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(p. 20) Conceptualizing Youth Mental Health Through a Dual-Factor Model 

(p. 20) Conceptualizing Youth Mental Health Through a Dual-Factor Model
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(p. 20) Conceptualizing Youth Mental Health Through a Dual-Factor Model
Author(s):

Shannon M. Suldo

and Beth Doll

DOI:
10.1093/med-psych/9780190918873.003.0002
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date: 25 January 2021

In this text, we advocate for conceptualizing student mental health through a dual-factor model that encompasses both wellness and pathology. This chapter sets the stage for a source book for practitioners and researchers that differs from previous resources on school mental health services in that this text applies the dual-factor model within a multitiered framework for mental health services that emphasizes universal practices and early intervention. A fundamental difference between dual-factor models and traditional pathology-based models of student mental health is that the promotion of wellness is equally important as prevention and intervention to ameliorate emotional and behavioral problems in children and adolescents. So what is the dual-factor model of mental health?

Defining Mental Health Through a Dual-Factor Model

Historically, mental health diagnosis has been defined by the presence of symptoms of disorders and associated negative outcomes. If criteria are not met for a disorder, an individual is viewed as subclinical and is not routinely targeted for intervention. In this chapter, we summarize the evidence that psychopathology and well-being among youth are related but distinct; the absence of psychopathology is correlated with but not equivalent to the presence of well-being. But, first, we define the key constructs in the dual-factor model: well-being and psychopathology.

(p. 21) Well-Being

Within positive psychology, personal happiness has been defined by feeling good about life (hedonic tradition) and/or striving for excellence and functioning well in life (eudaimonic tradition). Well-being has been conceptualized as positive emotions, engagement, relationships, meaning, and accomplishment (PERMA; Kern, Benson, Steinberg & Steinberg, 2016); as flourishing as indicated by hedonic and eudaimonic aspects of well-being (Keyes, 2006); or as high subjective well-being as indicated by high life satisfaction and more frequent positive relative to negative affect (Diener, Scollon, & Lucas, 2009). Seligman’s (2011) updated theory of well-being, PERMA, advances positive emotions as one of five key dimensions of flourishing, along with engagement, relationships, meaning, and accomplishment. However, empirical examinations have shown that PERMA is almost perfectly correlated with the hedonic model of emotional well-being (Goodman, Disabato, Kashdan, & Kauffman, 2017). Regardless of the language used, the phenomenon of well-being appears to be the same, providing some support for focusing on indicators of subjective well-being in assessments of student wellness in line with the methods used in studies conducted by Suldo and colleagues (Suldo & Shaffer, 2008; Suldo, Thalji-Raitano, Kiefer, & Ferron, 2016).

Psychopathology

Psychopathology has been conceptualized in terms of symptoms and diagnoses. Regarding the latter, forms of mental illness are diagnosed when all criterion specified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) or International Classification of Disorders (World Health Organization, 2016) are verified. In reference to the former, signs and symptoms of psychopathology clusters are assessed on a continuum (e.g., from “zero” to “all signs of depression currently present”). Clusters of often co-occurring forms of psychopathology are typically categorized as either internalizing or externalizing disorders. In this chapter, psychopathology is used to refer to the level of symptom severity an individual demonstrates on a particular disorder/diagnostic target.1

(p. 22) Considering Well-Being and Psychopathology Together in a Dual-Factor Model

Studies describing the mental health of youth demonstrate the importance of considering both psychopathology and subjective well-being, consistent with a dual-factor model of mental health in elementary schools (Greenspoon & Saklofske, 2001), middle schools (Antaramian, Huebner, Hills, & Valois, 2010; Suldo & Shaffer, 2008), high schools (Suldo et al., 2016), and higher education (Antaramian, 2015; Eklund, Dowdy, Jones, & Furlong, 2011; Renshaw & Cohen, 2014). These studies have used different methods to group the students according to their mental health needs including person-centered approaches that use cut scores to assign group membership to all youth in the sample ranging from near the cut point to extreme scores (Suldo & Shaffer, 2008; Suldo et al., 2016), cut scores that exclude youth with values in the middle of the distribution to sharpen contrasts between groups (Greenspoon & Saklofske, 2001; Magalhães & Calheiros, 2017), and latent class model analysis to identify underlying classes of mental health in youth (Rose, Lindsey, Xiao, Finigan-Carr, & Joe, 2017). The studies consistently identified four groups of students based on the presence or absence of wellness and psychopathology (see Figure 1.1), despite the methodological differences in procedures used by researchers to form groups.

