School Mental Health in Systems of Care

The Center for Mental Health Services (1997) estimates that from 9 to 13% of all children aged 9–17 have a serious emotional disturbance that either impairs or substantially interferes with their ability to function effectively at home, school, or within the community. More than 20 years ago, Knitzer (1982) found that two-thirds of children in need did not receive mental health services. Since the publication of that landmark report, concerns about the small number of youth with mental disorders who receive mental health services have not lessened (Leaf, Bogrov, & Webb, 1997; U.S. DePartment of Health and Human Services, 1999). Although recent research suggests that a greater proportion of children in need of mental services now receive them (Costello et aL, 1993; Leaf et al., 1996), few communities can claim that all or even most youth identified as having mental or emotional problems receive effective services

In most communities, mental health services have been provided primarily in outpatient clinics and inpatient units (Kiser, King, & Lefkovitz, 1999). Concern over the poor outcomes experienced by many youth with mental disorders, however, has led to a call for (1) the increased use of research-based treatments (Hoagwood et al., 2001; Kazdin & Weisz, 1998; Kutash & Rivera, 1996) and (2) a more effective “system of care” (Kiser, Lefkovitz, & Kennedy, 2001). The promise and controversy surrounding expanded use of research-based treatments has been widely discussed (Hoagwood et al., 2001; Kazdin & Kendall, 1998; Persons, 1995). Considerable evidence exists that, when implemented well, evidence-based services can result in significant improvements in children's outcomes. As discussed in other chapters in this volume, however, we are still learning how to implement and sustain these preventive and treatment interventions in school settings

A system of care is “a comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of severely emotionally disturbed children and adolescents” (Stroul & Friedman, 1996, p. 3). In response to the numerous reports describing deficiencies in the mental health services available to our nation's youth, the federal government, family advocacy groups, and academic training centers have devoted considerable time and effort to disseminating the concepts and philosophy of the Child and Adolescent Service System Program (cassp). This program develops infrastructures necessary for publicly funded community-based services for children and adolescents with serious emotional disturbances (Davis et al., 1995; Stroul & Friedman, 1986, 1996)

Communities will probably require both more effective systems of care and greater utilization of evidence-based practices to produce the outcomes they desire for emotionally disturbed children. To date, improvements in a community's system of care have been shown to improve access to and coordination between services for children but not, by themselves, to improve children's behaviors or school functioning significantly (Bickman, Noser, & Summerfelt, 1999). A community's system of care may coordinate services well between providers and between agencies such that more children with needs are identified and come into contact with service providers. The ultimate effectiveness of the system, however, remains dependent upon the individual, direct services provided to children and their families. If those delivering services to children continue to use practices not proven to affect children significantly, greater access to and coordination between services will not impact youth greatly

Most discussions concerning systems of care have focused on individual service needs of the youth and their families or home-based services (e.g., Multisys-temic Therapy; Schoenwald, Borduin, & Henggeler, 1998). Increasingly, however, mental health professionals and policymakers have focused on schools as a critical component of the system of care approach (Elias et al., 1997; Gottfredson, 2001; Leaf et al., 1997), Clinicians working in schools can access youth more easily than can those working in more traditional clinical settings (e.g., outpatient or inpatient clinics). In addition, these clinicians have a greater opportunity to establish procedures that will help preventmental disorders, substance abuse, and violence; that will facilitate the early detection and referral of youth with behavioral or emotional problems; that can provide an array of services delivered to children directly in the schools; and that can reintegrate youth with serious emotional or behavioral problems back into schools

This chapter suggests ways to think about school-based services from a system of care perspective. We first present six principles associated with the system of care approach and suggest ways in which mental health professionals working with and in schools might apply these principles to their work. We then provide an overview of the different types of services mental health clinicians might help provide within the school setting. As an example of a system of care approach, we then present a description of the school-based services provided within the Safe Schools, Healthy Students (ss-hs) project in Baltimore City. We conclude this chapter by suggesting ways in which to fund the system of care approach