FAQ Education Holiday 2003/2004

Holiday 2003/2004

What are the outcomes of school based mental health services? How do they compare to clinic-based services?

One in five children and adolescents experiences symptoms of a mental health disorder during the course of a year. It is estimated that 6 to 9 million children with serious emotional needs are not receiving the help they need. The majority of referrals involve impairments in school functioning and a large percentage of symptoms are manifested in the school setting (U.S. Department of Health and Human Services, 1999). It is therefore easy to understand the trend over the last 10 years to develop more service delivery models for the school environment. However, as the programs have increased, the studies examining the effectiveness of services in the schools have not.

Many studies speak to the lack of findings about the comparison ofservice delivery locations and methodologies. Evans (1999) suggests that research that directly compares services delivered in schools versus other sites adds to preliminary findings in a way that impacts systems of children's mental health services. The field is encouraged to examine questions such as the following: Are school-based mental health services as effective as those services provided in clinics? Additional factors, such as the impact on school functioning, the cost-effectiveness, and the impact over time should also be examined. From one-third to over one-half of all referrals to mental health agencies are for aggressive behaviors or conduct problems, which usually occur in schools (Atkins, McKay, Arvanitis et al., 1998). However, less than one-third of those referred receive adequate care and only 20-30 percent of poor and minority children have access to appropriate mental health services (Richardson, Keller, & Shelby-Harrington, 1996).

As schools are forced to deal with more behavioral and emotional needs of children, their programs have had to expand accordingly. Historically, special education was the primary service provider for children with these needs. As a result, most schools have expanded their programs to meet the wide range of mental health and social needs of today's students, such as school adjustment, consistent school attendance, physical and sexual abuse, emotional stability, or violence.

Outcomes of school-based services

Many studies have documented positive outcomes of school-based services for students: improved academic functioning; closeness to home; easy accessibility (Costello-Wells, 2003; Weist, 1999); user friendliness; lack of stigma; fewer discipline problems; fewer course failures; fewer school absences (Jennings, 2000); cost-effectiveness for Medicaid eligible students (Costello-Wells, 2003); and comparable results between school-based mental health services and clinic-based services (Armbruster & Lichtman, 1999; Armbruster, 2002). For those who focus solely on school-related outcomes, claims of effectiveness seem clear. However, the field is not so clear when it comes to clinical effectiveness based on the setting. Multiple research studies to support this position have not been conducted (Evans, 1999). However, a meta-analysis of various school-based prevention programs conducted by Durlak (1997) shows that these programs were more effective when delivered in schools rather than at other sites (Evans, 1999).

Effective Prevention and Intervention Practices

Greenberg, Domitrovich, and Bumbarger (2001) identified over 130 programs and reviewed 34 specific programs that met strict criteria for effective, positive outcomes for risk factors related to mental health disorders. The following conclusions were made: short-term preventive interventions produce time-limited benefits with at-risk groups, whereas multiyear programs are more likely to foster enduring benefits; preventive interventions are best directed at risk and protective factors rather than at categorical problem behaviors; interventions should be directed at changing institutions and environments rather than individuals; focus is not only on the child's behavior but on the teacher's and family's behavior; no single program component can prevent high-risk behaviors; for school aged children, the school ecology should be the central focus of intervention; and finally, create an integrated community care system.

A number of national initiatives within various agencies have adopted the basic aspects of the multi-tiered public health model. In school initiatives, such as the Positive Behavioral Supports and Interventions model, the "triangle" has green, yellow, and red zones. The basic three-tiered model starts with the bottom tier, the green zone, representing, the broadest base of universal interventions for all children. The middle tier, the yellow zone, represents early intervention of targeted supports for the moderate needs of some students. The top tier, red zone, represents a small percentage of students with intensive needs for interventions and supports. This framework supports a continuum of services or systems that can meet the social, emotional, and mental health needs of all children and youth (National Association of State Mental Health Program Directors, 2002).

Challenges faced in current programs

Many school employees are frustrated with some of the emerging roles for mental health providers in schools. Administrators may have hired new mental health personnel without involving other school staff. Many providers were placed in programs without planning, coordinating, or communicating with the existing program staff. In some cases, school positions were eliminated and outside agency staff were "hired." Many of these providers did not understand the school culture or the way to collaborate with teachers (Franklin, 2001). Many schools feel providing mental health services is not their job.

