Expanded school mental health: exploring program details and developing the research base

Expanded school mental health (ESMH) programs, the focus of this special issue, provide comprehensive mental health care to youth in general and special education through partnerships between schools and community mental health agencies and programs. As these programs progressively develop in the United States, there is a critical need to build the research and evidence base for them. This article presents background to the national movement toward ESMH and provides an overview of articles contained in this special issue, which provide in-depth details and early research findings on diverse aspects of mental health programs in schools. Advantages of greater involvement of behavioral professionals in ESMH are discussed.     

Understanding expanded school mental health services in Baltimore City

This article explores the nature of expanded school mental health (ESMH) services in Baltimore City, which at the time of the study were incorporated into 40% of the city's public schools. A provider survey was distributed to ESMH clinicians to gather information on the characteristics of service providers and recipients, types of services being provided, and their proposed outcomes. Provider reports indicated an impressive service capacity, augmentation of traditional school-based services, and the continual need for increased mental health service hours in their buildings. In addition, the most frequently voiced benefits of the ESMH programs were increased mental health awareness and improved school climate. Implications of the findings for future programming development and research are discussed.     

School-Related and Social–Emotional Outcomes of Providing Mental Health Services in Schools

This study evaluated student outcomes of an expanded school mental health (ESMH) model that placed community mental health clinicians on-site in schools to identify and treat children with mental health needs. The first aim of this study was to consider school-related outcomes (suspension rates and attendance rates) for those students who received ESMH treatment (n = 159) were compared to a matched high-risk sample that did not receive such services (n = 148). Results demonstrated differences between groups over time on measures of suspensions and attendance but not academic achievement. The second aim of this study was to evaluate change in social–emotional functioning (Strengths and Difficulties Questionnaire Scores) over time for the treatment group. Results indicated significant improvements on several parent and teacher ratings. Despite limitations of the ESMH framework examined in this study, the overall results suggest some promising advantages for students who received ESMH services.     

Effects of School-Based Mental Health Programs on Mental Health Service Use by Adolescents at School and in the Community

Many schools provide counseling to adolescents with behavioral and emotional problems on-site, but little is known about the use of school-based counseling services in the United States, and it is unclear whether these services complement or substitute for counseling services available outside of school. In this study data on mental health services offered in schools are used to estimate the probability of receiving emotional counseling at school and elsewhere. Where mental health services were available on-site, students were substantially more likely to see a counselor in the previous year, controlling for mental health status, health insurance coverage, and other factors. The effects of availability were greater for students enrolled in special education programs than for other students. However, these data also suggest that, relative to other schools, schools offering on-site mental health counseling do not increase or reduce use of counseling services outside of school on average.     

Three-year longitudinal study of school behavior and academic outcomes: results from a comprehensive expanded school mental health program

While there has been encouraging growth in the number of expanded school mental health programs (ESMH) across the country, few programs rigorously evaluate long-term academic outcomes associated with receipt of these services. This study examined the effects of services from an ESMH program on school behavior (number of out-of-school suspensions and attendance rates), and academic outcomes (standardized test scores in reading and math). Participants were 89 students from Kindergarten to 8th grade who received ESMH services and 89 students from a matched comparison group. Results revealed that ESMH services (i.e., treatment) did not have a statistically significant association with any of the school behavior or academic outcome variables. Findings are discussed in the context of theoretical and methodological challenges associated with program evaluations of ESMH. Implications for practitioners and researchers regarding program evaluation and response to stakeholders are addressed.     

Mental health screening of preschool children: validity and reliability of ABLE

Children with behavioral, emotional or language problems struggle to do well at school often with limited success. ABLE (Attention, Behavior, Language, and Emotions), a new screening tool, was used to estimate the prevalence and the severity of concerns parents and teachers have about children's school adjustment and evaluate their need for services. Data obtained from the parents and teachers of children randomly selected from public Pre-K classrooms in 6 states (N = 415) and from a mental health screening of rural and urban children (N = 5,577) support the validity and reliability of ABLE. Parents identified severe problems in 18.4% of children and Pre-K teachers identified 10.5%. By kindergarten, the proportion of children identified by their teachers with serious problems more than doubled to 23%. Inattention/overactivity and behavior problems were identified most often. These children were 3.4 times more likely to be certified later for special education services by kindergarten than children not identified with problems by ABLE. However, fewer than 14% of children in public Pre-K identified with serious problems in Pre-K had received mental health services by the end of Kindergarten.     

