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This study reviews findings for the first randomized controlled trial (RCT) on the Interconnected Systems Framework (ISF) for school mental health (SMH) and Positive Behavioral Interventions and Supports (PBIS). Since its development in the late 2000s, the ISF has been supported by federally funded centers for SMH and PBIS, and, guided by a national workgroup, is being implemented in50 communities in the United States. This experimental evaluation of the ISF involved an RCT implemented in 24 schools in two southeastern states, with the ISF implemented in eight schools, PBIS alone implemented in eight schools, and typically co-located PBIS+SMH implemented in eight schools. Related to very poor implementation, documented by two sources of fidelity data, two ISF schools were dropped from major analyses; hence, the study used a treatment on the treated (ToT; Rubin, 1974) as compared to a more traditional Intent-to-Treat approach (ITT; Lachin, 2000). This is the first paper from this large study, with emphasis here on proximal variables and school discipline. Within schools' multi-tiered systems of support (MTSS), ISF schools delivered more Tier 2 (early intervention) and Tier 3 (treatment) interventions to a greater proportion of students than the other two conditions by the second year of the intervention. There was also a dramatic difference in the provision of interventions by community mental health clinicians in ISF schools (almost half of interventions delivered) as compared to PBIS+SMH schools (around 3% of interventions delivered), underscoring the critical role of the ISF in integrating clinicians into MTSS teams and core school functions in SMH. As compared to the other two conditions, ISF schools also had reduced office discipline referrals (ODRs) and in-school suspensions, as well as reduced ODRs and out-of-school suspensions for African American students. Findings are discussed in relation to future directions of education-mental health system partnerships in improving the delivery and impact of SMH programs and services, demonstrated in the ISF.

Background: The integration of behavioral health and primary care is a best practice to improve patient outcomes and achieve health equity. However, the process of integrating is complex, requiring organizational change and sometimes a complete system overhaul. Implementation science offers useful ideas for helping healthcare organizations to implement effective care, including recognition that change occurs incrementally and is stymied by specific barriers and facilitators. Although determinants (i.e., barriers and facilitators) of successful care integration have been identified their relevance to organizations seeking to integrate care remains unknown. This study sought to understand which implementation determinants (defined by the R=MC2 framework, where Readiness is conceptualized as Motivation, Innovation-specific Capacity, and General Capacity) are most important in the process of integrating care across four implementation stages: Exploration, Installation, Initial Implementation, and Full Implementation. Methods: A participatory Delphi study design was used to gather practice-based evidence from ten integrated care practitioners, researchers, and technical assistance providers. Qualitative and quantitative data were collected across four rounds. Qualitative summaries were presented back to participants between rounds for reaction and recalibration. The Framework Method guided initial qualitative analyses, which were then triangulated with descriptive statistics from a process survey. Coders used fuzzy set theory to create the final results on perceived relevance of each determinant across stages of implementation. Results: Determinants most relevant across implementation stages are Leadership, Priority, a Champion, Supportive Climate, Culture, Innovativeness, and Staff Capacities. Determinant strength is most critical during active implementation stages. Conclusions: The present study is one of only a few that apply implementation science frameworks to the integration of behavioral health and primary care. Results provide a structure for assessing determinants by phase and could be used to determine precision and timing of resource allocation to facilitate integration.

In this article, we follow up on recommendations from the Division for Emotional and Behavioral Health (DEBH) for providing school mental health (SMH) services by offering additional implementation suggestions for teachers and school staff. We highlight the need for and urgency of SMH services, particularly during and after the pandemic, and also consider broad issues that interfere with the success of SMH. We then provide a number of specific recommendations for integrating the delivery of SMH services within a tiered system of supports that are intended to empower school staff to move toward implementation. Last, we address how effective implementation can be facilitated by strong administrative support along with capacity building.

There is a national movement to advance school behavioral health, involving the mental health system partnering with schools' multitiered systems of support. This article underscores the critical need for school behavioral health and presents strategies to advance effective programming at district, state, and regional levels. Themes include diverse stakeholder involvement, teaming, data-based decision-making, implementation of evidence-based practices, screening, coaching and implementation support, progress monitoring and outcome evaluation, and using findings to scale-up effective programming. Implications for research, practice, and policy are reviewed along with ideas for the future development of this field.

