Acceptability and feasibility of policy implementation strategies for taxes earmarked for behavioral health services.

Background: This study's aims are to: (1) Compare the acceptability and feasibility of five types of implementation strategies that could be deployed to increase the reach of evidence-based practices (EBPs) with revenue from policies that earmark taxes for behavioral health services, and (2) Illustrate how definitions of implementation strategies and measures of acceptability and feasibility can be used in policy-focused implementation science research. Methods: Web-based surveys of public agency and community organization professionals involved with earmarked tax policy implementation were completed in 2022-2023 (N = 211, response rate = 24.9%). Respondents rated the acceptability and feasibility of five types of implementation strategies (dissemination, implementation process, integration, capacity-building, and scale-up). Aggregate acceptability and feasibility scores were calculated for each type of strategy (scoring range 4-20). Analyses of variance compared scores across strategies and between organizational actor types. Findings: For acceptability, capacity-building strategies had the highest rating (M = 16.3, SD = 3.0), significantly higher than each of the four other strategies, p ≤ . 004), and scale-up strategies had the lowest rating (M = 15.6). For feasibility, dissemination strategies had the highest rating (M = 15.3, significantly higher than three of the other strategies, p ≤ .002) and scale-up strategies had the lowest rating (M = 14.4). Conclusions: Capacity-building and dissemination strategies may be well-received and readily deployed by policy implementers to support EBPs implementation with revenue from taxes earmarked for behavioral health services. Adapting definitions of implementation strategies for policy-focused topics, and applying established measures of acceptability and feasibility to these strategies, demonstrates utility as an approach to advance research on policy-focused implementation strategies.

Seasonal dynamics of the standard test species Lemna sp. in outdoor microcosms.

Lemna L. sp. is a free-floating aquatic macrophyte that plays a key role as a standard test species in aquatic risk assessment for herbicides and other contaminants. Population modeling can be used to extrapolate from laboratory to field conditions. However, there are insufficient data on longer-term seasonal dynamics of this species to evaluate such models. Therefore, several long-term growth experiments were conducted in outdoor microcosms (surface area 0.174 m2). Monitoring parameters included biomass, frond numbers, water parameters, and weather data. Three different datasets were generated: frond numbers and biomass from weekly to monthly destructively sampled microcosms; a year-round dataset of frond numbers from five continuously monitored microcosms; and seasonal growth rates without the effect of density dependence over 1-2 weeks in freshly inoculated microcosms. Lemna sp. reached a maximum of approximately 500 000 fronds m-2 and 190 g dry weight m-2. During the first winter, the microcosms were covered by ice for approximately four weeks, and Lemna sp. populations collapsed. The second winter was warmer, without any ice cover, and Lemna sp. populations maintained high abundance throughout the winter. Dry weight per frond was not constant throughout the year but was highest in autumn and winter. Growth rates without density dependence under outdoor environmental conditions reached 0.29 day-1 for frond number, 0.43 day-1 for fresh weight, and 0.39 day-1 for dry weight. In linear regressions, these growth rates were best explained by water temperature. For the populations continuously monitored throughout a year, the nitrogen-to-phosphorus ratio best explained the growth rate of frond numbers. This study yielded a relevant dataset for testing and refining Lemna population models used in chemical risk assessment as well as for managing ecosystems and combating the effects of eutrophication. Integr Environ Assess Manag 2024;00:1-14. © 2024 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

A Tale of Two Taxes: Implementation of Earmarked Taxes for Behavioral Health Services in California and Washington State.