Special Educators’ Conceptualizations of Emotional Disturbance and Educational Placement Decision Making for Middle and High School Students

The purposes of this study were to examine secondary school special educators’ perspectives on (1) the relative importance of the academic, mental health, and behavioral elements of the emotional disturbance (ED) special education classification in relation to determining eligibility for students with suspected ED, and (2) factors that are relevant both to education placement decision making for students classified with ED and to decision making regarding the degree of restrictiveness of education placements, including highly restrictive, alternative placements. A national survey was conducted with 1,025 middle and high school special educators. Results indicated that aggression was the most important factor for considering ED eligibility, followed by psychiatric diagnoses and, lastly, academic factors such as grades and achievement scores. Effectiveness was rated as very important in determining a student’s education placement, whereas financial cost and logistical issues were rated as less important. Some differences emerged between middle school and high school participants on items related to determining education placement. Compared to middle school educators, high school educators indicated that students themselves play a more active role in determining education placement. High school educators also indicated that they are more likely to consider homebound instruction and computer/web-based programs and that they better meet the vocational needs of students classified with ED. Middle school special educators indicated that they better meet the behavioral and emotional needs of students classified with ED.     

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE: The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools. METHOD: The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described. RESULTS: The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out. CONCLUSIONS: Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.     

School-Based Mental Health Programs for Students Who Have Emotional Disturbances: Academic and Social-Emotional Outcomes

Most schools offer some type of school-based mental health service to students, and there is a growing body of empirically rigorous studies examining the effects on academic and mental health outcomes for students. However, students classified as having emotional disturbances are under-represented in these studies. Using a convenience sample of four different types of school-based mental health programs, changes in achievement levels and social and emotional functioning in youth with emotional disturbances served in special education (n = 148) were examined. Longitudinal results reveal there was improvement in either the emotional or social functioning of these youth in all four programs, while results for improvement in achievement levels were less consistent. Results reveal that in the targeted sample of programs with intensive or multifaceted services, there was improvement in academic as well as social and emotional functioning in these youth. Implications for school-based mental health services are discussed.     

Teachers’ experiences collaborating in expanded school mental health: implications for practice,policy and research

Abstract

Teachers are critical partners in expanded school mental health (ESMH) collaborations that aim to bring educators, community mental health professionals and families together to leverage expertise and resources for addressing non-academic barriers to learning. Although teachers are in a unique position to observe the day-to-day mental health needs of students, their roles in ESMH collaborations have been largely ignored leaving little research-based guidance for maximizing this practice strategy. To address this gap, this study explored 384 teachers’ experiences with ESMH collaboration including the types of collaborations they are engaged in, what influences those relationships and what they perceive to be the benefits of this practice strategy. The findings support previous conceptual and research contributions focused on collaboration, as well as suggest some specific influences on collaborative relationships between teachers and community mental health professionals. Implications for practice, policy and research are offered.     

Effectiveness of the Parent Connectors Program: Results from a Randomized Controlled Trial

Parent education and support has been identified as a potential resource to help improve outcomes for youth who have emotional disturbances (ED). The current study builds on promising results from Parent Connectors (PCs) (Kutash et al. in Adm Policy Ment Health Ment Health Serv Res 38:412–427, 2011), a peer-to-peer program aimed at increasing the engagement of families in the education and treatment of their children who have ED. A total of 128 parents of students identified as having ED and enrolled in special education programs in 23 middle schools or special centers were randomly assigned to a treatment (had a PC) or comparison group. For parents who had a PC, results indicated positive program effects including increased perceived benefit of engagement, more engagement in their child’s services, and a more positive response to social norms. Students received more mental health services, were enrolled more days in school, and were suspended fewer times and for fewer days. The moderating effects of parent strain and child emotional functioning were examined, and implications for practice are discussed.     

Qualitative analysis of key informant interviews about adolescent stigma surrounding use of school mental health services

Given the increased access to mental health services that schools provide, there has been a growing consensus among mental health professionals for the delivery of services for youth in schools. Building the capacity of schools to provide evidence-based socio-emotional supports across a continuum of care has been prioritized in recent decades. However, despite policy changes to implement more mental health services in schools, these services still remain widely underutilized by adolescents experiencing mental health problems. Understanding the factors impacting students’ decisions to seek help or use resources provided in a school setting is crucial for actually increasing utilization of care. Yet, little is known about the role of stigma in students’ underutilization of school mental health services. The current study examined stigma about mental health and services in schools through a qualitative analysis of 15 school personnel and student interviews at three high schools in South Carolina. Thematic analysis of interviews indicated that students have a negative outlook of mental health services because of fear of being stereotyped or embarrassed as a result of receiving school counseling. Data from this exploratory study directly contribute to the field of education by providing a model for professionals to implement strategies to eliminate the stigma that causes underutilization of school mental health services.     

Teachers' beliefs about mental health needs in inner city elementary schools

OBJECTIVE: To survey teachers' beliefs about mental health service needs in inner city elementary schools. METHOD: A total of 119 teachers from six elementary schools in a major city in the midwestern United States were surveyed to assess their beliefs about the major mental health problems facing their schools, the major barriers to surmounting those problems, their preferences for mental health topics for in-service education, and their education, experience, knowledge, attitudes, and self-efficacy pertaining to mental health issues. RESULTS: Disruptive behavior was endorsed by approximately 50% of teachers as the largest mental health problem facing their schools, and lack of information/training was endorsed as the greatest barrier to surmounting mental health problems. The highest-rated topics for in-service education were disruptive behavior disorders and implementing behavior plans. Although most teachers had taught students with mental health problems, most had had little education in mental health and little consultation with mental health professionals. Correspondingly, teachers' knowledge about mental health issues was limited, and they did not feel confident about their ability to manage mental health problems in their classrooms. CONCLUSIONS: Teachers would benefit from education, training, and consultation from mental health professionals if they serve as effective gatekeepers to mental health services.     

