Building an interconnected policy-training-practice-research agenda to advance school mental health.

Building an interconnected policy-training-practice-research agenda to advance school mental health. Abstract School mental health (SMH SMH Sydney Morning Herald (Australia)SMH St Michael's HospitalSMH Shaking My HeadSMH Strong Memorial HospitalSMH Sanders Morris Harris Inc.SMH Screening for Mental Health, Inc. ) programs and services have grownprogressively in the United States United States,officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. in the past two decades, related toincreased acknowledgement of their advantages and prominent federalinitiatives (e.g., No Child Left Behind Act The No Child Left Behind Act of 2001 (Public Law 107-110), commonly known as NCLB (IPA: /ˈnɪkəlbiː/), is a United States federal law that was passed in the House of Representatives on May 23, 2001 President's New FreedomInitiative; 2003). Nonetheless, SMH is an emerging and tenuouslysupported field with many issues in need of attention. In this articlenine immediate challenges to the advancement of innovative andsuccessful SMH policies and programs are highlighted. Consideredtogether, these challenges suggest a picture of current SMH programs andproviders, and their educator partners, operating under often untenablecircumstances. As the field moves forward, enhanced commitment to a truepublic mental health promotion approach provides a framework forconcrete actions to be taken to advance an interconnectedpolicy-training-practice-research agenda in school mental health. ********** The unmet mental health needs of youth have been well documented.Between 20% and 38% of youth in the United States (U.S.) need mentalhealth intervention health interventionHealth care An activity undertaken to prevent, improve, or stabilize a medical condition , and 9-13% have serious disturbances (Goodman etal., 1997; Grunbaum et al., 2004; Marsh, 2004). However, as few asone-sixth to one-third of youth with diagnosable disorders receive anytreatment, and, of those who do, far less than half receive adequatetreatment (Burns et al., 1995; Leaf et al., 1996; Weisz, 2004). Although the idea of developing a comprehensive continuum of mentalhealth supports for children in U.S. public schools dates back to theearly 20th century (Breckenride, 1917 and Hunter, 1904 as cited inFlaherty & Osher, 2003), in the past two decades a national movementbegan to take hold and school mental health (SMH) programs have grownprogressively (Flaherty & Osher, 2003). This growth has been spurredby recognition of the crisis of youth mental health, appreciation of thefact that many more youth can be reached in schools, and acknowledgementof the benefits to schools of SMH programs and services in reducingbarriers to student learning (Adelman & Taylor, 2000). The growth ofthe field also has been supported by significant federal attention (seeNational Institute of Mental Health, 2001; U.S. Department of Health andHuman Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979Health and Human Services, HHS , 1999; U.S. Public Health Service, 2000). More recently,the final report of the President's New Freedom Commission onMental Health (www.mentalhealthcommission.gov) highlighted unmet needsand barriers to care, including (among others) fragmentation and gaps incare for children and lack of a national priority for mental health andsuicide prevention Suicide prevention is an umbrella term for the collective efforts of mental health practitioners and related professionals to reduce the incidence of suicide through proactive preventive measures. (President's New Freedom Commission on MentalHealth, 2003). In its proposal for transformed mental health care inAmerica, the commission made a specific recommendation to improve andexpand school mental health programs. The 2004 American Academy ofPediatrics Policy Statement on School-Based Mental Health Services health servicesManaged care The benefits covered under a health contract (Committee on School Health, 2004) also concluded that"school-based programs offer the promise of improving access todiagnosis of and treatment for the mental health problems of childrenand adolescents" (p. 1), that they improve opportunities forcoordination of services (especially coordination with educationalprograms) and that they offer strong potential for prevention as well asintervention efforts. Schools offer unparalleled access as a point of engagement withyouth to address their interrelated in��ter��re��late?tr. & intr.v. in��ter��re��lat��ed, in��ter��re��lat��ing, in��ter��re��latesTo place in or come into mutual relationship.in academic and mental health needs(President's New Freedom Commission, 2003). In fact, studiessuggest that for the small percentage of youth who receive mental healthservices, most actually receive them within schools (Rones &Hoagwood, 2000; U.S. Department of Health and Human Services, 1999,2001). In addition to enhancing access to services for youth (Weist,Meyers, Hastings, Ghuman, & Ham, 1999), SMH can reduce the stigma ofhelp seeking (Nabors & Reynolds, 2000), promote generalization andmaintenance of treatment gains (Evans, 1999), enhance capacity forprevention and mental health promotion (Elias, Gager gag��er?n.Variant of gauger. , & Leon, 1997;Weare, 2000), foster clinical efficiency and productivity (Flaherty& Weist, 1999), and promote a natural, ecologically groundedapproach to helping children and families (Atkins, Adil, Jackson, McKay,& Bell, 2001). Further, when done well, SMH programs and services are associatedwith strong satisfaction by diverse stakeholder stakeholdern. a person having in his/her possession (holding) money or property in which he/she has no interest, right or title, awaiting the outcome of a dispute between two or more claimants to the money or property. groups (Nabors,Reynolds, & Weist, 2000), improvement in student emotional andbehavioral functioning (e.g., Armbruster & Lichtman, 1999; Nabors& Reynolds, 2000), and improvements in school outcomes such asenhanced climate, fewer inappropriate