Show Summary Details
Page of

The Roles and Perspectives of School Mental Health Professionals in Promoting Adolescent Mental Health 

The Roles and Perspectives of School Mental Health Professionals in Promoting Adolescent Mental Health
Chapter:
The Roles and Perspectives of School Mental Health Professionals in Promoting Adolescent Mental Health
Author(s):

Daniel Romer

, and Mary McIntosh

DOI:
10.1093/9780195173642.003.0032
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2016. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy and Legal Notice).

date: 14 December 2018

This chapter presents research conducted as part of the Sunnylands Adolescent Mental Health Initiative to gain a greater understanding of the roles and prespectives of school mental health professionals in identifying, treating and preventing mental health problems in adolescents. The Surgeon General's report on the mental health of children (U.S. Department of Health and Human Services, 2000) estimated that 1 in 10 adolescents in the United States struggles with a mental health disorder that is severe enough to cause significant impairment. Because over 90% of adolescents under age 18 attend schools in the United States (U.S. Census, 2002), there is a unique opportunity to promote the mental health of youth in this setting, a role that has long been recognized by the public and mental health community (Allinsmith & Goethals, 1962; Starr, 1982).

The failure to treat adolescents suffering from mental conditions has severe consequences. Adolescents with mental disorders are at increased risk for poor academic achievement as well as continued mental disability (Puig-Antich, Kaufman, & Ryan, 1993; Randall, Henggeler, & Pickrel, 1999; Willcutt & Pennington, 2000). Many youth who suffer from mental disorders also end up in the juvenile justice system (Bilchik, 1998), an outcome that could be prevented if they were treated while still in school (American Psychiatric Association, 2004). Unfortunately, less than half of adolescents with significant mental health conditions are seen by a mental health professional in an average year (Costello, Angold, & Burns, 1996; Leaf et al., 1996; Sturm, Ringel, & Andreyeva, 2003). Therefore, increased efforts to identify and treat youth in need of services are a high priority.

The President's New Freedom Commission on Mental Health (2003) called for a transformation of the nation's mental health system and emphasized the importance of schools in this endeavor. In line with this agenda, this research was designed to learn what schools are doing to promote the mental health of adolescents and where future efforts should be directed to improve the delivery of services. To accomplish these goals, we interviewed professionals who are responsible for the mental health of adolescents in public schools to determine the programs they have in place, how well they think those programs are performing, and what changes they would make to improve their performance.

Previous research on the availability of mental health services in schools has found wide variation across states, regions of the country, and urban vs. rural locations (Brener, Martindale, & Weist, 2001; Slade, 2003). The largest of these surveys was conducted by the Centers for Disease Control and Prevention in 2000 (Brener et al., 2003). Another important source is the Add Health Study of school administrators conducted in 1994 (Slade, 2003). These studies indicate that only about half of all high schools have formal mental health counseling services on site. According to the President's New Freedom Commission, one of the biggest obstacles to receiving care for mental illness, especially for children, is the fragmentation of the mental health service delivery system. One way to integrate the system, according to the Commission, is to “rethink how state and Federal funding streams can be more efficiently partnered and utilized by school systems to deliver these services.”

Two major programs to improve access to health services in schools have shown growth in recent years: school-based health centers (SBHCs) and student assistance programs (SAPs). According to a recent survey (Center for Health and Health Care in Schools, 2003), over 1,500 SBHCs in at least 43 states frequently treat mental health conditions (Anglin, Naylor, & Kaplan, 1996; American Academy of Pediatrics, 2001). Student assistance programs, which were inspired by the employee assistance programs for workplaces, have also grown with over 60% of schools now offering such services (Brener et al., 2001). A third approach that overlaps with SAPs is the referral of students with mental health conditions to providers at other sites in the community. About half of all schools adopt the third approach for mental health care (Brener et al., 2001).

In addition to formal programs, most schools have at least one professional on staff on at least a part-time basis who is responsible for mental health programming. The three most common professionals, guidance counselors, school psy chologists, and school social workers, tend to have a masters degree in their discipline (Brener et al., 2001). Guidance counselors are present in over three-quarters of schools and have a wide range of responsibilities, including assisting students who are experiencing problems in coping with school (American School Counselors Association, 2004). Approximately two-thirds of schools have a part-time or full-time psychologist whose major responsibilities involve the assessment of cognitive, behavioral, and emotional conditions that may affect school performance (National Association of School Psychologists, 2004). About 40% of schools have a part-time or full-time social worker who serves as a liaison with parents and coordinates care with outside agencies (National Association of Social Workers,2004).

Despite considerable information about the presence of mental health services in schools, the quality of these services is largely unknown (Rones & Hoagwood, 2000). Research trials of model school-based programs indicate that many are effective (Armbruster & Lichtman, 1999; Rones & Hoagwood, 2000), but actual school programs are more difficult to assess. In this research, we took a step toward assessing quality by asking school professionals to evaluate the overall effectiveness of their mental health programs. We then used these evaluations to assess the contribution of various components to overall success.

We also were interested to learn about the potential roles that school mental health professionals can play to promote the mental health of adolescents. One approach already noted is to create school-based mental health services in schools that can diagnose and treat adolescents on site. Although this strategy has the ability to increase access to effective services for many adolescents (American Academy of Pediatrics, 2001; Armbrister & Lichtman, 1999), it is one that will be difficult to implement on a wide scale in the near term. In another, school professionals refer students for diagnosis and treatment off site by mental health specialists, much as expert panels recommend to primary care providers (Jellinek, Patel, & Froehle, 2002; Melnyk, Brown, Jones, Kreipe, & Novak, 2003).

In a third approach, school mental health professionals design programs for schools to prevent the onset of mental health problems and at the same time identify symptoms so that students can be referred to mental health specialists for care. This public-health approach may have the ability to use the skills of school mental health professionals to their best advantage while also benefiting all students (Adelman & Taylor, 1998; 2000; Atkins, Graczyk, Frazier, & Abdul-Adif, 2003; Hoagwood & Johnson, 2003; Strein, Hoagwood, & Cohn, 2003; Weist, 2003; Weist & Christodulu, 2000).

