Dr. Cunningham, Dr. Stephan, and Dr. Weist are affiliated with the Department of Psychiatry, University of Maryland School of Medicine, 737 W. Lombard St., Rm. 426, Baltimore, MD 21201 (e-mail: email@example.com). Dr. Paternite and Dr. Flaspohler are with the Department of Psychology, Miami University, Oxford, Ohio. Dr. Adelsheim is with the Department of Psychiatry, University of New Mexico, Albuquerque, where Mr. Schan also was affiliated at the time of the study.
In the past two decades there has been considerable development of expanded school mental health programs (1). Through family-school-community partnerships, these programs provide a full continuum of mental health promotion and intervention to youths in general and special education in schools. Despite this progress, many issues continue to present challenges, including tenuous funding, limited conceptual clarity and awareness of school mental health services, poor training and supervision in evidence-based practices, and poor data systems to track progress in treatment (2). In addition, interventions such as broad promotion of student mental health and early prevention and intervention programs for mental health problems are not accessible or available to many youths (3).
The current U.S. mental health system has been described as disconnected, disorganized, and inadequate to meet the needs of youths (4). Therefore, there is a critical need to understand how to improve child and adolescent mental health systems. The report by the President's New Freedom Commission on Mental Health highlighted this need and identified several goals and recommendations for improving the quality of care within the mental health system (4).
This brief report is part of a larger study that described stakeholders' perspectives on various facets of school mental health and the mental health system. The purpose of the study was to better understand the perspectives of stakeholders as they relate to the goals and recommendations identified in the report by the President's Commission.
A qualitative evaluation was conducted in Maryland, New Mexico, and Ohio to explore current views on school mental health service delivery and the mental health system. Data were collected between July 2004 and May 2005. The selection of the three sites for this study reflects the advanced status of these locations in implementing school mental health and their geographic and cultural diversity. Focus groups were held in each state with stakeholders from the several groups: youths, parents, school- and community-based "frontline" providers and staff (for example, counselors and nurses), and child and school mental health advocates.
In each state the students and parents who participated were recruited via flyers that were posted in the schools. The families from Maryland were recruited from an urban school district that has predominantly African-American students. In Ohio the families were recruited from a suburban area with predominantly white students. New Mexico participants were recruited from rural areas throughout the state. The recruitment strategy yielded a sample of youths who had a range of experiences with the mental health system. The coinvestigators worked with agencies in their communities to generate an invitation list of frontline providers and advocates who were well connected to the local schools. The project was reviewed and approved by institutional review boards at all three sites, and consent for participation was obtained from students and adults.
Across the sites, a total of 105 persons participated in 11 focus groups. In Maryland the focus groups consisted of eight parents, eight students, nine frontline providers, and 13 child advocates. At the Ohio site there were eight parents, nine students, nine frontline providers, and 14 child advocates. The focus groups at the New Mexico site consisted of nine parents, nine students, and nine providers. Because of time and budget constraints, a focus group with the advocates was not conducted at the New Mexico site. The sample of participants was from diverse backgrounds and communities and had various levels of involvement with mental health, which provided a unique opportunity to explore the differences and similarities in the stakeholders' views.
Each focus group lasted approximately two hours and was facilitated by one of the project investigators. The focus group questions centered on mental health services, available community resources, involvement of primary care physicians, and recommendations for improvements in the mental health system. Audiotapes of the focus groups were transcribed by research assistants, and the transcriptions were then coded by two graduate students in psychology. Agreement between the coders was used to determine the data that were identified as key points.
For the purposes of this brief report, the transcriptions were reviewed to illustrate how the participants' views related to the goals and objectives of the report of the President's New Freedom Commission (4). A team of experts in school mental health reviewed the interpretations of the data. Unfortunately, because of time and budget constraints, we were unable to have the study participants review the authors' interpretations of the focus group discussions.
The first goal identified in the commission's report indicates the need to understand how essential mental health is to overall health. All of the providers, parents, and advocates in each of the states believed that this should be a high priority for schools, despite the recognition that the primary focus for most schools is academics, with little emphasis on mental health. Many of the providers and parents in all three states agreed that the definition of school success should encompass social success. An advocate stated that the most effective approaches to raising healthy children are integrated—not simply academic. One of the Ohio advocates stated, "We don't want happy failing kids or unhappy passing kids. We want to have the whole child work here."
It is of interest that although the participants recognized the necessity of an enhanced understanding of mental health, many parents, students, and providers in all three states agreed that the term "mental health" has a negative connotation, which they identified as a significant barrier to advancing the goal of understanding the key role of mental health in overall health. In particular, many students expressed concerns about use of the word "mental." A provider from New Mexico suggested that implementation of culturally sensitive services can help address the stigma regarding use of mental health services.
Another goal identified by the commission is the elimination of disparities in mental health. Disparities in access, resources, and treatment for people from ethnic minority groups were identified as significant concerns across all three states. Every stakeholder group agreed that funding often determines whether services will be available. They also noted that even when funding is available, services are not equally available to all children because long waiting lists, lack of insurance, and a limited number of service providers pose significant barriers to gaining access to mental health services. Although Maryland and Ohio have communities with accessible mental health services, several parents and teachers in those locales expressed concerns that they were not aware of the services that existed in the schools or surrounding communities. Another concern expressed by some stakeholders is that students have more difficulty gaining access to services outside the school system because of transportation problems; however, some parents noted that availability of school-based clinicians limits family involvement.
