Dec 22, 2011 - These school-based mental health professionals (SBMHP) are engaged in practice in every public school in Illinois and use a variety of ...
Advances in School Mental Health Promotion
ISSN: 1754-730X (Print) 2049-8535 (Online) Journal homepage: http://www.tandfonline.com/loi/rasm20
Adopting a Data-Driven Public Health Framework in Schools: Results from a Multi-Disciplinary Survey on School-Based Mental Health Practice Michael S. Kelly & Colette Lueck To cite this article: Michael S. Kelly & Colette Lueck (2011) Adopting a Data-Driven Public Health Framework in Schools: Results from a Multi-Disciplinary Survey on School-Based Mental Health Practice, Advances in School Mental Health Promotion, 4:4, 5-12, DOI: 10.1080/1754730X.2011.9715638 To link to this article: http://dx.doi.org/10.1080/1754730X.2011.9715638
Published online: 22 Dec 2011.
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Special Issue: Data-Driven Decision Making in School-Based Mental Health
Michael S. Kelly Loyola University Chicago, USA Colette Lueck Illinois Children’s Mental Health Partnership, USA
Key words: evidence-based practice; 3-tier model; PBS; RTI; school social workers; school psychologists; school counselors; school nurses.
Introduction Illinois has a long and stable history of multiple schoolbased mental health providers working directly as school employees. As in many states in the U.S., a number of school-based mental health professions are active in most Illinois K-12 schools: school counselors, school
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Adopting a Data-Driven Public Health Framework in Schools: Results from a Multi-Disciplinary Survey on School-Based Mental Health Practice
nurses, school psychologists, and school social workers. These school-based mental health professionals (SBMHP) are engaged in practice in every public school in Illinois and use a variety of practice approaches. However, there is no current, representative data documenting the characteristics and practice context of these professionals in Illinois. This survey project involved a collaboration between a state public/private partnership, the Illinois Children Mental Health Partnership (ICMHP), and all four state SBMHP associations. The survey was conducted to update the current state of Illinois SBMH practice and
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School-based mental health (SBMH) is a growing and important
emphasize systematic collection of data on students and interventions
subspecialty within the variety of mental health professions. In Illinois,
designed to improve student outcomes by embedding this work in a
the state has its own state-driven certification process for four major
three-tier prevention framework drawn from public health approaches.
school-based mental health professions: school counselors, school nurses,
To date, no data about the field has been collected on all of these
school psychologists, and school social workers. To continue building the
professions at one time in Illinois. Findings from the survey data (N =
infrastructure of SBMH and inform practice in this field requires a
1874, overall response rate of 31%) indicate that SBMH in Illinois is
commitment to understanding the current work and context of these
located largely in tertiary activities involving individual and small-group
practitioners. The past decade has seen significant changes in education
counseling, and few school-based mental health professionals (SBMHP)
policy and thinking about service provision, as highlighted by Response to
show a consistent pattern of practice within the current PBS/RTI
Intervention (RTI) and Positive Behavior Supports (PBS), both of which
framework or use more than limited data to inform practice choices.
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to inform education, research, and practice in the field. Additional analysis in this article is added to examine the impact of the prevailing three-tier public health framework of intervention in schools on SBMH practice, as well as efforts to increase the use of datadriven decision-making by SBMHP.
