Journal of Child and Family Studies

, Volume 25, Issue 1, pp 290–298 | Cite as

School Referral Patterns Among Adolescents with Serious Emotional Disturbance Enrolled in Systems of Care

  • Jennifer Greif Green
  • Ziming Xuan
  • Lana Kwong
  • Kimberly Hoagwood
  • Philip J. Leaf
Original Paper


School staff play a critical role in referring adolescents with serious emotional disturbance (SED) to mental health services; however, the mechanisms underlying this referral process are poorly understood. We used data from adolescents (N = 4365) enrolled in SAMHSA’s Children’s Mental Health Initiative Systems of Care (SOC) and participating in a national evaluation to compare the profiles of youth referred for SOC services by school staff with youth referred for those services by professionals at other agencies. We sought to identify whether school staff referred a unique set of adolescents by examining indicators of global impairment and impairment in school functioning (i.e., absences, suspensions, failures). Using multilevel regression models, we estimated the association of global impairment and school functioning with referral source (i.e., school vs. other) and controlled for SOC community characteristics and individual-level socio-demographics. Findings indicated that adolescents referred from schools had significantly lower levels of global impairment than adolescents referred from mental health settings. However, they had considerable school-related impairment, with rates of absences, suspensions, and failures that were equivalent to youth referred from most other agencies. This study is the first to examine school-related impairment among youth receiving SOC services as a function of referral source. By identifying adolescents with more mild global impairment, who nonetheless experienced significant impairment in school functioning, schools can be key contributors to effectively identifying a unique set of adolescents for SOC services. Further, schools might meaningfully inform the provision of comprehensive services to this population by educating community agencies about school functioning among youth with SED.


Systems of care Adolescents School mental health Services Referral 



The project described was supported by Grant Number K01MH085710 from the National Institute of Mental Health to J. Green. We are grateful to the Substance Abuse and Mental Health Services Administration (SAMHSA) for providing the support for data collection, as well as the staff at ICF International, particularly Dr. Russell Carleton and Ye Xu, for their assistance with Children’s Mental Health Initiative (CMHI) data management. We thank Jennifer Keenan for her assistance with manuscript preparation and Grace McMillan for her comments on an earlier version of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health of SAMHSA.