Peer victimization is a widespread and heterogeneous phenomenon, especially during the transition to middle school, and is associated with numerous negative consequences. However, previous research...

South Carolina (SC) is a leading state for the delivery of comprehensive school mental health (SMH) services, involving mental health education system partnerships. Currently, more than 60% of SC s...

Background: Adolescence is defined by key transitional elements which are considered within a cross-cultural context. The importance of building mental health capacity for adolescents in low- and middle-income countries (LMICs) as well as high-income countries (HICs) is reviewed. Objectives: To review the developmental period of adolescence, global needs for mental health promotion, the needs of LMICs while emphasizing building adolescent mental health capacity, and the importance of efforts to promote mental health literacy. Methods: Mental health literacy (MHL) is presented as a strategy that can increase public awareness regarding mental health issues among adolescents. Increased awareness through an MHL framework is discussed as a way to build adolescent mental health capacity; with this work ideally occurring through global communities of practice (COP), dialogue, collaboration, and mutual support that aim to build innovation in systems of mental health promotion. Results: The authors review structural components in research, practice, and policy that seek to build global adolescent mental health capacity, nested within COPs involving HICs and LMICs working together to advance mental health promotion for children, adolescents, and young people. Conclusion: The article concludes with a discussion of how the three structural components (i.e., research, practice, and policy) can address gaps in the provision of global mental health services for adolescents to meet adolescent mental health needs in LMICs and HICs. A multi-sectoral approach emphasizing a global COP is presented as a way to scale up capacity and maximize outcomes.

Nearly 14% of all youth display disordered eating patterns. Despite the prevalence of these disorders, there is limited literature on the integration of eating disorder support services in schools. Further, there is often limited eating disorder knowledge and training for school mental health (SMH) professionals. This paper describes a two-phase study involving qualitative and quantitative components examining the perspectives of adolescents in recovery from eating disorders, family members, and SMH professionals. Fourteen participants were recruited from an eating disorder treatment facility in the southeastern USA. Eight adolescent females who received treatment for disordered eating while in primary or secondary school and six of their mothers completed interviews. In addition, 720 SMH and allied professionals were surveyed on their knowledge and training in disordered eating identification and intervention and their perspectives on service provision, with 561 complete and usable surveys. Analyses of adolescent and family data revealed the following themes that hindered or helped recovery: Isolation, Perfectionism, Difficulties with Self-Acceptance and Comparison to Others, Uncertainty, Teacher Identification, Support in Recovery. Themes surrounding the benefits of including SMH services for this population included: Increased Awareness, Support in Recovery, Family Involvement, and Linking to Resources. Results revealed that the majority of SMH professionals did not receive training in the identification and/or intervention of disordered eating. Data suggested that lack of referrals and limited knowledge, skills, and time interfered with their ability to effectively identify and intervene. Findings provide a foundation for understanding the experiences of adolescents with disordered eating and the role of SMH programs in assisting them.

This study examined associations between teacher-student relationship quality at school and teachers' responsiveness to students' emotional concerns in a classroom and (a) students' intention to seek help at school for mental health concerns and (b) mental health-related service use. Data for analyses came from the School Mental Health Survey, a cross-sectional survey of 31,120 grade 6–12 students, in 1968 classrooms, attending 248 schools in Ontario, Canada. Three-level (student, classroom, school) binary logistic regression was used to address the study objectives. Student ratings of the quality of teacher-student relationships and teachers' responsiveness were included as predictors, both at the individual student level and aggregated to represent a contextual level characteristic at the school and classroom level, respectively. At the student level, both teacher-student relationship quality and teacher responsiveness were positively associated with intentions to seek help at school among both elementary and secondary students (ORs ranged from 1.14–1.19 for relationships and 1.06–1.08 for responsiveness). Aggregated to the school level, teacher-student relationship quality was positively associated with mental health service use for secondary students (OR = 1.36, 95% CI [1.10, 1.69]). Positive and responsive teacher-student relationships were associated with help-seeking behaviors among students. Longitudinal studies are warranted to disentangle the temporality of these associations.

