Providing mental health services in schools, particularly those located in disadvantaged, underserved communities where service uptake is at its lowest, is increasingly considered a logical way to meet young people’s mental health needs.

As a team of U.S. psychiatrists points out, schools require attendance, are accessible to children and their families, and – when bolstered by support from mental health practitioners from other public agencies – have the potential to provide a range of preventative and treatment services for children in a location that may be less stigmatizing than traditional mental health service provision.

Now, a small pilot demonstration shows that delivering mental health services in elementary schools can indeed be very successful. Teachers and staff were enthusiastic about the program and children’s mental health improved. But can this approach be rolled out on a wider scale? Here, concerns about time, resources, and support remain.

Policy pressure
The U.S. government and a range of professional healthcare organizations are increasingly looking to schools as the ideal venue for delivering mental health services.

However, school mental health programs have historically been marginalized and fragmented. The U.S. Department of Education is trying to turn this around with the Positive Behavioral Interventions and Supports (PBIS) framework.

PBIS is guided by wide-ranging principles, including data-driven decision making, universal screening, and creating a pro-social environment in schools. Heather Walter, Professor of Psychiatry at Boston Medical Center, and colleagues at Chicago’s Children’s Memorial Hospital, set out to test whether such a grand design is feasible, would be endorsed and sustained by already-pressed schools, and would lead to increased uptake of mental health services by children and families with difficulties.

A year-long test
To this end, the psychiatrists undertook a small-scale pilot demonstration of the PBIS framework in two elementary schools in an economically deprived area of a major Midwestern city where academic performance was poor.

At the start of the pilot, it was estimated that two-fifths of children in these schools had some form of mental health impairment. Teachers reported that disruptive behavior in the classroom was the norm. They also reported low confidence in dealing with children’s mental health problems and said that lack of training and information was the largest barrier.

To help deal with this, staff in these schools were trained in classroom management practices and implemented two universal preventative interventions, Promoting Alternative Thinking Strategies (PATHS) and All Stars, designed to improve the behavior, mental health and social literacy of all children. Children were also screened for mental health problems, evidence-based intervention and treatment approaches were offered, and mental health professionals placed in schools on a part-time basis delivered the services.

So how did these strategies go down with children, parents, teachers and school staff? Generally well. “Satisfaction with the program among school staff was very high,” the researchers said. After the strategy was implemented, teachers rated themselves as more proficient in dealing with children’s mental health problems, and children’s mental health improved following the intervention. However, the lack of any comparison group limits the robustness of these findings.

Mental health services in schools: can these programs be sustained?
There were also problems of feasibility. To succeed in the long term, these programs need parent consent, professional support, and time in the classroom – and these are not always easy to get.

“A clear caveat,” say the authors, “is that program sustainability required ongoing internal and external support.” Despite treatment services being provided via schools, parent consent and engagement was still problematic. While teachers reported greater confidence in dealing with problems, “even after training, observing and co-leading,” say Walter and colleagues, “they were uncertain about their ability to effectively implement the universal and indicated prevention program components without support from mental health professionals.” Teachers also complained about relinquishing academic curriculum time for delivery of universal preventative interventions.

The long-term sustainability of such an approach is thus a concern. Walter and colleagues identify four areas to be addressed if mental health services are to be successfully embedded within schools: “(1) on-site mental health professionals dedicated solely to program implementation and coordination; (2) intensive training and ongoing support for school staff; (3) administrative support of dedicated time for program implementation; and (4) creation of culturally competent, non-stigmatizing strategies to achieve parental support and involvement.”

Only when these elements are in place may the promise of school-based mental health services be realized. The challenge lies in making such a framework a systematic part of school and mental health agency working and, crucially, providing the financing structures to underpin it.

References:
Walter, Heather J., Karen Gouze, Coleen Cicchetti, Richard Arend, Tara Mehta, Janet Schmidt, and Madelynn Skvarla. 2011. “A pilot demonstration of comprehensive mental health services in inner-city public schools.” Journal of School Health 81(4): 185-193.