School Mental Health

School mental health programs and services in the United States have grown rapidly, facilitated by the recommendations of important initiatives such as the U.S. Public Health Service, 2000; the President’s New Freedom Commission on Mental Health, 2003; and the American Academy of Pediatrics Committee on School Health, 2004. Schools offer access as a point of engagement with youth to address their academic and mental health needs; school mental health programs and services offer potential for reduced stigma for help seeking, increased generalization and maintenance of treatment gains, enhanced capacity for prevention and mental health promotion efforts, and ecologically grounded roles for clinicians.

School mental health is an emerging field with challenges confronted at many levels. Figure 1, an adaptation of a template proposed by Weist, Paternite, and Adelsheim and first published by Flaspohler, Anderson-Butcher, Paternite, Weist, and Wandersman, presents interrelated actions to support policies, infrastructures, resources, and practices to strengthen effective school mental health. Desired outcomes include student emotional and behavioral well-being and school success as well as enhanced family, school, and community systematic functioning. To achieve these outcomes, effective mental health promotion, primary and secondary prevention, assessment and early intervention, and intensive treatment programs and services are needed.

Undertaking a critical quality assessment and improvement agenda, in which delivery of culturally competent evidence-based practices are reflective of strong family and community engagement, helps to ensure effective school mental health practices. Service delivery infrastructures that reflect effective communication, strong collaboration, and meaningful training underpin the successful development and implementation of such programs and services. Policies that are based on a clear understanding of the current status and needs of the field promote effective school mental health practices and inform strategic planning. Judiciously allocated resources support well-coordinated, nonduplicative school mental health programs and services that reflect a common agenda for families and other stakeholders in child-serving systems (education, mental health, health, child welfare, and juvenile justice).

This entry presents several key themes for the advancement of school mental health. These include the importance of and challenges associated with achieving conceptual clarity about school mental health, the need to prioritize preventive services and mental health promotion, the move toward mental health and education systems integration, the need to strengthen the research base of the field, and future directions of school mental health.

Achieving Conceptual Clarity about School Mental Health

School mental health services have been delivered in a variety of forms, and there is not an explicit best practice model. However, the term expanded school mental health describes programs and services that incorporate key elements reflected in the recommendations of the President’s New Freedom Commission on Mental Health, 2003 and other important initiatives referred to above. These elements include the following: (a) family-school-community agency partnerships; (b) commitment to a continuum of mental health education, promotion, assessment, problem prevention, early intervention, and treatment; and (c) services for youth in general and special education.

Expanded conveys building on programs and services that exist in most schools, including the work of school-employed staff (e.g., school psychologists, social workers, counselors, school nurses, and teachers with behavioral expertise). The emphasis on effective collaboration between schools and community entities (e.g., mental health centers, health departments, university-affiliated centers) is based on the realization that schools cannot do all the work alone. Often, schools are overburdened with demands that could be addressed by other community systems. A strong connection between schools and community organizations also helps a community move toward a system of care. Expanded school mental health is a framework within which other critical elements are essential, including interdisciplinary collaboration, family and other stakeholder engagement, ongoing quality assessment and improvement, culturally competent services, and empirically supported practice.

Prioritizing Preventive Services and Population-Focused Mental Health Promotion

An essential intent of expanded school mental health is to contribute to the creation of a comprehensive and integrated system of support and care for youth, which necessitates attention to the promotion of healthy development and to primary-through-tertiary prevention of problems in their own right and as significant barriers to school success. One of the realities of delivering mental health services in schools is that providers find it hard to remain committed to a full spectrum of activity. Without diligence about preventive and mental health promotion efforts, drift can occur easily toward primarily individual services for students with severe or chronic problems. In part, this is due to a fundamental bias that undergirds how “mental health” is approached in the United States. Training, service delivery approaches, and fee-for-service funding are focused primarily on treating disorders that are presumed to exist within individuals, and school staff contend with a flood of referrals for students with serious problems and crises, making the implementation of preventive and health-promoting services difficult. For school mental health in everyday practice in the United States, the World Health Organization model of health-promoting schools, emphasizing population-based health promotion at the base and treatment for youth with serious problems at the apex, essentially is inverted.

Advocates for school mental health services emphasize the importance of prioritizing prevention and mental health promotion. For example, Atkins and colleagues have documented effective strategies for adapting school mental health programs to the needs and competencies of teachers, parents, and students to capitalize on schools’ unique opportunities to provide mental health-promoting activities. Clearly though, there is need for individual intervention in a school mental health program; however, that place should be circumscribed and informed by the evidence in support of its use.

In embracing the shift necessary to move toward enhanced preventive services and mental health promotion, examples from other countries are instructive. Australia, Cuba, and many Western European nations are prioritizing mental health promotion strategies for all youth in schools. In addition, important international groups are advancing the dialogue about school mental health promotion, such as the Clifford Beers Foundation, the World Federation for Mental Health, the International Union for Health Promotion and Education, the Society for Prevention Research, and the International Alliance for Child and Adolescent Mental Health and Schools.

