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

   

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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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