Three years ago, I was asked to leave my position as a therapist and take a leadership role as a supervisor of school-based mental health services. At the time, I was seeing a small caseload of children at their school because of problem behaviors in their classroom environment. When I accepted the role, I had no idea how expansive and demanding school-based services would become. I quickly learned a new branch of treatment was developing: clinical intervention provided in an environment where children often struggle the most, and consultation and support for educators to increase awareness on the effects of childhood mental health in the schools.
As funding dollars and financial resources diminish, an increased need exists for partnerships and collaborative efforts between mental health professionals and community resources. One such example is the partnership that has been cultivated between public school systems and community mental health agencies. New programming has developed in the form of school-based mental health service teams. These teams are formulated as an extension of outpatient services, provided to the child and family within the school environment through individual and family therapy, case management and access to psychiatric services. Providing mental health services in the community encourages systems to work in collaboration to address the complex issues and diagnoses that we see in child and adolescent mental health.
The necessity for additional support, training, consultation and clinical intervention within the academic environment has grown as school funding shortfalls have reduced the number of school counselors, school social workers and school psychologists available to address the emotional and behavioral needs of school-age children. Economic difficulties, lack of transportation and the growing need for two-income households has increased the rate of noncompliance to appointments in the office setting. However, in my experience, it is relatively easy for many parents to walk to or secure a ride to their child’s school. To this end, mental health agencies are finding that meeting the client in the comfort of his or her environment — home or school — leads to greater success in maintaining consistent clinical contact and achieving greater outcomes.
On average, children spend six to eight hours per day in an academic setting for at least nine months a year. Academic personnel, who are already faced with limited time and resources, experience the effects of routinely working with children who have externalizing and internalizing behaviors of varying frequency and intensity and who may have diagnoses such as oppositional defiant disorder, anxiety disorder, depression and posttraumatic stress. This could result in increased suspensions and expulsions for students and higher rates of burnout among educators. The school-based mental health model is a collaborative approach that brings clinical knowledge and services to the child and consultation, training and intervention support to educators.
Success within the collaborative approach
Several well-known school-based support models have been developed across the country through the advocacy efforts of local school systems and community mental health agencies. The Baltimore City Public Schools’ expanded school mental health program provides a framework for the most common design for school mental health programming. Baltimore city schools invited the inclusion of comprehensive mental health services such as individual, family and group therapy, and consultation and assessment services into their building through a partnership with community mental health providers.
Similarly, the Charlotte-Mecklenburg public school system in Charlotte, N.C., partnered with Behavioral Health Centers, a division of the Carolinas HealthCare System. Through this cooperative process, mental health services were provided to 24 public elementary schools.
The Salt Lake City public school system partnered with Valley Mental Health, a behavioral health care provider, to develop a treatment program that is similar to off-site day treatment programs. The program was designed to increase inclusion and support within the school environment for children with serious emotional disturbances. The integration of services within the public school setting reduces the risk of stigma for the child, while providing treatment and effective coping mechanisms in the least restrictive natural environment.
What diagnoses are schools seeing?
In 2011, Kathleen Ries Merikangas and colleagues published statistics on the utilization of services for adolescents with mental health disorders in the United States in the Journal of the American Academy of Child & Adolescent Psychiatry. They found the prevalence of childhood mental health issues in the United States estimated to be as high as 20 percent of all children. For a variety of reasons — financial, environmental, personal and cultural — underserved children were not receiving needed services an alarming 75-80 percent of the time. Considering the disparity between children identified for services and children who actually receive services, providing care in a natural environment such as a school could dramatically increase the number of children who receive therapeutic support.
At the elementary and middle school levels (ages 5-12), Merikangas and colleagues found that among children who received mental health services, 60 percent were diagnosed with attention-deficit/hyperactivity disorder, while one in every eight children experienced some form of anxiety, with the median onset occurring at age 6. Anxiety in young children is often manifested in behaviors such as fidgeting, distraction, poor concentration and irritability. These symptoms mirror those of attention deficit and can be difficult for educators to tease out without further assessment and training.
