School Mental Health: Role of the Substance Abuse and Mental
Health Services Administration and Factors Affecting Service
Provision (05-OCT-07, GAO-08-19R).
The U.S. Surgeon General reported in 1999 that about one in five
children in the United States suffers from a mental health
problem that could impair their ability to function at school or
in the community. Yet many children receive no mental health
services. While many of the existing mental health services for
children are provided in schools, the extent and manner of school
mental health service delivery vary across the country and within
school districts. Federally led initiatives have identified
schools as a potentially promising location for beginning to
address the mental health needs of children. Both the report of
the Surgeon General's Conference on Children's Mental Health and
the 2003 report of the President's New Freedom Commission on
Mental Health--Achieving the Promise: Transforming Mental Health
Care in America--identified school mental health services as a
means of improving children's mental and emotional well-being. At
the federal level, the Department of Health and Human Services'
(HHS) Substance Abuse and Mental Health Services Administration
(SAMHSA) has a stated mission of building resilience and
facilitating recovery for people--including children at risk for
mental health problems. Although SAMHSA is the federal
government's lead agency for mental health services, other
federal agencies and departments, such as HHS's Centers for
Disease Control and Prevention (CDC) and the Department of
Education (Education), engage in, or coordinate, activities
related to school mental health services in various ways. SAMHSA
works to achieve its mission chiefly by providing grants and
technical assistance. For example, the agency uses grant funds
and technical assistance to support the expansion of mental
health service capacity and the use of evidence-based practices
in mental health services. Typically, efforts that have been
validated by some form of documented scientific data are referred
to as evidence-based. Congress asked us to provide information on
school mental health services and the role of SAMHSA in this
area. In this report, we describe (1) SAMHSA's coordination with
other federal departments and agencies to support mental health
services in schools, (2) the efforts SAMHSA has made to identify
and support evidence-based school mental health services and best
practices for service delivery, and (3) factors that affect the
provision of mental health services in schools.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-08-19R
ACCNO: A77108
TITLE: School Mental Health: Role of the Substance Abuse and
Mental Health Services Administration and Factors Affecting
Service Provision
DATE: 10/05/2007
SUBJECT: Data collection
Educational facilities
Educational grants
Grants to states
Health care programs
Interagency relations
Mental health
Program evaluation
School districts
School health services
School management and organization
Students
Education programs
Program coordination
Program goals or objectives
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GAO-08-19R
* [1]PDF6-Ordering Information.pdf
* [2]Order by Mail or Phone
October 5, 2007
The Honorable Edward M. Kennedy
Chairman Committee on Health, Education, Labor, and Pensions
United States Senate
Dear Mr. Chairman:
Subject: School Mental Health: Role of the Substance Abuse and Mental
Health Services Administration and Factors Affecting Service Provision
The U.S. Surgeon General reported in 1999 that about one in five children
in the United States suffers from a mental health problem that could
impair their ability to function at school or in the community. Yet many
children receive no mental health services. While many of the existing
mental health services for children are provided in schools, the extent
and manner of school mental health service delivery vary across the
country and within school districts.^1 Federally led initiatives have
identified schools as a potentially promising location for beginning to
address the mental health needs of children. Both the report of the
Surgeon General's Conference on Children's Mental Health and the 2003
report of the President's New Freedom Commission on Mental
Health--Achieving the Promise: Transforming Mental Health Care in
America--identified school mental health services as a means of improving
children's mental and emotional well-being.^2
At the federal level, the Department of Health and Human Services' (HHS)
Substance Abuse and Mental Health Services Administration (SAMHSA) has a
stated mission of building resilience and facilitating recovery for
people--including children at risk for mental health problems. Although
SAMHSA is the federal government's lead agency for mental health services,
other federal agencies and departments, such as HHS's Centers for Disease
Control and Prevention (CDC) and the Department of Education (Education),
engage in, or
coordinate,^3 activities related to school mental health services in
various ways. SAMHSA works to achieve its mission chiefly by providing
grants and technical assistance.^4 For example, the agency uses grant
funds and technical assistance to support the expansion of mental health
service capacity and the use of evidence-based practices in mental health
services. Typically, efforts that have been validated by some form of
documented scientific data are referred to as evidence-based.
^1For the purposes of this report, we use the term "school mental health
services" to refer to both school-based services, i.e., services provided
in the school, and school-linked services, i.e., services provided by a
community provider through a link with the school. Throughout this report,
the term school is used to refer to elementary and secondary education,
i.e., kindergarten through 12th grade.
^2U.S. Public Health Service, Report of the Surgeon General's Conference
on Children's Mental Health: A National Action Agenda, Department of
Health and Human Services (Washington, D.C.: Sept. 18-19, 2000) and New
Freedom Commission on Mental Health, Achieving the Promise: Transforming
Mental Health Care in America: Final Report, Department of Health and
Human Services (Rockville, Md.: July 22, 2003).
You asked us to provide information on school mental health services and
the role of SAMHSA in this area. In this report, we describe (1) SAMHSA's
coordination with other federal departments and agencies to support mental
health services in schools, (2) the efforts SAMHSA has made to identify
and support evidence-based school mental health services and best
practices for service delivery, and (3) factors that affect the provision
of mental health services in schools.
To address these objectives, we reviewed materials related to SAMHSA's
efforts to coordinate activities related to school mental health services
with other federal departments and agencies. We also reviewed materials
related to SAMHSA's efforts to identify and support the use of
evidence-based interventions. These materials included program
descriptions and grant announcements related to federal programs that
support school mental health services, as well as agendas and summary
documents from interagency meetings related to children's mental health.
We conducted interviews with SAMHSA staff, as well as staff from other HHS
agencies who interact with SAMHSA or conduct activities related to school
mental health services. In addition, we interviewed staff from Education's
Office of Safe and Drug-Free Schools and the Department of Justice's (DOJ)
Office of Justice Programs, which participate in activities related to
mental health services and violence prevention programs in schools. We
also interviewed experts in the field of mental health services and
representatives of mental health provider groups and school administration
associations. Information on mental health services provided to students
who qualify for special education services through the Individuals with
Disabilities Education Act (IDEA) was outside the scope of our work.^5
To provide information on factors that affect the provision of school
mental health services, we conducted interviews with representatives from
seven selected sites--schools and school districts--and reviewed
documents, including their program descriptions, training materials,
and evaluation reports. We conducted interviews on site at five locations,
two in Connecticut and three in Ohio; and by telephone with two locations,
one in Florida and one in North Carolina.
^3Coordination can be broadly defined as any joint activity by two or more
organizations that is intended to produce more public value than could be
produced when organizations act alone. For the purposes of this report, we
use the term "coordination" to include activities variously described as
"cooperation," "collaboration," "integration," and "networking." See GAO,
Results-Oriented Government: Practices That Can Help Enhance and Sustain
Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: October
2005).
^4In this report, we use the term grants to include both grants and
cooperative agreements, except where otherwise indicated. The distinction
between a grant and a cooperative agreement is the degree of federal
involvement. A cooperative agreement is used when substantial involvement
is expected between an agency and the funding recipient, whereas a grant
is used when substantial involvement is not expected between an agency and
the funding recipient. In addition, for the purposes of this report, we
use the term technical assistance to refer to support provided to
organizations receiving federal funding to help them with the
implementation of their program, such as assistance with strategic
planning or program evaluation.
^5IDEA provides funding to support free, appropriate public educational
services to children with disabilities, including disabilities related to
mental health. 20 U.S.C. S 1400 et seq.
To select our seven sites we
o Interviewed officials from federal agencies and associations, as
well as experts in the area of school mental health, to identify
states, localities, school districts, and specific schools
considered to be active in the area of school mental health
services.
o Selected a sample of 7 sites from approximately 53 identified
locations based on the following criteria: The sites selected were
to include a mix of urban and rural settings, settings with
school-based health centers, and at least 1 site currently
receiving funds through the federal Safe Schools/Healthy Students
(SS/HS) and Grants for the Integration of Schools and Mental
Health Systems Programs.
Because we used a nongeneralizable sample to select our sites, the
information provided cannot be used to make inferences about other
programs. In addition, the information provided by program officials does
not reflect all efforts under way in their locations related to school
mental health services. (For additional information on our methodology,
see encl. I. For more information on sites in our review, see encl. II.)
We conducted our work from March 2007 through September 2007 in accordance
with generally accepted government auditing standards.
