Evaluation of expanded school mental health programs

Quality Improvement Activities and Expanded School Mental Health Services

Quality improvement (QI) activities, designed to enhance program evaluation efforts and to improve quality of care, have become increasingly important in children’s services research. QI activities examine outcomes and provide accountability data that can be very useful for telling the story of the development, implementation, and effectiveness of expanded school mental health (ESMH) programs. This article discusses the implementation and results of QI activities for two ESMH programs, one relatively new program, and one with 10 years of experience. When presenting each case example, the authors review key QI activities such as developing new measures and interventions, evaluating costs of care, and disseminating results to clinicians, program administrators, and funders. The article concludes with a discussion of the importance of QI in school-based mental health and reviews directions for future research and program development.

School-related and social-emotional outcomes of providing mental health services in schools

This study evaluated student outcomes of an expanded school mental health (ESMH) model that placed community mental health clinicians on-site in schools to identify and treat children with mental health needs. The first aim of this study was to consider school-related outcomes (suspension rates and attendance rates) for those students who received ESMH treatment (n = 159) were compared to a matched high-risk sample that did not receive such services (n = 148). Results demonstrated differences between groups over time on measures of suspensions and attendance but not academic achievement. The second aim of this study was to evaluate change in social-emotional functioning (Strengths and Difficulties Questionnaire Scores) over time for the treatment group. Results indicated significant improvements on several parent and teacher ratings. Despite limitations of the ESMH framework examined in this study, the overall results suggest some promising advantages for students who received ESMH services.

School mental health resources and adolescent mental health service use

OBJECTIVE

Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month DSM-IV mental disorders.

METHOD

Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use.

RESULTS

Nearly half (45.3%) of adolescents with a 12-month DSM-IV disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use.

CONCLUSIONS

School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with DSM disorders.

Cost-effectiveness of a school-based emotional health screening program

BACKGROUND

School-based screening for health conditions can help extend the reach of health services to underserved populations. Screening for mental health conditions is growing in acceptability, but evidence of cost-effectiveness is lacking. This study assessed costs and effectiveness associated with the Developmental Pathways Screening Program, in which students undergo universal classroom emotional health screening and those who have positive screens are provided with on-site clinical evaluation and referral.

METHODS

Costs are enumerated for screening and clinical evaluation in terms of labor and overhead and summarized as cost per enrolled student, per positive screen, and per referral. Cost-effectiveness is summarized as cost per student successfully linked to services. School demographics are used to generate a predictive formula for estimating the proportion of students likely to screen positive in a particular school, which can be used to estimate program cost.

RESULTS

Screening costs ranged from $8.88 to $13.64 per enrolled student, depending on the prevalence of positive screens in a school. Of students referred for services, 72% were linked to supportive services within 6 weeks. Cost-effectiveness was estimated to be $416.90 per successful linkage when 5% screened positive and $106.09 when 20% screened positive. A formula to estimate the proportion of students screening positive proved accurate to within 5%.

CONCLUSION

Information concerning costs and effectiveness of school-based emotional health screening programs can guide school districts in making decisions concerning resource allocation.

Innovations in preventive mental health care services for adolescents

PURPOSE

This descriptive study examined programs designed to provide mental health-related preventive services to at-risk adolescents.

METHODS

Qualitative interviews were conducted with state and local program directors and key personnel in public health and mental health departments and academic researchers who have initiated preventive services.

RESULTS

States and local communities offer varied mental health-related preventive services for high-risk adolescents in diverse settings. Services include public education, screening, early intervention for adolescents, and educational programs for primary care providers. Funding mechanisms include state general funds, foundation grants, and Medicaid and the State Children's Health Insurance Program dollars. Evaluation is essential to maintain services and to persuade funders and other stakeholders to sustain these efforts.

CONCLUSIONS

State and local prevention-related mental health programs have been implemented with limited funding, but significant local advocacy and community support. More extensive evaluation and cost effectiveness studies may encourage policymakers to expand services. Further data are necessary to determine how prevention-related mental health programs can best serve vulnerable youth.

Fulfilling the promise of school-based mental health: moving toward a Public Mental Health Promotion approach

School-based mental health (SBMH) programs and services are growing progressively in the United States for many reasons. However, the SBMH field is young and tenuously supported, and challenges are being confronted on many levels. There are major needs to continue to bring research-supported interventions into schools, and to better equip educators and mental health programs and staff in schools to function effectively. Articles in this special issue present the many challenges well and point to important directions for advancing SBMH. To truly advance the field a Public Mental Health Promotion approach is needed. Elements of this approach, in advancing training, quality assessment and improvement (including empirically supported practice), and advocacy and policy influence are discussed, as are strategic connections to the Community Science perspective and to the development of a growing Community of Practice in SBMH.

School-based mental health services in Baltimore: association with school climate and special education referrals

This study investigated the association between school-based mental health services and two proposed but untested outcomes of these services: (a) school climate and (b) patterns of referrals to special education. Results from a climate survey found that teachers and staff in eight elementary schools with expanded school mental health (ESMH) services gave higher ratings on the survey's mental health climate subscale than respondents from schools in a matched comparison group. No differences were found for the General Climate subscale of the survey. Results also indicated that teachers in ESMH schools referred fewer students to the special education eligibility process because of emotional and behavioral issues and that fewer students in ESMH schools were found eligible for special education for emotional and behavioral disabilities. Results of this study provide beginning evidence for the positive impact of ESMH programs on these two schoolwide indicators of functioning.