Early identification of behavioral health disorders can lead to children receiving treatment sooner and help mitigate some of the challenges related to coping and resiliency later in life. Within a given year, an average of 7.4% of youth under 18 years of age in the United States will have a mental health visit in a community. However, studies have shown children spend approximately 49% of their days in a school setting and are six times more likely to get evidence-based treatment when offered in schools than in other community settings. By linking programs and supports that foster a comprehensive school mental health system, states can not only reduce the number of children experiencing anxiety, depression and behavioral health disorders, but also save a considerable amount in economic costs. The National Academies of Sciences, Engineering and Medicine reports a national economic savings of approximately $247 billion per year. This brief explores opportunities to create and cultivate school mental health programs that fit individual communities and their budgets.
Core Components of a Comprehensive School Mental Health System
The core components and strategies to achieve a comprehensive school mental health system are informed by the National Quality Indicators, along with expert panels convened by Substance Abuse and Mental Health Services Administration (SAMHSA), and are outlined by a national team of mental health professionals, the Partnership of National School Mental Health Leaders. Released in 2019, its guidance document, “Advancing Comprehensive School Mental Health Systems: Guidance From the Field,” seeks to provide support for leaders pursuing agreement regarding domains of school mental health developed through national metrics, standards and experts. Among other goals, the document is designed to help leaders foster mental health and general well-being, while reducing the prevalence and severity of mental illness, and to provide state and local leaders guidance to develop a system for strengthening school mental health supports. According to the National Center for School Mental Health (NCSMH), comprehensive school mental health systems provide an array of supports and services that can promote positive school climate and social and emotional learning. Its framework for a comprehensive school mental health system outlines eight essential features for creating a system of services to address the challenges of mental and behavioral health disorders among children.
The core components of a comprehensive school mental health system identified by these experts are:
- Well-trained educators and specialized instructional support personnel: A full complement of school and district professionals, including specialized instructional personnel who can support the mental health needs of students in the school setting.
- Family-school-community collaboration and teaming: Partnerships among students, families, schools, community partners, policymakers, funders and providers to address the academic, social, emotional and behavioral needs of all students.
- Needs assessment and resource mapping: Ongoing evaluations of students and school and community resources to inform decision-making about needed support and services.
- Multi-tiered system of support: A full array of tiered, evidence-based processes, policies and practices that promote mental health and reduce the prevalence and severity of mental illness.
- Mental health screening: Use of screening and referral as a strategy for prevention, early identification, treatment and recovery.
- Evidence-based and emerging best practices: Use of effective strategies to ensure quality in the services and supports provided to students.
- Data: Use of data to monitor student needs and progress, assess quality of implementation, and evaluate supports and services.
- Funding: Use of diverse models and resources to track or identify new funding opportunities from federal, state and local sources to support a sustainable school mental health system.
Three Opportunities for State Leaders
As state leaders allocate limited resources, they are well-positioned to support and align the use of many of these eight core features to improve child mental and behavioral health in school settings through infrastructure and resource alignment across different sectors. Below, three of the eight core components states have implemented in recent years are highlighted. Using evidence-based programs to train educators and support personnel, fostering multi-tiered systems of support (MTSS) and developing innovative funding approaches are all building blocks that have enhanced schools’ ability to address the needs of students, including those who are at risk of developing or who have been diagnosed with mental health challenges.
Multi-Tiered Systems of Support
Research by the Center for Positive Behavioral Interventions and Supports indicates students are best served when schools offer behavioral supports at varying degrees of intensity, as part of an MTSS. This approach comprises three data-driven, problem-solving tiers. Dividing supports into these three tiers enhances outcomes for students who need assistance aligned with their academic, behavioral, social and emotional needs. The partnership, composed of national leaders who wrote the guidance document, has conceptualized the MTSS through a public health lens that highlights complementary roles for community partners and school districts, each providing a different tier of support depending on specific student needs.
- Tier 1—Mental-health-promotion services and supports: These can be mental-health-promoting activities, including the strengthening or reinforcement of positive social, emotional and behavioral skills designed to support the well-being of all students, regardless of whether they are at risk for mental health problems. Supports in this tier are primarily provided at the school-district level.
- Tier 2—Early intervention services and supports: Programs in this tier provide early intervention services and supports to address mental health concerns for students who have been identified through needs assessments, screening or referral when experiencing mild distress or functional impairment or are at risk for a given problem or concern. Because some clinical expertise is needed to provide supports in this tier, responsibility for these programs is typically shared equally between school districts and other community agencies.
