AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. December 2016, Volume 18, Number 12: 1218-1224.
doi: 10.1001/journalofethics.2016.18.12.pfor1-1612.

Policy Forum

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Promoting Access to School-Based Services for Children’s Mental Health

Disparities in children’s mental health care could be addressed through expansion of school-based programs via passage of the Mental Health in Schools Act.

MaryKatherine Brueck

Abstract

Mental health issues are widespread among children, but many never receive adequate treatment. One political solution proposed to address this disparity would be to fund mental health services through school-based programs and support collaboration among community and health organizations to address the needs of children. Regardless of whether this policy is implemented, health care professionals have a responsibility to promote access to care and patient health, which may include actively participating in the development of programs to provide services to children with mental health disorders.

Introduction

According to a compilation of research studies from the Centers for Disease Control and Prevention (CDC), up to 1 in 5 children experience a mental health disorder [1]. Mental health disorders among children are described by the CDC as “serious changes in the way children typically learn, behave, or handle their emotions,” which cause distress and compromise children’s ability to function [2]. This definition encompasses a wide range of conditions, including attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, obsessive-compulsive disorder (OCD), and substance use disorders, all with varying degrees of severity [2]. Of the 20 percent of children or adolescents experiencing mental health concerns, many never receive care [3]. A study funded by the National Institute of Mental Health (NIMH) found that access to care for mental health services for youth is limited. Of those diagnosed, roughly 36 percent with mental health disorders received further treatment through counseling, medication, therapy, or other assessments [3]. That only a third of youth receive effective diagnosis and treatment is significant, inciting a call to promote better access to care.

This article reviews a particular policy reform effort that would expand support for school-based programs that offer children mental health services, making not only more services available to children in need but also more extensive and effective training for teachers and other professionals who work with them. To date, this policy change has lacked the political momentum necessary to garner federal support for passage or implementation. Following the discussion of policy reform, this article will suggest interim mechanisms that public health advocates, including local stakeholders and health care professionals, can utilize to more effectively advocate for and support children’s mental health within their communities.

Promoting Access to Care through Policy

On March 3, 2015, during the first session of the 114th United States Congress, two similar bills, both titled the Mental Health in Schools Act (MHSA) of 2015, were simultaneously introduced in the House of Representatives and the Senate to amend the Public Health Service Act (PHSA) of 1944 [4, 5]. The PHSA was signed into law to consolidate all previously existing public health laws in a comprehensive document and to establish mechanisms to provide grants for research and qualified public health efforts [6]. Acting on a public health need, the MHSA 2015 promotes access to care through an efficient model: a school-based system for the provision of mental health services. The purpose of the MHSA 2015 is to:

  1. “Revise, increase funding for, and expand the scope of [existing programming] in order to provide greater access to more comprehensive school-based mental health services and supports”;
  2. “Provide for comprehensive staff development for school and community service personnel working in the school”;
  3. Provide comprehensive training for parents, siblings, and other family members of children with mental health disorders and for “concerned members of the community,” including educators and mentors who spend considerable time with students. This training involves the introduction of techniques used to identify at-risk behaviors, understand referral mechanisms, and support a positive school environment to prevent mental health disturbances [4, 5].

The MHSA 2015 was part of a package of legislation put forward to address the severe stigmatization of and lack of resources for children’s mental health. The bills aimed to augment a program developed in 1999 called the Safe Schools-Healthy Students (SS/HS) program. The SS/HS program awards grants to qualified local education agencies (school districts) throughout the United States to fund programs to prevent violence and drug abuse and to provide behavioral, emotional, and social supports and mental health services [7]. Since its inception, the program has developed and utilized a collaborative model that shares resources with educational and health-related programs to increase services, awarding grants to more than 365 school districts in partnership with local agencies as of 2013 [7]. Between 1999 and 2013, the SS/HS program has seen a 263 percent increase in the number of students receiving school-based mental health care [8]. Although the program has been successful in its efforts, to address the large disparity of mental health resources a more effective distribution of resources is needed—a cause recognized by the sponsors of the MHSA 2015 and other advocates dedicated to bettering public health.

After its introduction in the 114th Congress, the MHSA 2015 quickly received attention and support from public health advocates. On March 25th, a letter of endorsement was sent to the bills’ sponsors with 36 signatures from national organizations, including the American Psychiatric Association, the American Academy of Pediatrics, and the American Psychological Association [9]. However, even with this support from professional organizations, public health advocates, education systems, and other community organizations who have partnered with schools—local law enforcement agencies, YMCAs, and faith-based organizations, to name a few—the act has not yet gained the political momentum it needs to be adopted [8, 10]. Since 2007, five similar versions of the MHSA have been introduced in pairs to the House and Senate, all of which, after being referred to the subcommittee on Health, expired at the end of each session of Congress within which they were introduced [10]. While the attempts have been unsuccessful to date, advocates for children’s mental health continue to recognize the immense impact that the Mental Health in Schools Act could have for the SS/HS program and other school-based health programs.

