Academic journal article Education & Treatment of Children

A School Mental Health Issues Survey from the Perspective of Regular and Special Education Teachers, School Counselors, and School Psychologists

Academic journal article Education & Treatment of Children

A School Mental Health Issues Survey from the Perspective of Regular and Special Education Teachers, School Counselors, and School Psychologists

Article excerpt

Abstract

The purpose of this investigation was to determine the perceptions of regular and special education teachers, school counselors, and school psychologists on presenting problems of students, available community mental health services, family-based and community-based barriers to services, and the provision of mental health services in schools. A random national sample of participants completed a School Mental Health Issues Survey. The final sample included 413 respondents from all 50 states and the District of Columbia. The background of the study, survey development, administration and analysis, descriptive statistics and analyses of variance are provided. Significant differences based on position, school level, and school geography, as well as implications for mental health services in schools and future research are also discussed.

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Childhood and adolescent mental health issues cause pain and emotional distress, and may compromise a student's chances for fully using his or her learning opportunities and for ultimately succeeding in school and later life. These issues may be evident through overt behaviors such as aggression and disruption, but also may also be more subtle, causing internal turmoil through feelings such as anxiety and depression. By default, our nation's schools may be viewed as community mental health centers where up to 10% of the children in the general education population may have a psychiatric disorder (Rosenblatt & Rosenblatt, 1999). Between only 1 and 5% of these students are being served across the nation, and less than one-half of those with emotional or behavioral disorders are being identified and served in special education (Forness, Kavale, & Lopez, 1993). A recent Surgeon General's Report on Mental Health states that one in five children and adolescents experiences the signs and symptoms of a DSM-IV disorder during the course of a year, with about 5% of all children experiencing "extreme functional impairment" (Policy Leadership Cadre for Mental Health in Schools, 2001). Statistics from the Office of Technology Assessment (OTA) suggest that 12 to 15% of adolescents present emotional and behavioral problems at levels warranting intervention, while another 15% are believed to be at-risk (Flaherty et al., 1996; Rosenblatt & Rosenblatt, 1999; Werthamer-Larsson, 1994). The situation is even more dismal when one expands the focus beyond the limited landscape of diagnosable mental disorders to the number of young people experiencing psychosocial problems and who are at risk of not maturing into responsible adults (Dryfoos, 1990). Adelman and Taylor (2001) contend that up to 40% of young people are in very bad educational shape and at risk of failing to fulfill their promise. Taken together, these figures are of alarming concern, reinforcing the perception that this segment of our school population is either not being identified, not being served, or being served inadequately by not only our schools, but also by child welfare, juvenile justice, and/or mental healthcare systems.

The Carnegie Council Taskforce on the Education of Young Adolescents (1995) suggests that school systems are not responsible for meeting every need of their students. But when the need directly affects learning, the school must meet the challenge. Subsequently, leaving no child behind implies more than stronger accountability for results. The mission of schools should comprise not only a focus on academics and confronting obstacles to academic learning, but also a major role in promoting development related to social and emotional functioning. Outcomes should logically include safe, healthy, and resilient behavior. Strengthening firsthand mental health resources and services for school-age children and youth may provide preventive activities designed to reduce prevalence, as well as early intervention for problems (Cowen, Hightower, Pedro-Carroll, Work, Wyman, & Haffey, 1996; Reynolds & Gutkin, 1998; The Maternal and Child Health Bureau, 1998). Accordingly, there has been increased interest and support for more comprehensive programs aimed at providing more support for schools, students, and families.

Despite the perceptible benefits of school-based mental health services, as well as the awareness of the many related barriers to learning, much of our current research and reform continues to focus on the instruction, management, and governance of students, teachers, and schools. While emphasis on accountability, flexibility and control, options for parents, and teaching methods are important, these principles may not be sufficient in addressing the multiple, complicated, and overlapping barriers that interfere with learning, instruction, and administration. To date, most of our nation's school-based health and mental health services have failed to be fully integrated into their local community (Flaherty et al., 1996; Policy Leadership Cadre for Mental Health in Schools, 2001; Sedlak, 1997; Werthamer-Larsson, 1994). When available, services are criticized as being segregated, isolating, fragmented, or incomplete (Forness, Kavale, MacMillan, Astern, & Duncan, 1996; Young, 1990).

Despite the fact that a growing body of research exists regarding school-based mental-health programs, serious deficiencies exist in reference to the literature base and convergence across different sites. Progress is dependent on quantitative data via well designed and purposeful needs assessments and model programs demonstrating results. The paucity of current data is largely subjective, and untied to the real world needs or effectiveness of implementation in actual community and school conditions (Durlak, 1995; Schorr, 1997).

This study assesses presenting problems of students, available community mental health services, and mental health services in our nation's schools. Regular and special education teachers, school counselors, and school psychologists were selected as key informants best able to fulfill this responsibility. This survey is important because research and subsequent practice must document that services are meeting unmet needs of students, and doing so efficiently and effectively. Further, it may provide insight into differences of opinion between school personnel, and across the variables of school level and geography on this critical topic.

