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

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.

Study Overview

• Status: Recruiting
• Conditions: Anxiety
• Intervention / Treatment: Behavioral: Grow with Grit

Detailed Description

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.

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Donna Sanders R Principal Investigator, DNP-PMH, BSN; Phone Number: 406-799-6554; Email: donna.sanders@mclaughlinresearch.org
• Study Contact Backup: Name: Rebecca Brown Clinical Research Coordinator, BSN; Phone Number: 406-454-6045; Email: rebecca@mclaughlinresearch.org

Study Locations

• United States
  • Montana
    • Great Falls, Montana, United States, 59404
      • Recruiting
      • West Elementary School
      • Contact: Erica Harp Lead School Nurse, RN,BSN; Phone Number: 4062687700; Email: erica_harp@gfps.k12.mt.us
      • Contact: Rebecca Brown R Clinical Research Coordinator, RN; Phone Number: 406-454-6045; Email: rebecca@mclaughlinresearch.org
      • Principal Investigator: Donna Sanders, DNP, PMH
    • Great Falls, Montana, United States, 59405
      • Recruiting
      • Longfellow Elementary
      • Principal Investigator: Donna Sanders, DNP, PMH
      • Contact: Brianna St. Lawrence School Nurse, RN; Phone Number: 4062686845; Email: erica_harp@gfps.k12.mt.us
      • Contact: Erica Harp R Lead School Nurse, RN, BSN; Phone Number: 4062687700; Email: erica_harp@gfps.k12.mt.us
    • Great Falls, Montana, United States, 59405
      • Recruiting
      • Mountain View Elementary School
      • Principal Investigator: Donna Sanders, DNP, PMH
      • Contact: Erica Harp R Lead School Nurse, RN, BSN; Phone Number: 4062687700; Email: erica_harp@gfps.k12.mt.us
      • Contact: Laura Chouinard School Nurse, RN; Phone Number: 4062687305; Email: laura_chouinard@gfps.k12.mt.us
    • Great Falls, Montana, United States, 59405
      • Recruiting
      • Sunnyside Elementary School
      • Principal Investigator: Donna Sanders, DNP, PMH
      • Contact: Erica Harp R Lead School Nurse, RN, BSN; Phone Number: 4062687700; Email: erica_harp@gfps.k12.mt.us
      • Contact: Melanie Knutson School Nurse, RN, BSN; Phone Number: 4062687115; Email: melanie_knutson@gfps.k12.mt.us

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Screening
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Grow with Grit School Nurse-Led SBIRT; Participants complete child and parent anxiety screening. Students who screen positive receive a brief school nurse-led coping-skills intervention, referral through the school's existing mental health support pathway, and follow-up assessments at approximately three and six months. Students who screen negative do not continue into the intervention and follow-up phase.

Behavioral: Grow with Grit; After targeted case-finding and enrollment, students and their parents or guardians complete the child and parent versions of the Screen for Child Anxiety Related Emotional Disorders (SCARED). Students with a score of 25 or higher on either version receive a standardized three- to five-minute, school nurse-delivered micro-CBT intervention during the same or next clinically appropriate encounter. The nurse provides brief psychoeducation about connections among body signals, thoughts, feelings, and stress; practices a coping skill matched to the student's concern, such as paced breathing, grounding, gentle movement, or cognitive reframing; and develops a brief plan for using the skill and returning to class when appropriate. The nurse also initiates a referral through the school's existing MTSS-aligned mental health pathway. Coping skills may be reinforced during subsequent school nurse encounters. Students who screen negative do not receive the study micro-CBT intervention or enter the

