School-based Mental Health Services

For over a decade, investigators from the Research and Training Center for Children's Mental Health have been studying the role of school-based mental health services in systems of care for children with emotional/behavioral disorders and their families.

We believe that effective and integrated school-based mental health services will be a key ingredient in the current transformation of children's mental health services in America, and schools will be central to providing support for the nation’s youth in an increasingly complex societal context. Resources provided here describe what we've learned about school-based mental health services today, how we reached this point, and how good planning decisions might be made in the future.

Recent federal initiatives and acts promote the schools’ role as an effective vehicle to meet the social and emotional needs of all children while achieving the highest academic standards. The 1999 Report of the Surgeon General on the Mental Health of the Nation, the 2001 No Child Left Behind Act, and the 2003 report from the New Freedom Commission on Mental Health have all focused attention on the potential of increasing the effectiveness and capacity of school-based mental health services to improve the emotional well being of all children as well as their academic achievement.

While these federal initiatives have had an important role in increasing advocacy and interest in school-based mental health services, their recommendations lack the specificity needed for implementation at a scale necessary for significant improvement in outcomes for children. For example, they have triggered an explosion of interest and activity in school-based mental health programming, yet outcomes for children who have emotional disturbances continue to be the poorest of all disability groups (Wager et al., in press). The field can be characterized as being fragmented and underdeveloped, and confused by conflicting terminology and professional perspectives.

The School-based Mental Health Services Study

During the current grant cycle, Study 4: The School-based Mental Health Services Study is examining one of the components in the Center’s model of factors contributing to implementation of an effective system of care; namely, the promotion of collaboration between key agencies. It is essential that effective collaboration between the school and mental health systems exist in order to better serve individual children and families, and to facilitate significant improvement in the mental health service delivery system.

The current study will investigate school-mental health collaboration in the context of the overall mental health system, and will specifically investigate two other factors in the Center’s model: financing methods that are consistent with implementing an effective system of care, and mechanisms that ensure strong family voice at all levels of the system.

School-wide Reform and Mental Health Policies in Urban Schools

Conducted from 1999 - 2004, Study 3 described models of school reform operating in urban areas that served diverse populations, and examined the relationship between reform activities and measures of student functioning. The Urban School and Community Study (USACS) was designed to investigate the relationship between reforms in regular education, special education and mental health and outcomes for students who have emotional and behavioral disabilities. The domains of outcomes at the student level included academic, emotional, behavioral, and community functions. This study sought to explicate the reform and restructuring activities of several different school-based models associated with positive outcomes as they occurred in state and local contexts.

There were four key findings from this study:

(1) Urban schools engaged in more reform activities yield higher levels of academic achievement for students who have emotional disturbances. The amount of reform and improvement operating in a school and levels of math achievement for students who have emotional disturbances was examined. The amount of engagement in improvement and reform activities was found to be correlated .36 with math achievement of students with emotional disturbances. The size of this correlation is classified as “medium” by Cohen (1988). Additionally, greater levels of reform were also associated with higher levels of exposure to the general education curriculum for students with emotional disturbances. These findings are important as they link policy changes with improved outcomes for students with emotional disturbances served in special education.

(2) Multiple models of delivering mental health services are operating in urban schools. Schools that are actively engaging in reform and improvement have been creative and, in some cases, have leveraged community relations to increase services for these children. We have found several approaches to delivering these services that include the following: (a) all services provided by school personnel during school hours; (b) a combination of services from school personnel and staff from community agencies who provide service in the school; and (c) services provided by a community agency that acts as a lead agency in implementing a large scale community-based service program that includes the school system as a collaborator with the other child serving agencies. Interestingly, these various models have produced a higher level of service utilization for the students in this study as compared to estimates from national studies.

(3) Students from ethnically diverse backgrounds, served in special education due to emotional disturbances, display very high levels of psychopathology and impaired functioning across multiple domains and this condition has persisted since early childhood. Through interviews with parents, standardized measures of psychopathology (the Child Behavior Checklist (CBCL), and functional impairment (the Columbia Impairment Scale (CIS)), were administered along with questions that ascertained the history of services used by the student. CBCL scores for the first 158 students (average age of 11.8 years) revealed that 73% were classified as either in the clinical or borderline range, indicating significant emotional disturbance. Additionally, the majority of the students (58%) were also classified in the clinical range of the CIS indicating substantial impairment due to the emotional disturbances. According to reports from parents, their child’s emotional problems were first noticed at an average age of 5.4 years. The first service for these problems was received at average age of 6.9 years. On average the youth were first placed in special education classrooms at eight year of age or about third grade. Therefore, when the amount of time these students spent in a special education program is compared to their time in a general education classroom, this indicates these students have spent 67% of their school careers enrolled in a special education program (Kutash & Duchnowski, 2004).

