ACKNOWLEDGMENTS

We wish to thank Kelly Kelleher and Michael Murphy for their helpful comments on an earlier version of this chapter.

This chapter presents research conducted as part of the Sunnylands Adolescent Mental Health Initiative to gain a greater understanding of the roles and prespectives of school mental health professionals in identifying, treating and preventing mental health problems in adolescents. The Surgeon General's report on the mental health of children (U.S. Department of Health and Human Services, 2000) estimated that 1 in 10 adolescents in the United States struggles with a mental health disorder that is severe enough to cause significant impairment. Because over 90% of adolescents under age 18 attend schools in the United States (U.S. Census, 2002), there is a unique opportunity to promote the mental health of youth in this setting, a role that has long been recognized by the public and mental health community (Allinsmith & Goethals, 1962; Starr, 1982).

The failure to treat adolescents suffering from mental conditions has severe consequences. Adolescents with mental disorders are at increased risk for poor academic achievement as well as continued mental disability (Puig-Antich, Kaufman, & Ryan, 1993; Randall, Henggeler, & Pickrel, 1999; Willcutt & Pennington, 2000). Many youth who suffer from mental disorders also end up in the juvenile justice system (Bilchik, 1998), an outcome that could be prevented if they were treated while still in school (American Psychiatric Association, 2004). Unfortunately, less than half of adolescents with significant mental health conditions are seen by a mental health professional in an average year (Costello, Angold, & Burns, 1996; Leaf et al., 1996; Sturm, Ringel, & Andreyeva, 2003). Therefore, increased efforts to identify and treat youth in need of services are a high priority.

The President's New Freedom Commission on Mental Health (2003) called for a transformation of the nation's mental health system and emphasized the importance of schools in this endeavor. In line with this agenda, this research was designed to learn what schools are doing to promote the mental health of adolescents and where future efforts should be directed to improve the delivery of services. To accomplish these goals, we interviewed professionals who are responsible for the mental health of adolescents in public schools to determine the pro grams they have in place, how well they think those programs are performing, and what changes they would make to improve their performance.

Previous research on the availability of mental health services in schools has found wide variation across states, regions of the country, and urban vs. rural locations (Brener, Martindale, & Weist, 2001; Slade, 2003). The largest of these surveys was conducted by the Centers for Disease Control and Prevention in 2000 (Brener et al., 2003). Another important source is the Add Health Study of school administrators conducted in 1994 (Slade, 2003). These studies indicate that only about half of all high schools have formal mental health counseling services on site. According to the President's New Freedom Commission, one of the biggest obstacles to receiving care for mental illness, especially for children, is the fragmentation of the mental health service delivery system. One way to integrate the system, according to the Commission, is to “rethink how state and Federal funding streams can be more efficiently partnered and utilized by school systems to deliver these services.”

Two major programs to improve access to health services in schools have shown growth in recent years: school-based health centers (SBHCs) and student assistance programs (SAPs). According to a recent survey (Center for Health and Health Care in Schools, 2003), over 1,500 SBHCs in at least 43 states frequently treat mental health conditions (Anglin, Naylor, & Kaplan, 1996; American Academy of Pediatrics, 2001). Student assistance programs, which were inspired by the employee assistance programs for workplaces, have also grown with over 60% of schools now offering such services (Brener et al., 2001). A third approach that overlaps with SAPs is the referral of students with mental health conditions to providers at other sites in the community. About half of all schools adopt the third approach for mental health care (Brener et al., 2001).

In addition to formal programs, most schools have at least one professional on staff on at least a part-time basis who is responsible for mental health programming. The three most common professionals, guidance counselors, school psy

chologists, and school social workers, tend to have a masters degree in their discipline (Brener et al., 2001). Guidance counselors are present in over three-quarters of schools and have a wide range of responsibilities, including assisting students who are experiencing problems in coping with school (American School Counselors Association, 2004). Approximately two-thirds of schools have a part-time or full-time psychologist whose major responsibilities involve the assessment of cognitive, behavioral, and emotional conditions that may affect school performance (National Association of School Psychologists, 2004). About 40% of schools have a part-time or full-time social worker who serves as a liaison with parents and coordinates care with outside agencies (National Association of Social Workers,2004).

Despite considerable information about the presence of mental health services in schools, the quality of these services is largely unknown (Rones & Hoagwood, 2000). Research trials of model school-based programs indicate that many are effective (Armbruster & Lichtman, 1999; Rones & Hoagwood, 2000), but actual school programs are more difficult to assess. In this research, we took a step toward assessing quality by asking school professionals to evaluate the overall effectiveness of their mental health programs. We then used these evaluations to assess the contribution of various components to overall success.

We also were interested to learn about the potential roles that school mental health professionals can play to promote the mental health of adolescents. One approach already noted is to create school-based mental health services in schools that can diagnose and treat adolescents on site. Although this strategy has the ability to increase access to effective services for many adolescents (American Academy of Pediatrics, 2001; Armbrister & Lichtman, 1999), it is one that will be difficult to implement on a wide scale in the near term. In another, school professionals refer students for diagnosis and treatment off site by mental health specialists, much as expert panels recommend to primary care providers (Jellinek, Patel, & Froehle, 2002; Melnyk, Brown, Jones, Kreipe, & Novak, 2003).

In a third approach, school mental health pro fessionals design programs for schools to prevent the onset of mental health problems and at the same time identify symptoms so that students can be referred to mental health specialists for care. This public-health approach may have the ability to use the skills of school mental health professionals to their best advantage while also benefiting all students (Adelman & Taylor, 1998; 2000; Atkins, Graczyk, Frazier, & Abdul-Adif, 2003; Hoagwood & Johnson, 2003; Strein, Hoagwood, & Cohn, 2003; Weist, 2003; Weist & Christodulu, 2000).

In evaluating different strategies for school programming, we were also interested in examining potential obstacles to quality mental health care, including limitations in access due to inadequate or no insurance coverage and to inadequate resources in low-income schools. We also asked school professionals to identify solutions to inadequacies in mental health services in schools.

To accomplish these many objectives, the Annenberg Public Policy Center, with funding from the Sunnylands Adolescent Mental Health Initiative, commissioned Princeton Survey Research Associates International to conduct a nationwide survey of over 1,400 school mental health professionals. Interviews were conducted between April and May of 2004. A complete description of the survey methodology is contained in Appendix 31.1.