We asked our respondents to rate the extent to which various behaviors and conditions were problems in their schools. These ratings, shown in Table 31.3, are organized into three clusters obtained in a factor analysis of respondents' answers. The first cluster, corresponding to mental health problems, indicates that these conditions were seen as related and among the more serious problems affecting students. Indeed, according to the professionals, adolescent depression is one of the more serious problems in their schools, with over 60% saying it is either very (12%) or moderately serious (51%). Anxiety disorders were seen as somewhat less prevalent than depression. Nevertheless, 43% of professionals be lieved students struggle with anxiety at least to a moderate extent. At the same time, however, a majority of professionals (57%) said that anxiety disorders are at most a small problem in their schools.

Cutting or inflicting other forms of self-harm was also generally described as occurring to a small extent. A solid majority of professionals (75%) reported that students' attempting to harm themselves is at most a small problem, but about one in four described it as a problem to a moderate (21%) or great (4%) extent. Similarly, a majority of professionals (81%) said that eating disorders occur to a small or no extent. Fewer than 20% reported that eating disorders are a problem to a moderate (17%) or great (1%) extent.

The second cluster, corresponding to various drug-related behaviors, was also seen as an important set of problems. About half of respondents felt that alcohol (50%) and illegal drug (55%) use presented at least a moderate problem. Illegal use of prescription drugs was not as prevalent as the abuse of illegal substances. A majority of professionals (58%) reported that illegal use of prescription drugs is a small problem, and one in four (21%) said that this is not a problem at all.

Actual sale of drugs on school property was generally not seen as a big problem. A majority of mental health professionals (75%) said that

drug dealing is at worst a small problem in their schools. This is not to say that drug dealing was never a problem. About 22% reported that drug dealing presents a moderate or great problem in their schools.

The third cluster, conflict between individual students and school truancy, also contained some of the bigger problems in schools. A solid majority of professionals (66%) said that bullying or picking on other students is at least a moderate problem. Actual fighting among students was described as somewhat less prevalent. Nonetheless, close to half of mental health professionals said physical violence directed at other students is a problem to a great (10%) or moderate (36%) extent. In addition to interpersonal conflict, a majority of professionals (60%) described truancy as at least a moderate problem.

Despite the media attention of the past few years, students carrying or using weapons was rarely considered a big problem. Very few professionals (5%) reported that weapons are even a moderate problem, with a vast majority either characterizing it as a small problem (60%) or saying that it is not a problem at all (33%).

Although the three problem clusters tended to be distinct, they were also interrelated. Schools with high levels of mental health problems also were seen as having high rates of drug use (r = .48, p < .01) and interpersonal conflict (r = .47, p < .01). Drug use and conflict were slightly less related (r = .31, p < .01).

The context in which school professionals work greatly influences their perceptions of student problems. These perceptions vary greatly depending on the size and location of the school and the demographic characteristics of the student population, especially their age and socioeconomic background. We analyzed school characteristics by conducting multiple regres

sion analyses for each problem with size of school, urban vs. rural location, poverty level (percent eligible for school lunch), middle vs. high school, and region of the country as predictors.

Professionals working in middle schools often described a different set of problems from those described by mental health professionals working with adolescents attending high school. Interpersonal conflict problems tend to take center stage during the middle school years, whereas drug and alcohol use are more prevalent in high school. Professionals working in middle schools were considerably more likely (p < .001) to report that bullying or picking on other students (82% vs. 54%) and fighting (57% vs. 37%) are moderate or great problems than their counterparts working with high school students. At the same time, high school professionals were more likely (p < .001) to describe the use of illegal drugs (72% vs. 36%), excessive use of alcohol (71% vs. 28%), drug dealing (31% vs. 12%), and illegal use of prescription drugs (23% vs. 7%) as problematic.

Mental health conditions were also described as more prevalent in high schools than in middle schools. Professionals in high schools were more likely (p < .01) to say that depression (68% vs. 57%) and eating disorders (22% vs. 13%) are problems to a great or moderate extent than professionals in middle schools. However, anxiety disorders (44% vs. 42%) and cutting (26% vs. 26%) were seen as equally prevalent in middle and high schools.

