National Survey on Expanded School Mental Health ...

Advances in School Mental Health Promotion

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National Survey on Expanded School Mental Health Services Nancy A Lever , Kerri L Chambers , Sharon H Stephan , Matthew JL Page & Aya Ghunney To cite this article: Nancy A Lever , Kerri L Chambers , Sharon H Stephan , Matthew JL Page & Aya Ghunney (2010) National Survey on Expanded School Mental Health Services, Advances in School Mental Health Promotion, 3:4, 38-50, DOI: 10.1080/1754730X.2010.9715690 To link to this article: http://dx.doi.org/10.1080/1754730X.2010.9715690

Published online: 22 Dec 2011.

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Date: 12 April 2017, At: 12:42

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Nancy A Lever Kerri L Chambers Sharon H Stephan University of Maryland Center for School Mental Health, Baltimore, MD, USA

National Survey on Expanded School Mental Health Services

Matthew JL Page University of Miami, Coral Gables, FL, USA Aya Ghunney University of Massachusetts, Amherst, MA, USA

Key words: expanded school mental health; surveys; workforce; evidence-based programs; school policy

Introduction Despite a shift to results accountability and ongoing quality assessment and improvement in health care (Ganju, 2006), children’s mental health services, and school mental health services in particular, still do not have a strong literature base documenting ‘usual care’. Having a baseline understanding of what is typical and not typical in school mental health programs would

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provide a foundation for improving quality. In the past two decades, school mental health programs for students have increased in number and breadth of service (MasiaWarner et al, 2006; Stephan et al, 2007; Weist, 2005). While there is greater understanding of services provided by and the staffing of school-employed mental health professionals, less is known about the services provided by school-based community mental health providers and, more specifically, Expanded School Mental Health (ESMH) programs in the United States. The term ESMH is used to refer to programs that augment school mental health services by school-hired

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In the 2007–2008 academic year, the Center for School Mental

practises and programs, and partnerships. Respondents reported on

Health broadly disseminated an electronic survey to Expanded School

156 ESMH programs. This paper highlights the results of the

Mental Health (ESMH) stakeholders in order to better understand

ESMH survey. Findings from the ESMH survey add to the limited

ESMH programs in the United States. The survey asked respondents

literature on what may be typical and not typical in ESMH

to share data about their ESMH programs across several domains

services and programming in the United States. Implications related

including staffing, funding, service modalities, evidence-based

to research, practise and workforce development are discussed.

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VOLUME 3 ISSUE 4 - October 2010 © The Clifford Beers Foundation & University of Maryland

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staff to provide a full continuum of mental health promotion and intervention for students in general, and special education through strong family–school– community partnerships (Weist, 1997). ESMH programs typically are affiliated with university, hospital and community mental health centers and complement services offered by school staff, often filling gaps in care in a given school, particularly for general education students. Ideally, ESMH programs support a broad array of mental health services, including universal, selective, and targeted prevention services for students. Clinicians in ESMH programs are encouraged not only to provide high-quality, evidence-based individual, family, and group counseling, but also to integrate with and participate in school activities, committees, and programs. For example, ESMH clinicians may join school improvement teams, provide teacher consultation and professional development for school staff, assist with family events and activities, and help implement classroom/school-wide interventions (such as Positive Behavioral Interventions and Supports, PATHS to PAX, Good Behavior Game). Following a brief review of the existing literature on the state of school mental health services in the United States, this paper will present findings from a recent national survey of ESMH, and will consider the implications for research, policy, and practise.

Literature review Rones and Hoagwood (2000), in their review of school mental health services, noted that: precisely what is provided by schools under the rubric of mental health services… is largely unknown. In their review of the literature, they identified 47 school mental health research studies published between 1985 and 1999 that met rigorous scientific criteria. More specifically, they included only studies that used randomized, quasi-experimental, or multiple baseline research design, included a control group, used standardized outcome measures, and had pre- and post-outcome assessment. Each of the evaluated studies was categorized by the focus of the targeted intervention: emotional and behavioral problems, depression, conduct problems, stress management, and substance use. Although Rones and Hoagwood found evidence that there were schoolbased programs that have an impact on a variety of emotional and behavioral problems in children and adolescents, they also expressed concern that there