Figure 1.1 Youth mental health status as indicated from a dual-factor model.

Figure 1.1 Youth mental health status as indicated from a dual-factor model.

The dual-factor model identifies two groups that one would expect to find if mental health existed on a single continuum ranging from the presence of psychopathology and the absence of well-being at one extreme to the absence of psychopathology and the presence of well-being at the other extreme. These two groups are (a) individuals without psychopathology who report positive emotional well-being—a complete mental health profile—and (b) troubled individuals who experience psychopathology along with low emotional well-being. The dual-factor model also yields two additional groups of students who were overlooked in traditional unidimensional models of mental health: (c) vulnerable youth who are languishing emotionally but do not meet symptomatic criteria for psychopathology and (d) symptomatic but content youth who experience psychopathology but nevertheless give positive appraisals of their lives. Findings from a growing body of dual-factor research highlight the importance of planning for and supporting these previously overlooked students (Suldo, 2016). Students’ adjustment appears to be a function both of their level of subjective well-being and their demonstration of symptoms of mental disorders, and viewing mental health (p. 23) only through the lens of psychopathology is incomplete. These four groups are described in more detail next, with prevalence rates of students typically falling within each group described in Table 1.1 and supports for each group in Figure 1.1. Table 1.1 illustrates the expansion of a dual-factor framework to assessments of youth mental health status in diverse countries and settings. The consistent identification of individuals in the vulnerable or symptomatic but content groups supports the premise of the dual-factor model that wellness and pathology are distinct. Outcomes associated with wellness (described later) illustrate the importance of monitoring and promoting youth subjective well-being, the factor traditionally neglected in mental health practice and education.

Table 1.1 Investigations of the Dual-Factor Model of Mental Health in Children, Adolescents, and Young Adults

Study Authors

N

Sample Age

Sample Features

Complete Mental Health (%)

Vulnerable (%)

Symptomatic But Content (%)

Troubled (%)

Antaramian (2015)

561

M = 19.5 years

Undergraduate students in United States

47.4

26.0

5.5

21.0

Antaramian, Huebner, Hills, and Valois (2010)

764

7th (48.8%) and 8th (51.2%) grade

Middle school students in United States

66.9

8.1

17.3

7.7

Eklund, Dowdy, Jones, and Furlong (2011)

219

18–25 years

Undergraduate students in United States

78.1

8.7

4.1

9.1

Greenspoon and Saklofske, (2001)a

407

M = 10.5 years

Elementary school children (grades 3–6) in Canada

13.0–25.3

7.4

10.8

16.0–25.5

Lyons, Huebner, Hills, and Skinkareva (2012)

981

M = 14.26 years

Secondary students (grades 6–12) in United States

63.8

7.3

8.9

20.1

Magalhães and Calheiros (2017)

369

11–18 years

M = 14.75 years

Youth removed from homes and placed in residential care in Portugal

27.0

8.4

19.7

34.9

Renshaw and Cohen (2014)

1,356

17–51 years

(M = 19.18 years)

Undergraduate students in United States

61.4

18.7

4.8

15.1

Rose, Lindsey, Xiao, Finigan-Carr, and Joe (2017)

1,170

13–17 years

(M = 15 years)

Black males in United States

50.6

20.0

12.7

16.4

Smith, Suldo, Hearon, and Ferron (2020)

178

8–12 years

(M = 9.78 years)