Background of the Study

Weist, Myers, Danforth, and McNeil (2000) surveyed administrators on factors relevant to developing school-based mental health programs. Their goal was to conduct a broad needs assessment of life stressors, mental health problems, and resources for youth in elementary, middle, and high schools in urban, suburban, and rural communities in four states. They contended that results of theirs and similar surveys may provide initial guidance to expand school mental health programs tailored to address presenting issues of students as they vary based on school level and geographic locale. They also suggested that future studies should consider using multiple informants from diverse backgrounds to comprehensively assess the needs and available programs for youth in their communities. Subsequently, this study utilized their survey as a basis for further exploration of the perceptions of regular and special education teachers, school counselors, and school psychologists.

Method

Survey Development

For pilot purposes, the Weist et al. (2000) survey was administered to a group of graduate students (n = 46) at George Mason University. After modification based on pilot implications and statistics, it was streamlined, with the final version excluding some school demographic information, school staffing information, substance abuse ratings, and several individual items. Analysis of items and sections included in the revised survey retained internal consistency reliability coefficients ranging from .84 to .95. These results were generally consistent with Weist et al's (2000) coefficient alphas for each scale (ranging from .92 to .95).

Selection of Participants and Administration Procedures

Market Data Retrieval (MDR) was contacted to obtain a random sample from their database of counselors, psychologists, and teachers. A total of 1000 surveys were mailed to their random national sample of school counselors' (n = 250), school psychologists' (n = 250), regular education teachers' (n = 250), and special education teachers' (n = 250). The survey was accompanied by a cover letter explaining the purpose of the study, as well as a self-addressed, stamped return envelope. To improve response rate, a follow-up letter and another copy of the survey was mailed to non-respondents. Phone calls and email messages were also employed.

Data Analysis Procedures

Responses were analyzed using the Statistical Package for Social Sciences (SPSS) Version 9.0 (1998). Survey sections were treated as scales, with descriptive and frequency statistics providing summary data. Group comparisons (between school counselors, school psychologists, and regular and special education teachers) were conducted. An analysis of variance (ANOVA) was conducted on mean scores for the scales. Additional comparisons were conducted to assess the impact of school level and school geography variables. To provide protection from identifying too many differences as significant when they were not, the Tukey multiple range test was utilized.

Final Sample Description

Four hundred and thirteen respondents (41.3%) provided usable data. Of the total respondents, 76.5% were female and 19.9% were male. All 50 states and the District of Columbia were represented with responses, California, New York, and Texas provided the most (see Table 1). School psychologists were the most frequent respondents (n = 119, 28.8%), followed by special education teachers (n = 117, 28.3%), school counselors (n = 111, 26.9%), and regular education teachers (n = 61, 14.8%). Regarding education level, the largest percentage were Masters + 30 hours (n = 152, 36.8%), while over 60% of the respondents had more than 10 years of experience. Elementary was the most frequently occurring school level (n = 155, 37.9%). However, many respondents to this category (n = 91, 22%) checked more than one of the provided school levels. Accordingly, the researcher added the response category of Multiple to account for these incidences. The school geography of the respondents was primarily described as suburban (42.1%). Rural and Urban settings accounted for 29.5% and 26.2% of the respondents, respectively.

Results

Measured across all four key informant groups, the respondents rated impaired self-esteem, attention deficit/hyperactivity, and peer relationship problems as the most severe emotional and behavioral problems of students in their schools. They viewed suicidal thoughts and/or behavior, inappropriate sexual behavior, and alcohol/drug abuse as least critical (see Table 2). Respondent's additional presenting problems of students included Parents (n = 11, 2.7%), Aggression/Conduct (n = 8, 1.9%), and Academics (n = 6, 1.5%).

Respondents listed a total of 860 agencies providing mental health care, including local hospitals and organizations, and private practices and practitioners. In general, the respondents rated these agencies as more effective than ineffective. Family stress that precludes seeking help and family financial problems were viewed to be the greatest family-based obstacles to receiving services (see Table 3). Additional family-based barriers included Apathy (n = 17, 4.1%), Avoidance (n = 11, 2.7%), and Environment (n = 9, 2.2%). Family transportation problems were perceived to be the least. When asked to rank the five community/clinic-based barriers preventing youth from receiving mental health services, respondents placed managed care and long waiting lists for services as most problematic (Table 4). Additional community/clinic-based barriers included Effectiveness (n = 7, 1.7%), Location of Services (n = 5, 1.2%), and Financial (n = 5, 1.2%).

In general, it was believed that individuals in communities are receptive (M = 3.48) toward children and adolescents receiving mental health services in schools. There was, however, less perceived support (M = 3.27) in communities for the delivery of mental health services in schools. When asked to list reasons why community members are not receptive or supportive of mental health services in schools, most respondents implied that attitudes, financial issues, and stigma were most representative.