Practice trends in SBMH 2011 Several practice trends and frameworks have affected the landscape of SBMH since the 1990s: positive behavior supports (PBS), response to intervention (RTI), and evidence-based practice (EBP). We delineate briefly how each of these frameworks has come to affect schools in Illinois and at federal level. Each of these contemporary frameworks is designed largely to promote primary prevention and ensure that school-based intervention efforts have a greater likelihood of success. However, it is not clear how or whether any of these efforts have affected the provision of SBMH services. Some trends potentially affecting SBMH in the past decade involve advancement of contemporary education frameworks for organizing and delivering related services in the schools. The first framework is positive behavior interventions and supports, also referred to as positive behavior support, school-wide positive behavior support (k-12), or program-wide positive behavior support (preschool). PBS is the systematic application of effective, positive, strength-based, relevant, and efficient instructional and behavioral practices, often applied across whole schools, programs, states, or districts, that are designed to achieve desired social and learning outcomes while preventing problem behaviors (Sugai & Horner, 2008). PBS is an intervention framework embracing five core features: promotion of research-validated practices integration of multiple intervention elements to provide ecologically valid, practical supports commitment to substantive lifestyle outcomes implementation of supports within organizational systems to promote sustained effects building local capacity to sustain effective practices over time (Sailor et al, 2009). A second related framework of organizing and delivering related services is RTI. RTI is defined as the practice of providing effective instruction and interventions that match students’ needs, monitoring progress regularly to inform decision-making about changes in instruction
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or goals, and using child response data to guide these decisions (Batsche et al, 2007). RTI can provide a decision-making framework for identifying students who need more intensive levels of academic or behavioral support. Like PBS, it employs the three-tiered model (primary, secondary, and tertiary) to identify when more intensive interventions should be considered for individual students, based on their response (or lack thereof) to interventions at previous levels of prevention. For example, a student might go to a school that provides Second Step as a Tier 1 intervention to all students to teach social skills. If that student still appears to struggle socially, they may be referred to a small group to work on their social skills (Tier 2). If that doesn’t produce desired behavioral change, they may be referred to receive individual or small-group counseling at the school, delivered by a SBMHP (Tier 3). These frameworks have all been informed and inspired by the proliferation of school-based research in recent years. One theme in the school-based literature is that effective strategies employ a comprehensive approach that targets multiple intervention agents (such as teacher, parents, and peers) and intervenes at multiple levels (for example school, home, community) (Sloboda & David, 1997; Dupper, 2003; Kelly, 2008). A second theme supports primary prevention efforts. Prevention efforts that relate to family and community linkages to school have shown some success in promoting positive student outcomes (Henderson & Mapp, 2002; National Governor’s Association Task Force on School Readiness, 2005). A third theme which relates to the use of evidence-based practice (EBP) is that prevention and intervention strategies have only modest effects when applied as stand-alone programs not embedded in a larger intervention framework. Programs have larger effects when they are delivered by high-quality staff and incorporate evidence-based interventions that have been empirically validated in school settings (CASEL, 2007; Kelly et al, 2010). Whether the landscape of SBMH has changed in Illinois in light of these contemporary education frameworks, school-based research, and EBP is unknown.
Methods and survey design The Illinois SBMH Survey Project is an attempt to update the field’s knowledge of SBMH practice and examine how practitioner characteristics, practice context, and practice choices have evolved. The Survey Project was a collaborative effort of the authors and the multi-
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disciplinary team that makes up the School-Age Committee of the Illinois Children’s Mental Health Partnership (ICMHP). Members of the four major SBMH associations serve on the ICMHP, and offered access to their membership as well as expert consultation in the design of this survey. The survey was developed during 2008 and 2009 using an iterative process of research and practice professionals. Participants in the survey were recruited from the four state SBMH associations and from SBMH professionals who are currently working in school counseling programs funded by the Illinois State Department of Mental Health (DMH). The survey was distributed in an online format and yielded 1874 responses for an overall response rate of 31%. The survey gathered information related to school-based mental health professional (SBMHP) characteristics, practice context, population served, and practice choices. The Illinois SBMHP Survey was developed through an iterative process, involving researchers, school-age committee members, and an expert panel of state leaders in SBMH practice and research. In part, the survey was based on previously published work by the first author assessing the practice choices of school social workers in Illinois (Kelly, 2008) and nation-wide (Kelly et al, 2010). The recruitment process involved gathering the email addresses and contact information of respondents from the four state associations, and from SBMH providers who are currently operating in schools under Department of Mental Health (DMH) grants. All four major state SBMH associations agreed to participate fully and provided access to members through emails and/or listserv postings. Participation methods varied within each of the five sampled groups (school counselors, school nurses, school psychologists, school social workers, and DMH providers). Respondents yielded a final N of 1874 for an overall response rate of 31%. Data was collected between February and May 2009. Participants were sent an email link to the online survey. The survey was administered using Opinio (online) software (Opinio
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User Manual, 2008). Following survey completion, data was downloaded into Microsoft Excel and transferred to SPSS for analysis. Data analysis for this article included mainly descriptive statistics and frequencies to summarize and describe characteristics, practice context, and practice choices of SBMHP.