Results in Brief
SAMHSA coordinates formally and informally with other federal departments
and agencies on school mental health services. The agency currently
maintains two formal coordination efforts for school mental health
services. It coordinates with (1) Education and DOJ for the SS/HS
initiative, a key federal effort to directly support mental health
services in schools; and (2) several federal departments and agencies
serving children, including Education and DOJ, for the Federal/National
Partnership, an effort designed to promote coordination related to
children's mental health and substance use prevention. In addition to
formal coordination efforts, SAMHSA officials maintain multiple informal
or episodic coordination efforts with other federal departments and
agencies, such as Education, CDC, and the Health Resources and Services
Administration (HRSA), on a variety of activities related to school mental
health services; these are based largely on personal relationships among
agency staff.
SAMHSA both identifies and supports the use of evidence-based school
mental health interventions. To identify evidence-based interventions,
SAMHSA uses the National Registry of Evidence-based Programs and Practices
(NREPP). This searchable registry assists interested parties, including
school and school district staff members, in identifying interventions to
provide mental health services for children in schools. As of August 2007,
slightly more than one-fourth of the interventions listed on NREPP were
related to school mental health, including interventions designed to
address aggressive behavior, depression, or school violence. SAMHSA also
supports the use of evidence-based school mental health interventions
through grant programs, including the SS/HS program. SS/HS requires
grantees to use evidence-based interventions and provides technical
assistance for the implementation of these interventions. SAMHSA also
awards grants to support the use of evidence-based interventions through
other programs not specifically designed for the school setting.
Officials from the seven sites in our review identified coordination and
close working relationships, support from "program champions"--advocates
for the program--and school leadership, and sustainable funding and
staffing as factors that can affect the provision of school mental health
services. Because mental health professionals focus on students' emotional
health and education professionals focus on academic achievement,
coordination between these differing missions can enhance the provision of
school mental health services. School officials from sites in our review
recognized that addressing students' mental health needs can improve their
academic achievement. Site officials told us that, in addition to being
aware of a school's academic mission, mental health providers need to be
cognizant of students' academic schedules and responsibilities. For
example, sites avoided providing services during testing periods.
Coordination between sites and external stakeholders, such as community
mental health or social service agencies, can also enhance the provision
of school mental health services by allowing schools to build
relationships with other agencies that influence the lives of students.
Sites also emphasized the importance of working closely with existing
school health and mental health staff. By doing this, sites can avoid
overlap in services provided to students. Site officials stressed that one
or more program champions and support from school leaders can play a role
in implementing school mental health services; conversely, the loss of
either of these can threaten program continuity. Finally, site officials
noted that difficulties securing and sustaining both funding and mental
health service provider staff have affected the ability to implement
school mental health services.
In commenting on a draft of this report, HHS agreed with our
characterization of SAMHSA's efforts related to school mental health
services and stressed the importance of schools as a venue for the
delivery of mental health prevention and treatment programs, services, and
supports. Education told us it had no comments on the draft.
Background
Multiple federal agencies are involved to varying degrees in school mental
health services at the elementary and secondary level, including through
grants and technical assistance. While school mental health services vary
from location to location, most schools have some efforts in place to
address students' mental health needs, which can be provided by a variety
of mental health professionals.
Federal Role in Education and Mental Health Services for Children
Elementary and secondary education is primarily a responsibility of states
and localities. During the 2003-2004 school year, Education reported that
the state and local share of total revenues related to elementary and
secondary education equaled 91 percent--just over $420 billion. While
state and local agencies take the lead in elementary and secondary
education, a variety of federal departments and agencies are involved in
supporting or promoting mental health in schools.
SAMHSA has primary federal responsibility for issues related to children's
mental health services.^6 SAMHSA's Center for Mental Health Services
supports mental health services that are evidence-based, provided in
community settings, and designed to promote recovery for people with, or
at risk for, mental health disorders. The center provides this support
through
grants and technical assistance, and acts as SAMHSA's lead in the SS/HS
program, an effort that directly supports mental health services in
schools. Since its creation in 1999, the SS/HS grant program, a joint
effort of SAMHSA, Education, and DOJ, has awarded more than $1 billion to
support school mental health services and related activities. The program
is designed to promote safe, drug-free schools and healthy childhood
development and includes efforts to promote positive student behavior and
early identification and treatment of mental health problems. (See encl.
III for more information on the SS/HS program.) SAMHSA funds other
programs related to children's mental health that, while not focused on
schools, relate to school programs or efforts in the area of school mental
health.
^6SAMHSA's total fiscal year 2007 budget was about $3.2 billion.
In addition to SAMHSA, other agencies within HHS have roles related to
school mental health services. For example,
o HRSA funds the Mental Health in Schools Program to support two
centers related to school mental health.^7 These centers currently
focus on analysis of school mental health policies and programs
and have also provided training and technical assistance. Fiscal
year 2007 funding for this program was $900,000. HRSA's Health
Center Program, funded at approximately $1.78 million in fiscal
year 2006, supports community health centers, including centers
designed to provide services to specific populations such as
migrant workers, residents of public housing, and at-risk school
students. Services to students can be provided through
school-based health centers, which may provide mental health
services such as case management or therapy.
o CDC has developed the Coordinated School Health Program model,
made up of eight interrelated components addressing student
health, one of which is counseling and psychological services. CDC
also has a cooperative agreement with the National Assembly on
School-Based Health Care, an organization whose mission is to
support school-based health centers, for a 5-year "School Mental
Health Capacity Building Partnership" initiative. This initiative,
which according to CDC officials is funded at $175,000 per year,
is designed to strengthen efforts to improve school mental health
services and synthesize information on state and local efforts in
this area. CDC surveys, including student surveys and surveys of
school and school district staff, also collect information
directly or indirectly related to school mental health services.
o The National Institutes of Health's National Institute of Mental
Health (NIMH) funds research on school mental health services and
service delivery models.
o The Centers for Medicare and Medicaid Services' Medicaid
program, a joint federal-state program to finance health care
coverage for certain categories of low-income individuals, can in
some cases be used to pay for specific school mental health
services. For example, in some states, Medicaid may pay for
diagnosis of mental health issues or therapy provided in a school
setting for students enrolled in Medicaid.
^7These centers are the Center for Mental Health in Schools at the
University of California, Los Angeles and the Center for School Mental
Health Analysis and Action at the University of Maryland, Baltimore.
Other federal departments also support programs related to school mental
health services. For example,
o Education's Office of Safe and Drug-Free Schools participates in
the SS/HS program. In addition, it funds both the Grants for the
Integration of Schools and Mental Health Systems program, a grant
program designed to help school systems develop connections with
local mental health systems, and the Elementary and Secondary
School Counseling program, which provides funding to school
systems to establish or expand elementary and secondary school
counseling programs.^8 Grants for these two programs totaled just
under $40 million in fiscal year 2007. Education also supports
Project School Emergency Response to Violence (Project SERV), a
grant program that funds short-term and long-term
education-related services, including mental health assessments,
referrals, and counseling services, to school systems in which the
learning environment has been affected by a violent or traumatic
event. In fiscal year 2007, Project SERV was funded at $3
million.^9
o DOJ also participates in the SS/HS program. In addition, the
Office of Justice Programs has funded efforts to develop resources
related to youth violence and truancy prevention, which may
involve mental health programs in school settings. Through the
Antiterrorism and Emergency Assistance Program for Terrorism and
Mass Violence, the Office for Victims of Crime (OVC) provides
funds to states and localities, including schools, to address
issues, including mental health needs, stemming from intentional
acts of criminal mass violence. For example, OVC officials
reported that the program provided funds following the September
2006 shooting at Platte Canyon High School in Bailey, Colorado.
Delivery of School Mental Health Services to Children
Because decisions related to schools are typically made at the local
level, school mental health service delivery varies from district to
district, and can vary from school to school within the same district. A
variety of services can be provided, including prevention activities,
assessment, crisis intervention, case management, and counseling. Efforts
can focus on a wide range of problems, including specific mental health
diagnoses, bullying, violence, and discipline issues.
