School-based Mental Health Professionals Research Articles

Matters of Fidelity: School Provider Adherence and Competence in a Clustered Study of Adaptive Implementation Strategies

ABSTRACT Schools are a promising access point for youth with mental health concerns, but school-based mental health professionals (SPs) often need ongoing support to provide high-fidelity cognitive behavioral therapy (CBT). Adherence and competence, two critical elements of fidelity, were examined in a cluster-randomized implementation trial. We evaluated CBT adherence and then triangulated CBT adherence with end-of-study competence. We then evaluated the effects of two implementation supports, Coaching and (for slower-responding schools) Facilitation, on adherence and competence. By the end of the 43-week study period, 27.8% of SPs met adherence criteria. Adherent SPs scored higher on the competence measure, the CBT Competence Scale (t(116.2) = 3.71, p < .001). No significant difference in adherence was found among SPs at schools assigned to Coaching vs. not (Δ = 6.0%, p = .385), however SPs at schools randomized to Coaching scored significantly higher on two of the four competence subscales (Non-Behavioral and Behavioral skills). Among slower-responder schools, SPs at schools assigned to Facilitation were more likely to demonstrate adherence (Δ = 16.3%, p = .022), but there was no effect of Facilitation on competence. Approximately one quarter of SPs met adherence criteria in the trial; adequate delivery of exposure was a primary obstacle to reaching adherence. Facilitation may be especially suited to help SPs overcome barriers to delivery, whereas Coaching may be especially suited to help SPs improve CBT competence. Both are likely needed to build a mental health work force with the competence and ability to deliver EBPs in schools.

Help, Teach, Counsel: How Terminology Changes in the ProQOL-5 Impact Score Reliability

Objective: This study evaluated score reliability of the Professional Quality of Life Scale (ProQoL) when contextualizing help to a relevant derivative. Method: The researchers evaluated score reliability across three datasets among school-based professionals (n = 122), teachers (n = 216), and mental health professionals (n = 543) using Cronbach’s alpha, McDonald’s omega, inter-item correlations and visual analysis. Results: Score reliability was acceptable across samples. However, item analysis indicated variability in responses indicating participants’ extracting different meaning or relevance to the items. Terminology changes may extract different meaning based on profession resulting in measurement error. Conclusions: Findings highlight use of one-word derivative changes to items may impact score reliability based on the professional activities represented. Researchers should adjust item terminology for clarity and relevance to all the professions represented in the sample. Evidence of the nature of professional activities with client or student trauma to secondary traumatic stress is presented.

Trauma-Competent Approaches for Supporting Rural Students of Color

Rurality is a context, often overlooked by research and society, where trauma exposure is a prevalent feature in many young people’s lives. Rural Students of Color experience trauma at higher rates compared to rural White students. In turn, school systems must respond with trauma-competent systems of support to build protective factors for students. The purpose of this article is to discuss the history and modern trauma-informed practices and ways to begin shifting our mindset and language to better support rural Students of Color by understanding the historical and present contexts and trauma that influence their experiences. Furthermore, this article will highlight the needs of Students of Color in rural spaces as well as applications for trauma-competency within the Substance Abuse and Mental Health Services Administration (SAMHSA) model. Strategies for building connectedness and implementing anti-racist social-emotional learning will be identified. Additionally, implications for rural school leaders, school counselors, and school-based mental health professionals, and further research will be discussed.

Evidence-Based Strategies to Reduce Anxiety in Students With Autism Spectrum Disorder

Students with autism spectrum disorder (ASD) experience anxiety at higher rates than their neurotypical peers, which can negatively impact school performance. Anxiety symptoms for these students can be challenging to identify because they mimic diagnostic characteristics. As key intervention team members, school-based mental health professionals can assist with identifying and addressing anxiety in students with autism. Specific evidence-based strategies for school-based mental health professionals are detailed to support efforts to intervene successfully with students with autism who experience anxiety.

Development of an Online Training Platform and Implementation Strategy for School-Based Mental Health Professionals in Rural Elementary Schools: A Mixed-Methods Study.

