1
Chapter 1: Introduction to the Study
Twenty to twenty-five percent of children are estimated to have mental health
needs, yet only about one-third of them receive mental health services (Merikangas et al.,
2010; Merikangas et al., 2011). The Centers for Disease Control (CDC, 2013) reported
that between 13% and 20% of children experience a mental disorder annually. As many
as 50% of children ages 13 to 18 were reported have had a mental disorder in their
lifetime (CDC, 2013). Of those experiencing mental illnesses, 28% were noted to have a
severe impairment (CDC, 2013). Children’s unmet mental health needs can have a
significant impact on their ability to function. Children with mental health problems have
lower levels of academic achievement and educational attainment (Forest, Bevans, Riley,
Crespo, & Louis, 2011; McLeod, Uemura & Rhorman, 2012). Additionally, children with
mental health problems are more likely to have behavior and conduct problems, including
delinquency and school absenteeism (CDC, 2013; McLeod et al., 2012). Rates for the
use of alcohol, tobacco, and illicit drugs as well as suicidal thoughts and behavior are also
increased among children with mental health problems (CDC, 2013; Heneghan et al.,
2015).
Numerous barriers to community-based services exist. Barriers to services are
often financial, such as low income or lack of access to public or private insurance
(Alexandre, Dowling, Laris & Rely, 2008). The location and availability or the
appropriateness of programs or services can also be a barrier (Cummings, Wen & Druss,
2013; Wood, Chiu, Hwang, Jacobs, & Ifekunigwe, 2008). Dissatisfaction with providers,
lack of collaboration between community agencies, and the stigma of mental illness also
2
interfere with help seeking in the community (DeRigne, 2010; Garcia, Circo, Denard &
Hernandez, 2015; Thoits, 2011). Community-based mental health services have not been
sufficient to meet the mental health needs of children.
Support for expanding school-based mental health services for children has
grown, given that children spend the majority of their day in the school setting. Symptom
improvement appears to be similar for children receiving school-based and community-
based services; however, school-based programs have been found to have significantly
lower levels of attrition than community-based programs (Armbruster & Lictman, 1999;
Husky et al., 2011). Results from a longitudinal research study indicated that children
with mental health problems were more likely to receive services in the education system
as opposed to community or medical settings (Farmer, Burns, Phillips, Angold &
Costello, 2003). When services were initiated within community mental health, children
were more likely to seek services in education and medical settings. However, children
who initiated services in the education system were less likely to be connected with
services outside the educational setting (Farmer et al., 2003). Given that a school may be
the first and only location for mental health service delivery, it is troubling that mental
health personnel in the school setting have reported that their numbers are too few to
meet demand (Brener, Weist, Adelman, Taylor, & Vernon-Smiley, 2007). They also
reported insufficient training to provide mental health services (Brener et al., 2007).
Furthermore, collaboration between school and community mental health providers in
meeting children’s needs has been limited (Walsh, 2013).
3
The Individuals With Educational Disabilities Improvement Act (IDEA, 2004)
requires that schools identify and provide services to children with disabilities. Special
education services are necessary when disabilities impact students educationally, causing
them to need specialized instruction to make educational progress. Schools have a
responsibility to meet the emotional needs of students. Barriers to providing mental
health services to students within the school setting include role strain, lack of support
from administration, and lack of training in mental health service delivery (Suldo,
Friedrich, & Michalowski, 2010). Increasing collaboration between school- and
community-based mental health professionals may allow school and community
organizations to share responsibility for meeting children’s needs.
Even when school-based providers have training in evidence-based mental health
practices, implementation often does not occur (Langley, Nadeem, Katoaka, Stein, &
Jaycox, 2010). Support from community mental health service providers could help to
improve the number of children receiving services, but there is limited collaboration
between school and community mental health providers (Brener et al., 2007). Husky et
al. (2011) found that a well-developed screening and referral process improved students’
likelihood of accessing school-based services. However, community-based mental health
services were infrequently sought when students were referred for additional services by
school-based providers (Husky et al., 2011). Students appear to be more likely to access
and continue services when these services are available in the school setting.
4
Background of the Problem
Data from the National Comorbidity Survey—Adolescent Supplement (NCS-A),
a survey of adolescents aged 13 to 18, indicated that 1 in every 4 or 5 youths met the
criteria for a mental disorder (Merikangas et al., 2010). Anxiety disorders were most
commonly reported. Behavior disorders, mood disorders, and substance use disorders
were also prevalent (Merikangas et al., 2010). Twenty-two percent of survey participants
experienced severe impairment. Many of these individuals did not receive mental health
services to treat their mental health symptoms. Merikangas et al. (2011) reported that half
of individuals with mental disorders who described severe impairment had not received
treatment. Service rates were better, about 60%, for those with attention
deficit/hyperactivity disorder (ADHD). About one-third of adolescents reporting had
accessed services for their mental illness. Black and Hispanic teens were less likely than
White, non-Hispanic teens to receive services for anxiety or mood disorders, even when
reported impairment was more severe (Merikangas et al., 2011). Based on these data, it
appears that the majority of children with mental disorders do not receive any mental
health services. The problem is more significant for Black and Hispanic teens than White,
non-Hispanic teens (Merikangas et al., 2010). Issues of stigma or negative cultural
perceptions of help-seeking behavior or mental health professionals may cause these
differences (Merikangas, 2011). Financial costs or problems related to insurance or
accessibility of services may also be to blame (Merikangas, 2011).
Given the difficulty children have accessing mental health services, the public
school system has been identified and supported as a practical location for the delivery of
5
mental health services (Soleimanpour, Geierstanger, Kaller, McCarter, & Brindis, 2010).
