knowledge of the services," "communication," "awareness of services") was frequently cited. Specific barrier data revealed that "awareness about available mental health or social service programs in the community" was a "Significant Barrier" for 20% of respondents and "Somewhat of a Barrier" for 60%. ●​ Teacher/Staff Understanding and Support (Significant Barrier): Several comments ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 175 highlighted concerns with a lack of staff awareness. ●​ Systemic and Practical Barriers: ○​ Transportation and School Absences: Explicitly mentioned by some. ○​ Cost: While not always a primary barrier, it was noted as "Somewhat of a Barrier" (60%) or "Not a Barrier" (40%) among those who responded to this specific question in this dataset. ○​ Navigating the Process: "Difficulties navigating the process of getting help (e.g., referrals, paperwork)" was a "Significant Barrier" for 40% and "Somewhat of a Barrier" for 20%. ○​ Long Wait Times: This was identified as a "Major Barrier" by 20% and "Somewhat of a Barrier" by 20%. Theme 4: Suggestions for Improvement ●​ Increased Communication and Awareness: Suggestions repeatedly emphasized "more knowledge and support from the school to let students know it is ok to seek help," "electronic newsletter," and "agency fairs." ●​ Enhanced Staff Training: ●​ Better Follow Through: Many parents stressed the importance of consistent follow-through to ensure every student receives the necessary assistance. Parents expressed a strong desire for the school to take student needs seriously and prevent any student from feeling overlooked, ensuring they receive the focused help they deserve. Theme 5: Experiences Seeking Help (Parents' Perspective) ENHANCING MENTAL HEALTH PROGRAMMING​ ​ ​ ​ 176 ●​ Varied Access Points: For children who sought help in the past six months, access primarily occurred via "Private therapist or counselor" and "Telehealth services." One instance involved "onsite counseling through an outside facility" offered by the school. ●​ Mixed School Helpfulness: The school's assistance in finding mental health services was rated from "Not helpful" to "Very helpful." One positive experience highlighted the university's free school-based counseling. ●​ Lack of School Resources Provided: Most parents indicated that the school provided "None" of the listed resources during their search, though one mentioned "onsite counseling through an outside facility" and another "information on available mental health providers." This aligns with the perceived communication gap, as these resources are available.