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Chapter 1

1.0 Background and Study Methods

1.1 Introduction

Much of the recent research on the mental health status of children and youth points to public schools as the major providers of mental health services for school-aged children. The Surgeon General’s 1999 Report on Mental Health (U.S. Department of Health and Human Services [US DHHS], 1999) cited prevalence studies that found that approximately one fifth of the children and adolescents in this country experience the signs and symptoms of a mental health problem 1 in the course of a year. That report further suggests that schools are primary settings for the identification of mental disorders in children and youth.

More recently, the President’s New Freedom Commission on Mental Health recognized the critical role that schools can play in the continuum of mental health services. The Commission’s final report, Achieving the Promise: Transforming Mental Health Care in America (2004), emphasized the building of a system that is evidence-based, recovery-focused, and consumer- and family-driven. Continuing that effort, SAMHSA, in partnership with key Federal agencies, recently developed and issued the Federal Mental Health Action Agenda (2005). One of the Agenda’s goals is the initiation of a national effort focused on the mental health needs of children, which would promote early intervention for children identified to be at risk for mental disorders and identify strategies to appropriately serve children with mental health problems in relevant service systems.

One review of small area research studies (Weist, 1997) found that there has been some movement nationally in favor of enhancing and improving school mental health services. The focus on mental health problems of youth in the early 1980s, accompanied by consistent findings that some youth were not receiving the services they needed, led to national reforms for improving approaches to service delivery. Schools came to be seen as a natural entry point for addressing student mental health needs. This, along with recognition of the importance of sound mental health as an essential support for academic success, led to a growth in school mental health programs as part of broader school reform efforts. Advocates for a system of care for children’s mental health (Stroul & Friedman, 1986) and for school-based health centers (Advocates for Youth, 1998) have further underscored the critical role that integration of mental health services into the school setting has had in the recognition, assessment, and treatment of mental health problems.

While it is recognized that schools are playing an increasing role in the provision of mental health services to children and youth, less is known about how these services are organized, staffed, coordinated with community-based services, and funded. There is also a lack of information on the type of services being provided in school settings. One recent review of research concluded:

It is now well documented that, insofar as children receive any mental health services, schools are the major providers. However, precisely what is provided by schools under the rubric of mental health services…is largely unknown (Rones & Hoagwood, 2000).

Adding to the rationale for the current study is an analysis of data from the 1994–1995 National Longitudinal Study of Adolescent Health (Slade, 2003). That study concluded that although half of middle and high schools nationally offer some level of mental health counseling, there are serious disparities in availability by region, locale, and school size. Schools that are larger, either suburban or urban, situated in the Northeast, and have high Medicaid enrollment are more likely to provide counseling on site, while only 28 percent of Midwestern schools provide counseling (Slade, 2003). The author acknowledged, however, that the study findings were limited by the small sample size, and that further research is needed on a national sample of schools.

The current study, School Mental Health Services in the United States, 2002–2003, provides the first broad and comprehensive description of the prevalence and distribution of mental health services in a nationally representative sample of the approximately 83,000 public elementary, middle, and high schools in the United States. Sixty percent of these schools are elementary schools, 19 percent are middle schools, and 18 percent are high schools. The remaining three percent are combined schools, with grades spanning two or more levels (U.S. Department of Education, 2002–2003). 2

This study describes differences in resources, organization, delivery and funding of school mental health services across the country. Rather than focusing on children in special education, this study includes mental health services provided to all children in the school setting. It focuses on mental health services supported by the school or district, regardless of whether the services are provided by the school’s own staff or by community-based providers with whom the district has a formal or contractual arrangement. In order to capture how schools define providers of mental health services, nurses and other school staff such as outreach workers and behavioral aides were included, although their training may not be specific to mental health.

The primary focus of this study was on mental health interventions, but since school-wide prevention programs are increasingly common, data were collected and reported on prevention programs as well. For the purposes of this study, mental health interventions were defined as “those services and supports delivered to individual students who have been identified as having psychosocial or mental health problems.” The study is intended to provide baseline information on the characteristics of mental health services provided in U.S. schools; however, it was not designed to measure either the intensity or the quality of mental health services provided.