- Tier 3—Treatment services and supports: Programs in this tier support students who need individualized interventions for the significant distress and functional impairment they are experiencing. This tier will require less individualized assistance at the school district level and a more supportive community approach.
This public health approach to the MTSS illustrates the interconnection between community partners and school districts. With legislative support, both Virginia and New York schools were able to create programs for identification, prevention and treatment responses that fit their student mental health needs while incorporating a tiered approach and feedback from different stakeholders. In 2018, Virginia and New York legislatively instructed their respective education departments to incorporate mental health education into student learning standards.
Virginia SB 953 “recognized the multiple dimensions of mental health” and required the Virginia Board of Education to create a curriculum for expansive mental health material. The 2020 Health Standards of Learning curriculum includes identification of signs and symptoms of mental illnesses or challenges and factors that can influence an individual’s mental health, including family, social environment, trauma, genetics, brain chemistry, health behaviors, personal values, peers, media, technology, culture and community. While the legislation specifically addresses requirements for the ninth and 10th grades, the standards also incorporate Tier 1 components of mental health promotion and prevention starting in first grade.
New York amended its education law to clarify that all health education programs should include mental health and highlight the relationship between mental and physical health. The bill does not mandate a curriculum but codifies state regulations recognizing that health is multidimensional. It requires individual districts, schools and classrooms to design curricula and lesson plans that include information on mental health and mental health treatment. The New York State Board of Education provides resources for districts, schools and classrooms to develop and adopt curricula aligning with state learning standards for school mental health education. In response to this enacted legislation, the state Education Department also developed a comprehensive guide, “Mental Health Education Literacy in Schools: Linking to a Continuum of Well-Being,” to provide educators, school district personnel, parents or guardians, students and community organizations with information on mental health education provided in schools.
Evidence-Based Programs and Emerging Best Practices
Recognized by SAMHSA as an evidence-based approach, the eight core components of a comprehensive school mental health system can provide a framework for implementing evidence-based state and local programs. Within this framework, state and local school districts can identify and implement evidence-based programs and best practices appropriate for their communities. School personnel are often the first to recognize student mental health challenges. By equipping personnel with skills to address social emotion learning and health literacy, they can better identify and mitigate health challenges for students later on. SAMHSA’s Project AWARE (Advancing Wellness and Resiliency in Education) grant program seeks to expand the capacity of state educational agencies, in partnership with state mental health agencies, to increase mental health awareness among youth, to provide training to school personnel and adults interacting with school-aged youth, and to connect school-aged youth who are experiencing behavioral health challenges with services. The 2020 grant recipients include 14 states and one territory.
The Department of Health and Human Services (HHS) also recognizes evidence-based programs as interventions and activities that have been evaluated and shown to effectively address a health challenge. HHS notes that evidence-based programs are not a one-size-fits-all model, and therefore states should consider the target population, implementation settings, program outcomes and length of program to effectively address the issue. States can consider a number of national programs and grants to support trainings as part of a strategy to implement evidence-based programs. Mental Health First Aid (MHFA) is a program available in every state, and at least 20 states have required, encouraged or supported its implementation. These specialized training programs equip teachers, administrators, community leaders and emergency response personnel with skills to identify mental health warning signs and respond to crises. The trainings have contributed to a reduction in stigma around mental health and have helped people who may have been at risk of suicide or self-harm. After the success of MHFA, the National Council for Behavioral Health created the Youth Mental Health First Aid (YMHFA) program to assist adults working with youth. It also helps youth identify warning signs and learn techniques to handle mental and behavioral health challenges so they can assist their peers.
In 2017, Indiana prioritized mental health first aid training with the introduction of HB 1430. Enacted, this bill ensures all schools require suicide awareness and prevention training for all teachers, and may require training for other appropriate school staff, every three years. The bill also ensures emergency medical responders complete an evidence-based training program concerning suicide assessment, treatment and management.
States have taken other approaches to better understand student mental health and increase personnel training, including enacting laws to implement trauma-informed care policies. In 2019, Tennessee established trauma-informed discipline policies in schools to lessen long-term effects of adverse childhood experiences. SB 0170 requires each local board of education to adopt policies requiring an ACEs assessment before suspending or expelling a student or requiring a student to attend in-school suspension or alternative school. Through these policies, school personnel will also learn to teach and reinforce rules that do not allow for violent or abusive behavior, balance accountability while understanding traumatic behavior, and emphasize positive behavioral supports and intervention plans. According to SAMHSA, trauma doesn’t happen in a vacuum and it can affect communities through a shared identity. States, communities and schools considering a trauma-informed care approach have the potential to alleviate the effects of a traumatic event or experience and build resiliency for the well-being of everyone in the community.
