Improving mental health in schools

/ 9 December 2014 / Shawna
Eric Rossen, Katherine Cowan, Phi Beta Kappan Dec 2014/Jan 2015 vol 96 no. 4

Abstract

Students do not leave their mental health at the front door when they come to school. From wellness to serious illness, a student’s mental health status is integral to how they think, feel, interact, behave, and learn. Decades of research and experience have laid a solid foundation and framework for effectively providing mental health services in schools that protect student well-being, promote learning, reduce stigma, and improve access. Providing mental health services, ideally in a multitiered system of supports, is good for students, their families, educators, the community, and society at large. Until we take seriously the role of mental health in learning, school reform efforts, largely focused on teacher quality and instruction today, will fall far short of the goal of having all students thrive in school, at home, and in life. Raising awareness of the many children who come to school with mental health issues and then treating them appropriately is the best way to ensure they achieve their potential in school and life.

My son’s access to in-school counseling has been our door to hope that Cameron will have a successful life at home and at school. Parent statement on the Mental Health in Schools Act (Franken, 2013).

Every school has students who are struggling with mental health problems. Many face temporary challenges like conflicts with peers, divorce, deployment, or a death in the family. Some are dealing with chronic stressors that can cause psychological harm including poverty, community violence, homelessness, or abuse. And still others are coping with emerging or chronic mental illness such as depression, generalized anxiety disorder, and emotional-behavioral disorders.

Students struggling emotionally or psychologically cannot thrive or learn to their potential. Addressing student mental health is a prerequisite to learning and achievement, not an add-on or extracurricular luxury. In most cases, mental health problems don’t simply go away on their own but often become worse if they are not identified or if they are left untreated. The near-term consequences range from quiet misery and academic struggles to more serious behavior and safety risks. The long-term consequences contribute to our most intractable problems, including unemployment, civil disengagement, incarceration, substance abuse, lost productivity, and poor health (World Health Organization, 2003).

Raising awareness of the need for improved school-based mental health services is a central focus of our work at the National Association of School Psychologists (NASP). Our 25,000 members, like other school-employed mental health professionals — counselors, social workers and nurses — work side-by-side with teachers and administrators to address the learning, behavioral, and mental health needs of students. Schools are both ground zero for the effects of mental health problems in children and youth and critical players in providing services. Yet too many schools face this need with inadequate resources.

Wider angle focus

National attention given to children’s mental health has waxed and waned for years, mostly subject to the force of tragedies like high-profile suicides and school shootings. This narrow, crisis-driven focus is understandable given the intense public and media attention these events garner, but it misses the larger picture.

The country — and our schools — face widespread and intensive needs. More than one of five students at some point experiences a serious mental health disorder (Merikangas et al., 2010). This does not include students struggling with problems that don’t warrant an official diagnosis. Yet it equates to about 10 million students who need professional help in the K-12 public schools nationwide (National Center for Education Statistics, 2014). More to the point, in a high school of 750 students, about 150 students will experience a mental illness that at some point will interfere with their learning. Most struggle with issues related to thinking, mood, or behavior. These problems impair a student’s ability to concentrate, have positive relationships, and cope with adversity.

Faltering under the weight of this need is a grossly inadequate system of mental health services. With too few mental health providers, existing services often are not accessible and health insurance coverage is meager or nonexistent. Poor access and stigma result in the majority of students who need mental health services not getting them (Knopf, Park, & Mulye, 2008). This means that of those 150 high school students with a serious mental health problem, well over 100 are coming to school without receiving the help they need. Additional disparities exist in access to mental health services based on ethnicity, income, and location.

Where the kids are

Schools are a vital part of the solution to meeting this need. In many communities, schools are “the largest de facto provider of mental health services” (Foy & Perrin, 2010, p. S79), and, in some rural districts, schools are the only source of mental health supports for children. Among children who receive mental health services, an estimated 70% to 80% of them initially receive those services at school (Farmer et al., 2003; Rones & Hoagwood, 2000), largely through special education. School as a primary access point makes sense because almost every community has schools, and children and youth spend six or more hours a day there. Because adults in schools have regular contact with students, they can help create relationships, develop trust, and monitor students over time. Additionally, access to school-employed mental health professionals reduces many of the common barriers to seeking help, including cost, scheduling conflicts, transportation, fragmentation of interventions, and stigma associated with mental health issues.