Studies indicate that most of the approximately 90,000 public schools
nationwide have various efforts in place to address the mental health
needs of their students.^10 While the mechanisms for delivering school
mental health services vary greatly from location to location, several
general delivery mechanisms have been identified:^11
o School student support services: Services provided by
school-employed staff such as counselors or psychologists.
o School-district mental health units: Services provided to
students through a district-operated mental health unit or clinic.
o Agreements for services with community providers: Services
provided through an agreement between the schools and a community
provider, such as a school-based health center run by an entity
other than the school or school district.
o Classroom-based curricula: Services provided through curricula
in classrooms or as special programs, such as activities to
promote healthy emotional behavior and prevent behavioral
problems.
o Comprehensive, multifaceted, and integrated approaches: Services
provided through comprehensive systems that bring together
resources from both schools and communities in an integrated
fashion to promote student mental health.
^8Funding can be awarded to secondary schools only if grant funds exceed
$40 million.
^9Funds appropriated for Project SERV remain available for awards in
subsequent years if not used.
^10S. Foster et al., School Mental Health Services in the United States,
2002-2003 (Rockville, Md.: Center for Mental Health Services, SAMHSA,
2005).
^11These mechanisms are not mutually exclusive. For more information, see
Center for Mental Health in Schools, The Current Status of Mental Health
in Schools: A Policy and Practice Analysis (Los Angeles, Calif.: 2006).
According to a 2005 SAMHSA report, during the 2002-2003 school year about
one-third of school districts surveyed provided mental health services
using only school or school district employees.^12 More than half of the
schools surveyed reported that they contracted with one or more community
organizations or individual providers for mental health services. Almost
30 percent of these schools reported that they contracted with their local
mental health agency, while others reported contracting with a variety of
public and private providers. Six percent and 4 percent of schools,
respectively, reported contracting with hospitals or faith-based
organizations.
Regardless of the mechanism used, services generally fall into three
categories--universal, selective, or indicated:^13
o Universal: Services intended for all children, including
services related to creating a positive school environment or
improving students' social skills. These services may focus on
decreasing risk factors for future mental health problems and
increasing resilience by promoting positive school environments
and ensuring that students have access to appropriate supports to
allow healthy emotional development.
o Selective: Services targeting a smaller subset of the
population, usually those children identified as at-risk for
developing mental health problems or with identified mental health
needs. Services at this level may include targeted violence-,
suicide-, or dropout-prevention programs or group therapy.
o Indicated: Services targeting children with the greatest need
for support, which could include intensive services such as
one-on-one therapy.
^12S. Foster et al.
^13Other models for these categories exist. For more information on
various models, see K. Kutash, A.J. Duchnowski, and N. Lynn, School-Based
Mental Health: An Empirical Guide for Decision-Makers (Tampa, Fla.:
University of South Florida, 2006).
Staffing of Mental Health Service Provision in Schools
Providers of various types--school counselors, psychologists, social
workers, nurses, marriage and family therapists, and others--can address
students' mental health needs in schools. The roles of these professionals
overlap to some extent, but each has particular areas of expertise. (See
table 1.)
Table 1: Selected Professions That May Provide School Mental Health
Services
Provider
association's Provider
recommended association's
provider-to-student recommended
Provider type Provider description ratio^a training level^a
School Provide services 1 school counselor Master's level
counselors designed to address to every 250
students' academic, students
career, and
personal/social
development. These
services can include
individual or group
counseling,
consultation with
parents and teachers,
and referrals to other
school or community
resources.
School Assess students' 1 school Post-master's
psychologists psychological psychologist to specialist-level
functioning and needs, every 1,000 students degree program
and provide
consultation to
parents and school
staff on students'
behavioral, social,
emotional, and
instructional needs.
May provide some
prevention and direct
intervention services.
May focus on
assessment of the
special education
population.
School social Provide services 1 school social Master's level
workers designed to create worker to every 400
linkages among the students
school, family, and
community, including
case management,
support groups, crisis
intervention, and home
visits.
School nurses Implement school 1 school nurse to Licensure as a
health services, every 750 students registered nurse
including mental and a
health, for all baccalaureate
students. Can provide degree
services including
chronic care, general
health education and
promotion activities,
and teacher education.
May also act as a
contact within the
school for a family.
Marriage and Diagnose and treat No recommended ratio Master's level
family mental and emotional
therapists disorders within the
context of marriage,
couples, and family
systems. While not
exclusive to schools,
some work in school
settings.
Source: GAO analysis of information from HRSA and provider associations.
aRecommended by the relevant provider association: American School
Counselor Association, National Association of School Psychologists,
School Social Work Association of America, National Association of School
Nurses, and the American Association for Marriage and Family Therapy.
SAMHSA's 2005 report identified school counselors as the most common type
of school mental health provider, followed by school psychologists and
school social workers. The study also found that school nurses, with broad
responsibility for student health needs, spend one-third of their time
providing mental health services. In addition to the credentials
recommended by provider associations, a 2000 study found that most states
and school districts have developed minimum education and certification
requirements for school staff who provide mental health services.^14 Of
states with minimum educational requirements, most required a master's
degree for counselors and psychologists, while fewer than half required a
master's degree for social workers.^15
SAMHSA Coordinates Formally and Informally at the Federal Level on School
Mental Health Services
SAMHSA coordinates with other federal departments and agencies on school
mental health services. SAMHSA currently maintains two formal coordination
efforts for school mental health services--it coordinates with (1)
Education and DOJ for the SS/HS initiative and (2) several federal
departments and agencies serving children for the Federal/National
Partnership, an effort designed to promote collaboration related to
children's mental health and substance use prevention. In addition to
formal coordination efforts, SAMHSA officials maintain multiple informal
or episodic coordination efforts at the federal level related to school
mental health services.
SAMHSA Formally Coordinates with Federal Departments and Agencies on an
Ongoing Basis
SAMHSA, Education, and DOJ have coordinated on SS/HS by contributing
financial, technical, and administrative support through a collaborative
agreement.^16 SAMHSA's funds are used for mental health promotion,
prevention, early identification, and treatment services and supports for
students and their families. These activities can include early
identification and assessment in the school setting, and early childhood
development programs, such as nurse home visits for young children who
demonstrate behavior problems. The funds contributed by Education and DOJ
have been used for alcohol, drug, and violence prevention and early
intervention programs, as well as efforts to address student behavioral,
social, and emotional supports.^17
^14N.D. Brener, J. Martindale, and M.D. Weist, "Mental Health and Social
Services: Results from the School Health Policies and Programs Study
2000," Journal of School Health (2001): 305-312. The 2000 School Health
Policies and Programs Study provides the most recent data available and is
based on data from the 50 states plus the District of Columbia and a
nationally representative sample of school districts. CDC officials
anticipate that new data from the study will be available in fall 2007.
^15The study does not collect information regarding marriage and family
therapists or other provider types.
^16While the collaborative agreement that guides the SS/HS program has not
changed, DOJ has not contributed funds since fiscal year 2003 and does not
currently have staff assigned to the SS/HS program. However, the agency
still participates in making programmatic decisions, including grant
decisions, under the collaborative agreement.
^17Although Education's SS/HS funds can be used for prevention and early
intervention programs, Education cannot use these funds for medical
services (including mental health treatment) or drug treatment or
rehabilitation, except for pupil services or referral to treatment for
students who are victims of, or witnesses to, crime or who illegally use
drugs. 20 U.S.C. S 7164.
SAMHSA and DOJ have made funds available to Education, which also
contributes funds. Education acts as fiscal agent of the program and
issues grant awards. In addition, the agencies have coordinated peer
reviews of SS/HS grant applications,^18 while Education collects and
maintains final grantee progress and financial reports. SAMHSA also has a
cooperative agreement with a national organization to provide technical
assistance to SS/HS grantees. According to SAMHSA officials, the agency
coordination effort for SS/HS is organized into two teams, which meet to
discuss issues related to the program: (1) an interagency policy team made
up of high-level representatives from each agency, and (2) a supervisory
team consisting of agency staff who discuss day-to-day management issues,
including staff assignments and scheduling. In addition, program officers
from SAMHSA and Education--nine in total--monitor and manage from 11 to 18
grants each and meet monthly to discuss issues related to the program.
Experts in school mental health services told us that the SS/HS is a good
example of effective coordination at the federal level.