Children in rural settings are less likely to receive mental health services than their urban and suburban counterparts and even less likely to receive evidence-based care. Rural schools could address the need for mental health interventions by using evidence-based practices within a tiered system of supports such as positive behavioral interventions and supports. However, very few school professionals, with or without mental health training, have received training on evidence-based practices. Rural schools need implementation strategies focused on training to prepare school personnel for the implementation of interventions with fidelity. Little is known about training strategies that are feasible and appropriate for the rural school context. User-centered design is an appropriate framework for the development of training strategies for professionals in rural schools because of its participatory approach and the development of products that fit the context where they are going to be used. The purpose of the study was to develop and assess components of an online training platform and implementation strategy based on the user-centered design. Quantitative and qualitative data from 25 participants from an equal number of schools in rural areas of Pennsylvania were used in the study. A mixed-methods design utilizing complementary descriptive statistics and theme analyses indicated that the training platform and implementation strategy were perceived as highly acceptable, appropriate, feasible and usable by school professionals. The resulting training platform and implementation strategy will fill a void in the training literature in rural schools.

Mental Health and Student Support Service Providers in the Schools: Understanding Access and Equity Across the United States

School-based mental health professionals, including school psychologists, counselors, and social workers are critical to appropriate mental health services to youth in schools. However, the vast majority of states are chronically underserved by these professionals, despite policies that attempt to rectify the shortages. In this paper, we document variation in access to these professionals across the United States, assessing the school- and district-level factors associated with the presence and prevalence of these service providers using the Civil Rights Data Collection from 2017–2018. We analyze these results descriptively and with logistic regression and find evidence of varying degrees of inequity in all three positions with significant factors associated with the prevalence of these professionals. Implications for policy and future research are discussed. Impact Statement This paper seeks to elucidate the factors related to the prevalence of school-based mental health providers, including school psychologists, counselors, and social workers. An improved understanding of these implications will help policymakers and practitioners alike to make decisions regarding the allocation of resources for these important professionals.

The Jigsaw Method: Reviving a Powerful Positive Intervention

Schools in the United States are becoming more diverse with respect to race, ethnicity, gender, and sexuality, but many minority students experience disconnection from school for a variety of reasons. Longstanding research on the jigsaw method suggests that it has been an effective intervention for increasing interdependence among students and fostering prosocial behaviors that would increase social connection. More recent research on the jigsaw method has focused on its strong effects on academic learning and has largely overshadowed its original purpose to improve social interactions and increase inclusion. This paper is an attempt to revive the jigsaw method as an effective intervention to increase prosocial behavior while at the same time improving academic performance. Practical implementation information, including an implementation checklist, is offered for teachers and school-based mental health professionals looking to implement the intervention in classroom settings.

COVID-19 and the Impact on School-Based Mental Health Professionals

Abstract In March of 2020, many school systems transitioned to fully virtual platforms in an attempt to stop the spread of COVID-19. In the following months, schools remained online, transitioned to hybrid (partially online, partially in-person) models, or reopened completely. School-based mental health professionals (SBMHPs) remained responsible for meeting the mental health needs of students in the school system, regardless of the setting. This study sought to find out how COVID-19 and the subsequent changes in school setting have impacted SBMHPs. Through ethnographic observations of a nonprofit providing school-based mental health services as well as qualitative interviews with SBMHPs, this study uncovered a range of impacts. SBMHPs experienced an increase in demand for support with meeting basic needs and improving attendance and academics. Further, SBMHPs continued to provide counseling and crisis response services; however, these services had to be significantly adapted for each unique school setting (virtual, hybrid, and in-person). Despite these significant role changes, SBMHPs were adaptive and continued to meet the needs of students.

Perceptions of rural high school teachers - on the frontline of youth suicide.

This study aimed to investigate the perceptions and beliefs of rural high school teachers about student suicide completion in their school and their perceived self-efficacy in identification of suicidality in students (suicidal ideation, plans and behaviours). A cross-sectional survey methodology. Gippsland and the Loddon Mallee regions of Victoria, Australia. Rural high school teachers. A survey that aimed to obtain participants' perceptions and self-reports about students who had died by suicide in their school within the last 5 years, their perceived self-efficacy in identifying suicidal students and barriers to helping students at risk. Two hundred and seventy-seven rural high school teachers participated and 86% reported that a student from their school had died by suicide within the last 5 years. Sixty-five per cent believed that more than one student had died by suicide and 70% perceived they were currently aware of students experiencing suicidality in their class. Receiving professional development about suicide and obtaining help from mental health clinicians predicted perceived self-efficacy in identification of suicidality in students. Participants perceived the barriers to help students at risk included insufficient numbers of school-based mental health professionals and community mental health services. Many rural high school teachers perceive they are at the front line of the youth suicide crisis due to unmet service need in youth mental ill health. Increased access to effective services immediately after teachers become aware of suicidality may assist in reducing youth suicide in rural areas.

