School-Based Mental Health Programs and Services: Overview and Introduction to the Special Issue

School-based mental health (SBMH) programs and services have grown progressively in the United States in the past two decades, related in part to increased recognition of their advantages and heightened federal support. However, SBMH is an emerging field, with many issues needing attention. This introductory article provides a context for the special issue by highlighting the importance of increased conceptual clarity about SBMH, enhanced mental health—education systems integration, and advancement of the SBMH research base. Key elements for success of SBMH programs and services are discussed, as underscored recently by the report of the New Freedom Commission on Mental Health (2003) and other important initiatives. These elements include (a) school–family–community agency partnerships, (b) commitment to a full continuum of mental health education, mental health promotion, assessment, problem prevention, early intervention, and treatment, and (c) services for all youth, including those in general and special education. A synopsis of the articles in the special issue is provided, emphasizing their conceptual and empirical contributions to delivery and sustainability of effective mental health practices in schools.     

Mental health services for children. The state of the art

Throughout this century, people in the United States have been concerned about the serious deficiencies in the mental health care of our children. Despite eloquent needs assessment and recommendations for remediation, most of the unserved needs and deficiencies of our mental-health-care-delivery system remain the same. This article reviews the current status of mental health services to children, youth, and families to highlight the necessity of an integrated system of mental health care. The development of a continuum of care that is coordinated across the mental health and non-mental-health systems that naturally occur in all children's lives has the potential to vastly improve mental health services to children, youth, and families.     

Embedding prevention services within systems of care: Strengthening the nexus for children

System-of-care models that offer a continuum of integrated mental health services for children are being widely implemented in local communities. Preventive services, arising from the theoretically grounded prevention sciences, are an important but neglected component of this model. Studies of the use of mental health services by children are reviewed, and an integrative model is proposed to incorporate prevention services as a component of the child mental health service system. Construction of the prevention sciences has followed a linear phase model that has advantages and disadvantages for bridging prevention sciences and services research. As prevention science progresses into broader field tests of its effectiveness, studies of child services can be informative, especially in advancing the applicability and dissemination of research findings. Future directions are outlined to strengthen the nexus between services research and prevention science, and to construct a new genre of prevention services research.     

Fulfilling the Promise of School-Based Mental Health: Moving Toward a <Emphasis Type="Italic">Public Mental Health Promotion</Emphasis> Approach

School-based mental health (SBMH) programs and services are growing progressively in the United States for many reasons. However, the SBMH field is young and tenuously supported, and challenges are being confronted on many levels. There are major needs to continue to bring research-supported interventions into schools, and to better equip educators and mental health programs and staff in schools to function effectively. Articles in this special issue present the many challenges well and point to important directions for advancing SBMH. To truly advance the field a Public Mental Health Promotion approach is needed. Elements of this approach, in advancing training, quality assessment and improvement (including empirically supported practice), and advocacy and policy influence are discussed, as are strategic connections to the Community Science perspective and to the development of a growing Community of Practice in SBMH.     

The Role of Schools in Outcomes for Youth: Implications for Children's Mental Health Services Research

We explore the role of schools in children's mental health services research. Recent literature has suggested that schools play an important role in delivering services to children and adolescents with emotional and behavioral problems. Research in services research, though, has taken a fairly narrow view of which dimensions of school environments are relevant for inclusion in studies. We suggest that a broader view of school environments is appropriate and potentially beneficial to the field. Using Bronfenbrenner's ecological model as a guide, we conceptualize schools as microsystems. Such an approach suggests that all aspects of school environments (treatment as well as non-treatment) are likely to influence many of the outcomes that children's mental health services research frequently targets (e.g., behavioral problems, problematic peer relationships, academic achievement, school attendance). We review literature from a variety of disciplines to suggest relevant features of schools, with particular attention to the role of peer dynamics within schools. We conclude with implications of this expanded conceptualization of schools for children's mental health services research.     