Brener et al. (2007) reported on the CDC’s School Health Policies and Programs Survey
(SHPPS). This survey is conducted every 6 years in the U.S. with personnel in
elementary, middle, and high school. Surveys conducted at the state and district levels
address topics including collaboration, provision of services, evaluation of school-based
mental health services, and credentials for required personnel. Survey responses indicated
that three-fourths of schools had counselors available at least part time. Two-thirds of
schools had school psychologists at least part time. Less than half of schools reporting
had social workers (Brener et al., 2007). These data were similar to those collected in
2000. Schools were more likely to deliver counseling services than comprehensive
assessment or intake (Brener et al., 2007). When schools used community-based
providers, services were mostly delivered off of school property. Less than half of the
schools that responded to the survey had arrangements with providers of mental health
services to provide services to children (Brener et al., 2007). Too few mental health
providers were found to be employed by public education agencies, and school
professional’s connection with outside agencies was determined to be insufficient (Brener
et al., 2007). Schools are not able to independently meet the needs of children and
frequently do not assist children in accessing community resources.
In a follow-up to the SHPPS completed in 2012, Demissie, Parker, and Vernon-
Smiley (2013) reported that improvement in state- and district-level policies had
occurred. An increase in the number of policies that support school-based mental health
were reported. Greater collaboration between school and community health and mental
6
health agencies was also reported. However, inconsistency was noted at the state and
school district levels, and policies continued to favor separate rather than comprehensive
and collaborative support systems for children (Demissie et al., 2013). No quantitative
data were available to determine the frequency with which collaboration occurred.
Green et al. (2013) analyzed data from the U.S. National Comorbidity Survey—
Adolescent Supplement (NCS-A), in which a small sample of school principals or mental
health coordinators responded to surveys about school resources for students with
emotional needs. In an analysis of this information in conjunction with reports from
adolescent and parent interviews, it was found that almost half of adolescents with a
diagnosis from the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) received some school-based mental health service. Identification of
less severe mental health problems resulted in greater mental health service use among
adolescents with both mild and moderate mental disorders. A higher ratio of mental
health providers to students was associated with increases in the use of community-based
mental health services among students with DSM-IV diagnoses (Green et al., 2013).
Increasing availability of mental health services for children with mental disorders is
necessary to improve student outcomes.
Suldo et al. (2010) identified factors related to the delivery of school-based
mental health services in schools by school psychologists. Thirty-nine school
psychologists in two southern school districts reported on barriers to providing mental
health services to children during the school day. Primary barriers to providing school-
based mental health services were difficulties in using the school for service delivery,
7
problems with school district or department support, and problems working with other
school staff members (Suldo et al., 2010). Barriers also included inadequate training and
role strain. Even when school-based mental health professionals have proper training,
barriers to the delivery of mental health services persist. Langley et al. (2010) identified
competing responsibilities, problems with parent engagement, logistical issues (e.g.,
finding space, scheduling, interruptions), and lack of support from school administrators
and teachers as barriers to the implementation of a group crisis intervention.
Despite the difficulties that schools have in meeting the mental health needs of
their students, they are in an excellent position to identify students in need of mental
health services. Identification of children who have unmet mental health service needs
has been useful as a bridge to treatment in the school setting. Husky et al. (2011) studied
referral processes for identifying students in need of mental health services. To determine
if a screening procedure would be more efficient than the usual referral process for
identifying students in need of services, the researchers screened randomly assigned
students in a public education agency to be part of a screening group. Members of the
control group did not participate in screening activities and were referred as usual by
school personnel (Husky et al., 2011). Significantly more students were referred based on
the screening/interview process than were referred by school personnel. Most of the
students were referred through screening and school personnel initiated services in the
school setting. Among those who were referred by the school for additional services in
the community, very few sought those services (Husky et al., 2011). The screening
process was superior for identifying students in need of services, but limited success was
8
found with referrals to community mental health (Husky et al., 2011). This is consistent
with the findings of Farmer et al. (2003) and Tegethoff, Stalujanis, Belardi, and
Meinlschmidt (2014). Improved collaboration between school and community-based
mental health service providers may improve children’s access to services when they are
provided in the school setting.
Collaboration in mental health has become a necessity in order to coordinate
services. The Center for Mental Health Services (CMHS), Substance Abuse and Mental
Health Services Administration (SAMHSA), and U.S. Department of Health and Human
Services (DHHS; 2013) organized the Children's Mental Health Initiative to improve
collaboration and coordinated care in children's mental health treatment. Operated under
the Systems of Care Philosophy, the Children’s Mental Health Initiative emphasizes
several principles for service delivery, including coordinated care though
interprofessional collaboration (CMHS, SAMHSA, & DHHS, 2013). Outcome data
suggested that the Children's Mental Health Initiative improved access to services for
underserved children and youth (CMHS, SAMHSA, & DHHS, 2013). Brannan,
Brashears, Gyamfi, and Manteuffel (2012) found that interprofessional collaboration was
one of the most difficult aspects of the Children’s Mental Health Initiative to realize. Few
or no services were available as part of a collaborative, multiagency initiative (Brannan et
al., 2012).