In evaluating different strategies for school programming, we were also interested in examining potential obstacles to quality mental health care, including limitations in access due to inadequate or no insurance coverage and to inadequate resources in low-income schools. We also asked school professionals to identify solutions to inadequacies in mental health services in schools.

To accomplish these many objectives, the Annenberg Public Policy Center, with funding from the Sunnylands Adolescent Mental Health Initiative, commissioned Princeton Survey Research Associates International to conduct a nationwide survey of over 1,400 school mental health professionals. Interviews were conducted between April and May of 2004. A complete description of the survey methodology is contained in Appendix 31.1.

SURVEY METHODOLOGY

A sample of 2,000 public schools was drawn from the Common Core of Data Public Elementary/Secondary School Universe 2002–2003, a database of virtually all public elementary and secondary schools in the United States that is produced annually by the National Center for Education Statistics (NCES). The sample was selected to represent all schools that have at least 100 students and have classes in at least one middle or high school grade. This sample frame represents more than 90% of all adolescent students in the United States. The database is compiled from the administrative records provided by state education agencies.

The sample was drawn by taking into account the percentage of students enrolled nationwide defined by four parameters—region, urbanity, level, and school size. To illustrate, we determined from the NCES database that approximately 18 percent of the nation's middle and high school students attend schools in the Northeast. Hence, the sample design aimed for 18 percent of the complete interviews to occur among mental health professionals who work in schools that are located in the northeastern United States.

As seen in Table 31.1, the resulting sample of mental health professionals closely resembled the student population with the exception of school size. To correct for the slight underrepresentation of mental health professionals working in very large schools, the sample was weighted to more accurately reflect the NCES database. A small proportion of schools (11%) contained seventh-grade students or higher that were either in primary or other types of schools. These schools were included because they also contained adolescents, even though they could not be classified as either middle or high schools.

Table 31.1 Sample Composition (N = 1402)

Schools in Unweighted Sample

(N)

Students Nationwide

(%)

Schools in Unweighted Sample

(%)

Schools in Weighted Sample

(%)

Region

Northeast

231

18

17

16

Midwest

356

24

25

25

South

490

36

35

35

West

325

22

23

24

Urbanity

Urban

317

24

23

23

Suburban

636

46

45

45

Rural

279

18

20

19

Missing

170

12

12

12

School Level

Primary and other

162

13

12

11

Middle school

515

36

37

36

High school

725

51

52

53

Size of School

Less than 500

217

16

16

15

500–1000

518

35

37

35

1001–1500

395

22

28

22

More than 1500

272

27

19

27

In each of the sampled schools, we asked to speak to the school psychologist, counselor, social worker, or other school professional who was most knowledgeable about the mental health services offered in the school. The resulting distribution of professionals by title is shown in Table 31.2. In schools where more than one staff member met the criterion, one professional was randomly selected for the interview. Only one professional from each sampled school was eligible to participate. Professionals working in more than one school were asked to respond to the survey questions in reference to the school in which they were contacted. Most of the professionals interviewed were women who worked full time, were younger than age 50, and had a master's degree in their discipline. Over 40% of the respondents had worked in their school for more than 10 years.

Table 31.2 Sampled Professionals by Title and Demographic Characteristics (N = 1402)

Characteristic

Title

Sample (%)

Female (%)

Masters Degree (%)

Under Age 50 (%)

Current Position 10 Years (%)

School or guidance counselor

49.1

72.0

95.1

54.9

49.9

Psychologist

25.7

63.6

80.0

63.1

41.0

Social worker

11.2

84.7

90.4

66.2

41.6

Nurse or nurse practitioner

3.0

97.6

35.7

64.3

41.5

Special educator

2.9

80.0

75.0

60.0

52.5

Principal or assistant principal

2.8

46.2

79.5

51.3

64.1

Special services or student services director

2.3

81.3

71.9

56.3

54.6

Teacher

0.3

75.0

75.0

25.0

60.0

Other

2.8

80.0

70.0

55.0

40.0

The response rate for the survey was 72%, and the maximum margin of error (p < .05) for the entire survey sample was ± 2.7%. Significant differences between subsets of the sample, such as between professionals working in middle vs. high schools, are reported whenever relevant.

MAJOR FINDINGS

Depression and Anxiety Serious Problems

We asked our respondents to rate the extent to which various behaviors and conditions were problems in their schools. These ratings, shown in Table 31.3, are organized into three clusters obtained in a factor analysis of respondents' answers. The first cluster, corresponding to mental health problems, indicates that these conditions were seen as related and among the more serious problems affecting students. Indeed, according to the professionals, adolescent depression is one of the more serious problems in their schools, with over 60% saying it is either very (12%) or moderately serious (51%). Anxiety disorders were seen as somewhat less prevalent than depression. Nevertheless, 43% of professionals believed students struggle with anxiety at least to a moderate extent. At the same time, however, a majority of professionals (57%) said that anxiety disorders are at most a small problem in their schools.

Table 31.3 Problems Reported by School Professionals

Severity of Problem

Problem

Great Extent (%)

Moderate Extent (%)

Small Extent (%)

Not at All (%)

Mental Health

Depression

12

51

36

1

Anxiety disorder

6

37

54

3

Cutting or other forms of self-harm

4

21

66

9

Eating disorders

1

17

71

10

Substance Abuse Related

Use of illegal drugs, such as marijuana

12

43

40

4

Excessive use of alcohol

12

38

39

9

Drug dealing

3

19

59

16

Illegal use of prescription drugs

2

13

58

21

Violence and Truancy

Truancy

20

40

37

2

Bullying or picking on other students

18

48

33

0

Fighting among students

10

36

51

3

Carrying or using weapons

0

5

60

33

Cutting or inflicting other forms of self-harm was also generally described as occurring to a small extent. A solid majority of professionals (75%) reported that students' attempting to harm themselves is at most a small problem, but about one in four described it as a problem to a moderate (21%) or great (4%) extent. Similarly, a majority of professionals (81%) said that eating disorders occur to a small or no extent. Fewer than 20% reported that eating disorders are a problem to a moderate (17%) or great (1%) extent.

