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Factors that promote or inhibit a teacher’s ability to identify and refer students with anxiety or depression for evaluation
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Content
Running head: REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
1
FACTORS THAT PROMOTE OR INHIBIT A TEACHER’S ABILITY TO IDENTIFY AND
REFER STUDENTS WITH ANXIETY OR DEPRESSION FOR EVALUATION
by
Benjamin J. Gonzales
________________________________________________________________________
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
August 2017
Copyright 2017 Benjamin J. Gonzales
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
2
DEDICATION
This dissertation is dedicated to my wife and children. As anyone who has taken on the
challenge of a doctoral program knows, a doctorate requires the hard work, patience and support
of the loved ones in our lives as well as us as students. My wife and children have been the best
inspiration and cheerleaders anyone could have asked for. They picked up the slack and
understood my absences as part of a greater good. Their unshakable support through this process
has carried me through all of the reading and writing. I love you Christine, Miles and Gianna.
Further, this is also dedicated to the teachers who work every day to provide engaging
and safe educational experiences for students. Teaching is a passion and a labor of love full of
professionals who are devoted to creating positive outcomes for students.
Finally, I also want to recognize all of the students who deal with anxiety, depression or
any other social and emotional challenge. I hope in some small way this work is another small
step in supporting you and easing your struggles as you make your way in the world.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
3
ACKNOWLEDGMENTS
I would very much like to thank my advisor Dr. Mora-Flores. Your calming voice and
encouraging feedback has truly made the production of this work a reality. I have learned so
much from you as you have served as a great example of support. I would also like to thank the
other members of my committee; Dr. Hirabayashi, you made me work harder than I ever thought
I could and I often hear the words “how do you know” repeated in your voice in my head as I
approach problems…you have left a lasting impression. Dr. Plough, you are truly the best school
leader I have ever known. Your practical, thoughtful and compassionate approach to addressing
K-12 education has been a model that I often drawn upon.
Thank you to my mother for her support and encouragement. You gave me a great
foundation that allowed me to persevere and thrive. I love you!!
I want to thank my administrative colleagues at FHS who were with me when I started
this program and encouraged me when I began the journey toward my doctorate.
A big thank you to everyone at my current school district as you saw me through the final
stages of this process. Specifically, I need to thank Kathy, Kathie and Sabine for their steadfast
encouragement.
Thank you to the teachers and administrators that gave of their time and allowed me to do
the work required to gather data and look for documents.
A big thank you to Julio at the coffee shop where I wrote the majority of this dissertation
for keeping well stocked with food and drink during this process – AEKDB!!
Lastly, a big thank you to all the members of Cohort One – we are truly trailblazers. You
all have been so encouraging and giving of yourselves and I could not have asked for a more
wonderful group of people to share this adventure with. Thank you to Marianne specifically; we
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
4
started this together and you provided me with a grounded dose of reality and encouraging word
when needed. We will get you singing the USC fight song soon. Fight On!!
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
5
TABLE OF CONTENTS
Dedication 2
Acknowledgments 3
List of Tables 7
Abstract 9
Chapter 1: Introduction 10
Importance of the Evaluation 11
Organizational Context and Mission of the Project Site 12
Organizational Performance Status 13
Related Literature 14
Organizational Performance Goal for Project Site 15
Description of the Stakeholder Groups 16
Stakeholder Group for the Study 17
Purpose of the Project and Questions 18
Methodology and Framework for Project 19
Organization of the Dissertation 19
Chapter 2: Review of Literature 20
History of Youth Mental Illness 20
Impact of Mental Illness on Youth and Society 23
Emerging Trends of Mental Illness Related to a School Context 26
Clark and Estes Framework 30
Stakeholder Knowledge and Motivation Influences 31
Stakeholder Organizational Influences 40
Summary 43
Chapter 3: Methodology 45
Purpose of the Project 45
Conceptual Framework 45
Figure 1. Conceptual framework 46
Data Collection and Instrumentation 47
Participating Stakeholders 50
Sampling 51
Data Analysis 52
Credibility and Trustworthiness 53
Ethics 54
Validity and Reliability 55
Limitations and Delimitations 56
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
6
Chapter 4: Results and Findings 58
Participating Stakeholders 58
Results 60
Findings 72
Document Review 84
Synthesis 85
Summary 89
Chapter 5: Discussion and Recommendations 90
Discussion 90
Recommendations for Practice to Address KMO Influences 94
Integrated Implementation and Evaluation Plan 104
Conclusion 116
References 117
Appendices 131
Appendix A: Survey Protocol 131
Appendix B: Interview Protocol 134
Appendix C: Information/Factsheet for Research 136
Appendix D: Interview Volunteer Form 138
Appendix E: Satisfaction Survey 140
Appendix F: Blended Evaluation Tool 141
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
7
LIST OF TABLES
Table 1. Stakeholder Goals 17
Table 2. Knowledge Factors Related to Stakeholder Goals 33
Table 3. Motivational Influences on Stakeholder Goals 37
Table 4. Organizational Influences on Stakeholder Goals 41
Table 5. Demographic Profile of Interview Participants 59
Table 6. Survey Results for Anxiety Identification 61
Table 7. Survey Results for Depression Identification 62
Table 8. Survey Results for Available Services 63
Table 9. Survey Results for Procedural Knowledge Results 64
Table 10. Survey Results for Teacher Self-Efficacy 65
Table 11. Survey Results for Teacher Expectancy Value 66
Table 12. Survey Results for Cultural Setting — Depression 67
Table 13. Survey Results for Cultural Setting — Anxiety 68
Table 14. Survey Results for Cultural Setting — Training to Address Student Needs 69
Table 15. Survey Results for Cultural Setting — Anxiety Process 70
Table 16. Survey Results for Cultural Setting — Depression Process 70
Table 17. Survey Results for School Referral Process 71
Table 18. Survey Results for Teacher Perception About Responsibilities 72
Table 19. Summary of Knowledge Influences and Recommendations 95
Table 20. Summary of Motivation Influences and Recommendations 100
Table 21. Summary of Organization Influences and Recommendations 102
Table 22. Outcomes, Metrics, and Methods for External and Internal Outcomes 106
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
8
Table 23. Critical Behaviors, Metrics, Methods, and Timing for Evaluation 107
Table 24. Required Drivers to Support Critical Behaviors 108
Table 25. Components of Learning for the Program 111
Table 26. Components to Measure Reactions to the Program 112
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
9
ABSTRACT
With the rise of school age youth presenting with anxiety or depression, the role of school
systems as a place where students are identified and evaluated is being reexamined. The
traditional function of school as singularly focused on educational endeavors is increasingly
called into question. Given the concentration of young people for prolonged periods of time
gives rise to the notion that schoolhouses can play a significant part in identifying and supporting
students with anxiety or depression. In light of the continuous relationship teachers share with
students, this study seeks to examine the role teachers play in identifying and referring students
with anxiety or depression for evaluation. The Clark and Estes Gap Analysis Framework serves a
framework for the examination of the knowledge, motivation and organizational structures that
promote or inhibit a teacher’s ability to identify and refer a student suspected of having anxiety
or depression for evaluation. Through the use of a mixed methods evaluation model, this project
identified a need for teachers to increase their knowledge regarding symptoms of anxiety and
depression as well as knowledge of support services on their campuses. While teachers believe it
is value in referring a student for evaluation, they lack a strong sense of self-efficacy to identify
students in need evaluation. Lastly, there is an absence of a coherent and well-communicated
process for referral as well as an articulated and coordinated professional development plan. The
findings and results of data collection highlight the need for the development of process and
procedures that will guide teachers in referring a student for evaluation as well as the training
required to support the building of teachers capacity to identify students suspected of having
anxiety or depression.
Keywords: teacher, identify, refer, anxiety, depression
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
10
CHAPTER 1
INTRODUCTION
Mental illness can have a significant impact on the lives and families of those affected.
The United States Department of Health and Human Services (Perou et al., 2013) estimates that
approximately 13% to 20% of youth experience a mental illness within a given year. The
implications of mental illness are significant (Perou et al., 2013) given that care, lost wages and
impact on social services has an annual cost of $247 billion in the United States. In addition to
the fiscal impact of mental illness, there are a variety of social and educational ramifications that
can lead to negative outcomes for youth with mental illness.
Youth with mental illness encounter a variety of negative educational outcomes. McLeod
and Kaiser (2013) noted that these youths had lower graduation rates and were less likely than
similar peers to attend college. Further, these students were observed to have grade point
averages that were between .14 and .40 lower than youth without a mental health diagnosis
(McLeod, Uemura, & Rohrman, 2012). Along with grade and graduation implications, students
with mental health challenges reported suffering from unexplainable and nonspecific illnesses
that increased their rates of absenteeism (DeSocio & Hootman, 2004).
Students who fail to achieve academically, are more likely to have increased rates of
substance abuse, criminal activity, and struggle financially. It is estimated that the number of
youth engaging in substance abuse as a method of dealing with their mental illness is between
50% and 71% (Armstrong & Costello, 2002; Winstanley, Steinwachs, Stitzer, & Fishman, 2012).
While drug usage is not their only challenge, they are more likely to engage in crime and be
incarcerated (Coker, Smith, Westphal, Zonana, & McKee, 2014). In addition to criminal
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
11
behavior and reduced academic performance, students with mental illness are disproportionally
high school dropouts (McLeod & Kaiser, 2013; McLeod et al., 2012).
A challenge to meeting the social and emotional needs of students lies in the way schools
are structured. In the United States, schools are organized and funded as academic institutions.
However, the focus on academic achievement often is in direct conflict with the increasing social
service needs of the school age population (Adelman & Taylor, 2000). Within the current
structure of the American educational system, schools lack the necessary infrastructure to meet
the needs of students with mental illness.
School policies that mandate appropriate training are deficient as only 8.9% of states in
2006 had specific policies that required school personal to oversee and coordinate mental health
programs (Brener, Weist, Adelman, Taylor, & Vernon-Smiley, 2007). Additionally, programs
designed to build capacity among staff to identify students with mental illness are not generally
incorporated into district led professional development (Brener et al., 2007). While possible
solutions include developing partnerships that increase the utilization of community based
resources, Adelman and Taylor (2000) found schools lacked the coordination to facilitate such
partnerships. While policies, professional development and partnerships are meaningful ways to
support students with mental illness, strong site-based solutions can have the greatest direct
impact on the lives of students (Robertson, Pfeiffer, & Taylor, 2011). This project examines the
factors that influence a teacher’s ability to identify students diagnosed with, or suspected of
having, anxiety or depression and refer those students for evaluation.
Importance of the Evaluation
The evaluation of students with anxiety and depression is important, and it begins with
the identification and referral process by a teacher. Ensuring teachers have the proper training
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
12
and structures to support the identification and referral process is vital for positive student
outcomes. If students are not identified and referred for evaluation, they may not receive any
treatment and may encounter a variety of negative outcomes. Students with mood disorders are
less likely to graduate and attend four year universities (McLeod & Kaiser, 2013; McLeod et al.,
2012). The incidence of incarceration (Coker et al., 2014), as well as substance abuse
(Armstrong & Costello, 2002), is greater among this population. Additionally, lost wages,
treatment costs and utilization of social services by individuals with anxiety and depression has
an annual cost of $247 billion on the United States economy (Perou et al., 2013).
Organizational Context and Mission of the Project Site
The study site for this project is the Mission Valley Unified School District (Pseudonym).
The district has seventeen elementary schools, one K-8 school, three middle schools and two
comprehensive high schools serving approximately 15,000 students. Additionally, the district has
two alternative programs with 200 students and an adult education program with an enrollment
of 500 community members of various ages. The Mission Valley Unified School District
(MVUSD) is located in Santa Clara County, California. The residents of this county tend to be
very educated and employment in the area is dominated by high tech firms such as Google,
Apple and Yahoo. The district’s students represent many different ethnic races with roughly
equal representations of Hispanic, Caucasian and Asian students.
In addition to an ethnically diverse population, the MVUSD is socio-economically and
educationally diverse. Almost half of the students in the Mission Valley Unified School District
meet the requirements for free or reduced lunch. Twenty-seven percent of the students are
classified as English Language Learners and one-fifth are reclassified English Language
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
13
Learners. Students with disabilities, as defined as those students with an Individualized
Educational Plan comprise 17% of the student population.
The District has a mission statement that states, “The mission of the [Mission Valley
Unified] School District is to ensure students of all ages and abilities are prepared to succeed in
an evolving world.” This statement reflects the district’s commitment to all the students that
attend a district school or program. Additionally, the statement speaks to a recognition of a
diversity of abilities, and the need to address this diversity. While the MVUSD does not have a
vision statement, it does have a set of core values; those core values are Diversity, Bringing out
the full potential of all student and staff, Integrity, Fiscal responsibility, Parental support and
involvement and lastly, Professionalism. These terms have been operationalized by the district as
guiding principles for strategic planning and the Local Control Accountability Plan (LCAP) that
outlines key goals and metrics for the district.
Organizational Performance Status
The Mission Valley Unified School District has not engaged in any formal examination
of the capacity of teachers to identify and refer students suspected of having anxiety or
depression for evaluation. In recent history, the district has not instituted any formal or
coordinated actions designed to increase the skills of the teaching staff in the area of mental
health at the secondary level. There have been small pockets of independent discussions among
school-based mental health counselors and teachers; however, those conversations tend to be
infrequent, limited in scope and reactive; most commonly in response to an acute and immediate
situation.
An examination of the factors that influence a teacher’s ability to identify and refer
students with anxiety and depression for evaluation is in order to assess the current collective
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
14
ability of school staff to meet their stakeholder goal. The investigation of the teacher related
factors should include the organizational structures, motivation and the knowledge and skills of
the teachers and the organization.
Related Literature
Two legislative initiatives have played a major role in altering the mental health
landscape. The passage of the Affordable Care Act (ACA) in 2010 sought to increase the
accessibility of health coverage for all Americans (Patient Protection and Affordable Care Act,
2010). In addition to increasing access to general health coverage, the Affordable Care Act
included funding provisions for the establishment of school based health centers and the
streamlining of mental health services for youth (Keeton, Soleimanpour, & Brindis, 2012). While
the Affordable Care Act allocated financial resources in an attempt to meet the demand for
mental health services, it did not address underlying structural challenges like geographic
disparity and providing adequate training for providers and educators. The second legislative
initiative, the Every Student Succeeds Act of 2015 (ESSA), provided a remedy for some of the
gaps in the Affordable Care Act. The Every Student Succeeds Act, the follow-up to No Child
Left Behind, provided funding for training of educators in the area of mental health and paved
the way for public-private partnerships between educational institutions and health care
providers to address access and geographic challenges (Foxhall, 2016).
The ACA and ESSA represent a necessary shift in recognizing the role educational
institutions play in addressing the mental health needs of students. Educators can play an
important role in the identification and evaluation of students with mental illness. The legislative
emphasis on teacher training regarding mental illness is even more critical to anxiety and
depression in light of the non-externalizing nature of anxiety and depression. While externalizing
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
15
disorders like ADHD generally have symptoms like impulsivity, verbal outbursts and class
disruption that are more easily detectable, anxiety and depression manifest in symptoms like
sadness, being withdrawn and loss of appetite which are not disruptive and do not command the
attention of teachers (Cunningham & Suldo, 2014).
Anxiety and depression are under-identified due to their non-externalizing nature. A
study of 26 fourth and fifth grade teachers in two schools in an urban school district found that
teachers properly identified 50% of the students with depression and 40.7% of the students with
anxiety (Cunningham & Suldo, 2014). Papandrea and Winefield (2011) examined teachers’
perceptions related to the causality of the disparity in identification of non-externalizing mental
disorders. They surveyed 156 secondary teachers in Southern Australia and reported the 95% of
the teachers believed it was their responsibility to identify students with non-externalizing mental
illness, however, only 10% felt that they were capable of doing so. Further, 71% of the teachers
in the survey believed they were incapable of identifying students suspected of having anxiety or
depression due to lack of training. The inability to properly identify students with non-
externalizing disorders can lead to a delay in identification (Valdez, Lambert, & Ialongo, 2011)
which delays treatment and increase negative outcomes for students with anxiety or depression
(Suldo, Gormley, DuPaul, & Anderson-Butcher, 2013).
Organizational Performance Goal for Project Site
The organizational performance goal for the Mission Valley Unified School District is
that 100% of teachers will be able to identify and refer students with anxiety or depression for
evaluation by the end of the spring semester of the 2016-2017 school year. This goal aligns with
the district’s mission statement that aims to ensure “students of all ages and abilities are prepared
to succeed in an evolving world.” Starting in 2010, the district began to take a more proactive
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
16
approach in addressing the needs of student mental health. The first steps in this endeavor came
with the formation of a Mental Health Task Force. The Mental Health Task Force met for two
years before disbanding due to a lack of dedicated leadership. When the task force was
disbanded, the district began the process of developing a mental health support program that was
implemented in the fall of the 2012-2013 school year. The mental health support program was
named the Wellness Initiative and was only implemented at a minimal level at the elementary
school sites. Over time, the district has come to recognize the need to provide mental health
support to secondary students, and more specifically, to high school students. As a result of this
recognition, the performance goal was established.
Description of the Stakeholder Groups
The stakeholder groups directly contributing and benefiting from the completion of the
organizational goal are teachers, students, administrators and academic counselors. Teachers
contribute to the achievement of the goal by providing daily content instruction to the students.
Teachers are the primary point of contact with students and are uniquely situated to ensure
students are learning and provide remediation and intervention strategies when they are not
learning. Students contribute to the overall goal by engaging in activates necessary to the
learning process. When students are able to learn in a safe and consistent environment, they
perform better and will have greater post-high school options. When the global organizational
goal is met, students will benefit by having the ability to avail themselves of activities that will
increase their lifelong success after high school. Administrators provide overall direction to the
school community and enable the school staff to fulfil their job tasks. School administrators also
support training opportunities for teachers to increase organizational capacity. Lastly, school
counselors are tasked with tracking student progress toward graduation and exploration of post-
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
17
high school opportunities. Counselors meet with students to develop and maintain four-year
plans; these plans set individual goals for each student. Stakeholder groups’ performance goals
are shown in Table 1.
Table 1
Stakeholder Goals
Organizational Mission
The mission of the Mission Valley Unified School District is to ensure students of all ages and
abilities are prepared to succeed in an evolving world.
Organizational Performance Goal
By June 2017, 100% of teachers will be able to identify and refer students with anxiety or
depression for evaluation.
Teachers Students Administrators Counselors
By June 2017,
teachers will be able
to refer students for
assessment for
possible anxiety
and/or depression.
By June 2017, all
students will be able
to name campus
based support
programs for anxiety
and/or depression
By June 2017,
administrators will
train all teachers how
to refer students
suspected of having
anxiety and/or
depression for
assessment
By June 2017,
counselors will
participate in Student
Assistance Team that
will manage the
assessment process of
students suspected of
having anxiety or
depression.
Stakeholder Group for the Study
While the joint efforts of all stakeholders will contribute to the achievement of the
organizational mission, it is important to evaluate where the Mission Valley Unified School
District (MVUSD) staff members are currently with regard to their performance goal. Therefore,
the stakeholders of focus for this study are all MVUSD teachers at the two comprehensive high
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
18
schools. The stakeholders’ goal is that by the end of the Spring Semester of the 2016-2017
school year, 100% of teachers will be able to identify and refer students with anxiety and/or
depression for evaluation. Referral procedures include identification of students with possible
anxiety or depression, ability to list the referral procedures and capacity to name campus based
interventions. Failure to accomplish this goal will lead to continued negative student outcomes.
Negative student outcomes will lead to decreased attendance and lower grades, which will
adversely impact the MVUSD’s ability to achieve its overall organizational mission.
Purpose of the Project and Questions
The purpose of this project is to conduct a gap analysis to examine the knowledge,
motivation and organizational elements that prevent teachers from being able to identify and
refer students with anxiety or depression for evaluation. The analysis began by generating a list
of possible or assumed interfering elements and then by examining these systematically to focus
on actual or validated interfering elements. While a complete gap analysis would focus on all
stakeholders, for practical purposes the stakeholder to be focused on in this analysis is the high
school teaching staff at the Mission Valley Unified School District.