Findings Characteristics This sample represented 1874 SBMHP from all over Illinois. As shown in Table 1, below, the sample was predominantly female and Caucasian, and had an average of 10 years in school-based practice. (Please see Appendix A for more specific detail on the regional distribution of the sample.)
Practice context With the exception of school counselors, survey respondents reported most frequently that they worked in elementary school settings, high schools and junior high/middle schools coming in second and third on average in terms of practice context. (The DMH providers were the only sample that had any significant presence in pre-K/Early Childhood programs.) This may reflect actual practice context differences, or simply the fact that there are considerably more elementary schools than secondary schools (70% compared with 24%, respectively) (U.S. Department of Education, 2007). Roughly 91% of respondents reported practicing primarily in the public education system, few respondents representing private school employees. Given that more than 25% of schools are private (U.S. Department of Education Digest of Education Statistics, 2007), this may suggest that our survey did not adequately reach SBMHP in private schools, that SBMHP are under-used in this setting, or that SBMHP in these settings are not as heavily represented in state associations.
TABLE 1 Who are Illinois’ School-Based Mental Health Professionals? School-based Mental Health Professional School School School School
Social Workers Counselors Nurses Psychologists
Gender (% female) White 88 82 100 82
87% 90% 96% 91%
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Race
African American Hispanic 6% 3% 2% 1%
Asian American Other
5% 2% 5% 3% 1% 1% 3% 3%
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Av. years in field 12 10 11 12
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Population served Teachers were the most common referral source, the highest proportion of all referrals for all SBMHP except school nursing. However, the most commonly reported reasons for referral differed significantly between different SBMHP (Table 2, below). Study results also provide information on the characteristics of the students served by SBMHP. Roughly 25% reported that most or all of the children they served received government services such as Medicaid, TANF, SSI, or free/reduced lunch. Respondents differed significantly by profession in terms of serving students with individualized education plans (IEPs), school social workers having the highest percentage of IEP-related clients (50%). One common theme that could be discerned is that most Illinois SBMHP report that they are the only mental-health service provider to a significant portion of their client population, a solid majority (76%) saying that only a few of their clients get any outside therapy/mental health services beyond what the SBMHP provides.
Mapping practice across the three-tier model of intervention Respondents were asked to indicate the ideal and actual percent of their time they engaged in primary versus secondary/tertiary prevention in their SBMH practice. For all four types of SBMHP, respondents reported spending more time on secondary/tertiary prevention activities than they considered ideal. An average of 83% of the total sample said that they see a ‘significant discrepancy’ between their actual and ideal balance of prevention and Tier 3 activities.
This discrepancy was most often attributed to having too many students on respondents’ caseload who required direct Tier 3 acute clinical services, and having their role too strictly proscribed by their school setting. Clearly, efforts to expand the intervention repertoire of SBMHP are challenged by the very practice contexts in which they currently practice. Respondents reported spending an average of a third of their work week on paperwork and other administrative tasks (36% of their time). Of the primary prevention activities mentioned in the survey, all the SBMHP respondent groups indicated that they employ parental engagement most frequently (‘All of the time’ or ‘Most of the time’). The next ‘top two’ most commonly used primary prevention strategies differed between the different SBMH professions, and included: facilitating small groups as a Tier 2 prevention activity (SSW and SC) engaging the community (SSW, SN, and DMH providers) improving school culture by designing unified discipline systems in the school (SC) developing prevention and intervention protocols for the school (SPsych, SN, & DMH) analyzing data to support school decision-making (SPsych). The prevention strategies least frequently employed ‘All of the time’ or ‘Most of the time’ in all SBMH disciplines were delivering classroom- or school-wide social skills curriculum, teacher professional development, and, with the exception of school psychologists, analyzing data to support school decision making.