OBJECTIVE: The authors sought to characterize perceptions of the impacts, attributes, and support for taxes earmarked for behavioral health services and to compare perceptions of the taxes among professionals in California and Washington, two states differing in earmarked tax designs. METHODS: Surveys were completed by 155 public agency and community organization professionals involved in tax implementation in California (N=87) and Washington State (N=68) during 2022-2023 (29% response rate). Respondents indicated their perceptions of the taxes' impacts, attributes, and support. Responses were summed as aggregate scores and were also analyzed as individual items. Bivariate analyses were used to compare responses of professionals in California versus Washington State. RESULTS: Earmarked taxes were generally regarded positively. Of the respondents, >80% strongly agreed that the taxes increased funding for services and were helpful, and only 10% strongly agreed that the taxes decreased behavioral health funding from other sources. Substantially more respondents in California than in Washington State strongly agreed that taxes' reporting requirements were complicated (45% vs. 5%, p<0.001) and that the taxes increased unjustified scrutiny of services or systems (33% vs. 2%, p<0.001). However, more respondents in California than in Washington State also strongly agreed that the taxes increased public awareness about behavioral health (56% vs. 15%, p<0.001) and decreased behavioral health stigma (47% vs. 14%, p<0.001). CONCLUSIONS: Perceptions of the strengths and weaknesses of taxes earmarked for behavioral health services may vary by design features of the tax. Such features include stigma-reduction initiatives and tax spending and reporting requirements.

Propelling the Global Advancement of School Mental Health.

Rates of mental health problems and disorders in children and youth have been increasing for at least three decades, and these have escalated due to the pandemic and multiple other societal stressors. It is increasingly recognized that students and families frequently struggle to receive needed care through traditional locations such as specialty mental health centers. Upstream mental health promotion and prevention strategies are gaining support as a public health approach to supporting overall population well-being, better utilizing a limited specialty workforce, and reducing illness. Based on these recognitions, there has been a progressive and escalating movement toward the delivery of mental health support to children and youth "where they are," with a prominent and more ecologically valid environment being schools. This paper will provide a brief review of the escalating mental health needs of children and youth, advantages of school mental health (SMH) programs in better meeting these needs, example model SMH programs from the United States and Canada, and national and international SMH centers/networks. We conclude with strategies for further propelling the global advancement of the SMH field through interconnected practice, policy, and research.

A policy implementation study of earmarked taxes for mental health services: study protocol.

BACKGROUND: Insufficient funding is frequently identified as a critical barrier to the implementation and sustainment of evidence-based practices (EBPs). Thus, increasing access to funding is recognized as an implementation strategy. Policies that create earmarked taxes-defined as taxes for which revenue can only be spent on specific activities-are an increasingly common mental health financing strategy that could improve the reach of EBPs. This project's specific aims are to (1) identify all jurisdictions in the USA that have implemented earmarked taxes for mental health and catalogue information about tax design; (2) characterize experiences implementing earmarked taxes among local (e.g., county, city) mental health agency leaders and other government and community organization officials and assess their perceptions of the acceptability and feasibility of different types of policy implementation strategies; and (3) develop a framework to guide effect earmarked tax designs, inform the selection of implementation strategies, and disseminate the framework to policy audiences. METHODS: The project uses the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to inform data collection about the determinants and processes of tax implementation and Leeman's typology of implementation strategies to examine the acceptability and feasibility strategies which could support earmarked tax policy implementation. A legal mapping will be conducted to achieve aim 1. To achieve aim 2, a survey will be conducted of 300 local mental health agency leaders and other government and community organization officials involved with the implementation of earmarked taxes for mental health. The survey will be followed by approximately 50 interviews with these officials. To achieve aim 3, quantitative and qualitative data will be integrated through a systematic framework development and dissemination process. DISCUSSION: This exploratory policy implementation process study will build the evidence base for outer-context implementation determinants and strategies by focusing on policies that earmarked taxes for mental health services.

Effectiveness of a Brief Engagement, Problem-Solving, and Triage Strategy for High School Students: Results of a Randomized Study.