Interprofessional collaboration is also referred to as integrated care and
multiagency, multidisciplinary, interdisciplinary, cross-disciplinary, or interagency
collaboration (Odegard & Strype, 2009). In children's mental health, it refers to multiple
9
team members from different organizations or professions working together to support
children and their mental health needs. Improved interprofessional collaboration among
mental health service providers in school and community settings may increase children’s
access to mental health services and reduce pressure on school mental health
professionals to carry the burden of meeting the mental health needs of children. To
identify the factors that impact collaboration, Odegard (2005) conducted a qualitative
study of interprofessional collaboration in the mental health treatment of children in
Norway. Participants were school psychologists, teachers, a psychologist, and a medical
doctor, each with experience engaging in collaboration. Having a positive attitude
toward other professionals, understanding one another's roles, and having a common
understanding of the child's problems were factors identified as helping to facilitate
collaborative relationships (Odegard, 2005). Evaluating the collaborative process and
having leadership within the collaborative relationship were also reported to improve
collaboration (Odegard, 2005). Limiting factors that were noted included poor
leadership, unclear aims, different understandings of the problem, different professional
backgrounds, limited understanding of one another's roles, time pressures, a heavy
workload, and high turnover rates (Odegard, 2005).
Odegard (2006) surveyed Norwegian school and community mental health
professionals experienced in collaboration to assess their perceptions of interprofessional
collaboration across individual, group, and organizational aspects of the collaborative
process. Factors were classified as individual, group, or organizational (Odegard, 2006).
Individual factors included motivation, role expectations, personality style, and
10
professional power. Group factors included group leadership, coping, communication,
and social support. Organizational factors included organizational culture, organizational
goals, organizational domain, and organizational environment. Collaborating teachers,
special educators, psychologists, social workers, primary nurses, medical doctors, child
welfare workers, and other professionals working with children were later surveyed. The
results suggested that motivation was identified by participants as the most important
individual factor in interprofessional collaboration (Odegard & Strype, 2009). Among
group factors, leadership and social support were identified as most salient. At the
organizational level, the organizational culture was identified as most important to
participants’ attitudes about collaboration (Odegard & Strype, 2009). Differences were
noted based on workplace; school personnel were less likely to view organizational
culture as an important factor (Odegard & Strype, 2009).
Despite the establishment of policies that favor collaboration and the body of
research in support of collaboration in the delivery of mental health services for children,
collaboration between school and community mental health providers continues to be
limited in the U.S. Walsh (2013) conducted a national survey of school psychologists
and found that 25% reported that they did not engage in any collaboration with
community mental health professionals. Fifty percent did collaborate on average about
once per month (Walsh, 2013). Twenty percent reported collaboration more than once
per month. Barriers reported included time constraints, problems accessing community
providers, difficulty obtaining parent permission, turnover among community mental
health professionals, and having no information about community providers (Walsh,
11
2013). School psychologists with a higher number of hours of training in
interprofessional collaboration reported higher levels of collaboration with community
providers (Walsh, 2013).
Research about collaboration between school and community mental health
providers in the provision of services to children has helped to identify factors that impact
collaboration. Specifically, it appears that important individual, organizational, and group
characteristics can interfere with or support collaborative efforts. Research data have
largely been collected from inquiries to a particular group of providers (e.g., school
psychologists) or through program evaluation following a specific collaborative initiative.
More information is needed to determine what individual and organizational factors are
necessary for mental health providers in the school and community settings to initiate and
sustain collaborative efforts to meet children’s mental health needs.
Statement of the Problem
The problem of unmet mental health needs is one of the most critical issues facing
the nation’s youth (Merikangas et al., 2011). Children with mental health problems have
lower levels of educational success and more problems with delinquency, suicidality, and
substance use (CDC, 2013; Forest et al., 2012; Heneghan et al., 2015; McLeod et al.,
2012). These problems can persist into adulthood. Difficulties exist in identifying youth
with mental health needs and in helping those children connect with available services
(Farmer et al., 2003; Husky et al., 2011; Tegethoff et al., 2014). Barriers to community-
based mental health services particularly impact children from lower income families and
those from minority ethnic groups (Alegria et al., 2012; DeRigne, 2010; Kodjo &
12
Auinger, 2004). Some of these barriers are eliminated when mental health services are
available in the school setting; however, too few mental health service providers with
adequate training and support are employed by schools to meet the demand (Cummings,
Ponce, & Mays, 2010; Slade, 2002; Suldo et al., 2010; Walsh, 2013).
One way to meet the mental health needs of children is to increase collaboration
between agencies that support them. Improving collaborative efforts to identify children
with unmet mental health needs and increasing the ability to offer services within the
school setting has the potential to significantly improve outcomes for children (CMHS,
SAMHSA, & DHHS, 2013). Despite this, limited collaboration exists between school
and community mental health providers. Much of the information about factors that limit
and facilitate collaboration comes from studies that are designed to evaluate a particular
program or from studies that focus on information collected from a particular group of
mental health providers (Beckles, 2009; Brown, Dahlbeck, & Sparkman-Barnes, 2006;
Cross, 2013; Douglas, 2001; Kvarnstrom, 2008; Massey, Armstrong, Boroughs, Henson
and McCash, 2005; Walsh, 2013). It is necessary to understand the factors that facilitate
collaboration among school and community mental health providers outside of a program
evaluation by understanding the experiences of school- and community-based mental
health professionals and administrators with various levels of experience building
collaborative relationships.
Purpose of the Study
The purpose of this qualitative study was to understand the factors that may
improve school and community mental health service providers’ ability to initiate and
13
sustain collaboration in the provision of services to children. The study was primarily
phenomenological in nature, and its purpose was to understand the experiences of mental
health professionals. For this study, focus groups were made up of school counselors,
school psychologists, school social workers, and community-based counselors,
psychologists, and social workers. School district and mental health organization
administrators were also included in focus groups to develop an understanding of the
organizational policies that favored or constrained the fostering of collaborative
relationships as well as to understand participants’ experiences as leaders, including their
understanding of and stances on collaborative relationships. Participants engaged in
discussion about the factors involved in collaborating with one another in the provision of
services for children. Individual interviews supplemented information obtained through
focus groups.
Research Questions
The research questions were the following:
• What are the factors that may facilitate the initiation of collaborative
relationships, outside of program requirements or mandates in the provision of
services to children?