School Mental Health prevention approaches that use multi-tiered systems are advancing rapidly. However, there is a relative shortage of effective selective prevention programs feasible to implement within the school context. To optimize the effectiveness of selective prevention in this context, a Motivational Interviewing (MI)-based prevention program for an adolescent student population was developed and tested. Footprints utilizes MI to increase engagement in modular Cognitive-Behavioral Therapy and to promote academic protective factors. In this study, forty-three adolescents were randomly assigned to Footprints or a treatment-as-usual waitlist control. Participants in the experimental condition demonstrated significant increases in behavioral and emotional functioning, self-efficacy to regulate behaviors, positive expectations for success, academic motivation, and grades in mathematics. Simultaneously, Footprints received high ratings for feasibility and acceptability within a dynamic school context. This exploratory efficacy evaluation provides initial support for MI's potential to promote the effectiveness of school-based prevention programs and warrants further study.

Despite significant progress in research on the treatment and prevention of psychological, behavioral, and health problems, the translation of this knowledge into population-wide benefit remains limited. This paper reviews the state of America's children and families, highlighting the influence of stressful contextual and social conditions on child and family well-being and the concentration of disadvantage in numerous neighborhoods and communities throughout the nation. It then briefly reviews the progress that has been made in pinpointing policies that can reduce stressful contextual conditions such as poverty, discrimination, and the marketing of unhealthful foods and substances. It also describes numerous family and school interventions that have proven benefit in preventing psychological and behavioral problems as diverse as tobacco, alcohol, and other drug use; depression; antisocial behavior; academic failure; obesity prevention; and early childbearing. We argue that progress in translating existing knowledge into widespread benefit will require a nationwide effort to intervene comprehensively in neighborhoods and communities of concentrated disadvantage. We present a strategic plan for how such an effort could be organized. The first step in this organizing would be the creation of a broad and diverse coalition of organizations concerned with advancing public health and well-being. Such a coalition could increase public support both for the policies needed to focus on these disadvantaged areas and the research needed to incrementally improve our ability to help these areas.

Army family member health and resilience directly impact soldier readiness and are critical to maintaining a deployable force. Military families face unique stressors, including combat deployments,...

Purpose The purpose of this paper is to describe the relationship between privatization and school mental health (SMH) in the USA, as well as to present a case study of the SMH system in South Carolina. Design/methodology/approach The authors reviewed data regarding states’ mental health systems (e.g. public, private and hybrid of public and private), mental health budgets and percentages of schools with mental health clinicians. Findings The results demonstrate that the majority of states have public mental health systems. There is variability between states regarding general funding, as well as funding for SMH. Further, there was variability in the percentage of schools with SMH clinicians, with South Carolina reporting the greatest percentage. South Carolina’s mental health system, which is a public–private hybrid is reviewed, along with relevant history on the development of SMH programs in the state. Originality/value This paper contributes to the general knowledge by describing the provision and funding sources for SMH services within the USA. It yields important implications for integrating public mental health services within schools.

Background: Despite an established, comprehensive taxonomy of implementation strategies, minimal guidance exists for how to select and adapt strategies to specific services and contexts. We employed a replicable method to identify the most feasible and important implementation strategies to increase mental health providers’ use of measurement-based care (MBC) in schools. MBC is the routine use of patient-reported progress measures throughout treatment to inform patient-centered, data-driven treatment adjustments. Methods: A national sample of 52 school mental health providers and researchers completed two rounds of modified Delphi surveys to rate the relevance, importance, and feasibility of 33 implementation strategies identified for school settings. Strategies were reduced and definitions refined using a multimethod approach. Final importance and feasibility ratings were plotted on “go-zone” graphs and compared across providers and researchers to identify top-rated strategies. Results: The initial 33 strategies were rated as “relevant” or “relevant with changes” to MBC in schools. Importance and feasibility ratings were high overall for both survey rounds; on a scale of 1 to 5, importance ratings (3.61 - 4.48) were higher than feasibility ratings (2.55 – 4.06) on average. Survey 1 responses resulted in a reduced, refined set of 21 strategies, and six were rated most important and feasible on Survey 2: 1) assess for readiness and identify barriers and facilitators; 2) identify and prepare champions; 3) develop a usable implementation plan; 4) offer a provider-informed menu of free, brief measures; 5) develop and provide access to training materials; and 6) make implementation easier by removing burdensome documentation tasks. Provider and researcher ratings were not significantly different, with a few exceptions: providers reported higher feasibility and importance of removing burdensome paperwork than researchers, and providers reported higher feasibility of train-the trainer approaches than researchers; researchers reported higher importance of monitoring fidelity than providers. Conclusions: The education sector is the most common setting for child and adolescent mental health service delivery in the United States. Effective MBC implementation in schools has the potential to elevate the quality of care received by many children, adolescents, and their families. This empirically-derived, targeted list of six implementation strategies offers potential efficiencies for future testing of MBC implementation in schools.