referrals into special education(Bruns, Walrath, Siegel, & Weist, 2004), and reduced bullying andschool suspensions (Sugai et al., 2000; Zins, Weissberg, Wang, &Walberg, 2004). School mental health programs also help to accomplishmany of the recommended strategies for preventing and addressing theimpacts of violence on youth (U.S. Department of Health and HumanServices, 2001) and preventing drop-out (Schargel & Smink, 2001).Importantly, SMH can play a role in enhancing student connectedness toschool which is associated with many positive dimensions of studentmotivation, behavior and academic performance (Wingspread Declaration onSchool Connections, 2004). In association with the above factors and findings, strong examplesof policy advocacy, service-delivery, and technical assistanceprioritizing SMH have developed in U.S. cities (e.g., Baltimore, Dallas,Los Angeles Los Angeles(lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. , Memphis) and states (e.g., Hawaii, Maryland, New York New York, state, United StatesNew York,Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , NewMexico New Mexico,state in the SW United States. At its northwestern corner are the so-called Four Corners, where Colorado, New Mexico, Arizona, and Utah meet at right angles; New Mexico is also bordered by Oklahoma (NE), Texas (E, S), and Mexico (S). , Ohio, South Carolina South Carolina,state of the SE United States. It is bordered by North Carolina (N), the Atlantic Ocean (SE), and Georgia (SW).Facts and FiguresArea, 31,055 sq mi (80,432 sq km). Pop. (2000) 4,012,012, a 15. ). Collaborative SMH networks and traininginitiatives also have developed at state, national and internationallevels (e.g., New Mexico School Mental Health Initiative,www.nmsmhi.org; Ohio Mental Health Network for School Success,www.units.muohio.edu/csbmhp/network.html; Center for Mental Health inSchools at UCLA UCLA University of California at Los AngelesUCLA University Center for Learning Assistance (Illinois State University)UCLA University of Carrollton, TX and Lower Addison, TX , www.smhp.psych.ucla.edu; Center for School MentalHealth Analysis and Action at the University of Maryland University of Maryland can refer to: University of Maryland, College Park, a research-extensive and flagship university; when the term "University of Maryland" is used without any qualification, it generally refers to this school ,www.csmha.umaryland.edu; Collaborative for Academic, Social andEmotional Learning, www.casel.org; IDEA Partnership, www.nasdse.org;School Mental Health Alliance, www.kidsmentalhealth.org; and theInternational Alliance for Child and Adolescent Mental Health andSchools, www.intercamhs.org). In spite of progress that has been made, SMH is an emerging andtenuously supported field, with many areas in need of furtherdevelopment and many challenges to be overcome to advance innovative andsuccessful policies and programs. Nine immediate challenges to theadvancement of innovative and successful SMH policies and programs arediscussed below. Challenges to the Advancement of School Mental Health Challenges that must be addressed include: (a) marginalization mar��gin��al��ize?tr.v. mar��gin��al��ized, mar��gin��al��iz��ing, mar��gin��al��iz��esTo relegate or confine to a lower or outer limit or edge, as of social standing. ofschool mental health; (b) implications of federalism federalism.1 In political science, see federal government.2 In U.S. history, see states' rights. federalismPolitical system that binds a group of states into a larger, noncentralized, superior state while allowing them for child-servingsystems and related school decision-making realities; (c) fundingissues; (d) service delivery capacity and prioritization of mentalhealth promotion and problem prevention; (e) training needs of educatorsand school mental health staff; (f) licensing, credentialing, andcertification issues; (g) difficulties in partnering with families andrelated challenges in meeting diverse student needs; (h) confidentialityand privacy concerns, record-keeping, and bureaucratic bu��reau��crat?n.1. An official of a bureaucracy.2. An official who is rigidly devoted to the details of administrative procedure.bu requirements; and(i) ensuring the quality of services. Marginalization of School Mental Health A vital challenge for the SMH field involves effectively answeringthe question "Why mental health programs and services inschools?" For example, school leaders might explicitly resist anagenda to expand attention to mental health issues in schools, based ona conviction that schools are not in "the mental healthbusiness" and/or concern that schools will need to assume excessiveresponsibility for students' emotional and behavioral problems.Further, stigma and poor understanding of mental health issues clearlyserve to mitigate against progress in the field. School mental healthstaff (e.g., social workers, psychologists, counselors) and programshistorically have been viewed as "add-ons" that are notcentral to the academic mission of schools (see Paternite &Johnston, 2005; School Mental Health Alliance, 2005; Sedlak, 1997). Inaddition, school reforms generally have not incorporated a focus onaddressing non-cognitive barriers to development, learning, and teaching(Burke, 2002; Koller & Svoboda, 2002). These non-cognitive barriersinclude environmental/contextual factors (e.g., poor nutrition, familyconflict, negative peer influences, exposure to violence, neglect, etc.)as well as individual biological and psychological factors (e.g.,externalizing and internalizing mental health problems, traumareactions, etc.). Although school policy makers and reformersacknowledge that academic success promotes well-being, they do not oftenacknowledge that, in turn, well-being promotes academic success (Klern& Connell, 2004). This failure is reflected in the schoolbuilding-level and district-level "report card" indicatorsthat state departments of education employ to monitor federally-mandated"Adequate Yearly Progress Adequate Yearly Progress, or AYP, is a measurement defined by the United States federal No