Schools As a Vital Component of the Child and Adolescent Mental Health System
Abstract
This review examines the history and contemporary landscape of school mental health, describing evidence that schools are an essential component of the system of child and adolescent care and providing recommendations to advance this vital care delivery system. This literature review of scientific data and shifts to policy and practice in school mental health documents the evolution of collaboration between the education and mental health systems to support student mental health. This review describes best practices and provides examples for achieving the standards of the comprehensive school mental health systems model in states and local communities. Data demonstrate that multitiered systems of mental health support and services in schools, including mental health promotion, prevention, early intervention, and treatment, improve academic and psychosocial functioning and reduce risk of poor outcomes, including mental illness and school failure. Policy and practice shifts in the field reflect a movement toward integrating mental health systems into the education sector, including preparing the education workforce to promote mental health and to support early identification of and intervention to address mental illness. To create a full continuum of mental health supports for students, states and districts can draw on national best practices and state exemplars as they install multitiered systems of mental health supports in all schools, conduct universal student mental health monitoring, and coordinate school and community mental health systems.
HIGHLIGHTS
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With greater access to, adherence to, and participation in school mental health interventions, more children with mental health needs will receive support in schools than in other community mental health settings.
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Comprehensive school mental health systems draw on education and mental health resources and professionals to improve students’ mental health and academic outcomes.
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The establishment of a full system of care for children and adolescents requires states and districts to install multitiered systems of school mental health support, systematic student mental health monitoring, and coordination with other child-serving community systems.
One in five children is adversely impaired by a mental health condition (1). However, less than half of these children will receive treatment (2), and of those who do, most receive fewer than four sessions of care in community mental health settings (3, 4). For youths living in poverty, without insurance, or from racial-ethnic minority groups, access to mental health treatment is even more limited (2, 5). Many of these youths do not receive mental health care; rather, their mental health conditions too often are managed in the juvenile justice system (6).
Editor’s Note: This article is part of a series based on the Technical Assistance Coalition working papers, which were originally written for NASMHPD and funded by SAMHSA. Matthew L. Goldman, M.D., M.S., is series coordinator and has helped curate these papers for publication in Psychiatric Services.
Schools are an optimal setting to identify, manage, and sustain progress for children with mental health problems (7). An ever-growing body of evidence indicates that integrating mental health supports and services directly within the school setting is an effective delivery system for child mental health programming (8, 9). Delivering mental health treatments in schools has substantial benefits, including improved access to care for far more children (7, 10, 11), improved adherence and participation in treatment (12), early problem identification and diminished impacts of mental health conditions (13), decreased stigma among children and their families (14, 15), and positive impacts on academic and psychosocial functioning (16).
School mental health models position an interdisciplinary team of specialists to support children in a natural, inclusive setting. When more intensive services and other important specialty supports (e.g., speech therapy, occupational therapy, behavioral specialists) are needed for mental health challenges, they can often readily be added to the schools’ foundation of universal supports. School is a familiar meeting place for most children, providing a more accessible and comfortable site for students to receive mental health services than hospital or community mental health settings (17). This review examines the history and contemporary landscape of school mental health, providing evidence for schools as an essential component of the child and adolescent system of care and recommendations for advancing this vital care delivery system.
Knowledge and Limitations
Evolution of School Mental Health
Efforts to deliver mental health supports and services in schools originated with significant changes in recent decades within both the education and mental health systems. The education sector formally acknowledged its responsibility to address needs of students with disabilities, including those with serious emotional disturbance, with the passage of the Education for All Handicapped Children Act in 1975, now known as the Individuals With Disabilities Education Act (IDEA). The Substance Abuse and Mental Health Services Administration (SAMHSA) defines serious emotional disturbance as a “diagnosable mental, behavioral, or emotional disorder in children and youth experienced in the past year that resulted in functional impairment that substantially interfered with or limited the child’s or youth’s role or functioning in family, school, or community activities” (18). Some states have adopted terms like “emotional or behavioral disability” because “serious emotional disturbance” has been perceived as stigmatizing (19). Additionally, section 504 of the Rehabilitation Act of 1973 mandates that children with disabilities are entitled to a “free and appropriate education” and that children with a documented “physical or mental impairment that substantially limits one or more major life activities” must receive supports (20). Both policies positioned schools to deliver mental health support and necessary educational accommodations to students with emotional and behavioral disabilities (21).
Simultaneously, the mental health sector saw increased federal funding for community mental health demonstration projects that included children’s services, eventually leading to a mandate for children’s services to be part of community mental health programming. However, insufficient federal and state funding left these mandates largely unfulfilled (22).