  1. Adelman, H. S., & Taylor, L. (1999). Mental health in schools and system restructuring. Clinical Psychology Review, 19(2), 137–163.CrossRefPubMedGoogle Scholar
  2. Alegría, M., Lin, J. Y., Green, J. G., Sampson, N. A., & Kessler, R. C. (2012). Role of referrals in mental health service disparities for racial and ethnic minority youth. Journal of the American Academy of Child and Adolescent Psychiatry, 51(7), 703–711. doi: 10.1016/j.jaac.2012.05.005.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Anderson, J. A. (2011). Patterns of school functioning over time among students served in a system of care. Remedial and Special Education, 32(6), 482–495. doi: 10.1177/0741932510364545.CrossRefGoogle Scholar
  4. Anderson, J. A., Wright, E. R., Smith, J. S., & Kooreman, H. E. (2007). Educational profiles of students at enrollment in a system of care. Remedial and Special Education, 28(1), 9–20. doi: 10.1177/07419325070280010201.CrossRefGoogle Scholar
  5. Atkins, M. S., Hoagwood, K. E., Kutash, K., & Seidman, E. (2010). Toward the integration of education and mental health in schools. Administration and Policy in Mental Health and Mental Health Services Research, 37(1–2), 40–47. doi: 10.1007/s10488-010-0299-7.CrossRefPubMedPubMedCentralGoogle Scholar
  6. Bird, H. R., Shaffer, D., Fisher, P., & Gould, M. S. (1993). The Columbia Impairment Scale (CIS): Pilot findings on a measure of global impairment for children and adolescents. International Journal of Methods in Psychiatric Research, 3(3), 167–176.Google Scholar
  7. Bradshaw, C. P., Buckley, J. A., & Ialongo, N. S. (2008). School-based service utilization among urban children with early onset educational and mental health problems: The squeaky wheel phenomenon. School Psychology Quarterly, 23(2), 169–186.CrossRefGoogle Scholar
  8. De Los Reyes, A., & Kazdin, A. E. (2005). Informant discrepancies in the assessment of childhood psychopathology: A critical review, theoretical framework, and recommendations for further study. Psychological Bulletin, 131(4), 483–509.CrossRefPubMedGoogle Scholar
  9. Dowdy, E., Ritchey, K., & Kamphaus, R. W. (2010). School-based screening: A population-based approach to inform and monitor children’s mental health needs. School Mental Health, 2(4), 166–176. doi: 10.1007/s12310-010-9036-3.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Green, J. G., McLaughlin, K. A., Alegria, M., Costello, E. J., Gruber, M. J., Hoagwood, K., et al. (2013). School mental health resources and adolescent mental health service use. Journal of the American Academy of Child and Adolescent Psychiatry, 52(5), 501–510. doi: 10.1016/j.jaac.2013.03.002.CrossRefPubMedPubMedCentralGoogle Scholar
  11. Hodges, K. (1994). Child and adolescent functional assessment scale parent report. Ann Arbor, MI: Functional Assessment Systems.Google Scholar
  12. Husky, M. M., Sheridan, M., McGuire, L., & Olfson, M. (2011). Mental health screening and follow-up care in public high schools. Journal of the American Academy of Child and Adolescent Psychiatry, 50(9), 881–891. doi: 10.1016/j.jaac.2011.05.013.CrossRefPubMedGoogle Scholar
  13. Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), 1548–1555.CrossRefPubMedGoogle Scholar
  14. Kessler, R. C., Avenevoli, S., Costello, J., Green, J. G., Gruber, M. J., McLaughlin, K. A., et al. (2012). Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 69(4), 381–389. doi: 10.1001/archgenpsychiatry.2011.1603.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Kramer, T. L., Phillips, S. D., Hargis, M. B., Miller, T. L., Burns, B. J., & Robbins, J. M. (2004). Disagreement between parent and adolescent reports of functional impairment. Journal of Child Psychology and Psychiatry, 45(2), 248–259.CrossRefPubMedGoogle Scholar
  16. Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., Horwitz, S. M., Hoven, C. W., et al. (1996). Mental health service use in the community and schools: Results from the four-community MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 35(7), 889–897.CrossRefPubMedGoogle Scholar
  17. Levitt, J. M., Saka, N., Romanelli, L. H., & Hoagwood, K. (2007). Early identification of mental health problems in schools: The status of instrumentation. Journal of School Psychology, 45(2), 163–191. doi: 10.1016/j.jsp.2006.11.005.CrossRefGoogle Scholar
  18. Manteuffel, B., Stephens, R. L., & Santiago, R. (2002). Overview of the national evaluation of the comprehensive community mental health services for children and their families program and summary of current findings. Children’s Services: Social Policy, Research, and Practice, 5(1), 3–20.CrossRefGoogle Scholar
  19. Merikangas, K. R., He, J. P., Brody, D., Fisher, P. W., Bourdon, K., & Koretz, D. S. (2010). Prevelance and treatment of mental disorders among U.S. children in the 2001–2004 NHANES. Pediatrics, 125, 75–81.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., et al. (2011). Service utilization for lifetime mental disorders in U.S. adolescents: Results of the national comorbidity survey adolescent supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 32–45. doi: 10.1016/j.jaac.2010.10.006.CrossRefPubMedPubMedCentralGoogle Scholar
  21. President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Retrieved from
  22. Register, Federal. (1993). Final notice establishing definitions for (1) children with a serious emotional disturbance, and (2) adults with a serious mental illness. Substance Abuse and Mental Health Services Administration, 58, 29422–29425.Google Scholar
  23. SAS Institute. (2011). SAS ® 9.3. Cary, NC: SAS Institute.Google Scholar
  24. Schwab-Stone, M. E., Shaffer, D., Dulcan, M. K., Jensen, P. S., Fisher, P., Bird, H. R., et al. (1996). Criterion validity of the NIMH diagnostic interview schedule for children version 2.3 (DISC-2.3). Journal of the American Academy of Child and Adolescent Psychiatry, 35(7), 878–888.CrossRefPubMedGoogle Scholar
  25. Slade, E. (2003). The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States. The Journal of Behavioral Health Services & Research, 30(4), 382–392.CrossRefGoogle Scholar
  26. Stroul, B. A., & Blau, G. M. (2010). Defining the system of care concept and philosophy: To update or not to update? Evaluation and Program Planning, 33(1), 59–62.CrossRefPubMedGoogle Scholar
  27. Stroul, B. A., & Friedman, R. M. (1986). A system of care for severely emotionally disturbed children and youth. Washington, DC: Georgetown University Child Development Center.Google Scholar
  28. United States Public Health Service. (2000). Report of the surgeon general’s conference on children’s mental health: A national action agenda. Washington, DC: Department of Health and Human Services.Google Scholar
  29. Walrath, C., dosReis, S., Miech, R., Liao, Q., Holden, E. W., De Carolis, G., et al. (2001). Referral source differences in functional impairment levels for children served in the comprehensive community mental health services for children and their families program. Journal of Child and Family Studies, 10(3), 385–397.CrossRefGoogle Scholar
  30. Walsh, M. E., Madaus, G. F., Raczek, A. E., Dearing, E., Foley, C., An, C., et al. (2014). A new model for student support in high-poverty urban elementary schools: Effects on elementary and middle school academic outcomes. American Educational Research Journal, 51(4), 704–737.CrossRefGoogle Scholar
  31. Weist, M. D., Ambrose, M. G., & Lewis, C. P. (2006). Expanded school mental health: A collaborative community-school example. Children & Schools, 28, 45–50.CrossRefGoogle Scholar
  32. Weist, M. D., Mellin, E. A., Chambers, K. L., Lever, N. A., Haber, D., & Blaber, C. (2012). Challenges to collaboration in school mental health and strategies for overcoming them. Journal of School Health, 82(2), 97–105.CrossRefPubMedGoogle Scholar
  33. Wood, P. A., Yeh, M., Pan, D., Lambros, K. M., McCabe, K. M., & Hough, R. L. (2005). Exploring the relationship between race/ethnicity, age of first school-based services utilization, and age of first specialty mental health care for at-risk youth. Mental Health Services Research, 7(3), 185–196.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Jennifer Greif Green
    • 1
  • Ziming Xuan
    • 2
  • Lana Kwong
    • 3
  • Kimberly Hoagwood
    • 4
  • Philip J. Leaf
    • 5
  1. 1.School of EducationBoston UniversityBostonUSA
  2. 2.School of Public HealthBoston UniversityBostonUSA
  3. 3.Boston Medical CenterBostonUSA
  4. 4.Child and Adolescent PsychiatryNew York University School of MedicineNew YorkUSA
  5. 5.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA

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