The Partnership of National School Mental Health Leaders recognizes that funding a school mental health system can require multiple funding sources and that approaches to these sources may vary depending on the needs of each school and community. Additionally, research funded by the Children’s Mental Health Initiative and the Illinois Children’s Mental Health Partnership indicates that sustainable school funding for mental health can also be challenging for states facing limited resources and competing priorities. However, these challenges can lend themselves to legislative opportunities for innovative and coordinated use of limited dollars and multiple financial methods. The NCSMH released suggestions for states and local communities to help finance school mental health systems in the “Funding and Sustainability Quality Guide.”
States have also leveraged a number of school-community partnerships to improve children’s mental health systems. Financial approaches like blending or braiding funding have helped schools build the infrastructure needed to effectively partner with communities to implement school-based health programs that are evidence-based, youth-guided, culturally and linguistically competent, and that are individualized to a student or a whole community.
Utah used these funding strategies to increase systems integration and reduce duplication of services. In an effort to unify the state’s public schools and local substance use and mental health agencies, the Utah Office of Education and the Division of Substance Abuse and Mental Health created Utah’s Community of Practice (CoP) on School Behavioral Health. The CoP, under the Utah Human Services Code Chapter 15 Substance Abuse and Mental Health Act, developed the Framework for School Behavioral Health Services in 2008. This framework, developed by public education partners, mental health and substance use professionals, community members, and youth and family advocates, integrates existing school-based services with community supports. This approach to student support services illustrates collaboration with existing community-based agencies and available resources through a common mission, vision and shared accountability of school-based services.
Indiana, New York, Tennessee, Utah and Virginia demonstrate different tiered approaches to creating a comprehensive school mental health system through professional training, multi-tiered partnerships and new funding mechanisms. According to the partnership’s Guidance Document, the eight core features encompass different components state leaders can utilize for a comprehensive school mental health system and ultimately “improve access for all students, including traditionally underserved youth, and positively impacting student outcomes with improved academic performance, fewer special education referrals, decreased need for restrictive placements, fewer disciplinary actions, increased student engagement and feelings of connectedness to school and higher graduation rates.”
For many states, competing priorities and limited resources can present barriers to identifying or implementing any core feature of a comprehensive school mental health system. In conjunction with national, state and local school mental health leaders, the partnership has captured different system-level strategies for states to consider when identifying which core features could most easily align with their needs. This section includes three options for policy and legislative strategies. Policymakers at the local, state or federal levels can take part in these strategies. State examples are included for each.
- Convene state departments of education and mental health staff with community representatives, families, students and professional associations to enhance communication and opportunities to collaborate.
The National Center for School Mental Health (NCSMH) at the University of Maryland School of Medicine, together with the School-Based Health Alliance (SBHA), is leading a National Quality Initiative on School Health Services. A primary component of the work is facilitating collaborative improvement and innovation networks (CoIINs), which are intensive learning collaboratives focused on improving the quality and sustainability of school health services. The goal of the NCSMH CoIIN is to leverage collective knowledge and innovation to accelerate the application of evidence to practice and to test, implement, scale up and sustain improvements in comprehensive school mental health systems. With funding from the Health Resources and Services Administration (HRSA), the NCSMH conducted district-level CoIINs (2014-2018) and will support three state-district CoIIN cohorts (2018-2023). Each state-district CoIIN includes five districts from five states as well as youth and family leaders. As part of the CoIIN, districts regularly complete assessments of school mental health system quality using the School Health Assessment and Performance Evaluation System (SHAPE), a public-access, web-based workspace to support quality improvement.
According to the NCSMH and the SBHA, the district-level CoIINs (2014-2018) demonstrated considerable success. The majority of participating districts implemented school mental health screening and invested in data infrastructure to document students receiving Tier 2 and Tier 3 supports and those making psychosocial and academic improvements.
Arizona, Indiana, Minnesota, Rhode Island and Wisconsin participated in the first state-district CoIIN cohort from August 2019 to June 2020. At the end of the CoIIN, these states reported several accomplishments, including intentional collaboration across state agencies around school mental health, elevating conversation about mental health in schools at the state level and developing state policy goals related to school mental health. For example, in response to rising mental health challenges for youth in Minnesota, the legislature required the Department of Human Services to evaluate the current school mental health system and provide recommendations to the legislative committee. The recommendations included, among other ideas, adopting the NCSMH definition of comprehensive school mental health to help build a framework for school-linked mental health programs and expanding on previous work regarding reimbursement rates and rate methodology for sustainable school-linked services.