Child Left Behind Act that allows the U.S. Department of Education to determine how every public school and school district in the country is performing academically. " (AYP AYP Adequate Yearly Progress (National Assessment of Educational Progress)AYP Anarchist Yellow PagesAYP American Youth Philharmonic ) in fulfillment of the NoChild Left Behind requirements. These indicators reflect a nearexclusive focus on proficiency test proficiency testn → prueba de capacitaci��nperformance, attendance, andgraduation rate (Education Week, 2005). Arguably ar��gu��a��ble?adj.1. Open to argument: an arguable question, still unresolved.2. That can be argued plausibly; defensible in argument: three arguable points of law. , the school success ofmany students would be enhanced if assessment of AYP focused moredirectly and adequately on social, emotional, and behavioral conditions(barriers), and other important mediators of academic achievement(Honig, Kahne, & McLaughlin, 2001; Zins et al., 2004). Implications of Federalism for Child-Serving Systems and RelatedSchool Decision-Making Realities Federalism (states' rights, local control), which is ahallmark of governance in the U.S. (Hermann & Rollins, 2003), setsan important policy context for the SMH field. Related to federalism,there is notable variability in how child-serving systems (includingeducation and mental health) function both across and within states (seeWeist, Paternite, & Adelsheim, 2005). Because states and localcommunities have significant latitude in decisions about policy andpractice, the extent, type, and quality of services that are offeredvary tremendously. For example, one community in a state mightdemonstrate relatively advanced progress in SMH with a neighboring neigh��bor?n.1. One who lives near or next to another.2. A person, place, or thing adjacent to or located near another.3. A fellow human.4. Used as a form of familiar address.v. community showing no progress, with no dialogue or collaboration betweenthese communities. The significant variability in policies and practicesacross child-serving systems within and between localities contributesto inertia in local and state governments in advancing reforms andimprovements in these systems. Organization of state level initiativesthat reform and improve child-serving systems (described in more detaillater) is an important strategy to address existing variability in SMHpolicy and practice. Three major characteristics of school systems in the U.S. compoundthe challenges noted above. First, U.S. public schools are characterizedby substantial organizational fluidity associated with high rates ofmobility and turnover among administrators, teachers, and other schoolpersonnel (Guarino, Santibanez, Daley, & Brewer, 2004). Second,school district and building policies and practices are quite fluid andhighly reactive to shifting policy and programming realities associatedwith the No Child Left Behind mandate. Personnel changes and shiftingmandate-driven pressures necessitate repeated revisiting of agreementsmade between SMH programs and host schools and ongoing advocacy tosustain established relationships. Third, within most school districts,decentralized de��cen��tral��ize?v. de��cen��tral��ized, de��cen��tral��iz��ing, de��cen��tral��iz��esv.tr.1. To distribute the administrative functions or powers of (a central authority) among several local authorities. decision-making is the norm. In this site-based managementapproach, substantial decision-making authority is delegated from schoolboards and superintendents to individual school building principals andpersonnel. While such site-based decision-making reflects current bestpractice in the field of education, there are clear practicalimplications and challenges for SMH programs. Specifically, workingagreements regarding roles, functions, and communication between mentalhealth staff coming into schools and school personnel typically need tobe negotiated and maintained building by building. Funding Issues Realities associated with marginalization, federalism, andcharacteristics of schools in turn contribute to significant challengesin securing and sustaining funding for SMH programs and services. Manypotential funding sources for SMH (e.g., from the Early, PeriodicScreening, Diagnosis and Treatment [EPSDT EPSDT Early and Periodic Screening, Diagnosis, and Treatment ] mechanism of Medicaid, Safeand Drug Free Schools, Title I) are underutilized, and other sources offunding (e.g., Medicaid fee-for-service) are highly bureaucratic andcumbersome (Evans et al., 2003). Related to these factors, fundingprovided by education systems for mental health practices in schools islimited, leading to over-burdened school-employed mental healthprofessionals. When community mental health mechanisms (e.g., Medicaidfee-for-service) are used, they typically place significantadministrative burdens on community providers who work in schools, whoalso are over-burdened. Within SMH programs, funding for prevention andschool-wide mental health promotion initiatives is particularly limited(Calfee, 2004). If such funding challenges are to be overcome, it isincumbent upon SMH proponents to do a better job in making the case forthe value of SMH programs and services in addressing the interrelatedacademic and mental health needs of students. Service Delivery Capacity and Prioritization of Mental HealthPromotion and Problem Prevention School mental health programs also often struggle with insufficientcapacity to meet needs of students. Typically, SMH providers contendwith a flood of referrals for students with serious problems andcrises--far exceeding the available staffing to address the need (seeWeist, 1997). In turn, these SMH providers are unable to prioritizepreventive interventions and mental health promotion efforts. Ingeneral, efforts to improve school environments (Atkins et al., 2001),broadly promote student mental health (e.g., through life skillscurricula; see Botvin, 2000), proactively support and encourage positivestudent behavior (e.g., through Positive Behavior Intervention andSupport; see