1.2 Review of the Research Literature

In developing the survey, a targeted literature review was conducted on several topics that served as the basis for the survey instruments:

• Mental health problems and services in the school setting
• Staff providing mental health services in schools
• Administrative arrangements for the delivery and coordination of mental health services
• Funding for school mental health services

Several criteria were used for inclusion of research in the literature review: The research had been completed within the previous 10 years; was considered seminal in the field of school mental health; focused on school mental health interventions as opposed to broad-based prevention services; and pertained both to children in general education and in special education. To better understand the types of staff providing mental health services in schools, documents were obtained from various professional associations that described school mental health provider functions, guidelines for staff-to-student ratios, and standards for licensure and credentialing. The major results from the literature review are presented below.

Mental Health Problems and Services in the School Setting

National data on childhood mental illness, as well as smaller studies, describe the prevalence of various mental health problems in children and youth. The Surgeon General’s Report on Mental Health (US DHHS, 1999) cites the following prevalence estimates for various disorders of childhood and adolescence: 3–5 percent of school-aged children are diagnosed with attention-deficit/hyperactivity disorder in a 6-month period; 5 percent of children aged 9–17 are diagnosed with major depression; and the combined prevalence of various anxiety disorders for children ages 9–17 is 13 percent.

The Youth Risk Behavior Survey (Centers for Disease Control and Prevention, 1999), a nationally representative survey of youth, found problems covering a range of severity, from daily sadness and hopelessness (experienced by over one quarter of students) to thoughts of suicide (nearly 20 percent) to attempted suicide (8 percent). Many of the children with these conditions had not been identified and many had not received services.

A “small area” study of serious emotional disturbance among Appalachian children and youth in North Carolina found that three out of five children with diagnosed mental health problems had received no recent mental health services (Costello et al., 1996). Of those students who had received services, between 70 and 80 percent were seen by school-based providers.

The literature on school-based health centers 3 provides valuable information on other psychosocial problems that may not meet the criteria for serious emotional disturbance and special education services but can adversely affect school performance, particularly when combined with poverty or exposure to violence. However, due to the relatively small number of school-based health centers operating in U.S. schools, this information cannot be generalized across the entire public school population.

One such study of school-based health care services in urban minority middle schools found that one third of all health clinic visits were for mental health issues. Adolescents, predominantly females, were seen primarily for family problems, symptoms of emotional disturbance (e.g., anxiety, depression, suicidal tendencies), and situational problems such as bereavement (Walter et al., 1995).

In another study related to an inner-city school-based clinic, 65 percent of all mental health visits fell into three diagnostic clusters: pregnancy and sexuality; dysphoria; and conflict and violence (Jepson, Juszczak & Fisher, 1998).

Another study (Advocates for Youth, 1998) found that 65 percent of users of school-based health centers were females. The authors found that the use of these services was facilitated by extensive outreach to the adolescents themselves, and to teachers, other school officials, and community members, including parents.

The literature review revealed few studies of school problems or services by school level. One survey of 62 school administrators (Weist et al., 2000) found that behavioral problems were rated as more serious as students progressed through school levels. Urban youth were reported as experiencing greater stress and internalizing problems more than suburban or rural youth.

Increasingly, school systems are recognizing the need to address barriers to learning, such as substance abuse, violence, teen pregnancy, family problems, and behavioral issues, and they are restructuring their mental health services accordingly. Brener et al. (2001) reported that most schools offer some combination of mental health and social services and have developed some structure to support them. Some districts are enhancing service capacity by collaborating with health centers and other community-based agencies.

Staff Providing Mental Health Services in Schools

The research literature suggests that there are diverse staffing structures, types of professionals, roles and levels of service in school systems. Staffing structures may include individuals and groups of professionals working in programs operated by single schools, individual districts, and/or in collaboration with the community, city, and/or county agencies. Mental health providers typically provide direct and indirect services not only to students, but also to families, education staff, and school administrators.

The School Health Policies and Programs Study (SHPPS) provided national data on the staffing of school mental health services (Centers for Disease Control and Prevention, 2000). This study found that school guidance counselors, school psychologists, and school social workers typically provide school mental health services. 4 Although school nurses, special education and other health staff (e.g., resource teachers, rehabilitation, occupational therapists) are mentioned in the literature, it is not clear to what degree these professionals provide traditional mental health services (Flaherty et al., 1998).