Practice choices by SBMHP TABLE 2 Major Referral Reasons for SBMHP School-based MH professional
Top referral reason 2nd referral reason
School Counselor
Academic problems Emotional problems
School Nurse
Attendance
Emotional problems
School Psychologist Academic problems Behavior problems in school School Social Worker Behavior problems in school
Emotional problems
Department of Mental Health
Emotional problems
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Behavior problems in school
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For this section of the survey, SBMHP were asked to report on the frequency of their Tier 3 intervention choices. The categories for the section were: individual counseling of students small group counseling of students classroom groups (to deliver group-based intervention or programming) family-based practice (meeting with the student and his/her family) sessions between a student and their teacher. As shown in Table 3, opposite, SBMHP are engaged in a
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variety of secondary/tertiary activities as well. More than 60% report doing individual counseling ‘All of the time’ or ‘Most of the time’. The next most popular secondary/ tertiary activities differed between SBMHP. Tier 3 strategies used less frequently for most SBMHP included teacher– student sessions; school counselors, school psychologists and school social workers also reported that they rarely employ family-based practice as part of their work in schools. Finally, the survey asked SBMHP to describe how they measure the effectiveness of their practice. Table 4, below, shows that most SBMHP rely on teacher and student self-report, observation of student behavior, and school data (such as attendance, grades, and discipline referrals) to measure their practice, though each profession reported relying on these tools with differing levels of frequency. Interestingly, none of the four SBMHP rated as tools that they used standardized outcome measures or behavior plans that are monitored by a behavior intervention plan (BIP) team ‘all’ or ‘most of the time’ as one of the top three options in their repertoire.
Discussion This study is the first major effort this decade to characterize Illinois’ SBMHP. It is also the first time data on SBMHP choices have been examined in the context of recent trends in school-based related service fields. This section discusses the results in relation to previous studies of SBMH, and recent legislation, the evidence base on school-based services and EBP, and contemporary practice frameworks. Finally, it provides further analysis on the two crucial issues discussed earlier in this article: TABLE 3 Engagement in Activities ‘All of the time’ or ‘Most of the time’ School-based Most preferred 2nd Most MH professional Tier 3 activity preferred
3rd Most preferred
School Counselor Individual counseling
Group counseling
Classroom groups
School Nurse
Individual counseling
Family-based practice
Teacher-student sessions
School Psychologist
Individual counseling
Group counseling
Classroom groups
School Social Worker
Individual counseling
Group counseling
Classroom groups
Department of Mental Health
Individual counseling
Family-based practice
Group counseling
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TABLE 4 How SBMHP Measure the Effectiveness of their Interventions Most preferred School-based Measurement MH professional Tool(s)
2nd Most preferred
School Counselor Teacher & student Student self-report observation School Nurse
3rd Most preferred School data
Student observation
Teacher & student School data self-report
School School data Psychologist
Teacher & student Student self-report observation
School Social Worker
Teacher & student Student self-report observation
School data
how the three-tier public health framework for intervention in schools has affected Illinois SBMH practice how this three-tier framework has affected efforts to increase the use of data-driven decision-making by SBMHP. We also note the study’s limitations in methodology and in some of the processes involved in carrying out the survey. Finally, this section details how these issues will be further examined and disseminated in social work and education outlets. First, a few cautions about the data and our study methodology. As with any survey project, issues related to the sample warrant brief mention here. We chose to focus on the SBMHP who were members of their respective state associations, cognizant that not all Illinois SBMHP are members of their state association. Of those state association members, we achieved an overall response rate of only 31%, which, while acceptable for an online survey, limits our ability to generalize about the overall practice profile of all Illinois SBMHP. This study suggests that the characteristics of SBMHP remain largely unchanged from those found in previous studies with similar demographics and time spent in the field. Most SBMHP work in the public education system, and a larger percentage practice in elementary schools. Practice occurs in rural, suburban, and urban communities. The study suggests that SBMHP serve students who face complex issues of behavior, emotional problems, academics, and attendance and often do not receive mental health assistance outside the school setting. This leaves SBMHP as the primary, and often only, therapist or counselor with whom students are engaged. Many of these services are directly tied to a special education IEP.