In 2010, the National Institutes of Health (NIH) reported that anxiety-related disorders are most common at the high school level (ages 13-18). The Centers for Disease Control and Prevention’s 2005 Youth Risk Behavior Survey reported that 6 percent of students missed school due to anxiety related to feeling unsafe either at or on the way to school. The NIH says incidents of depression are also highly prevalent at this age, with eight of every 100 adolescents experiencing symptoms such as a drop in grades, social isolation, diminished interest in activities of previous enjoyment and change in eating or sleeping patterns. According to the National Alliance on Mental Illness, mental health issues during adolescence contribute to more than half of all instances of students dropping out at the high school level. During their high school years, it is critical that adolescents are linked to additional therapeutic support, including external service providers and programs that can increase their sense of self. Teaching educators and administrators about early identification and increasing their knowledge of community resources can be critical to a student’s success in treatment.
During the 2010-2011 school year, outcomes from the school-based program at my agency (N = 359) found the most common diagnoses for children enrolled were posttraumatic stress disorder, major depression (single episode), dysthymic disorder and attention deficit disorder. During the past two years, we have seen dramatic results in reducing anxiety and increasing resilience among children by teaching educators about early warning signs and the identification of hypervigilance versus hyperactivity, as well as providing educators with classroom management techniques.
By working in collaboration with the schools, treatment providers can reach those children and families who may not otherwise feel they have a trusting adult to advocate for them. Parents often view teachers, school counselors or principals as advocates for the best interests of their children and will trust these professionals’ opinion if they say additional supports may be needed. Community clinicians can assist with bridging the gap between the schools and external resources through services such as case management, mentor programs, wraparound services and psychiatric consultation.
Program development: What is needed
A population to serve: The development of a successful program depends on a model that meets the needs of the clients it serves. The school-based mental health program I have been developing for the past three years is located in Butler County, Ohio. Butler County is a mix of urban and rural living outside of Cincinnati; school-age children and adolescents make up 24.7 percent of the population, and the median household income is $53,543. The population our agency serves is Medicaid eligible, and we receive reimbursement through a combination of Medicaid and subsidy dollars from the local mental health board.
Since the development of this program, we have seen tremendous growth. In 2008, our agency supported the need for therapy in six schools. In 2012, our school-based program supported the need for services in almost 40 schools in Butler County. Currently, we serve 300 children in eight public school systems through a delicate marriage of collaboration, community, advocacy and education about mental health services in the school environment. The needs of the clients we serve support a model designed to include therapists, case managers, psychiatrists, trainers and consultants.
I would argue that aligning with the community has increased the trust level for our agency’s services among the families we serve. I also believe our agency’s ability to educate and train educators on the importance of addressing mental health concerns has provided them with new insights concerning what they see in their classrooms each day.
A referral process:
Each school we serve has an identified referral person such as the school counselor or school psychologist. This person has the necessary knowledge of the signs and symptoms needed to support an appropriate referral. Once the referral is made (with consent from the child’s parent or guardian), our centralized intake department meets the parent or guardian and child in the school to complete the diagnostic assessment. The school staff is supportive of our need for a confidential space to assess and treat the children they refer, oftentimes offering staff offices if needed. Therapist caseloads and placements are based on the number of referrals received from each school and can vary from one to five days per week. Once treatment begins, therapists work with individual children in a confidential office space and coordinate with teachers to pull children for therapy only during “specials” (for example, gym, music or art) or nonacademic time. Part of the process includes monthly family therapy sessions in an effort to provide continuity of care across environments. The therapist, case managers and school staff work to assist parents with transportation to the school. We have had principals and school psychologists pick parents up and bring them to appointments if needed.
Program development to meet the needs of the community: Unlike previously established programs, our program continuum provides training and consultation to educators and administrators on identified mental health topics. An annual summer institute designed for educators is geared toward continuing education on intervention strategies, classroom management and psychotropic medications. Additionally, clinicians meet with their school treatment teams monthly to debrief on progress, strengths of the child, changes in behavior and how to carry over successful interventions from the office to the classroom environment. My staff also attends weekly training sessions focused on trauma- and anxiety-related interventions in an effort to clinically address the needs of the students receiving the most frequently occurring diagnoses.
The growth and success of our model is based on the clinical care we provide and the belief that it takes a systemic effort to create lasting change. Clinical progress would not be possible without building a trusting and lasting relationship with the clients and the community we serve, and this has been made easier by the successful collaboration between our schools and community mental health.