Education and Training of Children's Mental Health Professionals: The Existing and Potential Role of Schools of Public Health

Since the early 1980s, increasing attention has been devoted in the literature to the conceptualization, development, and implementation of integrated and comprehensive mental health systems of care for children and adolescents. In establishing this new children's mental health paradigm of community-based systems of care, there are presently very few well-trained professionals and leaders focused on collaborative (including interagency) initiatives in the delivery of children's mental health services. Nevertheless, the field of public health offers an interdisciplinary setting for the education and training of individuals in children's mental health services. This national survey of all 27 accredited schools of public health in the United States and Puerto Rico examined the existing capacity for and potential to expand educational and training opportunities in the organization, financing, and delivery of children's mental health services.     

Mental Health Identification Practices of Jails: The Unmet Needs of the “Silent” Population

The overrepresentation of individuals with mental illness in the criminal/legal system is well documented. While professional associations urge diversion towards treatment, little is known about the practices these institutions use to identify this population. One understudied space in the criminal/legal continuum is jails. This exploratory study compares two types of mental health identification at jail booking to assess jail‐ and community‐based service outcomes by identification type (N = 2956): (a) staff observation and (b) a standardized screening instrument. Individuals identified through staff observation were significantly more likely to receive jail‐ and community‐based services, even though current symptomology and substance misuse were both significantly higher for individuals identified only by the screening instrument. These findings point to the importance of jails in providing stabilizing services during incarceration, but further, show the impact that identification practices have on individuals as they transition to the community. Community context showed varied rates of jail staff observations of mental illness, showing greater risks for individuals in rural communities. Implications include a need for system‐level changes by instituting evidence‐based identification practices in jails, and improving professional collaboration practices between mental health and criminal/legal practitioners as individuals enter and exit jails.     

School psychology: a public health perspective : I. Prevention, populations, and systems change

Concerns regarding American schools and mental health services for children abound, including inadequate educational achievement, school violence, over-referral to special education and disproportionate placement of minorities into special education, under-utilization of mental health services for children, and a poorly coordinated system of child mental health services. All of the above concerns share two common attributes: (a) they are statements regarding populations, rather than specific individuals; and (b) they are best addressed by changing system-wide elements of psychological service delivery. We argue that, although conceptualizing school psychology as primarily an indirect service specialty (e.g., J. Sch. Psychol. 28 (1990) 203) has advanced our thinking about effective service delivery, conceptualizing school psychological services from a public health perspective will provide an even broader framework that can increase both the efficacy and efficiency of school psychologists' work.     

Ethical Considerations of Multiple Roles in Forensic Services

Attorneys increasingly rely on the services of mental health practitioners. Although some practitioners lack training, the promise of professional rewards lead some to accept opportunities with resulting ethical quandaries. Due to significant differences between the objectives of traditional mental health services and expert testimony, problems occur when clinicians venture into forensic services. Attorneys and judges, unfamiliar with mental health specialties, may seek to press a mental health practitioner into multiple roles. Although not all multiple roles are ethically inappropriate, caution demands careful parsing of particular roles: (a) academic/behavioral science expert; (b) fact witness as a treating therapist; (c) expert witness based on a clinically oriented assessment; (d) pretrial and/or trial consultant; and (e) professional critic of other experts. Possible ethical issues and risks associated with accepting multiple roles are identified and strategies for avoiding or minimizing harm or exploitation are discussed.     

Research in Adolescent Suicide: Implications for Training,Service Delivery,and Public Policy

Four domains of research in adolescent suicide are reviewed: (1) the role of psychopathology, (2) family history of psychopathology, (3) mental health treatments, and (4) firearms in the home. Based on the extant literature, recommendations are made for changes in training, service delivery, and public policy. Among the recommendations for training professionals are: an emphasis on diagnostic proficiency, skill and attentiveness in the assessment of the entire family unit, and assessment of the availability of firearms in the home. With respect to changes in service delivery, we recommend treatment of the entire family system, and treatment of psychiatric and substance abuse problems in the same setting, and we show the need for a continuum of intensity of care from inpatient to outpatient. With respect to policy changes, we recommended parity of mental and physical health insurance coverage, screening for psychiatrically at-risk youngsters in schools and physicians' offices, providing funding to support a continuum of care between inpatient and outpatient, and gun control laws to restrict access to handguns. We believe that these changes can result in a substantial reduction in the adolescent suicide rate.     

