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PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦October 2007 Vol. 58 No. 10
11333300
The failure of the nation’s child
mental health system to fully
address the mental health
needs of children and adolescents has
been well documented and points to
the need to reconsider current policy
and practice (1–4). The lack of clear
direction or a unified vision to guide
efforts within the system arguably
contributes to the inadequacy of care
received by our nation’s youths.
In 2002, President George W. Bush
established the President’s New
Freedom Commission on Mental
Health to analyze the state of the
country’s mental health system. After
a year of study and input from more
than 2,000 stakeholders, the commis-
sion concluded that “the mental
health delivery system is fragmented
and in disarray . . . leading to unnec-
essary and costly disability, homeless-
ness, school failure and incarceration”
(5). The final report of the commis-
sion, Achieving the Promise: Trans-
forming Mental Health Care in Amer-
ica (5), highlighted unmet needs and
barriers to care, including fragmenta-
tion and gaps in care for children and
lack of a national priority for mental
health care. The report articulates six
goals and 19 recommendations that
target dramatic transformation and
improvement of child, adolescent,
and adult mental health systems (see
box on page 1332).
The commission unequivocally rec-
ognized that mental health services in
schools are a critical component in re-
building our mental health system for
children. Given that the recommen-
dations of the New Freedom Com-
mission report are consistent with the
goals of most school mental health
programs, efforts have been made to
identify the implications of the New
Freedom Commission report for ad-
vancing a school mental health policy
agenda (6,7). The New Freedom
Commission report includes very spe-
cific and direct linkage to school men-
tal health services and programs as
described in goal 4, “Early mental
health screening, assessment, and re-
ferral to services are common prac-
tice.” To reach this goal, the commis-
sion recommended that we “improve
and expand school mental health pro-
grams” (recommendation 4.2).
This article examines the intersec-
tion of school mental health and the
New Freedom Commission recom-
mendations in order to highlight the
role of school mental health in the
transformation of the child and ado-
lescent mental health system. We
conclude with specific recommenda-
tions for utilizing the New Freedom
Commission report as a meaningful
and useful framework for system
transformation.
Transformation of Children’s Mental Health
Services: The Role of School Mental Health
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Dr. Stephan and Dr. Weist are affiliated with the Department of Psychiatry, University
of Maryland School of Medicine, 737 W. Lombard St., Rm. 426, Baltimore, MD 21201 (e-
mail: sstephan@psych.umaryland.edu). Dr. Kataoka is with the Department of Psychia-
try, University of California, Los Angeles. Dr. Adelsheim is with the Department of Psy-
chiatry, University of New Mexico, Albuquerque. Ms. Mills is with the Department of
Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Pub-
lic Health, Baltimore.
The New Freedom Commission has called for a transformation in the de-
livery of mental health services in this country. The commission’s report
and recommendations have highlighted the role of school mental health
services in transforming mental health care for children and adolescents.
This article examines the intersection of school mental health programs
and the commission’s recommendations in order to highlight the role of
school mental health in the transformation of the child and adolescent
mental health system. Schools are uniquely positioned to play a central
role in improving access to child mental health services and in supporting
mental health and wellness as well as academic functioning of youths. The
New Freedom Commission report articulated several goals related to
school mental health: reducing stigma, preventing suicide, improving
screening and treating co-occurring disorders, and expanding school
mental health programs. The authors suggest strategies for change, in-
cluding demonstrating relevance to schools, developing consensus among
stakeholders, enhancing community mental health–school connections,
building quality assessment and improvement, and considering the orga-
nizational context of schools. (Psychiatric Services 58:1330–1338, 2007)
steph.qxd 9/19/2007 9:08 AM Page 1330
School mental health
Throughout the United States
schools offer youths unparalleled ac-
cess to resources to address interre-
lated academic, emotional, behav-
ioral, and developmental needs. With
more than 52 million youths attend-
ing over 110,000 schools and more
than six million adults working in
schools, one-fifth of the U.S. popula-
tion can be reached in schools (5). In
fact, reports have documented that
of the small percentage of children
and adolescents who receive needed
mental health services, schools are
the most common setting in which
children access this care (1,8,9). Fur-
ther, data indicate that these services
are indeed reaching youths, includ-
ing youths from ethnic minority
groups and students with less obvious
problems, such as depression and
anxiety, who are unlikely to access
services in specialty mental health
settings (10–13).