Promoting the Integration of Mental Health and Education Systems

Historically, school mental health programs and staff (e.g., social workers, psychologists, counselors) often have been considered by educators to be “addons.” The seeming incompatibility between the “nonacademic” interests of mental health providers and the “academic” interests of educators has resulted, at best, in uneasy cooperation. Adelman and Taylor and others have suggested that the mental health and education systems move beyond program cooperation and strive for program integration—with mental health staff and educators working together closely based on shared values and goals.

Several strategies promote the integration of mental health and education systems, including the following: (a) ensuring strong collaboration among families, school leaders, and mental health leaders in program planning; (b) ensuring that school mental health providers understand school cultures and how to work as collaborative partners and that they are well trained, closely supervised, and interpersonally skilled; (c) ensuring that school mental health practices are of high quality and are empirically supported; (d) emphasizing school mental health services as effective means for reducing barriers to learning and promoting school success; and (e) documenting that services lead to outcomes valued by youth, families, and schools. Much of this work addresses the need to achieve in-depth understanding of schools— and the people who live and work in them (especially teachers)—from multiple perspectives.

Although schools cannot be held responsible for meeting every need of every student, most educators endorse an educational agenda that involves enhancing academic skills and physical, social, emotional, and character development. In addition, many professionals advocate that schools address student needs that directly affect learning and school success. There is compelling evidence that emotional and behavioral health problems are significant barriers to learning and that there are strong positive associations between mental health and academic success.

If schools do not have expanded school mental health services and programs, linkages to community-based services can be employed, but these linkages generally are quite poor or nonexistent. In addition, in the absence of the expanded approach, there often is “tier drift” into special education, with excessive referrals in order to give students access to mental health services. This practice results in increased burdens to special education systems, often for services of questionable value for youth who might not truly have learning impairments. Alternatively, if schools embrace movement toward expanding mental health services, the challenge of enhancing integration of mental health and education systems is complex. There are many issues to be addressed, such as the following:

Who will the community partners be and how will their work be integrated with the efforts of school-employed mental health and educational staff?
How will broad stakeholder perspective be incorporated into the program model?
How will a full continuum of services be guaranteed?
How will ongoing training needs of personnel be addressed to ensure that they have the competencies needed to collaborate successfully and to deliver effective services?
How will the quality of service delivery be assessed along dimensions meaningful for all stakeholders, and what strategies will be used for promoting empirically supported practices?

Strengthening the Research Base

In spite of strong momentum to promote enhanced mental health practices in schools, the research base for school mental health is quite limited. Much current research is focused on development and delivery of evidence-based child mental health services. However, the impact of this research on everyday practice in community settings, and in schools, is restricted.

The promotion of effective mental health practices in schools involves more than simply trumpeting the selection of evidence-based approaches, most of which have not been examined for their effectiveness, palatability, durability, affordability, sustainability, and transportability in and to real world school or clinic settings. In addition, the dearth of research on diffusion, dissemination, and the processes of change in movement toward effective mental health practices all contribute to the continuing gulf between evidence-based and current, everyday practice. The literature on evidence-based practices in children’s mental health does not typically attend to features of the school context that influence intervention delivery.

The community science model proposed by Wandersman and the deployment-focused model of intervention development and testing proposed by Weisz and colleagues both emphasize that practice-based evidence is an undertapped resource in the development and delivery of effective school (and community-based) mental health services. Both models highlight the significance of and variability across everyday clinical practice conditions.

Wandersman proposed a “community science,” a multidisciplinary field that attempts to strengthen community functioning by investigating how to improve the quality of common approaches (health promotion, education, prevention, treatment) implemented in real world settings. Community science emphasizes community-centered models to complement the research-to-practice model that serves as the dominant paradigm for the development of best practice programs. Community-centered models focus attention on local needs, see best practice as process rather than magic bullet programs, and emphasize control by practitioner, client, or community. Key attributes of community-centered models also include emphasis on local evaluation and self- monitoring and on a research agenda that focuses on tailoring interventions to fit local needs and contexts.

In short, community science promotes local participation oriented toward accountability in the community delivery process (rather than just proven intervention content delivered with fidelity). Engaging practitioners in planning, implementing, evaluating, sustaining, and continuously improving prevention, risk reduction, and treatment efforts based on locally determined needs builds local capacity to improve the quality of practice and achieve positive health outcomes.

Even with evidence-based school mental health practices that have been shaped along dimensions noted above, successful implementation depends on many systemic factors, such as the support of school staff, negotiation of obstacles such as time in the curriculum, and school day and space. Efforts to promote evidence-based school mental health must be imbedded in a broader, ongoing commitment to quality assessment and improvement. However, systematic research and practice on quality assurance have been limited in school mental health. Currently, Weist and colleagues are studying school mental health quality assessment and improvement (QAI) programming at sites in three states. For the study, they developed the School Mental Health Quality Assessment Questionnaire, which assesses 10 principles for best practice in school mental health (see Table 1). An important goal of the study is to promote evidence-based structuring of the school mental health “independent variable,” which has important implications for developing a credible services (practice-based) research agenda for the school mental health field.