There has been a lack of comprehensive mapping and analysis of the amount of resources used to support mental health in schools or the way it is expended (UCLA School Mental Health Project, 2003). No cohesive policy or vision is available for the role schools have in addressing those factors that interfere with learning and teaching. Student support services and school health programs do not have priority in current education-policy initiatives. They are treated as desirable but not mandatory; therefore, the programs are marginalized (Adelman & Taylor, 2003).

There are many compelling reasons to create school-based mental health services; however, unless they are integrated as an inclusive piece of a much larger framework that addresses prevention, intervention, and intensive interventions, the outcomes will still be marginalized. There is an increasing need for more family and community involvement, and integrated, collaborative, and interagency approaches will replace an isolated, silo-driven approach that has been the norm. School-based mental health services need to be seen as a supportive piece of the framework that will support the social and emotional wellness of students and contribute to better outcomes. Better data on cost, use, and effectiveness across life domains will lead to support and policy development of initiatives in this field.

Reference List

Adelman, H., & Taylor. L. (2003). The policy problem related to advancing an agenda for mental health in schools. UCLA School Mental Health Project Center for Mental Health in Schools. Available at http://smhp.psych.ucla.edu/presidentrec.htm

Armbruster, P., & Lichtman, J. (1999). Are school based mental health services effective? Evidence from 36 inner city schools. Community Mental Health Journal, 35, 493-504.

Armbruster, P. (2002). The administration of school-based mental health services. Child and Adolescent Psychiatric Clinician North America, 11, 23-41.

Atkins, M., McKay, M., Arvanitis, P., London, L., Madison, S., Costigan, C., et al. (1998). An ecological model for school-based mental health service for urban low-income aggressive children. Journal of Behavioral Health Services Research, 5, 64-75.

Costello-Wells, B., McFarland, L., Reed, J., & Walton, K. (2003). School-based mental health clinics. Journal of Child and Adolescent Psychiatric Nursing, 16, 60-70.

Durlak, J. (1997). Primary prevention programs in schools. Advances in Clinical Child Psychology, 19, 283-318.

Evans, S. (1999). Mental Health Services in Schools: Utilization, Effectiveness, and Consent. Clinical Psychology Review, 19, 165-178.

Franklin, C. (2001). Establishing successful relationships with expanded school mental health professionals. Children and Schools, 23, 3-5.

Greenberg, M., Domitrovich, C., & Bumbarger, B. (2001). The Prevention of mental disorders in school-aged children: Current state of the field. Prevention & Treatment. Available at http://journals.apa.org/prevention/volume4/pre0040001a.html

Hoagwood, K. & Erwin, H. (1997). Effectiveness of school-based mental health services for children: A 10-year research review. Journal of Child and Family Studies, 6, 435-451.

Jennings, J., Pearson, G., & Harris, M. (2000). Implementing and maintaining school-based mental health services in a large, urban school district. Journal of School Health, 70, 201-205.

Policy Leadership Cadre for Mental Health in Schools (2001). Mental Health in Schools: Guidelines, Models, Resources, & Policy Considerations Los Angeles, CA: School Mental Health Project.

Richardson, L., Keller, A., Shelby-Harrington, M., & Parrish, R. (1996). Identification and treatment of children's mental health problems by primary care providers: A critical review of research. Archives of Psychiatric Nursing, 10, 293-303.

The National Association of State Mental Health Program Directors and the Policymaker Partnership for Implementing IDEA (2002). Mental Health, Schools and Families Working Together for All Children and Youth: Toward a Shared Agenda Washington, DC: The National Association of State Directors of Special Education.

U.S. Department of Health and Human Services Office of the Surgeon General (1999). Mental health: A report of the Surgeon General. U.S. Department of Health and Human Services. Available at http://www.surgeongeneral.gov/library/mentalhealth.home.html

UCLA School Mental Health Project (2003). Mental health in schools: an overview. UCLA School Mental Health Project Center for Mental Health in Schools. Available at http://smhp.psych.ucla.edu/aboutmhinschools.htm

Weist, M. (1997). Expanded school mental health services: A national movement in progress. Advances in Clinical Child Psychology, 19, 319-352.

Weist, M. D., Myers, C. P., Hastings, E., Ghuman, H., & Han, Y. L. (1999). Psychosocial functioning of youth receiving mental health services in the schools versus community mental health centers. Community Mental Health Journal, 35, 69-81.