The second cluster, corresponding to various drug-related behaviors, was also seen as an important set of problems. About half of respondents felt that alcohol (50%) and illegal drug (55%) use presented at least a moderate problem. Illegal use of prescription drugs was not as prevalent as the abuse of illegal substances. A majority of professionals (58%) reported that illegal use of prescription drugs is a small problem, and one in four (21%) said that this is not a problem at all.

Actual sale of drugs on school property was generally not seen as a big problem. A majority of mental health professionals (75%) said that drug dealing is at worst a small problem in their schools. This is not to say that drug dealing was never a problem. About 22% reported that drug dealing presents a moderate or great problem in their schools.

The third cluster, conflict between individual students and school truancy, also contained some of the bigger problems in schools. A solid majority of professionals (66%) said that bullying or picking on other students is at least a moderate problem. Actual fighting among students was described as somewhat less prevalent. Nonetheless, close to half of mental health professionals said physical violence directed at other students is a problem to a great (10%) or moderate (36%) extent. In addition to interpersonal conflict, a majority of professionals (60%) described truancy as at least a moderate problem.

Despite the media attention of the past few years, students carrying or using weapons was rarely considered a big problem. Very few professionals (5%) reported that weapons are even a moderate problem, with a vast majority either characterizing it as a small problem (60%) or saying that it is not a problem at all (33%).

Although the three problem clusters tended to be distinct, they were also interrelated. Schools with high levels of mental health problems also were seen as having high rates of drug use (r = .48, p < .01) and interpersonal conflict (r = .47, p < .01). Drug use and conflict were slightly less related (r = .31, p < .01).

Different Schools—Different Problems

The context in which school professionals work greatly influences their perceptions of student problems. These perceptions vary greatly depending on the size and location of the school and the demographic characteristics of the student population, especially their age and socioeconomic background. We analyzed school characteristics by conducting multiple regres sion analyses for each problem with size of school, urban vs. rural location, poverty level (percent eligible for school lunch), middle vs. high school, and region of the country as predictors.

Professionals working in middle schools often described a different set of problems from those described by mental health professionals working with adolescents attending high school. Interpersonal conflict problems tend to take center stage during the middle school years, whereas drug and alcohol use are more prevalent in high school. Professionals working in middle schools were considerably more likely (p < .001) to report that bullying or picking on other students (82% vs. 54%) and fighting (57% vs. 37%) are moderate or great problems than their counterparts working with high school students. At the same time, high school professionals were more likely (p < .001) to describe the use of illegal drugs (72% vs. 36%), excessive use of alcohol (71% vs. 28%), drug dealing (31% vs. 12%), and illegal use of prescription drugs (23% vs. 7%) as problematic.

Mental health conditions were also described as more prevalent in high schools than in middle schools. Professionals in high schools were more likely (p < .01) to say that depression (68% vs. 57%) and eating disorders (22% vs. 13%) are problems to a great or moderate extent than professionals in middle schools. However, anxiety disorders (44% vs. 42%) and cutting (26% vs. 26%) were seen as equally prevalent in middle and high schools.

We also found that larger schools tend to have more problems than smaller ones. It is not clear whether this perception is the result of the sheer likelihood that more problems occur in a larger school or that the prevalence is greater. Nevertheless, mental health conditions, such as depression (69% vs. 48%), anxiety (44% vs. 32%), and cutting (29% vs. 19%), were seen as more of a problem (p < .05) in schools with more than 1,500 students than in schools with less than 500 students. The same is true when it comes to students engaging in risky behaviors (p < .01). In particular, a solid majority of professionals (65%) working in schools with more than 1,500 students reported that the use of illegal drugs is a moderate or a great problem, compared to fewer than half of professionals (45%) working in schools with less than 500 students. Fighting (50% vs. 33%) and drug dealing (28% vs. 11%) were also seen as more problematic in very large schools than in small schools. Nevertheless, perceptions of excessive use of alcohol (55% vs. 49%), eating disorders (20% vs. 16%), and bullying (51% vs. 51%) were not related to school size.

Where the school is located also makes a difference. Professionals working in urban schools (69%) were more likely (p < .01) to see depression as a problem than those working in rural areas (53%). The same was true for fighting among students (59% vs. 33%) and weapon carrying (12% vs. 2%). At the same time, professionals in urban schools felt that alcohol abuse was less of a problem than those working in rural areas (40% vs. 52%).

Regionally, mental health professionals working in the South tended to see fewer problems than those working in other areas of the country. For example, professionals in southern schools (54%) were less likely (p < .01) to consider depression problematic than their colleagues in the Northeast (71%), Midwest (66%), and West (66%). Southerners also reported fewer problems regarding eating disorders, cutting, use of illegal drugs, alcohol abuse, fighting, and weapon carrying than professionals in other regions. The one exception was for abuse of prescription drugs, for which southerners saw more problems than professionals working in other regions (p < .01). Professionals working in the Northeast (56%) were also more likely to describe anxiety disorders as a great or moderate problem than either southern (39%) or western (36%) mental health professionals, with their counterparts in the Midwest (46%) falling in between.

The socioeconomic composition of the student population (measured by the proportion of students eligible for a free or reduced lunch program) also leads to differences in problems. Abuse of alcohol and prescription drugs, eating disorders, and cutting tended to be more problematic in wealthier schools than they were in schools with a higher proportion of low-income students. At the same time, drug dealing, fighting, bullying, and weapon carrying tended to be more problematic in low-income schools.

Half Offer Counseling on Premises

Consistent with earlier research, we found that many schools already offer at least some mental health services on site (Table 31.4). About half of the professionals reported that their schools offer counseling for conditions such as anxiety and depression on school premises (47%), and many (44%) have a program for dealing with students who have mental health issues, such as an SAP. Most of the schools that do not offer counseling on school premises are prepared to refer students to other providers in the community (48%). Only 1 percent of professionals reported that their school neither provides counseling for depressed or anxious students nor refers these students to a service provider outside the school.

Table 31.4 Reported Availability of Services

How Provided

Service

Provided at School

(%)

Provided by District but Not on Site

(%)

Referred to Other Providers

(%)

Neither Provided nor Referred

(%)

Counseling for mental health conditions, such as anxiety or depression

47

4

48

1

Counseling for students who are victims of physical, sexual, or emotional abuse

34

4

61

1

Counseling or help for families of students who have a mental health condition

25

4

68

3

Large proportions of schools (67%) also reported the presence of programs to counsel students on the prevention of alcohol and drug abuse or the prevention of suicide (68%). However, smaller proportions of schools have programs to help students who want to quit the use of tobacco (43%) or other drugs such as alcohol (24%).