School mental health programs of-
fer increased accessibility to students
by reducing many of the barriers to
seeking care in traditional settings,
such as transportation, child care, and
stigma, and by reducing the ineffi-
ciency of “no shows”; that is, when a
student does not keep an appoint-
ment, a school-based provider has the
ability to serve other students in the
time slot (14). Further, evidence sug-
gests that school mental health pro-
grams reduce stigma associated with
seeking mental health support (15),
increase opportunities to promote
generalization and maintenance of
treatment gains (16), and enhance ca-
pacity for mental health promotion
activities as well as universal and tar-
geted prevention effort (17,18). Com-
pared with traditional outpatient
mental health services, school mental
health services can offer more ecolog-
ically grounded roles for mental
health clinicians (that is, roles based
in the natural environment of the stu-
dent) (19). School mental health serv-
ices have been shown to enhance
clinical productivity, because students
are more accessible to mental health
staff (20).
In addition to these inherent ad-
vantages of school mental health serv-
ices, there is growing evidence that
school mental health programs can
have a positive impact on a number of
student, family, and school outcomes.
These services have resulted in re-
duced emotional and behavioral
problems, decreased disciplinary re-
ferrals, increased prosocial behavior,
increased family engagement, and
improvement in school outcomes,
such as fewer disciplinary referrals,
improved school climate, and fewer
special education referrals (21–28).
Further, there is growing recogni-
tion by policy makers and consumers
of the value of school mental health
programs and services. A recent poli-
cy statement on school mental health
released by the American Academy of
Pediatrics (29) underscores many of
these advantages, including improved
access to a range of services and en-
hanced opportunities for service co-
ordination. The policy statement ad-
vocates for effective collaboration be-
tween educators, primary health care
providers, and mental health profes-
sionals in implementing high-quality
school-based mental health services.
School mental health and
the commission report
The University of Maryland Center
for School Mental Health has con-
vened meetings and conducted policy
analyses to identify the most impor-
tant connections between the New
Freedom Commission report and the
Achieving the Promise Initiative and
school mental health. Four specific
recommendations of the New Free-
dom Commission report were deter-
mined to have the most proximal con-
nections to school mental health: re-
duce stigma, prevent suicide, screen
and treat comorbid mental and sub-
stance use disorders, and the obvious,
improve and expand school mental
health programs. Ideas explored by
the Center for School Mental Health
in relation to each of these themes are
discussed below, with an emphasis on
the role of school mental health in
creating system transformation.
Reduce stigma
Recommendation 1.1 of the New
Freedom Commission report advo-
cates for the implementation of a na-
tional campaign to reduce the stigma
of seeking mental health care and a
national strategy for suicide preven-
tion. Less than 30% of individuals
with psychiatric disorders seek treat-
ment (30,31), and stigma is a signifi-
cant barrier to help seeking and ac-
cessing services (32). Schools are a
key venue for supporting a campaign
to reduce stigma, and school mental
health services naturally reduce ob-
stacles to care related to stigma (32).
Focusing on mental health in
schools provides both natural and for-
mal opportunities for promoting anti-
stigma messages related to mental
health. With appropriate training and
community support, school staff can
normalize mental illness, convey pos-
itive messages about mental health,
and encourage students to engage in
activities that promote mental well-
ness. Formal avenues for reducing
mental health stigma in schools in-
clude integration of mental health
awareness into special and regular ed-
ucation curricula, including universal
PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦October 2007 Vol. 58 No. 10 11333311
Editor’s Note: This article is the
eighth in a series of articles ad-
dressing the goals that were es-
tablished by the President’s New
Freedom Commission on Men-
tal Health. The commission
called for the transformation of
the mental health system so that
all Americans have access to
high-quality services that pro-
mote recovery and opportunities
to pursue a meaningful life in
the community. The series is
supported by a contract with the
Substance Abuse and Mental
Health Services Administration
(SAMHSA). Jeffrey A. Buck,
Ph.D., and Anita Everett, M.D.,
developed the project, and Dr.
