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: sstephan@psych.umaryland.edu). Dr. Kataoka is with the Department of Psychiatry, University of California, Los Angeles. Dr. Adelsheim is with the Department of Psychiatry, University of New Mexico, Albuquerque. Ms. Mills is with the Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore.

The failure of the nation's child mental health system to fully address the mental health needs of children and adolescents has been well documented and points to the need to reconsider current policy and practice (1,2,3,4). The lack of clear direction or a unified vision to guide efforts within the system arguably contributes to the inadequacy of care received by our nation's youths.

In 2002, President George W. Bush established the President's New Freedom Commission on Mental Health to analyze the state of the country's mental health system. After a year of study and input from more than 2,000 stakeholders, the commission concluded that "the mental health delivery system is fragmented and in disarray … leading to unnecessary and costly disability, homelessness, school failure and incarceration" (5). The final report of the commission, Achieving the Promise: Transforming Mental Health Care in America (5), highlighted unmet needs and barriers to care, including fragmentation and gaps in care for children and lack of a national priority for mental health care. The report articulates six goals and 19 recommendations that target dramatic transformation and improvement of child, adolescent, and adult mental health systems (see box on page 1332).

The commission unequivocally recognized that mental health services in schools are a critical component in rebuilding our mental health system for children. Given that the recommendations of the New Freedom Commission report are consistent with the goals of most school mental health programs, efforts have been made to identify the implications of the New Freedom Commission report for advancing a school mental health policy agenda (6,7). The New Freedom Commission report includes very specific and direct linkage to school mental health services and programs as described in goal 4, "Early mental health screening, assessment, and referral to services are common practice." To reach this goal, the commission recommended that we "improve and expand school mental health programs" (recommendation 4.2).

This article examines the intersection of school mental health and the New Freedom Commission recommendations in order to highlight the role of school mental health in the transformation of the child and adolescent mental health system. We conclude with specific recommendations for utilizing the New Freedom Commission report as a meaningful and useful framework for system transformation.

Throughout the United States schools offer youths unparalleled access to resources to address interrelated academic, emotional, behavioral, and developmental needs. With more than 52 million youths attending over 110,000 schools and more than six million adults working in schools, one-fifth of the U.S. population can be reached in schools (5). In fact, reports have documented that of the small percentage of children and adolescents who receive needed mental health services, schools are the most common setting in which children access this care (1,8,9). Further, data indicate that these services are indeed reaching youths, including youths from ethnic minority groups and students with less obvious problems, such as depression and anxiety, who are unlikely to access services in specialty mental health settings (10,11,12,13).

School mental health programs offer increased accessibility to students by reducing many of the barriers to seeking care in traditional settings, such as transportation, child care, and stigma, and by reducing the inefficiency of "no shows"; that is, when a student does not keep an appointment, a school-based provider has the ability to serve other students in the time slot (14). Further, evidence suggests that school mental health programs reduce stigma associated with seeking mental health support (15), increase opportunities to promote generalization and maintenance of treatment gains (16), and enhance capacity for mental health promotion activities as well as universal and targeted prevention effort (17,18). Compared with traditional outpatient mental health services, school mental health services can offer more ecologically grounded roles for mental health clinicians (that is, roles based in the natural environment of the student) (19). School mental health services have been shown to enhance clinical productivity, because students are more accessible to mental health staff (20).

In addition to these inherent advantages of school mental health services, there is growing evidence that school mental health programs can have a positive impact on a number of student, family, and school outcomes. These services have resulted in reduced emotional and behavioral problems, decreased disciplinary referrals, increased prosocial behavior, increased family engagement, and improvement in school outcomes, such as fewer disciplinary referrals, improved school climate, and fewer special education referrals (21,22,23,24,25,26,27,28).

Further, there is growing recognition by policy makers and consumers of the value of school mental health programs and services. A recent policy statement on school mental health released by the American Academy of Pediatrics (29) underscores many of these advantages, including improved access to a range of services and enhanced opportunities for service coordination. The policy statement advocates for effective collaboration between educators, primary health care providers, and mental health professionals in implementing high-quality school-based mental health services.

