Providing Mental Health Services in Public Schools- What Educators Need to Know
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This article provides an overview of different methods of providing mental health services within the school setting, and makes the argument that schools should “stay out of the mental health business” of diagnosis and treatment, but should collaborate with other systems to assure that students have access to services that result in educational gains as well as cost savings to the school districts.
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Introduction
As school professionals become increasingly aware of mental health problems in the student population, they are grappling with the appropriate role of the school in the provision of services to these students. Many recognize that schools are in the “education business,” not the “mental health business,” yet school counsellors, social workers, nurses and psychologists all play a role in assisting these students. It may be unclear, at times, whether these services are educational in nature, or whether they constitute direct mental health treatment. This article provides an overview of different methods of providing mental health services within the school setting, and makes the argument that schools should “stay out of the mental health business” of diagnosis and treatment, but should collaborate with other systems to assure that students have access to services that result in educational gains as well as cost savings to the school districts.
The 2001 Surgeon General’s Report on Children’s Mental Health indicated that approximately 20% of children and adolescents have an emotional disorder, and that 5% have a severe mental health disorder. The report also noted that only one out of five students who have emotional disorders receives any treatment. If treatment occurs, it is most likely to be provided by a primary care physician rather than a mental health professional. Thus, in the average American classroom, there will be at least one student with a significant mental health impairment such as depression or other mood disorders, an anxiety disorder, Attention Deficit Hyperactivity Disorder or even a psychotic disorder, and the student will most likely not be receiving mental health services.
The implications of these statistics are significant not only for students and families, but also for the educational system. Mental health disorders can affect concentration, memory, on-task behavior, self-control, judgement, problem solving abilities, etc. It is not surprising that many students with such disorders manifest academic and behavioral difficulties. What might be surprising, however, is that most students who have mental health disorders, even those who are severely impaired, are not placed in special education. Sadly, if they are placed in special education under the “severe emotional disturbance” category,* they are likely to have poor outcomes: higher dropout, arrest, and unplanned pregnancy rates, lower employment and post secondary education rates, etc. The lack of appropriate mental health treatment is a primary factor leading to these poor outcomes.
For some of the students who currently receive special education under the “severe emotional disturbance” category, if mental health treatment had been provided at the pre-referral stage, it could have improved their academic and behavioural functioning, and prevented the need for a special education assessment at all. Unfortunately, access to treatment is difficult for many parents, who are unable to leave their place of employment on a weekly basis to pick up their child and bring him to a mental health appointment. Many, if not most, mental health providers do not provide evening or weekend hours. Also, access to qualified children’s mental health professionals is limited in many communities.
Mental health services can broadly be defined as being either counseling or therapy.
Counseling is the process of providing information, improving skills, and assisting a student in succeeding within the school environment. Counseling is routinely done by school social workers, psychologists, nurses and counsellors.
Therapy is a clinical service that constitutes treatment of a disorder; for example the treatment of clinical depression.
Many children who have mental health disorders are first identified in the school setting by teachers, counsellors, social workers, etc. An educational evaluation or other interventions may identify evidence of the mental health disorder, and the student’s parents may seek accessible treatment services that go beyond the typical counseling activities performed by school staff. Some schools have responded to this challenge by either having their own staff providing mental health diagnostic and treatment services within the school, or by entering a collaborative relationship with community providers who provide on-site, co-located diagnostic and treatment services in the school setting. Below, I describe several models that schools use to assure accessible mental health services in the school setting, and point out the relative advantages/disadvantages of each. In my opinion, the disadvantages of schools having their own professionals providing diagnostic and treatment services far outweigh the advantages, and I would therefore recommend that schools “stay out of the mental health business” of diagnosing and treating students.
Models of School-Based Mental Health Services
School-hired Professionals Provide Diagnostic and Treatment Services
Many school professionals such as school social workers have training and licensure that would allow them, if they were not working in the public school, to set up a practice in the community and provide diagnostic and treatment services. School districts that employ these professionals to provide treatment within the school setting have, in essence, set up that “practice” within the school.
There are advantages to this approach, in addition to the access to services it provides for students. School administrators have control over the therapist’s activities, and may potentially bill Medicaid for the service as well as receiving special education funding for the activity if it is identified as a related service on the student’s IEP.**
However, there are numerous potential problems with this approach:
Community Mental Health and/or Medical Professional Provides Mental Health Diagnostic and Treatment Services in the School
This model co-locates a community service provider such as a mental health or health clinic in the school setting. The clinic is on-site, but the school district maintains legal and financial firewalls that would not be present if the district were to provide these services. The clinic leases space from the school, and a contractual agreement clarifies roles and responsibilities regarding indemnification, data privacy, criminal background checks, licensure, financial tasks, administrative requirements, and the like.