Schools offer an advantageous setting for the prevention, early identification, and treatment of mental health problems for youth. However, school mental health (SMH) services are typically not based on evidence for effectiveness, nor are they efficiently delivered, with SMH practitioners (SMHPs) able to only treat a small number of students in need. The current study evaluated the feasibility, acceptability, efficiency, and outcomes of a four-session assessment, engagement, problem-solving, and triage strategy for SMHPs that aimed to improve efficiency while being based on elements of evidence-based care. The study, conducted in 15 US school districts in three states, used stratified random assignment to assign 49 high schools and their participating SMHP(s) to either the Brief Intervention for School Clinicians (BRISC; N = 259 students) or services as usual (SAU; N = 198 students). SMHPs implemented BRISC elements with adequate to excellent fidelity and reported the strategy was feasible and well-aligned with presenting problems. Students assigned to BRISC reported significantly greater engagement in SMH at 2 months and completion of SMH treatment by 6 months. BRISC-assigned SMHPs reported significantly greater treatment completion after four sessions (53.4%) compared to SAU (15.4%). Students in the BRISC condition also reported significantly greater reduction in problem severity as evaluated by the Youth Top Problems Assessment. No differences were found for anxiety or depression symptoms or overall functioning. Results indicate that BRISC is a feasible early intervention and triage strategy that may aid in more efficient provision of SMH services with no compromise to SMH effectiveness.

Are standard aquatic test species and methods adequate surrogates for use in environmental risk assessment of pesticides in tropical environments?

In regulatory risk assessment, surrogate species of fish, aquatic invertebrates, and primary producers are tested to assess toxicity and subsequently the risk of pesticides to freshwater biota. This study evaluates whether the standard, surrogate test species (mostly temperate in latitudinal distribution) used in many parts of the world are suitable surrogates for first-tier risk assessments involving tropical freshwater biota. Data for the toxicity of pesticides to tropical fish, invertebrates, and primary producer species were extracted from the USEPA ECOTOX database and peer-reviewed literature. For each pesticide, the most sensitive regulatory endpoint extracted from the US Environmental Protection Agency (USEPA) and European Food Safety Authority (EFSA) dossiers for freshwater fish, invertebrates, and primary producers was selected. The ratios of the endpoint for tropical species and for the most sensitive regulatory endpoint for the appropriate taxonomic group were determined. A value >1 indicates that the tropical species is less sensitive than the respective standard regulatory species. Tropical fish species were less sensitive than standard fish species in 84% of the comparisons, and in 93.5% of the comparisons, tropical fish were less or similarly sensitive (within a factor of 5). For aquatic invertebrates, 78.1% of the evaluated tropical species were less sensitive than standard species and 93.3% of tropical invertebrates species were less or similarly sensitive. For primary producers, 96% of tropical species were less sensitive than standard test species. Overall, standard species used globally were more sensitive or similarly sensitive compared to tropical species in more than 93% of the cases. In conclusion, the data show that freshwater toxicity data for pesticides from tests using standard test species, tested according to international accepted guidelines, are appropriate for use in first-tier risk assessments for tropical environments. Integr Environ Assess Manag 2023;19:202-212. © 2022 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

TWAc-Check: A New Approach to Determine the Appropriate Use of Time-Weighted Average Concentration in Aquatic Risk Assessment.