Elementary school children (grades 4–5) in United States

53.9

18.5

18.5

9.0

Suldo and Shaffer (2008)

341

10–16 years

(M = 12.96)

Middle school students (grade 6–8) in United States

56.9

12.9

12.9

17.3

Suldo, Thalji-Raitano, Kiefer, and Ferron (2016)

500

14–18 years

(M = 15.27 years)

High school students (grades 9–11) in United States

62.2

11.4

11.4

15.0

Xiong, Qin, Gao, and Hai (2017)

1,293

M = 14.71 years

Chinese secondary (grades 7–12) students

59.9

20.0

10.1

10.0

a In Greenspoon and Saklofske (2001), analyses conducted to create mental health groups were completed twice (once to categorize symptomatic but content and once to categorize vulnerable), and cases that were borderline were eliminated. Authors indicated there might be some overlap between classifications yielded from the two analyses. Percentages of students in groups do not equal 100% because 41.8% to 60.2% of cases were eliminated during attempts to sharpen contrasts between groups.

Complete mental health is best defined by few symptoms of psychopathology coupled with the presence of positive indicators of well-being. The latter manifests (p. 24) (p. 25) (p. 26) in positive appraisals of the quality of one’s life (i.e., life satisfaction) and frequent positive affect. Factors that predict such emotional wellness include satisfaction of basic psychological needs for competence, relatedness, and autonomy (Ryan & Deci, 2017); the presence of the building blocks of well-being as reflected in positive attitudes about oneself and others (e.g., self-efficacy and supportive peers, respectively), engaged living (e.g., optimism, gratitude), emotional competence (e.g., emotion regulation, empathy; Furlong, You, Renshaw, Smith, & O’Malley, 2014), and experiencing engagement and absorption, healthy relationships, meaning and purpose, and accomplishment (Seligman, 2011).

As summarized in Figure 1.1, universal efforts to promote flourishing include skill development in social and emotional competencies and other building blocks of well-being, for instance, through positive education programs (Morrish, Rickard, Chin, & Vella-Brodrick, 2018; also see Chapter 5, this volume). Alternatively, flourishing is also promoted by intentionally fostering a school or classroom environment that maximizes students’ opportunities to participate in rewarding relationships and grow in social competence and self-determination (Doll, Brehm, & Zucker, 2014). Beyond school-based supports, families and communities can promote flourishing by providing youth with a sense of safety, security, and belongingness. Moreover, opportunities to achieve and contribute are likely to promote flourishing. Multiple chapters in this book provide guidance on how to establish such foundations, with regard to healthy schools (see Chapter 6, this volume), classrooms (see Chapter 9, this volume), and families (see Chapter 11, this volume).

Vulnerable youth have few symptoms of psychopathology but also few indications of positive emotional well-being. In addition to having levels of subjective well-being that are lower than their peers with complete mental health, vulnerable youth also experience diminished eudaimonic well-being as reflected in reduced self-esteem, less academic competence and mastery beliefs, poorer social relationships, and less involvement in meaningful activities (Greenspoon & Saklofske, 2001; Rose et al., 2017; Suldo et al., 2016). Rose and colleagues (2017) found that vulnerable adolescents had more symptoms of depression on the Center for Epidemiologic Studies Depression Scale (Radloff, 1977) compared to youth with complete mental health, although few vulnerable adolescents had ever met criteria for a diagnosis of a mental disorder. Instead, when some but not all symptoms of disorders were present, the severity of their symptoms was low. In traditional unidimensional models, these youth might be described as showing a subclinical presentation of internalizing psychopathology.