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Next, the findings were examined in the context of the three-tier framework common to RTI and PBIS. Despite growing support for interventions targeted at multiple levels and assuming multiple causes, SBMHP in this study continue to report that most of their time is spent engaging in individual and group counseling, located largely at Tier 2 and Tier 3 levels. Their efforts are focused primarily on secondary and tertiary prevention, intervening with students who have been referred for services to reduce the severity of their problems, rather than on primary prevention efforts (typically seen in Tier 1) with an entire classroom or school. There is little evidence that they are engaged in building sustained and stable referral networks with outside community providers to build on their tertiary service delivery, which casts doubt on how effective their Tier 3 efforts can be, given recent policy and research discussions about building stronger linkages between SBMHP and outside clinical service providers (Hurwitz & Weston, 2010). The survey examined general practice choices (for example parental engagement, social skills interventions, small-group work, individual counseling), but was not designed to examine whether the specific intervention approaches used have evidence to support their use. It would be useful to glean this information in subsequent studies. With regard to EBP, few of the respondents reported using online research and journals/books (with the striking exception of the school nurse respondents) which are necessary to engage in an evidence-based process. Thus, if practitioners are engaging in practices that have research to support their use, it is not clear how they would acquire the necessary information. Current discourse related to EBP hopes that practitioners would use scholarly resources as a primary source of information, with strong ongoing coaching and supervision to supplement practice choices (Kelly, 2008; Raines, 2008). These findings suggest that SBMH in Illinois has not strayed far from its historical roots in terms of the characteristics of practitioners or practice choices, and in our view this extends to their use of data-driven decision making in their day-to-day practice. It is certainly true from the survey findings that children in schools served by Illinois SBMHP face complex difficulties and receive little support from outside agencies. It is clear that SBMHP remain the main providers of mental health services for many of the children and families with the greatest needs, yet are stretched by multiple demands and limited engagement in the broader activities of the educational system. This is, in our view, vital and important work and speaks to the time constraints
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many of our sample reported experiencing as they tried to carry out their work in their schools, as well as the continued struggle to create effective systems of care for young people and their families (Stroul & Blau, 2008). Yet it also appears, despite the apparent momentum towards developing more prevention-oriented practices rooted in RTI and PBS, that many IL SBMHP still have only limited ongoing contact with these frameworks in their day-to-day practice; indeed, roughly a third of the SBMHP surveyed aren’t involved at all in their school’s RTI team process. Finally, the primary driver of the threetier framework – use of data to inform practice choices and levels of intervention – appears to be only at a rudimentary level (self-report and classroom observation). Few practitioners (with the notable exception of school psychologists) say that they use systematic data-collection methods such as school data and standardized measures to inform their practice. This study helps us to assess the state of Illinois’ SBMHP and to begin a dialogue on how SBMHP can respond to the changing educational landscape. It is hoped that this survey will assist the field as we all work towards supporting SBMHP and making improvements in policy, teaching, practice, and research to help them best serve their school’s students and families. With regard to contemporary education frameworks, this survey provides some useful information. These contemporary education frameworks emphasize use of evidence-based practices, engagement in a data-based decision-making process, and provision of interventions along a continuum of support with an emphasis on primary prevention. SBMHP expressed a desire to do more primary prevention, but cite time constraints related to serving too many students and their prescribed role as the main barriers. SBMHP do report engaging families as a primary prevention approach, and some report doing family counseling. Although many SBMHP see the systems perspective as a major strength of the profession (Raines, 2006), their ability to approach student problems through primary prevention and environmental/systems change seems limited. SBMH continues to require development to move practitioners into policy making and leadership positions at their schools and to get them involved in more system-wide efforts. The items least endorsed with regard to prevention, developing prevention or intervention protocols, delivering classroomor school-wide social skills curriculum, teacher professional development, and analyzing data to support school decision-making, have been receiving increasing attention from school-based researchers as vital and
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important primary prevention activities. Some researchers argue that this is arguably where the future of SBMH is headed (Flaspohler et al, 2008). It will take a combined effort of research, teaching, and practice to move the field forward and be ready for the challenges of the future. However, armed with what is likely to be a fairly accurate description of the current Illinois SBMH landscape, the strengths to be built upon and the areas requiring more attention are now more apparent.
