are currently only able to care for a small percentage of adolescent mental health problems.

Adolescents in some parts of the country are much more likely to have access to health professionals on school premises than others (Table 31.5). In particular, schools in the Northeast are considerably more likely to employ mental health professionals than schools elsewhere in the country. The regional gap is also reflected in the fact that 32% of the schools in the Northeast employ a physician or nurse practitioner, whereas nearly as high a percentage of schools in the West (24%) do not even have a part-time school nurse.

We also found that schools located in both the Northeast (52%) and the Midwest (54%) are more likely (p < .01) to have a program, such as an SAP, for dealing with students who have mental health issues than schools in the western (39%) or southern (37%) parts of the country. Such programs are also more common in schools with a wealthier student base, defined as less than 25 percent of the student body eligible for free or reduced lunches, than schools in which more than half of students are eligible (53% vs. 36%). This disparity is somewhat offset by the fact that schools that receive Medicaid funding for the purpose of providing health care services to their students are more likely to offer coun seling for mental health conditions on school premises than schools that do not receive Medicaid funding (54% vs. 42%). These schools are also more likely to employ a full-time psychologist (21% vs. 13%) or social worker (24% vs. 15%). However, almost as high a percentage of schools with low proportions of poor students avail themselves of Medicaid funding as schools with high proportions of poor students (41% vs. 48%).

As might be expected, we also found that larger schools are more likely to employ full-time mental health professionals than smaller schools. Professionals working in larger schools were more likely to report that their school employs a full-time school nurse, counselor, social worker, or psychologist than mental health professionals working in smaller schools.

What school mental health professionals do varies considerably both across and within their job titles. We asked respondents with each of the three major job titles (Table 31.2) how they viewed their responsibilities in regard to mental health issues. The clearest finding (Table 31.6) is

that all three types of professionals viewed their job as referring students who might have a mental health condition such as depression or anxiety disorder to other professionals for further testing and treatment. Social workers appear the most likely of the three to see their job as performing any treatment themselves (86%). Both counselors (63%) and psychologists (57%) often viewed this as part of their job but not to the same level as social workers. The same general pattern appeared in regard to counseling parents; only the large majority of social workers viewed this as their responsibility.

When it comes to identifying students with potential mental health conditions, the vast majority of psychologists (82%) and social workers (88%) regarded this as part of their job. However, a smaller yet significant majority of school counselors agreed with this job description (65%). Differences were also apparent when the development of mental health programs for the entire school is considered. Here about two-thirds of counselors and social workers agreed with this description, but less than 40% of psychologists viewed this as a priority. School psychologists appear to have the major responsibility of administering tests to identify mental health conditions in students. Whereas about two-thirds of psychologists agreed with this description, very few counselors (6%) and only about a quarter of social workers saw this as part of their job.

These job descriptions suggest that school mental health professionals can help to identify students with mental health conditions and provide referrals but that actual treatment is more likely to occur elsewhere or with different providers. Most school mental health professionals are likely to refer students who are displaying symptoms of mental health conditions to another professional for further testing and counseling. As seen in Table 31.7, roughly 8 in 10 school professionals would refer students who were showing signs of depression (80%), anxiety (79%), or alcohol abuse (77%). Most of the rest said they would be somewhat likely to do so.

School mental health professionals are considerably less likely to say that they would treat or counsel students with potential mental health problems themselves. In the case of depression, fewer than 40% said they would be very likely to treat or counsel the student (Table 31.7). Even fewer said they would be very likely to treat or counsel students who were displaying symptoms of an anxiety disorder (30%) or alcohol abuse (27%). Sizable minorities indicated that they would not be too likely or would not be likely at all to treat or counsel students who were de

pressed (27%), had an anxiety disorder (34%), or were using excessive amounts of alcohol (38%).

Counseling or working with students who have mental health problems is clearly not the only thing that school mental health professionals do. Most school professionals actually spend much of their time doing other things. A majority of professionals (76%) spend less than half of their work week counseling or working with students who have mental health problems, and nearly half (47%) do this for less than 10 hours a week. A small minority (9%) spends more than 30 hours per week on this activity.

Not only do school professionals divide their time between a multitude of tasks, some also work in more than one school. Although a solid majority of professionals (69%) spend all their time in one school, 31% said they work in more than one school. Among psychologists, a solid majority (62%) reported that they work in more than one school.

Spending more time working with students who have mental health issues may sensitize one to the problem. Mental health professionals who spent at least 10 hours a week counseling or working with students who have mental health issues were considerably more likely to consider depression (73% vs. 52%), anxiety disorders (52% vs. 33%), cutting (31% vs. 18%), and eating disorders (21% vs. 14%) to be a problem in their school to a great or moderate extent than professionals who spent less time with such students (all differences significant at p < .01).

