School Mental Health
Role of the Substance Abuse and Mental Health Services Administration and Factors Affecting Service Provision Gao ID: GAO-08-19R October 5, 2007The U.S. Surgeon General reported in 1999 that about one in five children in the United States suffers from a mental health problem that could impair their ability to function at school or in the community. Yet many children receive no mental health services. While many of the existing mental health services for children are provided in schools, the extent and manner of school mental health service delivery vary across the country and within school districts. Federally led initiatives have identified schools as a potentially promising location for beginning to address the mental health needs of children. Both the report of the Surgeon General's Conference on Children's Mental Health and the 2003 report of the President's New Freedom Commission on Mental Health--Achieving the Promise: Transforming Mental Health Care in America--identified school mental health services as a means of improving children's mental and emotional well-being. At the federal level, the Department of Health and Human Services' (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) has a stated mission of building resilience and facilitating recovery for people--including children at risk for mental health problems. Although SAMHSA is the federal government's lead agency for mental health services, other federal agencies and departments, such as HHS's Centers for Disease Control and Prevention (CDC) and the Department of Education (Education), engage in, or coordinate, activities related to school mental health services in various ways. SAMHSA works to achieve its mission chiefly by providing grants and technical assistance. For example, the agency uses grant funds and technical assistance to support the expansion of mental health service capacity and the use of evidence-based practices in mental health services. Typically, efforts that have been validated by some form of documented scientific data are referred to as evidence-based. Congress asked us to provide information on school mental health services and the role of SAMHSA in this area. In this report, we describe (1) SAMHSA's coordination with other federal departments and agencies to support mental health services in schools, (2) the efforts SAMHSA has made to identify and support evidence-based school mental health services and best practices for service delivery, and (3) factors that affect the provision of mental health services in schools.
SAMHSA coordinates formally and informally with other federal departments and agencies on school mental health services. The agency currently maintains two formal coordination efforts for school mental health services. It coordinates with (1) Education and DOJ for the SS/HS initiative, a key federal effort to directly support mental health services in schools; and (2) several federal departments and agencies serving children, including Education and DOJ, for the Federal/National Partnership, an effort designed to promote coordination related to children's mental health and substance use prevention. In addition to formal coordination efforts, SAMHSA officials maintain multiple informal or episodic coordination efforts with other federal departments and agencies, such as Education, CDC, and the Health Resources and Services Administration (HRSA), on a variety of activities related to school mental health services; these are based largely on personal relationships among agency staff. SAMHSA both identifies and supports the use of evidence-based school mental health interventions. To identify evidence-based interventions, SAMHSA uses the National Registry of Evidence-based Programs and Practices (NREPP). This searchable registry assists interested parties, including school and school district staff members, in identifying interventions to provide mental health services for children in schools. As of August 2007, slightly more than one-fourth of the interventions listed on NREPP were related to school mental health, including interventions designed to address aggressive behavior, depression, or school violence. SAMHSA also supports the use of evidence-based school mental health interventions through grant programs, including the SS/HS program. SS/HS requires grantees to use evidence-based interventions and provides technical assistance for the implementation of these interventions. SAMHSA also awards grants to support the use of evidence-based interventions through other programs not specifically designed for the school setting. Officials from the seven sites in our review identified coordination and close working relationships, support from "program champions"--advocates for the program--and school leadership, and sustainable funding and staffing as factors that can affect the provision of school mental health services. Because mental health professionals focus on students' emotional health and education professionals focus on academic achievement, coordination between these differing missions can enhance the provision of school mental health services. School officials from sites in our review recognized that addressing students' mental health needs can improve their academic achievement. Site officials told us that, in addition to being aware of a school's academic mission, mental health providers need to be cognizant of students' academic schedules and responsibilities. For example, sites avoided providing services during testing periods. Coordination between sites and external stakeholders, such as community mental health or social service agencies, can also enhance the provision of school mental health services by allowing schools to build relationships with other agencies that influence the lives of students. Sites also emphasized the importance of working closely with existing school health and mental health staff. By doing this, sites can avoid overlap in services provided to students. Site officials stressed that one or more program champions and support from school leaders can play a role in implementing school mental health services; conversely, the loss of either of these can threaten program continuity. Finally, site officials noted that difficulties securing and sustaining both funding and mental health service provider staff have affected the ability to implement school mental health services.
GAO-08-19R, School Mental Health: Role of the Substance Abuse and Mental Health Services Administration and Factors Affecting Service Provision
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United States Government Accountability Office:
Washington, DC 20548:
October 5, 2007:
The Honorable Edward M. Kennedy:
Chairman:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
Dear Mr. Chairman:
Subject: School Mental Health: Role of the Substance Abuse and Mental
Health Services Administration and Factors Affecting Service Provision:
The U.S. Surgeon General reported in 1999 that about one in five
children in the United States suffers from a mental health problem that
could impair their ability to function at school or in the community.
Yet many children receive no mental health services. While many of the
existing mental health services for children are provided in schools,
the extent and manner of school mental health service delivery vary
across the country and within school districts.[Footnote 1] Federally
led initiatives have identified schools as a potentially promising
location for beginning to address the mental health needs of children.
Both the report of the Surgeon General's Conference on Children's
Mental Health and the 2003 report of the President's New Freedom
Commission on Mental Health--Achieving the Promise: Transforming Mental
Health Care in America--identified school mental health services as a
means of improving children's mental and emotional well-being.[Footnote
2]
At the federal level, the Department of Health and Human Services'
(HHS) Substance Abuse and Mental Health Services Administration
(SAMHSA) has a stated mission of building resilience and facilitating
recovery for people--including children at risk for mental health
problems. Although SAMHSA is the federal government's lead agency for
mental health services, other federal agencies and departments, such as
HHS's Centers for Disease Control and Prevention (CDC) and the
Department of Education (Education), engage in, or coordinate,[Footnote
3] activities related to school mental health services in various ways.
SAMHSA works to achieve its mission chiefly by providing grants and
technical assistance.[Footnote 4] For example, the agency uses grant
funds and technical assistance to support the expansion of mental
health service capacity and the use of evidence-based practices in
mental health services. Typically, efforts that have been validated by
some form of documented scientific data are referred to as evidence-
based.
You asked us to provide information on school mental health services
and the role of SAMHSA in this area. In this report, we describe (1)
SAMHSA's coordination with other federal departments and agencies to
support mental health services in schools, (2) the efforts SAMHSA has
made to identify and support evidence-based school mental health
services and best practices for service delivery, and (3) factors that
affect the provision of mental health services in schools.
To address these objectives, we reviewed materials related to SAMHSA's
efforts to coordinate activities related to school mental health
services with other federal departments and agencies. We also reviewed
materials related to SAMHSA's efforts to identify and support the use
of evidence-based interventions. These materials included program
descriptions and grant announcements related to federal programs that
support school mental health services, as well as agendas and summary
documents from interagency meetings related to children's mental
health. We conducted interviews with SAMHSA staff, as well as staff
from other HHS agencies who interact with SAMHSA or conduct activities
related to school mental health services. In addition, we interviewed
staff from Education's Office of Safe and Drug-Free Schools and the
Department of Justice's (DOJ) Office of Justice Programs, which
participate in activities related to mental health services and
violence prevention programs in schools. We also interviewed experts in
the field of mental health services and representatives of mental
health provider groups and school administration associations.
Information on mental health services provided to students who qualify
for special education services through the Individuals with
Disabilities Education Act (IDEA) was outside the scope of our
work.[Footnote 5]
To provide information on factors that affect the provision of school
mental health services, we conducted interviews with representatives
from seven selected sites--schools and school districts--and reviewed
documents, including their program descriptions, training materials,
and evaluation reports. We conducted interviews on site at five
locations, two in Connecticut and three in Ohio; and by telephone with
two locations, one in Florida and one in North Carolina.
To select our seven sites we:
* Interviewed officials from federal agencies and associations, as well
as experts in the area of school mental health, to identify states,
localities, school districts, and specific schools considered to be
active in the area of school mental health services.
* Selected a sample of 7 sites from approximately 53 identified
locations based on the following criteria: The sites selected were to
include a mix of urban and rural settings, settings with school-based
health centers, and at least 1 site currently receiving funds through
the federal Safe Schools/Healthy Students (SS/HS) and Grants for the
Integration of Schools and Mental Health Systems Programs.
Because we used a nongeneralizable sample to select our sites, the
information provided cannot be used to make inferences about other
programs. In addition, the information provided by program officials
does not reflect all efforts under way in their locations related to
school mental health services. (For additional information on our
methodology, see encl. I. For more information on sites in our review,
see encl. II.)
We conducted our work from March 2007 through September 2007 in
accordance with generally accepted government auditing standards.
Results in Brief:
SAMHSA coordinates formally and informally with other federal
departments and agencies on school mental health services. The agency
currently maintains two formal coordination efforts for school mental
health services. It coordinates with (1) Education and DOJ for the SS/
HS initiative, a key federal effort to directly support mental health
services in schools; and (2) several federal departments and agencies
serving children, including Education and DOJ, for the Federal/National
Partnership, an effort designed to promote coordination related to
children's mental health and substance use prevention. In addition to
formal coordination efforts, SAMHSA officials maintain multiple
informal or episodic coordination efforts with other federal
departments and agencies, such as Education, CDC, and the Health
Resources and Services Administration (HRSA), on a variety of
activities related to school mental health services; these are based
largely on personal relationships among agency staff.