SAMHSA's coordination with Education and DOJ for the SS/HS program
includes key practices that we have identified as helping to enhance and
sustain coordination among federal agencies.^19 To define and articulate a
common program outcome, the agencies overcame the differences in agency
missions by identifying a common mission--to create safe school
environments and healthy students. This effort to identify a common
mission was designed to create a seamless program for grantees at the
local level. To establish mutually reinforcing or joint strategies for the
program, agency leadership at the three agencies vested decision-making
authority in officials such as division directors and branch chiefs, who
assigned their staff to the SS/HS effort. The agencies established
compatible policies, procedures, and other means to operate across agency
boundaries and agreed on each agency's roles and responsibilities. For
example, because each agency had different program monitoring policies,
officials created a program monitoring system that was consistent across
all three agencies.^20 To develop mechanisms to monitor, evaluate, and
report on results, the agencies built an evaluation component into the
SS/HS program at the federal and local levels--grantees are required to
conduct local evaluations, and the federal agencies are conducting a
national evaluation for SS/HS.^21
^18Grant applications are screened by federal SS/HS staff and then
forwarded to a contractor for peer review. The peer review panel is
organized by the contractor and is made up of three independent reviewers,
with a federal program officer acting as a discussion facilitator. The
list of applications ranked by reviewers' scores is provided to SAMHSA,
Education, and DOJ for review prior to final grant awards. In fiscal year
2007, 27 new grants were awarded.
^19These key practices are (1) defining and articulating a common outcome;
(2) establishing mutually reinforcing or joint strategies; (3) identifying
and addressing needs by leveraging resources; (4) agreeing on roles and
responsibilities; (5) establishing compatible policies, procedures, and
other means to operate across agency boundaries; (6) developing mechanisms
to monitor, evaluate, and report on results; (7) reinforcing agency
accountability for collaborative efforts through agency plans and reports;
and (8) reinforcing individual accountability for collaborative efforts
through performance management systems. See GAO-06-15.
^20An official from DOJ noted that when creating this system, all the
agencies agreed that if they could not reach consensus, they would use
Education's policy or procedure, because of Education's role as fiscal
agent for the grant. However, SAMHSA officials noted this has not been
necessary as the agencies have been able to reach consensus.
^21SAMHSA and NIMH also co-sponsor a program announcement for SS/HS
grantee sites to participate in research opportunities unrelated to the
national and local evaluations.
SAMHSA's other formal coordination effort is the Federal/National
Partnership, formed in 2004 with SAMHSA designated as the lead agency.^22
The purpose of this partnership is to promote collaboration among federal
agencies to transform children's mental health and substance abuse
delivery systems nationally. The partnership includes representatives from
key federal agencies that serve children, national organizations, and
family and youth organizations.^23 During its first meeting in November
2004, the partnership established three workgroups focused on children's
mental health issues, one of which is the Integration of Mental Health and
Education Workgroup, which is focused on school mental health services.^24
The purpose of this workgroup is to develop a coordinated federal process
to support integration of school mental health services.
SAMHSA convened a meeting in August 2006 to begin planning the Integration
of Mental Health and Education Workgroup. At the August 2006 meeting, a
variety of organizations that provide technical assistance related to
children's mental health were brought together and a core group of
participants identified. As of July 2007, some tasks identified at the
August 2006 meeting had been completed. For example, SAMHSA has compiled a
list of programs by topic area, which can be found on the agency's Web
site. Program topics include school mental health, suicide prevention,
youth violence prevention, and other programs related to mental health and
substance abuse issues for children and families. SAMHSA also organized
events for National Children's Mental Health Awareness Day in May 2007,
which focused on school mental health services. Other tasks are in
progress. For example, a logic model--a model that describes how an
initiative should work and anticipated outcomes--for the integration of
education and mental health in schools is being developed. SAMHSA
officials expect to convene the first workgroup meeting in fall 2007 and
plan to include participation by education professionals and other federal
agencies. The agency also plans to invite participation from
representatives of community-based organizations and school-employed
providers.
SAMHSA Officials Coordinate with Federal Departments and Agencies on an
Informal or Episodic Basis
SAMHSA officials maintain informal or episodic coordination efforts on
issues related to school mental health services with Education and other
HHS agencies such as HRSA, CDC, and NIMH;^25 these are based largely on
personal relationships between agency staff. For example, at the request
of Education staff, SAMHSA staff reviewed and commented on the Grants for
the Integration of Schools and Mental Health Systems application before
its public release.^26 SAMHSA and Education officials told us they work on
an as-needed basis to ensure that their respective agencies are not
awarding funding to the same grantees for the same activities. SAMHSA
officials told us that personnel from the two agencies also communicate
with each other almost daily about the SS/HS program.
^22The Federal/National Partnership is organized as part of the Federal
Partners Senior Workgroup, made up of senior representatives of more than
20 federal agencies and offices. This Senior Workgroup is responsible for
implementing the Federal Action Agenda, which focuses on efforts at the
federal level to transform the mental health system. The Federal Action
Agenda was developed in response to the 2003 report from the President's
New Freedom Commission.
^23The federal partners include SAMHSA and other departments and agencies,
such as Education, the Department of Housing and Urban Development, DOJ,
the Department of Labor, the Department of Veterans Affairs, and the
Social Security Administration. This partnership also includes other
nongovernmental organizations working in the area of school mental health
services.
^24The Integration of Mental Health and Education Workgroup is also known
as the School-Based Mental Health Services Workgroup. The two other
workgroups are the Youth-Guided Policies and Services Workgroup and the
Early Identification Workgroup.
^25SAMHSA officials also maintain informal coordination efforts with HHS's
Indian Health Service and Administration for Children and Families.
While SAMHSA and HRSA had a formal cooperative agreement in the past to
co-fund two technical assistance centers for school mental health
services, SAMHSA officials told us that SAMHSA is no longer providing
funds for this effort, although HRSA continues to do so.^27 However, the
two agencies continue to have some informal interaction about the two
centers. For example, SAMHSA presents an award recognizing programs that
promote school mental health services at a conference hosted annually by
one of these centers. In addition to this interaction, SAMHSA and HRSA
staff meet on an ongoing basis to discuss how they can collaborate to
assist states with efforts to integrate health, mental health, and
education. For example, staff from the two agencies have met to discuss a
HRSA initiative that provides funds to states to promote availability and
quality of services focused on healthy child development and school
readiness. The two agencies are also working together to incorporate
information on the warning signs of mental health problems into an
existing SAMHSA program designed to serve children with serious emotional
disturbances.
SAMHSA and CDC officials also work together on an informal and episodic
basis. For example, a SAMHSA official participated on an expert panel
about 3 years ago to help CDC's Division of Adolescent and School Health
consider how to identify possible opportunities for the division to
promote and enhance the mental health component of the Coordinated School
Health Program. According to CDC officials, because the agency does not
have a strong focus on school mental health services, it reaches out to
SAMHSA for guidance in this area. For example, CDC directs its grantees to
SAMHSA's NREPP database to find appropriate interventions to implement at
the local level.
SAMHSA and NIMH officials have had informal discussions on the recent
redesign of SAMHSA's NREPP, and NIMH suggested researchers who could
review interventions for this registry of evidence-based programs and
practices. In some cases, NIMH encouraged its grantees to submit
evidence-based interventions to NREPP. Staff members from the two agencies
have discussed how research can be transferred into community practice,
and NIMH staff have also consulted with, and provided technical assistance
to, SAMHSA grantees.
SAMHSA Identifies and Supports Evidence-Based Interventions, Some of Which
Target School Mental Health Services
SAMHSA identifies evidence-based mental health interventions, including
some that can be used in school settings, and supports their use. To
identify evidence-based mental health interventions, SAMHSA uses its NREPP
database; as of August 2007, slightly more than one-fourth of the
interventions on NREPP were mental health services based in schools.
SAMHSA also supports the initial implementation and ongoing administration
of evidence-based interventions in the school setting through grant
programs, such as the SS/HS grant program. This program awards grants for
evidence-based interventions and provides technical assistance for the
implementation of these interventions. SAMHSA also supports the use of
evidence-based interventions through other grant programs that may be used
in schools but are not specifically designed for the school setting.
^26The Grants for the Integration of Schools and Mental Health Systems
program provides grants to state and local education agencies and tribes
for the purpose of developing linkages between school systems and local
mental health systems to increase student access to quality mental health
care.
^27In fiscal year 2006, HRSA contributed $600,000 to these centers, part
of the Mental Health in Schools Program, while SAMHSA contributed
$300,000. HRSA contributed $900,000 in fiscal year 2007, but the agency
has limited fiscal year 2008 funds for the program to $600,000.