Given the extent to which mental health professionals have to stretch their time, it is important to understand the procedures that schools employ to identify and deal with students who may have a mental health condition. We found that a solid majority of professionals claimed their schools have a clearly defined and coordinated process for providing referrals for students who may have a mental health condition. However, having an equally clear process for identifying, diagnosing, or treating students is less common.

In particular, 66% of professionals said their school has a “clearly defined and coordinated process for providing referrals to students who may have a mental health condition.” However, before students can be referred for further testing

and counseling, their condition needs to reach the attention of the professional in charge of referrals. Schools are less likely to have a clearly defined and coordinated process for identifying students who may have a mental health condition than they are to have a referral process. Only 37% of professionals said that their schools have a process to a great extent for identifying students. As many (37%) are in schools with a moderately clear process, and one in four said (25%) their process is only coordinated to a small extent or not at all.

Schools are even less likely to have a clear process for diagnosing students with a specific mental health condition. In fact, about half of professionals said (51%) their schools have a diagnostic process that is clearly defined and coordinated only to a small extent or not at all. Only half of professionals (49%) are in schools with a very (26%) or moderately (23%) clear and coordinated diagnostic process.

Similarly, the process for treating students with mental health conditions is clear to only a small extent or not at all in the about half of schools (53%). Less than half of professionals (46%) are in schools that have a very (17%) or moderately (29%) clear and defined process for treating students.

One way to minimize the chance that students with problems are overlooked is to systematically screen the entire student population. At present, however, only 2% of schools screen all and only 7% screen most of their students for mental health problems. Although a majority of schools (63%) report screening some of the students, about 26% conduct no screening at all.

One solution to increasing the identification of students in need of assistance is to train teachers to identify symptoms of mental health conditions. Here the situation is a little more encouraging. Only about 19% of schools provide no training at all to teachers in identifying mental health problems in students. However, it is unusual for schools to train all (9%) or most (12%) of the teachers to identify such problems. A little more than half (53%) trains only some of their teachers to identify mental health problems.

Another potential way to increase the likelihood that students will seek and find help when necessary is to teach students to identify potential symptoms of mental health conditions in themselves and in peers. A sizable minority of schools (38%) follows this practice for all or most of the students. However, in a solid majority of schools (59%), only some or none of them are taught these skills. Schools in the Northeast (49%) and Midwest (48%) are more likely (p < .01) to teach students to identify symptoms of mental health conditions than schools in the West (32%) or the South (30%).

It is also important that students feel comfortable asking for help themselves when they feel they need it. Most schools seem to recognize this, as a strong majority of professionals reported that all (60%) or most (21%) of the students in their school are encouraged to seek help if they think they or their peers might have a mental health condition. About 57% of respondents reported that they encouraged all of the parents in their school to seek help if they need it; 20% reported that they encouraged most of the parents in their school in the same way.

When it comes to identifying students who may have mental health issues, “clearly defined and coordinated” often means that the entire school is involved. Mental health professionals who said that their school's program for identifying students is clearly defined and coordinated to a great extent were more likely to indicate that not only mental health professionals but also other professionals working in the school are involved in the identification process. In particular, higher proportions (p < .01) of teachers (77% vs. 46%), supervisors of after-school programs (77% vs. 46%), health care professionals (70% vs. 54%), and administrators (66% vs. 44%) have at least moderate responsibility for identifying students than professionals who described their identification process as only coordinated to a small extent or not at all.

We asked school professionals to evaluate how well various staff members identify students with mental conditions. The results shown in Table 31.8 indicate that among those responsible for identifying students with potential mental

health problems, mental health professionals believed that both they and school nurses do a very good job. However, it is possible for teachers, administrators, and coaches to do a good job as well.

According to our respondents, mental health professionals and teachers are the ones who are seen as most often identifying a student who needs mental health services (Table 31.9). At the same time, more than half of respondents said that referrals by parents, peers, or the students themselves are also somewhat common. About 19% of school professionals reported that students who use the school's mental health services very often do so because they were referred by parents, and over half (55%) said parents are the initiating party somewhat often. At the same time, school professionals (24%) indicated that parents are not too often or not often at all involved.

Students are seen as somewhat less likely to ask for help on their own accord. About 38% of school professionals said that students do not often approach them on their own. Yet, a majority (60%) said this happens at least somewhat often. Sometimes peers identify students with mental health concerns, although school professionals were divided on how frequently this occurs. A slim majority (52%) said that peers identify students who may have a mental health condition at least somewhat often, but nearly as many (46%) said this happens not too often or not at all.

Adolescents in schools where the students are taught to identify symptoms of mental health conditions are said to be more likely (p < .01) to enter the system on their own accord (65% vs. 47%) or because peers identified them (60% vs. 33%) than adolescents in schools where only some or none of the students learn these skills.