1. Children’s Mental Health: Current Challenges and a Future Direction
Good afternoon. My name is Sarah Olbrich. I am currently completing my master of public health degree in maternal and child health at the George Washington University.
Today I will be talking about issues regarding the mental health of children.
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Sarah Olbrich
MPH Candidate, George Washington University
The Center for Health and Health Care in Schools
June 7, 2002

2. Objectives Background on Children’s Mental Health
Statistics
Disorders
Traditional service provision
A New Approach to Children’s Mental Health Services: School-Based Health Centers (SBHC)
Types of services provided
Types of mental health services and providers
Why SBHC-sponsored mental health services are a gold standard
Opportunities and Challenges
First I will address the current status of mental health in children living in the US. I will cover the extent of the need, review a few common mental health disorders that affect children, and discuss where mental health services have traditionally been accessed by this population.
I will then focus on a newer approach to mental health service delivery - the School-Based Health Center (SBHC). And why SBHCs are the ideal location for mental health service provision to children.
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3. Statistics
20% of children ages 9-17 have a diagnosable mental, emotional, or behavioral disorder (1)
70% of children with a diagnosable disorder do not receive mental health services (2)
Minority populations are less likely to have access to mental health services (1,2)
Greater than 50% of low-income children are at risk for a mental health problem (3)
As you can see current data point to a high level of unmet need in children’s mental health. 20% of children ages 9 to 17 have a diagnosable mental health disorder, yet 70% are not receiving care. Also, children from minority populations and children living in poverty have higher rates of unmet need and fewer accessible mental health services when compared with their more affluent peers.
The reason public health professionals should address the unmet mental health needs of children, is, according to Rones and Hoagwood, that children with undiagnosed or untreated mental health disorders have decreased ability to learn. Also, some of the goals of Healthy People 2010 include decreasing the number of youth with untreated mental illness, decreasing youth suicides, and decreasing lost days of school due to somatic problems.
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1) US DHHS. Executive Summary. Mental Health: A Report of the Surgeon General. 1999
2) RAND. Health Research Highlights: Mental Health Care for Youth. 2001
3) Adelman H., Taylor L. Guidebook: Mental Health and School-Based Health Centers. The School Mental Health Project. The Center for Mental Health in Schools

4. The Prevalence of Common Mental Health Disorders Affecting Children and Youth
Number of Children/Youth Affected
Anxiety
8 to 10 out of 100
Conduct
7 out of 100
Depression
6 out of 100
Learning
5 out of 100
Attention
Eating
1 out of 150
Substance Abuse
Not known
This table shows the prevalence of some common mental health disorders that affect children. As you can see there are many children with mental health disorders, and the highest prevalence is seen in anxiety disorders. These disorders can impact the daily life functioning of children.
For example a child with panic disorder, one of the anxiety disorders, may have difficulty taking tests or meeting deadlines, and problems handling social pressures.
Treatment for these conditions such as medication, counseling, and learning skills, while not always curative, should be able to help the child participate and succeed in school.
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CMHS. Mental, emotional, and behavior disorders in children and adolescents. The Center for Mental Health Services. Accessed at