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were no treatment studies in schools that evaluated impact of treatment by disorder type. They identified several evidence-based programs (EBPs) that were being implemented in some of these studies (including Positive Alternative Thinking Strategies, Project ACHIEVE, Family and Schools Together). While it is promising that programs with an evidence base are being used in schools and that many of these programs have been evaluated in school settings, it should be noted that there are numerous EBPs that have been developed and evaluated in university or clinic settings and have not specifically been developed and/ or evaluated in community, and more specifically, school settings (Burns et al, 1999; Weisz et al, 1992). Translating these programs into school settings may bring up challenges that interfere with standard programming as defined by the developers (for example length of session, number of subjects, supplies needed, quiet setting with no interruptions) and could thus affect outcomes. Little is known about the modifications, if any, that have been made to EBPs in order to deliver them in schools, and it is often unclear whether the ‘implementation’ of an EBP in a school involved the implementation support necessary (for example intensive coaching, fidelity evaluation) to ensure fidelity and program success. In another comprehensive national study conducted by the Centers for Disease Control and Prevention, the School Health Policies and Programs Study (Brenner et al, 2006), schools were surveyed on the provision of health and mental health care to students. State and district level data were collected using two questionnaires, one on mental health and another on social services. The questionnaires were self-administered and distributed by mail to a designated correspondent chosen by a lead education coordinator or assistant superintendant in each state or district. School-level data was obtained through computer-assisted interviews conducted with individuals selected because of their knowledge of the school mental health services available. Response rates were high, with completed questionnaires from 100% (N = 51) of state education agencies, 63% (N = 445) of districts, and 66% (N = 873) of schools. Respondents indicated that they provided many of the mental health or prevention services listed on the survey, the top five being crisis intervention for personal problems (83.8%), individual counseling (83.58%), identification of or counseling for behavioral or emotional disorders (79.18%), identification of or referral for physical, sexual, or emotional abuse (78.18%), and


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case management for students with behavioral or social problems (74.7%). The services provided least were services for gay, lesbian, or bisexual students (21.1%), physical activity and fitness counseling (28.2%), accident or injury prevention (30.2%), nutrition and dietary behavior counseling (34.0%), and eating disorders prevention (38.0%). It is important to note that, although this survey did not provide any specific information about the services provided by community agencies, it did show that 51.6% of schools reported having a contract or memorandum of understanding with community organizations or professionals, most (86.1%) communityprovided services coming from local mental health or social services agencies. While this survey helps to provide data that clarifies the types of mental health and social service provided in schools, it did not evaluate the quality of the services and, more specifically, which EBPs were being implemented in schools. Another study conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) examined mental health services in schools using a national survey (Foster et al, 2005). The primary goals of the survey included identification of mental health problems that are most frequently encountered in the school setting and the services delivered, coordination of services, qualifications of staff, and challenges related to use of data, funding, budgeting, and resource allocation. Information was collected using two questionnaires, one sent to the district that requested funding information, and another sent to the schools asking specific questions about mental health programming at each location. Random sampling was used to identify 2125 schools and 1595 districts across the nation, and an effort was made to capture a representative sample of public schools by level, size, region, and locale. There was a 61% response rate for schools and a 60% response rate for districts. Results from this survey indicate that schools are increasingly recognizing the importance of a public health model in provision of school mental health, as evidenced by the high percentage of schools nationally that are implementing prevention programs in regular education classrooms and providing services across a broad continuum. The study reported that 78% of schools were using school-wide strategies to promote safe, drugfree schools, and 72% are implementing universal programs to prevent alcohol, tobacco, or drug use. Many of these schools were providing individual and group therapeutic interventions for students. More specifically, 63% offered students prevention and pre-

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referral interventions for mild problems, 59% of schools provided students with curriculum-based programs to enhance social and emotional functioning, 47% offered peer counseling and support groups, 34% reached out to parents, and 15% provided school-wide screening for behavioral and emotional problems. Respondents from this survey identified some universal programs commonly used for enhancing social and emotional competency, but SAMHSA published only three of the specific programs that were used: Responsive Classroom, the Second Step Program, and Drug Abuse Resistance Education (DARE). Although the report of this survey identified a few programs used in schools, it did not include the full array of programs that were being implemented or whether these programs were considered to be evidence-based. In a more recent study, Kutash and colleagues (2006) reported on seven lists of empirically supported programs that were created by key organizations in the school mental health field. Although each of these organizations had various methods of evaluating each of the programs on their lists (creating a rating system, a set of criteria the programs must abide by, cost/benefit analysis, etc), none of the analyses involved reporting on the frequency of actual implementation of the programs listed. While there have been surveys of school mental health services as described above, and there is literature describing the ESMH framework (Mellin et al, 2010; Weist et al, 2006; Weist et al, 2005), little is written about the practical functioning of these programs, including staffing, funding, types of service modality offered, partnerships involved, and use of evidencebased practises and programs. There is no national repository of ESMH programs, but information about ESMH programs may be available at local and state levels. For example, in Maryland jurisdictions such as Baltimore City have compiled a directory of ESMH programs that is disseminated and made readily available to all stakeholders. In addition, led by the Maryland State Department of Education, several agencies, organizations, programs, and universities have collaborated on a survey to understand school mental health programs and services better. The Maryland Blueprint Committee, School Mental Health Workgroup (2009) surveyed and reported on findings related to services provided by school-hired staff as well as ESMH staff. The survey also asked about programs implemented, mental health staffing, data used to evaluate outcomes, family involvement, collaboration, and funding. The survey revealed that ESMH is available in 35.5% of