Schools are also less likely to be prepared to handle victims of abuse or the families of students with mental health conditions. Only 38% of schools offer counseling in the district for students who are victims of physical, sexual, or emotional abuse, and only 29% offer counseling or help for families of students who have a mental health condition. Nevertheless, nearly all of the schools that do not have programs on site refer students and families to outside providers.

Only Half Have a Full-Time Professional

Only a little more than half of the schools sampled (53%) have full-time access to a mental health professional—a psychologist, counselor, or social worker—whose main job is to deal with students' mental health issues. Even if one considers part-time staff, 23% do not even have access to a part-time mental health professional.

But even if mental health professionals are not always available, most schools employ other health professionals. A slim majority of schools (51%) have a school nurse on the premises full-time, while an additional 32% of schools employ a part-time nurse. If one considers all potential health professionals, including physicians and nurses, then about 74% of schools have a full-time health professional on site. If one considers both full-time and part-time staff, then nearly all schools (96%) have at least one health professional on site.

Seven percent of schools have a full-service health center on school property where students can receive primary health care, including diagnostic and treatment services by a doctor, nurse practitioner, or physician's assistant. However, not all of these centers offer mental health services (38% do not). It is clear that these centers are currently only able to care for a small percentage of adolescent mental health problems.

Adolescents in some parts of the country are much more likely to have access to health professionals on school premises than others (Table 31.5). In particular, schools in the Northeast are considerably more likely to employ mental health professionals than schools elsewhere in the country. The regional gap is also reflected in the fact that 32% of the schools in the Northeast employ a physician or nurse practitioner, whereas nearly as high a percentage of schools in the West (24%) do not even have a part-time school nurse.

Table 31.5 Health Resources by Region of the Country

Region

Health Resource

Northeast

(N = 226)

Midwest

(N = 349)

West

(N = 492)

South

(N = 333)

Total

(N = 1402)

School nurse

90a

84b

76c

84b

83

Counselor

62a

48b

50b

49b

51

Psychologist

58a

48c

55b

47c

51

Social worker

58a

56a

33b

26c

41

Student assistance program

52a

54a

39b

37b

44

Physician or nurse practitioner

32a

16b

20b

17b

20

School-based health center

8a

6a

7a

7a

7

Significant differences between regions are indicated by superscripts (p < .05).

a Percentages not significantly different from the Northeast. (p > .05)

b Percentages significantly lower than the Northeast (p < .05)

c Percentages significantly lower than outcomes labeled by footnote b.

We also found that schools located in both the Northeast (52%) and the Midwest (54%) are more likely (p < .01) to have a program, such as an SAP, for dealing with students who have mental health issues than schools in the western (39%) or southern (37%) parts of the country. Such programs are also more common in schools with a wealthier student base, defined as less than 25 percent of the student body eligible for free or reduced lunches, than schools in which more than half of students are eligible (53% vs. 36%). This disparity is somewhat offset by the fact that schools that receive Medicaid funding for the purpose of providing health care services to their students are more likely to offer counseling for mental health conditions on school premises than schools that do not receive Medicaid funding (54% vs. 42%). These schools are also more likely to employ a full-time psychologist (21% vs. 13%) or social worker (24% vs. 15%). However, almost as high a percentage of schools with low proportions of poor students avail themselves of Medicaid funding as schools with high proportions of poor students (41% vs. 48%).

As might be expected, we also found that larger schools are more likely to employ full-time mental health professionals than smaller schools. Professionals working in larger schools were more likely to report that their school employs a full-time school nurse, counselor, social worker, or psychologist than mental health professionals working in smaller schools.

What Do School Mental Health Professionals Do?

What school mental health professionals do varies considerably both across and within their job titles. We asked respondents with each of the three major job titles (Table 31.2) how they viewed their responsibilities in regard to mental health issues. The clearest finding (Table 31.6) is that all three types of professionals viewed their job as referring students who might have a mental health condition such as depression or anxiety disorder to other professionals for further testing and treatment. Social workers appear the most likely of the three to see their job as performing any treatment themselves (86%). Both counselors (63%) and psychologists (57%) often viewed this as part of their job but not to the same level as social workers. The same general pattern appeared in regard to counseling parents; only the large majority of social workers viewed this as their responsibility.

Table 31.6 Self-Described Job Responsibilities by Job Title (% Great to Moderate Extent)

Title

Description

Counselor (N = 675)

Psychologist (N = 374)

Social Worker (N = 154)

Refer students who may have a mental health condition such as an anxiety disorder or depression to other professionals for further testing and treatment

89

87

99

Identify students who may have a mental health condition such as an anxiety disorder or depression

65

82a

88a

Counsel students with mental health conditions

63

57a

86a

Develop programs to enhance the mental health of the entire student body

66

38a

66

Counsel or help families of students who may have a mental health condition

53

46a

82a

Administer tests to diagnose students with specific mental health conditions such as an anxiety disorder or depression

6

68a

24a

a Percentages were significantly different from counselors (p < .01).

When it comes to identifying students with potential mental health conditions, the vast majority of psychologists (82%) and social workers (88%) regarded this as part of their job. However, a smaller yet significant majority of school counselors agreed with this job description (65%). Differences were also apparent when the development of mental health programs for the entire school is considered. Here about two-thirds of counselors and social workers agreed with this description, but less than 40% of psychologists viewed this as a priority. School psychologists appear to have the major responsibility of administering tests to identify mental health conditions in students. Whereas about two-thirds of psychologists agreed with this description, very few counselors (6%) and only about a quarter of social workers saw this as part of their job.

These job descriptions suggest that school mental health professionals can help to identify students with mental health conditions and provide referrals but that actual treatment is more likely to occur elsewhere or with different providers. Most school mental health professionals are likely to refer students who are displaying symptoms of mental health conditions to another professional for further testing and counseling. As seen in Table 31.7, roughly 8 in 10 school professionals would refer students who were showing signs of depression (80%), anxiety (79%), or alcohol abuse (77%). Most of the rest said they would be somewhat likely to do so.

