Transforming Mental Health Care:
A Focus on the Schools
Larke Nahme Huang, Ph.D.
American Institutes for Research
9th Annual Conference on
Advancing School-Based Mental Health
Dallas, Texas
October 8, 2004
President’s New Freedom
Commission on Mental Health
The Mission
Conduct a comprehensive study of the U.S.
mental health service delivery system and
recommend improvements to the President.
President’s New Freedom
Commission on Mental Health
Charge
“ The Commission …shall…recommend
improvements to enable adults with
serious mental illnesses and children
with severe emotional disturbances to
live, work, learn, and participate fully in
their communities.”
About the Commission
 15 Commissioners
 Public, private; payers, providers, consumers, family
members, policy makers, researchers
 7 Federal Ex officio members:
 Labor, Education, Veterans Affairs, HUD
 CMS, SAMHSA, NIMH,
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Monthly meetings
Site Visits,Testimony and Town Hall meetings
Research Review/Consultants
Website Responses – content analysis
15 Subcommittees
15 Working Subcommittees
Acute Care
Children and Families
Consumer Issues
Co-occurring Disorders
Criminal Justice
Cultural Competence
Employment & Income
Support
 Evidence-based Practice
& Medication Issues
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 Housing and
Homelessness
 Medicare/Medicaid
 Mental Health Interface
with General Medicine
 Older Adults
 Rights and Engagement
 Rural Issues
 Suicide Prevention
Analysis of Federal Funding
Streams
President’s New Freedom
Commission on Mental Health
Interim Report, October 2002
“The mental health delivery system is fragmented
and in disarray – not from lack of commitment
and skill of those who deliver care, but from
underlying structural, financing, and
organizational problems… The system’s
failings lead to unnecessary and costly
disability, homelessness, school failure, and
incarceration.”
Selected Findings:
A Public Health Crisis in Mental Health
 20% adults/children have a mental health problem
 ½ have a serious emotional disorder
 20 million suffer from serious disabling mental illness
 Suicide: ~30,000 a year [80/day]
 ~40% had contact with primary care provider within the last
month
 Adolescents 15-19y/o: 3rd leading cause of death; 17-19%
think about killing themselves; 5-8% make attempt; only 1/3
get treatment
YET,
 Only half of individuals with serious mental illness get treatment,
services or supports
Scope of MH Needs of Youth
 “By the year 2020, childhood neuropsychiatric
disorders will rise by over 50% internationally
to become one of the five most common
causes of morbidity, mortality, and disability
among children… no other illnesses damage
so many children so seriously.”
World Health Organization, 2002
Presenting Problems of Youth
Admitted to MH Services: 1997
50%
46%
44%
41%
24%
20%
16%
16%
13%
11%
Update, www.ihhcpar.rutgers.edu, 2002
Selected Findings for Children
 Of children with serious emotional/behavioral
disorders: ~50% drop-out of high school (compared to
30% of students with other disabilities) (Dept of Education)
 Youth entering Juvenile Justice: ~66-75% have serious
emotional problems (Coalition on Juvenile Justice; Teplin)
 ~500,000 children in foster care: estimates up to 85%
have emotional/behavioral and/or substance abuse
problem; 44% < 5 yrs old (The AFCARS Report: Preliminary FY 2001
Estimates as of March 2003. Washington, D.C., DHHS, 2003. ( latest federal statistics on
foster care supplied by the states for the Adoption and Foster Care Analysis and Reporting
System; Zero to Three)
 1/3 children in mental health system have a cooccurring disorder (~age 11; ~age 17-18 SA)
Disparities for Children of Diverse
Racial and Ethnic Groups
 Black and Latino kids identified/referred at same rates as
general population, but less likely to receive specialty mental
health or meds (Kelleher, 2000)
 Minority children tend to receive mental health services through
juvenile justice and child welfare systems more often than
through schools or mental health setting (Alegria, 2000)
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African American and Latino children have highest rates of unmet need
(Sturm, 2000)
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Asian American and Latino female teens have highest rates of
depression (Commonwealth Fund, 1997)
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In child welfare, minority youth have poorer outcomes, fewer services,
less likely to have plans for family contact and more likely to be in outof-home placements (Courtney et al, 1996).
Rural Disparities
 Rates of mental disorders are similar between rural
and urban youth, although limited sampling in rural
America
 Exception: Rural adolescents have higher rate of
suicide than urban counterparts
 Significantly higher rate among Native American youth
 Child poverty higher in rural areas; children of color atrisk with 46% African American, 43% Native American
and 41% Hispanic rural children in poverty
President’s New Freedom
Commission on Mental Health
Final Report
Achieving the Promise:
Transforming Mental Health Care in America
“ We envision a future when everyone with a
mental illness will recover, a future when
mental illness can be prevented or cured, a
future when mental illnesses are detected
early, and a future when everyone with a
mental illness at any stage of life has access to
effective treatment and supports-essentials for
living, working, learning, and participating fully
in the community.”