It was not until the 1980s, amid growing recognition of the inadequacy of the quality and accessibility of children’s mental health care and overreliance on residential treatment (23), that mental health systems began to reflect child- and family-centered care in the “least restrictive environments.” Investment by the National Institute of Mental Health in the Child and Adolescent Services System Program, now managed by SAMHSA, advanced systems-of-care efforts for child-serving systems, including schools, to become valued partners in addressing the mental health of the nation’s youths. These federally funded grants reflected time-limited (up to 5 years) investments, typically to community mental health authorities but increasingly to state agencies and non–mental health agency recipients, including local and state education agencies. For example, SAMHSA recently solicited 4-year proposals from state governments, territories, tribal organizations, and municipalities (e.g., county, city, town) to expand and sustain comprehensive community mental health services for children with serious emotional disturbance. In contrast to the fragmentation too often characteristic of the child mental health system, systems of care emphasized the shared responsibility of agencies (mental health, education, juvenile justice, child welfare) to coordinate a full array of community-based services for children and their families (24, 25). This shift was a key advancement in the integration of mental health into schools; schools were no longer left to manage student mental health problems alone during school hours, yet they were also no longer able to make student mental health issues the province of the mental health sector. The proliferation of school-based health centers in the 1990s also set the stage for schools to become service delivery venues, demonstrating that primary care services could be offered to students in schools during school hours and that many concerns about students’ well-being were related to mental health (26).
Shifts in delivery systems also recognized that educators were well positioned to identify and address student mental health concerns (27, 28). Almost 2 decades ago, the U.S. Surgeon General identified teachers as “frontline” mental health workers and advocated training for them to help identify and manage child and adolescent mental health difficulties, beyond generally supporting positive social-emotional development for all students (28). Because school staff engage with students 6 hours per day, 5 days per week, for 30 weeks per year, while placing “performance demands” on children daily, they are best positioned to recognize any emerging or persisting struggles among these children. More importantly, school staff are similarly well positioned to work with families to coordinate organized responses to students’ needs, align interventions, and apply strategies in naturalistic situations where they can encourage students to use problem-solving skills while they continue their curricular education. Although teachers are not mental health clinicians, much of the education they provide students relates to the skills to manage stress with healthy alternatives (exercise, music, artistic expression), problem solve, work with staff and students, and manage daily adversities and frustrations. A recent review by the SAMHSA Mental Health Technology Transfer Center Network and the National Center for School Mental Health highlighted the growing pool of resources available to prepare educators to support the mental health needs of students in their classrooms (29).
A strong body of research literature demonstrates that building a continuum of mental health supports directly into schools leads to positive social, emotional, behavioral, and academic outcomes. Mental health promotion efforts for all students, including social-emotional learning (SEL) programs and efforts to elicit positive student behaviors (such as positive behavioral interventions and supports [PBIS]), reveal positive skill development (30–32), reduction in conduct problems and unwanted school outcomes (suspensions, office discipline referrals) (33, 34), and even prevention of student anxiety and depression (35, 36). Similarly, early intervention and treatment in schools can reduce mental illness, including substance use (37–43). Finally, among the most compelling arguments for educators to incorporate mental health supports and services in schools is the mounting evidence of positive impacts on academic indicators, including test scores, attendance, and grades (16).
For several decades, federal health and education administrations in the United States have invested in the integration of mental health supports and services into schools, including support for national, regional, and state technical assistance and policy centers to advance school mental health (21). Despite increases in funding and policy support for school mental health and a steadily growing evidence base for the positive impact of providing mental health supports to students in schools, implementation of beneficial, cost-effective mental health prevention and intervention within schools still lags, for myriad reasons.
Persistent Obstacles
Several challenges impede the integration of mental health supports and services into schools. First, schools are driven by competing and frequently changing priorities, often not informed by data. Despite evidence that school mental health positively influences students’ academic and psychosocial functioning, competing interests sometimes make it difficult to sustain resources and momentum for school mental health (44).
Second, education and mental health systems have operated largely in separate silos, in part because of youth and family concerns about seeking mental health care in school. Families are often cautious about seeking help for their children’s mental health concerns because of stigma, and stigmatizing attitudes toward mental illness make acquiring support even more challenging (45, 46). The impact of self-stigma and societal stigma toward mental illness varies by culture, with some racial-ethnic communities less likely to seek help (46). Furthermore, mental illness has historically been inappropriately and inequitably used to exclude students from regular learning environments, contributing to legitimate apprehensions about seeking mental health support in school (47).
Third, mental health systems do not easily navigate delivery systems (and reimbursement for services) within schools, often hindered by reimbursement models that do not recognize schools as sites of health or mental health service for children (even though schools are the places most frequented by children) (48). In addition, the density of services in schools and the availability of specialty child mental health services vary widely among communities, making a one-size-fits-all approach unrealistic and making task shifting more necessary in communities with fewer financial resources.