The most frequently available services on school grounds as part of the school program were evaluation of emotional/behavioral problems (91%), individual counseling services (84%), and crisis intervention services (81%). The most infrequently available services were family counseling services (28%), substance abuse services (38%), and educational presentations to students on mental health (51%). Comparably, respondents rated evaluation of emotional/behavioral problems, crisis intervention services, and individual counseling services as those they most strongly agree should be provided in schools (Table 5).

The last question of the survey asked respondents' opinion, if the mental health services in their school are effective in meeting the mental health needs of the students, based on a scale from 1 (very ineffective) to 5 (very effective). In general, respondents reported that services were more ineffective than effective (M = 2.85).

Position Perspectives

Group comparisons (between school counselors, school psychologists, and regular and special education teachers) were conducted to determine if the key informants differed in knowledge and perception, regarding presenting problems of students, available community mental health services, and mental health services in schools. Descriptives provided statistics for each group and the entire data set. A one-way analysis of variance (ANOVA) was utilized to determine if the population means differed on items and scales. Due to the large number of them, all comparisons were set at the .01 level to reduce the possibility of Type 1 errors. Significant differences were detected in 8 of the 33 analyses (24.2%). ANOVA results are provided in Table 6.

School psychologists rated depression more serious than counselors, special education or regular education teachers. Post hoc testing using the Tukey procedure was conducted on the mean scores for the scale and confirmed the significant differences between regular education teachers and counselors (p < .036), and regular education teachers and psychologists (p < .015).

Reaction to the item "poor knowledge of mental health services" showed significant disparity between groups F (3, 398) = 5.429, p = .001. Post hoc testing confirmed significant dissimilarity of opinion on this item between counselors and regular education teachers (p = .012), and counselors and special education teachers (p = .008). Regular education and special education teachers perceived a family's lack of knowledge as a much greater barrier than did the counselors.

On the scale of community/clinic-based barriers, the item "long waiting lists for services" indicated significant differences between the groups F (3, 368) = 5.29, p = .001. School psychologists perceived this as a greater problem than the other key informants. Post hoc testing substantiated the significant difference between psychologists and regular education teachers (p = .006), special education teachers (p = .008), and counselors (p = .028).

Significant differences also existed between groups on the survey section asking respondents to assess how receptive individuals are, F (3, 394) = 5.15, p = .002, and how much support there is, F (3, 387) = 5.52, p = .001, in communities toward children and adolescents receiving mental health services in schools. School psychologists and counselors sensed that individuals are more receptive toward in-school services than were regular or special education teachers. Counselors and school psychologists also believe there to be more community support than did the special education or regular education teachers.

Analysis of position's influence on "If services should be provided on school grounds as part of the school program," revealed significant differences between informants on the items of family counseling and substance abuse services. Regular and special education teachers, as well as counselors believed significantly more than psychologists that family counseling services should be provided. Regular and special education teachers believed significantly more than did psychologists, that substance services should be provided.

The survey's last question, asking the respondents' opinion if the mental health services in their school are effective in meeting the mental health needs of the students, revealed significant differences between groups F (3,392) = 10.911, p = .000. Descriptive statistics revealed the regular education teachers rating in-school services as the least effective (M = 2.43), followed by special education teachers (M = 2.62), and school psychologists (M = 2.97). Only school counselors (M = 3.20) rated services in their schools as being more effective than ineffective.

Demographic Influences

Additional group comparisons were also included (urban, suburban, rural, and elementary, middle, junior, secondary, high, multiple grade levels). In these assessments, significant differences were discovered on the presenting problems scale items of depression, suicidal thoughts and/or behavior, attention deficit/hyperactivity, alcohol/drug abuse, and inappropriate sexual behavior. High school respondents rated depression significantly higher than did their elementary counterparts. High school and multiple grade level respondents rated suicidal thoughts significantly higher than elementary persons. On the item of alcohol/drug abuse, multiple significant differences existed between groups, with high school and secondary school informants rating this issue most critical. Inappropriate sexual behavior was reported as far less significant by elementary than by secondary, high school, middle, or multiple staff.

On the scale of, "if mental health services in school should be provided," significant school level difference existed regarding substance abuse services. High school and secondary respondents believed most that substance abuse services should be provided in their schools, while elementary respondents believed them less vital. Table 7 depicts the school level ANOVAs.

Few significant differences existed based on the factor of school geography. On presenting problems of students, impulsive/dangerous behavior and classroom disruptiveness were significantly more concerning to urban persons than to suburban or rural ones. Additionally, suburban respondents deemed transportation problems as a significantly less barrier than did rural or urban respondents. School geography ANOVA findings are provided in Table 8.

Discussion

Survey findings pertaining to the presenting problems of students were generally consistent with the pilot study. Impaired self-esteem was viewed as the most serious problem. Suicidal thoughts and/or behavior and inappropriate sexual behavior were generally viewed of least concern.