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Maryland schools, the percentage of schools with ESMH services ranging from 4% to 100% across the 24 jurisdictions. To our knowledge, this is the first survey that formally documents the number, staffing, and services provided by ESMH programs throughout an entire state. During the 2007–2008 academic year, the Center for School Mental Health, a federally funded resource center focused on advancing research, training, policy, and practise in school mental health, conducted a survey better to understand ESMH programs across the United States. This paper will highlight the results of the national ESMH survey and will consider implications for research, policy, and practise.

The survey Method The questions developed for the survey were based on the content areas that were included in the earlier Directory of Expanded School Mental Health Programs (2000). This directory was a collaborative effort between the Center for School Mental Health (CSMH) and the National Assembly on School-Based Health Care (NASBHC; www.nasbhc.org). The initial directory surveyed all members of the Psychosocial Services Committee of the National Assembly on School-Based Health Care and asked them to provide descriptions of the ESMH programs. Information gathered in this directory included services offered, population served, mental health staff, program partners, program coordinator, quality assurance, program evaluation, and funding sources. The lead author of this paper used the content areas from the survey and translated them into survey questions that could be responded to easily. The questions were reviewed by a panel of researchers and faculty members at the Center for School Mental Health, and recommendations were made to revise some of the questions and to add two open-ended questions pertaining to empirically supported practise (see Appendix A for the survey questions). Data collection began in December, 2007 and continued through February, 2008. An Institutional Review Board exemption was obtained through the University of Maryland, Baltimore. The survey was disseminated nationally through email announcements via the two federally funded national school mental health resource centers, the CSMH, and the Center for Mental Health in Schools at the University of California, Los Angeles. Stakeholders


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with knowledge of the staffing, programming, and demographics of the students and communities served were asked to complete the survey about the expanded school mental health program they were affiliated with. As part of the listserv announcement, recipients were asked that only one person per ESMH program complete the survey. While the survey was sent out to more than 10,000 recipients between the two national centers, it is impossible to determine how many of the individuals who received the email were actually connected to an ESMH program. It is also important to note that, even when connected to a program, multiple individuals could be associated with the same program. The listservs for both centers include diverse stakeholders interested in school mental health including educators, families, mental health providers, policy makers, advocates, and administrators. Anyone can sign up to be a part of the listserv, solicitation occurring at conferences, on center websites, at meetings, and through resource sharing. Given the unknowns described above and the fact that there is no documented number of ESMH programs at national level, it is impossible to provide a response rate. The questionnaire comprised 18 items and was disseminated via the Internet using SurveyMonkey.com, a platform for designing surveys, collecting data, and analyzing basic descriptive information about the results. Sixteen questions focused on basic descriptive data about staff, schools/students served and services offered. Two open-ended questions were included which required respondents to provide information about the evidence-based practises/programs being offered in their schools. A total of 179 respondents completed the survey. The CSMH research team reviewed all surveys to verify that each program met the previously stated definition of an ESMH program. There were 23 surveys that were omitted from inclusion. Reasons for omission were duplicate responses (10), non-service-based initiatives such as advisory groups and steering committees not connected to any service provision (5), web-based resources and magazines (2), frameworks/interventions that were being implemented in many schools across the country, but not an ESMH program such as Positive Behavior Intervention and Supports (2), involved an ESMH program outside the United States (3), or because the respondent did not indicate any information about type of service provision that could inform whether the program was an ESMH program (1). The remaining 156 surveys reflected data from programs that met ESMH criteria, and were included in analyses.