Horner & Sugai, 2000), and implement a range ofprevention and early intervention ear��ly interventionn. Abbr. EIA process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. efforts in schools are limited (seeWeare, 2000). These represent critical need areas for the SMH field,consistent with the "transformation" called for by thePresident's New Freedom Commission on Mental Health (2003), withmany lessons in mental health promotion and problem prevention to belearned from other countries (Rowling & Weist, 2004). These problems in SMH reflect the generally poor capacity of thechild and adolescent mental health field in the U.S. (New FreedomCommission, 2003; U.S. Department of Health and Human Services, 1999;U.S. Public Health Service, 2000). Unfortunately, the capacity problemin SMH has contributed to reluctance of schools and collaboratingcommunity partners to initiate systematic mental health screening foryouth, which not only would improve much needed early identification andintervention efforts (New Freedom Commission, 2003), but also wouldassist in the development of compelling data-driven local communitysupport for advocacy and action to address urgent youth mental healthneeds and to promote the mental health of all youth (Center for SchoolMental Health Assistance [CSMHA], 2004). This service delivery capacityproblem, and its solution, are quite obviously related to themarginization and funding issues discussed above. Training Needs of Educators and School Mental Health Staff In general, in spite of the significant day-to-day role they playin promoting student mental health, teachers have not been trainedadequately and typically are not supported for this role (Collaborativefor Academic, Social, and Emotional Learning [CASEL], 2003). Forexample, in the second author's home county 1,179 classroomteachers completed a detailed Classroom Teacher Survey (Piland, 1999).Approximately 70% indicated that their pre-service college courses didnot address mental health issues in the classroom. Virtually all of them(97%) thought that they should be involved in some way in helpingstudents deal with their mental health problems, and 70% expressed aninterest in additional training about mental health issues (Paternite,2004). In a focus group and key informant interview study with schoolpersonnel in the same geographic region, Perez (2002) reported consensusamong school staff that they have insufficient knowledge about mentalhealth issues and that they have a strong interest in additionaltraining and resource materials. Participants also prioritized a highneed for more personnel who are available in schools on a daily basis toassist in dealing with crises, and they expressed enthusiastic supportfor SMH clinicians and expanded prevention programs. Such data indicatean urgent need to enhance educator pre-service and in-service training,based on careful analysis of issues confronted in the classroom and inthe school (Paternite & Johnston, 2005). Similar to the trainingneeds of educators, there is a significant need to enhance thepre-service and in-service training of mental health professionalscoming from the community to better prepare them to engage witheducators and to function effectively in and with schools. We have emphasized (e.g., Weist, 2003) that school-employed mentalhealth professionals such as school psychologists, social workers andcounselors (and specially trained nurses and educators) are the logicalleaders in the work of expanding and improving SMH services in a schoolbuilding. This is related to the knowledge of these staff on deliveringmental health services within the culture of schools and theirestablished relationships and connections in the school. However, thereare important and currently inadequately addressed needs related totraining and role re-definition for these staff. These needs arebeginning to be addressed in some training programs in schoolpsychology, social work, and counseling which are enhancing roles ofthese mental health professionals in the delivery of mental healthpromotion and intervention, and assisting them in expanding their scopeof work beyond traditional boundaries (e.g., in assessment, crisisresponse and academic advisement Deliberation; consultation.A court takes a case under advisement after it has heard the arguments made by the counsel of opposing sides in the lawsuit but before it renders its decision. ADVISEMENT. ; see Power, DuPaul, Shapiro, &Kazak, 2003; Rappoport, Osher, Garrison, Anderson-Ketchmark, &Dwyer, 2003). For mental health staff not employed by schools, in bothpre-service and in-service education there are needs to extract themfrom their entrenchment in "traditional" approaches to servicedelivery. In this regard, movements are encouraging within fields suchas clinical and counseling psychology Counseling psychology as a psychological specialty facilitates personal and interpersonal functioning across the life span with a focus on emotional, social, vocational, educational, health-related, developmental, and organizational concerns. , child and adolescent psychiatry A branch of psychiatry that specialises in work with children, teenagers, and their families. HistoryAn important antecedent to the specialty of child psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with ,and clinical social work, to empower mental health staff to shiftactivities out of underused offices and to teach them how to functionmore collaboratively and effectively as members of the school community(see Paternite & Johnston, 2005; Weist et al., 2005). A critical need for the field is for true interdisciplinarytraining, where staff from these mental health disciplines (school andcommunity employed) are training together and with educators, bothbefore and after beginning their professional service (Waxman, Weist,& Benson, 1999; Weist, Ambrose, & Lewis 2006). Unfortunately,this remains an area with almost no examples to build from. Licensing, Credentialing, and Certification Issues School mental health professionals from diverse disciplines areconfronting challenges related to