Three Sibling Survivors' Perspectives of their Father's Suicide: Implications for Postvention Support.

This qualitative case study describes three adult siblings’ experiences and their perceptions of support connected with the time before and after their father’s suicide. At the time of the suicide, participants were ages 1, 5, and 8 years old. We considered commonalities and disparities among the three survivors’ perceptions. We also considered how their reported experiences compared to extant literature on child survivors of parent suicide. Our findings suggest that, although the siblings experienced the same traumatic event, each had unique perceptions of the parent’s suicide. Immediately prior to closing each interview, to deescalate from the intense topic of suicide, participants offered their impressions of potentially therapeutic children’s books and how bibliotherapy may or may not support surviving children. Participants’ perceptions of selected children’s picture books offer insights about opening communication and addressing challenges specific to a parent’s suicide. Implications for teachers, parents, and school-based mental health professionals are provided. We conclude that postvention must consider and monitor each child’s perceptions and provide individualized interventions that encourage open communication and support adaptive coping to navigate the intense grief associated with a parent’s suicide.

Art Making Promotes Mental Health: A Solution for Schools That Time Forgot

This article presents art as a tool for promoting mental health in schools by examining the effects of art making in a sample of 104 school-based mental health professionals. It unites findings from unrelated disciplines to derive and test a new conceptual framework proposing that active engagement in a visual-tactile process over time mediates a shift to healthy mental states and that regular engagement in such process builds mental health capacity. Four hypotheses are tested through psychometrics with statistically significant findings for all (p &lt; .05). Through this study, we advance Flow Theory in identifying a new causal mechanism for accessing Flow; and we make a novel, interdisciplinary contribution to the field of mental health in providing psychometric evidence that making visual art promotes mental health.

Partnerships to Address School Safety through a Student Support Lens

School safety is a primary concern of school leaders, employees, parents, and a variety of community stakeholders. Attempts to mitigate and prevent school safety concerns often focus on strategies around school climate assessment, emergency communication, school safety plan development, and school resource officer employment (U.S. DHS et al., 2018). Involvement of key stakeholders, such as school social workers, school counselors, and school-based mental health professionals is emphasized in creating and assessing school safety in a wholistic manner. This article provides an overview of a Trainings to Increase School Safety grant program that was implemented with public school stakeholders through partnerships between a university and five public school districts in the Southeastern North Carolina region.