5. Current Mental Health Services
There are four sectors in which children in need of mental health services can receive care:
the specialty mental health sector
the general medical/primary care sector
the human services sector
the voluntary support network sector
Traditionally there are 4 areas where children in need of mental health services have been able to access them. Specialized mental health professionals (psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers) the general medical/primary care sector (family physicians, nurse practitioners, internists, pediatricians, etc.), the human services sector (social welfare, criminal justice, and education), and the voluntary support network (self-help groups and similar organizations).
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6. Limits of Current Mental Health Service Arrangements
Do not meet the need
Mental health system capacity
Provider Shortage
Insurance Coverage
Schools have become the de facto source of mental health services for children
However, current mental health service arrangements are not meeting the mental health needs of children and adolescents. As I have shown the majority of children in need of mental health services are not receiving care. And current service arrangements do not provide access to the population in general and do not provide early intervention services. Some reasons why traditional mental health services have not been successful in addressing these mental health needs are:
1. The provider shortage in childrens mental health. The number of children in need of services has grown at a faster rate than the number of professionals trained in child mental health. There is also a geographic maldistribution of providers (rural and areas of low-socioeconomic status)
AND 2. Many services that are being provided are considered to be “deep-end” and there is little $ available for prevention services. In 1998 only 3% of federal funds devoted to Childrens mental health went to early identification and intervention. This causes decreased system capacity for many children in need services as the majority of funds are being spent on deep-end services for the smallest number of children with mental health disorders.
3. The 3rd issue is insurance coverage. Many insurance providers limit or exclude mental health from benefit packages.
Current service arrangements are not providing access to the population in general and are not providing early intervention services. In part due to these issues Schools have become the de facto source of mental health services for this population.
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7. Schools as Mental Health Service Providers
Service Provider Arrangement
School Relationship
Provider Type
Services
Barriers
Special Education
Hired by school or school district
School Psychologists
Special Education Testing, IDEA implementation
Time spent on testing, not accessible to all students
Stand Alone School Program
School or school district hires providers or program
Social Workers, child psychologists, teachers
Counseling, Interventions for specific mental health issues
Stigma, Time, Program cost
Community Linked
School or school district contracts with organization for the provision of services
Social Workers, child psychologists, psychiatrist, crisis counselors
Varied – crisis/ as needed to comprehensive mental health services
Not linked to other school services, providing as needed does not address issue of lack of services
Other Service Provider Options
May occur on school premises but not during school hours
Varied
Not always linked to school services, may not reach all needy children
School Based Health Centers
Located at or near schools
Funding and space
As you can see in this table mental health services are provided in a variety of ways in the school setting.
1. School psychologist
2. Contracts with community organizations to provide care as needed
Of all these provider arrangements, the SBHC has the ability to provide the most comprehensive mental health services for children.
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8. School-Based Health Centers
1500 SBHC nationally
Provides primary care, intervention, and mental health services
Can provide comprehensive mental health services
Decreased stigma associated with mental health services
60% of SBHCs have mental health professionals on staff
80% of SBHCs provide crisis intervention services
What is a SBHC? SBHCs are health clinics usually located within the school or on school property that provide health care that can be accessible to all students in that school. SBHCs can provide primary health care, intervention services, health screenings, and mental health services.
SBHC are unique in that they can reduce the stigma of “having to visit the counselor” that is associated with other mental health service providers. It does so by placing mental health in the context of primary health care, which makes visiting the counselor a normalized and accepted behavior.
SBHCs are also able to address the children’s mental health goals of Healthy People 2010.
Approximately 60% of SBHCs have a mental health professional on staff.
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9. Mental Health Services and Providers in SBHCs
Assessment
Counseling (group & individual)
Intervention
Providers
Clinical Social Worker (36%)
Mental Health Unspecified (18%)
Psychologist (12%)
Substance Abuse Counselor (8%)
Psychiatrist (4%)
Some of the mental health services that can be provided in SBHCs are:
Assessment of children
Group and individual counseling
Early intervention
Prevention services
These services are provided by a variety of child mental health professionals. The majority of services, according to the 1999 NASBHC census, are provided by clinical social workers.
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Source: Census of the National Assembly on School-Based Health Care, NASBHC, Washington, DC 2000