Future Directions

With progressive development over the past two decades and significant recent support from federal initiatives, school mental health is becoming a force in the United States. Increasingly, communities are turning to school mental health to improve inaccessible and ineffective youth mental health systems and to assist families and schools in addressing youth mental health, which is inexorably linked to academic success. However, school mental health is an emerging field, and an integrated strategy is needed to advance policy, increase resources, improve training and support to programs and staff, emphasize quality and evidence-based practices, and document outcomes— in promotion of a true public mental health agenda.

Ten principles for best practice in school-based mental health:

All youth and families are able to access appropriate care regardless of their ability to pay.
Programs are implemented to address needs and strengthen assets for students, families, schools, and communities.
Programs and services focus on reducing barriers to development and learning, are student and family friendly, and are based on evidence of positive impact.
Students, families, teachers, and other important groups are actively involved in the program’s development, oversight, evaluation, and continuous improvement.
Quality assessment and improvement activities continually guide and provide feedback to the program.
A continuum of care is provided, including school-wide mental health promotion, early intervention, and treatment.
Staff hold to high ethical standards; are committed to children, adolescents, and families; and display an energetic, flexible, responsive, and proactive style in delivering services.
Staff are respectful of and competently address developmental, cultural, and personal differences among students, families, and staff.
Staff build and maintain strong relationships with other mental health and healthcare providers and with other educators in the school, and a theme of interdisciplinary collaboration characterizes all efforts.
Mental health programs in the school are coordinated with related programs in other community settings.

Related to federalism (states’ rights, local control), limited focus on health promotion and problem prevention, and inadequate access to care, the United States has not embraced a public health promotion agenda for any health condition, including emotional and behavioral health of children and adolescents. However, the President’s New Freedom Commission on Mental Health, the first presidential initiative addressing mental health in 30 years, provides an historic opportunity for the advancement of a public mental health promotion agenda, with school mental health a cornerstone. The final report of the commission focused on transforming mental health care in America and emphasized a specific recommendation to “expand and improve school mental health programs.” This recommendation, based on consensus of diverse national experts, provides sanction and credibility for federal- and state-supported and locally driven efforts to bring effective mental health promotion to youth where they are.

References:

Atkins, M. S., Frazier, S. L., Adil, J. A., & Talbott, E. (2003). School-based mental health services in urban communities. In M. Weist, S. Evans, & N. Tashman (Eds.), Handbook of school mental health: Advancing practice and research (pp. 165-178). New York: Kluwer Academic/Plenum.
Evans, S. W., Serpell, Z., & Weist, M. D. (in press). Advances in school-based mental health, Volume 2. Kingston, NJ: Civic Research Institute.
Evans, S. W., & Weist, M. D. (2004). Implementing empirically supported treatments in the schools: What are we asking? Clinical Child and Family Psychology Review, 7, 263-267.
Flaherty, L. T., & Osher, D. (2003). History of school-based mental health services. In M. D. Weist, S. W. Evans, & N. A. Lever (Eds.), Handbook of school mental health: Advancing practice and research (pp. 11-22). New York: Kluwer Academic/Plenum.
Flaspohler, P. D., Anderson-Butcher, D., Paternite, C. E., Weist, M. D., & Wandersman, A. (2006). Community science and expanded school mental health: Bridging the research to practice gap to promote child well being and academic success. Educational and Child Psychology, 23(1), 27-41.
Ghuman, H. S., Weist, M. D., & Sarles, R. M. (2002). Providing mental health services to youth where they are: School- and community-based approaches. New York: Brunner-Routledge.
Greenberg, M. T., Weissberg, R. P., O’Brien, M. U., Zins, J. E., Fredericks, L., Resnik, H., et al. (2003). Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist, 58, 466-474.
McNeely, C., & Falci, C. (2004). School connectedness and the transition into and out of health-risk behavior among adolescents: A comparison of social belonging and teacher support. Journal of School Health, 74, 284-292.
Paternite, C. E., & Johnston, T. C. (2005). Rationale and strategies for central involvement of educators in effective school-based mental health programs. Journal of Youth and Adolescence, 34, 41-49.
President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report (SMA Publication No. 03-3832). Rockville, MD: Author.
Robinson, K. E. (2004). Advances in school-based mental health interventions: Best practices and program models. Kingston, NJ: Civic Research Institute.
Wandersman, A. (2003). Community science: Bridging the gap between science and practice with community-centered models. American Journal of Community Psychology, 31, 227-242.
Weist, M. D., Evans, S. W., & Lever, N. A. (2003). Handbook of school mental health: Advancing practice and research. New York: Kluwer Academic/Plenum.
Weist, M. D., Sander, M. A., Walrath, C., Link, B., Nabors, L., Adelsheim, S., et al. (2005). Developing principles for best practice in expanded school mental health. Journal of Youth and Adolescence, 34, 7-13.