In pesticide risk assessment, regulatory acceptable concentrations for surface water bodies (RACsw,ch) are used that are derived from standard studies with continuous exposure of organisms to a test compound for days or months. These RACsw,ch are compared with the maximum tested concentration of more realistic exposure scenarios. However, the actual exposure duration could be notably shorter (e.g., hours) than the standard study, which intentionally leads to an overly conservative Tier 1 risk assessment. This discrepancy can be addressed in a risk assessment using the time-weighted average concentration (TWAc). In Europe, the applicability of TWAc for a particular risk assessment is evaluated using a complex decision scheme, which has been controversial; thus we propose an alternative approach: We used TWAc-check (which is based on the idea that the TWAc concept is just a model for aquatic risk assessment) to test whether the use of a TWAc is appropriate for such assessment. The TWAc-check method works by using predicted-measured diagrams to test how well the TWAc model predicts experimental data from peak exposure experiments. Overestimated effects are accepted because the conservatism of the TWAc model is prioritized over the goodness of fit. We illustrate the applicability of TWAc-check by applying it to various data sets for different species and substances. We demonstrate that the applicability is case dependent. Specifically, TWAc-check correctly identifies that the use of TWAc is not appropriate for early onset of effects or delayed effects. The proposed concept shows that the time window is a decisive factor as to whether or not the model is acceptable and that this concept can be used as a potential refinement option prior to the use of toxicokinetic-toxicodynamic models. Environ Toxicol Chem 2022;41:1778-1787. © 2022 Bayer AG. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Evaluation of a systems-level technical assistance program to support youth with complex behavioral health needs.

The National Technical Assistance Network for Children's Behavioral Health (TA Network) supports the development and implementation of Systems of Care (SOC) for youth with serious emotional disorders and their families in states, tribes, territories, and communities throughout the United States. The purpose of the current research was to conduct an evaluation of the TA Network to assess: The degree to which it has deployed research-based elements of TA; levels of participant satisfaction; types and scope of TA services provided; and systems-level outcomes. Study participants were drawn from a stratified random sample of SOC grant recipients who received technical support from the TA Network between 2013 and 2017. Results suggest that the TA Network has encompassed research-based elements of effective TA. Participants rated their interactions with the network very highly, and they accessed a wide variety of resources from the network. Finally, participants reported a variety of systems-level outcomes associated with TA Network support. Together, these findings underscore the importance of structuring TA systems to tailor support to fit with recipients' needs, build positive, proactive relationships, and offer services of sufficient dosage. Given the lack of rigorous evaluations on provision of TA, future studies can confirm the degree to which such tailored approaches to TA result in increased satisfaction, more effective implementation of SOC principles, and ultimately improved outcomes for youth and families.

Associations Between School Mental Health Team Membership and Impact on Service Provision.

Schools are the most common venue in which children and youth receive mental health services. To organize delivery of mental health care to such a large number of children, use of school teams is often recommended. Yet, there is limited empirical literature about the composition of school mental health teams or teams' relations to service provision. This study investigated team composition, including team multidisciplinarity (number of different types of professionals) and the presence of a community provider, and the relations of these two variables to service provision at Tier 1 (mental health promotion), Tier 2 (early intervention) and Tier 3 (intensive treatment) for 386 schools representing different school sizes, locations, and urbanicity. Results suggested team multidisciplinarity and the presence of a community provider were related to more frequent endorsement of service provision at schools. Practice and research implications are discussed including possible application to hiring decisions and further research with longitudinal data and information on service quality. Supplementary Information: The online version contains supplementary material available at 10.1007/s12310-021-09493-z.

What is the spatial-temporal behavior of a low, medium and high adsorptive compound in two contrasting natural sediments in OECD 218/219 test systems?

Artificial sediment used in studies according to OECD 218/219 (Sediment Water Chironomid Toxicity Test Using Spiked Sediment/Water) does not necessarily mirror the characteristics of natural sediments. To investigate the influence of sediment characteristics on the spatial-temporal behaviors of bixafen (KfOM = 2244 mL/g), fluopyram (KfOM = 162 mL/g) and N,N-dimethylsulfamide (KfOM ≈ 0 mL/g), experiments according to OECD 218/219 with two contrasting natural sediments were conducted. The silt loam sediment provided a high content of organic matter (OM) (13.1%), while the OM (0.45%) of the sandy sediment was low. Diffusion into (OECD 219) or out (OECD 218) of the sediment was dependent on the extent of adsorption, which is linked to the model compounds ́ adsorption affinities and the sediments ́ OM. Consequently, N,N-dimethylsulfamide showed unhindered mobility in each experimental set up, while the high adsorption affinities of fluopyram and bixafen limited the diffusion in the respective sediments. Therefore, in experiments with the silt loam sediment, both compounds revealed a limited mobility and either accumulated in the top 5 mm of the sediment (OECD 219) or remained homogenously distributed over the sediment depth (OECD 218). A greater mobility was observed within the sandy sediment.The influence of OM as found in a study using artificial sediment could be confirmed. Moreover, the applicability of a TOXSWA model was reassured to predict the measured concentrations at different sediment depths. TOXSWA is used in the regulatory exposure assessment to simulate the behavior of pesticides in surface waters. Calibration of three driving input parameters by inverse modelling (diffusion-, adsorption coefficient and OM) revealed no potential for improvement. The core sampling technique used and the model may contribute to a more realistic determination of concentration to which the Chironomid larvae are exposed to. This applies to water sediment test systems where the test organisms do not evenly inhabit the sediment.