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Results Characteristics of the populations and communities served Approximately 90% of the survey respondents reported serving 35 or fewer schools, with a median of eight schools served. A wide range of number of schools was reported, some serving as few as one and others as many as 250. The 156 ESMH programs that respondents described were located in 33 states, and an additional program was located in the Virgin Islands and another in Washington D.C. Four states, Maryland, New York, Ohio, and Pennsylvania, each had at least ten different ESMH programs represented in the dataset. It is not surprising that these states had such strong representation, since each of them has a history and reputation for having strong expanded school mental health networks (www.sharedwork.org). Respondents indicated that their ESMH programs were more likely to serve urban communities (57.1%) than suburban (42.3%) and rural (32.1%) communities, and many reported serving more than one type of community (for example urban and suburban, suburban and rural). With regard to school type served, a majority of respondents reported serving elementary (75%), middle (79.5%), and high school (73.7%) students, a smaller percentage indicating that they served preschools (34.6%) and alternative schools (41.7%). Many programs served more than one school type (Table 1, below).

Demographics of students served The categories used to identify the racial background of the students served by ESMH programs were based on those set by the U.S. Census Bureau (2000). Of the 156 respondents to the survey, 103 could be analyzed in relation to student demographics. Other responses suggested misinterpretation of the question (for examples reported percentages far greater or less than 100%). A TABLE 1 Population Served by ESMH Programs

Background of clinical staff Of the 156 surveys, 114 could be analyzed in relation to background of staff. As above, other responses suggested misinterpretation of the question (for example reported percentages far greater or less than 100%). Most of the clinical staff employed by ESMH programs (76.6%) were identified as being Caucasian, and 16.3% were identified as African–American. As was true with the children and adolescents served by ESMH programs, a small percentage of clinical staff were identified as American Indian/Native Alaskan (1.3%), Asian (2.0%), Native Hawaiian/Other Pacific Islander (0.5%), or mixed (2.1%). Again, the category of Hispanic or Latin origin was presented separately in following the format of the U.S. Census Bureau (2001), and 9.4% (N = 146) of staff were reported to be of Hispanic or Latino origin. These results are consistent with the current workforce literature (The Annapolis Coalition on the Behavioral Health Workforce, 2007) that finds that ethnic background of the clinical staff serving ESMH programs is often not reflective of the diversity of students receiving services (Table 2). A majority of programs reported that their staff TABLE 2 Estimated Percentages of Background of Students Served and Clinical Staff

Respondents

majority of the children and adolescents served by ESMH programs were identified as Caucasian (56.7%) and African American (32.5%). A relatively small percentage of students were identified as American Indian/Native Alaskan (0.7%), Asian (2.3%), Native Hawaiian/Other Pacific Islander (0.6%), or mixed (6.8%). Given that the survey inquired about ethnicity following U.S. Census guidelines, the category of Hispanic or Latino origin was presented separately from the ethnicities noted above, and 145 of the 156 survey respondents answered this question. These respondents indicated that 16.7% of the students they served were of Hispanic or Latino origin (Table 2, below).

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Elementary

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75.0

Middle

124

79.5

High

115

73.7

American Indian/Alaska Native Asian African-American Native Hawaiian/Other Pacific Islander Caucasian Mixed (two or more races) Hispanic or Latino Origin

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41.7

*N = 145, **N = 146

Population Preschool

Alternative

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Number

%


Students Clinical staff N = 103 N = 114 0.7 2.3 32.5 0.6 56.7 6.8 16.7

1.3 2.0 16.3 0.5 76.6 2.1 9.4


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comprised social workers (78.2%) and/or counselors (64.1%). Trainees in the fields of social work, psychology, school psychology, education and/or nursing were employed as service providers by 32.7% of the respondents. A few respondents (5.1%) indicated that their mental health staff consisted of professionals less commonly employed by ESMH programs, including art therapists, behavioral consultants, computer specialists, physician assistants and crisis intervention specialists.