As such, the questions that guide this study are the following:
1. What are the knowledge, motivation, and organizational elements that promote or
inhibit a teacher’s ability to identify students with anxiety or depression?
2. What are the knowledge and skills, motivation, and organizational elements that
promote or inhibit a teacher’s ability to refer students with anxiety or depression for
evaluation?
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
19
Methodology and Framework for Project
This study utilizes a modified version of the Clark and Estes (2008) gap analysis. The
Clark and Estes model serves as a foundation that provides a systemic evaluation of the goal of
the organization and identification of actual performance levels as measured against preferred
performance levels. Assumed interfering elements were generated based on personal knowledge
and related literature. Surveys, interviews, document analysis, and literature reviews will be
collected and evaluated. Research-based solutions will be recommended and evaluated in a
comprehensive manner.
Organization of the Dissertation
This dissertation is organized into five chapters. Introduced in this chapter is the
organizational context, stakeholders that are the focus of the study and organizational goals that
frame the project. The second chapter explores relevant literature as it relates to mental illness
overall, youth related mental illness and challenges to effectively addressing youth related
mental illness. The second chapter also examines the role the knowledge, motivation and
organizational factors as they relate to the stakeholder group. Chapter 3 frames the
methodological considerations in this study; including data collection methods, participants,
sampling criteria and ethical considerations. Results, findings and analysis of data collection
methods are in Chapter 4 and Chapter 5 provides a discussion of findings and results as well as a
comprehensive package of solutions.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
20
CHAPTER 2
REVIEW OF LITERATURE
This chapter examines the relevant literature regarding the nature of students with mental
illness in a school setting leading to the emergence of the role of teachers in the identification
and referral process for evaluation of students with anxiety and/or depression. The first section
will examine the historical treatment of students with mental illness in schools. Next is an
examination of the impact of youth mental illness. Following, is a discussion of emerging trends
related to the prevalence of school age youth with a mental illness diagnosis. Finally, the chapter
concludes with an analysis of the capacity of teachers to identify students with anxiety and/or
depression and refer them for evaluation through the lens of teacher knowledge and motivation
as well as the school’s organizational structure utilizing a the Clark and Estes (2008) gap
analysis approach.
History of Youth Mental Illness
Perception of Mental Illness
Stigma of mental illness is a barrier to effective mental health interventions. The stigma
associated with youth mental illness may be a factor which inhibits mental health professionals’
ability to effectively diagnose and treat students (Maag & Katsiyannis, 2010). Stigma can be
such an influential force that it was identified by parents as the single greatest deterrent to
seeking treatment for their children. In a study seeking to understand barriers to treatment for
students with mental illness, 74% of parents who stated they were concerned about their child’s
mental health did not seek treatment for their child and identified a fear of stigma as a reason for
not doing so (Ohan, Seward, Stallman, Bayliss, & Sanders, 2015). Ohan et al. (2015) went on to
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
21
note that parents believed their child would be “singled out by teachers as ‘not normal’” if their
student were to be diagnosed with a mental illness (p. 292).
In addition to general stigma, those with mental illness are perceived as having an
increased tendency towards violence. An examination of adult perceptions involving the
evaluation of vignettes describing depression in adults and youth found that the youth described
in the vignettes were more likely to be judged as violent (Perry, Pescosolido, Martin, McLeod, &
Jensen, 2007). Perry et al. (2007) also found that respondents were more likely to say “the way
he or she was raised” (p. 633) as a cause of depression for youth (81%) than adults (46%).
Further, the view of those with mental illness having violent tendencies is so strong, a study of
1,393 parents found that respondents reported an increased desire for their children to avoid any
social interaction with other children whom may have symptoms of depression as the parents
perceived children with depression to have violent tendencies (Martin, Pescosolido, Olafsdottir,
& McLeod, 2007).
While stigma of mental illness is quite pervasive and continues to inhibit effective
intervention strategies, frameworks exist to de-stigmatize mental illness. A comprehensive study
that evaluated 18 school-based mental health education programs across Canada found that
programs that included speakers whom had successfully dealt with their mental illness sharing a
message focused on recovery decreased negative stereotypes of the mentally ill (Chen, Koller,
Krupa, & Stuart, 2016). Potvin-Boucher, Szumilas, Sheikh, and Kutcher (2015) examined the
effect of integrating a literature based mental health education model into high school
curriculums and found that students had decreased negative views of peers with mental illness as
a result.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
22
Prevalence
Mental illness is prevalent in school aged youth. Up to 22% of all persons under the age
of 18 experience some type of diagnosable mental health disorder (Maag & Katsiyannis, 2010).
Of youth with an identified mental illness, the largest category of diagnosis are mood disorders,
specifically anxiety at 31.9% and depression at 14.3% (Merikangas et al., 2010). Further
compounding the impact of mental illness on young people, 40% of youth with a single
diagnosis will develop a secondary diagnosis as well (Perou et al., 2013). For example, it is quite
common for anxiety and depression to occur together. The average of onset for mental illness in
youth ranges from 6 to 13 years of age, additionally the earlier the age of onset, the more severe
the symptoms tend to be (McGorry, Purcell, Goldstone, & Amminger, 2011).
In the last twenty-five years, the occurrence of youth with mental illness has been
increasing. Between 1995 and 2010 mental illness diagnosis have increased at a higher rate for
youth under the age of 18 than for adults; further during the same time frame, visits for
psychotherapy have increased by one-third for school-aged populations while psychotherapy
visits for adults have decreased over the same time period (Olfson, Blanco, Wang, Laje, &
Correll, 2014). The rate of youth with a conduct-related disorder has doubled from 1974 to 1999
and the rate of emotionally related disorders has risen by 60% in youth during the same time
frame (Collishaw, Maughan, Goodman, & Pickles, 2004). Currently, up to 24% of youth under
the age of 12 have developed anxiety related symptoms to such a degree as to interfere with their
daily functioning (Headley & Campbell, 2013). Some research has suggested the upsurge in
mood related disorders may be related to an increased and more rigorous course of study
experienced by school aged youth (Suldo et al., 2013). Other research has attributed the rise to
better diagnostic instruments and procedures (Delaney & Smith, 2012). Irrespective of causality,
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
23
only approximately 38% of youth receive treatment for their mental health disorder (Suldo et al.,
2013). A study of nearly 20,000 youth found visiting a school counselor as the second most
common mental illness treatment option for youth. That same study concluded that the prevailing
need for mental health treatment significantly exceeds the ability of the currently existing
infrastructure to provide the required services (Winstanley et al., 2012).
A variety of intervention strategies are being utilized to address the increasing numbers
of youth with mental illness. In an editorial piece for the Journal of Psychology, Albers, Glover,
and Kratochwill (2007) argued for universal screening of all students as a method to identify
youth at risk for mental illness and target early intervention. Technology is also being utilized as
a tool for engaging youth with mental illness. An online mental health promotion site called
ReachOut.com, primarily aimed at Australian youth between the ages of 15 and 24, was the
subject of a qualitative study that found that 71% of visitors felt that ReachOut.com helped them
become more informed about their mental illness and more likely to seek treatment (Collin et al.,
2011). While identification tools and intervention strategies are important, a meta-analysis of 14
programs around the United States designed to address youth mental illness noted that the
greatest outcomes for youth were found in programs that had integrated identification and
intervention strategies into their models (Weisz, Sandler, Durlak, & Anton, 2005).
Mental Illness on Youth and Society
Educational Impact
Mental illness has a negative impact on student related educational outcomes. Students
with mental illness are less likely to graduate high school and less likely to enroll in college
compared to students without a mental health diagnosis (McLeod & Kaiser, 2013). A twenty-one
year longitudinal study conducted by Fergusson and Woodward (2002) found that students that
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
24
had developed depression in their adolescent years had an increased rate of dropping out and
lower rates of post-high school educational endeavors. Similarly, Duchesne, Vitaro, Larose, and
Tremblay (2008) concluded that the existence of an anxiety diagnosis in elementary school had
predictive value in determining if a student would complete high school. In addition to adverse
graduation and college outcomes, the presence of a mental health diagnosis is negatively
correlated with grade point average (McLeod et al., 2012). Furthermore, students with mental
illness also experience an increased level of negative school behaviors to a level that interferes
with educational attainment. In their investigation of first grade students, Valdez et al. (2011)
found a positive correlation between students with Major Depressive Disorder and Conduct
Disorder and these students were more likely to have poor academic performance than typical
peers.
Crime
Youth with a mental health diagnosis are at an increased risk of engaging in criminal
activity. Youth with a mental health diagnosis engage in crime at a higher rate than youth
without mental illness (Coker et al., 2014). Coker et al. (2014) went on to find youth criminal
activity increased as the number of diagnosis increased. As a result of increased criminal activity,
incarcerated individuals have a rate of mental illness which is 10 times that of the general
population (Brown, Cullen, Kooyman, & Forrester, 2015). Further, 70% of incarcerated youth
have at least one mental health diagnosis (DeSocio & Hootman, 2004). Exacerbating the rate of
incarceration of youth with mental illness is the high incidence of substance abuse among school
age populations (Carrà et al., 2015).
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25
Economic Impact
The cost of treatment of mental illness, as well as loss of productivity has an impact on
the economy. Treatment of adolescent mental illness has an annual cost of $247 billion in the
United States (Perou et al., 2013), with the individual cost of treatment over the course of the life
of a single student as high as $250,000 (DeSocio & Hootman, 2004). Not only does the direct
treatment cost have an impact on the economy, it is estimated the loss of productivity exceeds $2
million for a single individual with mental illness (DeSocio & Hootman, 2004).
Individuals with mental illness are more likely to encounter events that increase their
likelihood of living in poverty. A study comparing three different data sets that included over
20,000 under the age of 18 found that youth with mental illness were twice as likely as typical
peers to be fired from a job later in life and three times as likely to be homeless at some point in
life (Collishaw et al., 2004). In addition to homelessness and unemployment, criminal behavior
and drug use pose barriers to economic security. In their critique of current policies related to the
social contextual factors of mental illness, Draine, Salzer, Culhane, and Hadley (2002) argued
that an increased incarceration rate and higher instance of drug usage by the mentally ill created
significant roadblocks to economic independence. This assertion by Draine et al. (2002) was
supported by a study that analyzed the National Survey on Drug Use and Health in the years
2009 and 2010 and included over 75,000 adults in the United States. This study concluded that
adults with mental illness were twice as likely to live below the poverty line than adults without
mental illness (Luciano, Nicholson, & Meara, 2014).
Suicide
The presence of mental illness increases the likelihood of suicide in youth. The greatest
risk factor for suicide is the presence of a mental health disorder (Kutcher & Szumilas, 2008).
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26
Suicide is a serious concern for youth as fatalities by suicide is the second leading cause of death
among youth ages 12 to 17 (Perou et al., 2013). The role of early intervention is given greater
importance in light of evidence that suggests prompt school-based intervention and treatment
may reduce the incidence of suicide among youth. In an examination of Canadian strategies to
reduce the incidence of suicide, Kutcher and Szumilas (2008) noted that school-based screening
for mental illness and “gatekeeper” (p. 283) training of teachers so that they can act as early
identifiers as two key strategies for the reduction of suicide.
Mental illness is a complex health issue with a wide variety of implications for those
afflicted. There are a wide range of negative consequences that have physical, educational and
economic repercussions for youth with mental illness. While there are societal roadblocks to
effectively dealing with youth mental illness, school systems are not immune to structural,
financial and policy challenges that may complicate the path to creating effective strategies for
meaningful interventions.
Emerging Trends of Mental Illness Related to a School Context
Teacher Training Programs
Teacher training programs lack specific curriculum to increase a teacher’s ability to
identify and understand mental illness. In general, research has been silent regarding the
evaluation of a teacher’s ability to identify and refer students with mental illness for evaluation
(Headley & Campbell, 2013). Further, Headley and Campbell (2013) surveyed 315 primary
grade teachers from Australia and went on to attribute the lack of identification and referral of
students with mental illness for evaluation to the absence of meaningful professional
development for teachers. Additionally, when teachers do recognize some characteristics of
mental illness, the deficiency of functional systems prevents teachers from making referrals for
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
27
evaluation. Gowers, Thomas, and Deeley (2004) surveyed 291 primary teachers in England in an
effort to better understand factors associated with the identification and referral of students with
mental illness and found 95% of teachers surveyed reported the adequacy of training for
managing students with mental illness as either “inadequate” or “fairly inadequate” and 56% of
teachers rated their confidence in understanding mental illness as “inadequate” or “fairly
inadequate”. Ill-prepared teachers may result in missed opportunities for meaningful intervention
as 43% of students exhibit some symptoms of anxiety or depression at school (DeSocio &
Hootman, 2004) and teachers are uniquely positioned to recognize mental illness in students.
Current Capacity and Structural Constraints of School Systems
The traditional view of schools as learning institutions with a primary focus of
educational activities may inhibit structures to support mental health of students. School settings
are unique in their compulsory nature as students spend a great deal of time at school. A
literature review conducted by Malti and Noam (2008) noted that students are more likely to
access a service that is provided within their school context. However, a policy analysis of
school-based mental health services concluded that schools are still viewed by many as an
inappropriate context for mental health interventions (Adelman & Taylor, 2000).
As a result of prevailing attitudes about the role of mental health interventions in a school
setting, school systems lack the structures to effectively coordinate services to address students
with mental illness. Mental health programs tend to be viewed as supplementary in nature which
results in an ad hoc, and uncoordinated, delivery structure (Adelman & Taylor, 2000). The
prevailing view of mental health services has resulted in a condition where front line school staff
lack the time, resources and administrative support to properly address the increasing and diverse
nature of student needs (DeSocio & Hootman, 2004).
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Funding Constraints
Current funding structures do not reflect an importance of mental health programs.
School systems focus funding streams on activities which are considered “educational” in nature,
as a result, many schools have marginalized mental health support programs (Adelman & Taylor,
2000). School systems are often hesitant to develop comprehensive mental health systems of
support due to the perceived high cost of mental health services (Brener et al., 2007). Further,
Brener et al. (2007) also noted that as a result of the perceived costs of mental health services,
schools often utilize grant funding and third-party funders as a revenue source; this type of
funding results in fragmented and uncoordinated service delivery models. Additionally, third
party funding cycles and requirements are often at odds with the bureaucratic constraints present
in school systems (Guerra & Williams, 2003). The collective challenges associated with the
allocation of monetary supports has resulted in a paradigm where mental health programs are
frequently among the first services to be eliminated when schools are faced with financial
hardships (Adelman & Taylor, 2000).
Policy Constraints
The incoherent nature of educational policies relative to mental health programs is a
barrier to effective school-based mental health programs. Federal regulations related to youth
mental health can be found in the Affordable Care Act of 2010, Section 504 of the Individuals
with Disabilities Act, Social Security Act and Public Health Service Act (Maag & Katsiyannis,
2010). Much like funding policies, the piecemeal nature of legislative policies associated with
mental health services has contributed to the perception of mental health programs as
dispensable (Adelman & Taylor, 2000). While the government has extensively developed
learning frameworks such as Common Core, Next Generation Science Standards and College
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
29
and Career Readiness Standards, no similar effort has taken place for educationally related
mental health services. These standards establish a set of desired outcomes and suggest cohesive
methodologies that can be systemically applied to all educational contexts. National and state
level standards create a consistent model for educators and can contribute to equalized outcomes
for students. By contrast, mental health policies have not benefitted from a move towards
standardization as there has been no systemic effort to codify and distribute best practices
(Brener et al., 2007). Educational policy has not reflected the important relationship between
emotional well-being and educational outcomes (Sznitman, Reisel, & Romer, 2011). In 2000,
18.9% of states had adopted policies requiring school systems to have personnel overseeing or
coordinating mental health programs; however, that number had dropped to less than 10% by
2006 (Brener et al., 2007). The trend of reduced policies supporting mental health programs is
troubling. Vinciullo and Bradley (2009) conducted a correlation study utilizing data from three
national databases and their results indicated that students in states with policies that promote
emotional health have higher achievement scores and increased graduation rates.
School-Based Mental Health
In light of compulsory school attendance, school-based mental health programs can be
effective in increasing access to care for students. An analysis of a national survey of 7
th
through
12
th
graders from 132 schools in the United States found that schools that offer mental health
services increase the likelihood of students accessing care for mental illness when compared to
school sites without such services (Slade, 2002). DeSocio and Hootman (2004) conducted a
review of literature spanning ten years, from 1993 to 2003 and noted the presence of a health
provider on campus increased the identification of symptoms at an earlier age. While school-
based mental health services increase access and usage, only 30% of school districts nationally
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
30
have such a center (Brener et al., 2007). In light of a finding which indicated 70% of youth
receiving care for mental illness reported their primary intervention occurred at school (DeSocio
& Hootman, 2004), school-based mental health services can play a vital role for increasing
access to services for all students as well as traditionally underserved populations which may
lack traditional pathways to health care (Robertson et al., 2011).
School-based mental health programs can be effective in improving educationally related
outcomes for students. In their manuscript investigating the outcomes of school-based mental
health programs, Suldo et al. (2013) concluded that schools experienced a reduction in
behaviorally based suspensions, coupled with an increase in attendance after implementation of
school-based mental health services. In addition to positive behavioral and attendance outcomes,
students who participated in a school-base mental health program experienced academic gains
over those student not involved in a school-based mental health program (Dix, Slee, Lawson, &
Keeves, 2012). Further, the School Health Policies and Program Study, a national study of 445
school districts representing all 50 states found that students were more likely to access academic
support services after participating in mental health programs (Brener et al., 2007).
Clark and Estes Framework
The conceptual framework that is utilized to examine possible causes and solutions to a
teacher’s ability to identify and refer students with anxiety or depression for evaluation is the
Clark and Estes (2008) Gap Analysis model. The Gap Analysis model identifies performance
gaps of stakeholder groups as they relate to a desired state of function relative to a goal.
Performance is appraised through the lens of knowledge, motivation and organizational
structures that exist for a stakeholder group. The knowledge, motivation and organizational
factors that influence performance will be discussed and evaluated through a variety of methods
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
31
including a review of related literature, surveys, interviews and an examination of relevant
artifacts.
Stakeholder Knowledge and Motivation Influences
Knowledge and Skills
An important factor in achieving the goal of having all teachers referring students for
assessment for possible anxiety and/or depression is ensuring teachers responsible for carrying
out this task poses the requisite knowledge. The following discussion will focus on the
knowledge related factors teachers should have in order to be successful in achieving the goal of
referring students for assessment. In this discussion, I will examine existing literature regarding
the various types of knowledge, as well as how the different types of knowledge relate to the
achievement of the stated goal.
Knowledge types. In evaluating performance gaps, Clark and Estes (2008) identify
knowledge related factors as having a role in increasing performance. To that end, there are three
knowledge types that this section will focus on in relation to their importance in achieving the
stakeholder goal; the first of these knowledge types is declarative knowledge. Declarative
knowledge relates to the factual or conceptual pieces of a person’s understanding; or as Aguinis
and Kraiger (2009) describe, declarative knowledge is the “what” of knowing. From a
hierarchical perspective, declarative knowledge exists among the lesser complex tasks according
to Krathwohl’s (2002) revision of Bloom’s Taxonomy. The second knowledge type discussed in
this section is procedural knowledge. Where declarative knowledge is the “what” of knowing,
procedural knowledge is the “how” of knowing (Aguinis & Kraiger, 2009). Procedural
knowledge regarding tasks is a useful tool in increasing automaticity and thereby reducing
extraneous cognitive load (Spector, 2015). The last knowledge construct addressed in this section
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32
is metacognition. Metacognition is the reflective process a learner engages in to evaluate and
monitor their own thinking (Bower & Hilgard, 1981) and has been shown to have a positive
effect on learning outcomes (Baker, 2006).
Stakeholder knowledge influences. Following is a discussion of literature that is
relevant to the achievement of the stakeholder goal of teachers being able to refer students for
assessment for possible anxiety and/or depression. Relevant research is considered as it relates to
each of the distinct knowledge constructs. As identified in Table 2, there are declarative,
procedural and metacognitive factors that influence various facets of stakeholder performance.