Administrative Arrangements for the Delivery of Mental Health Services

Research on models of delivery of school mental health services suggests that there are many ways to describe and categorize service delivery arrangements. The Policy Leadership Cadre for Mental Health in Schools, a policy-oriented coalition facilitated by the Center for Mental Health in Schools at UCLA, describes five “delivery mechanisms and formats” for the provision of school mental health services:

• School-financed student support services, in which school districts hire professional staff to provide traditional mental health services
• Formal connections with community mental health services, in which formal agreements are made between schools and school districts and one or more community agencies to provide mental health services and to enhance service coordination; the service can be co-located within the school or provided at the community agency
• School-district mental health units or clinics, in which districts operate and finance their own mental health units and mental health clinics which provide services, training, and/or consultation to schools, or districts organize multidisciplinary teams to provide a range of psychosocial and mental health services
• Classroom-based curricula, which are activity-driven approaches aimed at optimizing learning by enhancing social and emotional growth. Interventions tend to be teacher-led and prevention-oriented

Funding for School Mental Health

Funding mechanisms for school mental health appear to be the least defined of the areas of interest to the present study. Although there have been studies of funding of school-based health centers, they did not distinguish mental health from other student health services. The SHPPS study, the most far-reaching study of health services in schools to date, identified the types of mental health staff providing services in schools, and included some references to funding for children in special education with mental health needs, such as the Individuals With Disabilities Education Act (IDEA). However, one of the limitations of SHPPS was a lack of data on funding, which has been recognized in other literature reviews (Robinson et al., 2000).

Information related to funding for mental health services in schools is different to collect because of the number and diversity of funding streams and the fact that costs for mental health services tend to be bundled with allocations for education. The Policy Leadership Cadre for Mental Health in Schools (2001) noted:

To date there has been no comprehensive mapping and no overall analysis of the amount of resources used for efforts relevant to mental health in schools or of how they are expended. Without such a “big picture” analysis, policymakers and practitioners are deprived of information that is essential to determining equity and enhancing system effectiveness.

hat is known from reviews of policy and legislative documents suggests that funding comes from multiple categorical funding streams, often with different missions and funding limitations. Multiple funding streams can lead to fragmentation of services. The Policy Leadership Cadre noted that the legislative support for mental health funding is generally for children with diagnosed emotional/behavioral disabilities and mental illness, or is intended to address violence and substance abuse. The Cadre also suggested that the cost-cutting measures of managed care are reshaping the nature of services, making comprehensive service provision difficult. The Cadre concludes that schools may be in a unique position to reverse the fragmentation and marginalization of student mental health services. .

1.3 Goals of the Study and Research Questions

The goal of this study was to provide a baseline regarding traditional mental health services delivered in schools to students who have been referred and identified as having psychosocial or mental health problems. The literature review conducted for the study identified research on the topics of interest and highlighted the need for baseline information on school mental health from a nationally representative sample of schools. While SHPPS moved the field forward, it was evident that more work was needed to describe actual mental health services provided, funding sources, student-staff ratios, and the amount of time allocated to the delivery of mental health services to students.

The literature specific to school-based health centers also provided valuable information on the types of mental health problems addressed in school settings, staffing configurations, services provided, and funding sources. However, school-based health centers operate in only a small proportion of schools (in 1,700 schools nationwide, according to the National Assembly on School-Based Healthcare), so these results cannot be generalized to the majority of schools in the nation. Other studies provide in-depth insights into issues such as mental health problems of youth, but they are either limited in scope and not related to school settings, or they have not been replicated at the national level.

Based on the information gaps identified in the review of the research literature, this purpose of this survey was to describe the following:

• Types of mental health problems encountered in the school setting and the mental health services available in schools to address those problems
• Administrative arrangements for the delivery and coordination of mental health services in schools
• Types and characteristics of providers of mental health services in schools
• Ways that school mental health services are funded, and how funding mechanisms may affect delivery of services

Although the survey focused on interventions delivered to individual students who had been referred and identified as having psychosocial or mental health problems, schools were also asked to report on the types of prevention and early intervention programs they offered.

