Transformation of children's mental health services: the role of school mental health

The New Freedom Commission has called for a transformation in the delivery of mental health services in this country. The commission's report and recommendations have highlighted the role of school mental health services in transforming mental health care for children and adolescents. This article examines the intersection of school mental health programs and the commission's recommendations in order to highlight the role of school mental health in the transformation of the child and adolescent mental health system. Schools are uniquely positioned to play a central role in improving access to child mental health services and in supporting mental health and wellness as well as academic functioning of youths. The New Freedom Commission report articulated several goals related to school mental health: reducing stigma, preventing suicide, improving screening and treating co-occurring disorders, and expanding school mental health programs. The authors suggest strategies for change, including demonstrating relevance to schools, developing consensus among stakeholders, enhancing community mental health-school connections, building quality assessment and improvement, and considering the organizational context of schools.     

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups.

OBJECTIVE: The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery. METHODS: Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates). RESULTS: The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services. CONCLUSION: Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.     

Consumer Focus Groups

Background: Consumer organizations involved in the Eastern Region Behavioral Health Initiative of the St. Louis Regional Health Commission sought to ensure that services were streamlined, easily accessible, and focused on consumer needs. To this end, in February 2007, they solicited feedback from consumers and family members affected by mental illness and substance abuse through a series of focus groups. Methods: Fifty-five individuals with severe mental illness and their family members, from across the St. Louis Region, shared their experiences and struggles in the mental health and substance abuse systems. The data, which were coded for six focus groups, were analyzed, summarized, and presented to system providers and community stakeholders. Results: Substantial problems still remain with medication management services, quality of inpatient care, and stigmatization. Conclusions: Consumer input is imperative to the successful implementation of any work related to systems change to both affirm and redirect organizational priorities. Stigma emerged as a pervasive theme throughout the six focus groups and was subsequently incorporated as a priority for improving services in the system. Stigma and cultural competency training is needed for health-care staff workers at all levels to increase access effectively to services.     

Establishing and Maintaining Important Relationships in School Mental Health Research

For this article, we investigated a complicated (and hypothesized, little-studied) area in school mental health research: namely how researchers establish and maintain successful relationships with key stakeholders in school settings. We identified key stakeholders that school mental health researchers have to consider when engaging in school-based research. Parents, youth, teachers, school leadership, school mental health professionals, district-level leaders, and community mental health partners are each specific stakeholders who may have differing (or even competing) agendas than that of the research team. In addition, professionals within these groups may have concerns or even suspicions about the researchers’ involvement in their school. To better understand these complex relational issues, we conducted a survey of leading school mental health researchers based on a convenience sample of researchers who attended a national school mental health research summit in October 2012. The survey data revealed that successful school mental health researchers have to continually work at creating and maintaining good relationships with school stakeholders, and consider these relationships crucial to conducting this research. In this article, we will describe barriers to recruitment and implementation and methods of overcoming the challenges identified in several case studies of school-based research in published articles and from our survey data. We present this information and propose a preliminary best practice model to developing and maintaining relationships with school professionals in SMH research.     

Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study

This is the first study evaluating obstetrics and gynecology (OB/Gyn) provider and staff perceptions of barriers to accessing pharmacotherapy for perinatal depression outside the obstetric setting. Four, 90 min focus groups were conducted with OB/Gyn physicians, advance practice nurses, and support and nursing staff (n = 28). Data were analyzed with a grounded theory approach. Participants perceived that community mental health providers and pharmacists often do not want to participate in pharmacotherapy for perinatal women. Participants believed the solution is training for community mental health providers in the risks and benefits of pharmacotherapy for perinatal depression and improved communication between OB/Gyn’s and community mental health providers. Community mental health provider and pharmacist reluctance to provide pharmacotherapy hinders OB/Gyn’s perceived ability to address perinatal depression. Community mental health provider and pharmacist training are needed to mitigate precipitous discontinuation of treatment and to improve access to pharmacotherapy for perinatal women.     

Innovations: child & adolescent psychiatry: Training in developmental responses to trauma for child service providers

Youths most at risk of exposure to community violence are often those who are least likely to receive the attention of mental health professionals. The column describes the development and testing of training about trauma for school personnel and other community providers of children's services. The curriculum was developed with input from focus groups of school nurses. The one-day training sessions address nine areas: normal responses to stress, abnormal responses to stress, posttraumatic stress disorder and acute stress disorder, stage theories of loss and grief, risk and protective factors, crisis and disaster planning, resilience, mental health referral sources, and self-care techniques.     

Barriers and Facilitators of a Healthy Lifestyle Among Persons with Serious and Persistent Mental Illness: Perspectives of Community Mental Health Providers

The investigators used qualitative methods to examine perspectives of community mental health professionals on obesity management in adults with serious mental illness (SMI). Data from 5 focus groups were subjected to constant comparison analysis and grounded theory. Results showed that influences at individual, social, community, and societal levels impact development and maintenance of obesity. Mental health providers desired a collaborative relationship with health promotion program staff. They also believed that frequent, group-based health promotion should include participation incentives for adults with SMI and should occur over durations of at least 6-months to achieve improved health outcomes for this population.     

International school mental health: global approaches, global challenges, and global opportunities

School mental health programs from developed countries demonstrate that both the practice and research are becoming more important to policy makers, educators, health providers, parents, and other stakeholders. Some United Nations agencies and other international organizations have begun work to advance school mental health internationally. School-based mental health programming needs to be considered as part of usual child and youth mental health policies and plans, whether those are national or other jurisdictional in nature. Currently, a paucity of evidence-based and cost effective child and youth global mental health policies/programs exist, limiting school-based mental health programs being developed, implemented, or sustained.     