Respondents listed 860 agencies and programs that provide mental health services to youth in their communities. In general, they rated these agencies as slightly more effective than ineffective. Cost, quality, and access, however, present real world dilemmas for healthcare providers and patients alike. One critical problem pertaining to access is the disparity between the number of children who receive mental health services and the number who need them. Even though multiple barriers to accessing services exist, some families navigate their way around them to receive the help they need. Others become part of systems such as state mandated services, or the juvenile justice system. Even when mental health services are readily available, some still fall through the cracks.

The literature suggests that many school-based programs grow out of community support and demand. For example, Kreichman (1985) discussed complaints by residents that community clinics were not providing education and health care services responsive to actual needs. Dikel (1994) spoke of the limited information schools have about the nature and degree of their student's problems. Poole (1997) and Simpson and Young (1998) described programs created to prevent early school failure, and to reduce risk factors and unhealthy lifestyle practices. In essence, all of these programs were established due to students' risk for clinical deterioration and potentially out-of-home/out-of-school placements. After implementation, they were positively received by school administrators, teachers, social workers, health care agencies, parents, and students alike. To assess community receptivity and support, survey respondents were questioned about the potential for the delivery of mental health services in schools. It was generally believed that individuals in their communities were more receptive than not toward children and adolescents receiving mental health services in schools. They also perceived general support in communities toward the delivery of these services. Comparing means from the two questions, respondents reported more receptiveness than support. This may be translated as a general attitude supporting mental health services in schools, but less action to put such programs into effect. Weist et al. (2000) indicated that stigma, denial, funding, confidentiality, and lack of knowledge were the greatest reasons. Similarly, this survey rated attitudes, financial, and stigma as the three greatest.

Flaherty (1996) suggested that an archetype of appropriate school-based mental health includes balanced functions of intervention, consultation, education, outreach, resource identification and development, and networking. More proactive measures may lead to greater efficiency in allocation of resources, with later intervention being less crucial, and preventing emotionally disturbed children from requiring the next level of services. Not surprisingly, evaluation of problems was the most widely available service in respondents' schools. Over 90% of respondents indicated this service as available. Individual counseling, crisis intervention, and group counseling were distant followers. Least available were family counseling services. Substance abuse services were also sorely lacking, potentially due to the large number of elementary respondents. Both services were believed by respondents as those that should be least provided. However, respondents generally believed that they both should be provided on school grounds as part of the school day, since their overall means approached four on the five point likert scale.

Perhaps most disconcerting, was the fact that the survey respondents felt that services in their schools were ineffective in meeting the mental health needs of their students. Counselors were the only respondents who viewed services as more effective than not (M = 3.20). Psychologists, special education and regular education teachers all viewed services as ineffective.

Including the survey's last question, significant differences were detected in nearly 25% of the group comparisons between school counselors, school psychologists, and regular and special education teachers, supporting the contention that these key informants differ in knowledge and perception. In general, school psychologists and school counselors, and regular education and special education teachers were most closely linked to each other in terms of perception. Findings pertaining to these perceptions were generally in expected directions.

School psychologists and counselors rated depression and suicidal thoughts and/or behavior as more serious, while regular and special education teachers rated issues such as attention deficit/hyperactivity more problematic. One may propose at least two possibilities for this phenomenon. First, special educators are trained in and equipped with preventive and interventive strategies to deal with presenting problems of students, and viewed the items as less serious. Second, special educators may be environmentally and populationally desensitized to these issues, and perceive them as more normal in their corner of the educational universe.

Counselor and teacher group differences found on the scale of family-based barriers preventing youth from receiving mental health services fell along similar lines, with teacher groups perceiving lack of knowledge a much greater barrier than the counselors. Psychologists also viewed barriers toward treatment differently, with significant difference of opinion on the community/clinic-based barrier of long waiting lists for services.

Groups differences at statistically significant levels also existed between groups on the section asking respondents to assess how receptive individuals are, and how much support there is in communities toward children and adolescents receiving mental health services in schools. School psychologists and counselors again perceived these questions similarly, believing there to be more community receptiveness and support than did the teacher groups.

Knowledge if services exist, and belief if they should be provided on school grounds as part of the school program revealed significant differences between informants on two of the ten items (family counseling and substance abuse services). Again, regular and special education teachers, and school counselors and psychologists were most closely paired/related. Looking at the data, it seemed that teachers generally believed least that mental health services should be provided. One might contend that teachers train for and value the educational mission of school, while counselors' and psychologists' train for and thus value more clinical services outside of the classroom. This trend may lay in contrast to the survey's last question, if the mental health services in schools are effective in meeting the mental health needs of students? The teacher groups rated services as the least effective, followed by school psychologists, with only school counselors believing that services in their schools are more effective than ineffective.