With regard to administrative arrangements, the survey aimed to determine whether or not community-based professionals and organizations were contracting with schools to provide mental health interventions. The study also sought to elicit the mechanisms by which mental health services were organized administratively (e.g., under the auspices of special education or in a separate department), how staffing was organized (e.g., hired by district or acquired via contract), and where authority rested for various administrative functions such as hiring and supervision. Also of interest were the mechanisms used by schools to coordinate mental health and educational services within the school setting and with the community.

Regarding staffing, the survey questions were not limited to traditional mental health providers. Rather, nurses and paraprofessional staff were included to determine the extent to which these staff types were considered to provide mental health services. Questions also sought to determine the qualifications of these staff, and how much of their time was devoted to mental health service provision as opposed to administrative duties.

The study also sought to elicit information about Federal, State, and local-level funding sources for school mental health services. This included questions about the extent to which school districts generated revenue via third-party reimbursement, or solicited grant funding. Information was also sought on funding allocation, restrictions on funding based on categorical funding streams, and other funding obstacles.

The survey was designed to address each of the above research questions at the national level for public schools and districts, and to provide comparisons by subgroups of schools and districts, as follows:

• School comparisons by level (elementary, middle, and high school), region of the country (Northeast, Midwest, South, and West), school size as measured by student enrollment (small, medium and large), race/ethnic minority enrollment of student body (low, medium, and high), and poverty status as measured by the proportion of students eligible for free and reduced price lunch (low, medium, high)
• District comparisons by region and district size, as measured by the number of schools in the district. These comprise the major categories or groupings that distinguish schools and school districts across the nation and are standard variables used for comparisons in education research. Several of these subgroups are described in more detail in the following section. A full description of the definitions of each of these variables may be found in Appendix D, available at http://www.mentalhealth.samhsa.gov/cmhs/ManagedCare/.

1.4 Overview of Survey Design and Methodology

School Mental Health Services in U.S. Schools, 2002–2003 involves a nationally representative sample of regular public K–12 schools and their associated school districts. The study was conducted as a self- administered mail survey during the 2002–2003 school year. The survey consisted of two questionnaires. The school questionnaire collected data on the types of mental health problems encountered in schools, the mental health services provided, the types and qualifications of staff providing services, the type and degree of care coordination, and the arrangements for delivering mental health services, including agreements with community-based providers. The district questionnaire collected data on funding sources for mental health services and issues related to funding. Both questionnaires are in Appendix D, available at http://www.mentalhealth.samhsa.gov/cmhs/ManagedCare/.

Instrument Design

The survey instruments were designed to address the information gaps identified in the literature review. An expert panel of school officials, mental health researchers, policymakers, and representatives of professional organizations participated in formulating the conceptual base of the survey and in reviewing the survey questionnaires. The expert panel also reviewed the literature synthesis to ensure that it reflected the most up-to-date thinking on the characteristics and funding of school mental health services. (Members of the expert panel are listed in Appendix A.) The questionnaires were reviewed and endorsed by professional mental health associations and representatives of state education associations. 5 The surveys were also pilot tested on a small number of school and district staff who represented the intended respondent types and revised prior to data collection. The instruments included a final open-ended question to elicit respondent comments.

The diversity of school systems and State guidelines for school mental health services made the construction of response categories difficult in some respects. Recognizing that there can be many staff titles for persons with similar training who perform similar functions in schools, the authors consulted with the expert panel to arrive at a set of staffing categories that were most likely to be recognizable to respondents across the country. Mental health problem categories were derived from the literature and adapted for the survey by a licensed child psychologist. These categories represented a range of severity, from interpersonal/family problems to major psychiatric disorders.

The questionnaires did not provide definitions of staffing categories, mental health problems, or services. Regarding staffing categories, the research team determined that without standardized definitions in the literature, and given the variability in functions among various staff types from district to district, it would be overly limiting to the respondent if a definition were imposed. The problems and services categories were developed to reflect commonly understood terminology. All terminology was vetted with respondents in several school districts in different geographic regions and with the expert panel prior to finalizing the survey instrument.