School Psychology: Training Individuals for One of the Best Kept Secrets in Professional Psychology

Abstract

School psychology training at the doctoral level is discussed. Given the increasing diversity in the schools as well as the varied education and mental health needs of the population, school psychology training is necessarily broad, involving traditional skills such as assessment, intervention, consultation, and counseling, all of which are taught within a context of a changing school population with changing needs. Because there is compulsory education, school psychologists’ interface with a broad cross-section of individual children, their parents, and their teachers. Moreover, school psychological practice is not limited to schools, as doctoral school psychologists are health service providers; many of these individuals work in other settings for which they are trained to provide services. The complexities and challenges of training school psychologists within this broad agenda effectively across domains are discussed.     

Mental health professionals' support of self‐help groups

Objective. Self‐help groups and other consumer‐led services are viewed as valuable additions to mental health services. This study describes professional support for self‐help groups and examines the hypothesis that professional support of self‐help is influenced by the degree to which professionally‐led groups are viewed as more helpful than self‐help groups. Method. Survey data were obtained from a representative sample of over 900 mental health professionals employed in mental health agencies in a large US State. The survey assessed beliefs, behaviours, attitudes, and intentions toward professional and self‐help groups. Results. Respondents who perceive professionally‐led groups to be significantly more helpful than self‐help groups were less inclined to support self‐help groups through referrals, help in organizing groups, or financially. Conclusion. To the extent that professional support of the self‐help movement is diminished, valuable allies in the struggle to expand the reach of mental health services are lost. It is proposed that mental health professionals should obtain additional information about the benefits of self‐help and the constructive role that self‐help groups can play in expanding the availability and continuum of beneficial mental health services. Copyright © 2001 John Wiley & Sons, Ltd.     

The Fort Bragg managed care experiment: Short term impact on psychopathology

Many concerns have been raised about mental health services for children and adolescents. These concerns have included not treating those in need and providing inappropriate services to those who are treated. The continuum of care philosophy purports to remedy these problems by offering a comprehensive and coordinated range of services emphasizing community-based treatment. Services in the continuum include alternatives to trditional restrictive forms of care such as hospitalization. The provision of more appropriate care is hypothesized to improve the clinical outcomes of children treated in a continuum of care. The Fort Bragg Evaluation compared quality, use, outcome, and cost of the continuum of care model to a more traditional, fragmented system of care. This paper presents the effects of a service delivery system on short term psychopathology outcomes.     

Measuring Child Mental Health Status for Services Research

Epidemiological studies of the prevalence of mental health disorders typically contain multiple measures of mental health, using different instruments and different informants (child, parent, and interviewer). We used the Methods for the Epidemiology of Child and Adolescents Mental Disorder (MECA) study of U.S. youth to assess the effects of employing a range of these measures in mental health services research. We examined the effect of including various measures of mental health status in regressions of income on mental health service use. The estimated effect of income on service use varied widely, depending on the measure of mental health status used. Some measures of mental health status have little explanatory power in service use regressions. Measures of mental health status based on parental assessment of impairment or need, such as the Columbia Impairment Scale, are less costly to collect and also have good explanatory power, but are more strongly correlated with income. The Non-Clinician Child Global Assessment Scale (NC-CGAS) performs best in terms of explanatory power and correlation with income. Higher income parents appeared to judge behaviors differently from lower income parents, so analyses based on measures derived from parental report may lead to an understatement of the effect of income on service use.     

