There is an urgency to improve accessibility of behavioral health services for children and families given both an increasing need and decreasing support. This special issue aims to advance our understanding of what works to make behavioral health services for children accessible through a collection of articles that examine the issue from research, policy, and practice perspectives. The five research articles included in this special issue examine the organizational and contextual features necessary to improve the accessibility of children’s behavioral health services, thus building upon the growing literature that can inform practice and policy. In addition, the special issue also includes three articles describing the practices and outcomes of innovative state and local community partnerships, with the goal of using practice to inform research and policy. The interconnectedness of research, policy, and practice—coupled with the need for ongoing communication in the arena of children’s behavioral health services—is further examined in the commentary that concludes this special issue. Taken together, the collection advances our understanding of how children’s behavioral health services can be more accessible to all, and provides a model for future integration across research, policy, and practice efforts.
The critical influence of behavioral health on child well-being has been widely acknowledged across research, policy, and practice arenas, yet a known gap persists between youth in need of behavioral healthcare and service receipt. For example, a 2013 report by the Centers for Disease Control and Prevention indicated mental disorders to be among the most prevalent health conditions for children (Perou et al., 2013), but substantial proportions never receive care (Merikangas et al., 2011; Olfson, Druss, & Marcus, 2015; Simon, Pastor, Reube, Huang, & Goldstrom, 2015). This is especially true for minority youth and youth experiencing elevated, but subclinical behavioral health concerns who might best respond to intervention efforts (Merikangas et al., 2011; Rapee, 2013; Simon et al., 2015).
School contexts have been repeatedly advocated as a potential setting to facilitate reducing the gap in identification, early intervention, and treatment access for behavioral health challenges (National Research Council and Institute of Medicine, 2009). Results of a recent meta-analysis by Sanchez and colleagues (2018) on the impact of behavioral health services delivered by school personnel without research involvement for elementary students support the use of schools as critical contexts for both access and service delivery. Findings of their meta-analysis demonstrating a small to medium effect on reducing behavioral health problems across a range of program foci (i.e., targeted, select) and components (e.g., service duration) are highly promising and further support the opportunity to promote delivery of behavioral health service in schools (Sanchez et al., 2018). However, critical questions regarding the roles that schools may best play continue to drive conversations and related agendas—whether it be that schools serve as a best setting for early identification (e.g., Olfson et al., 2015; Overstreet & Chafouleas, 2016), the setting for multi-tiered intervention delivered by school personnel or community-based providers (Barrett, Eber, & Weist, 2013) or both.
The vast majority of research to date in the area of school-based behavioral health services has focused on the development and testing of intervention programs to build our knowledge of what works. For example, several repositories of evidence-based programs exist for practitioners to search in relation to problem-specific programs, including the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (https://www.samhsa.gov/nrepp) and the U.S. Department of Education’s Institute of Education Sciences’ What Works Clearinghouse (https://ies.ed.gov/ncee/wwc/). Beginning in 1998, the Society of Clinical Child and Adolescent Psychology (Division 53 of the American Psychological Association) has published useful reviews and evidence-based updates for problem-specific programs and practices in the Journal of Clinical Child and Adolescent Psychology. Although building our repertoire of evidence-based practices in school-based behavioral and mental health services is necessary, an unintended consequence is that the efforts may impact a small proportion of youth in need (e.g., youth with pediatric elimination disorders; Shepard, Poler, & Grabman, 2017) and remain disconnected from one another given the problem behavior targeted.
Perhaps more importantly, the collective body of knowledge suggests only limited attention has focused on effective implementation and sustainment of services in school contexts, which means that the entire picture to inform policy and practice decisions is incomplete. This is particularly troubling in an era in which research funding for children’s behavioral health services is declining (Hoagwood et al., 2018) and children’s behavioral health needs are rising (National Academies of Sciences, Engineering, and Medicine, 2015). Thus, there is heightened demand to understand the system features and practices that make children’s behavioral health services accessible, effective, and efficient. To better inform policy, practice, and future research in this current context requires an increased attention to what is known to work and what is working in the current provider systems (Hoagwood et al., 2018). Therein lies the primary purpose of this special issue—that is, the articles in this issue of School Mental Health aim to (1) empirically elucidate the system features that make children’s behavioral health services accessible in the school context and (2) examine multi-system provider collaboratives working to overcome multiple barriers to meeting children’s behavioral health needs in schools. Articles in this special issue are organized around these two aims and concluded by a commentary further highlighting examples of the intersection of research, policy, and practice in efforts to improve children’s behavioral health services (Hoover, 2018).