Addressing the Problem of Youth Mental Health Services through an Effective School Model

Directing resources to school-based programs for children’s mental health provides services that are timely, accessible, and efficient and that reach the largest number of children possible [11]. The MHSA would provide the support needed to implement an increased number of successful onsite programs, providing systems of early intervention through prevention, assessment, and treatment for students whose mental health concerns could otherwise become a cause of disability [12]. For children whose mental health concerns go unnoticed or untreated, especially those between the ages of 12 and 17, rates of substance abuse, depression, and suicide substantially increase, leading to other health-related problems and lower quality of life [1, 13]. Early diagnosis allows for a more targeted allocation of resources and a more effective trajectory for health care [11]. Utilizing the school environment—where children spend a significant part of their day—for early intervention brings public health efforts to the students, meeting children where they are and therefore providing more accessible services to those in need. It also provides immediate and continuing resources to students without requiring families to search for already limited sources of care [13].

The existing SS/HS program aims to expand and provide care for students who would otherwise not receive it due to a lack of diagnosis or other barriers, such as restrictions on health insurance, lack of coverage, poor quality of services, or lack of health care providers within a reasonable proximity [14]. These barriers are augmented by social stigmas against mental health, which may discourage people from pursuing treatment [14]. The SS/HS program maximizes the potential for positive results throughout childhood development by providing preventative resources, early diagnostic testing, and follow-up care in a place where students spend much of their youth [15]. By providing teachers, parents, counselors, nurses, and other key parties with the proper resources to address student health—including mental health training, assessment documents, and increased access to professionals—the SS/HS program has contributed to reducing the rate of suicide and other forms of violence and abuse for students with mental health problems [7]. Providing teachers with better instruction on how to recognize behavioral problems and how to provide quality behavioral assessments for at-risk students might assist in diagnosing and treating children’s mental health concerns by making available to appropriate professionals information about their students’ daily habits and classroom behaviors [16]. Cooperating with counselors onsite assists in mitigating the barriers to care previously described, thus minimizing costs and travel time for the student. These school-based programs are successful when community partners come together to focus efforts in a centralized location that can address the largest number of students most efficiently and effectively.

Physicians’ Role in Collaboration—Advocacy and Other Methods

The MHSA 2015 requires a community partnership to be facilitated between an education system and one community collaborator before a program is eligible to receive funding [4]. These partnerships can be formed with mental health service systems, social welfare services, or health care services, as well as individual physicians. While the systemic, multidisciplinary approach supported by the MHSA would provide quality care if successfully implemented and granted adequate funding, the promise of resources has yet to be made. Community stakeholders—including physicians—should continue to advocate for additional resources to promote access to mental health care for children while pursuing alternative routes for the provision of care.

Recognizing the immense impact of mental health disorders on children in their youth and throughout their lives, physicians have a collective responsibility to support efforts to reduce disparities in access to care. The American Medical Association Code of Ethics states, “collectively, physicians should advocate for community resources designed to promote health and provide access to preventive services” [17]. The MHSA would strengthen an already-effective program for children’s mental health, the SS/HS. However, given that the bill has not passed Congress, physicians should look to other methods outside of advocacy to proactively promote access to mental health assessments, therapy, and treatment, and to strengthen initiatives that are already in place.

For example, physicians can partner with other professional organizations to become better equipped to respond to and treat children with mental health disorders. Primary care physicians are uniquely situated when it comes to mental health, as they may be on the frontline of recognizing mental health concerns in the children they see for regular appointments without necessarily having the training or resources to effectively address these concerns [18]. Partnering with local psychiatry and psychology clinics for training can improve a primary care physician’s ability to identify mental health disorders in children. Some states have already embraced this approach. In 2005, the Massachusetts Child Psychiatry Access Project (MCPAP) was developed to provide pediatricians with access to mental health specialists who help equip physicians with the skills necessary to effectively diagnose and treat mental health disorders. This goal is achieved by educating physicians to provide timely consultation when the patient is in the office, assess and treat the patient’s needs within the scope of informed practice, and refer patients whose needs require a trained psychiatrist [19]. Although limited knowledge might be gained in this way, participating physicians can fulfill their role in promoting access to adequate health care by filling a gap in situations in which children might otherwise go without help. Acts like these, along with advocacy for and implementation of legislation like the Mental Health in Schools Act, may go a long way in narrowing the disparities in access to mental health care for children.