• How can the known barriers to collaboration be overcome to increase the
development of collaborative relationships?
• What differences exist between school- and community-based mental health
service providers in how they view collaboration in serving children with
mental health needs?
14
• What differences exist between service providers and administrators in how
they view collaboration in serving children with mental health needs?
Theoretical and Conceptual Framework
This investigation is justified by the theoretical framework, which places the
development of children’s mental health in ecological perspective. Bronfenbrenner's
ecology of human development views the child through his or her interactions with the
multiple systems and contexts with which he or she comes in contact (Bronfenbrenner,
1979). The microsystem consists of those in the immediate environment, including
family, peers, neighbors, members of the school community. The mesosystem
encompasses the interaction of systems (e.g., home and school, school and community,
home and community). The exosystem includes the environments that impact the child,
but in which the child is not directly involved. The exosystem could include the parent's
work environment, local politics, social services, and school administration. The
macrosystem includes the beliefs and values of the culture. Finally, the chronosystem
involves the passing of time and how historical events outside of all systems can impact
development (Bronfenbrenner, 1994). When compatibility exists among systems and
contexts, the child's development is even. Difficulties, including the development of
mental health problems, may be experienced when expectations among the systems and
contexts are inconsistent and goals are not aligned.
This study was primarily concerned with the mesosystem and the interaction of
the school and community systems as a way to improve mental health in children. The
systems of care model was developed by SAMHSA out of a need to improve mental
15
health services for children. Class action lawsuits against state agencies including
juvenile justice systems, child welfare systems, education systems, and state Medicaid
systems became more frequent due to fragmented and delayed services and due to
agencies forcing parents to relinquish custody of children in order to access mental health
services (Pumariega, Winters, & Huffine, 2003). The establishment of the Children’s
Mental Health Initiative was intended to improve access and comprehensive mental
health treatment to children in need. The key principles of the systems of care
philosophy require that the child have access to early identification and intervention, as
well as individualized, culturally sensitive, nondiscriminatory, and comprehensive
treatment in the least restrictive environment, with case managers serving as advocates
who ensure collaboration among service sectors or agencies and families for the planning
of services and transition to adult services as needed (Miller, Blau, Christopher, &
Jordan, 2012; Pumariega et al., 2003). Outcomes assessed as of 2013 suggested that
children with services delivered under a systems-of-care approach improved their ability
to develop relationships, manage emotions, function in schools (fewer suspensions and
better grades) and at home, and manage anxiety, in addition to decreasing suicide
attempts and ideation (CMHS, SAMHSA, & DHHS, 2015). Increasing collaboration
among school and community mental health providers has the potential to improve
outcomes for children. Understanding the difficulties in initiating and sustaining
collaborative relationships outside program requirements and mandates is important to
this problem. In order to overcome barriers, it is necessary to develop a better
understanding of the factors that can facilitate collaboration.
16
Significance of the Study
The current view of mental health is that mental health is not merely the absence
of mental illness, but a positive sense of mental well-being (Antaramian, Huebner, Hills,
and Valois, 2010; Herrman, Saxena, & Moodie, 2005). Flourishing involves accentuating
the positive by increasing positive emotions, improving emotional well-being, and
increasing satisfaction and success in life (Keyes, 2007). Keyes (2007) noted that it is
important that people have a sense of belonging and comfort within their community, that
they engage in activities that are valued by others, and that they accept others. For teens,
the indicators of flourishing include psychological and social well-being, autonomy,
environmental success, self-acceptance, personal growth, life purpose, and positive
relationships (Keyes, 2006). Moderately mentally healthy teens have few mental
problems but do not have characteristics of flourishing, whereas those who are
languishing have mental health problems (Keyes, 2006). It is imperative to have systems
in place to identify students with mental health problems as well as those who are not
flourishing. Providing interventions for these children can improve their opportunity to
thrive, thereby improving lifelong outcomes. Mental health services may improve
children’s opportunity to achieve a state of well-being.
Barriers to community-based services interfere substantially with children’s use
of these services. For example, Alexandre, Dowling, Stephens, Laris, and Rely (2008)
found that children were more likely to use community-based services if their symptoms
were severe, if delinquent behavior was present, and if they had substance use disorders.
Children with less serious mental health problems did not receive treatment and may
17
have been at greater risk for worsening of mental health problems without support
(Alenxandre et al., 2008). Children from low-income and ethnic minority groups are
disproportionately affected by barriers to community-based services. Parents reported
that cost and health insurance coverage problems were primary barriers to mental health
treatment (Derigne, 2010). Children were more likely to use services if they came from
homes where household income was higher or if they were eligible for Medicaid
(Alexandre et al., 2008).
Cultural values and stigma also reduce treatment seeking for psychological
problems. African American children use fewer services than Caucasian children with
similar needs (Leslie, Hurlburt, Landsverk, Barth, and Slymen, 2004). Mexican American
families use fewer services or end treatment sooner due to the stigma within the culture
surrounding treatment for mental problems (Wood, Chiu, Hwang, Jacobs, & Ifekunigwe,
2008). It is necessary to improve access to treatment and eliminate barriers to treatment
that are present in community-based settings.