SAMHSA both identifies and supports the use of evidence-based school
mental health interventions. To identify evidence-based interventions,
SAMHSA uses the National Registry of Evidence-based Programs and
Practices (NREPP). This searchable registry assists interested parties,
including school and school district staff members, in identifying
interventions to provide mental health services for children in
schools. As of August 2007, slightly more than one-fourth of the
interventions listed on NREPP were related to school mental health,
including interventions designed to address aggressive behavior,
depression, or school violence. SAMHSA also supports the use of
evidence-based school mental health interventions through grant
programs, including the SS/HS program. SS/HS requires grantees to use
evidence-based interventions and provides technical assistance for the
implementation of these interventions. SAMHSA also awards grants to
support the use of evidence-based interventions through other programs
not specifically designed for the school setting.
Officials from the seven sites in our review identified coordination
and close working relationships, support from "program champions"--
advocates for the program--and school leadership, and sustainable
funding and staffing as factors that can affect the provision of school
mental health services. Because mental health professionals focus on
students' emotional health and education professionals focus on
academic achievement, coordination between these differing missions can
enhance the provision of school mental health services. School
officials from sites in our review recognized that addressing students'
mental health needs can improve their academic achievement. Site
officials told us that, in addition to being aware of a school's
academic mission, mental health providers need to be cognizant of
students' academic schedules and responsibilities. For example, sites
avoided providing services during testing periods. Coordination between
sites and external stakeholders, such as community mental health or
social service agencies, can also enhance the provision of school
mental health services by allowing schools to build relationships with
other agencies that influence the lives of students. Sites also
emphasized the importance of working closely with existing school
health and mental health staff. By doing this, sites can avoid overlap
in services provided to students. Site officials stressed that one or
more program champions and support from school leaders can play a role
in implementing school mental health services; conversely, the loss of
either of these can threaten program continuity. Finally, site
officials noted that difficulties securing and sustaining both funding
and mental health service provider staff have affected the ability to
implement school mental health services.
In commenting on a draft of this report, HHS agreed with our
characterization of SAMHSA's efforts related to school mental health
services and stressed the importance of schools as a venue for the
delivery of mental health prevention and treatment programs, services,
and supports. Education told us it had no comments on the draft.
Background:
Multiple federal agencies are involved to varying degrees in school
mental health services at the elementary and secondary level, including
through grants and technical assistance. While school mental health
services vary from location to location, most schools have some efforts
in place to address students' mental health needs, which can be
provided by a variety of mental health professionals.
Federal Role in Education and Mental Health Services for Children:
Elementary and secondary education is primarily a responsibility of
states and localities. During the 2003-2004 school year, Education
reported that the state and local share of total revenues related to
elementary and secondary education equaled 91 percent--just over $420
billion. While state and local agencies take the lead in elementary and
secondary education, a variety of federal departments and agencies are
involved in supporting or promoting mental health in schools.
SAMHSA has primary federal responsibility for issues related to
children's mental health services.[Footnote 6] SAMHSA's Center for
Mental Health Services supports mental health services that are
evidence-based, provided in community settings, and designed to promote
recovery for people with, or at risk for, mental health disorders. The
center provides this support through grants and technical assistance,
and acts as SAMHSA's lead in the SS/HS program, an effort that directly
supports mental health services in schools. Since its creation in 1999,
the SS/HS grant program, a joint effort of SAMHSA, Education, and DOJ,
has awarded more than $1 billion to support school mental health
services and related activities. The program is designed to promote
safe, drug-free schools and healthy childhood development and includes
efforts to promote positive student behavior and early identification
and treatment of mental health problems. (See encl. III for more
information on the SS/HS program.) SAMHSA funds other programs related
to children's mental health that, while not focused on schools, relate
to school programs or efforts in the area of school mental health.
In addition to SAMHSA, other agencies within HHS have roles related to
school mental health services. For example,
* HRSA funds the Mental Health in Schools Program to support two
centers related to school mental health.[Footnote 7] These centers
currently focus on analysis of school mental health policies and
programs and have also provided training and technical assistance.
Fiscal year 2007 funding for this program was $900,000. HRSA's Health
Center Program, funded at approximately $1.78 million in fiscal year
2006, supports community health centers, including centers designed to
provide services to specific populations such as migrant workers,
residents of public housing, and at-risk school students. Services to
students can be provided through school-based health centers, which may
provide mental health services such as case management or therapy.
* CDC has developed the Coordinated School Health Program model, made
up of eight interrelated components addressing student health, one of
which is counseling and psychological services. CDC also has a
cooperative agreement with the National Assembly on School-Based Health
Care, an organization whose mission is to support school-based health
centers, for a 5-year "School Mental Health Capacity Building
Partnership" initiative. This initiative, which according to CDC
officials is funded at $175,000 per year, is designed to strengthen
efforts to improve school mental health services and synthesize
information on state and local efforts in this area. CDC surveys,
including student surveys and surveys of school and school district
staff, also collect information directly or indirectly related to
school mental health services.
* The National Institutes of Health's National Institute of Mental
Health (NIMH) funds research on school mental health services and
service delivery models.
* The Centers for Medicare and Medicaid Services' Medicaid program, a
joint federal-state program to finance health care coverage for certain
categories of low-income individuals, can in some cases be used to pay
for specific school mental health services. For example, in some
states, Medicaid may pay for diagnosis of mental health issues or
therapy provided in a school setting for students enrolled in Medicaid.
Other federal departments also support programs related to school
mental health services. For example,
* Education's Office of Safe and Drug-Free Schools participates in the
SS/HS program. In addition, it funds both the Grants for the
Integration of Schools and Mental Health Systems program, a grant
program designed to help school systems develop connections with local
mental health systems, and the Elementary and Secondary School
Counseling program, which provides funding to school systems to
establish or expand elementary and secondary school counseling
programs.[Footnote 8] Grants for these two programs totaled just under
$40 million in fiscal year 2007. Education also supports Project School
Emergency Response to Violence (Project SERV), a grant program that
funds short-term and long-term education-related services, including
mental health assessments, referrals, and counseling services, to
school systems in which the learning environment has been affected by a
violent or traumatic event. In fiscal year 2007, Project SERV was
funded at $3 million.[Footnote 9]
* DOJ also participates in the SS/HS program. In addition, the Office
of Justice Programs has funded efforts to develop resources related to
youth violence and truancy prevention, which may involve mental health
programs in school settings. Through the Antiterrorism and Emergency
Assistance Program for Terrorism and Mass Violence, the Office for
Victims of Crime (OVC) provides funds to states and localities,
including schools, to address issues, including mental health needs,
stemming from intentional acts of criminal mass violence. For example,
OVC officials reported that the program provided funds following the
September 2006 shooting at Platte Canyon High School in Bailey,
Colorado.
Delivery of School Mental Health Services to Children:
Because decisions related to schools are typically made at the local
level, school mental health service delivery varies from district to
district, and can vary from school to school within the same district.
A variety of services can be provided, including prevention activities,
assessment, crisis intervention, case management, and counseling.
Efforts can focus on a wide range of problems, including specific
mental health diagnoses, bullying, violence, and discipline issues.
Studies indicate that most of the approximately 90,000 public schools
nationwide have various efforts in place to address the mental health
needs of their students.[Footnote 10] While the mechanisms for
delivering school mental health services vary greatly from location to
location, several general delivery mechanisms have been
identified:[Footnote 11]
* School student support services: Services provided by school-employed
staff such as counselors or psychologists.
* School-district mental health units: Services provided to students
through a district-operated mental health unit or clinic.
* Agreements for services with community providers: Services provided
through an agreement between the schools and a community provider, such
as a school-based health center run by an entity other than the school
or school district.
* Classroom-based curricula: Services provided through curricula in
classrooms or as special programs, such as activities to promote
healthy emotional behavior and prevent behavioral problems.
* Comprehensive, multifaceted, and integrated approaches: Services
provided through comprehensive systems that bring together resources
from both schools and communities in an integrated fashion to promote
student mental health.
According to a 2005 SAMHSA report, during the 2002-2003 school year
about one-third of school districts surveyed provided mental health
services using only school or school district employees.[Footnote 12]
More than half of the schools surveyed reported that they contracted
with one or more community organizations or individual providers for
mental health services. Almost 30 percent of these schools reported
that they contracted with their local mental health agency, while
others reported contracting with a variety of public and private
providers. Six percent and 4 percent of schools, respectively, reported
contracting with hospitals or faith-based organizations.
Regardless of the mechanism used, services generally fall into three
categories--universal, selective, or indicated:[Footnote 13]
* Universal: Services intended for all children, including services
related to creating a positive school environment or improving
students' social skills. These services may focus on decreasing risk
factors for future mental health problems and increasing resilience by
promoting positive school environments and ensuring that students have
access to appropriate supports to allow healthy emotional development.
* Selective: Services targeting a smaller subset of the population,
usually those children identified as at-risk for developing mental
health problems or with identified mental health needs. Services at
this level may include targeted violence-, suicide-, or dropout-
prevention programs or group therapy.
* Indicated: Services targeting children with the greatest need for
support, which could include intensive services such as one-on-one
therapy.