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FIGURE 1 Percentages of Services Offered by 80% or More of Respondents

Services offered All respondents (N = 156) responded to the question on services offered. The reported number of services ranged from one to 17, with a median of 13 and a mean of 12.2 (s.d. = 2.99). Service options included on the survey are listed in Table 3, below. Of the ESMH programs reported on in the survey, 84.0% (131 of 156) offered ten or more of the 17 services listed. Figure 1, below, shows the services ESMH programs provided most frequently. Psychiatric consultation, medication management, and psychological testing were the services reported as least offered by the ESMH programs. Many programs offered services that involved collaboration with teachers and school staff, such as participation in school teams, school climate enhancement, and classroom prevention activities. A number of respondents identified services that were not listed on the survey. Table 3 lists the additional services that respondents indicated under the ‘Other’ category that were provided within their ESMH program.

indicated that they collaborate with a School-Based Health Center (SBHC). The survey did not specify the extent of this collaboration. In addition to SBHCs, most ESMH programs reported having established partnerships with multiple school, hospital/university and community organizations. In fact more than half of the respondents reported partnering with community agencies, community mental health centers, social services and/or local departments of education. A few respondents indicated partnering with organizations not listed in the survey, such as parent/teacher associations, local library systems, and private non-profit organizations. Table 4,overleaf, shows the ten partnerships most frequently reported between ESMH programs and other organizations.

Funding

Partnerships All respondents (N = 156) provided information on partnerships. Approximately one third of respondents

All respondents (N = 155) reported information on funding (Figure 2, overleaf). More than half indicated receiving funding from local school systems. Other

TABLE 3 Additional Services Offered

Psychiatric rehabilitation program (PRP) Transition assistance/planning Collaboration with community organizations/agencies Community education Program development Recreational activities Employment preparation Community service opportunities Homework assistance/peer tutoring Adolescent alcohol and drug outpatient treatment


Safety/threat assessments and consultations Out-of-home placements Universal primary prevention programs Resource coordination Collaboration with school-based health center Consultation and strategic planning with community partners and funders PBIS Academic/college counseling and preparation Wrap-around


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TABLE 4 Top Ten Services Partnered with, by ESMH Programs Respondents

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Community agencies

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Community mental health centers

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Social services

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Local department of education

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Juvenile services

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Outpatient clinics

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Substance abuse agencies/programs

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Universities/colleges

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Other local agencies

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Hospitals

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37.2

common sources of funding include state and federal grants and the fee-for-service model, as well as grants awarded by private foundations and local mental health or public health administrations. In many cases, school mental health programs must acquire funding through multiple avenues (Evans et al, 2003), and results from the study followed this trend, 80.1% (125 of 156) of respondents indicating that they receive funding from more than one source.

Evidence-based practise Two open-ended questions were included in the survey which asked respondents to provide detailed information about the evidence-based practises/programs offered in their school(s). The first question enquired about specific evidence-based programs and practises being used (What evidence-based practises and programs does your program use?), and the second question inquired about how respondents emphasized evidencebased practise in their clinical programs (How are you

emphasizing high-quality evidence-based practise within your program?). Of the 156 eligible responses, 115 responded to both questions on evidence-based practises and programs in schools, 121 provided information about which programs his/her school was using and 123 indicated how evidence-based practises/programs are being emphasized. A list of all reported evidence-based practises and programs being used by respondents was generated, and those that had been identified by one of ten registries that evaluate the empirical evidence of such programs were incorporated in a summary matrix (Table 5, opposite). The matrix (csmh.umaryland.edu/resources/CSMH/ Matrix%206.08.pdf) includes a total of 33 programs, and provides the program name, intended age/grade level, issues or topics addressed by the program, the primary implementer, program structure and its inclusion in selected evidence-based registries. While the survey did not assess the extent of and fidelity of any implementation of EBPs, it did ask respondents about how the programs emphasized high-quality evidence-based practise within the ESMH. The question was intentionally open-ended, to allow respondents to provide their own perspectives on what is meant by how a program can encourage empirically supported practise. The responses on how the ESMH programs emphasized evidence-based practises and programs were classified into one or more of the following categories: using evidence-based programs and practises already established (N = 50), conducting evaluations and collecting outcome data to assess the impact of programs and services (N = 36), providing training/supervision to clinicians (N = 35), and following regulations/best practise principles (for example following National Wraparound Initiative guidelines, state regulations on quality and professional development (N = 13), and other (N = 10).