One way to eliminate barriers to treatment is to make treatment available where
students are—in schools. Outcomes for school-based mental health services have been
positive overall. Numerous studies have found that providing mental health services in
the school setting resulted in positive outcomes. Participation in school-based mental
health services is associated with a reduction in disciplinary referrals, decreased school
absenteeism, better grades and fewer course failures (Jennings, Pearson, & Harris, 2000;
Kastan, 2003; Walker, Kerns, Lyon, Bruns, & Cosgrove, 2010). Evidence-based therapy
provided within the school setting has also been demonstrated to reduce anger and
18
depressive symptoms, to improve social skills (Flanagan, Allen, & Henry, 2009), to
increase frustration tolerance, to reduce irrational thoughts (Vaida, Kallay, & Opre,
2008), and to improve psychosocial competence and resilience (Srikala & Kishore,
2010). Outcomes for school- and community-based mental health services have been
found to be similar, with lower levels of attrition noted in school-based programs
(Armbruster & Lictman, 1999; Husky et al., 2011). School-based mental health services
have been demonstrated to meet children’s mental health needs when they are available.
Barriers to implementation of evidence-based interventions within the school day
occur due to lack of training among school-based mental health professionals, role strain,
and lack of support by school administration (Suldo et al., 2010). Barriers make
collaboration with community-based mental health providers necessary to meet the needs
of children to improve their opportunities to flourish academically, psychologically,
socially, and behaviorally. Improvements in collaboration between school and
community mental health professionals can help to bridge gaps in school-based mental
health and improve children’s emotional health and ability to flourish. In line with the
efforts of the CMHS, SAMHSA, and DHHS (2013) to improve children’s mental health,
Blau, Christopher, and Jordan (2012) and Hodges, Ferreira, and Israel (2012) concluded
that in order to meet the needs for children's mental health services, systems-level change
is necessary to ensure the provision of comprehensive mental health services. It is
necessary to improve school and community collaboration and increase interprofessional
collaboration to expand the availability of mental health services for children. It is
necessary to understand the factors that facilitate the initiation of sustained collaboration
19
between school and community mental health providers to improve children's
opportunities to flourish.
Summary
Of the 20% to 25% of children who have mental health needs, two-thirds are not
accessing mental health services. Community-based mental health services are available,
yet barriers to accessing these services include problems with insurance, cost, availability
of appropriate services in the community, transportation, culture, providers, and
interprofessional collaboration. The use of school-based services has been proposed as an
alternative, given that students are present within the school setting. However, barriers
such as having too few mental health personnel, inadequate training, lack of support from
school district administration, and problems with collaboration between school and
community mental health providers have been cited.
Meeting children's mental health needs requires collaboration between school and
community mental health providers to provide comprehensive care and improve
outcomes for children. Although recent increases in collaboration have been reported
(Demissie et al., 2013), it is not clear whether this has improved the comprehensive
delivery of services between school and community agencies or what impact it has had
on outcomes for children. It could be that collaboration has increased because school-
based mental health providers are providing fewer services to children. It is clear that
providing a systematic way of identifying children with mental health needs can lead to
greater use of mental health services (Husky et al., 2011). When services are available
within the school setting, they are accessed more often than when schools refer to
20
community-based services (Farmer et al., 2003; Husky et al., 2011; Tegethoff et al.,
2014). Additionally, having services available in the school setting appears to reduce
racial/ethnic disparities in service use (Cummings et al., 2010).
Improving interprofessional collaboration to provide mental health services is a
way to remove barriers and reduce the costs associated with the provision of mental
health services. Literature on Norwegian interprofessional collaboration suggests that the
most salient factors relevant to sustaining collaborative efforts include organizational
factors such as organizational culture and organizational goals; group factors, particularly
leadership; and individual factors such as professional power and motivation for
interprofessional collaboration (Odegard & Strype, 2009). As many as 25% of school
psychologists in the U.S. report that they do not engage in any collaborative relationships
with community mental health providers (Walsh, 2013). It is necessary to determine the
factors that are needed to initiate sustained interprofessional collaboration between school
and community mental health providers in order to meet children’s mental health needs.
This study was phenomenological and used Bronfenbrenner's ecology of human
development as its backdrop. Focusing primarily on the mesosystem, which includes the
interaction of systems surrounding the child, such as home, school, and community, the
study was designed to identify factors that may encourage sustained interprofessional
collaboration and improve systems interactions to better meet the mental health needs of
children.
21
Chapter 2: Literature Review
The New Freedom Commission on Mental Health (2003) assessed the state of
mental health in the U.S. and offered this recommendation:
To transform the mental health care system, the Commission proposes a
combination of goals and recommendations that together represent a strong plan
for action. No single goal or recommendation alone can achieve the needed
changes. No level or branch of government, no element of the private sector can
accomplish needed change on its own. To transform mental health care as
proposed, collaboration between the private and public sectors and among levels
of government is crucial. (p. 86)
This transformation would involve helping Americans understand that mental health and
well-being are necessary for overall health. It would also make mental health services
consumer and family driven and would aim to eliminate disparities. Implementation of
screening, assessment, and referral practices would help in the early identification of
mental health needs. Technology would be used to improve access to mental health
records and to enhance the dissemination of research-based treatment (New Freedom
Commission on Mental Health, 2003). An effort to create a comprehensive system of
mental health services would not be complete without consideration of the unique needs
of children or without collaboration between school and community mental health
providers in their support of children with mental health needs.
The Department of Health and Human Services (2000) suggested that greater
collaboration among public organizations was needed to improve the state of children’s
22
mental health. Several goals were identified to improve the ability to meet children’s
mental health needs (Department of Health and Human Services, 2000). For one thing,
there is a need to reduce the stigma of help-seeking behavior by promoting awareness and
to eliminating cultural and socioeconomic disparities in access to treatment. Schools are
in a position to promote awareness of mental health problems and reduce stigma
(Livingston, Tugwell, Korf-Uzan, Cianfrone, & Coniglio, 2013; O'Mara et al., 2013).