Finally, the impetus for school mental health too often arises in the wake of catastrophes, most recently incidents of mass violence, with an urgency to make schools safe. In these circumstances, bursts of interest in school mental health often give way to the subsequent concern du jour, and investments are typically not well organized or sustained, often collapsing when grant funding provided in response to the specific catastrophe depletes (49). School mental health investments resulting from incidents of violence also present complexity for the mental health advocacy community; although funding and attention to school mental health may be welcomed, tying mental illness to violence can further entrench stigma (50). For all these reasons, schools and mental health systems have struggled to consistently develop and sustain adequate supportive and ancillary services (e.g., teacher consultation or student team meetings) essential to high-quality care in schools.
Best Practices
Evidence shows that schools enhance both access to and quality of mental health supports and services for students, while our current community mental health system is limited to supporting predominantly those young people most in need of care. Research demonstrating the link between well-being and academic achievement is motivating for education leaders seeking to improve students’ school performance (51). Hence, the education sector is primed to integrate mental health services, both as a part of the sector’s overall mission to produce healthy and productive citizens and in its effort to optimize student academic performance.
Comprehensive School Mental Health Systems
National school mental health performance standards in the United States emphasize a model of comprehensive school mental health systems (CSMHSs) (52). These systems provide a full array of tiered services, including universal mental health promotion activities for all students, early intervention services for some students with mild impairment or who are at risk for mental health concerns, and treatment for students with severe impairment (Box 1). CSMHSs rely on collaborative partnerships between school systems and community partners such that mental health supports offered by school-employed mental health professionals (e.g., school psychologists, school social workers, school counselors) are meaningfully augmented by community mental health providers (e.g., community mental health centers, hospitals, and universities). Recent efforts by federal partners, namely the Health Resources and Services Administration and SAMHSA, in partnership with national, state, and local leaders, have led to guidance from the field on the core components and strategies needed to actualize CSMHSs (48).
BOX 1. Core features of comprehensive school mental health systemsa
A full complement of school and district professionals, including specialized instructional support personnel, who are trained to support the mental health needs of students in the school setting
Collaboration and teaming among students, families, schools, community partners, policy makers, funders, and providers to address the academic, social, emotional, and behavioral needs of all students and the predictable problems of practice across systems and roles
A thorough and continuous needs assessment of school and student needs and strengths, coupled with resource mapping of school and community assets, to inform decision making about needed supports and services
A full array of tiered, evidence-based processes, policies, and practices that promotes mental health and reduces the prevalence and severity of mental illness
Use of screening and referral as a strategy for early identification and treatment
Use of evidence-based and emerging best practices to ensure quality in the services and supports provided to students
Use of data to monitor student needs and progress, assess quality of implementation, and evaluate the effectiveness of supports and services
Diverse and leveraged funding and continuous monitoring of new funding opportunities from national/federal, state, and local sources to support a sustainable comprehensive school mental health system
a Reprinted with permission by Hoover et al. (48) and the National Center for School Mental Health at the University of Maryland School of Medicine.
CSMHSs rely on a public health framework that strives to intervene early before problems worsen, often referred to in the education sector as a multitiered system of supports (MTSS). The MTSS has been well articulated and studied in the research on PBIS, the most widely adopted MTSS framework for supporting positive behaviors and, increasingly, mental health (33, 34, 53, 54). Aligned with tiered academic support models, MTSSs for mental health most often use a three-tiered model (see figure in online supplement ) with universal screening and progress monitoring to support early identification and intervention. Across tiers, several core functions are essential, including effective district and school teaming, data-driven decision making, and systems for installing and refining evidence-based practices (54). Interdisciplinary district and school teams composed of school and community partners gather and use data to inform mental health needs and resources and to seamlessly triage students to appropriate evidence-based and aligned supports and services across the MTSS continuum. The School Mental Health Quality Assessment (52), available at no cost on the School Health Assessment and Performance Evaluation (SHAPE) System platform (www.theshapesystem.com), articulates best practices in each domain of school mental health quality (teaming, needs assessment and resource mapping, screening, universal mental health promotion, early intervention and treatment, funding, impact). The tool offers a mechanism for individuals and school, district, and state teams to assess their school mental health infrastructure and implementation quality.
Tier 1: Universal mental health promotion and prevention for all students.