FIGURE 2 ESMH Funding Sources

Limitations One limitation of this is study is its use of self-report measures to obtain data. This creates the potential for respondents to present their program more favorably, particularly since this survey asked for contact information (although it was optional) and permission to contact if there were questions about the content of the response. It is uncertain how generalizable the results of this survey are with respect to ESMH programs nationwide; the current survey sample was a self-selected group, solicited via broad email listservs, and therefore it is not known

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TABLE 5 List of Evidence-Based Practises/Programs Aggression Replacement Training (ART) CARE (Care, Assess, Respond, Empower) Cognitive Behavioral Interventions for Trauma in Schools (CBITS) Coping Cat Coping Power Girls Circle Good Behavior Game (GBG) I Can Problem Solve: Raising a Thinking Child (ICPS) The Incredible Years Life Skills Training (LST) Lions Quest for Adolescence

Lions Quest Skills for Action Multisystemic Therapy (MST) Nurturing Parenting Program Olweus Bully Prevention Program Primary Project Promoting Alternative Thinking Strategies (PATHS) PATHS to Pax Positive Action Project ACHIEVE Project ALERT Project SUCCESS Project TNT: Towards No Tobacco

how representative these findings are with respect to all ESMH programs. Although this survey gathered information about the types of evidence-based practise and program being implemented in schools across the country, it did not obtain any data related to more specific fidelity issues including training, supervision, coaching, and general adherence to these programs. The degree of empirical support for identified EBPs varies considerably, and much of the research was not conducted in school settings.

Discussion Despite these limitations, the findings from this national study of ESMH programs provide helpful information about the array of models and programs offered. Based on a review of the literature, this is the only national study that focuses exclusively on the characteristics of ESMH programs across the United States. While there has been a lot of conjecture about what is typical and not typical in ESMH, the study provides some initial data to help better understanding of the composition and service provision of ESMH programs. Content areas of particular interest are staffing, funding, and the selection and implementation of evidence-based practises and programs. The implications of the survey for each of these categories are addressed below. With regard to staffing, the survey yielded several notable findings. First, expanded school mental health is an emerging interdisciplinary field that involves several types of professional and graduate trainee including social work, psychology, school psychology, counseling, psychiatry, education, and nursing. This interdisciplinary workforce presents unique education and training issues


Responsive Classroom (RC) Second Step Violence Prevention Program SOS Signs of Suicide Steps to Respect The Stop and Think Social Skills Program for Schools Strengthening Families Program (SFP) Teaching Students to be Peacemakers (Peacemakers) Teen Outreach Program (TOP) Teenscreen Too Good for Drugs and Violence Programs

and in general there is a dearth of approaches and research on such training (Huang et al, 2004, p174). Similarly, the survey documents challenges in delivering more intensive services, including psychiatric consultation and medication management, with findings consistent with the national shortage of child and adolescent psychiatrists (Thomas & Holzer, 2006). Also consistent with other national data, the survey documented a disparity in race/ethnicity between providers and recipients of services (Annapolis Coalition on the Behavioral Health Workforce, 2007), underscoring the need for enhanced training and recruitment of minority professional staff. The study found several existing models for funding ESMH services, most respondents reporting use of funding from a variety of sources, including local school system, federal and state grants, fee for service, private foundation, and local mental health/public health administration funding. This finding is consistent with the literature (Evans et al, 2003) and emphasizes the need for ‘braiding’ an array of funding avenues together, given the generally tenuous nature of funding for school mental health services. The findings of the survey highlight that many ESMH programs report using evidence-based programs and practises, ranging from universal programming to treatment interventions aimed at addressing specific mental health problems. However, the ‘depth’ of these evidence-based services is in question, given the significant demands to implement them with fidelity (Evans & Weist, 2004), including implementation support, moving beyond supervision to provide coaching, behavioral rehearsal, administrative support and peer support (Weist et al, 2009; Evans & Weist, 2004; Fixsen et al,


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2005; Graczyk et al, 2003). Self-assessment strategies are needed for ESMH programs to report honestly on strategies for high-quality and evidence-based services, to identify the need to implement these services and to share lessons learnt and collaborate on achievable approaches. Here, the University of Maryland Center for School Mental Health has developed the School Mental Health Quality Assessment Questionnaire (Weist et al, 2006), a self-assessment measure for school teams to assess and improve strategies for high quality and evidence-based services (see relevant resources on www.schoolmentalhealth.org). While only a descriptive survey with a relatively small sample reflecting a low return rate to an Internet-based recruitment strategy, this study does provide a snapshot of expanded school mental health programs in the U.S., involving collaboration between schools, families and other community systems (most commonly the mental health system). We hope that ideas here stimulate future efforts to track the progress of the field using methodologies that are descriptive, as in this case, and also qualitative, involving the perspectives of key stakeholders on limitations, strengths, barriers, ways to overcome barriers, and general recommendations to improve, grow and increase the impact of programs and services in this emerging field.

Acknowledgement Support for this project (Project # U45 MC00174) is provided in part by the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services.