Staffing of Mental Health Service Provision in Schools:
Providers of various types--school counselors, psychologists, social
workers, nurses, marriage and family therapists, and others--can
address students' mental health needs in schools. The roles of these
professionals overlap to some extent, but each has particular areas of
expertise. (See table 1.)
Table 1: Selected Professions That May Provide School Mental Health
Services:
Provider type: School counselors;
Provider description: Provide services designed to address students'
academic, career, and personal/social development. These services can
include individual or group counseling, consultation with parents and
teachers, and referrals to other school or community resources;
Provider association's recommended provider-to-student ratio[A]: 1
school counselor to every 250 students;
Provider association's recommended training level[A]: Master's level.
Provider type: School psychologists;
Provider description: Assess students' psychological functioning and
needs, and provide consultation to parents and school staff on
students' behavioral, social, emotional, and instructional needs. May
provide some prevention and direct intervention services. May focus on
assessment of the special education population;
Provider association's recommended provider-to-student ratio[A]: 1
school psychologist to every 1,000 students;
Provider association's recommended training level[A]: Post-master's
specialist-level degree program.
Provider type: School social workers;
Provider description: Provide services designed to create linkages
among the school, family, and community, including case management,
support groups, crisis intervention, and home visits;
Provider association's recommended provider-to-student ratio[A]: 1
school social worker to every 400 students;
Provider association's recommended training level[A]: Master's level.
Provider type: School nurses;
Provider description: Implement school health services, including
mental health, for all students. Can provide services including chronic
care, general health education and promotion activities, and teacher
education. May also act as a contact within the school for a family;
Provider association's recommended provider-to-student ratio[A]: 1
school nurse to every 750 students;
Provider association's recommended training level[A]: Licensure as a
registered nurse and a baccalaureate degree.
Provider type: Marriage and family therapists;
Provider description: Diagnose and treat mental and emotional disorders
within the context of marriage, couples, and family systems. While not
exclusive to schools, some work in school settings;
Provider association's recommended provider-to-student ratio[A]: No
recommended ratio;
Provider association's recommended training level[A]: Master's level.
Source: GAO analysis of information from HRSA and provider
associations.
[A] Recommended by the relevant provider association: American School
Counselor Association, National Association of School Psychologists,
School Social Work Association of America, National Association of
School Nurses, and the American Association for Marriage and Family
Therapy.
[End of table]
SAMHSA's 2005 report identified school counselors as the most common
type of school mental health provider, followed by school psychologists
and school social workers. The study also found that school nurses,
with broad responsibility for student health needs, spend one-third of
their time providing mental health services. In addition to the
credentials recommended by provider associations, a 2000 study found
that most states and school districts have developed minimum education
and certification requirements for school staff who provide mental
health services.[Footnote 14] Of states with minimum educational
requirements, most required a master's degree for counselors and
psychologists, while fewer than half required a master's degree for
social workers.[Footnote 15]
SAMHSA Coordinates Formally and Informally at the Federal Level on
School Mental Health Services:
SAMHSA coordinates with other federal departments and agencies on
school mental health services. SAMHSA currently maintains two formal
coordination efforts for school mental health services--it coordinates
with (1) Education and DOJ for the SS/HS initiative and (2) several
federal departments and agencies serving children for the Federal/
National Partnership, an effort designed to promote collaboration
related to children's mental health and substance use prevention. In
addition to formal coordination efforts, SAMHSA officials maintain
multiple informal or episodic coordination efforts at the federal level
related to school mental health services.
SAMHSA Formally Coordinates with Federal Departments and Agencies on an
Ongoing Basis:
SAMHSA, Education, and DOJ have coordinated on SS/HS by contributing
financial, technical, and administrative support through a
collaborative agreement.[Footnote 16] SAMHSA's funds are used for
mental health promotion, prevention, early identification, and
treatment services and supports for students and their families. These
activities can include early identification and assessment in the
school setting, and early childhood development programs, such as nurse
home visits for young children who demonstrate behavior problems. The
funds contributed by Education and DOJ have been used for alcohol,
drug, and violence prevention and early intervention programs, as well
as efforts to address student behavioral, social, and emotional
supports.[Footnote 17]
SAMHSA and DOJ have made funds available to Education, which also
contributes funds. Education acts as fiscal agent of the program and
issues grant awards. In addition, the agencies have coordinated peer
reviews of SS/HS grant applications,[Footnote 18] while Education
collects and maintains final grantee progress and financial reports.
SAMHSA also has a cooperative agreement with a national organization to
provide technical assistance to SS/HS grantees. According to SAMHSA
officials, the agency coordination effort for SS/HS is organized into
two teams, which meet to discuss issues related to the program: (1) an
interagency policy team made up of high-level representatives from each
agency, and (2) a supervisory team consisting of agency staff who
discuss day-to-day management issues, including staff assignments and
scheduling. In addition, program officers from SAMHSA and Education--
nine in total--monitor and manage from 11 to 18 grants each and meet
monthly to discuss issues related to the program. Experts in school
mental health services told us that the SS/HS is a good example of
effective coordination at the federal level.
SAMHSA's coordination with Education and DOJ for the SS/HS program
includes key practices that we have identified as helping to enhance
and sustain coordination among federal agencies.[Footnote 19] To define
and articulate a common program outcome, the agencies overcame the
differences in agency missions by identifying a common mission--to
create safe school environments and healthy students. This effort to
identify a common mission was designed to create a seamless program for
grantees at the local level. To establish mutually reinforcing or joint
strategies for the program, agency leadership at the three agencies
vested decision-making authority in officials such as division
directors and branch chiefs, who assigned their staff to the SS/HS
effort. The agencies established compatible policies, procedures, and
other means to operate across agency boundaries and agreed on each
agency's roles and responsibilities. For example, because each agency
had different program monitoring policies, officials created a program
monitoring system that was consistent across all three agencies.
[Footnote 20] To develop mechanisms to monitor, evaluate, and report on
results, the agencies built an evaluation component into the SS/HS
program at the federal and local levels--grantees are required to
conduct local evaluations, and the federal agencies are conducting a
national evaluation for SS/HS.[Footnote 21]
SAMHSA's other formal coordination effort is the Federal/National
Partnership, formed in 2004 with SAMHSA designated as the lead
agency.[Footnote 22] The purpose of this partnership is to promote
collaboration among federal agencies to transform children's mental
health and substance abuse delivery systems nationally. The partnership
includes representatives from key federal agencies that serve children,
national organizations, and family and youth organizations.[Footnote
23] During its first meeting in November 2004, the partnership
established three workgroups focused on children's mental health
issues, one of which is the Integration of Mental Health and Education
Workgroup, which is focused on school mental health services.[Footnote
24] The purpose of this workgroup is to develop a coordinated federal
process to support integration of school mental health services.
SAMHSA convened a meeting in August 2006 to begin planning the
Integration of Mental Health and Education Workgroup. At the August
2006 meeting, a variety of organizations that provide technical
assistance related to children's mental health were brought together
and a core group of participants identified. As of July 2007, some
tasks identified at the August 2006 meeting had been completed. For
example, SAMHSA has compiled a list of programs by topic area, which
can be found on the agency's Web site. Program topics include school
mental health, suicide prevention, youth violence prevention, and other
programs related to mental health and substance abuse issues for
children and families. SAMHSA also organized events for National
Children's Mental Health Awareness Day in May 2007, which focused on
school mental health services. Other tasks are in progress. For
example, a logic model--a model that describes how an initiative should
work and anticipated outcomes--for the integration of education and
mental health in schools is being developed. SAMHSA officials expect to
convene the first workgroup meeting in fall 2007 and plan to include
participation by education professionals and other federal agencies.
The agency also plans to invite participation from representatives of
community-based organizations and school-employed providers.
SAMHSA Officials Coordinate with Federal Departments and Agencies on an
Informal or Episodic Basis:
SAMHSA officials maintain informal or episodic coordination efforts on
issues related to school mental health services with Education and
other HHS agencies such as HRSA, CDC, and NIMH;[Footnote 25] these are
based largely on personal relationships between agency staff. For
example, at the request of Education staff, SAMHSA staff reviewed and
commented on the Grants for the Integration of Schools and Mental
Health Systems application before its public release.[Footnote 26]
SAMHSA and Education officials told us they work on an as-needed basis
to ensure that their respective agencies are not awarding funding to
the same grantees for the same activities. SAMHSA officials told us
that personnel from the two agencies also communicate with each other
almost daily about the SS/HS program.
While SAMHSA and HRSA had a formal cooperative agreement in the past to
co-fund two technical assistance centers for school mental health
services, SAMHSA officials told us that SAMHSA is no longer providing
funds for this effort, although HRSA continues to do so.[Footnote 27]
However, the two agencies continue to have some informal interaction
about the two centers. For example, SAMHSA presents an award
recognizing programs that promote school mental health services at a
conference hosted annually by one of these centers. In addition to this
interaction, SAMHSA and HRSA staff meet on an ongoing basis to discuss
how they can collaborate to assist states with efforts to integrate
health, mental health, and education. For example, staff from the two
agencies have met to discuss a HRSA initiative that provides funds to
states to promote availability and quality of services focused on
healthy child development and school readiness. The two agencies are
also working together to incorporate information on the warning signs
of mental health problems into an existing SAMHSA program designed to
serve children with serious emotional disturbances.