Buck and Kenneth S. Thomp-
son, M.D., are overseeing it for
SAMHSA. The series will fea-
ture 15 articles on topics such as
employment, housing, and lead-
ership, which will be solicited by
the journal’s editor and peer re-
viewed. Also planned are case
studies from each of the states
that received a SAMHSA-fund-
ed State Incentive Mental
Health Transformation Grant.
steph.qxd 9/19/2007 9:08 AM Page 1331
programs on social and emotional
learning, prevention programs, and
specialized interventions for prob-
lems. Simple messages, such as “men-
tal health refers to thoughts, feelings
and actions that contribute to success
in life,” can help to generalize the
concept of mental health as applica-
ble to everyone and to dispel negative
connotations that mental health
refers only to those with chronic men-
tal illness.
Schools also reduce stigma by of-
fering a naturalistic environment for
youths and families to seek assistance
for mental health needs. In contrast
to traditional community mental
health settings, which may be seen as
disconnected from a family’s daily en-
vironment, schools offer an ecologi-
cally sound alternative, providing
services directly in the living and
learning environment of children.
The availability and accessibility of
school mental health providers, ac-
cess to key informants such as teach-
ers, and the typical proximity of
schools to children’s neighborhoods
all further increase the likelihood of
care seeking. Because of their historic
ties to children, families, and commu-
nities, schools can also serve as a nat-
ural place for families to be exposed
to information about mental health
and available services.
Prevent suicide
Schools are also a critical venue for
developing and executing the second
proposal of recommendation 1.1—to
implement a national strategy to pre-
vent suicide. As noted, schools offer a
desirable site for both suicide preven-
tion campaigns and programs for
youths because of schools’ ability to
reach most youths, their inherent ties
to families and communities, and the
multiple opportunities for both for-
mal and informal education about
and prevention of mental health
problems and psychosocial problems,
including suicide.
Data from the 2003 Youth Risk Be-
havior Survey of a nationally repre-
sentative sample of more than 15,000
high school students throughout the
United States indicate that in the 12-
month period preceding the survey
16.9% had seriously considered at-
tempting suicide, 16.5% had made a
plan for attempting suicide, 8.5% had
attempted suicide one or more times,
and 2.9% had made an attempt re-
quiring medical attention (33). More
than 60% of adolescents who commit
suicide have mental health problems,
which often have existed for a year or
more before the suicide (34). There
is increasing national focus on pre-
venting teen suicide, as reflected in
the Call to Action to Prevent Suicide
by the U.S. Surgeon General (35)
and the more recent strategy docu-
ment (36) developed by the U.S. De-
partment of Health and Human Ser-
vices, the National Strategy for Sui-
cide Prevention, (www.mentalhealth.
samhsa.gov/suicideprevention). The
latter effort represents the first na-
tional blueprint to address suicide
and calls on schools to play a signifi-
cant role in efforts to prevent suicide
nationwide. Specifically, schools are
encouraged to collaborate with other
agencies, increase the implementa-
tion of research-supported preven-
tion programs, train key school per-
sonnel to identify youths at risk of sui-
cide, and develop effective suicide
screening programs that are directly
linked to needed services. It is also
noteworthy that the Substance Abuse
and Mental Health Services Adminis-
tration (SAMHSA) is providing key
federal leadership in suicide preven-
tion, including a grant program that
specifically emphasizes school-based
activities.