Seasonal dynamics of the macrophyte test species Myriophyllum spicatum over two years in experimental ditches for population modeling application in risk assessment.

Myriophyllum spicatum is a sediment-rooted, aquatic macrophyte growing submerged, with a wide geographical distribution and high ecological relevance in freshwater ecosystems. It is used in testing and risk assessment for pesticides in water and sediment. Population models enable effects measured under laboratory conditions to be extrapolated to effects expected in the field with time-variable environmental factors including exposure. These models are a promising tool in higher-tier risk assessments. However, there is a lack of data on the seasonal dynamics of M. spicatum, which is needed to test model predictions of typical population dynamics in the field. To generate such data, a two-year study was set up in outdoor experimental systems from May 2017 to May 2019. The growth of M. spicatum was monitored in 0.2025 m2 plant baskets installed in an experimental ditch. Parameters monitored included biomass (fresh weight [FW] and dry weight [DW]), shoot length, seasonal short-term growth rates of shoots, relevant environmental parameters, and weather data. The results showed a clear seasonal pattern of biomass and shoot length and their variability. M. spicatum reached a maximum total shoot length (TSL) of 279 m m-2 and a maximum standing crop above-ground DW of 262 g m-2 . Periodical growth rates reached up to 0.072, 0.095, and 0.085 day-1 for total length, FW, and DW, respectively. Multivariate regression revealed that pH (as a surrogate for the availability of carbon species) and water temperature could explain a significant proportion of the variability in M. spicatum growth rates (p < 0.05). This study has provided an ecologically relevant data set on seasonal population dynamics representative of shallow freshwater ecosystems, which can be used to test and refine population models for use in chemical risk assessment and ecosystem management. Integr Environ Assess Manag 2022;18:1375-1386. © 2021 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

The implementation potential of a method to monitor empirically-supported children's mental health treatment through claims data.

BACKGROUND: The delivery of evidence-supported treatments (EST) in children's mental health could be a valuable measure for monitoring mental healthcare quality; however, efforts to monitor the use of EST in real world systems are hindered by the lack of pragmatic methods. This mixed methods study examined the implementation and agency response rate of a pragmatic, claims-based measure of EST designed to be applied as a universal quality measure for child psychotherapy encounters in a state Medicaid system. METHODS: Implementation potential of the EST measure was assessed with healthcare leader rankings of the reporting method's acceptability, appropriateness and feasibility (n = 53), and post-implementation ratings of EST rate accuracy. Ability of the healthcare system to monitor EST through claims was measured by examining the agency responsivity in using the claims-based measure across 98 Medicaid-contracted community mental health (CMH) agencies in Washington State. RESULTS: The analysis found the reporting method had high implementation potential. The method was able to measure the use of an EST for 83% of children covered by Medicaid with 58% CMH agencies reporting > 0 ESTs in one quarter. Qualitative analyses revealed that the most significant barrier to reporting ESTs was the operability of electronic health record systems and agencies' mixed views regarding the accuracy and benefits of reporting. CONCLUSIONS: Measurement of child mental health ESTs through Medicaid claims reporting has acceptable implementation potential and promising real world responsiveness from CMH agencies in one state. Variation in reporting by agency site and low to moderate perceived value by agency leaders suggests the need for additional implementation supports for wider uptake.

