This Web site is a component of the SAMHSA Health Information Network

Enter Keywords Choose Website This Site Mental Health at HHS All Mental Health

Online Publications Order Publications National Library of Medicine National Academies Press Publications Homepage

printer friendly page e-mail this page bookmark this page shopping cart  current or new account

This Web site is a component of the SAMHSA Health Information Network.

Chapter 2

2.0 Mental Health Problems and Services in the School Setting

This chapter presents survey findings on the most frequently addressed mental health problems among students in public schools, student eligibility for mental health services and the services available to meet student mental health needs. On average, 20 percent of students had received mental health services during the previous school year (2001–2002).Since the survey did not ask for amount or units of service provided, these services could have ranged from a single encounter to long-term counseling. Because the survey included a broad range of potential providers of mental health services, such services could have been provided by staff with variable mental health training.

2.1 Eligibility for Mental Health Services

The survey asked which categories of students were eligible to receive mental health services (e.g., all students versus students in special education). Eligibility for mental health services varied across schools, although all students were eligible to receive mental health services in the vast majority of schools (87 percent). A small proportion of schools (10 percent) required students to have an Individualized Education Plan (IEP), indicating special education status, to qualify for mental health services. There were differences in eligibility, however, by region and by some school characteristics. The proportion of schools in which all students were eligible was higher in the Northeast (96 percent) than in other regions. While the overall percentage of schools with eligibility for all students was high, it was lower in schools with high enrollment of minority students. 7 Eighty-three percent of schools with high enrollment of minority students reported that all students were eligible for services, compared to 91 percent of schools with low minority enrollments (Appendix C, School Tables, Table 3).

2.2 Types of Mental Health Problems

The survey asked respondents to report on the problems most frequently presented by students in their school. From a list of 14 psychosocial or mental health problems, respondents were asked to rank the three most frequently seen problems for male and for female students. The list covered a broad spectrum of concerns, from relatively mild, commonly seen problems such as difficulty adjusting to a new school, to more significant behavior problems such as bullying, to serious psychiatric and developmental disorders. The complete list of problem categories, as presented in the survey instrument, appears in Exhibit 2.1.

Exhibit 2.1 Psychosocial and Mental Health Problem Categories

Source: School Mental Health Services in the United States, 2002–2003. Substance Abuse and Mental Health
Services Administration, U.S. Department of Health and Human Services.

Of these 14 problem categories, 6 were mentioned most frequently by respondents. These are shown in Exhibit 2.2. For both male and female students, the mental health problem category most frequently cited by schools, and across all school levels, was social, interpersonal, or family problems. The second and third most frequently cited concerns, however, were different for males and females. Aggression or disruptive behavior and behavior problems associated with neurological disorders (such as attention-deficit/hyperactivity disorder) were cited as the second and third most frequent problems for males. Anxiety and adjustment issues, respectively, were cited for females (Exhibit 2.2).

2.3 Mental Health Problems by School Level and Gender

There were differences in the frequency of some mental health problems according to school level and gender, as shown in Exhibit 2.3. Substance use or abuse and delinquency and gang-related problems were included here, although they were noted only for middle and high schools.

Among male students, behavior problems associated with neurological disorders were more frequently reported by elementary than by middle or high schools (51 percent versus 35 percent versus 20 percent, respectively). Aggressive or disruptive behavior was more frequently reported by elementary and middle schools (64 percent and 69 percent, respectively) than by high schools, although 54 percent of high schools reported it as among their top three problems. For boys, social, interpersonal, or family problems were cited most often by middle schools and least often by high schools. High schools were more likely than elementary or middle schools to report depression as one of the top three problems (Exhibit 2.3 and Appendix C, School Tables 15 and 15A).