Technical Assistance Partnership for Child and Family Mental Health

Education Frequently Asked Questions

Home About Us About Systems of Care Contact Us Events & Presentations Newsletter Consultant Pool Special Topics Column Grantee Locator Webinars Resource Specialties Child Welfare Education Family Involvement Juvenile Justice Mental Health Primary Care Substance Abuse Sustainability Youth Involvement Regional Technical Assistance Region I Region II Region III Region IV Region V Region VI Communities of Practice Cultural and Linguistic Competence Early Childhood Transition-Aged Youth	Education Frequently Asked Questions
	Holiday 2003/2004 What are the outcomes of school based mental health services? How do they compare to clinic-based services? One in five children and adolescents experiences symptoms of a mental health disorder during the course of a year. It is estimated that 6 to 9 million children with serious emotional needs are not receiving the help they need. The majority of referrals involve impairments in school functioning and a large percentage of symptoms are manifested in the school setting (U.S. Department of Health and Human Services, 1999). It is therefore easy to understand the trend over the last 10 years to develop more service delivery models for the school environment. However, as the programs have increased, the studies examining the effectiveness of services in the schools have not. Many studies speak to the lack of findings about the comparison ofservice delivery locations and methodologies. Evans (1999) suggests that research that directly compares services delivered in schools versus other sites adds to preliminary findings in a way that impacts systems of children's mental health services. The field is encouraged to examine questions such as the following: Are school-based mental health services as effective as those services provided in clinics? Additional factors, such as the impact on school functioning, the cost-effectiveness, and the impact over time should also be examined. From one-third to over one-half of all referrals to mental health agencies are for aggressive behaviors or conduct problems, which usually occur in schools (Atkins, McKay, Arvanitis et al., 1998). However, less than one-third of those referred receive adequate care and only 20-30 percent of poor and minority children have access to appropriate mental health services (Richardson, Keller, & Shelby-Harrington, 1996). As schools are forced to deal with more behavioral and emotional needs of children, their programs have had to expand accordingly. Historically, special education was the primary service provider for children with these needs. As a result, most schools have expanded their programs to meet the wide range of mental health and social needs of today's students, such as school adjustment, consistent school attendance, physical and sexual abuse, emotional stability, or violence. Outcomes of school-based services Many studies have documented positive outcomes of school-based services for students: improved academic functioning; closeness to home; easy accessibility (Costello-Wells, 2003; Weist, 1999); user friendliness; lack of stigma; fewer discipline problems; fewer course failures; fewer school absences (Jennings, 2000); cost-effectiveness for Medicaid eligible students (Costello-Wells, 2003); and comparable results between school-based mental health services and clinic-based services (Armbruster & Lichtman, 1999; Armbruster, 2002). For those who focus solely on school-related outcomes, claims of effectiveness seem clear. However, the field is not so clear when it comes to clinical effectiveness based on the setting. Multiple research studies to support this position have not been conducted (Evans, 1999). However, a meta-analysis of various school-based prevention programs conducted by Durlak (1997) shows that these programs were more effective when delivered in schools rather than at other sites (Evans, 1999). Effective Prevention and Intervention Practices Greenberg, Domitrovich, and Bumbarger (2001) identified over 130 programs and reviewed 34 specific programs that met strict criteria for effective, positive outcomes for risk factors related to mental health disorders. The following conclusions were made: short-term preventive interventions produce time-limited benefits with at-risk groups, whereas multiyear programs are more likely to foster enduring benefits; preventive interventions are best directed at risk and protective factors rather than at categorical problem behaviors; interventions should be directed at changing institutions and environments rather than individuals; focus is not only on the child's behavior but on the teacher's and family's behavior; no single program component can prevent high-risk behaviors; for school aged children, the school ecology should be the central focus of intervention; and finally, create an integrated community care system. A number of national initiatives within various agencies have adopted the basic aspects of the multi-tiered public health model. In school initiatives, such as the Positive Behavioral Supports and Interventions model, the "triangle" has green, yellow, and red zones. The basic three-tiered model starts with the bottom tier, the green zone, representing, the broadest base of universal interventions for all children. The middle tier, the yellow zone, represents early intervention of targeted supports for the moderate needs of some students. The top tier, red zone, represents a small percentage of students with intensive needs for interventions and supports. This framework supports a continuum of services or systems that can meet the