School-based efforts to address
suicide have been evaluated with
mixed results (37). One suicide pre-
vention strategy that is being imple-
mented in a number of districts
across the country is the school gate-
keeper training model, which has
several key components: training
school personnel (gatekeepers) to
improve their knowledge, attitudes,
and skills to appropriately intervene
with students at risk of suicide; pro-
PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦October 2007 Vol. 58 No. 10
11333322
PPrreessiiddeenntt’’ss NNeeww FFrreeeeddoomm CCoommmmiissssiioonn
GGooaallss aanndd RReeccoommmmeennddaattiioonnss
1.1. Advance and implement a national campaign to reduce the stigma of
seeking care and a national strategy for suicide prevention
1.2. Address mental health with the same urgency as physical health
2.1. Develop an individualized plan of care for every child with a serious
emotional disturbance
2.2. Involve consumers and families fully in orienting the mental health system
toward recovery
2.3. Align relevant federal programs to improve access and accountability for
mental health services
2.4. Create a comprehensive state mental health plan
2.5. Protect and enhance the rights of people with mental illness
3.1. Improve access to high-quality care that is culturally competent
3.2. Improve access to high-quality care in rural and geographically remote areas
4.1. Promote the mental health of young children
4.2. Improve and expand school mental health programs
4.3. Screen for co-occurring mental and substance use disorders and link with
integrated treatment strategies
4.4. Screen for mental disorders in primary health care across the life span and
connect individuals to treatment and supports
5.1. Accelerate research to promote recovery and resilience and ultimately to
cure and prevent mental illnesses
5.2. Advance evidence-based practices by using dissemination and demonstra-
tion projects and create a public-private partnership to guide their imple-
mentation
5.3. Improve and expand the workforce providing evidence-based mental health
services and supports
5.4. Develop the knowledge base in four understudied areas: mental health dis-
parities, long-term effects of medication, trauma, and acute care
6.1. Use health technology and telehealth to improve access and coordination of
mental health care, especially for Americans in remote areas or in under-
served populations
6.2. Develop and implement integrated electronic health record and personal
health information systems
steph.qxd 9/19/2007 9:08 AM Page 1332
viding crisis intervention to engage
suicidal students’ support networks;
and facilitating suicidal students’ re-
ferrals for treatment and counseling
(38). A recent study found that
among students who had been previ-
ously identified as at risk of suicide,
use of this gatekeeper model can in-
crease the proportion of students
who access specialty mental health
services in the community (39).
Some screening and prevention
efforts, including Columbia Univer-
sity’s TeenScreen Program (www.
teenscreen.org) and the SOS Suicide
Prevention Program (40), have
demonstrated positive findings with
respect to identifying at-risk youths,
increasing knowledge about suicide
and depression, and reducing sui-
cide attempts. However, their suc-
cess has also been paired with con-
troversy related to concerns about
the large number of false-positive
screens and the limited capacity of
schools to respond to serious mental
health issues that may be unveiled
when screening programs are imple-
mented (41). Some of the concerns
regarding school-based universal sui-
cide screening are likely rooted in the
stigma associated with mental health
problems compared with other med-
ical issues, such as vision and hearing,
for which there is already schoolwide
screening.
Federal support for universal men-
tal health screening, as evidenced in
the New Freedom Commission rec-
ommendations, reflects the recogni-
tion that for most individuals with
mental illness symptoms begin in
childhood, which suggests that early
screening can play a critical role in
providing prevention and early inter-
vention to delay or eliminate the on-
set of symptoms (30). Weist and col-
leagues (42) have outlined a process
for addressing concerns about
school-based mental health screen-
ing that includes intensive planning,
collaboration, training, supervision,
and support to ensure the selection
of age-appropriate screening meth-
ods; parental consent and student as-
sent; trained and available staff and
mental health providers to conduct
screenings and follow-up treatment;
and resolution of logistical and liabil-
ity issues.
Screen and treat
co-occurring disorders
The New Freedom Commission ar-
gues for the screening and integrat-
ed treatment of comorbid mental
and substance use disorders in rec-
ommendation 4.3. The reality is that
co-occurring disorders are more
common than not among people
with mental illness or substance use
disorders (43). Even though the rate
of youth substance use has been de-
clining overall in the past decade,
half of adolescents have tried an illic-
it drug by the time they graduate
from high school (44). Of youths
identified as having substance use
disorders, it is estimated that up to
75% may have a co-occurring mental
health disorder (45).
Despite this reality most communi-
ties do not have the capacity to re-
spond to any level of substance abuse
concerns among youths because of
stigma, resource limitations, limited
evidence-based approaches, and the
failure of child-serving systems to
take responsibility for the problem
(46). Lack of ownership by a single
community system is also reflected in
schools, where substance abuse serv-
ices are often not well integrated into
the full continuum of mental health
service delivery for youths (47). Al-
though school-based mental health
providers are often the “default”
providers of substance abuse services,
limitations in preservice training and
lack of supervision and support in ev-
idence-based substance abuse treat-
ment for mental health providers
leave many providers unprepared to
address co-occurring mental health
and substance use problems (48).