Universal services and supports (tier 1) are mental health–related activities, including promotion of wellness and positive social, emotional, and behavioral skills designed to meet the needs of all students regardless of whether they are at risk for mental health problems. These activities can be implemented schoolwide at the grade level, the classroom level, or both. One of the most well-researched and recognized examples of universal mental health is the Good Behavior Game. Over 60 studies have reviewed the Good Behavior Game, a 20-minute daily classroom activity to encourage students to work well in teams, sustain focus, etc. This universal intervention benefits student behavior and promotes achievement during the school year (55), and the positive outcomes persist into adulthood with lasting effects on young adult behaviors, including lower rates of substance use disorders, delinquency and incarceration, and suicidal ideation (56).
Multiple universal mental health promotion and prevention programs involve the promotion of social and emotional competence among all students, teaching core positive behaviors and relationship skills and mental health literacy. A solid evidence base exists to support the impact of school-based primary prevention (for a review of model programs, see http://www.CASEL.org). Students engaged in SEL programming demonstrate a significant increase in standardized academic test scores compared with their peers not engaged in SEL training (30). Additionally, educators trained to implement SEL curricula report lower depression and job-related anxiety (57), higher-quality interactions with students (58, 59), and greater perceived job control than (60) those not trained in SEL.
The importance of these outcomes for the school years and beyond has led 25 states to adopt learning goals that articulate guidelines for students’ social and emotional knowledge and abilities, up from only four states in 2015 (http://www.CASEL.org). Meta-analyses indicate that students participating in school SEL programs show significantly greater social-emotional skills, positive self-image, and prosocial behaviors, and significantly fewer conduct problems, less emotional distress, and fewer substance use problems than their peers not exposed to SEL training programs (30, 31).
Tier 2: Selective mental health services for students at risk for impairing mental health conditions.
Mental health early intervention (tier 2) services and supports, sometimes referred to as mental health prevention or secondary prevention services, are strategies designed to address mental health concerns for students experiencing mild distress or functional impairment or those at risk for a given problem or concern. Tier 2 interventions include small-group therapies for students identified as having similar needs, brief individualized counseling or coaching (e.g., motivational interviewing and problem solving), mentoring, and/or low-intensity classroom-based supports (e.g., a daily teacher check-in, and/or daily or weekly notes sent between families and teachers or school mental health clinicians).
School-based prevention and early intervention efforts have been effective in addressing risk factors associated with youth mental health problems, including conduct problems and substance misuse. For example, the Coping Power Program has demonstrated success in decreasing aggressive behavior, drug misuse, and delinquency among students identified as being at risk for developing such concerns (61). Evidence is also mounting for selective school-based approaches to support specific populations at greater risk of developing mental health concerns or of not engaging in mental health services, including refugee students, those from low-income urban settings (62, 63), and youths from racial-ethnic minority groups (64).
Tier 3: Onsite mental health treatment for students impeded by mental health conditions.
Indicated services and supports to address mental health concerns (tier 3) are individualized to meet the unique needs of each student who is already displaying a concern or problem and is displaying significant functional impairment. Sometimes these supports are referred to as “mental health interventions,” “tertiary services,” or “intensive services.”
Much effort is spent on tier 3 services within the child mental health system of care. Young people with the most complex and intensive needs require the most system resources to produce the greatest effects on their quality of life and that of their families. School mental health is not a substitute for intensive mental health care that may be necessary for youths with significant mental illness. However, adequate resourcing of a full continuum of mental health supports in schools may reduce the need for increasing expenditures on such intensive services.
Treatment interventions delivered in schools effectively reduce the impacts of mental illness. School-based interventions have demonstrated improvements in students’ anxiety and depression (28, 37, 65, 66), and treatments for child and adolescent posttraumatic stress delivered in schools have shown decreases in traumatic stress, anxiety, and depressive symptoms (37, 38). Tier 3 services in schools have also been effective in treating behavior disorders (33, 34) and substance use problems (42, 43). Although comparable in effectiveness to community-based treatments, school-based treatments are likely to reach more youths because of greater accessibility and higher attendance (12).
Universal mental health screening and monitoring for all students.
An effective MTSS for mental health relies on systematic and early identification of mental health concerns through screening and active progress monitoring. Reducing the incidence of mental illness through screening and early intervention not only improves quality of life for those starting to experience mental health impairments but also more effectively reduces the fiscal burden of mental health conditions (67, 68).