Further, an overarching goal is to reduce financial costs by increasing coordination of
services and improving the public infrastructure to support treatment (Department of
Health and Human Services, 2000). There must be efforts to train frontline providers to
recognize and manage children's mental health issues, improve assessment and diagnosis,
and implement scientifically proven prevention and treatment (Department of Health and
Human Services, 2000).
Given the difficulties in meeting children’s mental health needs, it is necessary to
consider how collaboration between different sectors can reach more children than is
currently the case. Schools are well situated to identify students with mental health needs
and to provide improved access to evidence-based interventions to improve mental
health. In 1975, U.S. Public Law 94-142 was first initiated, which required that children
with disabilities have access to a free and appropriate public education. Children with
disabilities that impact them educationally have the right to an Individualized Education
Program (IEP) identifying goals and services to help them meet educational
requirements. Disabilities can include health impairments (including mental health
problems) and emotional disturbances. Subsequent reauthorization of the IDEA (2004)
23
has stipulated that students who fail to respond to research-based interventions may also
need supports and services.
There are clear initiatives put forth that indicate the need for greater collaboration
in the provision of children's mental health services. The goal of collaboration should be
to improve children's ability to access mental health services and improve children’s
chances to reach a state of well-being. It is necessary to define children's mental health, to
assess the impact of children’s mental health problems, and to understand how the
identification of children’s mental health concerns takes place. Next, it is necessary to
consider the barriers to community-based mental health services. It is also important to
examine the effectiveness of school-based mental health services for children and the
barriers to services in the school setting. Finally, it is necessary to determine the state of
interprofessional collaboration in the provision of children's mental health services.
Literature Search Strategy
To conduct an exhaustive literature review, I used several research databases
available through the Walden Library. These included PsycINFO, ERIC, SAGE Premier,
Academic Search Complete, and ProQuest Central. In addition, Google Scholar was
linked to the Walden Library and was used to further the search for journal articles.
Government sites including those of the CDC, SAMHSA, and DHHS were also used to
obtain information on relevant findings and statistics associated with the research topics.
Several search terms were used to identify information on interprofessional
collaboration and children's mental health. Children and mental health yielded many
relevant records using the Walden library databases. School mental health, community
24
mental health and children, adolescent mental health, and expanded school mental health
were all used to find records describing the research in each of these areas. Search terms
for interprofessional collaboration also included interagency collaboration, school
community collaboration, interprofessional collaboration and mental health, and
collaboration and mental health.
Searches were also used to identify sources using phenomenological research and
focus groups. The terms phenomenology and focus groups, phenomenology and
interprofessional collaboration, focus groups and interprofessional collaboration, and
phenomenology and validation of findings were all used to identify relevant research
studies.
Children’s Mental Health
The World Health Organization defines mental health as “a state of well-being in
which the individual realizes his or her own abilities, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make a contribution to his or her
community” (Herrman et al., 2005, p. xviii). Improving outcomes for children requires
not only ensuring the absence of mental health problems, but also assuring a degree of
well-being, which is needed to move toward favorable outcomes (Keyes, 2006). This
study used the World Health Organization definition of mental health.
Antaramian, et al. (2010) assessed mental health and mental well-being in the
school setting. At-risk students (low subjective well-being and few mental health
symptoms) and troubled students (low subjective well-being, high mental health
symptoms) had lower levels of academic engagement. Students with more mental health
25
symptoms but high perceptions of well-being performed more poorly than students with
both positive mental health and positive sense of well-being (Antaramian et al., 2010).
Students who reported high subjective feelings of well-being who were also free from
psychological symptoms performed the best academically and were the most engaged
(Antaramian et al., 2010). Students with positive well-being, even if they had mental
health symptoms, had better social relationships and environmental supports (Antaramian
et al., 2010).
It is important to identify those with significant mental health needs as well as
those who are at risk for adverse outcomes. Interventions should be considered for
students with psychological symptoms and with low subjective well-being. Regular
student monitoring for mental health and subjective well-being can occur in schools to
identify those students who may benefit from collaborative mental health supports.
Lewis, Huebner, Reschly, and Valois (2009) found that increased school satisfaction and
school engagement (e.g., family, peer, and teacher support for learning, relevance of
school work with future goals) were associated with not only the absence of negative
emotions, but also the presence of positive emotions. The presence of positive emotions,
but not the absence of negative emotions, was also associated with increased coping skills
like seeking social support and problem solving (Lewis et al., 2009). Schools are
excellent locations to identify with whom to intervene in order to examine the impact of
unmet mental health needs.
26
Impact of Mental Health Problems
According to the CDC (2013), the prevalence of mental disorders among children
is increasing. The type of mental health problems reported differ in terms of gender. Boys
are more likely than girls to have a mental disorder. Boys are significantly more often
diagnosed with ADHD (12.3% to 5.3%, ever diagnosed; CDC, 2013), behavior/conduct
problems (6.2% to 3.0%, ever diagnosed), and cigarette dependence (3% to 2.5%). They
are also more often diagnosed with autism spectrum disorder (ASD; 1.7% to .5%, ever
diagnosed), anxiety (5% to 4.4%), and Tourette syndrome (0.4% to 0.2%; CDC, 2013).
They are more likely to complete suicide (6.54% to 1.83%; CDC, 2013). Girls are more
likely than boys to have an alcohol use disorder (4.7% to 3.7%) and depression (18.2% to
7.7%, lifetime; CDC, 2013).
Family and household factors were found to be related to prevalence rates.
Diagnoses of ADHD, anxiety, and ASD were more prevalent when health insurance was
in place, whereas substance use disorders were more common when health insurance was
absent (CDC, 2013). As the educational attainment of the household decreased, the
prevalence of behavior/conduct problems, depression, and anxiety increased. As poverty
increased, ADHD, behavior/conduct problems, depression, anxiety, illicit drug problems,
and cigarette dependence increased (CDC, 2013). The middle-income group had the
highest rates of depressed symptoms. The prevalence of certain disorders differed
regionally. For instance, the prevalence of alcohol and illicit drugs was high in the west
and low in the south. The prevalence of ADHD was greater in the south and lower in the
west (CDC, 2013).