Conclusion

Childhood mental health disorders are a significant public health concern in the United States. Community organizations, education systems, local governments, health care institutions, and other key parties should continue to advocate for policies such as the Mental Health in Schools Act that allocate resources necessary to address the problem but should also consider utilizing other mechanisms, such as the partnership described above. Until adequate resources are gathered, individual and collective action, in the form of education and treatment, must be encouraged to initiate solutions at the community level.



References

  1. Centers for Disease Control and Prevention. Children’s mental health report. http://www.cdc.gov/features/childrensmentalhealth/. Updated July 27, 2016. Accessed August 18, 2016.
  2. Centers for Disease Control and Prevention. Children’s mental health: basics. http://www.cdc.gov/childrensmentalhealth/basics.html. Updated August 8, 2016. Accessed August 18, 2016.
  3. Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in US adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32-45.
  4. Mental Health in Schools Act of 2015, HR 1211, 114th Cong (2015). https://www.congress.gov/bill/114th-congress/house-bill/1211/all-info. Accessed August 18, 2016.
  5. Mental Health in Schools Act of 2015, S 1588, 114th Cong (2015). https://www.congress.gov/bill/114th-congress/senate-bill/1588?
    q=%7B%22search%22%3A%5B%22Mental+Health+in+Schools
    +Act%22%5D%7D&resultIndex=1. Accessed August 18, 2016.
  6. Public Health Service Act of 1944, 42 USC ch 6A (2016).
  7. Substance Abuse and Mental Health Services Administration. The Safe Schools/Healthy Students Initiative: a legacy of success. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. http://store.samhsa.gov/shin/content//SMA13-4798/SMA13-4798.pdf. Accessed September 20, 2016.
  8. Substance Abuse and Mental Health Services Administration (SAMHSA). Safe Schools/Healthy Students (SS/HS) national evaluation. http://www.samhsa.gov/safe-schools-healthy-students/national-evaluation. Updated June 8, 2015. Accessed August 18, 2016.
  9. Mental Health Liaison Group. Support for the Mental Health in Schools Act (HR 1211). Letter to the Honorable Grace F. Napolitano and the Honorable Chris Gibson, March 25, 2015. http://downloads.aap.org/DOFA/MHLG%20Mental%20Health
    %20in%20Schools%20Act%20(MHSA)%20Support%20Letter.pdf. Accessed November 1, 2016.
  10. HR 1211: Mental Health in Schools Act of 2015. https://www.govtrack.us/congress/bills/114/hr1211. Accessed October 18, 2016.
  11. Fazel M, Hoagwood K, Stephan S, Ford T. Mental health interventions in schools 1: mental health interventions in high-income countries. Lancet Psychiatry. 2014;1(5):377-387.
  12. National Institute of Mental Health. US leading categories of diseases/disorders. https://www.nimh.nih.gov/health/statistics/disability/us-leading-categories-of-diseases-disorders.shtml. Accessed October 18, 2016.
  13. O’Connell ME, Boat TF, Warner KE, eds; National Research Council; Institute of Medicine. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: National Academies Press; 2009.
  14. Murphey D, Vaughn B, Barry M. Adolescent health highlight: access to mental health care. Child Trends. 2013;2:1-5. http://www.childtrends.org/wp-content/uploads/2013/04/Child_Trends-2013_01_01_AHH_MHAccessl.pdf. Accessed November 1, 2016.
  15. Hampton T. Programs aim to help schools identify and address mental illness in children. JAMA. 2013;309(17):1761-1762.
  16. Taras HL; American Academy of Pediatrics Committee on Social Health. School-based mental health services. Pediatrics. 2004;113(6):1839-1845.
  17. American Medical Association. Opinion 8.11 Health promotion and preventive care. Code of Medical Ethics.
  18. Knapp PK. Integrating mental health care into pediatric primary care settings. J Am Acad Child Adolesc Psychiatry. 2012;51(10):982-984.
  19. Kuehn B. Pediatrician-psychiatrist partnerships expand access to mental health care. JAMA. 2011;306(14):1532-1533.

MaryKatherine Brueck is a fourth-year undergraduate at Loyola University Chicago, where she studies philosophy with a concentration in bioethics. During the summer and fall of 2016, she was an intern for the American Medical Association’s Ethics Group.

Advocacy by Physicians for Patients and for Social Change, September 2014

The AMA Code of Medical Ethics’ Opinion on Disparities in Health Care, June 2014

Psychosis Risk: What Is It and How Should We Talk About It?, June 2016

Role of Schools in Monitoring Student Health, December 2007

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.