Declarative knowledge influences. An initial step in the achievement of the stakeholder
goal is ensuring teachers have the required knowledge to identify students with anxiety or
depression. A quantitative study of 52 teachers at a middle school in the Midwestern United
States attempted to discern the rate that teachers could properly identify students displaying
symptoms of depression. This study found that teachers successfully identified students with
depression symptoms 5% of the time (Auger, 2004). A study evaluating the skills of teachers in
the area of identification found that 50% of teachers surveyed believed they taught students with
mental health issues almost every day, however 98% those same teachers stated they had little or
no knowledge regarding signs and symptoms of students with mental health problems (Gowers
et al., 2004). According to the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (2013), anxiety presents with symptoms such as gastrointestinal
discomfort, irritability, restlessness and edginess and depression symptoms include weight loss,
decreased activity, mood swings and lack of concentration.
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33
Table 2
Knowledge Factors Related to Stakeholder Goals
Organizational Mission
The mission of the Mission Valley Unified School District is to ensure students of all ages
and abilities are prepared to succeed in an evolving world.
Organizational Performance Goal
By June 2017, 100% of teachers will be able to identify and refer students with anxiety or
depression for evaluation.
Assumed Knowledge Influence Knowledge Influence Assessment
Conceptual
Teachers need to have the knowledge of
what support and assessment options are
available for students with anxiety and/or
depression
Teaching staff asked to name the support
programs available for students with
anxiety and/or depression
Teachers do not know the symptoms of
anxiety and/or depression in students
Teaching staff asked to describe the
characteristics of a student with anxiety
and/or depression
Procedural
Teachers need to how to refer a student for
assessment for qualification for services.
Teaching staff asked to design a flow
chart demonstrating the referral process
for assessment.
Metacognitive
Teachers do not know how to evaluate their
effectiveness in engaging in the referral
process
Teachers asked to reflect on their success
in utilizing the referral process
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34
In addition to a teacher’s knowledge of symptoms of anxiety or depression among their
students, having knowledge of what supports exist within the school community can serve to
increase referral to appropriate supports. When medical professionals became aware of the
availability of support options, they were more likely to make a referral for support to mothers
displaying signs of maternal depression (Agapidaki et al., 2014). To further highlight the role of
knowledge regarding services for students with anxiety or depression in the referral process,
Vieira, Gadelha, Moriyama, Bressan, and Bordin (2014) demonstrated that teachers with
identification skills and knowledge of support programs were more likely to make a referral for
evaluation than teachers with only the ability to identify symptoms.
Procedural knowledge influences. Coupled with the ability to recognize the signs of
anxiety or depression and the awareness of support structures available, stakeholders need the
procedural knowledge how to connect students with relevant resources to achieve their goal.
Headley and Campbell (2013) provide evidence for the importance of procedural knowledge;
they found that teachers with a strong ability to identify students with mental health problems
were less likely to acknowledge symptoms when they lacked information regarding referral
procedures. It has been shown that teachers who lack a firm understanding of a mental health
referral process have decreased referral rates due to mistrust and a belief that students might take
advantage of the referral procedures (Guerra & Williams, 2003). The absence of a clearly
articulated referral process puts teachers in the role of gatekeepers and can have a negative
impact on connecting students to much needed services as Kutcher and Szumilas (2008) found as
part of their analysis of suicide rates and risk factors of Canadian youth ages 15-19.
Metacognitive knowledge influences. The last knowledge factor to be considered in
relation to the achievement of the stakeholder goal is metacognition. Metacognition plays an
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
35
important role in self-regulation (Bower & Hilgard, 1981) and engaging in metacognitive
practices can increase learning (Aguinis & Kraiger, 2009). The act of engaging in metacognitive
reflection can have a significant impact on a teacher’s rate of referral for evaluation of students
with anxiety or depression. Lee (2014) found that metacognitive processes on the part of teachers
accounted for 58% of the variance in referral rates for the evaluation of students suspected of
having attention deficit/hyperactivity disorder (ADHD). When teachers do not engage in
reflective practices, they begin to feel unsure of their practices and question their abilities to
effectively carry out their duties (Headley & Campbell, 2013). A key consideration in facilitating
the metacognitive process for teachers is their perception of significant time restraints; for
example Ekornes (2015) found that teachers identified a lack of time as a main reason for not
engaging in reflective activities.
Motivation
While knowledge offers a strong foundation for the achievement of the stakeholder goal,
motivational factors provide the engine that moves the knowledge towards action. The choice to
expend effort and persist is a key indicator of motivation (Clark & Estes, 2008) and an aspect of
accomplishing specific outcomes. Mayer (2010) defines motivation as “an internal state that
initiates and maintains goal directed behavior” (p. 39). Within the context of Mayer’s definition,
this section will explore the role of two motivational factors, self-efficacy and expectancy value,
each followed by a discussion of how the motivational factor relates to the goal of teachers
referring students with anxiety and/or depression for evaluation.
Self-efficacy theory. Vital to the completion of a task or goal is the theory of self-
efficacy. Self-efficacy can be defined as the belief that one “can produce desired effects and
forestall undesired ones by their actions” (Bandura, 2000, p. 75). A literature review that
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
36
examined the relationship between a learner’s sense of self-efficacy and learning outcomes
concluded there was a positive correlation between the learner’s self-efficacy and the learners
ability to achieve learning targets (Wigfield & Cambria, 2010). Additionally, an individual’s
sense of self-efficacy can increase the level of persistence in a challenging task which leads to an
increased likelihood of task completion (Grossman & Salas, 2011).
There are a number of factors that contribute to an individual’s sense of self-efficacy.
Rueda (2011) identified prior knowledge about a task or concept, meaningful feedback and prior
experience with success or failure as a few of the influences on self-efficacy. Further, purposeful
training has shown to increase and sustain self-efficacy for up to twelve months following the
exposure to the professional development (Aguinis & Kraiger, 2009). Lastly, Denler, Wolters,
and Benzon (2006) identified goal setting as a contributing element to increasing self-efficacy, as
the identification of goals increases the expectation of successful outcomes.
Teacher self-efficacy. Self-efficacy is an important motivational construct related to the
achievement of the stakeholder goal, as noted in Table 3. Teachers must believe they are capable
of identifying students with anxiety and/or depression in order to effectively refer students for
assessment. While there is a lack of research that directly evaluates the role of teacher self-
efficacy as it relates to teacher referrals for evaluation of anxiety or depression, there does exist
ample studies that examine the value of self-efficacy in other referral contexts. In an examination
of the relationship between self-efficacy of teachers and their rate of referral to a Student Study
Team (SST) for behavioral and academic interventions, Pas, Bradshaw, and Hershfeldt (2012)
hypothesized teachers with low self-efficacy would be more likely to make referrals to an SST
due their low belief in their own ability to assist students. However, contradictory to their
hypothesis, it was discovered that low self-efficacy actually resulted in fewer referrals. An
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
37
additional study to evaluate the role of self-efficacy and referral rates examined teachers in South
Korea and the United States and determined that low teacher self-efficacy had low levels of
referral for evaluation for Attention-deficit/Hyperactivity Disorder (Lee, 2014).
Table 3
Motivational Influences on Stakeholder Goals
Organizational Mission
The mission of the Mission Valley Unified School District is to ensure students of all ages
and abilities are prepared to succeed in an evolving world.
Organizational Performance Goal
By June 2017, 100% of teachers will be able to identify and refer students with anxiety or
depression for evaluation.
Assumed Motivation Influences How Will It Be Assessed?
Self-Efficacy
Teachers need to believe they are
capable of effectively identifying
students with anxiety and/or depression
Survey Items:
“I believe it is my responsibility to look for
students who may have anxiety or depression.”
(strongly disagree – strongly agree).
“I believe I am qualified to address the needs
of students with anxiety or depression.”
(strongly disagree – strongly agree).
Interview Item:
“How do feel about your ability to recognized
the signs of anxiety and depression in
students?”
Expectancy Value
Teachers need to see the value in
referring students for evaluation.
Survey Item:
“It is important for me to refer students
identified with anxiety and/or depression for
evaluation.” (very important – not important)
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
38
While low teacher self-efficacy is correlated to low referral rates, prior experience and
training can increase self-efficacy. In an examination of clergy, Hedman (2013) found that
priests with prior experience with mental illness had greater self-efficacy and increased levels of
referrals to mental health agencies for their parishioners. Hedman’s findings regarding clergy
highlight the need to have effective training programs to compensate for teachers with limited
prior experience with anxiety or depression. A comprehensive training program was identified as
a key factor in increasing self-efficacy in pediatricians. After participating in awareness
activities, pediatricians demonstrated higher rates of identification and referral for maternal
depression in new mothers (Agapidaki et al., 2013; Agapidaki et al., 2014). Additionally,
increased training for child psychiatry interns showed increases in self-efficacy and, in turn,
increased levels referral to drug treatment programs (Schram et al., 2015).
Expectancy-value. The construct of expectancy-value has multiple facets. Eccles and
Wigfield (2002) identify two key questions that compose the essence of expectancy-value: “Can
I do the task?” and “do I want to do the task?” Within these two questions lies a sub-set of ideas
that determine the expectancy-value of an individual. It has been argued that one’s belief
regarding their ability to do a task is similar to self-efficacy theory. Authors such as Wigfield and
Cambria (2010) make compelling arguments for a differentiation between beliefs in one’s ability
to engage in a task as conceptualized in expectancy-value and similarities to the main ideas of
self-efficacy. Pintrich (2003) claims that one’s expectancy-value regarding engaging in an
activity is a strong predictor of future action.
Expectancy-value is a contributor to learning outcomes. Student expectancy-value has
been identified as having predictive value relative to academic achievement, as well as
recognized as having a reciprocal relationship with learning outcomes (Wigfield & Cambria,
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
39
2010). In a business setting, workers with increased expectancy-value were shown to have
increased engagement in training and demonstrated higher degrees of transfer (McEnrue &
Groves, 2006). Contrasting the positive relationship between expectancy-value and learning,
environments which lack the underlying supporting factors of expectancy-value have shown
detrimental effects on learning outcomes (Eccles & Wigfield, 2002).
Teacher expectancy value. In addition to a teacher’s belief about their ability to identify
and refer a student with anxiety or depression for evaluation, teachers need to have the belief that
it is important to refer students for evaluation. Headley and Campbell (2013) surveyed 315
primary school teachers to examine their knowledge of, and ability to identify, anxiety and found
that even in instances where teachers have the ability to identify and acknowledge the
detrimental effects of anxiety, a low perception of the importance of referring a student for
evaluation was positively correlated to low referral rates. Given the variety of available
responses, including non-action, teachers make decisions as to which action to take based on
their internal ranking of the importance they have assigned to possible actions (Pas, Bradshaw,
Hershfeldt, & Leaf, 2010). In light of the findings by Pas et al. (2010), having teachers identify
the referral process as important is vital to the achievement of the stakeholder goal.
Training can increase the belief in the importance of an action. To illustrate the role of
training in increasing perceived importance, Agapidaki et al. (2014) conducted a study of
medical professionals to determine which factors contributed to the rate depressed patients were
referred to a mental health professional. They found that, although the medical professionals
initially identified the referral of depressive patients as important, the referral rate was low. After
training in identification and referral procedures, the rate of referral of patients by medical
professionals increased.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
40
Stakeholder Organizational Influences
An important factor in achieving the goal of having all teachers referring students for
assessment for possible anxiety and/or depression is ensuring teachers responsible for carrying
out this task are supported by the appropriate organizational structures. The following discussion
will focus on the organizational factors that should be present in order to be successful in
achieving the goal of referring students for assessment. In this discussion, I will examine existing
literature regarding the various aspects of organizational supports and systems, and how those
organizational supports and systems relate to the achievement of the stakeholder goal.
Following is a discussion of literature that is relevant to the achievement of the
stakeholder goal of teachers being able to refer students for assessment for possible anxiety
and/or depression. Relevant research is considered as it relates to each of the distinct
organizational constructs. As identified in Table 4, there are cultural setting and cultural model
influences that have an impact on stakeholder performance. A cultural setting refers to the
tangible and structural aspects of the environment while the cultural model speaks to the
underlying beliefs that are commonly held among the members of a community.
Cultural Setting Influences
A key component of successful organizations is the requirement that organizations ensure
employees have the necessary skills and tools to be successful (Hendry, 1996). In relation to the
achievement of the stakeholder goal, this study seeks to examine the role professional
development plays in relation to how teachers gain the knowledge and proficiency required to
identify the symptoms associated with anxiety and depression. Additionally, this study attempts
to understand how a coordinated professional development plan allows teachers to cultivate an
understanding of the referral process. The expectation of teachers to identify and refer students
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
41
with anxiety or depression is new and could be considered unreasonable without proper training.
A prerequisite for a successful change in behavior is the proper communication and allocation of
resources for those whom the change is expected (Moran & Brightman, 2000).
Table 4
Organizational Influences on Stakeholder Goals
Organizational Mission
The mission of the Mission Valley Unified School District is to ensure students of all ages
and abilities are prepared to succeed in an evolving world.
Organizational Performance Goal
By June 2017, 100% of teachers will be able to identify and refer students with anxiety or
depression for evaluation.
Assumed Organizational Influences Organizational Influence Assessment
Cultural Setting Influence #1
Teachers need professional development
needed to gain the necessary tools to
identify and refer for evaluation, a student
with anxiety and/or depression.
Survey or interview questions about
amount of professional development
teachers have received in the area of
identification and referral of students with
anxiety and/or depression, review of
professional development agendas.
Cultural Setting Influence #2
Teachers are not provided with a structure
and/or process for the referral of a student
suspected of having anxiety and/or
depression
Survey or interview questions about
teachers knowledge of the existence of a
process for the referral of students with
anxiety and/or depression, review of policy
and/or procedural manuals.
Teachers believe identifying and referring
students suspected of having anxiety or
depression should not be their
responsibility in light of their perception
that they are overwhelmed with their other
job duties
Survey or interview questions about
teachers perceptions of the value of
increasing their capacity in the area of
mental health initiatives.
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42
Proper training is desired by employees and it is the responsibility of management to
ensure it occurs. In a meta-analysis of compensation systems in the United States and the United
Kingdom, Reilly (2004) found employees valued meaningful and relevant training to the same
degree as a moderate increase in monetary compensation. When employees are provided with the
tools to be successful, they see it as a meaningful investment in their success. Further, it is the
responsibility of management to ensure training opportunities are afforded employees. The role
of the manager in the training process can increase the value employees place on the training
opportunity (Schneider, Brief, & Guzzo, 1996).
Another gap that may inhibit the achievement of the stakeholder goal is the degree to
which a clearly articulated process for the referral of a student suspected of having anxiety or
depression is in place. If a teacher is able to identify a student in need of evaluation, is there a
formalized methodology by which the teacher could utilize to have a mental health professional
assess the needs of the student? In addition to the operational aspects of the stakeholder goal, the
achievement of the goal may require a change in the core ideology of teachers in terms of their
beliefs about mental illness, and by extension, their behavior as it relates to the referral process.
Schneider et al. (1996) observed climate and behavior do not change by decree alone, rather
meaningful changes must be accompanied and supported by procedures. Not only is the
existence of procedures an important ingredient in the shaping of behavior (Krosgaard, Brodt, &
Whitener, 2002), but functional procedures can be an effective means of increasing a target
behavior (Anthony & Del Bueno, 1993).
Procedures must be thought out and supported by management. As procedures are being
developed, organizations should careful to ensure that “core work processes must be aligned with
organizational goals” (Moran & Brightman, 2000, p. 74). In the case of a process that facilitates
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43
the referral of a student for evaluation for anxiety or depression, the development of a system
that is efficient and allows for ease of use is a necessity. Further, as is the case for ensure proper
training, managers must take responsibility for the development, implementation and monitoring
of procedures to ensure the processes are facilitating the achievement of stakeholder goals
(Morrison & Milliken, 2000).
Cultural Model Influences
An assumed cultural model influence examined is the whether or not teachers at the
Mission Valley Unified School District believe identifying and referring students suspected of
having anxiety or depression should not be their responsibility in light of their perception that
they are overwhelmed with their other job duties. Teacher perceptions about workload may have
a negative impact on their career and willingness to engage in tasks they feel are “extra.” In a
study of 398 secondary school teachers, Torres (2016) found that 30% of the teachers who
viewed their workload as “unmanageable” left the teaching profession. By contrast, the same
study concluded that only 10% of teachers who believed their workload was “manageable” left
the teaching profession. A quantitative study of almost 2,000 public school teachers found that
as job stress increased in teachers, their willingness to take on tasks considered beyond basic job
functions decreased (Philipp & Kunter, 2013). A study conducted by Collie, Shapka, and Perry
(2012) mirrored the findings of Philipp and Kunter (2013) in their examination of 664 K-12
teachers and concluded that job stress was negatively correlated with a teacher’s willingness to
engage in social-emotional learning programs.
Summary
Anxiety and depression are serious mental illnesses that carry significant impact upon the
lives of youth dealing with them. The ramifications of youth suffering with anxiety or depression
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44
extend beyond negative educational outcomes as anxiety and depression can adversely impact
youth’s lives for the long term. Schools are uniquely positioned to be at the forefront of
identification and treatment of anxiety and depression. To that end, it is imperative that a
thoughtful examination of teacher related factors that promote or prohibit the identification and
referral for evaluation of youth with anxiety or depression be undertaken. Within the framework
of the Clark and Estes (2008) Gap Analysis model, the processes and instruments used to
validate the knowledge, motivational and organizational factors related to the achievement of the
stakeholder goal will be validated in Chapter 3.
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CHAPTER 3
METHODOLOGY
Purpose of the Project
This research study examined the knowledge, motivation and organizational factors that
promote, or inhibit, a teacher’s ability to identify and refer a student with anxiety or depression
for evaluation. As previously outlined, youth are beset with a host of negative consequences
when their mental illness is not properly diagnosed and treated. In light of the ideal nature of a
school campus as a context for identification and management of mental illness for youth, this
study is focused on a K-12 educational setting. Further, the daily interaction of teachers and
students is the ideal touchpoint for adults to be able to recognize the symptoms of students. It is
this touchpoint between teacher and student that serves as a focal point of examination for this
study.
Conceptual Framework
Maxwell (2013) explains that the conceptual framework provides grounding for a
research study. The conceptual framework contextualizes the problem of practice and research
questions within the larger picture of research design. Further, the conceptual framework is a
graphic that drives all aspects of research design. Figure 1 is a visual representation of my
research problem that examines the factors that promote or inhibit a teacher’s ability to identify
and refer a student suspected of having anxiety or depression for evaluation. This process
focuses on the main stakeholders, teachers, as noted by teachers being at the center of the
framework. There are two stages to the successful attainment of the goal by the stakeholders.
The stages are not as much sequential as they are interrelated. Stakeholders must be able to
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master identification factors (left side of Figure 1) as well as referral factors (right side of Figure
1) to achieve the stated goal.
Figure 1. Conceptual framework
Within the identification factors, the specific lenses of knowledge, motivation and
organizational influences will be examined. The research associated with identification factors
will focus on the teacher’s ability to recognize the symptoms of anxiety or depression, the self-
efficacy of teachers and professional development associated with the identification of students.
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47
The identification factors will be examined in terms of the degree to which teachers apply those
factors to students in their classes.
The second part of the framework seeks to establish what actions teachers engage in
when they do identify a student displaying the symptoms of anxiety or depression. The referral
factors are also grounded in the knowledge, motivation and organizational lenses. The referral
factors include a teacher’s knowledge of the process of referral and available supports, the
expectancy value of teachers in terms of their anticipated outcomes as well as the existence of
formalized support around a referral process. Additionally, it is important to recognize that
teacher resistance to new initiatives is also a referral factor.
The outcome of the entire framework is the evaluation of a student suspected of having
anxiety or depression. Ideally, teachers will: (1) have identification factors, (2) apply
identification factors to their students, (3) have the referral factors, and (4) apply the referral
factors to those students suspected of having anxiety or depression. Further, underlying this
process will be an examination of the degree to which teachers engage in a metacognitive
examination of their effectiveness in the identification and referral process. To operationalize the
conceptual framework, the following research questions are used to guide this study:
1. What are the knowledge, motivation, and organizational elements that promote or
inhibit a teacher’s ability to identify students with anxiety or depression?
