Assessing the Costs of School-Based Mental Health Services

By Nabors, Laura A.; Leff, Stephen S. et al. | Journal of School Health, May 2001 | Go to article overview
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Assessing the Costs of School-Based Mental Health Services

Nabors, Laura A., Leff, Stephen S., Mettrick, Jennifer E., Journal of School Health

School mental health programs represent an important setting for providing mental health services to youth. These programs reduce barriers to receiving services, such as offering access regardless of ability to pay for care. One important issue facing school-based programs involves sustainability of funding. This issue becomes more pressing as fewer programs are funded solely through grants and "carve-out" funds supplied by state governments and health departments.

Evaluations reviewing cost-effectiveness and costs for children's mental health programs,[1-3] and other reports describing ways to finance school health centers,[4,5] provide valuable guidance for evaluators. Initial studies on the effectiveness of school mental health services primarily assessed treatment quality and outcomes, but neglected examining costs of care. Studies on costs of school-based mental health services are needed to document the cost-effectiveness of these programs in comparison to other types of mental health care. If lower costs are associated with school-based mental health services, then this information might prove useful in arguing for sustaining and increasing funds for these programs, which play a vital role in the system of care for youth.[6,7]

Gathering information about the costs of services is an p important quality improvement activity to incorporate into program evaluation projects.[8,9] Research questions addressing measurement, practice, and cost-comparison issues in cost-effectiveness evaluations are presented in Figure 1. When conducting research on costs, evaluators need to consider variation in costs per client over different courses of treatment, such as duration and length of sessions, and the varying hourly reimbursement rates for clinicians. Statistical methods that consider change for the individual case -- such as growth curve analysis -- may be well suited to measuring change and costs of care for youth receiving school-based mental health services.

Figure 1

Questions for Future Studies on Costs of Care

Measurement Issues

What are appropriate measures of costs of care for school mental health programs?

How does one accurately examine or measure costs for youth who enter (and exit) treatment multiple times over the course of the school year?

Practice Issues

How does one justify costs for youth experiencing psychosocial stress, who do not receive a formal diagnosis?

How does one measure the costs of prevention services?

Cost-Comparison Issues

What are the costs of crisis services, and are cost-savings involved if children do not have to be hospitalized for psychiatric care?

What are the costs of school-based services in comparison to services provided elsewhere?


A pilot project evaluating costs of care for the School Mental Health Program (SMHP) in Baltimore, Md., involved calculating costs of care for adolescents who had participated in treatment. When the study was conducted, clinicians from the SMHP were providing services in several middle and high schools. Services are provided to children based on referrals and child needs, irrespective of the severity of diagnosis. Services typically included individual, group, and family counseling; crisis intervention; prevention activities; teacher consultation; collaboration with school staff and others in the community; case management activities; and focused assessments such as classroom observation and administration of measures assessing social and emotional functioning.

Costs for Treatment in Year One

Participants. Forty-eight youth ages 11 to 17 (Mean = 14 years) participated. Most students were African-American (n = 33) and female (n = 33). Clinicians reported clinical diagnoses on Axis I, using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition,[10] for most youth (n = 39).

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