The second state-district CoIIN cohort launched in August 2020. Participants include state and district leaders from Massachusetts, Nevada, Ohio, Pennsylvania and South Carolina.
- Build agreement among stakeholder groups in a structured process to determine priority issues and strategies in school mental health. Find an issue that is manageable and specific for immediate focus.
According to a 2019 report by NCSL, children’s caucuses are legislative affinity groups, generally open to the public, focused on public policy issues affecting children and families. At this time, at least eight states—Colorado, Connecticut, Delaware, Hawaii, Maine, New Hampshire, Pennsylvania and Wisconsin—have children’s caucuses. According to the Wisconsin Legislative Children’s Caucus, the purpose of the caucus is to cultivate a legislative dedication to advancing promising, evidence-informed public policy. These caucuses help legislators build knowledge and connections and develop strategies to support issues of mutual importance.
For example, the Colorado Children’s Caucus was created in 2012 to provide a forum for all members of the legislature to discuss the challenges facing Colorado youth and to work together to develop policy recommendations to strengthen families and improve the lives of children. The caucus is staffed by the Colorado Children’s Campaign, a nonprofit, nonpartisan organization, and co-chaired by a bipartisan team of legislators who provide a forum to educate their colleagues on current research in early childhood development, highlight questions to be addressed for further policy development and identify potential areas for policy change.
The Colorado Children’s Caucus discusses issues impacting every child in the hopes of strengthening families and supporting healthy communities. In the last several years, the caucus has introduced over 100 bills, including K-12 Breakfast After the Bell Nutrition Program, ensuring that every school in which at least 70% of students are eligible for free or reduced lunch also offers breakfast; a measure improving school attendance through community partnerships and the creation of a multidisciplinary plan to reduce chronic absence; and the Coordinated Behavioral Health Crisis Response, creating a coordinated and seamless behavioral health crisis response system of intervention services.
By establishing a forum like a children’s caucus, state legislatures can expand their knowledge and understanding of issues affecting their state’s youth and create a strategic process for addressing these challenges.
- Reassess practices and modify approaches in a continuous improvement process and include youth and others in this process.
In December 2018, the Maryland State Board of Education Task Force on Student Discipline Regulations reconvened to discuss “The Maryland Guidelines for a State Code of Discipline.” After adopting these guidelines in 2014, members of the task force reconvened to explore the implementation and impact of the disciplinary policies. Specifically, the task force:
- Considered the effect of current discipline regulations on students, teachers, classrooms, learning environments and schools.
- Determined best practices in student discipline inside and outside of Maryland, including, but not limited to, restorative justice and positive behavioral intervention supports.
- Made recommendations to the state board for regulatory, policy or guidance changes that could be adopted to improve the disciplinary environment in Maryland schools.
Final recommendations in August 2019 included recognizing student mental health as a major factor related to the issue of discipline; enhancing regulations regarding school counselors and psychologists to align with nationally recommended ratios; and providing a menu of best practices to address student discipline and provide adequate training and resources to ensure that programs (including restorative practices) are implemented with fidelity.
In 2020, the Maryland General Assembly passed HB 277, requiring the Departments of Education, Health, and Human Services to develop and distribute guidelines on trauma-informed approaches to local schools to assist in responding to individuals with symptoms of chronic and interpersonal trauma or traumatic stress. From an original task force meeting in 2009 to legislation passed in 2020, the Maryland Board of Education has reevaluated and made disciplinary policy changes as new findings were presented for continual institutional improvement for their students’ mental health needs.
These three strategies, along with the state examples, illustrate different approaches policymakers and states can consider given their understanding and resource allocation when creating or cultivating core features of a school mental health program.
In a time when communities are addressing different challenges, from school safety to a pandemic resulting in remote learning or tighter budgets, policymakers can create and foster school mental health programs that address these specific challenges. “Advancing Comprehensive School Mental Health Systems: Guidance From the Field” highlights core features for assessing, developing and implementing different policies at the local, state or federal level. These features, along with the state examples throughout this brief, represent different approaches policymakers can take within their communities as potential building blocks for a school mental health system. By linking programs and supports that foster a school mental health system, states have the capability to not only reduce the number of children experiencing anxiety, depression and behavioral health disorders but also save economic costs on services to address these disorders