Manuscript: Defining Quality Standards for Intensive Home Based Treatment Programs for Youth with Serious Emotional Disorders.

Intensive Home Based Treatment (IHBT) is a critical component of the continuum of community-based behavioral healthcare for youth with serious emotional disorder (SED) and their families. Yet despite being used nationwide at costs of over $100 million annually in some states, a well-vetted, research-based set of quality standards for IHBT has yet to be developed. The current project aimed to define program and practice standards for IHBT, drawing upon literature review, expert interviews, and a systematic Delphi process engaging over 80 participants, including IHBT developers, experts in evidence-based youth mental health, youth and family advocates, IHBT providers, and state policymakers. After two rounds of quantitative and qualitative input, adequate consensus was achieved on 32 IHBT Program Standards and 43 IHBT Practice Standards. These standards hold potential for informing efforts such as development of state regulations, provider contracts, memoranda of agreement, and training and workforce development initiatives. Translation of the quality standards into measurement strategies holds potential for providing a method of continuous quality improvement across multiple levels as well as use in research on IBHT.

What is the actual exposure of organic compounds on Chironomus riparius? - A novel methodology enabling the depth-related analysis in sediment microcosms.

A novel active sampling method enabled determination of sediment depth profiles revealing the spatial distribution of model compounds N,N-dimethylsulfamide, fluopyram and bixafen (low, medium, high adsorption affinity) in sediment microcosms according to OECD Test 218/219 (Sediment-Water Chironomid Toxicity Test Using Spiked Sediment/Spiked Water). After the overlying water was removed, plastic tubes were inserted into the sediment and the microcosms were frozen. For depth-related analysis, each "sediment core" was mounted in a cutting device and sawed into three 5-mm-slices, respectively (top, middle, bottom). Each slice was centrifuged for sediment and pore water separation. By various sampling dates within 28 days, we could follow the behavior of model compounds depending on sorption affinities and display specific distribution patterns within the sediment. N,N-dimethylsulfamide showing no sediment adsorption, migrated unhindered in (OECD 219) and out (OECD 218) of the sediment via pore water, resulting in homogenous distributions in both test designs. Fluopyram with moderate adsorption affinity revealed a concentration gradient with declining amounts from top to bottom layer (OECD 219) and higher amounts in the middle and bottom layer as compared to the top layer (OECD 218). Bixafen providing a strong adsorption affinity accumulated in the top layer in OECD 219, while no concentration gradients became visible in OECD 218. For establishing a Toxic Substances in Surface Waters (TOXSWA) model, we compared our measurements with simulated results revealing good agreements. The presented methodology is a useful tool to determine more realistic sediment and pore water concentrations, which the Chironomid larvae are exposed to.

Systematic Review and Meta-analysis: Effectiveness of Wraparound Care Coordination for Children and Adolescents.