This notion that a lack of mental illness does not signify the presence of wellness was vividly illustrated in a study of 69 survivors of the 11-M terrorist attacks who developed posttraumatic stress disorder (PTSD; Diaz, Stavraki, Blanco, & Bajo, 2018). Three years later, these adults were examined within a dual-factor mental health framework, using measures of psychopathology (PTSD symptoms) and hedonic and eudaimonic well-being. Forty-six of the survivors (66.67%) still met criteria for PTSD. Of the 23 who did not, only three evidenced positive levels of well-being on a majority of indicators. Thus, although a third of the original (p. 27) sample had improved their mental health to the point of being free of diagnosis, only 13% of those individuals without PTSD (and 0% of those who still had PTSD) also experienced the presence of positive well-being as defined by high subjective well-being, psychological well-being, and social well-being. These results led Diaz and colleagues (2018) to conclude, “It is important to continue working for victims’ positive health, even if they no longer meet diagnostic criteria for PTSD” with the goals of fostering greater positive affect, life satisfaction, self-acceptance, and positive relations (p. 670).

Observational, longitudinal study of youth mental health in a dual-factor framework found that the vulnerable group evidenced the least stability of all quadrants (Kelly, Hills, Huebner, & McQuillin, 2012; Xiong, Qin, Gao, & Hai, 2017). At four- to five-month follow-up, only 29% to 44% of youth remained in the vulnerable group, with more youth likely to improve to complete mental health (40%–46%) than to decline to troubled (12%–14%) at follow-up. Thus, a vulnerable mental health status appears especially malleable and perhaps susceptible to intervention. As summarized in Figure 1.1, supports for students with a vulnerable mental health profile include programs and practices that develop personal resiliency skills (e.g., coping and social skills; assets like hope and persistence) or enhance protective settings within the home, classroom, school, and community in ways that deliberately evoke positive affect and that attend to youth needs for autonomy, relatedness, and competence. Several chapters within this volume provide guidance in these areas, with discussions of student engagement and connectedness (see Chapter 8), emotional self-regulation (see Chapter 13), and positive emotions, character and purpose (see Chapter 14).

Symptomatic but content youth have elevated levels of psychopathology and may even meet criteria for mental disorders, but they also report moderate to high levels of life satisfaction, positive affect, or other positive indicators of well-being. Perhaps the strongest support for the notion that psychopathology and well-being can co-exist comes from studies of suicidal adults. Specifically, between 6% and 10% of adults who were receiving mental health treatment and who had suicidal thoughts also had moderate to high levels of subjective well-being (Teismann et al., 2018). Inpatients whose suicidality co-occurred with higher levels of positive mental health were less likely to attempt suicide.

Studies of youth have identified protective factors that may contribute to high subjective well-being even when psychopathology is present. For instance, Rose and colleagues (2017) examined the frequency of mental disorders and associated features among the four mental health groups. First, they found that only 9% of youth in the complete mental health group and 15% of youth in the vulnerable group met criteria for a mental disorder at some point in their lives. In contrast, 97% of youth in the troubled and 100% of those in the symptomatic but content group met criteria for at least one mental disorder in their lifetime, with some associated severity of illness. Compared to troubled youth, symptomatic but content youth had elevated self-esteem, more positive relations with others, fewer symptoms of depression on the Center for Epidemiologic Studies Depression Scale, and lower severity of symptoms of lifetime mental disorders. (p. 28) This describes the symptomatic but content youth as a group with strengths in social relationships and a history of mental health problems that, although marked by more disorders than complete mental health or vulnerable youth, features less internalizing symptoms than troubled students.

The protective nature of social relationships was also demonstrated by Magalhaes and Calheiros (2017), who found that youth in foster care who have complete mental health or are symptomatic but content perceive significantly greater social support compared to youth in the two groups defined by low wellness. Studies with general samples of children and adolescents confirm that compared to troubled youth, symptomatic but content youth are distinguished by facets of positive social relationships (e.g., greater support at school, minimal peer victimization, a sociable temperament) as well as intact self-esteem (Greenspoon & Saklofske, 2001; Suldo et al., 2016). Despite such strengths, those studies revealed that symptomatic but content students experience worse academic performance and more externalizing problems (e.g., hyperactivity, school rule violations) than their peers without psychopathology. Accordingly, as summarized in Figure 1.1, supports for this group are focused on the development of academic and behavioral skills. For specific examples, see discussions of schoolwide positive behavior interventions and supports (Chapter 4, this volume) and programs and practices that prevent school failure and school dropout (Chapter 19, this volume).