Contexts and Systems Associated with Youth’s Access to Mental Health Services
Children and youth do not access behavioral health services within a vacuum. That is, access to and outcomes of behavioral health services are influenced by ecological and systemic factors, including youths’ personal characteristics; family, community, and cultural contexts; continuum of interventions and intervention settings available; and the organizational context of intervention settings (Weisz, Sandler, Durlak, & Anton, 2005). Any examination of access and/or receipt of mental health services must take these variables into consideration. The first two articles of the special issue consider the individual and school characteristics that predict behavioral health service receipt, while the influence of different organizational or intervention settings and the professionals, policies, and resources associated with each are considered in the three subsequent articles.
First, Splett and colleagues (2018) examined demographic and service receipt history differences between youth with different emotional and behavioral problem profiles. Their study relied on data from a multi-state, school-based intervention study for youth school personnel believed to be most impaired by emotional and behavioral problems (Kern, Evans, & Lewis, 2011). However, as many as a third of referred and consenting youth had never accessed behavioral health services and youth with internalizing behavior problems reported lower rates of service use across multiple school and community-based treatment options than those with any level of externalizing concern. In the second article, Whitaker, Nicodimos, and colleagues (2018) examined both service receipt and retention in services delivered via school-based health centers. Researchers found demographic differences between those who accessed and continued in school-based behavioral health services and those who did not, as well as significant contextual influences. That is, students in middle schools, schools with a lower student/teacher ratio, and schools with a smaller percentage eligible for free/reduced lunch were more likely to remain in the school-based behavioral health services.
Next, the remaining articles in this section of the special issue examined systems that support accessible and effective behavioral health services in schools. Beginning with the consideration of professional development needs, Romer, Green, and Cox (2018) examined the influence of educator preparedness to provide mental health supports and access to related training, resources, and coaching on whether or not educators talked with students about social or emotional concerns. Their findings should inform training priorities for educators and multi-system behavioral health collaboratives. Whitaker, Fortier, and colleagues (2018) compared two different implementation processes of the same evidence-based intervention strategy. They found very little difference between implementation adherence, perceived relevance, and acceptability/feasibility of a research-based intervention strategy called BRISC (Brief Interventions for School Clinicians; Lyon et al., 2015) when it was implemented by community-employed versus school-employed clinicians in two different settings. However, differences in referral rates, baseline behavioral health needs of referred youth, and outcomes emphasized the need for provider systems and policymakers to consider contextual factors early during the process of adopting and installing any intervention strategy. Finally, Briesch, Chafouleas, and Chaffee (2018) extended consideration of system implementation features to the examination of social, emotional, and behavioral screening guidelines established by state departments of education in the USA. Given the increasing promotion of behavioral health screening practices, the findings of their study are an important first step in understanding the influence of state-level priorities (or lack thereof) on local practice. Researchers found mentions of universal behavioral health screening to be limited, brief, and even nonexistent on most state-level Web sites leaving substantial room for improving macro-level guidance and support to local systems seeking to improve the efficiency and effectiveness of their provider system.
Multi-system Collaboratives to Improve Youth’s Access to Behavioral Health Services
The papers included in this section were purposefully solicited as brief reports that provide description of a program, practice, or initiative aimed at improving school-based access to behavioral health services through a multi-system collaborative approach. This includes partnerships of multiple systems or organizations (e.g., healthcare, education, child welfare) at state, county-wide, and school district levels using data-driven, collaborative practices to make behavioral health services for youth more accessible. Two papers represent collaborations at the state and county level focused on connecting and using data to improve system and student-level practices, whereas another paper describes a local district partnership intended to improve students’ access to community-provided psychiatric care within schools. For each paper, authors were asked to describe the theory of change or implementation framework, components of implementation, iterative implementation history, and results of service access and receipt. The discussion then focused on implications for research and practice, with the intent that readers could reflect on these innovative ideas in extending their own work.