standards for practice (Adelsheim,2004). For example, school psychologists and school social workerstypically receive certification to practice in schools, whereas clinicaland counseling psychologists and clinical social workers receivelicenses to practice in the community. In general, certification andlicensure standards for different professions are not well integrated,and there are ambiguities in practice standards. An example is communityproviders practicing in schools under their professional licenses whichdo not assure adequate training to work in school settings (seeRappaport et al., 2003; Waxman et al., 1999). In addition, consistentwith the above discussion, distinctions among various child andadolescent mental health disciplines are becoming increasingly blurred.For example, school psychologists are being licensed and are practicingin community settings; clinical and counseling psychologists are workingin schools; and all child psychology disciplines are increasinglyinvolved in case management and outreach in the community, historicallythe domain of social work (see Flaherty et al., 1998; Weist et al., inpress). Intensified discussion of these important issues is warranted.For example, a national workgroup of leaders from multiple "schoolmental health disciplines" could develop recommendations fornegotiating confusing certification and licensure standards and forcredentialing for effective practice in the interdisciplinary SMHenvironment. Difficulties in Partnering With Families and Related Challenges inMeeting Diverse Student Needs Challenges in ensuring meaningful family participation in mentalhealth services for children are not necessarily resolved by offeringservices in schools. Access to services is enhanced for youth in SMH.However, access might not be enhanced for family members, depending on anumber of factors (e.g., parental attitudes toward the school,employment constraints, etc.). Without concerted efforts to engagefamilies it is quite easy for SMH providers to replicate the practice ofchild community mental health for which there is too often limitedfamily participation (Axelrod et al., 2004). Such practice isinconsistent with findings documenting the importance of familyparticipation for maximing the likelihood of successful intervention(Lowie, Lever, Ambrose, Tager, & Hill, 2003; Mease & Sexton sex��ton?n.An employee or officer of a church who is responsible for the care and upkeep of church property and sometimes for ringing bells and digging graves. ,2004; U.S. Department of Education, Office of Special EducationPrograms, 2002). Schools and SMH programs also struggle to meet the diverse needs ofincreasingly diverse student bodies. These pressures have beenformalized for��mal��ize?tr.v. for��mal��ized, for��mal��iz��ing, for��mal��iz��es1. To give a definite form or shape to.2. a. To make formal.b. in the mandates of No Child Left Behind, which indicates thatall schools and school systems must analyze and report on studentperformance for eight "cultural" groups: American Indian,Asian, African American African AmericanMulticulture A person having origins in any of the black racial groups of Africa.See Race. , White, Hispanic, Economically Disadvantaged,Students with Disabilities, and English Language English language,member of the West Germanic group of the Germanic subfamily of the Indo-European family of languages (see Germanic languages). Spoken by about 470 million people throughout the world, English is the official language of about 45 nations. Learners. To avoiddesignation as "failing," schools must promote comparableachievement across these groups. If disproportional dis��pro��por��tion��al?adj.Disproportionate.dispro��por achievement isidentified, appropriate remedial actions must be implemented, includingthe redistribution of resources. This challenge underscores the value ofSMH in implementing effective and culturally competent services toreduce barriers to learning for diverse student cultural groups. Thechallenge also highlights significant policy and training needs toenhance the cultural competence cultural competenceSocial medicine The ability to understand, appreciate, and interact with persons from cultures and/or belief systems other than one's own of SMH programs and services, a focusthat is currently quite limited. Culturally competent mental health carein schools pertains not only to diverse racial/ethnic groups but also tostudents presenting with vulnerabilities related to recent immigration immigration,entrance of a person (an alien) into a new country for the purpose of establishing permanent residence. Motives for immigration, like those for migration generally, are often economic, although religious or political factors may be very important. (Aponte & Bracco, 2000), and chronic illness and disablingconditions (Schaeffer, Weist, & McGrath, 2003). Confidentiality and Privacy Concerns, Record Keeping, andBureaucratic Requirements Unique confidentiality and privacy concerns must be addressed inSMH programs and services (Prodente, Sander, & Weist, 2002).Community mental health staff are accustomed to stringent protectionsinvolving informed consent, confidentiality and release of clientinformation, and adherence to the mandates of the Health InsurancePortability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996.According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when (HIPAA). School health and educationstaff typically are accustomed to more free-flowing communication andmight not know about or work within HIPAA guidelines. Legal mandatesdictated by the Family Education Rights Privacy Act (FERPA FERPA Family Educational Rights and Privacy Act (aka the Buckley Amendment)FERPA F��d��ration Europ��enne des Retrait��s et des Personnes Ag��es (French)) governschool information sharing See data conferencing. . Negotiating release and exchange ofinformation about students between community mental health staff inschools and school staff can be a particular challenge, especiallyrelated to the HIPAA-FERPA interface (Acosta, Tashman, Prodente, &Proescher, 2002). In