Table 31.7 Likely Course of Action in Treating a Student with a Common Mental Condition: Refer to Another Professional or Treat (% Very Likely)

Title

Condition and Action Taken

Counselor

(N = 675)

Psychologist

(N = 374)

Social Worker (N = 154)

Other

(N = 199)

Total

(N = 1402)

Alcohol Abuse

Refer

75

77

83

82

77

Treat

30

17a

33

26a

27

Depression

Refer

75

81

86

88a

80

Treat

38

33a

47

25a

36

Anxiety

Refer

80

73

81

85

79

Treat

31

28

42a

24a

30

All differences between rates of referral and treatment within each condition were statistically significant, p < .01.

a Significant differences (p < .01) compared to counselors.

School mental health professionals are considerably less likely to say that they would treat or counsel students with potential mental health problems themselves. In the case of depression, fewer than 40% said they would be very likely to treat or counsel the student (Table 31.7). Even fewer said they would be very likely to treat or counsel students who were displaying symptoms of an anxiety disorder (30%) or alcohol abuse (27%). Sizable minorities indicated that they would not be too likely or would not be likely at all to treat or counsel students who were de pressed (27%), had an anxiety disorder (34%), or were using excessive amounts of alcohol (38%).

Limited Time for Direct Care of Students

Counseling or working with students who have mental health problems is clearly not the only thing that school mental health professionals do. Most school professionals actually spend much of their time doing other things. A majority of professionals (76%) spend less than half of their work week counseling or working with students who have mental health problems, and nearly half (47%) do this for less than 10 hours a week. A small minority (9%) spends more than 30 hours per week on this activity.

Not only do school professionals divide their time between a multitude of tasks, some also work in more than one school. Although a solid majority of professionals (69%) spend all their time in one school, 31% said they work in more than one school. Among psychologists, a solid majority (62%) reported that they work in more than one school.

Spending more time working with students who have mental health issues may sensitize one to the problem. Mental health professionals who spent at least 10 hours a week counseling or working with students who have mental health issues were considerably more likely to consider depression (73% vs. 52%), anxiety disorders (52% vs. 33%), cutting (31% vs. 18%), and eating disorders (21% vs. 14%) to be a problem in their school to a great or moderate extent than professionals who spent less time with such students (all differences significant at p < .01).

Processes for Referrals, but Not Necessarily for Identification

Given the extent to which mental health professionals have to stretch their time, it is important to understand the procedures that schools employ to identify and deal with students who may have a mental health condition. We found that a solid majority of professionals claimed their schools have a clearly defined and coordinated process for providing referrals for students who may have a mental health condition. However, having an equally clear process for identifying, diagnosing, or treating students is less common.

In particular, 66% of professionals said their school has a “clearly defined and coordinated process for providing referrals to students who may have a mental health condition.” However, before students can be referred for further testing and counseling, their condition needs to reach the attention of the professional in charge of referrals. Schools are less likely to have a clearly defined and coordinated process for identifying students who may have a mental health condition than they are to have a referral process. Only 37% of professionals said that their schools have a process to a great extent for identifying students. As many (37%) are in schools with a moderately clear process, and one in four said (25%) their process is only coordinated to a small extent or not at all.

Schools are even less likely to have a clear process for diagnosing students with a specific mental health condition. In fact, about half of professionals said (51%) their schools have a diagnostic process that is clearly defined and coordinated only to a small extent or not at all. Only half of professionals (49%) are in schools with a very (26%) or moderately (23%) clear and coordinated diagnostic process.

Similarly, the process for treating students with mental health conditions is clear to only a small extent or not at all in the about half of schools (53%). Less than half of professionals (46%) are in schools that have a very (17%) or moderately (29%) clear and defined process for treating students.

Procedures for Identification

One way to minimize the chance that students with problems are overlooked is to systematically screen the entire student population. At present, however, only 2% of schools screen all and only 7% screen most of their students for mental health problems. Although a majority of schools (63%) report screening some of the students, about 26% conduct no screening at all.

One solution to increasing the identification of students in need of assistance is to train teachers to identify symptoms of mental health conditions. Here the situation is a little more encouraging. Only about 19% of schools provide no training at all to teachers in identifying mental health problems in students. However, it is unusual for schools to train all (9%) or most (12%) of the teachers to identify such problems. A little more than half (53%) trains only some of their teachers to identify mental health problems.

Another potential way to increase the likelihood that students will seek and find help when necessary is to teach students to identify potential symptoms of mental health conditions in themselves and in peers. A sizable minority of schools (38%) follows this practice for all or most of the students. However, in a solid majority of schools (59%), only some or none of them are taught these skills. Schools in the Northeast (49%) and Midwest (48%) are more likely (p < .01) to teach students to identify symptoms of mental health conditions than schools in the West (32%) or the South (30%).

It is also important that students feel comfortable asking for help themselves when they feel they need it. Most schools seem to recognize this, as a strong majority of professionals reported that all (60%) or most (21%) of the students in their school are encouraged to seek help if they think they or their peers might have a mental health condition. About 57% of respondents reported that they encouraged all of the parents in their school to seek help if they need it; 20% reported that they encouraged most of the parents in their school in the same way.

When it comes to identifying students who may have mental health issues, “clearly defined and coordinated” often means that the entire school is involved. Mental health professionals who said that their school's program for identifying students is clearly defined and coordinated to a great extent were more likely to indicate that not only mental health professionals but also other professionals working in the school are involved in the identification process. In particular, higher proportions (p < .01) of teachers (77% vs. 46%), supervisors of after-school programs (77% vs. 46%), health care professionals (70% vs. 54%), and administrators (66% vs. 44%) have at least moderate responsibility for identifying students than professionals who described their identification process as only coordinated to a small extent or not at all.

We asked school professionals to evaluate how well various staff members identify students with mental conditions. The results shown in Table 31.8 indicate that among those responsible for identifying students with potential mental health problems, mental health professionals believed that both they and school nurses do a very good job. However, it is possible for teachers, administrators, and coaches to do a good job as well.

