This Web site is a component of the SAMHSA Health Information Network
|
This Web site is a component of the SAMHSA Health Information Network |
| | | | | | |  |
||||||||||
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
This Web site is a component of the SAMHSA Health Information Network. |
|
Chapter 77.0 Discussion and Implications for Further ResearchThis study describes mental health problems, services, and funding in U.S. public schools. Several key findings suggest that in 2002–2003, public schools were being responsive to the mental health needs of their students. The study found that one fifth of students received some type of school-supported mental health services in the school year prior to the study. One fifth of the districts in the U.S. reported increased numbers of mental health providers on staff in schools over the year prior to the survey, and another 50 percent indicated that staffing levels remained the same. Almost half the schools were attempting to increase their capacity to provide mental health services by making formal arrangements with community-based providers. Close to 40 percent of districts increased parent outreach services, which have been associated with enhanced identification, assessment, and treatment of behavioral and emotional problems in children and youth (Advocates for Youth, 1998). The findings from this survey, however, also point to an ongoing need for mental health services, multiple challenges faced by schools in addressing those needs, increasing funding pressures, and inadequate community-based resources. This section discusses findings related to mental health problems, staffing, service array, and funding. It concludes with a summary of study limitations and implications for further research. 7.1 Mental Health ProblemsAs expected, the most common mental health problems among school students were social, interpersonal, and familial in nature. These issues were rated as the most resource-intensive among the mental health issues that were identified and treated in schools in the 2002–2003 school year. This school- and district-level study did not generate the kind of epidemiological data that would permit estimation of prevalence rates of mental health problems among children, but it does provide a picture of the kinds of children’s problems seen by school personnel, and it sheds light on the availability of services that are most suited to addressing reported problems. More than half of all schools offered services that were commonly used to treat social, interpersonal, and familial problems, but family support services and group counseling (such as social skills groups) were somewhat less available than other interventions (such as behavior management consultation and individual counseling). The survey found that the second- and third-ranked problems for males and females differed. Boys were thought to show more aggression and disruptive behavior and behavior problems associated with neurological disorders such as attention deficit-hyperactivity disorder (ADHD). Epidemiological studies suggest that ADHD is four times more prevalent in boys than girls (Ross & Ross, 1982). Girls were perceived as facing more anxiety and adjustment concerns. ADHD and the more severe anxiety disorders are often treated with medication as well as psychotherapy. It should be noted that schools have difficulty both in providing medication management and in making referrals for treatment with medication. Gender differences in mental health problems raise the question as to whether, overall, boys are more likely to receive services and/or to receive more intensive services because their problems are expressed as disruptive behaviors. Elementary, middle, and high schools face somewhat different challenges in responding to the mental health needs of their students. These differences have implications for teacher training and professional development, parent education, and prevention and intervention strategies for children. Many elementary schools were dealing with aggressive and disruptive behavior, which can negatively affect the learning environment for all children in a classroom. Almost two thirds of elementary schools used curriculum-based programs to enhance social and emotional functioning and reduce barriers to learning. Schools reported that using programs focusing on building skills such as anger management and conflict resolution were particularly helpful in improving the mental health of their students. At the middle school level, the same problems predominated, but overall findings reveal that depression, alcohol and drug problems, and delinquency were more frequently reported as significant concerns. It appears that approximately three quarters of all schools recognize the importance of prevention and use school-wide strategies to reduce the incidence of substance use and to promote drug-free environments but that substance abuse counseling was less available. In the high schools, alcohol and drug problems and depression were more often reported as top mental health problems and made more demands on mental health resources. The survey found that only 43 percent of schools could provide substance abuse counseling, and that this service was difficult or very difficult to deliver. Effective substance abuse counseling requires some specialized knowledge, which is absent from many master’s-level mental health professional training programs. Substance abuse counselors accounted for only 3 percent of all mental health staff in schools. This reality is reflected in the finding that only half of the substance abuse counseling delivered to students was provided by school- or district-based staff; the remaining half of substance abuse services were delivered by community-based providers. While the survey did not measure the prevalence of serious emotional disturbance among children in the schools in this sample, it is notable that 6 percent of schools named major psychiatric or developmental disorders as one of their top three concerns, most likely because these disorders required intensive intervention. Major psychiatric or developmental disorders were cited as a top three concern by