This article addresses key issues encountered in the growing movement in the United States toward expanded school mental health programs. These programs represent partnerships between schools and community mental health agencies. In such programs, school-hired mental health professionals work closely with community agency staff to provide a broad array of services to ensure effective prevention, assessment, and intervention for students in both general and special education (1). The primary goal of the collaboration between the education and mental health systems is to create a prevention-early intervention-treatment continuum and to develop a full range of care. This joint effort lessens the burdens on and liabilities of education systems, which are typically overtaxed (2). However, success depends on effective collaboration at many levels (3,4).
In this article, we describe the development of the national movement toward expanded school mental health programs and discuss issues related to the establishment of successful collaborations. In addition to calling for collaboration between education and mental health staff, we argue for the involvement of public health agencies in expanded school mental health programs to help in the development and enhancement of schoolwide efforts to promote mental wellness and to prevent emotional and behavioral problems.
This article is divided into three sections. The first section describes factors that have influenced the development of expanded school mental health programs. In the second section we outline several strategies for assessing the mental health needs of youths and the needs of existing programs, for obtaining resources, and for improving programs. In the third section we provide recommendations for improving collaboration between agencies that provide children's services in the development of school-based programs and for enhancing mental health promotion and prevention activities.
A serious gap exists between the mental health needs of children and adolescents and resources and effective programs available to meet these needs. The 1999 Surgeon General's report on mental health focused additional attention on this gap (5). Recent studies have confirmed suspicions that less than a third of youths who have documented mental health needs receive care (6). Barriers to care include poor knowledge of mental health issues and services, poor coordination within and between agencies, limitations in both the number and quality of staff, transportation issues, and excessive bureaucracy (1). These problems, along with difficulties associated with managed care in paying for services, severely compromise the mental health system.
Factors such as exposure to violence, mental health and substance abuse problems of caregivers, and abuse and neglect place children at risk of developing emotional and behavioral problems. At-risk children can be identified in the early grades of school, and effective interventions exist. However, early identification and intervention generally do not occur (7). When no interventions are implemented, risk factors have a cumulative effect. Children who experience two risk factors are four times more likely to be adversely affected than children who experience one risk factor; children with four risk factors are ten times more likely than children with one risk factor to experience an adverse impact (8).
Most school-age children and adolescents are not in a high-risk group. Nonetheless, many present needs for mental health intervention related to conditions of stress and risk in their lives. Dryfoos (9) estimated that at least a quarter of all children could benefit from mental health intervention. Despite the demonstrated need, a significant gap remains between those who could benefit from and those who receive mental health care (2,10). Moreover, prevention is a lauded but elusive goal.
As awareness of these problems increases, major efforts have been undertaken to improve the fragmented and incomplete nature of children's services and to proactively identify and address children's emotional and behavioral problems. Progress has occurred on several fronts. Major highlights of this progress include the creation of systems of care for youths with more serious emotional and behavioral problems, such as the Child and Adolescent Service System Program (10); efforts to improve education laws and regulations, such as the Individuals With Disabilities Education Act Amendments of 1997; the creation and improvement of school-based health centers, which bring a full array of health and mental health care to underserved youths (11); the development of interventions that focus on the strengths of children and their environments (12,13); and efforts to advance prevention science and to identify empirically validated skill training programs for children and adolescents in natural environments such as schools and neighborhoods (14,15).
These efforts are moving some communities toward the development of systems of care for all youths, not just those with more serious problems (16,17). Because schools are the most universal natural setting for delivering services to children, they are a major focus of the effort to improve children's mental health services (5). Significant progress has been made in the growth and improvement of mental health programs in schools. For example, the framework of expanded school mental health programs has been articulated, and critical issues have been addressed (1,2). Models for restructuring and improving mental health programs provided by education systems have been developed and disseminated (18). Additional progress has included the advancement of interdisciplinary approaches (3,4), development of quality improvement and evaluation approaches (19,20), and the progressive development of prevention science as it applies to the schools (21,22).