Addressing climate anxiety among young people in the Philippines

The climate crisis poses a serious threat to people's lives, with children and youth at high risk for mental health consequences.1Burke SE Sanson AV Van Hoorn J The psychological effects of climate change on children.Curr Psychiatry Rep. 2018; 20: 35Crossref PubMed Scopus (72) Google Scholar This is especially true among youth populations in climate-vulnerable countries such as the Philippines.2Hickman C Marks E Pihkala P et al.Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey.Lancet Planet Health. 2021; 5: e863-e873Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar The Philippines is repeatedly included in the German Watch Global Climate Risk Index and Global Peace Index as one of the countries that will be most affected by the extreme consequences of climate change.3Kreft S Epstein D Global climate risk index 2014. Who suffers most from extreme weather events? Weather-related loss events in 2012 and 1993 to 2012.https://www.germanwatch.org/sites/default/files/publication/8551.pdfDate: 2014Date accessed: December 18, 2021Google Scholar, 4Institute for Economics and PeaceGlobal Peace Index.https://www.visionofhumanity.org/wp-content/uploads/2020/10/GPI-2019web.pdfDate: 2019Date accessed: January 10, 2022Google Scholar At least 20 typhoons occur annually in the Philippines, some of which are categorised as super typhoons, which cause hundreds of deaths and damage thousands of homes and livelihoods. For example, Typhoon Haiyan, one of the most powerful typhoons ever recorded to make landfall, struck the Philippines in 2013. The typhoon caused at least 6300 casualties, the relocation of around 4 million people, and destroyed at least a million houses in the country.5Kure S Jibiki Y Quimpo M Manalo UN Ono Y Mano A Evaluation of the characteristics of human loss and building damage and reasons for the magnification of damage due to Typhoon Haiyan.Coast Eng J. 2016; 581640008Crossref Scopus (10) Google Scholar Emerging evidence from global surveys among children and adolescents in ten countries showed that extreme climate anxiety (ie, psychological distress associated with climate change and ecological crises) was the highest in the Philippines. We propose an agenda for research on climate anxiety in Filipino youth and inclusion of mental health into climate change education in school systems and universal health-care systems. First, validation of climate anxiety and ecoanxiety measures developed in western, educated, industrialised, rich, and democratic (WEIRD) countries among children and adolescents from non-WEIRD countries is recommended. Evidence on Filipino youth show that climate anxiety is associated with mental health outcomes.6Reyes MES Carmen BPB Luminarias MEP Mangulabnan SANB Ogunbode CA An investigation into the relationship between climate change anxiety and mental health among Gen Z Filipinos.Curr Psychol. 2021; (published online July 15.)https://doi.org/10.1007/S12144-021-02099-3Crossref PubMed Scopus (5) Google Scholar There is value in investigating the positive and negative mental health correlates of climate anxiety in children and adolescents across diverse cultures. Furthermore, longitudinal studies that examine the developmental trajectory of climate anxiety from childhood to adolescence can aid and inform the design of developmentally-appropriate interventions. Interventions might capitalise on the adaptive function of climate anxiety by encouraging sustainable behaviour among youth populations, with the aim of curtailing the negative impact of climate anxiety on youth mental health. Since there is evidence for hope-related strategies being employed by youth populations to cope with climate worry,7Ojala M Regulating worry, promoting hope: how do children, adolescents, and young adults cope with climate change?.Int J Environ Sci. 2012; 7: 537-561Google Scholar hope-based psychoeducational interventions that aim to empower future leaders show great promise. Second, the Philippine educational curricula should incorporate mental health, specifically climate anxiety, into the climate change education agenda since this has been generally neglected. The Climate Change Act (Republic Act 9729) in 2009 paved the way for the integration of climate change education into the Philippine school curricula (eg, DepEd order 82 series [2010] and the Enhanced Basic Education Act [2013]) in 2013, with particular emphasis on adaptation strategies considering the frequent disasters caused by droughts and typhoons.8Reyes M Diopenes VE Co R et al.Disaster resilience starts with the young: mainstreaming disaster risk reduction in the school curriculum.https://www.preventionweb.net/publication/disaster-resilience-starts-young-mainstreaming-disaster-risk-reduction-schoolDate: 2011Date accessed: December 18, 2021Google Scholar As evidence on extremely high levels of climate anxiety in young Filipinos continues to emerge,2Hickman C Marks E Pihkala P et al.Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey.Lancet Planet Health. 2021; 5: e863-e873Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar there is a growing need for psychological interventions to equip youth populations with skills to manage climate anxiety. There should be more intensive teacher training on climate change education and school-based mental health professionals (eg, school counsellors, psychologists) with specialised training for students experiencing climate anxiety. Third, since evidence for climate anxiety among Filipino youth is increasing,2Hickman C Marks E Pihkala P et al.Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey.Lancet Planet Health. 2021; 5: e863-e873Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 6Reyes MES Carmen BPB Luminarias MEP Mangulabnan SANB Ogunbode CA An investigation into the relationship between climate change anxiety and mental health among Gen Z Filipinos.Curr Psychol. 2021; (published online July 15.)https://doi.org/10.1007/S12144-021-02099-3Crossref PubMed Scopus (5) Google Scholar the Philippine Government should include climate anxiety in its universal health-care agenda. Currently, only a small proportion of the entire health budget is allocated for mental health, and there is a scarcity of trained mental health workforce to care for vulnerable young people.9Lally J Tully J Samaniego R Mental health services in the Philippines.BJPsych Int. 2019; 16: 62-64Crossref PubMed Scopus (26) Google Scholar One solution is to conduct capacity-building training in communities at the barangay (local village) level in providing psychological first aid specifically for vulnerable children and adolescent survivors of natural disasters, since they are the individuals most likely to develop severe climate anxiety. Such training for community members at the grassroot level increases the availability and accessibility of psychosocial services, and addresses the limited supply of mental health professionals especially in rural and remote communities. Implementation of the new Mental Health Act of 2019 should include competency enhancement of mental health professionals to meet the demands of an increasingly climate anxious Filipino youth population. The Philippines has incurred US$10 billion in losses from climate-related disasters in the past decade.10World AsiaPhilippines: 100,000 people evacuated as Rai turns into a ‘super typhoon.’.https://gulfnews.com/world/asia/philippines/philippines-100000-people-evacuated-as-rai-turns-into-a-super-typhoon-1.1639640920269Date: Dec 16, 2021Date accessed: December 18, 2021Google Scholar Investing in the mental health of children and adolescents who will be involved in future climate mitigation and adaptation efforts will prevent the loss of human capital and will be beneficial in the long term. Thus, the Philippine Government should allocate budget for producing evidence-based treatments for children and adolescents who have severe climate anxiety. In conclusion, more research is needed to develop creative solutions to deal with climate anxiety among Filipino children and adolescents.2Hickman C Marks E Pihkala P et al.Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey.Lancet Planet Health. 2021; 5: e863-e873Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar Preventing the potential long-term effects of climate anxiety on the mental health of children and adolescents will require collaboration among various stakeholders and policy makers. A well-educated youth population with good mental health that is empowered to effect changes would be a formidable resource in the fight against climate change. We declare no competing interests.