Table 31.8 Perceived Success of Staff in Identifying Students with a Mental Health Condition (if Responsible for This Activity)

Success

Staff Category (% Responsible)

Very Good (%)

Somewhat Good (%)

Somewhat or

Very Bad

(%)

Mental health professionals (97%)

73

25

1

Health care professionals, such as school nurse (86%)

56

37

4

Principal or assistant principal (92%)

38

50

9

Teachers (96%)

33

59

8

Coaches and other adults who supervise after-school activities (87%)

19

54

17

According to our respondents, mental health professionals and teachers are the ones who are seen as most often identifying a student who needs mental health services (Table 31.9). At the same time, more than half of respondents said that referrals by parents, peers, or the students themselves are also somewhat common. About 19% of school professionals reported that students who use the school's mental health services very often do so because they were referred by parents, and over half (55%) said parents are the initiating party somewhat often. At the same time, school professionals (24%) indicated that parents are not too often or not often at all involved.

Table 31.9 Perceived Source of Identification of Students Needing Attention for a Mental Health Condition

Likelihood

Source of Identification

Very often (%)

Somewhat Often (%)

Not Too Often (%)

Not Often at All (%)

School mental health professional

43

45

8

3

Teacher

29

54

13

3

Parent or guardian

19

55

20

4

Students on their own

16

44

28

10

Another student

10

42

32

14

Students are seen as somewhat less likely to ask for help on their own accord. About 38% of school professionals said that students do not often approach them on their own. Yet, a majority (60%) said this happens at least somewhat often. Sometimes peers identify students with mental health concerns, although school professionals were divided on how frequently this occurs. A slim majority (52%) said that peers identify students who may have a mental health condition at least somewhat often, but nearly as many (46%) said this happens not too often or not at all.

Adolescents in schools where the students are taught to identify symptoms of mental health conditions are said to be more likely (p < .01) to enter the system on their own accord (65% vs. 47%) or because peers identified them (60% vs. 33%) than adolescents in schools where only some or none of the students learn these skills.

Barriers to Receiving Care

We asked school professionals to evaluate two common barriers to receiving mental health care: inadequate insurance coverage and inadequate treatment resources in the community. A large proportion of professionals (85%) reported agreement with the statement that “inadequate insurance coverage prevents many students from getting the mental health services they need.” In addition, 54% of professionals agreed with the statement that the “treatment resources for adolescent mental health are adequate in the community.” These evaluations suggest that school professionals see the treatment barriers often cited by panels such as the President's New Freedom Commission as significant problems in the schools.

Similar to primary care physicians who see adolescents for routine check-ups (see Chapter 30), mental health professionals working in rural schools (52%) were more likely (p < .01) to indicate that the resources in their community are inadequate than mental health professionals working in suburban (44%) or urban (41%) schools. As a whole, mental health professionals gave a more positive picture of community resources than primary care physicians. Compared to fewer than half of school mental health professionals (46%), a solid majority of primary care physicians (67%) reported that the treatment resources for adolescent mental health disorders are inadequate in their community (Chapter 30).

Schools Serving Low-Income Students Differ from Higher-Income Schools

Adolescents going to schools in which a high proportion of their classmates come from low-income households are no more likely to have mental health services available than adolescents going to wealthier schools. In fact, as noted earlier, SAPs are actually less available in schools with high proportions of poor students. There are signs, however, that schools serving low-income students try to provide more services on site. First, schools that serve mostly low-income students (more than 75% qualify for free lunch) are more likely to have a school-based health center than schools that serve wealthier students (fewer than 25% qualify) (13% vs. 4%, p < .01). Second, professionals serving in low-income schools are more likely to report that their school has a well-defined process for treating students with mental health problems (24% vs. 15%, p < .05). In addition, schools that avail themselves of Medicaid funding are more likely (p < .01) to have a very clearly defined and coordinated process for diagnosing (31% vs. 21%) and treating (20% vs. 13%) students who may have a mental health condition. Schools that have Medicaid funding are also slightly more likely (p < .05) to screen all or most students for mental health problems (9% vs. 7%). Nevertheless, as noted earlier, schools with high proportions of poor students are only marginally more likely to take advantage of Medicaid funding than schools with wealthier students (48% vs. 41%).

Despite the signs that schools serving low-income students deliver more care, other practices promoting mental health are more likely to take place in wealthier schools. Students who go to schools in which fewer than 25 percent of the student body qualify for the free or reduced lunch program are more likely (p < .01) to be taught to identify symptoms of mental health conditions in themselves and others than students who go to schools with a large low-income population (50% vs. 27%). Parents in wealthier schools are also encouraged to a greater extent to get involved in identifying students who need help (62% vs. 53%). Perhaps as a consequence, professionals working in schools with a wealthier student population are more likely (p < .01) to report that students who are using the mental health services offered by the school often seek them on their own accord (65% vs. 53%) or because they were identified by another student (62% vs. 39%).

Evaluation of Available Services

To assess the quality and effectiveness of the available programs and services from the perspective of school professionals, we examined three somewhat related outcomes that might serve as criteria for the success of the services currently in place in schools serving adolescents (Table 31.10). The first was a rating of the overall effectiveness of the school's services. Most professionals (85%), regardless of the demographic characteristics of their schools, described the mental health services offered in their schools as at least somewhat effective. However, only about 18% believed they are “very effective,” with 67% characterizing the services offered as just “somewhat effective.” Fifteen percent of respondents described their mental health services as “not too effective” or “not effective at all.”

Table 31.10 Distributions of Response to Program Effectiveness Questions

Overall Effectiveness

%

Received Services in Total

%

Received Services on Site

%

Very effective

18

All

7

All

7

Somewhat effective

67

Most

30

Most

24

Not too effective

13

About 1 2

29

About 1 2

20

Not at all effective

2

About 1 4

17

About 1 4

19

Don't know

1

Only a few

13

Only a few

26

Don't know

4

Don't know

4

A second set of outcomes, school professionals' estimates of how well their programs connect students in their school with needed mental health services, depends on their perceptions of the need for such services. These perceptions varied widely, but on average, school professionals estimated that 18 percent of adolescents are in need of “counseling for mental health conditions such as anxiety disorders or depression.” According to several estimates, approximately 20 percent of adolescents suffer from a diagnosable mental disorder (U.S. Department of Health and Human Services, 2000), so their estimates were clearly in line with prevailing evidence.