(4) The School Improvement Index (SII) is a valid and reliable measure of school reform including special education. This instrument warrants widespread dissemination. Two types of psychometric studies have been conducted on the SII. The validity of the SII was established through a study that revealed the SII could discriminate between schools nominated as actively engaged in reform and schools nominated as not actively engaged in reform activities. The reliability of the SII has also been supported with high interclass correlations (.85) between multiple raters independent of the study. The psychometric properties of the SII are discussed in the article by Duchnowski, Kutash, and Oliveira (2004).

More Publications on School-based Mental Health Services

19th Annual Research Conference Proceedings (2007)

Features presentation summaries from symposia, paper presentations and poster presentations, organized around the central themes of the annual research conference.
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Voices from the Field: A Blueprint for Schools to Increase the Involvement of Families Who Have Children with Emotional Disturbances
(2006)

This 27 page document describes how the school and mental health systems can increase the involvement of parents in developing and assisting with services for their children with serious emotional disturbances.
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Community-based Theories of Change: Overview of Findings (2006)

Discusses results to date of the Community-based Theories of Change study. Four characteristics from this cross-site cross-phase study are also discussed: identity, integration, initiative, and innovation. The study examines organizational structures and processes that human service organizations believe allow them to carry out their mission and goals and to sustain this effort over time.
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Case Studies of System Implementation (2006)

This study identifies strategies undertaken by local communities in implementing community-based systems of care. The authors also seek to understand how factors affecting system implementation contribute to the development of local systems of care.
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Community-based Theories of Change: Study Background and Design (2006)

This article discusses the background and design of the Community-based Theories of Change Study. The study seeks to understand how child-serving organizations with a widely held theory of change carry out their mission and goals. Such a theory of change facilitates local policy implementation.
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Findings: Examining the Impact of Policy on Collaboration in Systems of Care (2006)

This article discusses how policy implementation affects collaboration at the state and community levels. Collaboration, in turn, contributes to effective systems of care.
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Promising Approaches in Care Management Systems (2006)

This study examined care management models by states or management entities within states that operate within a managed care environment. Using semi-structured interviews with key state and managed care informants, the study examined the types of care management models currently in use, and provides strategies for the successful implementation of a care management approach.
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A Model for Implementing Effective Systems of Care (2006)

Provides a discussion of the model of implementation factors developed by the Research and Training Center for Children's Mental Health. The Center's model includes 14 implementation factors and builds upon systems of care values.
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Building the Workforce Plan for Children's Mental Health (2006)

Discussion centers around the formation of the National Strategic Plan on Workforce Development in Behavioral Health. Includes a discussion of the Annapolis Coalition and its efforts related to workforce recruitment and retention. Ten strategic workforce goals are presented.
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Workforce Development and Emerging Technology in Children's Mental Health (2006)

This article describes, through the use of internet technology, plans for a system of care curriculum initiative listserve through which students will take classes in collaboration with 10 major universities.
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Structures and Processes Supporting the Mission and Goals of a Family-run Organization: King County Blended Funding Project (2006)

Using the King County Blended Funding Project as an example of a family-driven system that establishes collaborative partnerships with professionals and parents. The county was found to have a widely held theory of change, concept mapping was used to arrive at this finding.
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The Use of Qualitative Methods in Systems of Care Research (2006)

Presents a literature review of the Annual Conference Proceedings in an attempt to uncover qualitative research published by the Proceedings. 100 Studies were identified as qualitative. Descriptions of the most used qualitative study topics are provided.
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Organizational Structures and Processes within an Evidence-based Practice: Cross-site Findings from a Study of Teaching Family Organizations (2006)

Describes phase II findings of the Community-based Theories of Change Study. The summary provides an example of how actual service deliery relates to operations at the local end, and asks how organizations turn their ideas about implementation into action, what structures support and organization's ability to carry out its goals, and how such an organization sustains its focus.
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Educating Students with Emotional Disturbances: A National Perspective on Programs and Services (2006)