SAMHSA Uses a National Registry to Identify Evidence-Based Interventions,
and Some Are for Use in School Settings
SAMHSA uses NREPP, a searchable online database, to help interested
parties, including school officials, in identifying evidence-based
interventions.^28 The purpose of NREPP, which was initially designed in
1997 and redesigned in March 2007, is to help interested parties in
identifying evidence-based approaches to preventing and treating mental
illness and substance abuse. NREPP is funded by SAMHSA and is a core
component of the agency's Science to Service Initiative, which seeks to
promote broader adoption of effective, evidence-based interventions within
routine clinical and community-based settings. Because there is no
universally accepted definition for what constitutes evidence, SAMHSA has
stated that NREPP was not designed to serve as a single authoritative
source for evidence-based interventions.^29 Rather, SAMHSA acknowledges
that there are multiple ways of establishing and assessing the strength of
an intervention's evidence, such as research methods that include pre- and
posttest studies and controlled clinical studies. Agency officials
characterize NREPP as one of many tools for identifying and assessing
evidence-based interventions.
In order to update NREPP, SAMHSA anticipates publishing annual notices in
the Federal Register soliciting evidence-based interventions that may be
selected for review and placement on the registry. Interventions,
submitted by those seeking placement on the NREPP registry, are evaluated
through a standard process, which involves both a submission of materials
and an independent review process. (See fig. 1.) The submission process is
used to determine whether interventions submitted for review meet NREPP's
three minimum requirements: (1) the intervention must demonstrate one or
more positive outcomes, (2) the research findings related to the
intervention must have been published in a comprehensive evaluation report
or peer-reviewed publication, and (3) dissemination materials must be
available.^30
^28SAMHSA redesigned NREPP (http://www.nrepp.samhsa.gov) in order to make
it more comprehensive and interactive.
^29See Changes to the National Registry of Evidence-based Programs and
Practices, Notice, 71 Fed. Reg. (Mar. 14, 2006), and SAMHSA, "National
Registry of Evidence-based Programs and Practices (NREPP): An Important
Note for NREPP Users," 2007, http://www.nrepp.samhsa.gov/about-note.htm
(accessed Apr. 20, 2007).
^30The positive program outcomes must be statistically significant at a
level of 95 percent confidence. Dissemination materials could include
items such as program manuals, program process guides, and training
materials.
Figure 1: NREPP Review Process
aSAMHSA provides applicants with the opportunity to approve the summary
information before it is published on the Web site. However, NREPP will
not change the intervention's ratings unless new information is provided
by the applicant. If the applicant and SAMHSA do not agree on the Web
posting (i.e., intervention summary and ratings), then the intervention
will not be placed on NREPP.
Once it is determined that an intervention meets all three minimum
requirements and a senior SAMHSA official approves the intervention for
review, the intervention is reviewed by a panel of independent reviewers
with special knowledge in the subject area. These reviewers rate the
quality of the research on the intervention and its readiness for
dissemination on a zero-to-four point scale.^31 The quality-of-research
rating is obtained by using six criteria to score the strength of the
research supporting the intervention's stated
outcomes, and then averaging the six ratings.^32 The
readiness-for-dissemination rating is achieved by evaluating the
dissemination materials using three criteria and averaging the ratings of
these criteria.^33 A final rating for the intervention's quality of
research and readiness for dissemination is achieved by reaching reviewer
consensus if there are significant differences in their ratings. SAMHSA
posts the intervention's ratings on its Web site along with additional
descriptive information on the intervention.^34 (See fig. 2 for a sample
NREPP rating.)
^31Independent reviewers are not employed by SAMHSA; rather, they work as
agency consultants to the agency's NREPP contractor. SAMHSA recruits two
types of reviewers to rate each program's quality of research and
readiness for dissemination. Quality-of-research reviewers must have a
doctoral-level degree and, if possible, possess experience evaluating
prevention and treatment programs. Readiness-for-dissemination reviewers
can include consumers of services, service providers, and experts in
program implementation. Both types of reviewers must possess knowledge of
mental health and/or substance use prevention or treatment content areas.
Figure 2: Sample NREPP Rating
Note: Listed outcomes are examples.
^32Each program outcome is evaluated by reviewing the following six
"quality-of-research" criteria: (1) reliability of the outcome measures,
(2) validity of the outcome measures, (3) intervention fidelity--the
"experimental" intervention was implemented as designed, (4) missing data
and attrition, (5) potential confounding variables, and (6)
appropriateness of the analysis.
^33The three "readiness-for-dissemination" criteria are evaluated by
reviewing the amount and adequacy of the intervention's (1) implementation
materials, (2) training supports, and (3) quality improvement materials,
such as manuals on how to provide quality improvement feedback.
^34Prior to the 2007 redesign of NREPP, programs were rated in their
entirety by placing them into three categories of effectiveness: model,
effective, and promising. According to SAMHSA officials, the agency chose
to eliminate these categories because they appeared arbitrary to some
users and distinctions between them were unclear. The agency plans to
advertise these changes through several efforts, such as e-mail alerts to
notify users when new programs have been added to the registry.
Some interventions listed on NREPP were designed for use in the school
setting. Specifically, as of August 2007, 13 of NREPP's 46 interventions
were identified as school mental health interventions, including those
designed to address aggressive behavior, depression, or school violence.
Other settings for interventions listed on NREPP include correctional
facilities, residential settings, and the workplace. SAMHSA is in the
process of adding interventions to the registry and, according to a SAMHSA
official, approximately half of the intervention applications submitted in
fiscal year 2007 were mental health or substance abuse interventions that
could be appropriate for use in schools.
SAMHSA Supports Evidence-Based Mental Health Interventions That Can Be
Used in School Settings
SAMHSA supports the use of evidence-based interventions in the school
setting in the SS/HS grant program. SS/HS program policy requires that
grantees implement and administer evidence-based interventions, but does
not require its grantees to use a specific method of selecting those
interventions.^35 The program's grant application provides potential
grantees with guidance on how to choose an evidence-based intervention and
with a list of online resources, including NREPP. To help current grantees
identify and implement evidence-based interventions, the National Center
for Mental Health Promotion and Youth Violence Prevention provides
technical assistance to all active SS/HS grantees through a cooperative
agreement with SAMHSA. The National Center also provides current grantees
with additional technical assistance, such as support in implementing
culturally appropriate programs or designing and implementing program
evaluation tools.
SAMHSA also supports the use of evidence-based mental health interventions
when funding other programs that may be used in schools or community
settings. SAMHSA's Child Mental Health Initiative provides federal funds,
through cooperative agreements with state and local governments and tribal
organizations, to develop and sustain an effective system of care for
children with serious emotional disturbances. The funding recipients are
required to collaborate with other entities that serve children, such as
local child welfare and juvenile justice agencies. In fiscal years 2005
and 2006, most federal funding for the program was directly provided to,
and managed by, state and local governments. Child Mental Health
Initiative recipients may use the funds to provide mental health
interventions in schools and are required by SAMHSA policy to implement at
least one evidence-based intervention. However, according to a SAMHSA
official, funding recipients have noted that it can be challenging for
those outside schools to work within a school setting. Another program,
SAMHSA's State/Tribal Youth Suicide Prevention Grant Program, provides
funds through cooperative agreements with states, tribal communities, and
public or nonprofit organizations to support the development and
implementation of statewide or tribal youth suicide prevention and
intervention strategies. Preference is given to program participants that
collaborate with institutions that serve youth, which could include
schools, and SAMHSA policy requires program participants to report the
number of evidence-based interventions used.
^35The SS/HS program defines an evidence-based intervention as one that is
supported by scientific data to indicate its effectiveness. The statutes
authorizing SAMHSA, Education, and DOJ's programs do not require that
grantees implement evidence-based programs. 20 U.S.C. S 7131; 42 U.S.C. SS
290hh, 5614. The requirement is set forth in program selection criteria
developed by the agencies responsible for the SS/HS program and published
as a Notice of Final Priorities, Requirements, Selection Criteria, and
Definitions in the Federal Register.
Multiple Factors Affect the Provision of School Mental Health Services
Officials in the seven schools and school districts in our review told us
that coordination and close working relationships, support from program
champions--advocates for a program--and school leadership, and resources
are factors that can affect the provision of school mental health
services. Because the missions of mental health and education
professionals differ, coordination between them can enhance the provision
of school mental health services. Coordination with external stakeholders
(such as community mental health providers) and among internal
stakeholders (such as teachers and health care professionals) can also
affect the provision of school mental health services. Site officials
stressed that one or more program champions and support from school
leaders can play a significant role in implementing school mental health
services; conversely, the loss of either of these can threaten program
continuity. Site officials also noted that difficulties securing and
sustaining both funding and staffing have affected the ability to
implement school mental health services.