However, the movement toward expanding and improving school-based mental health services has not reached many communities, and broad school-based programs for prevention and promotion of mental health are lacking (5,6,16). Thus the challenge for communities is to develop a public mental health promotion and intervention system that emphasizes prevention, early intervention, and mental health promotion while providing effective treatment for children and adolescents (17). In the next section, we discuss strategies for moving toward such a system.
Recently, we developed a systematic strategy to analyze and plan for improvement in mental health programs for children and adolescents (17). Needs assessment is fundamental to this approach. Formal needs assessments are completed by analyzing sociodemographic data—for example, targeting schools for enhanced services on the basis of the proportion of students receiving free or reduced-cost lunches. Less formal assessments, such as focus groups, are conducted to obtain qualitative information about needs of youths in certain schools. When communities engage in such activities, they achieve a better sense of the immediate needs of youths and families.
The next step is to analyze the existing mental health programs of the various systems in which children are served. In most communities, these systems are the education, mental health, and public health systems. As part of the assessment, each system reports what is being done at three major levels of care: schoolwide or communitywide efforts that seek to prevent the development of mental health problems, efforts that seek to identify and intervene in emergent problems, and treatment programs for youths who have been identified as having problems (23). In most communities, such analysis reveals that only patchy tertiary care is being provided by schools for children and adolescents in special education and by public and private community mental health providers for youths with more established—and, typically, externalizing—problems (24). In general, public health agencies provide few or no population-based activities or support to promote mental wellness and to prevent emotional and behavioral problems among children and adolescents, even though promotion of mental wellness is within their missions.
Thus the challenge for the community is to fill in the gaps in the prevention-early intervention-treatment continuum and to develop a full range of care that involves close partnerships between major child-serving agencies. Moving toward such a system means structuring the roles of the education, mental health, and public health systems to maximize effectiveness. Even though the mental health and public health systems play substantial roles in such an approach, the leadership of the education system should be explicit, because the work is being conducted in the schools.
The role of the education system is to be involved in the spectrum of service provision from primary prevention to tertiary care, with tertiary care typically provided primarily to children and adolescents in special education. The education system's role can be structured through the use of the enabling framework (18,25), which includes programs in six service areas: classroom-based activities, student and family assistance, crisis prevention and response, support of students in transition, home involvement in schooling, and community involvement.
The mental health and public health systems would play augmenting roles. The framework for expanded school mental health programs (1,2) describes the role of the mental health system as assisting the school in the development of a comprehensive array of services by filling gaps from the early-intervention end of the continuum through the treatment end. Public health agencies can have a major impact in prevention. Although expanded school mental health programs already engage in some prevention activities, the demand for high-intensity services and the lack of time and resources impede their ability to do more, especially to undertake broad schoolwide prevention efforts (21). The resources of public health agencies could be used to help schools implement empirically supported primary prevention programs. Funds could be used for materials and training, to help advocates seek increased funding, and to provide staff support to facilitate program implementation by members of the school community.
The augmenting roles played by the mental health and public health systems can help address the significant need of many school systems to implement schoolwide prevention and mental health promotion programs. Because of limited resources and time, schools often are not able to implement these programs effectively. To be effective, such programs must provide highly interactive and engaging trainers, who meet with youths for many sessions—often 40 or more—over one or more years (22). The quality of the training could be improved and the demands on schools could be reduced if public health agencies sent outreach staff to the schools to provide the training.
When education, mental health, and public health systems collaborate closely, the community moves toward the development of a full continuum of prevention-early intervention- treatment for children and adolescents in the most natural setting—the schools. For collaboration to be effective and for real change to occur, individuals from diverse backgrounds and disciplines must work together. In the next section, we review important aspects of this collaborative work.
Multisystem collaboration is critical to improving children's mental health, and much has been written about it. However, collaboration is difficult to achieve. There are many barriers to true interdisciplinary work, including work schedules, the staggering amount of need, and the difficulties of merging activities when every person has preexisting commitments and limited time (3,26). However, these challenges may be surmounted as individuals recognize the benefits of creating collaborative relationships.