Although the provider in this co-located model can be an individual in private practice, I believe that it is preferable for the provider to be a community mental health or health clinic. These clinics can offer a broader array of mental health services, case consultation, psychiatric backup and broad coverage, as well as possible funding from counties or grant sources to reimburse services provided to uninsured clients.
The co-located model overcomes the problems outlined above for school-hired mental health professional services. Data are kept private, outside of the educational record. The provider can offer 24/7 crisis coverage, maximum billing approaches, services to both general and special education students, and adequate malpractice coverage. The provider is “in the school” but not “of the school.” Its employees cannot discuss students with school staff without a release of information, and the school maintains appropriate protective firewalls.
School-hired and Outside Professionals Collaborate to Provide Mental Health Diagnostic and Treatment Services
The collaboration model integrates services from providers inside and outside of the school system. In some states, schools can bill Medicaid for IEP services such as skills training and skills practicing. These activities are generally considered consistent with schools’ mandates. Schools can partner with community providers, splitting the therapy and skills training roles between them.
In all of the service models described above, school-hired professionals continue to provide educationally related counseling services to students in need.
Reimbursement
The cost of providing mental health services is an obvious hurdle for schools. Potential funding sources include private insurance and Medicaid billing for direct services; Consolidated Early Intervening Services funds; state, federal and private grants; discretionary local government funds; and Medicaid indirect service reimbursement funds.
As noted above, school districts will have access to IDEA funding for mental health-related services included on IEPs. I recommend, however, following the language of IDEA, and providing on an IEP only those related services required to assist the student to benefit from his special education, in order to avoid potential financial liabilities.
Ideally, on-site mental health services would be available to all students in need, regardless of the presence or type of insurance coverage. Community mental health centers generally provide this broad range of services. Co-located services can provide similar services, and generally have a significantly lower fail and cancel rate than clinic-based services, thus improving the reimbursement for the clinic. The reduction in client load during summer vacation, however, is a major financial liability for the school-based clinic. Some clinics shift their focus during the summer to address the needs of extended school year students; some follow students throughout the summer; and some have employees that take time off during the break.
Many programs are funded through grants, especially those serving uninsured patients and those providing non-billable ancillary services such as teacher consultation, inservice presentations, and attendance at meetings. However, many grant-funded programs have fallen by the wayside over the years as their grants have ended. I recommend maximizing reimbursement via insurance and Medicaid, and using grant funds only for start-up costs. Some states’ Medicaid benefit sets include ancillary services, and some insurance companies have partnered with school districts and clinics to create a higher “bundled rate” for school-based mental health services. The programs that have remained sustainable tend to be based on partnerships between mental health care stakeholders including clinics, school districts, counties, and insurance providers.
Target Populations
The following discernable populations of children with mental health disorders could gain much from school-hosted mental health services.
Role Definition
If co-located mental health services are to be successful, school districts must clearly define the roles of its own professionals as distinguished from the roles of co-located providers in order to avoid overlaps and gaps in services and to allay concerns about job security. School mental health staff (school social workers, psychologists, counsellors and, at times, nurses) have numerous roles, including coordinating services with families, documenting students’ symptomatic behaviours and communicating this information to students’ medical and mental health professionals, providing counselling as a related service, providing accurate educational assessments of students who have mental health disorders and interpreting mental health issues to teachers in order to have appropriate, effective accommodations and modifications.
Conclusion
School districts that offer on-site mental health treatment services provide a significant benefit to students, their families, mental health providers, and the school community. When provided correctly, the schools create bridges to the mental health system while maintaining legal and financial firewalls. These services can result in educational and behavioral improvements for students and significant cost savings to school districts.
References
As school professionals become increasingly aware of mental health problems in the student population, they are grappling with the appropriate role of the school in the provision of services to these students. Many recognize that schools are in the “education business,” not the “mental health business,” yet school counsellors, social workers, nurses and psychologists all play a role in assisting these students. It may be unclear, at times, whether these services are educational in nature, or whether they constitute direct mental health treatment. This article provides an overview of different methods of providing mental health services within the school setting, and makes the argument that schools should “stay out of the mental health business” of diagnosis and treatment, but should collaborate with other systems to assure that students have access to services that result in educational gains as well as cost savings to the school districts.
The 2001 Surgeon General’s Report on Children’s Mental Health indicated that approximately 20% of children and adolescents have an emotional disorder, and that 5% have a severe mental health disorder. The report also noted that only one out of five students who have emotional disorders receives any treatment. If treatment occurs, it is most likely to be provided by a primary care physician rather than a mental health professional. Thus, in the average American classroom, there will be at least one student with a significant mental health impairment such as depression or other mood disorders, an anxiety disorder, Attention Deficit Hyperactivity Disorder or even a psychotic disorder, and the student will most likely not be receiving mental health services.