2. What are the knowledge, motivation, and organizational elements that promote or
inhibit a teacher’s ability to refer students with anxiety or depression for evaluation?
Data Collection and Instrumentation
Surveys, interviews and inspection of documents and artifacts were utilized as data
collection for this mixed methods study in an attempt to address the research questions. The use
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48
of a survey, interviews and observations increased the validity of the findings of this study by
triangulating the data (Miles, Huberman, & Saldana, 2014). The stakeholder group that was the
focus of this study is high school teachers in the Mission Valley Unified School District
(pseudonym). The Mission Valley Unified School District (MVUSD) has two comprehensive
high schools and each of those schools has a teaching staff of roughly 90 teachers. The combined
teaching population of both schools comprised the population for all data collection methods.
Surveys were used to gain an overarching insight into the general factors outlined in the research
questions stated above. A survey provides a level of efficiency and, as Fink (2013) noted,
surveys all participants to “explain their knowledge, feelings, values, and behavior” (p. 1).
In addition to the administration of a survey, interviews were conducted with teachers at
each of the high schools in the MVUSD. The decision to conduct interviews is based on the
richness of discussion and wealth of data that can be provided in an interview format (Merriam
& Tisdell, 2016). Further, the use of interviews allowed the researcher to gain insight into the
beliefs, knowledge and attitudes held by participants. This insight can only be garnered in an
interview format, as observations will not readily yield this data. (Merriam & Tisdell, 2016).
Surveys
The survey portion of this study was administered at a staff meeting where the vast
majority of teachers were required to be present. The researcher contacted the site principals at
the two high schools to discuss the nature of the research study and obtain permission to attend
the staff meeting where the survey was given. The researcher began by discussing the nature of
the research study and informing the teachers that their participation was voluntary. Next,
informed consent was explained and obtained from the participants (Fink, 2013). The survey was
not translated into other languages as all participants in the sample speak English.
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The survey was given in a paper and pencil format. Often teachers do not bring their
laptops or other electronic devices to staff meetings and giving the survey in a manual format
allowed for the greatest level of participation. The goal was to remove as many barriers as
possible to increase participation rates (Fink, 2013). Surveys were collected immediately upon
completion at the staff meeting. Teachers’ names were not recorded in an effort to maintain
confidentiality.
The survey consisted of 13 items (Appendix A). Items on the survey were intended to
gage the knowledge, motivation and organizational factors associated with the research questions
and are grounded in the conceptual framework.
Interviews
As part of the qualitative data collection, interviews were conducted. Seven interviews
were conducted with each interview lasting sixty to ninety minutes in length. The researcher
elicited volunteers for the interviews in conjunction with the survey distribution. Teachers were
given a form they could fill out if they wanted to volunteer for the interview. From the pool of
volunteers, a stratified random sampling method was used to make final selections of participants
so that participants reflect the overall teaching population (Maxwell, 2013). The teachers
selected were sent an email that explained the nature of the study and invited them to participate
in the interview.
The interviews were held at a time and location that was convenient for the participant
and conducive to the interview process. The majority of interviews were held in the classrooms
of the teachers. The classrooms provided a confidential location that was free from distractions
and excessive noise (Bogdan & Biklen, 2007). Topics discussed during the interview were based
on the conceptual framework and consisted of previously developed questions, as well as
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50
questions that arose as a result of the survey data. The interview protocol (Appendix B) focused
on the examination of the teacher’s knowledge, motivation and organizational contexts they
encountered within their school environment. The researcher utilized a semi-structured
questioning format as the semi-structured format allowed for a dynamic examination of
responses as they arose during the interview (Merriam & Tisdell, 2016).
Documents and Artifacts
Documents and artifacts provided a historical trail of information that yielded a great
amount of data (Merriam & Tisdell, 2016). In relation to this study, school systems tend to be
associated with the production of a large amount of documentation. Professional development,
staff meeting agendas and process documents provided data related to the training provided to
teachers regarding the identification of students with anxiety or depression. Handbooks and
forms were examined to validate the existence, degree and training associated with a referral
process for student identified with anxiety or depression. Lastly, budgets were examined as they
reflect the allocation of resources to support the training of teachers in the area of identification
and referral of students with anxiety or depression for evaluation.
Participating Stakeholders
My stakeholder group consists of high school teachers at two different schools. The
participants were credentialed teachers who, at the time of the survey and interview, were
working at the two comprehensive schools in the district. I chose to focus on this population
because they are best positioned to provide relevant information regarding my problem of
practice. Teachers have the most consistent interaction with students over time; this level of
interaction allows them to observe the mental condition and symptomology of students.
Additionally, one of the outcomes my research is exploring deals with a teacher’s ability to refer
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51
a student for evaluation and teachers will be the ones whom have information regarding this
process.
Sampling
In an effort to address the research questions for this study, various data collection
methods were utilized. A key to meaningful data collection is the selection of participants that
will provide useful data. Proper sampling leads to an increased likelihood of obtaining accurate
data that reflects the information and experiences of a population (Fink, 2013). Following is a
discussion of the sampling criteria and rationale that guided this study.
Survey Sampling Criteria and Rationale
• Criterion 1. All of the teachers at both of the comprehensive high schools in the
Mission Valley Unified School District were selected to participate in the survey.
• Criterion 2. To participate in the survey teachers had to possess a teaching credential.
• Criterion 3. To participate in the survey teachers had to have a class of students
(teachers on special assignment without a class of students were excluded).
Survey Sampling (Recruitment) Strategy and Rationale
All teachers received a survey. Surveys were distributed and collected during a staff
meeting. Given there are roughly 100 teachers per site, it was reasonable to survey all
participants in a single setting. All teachers were selected because it is important to understand
the broad experience of teachers with different experiences, genders and content areas. The
survey was conducted first and the results were used to inform the line of questioning in the
components that follow, such as interviews.
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52
Interview Sampling Criteria and Rationale
• Criterion 1. All of the teachers at both of the two comprehensive high schools in the
Mission Valley Unified School District were eligible to participate in the interviews.
• Criterion 2. To be eligible to participate in the interview, teachers had to possess a
teaching credential.
• Criterion 3. To be eligible to participate in the interview, teachers had to have a class
of students (teachers on special assignment without a class of students are excluded).
Interview Sampling Strategy and Rationale
The following sampling strategy identified teachers who are willing to participate in an
interview. A total of seven individual interviews were conducted with teachers from both high
school. Each interview was semi-structured and consisted of eight questions with various follow-
up questions. Teachers were allowed to volunteer for participation in an interview by submitting
their name as part of the survey process. In order to maintain the confidential nature of the
survey, all teachers received a piece of paper that was not attached to the survey that they were
able turn in as a means of volunteering for the interview. From all of the volunteers, a random
stratified method was used to select participants to be interviewed. Participants were invited to
participate in the interview via electronic communication.
Data Analysis
Surveys were administered in person using a paper and pencil format. This was done to
reduce barriers to participation (Fink, 2013). Surveys were collected and the responses where
manually entered into a computer program, Qualtrics, by the principal researcher to aide in data
analysis. Frequencies were calculated and items with multiple response as well as for items with
scaled responses, such as strongly agree, agree, disagree and strongly disagree.
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53
During the course of the interview, observer comments were recorded regarding
observations and insights gleaned during the interview (Bogdan & Biklen, 2007). Once an
interview was completed, analytical memos were written to capture thoughts, observations and
reactions to the interview. Interviews were recorded and sent to a service for transcription
(Patton, 1987). Upon receipt of the transcription, coding of the interviews was conducted using
guidelines outlined by Miles et al. (2014). An initial reading of the transcripts was analyzed
utilizing open coding and a priori codes. The second stage of analysis consisted of the
application of axial codes and a final analysis was conducted to identify themes and patterns in
the data.
Finally, a review of documents was undertaken to triangulate other data analysis methods
(Miles et al., 2014). In this case, no documents were produced by the school or district as they
did not exist.
Credibility and Trustworthiness
In a qualitative research context, the researcher is the instrument of data collection
(Maxwell, 2013). As such, there is a need to ensure that measures are taken to ensure the
personal bias of a researcher does not infect the findings (Miles et al., 2014). Merriam and
Tisdell (2016) offer a number of strategies designed to “enhance the rigor-indeed, the
trustworthiness-of a qualitative study” (p. 258). Triangulation, the comparison of various pieces
of data with the aim of corroborating findings (Miles et al., 2014), increases the credibility and
trustworthiness of the data.
In this study, I have to acknowledge my relationship with the organization being studied,
as well as my inherent bias given the fact I am responsible for the development and
implementation for mental health programs for the school district. To combat any potential
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54
researcher bias, two methods will be utilized; first, a random stratified sampling approach will be
utilized to identify the sample for the interviews (Miles et al., 2014). Secondly, the data obtained
through the interviews will be redacted and then subject to a peer review process with colleagues
(Merriam & Tisdell, 2016). These two strategies will help to ensure the interpretation of the data
is not influenced by the researcher.
Ethics
In the course of engaging in research, it is important that I was mindful of various ethical
consideration designed to ensure the safe, informed and confidential involvement of research
participants (Fink, 2013; Glesne, 2011; Merriam & Tisdell, 2016). A key component of ensuring
the ethical treatment of participants was submitting my research study to the University of
Southern California Institutional Review Board (IRB) for their review and approval (Merriam &
Tisdell, 2016; Rubin & Rubin, 2012). In reviewing this study, the IRB certified and validated
that the various aspects of data collection conformed to the generally accepted standards and
procedures for ensuring fair and ethical treatment of participants (Merriam & Tisdell, 2016).
In the process of data collection, participants were informed of the purpose of the study
and made aware that they are under no obligation to participate in the study. Further, their
voluntary informed consent was obtained, in writing, prior to distribution of data collection tools
(Appendix C) or their participation in interview activities (Appendix D). Additionally,
participants were informed that they have the ability to cease their participation at any point in
the study for any reason. In an effort to protect the confidentiality of the participants, no
individually identifiable information was collected during the survey portion of the study and the
identification of participants has not been made public. Participants in the interview were
informed and acknowledged in writing, that the interviews were confidential. The interviews
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55
were recorded and only the principal researcher and a professional transcription service have had
access to the audio recordings. Once the transcript was obtained and verified, names of all
participants were changed in the transcript and all recordings were erased. Participants had the
ability to obtain, inspect and edit the recording transcripts and make any edits to ensure accuracy.
This information was conveyed verbally and through written documentation. Participation in the
survey took approximately 20 minutes, while participation in an interview took 60 to 90 minutes.
It is important to note that I am an employee of the school district where this study took
place. While this fact has the potential to create some ethical challenges, I do not serve in a
supervisory role to any of the participants in the study. I have no authority over the teachers at
the study sites in a direct or indirect manner. Further, this point was included in the voluntary
informed consent document that was presented to the participants.
Participants in the survey portion were entered into a drawing for a $10 gift card that was
drawn immediately upon completion of the survey. All participants in the interviews were sent a
thank you card and given a $10 gift card as a token of appreciation for their participation in the
interviews.
Validity and Reliability
Creswell (2008) notes that “validity and reliability of scores…lead[s] to meaningful
interpretations of data” (p. 155). As such, for findings of a research study to have any credence,
the attention to validity and reliability cannot be understated. As part of my research study,
quantitative research methods were employed in the form of a survey. Multiple methods were
used to increase the validity and reliability of data. Prior to the administration of the survey to the
teachers at the research sites, the survey was subjected to a pilot test with a small number of
teachers in a neighboring school district. Test items were adjusted based on feedback from
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teachers who piloted the survey. Pilot tests can increase content validity through the use of
feedback and revision as necessary to survey items (Creswell, 2008).
Another way to increase enhance validity and reliability of findings is to have a high
response rate (Fink, 2013) and effective sampling strategy. Both of these concerns were
addressed in the sampling procedures for this study. In cooperation with the administration of the
two school sites selected for this study, the survey was conducted at a staff meeting held on
campus. Except for illness, teachers are required to attend the staff meetings and approximately
90% of the teaching staff were present. I recognize that, while the teachers were required to be at
the meeting, they were not required to participate in the survey. That being said, giving the
survey in a paper-pencil format and giving teachers time to complete the survey served to reduce
barriers to completion.
Limitations and Delimitations
Conclusions and recommendations based on data gathered in this study are not
generalizable beyond the context of the study as the sample for this study was very narrow in
scope. Further limitations of this study include the fact that the qualitative sample was
established by those teachers who volunteered and it is unknown if those volunteers represent the
experiences and beliefs of the teachers at the study sites. Additionally, geographic, gender and
ethnic distributions of participants are not consistent with the population of teachers as a whole.
Delimitations include the limiting of the study population to high school teachers. This
was done to limit scope and focus as the experience of high school teachers and teachers of
lower grades are fundamentally different. An additional delimiting factor is limiting of
interviews to seven teachers. While a more thorough understanding of the teacher experience
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could have been established by significantly increasing the number of teachers interviewed, time
and logistical constraints were key considerations in not including more teachers in the sample.
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CHAPTER 4
RESULTS AND FINDINGS
The purpose of this study was to examine the factors that promote or inhibit a teacher’s
ability to identify and refer students with anxiety or depression for evaluation. The following
research questions were used to guide the investigation:
1. What are the knowledge, motivation, and organizational elements that promote or
inhibit a teacher’s ability to identify students with anxiety or depression?
2. What are the knowledge and skills, motivation, and organizational elements that
promote or inhibit a teacher’s ability to refer students with anxiety or depression for
evaluation?
To address the research questions, data collection efforts comprised the use of a survey,
semi-structured interviews and a review of documents. This chapter will present the results and
findings based on data analysis relative to the data collection techniques.
Participating Stakeholders
The participants in this study were teachers at the two comprehensive high school sites
for the district. Teachers represent all subject matters and grade levels. To be eligible to take the
survey, participants had to be a teacher with a teaching course load that exposed them to students
in a classroom environment on a regular basis. Teachers on special assignment, case managers
and other non-instructional positions were excluded due to their lack of student contact. Between
the two comprehensive school sites, a total of 194 teachers met the criteria to participate. The
survey was administered at a staff meeting at the school sites and surveys with less than 50%
completion were eliminated. This resulted in 131 surveys that were included in the sample for a
response rate of 68%. Specific demographic data of survey participants was not collected.
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59
At the time of survey administration, teachers were informed of the interview portion of
this study and were invited to participate. Volunteer forms were distributed separate from the
survey to maintain confidentiality and teachers who wanted to participate in the interview
completed the form and returned them to the investigator. A total of 46 teachers completed the
interview participation form. Forms were randomly numbered and an online number generator
was used to select participants. Those selected were contacted to confirm participation and those
who confirmed were scheduled for an interview. In all, seven teachers confirmed participation
and were interviewed. Four of the interview participants were male (57%) and three were female
(43%).
Table 5
Demographic Profile of Interview Participants
Name*
Gender
(M/F) Content Area Ethnicity
School Site
(A or B) Years Teaching
Alice F Special Education Filipino A 18
Gary M Math Latino A 9
Howard M English Caucasian A 10
John M Special Education Caucasian B 7
Robin F Social Studies Caucasian A 13
Sal M Math Asian B 7
Wendy F Mah Caucasian B 11
* all names are pseudonyms
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Results
Knowledge Results
Declarative knowledge is the factual information a person knows. Aguinis and Kraiger
(2009) refer to declarative knowledge as the “what” a person know. In contrast to declarative
knowledge, procedural knowledge is one’s knowledge relative to “how” to do something
(Aguinis & Kraiger, 2009). Teachers were surveyed regarding their declarative knowledge as it
relates to their ability to identify the symptoms of anxiety and depression and their procedural
knowledge regarding the process they are to utilize when referring a student for evaluation.
Declarative knowledge results. Participants were asked if they were able to identify the
symptoms of anxiety and were provided a list of seven symptoms. Four of the symptoms
provided meet the identification criteria for anxiety found in the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (2013) and three were not
identification criteria. As Table 6 shows, respondents were almost as likely to select non-
identification criteria as identification criteria. The DSM-5 characteristics were identified in a
range of 50% to 79% on the high end for sleepiness and non-attendance respectively. While the
characteristics that are not DSM-5 identification criteria were identified in a range of 41% to
78% for over-activity to withdrawn respectively. The identification patterns represented in these
findings are consistent with previous findings in similar contexts. Headley and Campbell (2013)
found that teachers were able to identify general broad categories of symptoms, but were unable
to see specific behaviors in students.
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Table 6
Survey Results for Anxiety Identification
Criteria Percent Responded (n) DSM-5 Identification Criteria
Non-attendance 79% (n=103) Yes
Sleepiness 50% (n=65) Yes
Lack of work completion 69% (n=90) Yes
Irritability 73% (n=95) Yes
Over-activity 41% (n=53) No
Constant need for validation 62% (n=81) No
Withdrawn 78% (n=102) No
None of the above > 1% (n=1) -
Similar to the process used to establish the level of declarative knowledge the teachers
had relative to anxiety, seven criteria were listed for teachers to select that were symptoms of
depression. Of the seven criteria, five were identification factors used in the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (2013) and two
were not. Table 7 presents the results and identifies each criteria as meeting a qualifying
characteristic found in the DSM. With the exception of “Rapid change in weight,” respondents
identified the DSM-5 criteria symptoms at a higher rate than those not found in the DSM-5. The
identification rates for DSM-5 criteria range from 62% for rapid weight change to 92% for
withdrawn. Identification rates for symptoms not found in the DSM-5 were 63% for irritability
and 70% for overly emotional. The pattern of false identification represented by these findings
were also seen by Cunningham and Suldo (2014) in their study of teacher sensitivity to
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62
depression symptoms in students. In that study, the authors theorized that the non-externalizing
nature of indicators may play a role in teachers not accurately identifying of symptoms.
Table 7
Survey Results for Depression Identification
Criteria Percent Responded (n=) DSM-5 Identification Criteria
Non-attendance 84% (n=110) Yes
Sleepiness 79% (n=104) Yes
Rapid change in weight 62% (n=81) Yes
Lack of work completion 84% (n=110) Yes
Withdrawn 92% (n=121) Yes
Overly emotional 70% (n=92) No
Irritability 63% (n=82) No
None of the above 2% (n=2) -
The other declarative construct explored was the ability of teachers to identify what
support options were available for students on their campus. In this case, of the five options
presented to participants, three were support programs available at their school and two were not.
As Table 8 shows, participants were able to identify two of the three options found on their
campus at a high rate. Individual counseling and 504 Plans are available support options at the
two school sites and were identified at a rate of 94% and 85% by respondents respectively.
However, group counseling, a service also available at the two school sites, was identified at a
lower rate of 22% by respondents. A mixed methods study of 252 teachers by Valdez and Budge
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63
(2012) found that teachers often lack the knowledge of support services available to students on
their campus.
Table 8
Survey Results for Available Services
Support Program Percent Responded (n=) Support offered at School
Individual counseling 94% (n=115) Yes
Group counseling 22% (n=27) Yes
504 Plans 85% (n=104) Yes
Peer support programs 18% (n=22) No
Mindfulness training 13% (n=16) No
None of the above 0% (n=0) -
Procedural knowledge results. The constructs that act in concert with a teacher’s ability
to identify a student with anxiety or depression, is a teacher’s ability to refer a student suspected
of having anxiety or depression for evaluation. Table 9 displays the results regarding what
actions a teacher would take when the teacher suspected a student had anxiety or depression.
Sixty-two percent of teachers surveyed responded they would refer the student for evaluation. By
contrast, 69% responded they would talk to a school based mental health professional, 73%
stated they would let an administrator know and 79% said they would talk directly to the student
about their concern. The inconsistent response pattern of multiple modes of responding to
students with anxiety or depression from the teachers in this survey is similar to what Gowers et
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64
al. (2004) found as a result of gaps in teacher’s knowledge relative to an articulated referral
process.