Among female students, adjustment issues, aggression or disruptive behavior, and behavior problems associated with neurological disorders were reported more frequently in elementary and middle schools than in high schools. Social, interpersonal, or family problems were more frequently cited for girls in middle schools and reported less frequently in high schools. For both boys and girls, depression and substance use/abuse were reported more frequently as school level increased (Exhibit 2.3). For example, one third of middle schools reported depression as a top mental health problem for females, while almost half of high schools did so. Although depression was less frequently cited as a top mental health problem in boys, reporting frequency rose substantially from middle school to high school. The frequency of citing substance abuse as a major problem also jumped sharply from middle school to high school (for males, from 4 percent of middle schools to 34 percent of high schools; for females, from 3 percent of middle schools to 19 percent of high schools).

Exhibit 2.3 Percentage of Schools That Cited the Following Mental Health Problems as Among Their Top Three Problems, by School Level, 2002 – 2003

2.4 Resource Use for Various Mental Health Problems

Schools were asked which mental health problem consumed most of their mental health resources. The top-ranked mental health problem reported by schools for both males and females (i.e., social, interpersonal, or family problems) was also the most frequently reported as consuming the most mental health resources. However, about one fifth of schools named aggression/disruptive behavior as the most resource-intensive, and over 10 percent named behavior problems associated with neurological disorders, such as attention deficit disorder. The other 11 problems on the list rated much lower on resource usage (Exhibit 2.4).

Behavior

Exhibit 2.4 Percentage of Schools Reporting That Various Mental Health Problems Use Most of Schools’ Mental Health Resources, by School Level, 2002–2003

Resource use for social, interpersonal, or family problems was high across all school levels, with 42 percent of elementary schools to 50 percent of middle schools reporting it as the mental health issue that used the most resources. However, aggression or disruptive behavior consumed the most resources at the elementary level, and successively fewer resources at the middle and high school levels. Similarly, resources expended on behavior problems associated with neurological disorders decreased as school level increased. These are similar to the patterns for the top three mental health problems encountered among male and female students: social, interpersonal, and family problems were consistently reported by elementary, middle, and high schools as among the top three problems; aggression and disruptive behavior and behavior problems associated with neurological disorders both tended to be more frequently cited by elementary and middle schools than by high schools. As the problems decrease, so too does the consumption of resources.

2.5 Mental Health Services in U.S. Schools

Mental health services were defined in this study as “those services and supports delivered to individual students who have been referred and identified as having psychosocial or mental health problems.” The survey focused on treatment services provided to individual students with identified mental health concerns, rather than on preventive services provided to all students. However, a question on the range of prevention services offered in schools was included as well as a question on the use of various funding sources for prevention or intervention purposes. Responses to these questions are discussed later in this section.

Exhibit 2.5 Mental Health Services Categories

Source: School Mental Health Services in the United States, 2002–2003. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

Types of Services Most Frequently Provided

Overall, the majority of schools in the nation provided almost all of the mental health services listed. A high percentage (87 percent) of schools provided assessment for mental health problems, behavior management consultation, and crisis intervention, as well as referrals to specialized programs (84 percent). Individual counseling, case management, and group counseling were also frequentlyprovided (by 76 percent, 71 percent, and 68 percent of schools, respectively). 8In general, short-term interventions, such as assessment for mental health problems, behavior management consultation, crisis intervention, and referral services were more commonly provided than were services that tend to be longer term, such as counseling of all types, case management, and family support services. Less than half of all schools reported that they provided substance abuse counseling, and medication/medication management was the least likely of all services to be provided (Exhibit 2.6).

Schools indicated that some services were more difficult to deliver than others. The service most frequently ranked as “difficult” or “very difficult” to deliver was family support services, followed by medication or medication management, substance abuse counseling, and referral to specialized programs or services (Appendix C, School Table 18). The services most frequently ranked as “not difficult” or only “somewhat difficult” to deliver were individual and group counseling, followed by behavior management and crisis intervention. For the most part, services provided most frequently by schools were not as difficult to deliver as those less frequently provided. Referral to specialized programs or services was an exception. Although 71 percent of schools provided referrals, 37 percent said that such referrals were difficult or very difficult to make.