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Positive Baseline Anxiety Screen Among Students Meeting the Somatic-Frequency Case-Finding Rule	Percentage of enrolled students who met the somatic-frequency case-finding rule, completed both baseline anxiety questionnaires, and had a positive baseline anxiety screen. The somatic-frequency rule is defined as three or more school-nurse visits involving qualifying somatic complaints within the previous six weeks. A positive screen is defined as a total score of 25 or higher on either the 41-item SCARED-Child Version or the 41-item SCARED-Parent Version. The percentage is calculated as the number of students meeting the rule who had a positive baseline screen divided by the number of students meeting the rule who completed both baseline questionnaires, multiplied by 100.	At baseline screening
Completion of Child and Parent Anxiety Screening	Percentage of students with parent or guardian consent and child assent for whom both the 41-item SCARED-Child Version and the 41-item SCARED-Parent Version are completed at baseline. The percentage is calculated as the number of students who complete both baseline questionnaires divided by the total number of students with parent or guardian consent and child assent, multiplied by 100.	At baseline screening following enrollment
Proportion of Students Meeting the Somatic-Frequency Case-Finding Rule	Percentage of enrolled students who met the somatic-frequency case-finding rule when identified as potentially eligible. The rule is defined as three or more school-nurse visits involving qualifying somatic complaints within the previous six weeks. The percentage is calculated as the number of enrolled students who met the somatic-frequency rule divided by the total number of enrolled students, multiplied by 100. Students may meet the somatic-frequency rule, the absenteeism trigger, or both.	During the six weeks preceding identification as potentially eligible
Fidelity to the School Nurse-Delivered Micro-CBT Intervention	Percentage of documented school nurse-delivered micro-CBT encounters in which all required intervention components are documented as completed: brief explanation of the connection between body signals and stress or worry, guided practice of one card-based coping skill, and development or reinforcement of a brief plan for using the skill. The percentage is calculated as the number of encounters in which all required components are documented as completed divided by the total number of documented micro-CBT encounters, multiplied by 100. Missing documentation of a required component will be treated as that component not being documented as completed. Optional body-distress ratings, reflection, and the student's disposition following the encounter are not required for intervention fidelity.	At each documented micro-CBT interaction from baseline through the 6-month follow-up
Completion of Behavioral Health Referrals Among Students with a Positive Baseline Anxiety Screen	Percentage of students with a positive baseline anxiety screen for whom a school-based or community-based behavioral health referral is documented as completed. A positive screen is defined as a total score of 25 or higher on either the 41-item SCARED-Child Version or the 41-item SCARED-Parent Version. The percentage is calculated as the number of students with a positive baseline screen whose referral is documented as completed divided by the total number of students with a positive baseline screen, multiplied by 100. School nurses initiate an MTSS-aligned referral for students with a positive screen. Referral initiation, status, engagement, completion, and barriers are documented through the school's MTSS-aligned tracking process and study case-report form.	From the positive baseline anxiety screen through the 6-month follow-up
Completion of the School Nurse-Delivered Micro-CBT Intervention	Percentage of students with a positive baseline anxiety screen who receive the standardized 3- to 5-minute school nurse-delivered micro-CBT interaction. A positive screen is defined as a total score of 25 or higher on either the 41-item SCARED-Child Version or the 41-item SCARED-Parent Version. The percentage is calculated as the number of students with a positive baseline screen who receive the micro-CBT interaction divided by the total number of students with a positive baseline screen, multiplied by 100. Completion is documented in the Individual Student Tracker and micro-CBT encounter record.	From determination of a positive baseline anxiety screen until completion of the standardized micro-CBT intervention, assessed up to 6 months after baseline

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change From Baseline in Child-Reported SCARED Total Score	Change in child-reported anxiety symptoms measured using the 41-item Screen for Child Anxiety Related Emotional Disorders-Child Version (SCARED-C). Each item is scored from 0 to 2, producing a total score ranging from 0 to 82; higher scores indicate greater anxiety symptoms. Change is calculated as the follow-up total score minus the baseline total score, with negative values indicating decreased anxiety symptoms. Change will be calculated separately from baseline to approximately Month 3 and from baseline to approximately Month 6.	Baseline, approximately 3 months after baseline, and approximately 6 months after baseline
Change From Baseline in SCARED-Parent Version Total Score	Change in anxiety symptoms measured using the 41-item Screen for Child Anxiety Related Emotional Disorders-Parent Version (SCARED-P), completed by the parent or guardian or obtained from the student's primary care provider as permitted by the approved protocol. Each item is scored from 0 to 2, producing a total score ranging from 0 to 82; higher scores indicate greater anxiety symptoms. Change is calculated as the follow-up total score minus the baseline total score, with negative values indicating decreased anxiety symptoms. Change will be calculated separately from baseline to approximately Month 3 and from baseline to approximately Month 6.	Baseline, approximately 3 months after baseline, and approximately 6 months after baseline
Somatic-Related School Nurse Visits During Follow-Up	Number of school nurse encounters related to somatic complaints documented for each participant during the six-month follow-up period. Encounters will be identified using routine school health-office records and study case-report forms. The number of documented encounters will be summarized descriptively.	From baseline through 6 months after baseline
Change From Baseline in Percentage of Enrolled School Days Absent	Change in the percentage of enrolled instructional days each participant was absent during the six-week periods preceding baseline, approximately Month 3, and approximately Month 6. At each assessment, the percentage is calculated as the number of enrolled instructional days absent divided by the total number of enrolled instructional days in the applicable six-week observation period, multiplied by 100. Change is calculated separately from baseline to approximately Month 3 and from baseline to approximately Month 6, with negative values indicating decreased absenteeism. Attendance information will be obtained from existing school records.	The six-week periods preceding baseline, approximately 3 months after baseline, and approximately 6 months after baseline