Table 9
Survey Results for Procedural Knowledge Results
Teacher Action
Percent Responded
(n=)
Speak directly with the student about my concern 79% (n=103)
Call the parent to discuss my concern 50% (n=65)
Talk to a school-based mental health professional 69% (n=90)
Let an administrator know of my concern 73% (n=95)
Discuss the student with a colleague 41% (n=53)
Make a referral to the appropriate person for the student to be
evaluated
62% (n=81)
None of the above > 1% (n=1)
Motivation Results
Motivation can be defined as “an internal state that initiates and maintains goal directed
behavior” (Mayer, 2010, p. 39). Having the sufficient level of knowledge regarding the
components of task completion is important. However, if an individual lacks the motivation to
engage in a task, the knowledge aspects will lie dormant within the person. For this reason,
motivation is a required mechanism for the achievement of the stakeholder goal of identifying
students with anxiety or depression and referring such students for evaluation. Following are the
results for the assumed motivational influences on stakeholder performance.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
65
Teacher self-efficacy. If it is expected that teachers engage in a specific process or
activity, it is imperative that teachers have the belief they are capable of doing so with success.
Teachers must have the confidence that they can effectively meet the goal they set out to
achieve. Table 10 shows that 88% (n=109) of respondents either agree or strongly agree that they
believe they have the goal of looking for students with anxiety or depression. However, by
contrast, only 41% of participants responded that they either believe or strongly believe they are
qualified to meeting the needs of students with anxiety or depression. Pajares (2006) noted that a
lack in belief about one’s qualifications and capabilities could have a negative impact on
motivation.
Table 10
Survey Results for Teacher Self-Efficacy
Strongly
Disagre
e (n=)
Disagre
e (n=)
Agree
(n=)
Strongly
Agree
(n=)
I believe it is my responsibility to look for
students who may have anxiety or depression
1%
(n=1)
11%
(n=13)
64%
(n=79)
24%
(n=30)
I believe I am qualified to address the needs of
students with anxiety or depression
6%
(n=8)
52%
(n=66)
35%
(n=44)
6%
(n=8)
Teacher expectancy value. In addition to the belief that one has the ability to
accomplish a task, it is also an important motivational factor to belief that there is value in doing
the task. In this case, participants were asked if they believed that there were any positive
outcomes that could occur as a result of their actions. Table 11 shows 84% of respondents either
agreed or strongly agreed with the statement “I believe I can have a great impact on the life of a
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
66
student with anxiety or depression.” Similarly, 91% agreed or strongly agreed they could help to
increase the academic achievement of a student with anxiety or depression. Hinchliffe and
Campbell (2016) conducted a qualitative study of 20 primary teachers and found that teachers
reported their perception of the degree of impact on the student played a key role in their
decision to refer a student for evaluation.
Table 11
Survey Results for Teacher Expectancy Value
Strongly
Disagre
e (n=)
Disagre
e (n=)
Agree
(n=)
Strongly
Agree
(n=)
I believe I can have a great impact on the life of
a student with anxiety or depression
2%
(n=3)
13%
(n=17)
64%
(n=83)
20%
(n=26)
I believe I can help to increase the academic
achievement of a student with anxiety or
depression
0%
(n=0)
9%
(n=12)
70%
(n=90)
21%
(n=27)
Organizational Results
The third factor examined in the survey is organization. It is necessary to have the
appropriate organizational structures in place to support the stakeholders in achieving their goal
of identifying and referring students with anxiety or depression for evaluation. The
organizational influences examined in the survey fall into two categories: cultural settings and
cultural models. Cultural settings are the tangible aspects of an environment in an organization
while cultural models are the underlying beliefs and practices that exist within an organization,
but are not codified in any formal manner.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
67
Cultural setting – professional development results. Professional development and
training often serve as a primary method of providing stakeholders with the required tools to be
successful. To understand the level of training teachers have received, they were asked if they
had received training relative to identification of symptoms of depression, how to refer a student
with depression, who to talk with about students suspected of having depression and how to
approach a student with depression. As shown in Table 12, 67% or respondents stated they had
received training about how to refer a student with depression and 63% reported being trained
about who to talk to regarding students suspected of having depression. Less than half (42%)
replied they had received training in how to identify students with depression and only 15% had
been trained in how to approach a student suspected of having depression.
Table 12
Survey Results for Cultural Setting — Depression
In the last 3 years the school district has trained me in the following areas
Percent
Responded (n=)
Identifying symptoms of depression 42% (n=42)
How to refer a student with anxiety for depression 67% (n=67)
Who to talk to regarding students whom I suspect may have depression 63% (n=63)
How to approach students I suspect may have depression 15% (n=15)
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
68
Similar to the line of questioning regarding the training of teachers relative to depression,
the teachers were also surveyed if they had received training relative to identification of
symptoms of anxiety, how to refer a student with anxiety, who to talk with about students
suspected of having anxiety, how to approach a student with anxiety and if none of the previous
options. As shown in Table 13, 49% or respondents stated they had received training about how
to refer a student with anxiety and 47% reported being trained about who to talk to regarding
students suspected of having anxiety. Twenty-two percent replied they had received training in
how to identify a student with anxiety, 14% had been trained in how to approach a student
suspected of having anxiety and 31% stated they had not had any of these training experiences in
the past three years. Cunningham and Suldo (2014) surveyed 238 teachers in an urban school
district in the Southeast United States and found that 84% of them had not received and formal
training in the identification of internalizing disorders (anxiety and depression) leading to
students being misidentified at a rate of 50%.
Table 13
Survey Results for Cultural Setting — Anxiety
In the last 3 years the school district has trained me in the following areas
Percent
Responded (n=)
Identifying symptoms of anxiety 22% (n=28)
How to refer a student with anxiety for evaluation 49% (n=63)
Who to talk to regarding students whom I suspect nay have anxiety 47% (n=61)
How to approach students I suspect may have anxiety 14% (n=17)
None of the above 31% (n=40)
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69
Finally, teachers were asked to assess if their school had properly trained them to meet
the needs of students with anxiety or depression. As reported in Table 14, 85% of respondents
either disagreed, or strongly disagreed that they had received the proper amount of training from
their school.
Table 14
Survey Results for Cultural Setting — Training to Address Student Needs
Strongly
Disagre
e (n=)
Disagre
e (n=)
Agree
(n=)
Strongly
Agree
(n=)
I believe my school has properly trained me to
meet the needs of students with anxiety or
depression
12%
(n=15)
73%
(n=90)
12%
(n=15)
2%
(n=2)
Cultural setting – process results. Having a clearly articulated structure and process
that facilitates stakeholders in successfully fulfilling their professional obligations is necessary
for organizations to achieve their overall goals. Participants were asked if they had been trained
on the process of referring a student with anxiety (Table 15) or depression (Table 16) in the past
three years. The results for these two questions were very similar with 79% or respondents
stating that they had been trained on the process for referring a student with anxiety never or
once in the past three years and 77% stating they had been trained on the process of referring a
student with depression never or once in the past three years.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
70
Table 15
Survey Results for Cultural Setting — Anxiety Process
In the last 3 years this school has trained me on the process for
referring a student with anxiety for evaluation
Percent
Responded (n=)
Never 38% (n=48)
Once 41% (n=51)
Twice 14% (n=17)
Three times 6% (n=7)
Four or more times 2% (n=2)
Table 16
Survey Results for Cultural Setting — Depression Process
In the last 3 years this school has trained me on the process for referring
a student with depression for evaluation
Percent
Responded (n=)
Never 30% (n=38)
Once 47% (n=59)
Twice 14% (n=18)
Three times 7% (n=9)
Four or more times 2% (n=2)
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
71
Teachers were also asked if their school had a clearly articulated process for referring a
student with anxiety or depression for evaluation. Half of respondents either agreed or strongly
agreed that their school did have a clearly articulated process (Table 17). These data are
consistent with Headley and Campbell’s (2013) findings when they studied 315 teachers
regarding the role of training in identification and referral of students with excessive anxiety.
They noted a pattern of irregular training regarding referral processes and went on to theorize
that increased training can have a positive impact on the rate of student referrals for mental
health services.
Table 17
Survey Results for School Referral Process
Strongly
Disagre
e (n=)
Disagre
e (n=)
Agree
(n=)
Strongly
Agree
(n=)
My school has a clearly articulated process for
referring a student with anxiety or depression for
evaluation
8%
(n=10)
42%
(n=52)
45%
(n=56)
5%
(n=6)
Cultural model results. In an effort to evaluate if teachers believe that they are too
inundated by competing stressors and therefore do not feel that identifying students with anxiety
or depression is part of their job duties, participants were asked to respond to the question “I
believe there are too many other responsibilities related to my teaching duties for me to be
responsible for identifying a student with anxiety or depression.” Thirty-two percent of the
respondents either agreed or strongly agreed with that statement (Table 18). When teachers feel
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
72
overwhelmed, they are less effective and often experience a decrease in motivation (Pas et al.,
2012).
Table 18
Survey Results for Teacher Perception About Responsibilities
Strongly
Disagre
e (n=)
Disagre
e (n=)
Agree
(n=)
Strongly
Agree
(n=)
I believe there are too many other
responsibilities related to my teaching duties for
me to be responsible for identifying a student
with anxiety or depression
7%
(n=9)
60%
(n=75)
24%
(n=30)
8%
(n=10)
Findings
In conjunction with the quantitative results discussed in this chapter, qualitative methods
were also employed in an effort to provide a deeper understanding of the participants’ experience
relative to the identification and referral of students with anxiety or depression for evaluation.
Findings are presented in alignment with the assumed influences of knowledge, motivation and
organizational factors.
Motivational influences examined are teacher self-efficacy regarding their capability of
identifying and referring students as well as the expectancy value for teachers relative to their
belief in their ability to contribute to a positive outcome for students. Finally, organizational
factors will be discussed. Findings around the professional development provided to teachers are
presented as well as the findings about the existence of district developed and supported referral
process. The last organizational finding presented focuses on the perception of teachers that they
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
73
are too overwhelmed with competing responsibilities to feel they should be responsible for the
identification and referral of students with anxiety or depression for evaluation.
Knowledge Influencers
Knowledge factors discussed are teachers’ awareness of support and assessment options,
knowledge of symptoms of anxiety or depression, knowledge of a referral process and the
presence of metacognitive strategies employed by teachers to evaluate their effectiveness in
referring students.
Support and assessment services. Having an awareness of what services and evaluation
options are available for students dealing with anxiety or depression is an important aspect of
identifying and referring students for evaluation. Six of the seven teachers interviewed appear to
have a vague understanding of assessment and support options but seem to lack a depth of
knowledge about specifics in terms of what support and assessment services are available to
students with anxiety or depression. One teacher who was an exception, as she was well aware of
support and assessment options for students. Her status as a Special Education teacher for
Emotionally Disturbed students created a situation where she had greater cause to be involved
with the social and emotional aspects of her students. More typical was Wendy, a math teacher;
when asked about the services and assessment options, she said:
I believe now we have a full-time, one or two full-time psychologist on staff. There used
to be two part-times and I never knew what day is. I don’t know exactly. I know that
there’s, besides the guidance counselors, there’s another level of counseling that I know
we have. I think that we have a full-time person. At least one full-time person. There
might be two. Marianne [mental health professional] is new. Marianne, she’s new. I don’t
know a lot of how it all fits together.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
74
Wendy’s response was typical of the knowledge base respondents had. The teachers interviewed
did have knowledge of some programs available for students like 504s and special education
services for more severe needs; however, they lacked clarity relative to the role individuals
within the school had in serving students. For example, John, a special education teacher,
identified counselors as school staff that provide service for students. When questioned further
regarding how counselors support students, John stated, “That I don’t know. My understanding is
they set up meetings. They’re confidential. I think they’re voluntary on the students’ side. Much
beyond that, I really don’t know too much about it.”
The lack of depth of knowledge about the breadth and depth of available services and
evaluation options may have the unintended consequence of reducing the likelihood a teacher
may make a referral for evaluation. Without an understanding of options, a teacher may assume
that there are minimal or no services for students. A quantitative research study of 75 secondary
school teachers found that teachers were aware of basic school level resources but lacked
extensive knowledge of additional and available services (Andrews, McCabe, & Wideman-
Johnston, 2014).
Awareness of symptoms. In a mixed methods study of 501 secondary school educators,
Berger, Hasking, and Reupert (2014) found that the fundamental skillset that must be present in
appropriately addressing and supporting students with anxiety or depression is the ability to
identify students as they present symptoms. While teachers were not able to directly state what
symptoms they would look for, they all indicated that they look for a broad category of
behavioral changes as a criteria for raising their concern about a student. In describing what
causes him to become concerned about a student, Sal, a math teacher, said:
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
75
Let’s say September I can see the energy is positive because it’s early in the year, they’re
engaged, then if all of a sudden I notice a lack of participation, a lack of engagement, a
lack of desire… But as far as just some of the symptoms, just seeing the kids, you can
tell. At least, just pure observation, looking at the kid, definitely their mind is not with
math or school, and their energy level, their interaction, their tone, it’s different than how
it was at the beginning of the year.
Howard, an English teacher, echoed the same sentiment when he relayed his knowledge
symptoms:
A couple of times when I feel I’ve identified students who have had depression has been
like a complete change from ... like almost like a polar opposite change. So from, wearing
brightly colored clothes to completely dark, like completely dark clothes. Um, maybe
from being well put together to being disheveled, or from being outgoing and bubbly to
being sort of sullen and withdrawn and, and just kind of a change in attitude perhaps
toward me and toward, um, towards the sort of classroom and the classroom
environment.
While relying on overarching changes as a method for identification of students with
anxiety or depression is not wholly without merit, there is a lack of a deeper knowledge of more
specific symptoms on the part of the teachers.
Referral process. Assuming a teacher has the knowledge of symptoms to conclude that a
student may be struggling with anxiety or depression, there needs to be a clear, consistent and
well-communicated process for the referral of a student for evaluation. Teachers must have
knowledge of this process so they can utilize it (Berger et al., 2014). Interviews with participants
revealed that all of the teachers do utilize a process, however the process they use is not
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
76
consistent from teacher to teacher and appears to be based on personal experience and
relationships rather than a universally agreed upon and systemic approach. Gary, a math teacher,
describes his method of referring a student as:
Kind of trial and error actually, this is my ninth year teaching but I’ve taught in…four
different school districts before coming here. Each one had their own kind of style but
across the board, it’s usually called the front office. It’s kind of like the go to. Call the
front office and they’ll call someone. I kind of got that ingrained in my head and usually
it’s an easy number and it’s on a speed dial because they call us the most so usually you
can just hit recent call and then ‘Boom,’ there they are, so it is kind of for convenient
sake and I know it’s a quick method for getting people on the radio.
Gary is taking what has been successful in the past and applying it to the current school site he is
at. Further evidence of a referral method that is inconsistent and based on personal experience
was noted by Robin, a social studies teacher. When Robin was asked if her school had a method
for referring students, she stated “not to my knowledge. Probably, but I just didn’t know, because
I always just would go to a counselor, and then go at it from there.” Robin went on to say that
she always took her concerns to this counselor “because that specific counselor kind of always
knew what to do, or who would find out. That specific counselor is always in the know, and if
that person didn’t know, then that person would find out.”
Here we see two teachers in the same district, at the same school with two vastly different
methods for referring a student in need.
Metacognitive reflection. Engaging in metacognitive practices as a method of self-
evaluation is an important practice. Examining one’s actions and processes can yield valuable
data that can be used in a formative way to alter and improve future functioning (Nicol &
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
77
Macfarlane-Dick, 2006). While teachers at the Mission Valley Unified School District do not
explicitly name their actions as metacognition, they do engage in metacognitive practices as a
tool for improvement. Six of the seven teachers interviewed stated they regularly engage in
metacognitive practices, for example, when asked if she ever thinks about how she supported a
student in her class with anxiety or depression, Robin stated:
There are so many different hats that I wear, I’m not just a teacher, I mean I’m a nurse
and I’m a guidance counselor, I’m a mom, I’m a lot of things to these students in my
room, and so if I get too hooked up on one and let it bring me down, then I know that I’m
doing disservice to the rest. I’m reflective 100% of the time, but my reflection time is
going to be different on a case-by-case basis.
If I feel, and in most cases I do, everything that I can possibly do, if I still haven’t hit that
with a kid, if I still haven’t been able to help them and get them services or get them the
things that they need, then I reflect not only on what I’ve done, but maybe on the process.
Did I refer a kid? Were they ever called in again? Were they not? Why not? Where did
maybe the chain break down, or was it me, did I not do enough? Was I not the squeaky
wheel, did I not bang down the door for this kid? Yeah, I absolutely reflect 100% of the
time.
Robin seems to indicate that she takes a very reflective and personal analysis of her
actions and the effect of her actions on a student. She wants to know if she was successful. Her
personal evaluation was echoed by many teachers, for example, when recalling a specific
incident with a young female student in his class, Gary stated he reflects on his actions
because part of me is concerned like, ‘Could I have handled that better?’ ‘Did I cover
everything that I need to cover…did I help her not just for this incident, for future
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
78
incidents?’ That was my biggest concern. I didn’t want her to feel like oh, this situation’s
done, I can move on. I wanted her to feel like this is done and I now know. I learn from
this, what I should do in the future.
The teachers expressed a genuine desire to support students. Part of this support comes in
the form of metacognitive reflection. Their reflection results in an iterative process that cycles
between reflection and action.
Motivation
Motivational influences examined are teacher self-efficacy regarding their belief about
their capability of identifying and referring students. Additionally, the expectancy value for
teachers relative to their belief in their ability to contribute to a positive outcome for students is
explored.
Teacher self-efficacy. Self-efficacy is the belief one holds in their ability to achieve an
outcome or complete a task (Pajares, 2006). Teachers need to have the belief that they can
identify students with anxiety or depression in order to effectively take action. All of the teachers
interviewed indicated that they do not have a strong sense of self-efficacy about their ability to
identify students with anxiety or depression. When asked if he believed he was able to accurately
identify students in his classes with anxiety or depression, John said, “I don’t know. I’m not
sure.” The cause for this lack of self-efficacy was generally attributed to two sources, the lack of
training and the volume of student contacts a teacher faces. To illustrate the former, Howard
stated that he wanted to be better at identifying students with anxiety or depression when he
offered, “I don’t know if I’m adequately trained to completely solve students’, all students’
anxiety and depression issues.”
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
79
Gary also questioned his belief in his ability to identify students with anxiety or
depression and felt the number of students he interacts with is prohibitive to his success. Gary
offered:
I definitely don’t catch them all the time…my classes are packed. With 170 students,
there are sometimes where it’s hard to get everyone, keep everyone in mind…But I don’t
feel like I catch everyone. I feel like I can do more and you know, every year I’m like
‘okay let me do a little bit more.’
The teachers are clearly expressing a desire to feel competent in their ability to identify
and refer students but are hindered by their perception that they lack training or have too many
students to look after. This finding mirrors that of Mazzer and Rickwood (2015) as their
qualitative study of 21teachers found that while teachers believed it was important for them to
serve students with mental illness, their lack of knowledge was a barrier to their increased sense
of self-efficacy.
Teacher expectancy value. In addition to the belief that they are capable of identifying a
student with anxiety or depression for evaluation, a teacher must also see value in intervening
(Hinchliffe & Campbell, 2016). Expectancy value is the idea that there is value in engaging in
some activity because one’s actions can lead to positive outcomes. Of the seven teachers
interview, six shared that they do believe that their actions can have a positive impact on the
lives of students. To illustrate this point, when asked if he believed his actions led to a positive
outcome for a student he previously referred for counseling, John replied “It’s like, ‘Okay, yeah.
I did something that really helped a kid,’ because I do like this kid.” When asked what he thinks
about when he makes the decision to refer a student, Sal stated, “we’re going to set up a meeting,
or do some sessions…or whatever. So it’s positive in that okay, at least we’re taking care of it.”