Differing Missions and Coordination of Efforts Affect Service Provision
Because the missions of mental health and education professionals differ,
coordination between them can enhance the provision of school mental
health services, according to experts and school staff. While mental
health providers typically focus on the emotional health of students, the
primary focus of schools is students' academic achievement. By framing
student mental health as a means of improving student academic
achievement, experts told us that mental health providers may improve the
likelihood of being able to implement a school program. School officials
we interviewed, including principals and teachers, said they recognized
that addressing students' social, emotional, and behavioral health needs
can improve their ability to focus on academics. The principal of one
school reported that, in the past, her teachers spent a large amount of
their time dealing with nonacademic issues, including behavioral problems,
in the classroom. This school now provides universal mental health
services for all students and selective services for a smaller subset of
students. For example, the school offers a schoolwide program to reduce
student aggression and behavior problems, and also works with community
mental health providers to obtain services for children with more serious
needs. Teachers said that because of these efforts, disruptions associated
with students' behavioral issues have been reduced and they are better
able to focus on academics.
Site officials told us that to provide services in the school setting,
mental health professionals need to be cognizant not only of a school's
academic mission, but also of students' academic schedules and
responsibilities. Staff members at one site reported that they avoided
scheduling appointments for services during school testing periods, while
staff from another reported that they tried to provide as many services as
possible during nonacademic times, such as lunch. Some school officials
noted that working with external providers could pose difficulties because
these providers might not recognize the priority of the school's academic
schedule. An official from one site with multiple school-based health
centers stated that a past contract it had with a community provider to
run one of its centers was terminated because the provider was not able to
work within the schedule constraints of the school.
Site officials told us that coordinating with external stakeholders--local
government agencies, providers, or community organizations--is important
when implementing school mental health services. Two sites in one state
partner with county councils made up of multiple local agencies serving
children and families.^36 Staff from these two sites reported that the
partnership helped them establish a relationship with other agencies, such
as juvenile justice or job and family service agencies, that may influence
the lives of their students. A representative from one of the county
councils stated that prior to the council's work with school officials,
agencies in the county had been interested in working with schools but did
not know how to bring that about. Officials at some sites told us they
also had developed relationships with local religious organizations. At
one site, officials reported that this resulted in the organizations'
supporting after-school and summer activities and acting as a source of
volunteers to help organize these events when needed. Officials from sites
in our review also told us that family involvement in the services
provided to children was an important factor and that they typically
required parental consent for students to receive services.
In addition, staff at sites in our review emphasized the importance of
working closely with existing school health and mental health
staff--including counselors, social workers, psychologists, and nurses--to
ensure the success of school mental health services. They noted that it
was particularly important to work together when implementing initiatives,
in order to reduce service overlap or potential conflict between
providers. In schools with a school-based health center, officials
reported that the school nurse often worked in collaboration with the
centers, providing care to students not enrolled in the center or
identifying enrolled students in need of services.^37 In one school
without a school-based health center, the school nurse and the school
social worker who coordinates the universal mental health programs meet
regularly to discuss students referred for physical and mental health
problems. Officials at sites in our review also noted that school nurses
may help identify when students who come in for physical health reasons
may have symptoms related to mental health issues. Officials told us that,
in some cases, failure to recognize the roles of existing school staff
members had created tension.
Sites also work to include teachers and administrative staff in their
school or school district programs and to provide teachers with training
or materials on mental health issues. Two sites have developed
multidisciplinary teams, including teachers and school administrators as
well as mental health professionals, that meet to identify and coordinate
services for students showing signs of mental health problems. By
including teachers and school administrators in efforts, sites try to
ensure that all staff members are involved in the program. Officials from
one of these sites also reported providing training to teachers on a
variety of issues, including understanding mental health diagnoses, the
impact of trauma on children, and nonacademic barriers to learning, such
as issues related to poverty. Staff members at a third site have created
documents for teachers, including handouts providing information on when
to refer students for mental health services, the protocol for referrals,
and the role of case managers.
^36This state has developed an initiative that includes both state- and
county-level partnerships focused on improving the well-being of children
and their families. The partnerships are composed of government agencies,
and, at the county level, also include community organizations.
County-level councils, formed by the county board of commissioners, must
include representation from families, schools, and multiple agencies,
including alcohol, drug addiction, mental health, and job and family
services.
^37Eligible students who wish to receive services through the school-based
health center at the sites we reviewed are required to join the center by
enrolling.
Program Champions and School Leadership Affect Provision of Services
Officials at sites in our review stressed the importance of having a
program champion and the support of school and school district leadership
when implementing programs. At one site, officials stated that their
effort to introduce a school mental health services program had multiple
champions, including staff from the local educational service center^38
and local mental health providers. Officials at this site reported
bringing together community agencies that work with children, including
local school districts, and said that they were able to hire a program
director who, according to site staff, had the "passion" to run the
program. The staff from the multiple agencies involved believed that
without this program director to further champion the program, they would
not have been able to continue to dedicate sufficient attention to the
program to keep it moving forward. At another site, officials told us that
the principal was the champion for mental health services at the school
and provided the school leadership needed to implement programs. Because
of the success of efforts at that school, the superintendent of the
district asked this principal to examine how services could be expanded to
another district school.
Officials we spoke with told us, however, that initiatives may become
dependent on the program champion and expressed concern that such
initiatives might not be able to survive the champion's departure.
Similarly, officials told us that wavering support at the administrative
level or a change in leadership--particularly principals and
superintendents--could raise concerns for program sustainability. In one
school district, staff told us that while the indicated mental health
services provided through their school-based health centers were well
established, the universal mental health initiatives they had implemented,
such as a classroom-based violence prevention program, would not have
existed without the leadership of one particular staff member. The person
identified as the program champion told us that she would like to train a
successor but, because of budget constraints, it would be difficult to
hire a new staff person to train while she was still in her position.
Officials at another site told us their program champion was the school
principal, who planned to retire in 3 years. To ensure that the existing
mental health initiatives continue, the principal was working to fully
train school staff, including teachers, to maintain and advocate for these
initiatives. Because staff from this school will be involved in the
process of hiring a replacement, the current principal hopes that they
will be in a position to identify a potential replacement who will
continue the initiatives.
Securing and Sustaining Funding and Appropriate Staff for School Mental
Health Services Affect Service Provision
Site officials told us that difficulty securing and sustaining funding and
mental health service provider staff had affected their ability to
implement school mental health services. According to experts, no single
funding stream specifically focuses on school mental health services, and
sites reported piecing together multiple funding streams to support their
programs. For example, officials at one site reported combining funds from
at least four different sources, including private grants, the state
Department of Education, and federal
sources, to support its mental health services.^39 Officials at this site
said that while their school district provided space for service delivery,
it provided no monetary support for the site's programs. Funding streams
that staff identified often came with restrictions on use. For example,
one site provided case management services to students, but because of
funding restrictions, these services could be provided only to elementary
students who qualified for free and reduced lunches.^40 Officials stated
that Medicaid, while a possible funding source for some services, was
difficult to use. In particular, they expressed concerns related to
Medicaid's paperwork, reimbursement rates, and enrollment of eligible
students in the Medicaid program. In addition, changes in funding
priorities can affect sites' funding for programs. At the time of our site
visits, two sites in one state told us they had just been notified that
state-level funding priorities had shifted. As a result, these sites
anticipated laying off, or cutting the hours of, case management or mental
health staff.^41
^38This center provides services, including technical and operational
assistance, professional development, and curriculum services, to the
eight school districts within its area.
Officials at the sites in our review said they appreciated the flexibility
of grant funding, but said that grants might not last long enough to allow
a program to stabilize and that other funds to sustain initiatives were
not always available.^42 Officials from one site, located in a town
surrounded by rural counties, noted that while grants often required them
to consider sustainability when applying for funds, the school district
and county had no funds to support initiatives started through grants and
they were not aware of local foundations or organizations that might be
able to provide additional funds.