Troubled youth have the combination of low wellness and elevated psychopathology. These youth are the most mentally unhealthy and tend to experience the worst functioning across domains—social, academic, and even physical health. Moreover, findings from longitudinal studies indicate that troubled middle school students experience the most academic decline as measured by cognitive engagement and grade point averages (GPA; Lyons, Huebner, & Hills, 2013; Suldo, Thalji, & Ferron, 2011). In line with their risk for poor outcomes concurrently and in the future, troubled students need the most intense mental health supports to meet the dual goals of reducing psychopathology and fostering subjective well-being (see Chapters 2 and 9, this volume).

The different determinants of psychopathology and subjective well-being (Haworth, Carter, Eley, & Plomin, 2017; Rees, 2018) suggest that a single intervention is unlikely to be effective for addressing each factor of mental health, as the targets to be addressed are not the same. Case in point, Haworth et al.’s (2017) study of genetic and environmental determinants of subjective well-being and depression among 4,700 pairs of teenage twins concluded that there are significant predictors of well-being that go beyond the absence of mental illness; these researchers assert “different interventions will be needed for treating mental illness and promoting mental health . . . interventions will need to target different biological pathways” (p. 7).

This phenomenon was illustrated in an evaluation of a targeted positive psychology intervention for students whose screening data indicated relatively low life satisfaction (Roth, Suldo, & Ferron, 2017). These students participated in 10 weekly small group sessions and were assigned either to the intervention group which focused on increasing positive emotions about one’s past, present, and (p. 29) future or to a delayed intervention condition. This randomized controlled trial revealed statistically significant, positive effects of intervention on all indicators of subjective well-being (including medium effects sizes of 0.53 and 0.76 on life satisfaction and positive affect, respectively). At the same time, the effects on reductions in internalizing and externalizing symptoms were smaller (d = 0.37) and not statistically significant.

It is plausible that students whose low subjective well-being co-occurs with elevated psychopathology will need evidence-based treatments appropriate for their specific type of internalizing or externalizing problems. Such comprehensive supports are often individualized and best developed through partnerships with key stakeholders at home, in school, and in the community, as described in Chapter 24 (this volume). Likewise, because the presence of psychopathology and the absence of well-being are distinct albeit correlated phenomena, interventions developed to prevent and reduce psychopathology may not fully promote youth well-being. Thus, the implementation of wellness-promoting strategies in addition to evidence-based treatment of disorders will likely result in even stronger mental health. Examples of strategies for promoting wellness within a school or community are described thoroughly in several chapters in this volume and pertain to creating culturally responsive schools (see Chapter 3); building positive emotions, character, and purpose (see Chapter 14); trauma-informed approaches that build on student strengths (see Chapter 15); and statewide practices that promote wellness (see Chapter 22). Guidance on how to support students at-risk for a troubled emotional status due to significant environmental stressors are covered in different chapters in this volume, including chapters that pertain to supporting students who are highly mobile (see Chapter 17), socially marginalized (see Chapter 18), or have experienced a school crisis event (see Chapter 20).

Links Between Emotional Wellness and Later Improved Mental Health

Within traditional mental health models, multitiered frameworks for providing school mental health services are grounded in the premise that well-positioned supports address the targets that ultimately relate to the onset of mental illness. Alternatively, this chapter suggests that prevention of mental illness and the promotion of emotional wellness are both appropriate targets in their own right. Further, level of subjective well-being is one such factor that predicts later psychopathology. Case in point, a meta-analysis of findings from longitudinal studies that examined associations among positive emotions (e.g., positive affect, extraversion, and behavioral activation) found that low levels of positive emotions predicted increased symptoms of anxiety and depression at a later time (Khazanov & Ruscio, 2016). Positive emotions and internalizing psychopathology (i.e., negative emotions) emerged as separate but related constructs that influence each other, and the presence of positive emotions acted as a protective factor predicting reduced psychopathology in the future. As one example, a longitudinal study of (p. 30) 5,500 adults found that those who had low positive psychological (eudaimonic) well-being (i.e., positive relationships, personal growth, purpose, autonomy, self-acceptance) were seven times more likely to be depressed when assessed 10 years later (Wood & Joseph, 2010). Khazanov and Ruscio (2016) concluded that effective early intervention to increase positive emotions may reasonably be expected to prevent the recurrence of internalizing psychopathology, and problem-focused treatments that focus narrowly on reducing negative emotions may not repair the deficits in positive emotions that could be addressed through positive interventions.