The University of Maryland Center for School Mental Health has convened meetings and conducted policy analyses to identify the most important connections between the New Freedom Commission report and the Achieving the Promise Initiative and school mental health. Four specific recommendations of the New Freedom Commission report were determined to have the most proximal connections to school mental health: reduce stigma, prevent suicide, screen and treat comorbid mental and substance use disorders, and the obvious, improve and expand school mental health programs. Ideas explored by the Center for School Mental Health in relation to each of these themes are discussed below, with an emphasis on the role of school mental health in creating system transformation.

Reduce stigma

Recommendation 1.1 of the New Freedom Commission report advocates for the implementation of a national campaign to reduce the stigma of seeking mental health care and a national strategy for suicide prevention. Less than 30% of individuals with psychiatric disorders seek treatment (30,31), and stigma is a significant barrier to help seeking and accessing services (32). Schools are a key venue for supporting a campaign to reduce stigma, and school mental health services naturally reduce obstacles to care related to stigma (32).

Focusing on mental health in schools provides both natural and formal opportunities for promoting antistigma messages related to mental health. With appropriate training and community support, school staff can normalize mental illness, convey positive messages about mental health, and encourage students to engage in activities that promote mental wellness. Formal avenues for reducing mental health stigma in schools include integration of mental health awareness into special and regular education curricula, including universal programs on social and emotional learning, prevention programs, and specialized interventions for problems. Simple messages, such as "mental health refers to thoughts, feelings and actions that contribute to success in life," can help to generalize the concept of mental health as applicable to everyone and to dispel negative connotations that mental health refers only to those with chronic mental illness.

Schools also reduce stigma by offering a naturalistic environment for youths and families to seek assistance for mental health needs. In contrast to traditional community mental health settings, which may be seen as disconnected from a family's daily environment, schools offer an ecologically sound alternative, providing services directly in the living and learning environment of children. The availability and accessibility of school mental health providers, access to key informants such as teachers, and the typical proximity of schools to children's neighborhoods all further increase the likelihood of care seeking. Because of their historic ties to children, families, and communities, schools can also serve as a natural place for families to be exposed to information about mental health and available services.

Prevent suicide

Schools are also a critical venue for developing and executing the second proposal of recommendation 1.1—to implement a national strategy to prevent suicide. As noted, schools offer a desirable site for both suicide prevention campaigns and programs for youths because of schools' ability to reach most youths, their inherent ties to families and communities, and the multiple opportunities for both formal and informal education about and prevention of mental health problems and psychosocial problems, including suicide.

Data from the 2003 Youth Risk Behavior Survey of a nationally representative sample of more than 15,000 high school students throughout the United States indicate that in the 12-month period preceding the survey 16.9% had seriously considered attempting suicide, 16.5% had made a plan for attempting suicide, 8.5% had attempted suicide one or more times, and 2.9% had made an attempt requiring medical attention (33). More than 60% of adolescents who commit suicide have mental health problems, which often have existed for a year or more before the suicide (34). There is increasing national focus on preventing teen suicide, as reflected in the Call to Action to Prevent Suicide by the U.S. Surgeon General (35) and the more recent strategy document (36) developed by the U.S. Department of Health and Human Services, the National Strategy for Suicide Prevention, (www.mentalhealth.samhsa.gov/suicideprevention). The latter effort represents the first national blueprint to address suicide and calls on schools to play a significant role in efforts to prevent suicide nationwide. Specifically, schools are encouraged to collaborate with other agencies, increase the implementation of research-supported prevention programs, train key school personnel to identify youths at risk of suicide, and develop effective suicide screening programs that are directly linked to needed services. It is also noteworthy that the Substance Abuse and Mental Health Services Administration (SAMHSA) is providing key federal leadership in suicide prevention, including a grant program that specifically emphasizes school-based activities.