In the first paper of this section, Williams and colleagues (2018) focused on increasing our understanding of factors associated with the implementation of targeted interventions in schools. Using data collected through a statewide measurement system of school health best practices, the authors explored the association between collaboration with community-based mental health centers and the use of targeted interventions in schools. Results demonstrated that schools who engaged in cross-sector collaborations were more likely to include targeted mental health programming among their school-based service delivery options than schools who did not. In the second paper, Reinke and colleagues (2018) described the efforts of a multi-disciplinary and cross-sector coalition working to improve data-based systems for early identification, prevention, and the use of evidence-based practices related to youth behavioral health. The authors focused on the description of the coalition, and the initial processes and procedures involved in building a comprehensive data-based model for using screening data at county, district, school, grade, and individual student levels. And finally, in the paper authored by Herman, Cho, Marriot, and Young Walker (2018), the Bridge program is described, which was specifically developed in response to local needs assessments indicating lengthy delays between referral and receipt of services. The Bridge program was designed to reduce barriers around timely access to psychiatric services for youth by delivering cost-free interim psychiatry service in schools until outpatient community-based services are accessed. In the first year, results supported substantial drop in wait time (10 days compared to typical 8 weeks), with parent and teacher ratings supporting symptom improvements in one or more areas. Taken together, the papers in this section collectively facilitate our thinking about policy and practice possibilities in reducing barriers to youth behavioral health access through engaging cross-sector collaborations with common goals.
Advances Made and Remaining Gaps
As recently noted by Hoagwood and colleagues (2018), the absence of national cross-system policy in behavioral health for children establishes a unique set of pressing concerns and questions whether the landscape of children’s unmet behavioral health needs is going to change. Although knowledge and acceptance of evidence-based practices has increased, gaps remain related to how these practices are integrated and used in systems given their typical problem-specific, research-driven nature (Splett & Maras, 2011). Reducing these gaps around access and practice implementation is a substantial challenge in the context of federal funding portfolios that favor neuroscience and basic behavioral research over children’s mental health service research and decreased reimbursement for such services (Hoagwood et al., 2017, 2018). Research focused on the systems needed to reduce these gaps is critical to informing policy and practice arenas tasked with making decisions about behavioral health services for children and youth in this challenging context. In response to this call, the collection of articles presented in this special issue aims to continue building upon our understanding of the context in which behavioral health services in schools are accessible to all children and families.
A well-known gap between research, practice, and policy exists, and translating research into practice and policy has been a persistent problem in the research arena. In this issue, we have also aimed to consider the gap from an alternate lens by evaluating practice to inform research and policy. Despite national challenges in research and service funding, state and local communities are tasked with finding innovative new ways to address the increasing need for providing accessible behavioral health services to children and families. As demonstrated by evaluations of the County Schools Mental Health Coalition (Reinke et al., 2018), Bridge program (Herman et al., 2018), and Colorado Healthy Schools Smart Source (Williams et al., 2018) in this special issue, there is a great deal of promising practice occurring nationally and even internationally. The closing commentary provided by Dr. Sharon Hoover, Associate Professor of Child and Adolescent Psychiatry, at University of Maryland School of Medicine and Co-Director of the National Center for School Mental Health, highlights additional examples of this work and emphasizes the need for an improved communication between researchers, practitioners, and policymakers.
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Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants performed by any of the authors.
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Splett, J.W., Chafouleas, S.M. & George, M.W.R. Accessing Behavioral Health Services: Introduction to a Special Issue of Research, Policy, and Practice. School Mental Health 10, 91–95 (2018). https://doi.org/10.1007/s12310-018-9262-7
- Research to practice
- School mental health
- Children’s behavioral health services
- Service receipt
- Access to school mental health services