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change From Baseline in Child-Reported SCARED Panic Disorder or Significant Somatic Symptoms Subscale Score	Change in child-reported panic and somatic anxiety symptoms measured using the 13-item panic disorder or Significant Somatic Symptoms subscale of the SCARED-Child Version. Each item is scored from 0 to 2, producing a subscale score ranging from 0 to 26; higher scores indicate greater symptoms. Change is calculated as the follow-up subscale score minus the baseline subscale score, with negative values indicating decreased symptoms. Change will be calculated separately from baseline to approximately Month 3 and from baseline to approximately Month 6	Baseline, approximately 3 months after baseline, and approximately 6 months after baseline
Immediate Change in Student-Reported Body Distress Following Micro-CBT Skills Practice	Change in student-reported body distress measured immediately before and after micro-CBT skills practice using a study-developed rating ranging from 0 to 10, where 0 indicates that the student's body feels calm or has no distress and 10 indicates the greatest body distress the student can imagine. The scale is presented using numbers and corresponding visual indicators. The student may state a number, select a number, or point to the matching visual indicator; one score from 0 to 10 is recorded. Change is calculated as the post-practice rating minus the pre-practice rating, with negative values indicating decreased distress. Optional free-text notes may be recorded but will not be included in the numerical change score. Encounters without both ratings will be reported as missing from the paired analysis.	Immediately before and after each micro-CBT skills-practice encounter, from baseline through the 6-month follow-up
Proportion of Enrolled Students Meeting the Absenteeism Case-Finding Trigger	Percentage of enrolled students who met the absenteeism case-finding trigger when identified as potentially eligible. The trigger is defined as absence from at least 10% of enrolled school days during the previous six weeks due to qualifying somatic complaints. The percentage is calculated as the number of enrolled students who met the absenteeism trigger divided by the total number of enrolled students, multiplied by 100. Students may meet the absenteeism trigger, the somatic-frequency trigger, or both.	During the 6 weeks preceding identification as potentially eligible
School Nurse-Reported Feasibility and Acceptability of the SBIRT Workflow	Descriptive school nurse feedback regarding implementation of the SBIRT workflow, including workflow fit, burden or logistical challenges, confidence delivering screening and micro-CBT procedures, and integration with existing MTSS processes. Feedback collected through the Nurse Weekly Tally Sheet will be summarized descriptively. No composite score will be calculated.	Weekly during study recruitment and implementation, up to one academic year

Collaborators and Investigators

• Sponsor: McLaughlin Research Institute for Biomedical Sciences, Inc.

Publications and helpful links

General Publications

• Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6. doi: 10.1097/00004583-199910000-00011.
• Ruth D, Hammersla M, Tanner A. Implementation of a School Nurse-Led Case-Finding and Targeted Anxiety Testing Protocol (SBIRT-Informed) in an Elementary School: A Quality Improvement Initiative. J Sch Nurs. 2026 Jun 15:10598405261455898. doi: 10.1177/10598405261455898. Online ahead of print.

Study record dates

Study Major Dates

• Study Start (Actual): February 9, 2026
• Primary Completion (Estimated): August 1, 2027
• Study Completion (Estimated): December 1, 2027

Study Registration Dates

• First Submitted: August 5, 2026
• First Submitted That Met QC Criteria: August 10, 2026
• First Posted (Actual): August 17, 2026

Study Record Updates

• Last Update Posted (Actual): August 17, 2026
• Last Update Submitted That Met QC Criteria: August 10, 2026
• Last Verified: August 1, 2026

More Information

Terms related to this study

• Keywords: SBIRT; rural health; school absenteeism; early identification; somatic symptoms; school-based mental health; pediatric anxiety; school nursing; anxiety screening; Brief cognitive behavioral intervention; elementary school students
• Additional Relevant MeSH Terms: Mental Disorders; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Medically Unexplained Symptoms; Anxiety Disorders; ARHGAP32 protein, human
• Other Study ID Numbers: MRI0005

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No