More than half of professionals (59%) estimated that only about half or fewer of students who are in need of counseling actually receive these services either at school or elsewhere. Only about 37% of professionals reported that all (7%) or most (30%) of the students receive the care they need. When asked about the proportion that receives the services they need on site, the level of success understandably dropped even lower. In this case, 65% of professionals estimated that half or fewer of the students received the services they needed at the school. Despite the weak performance of most of the school programs, there was considerable variation in perceived success in delivering care to students in need, with a solid core of school professionals seeing their schools' programs as reaching most of the students in need.

Predictors of School Effectiveness

Which of the things that schools do to promote the mental health of their students best predict whether a school is evaluated as effective in dealing with students who may have a mental health condition? To answer this question, we first conducted a factor analysis of the services and programs provided, including the professionals on staff and the procedures for identification and screening as well as those for diagnosis, treatment, and referral. We then grouped the results of this analysis into 10 factors that represented the dominant clusters of services, providers, and policies in place in schools. The 10 factors were then entered stepwise into a regression analysis after first holding constant demographic differences between schools, including region of the country, size of school, type of school (primary, middle, high, other), urban vs. rural location, percent of students eligible for free lunch, use of Medicaid funding for health services, and differences between respondents, including age, gender, professional title, length of service at school, and number of hours per week spent on counseling of students. We also included the two measures that assessed the adequacy of treatment resources in the community and the importance of access to health insurance as an ob stacle to receiving care in the community. Because the three measures of school effectiveness were only moderately correlated with each other (r values ranging from .30 to .40), we analyzed each one separately.

Table 31.11 shows the results of the analysis for each outcome: overall evaluation of the school's mental health program, proportion of students in need of services who received them in total, and proportion of students in need of services who received them primarily at school. Five of the 10 school program factors consistently predicted success. Schools that had well-defined and coordinated processes for both identifying and referring students and for diagnosing and treating them were significantly more likely to perform well on all three criteria. The same was true of schools that had staff that were effective in identifying students at risk for mental health problems, as well as schools that had counseling programs on site and schools that were in communities with adequate treatment resources.

Table 31.11 Regression Analysis of Three School Program Outcomes as a Function of Program Characteristics (Significant Standardized Coefficients)

Outcome

Program Factor

Overall Effectiveness

Receipt of Services (Total)

Receipt of Services in School

Procedures for identification and Referral

.201

.125

.081

Staff effectiveness in identifying students

.134

.057

.047a

Mental health professionals on staff

.133

.064

Screening programs and staff training

.110

.061

Good treatment resources in community

.098

.052a

.062

Counseling programs on site

.104

.059

.197

Procedures for diagnosis or treatment

.053

.162

.229

Parents and students encouraged to seek care

.135

.048

Adequate insurance for mental health care

.105

Student health center

.050

Adjusted R 2 were 26.1% for effectiveness, 18.5% for total service, and 22.5% for service on site.

ap <.10

Schools that had mental health professionals on site full time and that had screening programs and staff training for identification of mental health problems were more likely to perform well on overall effectiveness and on delivery of services in total. Schools that encouraged students and parents to seek care performed well on the two service delivery outcomes. Finally, schools that had student health centers were seen as more effective in providing services on site. Prevention programs for problems such as suicide and drugs as well as SAPs did not appear to add any incremental effectiveness beyond the other programs.

In addition to the programs employed in the school, community resources outside the school also mattered. Schools were judged more effective and providing more services if the treatment resources for students in the community were viewed as adequate. In addition, it was seen as easier to deliver services to students if their families had insurance coverage for mental health treatment.

When we examined the many school and respondent characteristics in the analysis, a few school characteristics were consistent predictors of success. In particular, professionals working in middle schools consistently saw their schools as more effective and as delivering services to a higher proportion of students. Schools with high proportions of students eligible for free lunch and those in rural areas were more likely to have successful programs for delivering care on site. In addition, professionals working in schools in the Northeast and South felt their programs did a better job of delivering services on site than those working in the West and Midwest. However, perceptions of overall school effectiveness did not vary by region of the country, urbanity, or income.

SUMMARY AND DISCUSSION

This survey of school professionals' knowledge about mental health issues supports the need for increased resources and programming in the nations' schools for adolescent mental health promotion and care. Mental health problems are seen as extremely prevalent in schools that serve adolescents, and the schools are seen as only somewhat effective in meeting the mental health needs of students. Most schools have a well-defined and coordinated program to refer students for mental health problems. However, a much smaller proportion of schools have a similar system to identify students who may need assistance. Although about half of schools have some form of counseling on site to help students with mental health concerns, resources in these programs are stretched very thin, with most professionals not able to spend even half their time on these activities.

The findings that depression and substance use are highly prevalent and serious problems, especially in high schools, is consistent with considerable research indicating that most adolescents with mental health problems do not receive appropriate treatment for their conditions (Kataoka, Zhang, & Wells, 2002; Sturm, Ringel, & Andreyeva, 2003). In addition, adolescent substance use is often comorbid with mental health conditions (see Part V). However, adolescents who experience substance use dependency are either not appropriately treated (see Chapter 29) or, when they are treated, do not receive care for comorbid mental health conditions (Jaycox, Morral, & Juvonen, 2003). Indeed, it is disheartening to find that so few schools (24%) have treatment programs for drug dependence available on site. Hence, our findings indicate that despite the considerable resources devoted to adolescent mental health in schools, the unmet need for services remains large and is unlikely to be reduced without additional resources devoted to the prevention and identification of mental health problems.

In view of our findings, it is not surprising that many school professionals say they could use more help to identify and treat students in need of care. In a separate set of questions, roughly half of mental health professionals (47%) said that having more mental health professionals is one of the top ways that the mental health services in their school could be improved. More than half of mental health professionals (53%) said they very often feel limited by time constraints to adequately assess and deal with students who may have a mental health condition. Many mental health professionals (32%) also reported feeling hampered because of a lack of available support resources.