Schools and research partners are increasingly implementing complex, multicomponent interventions and school-wide frameworks to better meet students' social, emotional, behavioral, and academic needs; however, in the research and real-world contexts, implementation is often fraught with many challenges and barriers to success. This study explores implementation barriers encountered during a randomized controlled trial testing effects of one complex intervention strategy-the Interconnected Systems Framework-from the lens of a practical model for conceptualizing organizational readiness-the Interactive Systems Framework for Dissemination and Implementation. Implementation of the Interconnected Systems Framework was explored via focus group and key informant interviews with school and mental health professionals, and research team members responsible for implementing the intervention in randomly assigned study schools. Results from inductive thematic analysis of verbatim transcripts identified three primary implementation challenges: staff turnover, inadequate leadership buy-in, and insufficient time for training/planning. Each challenge is explored from interview participants' perspectives and the extant literature, then connected to recommendations from implementation science to help others avoid similar challenges in their well-intentioned efforts to address the mounting concern for students' wellbeing.

This study examined the relational factors influencing school engagement for parents of high school youth with emotional/behavioral disorders. Fourteen parents of high school students (12 mothers, two fathers) who received special education services participated in semistructured interviews. Formal qualitative analyses of audiotaped phone interviews revealed some positive and some negative experiences by parents, the importance of coparenting to increase supportiveness to their child (and dimensions of effective coparenting), and recommendations from them for improving family engagement processes. In general, parents appreciated and recommended proactive and positive communication and collaboration with school staff emphasizing student strengths, being genuinely and meaningfully involved in the Individualized Education Program (IEP) process, with adequate time allowed for this involvement, and for staff to be organized and engaged in working with them. Findings are discussed in relation to ideas for practice and policy enhancement, and future research directions.

As schools increasingly implement multitiered systems of support, there is a pressing need to develop psychometrically sound implementation fidelity measures. The interconnected systems framework (ISF) is a multitiered model blending systems of positive behavioral interventions and supports with promotion, prevention, and intervention strategies of school mental health. The ISF is being implemented in communities across the United States with ongoing evaluation in several randomized controlled trials. The ISF-Implementation Inventory (ISF-II) was developed to measure fidelity of the ISF within a school building. We conducted a national validation study including completion of the ISF-II by 398 educators in 49 schools, 16 school districts, and 9 states. Results indicate the ISF-II produces scores that are internally consistent and structurally valid when items are organized into a three-tiered model. Additionally, the ISF-II was rated as feasible, acceptable, and beneficial. Limitations of the study, including the need for additional psychometric testing, are discussed in light of these results that suggest educators and researchers, alike, should feel confident in using the ISF-II as a measure of ISF implementation quality. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

School Mental Health prevention approaches that use multi-tiered systems are advancing rapidly. However, there is a relative shortage of effective selective prevention programs feasible to implement within the school context. To optimize the effectiveness of selective prevention in this context, a Motivational Interviewing (MI)-based prevention program for an adolescent student population was developed and tested. Footprints utilizes MI to increase engagement in modular Cognitive-Behavioral Therapy and to promote academic protective factors. In this study, forty-three adolescents were randomly assigned to Footprints or a treatment-as-usual waitlist control. Participants in the experimental condition demonstrated significant increases in behavioral and emotional functioning, self-efficacy to regulate behaviors, positive expectations for success, academic motivation, and grades in mathematics. Simultaneously, Footprints received high ratings for feasibility and acceptability within a dynamic school context. This exploratory efficacy evaluation provides initial support for MI's potential to promote the effectiveness of school-based prevention programs and warrants further study.