In some districts, screening has been reconceptualized as ongoing mental health monitoring, where identification of mental health problems moves beyond one-time screenings to continuous monitoring of students’ social, emotional, behavioral, and academic functioning (69). Multiple assessments of student mental health may best be administered in the context of curricular mental health literacy (i.e., what positive mental health is, how to recognize psychological distress and disorders, and how to seek help for self and others [70]). Multiple states (e.g., New York, Virginia) have recently mandated the inclusion of mental health literacy in their school curriculum. For example, the New York curriculum includes four key mental health literacy components (71): understanding how to obtain and maintain good mental health, decreasing stigma related to mental health, enhancing help-seeking efficacy (knowing when, where, and how to obtain mental health skills to promote self-care), and understanding mental disorders and treatments. Students may engage in frequent “well-being check-ups” to identify concerns. This model is being implemented in the Los Angeles Unified School District, where parents are asked to provide active consent for their children to engage in a social-emotional curriculum that includes well-being check-ups. Given evidence that mental health training for teachers improves their knowledge and attitudes (72), teachers may benefit from training on how to continuously monitor student mental health. This approach includes skills training on approaching and referring students for supports as well as training about cultural and linguistic factors and expressions of mental health and illness.
Some have argued for screening to shift from focusing solely on psychopathology to instead focus on a “dual-continua” model of mental health (73, 74). Sometimes referred to as “complete mental health,” this model assesses for positive affective experiences and life satisfaction in addition to symptoms of psychological distress. Until now, school-based screening has been incomplete, focusing almost exclusively on risk factors or symptoms of mental distress (75–77). Students with higher levels of strengths and lower levels of distress report better quality of life, better academic performance, and higher life satisfaction. Moreover, students with complete mental health (i.e., have high social well-being and low psychopathology) report better life outcomes than do vulnerable students (i.e., have low social well-being despite low psychopathology) (73). Students who report low life satisfaction also report the lowest sense of school belonging compared with their peers, regardless of psychological distress level (78). Student subjective well-being serves as a predictor for multiple problem behaviors, including antisocial behaviors, substance use, suicidal tendencies, bad nutritional habits, and dropping out of school (79). Instruments that have recently been devised to assess the dual-continua approach (e.g., the Behavioral and Emotional Screening System and the Social-Emotional Health Survey) enable schools to triage students by assessing both their mental health risk symptoms and their strengths (80, 81).
Significant implementation planning is required for any student mental health monitoring, including specifying how parents and families will participate in the process (e.g., prioritizing what to assess at different student ages, providing a description of monitoring to students and parents, and defining how the school and community providers will respond to positive or concerning findings); how to support students who frequently move between schools or are chronically absent; what instruments to use; how to configure appropriate and timely follow-up; and the role of new technologies and secure data systems to support repeated, longitudinal measurement. Table 1 describes frequent concerns about school mental health screening and monitoring (e.g., mental health being a family/personal concern, measurement error, inadequate staffing and resources, stigma) as well as strategies to address these challenges (e.g., messaging about the link between mental health and academic success, psychometrically sound measurement, cost-benefit considerations, mental health literacy to reduce stigma).
| Concern | Strategy |
|---|---|
| Mental health is a family or personal concern, not a school concern | Communicate that mental health affects academic success, that school staff are often trusted partners familiar with the student and family over time, and that student and family input shape implementation. |
| Measurement error (e.g., false positives) | Use psychometrically sound measures to identify problems early, a multigated procedure to produce more accurate findings, and continuous monitoring (instead of one-and-done screening); measure impact on functioning beyond symptomatology. |
| Inadequate staffing and resources | Start small (limit number of students screened, scope of screening target); leverage school and community resources and staffing; use no-cost/low-cost tools; perform cost-benefit analysis of early identification/intervention. |
| Disagreement among collateral reporters | Collect information from multiple reporters and resolve discrepancies. |
| Privacy of information and data | Develop a consent/assent process that allows students and families to easily opt in or out; address concerns about data privacy (e.g., HIPAA and Family Educational Rights and Privacy Act regulations). |
| Stigma of mental illness and labeling | Use mental health literacy for students, families, and school staff to decrease stigma and promote help-seeking; address student and family concerns about how findings will be used; assess student strengths and assets to avoid pathologizing and negative impacts of labeling. |
A recent quality guide on school mental health screening published by the National Center for School Mental Health reviewed best practices for the screening implementation process (82). Beyond choosing psychometrically sound and feasible measures, the quality guide emphasizes the importance of consent and assent procedures, describing options for both active and passive (or “opt-out”) parental consent. Family engagement can be facilitated by sharing screening information in multiple formats, including automated phone calls to all families, information on the school website, written notification, and signage in the school building. Prior to screening, a triage system should be in place that includes guidelines for referring students to in-school or community services depending on identified need and timelines for addressing needs based on level of severity (with protocols for responding to urgent or emergency needs).
Policy Implications
To fully include schools as a vital component of our system of care for children and adolescents, federal and state education and mental health leadership must collaborate to support local establishment of an MTSS. To that end, several policy considerations are described that connect the evidence about best practices in school mental health to policy levers that support three primary goals: universal mental health promotion in schools; early identification, intervention, and treatment in schools; and coordination between school and community mental health systems and other child-serving systems.