Whereas a paucity of positive emotions sets the stage for diminished mental health, the presence of well-being may protect individuals from poor psychological outcomes. For instance, a longitudinal study of college students found that high levels of life satisfaction and positive emotions (e.g., joyful, calm, confident) protected students who were demonstrating early depressive symptoms from experiencing suicide ideation the following year (Teismann et al., 2017). Such research highlights the predictive and protective function of subjective well-being on later psychopathology. It is most plausible that the associations between wellness and psychopathology are bidirectional, as demonstrated by Lamers, Westerhof, Glas, and Bohlmeijer’s (2015) cross-panel analysis of multiple assessments (four waves in one year) of mental health within a large community sample of 1,932 adults. Changes in psychopathology predicted levels of well-being and changes in well-being predicted levels of psychopathology, even after controlling for initial levels of symptoms and subjective well-being (Lamers et al., 2015). The direction of these associations was consistently inverse, such that increases in psychopathology predicted lower well-being, and decreases in well-being predicted more psychopathology.

Links Between Emotional Well-Being and Academic Outcomes

A large body of literature has established that psychopathology—including internalizing (Riglin, Petrides, Frederickson, & Rice, 2014) and externalizing problems (e.g., Obradovic, Burt, & Masten, 2010)—predict subsequent academic outcomes such as course grades and graduation. Historically, less attention has been paid to outcomes linked to psychological wellness. Recent work, however, indicates that positive indicators of subjective well-being are indeed associated with concurrent and later academic engagement and success. As one example, Bucker, Nuraydin, Simonsmeier, Schneider, and Luhmann’s (2018) meta-analysis of 47 studies established significant links between students’ subjective well-being and their academic performance (GPA or test scores), with a small to medium effect size (r = 0.16) that was not moderated by demographic variables. The positive association between subjective well-being and academic performance held regardless of student's gender, age, and country. The size of the association indicates that there is a trend for boys and girls who are happier to also get better grades (p. 31) or test scores although not all high-achieving students also have high subjective well-being. Beyond cross-sectional associations, subjective well-being is a significant, unique predictor of later course grades (GPA; Suldo et al., 2011) and student engagement (Lyons et al., 2013), even after controlling for psychopathology and baseline levels of outcomes. Ng, Huebner, and Hill’s (2015) longitudinal study of middle school students confirmed a reciprocal relationship between life satisfaction and GPA, with life satisfaction also predicting GPA one year later.

A large scale study of youth in the United Kingdom found that those who enjoyed school more also experienced greater cognitive engagement in learning three years later. Taken to its logical conclusion, this suggests that students who enjoy school are subsequently more likely to be stimulated and interested in their school work, which may, in turn, increase the likelihood of school completion given that engagement historically leads to successful academic performance (Morrison-Gutman & Vorhaus, 2012). There is good reason to believe that students’ positive emotions predict stronger school engagement. In one nationally representative sample of 1,170 Black adolescents, youth with complete mental health reported significantly higher levels of school bonding and connectedness than students from the other three mental health groups (Rose et al., 2017). At the same time, there were no between-group differences in one item describing school grades or another item describing suspension histories. Taken together, this growing body of research that illustrates concurrent and predictive relationships between emotional well-being and student outcomes provides a data-based rationale for attending to the wellness of our youth.