Background Improving child and adolescent mental health requires states and jurisdictions to invest in school mental health efforts. In recent years, there has been notable expansion and improvement in school mental health services in the state of South Carolina related to a number of investments that are cumulatively promoting capacity building. Methods This narrative overview examines the history of the school mental health movement in one southern state and details efforts by multiple key stakeholders that have coalesced to form a strong system for advancing school mental health. Results Resting on a strong university-community partnership, five separate initiatives are described that together provide enhanced workforce training and support and expansion of school mental health services. Themes of this work are identified with a goal of supporting and advancing the development of school mental health systems in the United States. Conclusion Strong collaborations and communication efforts both within the university setting and between partners in education and community settings, along with engaged funders keen to enhance well-being of children, youth, and families statewide have set the stage for the growth and expansion of school mental health services.

Reviews the development of the Southeastern School Behavioral Health Community (SSBHC, see www.schoolbehavioralhealth.org), a regional community of practice focused on improving and expanding school behavioral health (SBH) programs involving clinicians from the mental health system joining schools’ multitiered systems of support (MTSS). The community was strengthened by a Eugene Washington Engagement Award from the Patient-Centered Outcomes Research Institute (PCORI), and this support also enabled the conduct of eight focus groups, each including diverse representatives (e.g., teachers, mental health clinicians, family members, youth, systems leaders) in locations around South Carolina. Focus groups included five critical theme areas focusing on improving collaboration, school-wide strategies, cultural humility, overall program quality, and implementation support. Three final focus groups focused on priority populations of students connecting to juvenile justice or child welfare systems, or from military families. This introductory chapter to the book briefly reviews these eight themes, reviews methodology for qualitative analyses of focus group data, and discusses the advancement of SBH in the context of the COVID-19 pandemic.

Distills ideas from each chapter in this book reflecting stakeholder recommendations for advancing school behavioral health (SBH) in a community related to major critical themes (collaboration, school-wide approaches, cultural humility, program quality, implementation support) and priority populations (juvenile justice, child welfare, military families). Reflecting ideas from the eight focus groups, and the experiences of contributors to the book, 34 specific recommendations for advancing SBH in a community are presented. This concluding chapter also underscores the importance of the community of practice approach, discusses the COVID-19 interface, and presents a number of pragmatic resources for this work.

A prevailing model for mental health care for youth and families is to provide services within a "psychopathology" focused framework. This approach can compound problems for youth by imparting negative labels on them, and may be associated with iatrogenic impacts of interventions (e.g., stigmatization, lowered self-efficacy, dependency). This study assessed perceptions of the term "psychopathology" among 486 youth aged 18-25, with 39% of these youth receiving prior mental health services. Results indicated statistically significant differences in perception of the term, with youth who had received mental health services perceiving it more negatively than youth who had not. Findings suggest receipt of mental health services among young people may sensitize them to negative aspects of the term psychopathology, indicating the need for caution in using this term and other terms that may have negative impacts on mental health service use among youth.

Despite schools increasingly adopting multitiered systems of support (MTSS) for prevention and intervention of mental health concerns, many are slow to adopt universal mental health screening (UMHS), a core MTSS feature, due to concerns about their limited capacity to meet the needs of all identified. In this study, we examined differences in the number and characteristics of students who would be identified for intervention services when UMHS in an MTSS were added to those students already receiving social, emotional, and behavioral supports. In a sample of 3,744 students in Grades 1 to 5 from six schools, 679 (18.1%) additional students were identified by screening, representing a 180.1% increase in students identified with behavioral risk or need for mental health interventions. Using a series of stepwise logistic regression analyses, we identified significant predictors of newly identified students including gender, number of office discipline referrals, and externalizing, internalizing, and adaptive behavior ratings. Findings are discussed in relation to opportunities for prevention and the systems needed in an MTSS to meet the needs of newly identified students.

Although it is known some youth access mental health services more readily than others, most service use studies used variable-centric approaches that produced heterogeneous groups and results that require parents and educators to understand diagnostic categories. Person-centered approaches group youth with similar patterns of behavioral and mental health concerns and thus are more homogenous and comparable to the presentation of behavioral and mental health problems noticed by parents and educators, who most typically facilitate access to care for those youth in need. We examined the behavioral and mental health symptom profiles, demographic characteristics and service use histories of youth referred for intervention in a multi-state, randomized controlled trial intervening in severe emotional/behavioral problems (n = 647; Kern et al. in Educ Treat Child 34(4):593–617, 2011). Latent profile analysis of parent-reported hyperactivity, aggression, and conduct, and adolescent-reported anxiety and depression on a broadband measure of student emotional and behavioral functioning was conducted. Model fit indices and theoretical interpretation supported five latent profiles; Class 1 showed severe externalizing behavior problems (7.18%, n = 45), Class 2 showed normative behaviors (37.78%, n = 237), Class 3 showed elevated internalizing behavior problems (12.76%, n = 80), Class 4 showed elevated externalizing behavior problems (33.01%, n = 207), and Class 5 showed elevated internalizing and externalizing behavior problems (9.25%, n = 58). We detected demographic and service use history difference between these profiles using multinomial logistic regression. Findings are discussed in relation to improving children’s mental health services, including universal screening, training emphasizing recognition and concern for internalizing behavior problems, and increased availability of mental health professionals in school settings.