addition, securing consistently available,comfortable, and private space in school buildings for confidentialinteractions typically is a significant challenge for all SMH staff,whether employed by the school or a by a community agency. There also are ambiguities in record keeping and other relevantregulations and practices for SMH programs and staff. Reflective ofdifferences between HIPAA and FERPA regulations, there are differencesin the way mental health service records typically are kept by agencies,compared to educational records in schools. In addition, federal andstate standards for providing mental health services to youth throughcommunity mental health centers (CMHCs) might or might not apply to SMHprograms. Some SMH programs operate outside of the purview The part of a statute or a law that delineates its purpose and scope.Purview refers to the enacting part of a statute. It generally begins with the words be it enacted and continues as far as the repealing clause. of CMHC CMHCcommunity mental health center. standards. These often are grant and contract-funded programs, some ofwhich are affiliated with graduate training programs in various mentalhealth fields, and they typically do not bill for services, whichusually requires status as a licensed CMHC (Lever, Stephan, Axelrod,& Weist, 2004). In addition to the lost potential revenue throughreimbursement, these programs also operate with a heightened degree ofrisk and liability if they are not affiliated formally with a mentalhealth or educational system. Alternatively, other SMH programs operateunder the auspices of a CMHC and bill for services. Such billing, whichrequires considerable (and often inadequately provided) administrativesupport, can dramatically shape the focus of the program and servicestoward treatment of individuals with established diagnoses and away fromimportant preventive and mental health promotion services whichtypically are "non-billable" (e.g., school and classroomclimate interventions, participation on school teams and committees,consultation with teachers, attendance at IEPs, in-servicepresentations) (Lever et al., 2004). This problem is exacerbated by thefact that CMHC standards for outpatient therapy are based on traditionalindividual, intrapsychic intrapsychic/in��tra��psy��chic/ (-si��kik) arising, occurring, or situated within the mind. in��tra��psy��chicadj.Existing or taking place within the mind or psyche. models for intervention with youth--wellarticulated standards for more flexible and contextually drivenintervention and prevention services that should characterize the SMHfield have not been developed (Evans et al., 2003). Ensuring Quality of Services Well-coordinated infrastructure to ensure a full continuum ofmental health practices in schools usually is lacking, resulting in afragmented and ineffective approach (Adelman & Taylor, 1999). Inaddition, there are significant training needs to ensure coordination ofefforts, interdisciplinary practice, family-educator-mental healthcollaboration and delivery of effective services (Power et al., 2003;Rappoport et al., 2003). Contemporary child and adolescent mental healthand educational professional literatures emphasize the importance ofevidence-based practices. However, in reality, mental health andeducation staff receive minimal if any training in these practices, andgenerally they do not receive ongoing training, technical assistance,and support to sustain their implementation (Graczyk, Domitrovich, &Zins, 2003). Similarly, research and practice in quality assessment andimprovement (QAI QAI Quality Assurance InternationalQAI Quality Assurance Institute (Orlando, Florida)QAI Quality Assurance InspectionQAI Quality Auditing InstituteQAI Quantitative Analytics Inc.QAI Quality Assurance Instructions ) is limited in the child and adolescent mental healthfield, and especially within SMH (see Leatherman & McCarthy, 2004;Weist et al., 2002). Descriptions of QAI approaches in the professionalliterature tend to focus on bureaucratic processes (e.g., credentialing,paperwork requirements) and/or liability protection (e.g., proceduresfor handling crises; Weist et al., 2002). However, in recent years QAI in SMH has received increasedattention. Numerous dimensions of quality have been articulated,including: (a) amount and quality of stakeholder input in programdevelopment, implementation, and evaluation; (b) extent of collaborativerelations among families, school staff and community providers; (c)range of preventive and treatment services provided; (d) productivity ofstaff; (e) extent and quality of training and supervision of staff; (f)strategies used to coordinate services and avoid duplication; (g) use ofempirically supported interventions; (h) use of appropriate evaluationstrategies; (i) use of evaluation findings to continuously improveprograms and services; and (j) extent of awareness of and support forschool mental health efforts (see Ambrose, Weist, Schaeffer, Nabors,& Hill, 2002; Evans, Sapia, Axelrod, & Glomb, 2002; Nabors,Lehmkuhl, & Weist, 2003). The Way Forward The above challenges suggest a picture of SMH programs andproviders, and their educator partners, operating in stressfulenvironments characterized by many conflicting agendas, in demandingpositions with unrealistic workloads, and with insufficient training,support and ongoing technical assistance to function effectively. Inthis context, it is not surprising that SMH programs have struggled toconsistently document impacts on outcomes valued by families, schoolsand communities. That is, services easily can be stretched too thin,contributing to weakened impacts. This problem is consistent withdifficulties faced by child and adolescent mental health therapists ingeneral, who struggle in everyday practice to deliver outcomes of themagnitude reported by providers working within the context of awell-supported, well-resourced research grant (Weisz, 2004). In school mental health, there is a need for a substantialinterconnected policy-training-practice-research agenda tosystematically advance school mental health, with