Integration of the Dual-Factor Model With Multitiered Systems of Support

Traditional school mental health services grounded in unidimensional models of pathology have the goal of identifying and treating or diminishing the symptoms of mental illness. Traditional assessment is problem-focused, and psychopathology typically considered to reside within the individual, although there is good evidence that the social and physical context also plays an important role in the incidence of problems (Werner, 2013). Over the past four decades, substantial progress has been made in building an evidence base for reliably identifying disorders using standardized diagnostic interviews (e.g., Kiddie Schedule for Affective Disorders and Schizophrenia [Kaufman et al., 1997]), diagnostic checklists (e.g., Achenbach System for Empirically Based Assessment [Achenbach & Rescorla, 2001]; Behavior Assessment System for Children, Third Edition [Reynolds & Kamphaus, 2015]), and nested screening procedures (e.g., Systematic Screening for Behavior Disorders [Walker, Severson, & Feil, 2014]). Since symptoms of pathology were located within the individual, the early emphasis of these models was on a combination of individual and small-group intervention (Dowdy et al., 2015). Within school mental health services, multitiered systems of support (MTSS; National Association of School Psychologists, 2016) frame (p. 32) decisions about each student’s need for more intense intervention services based on that student’s responsiveness to progressively more intense interventions. Dowdy et al. (2015) have successfully argued that multitiered systems of support can be adapted to dual-factor mental health models, incorporating both wellness promotion and problem prevention components.

A premise of this volume is that the dual-factor model for mental health is not a simple embellishment of the traditional unidimensional model. Instead, the dual-factor model has the potential to provide a more complex but ultimately more powerful conceptual framework for identifying students most in need of high intensity mental health services and for defining the appropriate nature, context, and extent of intervention services. Given the dual-factor model’s emphasis on assessing both emotional well-being and symptoms of disorders, it is possible to identify troubled youth who struggle with both low levels of well-being and high levels of psychopathology. These youth require comprehensive intervention services (often akin to Tier 3 supports) that promote positive emotional experiences as well as interventions to diminish symptoms of psychopathology. Vulnerable youth were overlooked in unidimensional mental health models, but emerging evidence suggests that they are also at significant risk and urgently require interventions to boost their positive emotional experiences and build their sense of well-being. Symptomatic but content youth demonstrate somewhat better outcomes than vulnerable and troubled youth in various domains of adjustment (e.g., social and identity development, respectively) but nevertheless require intervention to address psychopathology; given their strong sense of well-being and social support, these youth are good candidates for self-management strategies that build their autonomous management of symptoms. Thriving youth with a complete mental health status can become a resource for mental health services, contributing to the systems of support and emotional well-being that populate the social ecology of the school.

Within the unidimensional model of mental health, tradition vested responsibility for treating pathology with therapeutic experts, and teachers and other educators were charged with referring youth with disturbing behaviors to experts for mental health services (U.S. Surgeon General, 1999). However, in the complex decisions framed by the dual-factor model, experiences of well-being and positive emotions emerge within the larger social ecology of the peer group, school, and community. While the diagnosis of and intervention of psychopathology is an activity regulated by advanced training and credentials, the promotion of psychological wellness lends itself to intervention by the “caring community” and well-meaning adult caretakers. In the United States, schools have historically owned this responsibility for promoting youths’ competence, life success, and achievements given that schools have been the primary strength-promoting institutions of communities (Goldstein, 2014). Thus, the well-being dimension of mental health extends responsibility for effective intervention to most adults in a building because teaching and education are integrally related to students’ well-being (see Sulkowski & Lazarus, 2017).

(p. 33) At the same time, the dual-factor model’s emphasis on community-embedded positive emotional experiences lends new importance to recognizing and understanding the adversities that face youth in many communities. Developmental risk and resilience research provides ample evidence that socioecological adversities predict very poor social outcomes for students. Students’ exposure to poverty, family violence, parental mental illness, poor health, or community violence significantly decreases their chances of succeeding academically and socially, while their access to nurturing adults, prosocial organizations, effective schools, and peer friendships predicts their ultimate life success (Werner, 2013). One challenge facing school mental health service delivery is that the prevalence of these adversities is increasing in recent decades, and these risk factors are sometimes concentrated in very high risk communities (Annie E. Casey Foundation, 2018; Children’s Defense Fund, 2017; Pianta, 1999). Thus, even for youth who do not evidence psychopathological symptoms, the high rates of adversity may contribute to sizeable rates of vulnerable youth.