Address for correspondence Michael S Kelly PhD, LCSW, Loyola University Chicago School of Social Work, 111 E. Pearson, Lewis Towers 1245, Chicago, IL 60611, USA. Email: mstokek@ yahoo.com
References Astor R, Behre WJ, Wallace JM & Fravil KA (1998) School social workers and school violence: personal safety, training, and violence programs. Social Work 43 (3) 223–32. Batsche GM, Curtis MJ, Dorman C, Castillo JM & Porter LJ (2007) The Florida problem-solving/response to intervention model: implementing a statewide initiative. In: SR Jimerson, M Burns & AM VanDerHeyden (Eds) Handbook of Response to Intervention. New York: Springer. CASEL (2007) What is SEL? Retrieved on May 30, 2007 from http://www.casel.org/basics/definition.php Dupper DR (2003) School Social Work: Skills and interventions for effective practice. Hoboken, New Jersey: Wiley & Sons. Flaspohler P, Anderson-Butcher D, Bean J, Burke RW & Paternite CE (2008) Readiness and school improvement: strategies for enhancing dissemination and implementation of expanded school mental health practices. Advances in School Mental Health Promotion 1 (1) 16–27. Henderson AT & Mapp KL (2002) A New Wave of Evidence: The impact of school, family, and community connections on student achievement. Austin, TX: National Center for Family & Community Connections with Schools. (ERIC Document Reproduction Service N. ED ED474521)
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Hurwitz L & Weston K (2010) Using Coordinated School Health to Promote Mental Health for all Students. www.nabhc.org. Kelly MS (2008) The Domains and Demands of School Social Work Practice: A guide to working effectively with students, families, and schools. New York: Oxford. Kelly MS, Berzin SC, Frey et al (2010) The state of school social work: findings from the national school work survey. School Mental Health Journal 2 (3) 132–41. Kelly MS, Raines JC, Stone S & Frey A (2010) School Social Work: An evidence-informed framework for practice. New York: Oxford University Press. National Governor’s Association Task Force on School Readiness (2005) Building the Foundation for Bright Futures. www.nga.org/Files/pdf/0501TaskForce Readiness.pdf. Opinio User Manual (2008) User Manual for Opinio Survey Software. www.objectplanet.com/opinio/ documentation.html. Phillips DL & Clancy KJ (1972) Some effects of ‘social desirability’ in survey studies. American Journal of Sociology 77 (5) 921–41. Raines J (2006) SWOT! A strategic plan for school social work in the 21st century. School Social Work Journal 132–50. Raines J (2008) Evidence-Based Practice in School-based Mental Health. New York: Oxford. Sailor W, Dunlap G & Sugai G and Horner R (2009) Handbook of Positive Behavior Support. New York: Springer. Sloboda Z & David SL (1997) Preventing Drug Use among Children and Adolescents: A research-based guide. Rockville, MD: National Clearinghouse for Alcohol and Drug Information. (ERIC Document Reproduction Service No. ED 424525) Strohl BA & Blau GM (2008) The System of Care Handbook: Transforming mental health services for children, youth, and families. Baltimore, MD: Brookes Publishing. Sugai R & Horner R (2007) SW-PBS and RtI: Lessons being learned. www.pbis.org/main.htm. U.S. Department of Education (2007) Digest of Education Statistics 2007. http://nces.ed.gov/programs/digest/ d07/index.asp.
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Appendix A: Description of the Sample In this report findings are provided for all SBMHP who are part of state professional associations. Data is available on all SBMHP upon request. State results were divided into U.S. Census regions and colloquially defined regions in Illinois, for example Metro East, Fox Valley, Central Illinois. The top three regions that responded to the survey for each of the SBMHP are reported in Table A1, below.
TABLE A1 Survey Participation by School-Based Mental Health Professional School-Based Mental Health Professional School Counselor School Nurse School Psychologist School Social Worker Department of MH Total
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Survey Response respondents rate % 400 359 444 572 99
31 35 25 35 48
1874
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Top state region reporting Chicago Chicago Chicago Chicago Chicago
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Suburbs Suburbs Suburbs Suburbs (city)
2nd most sampled region Central Illinois Northwestern Illinois Central Illinois Central Illinois Central Illinois
3rd most sampled region Northwestern Illinois Central Illinois Northwestern Illinois Chicago/Southern Illinois (tie) Chicago Suburbs
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