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
80
The belief that the intervention of a teacher serves an important role as a catalyst in
process of obtaining help was expressed by Howard when he stated:
I think often the first step toward solving a problem can be the hardest and the biggest
step. So, if it’s a student that hadn’t had someone listen to them before or had been
unable to open up to someone before or had never really had someone say, “Hey are you
okay, what’s up?” And they were able to alleviate some of that anxiety and then maybe
move on from that first step of finding more help and support with whatever the issues
were that they had. I think that, then to them, that kind of first step that perhaps I had
aided them with what could’ve had a big impact
Having the belief that their actions can increase the likelihood of a student getting the
assistance they need, can have the practical effect of increasing the probability a teacher will
make a referral for evaluation.
Organization
Organizational features give structure to knowledge and motivational factors. The
following organizational findings are organized into a cultural setting and a cultural model. A
cultural setting is the tangible facets of an environment: the rules, policies and processes that can
be codified and are formalized. A cultural model is the unspoken or informal aspects of an
environment; those rituals of conduct that cannot be found in a policy manual. Following are the
findings for a cultural setting and a cultural model. The cultural setting assumed influence
examined is the extent to which professional development is provided by the school or district in
an effort for teachers to gain the necessary tools to identify and refer for evaluation, a student
with anxiety and/or depression. The cultural model influence examined is the belief by the
teachers that identifying and referring students suspected of having anxiety or depression should
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
81
be their responsibility in light of their perception that they are overwhelmed with their other job
duties.
Organized professional development. Training and professional development is a
common method for building the capacity of teachers to increase performance. It is incumbent
upon the district to provide the organizational tools required to achieve an expected outcome. A
study that surveyed 119 teachers conducted by Walter, Gouze and Lim (2006) found that a lack
of training was a significant barrier that impeded teachers from identifying and referring students
for evaluation. All of the teachers interviewed shared that have not been provided the necessary
professional development for them to obtain the skills required to identify and refer students
suspected of having anxiety or depression for evaluation. When asked to discuss the training she
had received from the district or her school, Wendy stated:
I don’t know. I don’t think we’ve had any ... That’s not true. We had something. It was
awhile ago…maybe four, five years ago. Five years ago. There was some kind of a video
or a movie or something and then we were going to have a discussion about it.
This type of sporadic training is not an effective method for ensuring teachers have the latest
information is too distant to be meaningful.
It seems that professional development is a source of frustration for the teachers
interviewed due to the fact that many teachers do not see their activities as relevant to their jobs.
Alice, a special education teacher, was asked what her school could do to support her in
identifying and referring students with anxiety or depression, she replied:
I would say training. I always ask or share with my colleague that on PD (professional
development) days we should get more training on how to deal with behavior rather
than…check essays as a PD. It’s not applicable to what I’m doing in my classroom. My
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
82
point is things that we learn from the program, from master’s credentials, or degrees, it
helps, but if we combine it with hands-on training, it’s better.
The lack of training seems to have a chilling effect on the teachers. It appears to inhibit a
teacher’s ability to approach a student and inquire as their mental health status. Robin expressed
this very idea:
I guess I was not ever really trained to figure out if a kid had depression or anxiety. It was
just kind of expected that that’s something that we know how to see and how to find…I
have no formal training in it, and so with something like that, I would never walk up to a
kid and say, “I think you’re depressed, or maybe you have anxiety,” because I don’t
know what the repercussions of something like that would be.
Without proper training, the district has not supported the development of the requisite skills for
teachers to achieve the goal of identifying and referring students with anxiety or depression for
evaluation.
Teacher responsibility. Educating the population is the primary task of schools. As a
cultural model, it was suspected that teachers would feel that they are too overwhelmed with the
base function of teacher to feel it was their responsibility to identify and refer students with
anxiety or depression for evaluation. While the teachers of the MVUSD do feel overwhelmed, all
of the teachers interviewed conveyed that they did feel it was their responsibility. The internal
struggle of the role of a teacher is best illustrated by an exchange with Robin. She initially said
“no” when asked if it was a teacher’s job to identify and refer students in light of the other duties
teachers have. When asked to explain her answer she said:
That’s such a hard question…you know we get into this job because we’re compassionate
and we want to help, but we also get into this job because we want to teach. There’s only
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
83
so many things that I can do in a day, and I don’t necessarily want more things on my
plate, but then on the flip side, who if not me? I mean, I see these kids, I come into
contact with them every day, so who else would I expect to be able to make the referral if
it isn’t me? No, I don’t want more work, but yes, it makes sense.
Robin appears to contradict her initial response of “no” as she replies and this is pointed out to
her. She is asked the question again if she believes it is her job to identify and refer students and
she states:
Yes, yes it is. Well…I want to say no, because I do a lot, and that just means more
training, more everything, but yeah, I mean that’s part of it. We see them probably more
than their parents do in some situations.
While Robin was initially hesitant to acknowledge her belief that she did feel it was her
responsibility, other teachers were far more forthright in their ownership of this task. Wendy
provides a good example of teacher with a strong ownership this responsibility as she said:
It is my job. I’m right in there with them every day. I see these kids so many hours a
week. If something is different with them, I should notice that. We have a lot of kids. We
have ton of kids, but it doesn’t matter. That’s what we’re here for. I’m here to teach a
subject, yeah, but life is life. We were trained one time on using an EpiPen and we had a
teacher who said, “I’m not going to do it.” “What do you mean you’re not going to do
it?” “I’m not responsible for that. That’s not in my job.” “If they’re laying on the floor
having anaphylaxis…you’re not going to do anything? Really? They’re going to die in
front of you. What do you mean you’re not going to do anything?” “It’s not my job.” Oh
my gosh, I couldn’t believe this person was saying something. I couldn’t believe it.
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All teachers interviewed fell between these two extremes, with some reluctantly acknowledging
that they did feel it was their responsibility and others who truly embraced the caretaker role.
Document Review
Another vehicle for data collection was a document review. A document review can serve
as an open window with a view into the history of an organization. Additionally, a document
review can shed light on the values, priorities and culture of an organization. In this study,
document review was used as a method of examining the assumed cultural model influence of
the existence of a process that has been designed and implemented by the school or district for
the teachers to utilize as a method of referring students for evaluation.
Referral Process
In attempting to establish the existence of a process that has been developed and
implemented by the school or district for teachers to utilize when they want to refer a student
suspected of having anxiety or depression for evaluation, a series of documents were requested
for review. Schools were asked to provide any process forms, such as flow charts, that were
given to teachers. In both study schools, these forms or charts did not exist. Further, budget
documents were requested that would identify the allocation of financial resources toward the
development and implementation of a referral process and in both study schools, there was no
record that specifically allocated financial resources for the this. Additionally, agendas for staff
meetings were requested where the topic discussed was a school sanctioned referral process and
for both study schools, no agendas in the past three years were provided that reflected a
discussion of a school supported referral process.
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Synthesis
Quantitative, qualitative and document data collection methods were used to gather
evidence to validate the assumed influences relative to a teacher’s ability to identify and refer a
student suspected of having anxiety or depression for evaluation. Following is an examination of
the intersection of the data collection methods.
Knowledge
The survey and interview data for a teacher’s ability to identify the symptoms of anxiety
or depression seem to support the notion that teachers lack the ability to discern the specific
symptoms of anxiety and depression. Teachers were generally able to identify symptoms from a
list of factors used to diagnose anxiety and depression from the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (2013). However, the
teachers were also almost as likely to misidentify characteristics that were not symptoms of
anxiety and depression in the Diagnostic and Statistical Manual of Mental Disorders. In
interviews, teachers reported that they are not able to articulate specific symptoms of anxiety or
depression, rather they rely on the observation of generalized change as a tool for identification.
These data suggest that teachers are unable to recognize the specific symptoms of anxiety or
depression.
The teachers have a generalized knowledge of the support and assessment services
available at their schools. In the surveys teachers were able to articulate a base level of services
that seem to be based on the individuals and services that they have had personal experience
with. While they are aware of the existence of some personnel and services, many do not have a
command of the full breadth options available for students with anxiety or depression. The
survey data supports this assertion as the teachers surveyed identified two services found on
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86
campus, 504 plans (85%) and individual counseling (94%), at a high rate but under identified
another service found at campus, group counseling (22%).
In relation to the process teachers utilize when they suspect a student has anxiety or
depression, it appears that teachers use a variety of methods with no clear and consistent strategy
from teacher to teacher and school to school. Teachers shared that they use methods that are
based on their personal connections and experiences. Two teachers at the same school may use
entirely different strategies in dealing with a student suspected of having mental illness. The
survey results reflect this scattered approach to referring students. On the survey, teachers replied
that they would speak directly to the student (79%), let an administrator know their concern
(73%), talk to a school base mental health professional (69%), make a referral for evaluation
(62%) and call a parent (50%). Additionally, the lack of a district or school supported
methodology for referring students contributes to the differentiated response. These data paint of
a picture of a staff that lack a clear direction on how to proceed when a student is suspected of
having anxiety or depression.
Teachers do engage in a metacognitive process to evaluate their performance with an
outcome of shaping future actions. Teachers reported they often reflect on their actions when it
comes to identification and referral of students with anxiety or depression. The teachers shared
they question if they “did enough” or what they “should do in the future.” It seems the teachers
are not purposefully engage in metacognitive practices, but rather, they view the reflection as an
extension of their natural operation as an educator.
Motivation
This study also examined teacher motivation. Teachers lack a deep sense of self-efficacy
regarding their ability to identify a student with anxiety or depression. In the survey, 88% of
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respondents agreed or strongly agreed they were responsible for the identification of students
with anxiety or depression, however only 41% agreed or strongly agreed they were qualified to
do so. The interviews reflect an agreement with this conflicted view the teachers hold as many
respondents shared the belief that a lack of training and the volume student contacts give them
cause to question their abilities. Many teachers appeared visibly anguished when considering
their answers to this line of inquiry. The internal dissonance may come from a strong feeling
from the teachers that they believe their actions can lead to positive outcomes for kids. This high
degree of expectancy value can be seen in the survey results as 84% or respondents agreed or
strongly agreed that they could have a great impact on the life of a student with anxiety or
depression and 91% or respondents replied that they agree or strongly agree that they can
increase the academic achievement of student with anxiety or depression. During interviews, the
participants validated the survey findings with statements like “I did something that really
helped” and “perhaps I had aided them with what could’ve been a big impact.”
Organization
The last major construct examined in this study is the organizational influences that
impact the stakeholder’s ability to achieve their goal. Teachers were surveyed regarding the type
of training for the identification and referral of students with anxiety or depression the school has
provided over the past three years. Sixty-seven percent of respondents indicated they had
received training on how to refer a student with depression and 63% replied they had been
trained on who to talk to regarding students suspected of having depression. Of the nine
questions about training around anxiety and depression, those two responses were the only ones
above 50%. The remainder of the responses range from “How to refer a student with anxiety for
evaluation” at 49% to “How to approach students I suspect may have anxiety” at 14% and, most
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notably, “None of the above” with 31%. Additionally, only 14% of those surveyed agreed or
strongly agreed with the statement “I believe my school has properly trained me to meet the
needs of students with anxiety or depression.” An additional data point to consider is the lack of
staff meeting agendas that address the specific topic of identification of students with anxiety or
depression.
These feelings described by the teachers during the interviews appear to support the
survey results as the vast majority of those interviewed indicated they did not feel the training
that the district provided was adequate or they could not recall the last time they were trained
with any degree of accuracy. Most teachers had a vague recollection of some type of training but
spoke of it as it was a very distant activity. Further, some teachers felt that the professional
development provided by their school was not relevant to their achievement of the goal of
identifying and referring students with anxiety or depression for evaluation.
Another organizational aspect examined was the degree to which the school had a clearly
articulated process in place for the referral of a student suspected of having anxiety or depression
for evaluation. In this case, 50% of the teachers indicated they agreed or strongly agreed that
their school did have clearly articulated process in place, however upon a review of documents,
no such process was discovered. Part of this articulated process would be the training of staff as
to the protocol and, much like to existence of the protocol, no such documentation was produced
as evidence.
The final organizational construct explored was the feeling of teachers regarding the level
of responsibility they feel to identify students with anxiety or depression in light of their other
job related responsibilities. In this case, 67% of the teachers surveyed disagreed or strongly
disagreed that there were too many other responsibilities related to job for them to be responsible
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for the identification of students with anxiety or depression. The response to this question
indicates that two-thirds of teachers feel they are responsible for this activity.
While agreement by 67% of the respondents is not an overwhelming number, the
interviews shed some light on the feelings held by teachers. The teachers interviewed indicated
they were conflicted by their role of being responsible. They indicated that they do feel pressures
from other aspects of their jobs but they also indicated a general agreement that they were best
positioned to identify if a student was dealing with anxiety or depression based on their daily
interaction with the students. This conflict was exemplified by one teacher who initially
indicated it was not reasonable for a teacher to be responsible for the identification of students.
In the process of explaining why this was so, she arrived at the conclusion she was uniquely
positioned to identify students with anxiety or depression and then she went on to contradict her
earlier belief. When asked the same question about if it is reasonable for a teacher to be
responsible for the identification of students with anxiety or depression, she stated “Yes, yes it
is…I want to say no…but yeah.”
Summary
In this chapter, the assumed influences outlined in previous chapters were explored as
they related to the findings from the qualitative inquiry, results from the quantitative survey and
items gathered in the documentation review. Chapter 5 will offer strategies required for the
achievement of the stakeholder goal of 100% of teachers being able to identify and refer students
suspected of having anxiety or depression for evaluation.
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CHAPTER 5
DISCUSSION AND RECOMMENDATIONS
This study seeks to understand identify the factors that promote or inhibit a teacher’s
ability to identify and refer students with anxiety or depression for evaluation. In an effort to
answer this question, data collection was undertaken utilizing quantitative, qualitative and
document review methodologies. In the previous chapter the results and findings associated with
the data collection was reported and synthesized. Based on the results, findings and synthesis,
this chapter provides a plan to close the gap between the current state of stakeholders and their
achievement of the goal of having 100% of teachers able to identify and refer students suspected
of having anxiety or depression for evaluation. The Kirkpatrick and Kirkpatrick New World
Model (2016) offers a framework for the following recommendations.
Discussion
Knowledge
Analysis of the qualitative and quantitative data revealed interesting discoveries. An
overarching theme that was revealed by the data is the notion that teachers will find a way when
none is provided. They leverage what circumstances they have to achieve their objectives, even
if those objectives are not explicit or clear. For example, while teachers were able to pick from a
list of symptoms for anxiety and depression, they did not key in on the identification of specific
symptoms as a means of detecting which students they felt were struggling with anxiety or
depression. Without fail, all of the teachers interviewed stated that they just looked for any
significant and unexplainable change in the students as an indicator. What is further interesting
about this consistent and preferred method of identification is the fact that they all seem to have
arrived at the use of this method independent of any coordinated cause. Rather, they leverage the
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power of their daily interaction with students as tool for care and intervention. The lack of a
knowledge relative to identification criteria can have a negative impact on a teacher’s ability to
properly identify a student with anxiety or depression. Given that identification is the initiating
step on the path towards evaluation and, ultimately, a student receiving services, ensuring a
clearer understanding of symptoms seems to be key to increasing the ability of teachers to
properly identify students with anxiety or depression.
The teachers procedural knowledge of the referral process also serves an example of
teachers “making it work.” Teachers reported that the methods they use to get help for students
they are concerned about is not grounded in some clearly articulated process; rather teachers use
a trial and error method. Many teachers explained that they go to individuals on campus that they
trust and have had good results with in the past as a means of referring a student. Again, rather
than accepting the idea that there is not process, the teachers persisted and acted to get a student
to a person who they believed could help. While this is admirable, one is left to think how a
coherent process with defined roles and actions could affect better results for students and more
support for teachers. An inconsistent referral method can lead to differential levels of support
and inconsistent results for students. Dix et al. (2012) found that a coordinated response to
mental illness resulted in better outcomes for students. The level of care that a student receives
can vary greatly based on the teacher. A student in the class of a well-informed and connected
teacher will benefit while a similar student in the classroom next door could languish as a result
of the random chance of teacher assignment.
The engine that seems to drive teachers to strive to help students absent methods to do so
is the presence of metacognitive reflection. The teachers all reported that they do reflect on their
performance as a method of formative feedback. The teachers all intimated they want to help
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students and consistently evaluate their performance which causes them develop and use a
method for identification and referral where one has not been clearly provided by the school.
Further, their metacognitive reflection can serve as the catalyst that leads them to continually
refine their individual process. As a result of their internal interactive progression, the teachers
arrive at actions that guide future methods. The result is a system of continuous enhancement and
refinement that functionally impacts students in a positive way. When teachers improve their
practice relative to the identification and referral of students with anxiety or depression for
evaluation, students are better served.
Motivation
Two motivational influences, self-efficacy and expectancy value, were investigated as
part of this survey. It was assumed that teachers lacked self-efficacy regarding their ability to
identify students with anxiety or depression. The data did validate that teachers lacked a strong
belief in their ability, however it seems that their belief in their ability to do this task is at odds
with their performance in this area. As previously discussed, even in the face of no real training
or support structure, the teachers do seem able to identify students as potentially having anxiety
or depression. Many of the teachers expressed the lack of specific training as a reason to cast
doubt on their ability to identify students as opposed to their actual performance. As a result of
their lack of self-efficacy, teachers may be hesitant to believe that they are correctly identifying
the criteria that would cause them to suspect a student may have anxiety or depression.
Consequently, the likelihood that a student may go unnoticed increases resulting in the absence
of evaluation and support services. The paradigm of teachers performance being at odds with
their perception provides for a strong base to grow from and highlights the need for training and
support services and tools.
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The data did not support the assumed influence that teachers did not see value, relative to
positive outcomes for students, in referring students for evaluation. The teachers did express that
they felt that their actions could have a positive impact on students. The teachers expressed that
even when they do not get the results they desire, or receive any feedback about the outcome
when they do refer a student, they still see the value of acting. Here too, the feelings expressed
by the teaching staff serves as a strong foundation upon which a coherent training plan could
have a solid footing.
Organization
Organizational influences are the last area of discussion. In this arena, there were few
findings that were surprising. The data confirmed that teachers have not really been the
beneficiaries of thoughtful, coherent and communicated processes or training. Most of the
teachers were hard pressed to recall a training that had given them the tools to identify or refer
students suspected of having anxiety or depression. Rather they would often appeared to have
strained expressions attempting to recall a professional development experience that increased
their capacity to identify or refer students with anxiety or depression. The tense expression of the
teachers was equaled by administrators when asked to produce documentation that outlined a
school created or sanctioned referral process. It appears that the district relies on an archival
system built on an oral tradition as opposed to one that is codified in writing. The absence of
objective training and process could result in students going undetected and not being evaluated;
this will lead to students being underserved and not able to fully access the curriculum.
While it was assumed that teachers would take the position that they have too many other
job related responsibilities for them to reasonably be expected to identify and refer students,
however teachers expressed the exact opposite. This area provided very interesting insights as
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some teachers were very conflicted about whether or not identifying or referring students should
be their responsibility. This conflict highlights the seriousness that teachers give to their role as
educators and as adults charged with the care of young people who are still developing. Even
though one-third of the survey respondents expressed their belief that it is unreasonable for
teachers to have the responsibility of identifying and referring students, when pressed, many of
the interview participants would likely acknowledge they do have an integral role in caring for
the emotional wellbeing of students in addition to their responsibility of math, science or history
instruction. When teachers have a belief that a particular task falls within their realm of
responsibility, they are far more likely to engage in that task. As a result, teachers are more likely
to look for students who might be struggling with anxiety or depression and refer those students
for evaluation.
Recommendations for Practice to Address KMO Influences
Knowledge Recommendations
Table 19 is a list of the assumed knowledge influences and whether the influence is
validated based on data collection through surveys and semi-structured interviews with
stakeholders. Clark and Estes (2008) have noted that knowledge related factors are integral in
increasing stakeholder performance. The assumed knowledge influences are separated into three
knowledge types. The first, declarative knowledge, describes factual or conceptual
understandings. Aguinis and Kraiger (2009) call this the “what” of knowing. The second
knowledge type is procedural knowledge, or the “how” of knowing (Aguinis & Kraiger, 2009).