Universal Mental Health Promotion in Schools
Screening for and addressing developing or existing conditions is not adequate to support the well-being or academic success of children and adolescents. Rather, federal and state policy can support schools in promoting healthy mental development of all students. Support for universal mental health promotion in schools could include several policy actions.
Require the selection of indicators of student mental health and well-being.
Indicators of student mental health and well-being could be required as a core metric of school performance under federal education funding, with provisions to assist schools as they strive to perform well on these indicators. Indicators may include school climate, student-reported subjective well-being and distress, and reports of school connectedness.
Incentivize teaching education programs to include mental health literacy.
This approach may improve the capacity of the educator workforce to promote mental health of all students in the classroom, including by teaching SEL competencies; identify mental health concerns and link students to needed supports and services; reduce stigma related to mental illness; and promote student and family help-seeking.
Establish mental health as a state-required component of K–12 curricula.
The federal government could support this state-level effort by passing a resolution encouraging states to follow existing state efforts in New York and Virginia to integrate mental health into curricula and by providing direct funding for educator training and ongoing professional development.
Leverage federal Title I and Title IV funding to provide universal mental health programming, including SEL, for students.
Joint guidance by the U.S. Department of Education and the U.S. Department of Health and Human Services (HHS) could support states as they navigate these funding mechanisms to support universal mental health in schools.
Expand federal grants to state and local education and behavioral health authorities to increase mental health awareness and promotion in schools.
This step could include the expansion of grant programs initiated in recent years by SAMHSA (e.g., Project AWARE [Advancing Wellness and Resiliency in Education]) and the U.S. Department of Education (e.g., School Climate Transformation Grant) that require funded states to partner with three local jurisdictions to promote student well-being and mental health training and awareness for school staff and the subsequent scaling of successful efforts statewide.
Early Identification, Intervention, and Treatment in Schools
The purpose of advancing school mental health as a vital component of the children’s mental health system is not to discourage community mental health treatment for children; rather, children’s mental health concerns are simply much more likely to be recognized and addressed in school settings than in the community. Compared with other community mental health settings, schools can much more easily promote mental health, monitor ongoing progress, and provide interventions for specific issues impeding a child’s progress, all while minimizing logistical barriers (9–12).
CSMHSs are built on a foundation of school and district professionals, including specialized instructional support personnel, who are well trained to support the mental health needs of students in the school setting (48). This foundation includes adequate staffing and training of school psychologists, school social workers, school counselors, school nurses, and other school health providers. To leverage the resources and expertise of both school and community professionals, MTSSs also rely on partnerships with community mental health providers. Optimally, these partnerships should be aligned with common goals, usually academic success and improved interpersonal functioning and classroom behavior. Community partners can augment services within the school building, support mental health with administrators and staff, and link students to other services and supports in the community. In many schools, community partners are integrated across all tiers of support but are primarily involved in more intensive treatment supports for youths with identified mental health challenges (48). Several policy actions could help achieve early identification, intervention, and treatment in schools.
Expand existing federal workforce development programs.
Existing federal workforce development programs (e.g., Behavioral Health Workforce Education and Training Program, National Health Service Corps, Minority Fellowship Program) may be expanded to increase the school mental health workforce. This strategy also can be applied to federal loan repayment programs by increasing incentives for providers who choose schools as a service setting.
Expand federal, state, and local funding for student instructional support personnel.
Funding could be expanded to ensure adequate staffing and professional development for student instructional support personnel, including school psychologists, school social workers, school counselors, and school nurses. Funding expansion could include increased investments in Title I of the Every Student Succeeds Act (ESSA) to provide additional mental health staffing for students living in poverty and in Title I, Title II, and Title IV of ESSA and IDEA to increase opportunities for professional development. State and local investments could include competitive salary and benefits packages to recruit and retain school mental health providers and supplemental federal funding for staffing and professional development.
Require health plans to reimburse for mental health screenings conducted in schools.
Counter to guidance from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry to cover universal mental health screening as a mechanism for improving mental health and reducing mental illness, many health plans do not reimburse for mental health screening. Coverage should include screening not only conducted during well-child exams in pediatric primary care but also extended to schools.
Maximize reimbursement for school mental health services.
Medicaid, Children’s Health Insurance Program (CHIP), and private reimbursement could be maximized for school mental health services, including early identification, intervention, and treatment. This step may involve better understanding and leveraging of existing state Medicaid allowances for school mental health or the initiation of state plan amendments to improve school mental health coverage. As outlined in the 2019 Joint Informational Bulletin from the Centers for Medicare and Medicaid Services (CMS) and SAMHSA (83), several states already access Medicaid and other payers, including private insurers, to cover school and community professionals’ delivery of mental health services in schools. CMS, the U.S. Department of Education, and HHS could offer technical assistance to states seeking to improve Medicaid and other payer coverage of school mental health.