key elements describedhere (also see Kratochwill, Albers, & Shernoff, 2004). Althoughthere are many steps to get to this point (see Lever et al., 2003), webegin with a community showing a commitment to and broadly involved inadvancing the full continuum (from broad mental health promotion anduniversal prevention to intensive intervention) of effective SMHpractices (see Wandersman, 2003). From this point, the development of asystematic quality assessment and improvement (QAI) agenda isimperative. The QAI agenda should emphasize collaboration at allpossible levels (e.g., between all mental health staff and with youthand families, educators, school leaders), evidence-based practices,developmental and cultural competence, ongoing evaluation, andcontinuous quality improvement. School mental health practice should besupported with strong training, technical assistance, pragmatic ongoingsupport (e.g., updated files of assessment measures and resourcematerials) and high quality ongoing supervision and on-site coaching(see Graczyk et al., 2003). With these factors in place, the likelihoodof achieving positive outcomes is increased, with outcome findings inturn fueling advocacy and policy improvement agendas. Advocacy andpolicy enhancement in turn leads to increased resources, which arestrategically applied to expand and improve the quality of services,leading to a positive "snowballing SnowballingUsed in the context of general equities. Process by which the exercise of stop orders in a declining or advancing market causes further downward or upward pressure on prices, thus triggering more stop orders and more price pressure, and so on. " process of growth andimprovement of services in schools across the community and beyond (seePaternite, Weist, Burke, & Flaspohler, 2005). These key elementsreflect SMH as a cornerstone in the development of a public mentalhealth promotion system in the U.S., emphasizing more preventiveservices for children and youth "where they are" andconsistent with experiences occurring in other nations (see Rowling& Weist, 2004; Weist, in press). However, while movement toward this vision of public mental healthpromotion has been called for by the Surgeon General The U.S. Surgeon General is charged with the protection and advancement of health in the United States. Since the 1960s the surgeon general has become a highly visible federal public health official, speaking out against known health risks such as tobacco use, and promoting disease (U.S. Department ofHealth and Human Services, 1999, 2000) and more recently by thePresident's New Freedom Commission on Mental Health (2003), thereality in most schools and communities in the U.S. is very far from thevision. In a recent report to the Institute of Medicine (Weist,Paternite, & Adelsheim, 2005), we offered a number ofrecommendations to help bridge this vision-reality gap: Strong federal and national support of SMH Strong federal and national support of SMH should build on currentinitiatives. For example, as noted above, the final report of the NewFreedom Commission on Mental Health (2003), outlined a set ofrecommendations for transforming mental health care in the U.S. and madean explicit recommendation to "improve and expand school mentalhealth programs" (recommendation 4.2). This report, the firstpresidential report on mental health in 30 years, offers sanction,credibility and authority to state and local planning efforts, based onfederal consensus developed by many national experts and endorsed by thePresident (CSMHA, 2004). However, the onus is on state and local leadersto publicize and advocate for implementation of the recommendations ofthe report and to utilize them to advance the cause of SMH (Hogan,2003). There also are many related national initiatives (e.g.,Schools/Healthy Students, Child and Adolescent Service System, andCoordinated School Health programs) and resources (e.g., nationaltraining, technical assistance and policy dissemination efforts) thatcan be marshalled to support state and local efforts. Organized State Level Initiatives for SMH Around the country, through federal and other support, strongstate-level initiatives for SMH are emerging (e.g., in Hawaii, Maryland,Ohio, New Mexico, New York, South Carolina). These initiatives arestriving to be broadly inclusive, reflecting the engagement of families,schools, the mental health, child welfare and juvenile justice systems,and other key stakeholders. They have common commitments to: (a)advancement of SMH as a part of broader efforts to develop systems ofcare and to partner with schools to address the essential links betweenmental health and school success; (b) statewide and regional training,technical assistance and support to improve and expand services thatreach down to community and school building levels; (c) a strong focuson public awareness and involvement; and (d) strong policy andlegislative advocacy. It also is critical that such state-levelinitiatives work to infuse in��fusev.1. To steep or soak without boiling in order to extract soluble elements or active principles.2. To introduce a solution into the body through a vein for therapeutic purposes. knowledge about effective practice into everyday service delivery. In this regard, the work of key opinion leaders isessential, through their efforts to champion effective practices anddissuade TO DISSUADE, crim. law. To induce a person not to do an act. 2. To dissuade a witness from giving evidence against a person indicted, is an indictable offence at common law. Hawk. B. 1, c. 2 1, s. 1 5. against the continuation of ineffective practices. Strong Local Leadership for School Mental Health Strong local leadership in communities that brings togetherfamilies, schools and staff from other child-serving systems(particularly mental health) is essential (Wandersman, 2003). Suchleadership should advocate for movement toward a full continuum ofeffective school-wide mental health promotion, problem prevention, earlyintervention, assessment and treatment, for all youth in schoolsincluding those in general and special education (Weist, 