Grow With Grit: A School Nurse-Led SBIRT Pilot for Early Anxiety Detection

Grow With Grit: A Nurse-Led SBIRT Model for Early Anxiety Detection and School-Based Mental Health Intervention in Rural Youth

All enrolled students and their parents or guardians will complete baseline anxiety questionnaires. Students with a positive baseline screen will receive a brief school nurse-delivered coping skill, referral support when indicated, and follow-up assessments at approximately three and six months. Students with a negative screen will not enter the intervention and follow-up phase.

Anxiety in elementary-aged children may first appear as headaches, stomachaches, fatigue, nausea, dizziness, or other physical symptoms. These concerns can lead to repeated school health-office visits, difficulty remaining in class, and missed school before a child recognizes or reports feeling anxious. Such patterns are particularly important in rural schools, where access to onsite behavioral health professionals may be limited.

Grow with Grit is a prospective, single-cohort Hybrid Type II pilot clinical trial conducted in four public elementary schools in Great Falls, Montana. The study includes students ages 8 to 12 who are enrolled in grades 3 through 5. It evaluates a school nurse-led Screening, Brief Intervention, and Referral to Treatment (SBIRT) workflow while examining how well the workflow functions in routine school practice. The pilot focuses on feasibility, acceptability, fidelity, and preliminary changes in student outcomes. Because the study has no comparison group, its findings will be used to inform a future controlled trial.

The workflow uses targeted case-finding rather than screening every student. School nurses review routine health-office and attendance records to identify students who have repeated physical complaints or an attendance pattern associated with those complaints, as defined in the study eligibility criteria. Physical symptoms must not be fully explained by an acute illness, injury, or known medical condition. Meeting a case-finding threshold indicates that anxiety screening may be appropriate; it does not mean that the student has an anxiety disorder. Attendance is also examined as a measure of school engagement and as a possible identification signal for future studies in schools with limited nursing coverage.

After parent or guardian permission and child assent are obtained, the student and parent or guardian complete the child and parent versions of the Screen for Child Anxiety Related Emotional Disorders (SCARED). This validated, 41-item questionnaire assesses symptoms related to generalized anxiety, separation anxiety, social anxiety, panic or physical symptoms, and school avoidance. A score of 25 or higher on either version is considered a positive screen and suggests that further evaluation or support may be appropriate.

Students with a negative screen do not enter the intervention and six-month follow-up phase. The nurse informs the student and parent or guardian of the result. The student may continue to receive routine school health services and use universal school wellness resources. Re-screening may be considered through usual school processes if symptoms persist or new concerns develop.

Students with a positive screen receive a standardized, three- to five-minute intervention from the school nurse during the same or next clinically appropriate encounter. The intervention uses cognitive behavioral therapy principles to help the student understand connections among body signals, thoughts, feelings, and stress. The nurse introduces and practices a skill matched to the student's concern, such as paced breathing, grounding, gentle movement, or reframing an unhelpful thought. The nurse and student then make a brief plan for using the skill and returning to class when appropriate. Skills may be reinforced during later school nurse encounters.

Following a positive screen, the nurse initiates a referral through the school's existing Multi-Tiered System of Supports (MTSS) mental health pathway. Support may involve a school counselor, psychologist, social worker, school-based program, primary care professional, or community behavioral health provider. The school team and family determine which services best fit the student's needs and available local resources. Referral progress, engagement, and barriers to obtaining services are documented as part of the study workflow.

Students who screen positive are followed for approximately six months. The child version of the SCARED is completed at baseline and again at approximately three and six months. The parent version is completed by the parent or guardian at baseline and by the parent, guardian, or primary care provider at follow-up, as permitted by the protocol. During routine school nurse encounters, nurses document relevant physical complaints, coping-skill use, skill reinforcement, and referral progress. Health-office and attendance records are also reviewed to examine changes during participation. The study does not require separate research visits outside regular school activities.

At the six-month follow-up, parents or guardians and, when appropriate, students may participate in an optional 10- to 15-minute exit interview. The interview asks about the acceptability, usefulness, and feasibility of the study procedures. Interviews are not audio-recorded, and participation is not required to remain in the study or receive services.

The implementation evaluation is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. It examines whether the workflow reaches eligible students, can be completed consistently, fits within school nursing and MTSS practices, and may be maintained over time. School nurse feedback is used to identify workflow burden, training needs, implementation barriers, and needed refinements. Findings will guide future case-finding procedures, nurse training, referral processes, data collection, and the design of a larger trial.

Inclusion Criteria:

1. GFPS students aged 8-12 years and enrolled at one of the following schools:

   Mountain View Elementary West Elementary Longfellow Elementary Sunnyside Elementary School

2. Participants will be identified through a weekly review of school nurse electronic health records (Frontline EHR) and attendance logs, and will include students who have either:

   1. Three or more nurse visits for somatic complaints within the past 6 weeks. For this study, somatic complaints are defined as the following physical symptoms that are not otherwise linked to exclusionary illness or chronic medical processes: stomach aches, headaches, fatigue, & generalized muscle aches.
   2. Absenteeism greater than or equal to 10% of total school days due to the previously defined somatic complaints, within the past 6 weeks.
   3. English-speaking without an interpreter (both student and guardian).

Exclusion Criteria

1. Currently receiving ongoing behavioral health services, including psychotherapy, psychiatric medication management, or active behavioral health case management.

   1. Brief, one-time crisis counseling is not considered ongoing services.
   2. Questions about eligibility should be directed to the Principal Investigator.

2. Presence of a chronic medical diagnosis that fully accounts for the student's repeated somatic visits (e.g., asthma with frequent exacerbations, epilepsy, diabetes, sickle cell disease, or active cancer treatment).

   a. Students with partially explained symptoms who are also suspected to have co-occurring anxiety may be reviewed on a case-by-case basis by the PI/designee.

3. Documented cognitive or communication impairments that preclude meaningful completion of the SCARED screening tool or informed assent.

   1. Examples include moderate to severe intellectual disability or severe receptive/expressive language disorder without feasible accommodations.
   2. Students with an IEP or 504 plan that includes communication supports may be included if they can complete the tool with reasonable accommodations.

4. Students who are wards of the state or in foster care.

5. Non-English speaking students or guardians.

6. Acute safety concerns at the time of screening (e.g., active suicidal ideation with plan/intent, recent suicide attempt, or other crisis requiring immediate intervention).

   1. Such students will be triaged to crisis protocols and excluded from study participation at that time.