Challenges and opportunities in expanded school mental health

Promoting equity and justice in school mental health

Advancing equity and justice in school mental health can address inequities in school-based services and outcome disparities. The purpose of this special issue is to promote equitable and just systems and practices in school mental health to promote change in institutional practices that have produced and reproduced inequities over time. The four articles in this special issue clarify a process for advancing equity in school mental health by addressing justice-centered variables to promote connections across and within systems to realize a vision of comprehensive and integrated school mental health.

The Impact of Social Determinants of Health on the Efficacy of School-Based Interventions for Adolescents with ADHD

Adolescents with Attention-deficit/hyperactivity disorder (ADHD) experience significant impairment in functioning. There are multiple clinic-based interventions that address these impairments (e.g., behavioral parent training). However, clinic-based interventions are often associated with barriers to care (e.g., transportation and financial resources), which can limit access based upon social determinants of health (e.g., parental income). School-based interventions have been developed to address the impairments adolescents with ADHD experience, with the goal of also improving access to care and limiting the impact social determinants of health. Despite this, to date, there has been almost no research evaluating the role of social determinants of health on the efficacy of school-based ADHD interventions. In a sample of 222 adolescents with ADHD randomly assigned to receive two different interventions, the present study evaluates the impact of income, maternal education, single-parent status, and race, on intervention efficacy. Single-parent status had the greatest impact on intervention efficacy, resulting in diminished improvements for two of the three outcomes. There was also a significant moderation effect for income, but only for parent-rated homework performance. In addition, main effects were found for single-parent status and race that represent disparities present at baseline that remained post-intervention. Overall, this study suggests that although school-based models of service delivery have the potential to significantly improve access to care, social determinants of health, and single-parent status, in particular, still need to be considered and addressed.

Mental health provision in schools: priority, facilitators and barriers in 10 European countries

BACKGROUND

Although schools are a key setting for the provision of mental health support for young people, little is known about the facilitators and barriers for providing such support. This study aimed to collect information from schools in 10 European countries regarding the priority given to mental health support for students, existence of a mental health-related school policy, links with relevant external agencies, schools' perceptions on whether they are providing sufficient mental health support and the barriers to provision of mental health support.

METHODS

Data from 1346 schools were collected in France, Germany, Ireland, the Netherlands, Poland, Serbia, Spain, Sweden, United Kingdom and Ukraine through an online survey.

RESULTS

Around 3% of the surveyed schools indicated that mental health provision was not a priority, compared to 47% indicating that it was a high/essential priority. More than half the surveyed schools did not implement a school policy regarding mental health. Half the surveyed schools reported not providing sufficient support with the key barriers identified including limited staff capacity, funding, access to specialists and lack of national policy and less than a third of schools reported good or excellent links with local mental health services. However, the responses varied by country with 8-19% between-country variation across the study outcomes. Secondary schools reported significantly better links with agencies, were more likely to have a school policy and were less likely to indicate having sufficient existing support compared to primary schools. Privately funded schools reported that mental health support was a higher priority and identified less barriers to provision compared to publicly funded schools.

CONCLUSIONS

This study provides an up-to-date and cross-country insight into schools' perceptions regarding priority given to mental health support and the barriers they face in providing sufficient mental health and wellbeing support for their students. The cross-country comparisons allow for a better understanding of the relationships between policy, practice and implementation and provide a platform for shared experiences and learning.

Assessment, Prevention, and Intervention Activities in a School-Based Program for Children Experiencing Homelessness

Children who experience homelessness are at increased risk for a range of health and mental health problems. In spite of this increased risk, they are often less likely to receive appropriate services. School-based programs offer considerable potential to reduce the gap between needs and appropriate services for these youth; however, there are few examples of such programs in the published literature. This article provides information from a mental and physical health prevention program and needs assessment for at-risk children, who were experiencing homelessness or were from very low-income families, which was piloted during a summer camp program in an urban school. Results of the needs assessment indicated that children residing in homeless shelters reported less consistent access to medical and dental care than children residing with their families. It is interesting that children experiencing homelessness were more likely to report that they had participated in counseling than did children from low-income families. Satisfaction ratings of prevention activities conducted in the program were positive for students and teachers.