School-based efforts to address suicide have been evaluated with mixed results (37). One suicide prevention strategy that is being implemented in a number of districts across the country is the school gatekeeper training model, which has several key components: training school personnel (gatekeepers) to improve their knowledge, attitudes, and skills to appropriately intervene with students at risk of suicide; providing crisis intervention to engage suicidal students' support networks; and facilitating suicidal students' referrals for treatment and counseling (38). A recent study found that among students who had been previously identified as at risk of suicide, use of this gatekeeper model can increase the proportion of students who access specialty mental health services in the community (39).

Some screening and prevention efforts, including Columbia University's TeenScreen Program (www.teenscreen.org) and the SOS Suicide Prevention Program (40), have demonstrated positive findings with respect to identifying at-risk youths, increasing knowledge about suicide and depression, and reducing suicide attempts. However, their success has also been paired with controversy related to concerns about the large number of false-positive screens and the limited capacity of schools to respond to serious mental health issues that may be unveiled when screening programs are implemented (41). Some of the concerns regarding school-based universal suicide screening are likely rooted in the stigma associated with mental health problems compared with other medical issues, such as vision and hearing, for which there is already schoolwide screening.

Federal support for universal mental health screening, as evidenced in the New Freedom Commission recommendations, reflects the recognition that for most individuals with mental illness symptoms begin in childhood, which suggests that early screening can play a critical role in providing prevention and early intervention to delay or eliminate the onset of symptoms (30). Weist and colleagues (42) have outlined a process for addressing concerns about school-based mental health screening that includes intensive planning, collaboration, training, supervision, and support to ensure the selection of age-appropriate screening methods; parental consent and student assent; trained and available staff and mental health providers to conduct screenings and follow-up treatment; and resolution of logistical and liability issues.

Screen and treat co-occurring disorders

The New Freedom Commission argues for the screening and integrated treatment of comorbid mental and substance use disorders in recommendation 4.3. The reality is that co-occurring disorders are more common than not among people with mental illness or substance use disorders (43). Even though the rate of youth substance use has been declining overall in the past decade, half of adolescents have tried an illicit drug by the time they graduate from high school (44). Of youths identified as having substance use disorders, it is estimated that up to 75% may have a co-occurring mental health disorder (45).

Despite this reality most communities do not have the capacity to respond to any level of substance abuse concerns among youths because of stigma, resource limitations, limited evidence-based approaches, and the failure of child-serving systems to take responsibility for the problem (46). Lack of ownership by a single community system is also reflected in schools, where substance abuse services are often not well integrated into the full continuum of mental health service delivery for youths (47). Although school-based mental health providers are often the "default" providers of substance abuse services, limitations in preservice training and lack of supervision and support in evidence-based substance abuse treatment for mental health providers leave many providers unprepared to address co-occurring mental health and substance use problems (48).

Despite the existing challenges to providing high-quality services to youths with comorbid mental and substance use problems, schools offer inherent advantages in this arena. Specifically, the federal focus on funding prevention programs, such as Safe and Drug Free Schools and initiatives of the Center for Substance Abuse Prevention, have advanced the integration of substance abuse programming into schools across all grade levels. Further, when evidence-based substance abuse prevention activities are implemented appropriately in schools, outcomes are positive and strong, including delayed initiation of use, decreased frequency of use, and slowed or arrested progression to the use of more hazardous substances (49). As discussed above, schools are also uniquely staged to offer screening of co-occurring mental health and substance use problems, given their ability to reach many students, the growing infrastructure to implement screening, and the evolution of guidelines to promote responsible, effective screening protocols (42). In addition, a number of prevention and intervention programs have been successfully implemented in school settings.

Improve and expand school mental health programs

Recommendation 4.2 of the New Freedom Commission report is to "improve and expand school mental health programs." When detection, prevention, and early intervention services for youths are provided in the context of schools, negative consequences such as school failure and comorbid substance abuse can be prevented. Coordinated school service approaches have been described that integrate assessments with on-campus prevention services, early intervention programs, and more intensive systems-of-care services for the few students who require multimodal treatments across child-serving agencies. However, as the Blueprint for Change: Research on Child and Adolescent Mental Health from the National Institute of Mental Health has noted, research advances in the development of efficacious mental health treatments for children and adolescents have had minimal translation into community practice settings such as schools (50).

