November/December 2012 Issue

School-Based Adolescent Mental Health Programs
By Terry Richardson, MS, LMHC, CMHS; Melissa Morrissette, LICSW, CDP, CMHS, MHP; and Laura Zucker, LICSW, CMHS, MHP
Social Work Today
Vol. 12 No. 6 P. 24

A supplementary team of community mental health professionals integrated into school services is a plus for the early identification and treatment of adolescent mental health conditions.

Even for professionals who work with adolescents and practically have seen it all, the number of youths with mental health challenges is simply staggering. One-half of all lifetime diagnosable mental health conditions begin by the age of 14 (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005). One in five adolescents in this country shows significant symptoms of emotional distress, with nearly 10% having symptoms that impair everyday functioning (Knopf, Park, & Mulye, 2008).

The presence of mental illness in children and adolescents, if not properly diagnosed and treated, increases the likelihood of significant health issues for them as adults and greatly limits their ability to become productive members of society (Wu et al, 2006).

For adolescents, the first signs of mental illness or emotional distress can emerge in the school environment. It’s well known that mental health issues such as anxiety, depression, and family problems often are the root causes of poor academic performance, disciplinary issues, and truancy.

While many schools have school psychologists, social workers, and/or counselors, progressive school districts recognize the value of a more comprehensive approach in which a supplementary team of community mental health professionals is integrated into the school service array. These services may range from intensive programs targeting underperforming schools or those designed to augment existing school health and wellness programs. Research shows that emotional and behavioral health issues present significant barriers to learning, academic achievement, and high standardized test scores (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009). This same research shows that mental health interventions are effective and can significantly improve academic performance scores.

The practical guidelines detailed in this article may provide school districts with a realistic look at the elements necessary to create and implement a comprehensive school-based model that effectively serves the behavioral health needs of adolescents.

Why It Makes Sense
From our experience, there are advantages of teaming with a comprehensive community mental health organization. Services are available to youths year-round, beyond the academic school year and during breaks when support for children and youths can be limited. Community mental health clinicians, unlike their school counterparts, can see students even if they are suspended, not attending school, in detention, or in the hospital. They can support adolescents after hours through crisis and psychiatric services.

Community mental health clinicians apply the latest evidence-based practices, including dialectical behavioral therapy, trauma-focused cognitive behavioral therapy, and functional family therapy. They also are effective practitioners of assertive community outreach; wraparound services that include family, community, and peer support; substance abuse treatment; crisis intervention; and additional services that school district mental health professionals may not have the capacity or experience to utilize. For many students, a key benefit is awareness. The presence of these services at school provides a level of access not typically available through the standard approach.

School-based mental health programs, to be most effective, must be correctly constructed. While they may vary from school to school, there are some key characteristics consistent across all of them. School-based programs will not be effective unless there is collaboration and relationship building among parents, teachers, administrators, community mental health professionals, and students. An infrastructure, process, and clearly defined roles must be painstakingly developed to address the varying needs of the student body. And the program must have the right team members, who bring unique skill sets and experiences to the endeavor.

School-Based Mental Health Programs Defined
What distinguishes a comprehensive school-based mental health program from what is commonly used in many schools today? Comprehensive school-based programs incorporate a team of behavioral health professionals from an outside organization, such as a community mental health provider, that partners with a school’s staff. This approach is effective because it enables specialists to quickly identify student issues and immediately triage care based on the severity of circumstances.

Whether it is a minor emotional disturbance that requires basic support or a far more complicated mental health issue mandating a more intensive intervention, a comprehensive school-based approach enables a full range of options to schools that deploy them. Appropriate levels of care can then be structured based on severity of emotional/mental health issues. Team members from the community mental health organization can be activated when more intensive services are needed. School psychologists or social workers can provide wellness, education, and prevention programs.

Concurrently, members of both teams consult at regular intervals and as needed so that the entire team is current and up-to-date.

Key Elements
School districts benefit from teaming with community mental health providers who have unique competencies, such as integrated substance abuse and mental health services for youths; family, individual, and group therapies; medication management; case management; and an orientation toward assertive community outreach principals.

When complex interventions are needed, often under extreme crisis situations, schools will need to quickly mobilize a mental health team that brings a wide range of specialties to any situation. Most schools don’t have the capacity or adequate staff on site to respond to (or anticipate) a situation that requires skilled crisis intervention, evaluation, medication management, and other services that a contracted team should.

Team Blueprint
What should an ideal treatment/intervention team look like? What expertise is needed? How many staff members should be accessible? How does a supplemental team interact with the on-site school staff?

Given the wide range of issues that may emerge in a school setting, teams should be structured in such a way that expertise or practice areas can quickly be invoked when needed. While contracted staff are not always on site at the school, another advantage to engaging professionals from a community mental health provider is the fact that they can quickly assemble in the event they are needed.

By far the most important member of the team is the “point person,” who serves as an intermediary between the school and the community mental health organization. Some school-based programs may utilize a care coordinator from the community mental health organization. This individual is on site and dedicated to quickly assessing, triaging, and identifying needs that connect students and their families with appropriate service providers. Other schools with less intensive needs assign a member of the community mental health team to serve as the point person. Either way, this point of contact is crucial.

The point person ensures optimal communication and quick mobilization. He or she collaborates with school nursing staff and administrators and deploys the services of the community mental health provider when needed. This person represents and has access to all the services that the agency provides, such as individual and group therapists, family counselors, chemical dependency advisors, experts in crisis management, and psychiatrists for medication management. These teams will play a role in developing care plans for students.