Connecting Students to Mental Health Care: Pilot Findings from an Engagement Program for School Nurses

Schools function as the major provider of mental health services (MHS) for youth, but can struggle with engaging them in services. School nurses are well-positioned to facilitate referrals for MHS. This pilot study examined the feasibility, acceptability, and preliminary efficacy of an engagement protocol (EP) designed to enhance school nurses' utilization of evidence-based engagement practices when referring youth to MHS. Participants were six school nurses and twenty-five adolescents in a large, urban school district. School nurses reported positive attitudes towards the EP, suggesting that they found it feasible and acceptable. Though there were small increases in school nurses' use of engagement practices and in adolescents' readiness for services following training, due to limited sample size, differences were not statistically significant. Still, pilot results suggest preliminary efficacy of training school nurses to strategically implement evidence-based engagement practices to increase adolescents' engagement in MHS.

Research Protocol: Development, implementation and evaluation of a cognitive behavioural therapy-based intervention programme for the management of anxiety symptoms in South African children with visual impairments

BACKGROUND

Childhood anxiety presents a serious mental health problem, and it is one of the most common forms of psychological distress reported by youth worldwide. The prevalence of anxiety symptoms amongst South African youth is reported to be significantly higher than in other parts of the world. These high prevalence rates become even more significant when viewed in terms of children with visual impairments, as it is suggested that children with physical disabilities may be more prone, than their non-disabled peers, for the development of psychological difficulties.

OBJECTIVES

The main aim of this study is to develop, implement and evaluate a specifically tailored anxiety intervention programme for use with South African children with visual impairments.

METHOD

A specifically tailored cognitive-behavioural therapy-based anxiety intervention, for 9-13 year old South African children with visual impairments, will be evaluated in two special schools. The study will employ a randomised wait-list control group design with pre- post- and follow-up intervention measures, with two groups each receiving a 10 session anxiety intervention programme. The main outcome measure relates to the participants' symptoms of anxiety as indicated on the Revised Child Anxiety and Depression Scale.

CONCLUSION

If the anxiety intervention programme is found to be effective in reducing symptoms of anxiety, this universal intervention will lay down the foundation upon which future contextually sensitive (South African) anxiety intervention programmes can be built.

Engaging youth and families in school mental health services

In this article, an overview is provided of strategies to engage youth and their families in school mental health (SMH) services throughout the course of treatment. Resources are outlined to help SMH providers determine which strategies are most suitable for youth and their families, based on outcomes desired, barriers to engagement, and stage of treatment. Four case vignettes are presented to describe implementation of these strategies.

A cluster randomized trial to evaluate external support for the implementation of positive behavioral interventions and supports by school personnel

Background

Urban schools lag behind non-urban schools in attending to the behavioral health needs of their students. This is especially evident with regard to the level of use of evidence-based interventions with school children. Increased used of evidence-based interventions in urban schools would contribute to reducing mental health services disparities in low-income communities. School-wide positive behavioral interventions and supports (SWPBIS) is a service delivery framework that can be used to deliver universal preventive interventions and evidence-based behavioral health treatments, such as group cognitive behavioral therapy. In this article, we describe our ongoing research on creating internal capacity for program implementation. We also examine the cost-effectiveness and resulting school climate when two different levels of external support are provided to personnel as they implement a two-tier SWPBIS program.

Methods/Design

The study follows six K – 8 schools in the School District of Philadelphia randomly assigned to consultation support or consultation-plus-coaching support. Participants are: approximately 48 leadership team members, 180 school staff and 3,900 students in Tier 1, and 12 counselors, and 306 child participants in Tier 2. Children who meet inclusion criteria for Tier 2 will participate in group cognitive behavioral therapy for externalizing or anxiety disorders. The study has three phases, baseline/training, implementation, and sustainability. We will measure implementation outcomes, service outcomes, child outcomes, and cost.