Address for correspondence Dr Nancy Lever, Center for School Mental Health, 737 West Lombard Street, Baltimore, MD, USA. Tel: 01 410 706 0980. Email: [email protected]

References Annapolis Coalition on the Behavioral Health Workforce (2007) An Action Plan for Behavioral Workforce Development. SAMHSA: US. Department of Health and Human Services. Associated Press (2006) Shortage of child psychiatrists taking big toll. www.msnbc.msn.com/id/12190434/.

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Brenner ND, Martindale J & Weist MD (2006) Mental health and social services: results from the School Health Policies and Programs Study 2000. Journal of School Health 71 (7) 305–12. Burns B, Hoagwood K & Mrazek P (1999) Effective treatment for mental disorders in children and adolescents. Clinical Child and Family Psychology Review 2 (4) 199–254. Center for School Mental Health Assistance and National Assembly on School-Based Health Care (2000) Directory of Expanded School Mental Health Programs. Baltimore, MD: Author. Evans SW, Glass-Siegel M, Frank A et al (2003) Overcoming the challenges of funding school mental health programs. In: MD Weist, SW Evans & NA Lever (Eds) Handbook of School Mental Health: Advancing practice and research. New York, NY: Kluwer Academic/Plenum Publishers. Evans SW & Weist MD (2004) Implementing empirically supported treatments in the schools: what are we asking? Clinical Child and Family Psychology Review 7 (4) 263–67. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F (2005) Implementation Research: A synthesis of the literature. FMHI Publication #231. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network. Foster S, Rollefson M, Doksum T et al (2005) School Mental Health Services in the United States, 2002– 2003. DHHS Pub. No. (SMA) 05-4068. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Ganju V (2006) Mental health quality and accountability: the role of evidence-based practices and performance measurement. Administration and Policy in Mental Health and Mental Health Services Research 33 (6) 659–65. Graczyk PA, Domitrovich CE & Zins JE (2003) Facilitating the implementation of evidence-based prevention and mental health promotion efforts in schools. In: MD Weist, SW Evans & NA Lever (Eds) Handbook of School Mental Health: Advancing practice and research. New York, NY: Springer. Huang L, Macbeth G, Dodge J & Jacobstein D (2004) Transforming the workforce in children’s mental health. Administration and Policy in Mental Health 32 (2) 167–87. Kutash K, Duchnowski AJ & Lynn N (2006) SchoolBased Mental Health: An empirical guide for decisionmakers. Tampa, FL: University of South Florida, The Louis de la Parte Florida Mental Health Institute, Department of Child & Family Studies, Research and


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Training Center for Children’s Mental Health.

population/www/socdemo/race/racefactcb.html.

Maryland Blueprint Committee, School Mental Health Workgroup (2009) Maryland School Mental Health Survey. Maryland: Author.

Weist, MD (1997) Expanded School Mental Health services: a national movement in progress. In: T Ollendick and R Prinz (Eds) Advances in Clinical Child Psychology, Volume 19. New York: Plenium Press.

Masia-Warner C, Nangle DW & Hansen DJ (2006) Bringing evidence-based child mental health services to the schools: general issues and specific populations. Education and Treatment of Children 29 (2) 165–72. Mellin EA, Bronstein L, Anderson-Butcher D et al (2010) Measuring interprofessional team collaboration in expanded school mental health: model refinement and scale development. Journal of Interprofessional Care 24 (5) 514–23. Rones M & Hoagwood K (2000) School-based mental health services: a research review. Clinical Child Family Psychological Review 3 (4) 223–41. Stephan SH, Weist M, Kataoka S, Adelsheim S & Mills C (2007) Transformation of children’s mental health services: the role of school mental health. Psychiatric Services 58 1330–8. Thomas CR & Holzer CE (2006) The continuing shortage of child and adolescents psychiatrists. Journal of the American Academy of Child and Adolescent Psychiatry 45 (9) 1–9. U.S. Census Bureau (2000) Racial and ethnic classifications used in Census 2000 and beyond. www.census.gov/


Weist MD (2005) Fulfilling the promise of school-based mental health: moving toward a public mental health promotion approach. Journal of Abnormal Child Psychology 6 735–41. Weist MD, Ambrose MG & Lewis CP (2006) Expanded School Mental Health: a collaborative community-school example. Children and Schools 28 45–50. Weist M, Lever N, Stephan S et al (2009) Formative evaluation of a framework for high quality, evidencebased services in school mental health. School Mental Health 1 (4) 196–211. Weist MD, Sander MA, Walrath C et al (2005) Developing principles for best practice in Expanded School Mental Health. Journal of Youth and Adolescence 34 7–14. Weist MD, Stephan S, Lever N, Moore E & Lewis K (2006) School Mental Health Quality Assessment Questionnaire. Baltimore, MD: Center for School Mental Health Analysis & Action. Weisz JR, Weiss B & Donenberg GR (1992) The lab versus the clinic: effects of child adolescent psychotherapy. American Psychologist 47 (12) 1578–85.