Despite the existing challenges to
providing high-quality services to
youths with comorbid mental and
substance use problems, schools offer
inherent advantages in this arena.
Specifically, the federal focus on
funding prevention programs, such as
Safe and Drug Free Schools and ini-
tiatives of the Center for Substance
Abuse Prevention, have advanced the
integration of substance abuse pro-
gramming into schools across all
grade levels. Further, when evidence-
based substance abuse prevention ac-
tivities are implemented appropriate-
ly in schools, outcomes are positive
and strong, including delayed initia-
tion of use, decreased frequency of
use, and slowed or arrested progres-
sion to the use of more hazardous
substances (49). As discussed above,
schools are also uniquely staged to of-
fer screening of co-occurring mental
health and substance use problems,
given their ability to reach many stu-
dents, the growing infrastructure to
implement screening, and the evolu-
tion of guidelines to promote respon-
sible, effective screening protocols
(42). In addition, a number of pre-
vention and intervention programs
have been successfully implemented
in school settings.
Improve and expand school
mental health programs
Recommendation 4.2 of the New
Freedom Commission report is to
“improve and expand school mental
health programs.” When detection,
prevention, and early intervention
services for youths are provided in the
context of schools, negative conse-
quences such as school failure and co-
morbid substance abuse can be pre-
vented. Coordinated school service
approaches have been described that
integrate assessments with on-cam-
pus prevention services, early inter-
vention programs, and more intensive
systems-of-care services for the few
students who require multimodal
treatments across child-serving agen-
cies. However, as the Blueprint for
Change: Research on Child and Ado-
lescent Mental Health from the Na-
tional Institute of Mental Health has
noted, research advances in the de-
velopment of efficacious mental
health treatments for children and
adolescents have had minimal trans-
lation into community practice set-
tings such as schools (50).
Contributing to the slow progress
of bringing improved services into
schools is the reality that schools are
underresourced to address nonacade-
mic barriers to learning. Most dis-
tricts offer mental health supports to
only a small percentage of students,
often those in or being referred to
special education. Further, the quali-
ty of services for emotional or behav-
ioral disabilities that are provided to
youths in special education is ques-
tionable (51), with many youths re-
PSYCHIATRIC SERVICES ♦ps.psychiatryonline.org ♦October 2007 Vol. 58 No. 10 11333333
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ceiving “no or poor” services to ad-
dress their individual needs (52).
SAMHSA recently released the re-
port of the first national survey of
school mental health in the United
States for the 2002–2003 school year
(53). According to the report, over
80% of U.S. schools provided assess-
ment for mental health issues, consul-
tation for behavioral problems, and
some level of crisis intervention serv-
ices. Children with more serious is-
sues are commonly referred to com-
munity agencies. Around two-thirds
of schools reported providing individ-
ual and group counseling and some
case management services. However,
because of the way the survey was
structured, respondents could indi-
cate that a service was provided even
it was for only one student or a few
students, which likely resulted in ex-
aggeration of services actually provid-
ed. Also notable was that education
leaders at local and state levels ex-
pressed the perception that mental
health needs of students were in-
creasing while funding was not ade-
quate to meet these needs and was
predicted to decrease, not increase.
These school leaders also expressed
concern about the many barriers to
successfully referring students for
services in other community agen-
cies. Thus these findings suggest that
the majority of schools offer some lev-
el of mental health services but that
these services are not sufficient to
meet youths’ needs and that connec-
tions with other community systems
remain a significant challenge.
It has been challenging to advocate
for school mental health services as a
transformative force in children’s
mental health when schools are in
essence undergoing their own trans-
formation related to the No Child
Left Behind Act. Despite evidence
linking empirically supported mental
health promotion to academic ach-
ievement and school success (28,
54–58), education system reform has
directed relatively little attention to
nonacademic barriers to learning. In-
stead, these educational reforms have
for the most part focused on grades
and test scores for reading and math
to the exclusion of other subjects,
with no attention to the mental health
and well-being of students. Further
research is needed to bridge this di-
vide between educational reform ef-
forts and the transformation of school
mental health and to encourage
greater collaboration between educa-
tors and school mental health pro-
viders in the development of pro-
grams that support academic success.
