We asked school professionals to evaluate two common barriers to receiving mental health care: inadequate insurance coverage and inadequate treatment resources in the community. A large proportion of professionals (85%) reported agreement with the statement that “inadequate insurance coverage prevents many students from getting the mental health services they need.” In addition, 54% of professionals agreed with the statement that the “treatment resources for adolescent mental health are adequate in the community.” These evaluations suggest that school professionals see the treatment barriers often cited by panels such as the President's New Freedom Commission as significant problems in the schools.

Similar to primary care physicians who see adolescents for routine check-ups (see Chapter 30), mental health professionals working in rural schools (52%) were more likely (p < .01) to indicate that the resources in their community are inadequate than mental health professionals working in suburban (44%) or urban (41%) schools. As a whole, mental health professionals gave a more positive picture of community resources than primary care physicians. Compared to fewer than half of school mental health professionals (46%), a solid majority of primary care physicians (67%) reported that the treatment resources for adolescent mental health disorders are inadequate in their community (Chapter 30).

Adolescents going to schools in which a high proportion of their classmates come from low-income households are no more likely to have mental health services available than adolescents going to wealthier schools. In fact, as noted earlier, SAPs are actually less available in schools with high proportions of poor students. There are signs, however, that schools serving low-income students try to provide more services on site. First, schools that serve mostly low-income students (more than 75% qualify for free lunch) are more likely to have a school-based health center than schools that serve wealthier students (fewer than 25% qualify) (13% vs. 4%, p < .01). Second, professionals serving in low-income schools are more likely to report that their school has a well-defined process for treating students with mental health problems (24% vs. 15%, p < .05). In addition, schools that avail themselves of Medicaid funding are more likely (p < .01) to have a very clearly defined and coordinated process for diagnosing (31% vs. 21%) and treating (20% vs. 13%) students who may have a mental health condition. Schools that have Medicaid funding are also slightly more likely (p < .05) to screen all or most students for mental health problems (9% vs. 7%). Nevertheless, as noted earlier, schools with high proportions of poor students are only marginally more likely to take advantage of Medicaid funding than schools with wealthier students (48% vs. 41%).

Despite the signs that schools serving low-income students deliver more care, other practices promoting mental health are more likely to take place in wealthier schools. Students who go to schools in which fewer than 25 percent of the student body qualify for the free or reduced lunch program are more likely (p < .01) to be taught to identify symptoms of mental health conditions in themselves and others than students who go to schools with a large low-income population (50% vs. 27%). Parents in wealthier schools are also encouraged to a greater extent to get involved in identifying students who need help (62% vs. 53%). Perhaps as a consequence, professionals working in schools with a wealthier student population are more likely (p < .01) to report that students who are using the mental health services offered by the school often seek them on their own accord (65% vs. 53%) or because they were identified by another student (62% vs. 39%).

To assess the quality and effectiveness of the available programs and services from the perspective of school professionals, we examined three somewhat related outcomes that might serve as criteria for the success of the services currently in place in schools serving adolescents

(Table 31.10). The first was a rating of the overall effectiveness of the school's services. Most professionals (85%), regardless of the demographic characteristics of their schools, described the mental health services offered in their schools as at least somewhat effective. However, only about 18% believed they are “very effective,” with 67% characterizing the services offered as just “somewhat effective.” Fifteen percent of respondents described their mental health services as “not too effective” or “not effective at all.”

A second set of outcomes, school professionals' estimates of how well their programs connect students in their school with needed mental health services, depends on their perceptions of the need for such services. These perceptions varied widely, but on average, school professionals estimated that 18 percent of adolescents are in need of “counseling for mental health conditions such as anxiety disorders or depression.” According to several estimates, approximately 20 percent of adolescents suffer from a diagnosable mental disorder (U.S. Department of Health and Human Services, 2000), so their estimates were clearly in line with prevailing evidence.

More than half of professionals (59%) estimated that only about half or fewer of students who are in need of counseling actually receive these services either at school or elsewhere. Only about 37% of professionals reported that all (7%) or most (30%) of the students receive the care they need. When asked about the proportion that receives the services they need on site, the level of success understandably dropped even lower. In this case, 65% of professionals estimated that half or fewer of the students received the services they needed at the school. Despite the weak performance of most of the school programs, there was considerable variation in perceived success in delivering care to students in need, with a solid core of school professionals seeing their schools' programs as reaching most of the students in need.

Which of the things that schools do to promote the mental health of their students best predict whether a school is evaluated as effective in dealing with students who may have a mental health condition? To answer this question, we first conducted a factor analysis of the services and programs provided, including the professionals on staff and the procedures for identification and screening as well as those for diagnosis, treatment, and referral. We then grouped the results of this analysis into 10 factors that represented the dominant clusters of services, providers, and policies in place in schools. The 10 factors were then entered stepwise into a regression analysis after first holding constant demographic differences between schools, including region of the country, size of school, type of school (primary, middle, high, other), urban vs. rural location, percent of students eligible for free lunch, use of Medicaid funding for health services, and differences between respondents, including age, gender, professional title, length of service at school, and number of hours per week spent on counseling of students. We also included the two measures that assessed the adequacy of treatment resources in the community and the importance of access to health insurance as an ob

stacle to receiving care in the community. Because the three measures of school effectiveness were only moderately correlated with each other (r values ranging from .30 to .40), we analyzed each one separately.

Table 31.11 shows the results of the analysis for each outcome: overall evaluation of the school's mental health program, proportion of students in need of services who received them in total, and proportion of students in need of services who received them primarily at school. Five of the 10 school program factors consistently predicted success. Schools that had well-defined and coordinated processes for both identifying and referring students and for diagnosing and treating them were significantly more likely to perform well on all three criteria. The same was true of schools that had staff that were effective in identifying students at risk for mental health problems, as well as schools that had counseling programs on site and schools that were in communities with adequate treatment resources.

Schools that had mental health professionals on site full time and that had screening programs and staff training for identification of mental health problems were more likely to perform well on overall effectiveness and on delivery of services in total. Schools that encouraged students and parents to seek care performed well on the two service delivery outcomes. Finally, schools that had student health centers were seen as more effective in providing services on site. Prevention programs for problems such as suicide and drugs as well as SAPs did not appear to add any incremental effectiveness beyond the other programs.

In addition to the programs employed in the school, community resources outside the school also mattered. Schools were judged more effective and providing more services if the treatment resources for students in the community were viewed as adequate. In addition, it was seen as easier to deliver services to students if their families had insurance coverage for mental health treatment.

When we examined the many school and respondent characteristics in the analysis, a few school characteristics were consistent predictors of success. In particular, professionals working in middle schools consistently saw their schools as more effective and as delivering services to a higher proportion of students. Schools with high proportions of students eligible for free lunch and those in rural areas were more likely to have successful programs for delivering care on site. In addition, professionals working in schools in the Northeast and South felt their programs did a better job of delivering services on site than those working in the West and Midwest. However, perceptions of overall school effectiveness did not vary by region of the country, urbanity, or income.