Children's Mental Health: Current Challenges and a Future Direction

Organizing Mental Health Services for Children

Traditional Mental Health Services for Children: Current Arrangements and Challenges

Traditional mental health services for children and youth are provided in four sectors: the specialty mental health sector, the general medical/primary care sector, the human services sector, and the voluntary support network sector. Specialty mental health services include services provided by specialized mental health professionals (psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers) the general medical/primary care sector (family physicians, nurse practitioners, internists, pediatricians, etc.), the human services sector (social welfare, criminal justice, educational, religious, and charitable services), and the voluntary support network (self-help groups and organizations).

Even though mental health services are provided in a variety of locales (inpatient hospitals, day treatment programs, outpatient clinics, community health centers, offices of individual providers and schools), many children are not accessing services, and services that are being provided may not be reaching the majority of children in need. Basic barriers to care include accessibility of available services, lack of health insurance, mental health system capacity, misdiagnosis, and parents' own mental health issues.

A significant issue affecting the availability of appropriate services is the emphasis on funding for "deep-end" services. Overall, of the $137 million dollars in federal funds devoted to children's mental health in 1998, only 3 percent went to early identification and intervention efforts.¹⁵ Of the remaining money, the majority is spent on services for youth with serious mental health disorders, the group that represents the smallest proportion of children receiving mental health services.¹⁶ A result of this funding focus is that children may only secure the resources or access to a provider for therapeutic services after they have entered systems such as special education or the juvenile justice system.

Some childhood mental illnesses can be prevented, and many others can be prevented from causing long-term damage. But this will only happen with early identification and intervention. Failure to identify and treat early has extreme costs - in both human and financial terms. Of the 15 million children and adolescents who receive mental health services annually, nine percent receive care from the health care sector, mainly from the specialty mental health sector, and seventeen percent receive care from the human services sector, mostly in the school system.²

Expanding Access to Mental Health Services: The Potential of School-Based Care

Schools often function as the de facto mental health system for children School-based mental health services have been defined as any program, or intervention that has been applied in a school setting that was designed to influence the students emotional, behavioral or social functioning.⁵ The school environment is tailored to learning and development, a natural context for prevention and intervention, connected to community resources, familiar and accessible to students and parents, designed to promote communication between home and school, and provides personalized special education services under the Individuals with Disabilities Education Act (IDEA).¹⁷

Mental health services in schools are provided through different arrangements, which vary, by school environment. Currently in the US there are a wide variety of providers and employers, with varied training and skills, providing mental health services to children in schools. Services in schools can be provided through various arrangements: through the school as stand-alone services, through the community at the school as stand-alone services, through programs for specific mental health issues, and through school based health centers. Each of these provider arrangements is described in more detail in order to provide a clearer picture of how children receive services and which services are provided by each arrangement (see Table 2).

Table 2:
A Comparison of Different Mental Health Service Arrangements Related to Schools

Mental Health Service Provider Arrangements in Schools

Schools employ or contract for a number of provider types offering a range of mental health services to schools. Providers include psychologists, mental health counselors, social workers, and psychiatrists. Services can include evaluation, individual and group counseling, crisis intervention and counseling, and referral for outside services. Schools, school districts, and states contract with and employ mental health providers to provide services in the school, in conjunction with the school but off school property, or to provide specific programs addressing specific mental health issues within the school. Programs and services vary widely based on what each individual principal wants in the school, school and state funding for "extra" programs, and the beliefs of school personnel on the extent of the mental health need. Other issues that schools face in the provision of mental health services include reimbursement from Medicaid and other insurance programs, accessibility of services by students, number of students served, confidentiality, and stigma associated with having to "visit the counselor".

School Psychologist Services

School psychologists provide an array of services to children, including consultation with teachers and families, assessment, prevention, intervention, education, research and planning.¹⁸ School psychologists, with a background in psychology and education, may have different training than clinical psychologists. These professionals are the key people for diagnosis and evaluation of children for special education and IDEA services. One study found that 59% of school psychologists spend greater than 70% of their time conducting special education assessments and evaluations.¹⁹ During the 1999/2000 school year there were 24,495 fully certified full time equivalent school psychologists employed in the United States, District of Columbia and Puerto Rico serving 53 million children and youth in 117,000 elementary, middle, and high schools.^20,21 There are an additional 14, 957 social workers providing similar services to children and youth in schools.²⁰

School Counselors

School counselors not only address student career planning, but also help students to improve communication skills and solve a variety of learning issues.²² School counselors work with all students, including those who are considered at-risk and those with special needs. The recommended ratio, from the American School Counselor Association, of school counselor to students is 1:250, however the national average is 1:490 and only Louisiana and Wyoming have equal to or less than the recommended ratio.²³

Community Partnership Services

Schools and/or school districts also contract with organizations from within the community to provide mental health services. In programs implemented and provided by community organizations, a wide range of mental health professionals (psychologists, social workers, child psychiatrists, etc.) provides services. These services are provided on-site and in satellite locations (schools, public housing, homeless shelters).²⁴ Community based programs are able to provide a more comprehensive range of services than a school psychologist or counselor; they provide individual, family and group counseling, crisis intervention, preventive services, and referrals. Many schools may have opted to contract for "as needed" or crisis services after the Columbine shootings and the September 11, 2001 terrorist attack on the United States. However, providing mental health care after a crisis has occurred only supplies services once the problem is severe, and does not provide prevention and early intervention services which may prevent a crisis from occurring.