27
Vulnerable groups tend to be at greater risk for mental health concerns. For
example, teens in out-of-home placements were more likely to report suicidality when
compared with a nonclinical-teen sample (Heneghan et al., 2015). Burton, Marshal, and
Chisolm (2014) found that sexual minority youth with depression and anxiety symptoms
were more likely to have unexcused absences. Student engagement was observed to be
lower for students who had functional limitations or behavior problems. Such students
demonstrated poor grades, below average performance on standardized tests, and more
disruptive behaviors (Forest et al., 2011). School absenteeism among adolescents
increased when they reported symptoms of depression or anxiety (CDC, 2013).
Children with mental health problems are at risk for lower academic achievement
and educational attainment. Analysis of data from the National Longitudinal Study of
Adolescent Health provided evidence that youth with externalizing behavior problems
including attention problems, delinquency, or substance use (especially cigarette use) but
not depression were associated with decreased academic achievement in high school
(McLeod et al., 2012). The presence of delinquency and substance use disorders lowered
educational attainment (highest degree received). Attention problems, alone, were not
predictive of lower educational attainment (McLeod et al., 2012).
Child mental illness significantly impacts educational attainment, and lifelong
consequences are likely when mental health issues persist. At-risk and vulnerable
children are at greater risk for problems including school problems, anxiety, depression,
substance abuse, and suicidal thoughts and behavior. It is important to look at how youth
28
with mental health needs are identified and how increasing collaborative efforts can
improve children’s access to mental health care.
Identification of Children With Mental Health Needs
Community agencies, schools, and primary mental health may be suitable
locations for screening adolescent mental health. Farmer, et al. (2003) evaluated the
results of a longitudinal study of children in the southeastern U.S. concerning access to
mental health services. They found that children were most likely to receive services in
the education system. Specialty mental health and general medicine followed.
Significantly less often, services were initiated through child welfare or the juvenile
justice system. About 9% of children accessing mental health services were involved
with multiple sectors. Simultaneous participation in specialty mental health and education
was most common. Mental health and child welfare, and then mental health and general
medicine followed (Farmer et al., 2003). Children entering services through education
had a lower level of symptoms overall. Children who initiated services through the school
system and who had a high level of symptoms often did not access additional services in
the community (Farmer et al., 2003). Schools and primary care physicians’ offices may
be suitable locations to implement screening practices that could result in referrals for
mental health services.
School-based screening may improve efforts to identify students in need of
referrals for mental health services. Husky et al. (2011) found that using a school-wide
screening tool and individual follow-up with school mental health staff effectively
increased participation in school-based treatment. A smaller number of students who
29
were referred for additional mental health support within the community accessed those
services (Husky et al., 2011). Although screening procedures improved service delivery
in the school setting, students remained less likely to seek recommended community
mental health services. Improving collaborative interprofessional efforts may positively
impact this problem.
Screening for mental health symptoms can also be completed through interactions
with primary care physicians. Gadomski et al. (2015) compared patient/doctor
interaction during an annual health exam both with and without the use of a mental health
screening tool completed electronically just prior to the visit. Analysis of the interaction
suggested that the amount of patient/physician time spent was similar between the group
that used the screening tool and the group that did not. Use of the screening tool was
consistent with increased discussion of psychosocial issues (Gadomski, 2015).
Information obtained from similar screenings completed with the primary care physician
could result in follow up with school and community agencies to meet children’s mental
health needs.
Mental health screening procedures improve the identification of students with
mental health needs. Whether in the school or the community setting, mental health
screening may be a valuable step forward when collaboration exists among professionals
in multiple sectors. At present, community-based mental health and school-based mental
health programs separately are unable to resolve unmet mental health needs. An
examination of barriers to community-based mental health services follows.
30
Community-Based Mental Health
Children’s mental health needs are not being met with community-based mental
health services. Garland et al. (2013) reviewed the literature on the limitations of
community-based mental health services for children and identified several targets for
improvement. First, they indicated a need for improving access to services.
Improvements were deemed necessary in the referral process and in retention in services.
A second target was increasing the use of evidence-based practices and increasing the
frequency and intensity of delivering these services. A third goal involved measuring
outcomes regularly before, during, and after therapy to ensure that interventions are
effective (Garland et al., 2013). Barriers to treatment in community-based settings
significantly impact both access to services for children and the length of time children
spend in treatment.
Barriers to Treatment
Barriers to the use of mental health services have been identified related to
availability of services, transportation, health insurance and finances, social and cultural
values, and family contextual factors such as social support and family stress (Olin et al.,
2010). Barriers can be identified as belonging to the following categories.
Structural barriers. Spears (2010) reported that children without medical
insurance are more likely than children with private medical insurance to have unmet
mental health needs. DeRigne (2010) found that parents most often reported financial
barriers to accessing mental health services for their children. The cost of services and
health plan problems constituted the most cited reason for unmet mental health needs in
31
children. Parents more often reported these problems with a private rather than a public
health plan. Families without insurance indicated that cost was the primary barrier to
services for their children (DeRigne, 2010). Household income and Medicaid eligibility
appeared to increase community-based mental health service use among youth
(Alexandre, Dowling, Laris, & Rely, 2008). Curiously, amounts of Medicaid dollars
spent on mental health costs for children differ substantially from state to state (Howell &
Teich, 2008). Funding is a barrier to developing mental health programs for children.