1997).Strategies for enhancing public awareness and actively engaging thepublic in planning (e.g., through relationships with multiple media) areessential (Clauss-Ehlers & Weist, 2002). A true commitment to aninterdisciplinary approach (with families considered a discipline) alsois critically important at the local level, includinguniversity--community partnerships and well supported efforts togenuinely bridge research and practice. Active, Ongoing Communication and Linkage Across Local, State andFederal/National Initiatives States have an essential organizing role in ensuring effectivefederal-state-local communication and linkage, because they oftenmediate federal/national funding, resources, and information tolocalities. Much of the progress in SMH over the past two decades hasrelated to effective networking across localities and states, andsharing lessons learned about best practices (Lever et al., 2003).Organization of initiatives for SMH at the state level facilitates suchinformation-sharing and helps to address local community and state levelisolation from valuable information about innovations and effectivepractices. Such isolation is one of the most serious negativeimplications of federalism. Conclusion Although the idea of developing a comprehensive continuum of mentalhealth supports for children in U.S. public schools dates back to theearly 20th century (Breckenride, 1917; Hunter, 1904; as cited inFlaherty & Osher, 2003), it was not until the late 20th century thata national movement began to take hold (see Robinson, 2004; Weist,Evans, & Lever, 2003). Currently, SMH programs and services arereceiving considerable attention; are being emphasized in historicnational initiatives (e.g., New Freedom Initiative, No Child Left BehindAct); are the focus of growing and increasingly integrated nationalcoalitions; and are being supported by the voices of family, school, andcommunity stakeholders throughout the country. In spite of thisrecognition, there is a disconnect between what we know would be helpfulto improve and expand SMH programs and services and what actually ishappening in most school buildings in the U.S. Moving toward a truepublic mental health promotion approach, building from major policyinitiatives such as the President's New Freedom Initiative (2003),and pursuing an interconnected policy-training-practice-research agenda,with states as the key change agents, is in our view the way forward. Acknowledgments 1 Based on a report: Weist, M.D., Paternite, C.E., & Adelsheim,S. (2005). School-Based Mental Health Services, submitted to theInstitute of Medicine, Board on Health Care Services, Crossing theQuality Chasm: Adaptation to Mental Health and Addictive Disorders Addictive disordersAddictive disease disorders are characterized by the chronic use of a drug (such as heroin, cocaine, or amphetamines), alcohol, or similar substances. Committee 2 Supported by cooperative agreement U45 MC 00174-10-0 from theOffice of Adolescent Health, Maternal and Child Health Bureau (Title V,Social Security Act), Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency within the United States Department of Health and Human Services whose goal is to improve access to health care for those without insurance. , withco-funding by the Center for Mental Health Services For the California public school, see .The Center for Mental Health Services (CMHS) is a unit of the Substance Abuse and Mental Health Services Administration (SAMHSA) witin the U.S. Department of Health and Human Services.US government-supported group. , Substance Abuse andMental Health Services Administration The Substance Abuse and Mental Health Services Administration (SAMHSA), an operating division of the Health and Human Services Department (HHS), was established in 1992 by the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Pub. L. No. 102-321). . Also supported by grant1R01MH71015-01A1 from the National Institute of Mental Health. 3 Supported in part by the Ohio Department of Education(project#062984-6B-PB-05P). Thanks are extended to Elizabeth Moore forher significant assistance in developing this article. References Acosta, O. M., Tashman, N. A., Prodente, C., & Proescher, E.(2002). Implementing Successful school mental health programs:Guidelines and recommendations. In H. S. Ghuman, M. D. Weist, & R.Sarles (Eds.), Providing mental health services to youth where they are:School- and other community-based approaches (pp. 57-74). New York:Brunner-Routledge. Adelman, H. S., & Taylor, L. (1999). Mental health in schoolsand system restructuring. Clinical Psychology Review, 19, 137-163. Adelman, H. S., & Taylor, L. (2000). 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New York: CambridgeUniversity Press Cambridge University Press (known colloquially as CUP) is a publisher given a Royal Charter by Henry VIII in 1534, and one of the two privileged presses (the other being Oxford University Press). . Wingspread Declaration on School Connections (2004). Journal ofSchool Health, 74, 233-234. Zins, J. E., Weissberg, R. P., Wang, M. C., & Walberg, H. J.(Eds.). (2004). Building academic success on social and emotionallearning: What does the research say? New York: Teachers College Press. Mark D. Weist (2) Division of Child and Adolescent Psychiatry, University of MarylandSchool of Medicine Carl E. Paternite (3) Department of Psychology, Miami University Miami University,main campus at Oxford, Ohio; coeducational; state supported; chartered 1809, opened 1824. The library has extensive collections in literature and American history, including the William Holmes McGuffey Library and Museum and the Edgar W. (Ohio) Correspondence: Mark D. Weist, Ph.D., Division of Child andAdolescent Psychiatry, Center for School Mental Health Analysis andAction, University of Maryland School of Medicine, 737 West LombardStreet Lombard Street,in London, England. It is a street of banks and financial houses that takes its name from the Lombard merchants and moneylenders who settled there in the 13th cent. , 4th Floor, Baltimore, MD 21201. E-mail:mweist@psych.umaryland.edu.