OBJECTIVE: Wraparound is a common method for coordinating care for children and adolescents with serious emotional disorders (SED), with nearly 100,000 youths served annually in the United States. The current systematic review and meta-analysis estimated effects on youth outcomes (symptoms, functioning, school, juvenile justice, and residential placement) and costs. METHOD: A literature search identified 17 peer-reviewed and gray literature studies meeting criteria, which were coded on characteristics of sample, design, implementation, and outcomes. Random effects modeling was conducted using Comprehensive Meta-Analysis Version 3.0. Effect sizes were calculated using Hedges g. Homogeneity of effects were assessed using Q statistics. RESULTS: Medium-sized effects favored Wraparound-enrolled youths for costs (g = 0.391, CI = 0.282-0.500, p < .001), residential outcomes (g = 0.413, CI = 0.176-0.650, p = .001), and school functioning (g = 0.397, CI = 0.106-0.688, p = .007); small effects were found for mental health symptoms (g = 0.358, CI = 0.030-0.687, p = .033) and functioning (g = 0.315, CI = 0.086-0.545, p = .007). Larger effects were found for peer-reviewed studies, quasi-experimental designs, samples with a larger percentage of youths of color, and Wraparound conditions with higher fidelity. CONCLUSION: Results indicate positive effects for Wraparound, especially for maintaining youths with SED in the home and community. However, many studies showed methodological weaknesses, and fidelity measurement was largely absent, suggesting a need for additional research. Nonetheless, the results should aid decisions around resource allocation, referral practices, and system partnerships among child psychiatrists and other behavioral health professionals.

Disentangling Mechanisms Behind Chronic Lethality through Toxicokinetic-Toxicodynamic Modeling.

Ecotoxicological profiles of the 3 insecticides imidacloprid, thiacloprid, and flupyradifurone in terms of acute and chronic effects were analyzed in Chironomus riparius. Toxicokinetic-toxicodynamic modeling revealed that chironomids would die from starvation as a result of prolonged feeding inhibition under chronic exposures. The starvation effect is an indirect cause for mortality, which, for the neonicotinoids, adds to the direct/acute mortality, although the results suggests that this additional effect is not relevant for flupyradifurone. Environ Toxicol Chem 2021;40:1706-1712. © 2021 Bayer Inc. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

What Happens When Training Goes Virtual? Adapting Training and Technical Assistance for the School Mental Health Workforce in Response to COVID-19.

The Northwest Mental Health Technology Transfer Center (MHTTC) provides workforce training and technical assistance (TA) to support evidence-based school mental health practices. Historically, this support targeted school professionals through in-person and online trainings, workshops, and coaching. However, in response to COVID-19 restrictions, all support moved to online formats, and the Center introduced trainings for families and caregivers. The purpose of this article is to present preliminary process and outcome data that compare the reach and impact of support before and following COVID-19-related restrictions. Results suggest that transition to online support resulted in a wider reach and a more diverse audience, with no decrease in trainee satisfaction and perceived impact. Furthermore, families and caregivers reported positive gains in knowledge and behaviors following participation in a virtual youth suicide prevention training. Together, these findings suggest that online training and TA can provide tangible benefits to professionals and family members who support student mental health.

Rates of Mental Health Service Utilization by Children and Adolescents in Schools and Other Common Service Settings: A Systematic Review and Meta-Analysis.

A meta-analysis was conducted to examine the relative rates of youth mental health service utilization across settings among the general population and among those with elevated mental health symptoms or clinical diagnoses. Rates of school-based mental health were compared to outpatient, primary care, child welfare, juvenile justice, and inpatient. Nine studies presented rates of mental health service use for general-population youth in the U.S., and 14 studies presented rates for youth with elevated symptoms or clinical diagnoses. Random effects meta-analysis was used to calculate mean proportions of youth receiving care in each sector. Of general population youth, 7.28% received school mental health services. Rates for other sectors are as follows: 7.26% in outpatient settings, 1.76% in primary care, 1.80% in inpatient, 1.35% in child welfare, and 0.90% juvenile justice. For youth with elevated mental health symptoms or diagnoses, 22.10% of youth were served by school-based mental health services, 20.56% outpatient settings, 9.93% primary care, 9.05% inpatient, 7.90% child welfare, and 4.50% juvenile justice. Schools and outpatient settings are the most common loci of mental health care for both the general population and samples of youth with elevated symptoms or clinical diagnoses, although substantial amounts of care are also provided in a range of other settings. Results hold potential for informing resource allocation, legislation and policy, intervention development, and research. Given that mental health services are delivered across many settings, findings also point to the need for interconnection across child-serving sectors, particularly schools and outpatient clinics.