Principles Underlying
Transformation
Services and treatments that –
 Are consumer and family-driven, not
focused primarily on the demands of
bureaucracies
 Provide real and meaningful choice of
treatments, services and supports –
and providers
 Engage consumers, families, youth
Principles Underlying
Transformation
Care is focused on:
 Promoting consumers’ and family’s ability
to manage life’s challenges successfully
 Facilitating recovery
 Building resilience, not just managing
symptoms
President’s New Freedom
Commission on Mental Health
Goals of a Transformed System:
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Americans Understand that Mental Health is
Essential to Overall Health
Mental Health Care is Consumer and Family Driven
Disparities in Mental Health Care are Eliminated
Early Mental Health Screening, Assessment, and
Referral to Services are Common Practice
Excellent Mental Health Care is Delivered and
Research is Accelerated
Technology is Used to Access Mental Health Care
and Information
Transforming Concepts:
Recovery and Resiliency
“Consumers and families told the Commission that having hope
and the opportunity to regain control of their lives was vital to
their recovery. Indeed, emerging research has validated that
hope and self-determination are important factors
contributing to recovery”
Metro Youth, Chicago: compelling testimony and
survey data presented importance of youth
voice.
President’s New Freedom Commission
Transforming Concept:
Consumer & Family-Driven
“…the effectiveness of services, no matter what they are, may hinge less on
the particular type of service than on how, when, and why families or
caregivers are engaged in the delivery of care…it is becoming
increasingly clear that family engagement is a key component not only of
participation in care, but also in the effective implementation of it”
(Burns, Hoagwood, & Mrazek, 1999)
“Not all the studies show that the improvements resulted from the
intervention specifically. Family engagement may play a stronger role in
outcomes than the actual intervention program”
(Thomlison, 2003)
Direct implications for schools: have the interventions, have the
technology, but how do we ENGAGE students?
So, what?
How is the NFC relevant to what you do?
How can you use the report?
Is there a children’s goal?
 What will it take to
transform mental
health care for
children and
families?
 There is no single
children’s goal or
recommendation.
 Children’s issues
embedded
throughout.
Recommendations with Implications
for Children and Families
 1.1- National anti-stigma campaign, and
national strategy for suicide prevention
 2.1- Individualized plans of care
 2.2 -Consumers and families fully involved
in orienting system toward recovery
 2.3 -Align federal programs to improve
access and accountability
 2.4 -Comprehensive State Mental Health
Plan
 2.5 -Protect and enhance rights of people
with mental illnesses
Recommendations with Implications
for Children and Families
 3.1- Improve access to quality, culturally
competent care
 4.1- Promote mental health of young
children
 4.2- Improve and expand school
mental health programs
 4.3- Screen for co-occurring disorders,
and link with integrated treatment
 4.4- Screen in primary care, and
connect to treatment and supports
Recommendations with Implications
for Children and Families
 5.2- Advance evidence-based practice
using dissemination & demonstration
projects
 5.3- Improve and expand workforce
providing evidence-based
services and supports
 5.4- Develop knowledge base in four
understudied areas (trauma, medications,
disparities, acute)
 6.2- Integrated electronic health record, and
online personal health information
systems/resources
Is there a school-related goal?
“The fundamental policy problem related to mental health
in schools is that
 existing student support services and school health
programs do not have high status in the educational
hierarchy…
 schools and districts treat such activity, in policy and
practice, as desirable but not a primary consideration…
 the programs and staff are marginalized…
 interventions are referred to as”auxiliary”…
 Student support personnel almost never a prominent
part of a school’s organizational structure…deemed
dispensable as budgets tighten.”
Adelman & Taylor, Submitted to the NFC
Goal 4/Rec 4.2 - Improve and Expand
School Mental Health Programs
 Work with parents, local providers, local agencies to
support screening, assessment and early intervention;
 Ensure that mental health services are part of school
health centers
 Ensure that these services are federally funded as
health, mental health and education programs
 Implement empirically supported prevention, early
intervention approaches at the school district, local
school, classroom, and individual student levels;
 Create State-level structure for school-based mental
health services to provide state leadership and
collaboration among education, general health, and
mental health
Key Learnings:
 Mental health consumers/
youth/families are not in the mental
health system – de facto systems
 Stigma: key barrier to changing
practice
 Gap between what we know works
and what we practice.