SAMHSA and CDC officials also work together on an informal and episodic
basis. For example, a SAMHSA official participated on an expert panel
about 3 years ago to help CDC's Division of Adolescent and School
Health consider how to identify possible opportunities for the division
to promote and enhance the mental health component of the Coordinated
School Health Program. According to CDC officials, because the agency
does not have a strong focus on school mental health services, it
reaches out to SAMHSA for guidance in this area. For example, CDC
directs its grantees to SAMHSA's NREPP database to find appropriate
interventions to implement at the local level.
SAMHSA and NIMH officials have had informal discussions on the recent
redesign of SAMHSA's NREPP, and NIMH suggested researchers who could
review interventions for this registry of evidence-based programs and
practices. In some cases, NIMH encouraged its grantees to submit
evidence-based interventions to NREPP. Staff members from the two
agencies have discussed how research can be transferred into community
practice, and NIMH staff have also consulted with, and provided
technical assistance to, SAMHSA grantees.
SAMHSA Identifies and Supports Evidence-Based Interventions, Some of
Which Target School Mental Health Services:
SAMHSA identifies evidence-based mental health interventions,
including some that can be used in school settings, and supports their
use. To identify evidence-based mental health interventions, SAMHSA
uses its NREPP database; as of August 2007, slightly more than one-
fourth of the interventions on NREPP were mental health services based
in schools. SAMHSA also supports the initial implementation and ongoing
administration of evidence-based interventions in the school setting
through grant programs, such as the SS/HS grant program. This program
awards grants for evidence-based interventions and provides technical
assistance for the implementation of these interventions. SAMHSA also
supports the use of evidence-based interventions through other grant
programs that may be used in schools but are not specifically designed
for the school setting.
SAMHSA Uses a National Registry to Identify Evidence-Based
Interventions, and Some Are for Use in School Settings:
SAMHSA uses NREPP, a searchable online database, to help interested
parties, including school officials, in identifying evidence-based
interventions.[Footnote 28] The purpose of NREPP, which was initially
designed in 1997 and redesigned in March 2007, is to help interested
parties in identifying evidence-based approaches to preventing and
treating mental illness and substance abuse. NREPP is funded by SAMHSA
and is a core component of the agency's Science to Service Initiative,
which seeks to promote broader adoption of effective, evidence-based
interventions within routine clinical and community-based settings.
Because there is no universally accepted definition for what
constitutes evidence, SAMHSA has stated that NREPP was not designed to
serve as a single authoritative source for evidence-based
interventions.[Footnote 29] Rather, SAMHSA acknowledges that there are
multiple ways of establishing and assessing the strength of an
intervention's evidence, such as research methods that include pre-and
posttest studies and controlled clinical studies. Agency officials
characterize NREPP as one of many tools for identifying and assessing
evidence-based interventions.
In order to update NREPP, SAMHSA anticipates publishing annual notices
in the Federal Register soliciting evidence-based interventions that
may be selected for review and placement on the registry.
Interventions, submitted by those seeking placement on the NREPP
registry, are evaluated through a standard process, which involves both
a submission of materials and an independent review process. (See fig.
1.) The submission process is used to determine whether interventions
submitted for review meet NREPP's three minimum requirements: (1) the
intervention must demonstrate one or more positive outcomes, (2) the
research findings related to the intervention must have been published
in a comprehensive evaluation report or peer-reviewed publication, and
(3) dissemination materials must be available.[Footnote 30]
Figure 1: NREPP Review Process:
[See PDF for image]
This figure is a flow chart of the NREPP Review Process, with the
following data depicted:
(1) Applicant submits intervention to SAMHSA for placement on NREPP.
(2) The application is evaluated by SAMHSA to determine if the
intervention meets NREPP‘s minimum requirements.
Does not meet requirements:
(3) Intervention is not placed on NREPP.
Or:
(1) Applicant submits intervention to SAMHSA for placement on NREPP.
(2) The application is evaluated by SAMHSA to determine if the
intervention meets NREPP‘s minimum requirements.
Meets minimum requirements and SAMHSA approves for review:
(3) SAMHSA and applicant prepare necessary documentation for review;
(4) The intervention is reviewed and quality-of-research and readiness-
for-dissemination ratings are given by independent reviewers;
(5) Ratings and intervention summaries are submitted to the applicant
to obtain agreement on the content of the NREPP posting[a]; if no
agreement:
(6) Intervention is not placed on NREPP. If agreement:
(7) Intervention summary and ratings are placed on NREPP Web site.
Source: GAO analysis of SAMHSA documents.
[A] SAMHSA provides applicants with the opportunity to approve the
summary information before it is published on the Web site. However,
NREPP will not change the intervention's ratings unless new information
is provided by the applicant. If the applicant and SAMHSA do not agree
on the Web posting (i.e., intervention summary and ratings), then the
intervention will not be placed on NREPP.
[End of figure]
Once it is determined that an intervention meets all three minimum
requirements and a senior SAMHSA official approves the intervention for
review, the intervention is reviewed by a panel of independent
reviewers with special knowledge in the subject area. These reviewers
rate the quality of the research on the intervention and its readiness
for dissemination on a zero-to-four point scale.[Footnote 31] The
quality-of-research rating is obtained by using six criteria to score
the strength of the research supporting the intervention's stated:
outcomes, and then averaging the six ratings.[Footnote 32] The
readiness-for-dissemination rating is achieved by evaluating the
dissemination materials using three criteria and averaging the ratings
of these criteria.[Footnote 33] A final rating for the intervention's
quality of research and readiness for dissemination is achieved by
reaching reviewer consensus if there are significant differences in
their ratings. SAMHSA posts the intervention's ratings on its Web site
along with additional descriptive information on the
intervention.[Footnote 34] (See fig. 2 for a sample NREPP rating.)
Figure 2: Sample NREPP Rating:
[See PDF for image]
This figure contains two graphs representing Sample NREPP Ratings.
Graph one: Quality-of-research ratings by criteria (0.0–4.0 scale):
Outcome:
Outcome 1: School disciplinary code violations;
Reliability: 1.0;
Validity: 2.5;
Fidelity: 2.3;
Missing data/attrition: 2.0;
Confounding variables: 2.3;
Data analysis: 3.5;
Overall rating: 2.3.
Outcome:
Outcome 2: Violent/aggressive behavior-self-reports;
Reliability: 2.5;
Validity: 2.5;
Fidelity: 2.3;
Missing data/attrition: 2.0;
Confounding variables: 2.3;
Data analysis: 3.5;
Overall rating: 2.5.
Outcome:
Outcome 3: Victimization;
Reliability: 2.5;
Validity: 2.5;
Fidelity: 2.0;
Missing data/attrition: 2.0;
Confounding variables: 2.5;
Data analysis: 3.5;
Overall rating: 2.5.
Outcome:
Outcome 4: Peer provocation;
Reliability: 2.5;
Validity: 2.5;
Fidelity: 2.0;
Missing data/attrition: 2.0;
Confounding variables: 2.3;
Data analysis: 3.3;
Overall rating: 2.4.
Outcome:
Outcome 5: Life satisfaction;
Reliability: 2.5;
Validity: 2.5;
Fidelity: 2.0;
Missing data/attrition: 2.0;
Confounding variables: 2.5;
Data analysis: 3.5;
Overall rating: 2.5.
Graph two: Readiness-for-dissemination ratings by criteria (0.0–4.0
scale):
Readiness for dissemination:
Readiness-for-dissemination rating for intervention;
Implementation materials: 3.0;
Training and support: 3.8;
Quality assurances: 2.0;
Overall rating: 2.9.
Source: NREPP.
Note: Listed outcomes are examples.
[End of figure]
Some interventions listed on NREPP were designed for use in the school
setting. Specifically, as of August 2007, 13 of NREPP's 46
interventions were identified as school mental health interventions,
including those designed to address aggressive behavior, depression, or
school violence. Other settings for interventions listed on NREPP
include correctional facilities, residential settings, and the
workplace. SAMHSA is in the process of adding interventions to the
registry and, according to a SAMHSA official, approximately half of the
intervention applications submitted in fiscal year 2007 were mental
health or substance abuse interventions that could be appropriate for
use in schools.
SAMHSA Supports Evidence-Based Mental Health Interventions That Can Be
Used in School Settings:
SAMHSA supports the use of evidence-based interventions in the school
setting in the SS/HS grant program. SS/HS program policy requires that
grantees implement and administer evidence-based interventions, but
does not require its grantees to use a specific method of selecting
those interventions.[Footnote 35] The program's grant application
provides potential grantees with guidance on how to choose an evidence-
based intervention and with a list of online resources, including
NREPP. To help current grantees identify and implement evidence-based
interventions, the National Center for Mental Health Promotion and
Youth Violence Prevention provides technical assistance to all active
SS/HS grantees through a cooperative agreement with SAMHSA. The
National Center also provides current grantees with additional
technical assistance, such as support in implementing culturally
appropriate programs or designing and implementing program evaluation
tools.