Which Anxiety Symptoms are Associated with Perceived Ethnic Discrimination in Adolescents With an Immigrant Background?

This study assesses the specific anxiety symptoms that are present in the context of perceived ethnic discrimination in 696 (M age = 13.3, σ = .77, 57% girls) seventh and eighth-grade students with immigrant backgrounds from four different Canadian high schools. Multiple hierarchical linear regressions were conducted to determine the association between perceived ethnic discrimination and specific anxiety symptoms. Results demonstrate that perceived ethnic discrimination is significantly associated with more anxiety symptoms, such as panic/somatic, generalized anxiety, social phobia, and school phobia. Findings provide a better understanding of the association between perceived ethnic discrimination and anxiety symptoms reported by adolescents with an immigrant background. These findings could help school-based mental health professionals in the implementation of prevention and intervention measures aimed at reducing specific anxiety symptoms that are often present in the context of perceived ethnic discrimination.

School Mental Health Providers’ Perspectives on the Impact of COVID-19 on Racial Inequities and School Disengagement

School disengagement is a critical factor that will likely exacerbate long-standing racial inequities in educational outcomes during the aftermath of the coronavirus disease (COVID-19) pandemic. Due to their training and contact with at-risk students, school social workers and other school-based mental health professionals (SMHP) are in an ideal position to understand the impact of COVID-19 and virtual learning on K–12 students. To that end, this study reports on findings from a survey of SMHP about the differential impact that the COVID-19 outbreak is having on students and their families. The findings suggest that COVID-19 has had a tremendous impact on families overall, especially among populations who were experiencing hardships before the current outbreak. In addition, several barriers were noted for student learning, with many students—particularly students of color—completely disengaging from school during spring 2020. However, SMHP reported several important insights on how to support students and their families—some requiring immediate action on the part of school districts and others requiring greater community-level investment into the economic, social, emotional, and overall health of families. Findings are discussed in light of addressing disengagement and educational inequities for students of color.