Barriers to Delivery of Services

Schools were asked to rank the extent to which various factors were barriers to the delivery of mental health services, using a scale of 1 to 4, where 1 was “not a barrier” and 4 was a “ serious barrier.” Exhibit 2.7 shows the percentage of schools that responded 1 or 2 versus 3 or 4. Although schools reported providing a wide array of services, they also described barriers to ensuring that children and youth receive the services they need. Financial constraints of families (defined in the survey instrument as “can’t afford services or lack of insurance”) and insufficient school and community-based resources were the factors most often reported as barriers or serious barriers.This finding suggests that even if some mental health services are provided free of charge by school staff, families must pay for other services. This survey did not ask which services require payment, but this issue bears further investigation.

Competing priorities for use of funds and difficulties with transportation were also considered barriers. Least often reported as serious barriers were protection of student confidentiality and language and cultural barriers. However, in open-ended comments, several district-level respondents noted that a high number of students were not able to access mental health services in the community due to linguistic and insurance barriers; in these cases, counseling provided by the school was the only service available.

Many respondents to the school questionnaire provided comments to explain the financial constraints faced by students and their families in attempting to obtain mental health services. Explanations ranged from inadequate Medicaid reimbursement to limitations on benefits for those who are privately insured and a dearth of mental health services for the uninsured.

Prevention and Early Intervention Programs and Services

Increasingly, education and mental health experts recognize a definition of mental health in schools that includes not only treatment, but promotion of social and emotional development and efforts to address psychosocial and mental health problems as barriers to learning (Policy Leadership Cadre for Mental Health in Schools, 2001). Schools have begun to direct resources to school-wide and/or curriculum-based programs intended to reach the broader student population, not just those individual students identified with mental health problems. Early intervention by mental health staff or multidisciplinary teams is gaining ground as a means to address mild psychosocial problems quickly and thereby prevent unnecessary entry into special education. Although the focus of the current survey was on traditional mental health treatment, schools were also asked to report on the types of prevention and early intervention programs that they offer.

While school-wide screening for behavioral and emotional problems is uncommon, 15 percent of schools reported that they provided this service (Exhibit 2.8). Many more schools (63 percent) have implemented prevention and prereferral interventions (e.g., team and family meetings for students with behavioral problems) and curriculum-based programs (59 percent). School-wide strategies to promote safe and drug-free schools (e.g., Safe Schools/Healthy Students Initiative) and to prevent alcohol, tobacco, or drug use, both with widely available funding, were provided by three quarters of schools (78 percent and 72 percent, respectively). Less frequently reported approaches to prevention and early intervention were peer counseling and mediation and peer support groups (47 percent) and outreach to parents regarding mental health issues (34 percent).

In an open-ended question, schools were asked to describe approaches or strategies that have proven most successful in improving student mental health. Some respondents described curriculum-based programs and classroom guidance to enhance social and emotional functioning as their most successful approaches. Topics for such programs included anger management, prevention of violence and bullying, conflict resolution, resisting peer pressure, communication skills, substance abuse, and character education (e.g., developing citizenship skills, responsibility, honesty, fairness, patience). Several specific programs were named repeatedly, including Responsive Classroom (www.responsiveclassroom.org), the Second Step program (www.cfchildren.org), and Drug Abuse Resistance Education (DARE) (www.dare.com).

2.6 Summary

The problem category that schools reported most frequently as a top mental health issue was social, interpersonal, or family problems. This problem was also most frequently reported to consume the most resources, followed by aggression or disruptive behavior and behavioral problems associated with neurological disorders. Depression was more frequently reported as a top mental health problem in high school (for both boys and girls) than in middle school, as was substance abuse. Most schools reported that they provide a range of mental health services, but these results are tempered by the fact that half of schools also reported that inadequate mental health supports in schools are a serious barrier. Financial constraints of families were reported by over half of schools as barriers to service. The majority of schools also reported that they provide school-wide or curriculum-based prevention and early intervention programs.

Previous | TOC | Next