Mental Health in Schools

Mental Health in Schools


Since almost all children attend school and since children with mental health problems do not leave their problems at the door when they walk into school, the provision of mental health services presents a unique opportunity for intervention. Mental health services in school are highly varied. Schools have clear mandates to serve the needs of children with disabilities but historically have tended to focus on things like autism and attention-deficit hyperactivity disorder and have generally been less interested in other mental health problems. In one recent national survey (Whitney & Peterson, 2019), 16.5% of children (about 7.7 million) had at least one mental disorder although slightly less than 50% received treatment. Furthermore, marked state-to-state variations were noted both in prevalence and numbers of untreated cases. Unfortunately, the rate of attrition in services outside schools is high (Bostic & Hoover, 2018; Merikangas et al., 2011).

Schools present an obvious place for screening and intervention. At the same time, schools have come under pressure from an increasing range of mandates for meeting education goals and metrics designed to evaluate school performance (Bostic & Hoover, 2018). Consultants must be aware of the potential complexities of the school as an organization, the many different professionals involved, the multiple levels of need, and the potential for sometimes even small gains to have a major impact. Consultation issues to students may change somewhat in dealing with private, parochial, or charter schools. In these settings, some of the pressure from government mandates may not apply although lack of support may be a challenge. It is important for the consultant to have a clear sense of the school and the purpose of the consultation. Visiting the school can provide information on issues as varied as the building, classroom, school personnel, support services, and overall atmosphere (see Bostic & Hoover, 2018 for a detailed discussion), as well as providing opportunities for in-person observation of the child’s behavior and that of peers and others including teachers. Students in special education or those with “504” plans because of a learning disability, autism, and so forth present special problems. They may already have some mandated intervention services, but the provision of additional mental health supports in the school can further strengthen their intervention program.

School-based intervention programs stem from various sources. Understanding these various roots of mental health provision in schools helps in understanding the range of models currently available to mental health consultants. Table 25.1 summarizes some of the major events relative to evaluation of school-based consultation services in the United States.

The challenges for providing mental health services include lack of insurance, minority status, and problems in screening and detection of those needing service as well as administrative obstacles to provision of service. Schools sometimes lack sufficient resources, for example, they lack guidance counselors, school psychologists, and social workers who could be expected to address behavioral and emotional issues of students.

There are many potential benefits of school-based mental health centers that provide direct access to services. These can include higher achievement, improved attendance, and lower rates of behavioral problems at schools and at home (Bostic & Hoover, 2018; Oberle et al., 2018; Platt et al., 2020). Benefits can also be observed for teachers and other supporters within the school (Kidger et al., 2016).

There also is the potential for programs to offer expanded services with referrals and links to outside services as needed. Importantly, school-based services provide the opportunity for early intervention and prevention of subsequent mental health and education problems. These models coordinate and integrate family, community, and school services (see Bostic & Hoover, 2018).

Advances in technology and telemedicine (Myers & Roth, 2018) have also impacted provision of consultation services in schools and other settings. Sometimes, these provide services of child psychiatrists to areas or populations with limited access to services. At other times, they help schools plan for intervention for students with special needs. Although offering many potential advantages, other issues including confidentiality and billing can pose obstacles to implementation.


Many models for school-based service provision have now emerged (see Table 25.2). The mental health consultation model utilizes the consultant to help clarify how mental health problems may interact with school performance and how interventions might be developed

to optimize student learning and functioning. This model is often an indirect one, that is, information may come to the consultant from parents or school staff and the consultant provides guidance based on this information without necessarily seeing the specific student. In this model, services may be reimbursed either by the school or potentially by insurance or sometimes an outside agency. In this model, the school can decide how best to use (or not use) recommendations made by the consultant.

In the behavioral consultation model, the consultant adopts a traditional behavioral psychology approach. Thus, the problem is viewed in the context of its antecedents and consequences; an intervention plan is then developed and refined through further evaluation. The implementation of specific goals and objectives following the behavioral analysis is an important advantage of this model that can engage teachers in implementation and evaluation of the intervention. This model relies heavily on data collection and thoughtful observation. This approach differs from the earlier behavioral models in that it assumes that students often lack appropriate behaviors to employ in dealing with complicated situations and then make use of less adaptive behaviors, for example, aggression or acting out (Putnam et al., 2005; Stephan et al., 2015).

The organizational consultation model views schools as systems and uses behavioral principles and the engagement of the range of school staff (i.e., administration staff as well as teachers) to produce organizational change. It seeks to utilize behavioral science concepts and the involvement of multiple system members to evaluate the school in a broader sense. It views difficulties as resulting from discrepancies in expectations and muddled communication leading to inconsistency and ambiguity. This broader systems view may help reveal specific aspects of staff or programs that are associated with student difficulties. In this model, the problems of a single student are viewed more broadly as reflecting system issues, an approach that may clarify how school policies or misunderstanding contribute to mental health and behavioral issues in the student who is confronted by ambiguous or contradictory demands. Models addressing low-achieving schools, such as the Comer School Development Program, precipitated school restructuring and change in school culture and climate, positively impacting student self-esteem, motivation, and achievement (Comer & Woodruff, 1998).

The School Consultation Process

Mental health consultants must be aware of the varied roles of the school staff. Teachers and special educators are the school staff who have the most prolonged and enduring contact with students (Bostic & Hoover, 2018). Other involved staff may include school nurses, social workers, and administrators. Aides may, in actuality, provide the most support to students needing special services during the day; the education requirements of teacher aides are quite varied from state to state. Occupational and physical therapists may be providing services to students with Individualized Education Plans (Bostic & Hoover, 2018). Given the complexity of schools and the marked variations that occur, it is important for a consultant to have a good working relationship and familiarity with schools to which they provide consultations.

The mental health consultant should consider the various aspects of the school environment because they impact students and provision of mental health services. Some of these conditions are summarized in Table 25.3. Box 25.1 provides a framework for the consultant to consider when engaging in a school consultation.

As presented in the table and box, Bostick and Hoover (2018) provide a comprehensive summary of the goals for school consultation. The consultant must be aware of the potential sources of difficulty in this process. Some of the techniques useful in this process are summarized in Box 25.2.

Jun 19, 2022 | Posted by in PSYCHOLOGY | Comments Off on Mental Health in Schools
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