Discussion

Findings from this study will provide evidence as to the appropriateness of school-wide prevention and treatment service delivery models for addressing services disparities in schools. The effectiveness and cost-effectiveness analyses of the two levels of training and consultation should help urban school districts and policymakers with the planning and deployment of cost-effective strategies for the implementation of evidence-based interventions for some of the most common behavioral health problems in school children.

Trial registration

ClinicalTrials.gov identifier: NCT01941069

Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health

This article reviews the progression of a research program designed to develop, implement, and study the implementation of "achievable" evidence-based practices (EBPs) in schools. We review challenges encountered and ideas to overcome them to enhance this avenue of research. The article presents two federally funded randomized controlled trials involving comparison of a four-component targeted intervention (Quality Assessment and Improvement, Family Engagement and Empowerment, Modular Evidence-Based Practice, Implementation Support) versus a comparison intervention focused on personal wellness. In both studies, primary aims focused on changes in clinician attitudes and behavior, including the delivery of high-quality EBPs and secondary aims focused on student-level impacts. A number of challenges, many not reported in the literature, are reviewed, and ideas for overcoming them are presented. Given the reality that the majority of youth mental health services are delivered in schools and the potential of school mental health services to provide a continuum of mental health care from promotion to intervention, it is critical that the field consider and address the logistical and methodological challenges associated with implementing and studying EBP implementation by clinicians.

School-based anxiety treatments for children and adolescents

Anxiety disorders are the most common class of psychopathology among youth, yet many of these youngsters do not receive treatment. This is particularly concerning given the chronic course of anxiety disorders, which often lead to mood disorders, substance abuse, and serious impairment. Schools are an optimal venue for identifying anxious students and delivering mental health treatment given access to youth and ability to overcome various barriers to treatment. This article reviews four school-based treatments for anxiety disorders that have been evaluated in controlled trials. Discussion centers on feasibility, challenges to school-based implementation, and future research directions for this critical area.

Self-Disclosure and Mental Health Service Use in Socially Anxious Adolescents

Social anxiety disorder is highly prevalent in adolescence, persistent into adulthood, and associated with multiple impairments. Despite the development of efficacious treatments for socially anxious youth, few affected adolescents receive such treatment. This study examined service use in a sample of high school students (n = 1,574), as well as predictors of treatment delay and factors associated with adolescents' disclosure of social difficulties. Self-report measures of social anxiety and service utilization were administered by study staff to 10th- and 11th-grade classrooms across three public high schools. Consistent with the literature, results indicated low treatment utilization (14 %) and lengthy delays in treatment initiation. Symptom severity, impairment, and disclosing anxiety to school personnel were significant predictors of service utilization. Several demographic and illness-specific factors were associated with a higher likelihood of disclosing social discomfort. These findings underscore the important role of school personnel in identifying and referring youth with anxiety disorders. Implications are discussed for increasing access to services, including school-wide screenings and training of school personnel to recognize and provide intervention for anxious youth.

Prevention of anxiety symptoms in children: results from a universal school-based trial

The present study evaluated the effectiveness of a universal school-based cognitive behavior prevention program (the FRIENDS program) for childhood anxiety. Participants were 638 children, ages 9 to 12 years, from 14 schools in North Rhine-Westphalia, Germany. All the children completed standardized measures of anxiety and depression, social and adaptive functioning, coping strategies, social skills, and perfectionism before and after the 10-week FRIENDS program and at two follow-up assessments (6 and 12 months) or wait period. Children who participated in the FRIENDS program exhibited significantly fewer anxiety and depressive symptoms, and lower perfectionism scores than children in the control group at 12-month follow-up. Younger children (9-10-year-olds) displayed treatment gains immediately after the intervention, whereas older children (11-12-year-olds) showed anxiety reduction only at 6- and 12-month follow-up. Perfectionism and avoidant coping acted as mediators of pre- to postintervention changes in anxiety scores. This study provides empirical evidence for the utility of the FRIENDS program in reducing anxiety and depressive symptoms among German children.