Deep roots

Recognizing that students’ mental health affects their schooling has been a focus of forward thinking educators since the introduction of compulsory public education in the late 1800s. The concerns then, much like today, focused on the number of students coming to school with barriers to learning, related behavior and discipline problems, cultural disconnects between school staff, curriculum, and students and their families, and the conviction that failing to educate these students was bad for them, their families, and society (Flaherty & Osher, 2002).

In their infancy, school mental health services focused on a narrow subset of students in an attempt to identify and isolate those with problems. Educators and mental health professionals who dealt with them were often also segregated from the general education population and processes. Over the course of nearly 100 years, practices evolved in response to improved knowledge, growing need, and advocacy on the part of some educators and families of children with mental health problems.

Federal policy followed suit, albeit slowly, with the Education for All Handicapped Children Act in 1975. More than two decades later, the Individuals with Disabilities Education Improvement Act (IDEA) brought the most comprehensive standards and services requirements for meeting the needs of students with disabilities, including those with mental health needs. In 2002, the No Child Left Behind Act added limited grant programs for school safety and violence prevention that included funds for mental health services. Despite these important efforts, attention to need and access to help were structured primarily outside general education and not considered relevant to most students who did not meet criteria for a disability or disorder.

History reminds us that the very foundation of public education sought to address mental health, not ignore it. Our challenge today is to move away from the siloed approach and ensure that all students have access to a range of mental health services and to acknowledge the effect of mental health on academic, social, occupational, and life outcomes.

Ripple effects

The consequences of untreated mental health problems are significant and can ripple across a classroom or entire school community. They can touch every aspect of school life including discipline and safety, school climate, family engagement, instructional time, and teacher stress.

On an individual level, they can lead to difficulty following instructions, concentrating, problem solving, staying engaged and motivated, and exhibiting self-control. In many cases, educators incorrectly attribute these behaviors to willful disobedience or noncompliance. Students can also have difficulty regulating emotions and maintaining friendships, which can lead to a sense of isolation and disconnectedness. Some can be so immobilized by fear, depression, or anxiety that they avoid school completely.

Mental health problems do not solely affect students and their families. Mental illness often manifests in ways that are distracting and stressful to classmates and teachers. Other students engage in more risky or harmful behaviors, ranging from physical aggression and bullying to substance abuse and self-injury — all of which can undermine the perceived or actual safety of the school. However, most individuals with mental health problems are not violent, and extreme violence is very rare.

Viewed through this lens, we can see how mental health problems can impede achievement and why a comprehensive and integrated approach to school-based mental health is necessary.

Multitiered system of supports

Mental health exists on a continuum that encompasses mental wellness, temporary problems (e.g., parent deployment), chronic stressors (e.g., poverty, homelessness, community violence), and serious mental illness (e.g., depression, anxiety, bipolar disorder). Schools have a role at every stage along the continuum, including prevention and wellness promotion for the entire student population, identification and early intervention for those deemed at risk, and more intensive interventions for students with more serious, ongoing problems. (See Figure 1.) A multitiered system of supports (MTSS) is an effective framework for service delivery that reflects this continuum and integrates within the learning environment. MTSS, with three tiers, encompasses:

Universal wellness promotion and primary prevention — Tier 1 goals focus on promoting resilience, positive behavior and safety, developing a supportive school environment where all students feel valued, connected, and respected, and identifying students who may be at risk for or experiencing a mental health problem. This process employs whole-school approaches such as positive behavior interventions and supports, social-emotional learning curricula, and positive discipline practices, as well as universal screening for problems like depression or suicide risk. Effective primary prevention involves all school staff, emphasizes skills development, and can significantly reduce more costly, time-intensive individual interventions.

Targeted prevention and intervention — Tier 2 targets specific problems at the school- or classroom-level and is applied when an identified problem exists among a subset of students, such as social skills or small group counseling for anger management or grief. School mental health professionals assess students for and guide these interventions, often collaborating with classroom teachers.

From wellness to serious illness, a student’s mental health status is integral to how they think, feel, interact, behave, and learn.

Individual/tertiary intervention — Tier 3 provides indirect and direct student-level mental health services, including counseling and other therapeutic interventions. School-employed mental health professionals coordinate with community agencies and clinicians who often assist in providing time-intensive, clinical services.