An Initial Evaluation of the Helping Students at Risk for Suicide Professional Development Workshop

Youth suicide is an urgent public health problem. However, schools often lack standardized protocols for suicide intervention, and many school-based mental health professionals are not prepared adequately to assess and respond to students at risk for suicide. This paper describes a professional development workshop, Helping Students At-Risk for Suicide, developed collaboratively by a state school psychology association, a state Office of Mental Health Suicide Prevention Center, and a university center. The workshop includes an integrated theoretical model of risk that serves as a foundation, introduces standardized procedures and evidence-based tools, and provides support for a collaborative process that guides school personnel from risk assessment through the student’s safe return to school. Results of preliminary evaluations of the workshop, including pilot testing (N = 71) and satisfaction data from workshop participants (N = 251) are presented, in addition to other evidence of impact and future directions. Impact Statement Youth suicide is an urgent public health issue, yet schools often lack standardized procedures and training to assess and respond to students at-risk for suicide. Helping Students At-Risk for Suicide is a professional development workshop that offers standardized procedures and practices with evidence-based tools (Columbia Suicide Severity Rating Scale and safety planning intervention) to meet this need.

Improving well-being and behavior in adolescents utilizing a school-based positive psychology intervention

ABSTRACT This study is a multi-component Positive Psychology Intervention (PPI) with the goal of improving daily happiness and classroom behavior in a sample at-risk high-school students. PPIs have increasingly been used in school settings to enhance student well-being, student success, and to increase positive affect. The current study utilized a multiple baseline design, across five adolescents, to examine whether a manualized PPI implemented in individual school-based counseling sessions with at-risk high-school students, would lead to increased happiness, improved classroom behavior, and life satisfaction, measured through a Daily Happiness survey, the Direct Behavior Rating (DBR), General Happiness Scale, Brief Multidimensional Students’ Life Satisfaction Scale, and the Student Life Satisfaction Scale. Results demonstrated high variability in the data and an overall null effect of the intervention on the two dependent variables of daily happiness and classroom behavior. Limitations included individual impacts of outside factors on student reports and behavior. Due to the small scale of the study and lack of observed intervention effects, more research is needed to draw conclusions about the application of the intervention. However, social validity data revealed that school-based mental health professionals may still consider this intervention to teach students strategies to improve life satisfaction.

Case Study Illustrating Family Systems Interventions in a School Setting to Address Anxiety and School Avoidance

ABSTRACT Collaborating with parents is an important skill set for school-based mental health professionals. While school districts expect school psychologists and school counselors to facilitate family-school collaboration, most receive little training in family counseling and systems theory in their graduate programs. School psychologists and school counselors could benefit from resources that demonstrate how to use a family systems approach in a school setting. This article uses a single case study to illustrate how school-based mental health professionals can use brief family counseling to address anxiety and school avoidance. The article describes a family systems approach and interventions such as reframing, subsystems work, consultation, and encouraging gradual progress.

Mental Health in Schools: An Overview of Multitiered Systems of Support

Mental health–related disabilities are a leading cause of health issues worldwide. Because of this, an argument can be made that schools integrate mental health services for their students to positively impact their mental health outcomes. This article outlines how multitiered systems of support (MTSS) can assist schools in providing all students with mental health services including students with disabilities. The role of school-based mental health professionals (i.e., school counselor, school psychologist, school social worker) within the MTSS framework is discussed to better assist teachers in helping their students access school-based mental health services.

Improving Schools' Readiness for Involvement in Suicide Prevention: An Evaluation of the Creating Suicide Safety in Schools (CSSS) Workshop.

Schools have an important role to play in combatting suicide, a significant public health problem that disproportionately affects adolescents and young adults. Schools can work to reduce youth suicidality by adopting policies that align with best practice recommendations pertaining to suicide prevention, intervention, and postvention. This study examined the impact of a one-day training, the Creating Suicide Safety in Schools (CSSS) workshop, on the readiness of school personnel to improve their schools’ suicide-related policies and procedures. Participants (N = 562) consisted predominantly of school-based mental health professionals working in communities of low or mixed socioeconomic status in New York State. Survey data were collected according to a one-group pre-test—post-test design with a 3-month follow-up. Workshop participants demonstrated improvements from pre-test to post-test in their attitudes about the importance of school-based suicide prevention, knowledge of best practices, perceptions of administrative support, and feelings of empowerment to work collaboratively to enhance their schools’ suicide safety. At follow-up, participants reported barriers to implementing changes, most commonly in the form of insufficient time and stigma surrounding the topic of suicide. The results of this study provide preliminary evidence for the effectiveness of the CSSS workshop as a promising method for improving schools’ suicide safety, yet additional research using randomized controlled trials needs to be conducted.