Although the arrangements for service delivery identified by the Policy Leadership Cadre for Mental Health in Schools described earlier served as the basic framework for the design of questions related to administration of mental health services in schools, certain aspects of the delivery mechanisms were determined to be not mutually exclusive. It was further recognized that schools and districts might not fit into any particular model (or might combine different aspects of these models). Therefore, the models were broken down into dimensions, such as whether mental health services are district-, school-, or community-based; the types and combinations of staff providing mental health services; the types and range of services provided; the settings in which services are delivered; the extent of coordination and linkage with community services; and the extent to which services and staff are integrated into teams or units versus operating as single providers. Questionnaire items were then developed to measure the different dimensions independently.

Sampling Strategy

School Mental Health Services in the United States, 2002–2003 is a nationally representative sample of public K–12 schools and their associated school districts. A random sample of 2,125 schools and the 1,595 districts associated with them was drawn from the U.S. Department of Education’s public school data file, the Common Core of Data for 2000–2001. The size of the sample was designed to provide reliable estimates of the universe of regular public schools by level (elementary, middle, and high school) and by size, as measured by student enrollment: small (from 1 to 250 students); medium (251–500 students); large (501–1,000 students); and very large (1,001 and more students). The sampling strategy was also designed to yield estimates by each region (Northeast, Midwest, South, West) and locale (urban/central city, suburban/large town, small town/rural) and to populate the standard table shell used in this report. The composition of the four regions is provided in the supplementary tables in Appendix C.

Data Collection and Response Rate

Data collection began in November of 2002, with advance letters sent to superintendents in each of the school districts in the sample, notifying them of the survey and requesting contact information for the respondent designated by the superintendent as the most knowledgeable about mental health services. District respondents ranged from superintendents to assistant superintendents and directors of Pupil Services or Special Education. School surveys were sent to the principal, who in turn, passed them on to the ultimate respondents. Survey responses reflect the best estimates of the respondent as to mental health staffing and services.

A total of 58 districts, 3.5 percent of the sampled districts, required that a research application be submitted prior to conducting the study in their districts. The great majority of these applications were ultimately approved. The survey forms were mailed in late January of 2003 and data collection continued throughout the school year and into the early summer, with the remailing of survey forms and telephone follow-up calls for nonresponding schools and districts.

Trained interviewers conducted follow-up phone calls and “refusal conversion” interviews with respondents. During these calls, interviewers often learned that questionnaires had been forwarded to another person in the school, or that the questionnaire had been lost. This resulted in numerous calls to track down the ultimate respondent. Over 30 percent of districts and 39 percent of schools requested remailings.

The survey did not include a screener question asking schools to report whether or not the school provided mental health services, out of concern that respondents might opt out of responding to the survey prior to reading the questions. Once questionnaires were received, the research team reviewed incomplete questionnaires to determine whether or not they contained enough information to be included in the final sample. About 2 percent of the returned questionnaires had to be removed from the sample, because it was determined by reviewing their responses and comments that they did not provide mental health services and therefore could not answer the survey questions. The estimates in this report reflect the remaining 98 percent of returned survey questionnaires, or 1,147 questionnaires.

It is important to note that the estimates presented here represent any mental health services provided, including identification, assessment, and/or referral to outside mental health service providers. Further, the estimates do not indicate the quantity of services available in schools, nor do they indicate whether services were provided by trained mental health professionals or by other school personnel. Differences in the estimates of the availability of mental health services in public schools may be due to differences in sample design, definitions of mental health services, location of services, and year of data collection. 6

Ultimately,1,147 schools in 1,064 districts across the country responded to the survey. “Critical items” information was collected from an additional 150 schools. The quantifiable data were weighted to create national estimates for numbers of schools and districts by region and by size. This was done so that the total numbers and the distributions would match those of all schools and districts in the nation in the 2002–2003 school year. The final weighted response rates were 60.5 percent for schools and 59.85 percent for school districts.

Analysis

The exhibits in the report are intended to highlight the findings. More detail can be found in the analytic tables in Appendix C. These analytic tables are organized according to the order in which the questions appeared in the survey. The school tables display results by percentage of schools, with cross-tabulations by key school characteristics where it is possible to make comparisons. The report highlights differences by school characteristics when they were statistically significant; that is, when these differences were not likely due to chance (less than a 5 percent chance). The district tables are similarly organized, and comparisons are made by district characteristics.

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