The implications of these statistics are significant not only for students and families, but also for the educational system. Mental health disorders can affect concentration, memory, on-task behavior, self-control, judgement, problem solving abilities, etc. It is not surprising that many students with such disorders manifest academic and behavioral difficulties. What might be surprising, however, is that most students who have mental health disorders, even those who are severely impaired, are not placed in special education. Sadly, if they are placed in special education under the “severe emotional disturbance” category,* they are likely to have poor outcomes: higher dropout, arrest, and unplanned pregnancy rates, lower employment and post secondary education rates, etc. The lack of appropriate mental health treatment is a primary factor leading to these poor outcomes.
For some of the students who currently receive special education under the “severe emotional disturbance” category, if mental health treatment had been provided at the pre-referral stage, it could have improved their academic and behavioural functioning, and prevented the need for a special education assessment at all. Unfortunately, access to treatment is difficult for many parents, who are unable to leave their place of employment on a weekly basis to pick up their child and bring him to a mental health appointment. Many, if not most, mental health providers do not provide evening or weekend hours. Also, access to qualified children’s mental health professionals is limited in many communities.
Mental health services can broadly be defined as being either counseling or therapy.
Counseling is the process of providing information, improving skills, and assisting a student in succeeding within the school environment. Counseling is routinely done by school social workers, psychologists, nurses and counsellors.
Therapy is a clinical service that constitutes treatment of a disorder; for example the treatment of clinical depression.
Many children who have mental health disorders are first identified in the school setting by teachers, counsellors, social workers, etc. An educational evaluation or other interventions may identify evidence of the mental health disorder, and the student’s parents may seek accessible treatment services that go beyond the typical counseling activities performed by school staff. Some schools have responded to this challenge by either having their own staff providing mental health diagnostic and treatment services within the school, or by entering a collaborative relationship with community providers who provide on-site, co-located diagnostic and treatment services in the school setting. Below, I describe several models that schools use to assure accessible mental health services in the school setting, and point out the relative advantages/disadvantages of each. In my opinion, the disadvantages of schools having their own professionals providing diagnostic and treatment services far outweigh the advantages, and I would therefore recommend that schools “stay out of the mental health business” of diagnosing and treating students.
Models of School-Based Mental Health Services
School-hired Professionals Provide Diagnostic and Treatment Services
Many school professionals such as school social workers have training and licensure that would allow them, if they were not working in the public school, to set up a practice in the community and provide diagnostic and treatment services. School districts that employ these professionals to provide treatment within the school setting have, in essence, set up that “practice” within the school.
There are advantages to this approach, in addition to the access to services it provides for students. School administrators have control over the therapist’s activities, and may potentially bill Medicaid for the service as well as receiving special education funding for the activity if it is identified as a related service on the student’s IEP.**
However, there are numerous potential problems with this approach:
- Therapists are required to document pertinent mental health information in their diagnostic and treatment notes; and in the case of a school-hired therapist, all of these notes become part of the student’s educational record. This would include sensitive information about parents and siblings (e.g., in cases of fetal alcohol syndrome, child abuse, etc.).
- If a tragic event such as suicide were to occur, the therapist may be covered by malpractice insurance, but the school district could be sued for poor supervision of the therapist. School districts cannot obtain malpractice insurance, and cannot necessarily rely on their Errors and Omissions insurance coverage to protect them. Coverage for the school district would pivot on the question of whether the supervision of mental health treatment professionals is considered an appropriate activity of a school district.
- Mental health professionals are required to be “on call,” or to provide backup coverage on evenings, weekends and vacations.
- Schools are accustomed to billing Medicaid for IEP related services, and frequently do. They generally don’t bill private insurance, however, due to co-pays and deductibles that would conflict with the requirement of providing a Free Appropriate Public Education (FAPE).
- In billing Medicaid for IEP mental health related services, some school districts essentially lower the legal threshold by providing services that would be helpful to the student, rather than following the IDEA mandate to provide related services that are “required to assist a child with a disability to benefit from special education.”*** If the student were to lose Medicaid coverage, the district would be on the hook for continuing to provide these helpful, but not required, services, and potentially other costly services such as residential treatment.
Community Mental Health and/or Medical Professional Provides Mental Health Diagnostic and Treatment Services in the School
This model co-locates a community service provider such as a mental health or health clinic in the school setting. The clinic is on-site, but the school district maintains legal and financial firewalls that would not be present if the district were to provide these services. The clinic leases space from the school, and a contractual agreement clarifies roles and responsibilities regarding indemnification, data privacy, criminal background checks, licensure, financial tasks, administrative requirements, and the like.
Although the provider in this co-located model can be an individual in private practice, I believe that it is preferable for the provider to be a community mental health or health clinic. These clinics can offer a broader array of mental health services, case consultation, psychiatric backup and broad coverage, as well as possible funding from counties or grant sources to reimburse services provided to uninsured clients.
