Navigating school-based mental health services

Schools have become one of the largest providers of mental health services for children, who spend a large portion of their lives in the classroom, note the American Academy of Pediatrics (AAP).¹

An estimated 1 in 5 children have an emotional, mental, or behavioral disorder, and more than 75% of those children who are treated, are treated in school. School-based mental health services are more likely to lead to a child receiving service overall, states the AAP.²

Teachers or other school personnel may notice several mental health issues, which could lead to a discussion with parents, which in turn could result in a discussion with their pediatricians. Such discussions offer an opportunity for the provider and school to work closely together to benefit the child.

“Part of our job as pediatricians is to figure out [solutions] and support patients and families as they are navigating the process to make sure that their child can be successful,” said Nathaniel Beers, MD, MPA, FAAP, executive vice president of community and population health, and clinical professor of pediatrics at Children’s National Hospital in Washington, DC.

“That [includes] thinking with them about what services a child might be eligible for in school, as a child is spending most of their waking hours in school,” said Beers.

“If there are services that can help them be successful in school and…in life that we can help them access in the school day, that can be really beneficial. [This is] partly because the children are there so frequently and less likely to miss out on those services, and partly because there’s often spillover of those behavioral health issues into the classroom.”

According to the AAP, pediatricians should strive to build relationships with school-based providers to comanage children with mental health conditions. Many pediatricians agree with and strive for this goal, although it is not without challenges. Given the increasing number of responsibilities providers have taken on, paired with the crucial aspect of communicating with the school, navigating school-based services can prove difficult.²

“Medicine and education have different ways [of thinking] about children and [teenagers],” said James Wallace, MD, associate professor of psychiatry and pediatrics, University of Rochester Medical Center, New York, and child and adolescent psychiatry faculty trainer, The REACH Institute, New York, New York.

“Each uses different language, follows different laws and regulations, and uses different strategies to intervene,” said Wallace. “Therefore collaboration requires that both parties work hard to understand each other. Without collaboration and communication, there are always missing pieces.”

If students are on individualized education plans (IEPs) or 504 plans, it’s important that the pediatrician receives a copy to help with care. Beers said many children with attention-deficit/hyperactivity disorder or anxiety can qualify for these plans if they need extra time for testing or a quiet setting, rather than an alteration to their education on a greater level.

Implementing 504 plans or IEPs can require routine communication procedures such as the exchange of plan copies between schools and pediatrician offices. Wallace said there are ways to streamline the process to ease communication efforts.

“Pediatric offices could develop a liaison for schools (clerical, medical assistant, nurse) and schools could develop a liaison for medical offices (clerical, teacher on special assignment, school nurse, counselor, administrator),” said Wallace. “To follow confidentiality laws [eg, Health Insurance Portability and Accountability Act, Family Educational Rights and Privacy Act], having convenient releases of information and making routine communication an expectation are huge steps in the right direction.”³

“I think the reality is that it’s a very complex landscape, and there are wholly inadequate services across the whole mental health domain,” added Beers. “Part of our job in navigating that with a school is the school may have great support services when it comes to counseling. That counseling may be what the school is able to do, and the family may be willing to access those services. But they rarely have individuals who are willing or able to provide medication support, so it may be that the pediatrician is supporting the family in that space to make sure [that] if there is a pharmacological need that a child has, they are supporting that child and family in that space.”

Beers explains that part of the job also entails providing options and suggestions to families that may not want their child to receive school-based mental health services.

“If they feel like the school is going to be either too punitive or they’re worried about getting services on their [child’s] educational record, which can be a concern for some families,” noted Beers. “It’s [the pediatrician] understanding that while that may be the optimal setting, it may not be the best setting for that child and that family.”

These reasons, in addition to the potential limited availability of school-based resources, may lead to community-based approaches for families.

“Both schools and PCPs [primary care providers] should keep a list of providers in the community with whom they have had good experiences and share that resource list,” said Wallace. “Many states have [National Network of] Child Psychiatry Access Programs, where primary care providers can call to get a list of appropriate referrals.”⁴

These approaches can go hand-in-hand with school-based services or be a substitute if a school is lacking or has limited services. Wallace added, “Students often continue with their school-based counseling as they enter community-based services. Collaboration between these 2 providers, using the same language and skill building, can boost the impact of interventions and help generalize changes to more settings.”

The complexity of mental health services, especially in a school setting, can change with each child who is having trouble. Abrupt changes to behavior, mood, relationships, and academic performances can be signs for parents, teachers, and pediatricians.

Teachers may have an advantage in recognizing these signs because they spend so much time with the student. This acquaintance can help the child who needs or wants assistance.

“Familiar faces make it easier for students/patients and their families to disclose their concerns and seek help,” said Wallace, who added that the United States Preventive Services Task Force recommends universal screenings for suicidality, depression, and anxiety.5

“We must all be on the lookout for significant changes in mood, anxiety, aggression, relationships, and academic performance so we can help these students/patients and all children and [teenagers] get the help they need,” added Wallace.

For providers, adjusting and finding the best “fit” for the family is the top priority, according to Beers, who said these fits may look different for each child.

“It’s really thinking about where’s the best location for that child and family and recognizing that the patients and their families know themselves best,” said Beers. “If the family is expressing concerns to us as pediatricians, helping them get connected to services is an important part of what we can do. In some communities that means helping them overcome some stigma that may exist for them when it comes to accessing behavioral health services, and helping them normalize that for themselves.”

References:

1. Mental health in schools. The American Academy of Pediatrics. Accessed February 9, 2024. https://www.aap.org/en/patient-care/school-health/mental-health-in-schools/

2. School-based mental health: Pediatric mental health minute series. The American Academy of Pediatrics. Accessed February 9, 2024. https://www.aap.org/en/patient-care/mental-health-minute/school-based-mental-health/

3. Families thrive with good mental health. Project Teach. Accessed February 9, 2024. https://projectteachny.org/

4. Integrating physical and behavioral health care for every child. National Network of Child Psychiatry Access Programs. Accessed February 9, 2024. https://www.nncpap.org/

5. Mental health conditions and substance abuse. US Preventive Services Task Force. Accessed February 9, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?category%5B%5D=20&searchterm=