School Mental Health:
Role of the Substance Abuse and Mental Health Services Administration and Factors Affecting Service Provision
GAO-08-19R, Oct 5, 2007
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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.
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.