School mental health
and transformation
An analysis of school mental health
services and the New Freedom Com-
mission report reveals their mutual
goal of maximizing healthy develop-
ment and success for all children
through the provision of high-quality
mental health services in a public
health framework that ensures access
to all youths and families. Although
the New Freedom Commission re-
port reviews critical dimensions for
needed change, it does not detail how
such change will occur or be funded.
Systemic change is extremely chal-
lenging partly because of limited re-
sources and resistance to movement
away from the status quo. Without
purposeful action from a diversity of
stakeholders aimed at implementa-
tion of the New Freedom Commis-
sion recommendations, it is likely that
the document will remain relatively
unused. From a historical perspec-
tive, Friedman (59) noted, “the mere
articulation of policy through legisla-
tion or regulation is rarely adequate
to accomplish the goals of the policy.”
Below are suggestions for facilitating
transformation of child and adoles-
cent mental health services through
the school system.
Demonstrate relevance to schools
In an era of paramount attention to
the academic achievement of our
children, school mental health has
the advantage of articulating a pow-
erful message linking mental health
to school success. The argument for
integrated approaches to reduce
both academic and nonacademic bar-
riers to learning is supported by
mounting evidence demonstrating a
strong positive association between
psychological wellness and academic
success (28,54–58). Research sug-
gests that 46% of the failure to com-
plete secondary school is attributable
to psychiatric disorders (60). Thus it
is not difficult to conceive of advoca-
cy and public awareness efforts that
highlight the need for attention to
school mental health in overall men-
tal health system change. For the
transformation of children’s mental
health services to expand school
mental health, it is necessary to gen-
erate understanding and buy-in from
educators through the dissemination
of clear and strong messages about
the importance of mental health and
the negative impact of mental illness
on school success. To that end, the
school mental health field must
clearly define specific academic fac-
tors—for example, grades, discipline
referrals, promotion, dropout, and
school connectedness—that are in-
fluenced by mental health promotion
and intervention.
Develop consensus
among stakeholders
One way to develop messages about
school mental health and programs
that speak to the school community
more clearly is to develop consensus
across diverse school stakeholders in
a true participatory partnership.
From mental health antistigma cam-
paigns on campus to early mental
health intervention programs target-
ing at-risk students, all school mental
health activities would benefit from
being informed, created, implement-
ed, and disseminated through a part-
nership of school stakeholders, in-
cluding youths, families, educators,
administrators, providers, and com-
munity members and leaders. This
would help to ensure that the multi-
ple missions and goals of school and
community stakeholders are ad-
dressed and that school mental health
programs are both feasible and cul-
turally relevant and acceptable.
There is a significant need to pro-
mote true involvement of the public
in discussions about mental health
and transformation of the education
system and ideas to advance school
mental health. A number of strategies
could be used to promote such public
involvement. First, the New Free-
dom Commission report can be used
as a tool for discussions about school
mental health among diverse stake-
holder groups. This is currently being
done by the IDEA Partnership (www.
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steph.qxd 9/19/2007 9:08 AM Page 1334
ideapartnership.org and www.shared
work.org). Second, the interdiscipli-
nary nature of school mental health
(with families and youths included as
one of the disciplines) can be ac-
knowledged, and interdisciplinary
networking and training can be in-
creased, such as the networking and
training that occurs at the Center for
School Mental Health annual confer-
ence on advancing school mental
health (csmh.umaryland.edu). Third,
social marketing efforts can be devel-
oped that speak to the promise and
challenges of school mental health in
plain language written for diverse
stakeholder audiences.
Enhance community mental
health–school connections
A major focus for the authors of this
article has been advancing a shared
family-school-community agenda, ev-
idenced by strong family and youth
leadership and strong collaboration
between the education system and
the child and adolescent mental
health system in building school men-
tal health. This has also been a major
theme in the expanded school mental
health framework and at the Univer-
sity of Maryland Center for School
Mental Health.
A number of strategies to strength-
en these partnerships are promising.