SAMHSA also supports the use of evidence-based mental health
interventions when funding other programs that may be used in schools
or community settings. SAMHSA's Child Mental Health Initiative provides
federal funds, through cooperative agreements with state and local
governments and tribal organizations, to develop and sustain an
effective system of care for children with serious emotional
disturbances. The funding recipients are required to collaborate with
other entities that serve children, such as local child welfare and
juvenile justice agencies. In fiscal years 2005 and 2006, most federal
funding for the program was directly provided to, and managed by, state
and local governments. Child Mental Health Initiative recipients may
use the funds to provide mental health interventions in schools and are
required by SAMHSA policy to implement at least one evidence-based
intervention. However, according to a SAMHSA official, funding
recipients have noted that it can be challenging for those outside
schools to work within a school setting. Another program, SAMHSA's
State/Tribal Youth Suicide Prevention Grant Program, provides funds
through cooperative agreements with states, tribal communities, and
public or nonprofit organizations to support the development and
implementation of statewide or tribal youth suicide prevention and
intervention strategies. Preference is given to program participants
that collaborate with institutions that serve youth, which could
include schools, and SAMHSA policy requires program participants to
report the number of evidence-based interventions used.
Multiple Factors Affect the Provision of School Mental Health Services:
Officials in the seven schools and school districts in our review told
us that coordination and close working relationships, support from
program champions--advocates for a program--and school leadership, and
resources are factors that can affect the provision of school mental
health services. Because the missions of mental health and education
professionals differ, coordination between them can enhance the
provision of school mental health services. Coordination with external
stakeholders (such as community mental health providers) and among
internal stakeholders (such as teachers and health care professionals)
can also affect the provision of school mental health services. Site
officials stressed that one or more program champions and support from
school leaders can play a significant role in implementing school
mental health services; conversely, the loss of either of these can
threaten program continuity. Site officials also noted that
difficulties securing and sustaining both funding and staffing have
affected the ability to implement school mental health services.
Differing Missions and Coordination of Efforts Affect Service
Provision:
Because the missions of mental health and education professionals
differ, coordination between them can enhance the provision of school
mental health services, according to experts and school staff. While
mental health providers typically focus on the emotional health of
students, the primary focus of schools is students' academic
achievement. By framing student mental health as a means of improving
student academic achievement, experts told us that mental health
providers may improve the likelihood of being able to implement a
school program. School officials we interviewed, including principals
and teachers, said they recognized that addressing students' social,
emotional, and behavioral health needs can improve their ability to
focus on academics. The principal of one school reported that, in the
past, her teachers spent a large amount of their time dealing with
nonacademic issues, including behavioral problems, in the classroom.
This school now provides universal mental health services for all
students and selective services for a smaller subset of students. For
example, the school offers a schoolwide program to reduce student
aggression and behavior problems, and also works with community mental
health providers to obtain services for children with more serious
needs. Teachers said that because of these efforts, disruptions
associated with students' behavioral issues have been reduced and they
are better able to focus on academics.
Site officials told us that to provide services in the school setting,
mental health professionals need to be cognizant not only of a school's
academic mission, but also of students' academic schedules and
responsibilities. Staff members at one site reported that they avoided
scheduling appointments for services during school testing periods,
while staff from another reported that they tried to provide as many
services as possible during nonacademic times, such as lunch. Some
school officials noted that working with external providers could pose
difficulties because these providers might not recognize the priority
of the school's academic schedule. An official from one site with
multiple school-based health centers stated that a past contract it had
with a community provider to run one of its centers was terminated
because the provider was not able to work within the schedule
constraints of the school.
Site officials told us that coordinating with external stakeholders--
local government agencies, providers, or community organizations--is
important when implementing school mental health services. Two sites in
one state partner with county councils made up of multiple local
agencies serving children and families.[Footnote 36] Staff from these
two sites reported that the partnership helped them establish a
relationship with other agencies, such as juvenile justice or job and
family service agencies, that may influence the lives of their
students. A representative from one of the county councils stated that
prior to the council's work with school officials, agencies in the
county had been interested in working with schools but did not know how
to bring that about. Officials at some sites told us they also had
developed relationships with local religious organizations. At one
site, officials reported that this resulted in the organizations'
supporting after-school and summer activities and acting as a source of
volunteers to help organize these events when needed. Officials from
sites in our review also told us that family involvement in the
services provided to children was an important factor and that they
typically required parental consent for students to receive services.
In addition, staff at sites in our review emphasized the importance of
working closely with existing school health and mental health staff--
including counselors, social workers, psychologists, and nurses--to
ensure the success of school mental health services. They noted that it
was particularly important to work together when implementing
initiatives, in order to reduce service overlap or potential conflict
between providers. In schools with a school-based health center,
officials reported that the school nurse often worked in collaboration
with the centers, providing care to students not enrolled in the center
or identifying enrolled students in need of services.[Footnote 37] In
one school without a school-based health center, the school nurse and
the school social worker who coordinates the universal mental health
programs meet regularly to discuss students referred for physical and
mental health problems. Officials at sites in our review also noted
that school nurses may help identify when students who come in for
physical health reasons may have symptoms related to mental health
issues. Officials told us that, in some cases, failure to recognize the
roles of existing school staff members had created tension.
Sites also work to include teachers and administrative staff in their
school or school district programs and to provide teachers with
training or materials on mental health issues. Two sites have developed
multidisciplinary teams, including teachers and school administrators
as well as mental health professionals, that meet to identify and
coordinate services for students showing signs of mental health
problems. By including teachers and school administrators in efforts,
sites try to ensure that all staff members are involved in the program.
Officials from one of these sites also reported providing training to
teachers on a variety of issues, including understanding mental health
diagnoses, the impact of trauma on children, and nonacademic barriers
to learning, such as issues related to poverty. Staff members at a
third site have created documents for teachers, including handouts
providing information on when to refer students for mental health
services, the protocol for referrals, and the role of case managers.
Program Champions and School Leadership Affect Provision of Services:
Officials at sites in our review stressed the importance of having a
program champion and the support of school and school district
leadership when implementing programs. At one site, officials stated
that their effort to introduce a school mental health services program
had multiple champions, including staff from the local educational
service center[Footnote 38] and local mental health providers.
Officials at this site reported bringing together community agencies
that work with children, including local school districts, and said
that they were able to hire a program director who, according to site
staff, had the "passion" to run the program. The staff from the
multiple agencies involved believed that without this program director
to further champion the program, they would not have been able to
continue to dedicate sufficient attention to the program to keep it
moving forward. At another site, officials told us that the principal
was the champion for mental health services at the school and provided
the school leadership needed to implement programs. Because of the
success of efforts at that school, the superintendent of the district
asked this principal to examine how services could be expanded to
another district school.
Officials we spoke with told us, however, that initiatives may become
dependent on the program champion and expressed concern that such
initiatives might not be able to survive the champion's departure.
Similarly, officials told us that wavering support at the
administrative level or a change in leadership--particularly principals
and superintendents--could raise concerns for program sustainability.
In one school district, staff told us that while the indicated mental
health services provided through their school-based health centers were
well established, the universal mental health initiatives they had
implemented, such as a classroom-based violence prevention program,
would not have existed without the leadership of one particular staff
member. The person identified as the program champion told us that she
would like to train a successor but, because of budget constraints, it
would be difficult to hire a new staff person to train while she was
still in her position. Officials at another site told us their program
champion was the school principal, who planned to retire in 3 years. To
ensure that the existing mental health initiatives continue, the
principal was working to fully train school staff, including teachers,
to maintain and advocate for these initiatives. Because staff from this
school will be involved in the process of hiring a replacement, the
current principal hopes that they will be in a position to identify a
potential replacement who will continue the initiatives.
Securing and Sustaining Funding and Appropriate Staff for School Mental
Health Services Affect Service Provision:
Site officials told us that difficulty securing and sustaining funding
and mental health service provider staff had affected their ability to
implement school mental health services. According to experts, no
single funding stream specifically focuses on school mental health
services, and sites reported piecing together multiple funding streams
to support their programs. For example, officials at one site reported
combining funds from at least four different sources, including private
grants, the state Department of Education, and federal sources, to
support its mental health services.[Footnote 39] Officials at this site
said that while their school district provided space for service
delivery, it provided no monetary support for the site's programs.
Funding streams that staff identified often came with restrictions on
use. For example, one site provided case management services to
students, but because of funding restrictions, these services could be
provided only to elementary students who qualified for free and reduced
lunches.[Footnote 40] Officials stated that Medicaid, while a possible
funding source for some services, was difficult to use. In particular,
they expressed concerns related to Medicaid's paperwork, reimbursement
rates, and enrollment of eligible students in the Medicaid program. In
addition, changes in funding priorities can affect sites' funding for
programs. At the time of our site visits, two sites in one state told
us they had just been notified that state-level funding priorities had
shifted. As a result, these sites anticipated laying off, or cutting
the hours of, case management or mental health staff.[Footnote 41]
Officials at the sites in our review said they appreciated the
flexibility of grant funding, but said that grants might not last long
enough to allow a program to stabilize and that other funds to sustain
initiatives were not always available.[Footnote 42] Officials from one
site, located in a town surrounded by rural counties, noted that while
grants often required them to consider sustainability when applying for
funds, the school district and county had no funds to support
initiatives started through grants and they were not aware of local
foundations or organizations that might be able to provide additional
funds.