This article presents results of a study of students with emotional disturbances (ED) and their experiences at the elementary, middle, and high school grade levels. In addition, school characteristics, resources, educational programs and services are discussed. Data are from the Special Education Elementary Longitudinal Study (SEELS) and the National Transition Study-2 (NLTS2).
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School-Based Mental Health: An Empirical Guide for Decision-Makers (2006)

The "Yellow Book" provides a discussion of barriers to school-based services with the intention of improving service effectiveness and capacity. Reviews the history of mental health services supplied in schools, implementation of serviced, and provides an overview of the evidence base for school-based interventions. Includes recommendations for evidence-based mental health services in schools.
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Annual Research Conference Proceedings (2006)

Features presentation summaries from symposia, paper presentations and poster presentations, organized around the central themes of the annual research conference.
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The Special Education Elementary Longitudinal Study (SEELS) and the National Longitudinal Transition Study (NLTS2): Study Designs and Implications for Youth With Emotional Disturbance (2005)

This article describes design features of two longitudinal studies, the Special Education Elementary Longitudinal Study (SEELS) and the National Longitudinal Transition Study (NLTS2), and to outline their potential implicatios for policy, practice, research, advocacy, and system development for children and youth with emotional disturbances (ED).
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The System of Care Twenty Years Later (2005)

In this chapter the authors discuss the current impact and relevancy of the system of care model for the children’s mental health services system. The chapter begins with a brief description of the context that led to the development of the systems of care nationally. This is followed by an examination of recent empirical advances that have been made in understanding the number of youth who have emotional disorders, components within systems of care, and outcomes related to the model. The chapter concludes with recommended next steps for systems of care research.
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Real Manuals for Real Teachers (2005)

A research demonstration project was developed through a unique partnership of special educators, parents, administrators, and researchers, in order to increase the use of evidence-based practices in special education programs and to improve student outcomes. A major product of this project was the development of four teacher-friendly manuals that are guides to the implementation of evidence-based practices by special education teachers. A fidelity instrument was also developed to measure the level of implementation of these evidence-based practices.
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The Children and Youth We Serve: A National Picture of the Characteristics of Students with Emotional Disturbances Receiving Special Education (2005)

This article provides a national perspective of children and youth with emotional disturbances (ED) served in special education using data from the Special Education Elementary Longitudinal Study (SEELS) and the National Longitudinal Transition Study-2 (NLTS2). Data sources include teachers, school records, the students, and their parents. Results indicate that children and youth with ED live in households in which there are multiple risk factors for poor life outcomes.
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The Special Education Elementary Longitudinal Study (SEELS) and the National Longitudinal Transition Study (NLTS2): Study designs and implications for youth with emotional disturbance (2005)

This article describes the design features of two longitudinal studies, the The Special Education Elementary Longitudinal Study (SEELS)and the National Longitudinal Transition Study (NLTS2). Implications for policy, practice, research, advocacy, and system development for children with emotional disturbance (ED) are discussed.
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Systematically Examining School Improvement Activities Including Special Education (2004)

Methodological and practical challenges present formidable barriers to conducting empirical evaluations of school reform initiatives. Systematic information about school reform and improvement, and its relationship to special education, is even more difficult to obtain. In this study, the authors developed a reliable and valid method to (a) systematically describe and assess the school improvement process and (b) examine its relationship to special education by including the investigation programs for students with emotional disturbance. A rigorous case-study design was used with 20 schools that varied in their levels of improvement activity. Results indicated that the School Improvement Index (SII) could reliably and validly discriminate between schools engaging in high levels of school improvement activities and those schools engaging in low levels. The use of the SII as a research tool and an aid to local schools engaged in school improvement is discussed.
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The Mental Health Needs of Youth with Emotional and Behavioral Disabilities Placed in Special Education Programs In Urban Schools (2004)

This paper describes the psychosocial characteristics of youth served in special education due to emotional disturbances in urban communities (N = 158). Data were also collected describing service utilization, academic functioning, and family characteristics. Ten schools in three mid-size urban cities participated. Results from the administration of standardized assessments revealed that the majority of students scored in the clinical range on the parent version of the Child Behavior Checklist and the Columbia Impairment Scale, indicating significant levels of emotional and behavioral impairment. Further, behavior problems began at an early age, and most of the youths’ school careers have been in a special education setting. The most common services currently being supplied by school personnel was individual counseling, while child-serving agency personnel were providing individual counseling for 17% of the youth.
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Mental Health Services: A Public Health Perspective (2004)