Expand reimbursement and technical assistance for telepsychiatry services in schools.
Given the current national shortage of mental health specialists, particularly in rural settings, schools will benefit from access to telepsychiatry consultation and direct service, facilitated by public and private insurance coverage and federal- and state-supported technical assistance.
Require evidence-based practices that align with national performance standards for school mental health.
Accountability mechanisms could be adopted that require the implementation of high-quality evidence-based practices that align with national performance standards for school mental health. Federal, state, and local investments should shift their metrics away from counting frequency and duration of services to measuring the implementation of national best practices for school mental health care and the impact of school mental health services provision on psychosocial and academic outcomes.
Coordination of School and Community Mental Health Systems and Other Child-Serving Systems
Schools alone cannot bear the burden of children’s mental health, and community mental health retains an important role in supporting child and adolescent mental health. Students with complex and intensive mental illness and those whose families prefer accessing services outside of the education sector may still benefit from alternative options provided through community mental health. Students who show behaviors that threaten their own safety or the safety of others in the school environment may benefit from crisis or short-term (e.g., partial-day) services and may at some points require a nonschool setting, at least until their behaviors resolve.
Our historical approach of isolating mental health care within a community mental health center, disconnected from students’ educational experiences, does not reflect a “whole child approach” that coordinates all child-serving systems in working toward mutual goals. When students’ educational needs are not addressed while in more intensive psychiatric care in the community, they are more likely to struggle when they return to school and then be readmitted to inpatient care (84). Too many children with mental health challenges are still managed initially and primarily in the juvenile justice or child welfare systems, a circumstance that calls for coordination across all child sectors, not just education and mental health (24).
These different children’s services must be aligned to optimize identification and coordination of care, particularly in early recognition of psychiatric symptoms and using all available locations to cultivate strengths to diminish the impacts of those symptoms. The preference to return children to the least restrictive settings to widen social, career, and academic opportunities suggests that schools should be involved whenever a child is being served by other systems, including juvenile justice, child welfare, and intensive psychiatric care. Community mental health remains the hub of mental health delivery for adults, and therefore, strategic planning must account for the transition of students receiving school mental health supports once they graduate and are likely to move to community-based supports. Ultimately, coordination is best achieved when all systems are actively engaged in a process of defining roles and responsibilities and of aligning supports and services to promote efficiencies and high-quality care and to avoid redundancy. The following policy actions could promote seamless coordination.
Establish centralized state organizational infrastructures.
States may establish centralized organizational infrastructures comprising state public agencies (including education, behavioral health, child welfare, juvenile justice) and youth and family advocacy and leadership organizations. These associations would be responsible for advancing a shared school mental health vision and priorities that can inspire and inform local action. Several states (e.g., Massachusetts, Minnesota, Pennsylvania) have established these entities in the form of children’s cabinets, communities of practice, and state consortia. These state entities can offer guidance and technical assistance to local agencies on the establishment of seamless and coordinated care systems, including guidance on developing memoranda of understanding between child-serving agencies and delineating roles, responsibilities, and financing to support school mental health.
Implement Medicaid waivers or state plan amendments that align Medicaid, early intervention, and individual education program services.
These measures could be implemented to create coordinated systems of mental health care. The federal government can support this action by offering planning grants and learning collaboratives for states to facilitate shared learning, efficiency, and innovation.
Provide federal grants to state and local child-service agencies that require cross-agency coordination and investment in school mental health.
Grants from the Safe Schools/Healthy Students Initiative, originally jointly administered by three federal agencies, required this type of cross-agency commitment and produced several state and local exemplars of shared leadership and braided or blended funding to support school mental health. At minimum, strategic planning and funding should include a partnership among education, behavioral and mental health, child welfare, and juvenile justice.
Offer federal and state guidance and funding to support navigating privacy and data sharing across child-serving systems.
This support could include federal and state guidance on navigating the HIPAA–Family Educational Rights and Privacy Act and investments in health information technologies designed to integrate data systems between education and behavioral health.