While officials indicated that it was difficult to secure funding, some
reported that by coordinating the efforts of multiple local agencies or
securing the support of the school administrator, they were able to
identify resources to support their programs. By partnering with local
government agencies and other stakeholders, staff from one site were
able to use resources available to those organizations, including
resources that might not otherwise be available to schools. In
addition, relationships with external agencies helped create advocates
in the community for another school district's program, according to
officials. At another site, officials reported that while they had not
formally secured funding for the staff needed to continue a grant
program, the principals of some schools participating in the program
said they were willing to include the salary of the schools' program
staff members in their general school budgets for the upcoming year.
One principal told us that she was willing to do this because the
program was an asset to the school.[Footnote 43]
Site officials told us that, in addition to securing and sustaining
funding, it could be difficult to hire and retain mental health
professionals to provide school services, particularly in small towns
and rural areas. Providers at one site noted that the site's program
could expand only to a limited degree because there were no more
available mental health providers in the area.[Footnote 44] Staff
reported difficulty recruiting providers to the area, a town located
about 1 hour from a metropolitan area where mental health providers are
paid significantly more. Staff members from a rural school district
similarly told us that they had been trying to hire a behavioral health
specialist since October 2006 but had not been able to find one willing
to move to their district until June 2007.
Contrary to the experience of some sites, schools and school districts
located near universities reported having better access to providers.
Officials from one urban school district reported working with local
universities to offer internship opportunities, which allowed it to
attract former interns to positions as permanent staff. At another
site, which has had difficulties attracting mental health staff,
providers involved in the program are working with a local university
to expand the university's social work program, and hope this expansion
will be a source of future mental health staff.
Agency Comments:
We provided a draft of this report to HHS and Education for comment.
HHS provided written comments on the draft of this report, which are
provided in enclosure IV. HHS also provided technical comments, which
we incorporated where appropriate. HHS indicated that the report
accurately reflects SAMHSA's efforts regarding school mental health
services. The agency also stressed the importance of schools as a venue
for the delivery of mental health prevention and treatment programs,
services, and supports. Education told us it had no comments on the
draft.
As we agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution of
this letter until 30 days after the date of this letter. At that time,
we will send copies to the Administrator of SAMHSA, appropriate
congressional committees, and other interested parties. In addition,
the report will be available at no charge on the GAO Web site at
[hyperlink, http://www.gao.gov]. If you or your staff have any
questions about this report, please contact me at (202) 512-7114 or
bascettac@gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
report. GAO staff who made major contributions to this report are
listed in enclosure V.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director:
Health Care:
[End of section]
Enclosure I:
Scope and Methodology:
We examined the Substance Abuse and Mental Health Services
Administration's (SAMHSA) efforts to coordinate with federal
departments and agencies to support school mental health services and
to identify and support evidence-based school mental health
services.[Footnote 45] To do this, we reviewed multiple documents,
including a collaborative agreement related to federal school mental
health funding, interagency meeting minutes, documents describing
changes in the National Registry of Evidence-based Programs and
Practices (NREPP), and Federal Register notices. We interviewed staff
at SAMHSA, including program staff charged with implementing
interagency programs related to children's mental health and developing
and implementing NREPP. We also interviewed staff from the Department
of Health and Human Services' Health Resources and Services
Administration, Centers for Disease Control and Prevention, and
National Institutes of Health. We spoke with staff from the Department
of Justice and the Department of Education who interact with SAMHSA
with regard to school mental health.
To describe factors that have affected the provision of school mental
health services, we reviewed relevant research and interviewed experts
working in the area of school mental health, including representatives
of the Center for Health and Health Care in Schools, Center for Mental
Health in Schools, Center for School Mental Health Analysis and Action,
Center for School-Based Mental Health Programs, Research and Training
Center for Children's Mental Health, and National Assembly on School-
Based Health Care. To obtain information on their constituents' roles
in school settings, we also reviewed documents and interviewed
representatives from professional associations whose members provide
school mental health services, including the National Association of
School Psychologists, American School Counselor Association, School
Social Work Association of America, National Association of School
Nurses, and the American Association for Marriage and Family Therapy.
In addition, we interviewed officials with associations representing
education service providers, such as the American Association of School
Administrators and the National School Boards Association.
To provide information on factors that selected sites considered
important when providing school mental health services, we conducted
interviews with representatives from seven selected schools and school
districts. To identify states, localities, specific schools, and school
districts considered to be active in the area of school mental health
services, we interviewed officials from federal agencies, experts in
the area of school mental health, and provider associations. From the
approximately 53 locations they identified, we selected a judgmental
sample of 7 sites: two school districts in Connecticut, one school
district in Florida, one multidistrict program in North Carolina, and
one school district, one school, and one multidistrict program in Ohio.
These sites were selected because they represented a mix of urban and
rural settings and settings with and without school-based health
centers. We also ensured that we included sites that were currently
receiving funds through the joint SAMHSA, Department of Education, and
Department of Justice Safe Schools/Healthy Students program and the
Department of Education Grants for the Integration of Schools and
Mental Health Systems program. Because we used a nongeneralizable
sample to select our sites, the information provided cannot be used to
make inferences about other programs. In addition, the information
provided by program officials does not reflect all efforts under way in
their locations related to school mental health services.
We conducted our work from March 2007 through September 2007 in
accordance with generally accepted government auditing standards.
[End of enclosure]
Enclosure II:
Characteristics of Sites in Our Review:
State: Connecticut;
Location characteristics: School district located in an urban area;
School district size[A]: The school district consists of 41 schools;
School or school district population[A]: 22,296 students in the school
district;
Safe Schools/Healthy Students grantee: Yes;
School-based health center: Yes;
Program description: The school district provides universal services
throughout the district using an evidence-based program that has been
in place for several years. This school district also provides a
variety of selective and indicated services to students through its
multiple school-based health centers. To assist students in need of more
intensive support, such as therapy services, the district works with a
community mental health provider; through the Safe Schools/Healthy
Students (SS/HS) Initiative, it has also been able to secure funding
for a child psychiatrist. Students in certain high schools also receive
services through centers, staffed in large part by master's-level social
work interns, designed to provide counseling and support to students and
their families. These centers are part of the district's SS/HS Initiative.
State: Connecticut;
Location characteristics: School district located in an urban area;
School district size[A]: The school district consists of 35 schools;
School or school district population[A]: 22,264 students in the school
district;
Safe Schools/Healthy Students grantee: No;
School-based health center: Yes;
Program description: Universal mental health services, including
violence and bullying prevention, are provided using multiple evidence-
based programs. Mental health services at both the selective and the
indicated level are provided to regular education students through
multiple school-based health centers. The centers are staffed by mental
health providers, including social workers. For students needing more
intensive services or to respond to crisis situations, the centers also
have psychiatric staff on call.
State: Florida;
Location characteristics: School district located in a rural county;
School district size[A]: The school district consists of 2 schools[B];
School or school district population[A]: 1,058 students in the school
district[B];
Safe Schools/Healthy Students grantee: Yes;
School-based health center: No;
Program description: This school district provides universal services,
including a bullying prevention program, after-school activities, and
drug and alcohol prevention activities. A counselor is available to
provide mental health services to students across the district. The
school district works with a private contractor to provide more
intensive services, such as therapy, to students who need them. The
district also partners with the state health department and local
agencies serving children as part of the SS/HS Initiative.
State: North Carolina;
Location characteristics: Regional grouping of school districts located
in 3 rural counties;
School district size[A]: The regional grouping consists of 3 school
districts with 21 schools[C];
School or school district population[A]: 7,014 students in the combined
3 school districts[ C];
Safe Schools/Healthy Students grantee: Yes;
School-based health center: Yes;
Program description: The districts have implemented universal services
for students, including a violence and drug abuse prevention program,
and are conducting training for teachers and administrators on mental
health issues. Using funds from the SS/HS Initiative, three school
districts are implementing school nurse-school counselor teams in
schools throughout their districts. These teams act as the initial
contact for students in need of selective or indicated mental health
services and work in coordination with community providers to secure
services for students. In addition, the districts have developed a
council of key agencies and organizations that may impact students'
lives.
State: Ohio;
Location characteristics: Regional grouping of school districts in and
around a small town;
School district size[A]: The regional grouping consists of 8 school
districts with 43 schools;
School or school district population[A]: 18,193 students in the
combined 8 school districts;
Safe Schools/Healthy Students grantee: No;
School-based health center: No;
Program description: This regional effort focuses on providing services
through multidisciplinary teams. These teams can include school
administrators and teachers, staff from local community mental health
providers, substance abuse professionals, and staff from the local
health department and juvenile court. The composition of the teams
varies by school, and others may be invited to participate as needed.
The teams provide services at the universal, selective, and indicated
level. They build a complete system of services for students and their
families based in a school setting, and include an after-school
component, skill/asset building, mentoring, and counseling services.
State: Ohio;
Location characteristics: Single school within the school district of a
midsize town;
School district size[A]: The school is part of a school district with
12 schools;
School or school district population[A]: 370 students in the school[D];
Safe Schools/Healthy Students grantee: No;
School-based health center: No;
Program description: This elementary school works with community
partners, including local government agencies and nonprofits, to
provide universal, selective, and indicated services. It provides
universal services through an evidence-based classroom program and uses
the combined services of a school nurse and school social worker to
provide selective services to children in need of additional support.
If students need intensive services, the school works with a local
mental health provider to obtain services. This same provider also
offers case management support for the school.