The last knowledge construct is metacognition, or as Bower and Hilgard (1981) note, it is the
reflective process a learner engages in to evaluate and monitor their own thinking. In addition to
assumed knowledge influences, Table 19 also address the influences status as being validated,
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their priority, proposed recommendations to address gaps and the research to support
recommendations.
Table 19
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence
Validated
(Y,N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Declarative
Teachers do not have
the knowledge of
what support and
assessment options
are available for
students with anxiety
and/or depression
Y Y How individuals
organize
knowledge
influences how
they learn and
apply what they
know (Spector,
2015)
Mental health staff
will provide
teaching staff with
a job aid (graphic
organizer) listing
all support and
assessment options
for students with
anxiety and/or
depression.
Teachers do not
know the symptoms
of anxiety and/or
depression in
students
Y Y Information
learned
meaningfully and
connected with
prior knowledge is
stored more
quickly and
remembered more
accurately because
it is elaborated
with prior learning
(Spector, 2015).
Teachers will
participate in a
training where they
will evaluate a
series of scenarios
involving students
with anxiety and/or
depression and
receive feedback
regarding their
assessments.
Additionally,
teachers will
review a checklist
of symptoms and
characteristics they
should be aware of.
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Table 19, continued
Assumed Knowledge
Influence
Validated
(Y,N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Procedural
Teachers need to
utilize a process to
refer a student for
assessment for
qualification for
services.
Y Y To develop
mastery,
individuals must
acquire
component skills,
practice
integrating them,
and know when to
apply what they
have learned
(Spector, 2015).
Mental health staff
will lead an
exercise that guides
teachers through
role playing
scenarios where
teachers will apply
the process of
referring students.
Metacognitive
Teachers do not
know how to
evaluate their
effectiveness in
engaging in the
referral process
N N Provide
opportunities for
learners to debrief
the thinking
process upon
completion of
learning task
(Baker, 2006).
Mental health staff
will train teachers
in a questioning
exercise to enable
the teachers to self-
evaluate their
effectiveness in
utilizing the referral
process.
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97
Declarative knowledge solutions, or description of needs or assets.
Declarative knowledge relates to the factual or conceptual pieces of a person’s
understanding; or as Aguinis and Kraiger (2009) describe, declarative knowledge is the “what”
of knowing. The data gathered from the teaching staff of the two comprehensive high schools of
the Mission Valley Unified School District (MVUSD) indicates the teachers are not aware of the
support and assessment services available to students with anxiety or depression. An appropriate
method for increasing the knowledge of the teaching staff so they are more aware of the support
and assessment options for students with anxiety and depression is to provide a job (Clark &
Estes, 2008). In this case, the mental health staff at the two high schools of MVUSD will provide
teaching staff with graphic organizer that contains all the support and assessment options for
students with anxiety or depression. The introduction and use of a job aid assists learners in the
organization of knowledge and can influence how the learners apply their knowledge with the
goal of increasing outcomes (Spector, 2015).
An additional declarative knowledge influence explored was the degree to which the high
school teachers of the MVUSD are able to identify the symptoms of anxiety or depression. In
this case, the data revealed they are not aware of the specific symptoms of anxiety or depression.
In an effort to increase their ability to identify the symptoms of anxiety or depression in students,
training is recommended. Clark and Estes describe training as “any situation where people must
acquire…knowledge and skills, and need practice and corrective feedback to help them achieve
specific work goals” (p. 59). In this case, teachers will participate in a training where they will
evaluate a series of scenarios involving students with anxiety and/or depression and receive
feedback regarding their assessments. Additionally, teachers will receive and review a job aid in
the form of a checklist of symptoms and characteristics of anxiety and depression they should be
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98
aware of. Learning the symptoms of anxiety and depression in this fashion will increase the
teacher’s ability to retain and apply the new material because information learned meaningfully
and connected with prior knowledge is stored more quickly and remembered more accurately
when elaborated with prior learning (Spector, 2015).
Procedural knowledge solutions, or description of needs or assets.
Procedural aspects of knowledge were also examined for this study. In his revision of
Bloom’s Taxonomy, Krathwohl (2002) indicates that procedural knowledge relates to “how to
do something” (p. 214). The teachers of the MVUSD are largely unaware of a procedure for the
referral of students suspected of having anxiety or depression for evaluation as they have
indicated they have not had specific training in utilizing an articulated process for referral.
Schraw and McCrudden (2003) note that individuals are not able to build their capacity for the
application of procedures without the acquisition of the component skills, practice in applying
those skills and support in the integration of procedures in daily tasks. The findings of Schraw
and McCrudden would suggest learners could increase procedural knowledge through a series
training opportunities that include information and feedback on performance. To that end, it is
recommended the Mental Health staff design and implement training that instructs teachers about
the procedure for referring a student with anxiety or depression for evaluation. Additionally, the
training should include scenarios where teachers can apply their knowledge and receive feedback
regarding performance.
A study of 32 middle school teachers in Sao Paulo, Brazil by Vieira et al. (2014)
examined the role of training in increasing the rate of referrals for mental health concerns. The
study had teachers review scenarios to establish a baseline of referral rates. After a baseline was
established, the teachers participated in a training program that was followed up with another set
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of scenarios. The post-test showed that the number of teachers who were able to correctly refer
students with mental health concerns increased by 60% as a result of their participation in a
training program.
Motivation Recommendations
Based on the completed data collection for this project, Table 20 is a list of the assumed
motivational influences and whether the assumed influence has been validated based on data
collection through surveys and semi-structured interviews with stakeholders. Motivation is an
important catalyst that is the foundation for converting one’s knowledge into action. Clark and
Estes (2008) have described motivation as the choice to expend effort and persist in a task with
the goal of accomplishing specific outcomes. Mayer (2010) expands on the definition of
motivation and states that motivation is “an internal state that initiates and maintains goal
directed behavior” (p. 39). The assumed motivational influences in Table 20 are grounded in the
motivational constructs of self-efficacy and expectancy value. Bandura (2000) defined self-
efficacy as the belief that one “can produce desired effects and forestall undesired ones by their
actions” (p. 75). Expectancy-value is the utility one assigns to the engagement or completion in a
task (Eccles & Wigfield, 2002). Table 20 also address those influences that were validated, their
priority, proposed recommendations to address gaps and the research to support
recommendations.
Teachers of the MVUSD lack self-efficacy relative to their belief in their ability to
identify students with anxiety or depression. Providing learners with modeling and effective
feedback can increase self-efficacy (Pajares, 2006). Utilizing a professional development plan
that incorporates the use of trained staff to serve as models and offer instantaneous and
interactive feedback can increase self-efficacy. With the finding of Pajares in mind, it is
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100
recommended that the Mental Health staff implement a staff development opportunity where
they serve as the model for the identification of students with anxiety or depression. Further, the
training should allow teachers to test their identification skills using scenarios and receive
feedback regarding their performance from the Mental Health staff.
Table 20
Summary of Motivation Influences and Recommendations
Assumed Knowledge
Influence
Validated
(Y,N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Self-Efficacy
Teachers need to
believe they are
capable of
effectively
identifying students
with anxiety and/or
depression
Y Y Feedback and
modeling
increases self-
efficacy
(Pajares, 2006).
Mental health staff will
train teachers to
identify the signs of
anxiety and depression
in students. During the
training process,
teachers will receive
feedback and coaching
regarding their
performance.
Expectancy Value
Teachers need to see
the value in referring
students for
evaluation.
N N
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While specific examinations relative to the relationship between training and self-efficacy
of educators is scarce, a study of the role of training for clergy and its impact on identification
rates of mental illness conducted by Hedman (2013) provides support for the previous
recommendation. Hedman studied 367 members of the clergy in Minnesota regarding their
perceived ability to identify parishioners with mental health needs. While a variety of factors
were positively correlated to a clergy member having high self-efficacy relative to their ability to
identify those with mental illness, prior training had the strongest correlation with self-efficacy.
Organization Recommendations
With data collection complete for this project, Table 21 is a list of the assumed
organizations influences and whether the assumed influence has been validated based on data
collection through surveys and semi-structured interviews with stakeholders as well as document
review. While motivation and knowledge influences are key in identifying and referring students
suspected of having anxiety or depression for evaluation, organizational influences give structure
to the will and the skill of stakeholders. The organizational influences fall into the categories of
cultural settings or cultural models. According to Rueda (2011), cultural settings are the tangible
aspects of a work environment and cultural models are the rules, structures and norms that are
not formal or written, but rather cultural models are functionally invisible. Table 21 also address
those influences that have been validated, their priority, proposed recommendations to address
gaps and the research to support recommendations.
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Table 21
Summary of Organization Influences and Recommendations
Assumed Knowledge
Influence
Validate
d
(Y,N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Cultural Setting
Influence
Teachers lack the
professional
development needed
to gain the necessary
tools to identify and
refer for evaluation,
a student with
anxiety and/or
depression.
Y Y Ensuring staff’s
resource needs are
being met is
correlated with
increased student
learning outcomes
(Waters, Marzano, &
McNulty, 2003).
School leadership will
allocate resources to
have mental health staff
develop and implement a
series of trainings
designed to build
capacity of teachers to
identify and refer
students with anxiety or
depression for evaluation
Cultural Setting
Influence
Teachers are not
provided with a
structure and/or
process for the
referral of a student
suspected of having
anxiety and/or
depression
Y Y Goals must be
aligned with the
structures and
processes so that
workers can be
successful in
achieving objectives
(Clark & Estes,
2008).
School staff will work to
develop a process
teachers will use to refer
students for evaluation
and create a job aid (flow
chart) for teachers to use
in referring students.
Additionally, staff will
implement a series of
professional
development modules to
train staff on referral
procedures.
Cultural Model Influence
Faculty are resistant
to taking on new
initiatives due a
feeling that new
initiatives are
temporary and
passing.
N N None
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Site and district administrators have not provided the necessary professional development
teachers need to acquire the tools to identify and refer students with anxiety or depression for
evaluation. Waters et al. (2003) noted that meeting the resource needs of workers is positively
correlated with increased outcomes. Based on this idea, it is incumbent upon leadership to
ensure, through training, that teachers have the skills required to identify the characteristics of
anxiety or depression in students and use the referral process. To meet objective, it is
recommended school site and district leadership allocate resources to have the mental health staff
develop and implement a series of trainings designed to build capacity of teachers to identify and
refer students with anxiety or depression for evaluation.
Trudgen and Lawn (2011) found that teachers believed their lack of training regarding
mental illness as the greatest factor in their inconsistent and variable rate of identification of
students with mental health disorders. This would support what the teachers at the MVUSD
reported regarding their experiences relative to their feelings about their training. A meta-
analysis of various mental health identification approaches for educators concluded training
approaches that consist of multiple modes can increase the learner’s ability to better recognize
mental illness in students (Lyon, Wiltsey, Kerns, & Bruns, 2011). Further, a study of Brazilian
teachers found training to increase the ability of teachers to identify and refer student with
mental illness by 60% (Vieira et al., 2014). The recommendation for increased professional
development as a method of increasing a teacher’s ability to identify and refer student with
anxiety and depression is supported by research.
Teachers of the MVUSD reported the school site does not have an articulated process for
referring a student suspected of having anxiety or depression. Clark and Estes (2008) note that
structures and processes must be aligned with goals to facilitate stakeholder success in meeting
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
104
expected outcomes. For teachers to meet anticipated outcomes, the school site should have a
clear, consistent and articulated method for referral of students suspected of having anxiety or
depression. To facilitate the teachers in achieving their goal, school site staff should work
collaboratively to develop a process for the referral of students, create a job aid in the form of a
flow chart for dissemination among the school staff and, lastly, implement a series of trainings to
build capacity of teachers to utilize the referral process.
If there is an expectation that teachers achieve a specific outcome, referring students for
evaluation in the present case, there must be an accompanying structure to support the teacher in
accomplishing their task. Schneider et al. (1996) noted a directive from management alone does
not constitute a sufficient level of structure to facilitate a behavioral change. The establishment
of functional procedures have been shown to serve as an effective means of increasing the
likelihood of workers to engage in desired behavior (Anthony & Del Bueno, 1993). Additionally,
when managers accept responsibility and facilitate the development, implementation and
monitoring of procedures, there is an increase in use of those procedures. The recommendation
for addressing the lack of procedures and structures for referring students suspected of having
anxiety or depression is well supported by the body of literature referenced here.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The foundation for the implementation and evaluation framework is the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016). This model consists of four distinct
Levels. The first is Level 1 and consists of reaction by learners to a training experience. Level 2
address the learning that takes place as a result of engaging in a training. The next level is Level
3 and examines the degree to which a behavioral change has occurred by the learning in their
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
105
work context. Level 4 deals with the results that are realized by the overall organization as an
outcome of engaging in the overall training program. Along the way, monitoring and feedback
are included to ensure that desired behaviors are occurring and are reinforced.
Organizational Purpose, Need and Expectations
The ability of teachers to identify and refer students with anxiety or depression for
evaluation is an important component of ensure students can access services. When students are
identified, and receive support services, they are better positioned to avail themselves of the
educational program the school has to offer. This project examined the knowledge, motivation
and organizational factors that promote or inhibit a teacher’s ability to identify and refer students
with anxiety or depression for evaluation. Proposed recommendations include the development
of a system for referral, job aids and increased training. Adherence to the proposed
recommendations should bring about the desired outcome of increasing a teacher’s ability to
identify students with anxiety or depression and successfully referring those students for
evaluation so the students can receive services to address their mental health challenges.
Level 4: Results and Leading Indicators
The proposed Level 4 Results and Leading Indicators broken out by outcomes, metrics
and methods for internal, as well as external indicators are indicated in Table 22. If the outcomes
identified in Table 22 are achieved, accurate identification of students with anxiety or depression
should occur followed by the achievement of external indicators.
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106
Table 22
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
External Outcomes
Improved parent
perception regarding
school support
The rate of parents reporting
they feel the school provides a
supportive environment for
their student
Compare annual survey
results on Parent section of
California Healthy Kids
Survey
Internal Outcomes
Increased usage of site
defined referral process
The number of referrals the site
based Multi-Disciplinary Team
receive.
Aggregate data collected by
Multi-Disciplinary Teams.
Increased ability of
teachers to identify the
signs of anxiety and
depression in students
Increased ratings on key
questions
Compare annual survey
results
Level 3: Behavior
Critical behaviors. Table 23 reflects the behaviors identified as indicators that the
stakeholder group, teachers, are progressing toward the achievement of their goal. To meet the
stated goal teachers must be able to accurately identify students suspected of having anxiety or
depression. The second critical behavior requires teachers to correctly complete the referral
process for those students believed to have anxiety or depression. The last critical behavior is the
evaluation of students by a multi-disciplinary team to determine if the student has anxiety or
depression.
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107
Table 23
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s) Method(s) Timing
1. Teachers identify
symptoms of anxiety
and depression in
students
Teacher rating on
assessment
Mental Health team
will assess teachers
ability at staff
meetings
Monthly for the first
school year.
Thereafter — semi-
annually so long as
previously successful
2. Teachers correctly
complete referral
process
The number of
referrals correctly
routed to
appropriate staff
The Multi-disciplinary
Team Lead will track
the incoming referrals
Bi-weekly for the
first 90 days
Thereafter —
monthly so long as
previously successful
3. Multi-Disciplinary
Teams evaluate
students suspected of
having anxiety or
depression
The number of
students referred
to the Multi-
Disciplinary
Team
Multi-Disciplinary
Team will report to
the administration the
number of students
evaluated each month
Monthly for the first
school year.
Thereafter — semi-
annually so long as
previously successful
Required drivers. To reinforce the stakeholders in attaining the goal, the site and
district administration should provide job aids to assist teachers in identification or students with
anxiety or depression and assessments to evaluate the teacher’s skills. Counselors or
administrators will provide timely feedback regarding the teacher’s successful completion the
referral process as a means of encouraging teachers. Additionally, feedback about the positive
impact experienced by students as a result of being referred for evaluation will be shared with
staff.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
108
Table 24
Required Drivers to Support Critical Behaviors
Methods Timing
Critical Behaviors
Supported (1, 2, 3)
Reinforcing
Job aid outlining the referral process for teachers to
reference
Ongoing 1, 2, 3
Job aid with signs of anxiety and depression for teachers
to reference
Ongoing 1, 2, 3
Assessments to evaluate teachers ability to identify
students with anxiety and depression
Monthly 1, 2, 3
Encouraging
Feedback regarding usage of evaluation process Ongoing 1, 2, 3
Rewarding
Feedback from students regarding the impact of receiving
help from teachers
Monthly 1,2,3
Monitoring. A variety of methodologies will be utilized to ensure accountability of
stakeholders and support the implementation of desired behaviors with an overall goal of
achieving the overall organizational performance. Monitoring activities include the use of
surveys, observational data, evaluation of key outcome measures like referral rates and
individual interviews. Consistent monitoring will allow for formative evaluation and the ability
to make real-time adjustments to training plans in an effort to better support stakeholders in the
achievement of their performance goals.
Organizational support. Organizational support of the suggested recommendation is
key to their successful implementation. The MVUSD should support the stakeholders in
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
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achieving their goals by ensuring that training programs, organizational structures and job aids
are in place. The school district will find a greater level of success in achieving its overall
mission and goals when the support mechanisms are operationalized for stakeholders. In doing
this, stakeholders will be better positioned to integrate new behaviors into their existing job
functions, thereby moving the organization in the direction of systemic change.
Level 2: Learning
Learning goals. At the completion of the recommended training and professional
development experiences, the stakeholders will be able to:
1. Identify the signs and symptoms of anxiety and depression in youth,
2. Describe the role of the Multi-Disciplinary Team within the context of the referral
process,
3. Apply the process of referring a student for evaluation using the prescribed
procedure,
4. Express value in identifying and referring students with anxiety or depression for
evaluation,
5. Express confidence in their ability to accurately identify a student displaying the signs
and symptoms of anxiety and depression
6. Express confidence in their ability to accurately utilize the correct referral procedure.
Program. The previous learning goals will be achieved through a professional
development that stakeholders will participate in. At the end of the training, the stakeholders will
be able to describe the signs and symptoms of anxiety and depression in students, describe the
process for referring students suspected of having anxiety or depression and complete the referral
process. Stakeholders will gain the required knowledge and skills by engaging a variety of
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
110
activities. Information will be presented and participants will have the opportunity to utilize a job
that will outline the signs and symptoms of anxiety and depression that might be displayed by
students. Additionally, participants will apply their identification skills by reviewing scenarios
and stating which students in the scenarios are displaying the symptoms of anxiety or depression.
Instructors will provide timely feedback to participants during this phase of the training.
An additional job aid will be given that guides participants through the referral process.
Using the job aid for the referral process, participants will practice completing a referral for
evaluation with real-time feedback provided by instructors. At the completion of the referral
exercise, participants will engage in a facilitated conversation regarding their belief about their
ability to apply learning to their work environment. This discussion will be followed by an
exercise where stakeholders will complete an action plan outlining their proposed steps to
integrate the identification and referral skills into their work context.
Components of learning. In an effort to support the learning and application of new
knowledge and skills, a comprehensive evaluation plan will be used. Table 25 outlines the tools
and timelines used to evaluate and reinforce the knowledge and skills required to achieve target
behaviors. Participants must be knowledgeable and confident in their new abilities. Additionally,
participants need to believe there is value in transferring learning to their daily work tasks.
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
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Table 25
Components of Learning for the Program
Methods or Activities Timing
Declarative Knowledge “I know it.”
Checks for understanding using multiple choice Pre-training
Checks for understanding using multiple choice Periodically during
training experience
Group presentations/Gallery walk Periodically during
training experience
Procedural Skills “I can do it right now.”
Scenario analysis and feedback using multiple choice Periodically during
training experience
Completion of documents using scenarios Periodically during
training experience
Pre and post survey regarding participants ability to apply
knowledge and skills
Post-training
Attitude “I believe this is worthwhile.”
Participant discussions regarding positive outcomes as a
ramification of using skills and knowledge
Periodically during
training experience
Pre and post survey regarding participants belief about value of
using skills and knowledge
Post-training
Confidence “I think I can do it on the job.”
Discussions following scenarios Periodically during
training experience
Pre and post survey items Post-training
Commitment “I will do it on the job.”