A Universal Prevention Trial of Anxiety and Depressive Symptomatology in Childhood: Preliminary Data from an Australian Study

This paper describes the development and preliminary findings of a program designed to prevent the development of anxiety and depressive symptoms in children aged 10 to 13 years. Using a universal prevention approach, a total of 594 children were randomly assigned on a class-by-class basis to either a 10-session family group CBT program (FRIENDS) routinely implemented as part of the school curriculum, or to a comparison group. Pre-post intervention changes were examined universally, and for children who scored above the clinical cut-off for anxiety at pretest. Results revealed that children in the FRIENDS intervention group reported fewer anxiety symptoms, regardless of their risk status, than the comparison group at posttest. In terms of reported levels of depression, only the high anxiety group who completed the FRIENDS intervention evidenced improvements at posttest. Overall, these preliminary results appear to support the benefits of a school-based universal cognitive-behavioural intervention program. Implications of this study are discussed, and long-term follow-up measures are currently underway.

A Universal Prevention Trial of Anxiety Symptomology during Childhood: Results at 1-Year Follow-up

In 2001 we evaluated a universal prevention trial of anxiety during childhood, and also examined the effects of the program on levels of depression. Participants were 594 children aged 10—13 years from seven schools in Brisbane, Australia, who were randomly assigned to an intervention or control group on a school-by-school basis. The intervention was based on the group CBT program FRIENDS (Barrett, Lowry-Webster & Holmes, 1999a, 1999b, 1999c). Results were examined universally (for all children) and for children who scored above the clinical cut-off for anxiety at pre-test. At 12-month follow-up, intervention gains were maintained, as measured by self-reports and diagnostic interviews. Eighty-five per cent of children in the intervention group who were scoring above the clinical cut-off for anxiety and depression were diagnosis free in the intervention condition, compared to only 31.2% of children in the control group. Implications of these findings are examined, alongside limitations and directions for future research.

School-Based Mental Health Services: Funding Options and Issues

Approximately 18% to 22% of youngsters experience mental health problems and, of those, 5% to 8% have diagnosable mental disorders or serious emotional disturbance. Children in foster care experience even higher levels of mental health problems. Unfortunately, only 7% to 16% of those children actually receive mental health services—typically provided by schools. Consequently, school-based mental health services have moved in new directions in recent years, including increased training for teachers, infusion of more mental health practitioners, and renewed commitment to the wraparound approach. However, all of these require time and money. An often neglected area is the availability of federal funding intended to provide children and adolescents with access to mental health services in schools. The purpose of this article is to describe federal legislative mandates and initiatives that have funding mechanisms to provide mental health services to children in schools. The challenges schools face in implementing these services are also addressed.

Child and Adolescent Social-Emotional Development Within the Context of School

Children and adolescents exposed to violence may develop mental health problems, impacting their ability to develop appropriate social-emotional skills. Limited development of social-emotional skills has been associated with poor performance in school. A review of the literature was conducted to better understand social-emotional development in children and its role in a child's ability to function in the school setting. The developmental psychopathology framework is used to illuminate the dynamic relationship between children and their contexts. Specifically, the context of school is explored to identify its role in providing services that address the needs of children and adolescents with social-emotional limitations.

School-Based Intervention for Adolescents with Social Anxiety Disorder: Results of a Controlled Study

Social anxiety disorder, whose onset peaks in adolescence, is associated with significant impairment. Despite the availability of effective treatments, few affected youth receive services. Transporting interventions into schools may circumvent barriers to treatment. The efficacy of a school-based intervention for social anxiety disorder was examined in a randomized wait-list control trial of 35 adolescents (26 females). Independent evaluators, blind to treatment condition, evaluated participants at preintervention, postintervention, and 9 months later. Adolescents in the intervention group demonstrated significantly greater reductions than controls in social anxiety and avoidance, as well as significantly improved overall functioning. In addition, 67% of treated subjects, compared to 6% of wait-list participants, no longer met criteria for social phobia following treatment. Findings support the possible efficacy of school-based intervention for facilitating access to treatment for socially anxious adolescents.