A first strategy is reaching out to and
encouraging leadership in relevant
professional organizations to support
this agenda. Such organizations in-
clude the National Association of
State Directors of Special Education,
the National Association of State
Mental Health Program Directors,
the Council of Chief State School Of-
ficers, the National Council of State
Legislatures, and the American Col-
lege of Mental Health Administra-
tors, which already espouse and
demonstrate support for such an inte-
grated agenda. A second strategy is
tracking strong examples of family-
school-community collaboration to
advance school mental health, which
is done at annual conferences and in
books (61,62), and moving toward In-
ternet-based evolving directories of
programs to promote networking and
collaboration across communities,
states, and organizations (www.shar
edwork.org). A third strategy to
strengthen partnerships is to capitalize
on federal grant opportunities that pro-
mote such partnerships, such as Sys-
tem of Care (SAMHSA), Safe Schools/
Healthy Students (SAMHSA and De-
partment of Education), and Mental
Health Integration Into the Schools
(Department of Education).
Build quality assessment
and improvement
An overarching construct in school
mental health is advancing quality as-
sessment and improvement, which
can be viewed as inclusive of all rele-
vant processes—needs assessment
and resource mapping; stakeholder
involvement; coordination of services
in schools; connecting school mental
health services in schools to related
community programs and efforts; se-
lecting, training, supporting, and
coaching staff; emphasizing high-
quality and evidence-based services;
evaluating services provided to indi-
vidual students and at the program
level; and connecting evaluation
findings to continuous quality im-
provement cycles and advocacy ef-
forts. There is a great need for ap-
proaches to measure and improve
the quality of school mental health
services, and some measures are now
available, including the School Men-
tal Health Quality Assessment Ques-
tionnaire (63) and the Mental Health
Planning and Evaluation Template
(www.nasbhc.org).
Central in the quality agenda, and
receiving increased attention, is the
goal of making evidence-based servic-
es feasible in schools (64,65). Several
successful models of development
and implementation of mental health
services in schools exist along the con-
tinuum of care and should be consid-
ered examples for future work in the
area. Two representative examples
are LifeSkills Training (www.lifeskill-
straining.com) and Cognitive Behav-
ioral Intervention for Trauma in
Schools (66), both of which were de-
veloped for implementation in
schools. These two programs have
demonstrated positive outcomes
among participants according to both
psychosocial and academic indicators
and have been endorsed by SAMHSA
as model programs.
It is important to note that promot-
ing quality assessment and improve-
ment in school mental health will
help to increase the likelihood of ef-
fective services that achieve out-
comes valued by families and
schools. This in turn will help to pro-
pel school mental health agendas in
communities and states, contributing
to real systems transformation as
called for by the Achieving the
Promise initiative.
Consider the organizational
context of schools
In addition to improving the quality
of school mental health at the
provider and program levels, trans-
formation of mental health services
for youths must also attend to the sys-
tem and organizational issues that are
relevant for schools. Leadership sup-
port within an organization has been
found to be an important factor in the
adoption of new programs, and com-
mitment from school administrators
has been shown to strongly influence
the implementation of prevention
programs (67,68). Successful adop-
tion of mental health programs has
also been shown to be related to the
climate and structure of the organiza-
tion (69,70) and may be related to the
readiness of a school to adopt a new
school mental health program. Simi-
larly, school mental health programs
may be more successfully implement-
ed if there is minimal burden on in-
structional staff in schools, especially
given heightened pressures to per-
form under No Child Left Behind.
As evidence-based mental health
programs are implemented in the
school system, factors such as federal
and state policies that influence the
financing of school mental health pro-
grams can also greatly influence dis-
semination of evidence-based pro-
grams in schools. For example,
SAMHSA’s National Child Traumatic
Stress Initiative has supported the
dissemination of trauma-informed
best practices in community settings
such as schools (www.nctsn.org),
which has resulted not only in im-
proved quality of services in schools
for traumatized youths but also in sus-
tained services through community-
school partnerships (25,71). Similarly
the Mental Health Services Act in
California provides for additional
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funds through state taxes to support
the dissemination of mental health
care, including prevention and early
intervention services for children and
adolescents in school settings. By hav-
ing access to funding that does not
compete with education dollars,
schools may have more incentive to
support mental health services on
campus.