Staff from many agencies and various backgrounds must recognize each other's skills and strengths and rise above turf issues; defensiveness and negative attitudes will ultimately sabotage planning (16,27,28). An important strategy is to systematically identify potential barriers to collaborative efforts between staff of different disciplines (3). For example, positive relationships between teachers and mental health professionals will likely not develop if these groups do not understand each other's roles. When teachers misunderstand the roles of mental health professionals, they may refer only children who have discipline problems to mental health staff. For their part, mental health professionals may devalue teachers' abilities to manage classroom behavior. Such misunderstandings can sabotage relationships from the outset. Effective collaboration calls for mutual education about areas of expertise and desired roles (27).
To address these concerns, Flaherty and colleagues (4) described the responsibilities of the different disciplines working in the schools and illustrated how effective interdisciplinary teams can form and operate. The various disciplines—counseling, nursing, psychiatry, psychology, and social work—have overlapping areas of expertise. However, each has its own unique set of core skills. Increasing a group's awareness of what each member can contribute helps reduce confusion and enhances effective collaboration (16). It is particularly important to educate teachers about the expertise and skills of mental health professionals, because many teachers have not had opportunities to work with mental health professionals. Communication, establishment of clear and achievable goals, and expectations for emotional and behavioral change can prevent or minimize tensions between professionals.
An overarching goal is for mental health professionals and education staff to develop respect for each other's skills and talents. Generally, services improve significantly when respect and mutual trust are established. Establishing trust requires clearly defined roles and expectations; mutual understanding of the unique challenges of working in schools, including challenges related to legal and ethical issues; and cross-training and sharing of discipline-specific knowledge (3,4).
A key question in this work is how to effectively join resources and staff of community health and education agencies to expand the continuum of services available in the schools (16,27). An initial step is to bring leaders and staff from the agencies together with community stakeholders and to identify neighborhoods and schools with the greatest need for these services. The highest priority for new services should be given to schools in which children are at high risk because of such problems as neighborhoods characterized by high poverty and crime rates and schools characterized by transient students and poor academic performance. However, in most communities all schools would benefit from expanded and improved mental health services.
After a school has been selected, the next step is to develop an approach to service provision that meets the full spectrum of needs. The needs assessment described above lays the foundation for the development of services to meet local needs.
Any reform effort must confront the reality that the mental health needs of children and adolescents far outstrip our ability to respond to them. Thus we must ration prevention and care programs. How do we allocate services to ensure that the needs of youths in our most troubled schools are met and that the schools most receptive—and thus responsive—to system change are targeted (16)? Unfortunately, the neediest schools are often the ones that are the least receptive to change. Severe sociodemographic problems often contribute to an "entropy" that blocks a school's responsiveness to innovation. The ultimate goal should be the development of adequate funding to provide a full continuum of prevention, mental health promotion, early intervention, and treatment services in all schools.
The mental health needs of children and adolescents far surpass the ability of current systems to respond to them. Many youths who could benefit from effective mental health care do not receive it. Fortunately, a national movement is under way to close this gap and to enhance prevention, mental health promotion, and intervention programs in the schools. However, the development of more comprehensive school-based programs will bring together people who have not had close working relationships. As collaboration of people from different systems increases, tensions are unavoidable. These tensions can be minimized when mental health and education professionals and community stakeholders work together to plan, solve problems, and share knowledge with the goal of developing a true system of care for youths and families in their community.
This work was supported by cooperative agreement U93 MC 00174 with the office of adolescent health in the maternal and child health bureau of the Health Resources and Services Administration and with the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration.
The authors are affiliated with the University of Maryland School of Medicine. Send correspondence to Dr. Weist at the Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Maryland, 680 West Lexington Street, 10th Floor, Baltimore, Maryland 21201 (e-mail, firstname.lastname@example.org). This paper is part of a special section on multidisciplinary roles in the delivery of psychiatric services in the 21st century.