What should screening and assessment look like within this more complex dual-factor model? Given that positive emotions, positive cognitions, and positive relationships and interactions are, to some extent, a felt experience of the student, the indices of well-being are best assessed through students’ self-report via surveys, interviews, or ratings. Examples include Dowdy et al.’s (2015) comprehensive universal screening to identify personal strengths as well as distress and Wingate, Suldo, and Peterson’s (2018) use of a life satisfaction monitoring scale. An elaborated description of assessment and intervention is provided in Chapter 2 of this volume. Regarding interventions, and given the strong evidence that positive experiences are contagious, there is a natural inclination for schools to focus at the group level— such as a class, grade level, or the entire population of a school—for both assessment and intervention (Dowdy et al., 2015; Furlong, 2015; Shoshani & Steinmetz, 2014). Recent evaluation studies of universal positive psychology interventions with teacher and student components have focused on strengthening relationships through strategies such as identification of character strengths in self and others and encouraging use of one’s strengths (Quinlan, Swain, Cameron, & Vella-Brodrick, 2015; Shoshani, Steinmetz, & Kanat-Maymon, 2016). These studies have found positive impacts on students’ engagement, course grades, positive affect, and classroom relationships, compared to peers in no-treatment control classrooms. Such findings demonstrate the promise of promoting emotional well-being and related academic outcomes through Tier 1 interventions that involve all individuals in an educational setting.

Conclusion

The transition to a dual-factor model of youth mental health has occurred gradually over the past two decades. It has contributed to the identification of a differentiated pool of students needing targeted mental health services (Tier 2 supports) and refined goals for each group’s service needs. This transition holds (p. 34) particular importance for school-based mental health services because of its relation to schools’ historical roles of strengths-promotion and their responsibility for fostering the life success of a community’s youth. Key advantages of the dual-factor model (see Box 1.1) lie with its potential to greatly extend the power of (p. 35) multitiered systems of support because of its enhanced description of students with mental health needs. Evidence for the validity of various strengths-based assessments is accruing rapidly, providing school mental health providers with options for the assessment of complete mental health. Early evidence of the impact of likely intervention strategies is promising. The remainder of this volume provides multiple, alternative examinations of the contributions of the dual-factor model for multitiered systems of support and universal mental health practices that diminish pathology and promote students’ emotional well-being.

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Notes:

1. Although the term psychopathology was selected deliberately due to reasons pertaining to specificity and consistency with existing literature, we struggle with utilizing phrases such as psychopathology, mental illness, psychiatric disorders, and similar terms that are rooted in a historically medical, within-child, and pathology-based conceptualization of psychological functioning. Such phrases stifle attention to prevention, early intervention efforts, and health promotion (Seligman & Csikszentmihalyi, 2000). Recent work by Weist and colleagues (2019) illustrates the potentially stigmatizing nature of the term psychopathology. Young adults who had previously received mental health services were especially likely to indicate the term should not be used in mental health services for youth in part because it conjured negative thoughts of people as crazy, insane, psycho/psychopath, dangerous, etc. Alternative terms used in mental health services, such as behavioral health or psychological problems, may be less stigmatizing but are also less precise, less inclusive of symptoms from various mental disorders (spanning internalizing, externalizing, thought problems), and less familiar to the range of mental health professionals from allied disciplines (e.g., psychology, psychiatry, social work). Terminology in mental health services is not just a semantic concern; stigma is associated with real-life consequences including youth in need going underidentified and underserved. In sum, although we are sensitive to challenges associated with psychopathology in particular, no one label or term seems entirely satisfactory.