State: Ohio;
Location characteristics: School district in a small urban jurisdiction
co-located with a large urban area;
School district size[A]: The school district consists of 3 schools;
School or school district population[A]: 1,098 students in the school
district;
Safe Schools/Healthy Students grantee: No;
School-based health center: Yes;
Program description: This school district includes a school-based
health center and provides a variety of mental health services to
elementary and middle school students. Universal services are provided
at the district's two elementary schools using two evidence-based
programs identified through the Substance Abuse and Mental Health
Services Administration. One of these programs is also used to provide
services to students at the district's middle school. These services
are implemented by a contracted prevention coordinator (a licensed
mental health provider) and a doctoral intern from an area university.
Selective and indicated services, including limited therapy and case
management services, are provided by staff from the school-based health
center and through a contract with a community-based mental health
provider. The school-based health center is supported by a pediatrician
who can assist in the referral of children in need of mental health
services to outside providers.
Source: GAO analysis of information from sites and U.S. Department of
Education.
Note: Universal services are those intended for all children; selective
services are those targeting a smaller subset of children, usually
those identified as at-risk for developing mental health problems;
indicated services are those targeting children with the greatest need
of support.
[A] Unless otherwise noted, data are for the 2004-2005 school year for
public schools.
[B] Officials at this site reported that the school district also
provides services to the one local private school in its district,
which has about 100 students.
[C] These data are for the 2005-2006 school year for public schools.
[D] The total school district population was 4,994 students.
[End of table]
[End of enclosure]
Enclosure III:
Information on the Safe Schools/Healthy Students Grant Program, as of
August 2007:
Participating agencies and offices:
Office of Safe and Drug-Free Schools within the Department of
Education, Substance Abuse and Mental Health Services Administration
(SAMHSA) within the Department of Health and Human Services (HHS), and
Office of Juvenile Justice and Delinquency Prevention within the
Department of Justice.
Type of assistance:
Discretionary/Competitive Grant.
Who can apply:
Local Educational Agencies (LEAs)[A].
Program description:
Safe Schools/Healthy Students (SS/HS) grants support LEAs in the
development of communitywide approaches to creating safe and drug-free
schools and promoting healthy childhood development. Programs are
intended to prevent violence and the illegal use of drugs and to
promote safety and discipline. LEAs are required to partner with local
law enforcement, public mental health, and juvenile justice agencies.
This program has been jointly funded and administered by HHS and the
Departments of Education and Justice.[B] Within HHS, SAMHSA has primary
responsibility for this program.
Maximum grantee awards:
* $2,250,000 per year for 4 years for an LEA with at least 35,000
students;
* $1,500,000 per year for 4 years for an LEA with at least 5,000
students but fewer than 35,000 students;
* $750,000 per year for 4 years for an LEA with fewer than 5,000
students.
Education level:
Kindergarten through 12th grade[C].
New SS/HS awards, by fiscal year:
Fiscal year 2007: $37,454,964;
Fiscal year 2006: $30,913,344;
Fiscal year 2005: $76,367,807.
Legislative citation:
Public Health Service Act, as amended, § 581, 42 U.S.C. § 290hh
Juvenile Justice and Delinquency Prevention Act, as amended, § 204, 42
U.S.C. § 5614 Elementary and Secondary Education Act of 1965, as
amended, Title IV, Part A, Subpart 2, § 4121; 20 U.S.C. § 7131.
Number of new awards, by federal fiscal year:
Fiscal year 2007: 27 awards;
Fiscal year 2006: 19 awards;
Fiscal year 2005: 40 awards.
Program elements:
* Safe school environments and violence prevention activities: Support
a continuum of strategies--including universal prevention, early
intervention, and intensive activities, curricula, programs, and
services--focused on the entire school population as well as students
with disruptive, destructive, or violent behaviors;
* Alcohol, tobacco, and other drug prevention activities: Support the
prevention or reduction of substance use and abuse among youth, in
coordination with broader environmental strategies that address change
at the individual, classroom, school, family, and community level;
* Student behavioral, social, and emotional supports: Support
strategies to promote positive relationships for youth and meaningful
parental and community involvement, and to recognize the role of
students' social and emotional needs in their development;
* Mental health services: Support enhanced integration, coordination,
and resource sharing among education, mental health, and social service
providers, including early identification and assessment and providing
early intervention services for at-risk children and their families,
and referral and follow-up with local public mental health agencies as
needed. Also support school staff training and consultation, supportive
services to families, and revision of policies and procedures to
address communication and sharing of information across service
systems;
* Early childhood social and emotional learning programs: Support ways
to overcome barriers to identifying and serving children and families
in need of services and to identify and consult appropriate community
partners in developing services to address early childhood social and
emotional learning programs.
Selected grant requirements:
* Memorandum of agreement among required partners;
* Logic model of the proposed project[D];
* Use of evidence-based programs;
* Local evaluations conducted by grantees.
Source: GAO analysis of documents from SAMHSA and Department of
Education. GAO analysis of Department of Education, "Safe Schools/
Healthy Students Initiative," 2007, [hyperlink,
http://www.ed.gov/programs/dvpsafeschools/index.html] (accessed August
6, 2007).
[A] LEAs are public boards of education or other public authorities
legally constituted within a state for either administrative control or
direction of, or to perform a service function for, public elementary
or secondary schools in a city, county, township, school district, or
other political subdivision of a state, or for a combination of school
districts or counties that are recognized in a state as administrative
agencies for their public elementary or secondary schools.
[B] The Department of Justice contributed funding and administrative
support to the SS/HS program from 1999 through 2003. While the
Department of Justice signs the collaborative agreement that guides the
program, the agency no longer provides funding or administrative
support.
[C] The SS/HS program also supports efforts focused on early education
for children.
[D] According to the SS/HS Fiscal Year 2007 Application Procedures, a
logic model is a graphic presentation of the project in chart format
that shows, by element: identified needs and gaps, goals, objectives,
activities, partners' roles, outcomes, and processes for measuring
outcomes.
[End of table]
[End of enclosure]
Enclosure IV:
Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office of the Assistant Secretary for Legislation:
Washington, D.C. 20201:
September 14 2007:
Cynthia A. Bascetta:
Director:
Health Care:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Ms. Bascetta:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled, " School Mental
Health: Role of the Substance Abuse and Mental Health Services
Administration and Factors Affecting Service Provision" (GAO 08-19R).
The Department found the report to be well written and accurate in its
portrayal of the Center's school mental health initiatives and SAMHSA
related collaborations with other Federal partners. School-based mental
health is an important venue for the delivery of prevention and
treatment programs, services and supports for children and families.
Your report recognizes and supports this important role.
The Department appreciates the opportunity to comment on this report
before its publication.
Sincerely,
Signed by:
Vincent J. Ventimiglia
Assistant Secretary for Legislation
[End of enclosure]
Enclosure V:
GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta, (202) 512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the person named above, Helene F. Toiv, Assistant
Director; Jennie F. Apter; Emily R. Gamble Gardiner; Jeremie C. Greer;
Neetha Rao; and Jennifer Whitworth made key contributions to this
report.
[End of enclosure]
Footnotes:
[1] For the purposes of this report, we use the term "school mental
health services" to refer to both school-based services, i.e., services
provided in the school, and school-linked services, i.e., services
provided by a community provider through a link with the school.
Throughout this report, the term school is used to refer to elementary
and secondary education, i.e., kindergarten through 12th grade.
[2] U.S. Public Health Service, Report of the Surgeon General's
Conference on Children's Mental Health: A National Action Agenda,
Department of Health and Human Services (Washington, D.C.: Sept. 18-19,
2000) and New Freedom Commission on Mental Health, Achieving the
Promise: Transforming Mental Health Care in America: Final Report,
Department of Health and Human Services (Rockville, Md.: July 22,
2003).
[3] Coordination can be broadly defined as any joint activity by two or
more organizations that is intended to produce more public value than
could be produced when organizations act alone. For the purposes of
this report, we use the term "coordination" to include activities
variously described as "cooperation," "collaboration," "integration,"
and "networking." See GAO, Results-Oriented Government: Practices That
Can Help Enhance and Sustain Collaboration among Federal Agencies, GAO-
06-15 (Washington, D.C.: October 2005).
[4] In this report, we use the term grants to include both grants and
cooperative agreements, except where otherwise indicated. The
distinction between a grant and a cooperative agreement is the degree
of federal involvement. A cooperative agreement is used when
substantial involvement is expected between an agency and the funding
recipient, whereas a grant is used when substantial involvement is not
expected between an agency and the funding recipient. In addition, for
the purposes of this report, we use the term technical assistance to
refer to support provided to organizations receiving federal funding to
help them with the implementation of their program, such as assistance
with strategic planning or program evaluation.
[5] IDEA provides funding to support free, appropriate public
educational services to children with disabilities, including
disabilities related to mental health. 20 U.S.C. § 1400 et seq.
[6] SAMHSA's total fiscal year 2007 budget was about $3.2 billion.
[7] These centers are the Center for Mental Health in Schools at the
University of California, Los Angeles and the Center for School Mental
Health Analysis and Action at the University of Maryland, Baltimore.
[8] Funding can be awarded to secondary schools only if grant funds
exceed $40 million.