10. Strengths and Weaknesses to Mental Health Care Via SBHC
Accessibility
Decreased Stigma
Weaknesses
Provider Shortage Remains
Funding Problems Remain
Dependent on School Collaboration
1. The strengths of SBHCs as mental health providers, as I have already mentioned, are the accessibility of services by all students and the centers location within the school (students don’t have to travel to receive care) and the decreased stigma associated with mental health services.
In fact during the school year in Connecticut, 1/3 of all visits to SBHCs were for mental health issues.
2. The weaknesses of Mental Health service provision in SBHCs are not unique to either SBHC or MH services in SBHC; they are seen throughout the Child MH Service arena
They include
Provider shortage
Funding problems; for example 3rd party reimbursements can be difficult for SBHCs to obtain especially for mental health services
There also must be collaboration with school officials. Discord between providers employed by the school and employed by the SBHC can decrease a child’s access to services
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11. Funding Issues SBHC SBHC Mental Health
Grants (Federal, State, Local, Private)
3rd Party Reimbursement
In-Kind Contributions from Community
SBHC Mental Health
Grant
3rd Party
Parity Issues
SBHCs are funded by many sources including Grants, 3rd party reimbursement, and in-kind contributions. Mental health services in SBHC are funded the same way. In the handouts I have included a flow chart demonstrating the complexity and variety of SBHC funding.
Results from the NASBHC survey of all SBHC in the US and the CHHCS 2000 survey of state policies regarding SBHC both point to State Funding as the major source of revenue for SBHC
One of the keys to self-sustainability for SBHCs and mental health services in SBHCs is the collection of patient revenue from 3rd party reimbursement. Currently there is a push for private insurance companies and HMOs to create parity between physical and mental health services (this does not include Medicaid or SCHIP, programs that much of the SBHC population are eligible for). The push for parity needs to be extended to public insurance programs.
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12. State Policy Support for Reimbursing SBHC
SBHC are eligible for Medicaid reimbursement in 36 states
SBHC are eligible for SCHIP reimbursement in 30 states
SBHC contract with Medicaid managed care in 17 states
Even though SBHCs are eligible for Medicaid reimbursement in 36 states and SCHIP reimbursement in 30 states, it does not mean that SBHCs are receiving reimbursement funds. This is due to several things
1. complex requirements and regulations regarding the submission of claims as well as the time it takes to fill out all the forms.
2. even when SBHCs are eligible under state policy to receive Medicaid reimbursement, they may not be included as providers in Medicaid managed care organizations.
3. Mental health services provided by SBHCs are hard to reimburse. Each state and insurance program decides what providers are eligible to provide mental health services in SBHC and what services can be reimbursed. Therefore services, such as early intervention, prevention, and services to enrolled children without a definitive covered mental health diagnosis, will not be reimbursed.
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13. SBHC Mental Health Services
Reasons for Optimism
Strong State Support
Increased Public Awareness of Children’s Mental Health
Columbine Shootings
Effects of WTC Attack on NY City School Children
Reasons for Concern
Complexity of Funding
On-going Provider Shortage
There are reasons for optimism. State support of mental health services has been increasing. There is increased public awareness about mental health issues in children. Unfortunately this has developed as a result of tragedies such as the Columbine school shootings and the September 11 terrorist attacks. In early May the NYC board of education released a preliminary report on the after affects of the WTC attacks on NYC school children. This report showed that 25% of 4th through 12th graders have a trauma related mental health disorder many of which are anxiety disorders as a result of the attacks.
There are also reasons for concern. Funding SBHCs is complex and SBHCs usually need more than one source to remain open and they are constantly having to look for new sources of funding. There is also the ongoing provider shortage in childrens mental health (and unless more mental health professionals train in children’s mental health, even if SBHCs have funding for services, they may not have providers).

14. The Future of Mental Health and SBHC
SBHC are increasing the number of mental health providers and services in schools
Decreased numbers of children with unmet mental health needs
Reaching goals of Healthy People 2010
In conclusion, SBHC are the ideal location for mental health service provision to children.
SBHC are continually increasing the number of mental health providers and services they offer by providing a framework for mental health service delivery.
And from a public health perspective, SBHCs are decreasing the percentage of children with undiagnosed and untreated mental health issues.
By providing children and youth with mental health services in SBHCs, a portion of the goals outlined in Healthy People 2010 will be met.

15. For More Information
The Center for Health and Health Care in Schools
Center for Mental Health Services
Mental Health: The Surgeon General's Report
National Institute of Mental Health
University of Maryland Center for School Mental Health Assistance
School Mental Health Project
If you would like more information on SBHCs or children’s mental health these are a few websites I would recommend that you check out.
Thank you.
Any questions?