Partnerships
Partnerships that are key to the success of a school-based program include a school district’s safety and security division since care plans, communications, and confidentiality issues must comply with established protocols and policies. Family members, of course, should not be overlooked, as they will play perhaps the most important role in outcomes for the adolescent, providing ongoing guidance during therapy, maintaining a nurturing and understanding environment in which adolescents can recover, and participating in family therapy. Community mental health organizations experienced in family settings will prove valuable here.

Another place where community mental health organizations are indispensible is through established relationships with state agencies serving children. These include the juvenile rehabilitation administration and the department of children and family services. For youths with a history of being in “the system,” partnerships with these agencies can maintain continuity of care, cut through bureaucratic red tape, and provide exposition and context for tailoring care plans.

One of the most fruitful partnerships in this relationship is that of the school itself. School administrators, teachers, and medical staff are the foot soldiers of the program and, through their active collaboration with the community mental health organization, are the “eyes and ears” providing early detection. Through frequent collaboration and interaction with community mental health agencies, school staff members become more adept at recognizing early warning signs and distinguishing nuanced behaviors. They even serve as mental health ambassadors of sorts, bringing much needed approachability and accessibility to the concept of mental health and the various services that might be available to students.

Challenges
Most helping professionals would quickly sign up for a comprehensive school-based mental health program. Still, several challenges exist that must be considered when implementing such a program, including the following.

Despite the incredible benefits and relative minimal costs of a school-based model, some funding mechanism is essential. Whether through Medicaid or private or foundation funding, it is unlikely that a comprehensive school-based mental health program can sustain itself without outside support.

It’s never easy being the “outsider.” For community mental health professionals being contracted with a school district, it is prudent to expect initial resistance. Territoriality may emerge. There may be the perception that you are there to make big changes. Some educators may not have been exposed to mental health programs, nor have they had training in the field. For this reason, mental health professionals must make themselves visible and be consistent and proactive in initiating meetings with key school staff, students, and parents when necessary.

Another important factor is providing psych education to staff to help them understand mental health’s central role in adolescent life, relationships, and academic performance. The mental health professionals must take the time to educate the school about other services available through the agency. Inform school staff that functions such as psychiatric evaluation, medication management, group therapy, family therapy, case management, psychological evaluation, and crisis services can reduce their burden. It may take time, but a proactive, vigilant, and opportunistic approach to educating staff will pay off.

Roles and Boundaries
Clarifying roles and setting clear boundaries as a school-based clinician is an important component to implementing agency/school counseling. Without it, there will be confusion and unreasonable expectations.

Clearly, the first place to start in defining roles and setting boundaries will be through initial planning with school administrators and agency leadership. Once the framework for these roles is established and consensus is reached, it will be much easier to refine role clarity among the other service providers, such as the school social worker, counselor, nurse, and/or family support worker.

For school staff, it will let everyone know their roles and contributions early on. They will feel less threatened; tensions are eased; and the groundwork for better working relations is ensured. Mental health professionals know where they fit in the equation, can prioritize their work and, in the long term, meet the school district’s expectations.

The Minefield: Confidentiality
School staff members take the welfare of their students seriously. While it is natural for school staff to inquire about a student’s welfare, contracted mental health staff must be conscious—even in the most ostensibly innocuous circumstances—about confidentiality. As in any other client situation, applicable confidentiality regulations such as HIPAA and the National Association of Social Workers Code of Ethics exist to protect client privacy.

Whether it’s the principal stepping into your office for a chat, a teacher having a conversation with you in the hall, or administrative assistants requesting basic information over the phone, mental health staff must always exhibit caution, using tact and diplomacy. Professionals must be prepared to draw the line while still building trust, promoting collaboration, and investing in the team work necessary to support students. For this reason, mental health staff should always ensure they have proper release forms and, when applicable, the direct consent of any student before discussing a case. It is also important that mental health staff release only information that is relevant to a student’s school-life issues.

Final Thoughts
Being an adolescent already comes with many challenges and difficulties. For youths who also have mental health conditions, it is clear they stand to benefit from better access to mental health services. The school is the most efficient delivery system for these services. Studies show that students who participate in comprehensive and collaborative school-based mental health programs have significantly less disciplinary issues, enjoy better mental health and, not surprisingly, perform better in school (SAMHSA).

As more school districts consider expanding their mental health care for students, they should strongly consider engaging community mental health organizations with the required qualities and characteristics. They’ll bring a comprehensive program offering to the partnership. They’ll be well versed in the facets of successful partnerships with school districts and staff. Most importantly, they’ll bring a pervading interest in helping youths remove barriers that impact mental and emotional well-being, undermine school life, and obstruct academic achievement.

— Terry Richardson, MS, LMHC, CMHS, has more than 30 years of experience working with children, youths, and families. Over the past decade, she has managed Seattle-based Sound Mental Health’s school-based and community-support programs and is a member of the Readiness to Learn Consortium and the King County Metro Community Resource Team.

— Melissa Morrissette, LICSW, CDP, CMHS, MHP, and Laura Zucker, LICSW, CMHS, MHP, are clinicians at Sound Mental Health, Child and Family Services.

References
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comoridity Survey replication. Archives of General Psychiatry, 62(6), 593-602.

Knopf, D., Park, M. J., & Mulye, T. P. (2008). The Mental Health of Adolescents: A National Profile, 2008. San Francisco, CA: National Adolescent Health Information Center, University of California, San Francisco.

Substance Abuse and Mental Health Services Administration. (2009). Working Together to Help Youth Thrive in Schools and Communities. Washington, DC: U.S. Department of Health and Human Services.

 Wu, P., Bird, H. R., Liu, X., et al. (2006). Childhood depressive symptoms and early onset of alcohol use. Pediatrics, 118(5), 1907-1915.