 Places that have changed their
systems: better outcomes and cost
savings
Mental health consumers/youth/families are
not in the mental health system – de facto
systems - schools
 Over 52 million children in ~ 100,000 schools in U.S.;
6 million adults working in the schools: 1/5 of U.S.
population
 Children receive more MH services through schools
than any other public system
 Student support services/school health programs
need greater focus in health and education policy
initiatives
 Must serve ALL children….. so they can learn in
schools.
Stigma:
prevents accessing mental health
 Schools are accessible, familiar to families
 Stigma and school-comfort level variable
among diverse groups
 Generally, stigma, non-compliance,
inaccessibility lesser in schools
 Youth report: painful stigma in classroomprefer jj involvement, SA disorder rather
than MH disorder
 Schools- pivot point to families, community
stakeholders
Gap between what we know works
and what we practice.
 School MH programs decrease absence
and discipline referrals, improve test scores
(Jennings et al., 2000).
 School “connectedness” related to
academic, behavioral and social success in
schools (Blum & Hibbey, 2004).
 School-based wraparound decrease out-ofschool & out-of-home placements (Eber et al.,
1996).
 Positive behavioral interventions and
supports (PBIS- Horner & Carr, 1997; Sugai et al.2000)
 Promotion and Prevention Interventions
Children and Families Issue Paper:
Background Report
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Comprehensive
overview of children’s
issues; resources and
rationale
9 Policy Areas, 26
Recommendations and
120 Implementation
Options
Broad stakeholder
Input
Children and Family Issue Paper:
9 Policy Areas
1) Cross Agency Responsibility, Coordination
and Financing to Reduce Fragmentation
2) Family & Youth Partnerships and Support
3) Access to Care and Reducing Disparities
4) Broaden Array of Services and Supports
5) Develop & Apply Knowledge
6) Build Workforce
7) Prevent Disorders
8) Communication Strategy and Stigma
9) Accountability and Quality Improvement
Built on:
 Surgeon General’s Reports: Mental Health;
Mental Health: Culture, Race & Ethnicity
 Surgeon General’s National Action Agenda for
Children
 National Academy of Sciences: From Neurons
to Neighborhoods
 New Freedom Commission on Excellence in
Special Education
 Reviews of Evidence-base Practices in
Prevention and Treatment
 Etc.
Stakeholder Input & Key Experts
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American Psychological
Association
AACAP
CWLA
NASP
Federation of Families for
Children’s Mental Health
State Family Organizations
NMHA
NAMI
CHADD
Professional Guilds/Associations
NASMHPD
State Children’s MH Directors
National Racial/Ethnic Associations
Child Policy Centers
Natl Assoc. State Directors of
Special Education
Policymaking Partnership
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Families & Youth
National Assembly on Schoolbased Health Care
University Child Study Centers
Bazelon Center for MH Law
Amer. Acad. Pediatrics
Gains Center (JJ)
Natl Council on Disability
Natl Assoc Psychiatric Health
Systems
Calif. Institute of Mental Health
Early Childhood Programs
Community Agencies
NASADAD
School Mental Health Projects
Coalition for Juvenile Justice
Natl Council for Community
Behavioral HealthCare
School-related Recommendations in
C&F Background Issue Paper
 Policy option IV.4.3: Promote
Mental Health in the
Education System
 Multi-level, tiered approach
 Collaboration at Federal, State,
local level
 Workforce
(1) Strengthen mental health services in
schools and the role of schools in promoting
social and emotional well-being
 ED & DHHS Collaborate to Strengthen and
Develop/Implement Plan:
 Identify strategies to promote the social and
emotional well-being of children in schools
 Identify children who need specialized services
 Encourage partnerships with families
 Provide or link children with needed services and
supports
 TA on service options, payment mechanisms,
outcomes
(2) Expand Prevention and Early Intervention
Approaches and Positive Behavioral
Supports in Schools
 ED and SAMHSA work together to expand
existing efforts and develop prevention/early
intervention approach to social and emotional
well being of children in schools. Include
interventions at:
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School system/district level
School building level
Classroom level
Individual level with students with special needs
(3) Ensure that Mental Health Services are
Provided as Part of School Health Centers
 DHHS ensure that mental health services are
provided through school health centers and
allocate funding for this as part of Federally
funded mental health and education programs.
This will increase access to care.