Understanding the Behavioral Determinants of Mental Health Service Use by Urban, Under-Resourced Black Youth: Adolescent and Caregiver Perspectives

Black adolescents with mental health problems are less likely than non-Black adolescents with mental health problems to receive treatment, primarily for non-financial reasons including negative perceptions of services and providers, and self-stigma associated with experiencing mental health problems. To better understand these obstacles, 16 adolescents and 11 caregivers, recruited from two K-8th grade elementary-middle schools, participated in four focus groups guided by the unified theory of behavior to explore mental health help-seeking behaviors and perceptions of mental health services. In the focus groups, caregivers acknowledged more positive attitudes about seeking mental health services than adolescents, but both expected the experience of actually doing so to be negative. Adolescents and caregivers also acknowledged social norms that inhibit their mental health help-seeking. Therefore, we conclude that interventions targeting expectancies and social norms might increase the connection of urban, under-resourced Black adolescents and their families to mental health services, and be particularly important given the long-term consequences of untreated mental health problems for this group.     

The equivalence of computerized and paper-and-pencil psychological instruments: Implications for measures of negative affect

The use of computerized psychological assessment is a growing practice among contemporary mental health professionals. Many popular and frequently used paper-and-pencil instruments have been adapted into computerized versions. Although equivalence for many instruments has been evaluated and supported, this issue is far from resolved. This literature review deals with recent research findings that suggest that computer aversion negatively impacts computerized assessment, particularly as it relates to measures of negative affect. There is a dearth of equivalence studies that take into account computer aversion’s potential impact on the measurement of negative affect. Recommendations are offered for future research in this area.     

Physicians’ views on men's mental health and the role of counselling services – a pilot study

This pilot study aimed to explore how physicians understand men's avoidance of mental health counselling services and to elicit physicians’ views on pairing mental health assessment with routine physical examination. Initially, physicians’ views on men's avoidance of mental health counselling services were explored through a focus group. A short survey exploring views on pairing mental health assessment with a routine physical examination was then developed and sent to 125 physicians at a local medical centre. Physicians discussions indicated that male socialisation processes, the stigma of needing help, and ignorance about counselling sessions, all contribute to men's avoidance of mental health counselling services. The survey results suggest that combining a mental health assessment with an annual physical examination was viewed positively by most physicians (80%), that they would encourage this approach (75%), and would appreciate the support of counselling services in this process (80%). However, these survey results were influenced by the age and sex of the physician. The focus group suggestion to pair mental health assessments with routine medical examinations, with support from counselling services, was viewed by most physicians as a positive way to engage men. Preliminary services could be established that utilise this approach and examine its efficacy.     

Kultursensible Diagnostik in Forschung und Praxis

Nearly one fifth of the German population are migrants of the first and second generation. Evidence-based knowledge about mental health of migrants, their health care needs and the actual mental health care situation of this population is limited. Psychometric instruments are helpful for the assessment of mental disorders. Although a culture-sensitive approach in diagnostics is necessary it is often neglected in research as well as in clinical practice. This article describes culture-specific and linguistic challenges and specifies specific communication problems. In most cases psychometric instruments are not developed simultaneously in different languages but are translated later on. After translation psychometric instruments should be culturally validated and adapted with respect to linguistic, cultural and metric equivalence. The article gives an overview about the different aspects of equivalence and explains these aspects on the example of the PHQ-9.     

群体认同与个体心理健康的关系:调节变量与作用机制

近年来,群体认同与个体心理健康的关系得到了研究者的关注。本研究通过对相关文献的梳理与归纳发现:民族、国家、学校、家庭等不同种类群体的认同,群体认同数量与个体心理健康的关系显著;群体认同与个体心理健康之间的关系受群体认同动机和个体对群体评价的调节,并依赖于自尊、社会支持、控制知觉、归因方式等因素的中介;未来应利用多种方法继续研究群体认同与个体心理健康关系的调节变量与作用机制。