School Entry After a Community-Wide Trauma: Challenges and Lessons Learned from September 11th, 2001

The purpose of this paper is to describe the implementation of a school-based trauma-specific mental health program in New York City following the terrorist attacks on September 11, 2001. This program aimed to serve children most at risk for developing mental health problems as a result of physical proximity (e.g., evacuation from schools surrounding the World Trade Center) to the trauma. As we present the components of the program, we will review the literature that guided our decision making. The ongoing struggle between searching for answers from established science and immediate needs in a crisis is highlighted. Lastly, a discussion of the lessons learned and recommended next steps is presented.

Mental health services in schools: the challenge of locating a psychotherapy service for troubled adolescent pupils in mainstream and special schools

In Part 1, the case is presented for school-based mental health services in terms of the low utilization of community-based clinics and the high dropout rate among young adolescents attending clinics in the community. The advantages and potential pitfalls of school-based services are also assessed. In Part 2, the paper discusses the lessons learned from delivering psychotherapy services in mainstream and special schools to tackle the mental health problems presented by troubled pupils. The author describes the schools and discusses the expectations among teachers of the psychotherapist and psychologist. The role of the psychotherapist and psychologist in the schools is outlined. The types of treatment approach, the setting for treatment, method of referral, parental consent, and links with the wider network of adolescent mental health services and evaluation of outcome are considered. Finally, the author discusses the tensions that can arise between the psychotherapist and psychologist and school staff and ways of overcoming them.

Toward a public mental health promotion and intervention system for youth

Substantial limitations exist at all levels of mental health care for youth in most communities in the United States. Particular gaps exist in the areas of prevention, mental health promotion, and early intervention programs. The national movement toward enhancing mental health programs for youth in schools offers an important opportunity to fill gaps in the prevention-services continuum toward the development of a Public Mental Health Promotion and Intervention System for Youth. A strategy--the Child and Adolescent Program Planning Schema (CAPPS)--is presented to analyze gaps in a community's system of mental health programs for youth, and to facilitate planning toward development of a full continuum of programs from broad, population-based prevention, and mental health promotion strategies to treatment of youth with more established problems.

Expanded school mental health programs: advancing reform and closing the gap between research and practice

Expanded school mental health (ESMH) programs provide a range of mental health services to youth in special and regular education including prevention, assessment, treatment, and case management. Despite the rapid growth of ESMH programs in the United States and elsewhere, many communities still do not have ESMH programs and those that do exist often fail to implement empirically validated intervention and treatment strategies. Systematic prevention efforts remain a lauded, yet illusive goal. For ESMH programs to fulfill their promise of improved access, increased productivity and improved behavioral outcomes, researchers, school-based mental health service providers, and educators must work together to move child mental health programs beyond limiting constructs and approaches. These issues are reviewed and an example of an "ideal" approach to implement best practices in schools and close the gap between research and practice is offered.

Implementing and maintaining school-based mental health services in a large, urban school district

The Dallas (Texas) Public Schools established the first school-based health center in the United States in 1969. In 1993 a partnership between two school principals, a school mental health professional, and the medical director of the county mental health center was the impetus for the first comprehensive school-based mental health center in Texas. In 1995 the programs joined together as Youth and Family Centers (YFCs) to provide physical health, mental health, and other support services to students and their families. The 10 strategically located school-based centers are directed by licensed mental health professionals employed by the district who lead a multidisciplinary team of physical health and mental health providers. Students served by the YFCs have fewer discipline problems, course failures, and school absences.