While officials indicated that it was difficult to secure funding, some
reported that by coordinating the efforts of multiple local agencies or
securing the support of the school administrator, they were able to
identify resources to support their programs. By partnering with local
government agencies and other stakeholders, staff from one site were able
to use resources available to those organizations, including resources
that might not otherwise be available to schools. In addition,
relationships with external agencies helped create advocates in the
community for another school district's program, according to officials.
At another site, officials reported that while they had not formally
secured funding for the staff needed to continue a grant program, the
principals of some schools participating in the program said they were
willing to include the salary of the schools' program staff members in
their general school budgets for the upcoming year. One principal told us
that she was willing to do this because the program was an asset to the
school.^43
^39The federal funds came from Medicaid and the Temporary Assistance for
Needy Families (TANF) program, which provides funds to states to provide
assistance and work opportunities to needy families. Both federal and
state governments contribute to Medicaid and TANF.
^40For elementary students who did not qualify for services, this site
used its prevention coordinator--a grant-funded contractor responsible for
schoolwide prevention activities--to provide limited individual
assistance. However, an official at this site noted that restrictions
limiting services to only certain populations, such as students in certain
grades or at certain income levels, could lead to resentment over services
not being available to all students.
^41Officials in one of these school districts reported that with 2 weeks
left before the end of the school year, they had not been told whether
they would have funds to retain their case management staff for the
upcoming school year. As of August 2007, all case management positions had
been eliminated, and this site was no longer offering case management
services.
^42An official from one site also told us that funding streams may not be
consistent, noting that funding that may have been available 2 or 3 years
before may no longer be available.
Site officials told us that, in addition to securing and sustaining
funding, it could be difficult to hire and retain mental health
professionals to provide school services, particularly in small towns and
rural areas. Providers at one site noted that the site's program could
expand only to a limited degree because there were no more available
mental health providers in the area.^44 Staff reported difficulty
recruiting providers to the area, a town located about 1 hour from a
metropolitan area where mental health providers are paid significantly
more. Staff members from a rural school district similarly told us that
they had been trying to hire a behavioral health specialist since October
2006 but had not been able to find one willing to move to their district
until June 2007.
Contrary to the experience of some sites, schools and school districts
located near universities reported having better access to providers.
Officials from one urban school district reported working with local
universities to offer internship opportunities, which allowed it to
attract former interns to positions as permanent staff. At another site,
which has had difficulties attracting mental health staff, providers
involved in the program are working with a local university to expand the
university's social work program, and hope this expansion will be a source
of future mental health staff.
Agency Comments
We provided a draft of this report to HHS and Education for comment. HHS
provided written comments on the draft of this report, which are provided
in enclosure IV. HHS also provided technical comments, which we
incorporated where appropriate. HHS indicated that the report accurately
reflects SAMHSA's efforts regarding school mental health services. The
agency also stressed the importance of schools as a venue for the delivery
of mental health prevention and treatment programs, services, and
supports. Education told us it had no comments on the draft.
- - - - -
As we agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution of this letter
until 30 days after the date of this letter. At that time, we will send
copies to the Administrator of SAMHSA, appropriate congressional
committees, and other interested parties. In addition, the report will be
available at no charge on the GAO Web site at [3]http://www.gao.gov . If
you or your staff have any questions about this report, please contact me
at (202) 512-7114 or [4][email protected] . Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this report. GAO staff who made major contributions to this
report are listed in enclosure V.
^43School officials noted that these individual school budgets require
approval at the superintendent level, so these positions could still be
cut. As of June 2007, staff and school officials did not know whether
these positions would be approved for the 2007-2008 school year.
^44Staff at this site told us that they were willing to use a variety of
mental health provider types, although they preferred to use
master's-level counselors. Officials from other sites also indicated that
they were willing to use, and had used, a variety of mental health
provider types including social workers, counselors, and marriage and
family therapists.
Sincerely yours,
Cynthia A. Bascetta
Director, Health Care
Enclosure I
Scope and Methodology
We examined the Substance Abuse and Mental Health Services
Administration's (SAMHSA) efforts to coordinate with federal departments
and agencies to support school mental health services and to identify and
support evidence-based school mental health services.^45 To do this, we
reviewed multiple documents, including a collaborative agreement related
to federal school mental health funding, interagency meeting minutes,
documents describing changes in the National Registry of Evidence-based
Programs and Practices (NREPP), and Federal Register notices. We
interviewed staff at SAMHSA, including program staff charged with
implementing interagency programs related to children's mental health and
developing and implementing NREPP. We also interviewed staff from the
Department of Health and Human Services' Health Resources and Services
Administration, Centers for Disease Control and Prevention, and National
Institutes of Health. We spoke with staff from the Department of Justice
and the Department of Education who interact with SAMHSA with regard to
school mental health.
To describe factors that have affected the provision of school mental
health services, we reviewed relevant research and interviewed experts
working in the area of school mental health, including representatives of
the Center for Health and Health Care in Schools, Center for Mental Health
in Schools, Center for School Mental Health Analysis and Action, Center
for School-Based Mental Health Programs, Research and Training Center for
Children's Mental Health, and National Assembly on School-Based Health
Care. To obtain information on their constituents' roles in school
settings, we also reviewed documents and interviewed representatives from
professional associations whose members provide school mental health
services, including the National Association of School Psychologists,
American School Counselor Association, School Social Work Association of
America, National Association of School Nurses, and the American
Association for Marriage and Family Therapy. In addition, we interviewed
officials with associations representing education service providers, such
as the American Association of School Administrators and the National
School Boards Association.
To provide information on factors that selected sites considered important
when providing school mental health services, we conducted interviews with
representatives from seven selected schools and school districts. To
identify states, localities, specific schools, and school districts
considered to be active in the area of school mental health services, we
interviewed officials from federal agencies, experts in the area of school
mental health, and provider associations. From the approximately 53
locations they identified, we selected a judgmental sample of 7 sites: two
school districts in Connecticut, one school district in Florida, one
multidistrict program in North Carolina, and one school district, one
school, and one multidistrict program in Ohio. These sites were selected
because they represented a mix of urban and rural settings and settings
with and without school-based health centers. We also ensured that we
included sites that were currently receiving funds through the joint
SAMHSA, Department of Education, and Department of Justice Safe
Schools/Healthy Students program and the Department of Education Grants
for the Integration of Schools and Mental Health Systems program. Because
we used a nongeneralizable sample to select our sites, the information
provided cannot be used to make inferences about other programs. In
addition, the information provided by program officials does not reflect
all efforts under way in their locations related to school mental health
services.
^45School mental health services provided to students who qualify for
special education services through the Individuals with Disabilities
Education Act were outside the scope of our work.
We conducted our work from March 2007 through September 2007 in accordance
with generally accepted government auditing standards.
Enclosure II
Characteristics of Sites in Our Review
Safe
School or Schools/ School-
School school Healthy based
Location district district Students health Program
State characteristics size^a population^a grantee center description
Connecticut School district The 22,296 Yes Yes The school
located in an school students in district provides
urban area district the school universal
consists district services
of 41 throughout the
schools district using an
evidence-based
program that has
been in place for
several years.
This school
district also
provides a
variety of
selective and
indicated
services to
students through
its multiple
school-based
health centers.
To assist
students in need
of more intensive
support, such as
therapy services,
the district
works with a
community mental
health provider;
through the Safe
Schools/Healthy
Students (SS/HS)
Initiative, it
has also been
able to secure
funding for a
child
psychiatrist.
Students in
certain high
schools also
receive services
through centers,
staffed in large
part by
master's-level
social work
interns, designed
to provide
counseling and
support to
students and
their families.
These centers are
part of the
district's SS/HS
Initiative.
Connecticut School district The 22,264 No Yes Universal mental
located in an school students in health services,
urban area district the school including
consists district violence and
of 35 bullying
schools prevention, are
provided using
multiple
evidence-based
programs. Mental
health services
at both the
selective and the
indicated level
are provided to
regular education
students through
multiple
school-based
health centers.
The centers are
staffed by mental
health providers,
including social
workers. For
students needing
more intensive
services or to
respond to crisis
situations, the
centers also have
psychiatric staff
on call.
Florida School district The 1,058 Yes No This school
located in a school students in district provides
rural county district the school universal
consists district^b services,
of 2 including a
schools^b bullying
prevention
program,
after-school
activities, and
drug and alcohol
prevention
activities. A
counselor is
available to
provide mental
health services
to students
across the
district. The
school district
works with a
private
contractor to
provide more
intensive
services, such as
therapy, to
students who need
them. The
district also
partners with the
state health
department and
local agencies
serving children
as part of the
SS/HS Initiative.