Contributing to the slow progress of bringing improved services into schools is the reality that schools are underresourced to address nonacademic barriers to learning. Most districts offer mental health supports to only a small percentage of students, often those in or being referred to special education. Further, the quality of services for emotional or behavioral disabilities that are provided to youths in special education is questionable (51), with many youths receiving "no or poor" services to address their individual needs (52).

SAMHSA recently released the report of the first national survey of school mental health in the United States for the 2002—2003 school year (53). According to the report, over 80% of U.S. schools provided assessment for mental health issues, consultation for behavioral problems, and some level of crisis intervention services. Children with more serious issues are commonly referred to community agencies. Around two-thirds of schools reported providing individual and group counseling and some case management services. However, because of the way the survey was structured, respondents could indicate that a service was provided even it was for only one student or a few students, which likely resulted in exaggeration of services actually provided. Also notable was that education leaders at local and state levels expressed the perception that mental health needs of students were increasing while funding was not adequate to meet these needs and was predicted to decrease, not increase. These school leaders also expressed concern about the many barriers to successfully referring students for services in other community agencies. Thus these findings suggest that the majority of schools offer some level of mental health services but that these services are not sufficient to meet youths' needs and that connections with other community systems remain a significant challenge.

It has been challenging to advocate for school mental health services as a transformative force in children's mental health when schools are in essence undergoing their own transformation related to the No Child Left Behind Act. Despite evidence linking empirically supported mental health promotion to academic achievement and school success (28,54,55,56,57,58), education system reform has directed relatively little attention to nonacademic barriers to learning. Instead, these educational reforms have for the most part focused on grades and test scores for reading and math to the exclusion of other subjects, with no attention to the mental health and well-being of students. Further research is needed to bridge this divide between educational reform efforts and the transformation of school mental health and to encourage greater collaboration between educators and school mental health providers in the development of programs that support academic success.

An analysis of school mental health services and the New Freedom Commission report reveals their mutual goal of maximizing healthy development and success for all children through the provision of high-quality mental health services in a public health framework that ensures access to all youths and families. Although the New Freedom Commission report reviews critical dimensions for needed change, it does not detail how such change will occur or be funded. Systemic change is extremely challenging partly because of limited resources and resistance to movement away from the status quo. Without purposeful action from a diversity of stakeholders aimed at implementation of the New Freedom Commission recommendations, it is likely that the document will remain relatively unused. From a historical perspective, Friedman (59) noted, "the mere articulation of policy through legislation or regulation is rarely adequate to accomplish the goals of the policy." Below are suggestions for facilitating transformation of child and adolescent mental health services through the school system.

Demonstrate relevance to schools

In an era of paramount attention to the academic achievement of our children, school mental health has the advantage of articulating a powerful message linking mental health to school success. The argument for integrated approaches to reduce both academic and nonacademic barriers to learning is supported by mounting evidence demonstrating a strong positive association between psychological wellness and academic success (28,54,58). Research suggests that 46% of the failure to complete secondary school is attributable to psychiatric disorders (60). Thus it is not difficult to conceive of advocacy and public awareness efforts that highlight the need for attention to school mental health in overall mental health system change. For the transformation of children's mental health services to expand school mental health, it is necessary to generate understanding and buy-in from educators through the dissemination of clear and strong messages about the importance of mental health and the negative impact of mental illness on school success. To that end, the school mental health field must clearly define specific academic factors—for example, grades, discipline referrals, promotion, dropout, and school connectedness—that are influenced by mental health promotion and intervention.

Develop consensus among stakeholders

One way to develop messages about school mental health and programs that speak to the school community more clearly is to develop consensus across diverse school stakeholders in a true participatory partnership. From mental health antistigma campaigns on campus to early mental health intervention programs targeting at-risk students, all school mental health activities would benefit from being informed, created, implemented, and disseminated through a partnership of school stakeholders, including youths, families, educators, administrators, providers, and community members and leaders. This would help to ensure that the multiple missions and goals of school and community stakeholders are addressed and that school mental health programs are both feasible and culturally relevant and acceptable.