(4) Train teachers and school personnel to recognize
signs of emotional problems in children and to make
appropriate referrals for assessment and services
 Pre-service and professional development and staff
training for teachers and school personnel to increase
ability to recognize “early warning signs” and take
appropriate action:
 Referrals for assessment/services
 Classroom accommodations
 Partnering with families
 Maximize established funding streams (IDEA,No
Child Left Behind)
(5) Ensure Special Education and Related
Services for Children with Emotional
Disturbances under IDEA
 ED work with States to more effectively
implement IDEA
 Services coordination should be considered
related services and included in IEPs for
children with emotional disturbances under
Part B of IDEA.
(6) Create a State-level Infrastructure for
School-based Mental Health Services
 Ensure clear, coordinated State agenda for
school health and mental health services
 Collaboration between Education and Mental
Health
 Pool funding for school-based mental health
services
 Link with State’s comprehensive plan for
children’s mental health (Goal 2, NFC)
(7) Create Specific Funding Streams for
School Mental Health Services
 To support provision of mental health and
substance abuse services, designate small
percentage of funds from selected programs:
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Safe and Drug Free Schools
No Child Left Behind
Safe Schools/Healthy Students
Title V
School-based Health Center Grants
(8) Create a Collaborative Grant
Program to Support Effective SchoolBased Mental Health Approaches
 SAMHSA and ED grants to States, other units
of government, and private nonprofit
organizations to schools in providing:
 Screening and assessment
 Early intervention, crisis interventions, and
mental health services to children with or atrisk of emotional/behavioral disorders
(9) Study the Role of School Culture in
Promoting Social and Emotional Well-being
 ED, SAMHSA, NIMH study and identify
evidence-based interventions for promoting
both academic success and social and
emotional well-being through strengthening
school culture.
 Information on these interventions to be
disseminated and technical assistance
provided to increase “uptake”
(10) Develop a Comprehensive Strategy
for School-based Response to Trauma
 DHHS, Federal Homeland Security & ED
 Train/prepare teachers and other school personnel
 Develop linkages with trained mental health
providers for trauma response
 Include school-based mental health interventions in
Federal, State and community disaster and
emergency response plans
 Consider needs of children beyond initial crisis to
identify/refer/treat PTSD and other mental health
problems following trauma
Policy Option IV.5:
Achieve Cultural Competence
 Develop federal leadership to focus on
disproportionate numbers of youth of color with
MH problems in JJ, foster care and special
education.
 Strengthen capacity of schools to be key link to
comprehensive, seamless system of school- and
community-based identification, assessment and
treatment services.
 Involve SAMHSA, CMS, Office of SpEd and
Rehabilitation Services (0SERS), State agencies
Thrust of Recommendations
 Build a continuum of mental health
services in schools: promotion,
prevention, early identification, and
treatment
Federal Level:
SAMHSA Child and Families
Action Plan – FY 05
 New Initiatives
 State MH Transformation Grants to
include children and families (offered)
 Prototype grants to fund State
adolescent SA treatment coordinators
to build infrastructure/capacity for
services integration
 Enhance TA Efforts
 Develop toolkit on SA and MH
screening for use in multiple settings
with multiple age groups, strategies and
incentives for linking to care
 Develop prototype of individualized plan
of care for children and their families
Federal Level:
SAMHSA Child and Families
Action Plan
 Align Federal Programs
 Collaborate with Dept of Education
to expand school-based mental
health programs
 Collaborate with ASPE, ACF,CMS
and Depts. of Education and Justice
on eliminating practice of parents
giving up custody for treatment
 Track and Report Child/Family focus
across relevant grants
Leverage NFC Report for
State-Level Reform
 MH/School Leadership participate in State
Mental Health Plans (use experience,
outcome and cost data).
 Major reform efforts in New Mexico (legislation
May 2004 Purchasing Collab.17 agencies), Illinois(Ch MH
Partnership), South Carolina drawing on NFC
 Different strategies: focus on specific goal
areas or general concept of transformation
and recovery (www.nasmhpd.org for state
implementation activities)
Leverage NFC Report for
Local Reform
 Educate public officials about NFC report and its
alignment with mental health in school efforts
 Use NFC recommendations to fuel innovation,
e.g., Westchester County implement recommendation in
Goal 4; screening for mental health in Latino primary care
clinics
 Use NFC financing discussion to map behavioral
health financing and expenditures across childserving systems to identify opportunities for
improved integration and efficiency
 Social marketing of NFC to gain political will
Using the Report Strategically
1. Alignment of NFC principles with
underlying principles in school-based
mental health
2. Leverage NFC report for local reform
3. Leverage NFC report and local & State
data for State level reform
4. NFC report and background papers for
advocacy, promoting transformation
Websites to Access (Pending)
Report
 www.samhsa.gov.
 www.mentalhealthcommission.gov
 www.tapartnership.org