Several significant school level differences were discovered on the presenting problems of students, and if mental health services in school should be provided, while non-significant differences existed regarding family-based or community/clinic-based barriers to receiving treatment, how receptive/supportive communities are toward mental health services in schools, and the effectiveness of services toward meeting the mental health needs of the students. It should be noted that the large number of respondents who placed themselves in multiple school levels (N = 91) might have affected some of the analyses at this level.

In their survey of school administrators, Weist et al. (2000) implied that behavioral and substance abuse problems grew progressively more serious as grade level increased. Not surprisingly, as informants in this survey rose in grade level, they generally rated depression, suicidal thoughts, alcohol/drug abuse, and inappropriate sexual behavior as significantly more serious. Both surveys are consistent with extensive epidemiological studies suggesting that the predominance of depression and suicidal behavior in children increases with age. When asked if mental health services in school should be provided, respondents at higher grade levels believed most that substance abuse services should be provided in their schools, while those at lower grade levels believed them to be less vital.

Elementary respondents tended to rate problems such as ADHD, impulsive/dangerous behavior, and classroom disruptiveness as most serious. Elementary respondents were also more fervent than the others, most strongly agreeing that four of the ten mental health services (evaluation of emotional/behavioral problems, consultation on mental health issues for teachers, group counseling services, and school-wide programs to address pressing problems) should be provided on school grounds as part of the school program.

Only the secondary respondent group rated services in their schools as effective in meeting the mental health needs of the students, while the high school and middle school groups rated services as mostly ineffective. Significant school geography (urban, suburban, rural) differences were also found regarding presenting problems of students and family-based barriers toward treatment, with differences approaching significance on receptiveness toward children and adolescents receiving mental health services in schools, what mental health services should be provided in school, and the effectiveness of existing mental health services in schools.

Presenting problems also varied pending geographic locale, with urban respondents generally rating each of the ten problems as more serious than the suburban or rural staff. Their mean was the highest on five of the ten presenting problems (impaired self-esteem, impulsive/dangerous behavior, classroom disruptiveness, attention deficit/hyperactivity, and peer relationship problems), and second highest on three (suicidal thoughts and/or behavior, worrying/anxiety/nervousness, and alcohol/drug abuse). These results are remarkably similar to Weist et al. (2000), who stated that urban youth were reported to encounter serious or very serious levels of stress in almost every stressor assessed, and further noted that they were reported to experience higher stress and display more severe internalizing problems than suburban or rural youth.

Rural respondents reported alcohol/drug abuse as a significantly more serious issue than did urban or suburban ones, as well as family stress that precludes seeking help significantly greater than in suburban regions. Rural respondents also perceived the least amount of community receptiveness and support for mental health services in schools, and the mental health services in their schools to be least effective in meeting the needs of the students. This is of serious concern. Due to sparsely distributed populations and other related geographical factors, rural communities tend to have fewer providers, programs, and services than other communities (Cohen & Hesselbart, 1993). Another similarity to Weist et al. (2000) was that poor knowledge of mental health services was reported to be a greater barrier in rural and urban settings, than in suburban ones.

Finally, suburban respondents identified worrying/anxiety/nervousness as more serious, while urban respondents contended that impulsive/dangerous behavior and classroom disruptiveness were more serious. Suburban respondents deemed transportation problems as a significantly less barrier that did rural or urban respondents. Suburban settings reported more receptiveness toward children and adolescents receiving mental health services in schools than did rural ones.

Limitations

One potential limitation of this study is the potential for nonresponse error. A response of 50 to 60% is often considered a desirable return rate for survey research (Diem, 2003). Accordingly, this study's return rate of 41.3% might be considered sub-optimal, thereby affecting the how representative or valid the study is. However, data collection processes such as the use of a cover letter, a return-addressed stamped envelope, sending a follow-up mailing with a second copy of the survey, phone calls, and email messages were all utilized in attempt to minimize this issue.

Intrinsically, all self-report inventories have potential for problems. These include the possibility that the respondent is unaware of how they are thinking or feeling about the subject, that the respondent may lie or intentionally attempt to deceive, or that the respondent may be subject to response sets in their answers. Although some respondents refrained from providing identifying information, the survey did not seek anonymity. It is possible that some respondents may have not answered the survey with veracity, since many of the positions require contact with various community agencies. In addition, they may have not wanted to identify or disclose negative information about their respective schools. The survey's informed consent statement regarding the confidentiality of participant responses attempted to minimize this potential limitation.

Finally, it must be noted that survey respondents' day-to-day job functions are predetermined, and that their available time to spend on mental health activities may be limited by other essential job duties. Resultantly, if the majority of respondents' time is occupied by responsibilities such as teaching, lesson planning, conducting assessments, scheduling, and bus or lunchroom duty, available mental health services may be perceived as less than effective. Subsequently, this study may be considered primarily descriptive in nature, and may only illustrate position perspectives and infer as to why differences between professional groupings, school level, and school geography exist.