Best practices: New York's outpatient mental health clinic licensing reform: using tracer methodology to improve service quality

This column describes how the New York State Office of Mental Health (OMH) redesigned licensing procedures for outpatient clinics by applying a person-centered focus and clinically relevant standards of care. OMH incorporated a tracer methodology to assess services; a licensing instrument that reflected OMH goals; and a systematic piloting, feedback, and implementation process. Clinic staff reported that the new procedures facilitated communication between OMH and clinics, accurately identified clinics' successes, and provided actionable and programmatic feedback. This initiative represents the first step by a state mental health authority to create a system of accountability that is clinically relevant and supported by stakeholders.     

The Role of Teachers in School-Based Suicide Prevention: A Qualitative Study of School Staff Perspectives

In response to concerns over youth suicide, there has been an increase in school-based suicide prevention programs. However, we know little about teacher perspectives on school-based suicide prevention and mental health programs. This study examined teacher roles in the implementation of a district-wide suicide prevention program through focus groups and interviews with middle school teachers, administrators, and other school personnel. Study results highlighted teachers’ critical role in detecting students at risk for suicide. Factors that appeared to facilitate teacher participation in the suicide prevention program included well-defined crisis policies and procedures, communication of these procedures, collaboration across staff, and the presence of on-campus mental health resources. Participants identified a need for direct teacher training on risk factors for suicide, crisis response, and classroom management. Other strategies for improving suicide prevention efforts included in-school trainings on mental health resources and procedures, regular updates to these trainings, and greater visibility of mental health staff.     

International Efforts to Advance Mental Health in Schools

The article presents background to the international movement to enhance mental health promotion and intervention programs in schools and discusses factors behind the growth of the movement, and the paradigmatic change that is occurring as programs move to a focus on health promotion, environmental enhancement, interdisciplinary collaboration, and leadership by young people, families and other stakeholders. Hundreds of issues are being confronted as school mental health programs develop in various nations, and international dialogue is of critical importance in sharing ideas and lessons learnt in addressing these issues and advancing this emerging field. We set the stage for discussions of issues important for the advancement of school mental health from the perspective of people from five nations: Australia, Canada, Mexico, the United Kingdom, and the United States.     

Exploring School Mental Health Collaboration in an Urban Community: A Social Capital Perspective

Collaboration between community mental health professionals and school professionals involves sharing knowledge and resources to accomplish more than could be achieved by practicing in isolation. Despite its role in school mental health (SMH), there is little research evidence that collaboration is associated with improved outcomes. This qualitative study used focus group methodology to explore collaboration among 26 mental health and school professionals. The constant comparative method was used to analyze focus group data. Central categories that emerged from the analysis included the importance of integrating professionals from collaborating agencies into the school community, communication between school professionals and community providers, and the perceived positive contributions of SMH collaboration for engaging families in schools. Study findings are interpreted from a social capital perspective and implications for SMH practice and research are offered.     

Common ground: a framework for selecting core quality measures for mental health and substance abuse care

There is widespread interest throughout the mental health system in routine quality assessment to facilitate quality improvement, oversight, purchasing, and consumer choice. In the absence of agreement on a limited number of meaningful and feasible quality measures, delivery systems, payers, managed care organizations, regulators, and accreditors have each implemented unique measures and specifications. The resulting heterogeneity among measures has increased the burden on providers, limited the comparability of results, and hindered efforts to focus limited resources on further development of the most promising measures. Policy makers have initiated efforts for stakeholders to reach consensus on a core set of measures for common use, but barriers to progress remain, including differences in stakeholder needs and trade-offs between prioritizing desirable attributes of measures and representing the mental health system broadly. The authors present a framework for the selection of a core set of measures, clarify divergent perspectives, and make recommendations for further development of core quality measures for mental health care.     

Family perspectives on evidence-based practice

The focus on evidence-based practices has come to dominate discussions in medicine and mental health. Whereas professionals and providers focus on complex barriers to implementing and engaging administrative support, the realities for families are different. The mental health system in most communities is still fragmented and inaccessible, leaving parents overwhelmed and frustrated. To truly implement system reform, the practical needs and experiences of families must become a key strategic element.     

Manpower information and the community mental health system

The lack of knowledge about basic manpower issues in the community mental health system led the authors to devise five questions that address manpower issues of general interest to community mental health system managers. The questions concern the ratio of staff to population, the types of professionals on staff and their demographic characteristics, the amount of time staff spend on various activities, the cost of the work force, and the outcomes of services. The authors discuss how these questions have been considered in the literature, and they illustrate with analyses of data from a survey of staff of New Jersey's mental health agencies how the issues of number, type, and cost of staff can be explored. The authors believe that basic manpower information can contribute directly to the decisions of managers of mental health service systems.     

Improving medical care for persons with serious mental illness: challenges and solutions

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand and seek to improve the medical care that they receive. Medical quality deficits for persons with serious mental illness include problems related to overuse of certain medical services, such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health care systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: (1) geographic (lack of co-located medical and mental health services), (2) financial (separate funding streams for medical and mental health services), (3) organizational (difficulty in sharing information and expertise across these systems), and (4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders that are tailored to patients' needs, mental health system capacities, and local community resources.