There is a significant need to promote true involvement of the public in discussions about mental health and transformation of the education system and ideas to advance school mental health. A number of strategies could be used to promote such public involvement. First, the New Freedom Commission report can be used as a tool for discussions about school mental health among diverse stakeholder groups. This is currently being done by the IDEA Partnership (www.ideapartnership.org and www.sharedwork.org). Second, the interdisciplinary nature of school mental health (with families and youths included as one of the disciplines) can be acknowledged, and interdisciplinary networking and training can be increased, such as the networking and training that occurs at the Center for School Mental Health annual conference on advancing school mental health (csmh.umaryland.edu). Third, social marketing efforts can be developed that speak to the promise and challenges of school mental health in plain language written for diverse stakeholder audiences.

Enhance community mental health-school connections

A major focus for the authors of this article has been advancing a shared family-school-community agenda, evidenced by strong family and youth leadership and strong collaboration between the education system and the child and adolescent mental health system in building school mental health. This has also been a major theme in the expanded school mental health framework and at the University of Maryland Center for School Mental Health.

A number of strategies to strengthen these partnerships are promising. A first strategy is reaching out to and encouraging leadership in relevant professional organizations to support this agenda. Such organizations include the National Association of State Directors of Special Education, the National Association of State Mental Health Program Directors, the Council of Chief State School Officers, the National Council of State Legislatures, and the American College of Mental Health Administrators, which already espouse and demonstrate support for such an integrated agenda. A second strategy is tracking strong examples of family-school-community collaboration to advance school mental health, which is done at annual conferences and in books (61,62), and moving toward Internet-based evolving directories of programs to promote networking and collaboration across communities, states, and organizations (www.sharedwork.org). A third strategy to strengthen partnerships is to capitalize on federal grant opportunities that promote such partnerships, such as System of Care (SAMHSA), Safe Schools/Healthy Students (SAMHSA and Department of Education), and Mental Health Integration Into the Schools (Department of Education).

Build quality assessment and improvement

An overarching construct in school mental health is advancing quality assessment and improvement, which can be viewed as inclusive of all relevant processes—needs assessment and resource mapping; stakeholder involvement; coordination of services in schools; connecting school mental health services in schools to related community programs and efforts; selecting, training, supporting, and coaching staff; emphasizing high-quality and evidence-based services; evaluating services provided to individual students and at the program level; and connecting evaluation findings to continuous quality improvement cycles and advocacy efforts. There is a great need for approaches to measure and improve the quality of school mental health services, and some measures are now available, including the School Mental Health Quality Assessment Questionnaire (63) and the Mental Health Planning and Evaluation Template (www.nasbhc.org).

Central in the quality agenda, and receiving increased attention, is the goal of making evidence-based services feasible in schools (64,65). Several successful models of development and implementation of mental health services in schools exist along the continuum of care and should be considered examples for future work in the area. Two representative examples are LifeSkills Training (www.lifeskillstraining.com) and Cognitive Behavioral Intervention for Trauma in Schools (66), both of which were developed for implementation in schools. These two programs have demonstrated positive outcomes among participants according to both psychosocial and academic indicators and have been endorsed by SAMHSA as model programs.

It is important to note that promoting quality assessment and improvement in school mental health will help to increase the likelihood of effective services that achieve outcomes valued by families and schools. This in turn will help to propel school mental health agendas in communities and states, contributing to real systems transformation as called for by the Achieving the Promise initiative.

Consider the organizational context of schools

In addition to improving the quality of school mental health at the provider and program levels, transformation of mental health services for youths must also attend to the system and organizational issues that are relevant for schools. Leadership support within an organization has been found to be an important factor in the adoption of new programs, and commitment from school administrators has been shown to strongly influence the implementation of prevention programs (67,68). Successful adoption of mental health programs has also been shown to be related to the climate and structure of the organization (69,70) and may be related to the readiness of a school to adopt a new school mental health program. Similarly, school mental health programs may be more successfully implemented if there is minimal burden on instructional staff in schools, especially given heightened pressures to perform under No Child Left Behind.