Implications for Future Research

This study may serve as an illustration to identify and investigate ways to solve serious problems in existing service systems. In the past, many school-based mental health programs were not developed based on calculated needs assessments. With increasing demands for accountability in our schools, school-based programs must be developed through careful planning, including documentation of life stressors and presenting problems, available resources and barriers to them, and the efficacy of existing services.

Targeting key informants such as regular and special education teachers, school counselors, school psychologists, administrators, and even parents and students may glean a broad and accurate perspective of need and guide the development of school-based programs to address district-specific mental health needs of students. The data provided by these assessments may also spotlight areas of problem and need, thus promoting community and school receptiveness and support for services.

After carefully planned implementation, the benefits of these programs may be documented by conducting research with equivalent intervention and comparison groups. Experimental designs such as these are needed to attribute improvements in student functioning to the school-based interventions because alternative plausible interpretations may be ruled out. Subsequently, the challenge will be methodological issues that threaten the validity of the studies.

Implications for Practice

Mental health care is expensive and often without immediately visible benefits. It is therefore easy to give into the numerous barriers toward receiving help or to justify ignoring the need for help. Families and communities often find more visible and seemingly more pressing needs on which to focus. Special education may provide mental health help for students who are evaluated and deemed eligible to become part of that system. However, many students remain outside of special education and reach crisis before services may be obtained. Still others needing help are often required to fail to the next level of care. Finally, all school staff are expected to complete all of the duties outlined in their job description and/or laid out by their administrator. It is unfair to imply that the failure to provide services is a programming problem totally in the hands of the school-based service providers. However, children and adolescents who have access to school-based services are more likely to have their mental health care needs met.

For these students, making services available in school-based programs is vital. This study may contribute to converging evidence for policymakers, practitioners, and other researchers, and emphasize the need for programs to meet the mental health needs of our nation's youth. Not leaving these children behind will require a major paradigm shift, with school systems rethinking exactly what services these staff members should be facilitating. For it to make social, political, and economic sense, the delivery of services must expand and evolve based on continued investigation and analysis at the state and local levels, including careful assessment of the problems faced by youth and the resources that are available to them in their schools and communities.

Needs assessments or surveys such as this one may be catalysts for discussion about student problems and clinical issues at the school or district level. Taken further, they may provide initial guidance to developers of school-based programs to tailor their services to address presenting problems of students as they vary based on variables such as school level and geography. Ensuing programs must take into consideration the school's role related to both positive mental health (promotion of social and emotional development) and mental health problems (psychosocial concerns and mental disorders) of students, their families, and school staff. These services need not be presented separately, but may be integrated as part of a holistic, comprehensive, and multifaceted continuum of programs and services schools need to enable effective learning and teaching.

These services may enhance classroom strategies for students with mild-to-moderate behavior and learning problems, assist students and families as they negotiate the many school-related transitions, increase home and community involvement with schools, respond to crises, and offer additional assistance to students and families when necessary.

School is a predominant influence in a child and adolescent's life, where a lot of time is spent. With services located at a school, many family-based or community-based barriers are eliminated. Transportation problems become less of a factor if the services are located at the school. A school-based provider who is a known entity to the student or family may more easily establish the trusting, caring relationship, which is paramount for services to be effective. Finally, the stigma of mental health care may be reduced, by allowing many students to seek help and visit on their own terms in familiar territory.

Presently, the majority of students receive services at the high-intensity end of the mental health services continuum, with often only the worst cases receiving help. However, most individuals fall into the continuum in the less intense range. In a more integrated model, these students who require less intense mental health assistance may get their needs met by preventive and trickle-down processes such as educational presentations to students, school-wide programs to address pressing problems, and/or consultation on mental health issues for teachers.

Despite mandated education for all children in the least restrictive environment and more stringent requirements for school districts to provide services, inadequacies remain. At the present time, the mental health services in our nation's schools are believed to be ineffective in meeting the mental health needs of the students. Without sufficient services, students will be forced to look for help elsewhere, resulting in fewer of them receiving the help they need. Subsequent problems contribute to high drop out rates and also account for a substantial proportion of child morbidity (Werthamer-Larsson, 1994). Moreover, students may be forced to seek their own methods to meet their needs. These methods are often unhealthy ones, such as aggression, defiance, and rule breaking, social isolation and withdrawal, self-mutilation, substance abuse, and gang involvement.

By making services readily available, the appropriate level of intervention at the appropriate time will positively impact students and their families. Without available help, there is little hope for a positive outcome.

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Please note: Interested readers may request a copy of the survey instrument by contacting the author by email at mrepie@gmu.edu.