Many stakeholders expressed concerns about the quality of care provided in schools and communities. Several identified gaps in services provided in school mental health programs and community-based programs, including limited use of empirically supported interventions and the absence of a true continuum of care. All the stakeholder groups acknowledged that to provide high-quality mental health services, a sense of community needs to be established between mental health providers and the larger community, and providers need to conduct outcome research, increase coordination of services, and improve marketing efforts.
Remaining sensitive to the client's culture and environmental context emerged repeatedly in all of the focus groups as a theme in the discussion of the mental health needs of youths. Some Maryland parents believed that a lack of understanding of an individual's culture could lead to inaccurate diagnoses and family disengagement from treatment. Some students and parents believed that providers should have more "real-life experiences" so that they can relate better to the students. A student from New Mexico suggested that the service providers should be involved in various facets of the school and community so that they are recognized and more readily accepted by the public. Implementing the suggestions of these youths and parents could certainly aid in the provision of culturally competent services and reduction of mental health disparities.
The President's Commission identified early screening, assessment, and referral as priorities in advancing the mental health system and specifically recommended that school mental health programs be expanded and improved. All the advocates recognized that schoolwide mental health interventions can improve students' school performance; however, they noted the difficulty in obtaining the resources and support to implement such initiatives. Many of the students and parents expressed concerns about a lack of full-time counselors, staff turnover, ability to trust the counselor, and stigma associated with seeking mental health services as roadblocks to service accessibility in the schools. The concern about confidentiality was especially prevalent in New Mexico, because of the lack of anonymity that is common in small communities. Despite the aforementioned concerns, many students appreciated having mental health services provided in the schools.
All of the stakeholder groups agreed that physicians, students, parents, and school staff do not have enough information about mental health issues that affect youths. Even though they noted that that many school staff feel uncomfortable discussing mental health issues with students, several providers in New Mexico indicated that many teachers in their locales had successfully made appropriate referrals. Although many focus group participants suggested that teachers receive increased training so that they would be adequately informed about the mental health needs of youths, the community leaders and providers also recognized that many of the teachers are overwhelmed and already operating on "information overload."
To fully understand child and adolescent mental health systems and achieve momentum in efforts to improve them and identify potential obstacles to progress, it is critical that all stakeholders provide input into mental health programs and policies. One of the goals of the President's New Freedom Commission is for mental health care to be consumer and family driven. Listening to consumers and families can reveal strategies for marketing, collaborating, decreasing stigma, and improving service provision and access to care. The parents and students who participated in this study highlighted the need to include their voices in the transformation of the mental health system.
In light of recent policies related to requirements for academic achievement, stakeholders recognized the need for schools to raise their commitment to implementing school mental health services as a way to advance integrated strategies to reduce academic and nonacademic barriers to learning. To make this prospect appealing to school systems and administrators, it is critical to recognize system pressures to focus on academic interventions and to highlight the effectiveness of school mental health services in terms of outcomes that are relevant to schools.
Data from this study highlight the desire of school staff to have more training in mental health issues. However, staff often have limited time to engage in additional training initiatives. It is critical to resolve this conflict because teachers and school staff often become de facto mental health service providers. Working with school administrators to develop a plan to empower their staff with appropriate knowledge, skills, and resources is an imperative step in ensuring that youths with mental health problems are accurately identified and referred as early as possible.
Participants in this project recognized the inherent advantages of school mental health with respect to increasing accessibility and decreasing disparities in service delivery. However, they also noted that to eliminate disparities and improve access, efforts need to continue to decrease stigma, increase the number of providers in remote areas, improve family involvement, and address funding constraints that prevent schools from providing services to all youths and families.
Many of the parents and youths expressed concerns about providers' lack of integration in the larger community. To improve collaboration and decrease stigma, providers should consider engaging in activities that promote positive perceptions of mental health, such as hosting activities in the community (for example, family movie nights or discussion groups for teens), facilitating focus groups with community members, and sharing testimonies of service users. It is of interest that despite the diversity among the study participants, many expressed similar views on many of the topics. In fact, dissimilarities in the ideas expressed were limited.
Because most of the student and family participants in the focus groups were consumers of school mental health services, they may not provide a comprehensive view of all barriers to care. In addition, because of the small number of participants in the focus groups, we cannot draw conclusions about any particular group of stakeholders in a state, nor can we generalize from specific school districts to statewide initiatives. However, the stakeholders' voices illustrate some of the changes necessary to improve school mental health services and the mental health system. Obtaining the views and recommendations of those who are not using treatment and reaching out to the broader population are critical steps in making those improvements.
Recommendations from the stakeholders suggest a critical need for a shared agenda among schools, families, and communities. There is a great need not only for training but also with respect to addressing funding constraints, decreasing stigma, and developing quality services. The findings of this project underscore the need to involve key stakeholders in transforming the children's mental health system, and more specifically in efforts to expand the focus on mental health in schools. Analyses of advantages and challenges facing school mental health programs reveal that establishing collaborative partnerships with key stakeholders is imperative in the growth and success of this movement (5,6).
This project was supported by cooperative agreement U45 MC 00174-10-0 from the Office of Adolescent Health, Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, with cofunding by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. This project was also supported in part by project contract 062984-6B-PB-05P from the Ohio Department of Education. The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of Substance Abuse and Mental Health Services Administration or Department of Health and Human Services.
The authors report no competing interests.