State and Provincial Examples of Advancing School Mental Health
There are many examples across the United States and internationally of how to move toward comprehensive school mental health. Table 2 provides some exemplars to illustrate the diverse strategies being employed to develop and sustain effective integration of mental health into education systems. These range from locally driven statewide learning communities to innovative statewide funding strategies and may be generalized to other communities seeking to advance school mental health.
| State/province | Innovation | Details |
|---|---|---|
| Maryland | Building school mental health infrastructure, training, and implementation support into state school safety budget | Passage of the 2018 Safe to Learn Act included mandates and funding to provide support within all local school districts; appointment of mental health services coordinators to develop plans and maximize funds for mental health and wraparound services and to ensure students referred for mental services receive care; grants from Safe Schools Fund may be used to develop plans and provider training to deliver school mental health services (https://www.safeschoolsmd.org) |
| Massachusetts | Locally driven statewide school mental health consortium to enhance shared learning and networking across districts | Initiated by director of school counseling in one local district; relied on a community-of-practice framework to develop a rapidly evolving network of local school districts, all interested in joining a community focused on improving school mental health quality; member districts voluntarily participate on the basis of their recognition of the growing mental health and substance use needs of students; promotes shared learning, collaboration, and consultation between districts; gained support from state education and behavioral health agency leadership (http://www.methuen.k12.ma.us/departments/special-education/guidance/massachusetts-school-mental-health-consortium-masmhc) |
| Minnesota | Using local school mental health impact data to compel state government and Medicaid leaders to fund statewide school mental health | Local district demonstrated success of community-partnered school mental health efforts through systematic data collection and dissemination; local success led state legislature to fund state infrastructure grants that now support school-linked mental health services throughout state; partnered with state Medicaid leadership to amend Medicaid state plan to provide reimbursement for ancillary mental health supports in school (e.g., teacher consultation, school team meetings); starting in 2018, $4.9 million in school innovation grants awarded to 5 districts over 2 years to improve student mental health, including returning students to home school district and reversing disproportionate impact on students from racial-ethnic minority groups |
| Ontario | Implementation-support team funded by Ministry of Education to support mental health in provincial schools | Provincial implementation support team designed to support all Ontario school boards (districts) to promote student mental health and well-being using evidence-based approaches; infused implementation science into local school mental health efforts via mental health leadership team, offering direct support to local boards through ongoing coaching and resources; supports scaling up of evidence-based, multitiered mental health supports and services via ACQESS (alignment, consistency, quality, engagement, scalability, and sustainability) framework (https://smho-smso.ca/) |
| Wisconsin | Leveraging federal funding to establish state school mental health framework | Three large-scale grants awarded in 2014: Safe Schools/Healthy Students, Project AWARE (Advancing Wellness and Resiliency in Education), and School Climate Transformation; adoption of state school mental health framework; establishment of state and community management teams to carry out efforts; braided funding from teams to engage >100 schools in professional development, technical assistance, and coaching (https://dpi.wi.gov/sspw/mental-health; www.schoolmentalhealthwisconsin.org) |
Ultimately, CSMHSs will best succeed when political and societal will is matched by a level of resource allocation that supports a sustainable delivery system. Federal funding streams to expand school mental health efforts are helpful to seed state and local efforts but are unreliable in sustaining programs on their own. Although Medicaid reimbursement remains a critical source of funding for school mental health systems, state budgets (which vary widely) represent the largest share of funding for school mental health programming. To achieve a fully resourced system of care for children, state leadership from all child-serving sectors must commit to engaging the education system as a partner, including by identifying funding to support a full continuum of school mental health supports and services in seamless coordination with community mental health providers.
Conclusions
Young people spend approximately 15,000 hours in schools by age 18, so schools are, de facto, a significant partner to the mental health system, invested daily in cultivating each child’s social-emotional health and skills for coping with stress and adversity. Schools are a vital component of the mental health system for ensuring that all youths in the United States have access to a comprehensive array of mental health supports and for remedying many of the limitations of existing mental health systems that are not truly accessible for too many students. Federal, state, and local investments in school mental health acknowledge this potential, with MTSSs now a regular part of the dialogue among educators.
A systematic and streamlined partnership between schools and communities to support a full continuum of mental health supports in schools can lead to better mental health for all students as well as increased access to mental health care, earlier identification and intervention, and ultimately, better outcomes for students with mental health challenges. This approach embraces natural supports for students, includes families and educators as team partners for children, and demands less from a mental health system with a limited children’s mental health workforce and limited resources.
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Received: 25 November 2019
Revision received: 29 March 2020
Revision received: 13 May 2020
Revision received: 27 June 2020
Accepted: 4 July 2020
Published online: 3 November 2020
Published in print: January 01, 2021
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The authors report no financial relationships with commercial interests.
Funding Information
Center for Mental Health Services/Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services through the National Association of State Mental Health Program Directors.:
This work was supported by the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services. Development of this work was partially supported by a contract from SAMHSA to the National Association of State Mental Health Program Directors.Metrics & Citations
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