The program aims to increase school/community competence in responding to and preventing student emotional and behavioral health crises. This program is rated Promising. Compared with control schools, intervention schools had statistically significantly lower rates of suspensions and office referrals and had conducted more threat assessments and crisis interventions. However, there were no significant effects on bullying, juvenile justice referrals, and emotional or behavioral health incidents.
Program Goals/Target Population
This Emotional and Behavioral Health Crisis Response and Prevention (EBH–CRP) intervention is a comprehensive training, organization, and support protocol for school and community stakeholders in Baltimore County (Md.) Public Schools (BCPS) aimed at increasing school/community competence in responding to and preventing student emotional and behavioral health crises. The BCPS Urgent Crisis Intervention Committee developed the intervention after identifying gaps in the prevention and response to emotional behavioral health crises; the committee wanted to provide additional resources to address student health needs (Lewis et al. 2019).
The EBH–CRP intervention is intended for students who display intense emotional behaviors that are not quickly diffused or resolved. Specifically, the primary targets of the intervention include students who act out in class; students who threaten classmates, teachers, principals, school buildings, and themselves; and students who engage in other potentially dangerous activities and behaviors.
The EBH–CRP intervention uses a five-tier approach to address emotional and behavioral health concerns across the continuum of services and supports, including universal emotional and behavioral health and safety promotion as well as prevention, early intervention, and crisis response and relapse prevention. This model builds on the Multitiered System of Student Emotional and Behavioral Health Supports (MTSS) that was previously employed by BCPS (NCSMH 2018). The first three of the five EBH–CRP tiers are adopted from the MTSS model, but EBH–CRP expands the third tier to enhance the schools’ capacity to address emotional and behavioral health crises and prevent relapse, and two additional tiers were added.
Tier 1 is universal prevention, aimed at all students. The goal of universal prevention is to improve school climate by using the Safe School Ambassador (SSA) program. The SSA program introduces influential student leaders to practical, nonviolent communication and intervention skills with which they may engage their peers and prevent bullying and harassment. SSA students are trained to notice mistreatment among peers and meet regularly with school staff to discuss what they have observed and intervened with.
Tier 2 is early identification of emotional and behavioral health concerns. This is addressed through Kognito At-Risk Online Training, which provides staff with online simulations of situations related to the emotional and behavioral health of students and increases their skills in identifying, approaching, and referring students.
Tier 3 is assessment and service linkage. The goals of this tier are to map and coordinate existing school and community supports and to streamline the referral and assessment processes. School officials are interviewed regarding students’ emotional and behavioral health, what kind of assistance these students seek, and what interventions and outcomes are most frequently utilized. These interventions are documented on a School Resource Map, which aids program staff in developing a Crisis Resource List to support students when additional resources are requested.
Tier 4 is crisis response. Schools develop and implement a standardized crisis response—culturally sensitive, school-informed protocol focused on de-escalation and diversion in an emotional or behavioral health incident. Crisis response is implemented by licensed certified social workers who act as school district mobile crisis coordinators. These coordinators are contacted when a student is in crisis, which is defined by the EBH–CRP protocol as “marked and ongoing aggression, impulsivity, erratic actions, irritability, anger, anxiety, sadness, and/or bizarre actions or statements in which the student is unable and/or unwilling to respond to school routines and interventions as normally provided” (Lewis et al., 2019:, p. 5). In addition, staff are trained in Life Space Crisis Intervention (LSCI) to use in their daily interactions with students. LCSI is an intervention that focuses on cognitive behavior modification and prosocial skills training. This helps enable staff to better prevent and resolve crises on their own.
Finally, Tier 5 is postcrisis relapse prevention, which is addressed through a manualized procedure called the Process for Crisis Assessment and Relapse Prevention (P–CARP). The P–CARP helps staff identify and evaluate why a particular crisis happened and to plan what response can help prevent a similar crisis from reoccurring with the student (Lewis et al. 2019).
Lewis and colleagues (2019) found schools that implemented the Emotional and Behavioral Health Crisis Response Crisis Response and Prevention (EBH–CRP) intervention had 56 percent fewer suspensions compared with control group schools. This difference was statistically significant.
Intervention group schools had 75 percent fewer office referrals compared with control group schools. This difference was statistically significant.
There were no statistically significant differences between groups in bullying reports.
Juvenile Justice Referrals
There were no statistically significant differences between groups in juvenile justice referrals.
Number of Reported Emotional and Behavioral Health Incidents
There were no statistically significant differences between groups in the number of reported emotional and behavioral health incidents.
Intervention group schools conducted more threat assessments compared with control group schools. This is considered a positive finding for intervention group schools because it indicates a higher awareness of students’ problem behaviors. This difference was statistically significant.
Intervention group schools conducted more crisis interventions (actions taken by the school psychologist to respond to a student crisis incident) compared with control group schools. This is considered a positive finding for intervention group schools because it indicates a higher awareness of students’ problem behaviors. This difference was statistically significant.
Lewis and colleagues (2019) conducted a randomized controlled trial to determine the effects that the Emotional and Behavioral Health Crisis Response Crisis Response and Prevention (EBH–CRP) intervention had on school safety and discipline outcomes and on students’ emotional and behavioral health. The study took place in Baltimore County Public Schools (BCPS) in Maryland and was implemented across elementary, middle, and high schools.
BCPS students are 43.2 percent white, 38.7 percent African American, 7.2 percent Hispanic, 6.4 percent Asian American, and 4.0 percent multiracial. Nearly half (46 percent) of the students in the BCPS district are eligible for free or reduced-price meals. The study authors did not provide specific demographic information about the schools that participated in the study. Of the 173 schools in the BCPS district, 40 schools were matched on key demographic variables—such as race/ethnicity, student enrollment, and poverty—and randomized to either the intervention or the control condition. Twenty intervention group schools consisted of 13 elementary schools, 5 middle schools and 2 high schools, and 20 control group schools consisted of 14 elementary schools, 4 middle schools, and 2 high schools. Baseline data was collected from the 2014–15 school year, and the intervention was implemented between 2015 and 2017. Schools in the intervention group implemented the EBH–CRP intervention, while control group schools employed existing BCPS resources to deal with emotional and behavioral health crises.
Outcomes of interest included suspensions, office referrals, bullying reports, juvenile justice referrals, emotional and behavioral health incidents, threat assessments, and crisis interventions. This data was collected by the school system at baseline, the end of year 1, and the end of year 2. Suspensions, office referrals, bullying reports, and juvenile justice referrals were analyzed using poisson regression models. Emotional and behavioral health crisis incidents were compared using independent samples t–tests to compare the frequency and ratio of types of incidents. Threat assessment and crisis response reports were collected from existing School Psychologist Year-End Cumulative Reports and were analyzed using poisson regression models. The study did not conduct subgroup analyses.
The Emotional and Behavioral Health Crisis Response and Prevention (EBH–CRP) intervention required a total investment of $1,429,713. Most of this cost ($491,161 in the first school year and $389,135 in the second school year) was for direct purchases, while the rest went toward training (Lewis et al. 2019).
Evidence-Base (Studies Reviewed)
These sources were used in the development of the program profile:Study 1
Lewis, April K., Cindy Nguyen, Carrie Freshour, Sharon Hoover, Jill Bohnenkamp, Cindy Schaeffer, and Eric Slade. 2019. Promoting School Safety: A Comprehensive Emotional and Behavioral Health Model.
Baltimore, Md.: University of Maryland School of Medicine, National Center for School Mental Health.https://www.ncjrs.gov/pdffiles1/nij/252849.pdf