One school district that has arranged for a more comprehensive service agreement through the community is Baltimore, Maryland. Baltimore City Schools participate in the Expanded School Mental Health program. This program provides services through adjuncts to school-based health centers, satellite programs of community mental health centers, and stand alone programs that places a single clinician in the school by the lead/responsible agency (majority of participating schools use this arrangement).²⁵ The program has placed 20 clinicians in schools through the University of Maryland School Mental Health Program. Services include individual psychotherapy, group and family therapy, and consultation with school staff.²⁵ One of the biggest obstacles to implementing and providing services is the potential for fragmentation of services because personnel may not be integrated with other school support programs. There is also the associated stigma of "visiting the counselor" which may decrease the use and effectiveness of services.

Other Service Provider Options

Another type of arrangement for child mental health services are programs that serve school children and may be located in the school but that are not associated with school based services. There are a variety of independent programs that fall into this category, but there is no data on exactly how many programs there are and how many programs are being implemented. However, these programs provide important mental health services to children and must be taken into account when looking at all service availability to school children. An example of this type of program is The Neighborhood Place located in New Haven Connecticut. This is an arts based mental health program open to all students and youth living in New Haven.²⁶ The program offers classes before and after school, on weekends, and during the summer in visual and material arts, theater, dance, music and creative writing. The program also provides student workshops on behavior modification and access to psychotherapy, as well as information and classes for parents.²⁶ By incorporating mental health services into art classes The Neighborhood Place is reaching children and families afraid of the stigma of mental health.

School-Based Health Center Services

The mental health service arrangement that has the ability to provide the most comprehensive services is the school-based health center (SBHC). The SBHC provides a range of services including primary health care services, health screenings, physicals, and mental health services. Currently 79.5% of states have at least one SBHC that provides services to meet the mental health and social service needs of students, and of those states, 87.1% of SBHCs serve as Medicaid providers.²⁷ Mental health services, like all health services provided in SBHCs, are dependent on funding and personnel availability. SBHCs were initially established with the goal of making health care more accessible to adolescents and reducing the incidence of behavioral health problems, as well as increasing use of primary health care. School based health centers reduce barriers to learning and help keep children in school by making it possible for children to receive care while their parents remain at work.

Two examples of the varying mental health service possibilities are seen in the SBHCs sponsored by the Buncombe County Health Center in Buncombe County, North Carolina and Public Health - Seattle-King County in Washington. Both of these SBHC sponsors are recipients of a grant under the Caring for Kids: Expanding Dental and Mental Health Services through School-Based Health Centers initiative of The Robert Wood Johnson Foundation (RWJF). The program is administered by The Center for Health and Health Care in Schools.

Buncombe County currently provides limited mental health services by employing an independent Licensed Clinical Social Worker (LCSW) at their 3 SBHCs. Funding from the RWJF grant and local sources will allow them to have 3 LCSW, one at each SBHC it sponsors, providing increased early intervention services, on-site counseling, case management and referral for more intensive services. Public Health - Seattle-King County already provides extensive mental health services through on-site mental health counselors. The Seattle SBHCs will use funding from the RWJF to expand existing mental health services to include services provided by a psychiatrist. The psychiatrist will evaluate and assess students, provide consultation, oversee administration of medication, and will support and assist current staff with treatment goal development at 7 of the 12 SBHC located in Seattle Washington.

Although both these arrangements provide students with comprehensive mental health services, Public Health - Seattle-King County provides a more extensive array of services. Seattle SBHCs will be able to provide both early intervention as well as "deep end" services for those with greater need. School-based health centers are ideal locations for the provision of mental health services, and are able to provide a wide range of services the extent of which is dependent on funding and provider availability.

Advantages of Mental Health Services Located in School-Based Health Centers

Youth in need of mental health services, who do not receive care, are at risk for educational underachievement and failure, as well as increasingly serious psychological and social problems.  By providing services in the schools, clinicians and educators maximize the opportunities for children to receive services, and therefore have a greater chance of school success. The school-based health center is the ideal provider of these services because the SBHC is not only accessible to all students in the schools it serves, but because it provides multiple services - primary care and health education, as well as mental health services. By providing mental health services SBHCs can reach out to students whose physical complaints may have a psychosocial background. Due to its location within the school and its accessibility to all students, the SBHC is able to provide stigma-free care in a convenient, usually no-fee (to the patient) environment.

Barriers to Mental Health Services Located in School-Based Health Centers

School-based health center mental health services provide access to services for underserved youth, provide prevention services to at risk youth, serve to identify students who may need services, and provide crisis help to the school at large. However, there are challenges to the provision of mental health services by a school-based health center. For example, if the school and the SBHC do not collaborate on the provision of mental health services, children may have difficulty accessing services. School support is essential, without it a school may make it difficult for students to access services during school hours. There may also be discord between the school psychologist, employed by the school, and the mental health counselors employed by the SBHC. While most schools do not have a full time psychologist, building a partnership rather than a competitive arrangement is essential to assure referrals and the best use of available resources.

Other challenges include the shortage of licensed providers in child mental health and varying state policy regarding the provision of mental health services to children in a SBHC. The number of professionals trained to provide mental health services to children has not grown at the same rate as the number of children who need services.²⁸ This problem is exacerbated by a geographic and economic maldistribution of providers reducing access to services by children and youth living in rural areas or areas of low socio-economic status.²⁸ Even when providers are available to supply services access can still be difficult because of state policy concerning mental health services. Each state has different licesensure requirements for mental health providers, and determines what services mental health providers are eligible to provide. This impacts who is eligible to provide services in a SBHC and who is eligible to receive reimbursement from third party payers.

The major barrier faced by school-based health centers in the provision of mental health services is funding. Most school-based health centers are funded through several sources including private grants, public grants, and Medicaid/ state child health insurance program reimbursement. SBHCs are reliant on all of their funding in order to continue to provide services. Often times if the SBHC is able to bill insurance for health services, it is only able to bill for specified mental health diagnoses, and may not be able to get reimbursement for care provided to at risk students.

Next: Financing Children's Mental Health Services