We also found that larger schools tend to have more problems than smaller ones. It is not clear whether this perception is the result of the sheer likelihood that more problems occur in a larger school or that the prevalence is greater. Nevertheless, mental health conditions, such as depression (69% vs. 48%), anxiety (44% vs. 32%), and cutting (29% vs. 19%), were seen as more of a problem (p < .05) in schools with more than 1,500 students than in schools with less than 500 students. The same is true when it comes to students engaging in risky behaviors (p < .01). In particular, a solid majority of professionals (65%) working in schools with more than 1,500 students reported that the use of illegal drugs is a moderate or a great problem, compared to fewer than half of professionals (45%) working in schools with less than 500 students. Fighting (50% vs. 33%) and drug dealing (28% vs. 11%) were also seen as more problematic in very large schools than in small schools. Nevertheless, perceptions of excessive use of alcohol (55% vs. 49%), eating disorders (20% vs. 16%), and bullying (51% vs. 51%) were not related to school size.

Where the school is located also makes a difference. Professionals working in urban schools (69%) were more likely (p < .01) to see depression as a problem than those working in rural areas (53%). The same was true for fighting among students (59% vs. 33%) and weapon carrying (12% vs. 2%). At the same time, professionals in urban schools felt that alcohol abuse was less of a problem than those working in rural areas (40% vs. 52%).

Regionally, mental health professionals working in the South tended to see fewer problems than those working in other areas of the country. For example, professionals in southern schools (54%) were less likely (p < .01) to consider depression problematic than their colleagues in the Northeast (71%), Midwest (66%), and West (66%). Southerners also reported fewer problems regarding eating disorders, cutting, use of illegal drugs, alcohol abuse, fighting, and weapon carrying than professionals in other regions. The one exception was for abuse of prescription drugs, for which southerners saw more problems than professionals working in other regions (p < .01). Professionals working in the Northeast (56%) were also more likely to describe anxiety disorders as a great or moderate problem than either southern (39%) or western (36%) mental health professionals, with their counterparts in the Midwest (46%) falling in between.

The socioeconomic composition of the student population (measured by the proportion of students eligible for a free or reduced lunch program) also leads to differences in problems. Abuse of alcohol and prescription drugs, eating disorders, and cutting tended to be more problematic in wealthier schools than they were in schools with a higher proportion of low-income students. At the same time, drug dealing, fighting, bullying, and weapon carrying tended to be more problematic in low-income schools.

Consistent with earlier research, we found that many schools already offer at least some mental health services on site (Table 31.4). About half of the professionals reported that their schools offer counseling for conditions such as anxiety and depression on school premises (47%), and many (44%) have a program for dealing with students who have mental health issues, such as an SAP. Most of the schools that do not offer counseling on school premises are prepared to refer students to other providers in the community (48%). Only 1 percent of professionals reported that their school neither provides counseling for depressed or anxious students nor refers these students to a service provider outside the school.

Large proportions of schools (67%) also reported the presence of programs to counsel students on the prevention of alcohol and drug abuse or the prevention of suicide (68%). However, smaller proportions of schools have programs to help students who want to quit the use of tobacco (43%) or other drugs such as alcohol (24%).

Schools are also less likely to be prepared to handle victims of abuse or the families of students with mental health conditions. Only 38% of schools offer counseling in the district for students who are victims of physical, sexual, or emotional abuse, and only 29% offer counseling or help for families of students who have a mental health condition. Nevertheless, nearly all of the schools that do not have programs on site refer students and families to outside providers.

Only a little more than half of the schools sampled (53%) have full-time access to a mental health professional—a psychologist, counselor, or social worker—whose main job is to deal with students' mental health issues. Even if one considers part-time staff, 23% do not even have access to a part-time mental health professional.

But even if mental health professionals are not always available, most schools employ other health professionals. A slim majority of schools (51%) have a school nurse on the premises full-time, while an additional 32% of schools employ a part-time nurse. If one considers all potential health professionals, including physicians and nurses, then about 74% of schools have a full-time health professional on site. If one considers both full-time and part-time staff, then nearly all schools (96%) have at least one health professional on site.

Seven percent of schools have a full-service health center on school property where students can receive primary health care, including diagnostic and treatment services by a doctor, nurse practitioner, or physician's assistant. However, not all of these centers offer mental health services (38% do not). It is clear that these centers