by Charles Soule', Ph.D, Director of School-Based Mental Health Programs at the Morgan Stanley Children's Hospital of New York-Presbyterian.

Many families are unaware that they may be able to obtain needed mental health care for their children in their local schools. These services are typically referred to as School-Based Mental Health or "SBMH" and date back to efforts by the federal and state governments in the 1970's and 1980's to increase the availability and accessibility of mental health care for children and teens.

Many people are initially surprised by the idea of placing mental health care in schools, asking, "Aren’t the schools supposed to educate?" But most child and teen mental health problems play out in schools and, when unaddressed, these problems negatively affect a student's ability to succeed at school.

After families, schools are the most important influence on most kids. Most children and teens spend the majority of their time in school, and their success or failure there -- both academic and social -- predicts all sorts of other outcomes. Kids who chronically fail at school are more likely to suffer later from unemployment or underemployment, drug and alcohol use, violent relationships, and legal difficulties. While at school, these children and teens also have a larger-than-life impact on the school environment for everyone, often disrupting learning and social relationships for everyone.

Another common misconception is that the needed mental health services are already provided in schools by guidance counselors, school psychologists and school social workers. These professionals are typically employed by local school districts and are often generally referred to as student support service personnel. Although there are exceptions, in most cases these professionals do not provide formal mental health care of the type meant in this article. Most school student support personnel provide vital educational evaluation and placement services for students, and provide individual and/or group counseling to help students to better cope at school. When children or teens have more serious mental health problems, these professionals typically refer out to community mental health clinics or private mental health practitioners.

SBMH programs of the type meant here are sometimes provided by local school districts, but are often provided by outside health and mental health agencies in partnership with their local schools. These programs can either be only mental health services on-site at a school (common in elementary schools), or they can be full school health clinics with mental health components (common at middle and high schools). A more detailed description of these programs can be found in the 2000 scholarly article in Clinical Child & Family Psychology Review by Michelle Rones and Kimberley Hoagwood (abstract online).

Placing mental health services in schools has many benefits, including:

*Increasing mental health care openings - community mental health clinics cannot serve all the children, teens and families who need care, leading to long waiting times for an initial appointment and discouraging many from seeking help.

*Decreasing barriers -- distance from clinics, lack of insurance, and caretakers who must work long hours all make it difficult for families to get children and teens into clinics, even when space is available.

*Increasing comfort and decreasing stigma -- many children, teens and families feel more comfortable accessing mental health care in familiar school surroundings, as opposed to hospitals and clinics.

*Increasing participation in care-- mental health providers who work directly in the schools have much more access to kids and the number of missed appointments is far fewer than in clinics. Because of decreased stigma, parents and family may come more often also.

*Increasing coordination with schools mental health providers who work directly in the schools also have much more access to teachers and school administrators. For younger children, mental health evaluations in the school routinely include observations in class, the lunchroom and elsewhere, improving the provider's knowledge and understanding of a child. Providers also meet regularly with teachers and other school staff to get their feedback and to discuss ways that the classroom and school might better support individual children with mental health needs.

*Decreasing problem behavior from kids with serious mental health problems improves the learning and social environment for everyone -- teachers are able to spend more time on instruction and less time on discipline, and everyone benefits from a calmer, more civil and respectful school climate.

*Introducing classroom and school-wide changes that improve everyone’s mental health -- together with school staff, school-based mental health providers can design and implement campaigns that:

o educate students, families and school staff about important issues in child and
teen mental health;
o promote healthy coping skills;
o teach conflict resolution and anger management;
o and, improve the overall social climate in schools.

Nationally, SBMH programs tend to follow one of two models:

*Prevention and early identification programs-- the more common model emphasizes the kinds of classroom and school-wide mental health education and intervention campaigns described in the last paragraph. The rationale is that we need to improve mental health awareness and the classroom and school conditions that support everyone’s healthy functioning. Children and teens who have specific mental health problems serious enough to require care are identified through screening and/or consultation with school staff, are referred to local clinics for care. This is a great model, but it assumes both that there are adequate clinic spots for kids who need care, and that their families can get them there. When the children and teens in need of care don’t get it, their continued problem behavior pulls everyone down and reduces the effectiveness of the mental health campaigns.

*Mental health evaluation and treatment -- some mental health clinics duplicate some or all of their clinic-based services in their local school. The rationale is to provide the same level of care that a child and family would get at the clinic, but deliver it at the school. Again this is a great model because it increases the number of students with serious problems who get care, but the downside is that it is expensive and hard to support financially, and can serve many fewer children and families than the prevention model above. Beyond that, it is also less effective to focus all the SBMH resources on direct care, because the students served this way still return to classrooms and school environments that are less able to support them.

The better (but more expensive) SBMH model is a combination of these two -- providing full mental health care on-site in schools, but surrounded by very active education, outreach and prevention programs. To date, this comprehensive model exists in very few schools. One such example, however, comes from a large, public, inner-city elementary school with 900 children from pre-kindergarten through fifth grade. Based on conservative estimates of child mental health needs found in Mental Health: A Report of the Surgeon General (1999), approximately 90 children (10%) at this school would have diagnosable mental health problems that impair their ability to function. Off-site local clinics only serves about a third of these children. A combination of public and private grants allows the local hospital to provide mental health clinicians (psychologists, social workers, child psychiatrists and case managers) who treat 40 children and families annually at the school. These professionals meet frequently and intensively with school staff and families, both to coordinate care for the 40 children receiving direct mental health treatment, and to educate the larger school and family communities about child development and child mental health. Even with these school-based services, another 20 children need care that is not currently available.

The SBMH clinic at this elementary school is linked to a much larger health and mental health education and early intervention program provided by the local hospital's departments of pediatrics and child psychiatry. Literally every child and teacher participates in some arm of the prevention program, whose services include: reading readiness for Pre-K and Kindergarten children and families, nutrition and healthy lifestyles education for children and families, conflict resolution and stress management programs, social-emotional education and healthy coping, short-term activity groups (art, music, dance, and writing), and after-school and summer day camp programs.

Since the 1980's SBMH programs have spread to all 50 states and many communities nationwide. Still, due to funding limitations and continuing unfamiliarity with the need, SBMH programs of all stripes (prevention, treatment and comprehensive models) serve only a fraction of all children, teens and schools. Families interested in SBMH services should begin by asking school staff (principals and other administrators, guidance counselors, school psychologists and school social workers, teachers) whether such programs already exist at their school or at least in their district. If not, families can advocate actively and very effectively with local school boards and school superintendents to partner with local public mental health authorities, community health and mental health agencies, mental health training programs and medical schools to create and spread these vital services.

Many more resources for families and educators are available online through the two
large federally funded research and technical assistance centers for SBMH: The Center for School Mental Health Analysis and Action at the University of Maryland-Baltimore and The School Mental Health Project at the University of California, Los Angeles.