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Appendix A: Survey of Expanded School Mental Health Programs: List of Questions and Response Categories* The goal of this survey is to learn more about and develop a database of existing expanded school mental health (ESMH) programs across the United States. Expanded school mental health (ESMH) programs provide a full continuum of mental health promotion and intervention for students through school-family-community partnerships. 1.

Please provide the following information about your expanded school mental health program Program Name: Address: Address 2: City/Town: State: Zip Code: Phone Number: Fax: Email: Web Address (if applicable):

2.

Who can we contact for more information regarding your program? Name: Phone Number: Email Address:

3.

How many schools does your program serve?

4.

How would you classify the community served by your expanded school mental health program? (Check all that apply) g Rural Suburban Urban

5.

Please use the categories below to document (approximately) the background of your clinical staff. Please use percentages*. American Indian/ Alaska Native Asian Black/ African-American

Native Hawaiian/Other Pacific Islander White Mixed (Two or More Races)

6.

For your clinical staff, approximately what percentage are of Hispanic or Latino origin?

7.

Please use the categories below to document (approximately) the background of the children and adolescents served by your school program. Please use percentages. American Indian/ Alaska Native Asian Black/ African-American

8.

Native Hawaiian/Other Pacific Islander White Mixed (Two or More Races)

For your students served, approximately what percentage are of Hispanic or Latino origin?

*Categories for Questions 5-8 were based on U.S. Census Bureau (2001) standards.

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What services does your program offer? (Check all that apply) Case Management Clinical Intakes/Evaluations Family Outreach/Collaborative Activities Group Therapy Medication Management Professional Development Psychological Testing School Climate Enhancement Teacher and Staff Consultation Other (please specify)

Classroom Prevention Activities Crisis Management Family Therapy Individual Therapy Participation on School Teams Psychiatric Consultation Referrals to Community Resources Small Group Prevention Activities

10. What population does your program serve? (Check all that apply) Preschool Middle School Alternative Schools

Elementary School High School

11. Check the composition of your current mental health staff and trainees (if applicable). For mental health staff, please only provide information on individuals who are employed by your program. (Check all that apply) Case Managers Education Specialists Marriage and Family Therapists Nursing Trainees Parent Educators/Specialists Play Therapists Psychologists School Psychologists Social Workers Other (please specify)

Counselors Education Trainees Nurses Paraprofessionals Pediatrician/Family Medicine Psychiatrists Psychology Trainees School Psychologist Trainees Social Work Trainees

12. Is your expanded school mental health program affiliated with any School-Based Health Centers? Yes No 13. What other school, hospital/university and community programs do you partner with as part of your expanded school mental health program? (Check all that apply) Advocacy Organizations Community Mental Health Centers Domestic Violence Programs Educational/Tutoring Programs Family Support/Advocacy Inpatient Programs Legal Assistance Programs Other State Agencies Outpatient Clinics Recreational Programs Social Services Student Mentoring Programs Universities/Colleges


Community Agencies Day Hospital Programs Early Childhood Education Programs Faith-based Community Organizations Hospitals Juvenile Services Local Department of Education Other Local Agencies Pediatricians and Other Health Providers Sexual Assault Programs State Department of Education Substance Abuse Agencies/Programs Other (please specify)


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14. How are you emphasizing high quality evidence-based practice within your program?

15. What evidence-based practices and programs does your program use?

16. What are your program’s funding sources? (Check all that apply) Federal Grants Hospital/University Funding Local Health Department Local School System State Budget Line Items State Health Department State School System Other (please specify)

Fee-for-service Local Budget Line Items Local Mental/Public Health Administration Private Foundations State Grants State Mental/Public Health Administration Taxes/Levies

17. Would you be willing to have this information shared in a database maintained by the Center for School Mental Health? This database will be used to answer technical assistance questions and will be shared at an aggregate level to document local, state and national trends. Yes No

18. If professionals are interested in contacting you for more information about your program, could we share your email address with them so that they can contact you directly? Yes No

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