Michael S. Repie

George Mason University

Falls Church, VA

Contact Information: Michael S. Repie, Dominion Hospital, 2960 Sleepy Hollow Road, Falls Church, VA 22044, 703-531-6115, mrepie@gmu.edu

Table 1 State Frequency

State    Frequency   %     State  Frequency  %

CA        36          8.7  AL     4          1.0
NY        34          8.2  MN     4          1.0
TX        25          6.1  NE     4          1.0
FL        18          4.4  UT     4          1.0
IL        18          4.4  VA     4          1.0
OH        18          4.4  AR     3           .7
MI        17          4.1  DE     3           .7
NJ        15          3.6  HI     3           .7
PA        14          3.4  NV     3           .7
GA        13          3.1  NH     3           .7
WA        13          3.1  OR     3           .7
MO        11          2.7  RI     3           .7
NC        11          2.7  SD     3           .7
WI        11          2.7  WV     3           .7
CO         9          2.2  IA     2           .5
MA         9          2.2  KS     2           .5
TN         9          2.2  ME     2           .5
AK         8          1.9  MS     2           .5
KY         8          1.9  MT     2           .5
MD         8          1.9  OK     2           .5
SC         7          1.7  NM     1           .2
CT         6          1.5  ND     1           .2
LA         6          1.5  VT     1           .2
AZ         5          1.2  WY     1           .2
ID         5          1.2  DC     1           .2
IN         5          1.2
Total    403         97.6
Missing   10          2.4
Total    413        100.0

Table 2 Presenting Problems of Students

Problem                              n    Mean  Standard Deviation

Impaired self-esteem                 404  3.55  1.00
Attention Deficit/Hyperactivity      409  3.53   .98
Peer relationship problems           408  3.43   .99
Classroom disruptiveness             408  3.39  1.12
Worrying/anxiety/nervousness         404  3.33   .96
Depression                           404  2.98  1.03
Impulsive/dangerous behavior         407  2.90  1.20
Alcohol/drug abuse                   402  2.56  1.33
Inappropriate sexual behavior        404  2.52  1.21
Suicidal thoughts and/or behavior    402  2.40  1.09
Valid n (listwise)                   386

Table 3 Family-Based Barriers

Problem                                    n    Mean  Standard Deviation

Family stress that precludes seeking help  401  3.71  1.00
Family financial problems                  406  3.70  1.16
Poor knowledge of mental health services   403  3.54   .98
Perceived stigma                           402  3.41  1.09
Family transportation problems             405  3.17  1.16
Valid n (listwise)                         398

Table 4 Community/Clinic-Based Barriers

Problem                             n    Mean  Standard Deviation

Managed care/insurance issues       377  3.52  1.08
Long waiting lists for services     369  3.25  1.28
Not enough clinics or centers       381  3.19  1.23
Not enough services in the clinics  378  3.09  1.18
Poor management of services         371  2.84  1.03
Valid n (listwise)                  355

Table 5 Mental Health Services in Schools

                                    Available?  Should be Provided?
Service                             n    Yes %  n    M

Evaluation of problems              390  91.0   363  4.59
Consultation for teachers           383  61.6   376  4.40
Individual counseling               389  84.1   370  4.49
Group counseling                    384  77.9   368  4.35
Family counseling                   380  28.4   383  3.69
Substance abuse services            380  38.7   367  3.82
Referral for more intense services  374  63.4   364  4.14
Crisis intervention services        386  81.3   362  4.51
Educational presentations           372  51.6   375  4.20
School-wide programs                381  58.5   371  4.34

Table 6 Between Position Groups ANOVA Table

Survey Item                           df     MSE     F       p

Presenting Problems
Depression                            3,399   4.432   4.286  .005*
Suicidal thoughts/behavior            3,397   3.072   2.610  .051
Worrying/anxiety/nervousness          3,399    .714    .773  .510
Impaired self-esteem                  3,399    .265    .263  .852
Impulsive/dangerous behavior          3,402   1.185    .815  .486
Classroom disruptiveness              3,403   1.139    .911  .436
Attention deficit/hyperactivity       3,404   1.029   1.070  .362
Peer relationship problems            3,403   1.346   1.370  .251
Alcohol/drug abuse                    3,397   2.058   1.167  .322
Inappropriate sexual behavior         3,399   3.081   2.130  .096
Family-Based Barriers
Transportation problems               3,400    .298    .221  .882
Financial problems                    3,401    .820    .609  .609
Poor knowledge of services            3,398   5.028   5.429  .001*
Perceived stigma                      3,397   1.684   1.422  .236
Family stress                         3,396    .380    .380  .767
Community/Clinic-Based Barriers
Managed care/insurance issues         3,372    .200    .168  .918
Poor management of services           3,366    .863    .811  .489
Not enough clinics or centers         3,376   2.985   1.987  .115
Not enough services in clinics        3,373   1.062    .756  .519
Long waiting lists for services       3,364   8.415   5.292  .001*
Receptiveness/Support
How receptive are individuals?        3,394   5.078   5.154  .002*
How much support is there?            3,387   5.528   5.421  .001*
Mental Health Services in Schools
Evaluation of problems                3,358    .871   1.558  .199
Consultation for teachers             3,371   1.476   1.799  .147
Individual counseling services        3,365    .735   1.009  .389
Group counseling services             3,363    .777    .880  .452
Family counseling services            3,378  15.565   8.276  .000*
Substance abuse services              3,362  10.020   5.926  .001*
Referral for more intensive services  3,359   1.573   1.230  .299
Crisis intervention services          3,357   1.209   1.780  .151
Educational presentations             3,370    .711    .822  .483
School-wide programs                  3,366    .543    .762  .516
Are services effective?               3,392  10.487  10.911  .000*

*The mean difference is significant at the .01 level.