The co-located model overcomes the problems outlined above for school-hired mental health professional services. Data are kept private, outside of the educational record. The provider can offer 24/7 crisis coverage, maximum billing approaches, services to both general and special education students, and adequate malpractice coverage. The provider is “in the school” but not “of the school.” Its employees cannot discuss students with school staff without a release of information, and the school maintains appropriate protective firewalls.
School-hired and Outside Professionals Collaborate to Provide Mental Health Diagnostic and Treatment Services
The collaboration model integrates services from providers inside and outside of the school system. In some states, schools can bill Medicaid for IEP services such as skills training and skills practicing. These activities are generally considered consistent with schools’ mandates. Schools can partner with community providers, splitting the therapy and skills training roles between them.
In all of the service models described above, school-hired professionals continue to provide educationally related counseling services to students in need.
Reimbursement
The cost of providing mental health services is an obvious hurdle for schools. Potential funding sources include private insurance and Medicaid billing for direct services; Consolidated Early Intervening Services funds; state, federal and private grants; discretionary local government funds; and Medicaid indirect service reimbursement funds.
As noted above, school districts will have access to IDEA funding for mental health-related services included on IEPs. I recommend, however, following the language of IDEA, and providing on an IEP only those related services required to assist the student to benefit from his special education, in order to avoid potential financial liabilities.
Ideally, on-site mental health services would be available to all students in need, regardless of the presence or type of insurance coverage. Community mental health centers generally provide this broad range of services. Co-located services can provide similar services, and generally have a significantly lower fail and cancel rate than clinic-based services, thus improving the reimbursement for the clinic. The reduction in client load during summer vacation, however, is a major financial liability for the school-based clinic. Some clinics shift their focus during the summer to address the needs of extended school year students; some follow students throughout the summer; and some have employees that take time off during the break.
Many programs are funded through grants, especially those serving uninsured patients and those providing non-billable ancillary services such as teacher consultation, inservice presentations, and attendance at meetings. However, many grant-funded programs have fallen by the wayside over the years as their grants have ended. I recommend maximizing reimbursement via insurance and Medicaid, and using grant funds only for start-up costs. Some states’ Medicaid benefit sets include ancillary services, and some insurance companies have partnered with school districts and clinics to create a higher “bundled rate” for school-based mental health services. The programs that have remained sustainable tend to be based on partnerships between mental health care stakeholders including clinics, school districts, counties, and insurance providers.
Target Populations
The following discernable populations of children with mental health disorders could gain much from school-hosted mental health services.
- Students with treatable disorders who have not yet been referred for a special education evaluation. As indicated above, early intervention has the best chance of producing a positive outcome for a child struggling with a mental health disorder. For this reason, I recommend appropriate diagnosis and treatment at the pre-referral stage. This effort would identify treatable disorders and can prevent the need for a special education assessment in some cases.
- Students who currently receive special education services, yet continue to have emotional, behavioral and academic difficulties.
- Special education students who are at risk of referral to Federal Setting 4 (self-contained at a separate school site) programs; and students who are served in these restrictive placements. Ironically, many Setting 4 students in “emotionally disordered” programs have mental health disorders that are at least as severe as those in day treatment programs, but are not seen as being appropriate for day treatment due to their behavior problems, oppositionality, difficulty with traditional therapeutic interventions, or other factors. This leads to poor outcomes for this population. I recommend moving away from a fixed “day treatment” model towards a no-reject “intensive, intermediate level on-site mental health services” model.
Role Definition
If co-located mental health services are to be successful, school districts must clearly define the roles of its own professionals as distinguished from the roles of co-located providers in order to avoid overlaps and gaps in services and to allay concerns about job security. School mental health staff (school social workers, psychologists, counsellors and, at times, nurses) have numerous roles, including coordinating services with families, documenting students’ symptomatic behaviours and communicating this information to students’ medical and mental health professionals, providing counselling as a related service, providing accurate educational assessments of students who have mental health disorders and interpreting mental health issues to teachers in order to have appropriate, effective accommodations and modifications.
Conclusion
School districts that offer on-site mental health treatment services provide a significant benefit to students, their families, mental health providers, and the school community. When provided correctly, the schools create bridges to the mental health system while maintaining legal and financial firewalls. These services can result in educational and behavioral improvements for students and significant cost savings to school districts.
References
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* In its list of impairments which may make a child eligible for special education services, the federal Individuals with Disabilities Education Act (IDEA) uses the term “serious emotional disturbance.” Some states use “emotional/behavioural disorder.”
** Individualized Educational Program, the “contract” between a school district and the family of a child with a disability found eligible for services under IDEA. *** 20 U.S.C. §1401(26), emphasis added. |