[9] Funds appropriated for Project SERV remain available for awards in
subsequent years if not used.
[10] S. Foster et al., School Mental Health Services in the United
States, 2002-2003 (Rockville, Md.: Center for Mental Health Services,
SAMHSA, 2005).
[11] These mechanisms are not mutually exclusive. For more information,
see Center for Mental Health in Schools, The Current Status of Mental
Health in Schools: A Policy and Practice Analysis (Los Angeles, Calif.:
2006).
[12] S. Foster et al.
[13] Other models for these categories exist. For more information on
various models, see K. Kutash, A.J. Duchnowski, and N. Lynn, School-
Based Mental Health: An Empirical Guide for Decision-Makers (Tampa,
Fla.: University of South Florida, 2006).
[14] N.D. Brener, J. Martindale, and M.D. Weist, "Mental Health and
Social Services: Results from the School Health Policies and Programs
Study 2000," Journal of School Health (2001): 305-312. The 2000 School
Health Policies and Programs Study provides the most recent data
available and is based on data from the 50 states plus the District of
Columbia and a nationally representative sample of school districts.
CDC officials anticipate that new data from the study will be available
in fall 2007.
[15] The study does not collect information regarding marriage and
family therapists or other provider types.
[16] While the collaborative agreement that guides the SS/HS program
has not changed, DOJ has not contributed funds since fiscal year 2003
and does not currently have staff assigned to the SS/HS program.
However, the agency still participates in making programmatic
decisions, including grant decisions, under the collaborative
agreement.
[17] Although Education's SS/HS funds can be used for prevention and
early intervention programs, Education cannot use these funds for
medical services (including mental health treatment) or drug treatment
or rehabilitation, except for pupil services or referral to treatment
for students who are victims of, or witnesses to, crime or who
illegally use drugs. 20 U.S.C. § 7164.
[18] Grant applications are screened by federal SS/HS staff and then
forwarded to a contractor for peer review. The peer review panel is
organized by the contractor and is made up of three independent
reviewers, with a federal program officer acting as a discussion
facilitator. The list of applications ranked by reviewers' scores is
provided to SAMHSA, Education, and DOJ for review prior to final grant
awards. In fiscal year 2007, 27 new grants were awarded.
[19] These key practices are (1) defining and articulating a common
outcome; (2) establishing mutually reinforcing or joint strategies; (3)
identifying and addressing needs by leveraging resources; (4) agreeing
on roles and responsibilities; (5) establishing compatible policies,
procedures, and other means to operate across agency boundaries; (6)
developing mechanisms to monitor, evaluate, and report on results; (7)
reinforcing agency accountability for collaborative efforts through
agency plans and reports; and (8) reinforcing individual accountability
for collaborative efforts through performance management systems. See
GAO-06-15.
[20] An official from DOJ noted that when creating this system, all the
agencies agreed that if they could not reach consensus, they would use
Education's policy or procedure, because of Education's role as fiscal
agent for the grant. However, SAMHSA officials noted this has not been
necessary as the agencies have been able to reach consensus.
[21] SAMHSA and NIMH also co-sponsor a program announcement for SS/HS
grantee sites to participate in research opportunities unrelated to the
national and local evaluations.
[22] The Federal/National Partnership is organized as part of the
Federal Partners Senior Workgroup, made up of senior representatives of
more than 20 federal agencies and offices. This Senior Workgroup is
responsible for implementing the Federal Action Agenda, which focuses
on efforts at the federal level to transform the mental health system.
The Federal Action Agenda was developed in response to the 2003 report
from the President's New Freedom Commission.
[23] The federal partners include SAMHSA and other departments and
agencies, such as Education, the Department of Housing and Urban
Development, DOJ, the Department of Labor, the Department of Veterans
Affairs, and the Social Security Administration. This partnership also
includes other nongovernmental organizations working in the area of
school mental health services.
[24] The Integration of Mental Health and Education Workgroup is also
known as the School-Based Mental Health Services Workgroup. The two
other workgroups are the Youth-Guided Policies and Services Workgroup
and the Early Identification Workgroup.
[25] SAMHSA officials also maintain informal coordination efforts with
HHS's Indian Health Service and Administration for Children and
Families.
[26] The Grants for the Integration of Schools and Mental Health
Systems program provides grants to state and local education agencies
and tribes for the purpose of developing linkages between school
systems and local mental health systems to increase student access to
quality mental health care.
[27] In fiscal year 2006, HRSA contributed $600,000 to these centers,
part of the Mental Health in Schools Program, while SAMHSA contributed
$300,000. HRSA contributed $900,000 in fiscal year 2007, but the agency
has limited fiscal year 2008 funds for the program to $600,000.
[28] SAMHSA redesigned NREPP [hyperlink, http://www.nrepp.samhsa.gov]
in order to make it more comprehensive and interactive.
[29] See Changes to the National Registry of Evidence-based Programs
and Practices, Notice, 71 Fed. Reg. (Mar. 14, 2006), and SAMHSA,
"National Registry of Evidence-based Programs and Practices (NREPP): An
Important Note for NREPP Users," 2007, [hyperlink
http://www.nrepp.samhsa.gov/about-note.htm] (accessed Apr. 20, 2007).
[30] The positive program outcomes must be statistically significant at
a level of 95 percent confidence. Dissemination materials could include
items such as program manuals, program process guides, and training
materials.
[31] Independent reviewers are not employed by SAMHSA; rather, they
work as agency consultants to the agency's NREPP contractor. SAMHSA
recruits two types of reviewers to rate each program's quality of
research and readiness for dissemination. Quality-of-research
reviewers must have a doctoral-level degree and, if possible, possess
experience evaluating prevention and treatment programs. Readiness-
for-dissemination reviewers can include consumers of services, service
providers, and experts in program implementation. Both types of
reviewers must possess knowledge of mental health and/or substance use
prevention or treatment content areas.
[32] Each program outcome is evaluated by reviewing the following six
"quality-of-research" criteria: (1) reliability of the outcome
measures, (2) validity of the outcome measures, (3) intervention
fidelity--the "experimental" intervention was implemented as designed,
(4) missing data and attrition, (5) potential confounding variables,
and (6) appropriateness of the analysis.
[33] The three "readiness-for-dissemination" criteria are evaluated by
reviewing the amount and adequacy of the intervention's (1)
implementation materials, (2) training supports, and (3) quality
improvement materials, such as manuals on how to provide quality
improvement feedback.
[34] Prior to the 2007 redesign of NREPP, programs were rated in their
entirety by placing them into three categories of effectiveness: model,
effective, and promising. According to SAMHSA officials, the agency
chose to eliminate these categories because they appeared arbitrary to
some users and distinctions between them were unclear. The agency plans
to advertise these changes through several efforts, such as e-mail
alerts to notify users when new programs have been added to the
registry.
[35] The SS/HS program defines an evidence-based intervention as one
that is supported by scientific data to indicate its effectiveness. The
statutes authorizing SAMHSA, Education, and DOJ's programs do not
require that grantees implement evidence-based programs. 20 U.S.C. §
7131; 42 U.S.C. §§ 290hh, 5614. The requirement is set forth in program
selection criteria developed by the agencies responsible for the SS/HS
program and published as a Notice of Final Priorities, Requirements,
Selection Criteria, and Definitions in the Federal Register.
[36] This state has developed an initiative that includes both state-
and county-level partnerships focused on improving the well-being of
children and their families. The partnerships are composed of
government agencies, and, at the county level, also include community
organizations. County-level councils, formed by the county board of
commissioners, must include representation from families, schools, and
multiple agencies, including alcohol, drug addiction, mental health,
and job and family services.
[37] Eligible students who wish to receive services through the school-
based health center at the sites we reviewed are required to join the
center by enrolling.
[38] This center provides services, including technical and operational
assistance, professional development, and curriculum services, to the
eight school districts within its area.
[39] The federal funds came from Medicaid and the Temporary Assistance
for Needy Families (TANF) program, which provides funds to states to
provide assistance and work opportunities to needy families. Both
federal and state governments contribute to Medicaid and TANF.
[40] For elementary students who did not qualify for services, this
site used its prevention coordinator--a grant-funded contractor
responsible for schoolwide prevention activities--to provide limited
individual assistance. However, an official at this site noted that
restrictions limiting services to only certain populations, such as
students in certain grades or at certain income levels, could lead to
resentment over services not being available to all students.
[41] Officials in one of these school districts reported that with 2
weeks left before the end of the school year, they had not been told
whether they would have funds to retain their case management staff for
the upcoming school year. As of August 2007, all case management
positions had been eliminated, and this site was no longer offering
case management services.
[42] An official from one site also told us that funding streams may
not be consistent, noting that funding that may have been available 2
or 3 years before may no longer be available.
[43] School officials noted that these individual school budgets
require approval at the superintendent level, so these positions could
still be cut. As of June 2007, staff and school officials did not know
whether these positions would be approved for the 2007-2008 school
year.
[44] Staff at this site told us that they were willing to use a variety
of mental health provider types, although they preferred to use
master's-level counselors. Officials from other sites also indicated
that they were willing to use, and had used, a variety of mental health
provider types including social workers, counselors, and marriage and
family therapists.
[45] School mental health services provided to students who qualify for
special education services through the Individuals with Disabilities
Education Act were outside the scope of our work.
[End of section]
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