Conclusions
The President’s New Freedom Com-
mission report provides a launching
point from which school mental
health programs can expand the
scope and depth of child mental
health services. By delivering these
services in a naturalistic community
setting that minimizes some of the
barriers to accessing care for youths
and their families, school mental
health programs can play a critical
role in operationalizing the recom-
mendations of the New Freedom
Commission report, both in terms of
supporting the resiliency of youths
and providing effective services for
those who need mental health care.
The New Freedom Commission has
built upon previous federal initiatives,
such as the U.S. Surgeon General’s
reports on mental health (8,9) and the
Children’s Mental Health Confer-
ence (72), by emphasizing the need to
improve the dissemination of evi-
dence-based treatments in communi-
ty settings and increasing the aware-
ness of mental health issues across
child-serving agencies.
This article has outlined some of
the ways in which national school
mental health efforts are aligned with
the goals and recommendations of
the New Freedom Commission.
From this national agenda for trans-
forming mental health care in the
United States, several key strategies
have also been discussed in terms of
addressing these goals in schools, in-
cluding demonstrating relevance to
schools, developing consensus among
stakeholders, enhancing community
mental health–school connections,
building quality assessment and im-
provement, and transforming school
mental health services in the organi-
zational context of schools.
Implications for a research agenda
to support this transformation would
also involve greater collaboration
across academic disciplines and true
partnerships with community stake-
holders that inform the direction of
the research questions and the de-
sign, implementation, and dissemina-
tion of services in schools. If school
mental health programs are to im-
prove and expand effectively, joint ef-
forts by education and mental health
researchers toward the achievement
of both academic success and emo-
tional well-being for students are nec-
essary. Greater participatory research
with school-community partners can
enlighten the research agenda in such
a way that barriers to providing serv-
ices on campuses are reduced. Ap-
proaching mental health services in
schools through the lens of an educa-
tor, a student, or an administrator will
enhance the development of novel
approaches to address stigma, treat
co-occurring disorders, and prevent
suicide—all of which are relevant to
the school culture as well as cultural-
ly appropriate for the community be-
ing served.
Recent federal legislation to sup-
port mental health in schools reflects
progress in advancing the school
mental health agenda. Namely, the
Mental Health in Schools Act of
2007, introduced by Senators Dodd,
Domenici, and Kennedy, proposed
significant funding to local education
agencies to expand existing school
mental health efforts through com-
munity-family-school partnerships.
The bipartisan legislation emphasizes
a public health approach to mental
health that includes prevention and
promotion, positive behavioral sup-
ports, and targeted intervention and
stresses cultural and linguistic com-
petence. Further, the proposed legis-
lation underscores the importance of
program accountability by requiring
the use of evidence-based practices
and outcome measurement.
Two other recent Senate bills re-
flect critical federal support for
school-based services, including men-
tal health: Senate Bill 600, the
School-Based Health Clinic Estab-
lishment Act (introduced February
15, 2007) and Senate Bill 1669, the
Healthy Schools Act of 2007 (intro-
duced June 20, 2007). If passed, Sen-
ate Bill 600 would authorize the first-
ever federal program for school-
based health centers, the large major-
ity of which would include mental
health providers and all of which
would provide at least some level of
mental health care to students. The
Healthy Schools Act of 2007 similarly
supports the inclusion of mental
health services in school-based health
centers by ensuring procedures for
payment under Medicaid and the
State Children’s Health Insurance
Program to school centers certified
by the Department of Health and
Human Services. In addition, the leg-
islation recognizes that mental health
must be considered a part of compre-
hensive care by establishing a mini-
mum criterion for “primary health
services” as the core group of services
offered by school-based health cen-
ters, including comprehensive health
and mental health assessments, inter-
vention, and treatment. Together
with enhanced advocacy, effective
policy, and development of estab-
lished models of mental health care in
schools, federal legislation of this na-
ture is necessary to ensure that trans-
formation of the children’s mental
health system is inclusive of schools.
Acknowledgments and disclosures
This work was supported by cooperative agree-
ment U45-MC-00174-10-0 from the Office of
Adolescent Health, Maternal and Child Health
Bureau (Title V, Social Security Act), Health
Resources and Services Administration, with
cofunding from the Center for Mental Health
Services, Substance Abuse and Mental Health
Services Administration. It was also supported
by grant 1-R01-MH-71015-01-A1 from the
National Institute of Mental Health.
The authors report no competing interests.
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