Table 7 Between School Level Groups ANOVA Table

Survey Item                           df     MSE     F       p

Presenting Problems
Depression                            5,398   3.602   3.515  .004*
Suicidal thoughts/behavior            5,396   6.465   5.761  .000*
Worrying/anxiety/nervousness          5,398   1.409   1.542  .176
Impaired self-esteem                  5,398    .350    .345  .885
Impulsive/dangerous behavior          5,401    .752    .515  .765
Classroom disruptiveness              5,402   2.614   2.117  .063
Attention deficit/hyperactivity       5,403   3.039   3.251  .007*
Peer relationship problems            5,402   2.032   2.095  .065
Alcohol/drug abuse                    5,396  56.045  52.026  .000*
Inappropriate sexual behavior         5,398  23.585  20.022  .000*
Family-Based Barriers
Transportation problems               5,399   1.256    .939  .455
Financial problems                    5,400   2.070   1.556  .171
Poor knowledge of services            5,397   1.334   1.396  .225
Perceived stigma                      5,396   1.484   1.251  .285
Family stress                         5,395    .490    .491  .783
Community/Clinic-Based Barriers
Managed care/insurance issues         5,371    .895    .759  .580
Poor management of services           5,365    .832    .780  .565
Not enough clinics or centers         5,375   2.394   1.596  .160
Not enough services in clinics        5,372   2.127   1.530  .180
Long waiting lists for services       5,363   3.414   2.111  .064
Receptiveness/Support
How receptive are individuals?        5,393    .669    .657  .656
How much support is there?            5,386   1.566   1.496  .190
Mental Health Services in Schools
Evaluation of problems                5,357    .214    .356  .878
Consultation for teachers             5,370    .819    .958  .443
Individual counseling services        5,364    .279    .363  .874
Group counseling services             5,362   1.474   1.633  .150
Family counseling services            5,377   4.910   2.524  .029
Substance abuse services              5,361  11.410   6.945  .000*
Referral for more intensive services  5,358   3.569   2.802  .017
Crisis intervention services          5,356    .625    .872  .500
Educational presentations             5,369    .391    .437  .823
School-wide programs                  5,365    .655    .885  .491
Are services effective?               5,391   1.441   1.405  .221

*The mean difference is significant at the .01 level.

Table 8 Between School Geography Groups ANOVA Table

Survey Item                           df     MSE     F       p

Presenting Problems
Depression                            2,396    .804    .758  .469
Suicidal thoughts/behavior            2,394    .385    .322  .725
Worrying/anxiety/nervousness          2,396   2.779   3.022  .050
Impaired self-esteem                  2,396    .938    .927  .397
Impulsive/dangerous behavior          2,399  11.538   8.309  .000*
Classroom disruptiveness              2,400   7.365   5.999  .003*
Attention deficit/hyperactivity       2,401   1.416   1.479  .229
Peer relationship problems            2,400   1.068   1.088  .338
Alcohol/drug abuse                    2,394   6.158   3.529  .030
Inappropriate sexual behavior         2,396   2.884   2.004  .136
Family-Based Barriers
Transportation problems               2,397  10.344   7.962  .000*
Financial problems                    2,398   2.600   1.939  .145
Poor knowledge of services            2,396    .213    .222  .801
Perceived stigma                      2,395   1.656   1.388  .251
Family stress                         2,394   3.826   3.934  .020
Community/Clinic-Based Barriers
Managed care/insurance issues         2,370    .785    .670  .512
Poor management of services           2,363    .621    .582  .559
Not enough clinics or centers         2,373   3.752   2.517  .082
Not enough services in clinics        2,370   2.492   1.791  .168
Long waiting lists for services       2,361    .195    .118  .889
Receptiveness/Support
How receptive are individuals?        2,391   3.440   3.435  .033
How much support is there?            2,384   1.262   1.194  .304
Mental Health Services in Schools
Evaluation of problems                2,355   1.761   2.995  .051
Consultation for teachers             2,368    .976   1.140  .321
Individual counseling services        2,362    .374    .486  .616
Group counseling services             2,360    .501    .544  .581
Family counseling services            2,375   7.905   4.023  .019
Substance abuse services              2,359   3.711   2.095  .125
Referral for more intensive services  2,356   3.930   3.030  .050
Crisis intervention services          2,354    .796   1.111  .330
Educational presentations             2,367    .082    .093  .911
School-wide programs                  2,363    .391    .527  .591
Are services effective?               2,389   3.581   3.516  .031

*The mean difference is significant at the .01 level.
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