This chapter reviews the child mental health policy of the United States and identifies key policy issues at a time when greater attention is being paid to the area of children's mental health. The attention reflects both the severity of the problem of emotional, behavioral, and mental disorders in children and adolescents, and the inadequacy of present attempts to address these disorders. A brief history of child mental health policy is reviewed, and the prevalence and seriousness of the problem is discussed.
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Community-based Interventions in a System of Care and Outcome Framework. (2002)

This chapter summarizes the various initiatives and research findings that are driving the shift in the children’s mental health services system from the almost exclusive reliance on office-based or residential treatment to a community-based continuum of service options. The chapter introduces the topics covered in the remaining chapters in this book and presents an overview of the recent history of children’s mental health services and the current status of the field. The chapter summarizes the current emphasis and work on evaluating outcomes in the service delivery system for children and their families.
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A School, Family, and Community Collaborative Program for Children who have Emotional Disturbances. (2002)

This article provides the rationale, development, implementation and evaluation of a school-based program for students with emotional disturbances and who are served in a special education setting. The essential features of this program included a training program for professionals from the school and community agencies, the development and implementation of a strengths–based plan in which students and families are included as partners, and a method for evaluating the fidelity of program implementation. Results indicated a reduction in discipline referrals, better retention of students with emotional disturbances in their community school, and a trend toward improved emotional functioning. In addition, fidelity was positively related to higher reading achievement.
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A Comparison of the Academic Progress of Students with Emotional and Behavioral Disabilities and Students with Learning Disabilities. (2001)

This article presents findings from a study comparing academic progress over five years for students with emotional and behavioral disorders and students with learning disabilities. Factors related to academic achievement (attendance, behavior offenses, type of special education setting, school mobility and early retention) were examined as to their contribution to achievement over time for these two groups.
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Child and Adolescent Measures of Functional Status. (2000)

This chapter provides an overview of the commonly used assessments to measure functioning in children and adolescents. A description of each assessment is provided along with the psychometric properties, estimated time to administer, and the cost. Each measure is evaluated for its components, reliability, validity, and utility, including its strengths and weaknesses. Instruments reviewed include the Child and Adolescent Functioning Assessment Scale (CAFAS) and the Columbia Impairment Scale (CIS).
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The School and Community Study: Characteristics of Students who have Emotional and Behavioral Disabilities Served in Restructuring Public Schools. (2000)

This article presents preliminary results from an ongoing study of the effects of school reform and restructuring on students with serious emotional and behavioral disabilities (SED). Ten schools, ranging from grades K through 12, were studied with regard to accountability, governance, parent involvement, “includedness,” curriculum and instruction, and pro-social discipline. The schools in this study identify and serve students in special education programs at a higher rate than the national average. While school reforms varied between schools, similar patterns emerged, e.g., “a strong shared value among the staffs of these schools that everyone felt responsible for the education of all children” (p. 18). Methodology of the study is emphasized, and longitudinal studies of the children and their families will continue for two years.
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The Alternatives to Residential Treatment Study (ARTS): 12 Month Outcomes (1998)

This chapter reviews the Alternatives to Residential Treatment Study (ARTS) used to describe children and adolescents served in five innovative programs, and their outcomes over time (one year). Significant similarities and differences between the National Adolescent and Child Treatment Study (NACTS) and the ARTS outcomes are discussed. Findings from both studies reveal a long delay between symptom onset and implementation of comprehensive services, thus having implications for policymakers.
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Create Comprehensive and Collaborative Systems (1997)

The article presents a review of comprehensive and collaborative service systems for children with serious emotional disturbance and their families from the advocacy of the 1960s to its current status. A coalition of child-serving agencies (education, mental health, child welfare, and juvenile justice), health care, agency practitioners and the families they serve represent these systems. Recommended are strategies for overcoming the challenges of creating and maintaining comprehensive and collaborative systems in Vermont and other state models.
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National Adolescent and Child Treatment Study (NACTS): Outcomes for Children with Serious Emotional and Behavioral Disturbance (1996)

This article describes the results of a seven-year longitudinal study designed to gather information on the demographics and family characteristics, level of psychological and adaptive functioning, services received, and outcomes of children with serious emotional disturbances.
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For more information:

Krista Kutash, Ph.D.
Al Duchnowski, Ph.D.
Louis de la Parte Florida Mental Health Institute - MHC 2333
13301 Bruce B. Downs Blvd.
Tampa, FL 33612
813-974-4661

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