Participants develop plan for integrating skills and knowledge
into work context
Periodically during
training experience
Pre and post survey items Post-training
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Level 1: Reaction
Three aspects of reaction to the training experience will be evaluated in a variety of
methods. The three aspects of reaction are Engagement, Relevance and Customer Satisfaction.
Table 26 outlines the methodologies and tools used, as well as timing for Level I evaluation
activities.
Table 26
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Observable on-task behavior During the training experience
Completion of training activities During the training experience
Course evaluation Two weeks post-training
Relevance
Course evaluation Two weeks post-training
Instructor evaluation of participant discussion During the training experience
Customer Satisfaction
Course evaluation Two weeks post-training
Instructor evaluation of participant discussion During the training experience
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Evaluation Tools
Immediately following the program implementation. Course evaluation surveys will
be used to collect Level I data relative to Engagement, Relevance and Customer Satisfaction.
Participants will complete brief survey (Appendix E) items about the applicability of learned
skills within their work context as well as the degree to which the participants they believed the
professional development was of interest to them. Finally, the survey will serve to ascertain the
participants beliefs and feelings about the professional development overall.
Additional Level 1 data will be be collected during the professional development
experience. Presenters will monitor participants to evaluate the degree to which participants are
engaged in the specified professional development activities and rate of completion of activities.
Presenters will also monitor the type and depth of discussions participants are engaged in while
they are performing tasks.
Delayed for a period after the program implementation. In an effort to support the
transition of new learning into a sustained and actionable workplace implementation, post-
training evaluation will be conducted. Six and 15 weeks after training a Blended Evaluation tool
(Appendix F) will be used to gain insight into the degree to which participants believe the
training was relevant and if they are satisfied with experience (Level I). Additionally, the survey
will also seek to understand the participant’s perspective regarding the degree to which the
content of the training can be applied to their work (Level II). Lastly, the survey will gather data
about the amount of behavioral change that has been realized as a result of professional
development activities (Level III).
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Data Analysis and Reporting
The Level IV goal of teachers identifying and referring students with anxiety or
depression for evaluation will be tracked and presented on a weekly basis. Administrators will
track the number of referrals made using the prescribed process as well as the number of referrals
made using the incorrect process. A visual tracking system consisting of a dashboard that
displays the number of referral correctly and incorrectly made will be used to convey the
referrals in actual numbers as well as on a percentage basis. A visual reporting process will be
used to report the data gathered for Level 1, 2 and 3 monitoring as well.
Recommendations for Implementation
While the previous recommendations have been primarily focused on the sites that were
the focus of this study, it is important to recognize that the MVUSD is a unified school district
with multiple schools and the school district as a whole could benefit from a systemic approach
to building the capacity of all teachers and administrators. As such, it is recommended that the
MVUSD engage in a systemic approach to training and monitoring. As a unified school district,
it is not uncommon for students to move between schools. Absent a district wide initiative, it is
likely that a student may have a vastly different experience from school to school and allowing
this to continue can lead to unequitable academic outcomes.
To achieve this systemic change, the inclusion of administrative staff in development and
training activities can serve to build their capacity to own and drive the necessary changes to
achieve the stakeholder goals. Administrators would be well served to be exposed to the
professional development strands designed to increase their knowledge and motivation around
identification and referral of students with anxiety or depression. Additionally, given the
importance of monitoring for the successful implementation of a change initiative, the addition
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
115
of the ideals set forth by the Kirkpatrick and Kirkpatrick (2016) model could provide for a
common understanding among administrative staff.
Early participation by administrators is also recommended. Administrators have the
ability to influence the message delivered to their site staff. If administrators feel they are
subjected to another “district” initiative, they may present change efforts to their teachers in a
manner that conveys ambivalence or disdain. However, if administrators are part of the
development and creation of a common vision, they may have an increased sense of buy in that
can translate to a message of importance and ownership to staff. Early foundational activities
such as resource mapping, mission development and process creation can be valuable steps
toward a successful implementation.
Lastly, given the infinite competition for finite time and resources, the district should
explore a variety of training modes. In person training is expensive as well as time consuming,
however, internet based training can be delivered for less cost and significantly less human
capital. While not appropriate for all training topics, more basic subjects can be covered through
instructional videos or automated presentations. Monitoring of completion can be achieved
through checks for understanding built into the training platform and final certification at the
completion of specified modules. In concert with teachers and administrators, additional training
options can be explored and piloted.
Summary
The New World Kirkpatrick Model is designed to guide the change process of an
organization toward the achievement of an overall objective or goal. The overall of goal of
having 100% or teachers with the ability to identify and refer students with anxiety or depression
for evaluation is supported through the application of the New World Kirkpatrick Model. The
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
116
four phases support the training and implementation of new behaviors for teachers. Training is
designed to be engaging and provide the necessary tools for stakeholders to transfer learned
skills into their existing work context. Further, the monitoring aspects of the Model are key in
ensuring that key drives and behaviors are extended beyond a training context. Additionally,
Level 4 monitoring is used to track progress toward an overall organizational goal and allows for
adjustments to be made in an effort to make course corrections as needed. It is expected that
when the MVUSD supports and implements the training and monitoring, as laid out in the New
World Kirkpatrick Model, the organization will realize the achievement of the stated goal.
Conclusion
With the rise in school age youth afflicted with some type of mental illness coupled with
the increasing pressures on school systems to increase academic outcomes for students, this
study sought to examine the role teachers could play in connecting students to support services.
In light of the continuous relationship students and teachers have, it is logical to explore the
knowledge, motivational and organizational factors that allow or impede teachers in identifying
and referring students suspected of having anxiety or depression for evaluation.
This study exposed areas for growth for a school system and highlighted some strong
foundational characteristics that can serve as a point of departure for increasing the capacity of
teachers to better identify and refer students suspected of having anxiety or depression. Further,
this study presented the need for a coordinated and well communicated organizational structure
that builds the knowledge of teachers and increases their motivation so students can be better
served. When schools can create supports that free students of external stressors, students,
teachers and school communities are better positioned to realize their full potential.
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APPENDIX A
SURVEY PROTOCOL
This section examines anxiety related factors
1. If you have a student in your class you suspect may have anxiety, which of the following
symptoms (if any) would you look for in the student (check all that apply)?
__ Non-attendance
__ sleepiness
__ over activity
__ constant need for validation
__ lack of work completion
__ irritability
__ withdrawn
__ none of the above
2. In the last 3 years, the school district has provided me training on the following areas (check
all that apply)
__ identifying symptoms of anxiety
__ how to refer a student with anxiety for evaluation
__ who to talk to regarding students whom I suspect may have anxiety
__ how to approach students I suspect may have anxiety
__ none of the above
3. In the past 3 years, this school has trained me on the process for referring a student with
anxiety for evaluation
__ never
__ once
__ twice
__ 3 times
__ 4 or more times
This section examines depression related factors
4. If you have a student in your class you suspect may have depression, which of the following
symptoms (if any) would you look for in the student (check all that apply)?
__ Non-attendance
__ sleepiness
__ overly emotional
__ rapid change in weight
__ lack of work completion
__ irritability
__ withdrawn
__ none of the above
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5. In the last 3 years, the school district has provided me training on the following areas (check
all that apply)
__ identifying symptoms of depression
__ how to refer a student with depression for evaluation
__ who to talk to regarding students whom I suspect may have depression
__ how to approach students I suspect may have depression
6. In the past 3 years, this school has trained me on the process for referring a student with
depression for evaluation
__ never
__ once
__ twice
__ 3 times
__ 4 or more times
7. As a teacher, in thinking about my role in assisting a student with anxiety, indicate your level
of agreement with the following statements:
I believe I can have a great impact on the life of a student with anxiety or depression
Strongly Disagree Disagree Agree Strongly Agree
I believe I can help to increase the academic achievement of a student with anxiety or
depression
Strongly Disagree Disagree Agree Strongly Agree
I believe I can have a positive impact on a student with anxiety or depression
Strongly Disagree Disagree Agree Strongly Agree
I believe it is my responsibility to look for students who may have anxiety or depression
Strongly Disagree Disagree Agree Strongly Agree
My school has a clearly articulated process for referring a student with anxiety or depression
for evaluation
Strongly Disagree Disagree Agree Strongly Agree
I believe I am qualified to address the needs of students with anxiety or depression
Strongly Disagree Disagree Agree Strongly Agree
I believe my school has properly trained me to meet the needs of students with anxiety or
depression
Strongly Disagree Disagree Agree Strongly Agree
I believe I there are too many other responsibilities related to my teaching duties for me to be
responsible for identifying student with anxiety or depression
Strongly Disagree Disagree Agree Strongly Agree
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8. When I am concerned about a student whom I suspect may have anxiety, I do the following
(check all that apply)
__ speak directly with the student about my concern
__ call the parent to discuss my concern
__ talk to a school-based mental health professional
__ let an administrator know of my concern
__ discuss the student with a colleague
__ make a referral to the appropriate person for the student to be evaluated
__ None of the above
9. My school has the following services available for students with anxiety or depression
__ individual counseling
__ group counseling
__ 504 plans
__ peer support programs
__ mindfulness training
__ none of the above
10. I have received training on identifying students with anxiety or depression from the
following sources (check all that apply)
__ my current school district
__ a previous school district
__ my credential program
__ my undergraduate degree program
__ professional development outside of school
__ none of the above
__ other _____________________________________________________________
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APPENDIX B
INTERVIEW PROTOCOL
1. In thinking of a time when you had a student in your class you suspected had anxiety, what
was that experience like?
a. How did you discover the student had anxiety?
b. What did you do once you discovered the student had anxiety?
c. Were you successful in getting help for the student?
d. Why or why not?
e. What do you think would have happened to the student if you had not realized he/she
had anxiety?
2. In thinking of a time when you had a student in your class you suspected had depression,
what was that experience like?
a. How did you discover the student had depression?
b. What did you do once you discovered the student had depression?
c. Were you successful in getting help for the student?
d. Why or why not?
e. What do you think would have happened to the student if had not realized he/she had
depression?
3. What are some of the ways you have developed your knowledge about student mental health
challenges?
a. How has the school supported you in developing your knowledge?
b. How did your teacher preparation program support you in developing your
knowledge?
c. Are there any other ways you have developed your knowledge of mental health
challenges?
d. In thinking about all of your training and experience, do you believe you are capable
of identifying students with anxiety or depression?
e. Why or why not?
4. What services are available at your school to support students with anxiety or depression?
a. How do these services support students with anxiety or depression?
b. How effective are these programs?
5. How do you know if you have done a good job meeting the mental health needs of students?
a. What process do you use to make this determination?
6. If you had a student in your class tomorrow you suspected had anxiety or depression, what
process would you use to refer that student for evaluation?
a. How did you become aware of this process?
b. Typically, what type of information do you receive about the results of the evaluation
process for the students you refer?
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7. In thinking of your responsibilities as a teacher, is it reasonable for teachers to be expected to
identify and refer students with anxiety or depression for evaluation?
a. Why or why not?
8. How could your school build your capacity in the area of supporting students with anxiety or
depression?
a. What training is needed?
b. How can the district facilitate your needs?
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136
APPENDIX C
INFORMATION/FACTSHEET FOR RESEARCH
University of Southern California
Rossier School of Education
3470 Trousdale Parkway
Los Angeles, CA 90089
INFORMATION/FACTS SHEET FOR EXEMPT NON-MEDICAL RESEARCH
Factors That Promote or Prohibit a Teacher ’s Ability to Identify and Refer Students with
Anxiety or Depression for Evaluation
You are invited to participate in a research study. Research studies include only people who
voluntarily choose to take part. This document explains information about this study. You should
ask questions about anything that is unclear to you.
PURPOSE OF THE STUDY
The purpose of this study is to understand the factors which effect your ability to identify and
refer students with anxiety or depression for evaluation so strategies can determined which will
assist educators in improving educational outcomes for students.
PARTICIPANT INVOLVEMENT
If you agree to participate in the study, you will be asked to fill out a survey which is anticipated
to take 15 minutes. You do not have to answer any questions you do not want to. You may also
be asked to participate in an interview lasting approximately 1 hour. Guided questions will be
asked but the interview will be conversational and follow-up questions may be asked as well.
The interview will be audio recorded. You do not have to answer any questions you do not want
to. If you do not want to be taped, you will not be able to participate in the interview portion of
the study.
PAYMENT/COMPENSATION FOR PARTICIPATION
All participants in the survey portion of the study will be entered into a drawing for a $10 gift
card. The drawing will be held upon completion of the survey and winner will be notified in
person. All participants in the interviews will receive $10 visa gift card for your time. You do not
have to answer all of the questions in order to receive the card. The card will be given to you at
the completion of the interview session.
ALTERNATIVES TO PARTICIPATION
Your alternative is to not participate. Your relationship with your employer will not be affected
whether you participate or not in this study.
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CONFIDENTIALITY
You will not be asked to identify yourself in the survey or the interview. The interview will be
facilitated by a researcher. You have the right to review and edit the audio recordings or
transcripts. Only the professional transcriber and lead researcher will have access to the audio
recordings. The audio recording will be destroyed once they have been transcribed. The
transcripts will be stored on a password protected computers in a secure office by the lead
researcher.
The members of the research team, the funding agency and the University of Southern
California’s Human Subjects Protection Program (HSPP) may access the data. The HSPP
reviews and monitors research studies to protect the rights and welfare of research subjects.
When the results of the research are published or discussed in conferences, no identifiable
information will be used.
INVESTIGATOR CONTACT INFORMATION
Principal Investigator
Benjamin J. Gonzales
Tel: (408) 823-7208
Email: bjgonzal@usc.edu
IRB CONTACT INFORMATION
University Park Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los
Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu
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138
APPENDIX D
INTERVIEW VOLUNTEER FORM
University of Southern California
Rossier School of Education
3470 Trousdale Parkway
Los Angeles, CA 90089
Interview Volunteer Form
Factors That Promote or Prohibit a Teacher ’s Ability to Identify and Refer Students with
Anxiety or Depression for Evaluation
You are invited to participate in an interview as part of a research study. Research studies
include only people who voluntarily choose to take part. This document explains information
about this study. You should ask questions about anything that is unclear to you.
PURPOSE OF THE STUDY
The purpose of this study is to understand the factors which effect your ability to identify and
refer students with anxiety or depression for evaluation so strategies can determined which will
assist educators in improving educational outcomes for students.
PARTICIPANT INVOLVEMENT
If you agree to participate in the interview portion of this study, you will be asked to participate
in an interview lasting approximately 1 hour. Guided questions will be asked but the interview
will be conversational and follow-up questions may be asked as well. The interview will be
audio recorded. You do not have to answer any questions you do not want to. If you do not want
to be taped, you will not be able to participate in the interview portion of the study.
PAYMENT/COMPENSATION FOR PARTICIPATION
All participants in the interviews will receive $10 visa gift card for your time. You do not have to
answer all of the questions in order to receive the card. The card will be given to you at the
completion of the interview session.
ALTERNATIVES TO PARTICIPATION
Your alternative is to not participate. Your relationship with your employer will not be affected
whether you participate or not in this study.
CONFIDENTIALITY
You will not be asked to identify yourself in the survey or the interview. The interview will be
facilitated by a researcher. You have the right to review and edit the audio recordings or
transcripts. Only the professional transcriber and lead researcher will have access to the audio
recordings. The audio recording will be destroyed once they have been transcribed. The
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
139
transcripts will be stored on a password protected computers in a secure office by the lead
researcher.
The members of the research team, the funding agency and the University of Southern
California’s Human Subjects Protection Program (HSPP) may access the data. The HSPP
reviews and monitors research studies to protect the rights and welfare of research subjects.
When the results of the research are published or discussed in conferences, no identifiable
information will be used.
INVESTIGATOR CONTACT INFORMATION
Principal Investigator
Benjamin J. Gonzales
Tel: (408) 823-7208
Email: bjgonzal@usc.edu
IRB CONTACT INFORMATION
University Park Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los
Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu
I would like to volunteer to participate in the interview portion of this study. I understand that I
will be contacted to arrange an interview at a time a location that is agreeable to myself and the
researcher. I will make reasonable efforts to make myself available to the researcher for the
purposes of completing the interview. I further understand that, even though I volunteer to
participate in the interview portion of this study, I may not be chosen to participate.
My name is ___________________________________________________________________
My email address is _____________________________________________________________
My phone number is ____________________________________________________________
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
140
APPENDIX E
SATISFACTION SURVEY
Level II – Declarative
I know the process for referring a student I suspect has anxiety or depression for evaluation
Strongly Disagree Disagree Agree Strongly Agree
Level II – Procedural
Participants will complete a sample referral form and trainers will collect them and give
feedback during the training
Level II – Attitude
I believe it is important to refer a student I suspect has anxiety or depression for evaluation
Strongly Disagree Disagree Agree Strongly Agree
Level II – Commitment
When I encounter a student whom I suspect has anxiety or depression, I will refer that student for
evaluation
Strongly Disagree Disagree Agree Strongly Agree
Level I – Engagement
The information provided in the training was interesting to me
Strongly Disagree Disagree Agree Strongly Agree
Level I – Relevance
The information presented in the training was useful in the execution of my job duties
Strongly Disagree Disagree Agree Strongly Agree
Level I – Customer Satisfaction
The training I participated in today met my expectations
Strongly Disagree Disagree Agree Strongly Agree
REFERRAL OF STUDENTS WITH ANXIETY OR DEPRESSION
141
APPENDIX F
BLENDED EVALUATION TOOL
1. Participating in the training was a good use of my time
Strongly Disagree Disagree Agree Strongly Agree
2. I know the process for referring a student I suspect has anxiety or depression for evaluation
Strongly Disagree Disagree Agree Strongly Agree
3. I am able to complete the process for referring a student with anxiety or depression for
evaluation.
Strongly Disagree Disagree Agree Strongly Agree
4. In the past three months I have successfully referred a student with anxiety or depression for
evaluation.
Strongly Disagree Disagree Agree Strongly Agree
Abstract (if available)
Abstract
With the rise of school age youth presenting with anxiety or depression, the role of school systems as a place where students are identified and evaluated is being reexamined. The traditional function of school as singularly focused on educational endeavors is increasingly called into question. Given the concentration of young people for prolonged periods of time gives rise to the notion that schoolhouses can play a significant part in identifying and supporting students with anxiety or depression. In light of the continuous relationship teachers share with students, this study seeks to examine the role teachers play in identifying and referring students with anxiety or depression for evaluation. The Clark and Estes Gap Analysis Framework serves a framework for the examination of the knowledge, motivation and organizational structures that promote or inhibit a teacher’s ability to identify and refer a student suspected of having anxiety or depression for evaluation. Through the use of a mixed methods evaluation model, this project identified a need for teachers to increase their knowledge regarding symptoms of anxiety and depression as well as knowledge of support services on their campuses. While teachers believe it is value in referring a student for evaluation, they lack a strong sense of self-efficacy to identify students in need evaluation. Lastly, there is an absence of a coherent and well-communicated process for referral as well as an articulated and coordinated professional development plan. The findings and results of data collection highlight the need for the development of process and procedures that will guide teachers in referring a student for evaluation as well as the training required to support the building of teachers capacity to identify students suspected of having anxiety or depression.
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University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Gonzales, Benjamin Joseph
(author)
Core Title
Factors that promote or inhibit a teacher’s ability to identify and refer students with anxiety or depression for evaluation
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Publication Date
07/14/2017
Defense Date
06/20/2017
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anxiety,Depression,identify,OAI-PMH Harvest,refer,teacher
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Mora-Flores, Eugenia (
committee chair
), Hirabayashi, Kimberly (
committee member
), Plough, Barbara (
committee member
)
Creator Email
begonz@sbcglobal.net,bjgonzal@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c40-398552
Unique identifier
UC11264307
Identifier
etd-GonzalesBe-5510.pdf (filename),usctheses-c40-398552 (legacy record id)
Legacy Identifier
etd-GonzalesBe-5510.pdf
Dmrecord
398552
Document Type
Dissertation
Rights
Gonzales, Benjamin Joseph
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
anxiety
identify
refer