All three levels provide an important function in meeting the diverse needs of all students — not just those with an identified mental illness — and can be offered concurrently within a school. (See the article by John E. Desrochers, p. 34 in this issue for a more extensive discussion of MTSS.)

Assessment and identification

Appropriate assessment and identification methods are key factors in helping inform mental health supports for students who need Tier 2 or Tier 3 services. Given that many schools already engage in schoolwide screening for academic problems, the infrastructure may be in place to integrate mental health concerns. Individual identification processes involve referrals by parents, staff, and other adults. Educators are particularly well-equipped to recognize a problem because of their ongoing relationships and interactions with individual students. Schools must be prepared to respond to identified needs through direct services or referrals to community providers. School-employed mental health professionals can offer comprehensive evaluations that take into account the overall school and learning context. Also, as active members of the school community, they can work directly with the student’s teachers and observe the student in various settings.

Lowering barriers and building bridges

A multitiered system of supports offers three crucial strategic advantages:

  • #1. They enable integrating mental health services with academic and behavioral supports by aligning with well-established models like response-to-intervention and positive behavioral interventions and supports.

  • #2. MTSS lowers barriers and builds bridges between special and general education by coordinating planning, expertise, and interventions. This collaborative approach benefits all students while reducing inappropriate special education referrals.

  • #3. MTSS facilitates coordination with community providers while also ensuring that services provided in school are appropriate to the learning context. This is very important as more schools are seeking partnerships with community agencies to meet student needs.

 

Just as children are not simply small adults, schools are not merely clinics with chalkboards. Services that fail to reflect the unique aspects of the school context risk being less than effective by missing opportunities to connect interventions and can be potentially counterproductive by interfering with instructional time or violating school law. MTSS allows schools to improve collaboration and make the best use of the expertise of both community providers and of mental health professionals on staff.

Untapped resources

Schools must have effective policies and funding before they can fully implement comprehensive mental health services, and educators should advocate for these supports at all levels of government. However, school leaders can take several steps to improve services without waiting for major policy shifts.

Make optimal use of school-employed mental health professionals. In many districts, due to poor staffing ratios and misunderstanding regarding their skills and expertise, these professionals are putting out fires, not providing necessary prevention and consultation services. Improving staffing ratios is important, and many professional associations, like NASP, have models of practice that guide districts in moving toward a comprehensive service delivery model.

Mine your data with purpose. Collecting schoolwide data on behavioral and mental health issues can help identify relevant issues and services to focus on. School psychologists can be a particularly good resource to help identify assessment tools and collect, analyze, and interpret data.

Work collaboratively. Schools must accept their role in providing mental health supports to all students if they wish to realize their goals for achievement. However, schools cannot and should not expect to meet the needs of all students alone; instead they should collaborate with community partners or even other schools or districts.

Tap all potential funding sources. In many states, school-employed mental health professionals are eligible providers under Medicaid, and schools can seek reimbursement for services. Public and private grants also can be good sources of funding for mental health services, particularly if they address a specific issue or involve a school-community partnership. Also, IDEA allows districts to spend up to 15% of funds on learning supports for general education students.

Engage families. Families are critical partners in supporting students’ mental health, yet often are one of the greatest untapped resources. Understanding their cultural attitudes and personal experiences toward mental health and seeking help is critical to successfully engaging families.

Among children who receive mental health services, an estimated 70% to 80% of them initially receive those services at school.

Conclusion

Students do not leave their mental health at the front door when they come to school. From wellness to serious illness, a student’s mental health status is integral to how they think, feel, interact, behave, and learn. Decades of research and experience have laid a solid foundation and framework for effectively providing mental health services in schools that protect student well-being, promote learning, reduce stigma, and improve access. Providing mental health services, ideally in a multitiered system of supports, is good for students, their families, educators, the community, and society at large. Until we take seriously the role of mental health in learning, school reform efforts, largely focused on teacher quality and instruction today, will fall far short of the goal of having all students thrive in school, at home, and in life.

 

Eric Rossen (erossen@naspweb.org) is director of professional development and standards at the National Association of School Psychologists, Bethesda, Md.

Katherine C. Cowan (kcowan@naspweb.org) is director of communications.

References