social, emotional, and mental health needs of all children and youth (National Association of State Mental Health Program Directors, 2002). Challenges faced in current programs Many school employees are frustrated with some of the emerging roles for mental health providers in schools. Administrators may have hired new mental health personnel without involving other school staff. Many providers were placed in programs without planning, coordinating, or communicating with the existing program staff. In some cases, school positions were eliminated and outside agency staff were "hired." Many of these providers did not understand the school culture or the way to collaborate with teachers (Franklin, 2001). Many schools feel providing mental health services is not their job. There has been a lack of comprehensive mapping and analysis of the amount of resources used to support mental health in schools or the way it is expended (UCLA School Mental Health Project, 2003). No cohesive policy or vision is available for the role schools have in addressing those factors that interfere with learning and teaching. Student support services and school health programs do not have priority in current education-policy initiatives. They are treated as desirable but not mandatory; therefore, the programs are marginalized (Adelman & Taylor, 2003). There are many compelling reasons to create school-based mental health services; however, unless they are integrated as an inclusive piece of a much larger framework that addresses prevention, intervention, and intensive interventions, the outcomes will still be marginalized. There is an increasing need for more family and community involvement, and integrated, collaborative, and interagency approaches will replace an isolated, silo-driven approach that has been the norm. School-based mental health services need to be seen as a supportive piece of the framework that will support the social and emotional wellness of students and contribute to better outcomes. Better data on cost, use, and effectiveness across life domains will lead to support and policy development of initiatives in this field. *Reference List* Adelman, H., & Taylor. L. (2003). The policy problem related to advancing an agenda for mental health in schools. UCLA School Mental Health Project Center for Mental Health in Schools. Available at http://smhp.psych.ucla.edu/presidentrec.htm Armbruster, P., & Lichtman, J. (1999). Are school based mental health services effective? Evidence from 36 inner city schools. Community Mental Health Journal, 35, 493-504. Armbruster, P. (2002). The administration of school-based mental health services. Child and Adolescent Psychiatric Clinician North America, 11, 23-41. Atkins, M., McKay, M., Arvanitis, P., London, L., Madison, S., Costigan, C., et al. (1998). An ecological model for school-based mental health service for urban low-income aggressive children. Journal of Behavioral Health Services Research, 5, 64-75. Costello-Wells, B., McFarland, L., Reed, J., & Walton, K. (2003). School-based mental health clinics. Journal of Child and Adolescent Psychiatric Nursing, 16, 60-70. Durlak, J. (1997). Primary prevention programs in schools. Advances in Clinical Child Psychology, 19, 283-318. Evans, S. (1999). Mental Health Services in Schools: Utilization, Effectiveness, and Consent. Clinical Psychology Review, 19, 165-178. Franklin, C. (2001). Establishing successful relationships with expanded school mental health professionals. Children and Schools, 23, 3-5. Greenberg, M., Domitrovich, C., & Bumbarger, B. (2001). The Prevention of mental disorders in school-aged children: Current state of the field. Prevention & Treatment. Available at http://journals.apa.org/prevention/volume4/pre0040001a.html Hoagwood, K. & Erwin, H. (1997). Effectiveness of school-based mental health services for children: A 10-year research review. Journal of Child and Family Studies, 6, 435-451. Jennings, J., Pearson, G., & Harris, M. (2000). Implementing and maintaining school-based mental health services in a large, urban school district. Journal of School Health, 70, 201-205. Policy Leadership Cadre for Mental Health in Schools (2001). Mental Health in Schools: Guidelines, Models, Resources, & Policy Considerations Los Angeles, CA: School Mental Health Project. Richardson, L., Keller, A., Shelby-Harrington, M., & Parrish, R. (1996). Identification and treatment of children's mental health problems by primary care providers: A critical review of research. Archives of Psychiatric Nursing, 10, 293-303. The National Association of State Mental Health Program Directors and the Policymaker Partnership for Implementing IDEA (2002). Mental Health, Schools and Families Working Together for All Children and Youth: Toward a Shared Agenda Washington, DC: The National Association of State Directors of Special Education. U.S. Department of Health and Human Services Office of the Surgeon General (1999). Mental health: A report of the Surgeon General. U.S. Department of Health and Human Services. Available at http://www.surgeongeneral.gov/library/mentalhealth.home.html UCLA School Mental Health Project (2003). Mental health in schools: an overview. UCLA School Mental Health Project Center for Mental Health in Schools. Available at http://smhp.psych.ucla.edu/aboutmhinschools.htm Weist, M. (1997). Expanded school mental health services: A national movement in progress. Advances in Clinical Child Psychology, 19, 319-352. Weist, M. D., Myers, C. P., Hastings, E., Ghuman, H., & Han, Y. L. (1999). Psychosocial functioning of youth receiving mental health services in the schools versus community mental health centers. Community Mental Health Journal, 35, 69-81.