more elementary schools (8 percent) than middle or high schools (3 percent each). Current estimates of the prevalence of serious emotional disturbance in the school-age population range from 5 to 9 percent (U.S. DHHS, 1999).7.2 Mental Health ServicesSeveral basic mental health services―assessment, behavior management, crisis intervention, and counseling―were widely available in schools. The extent of the reported service array might suggest that schools were providing the full continuum of services required by students with mental health needs, but this finding should be interpreted cautiously since the survey did not ask the respondents to report on the intensity of these services, the specific qualifications of those providing the services, or the extent of unmet need for services. The survey findings also revealed that schools were providing a variety of prevention and early intervention programs, primarily aimed at drug and alcohol abuse, mild mental health problems, and enhancing student mental health. Peer counseling and parent outreach were also available, but to a lesser extent, and although school-wide screening for mental health problems was reported by some schools, it was rarely available. Respondents were not asked to rate the effectiveness of these programs or to comment on the extent to which they were replacing traditional mental health treatment services, but given their prevalence, it would benefit the field to further study how, and to what extent, these prevention programs combine with treatment services and service providers to promote a continuum of care within the school setting. In spite of the extensive array of mental health services available in schools, financial constraints of families was the most frequently reported barrier to receiving services; furthermore, almost half of the schools cited inadequate internal and community mental health resources as barriers or serious barriers to services. This finding suggests that while schools and their community partners were attempting to meet students’ mental health needs, the systems put in place to respond to these needs were not deemed to be adequate, and that accessing services under the current system was often dependent on the financial resources of the family (rather than the school system). In the majority of schools, all students, as opposed to only special education students, were eligible to receive mental health services. However, schools with high minority enrollment were more likely to restrict mental health services to special education students only. This finding suggests that disparities by race/ethnicity may exist regarding access to mental health services in schools, but this is an area that should be pursued for further study.7.3 StaffingThe survey found that the vast majority of schools had at least one staff member with a graduate degree and license in his/her field who provided mental health services. These percentages held for schools regardless of urbanicity, size, or minority enrollment. The study determined the average amount of time (ranging from 40 percent for psychiatrists to 61 percent for substance abuse counselors) that each type devoted to the provision of mental health services. The survey found that competing priorities (e.g., educational, administrative, direct service provision) for mental health staff time were a primary concern. This has implications for the proportion of the day that staff can devote to directly serving children, youth, and families, especial in general education. The study also found that the need for mental health services has been rising and that funding has not kept pace with increased need. Nationally, schools most commonly had between two and five staff providing mental health services. Although many different combinations were reported, the most common were: (1) school counselor, school psychologist, and nurse; and (2) school counselor, school psychologist, nurse, and social worker. Types of staff in schools varied somewhat by school level. High schools were most likely to have a school counselor and a nurse, and when there were four or more staff, they were most likely to have a psychologist and a social worker in addition to a school counselor and a nurse. Middle schools were most likely to have a combination of a counselor, psychologist, social worker, and nurse. Elementary schools typically had a counselor and a nurse when there were two staff, and a psychologist and social worker were the most likely additions when there were four staff. Schools were much less likely to report that they had a clinical (Ph.D.) psychologist or a mental health counselor, and psychiatrists were rarely reported to be on staff. The paucity of clinical psychologists and mental health counselors in schools is of concern, given that respondents also reported an increasing need for mental health services. The limited availability of psychiatrists in schools no doubt contributes to the dearth of medication management services. The survey did not ask about the mental health functions specific to nursing, but it is possible that the rise of medication use among children and youth with mental health problems (LeFever et al., 1999; Olfson et al., 2002; and Zito et al., 1998) raises the question of the means by which psychotropic medications are administered and monitored by schools. More research is needed into the mental health functions specific to nursing in the school setting, the time nurses spend on providing mental health services and coordinating medication management with outside providers, and their training needs.7.4 Service Delivery ArrangementsOver half of the schools nationwide had agreements with community mental health providers to provide services to their students. The survey found that most schools, even if they did not have formal arrangements, referred out, and 40 percent of schools reported that they participated in team meetings with community providers. These findings may support recent research (Brener, Martindale, & Weist, 2001; Weist et al., 2001;) asserting that some districts are moving toward a full continuum of care by partnering with community agencies and individual providers.