Expanded School Mental Health Services: Assessing Needs Related to School Level and Geography

We surveyed 62 school administrators from three midatlantic (MD, VA, WV) and one northeastern (CT) state on factors relevant to developing school-based mental health programs. Administrators were from schools that varied on education level (elementary, middle, and high) and geographic location (urban, suburban, and rural), with equivalent numbers in each subgroup. Administrators provided ratings to questions grouped in five categories: (a) Stressful Conditions, (b) Internalizing Behavioral Problems, (c) Externalizing Behavioral Problems, (d) Substance Abuse, and (e) Barriers to Mental Health Care, and provided open-ended comments on needs of youth and mental health programs for them. They rated behavioral and substance abuse problems as progressively more serious as students advanced in school level. Urban youth were reported to encounter higher stress and present more severe internalizing problems than suburban or rural youth. Suburban and rural schools provided more health and mental health services than urban schools. Across geographic locales, physical health services far outnumbered mental health services. Findings related to barriers to mental health care, and the viability of schools as delivery sites for comprehensive mental health services, are discussed.     

Universal Emotional Health Screening at the Middle School Transition

This article describes the implementation of the Developmental Pathways Screening Program (DPSP) and an evaluation of program feasibility, acceptability, and yield. Using the Mood and Feelings Questionnaire (MFQ) and externalizing questions from the Youth Self Report (YSR; Achenbach, 2001), universal classroom-based emotional health screening was implemented with students as they began middle school. Of all sixth graders enrolled in four participating Seattle schools, 861 (83%) were screened. Students who screened positive for emotional distress (15% of students screened) received onsite structured clinical evaluations with children's mental health professionals. Seventy-one percent of students who were evaluated were found to be experiencing significant emotional distress, with 59% warranting referral to academic tutoring, school counselor, and/or community mental health services. Successful implementation of in-class screening was facilitated by strong collaboration between DPSP and school staff. Limitations of emotional health screening and the DPSP are discussed, and future steps are outlined.     

Toward the Integration of Education and Mental Health in Schools

Education and mental health integration will be advanced when the goal of mental health includes effective schooling and the goal of effective schools includes the healthy functioning of students. To build a solid foundation for this reciprocal agenda, especially within the zeitgeist of recent educational reforms, a change in the fundamental framework within which school mental health is conceptualized is needed. This change involves acknowledging a new set of priorities, which include: the use of naturalistic resources within schools to implement and sustain effective supports for students’ learning and emotional/behavioral health; inclusion of integrated models to enhance learning and promote health; attention to improving outcomes for all students, including those with serious emotional/behavioral needs; and strengthening the active involvement of parents. A strong research agenda to support these new priorities is essential.     

Persistently Dangerous Communities and Schools in the United States: How Might School Mental Health Help?

With increasing pressure on schools in the United States to address violence and school safety, school mental health (SMH) programs and services are well positioned to assist school administrators, teachers, and other school staff to prevent and/or reduce inappropriate and violent student behavior in schools. It is a struggle for persistently dangerous schools to provide educational environments that are safe and supportive for all students, and their academic achievement is threatened. The process of identifying and reforming these schools is explored briefly, followed by the ways in which school mental health strategies and programs can reduce suspensions and expulsions. Finally, opportunities are highlighted in which school mental health professionals can work with school administrators to produce effective change to promote safe schools and communities.     

Evaluation of Expanded School Mental Health Programs

Expanded school mental health programs provide a full range of mental health services (assessment, treatment, case management, prevention) to youth in regular and special education, and typically involve close collaboration between schools and community agencies. A major challenge for these programs is documenting that provided services are of high quality and leading to enhanced outcomes for the youth and schools served by them. Dimensions of school mental health evaluations and a step-by-step process for conducting them are presented, using the example of a well established program in Baltimore. Challenges to such evaluation and strategies for overcoming challenges are also presented.     

School law for the child psychiatrist: legal principles and case implications

Schools are evolving to support all students, including those with mental health issues. Clinicians can help patients and schools by providing diagnostic clarity about a child’s condition, how that condition interferes with school progress, and what interventions are needed in the school setting. State and Federal legislation supports timely response by schools to mental health issues emerging in students through special education laws and general education accommodations, such as Response To Intervention (RTI), which encourages schools to implement evidence-based interventions for students exhibiting mental health conditions. Case examples illuminate important legal considerations when clinicians are faced with issues such as therapeutic placements, home hospital forms, and substance abuse, and student misconduct.