Despite the limitations in the school mental health system, the results suggest that some schools have the capability of identifying students with mental conditions sufficiently early so that school staff can take appropriate action. Schools that are seen as doing this effectively involve the entire professional staff as well as students to identify persons needing help. They also encourage parents and students to identify themselves if they feel that they are in need of mental health evaluation. Nevertheless, most schools do not have adequate diagnostic and treatment facilities on site, and so many students need to be referred to outside providers for care. In these schools, mental health professionals serve primarily as facilitators of early identification and referral for mental health care. They are also in the best position to train teachers and other staff in the adoption of other schoolwide practices that can create a favorable climate for promoting mental health.

One possible direction for mental health care in the schools is to increase the presence of school-based health centers. At present, very few schools have these facilities, and many of those that exist do not have the capability to provide a full range of mental health care. This approach will take considerable time and cost to implement. However, based on the perceived effectiveness of the programs that are currently in place in many schools, it is possible to have an effective program that provides some counseling on site for less serious mental health conditions if the entire school is poised to identify students in need of help. If these programs were supplemented by other schoolwide programs that can advance the positive development of students (see Romer, 2003; Chapter 26, this volume), many student mental health problems may also be prevented.

The approach that emphasizes prevention and schoolwide programming is consistent with recent calls for school mental health professionals to adopt more of a public health outlook on their role (Adelman & Taylor, 2000; Atkins et al., 2003; Hoagwood & Johnson, 2003; Weist & Christodulu, 2000). This approach emphasizes universal programming that can also be supplemented by selective programs for students in need of special care. Such an approach focuses on the strengths of school mental health professionals as the experts on mental health in school settings without taxing their time and skills to provide one-on-one counseling and treatment for students who need selective and indicated care better provided by other mental health specialists. This facilitator role is already consistent with how school mental health professionals view their job; the majority view their work as identifying students in need of further care and providing referral to other providers for treatment.

Even if schools could do a perfect job of identifying students at risk for mental health problems, two major barriers to effective care for adolescents would remain. One is the inadequacy of treatment resources in the community, a reality endorsed by school professionals as well as primary care providers (Chapter 30). This barrier is greatest in rural areas where appropriate medical providers are less available. A second barrier is inadequate insurance coverage for mental health treatment. However, it is encouraging that schools with high proportions of poor youth are reported to be able to provide mental health services in schools. This may reflect the use of Medicaid funding to provide those services or greater ability to bill for services under State Children's Health Insurance Programs.

Despite evidence that schools serving poor children are managing to deliver mental health services, it is also clear that many of these schools do not avail themselves of Medicaid funding to provide mental health services. Use of Medicaid funding appears to be nearly as prevalent in schools serving wealthier students as in those serving poorer students. Hence, there appears to be a large opportunity to improve the delivery of services to poor youth by greater use of Medicaid funds than is currently the practice.

A major limitation in our research's conclusions regarding effective services is that we relied completely on school professionals' perceptions of their programs. However, we did hold constant many characteristics of both the respondents and their schools. Hence, the relations between school programs and perceived effectiveness were not simply the result of those characteristics. It remains for future research to evaluate the effectiveness of school programs using actual mental health outcomes as criteria. In conducting this research, our findings suggest that schoolwide programs that involve the entire teaching and administrative staff as well as parents and students should be evaluated as potential strategies to promote the mental health of students. Universal screening programs, such as the Columbia Teen Screen (McGuire & Flynn, 2003), could also be evaluated as potential mechanisms to identify and refer students in need of further diagnosis and care.

According to the President's New Freedom Commission on Mental Health (2003),

In a transformed mental health system, the early detection of mental health problems in children and adults—through routine and comprehensive testing and screening—will be an expected and typical occurrence. At the first sign of difficulties, preventive interventions will be started to keep problems from escalatingQuality screening and early intervention will occur in both readily accessible, low-stigma settings, such as primary health care facilities and schools.

Our findings indicate that this objective is attainable in the nations' schools if we are willing to make the needed investments.

Appendix 31.1 Survey Methodology

To assess the status of mental health services provided in American schools and to learn what types of barriers and opportunities school mental health service providers face, the Annenberg Public Policy Center commissioned Princeton Survey Research Associates International (PSRAI) to conduct a nationwide telephone survey of 1,402 school mental health professionals. The survey was funded by the Sunnylands Adolescent Mental Health Initiative and follows a fall 2003 survey that examined the attitudes and practices of 727 primary care physicians who regularly treat adolescents.

A total of 1,402 school-based mental health professionals were interviewed by Princeton Data Source, LLC, between April 5 and May 28, 2004. The margin of sampling error for results based on the full sample is ±2.6%. Details on the design, execution, and analysis of the survey are discussed below.

Contact Procedures

Interviews were conducted by telephone from April 5 to May 28, 2004. A minimum of 20 attempts were made to contact a mental health professional at each school. Calls were staggered over different times of the day and days of the week to maximize the chance of making contact with potential respondents. Prior to being called, the principal of each school was sent a letter introducing the research and explaining that a mental health professional in the school could expect a call to participate in the study in the coming weeks. In addition, the principals as well as the respondents were told that for their participation a $20,000 charitable donation would be made in the name of all participating schools to an organization that works to improve mental health care among adolescents. The letter also gave a toll-free telephone number so that mental health professionals could call in and take the survey at their own convenience.

The sample was released for interviewing in replicates, which are representative subsamples of the larger sample. Use of replicates to control the release of sample ensures that complete call procedures are followed for the entire sample.

Response Rate

The response rate estimates the fraction of all eligible schools in the sample where a mental health professional was interviewed. At PSRAI, the response rate is calculated by taking the product of three component rates as recommended by the American Association for Public Opinion Research:

  • Contact rate: the proportion of working numbers through which a request for interview was made (84%)

  • Cooperation rate: the proportion of contacted numbers through which a consent for interview was at least initially obtained, vs. those refused (87%)

  • Completion rate: the proportion of initially cooperating and eligible interviews that were completed (100%)

The response rate for the survey was 72%.

Acknowledgments

We wish to thank Marc Atkins, Kimberly Hoagwood, and James G. Kelly for their helpful comments on an earlier version of this chapter.