The Interconnected Systems Framework (ISF) blends school mental health practices, systems, and resources into all levels of a multitiered system of supports (e.g., positive behavior interventions and supports). The ISF aims to improve mental health and school performance for all students by emphasizing effective school-wide promotion and prevention; early identification; and social-emotional, behavioral, and mental health intervention. Teaming is 1 of 3 foundational components of quality ISF implementation at school, district, and state levels. After introducing the ISF, the authors highlight the core implementation components (i.e., teaming, data-based decision making, and evidence-based practices) and then elaborate on characteristics of well-functioning ISF teams. The authors provide a case example to illustrate each characteristic and review 5 measures teams may consider using to evaluate their functioning and SF implementation.

All around the world, partnerships among schools and other youth-serving systems are promoting more comprehensive school-based mental health services. This article describes the development of international networks for school mental health (SMH) including the International Alliance for Child and Adolescent Mental Health and Schools (INTERCAMHS) and the more recent School Mental Health International Leadership Exchange (SMHILE). In conjunction with World Conferences on Mental Health Promotion, SMHILE has held pre-conference and planning meetings and has identified five critical themes for the advancement of global SMH: 1) Cross-sector collaboration in building systems of care; 2) meaningful youth and family engagement; 3) workforce development and mental health literacy; 4) implementation of evidence-based practices; and 5) ongoing monitoring and quality assurance. In this article we provide general background on SMH in four nations, two showing strong progress (the United States and Canada), one showing moderate progress (Norway), and one beginning the work (Liberia). Following general background for each country, actions in relation to the SMHILE themes are reviewed. The article concludes with plans and ideas for future global collaboration towards advancement of the SMH field.

This chapter will provide an overview of the school mental health field which has grown significantly since its beginning days in child guidance clinics and primary focus on expanded models inclusive only of community providers. The opportunity to provide mental and behavioral health services within the school setting has been an ongoing goal for many mental health professionals (e.g., social workers, psychologists, counselors) who desire to improve access to care by providing evidence-based interventions to a greater number of children and families. Service delivery models that emphasize teaming and collaboration across school, community, and family stakeholders within the system of a multitiered public health continuum of promotion, prevention, early intervention, and treatment are increasingly showing positive outcomes for children in need.

As schools increasingly adopt universal social, emotional, and behavioral screening, more research is needed to examine the effects of between-teacher differences due to error and bias on students' teacher-rated screening scores. The current study examined predictors of between-teacher differences in students' teacher-rated risk across one global and three narrow domains of behavioral functioning. Participants included 2450 students (52.1% male, 54.2% White) and 160 teachers (92.1% female, 80.3% White) from four elementary schools in one Southeastern U.S. school district. Teachers rated student behavior on the Behavior Assessment System for Children (Third Edition) Behavioral and Emotional Screening System (BESS)-Teacher Form and completed a survey about their training and perspectives of common behavior problems. Results of multilevel linear regression found between-teacher effects to be greater for internalizing risk scores (intraclass correlation = 0.23) than for externalizing risk scores (intraclass correlation = 0.12) or adaptive behavior scores (intraclass correlation = 0.14). Statistically significant student predictors in most models included student grade, gender, race and/or ethnicity, office discipline referrals, and course grades. We also detected effects of several teacher-level variables in one or more of the models, including teacher gender, teacher ratings of problem severity and concern for hypothetical children displaying behavior problems, and the covariance of random teacher intercept and teacher random slopes for students' office discipline referrals. Although these factors explained some teacher-level variance in students' risk scores, a notable amount of variance between teachers remains unexplained. Future research is needed to fully understand, reduce, and account for differences between teacher ratings due to error and bias.