7.5 FundingFunding for school mental health services comes from multiple categorical funding streams. The top funding sources, reported by over half of districts as supporting school mental health were IDEA, Safe and Drug-Free Schools and Communities, State special education funds, and local funds. Almost 40 percent of districts reported that Medicaid was a funding source. This was particularly true of medium and large districts, suggesting that districts of this size may be developing the administrative capacity to bill Medicaid for mental health services. Alternatively, their collaborating providers may be billing for services provided in the school. Answering these questions was beyond the scope of this study. Small districts were much less likely to access Medicaid or other third-party reimbursement, suggesting that they may not yet have the capacity to do so, and that as a result may not be able to provide the amount of counseling services that larger districts can. A majority of districts cited competing priorities (e.g. academic achievement versus mental health services) for the use of funds as a major impediment to providing mental health services in schools. Survey findings suggest that there were few Federal, State, or local funding sources that are earmarked for mental health services to students who were not in special education. Without dedicated funds, it is up to the school district to determine how to allocate the funds available, and it appears that resources may go to mandated educational interventions rather than to mental health in many cases. Lack of (or inadequate) insurance and insufficient mental health resources also impeded access to mental health services for students. These constraints likely place increasing demands on schools to address the mental health problems of students. Finally, respondents reported that service use and need are increasing, while funding for mental health remains static or is declining. Other findings, such as the lack of funding earmarked for mental health and the reported lack of community-based mental health resources, together with rising need, indicate that schools face numerous challenges in their attempts to maintain optimal student functioning.7.6 Implications for Further ResearchThis survey is the first comprehensive, nationally representative survey of mental health services in U.S. public schools. Obtaining an unbiased sample of schools and districts was a time-consuming, labor-intensive process. While the survey provides important baseline information, it also leaves many questions unanswered and raises additional questions. It provides measures of the mental health problems encountered in school settings, but it does not address how many students present with each type of problem and how these problems differ by demographic background characteristics of students. Research Needed on Effectiveness of Combinations of Services While the survey found widespread eligibility for mental health services and a surprisingly wide array of services provided, the measures of service eligibility and provision are fairly broad. The survey revealed the percentage of schools offering various types of services, but it did not ask about the intensity or duration of different services, which services were provided for which mental health problems, the adequacy or appropriateness of the services to the needs of the students, or the degree to which the need for various services was met. Further, the survey gathered only limited information about prevention. Future research should be conducted to guide school officials regarding the most effective combinations of prevention and intervention services for their schools. Research Needed on Specialty Staff Training and Qualifications The individuals who provide mental health services in schools include specialists with graduate degrees and licensure in their fields as well as nurses and paraprofessionals, but this survey does not address whether these staff have specific qualifications to treat the major presenting problems at each school level. Several open-ended comments also pointed to the inadequacy of staff-to-student ratios. Future research should measure specific staff and service assignments, the qualifications of staff to provide those services, and the professional development needs and experiences of staff. Research Needed on Distribution of Funding Sources It would be important to learn more about the amount of funding allocated to different types of prevention, assessment, and treatment services according to the number of children served and their presenting problems. Such an analysis would shed light on equity of funding, disparities between well-resourced and under-resourced schools, and would guide policymakers in their decisions about funding allocation for mental health services. The survey identified the top sources of funding for mental health services and which sources were used for prevention versus intervention services. However, additional information is needed about the specific services that various funding streams support . Further, more research is needed to determine the distribution of funding and other resources for mental health services by region, urbanicity, minority enrollment, and other school characteristics. Conclusion This study, School Mental Health Services in the United States, 2002–2003, provides the first source of information on the mental health services provided in the approximately 83,000 public elementary, middle, and high schools and their associated school districts in the United States. The study's findings confirm that mental health services currently play an integral role in the school setting. The findings also suggest that needs for mental health services are increasing, and that adequate funding and availability of community resources are essential if schools are to meet the challenge of addressing these needs. |
|
|
| Home | Contact Us | About Us | Awards | Accessibility | Privacy and Disclaimer Statement | Site Map |