As evidence-based mental health programs are implemented in the school system, factors such as federal and state policies that influence the financing of school mental health programs can also greatly influence dissemination of evidence-based programs in schools. For example, SAMHSA's National Child Traumatic Stress Initiative has supported the dissemination of trauma-informed best practices in community settings such as schools (www.nctsn.org), which has resulted not only in improved quality of services in schools for traumatized youths but also in sustained services through community-school partnerships (25,71). Similarly the Mental Health Services Act in California provides for additional funds through state taxes to support the dissemination of mental health care, including prevention and early intervention services for children and adolescents in school settings. By having access to funding that does not compete with education dollars, schools may have more incentive to support mental health services on campus.

The President's New Freedom Commission report provides a launching point from which school mental health programs can expand the scope and depth of child mental health services. By delivering these services in a naturalistic community setting that minimizes some of the barriers to accessing care for youths and their families, school mental health programs can play a critical role in operationalizing the recommendations of the New Freedom Commission report, both in terms of supporting the resiliency of youths and providing effective services for those who need mental health care. The New Freedom Commission has built upon previous federal initiatives, such as the U.S. Surgeon General's reports on mental health (8,9) and the Children's Mental Health Conference (72), by emphasizing the need to improve the dissemination of evidence-based treatments in community settings and increasing the awareness of mental health issues across child-serving agencies.

This article has outlined some of the ways in which national school mental health efforts are aligned with the goals and recommendations of the New Freedom Commission. From this national agenda for transforming mental health care in the United States, several key strategies have also been discussed in terms of addressing these goals in schools, including demonstrating relevance to schools, developing consensus among stakeholders, enhancing community mental health-school connections, building quality assessment and improvement, and transforming school mental health services in the organizational context of schools.

Implications for a research agenda to support this transformation would also involve greater collaboration across academic disciplines and true partnerships with community stakeholders that inform the direction of the research questions and the design, implementation, and dissemination of services in schools. If school mental health programs are to improve and expand effectively, joint efforts by education and mental health researchers toward the achievement of both academic success and emotional well-being for students are necessary. Greater participatory research with school-community partners can enlighten the research agenda in such a way that barriers to providing services on campuses are reduced. Approaching mental health services in schools through the lens of an educator, a student, or an administrator will enhance the development of novel approaches to address stigma, treat co-occurring disorders, and prevent suicide—all of which are relevant to the school culture as well as culturally appropriate for the community being served.

Recent federal legislation to support mental health in schools reflects progress in advancing the school mental health agenda. Namely, the Mental Health in Schools Act of 2007, introduced by Senators Dodd, Domenici, and Kennedy, proposed significant funding to local education agencies to expand existing school mental health efforts through community-family-school partnerships. The bipartisan legislation emphasizes a public health approach to mental health that includes prevention and promotion, positive behavioral supports, and targeted intervention and stresses cultural and linguistic competence. Further, the proposed legislation underscores the importance of program accountability by requiring the use of evidence-based practices and outcome measurement.

Two other recent Senate bills reflect critical federal support for school-based services, including mental health: Senate Bill 600, the School-Based Health Clinic Establishment Act (introduced February 15, 2007) and Senate Bill 1669, the Healthy Schools Act of 2007 (introduced June 20, 2007). If passed, Senate Bill 600 would authorize the first-ever federal program for school-based health centers, the large majority of which would include mental health providers and all of which would provide at least some level of mental health care to students. The Healthy Schools Act of 2007 similarly supports the inclusion of mental health services in school-based health centers by ensuring procedures for payment under Medicaid and the State Children's Health Insurance Program to school centers certified by the Department of Health and Human Services. In addition, the legislation recognizes that mental health must be considered a part of comprehensive care by establishing a minimum criterion for "primary health services" as the core group of services offered by school-based health centers, including comprehensive health and mental health assessments, intervention, and treatment. Together with enhanced advocacy, effective policy, and development of established models of mental health care in schools, federal legislation of this nature is necessary to ensure that transformation of the children's mental health system is inclusive of schools.

This work 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 from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. It was also supported by grant 1-R01-MH-71015-01-A1 from the National Institute of Mental Health.

The authors report no competing interests.