North Regional The 7,014 Yes Yes The districts
Carolina grouping of regional students in have implemented
school grouping the combined universal
districts consists 3 school services for
located in 3 of 3 districts ^c students,
rural counties school including a
districts violence and drug
with 21 abuse prevention
schools^c program, and are
conducting
training for
teachers and
administrators on
mental health
issues. Using
funds from the
SS/HS Initiative,
three school
districts are
implementing
school
nurse-school
counselor teams
in schools
throughout their
districts. These
teams act as the
initial contact
for students in
need of selective
or indicated
mental health
services and work
in coordination
with community
providers to
secure services
for students. In
addition, the
districts have
developed a
council of key
agencies and
organizations
that may impact
students' lives.
Ohio Regional The 18,193 No No This regional
grouping of regional students in effort focuses on
school grouping the combined providing
districts in consists 8 school services through
and around a of 8 districts multidisciplinary
small town school teams. These
districts teams can include
with 43 school
schools administrators
and teachers,
staff from local
community mental
health providers,
substance abuse
professionals,
and staff from
the local health
department and
juvenile court.
The composition
of the teams
varies by school,
and others may be
invited to
participate as
needed.
Ohio The teams provide
(cont'd.) services at the
universal,
selective, and
indicated level.
They build a
complete system
of services for
students and
their families
based in a school
setting, and
include an
after-school
component,
skill/asset
building,
mentoring, and
counseling
services.
Ohio Single school The 370 students No No This elementary
within the school is in the school works with
school district part of a school^d community
of a midsize school partners,
town district including local
with 12 government
schools agencies and
nonprofits, to
provide
universal,
selective, and
indicated
services. It
provides
universal
services through
an evidence-based
classroom program
and uses the
combined services
of a school nurse
and school social
worker to provide
selective
services to
children in need
of additional
support. If
students need
intensive
services, the
school works with
a local mental
health provider
to obtain
services. This
same provider
also offers case
management
support for the
school.
Ohio School district The 1,098 No Yes This school
in a small school students in district includes
urban district the school a school-based
jurisdiction consists district health center and
co-located with of 3 provides a
a large urban schools variety of mental
area health services
to elementary and
middle school
students.
Universal
services are
provided at the
district's two
elementary
schools using two
evidence-based
programs
identified
through the
Substance Abuse
and Mental Health
Services
Administration.
One of these
programs is also
used to provide
services to
students at the
district's middle
school. These
services are
implemented by a
contracted
prevention
coordinator (a
licensed mental
health provider)
and a doctoral
intern from an
area university.
Ohio Selective and
(cont'd.) indicated
services,
including limited
therapy and case
management
services, are
provided by staff
from the
school-based
health center and
through a
contract with a
community-based
mental health
provider. The
school-based
health center is
supported by a
pediatrician who
can assist in the
referral of
children in need
of mental health
services to
outside
providers.
Source: GAO analysis of information from sites and U.S. Department of
Education.
Note: Universal services are those intended for all children; selective
services are those targeting a smaller subset of children, usually those
identified as at-risk for developing mental health problems; indicated
services are those targeting children with the greatest need of support.
aUnless otherwise noted, data are for the 2004-2005 school year for public
schools.
bOfficials at this site reported that the school district also provides
services to the one local private school in its district, which has about
100 students.
cThese data are for the 2005-2006 school year for public schools.
dThe total school district population was 4,994 students.
Enclosure III
Information on the Safe Schools / Healthy Students Grant Program, as of August
2007
Participating agencies Office of Safe and Drug-Free Schools within the
and offices Department of Education, Substance Abuse and Mental
Health Services Administration (SAMHSA) within the
Department of Health and Human Services (HHS), and
Office of Juvenile Justice and Delinquency
Prevention within the Department of Justice
Type of assistance Discretionary/Competitive Grant
Who can apply Local Educational Agencies (LEAs)^a
Program description Safe Schools/Healthy Students (SS/HS) grants
support LEAs in the development of communitywide
approaches to creating safe and drug-free schools
and promoting healthy childhood development.
Programs are intended to prevent violence and the
illegal use of drugs and to promote safety and
discipline. LEAs are required to partner with local
law enforcement, public mental health, and juvenile
justice agencies. This program has been jointly
funded and administered by HHS and the Departments
of Education and Justice.^b Within HHS, SAMHSA has
primary responsibility for this program.
Maximum grantee awards o $2,250,000 per year for 4 years for an LEA
with at least 35,000 students
o $1,500,000 per year for 4 years for an LEA
with at least 5,000 students but fewer than
35,000 students
o $750,000 per year for 4 years for an LEA with
fewer than 5,000 students
Education level Kindergarten through 12th grade^c
New SS/HS awards, by Fiscal year 2007: $37,454,964 Fiscal year 2006:
fiscal year $30,913,344 Fiscal year 2005: $76,367,807
Legislative citation Public Health Service Act, as amended, S 581, 42
U.S.C. S 290hh Juvenile Justice and Delinquency
Prevention Act, as amended, S 204, 42 U.S.C. S 5614
Elementary and Secondary Education Act of 1965, as
amended, Title IV, Part A, Subpart 2, S 4121; 20
U.S.C. S 7131
Number of new awards, Fiscal year 2007: 27 awards Fiscal year 2006: 19
by federal fiscal year awards Fiscal year 2005: 40 awards
Program elements o Safe school environments and violence
prevention activities: Support a continuum of
strategies--including universal prevention,
early intervention, and intensive activities,
curricula, programs, and services--focused on
the entire school population as well as students
with disruptive, destructive, or violent
behaviors.
o Alcohol, tobacco, and other drug prevention
activities: Support the prevention or reduction
of substance use and abuse among youth, in
coordination with broader environmental
strategies that address change at the
individual, classroom, school, family, and
community level.
o Student behavioral, social, and emotional
supports: Support strategies to promote positive
relationships for youth and meaningful parental
and community involvement, and to recognize the
role of students' social and emotional needs in
their development.
o Mental health services: Support enhanced
integration, coordination, and resource sharing
among education, mental health, and social
service providers, including early
identification and assessment and providing
early intervention services for at-risk children
and their families, and referral and follow-up
with local public mental health agencies as
needed. Also support school staff training and
consultation, supportive services to families,
and revision of policies and procedures to
address communication and sharing of information
across service systems.
Program elements o Early childhood social and emotional learning
(cont'd.) programs: Support ways to overcome barriers to
identifying and serving children and families in
need of services and to identify and consult
appropriate community partners in developing
services to address early childhood social and
emotional learning programs.
Selected grant o Memorandum of agreement among required
requirements partners
o Logic model of the proposed project^d
o Use of evidence-based programs
o Local evaluations conducted by grantees
Source: GAO analysis of documents from SAMHSA and Department of Education.
GAO analysis of Department of Education, "Safe Schools/Healthy Students
Initiative," 2007, http://www.ed.gov/programs/dvpsafeschools/index.html
(accessed August 6, 2007).
aLEAs are public boards of education or other public authorities legally
constituted within a state for either administrative control or direction
of, or to perform a service function for, public elementary or secondary
schools in a city, county, township, school district, or other political
subdivision of a state, or for a combination of school districts or
counties that are recognized in a state as administrative agencies for
their public elementary or secondary schools.
bThe Department of Justice contributed funding and administrative support
to the SS/HS program from 1999 through 2003. While the Department of
Justice signs the collaborative agreement that guides the program, the
agency no longer provides funding or administrative support.
cThe SS/HS program also supports efforts focused on early education for
children.
dAccording to the SS/HS Fiscal Year 2007 Application Procedures, a logic
model is a graphic presentation of the project in chart format that shows,
by element: identified needs and gaps, goals, objectives, activities,
partners' roles, outcomes, and processes for measuring outcomes.
Enclosure IV
Comments from the Department of Health and Human Services
Enclosure IV
GAO Contact and Staff Acknowledgments
GAO Contact
Cynthia A. Bascetta, (202) 512-7114 or [5][email protected]
Acknowledgments
In addition to the person named above, Helene F. Toiv, Assistant Director;
Jennie F. Apter; Emily R. Gamble Gardiner; Jeremie C. Greer; Neetha Rao;
and Jennifer Whitworth made key contributions to this report.
(290592)
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