Rarely has research compared the cost of intervention programs with the cost savings if
children use fewer government resources across their lifespan (Stevens, Roberts, &
Shiell, 2010).
Following cost and health care problems, parents reported barriers such as lack of
availability or accessibility of services in their immediate area, transportation issues,
problems with appointment times and problems with clinicians (DeRigne, 2010). At the
same time clinicians reported limited use of strategies, including appointment reminders,
flexible scheduling, and providing transportation to improve accessibility (Watt & Dadds,
2007). Just over 60% of counties in the U.S. have outpatient facilities that provide mental
health services to youth. Urban and suburban areas are more likely to have these types of
services available with more than 70% of counties serving children. In rural areas, less
than half of counties offer mental health services to youth (Cummings et al., 2013).
Significantly fewer have special programs designed to treat youth with severe emotional
disturbance. Less than half of counties have tailored programs for young people with
significant mental illness. Sixty percent of urban/suburban counties have this type of
32
programming while just over 30% of counties in rural communities have programs
designed for mentally ill youth (Cummings et al., 2013). Location and convenience of
services significantly impact the use of mental health services for children.
The atmosphere of the clinic (non-sterile, child friendly, privacy), and time issues
(timeliness of appointments, phone support between sessions, reminder calls/notices, and
follow-up with the family for missed appointments) were also noted (Watt & Dadds,
2007). Convenience (time of available appointments), not getting a referral, and problems
getting an appointment time, were also cited as reasons for unmet mental health needs in
children (DeRigne, 2010). Garcia et al. (2015) looked at the barriers to effective mental
health practices for youth in the child welfare system. They talked with child welfare case
managers who are responsible for helping their child clients and families access needed
supports. Besides the lack of funding for mental health, case managers reported a lack of
knowledge of effective practices. Children and families resistant to treatment and who
reenter the system repeatedly were most difficult for case managers to help (Garcia et al.,
2015). The proximity of families to mental health services and problems with
collaboration between multiple agencies were significant barriers to services for children
in the welfare system. Structural factors clearly play a role in facilitating or limiting
children’s access to mental health services.
Social/cultural barriers. Stereotypes, prejudice, and discrimination associated
with mental illness and treatment seeking can reduce the likelihood that children will
accept treatment even if it is readily available (Thoits, 2011). Gender differences in
attitudes about mental health exist. Eighth-grade girls are more willing than boys to
33
access mental health services (Chandra & Minkovits, 2006). Perceived parental
disapproval and stigma influenced this difference. Parents have also reported
dissatisfaction with provider and child refusal to attend services as reasons for unmet
mental health needs (DeRigne, 2010).
Cultural values play a role in the likelihood that families will seek out treatment
for their children. Some cultural groups hold negative views of mental health services and
it may be necessary to make adaptations to traditional therapy to make therapy more
relevant for these cultural groups (Wood, Chiu, Hwang, Jacobs, and Ifekunigwe, 2008).
Among welfare case managers of children with mental health needs, client engagement
problems, including issues related to stigma, and cultural competence were reported
(Garcia et al., 2015). For example, many Mexican American families believe that there is
a stigma in using mental health services for mental health problems. Mexican Americans
use fewer mental health services, and when services are initiated, they tend to end
treatment earlier (Wood et al., 2008).
A disproportionate number of children belonging to ethnic minority groups and
low-income families face barriers to community-based mental health services. White
children were more likely than African-American or Latino children to be in "very good"
or "excellent" general health (Stevens, 2006). Developmental delays were more likely
for Latino children than White children (Stevens, 2006). Results of the National
Longitudinal Study of Adolescent Health indicated that Black adolescents were
significantly less likely than White or Hispanic adolescents to receive counseling services
regardless of symptom severity (Kodjo & Auinger, 2004). When family income and
34
educational attainment of parents were accounted for this difference persisted. Referrals
for services are also lower for certain ethnic minority groups. African American children
with internalizing disorders were less likely than Caucasian or Hispanic/Latino children
to seek treatment. They were also less likely to receive referrals and encouragement to
seek treatment for mental health problems (Alegria et al., 2012). Social and cultural
factors can present barriers to mental health services.
Barriers related to family systems. According to Stevens (2006) developmental
delays were more likely to be observed in families with lower social class status and
when mothers reported poorer mental health. Children with parents who have mental
health problems are not only more likely to be at risk for developmental delay, they are
also more likely to have mental health problems themselves. This finding was true when
either mothers or fathers had mental health problems (Amrock & Weitzman, 2014).
Emotional symptoms, conduct disorder, and hyperactivity increased. Acri and Hoagwood
(2014) analyzed studies that contained interventions to treat children’s mental health that
also offered a parent program. Very few studies included any parent program. The few
that included parent programs showed inconsistent results in improving parent mental
health.
Certain at-risk groups may be perceived as having greater mental health needs.
Fifty percent of foster children ages 2-15 placed for at least 12 months have at least one
outpatient mental health service (Leslie, Hurlburt, Landsverk, Barth, and Slymen, 2004).
The presence of delinquent behavior, substance use disorders, and a greater severity of
symptoms were predictive of mental health service use (Alexandre et al., 2008).
35
However, African-American children used fewer services than Caucasian children overall
despite similar levels of need (Leslie et. al, 2004). Family related issues impact children’s
access to mental health services.
Community-based mental health services have not been sufficient to meet the
demands of children's mental problems. Numerous barriers exist. Structural barriers,
social/cultural barriers, and barriers related to the family system continue to impact
children’s likelihood of accessing mental health services, and disproportionately affect
children from low-income or minority groups. Given that children are required to attend
school and because mental health problems often impact behavior or performance in the
school setting, the next topic to address is school-based mental health.
School-Based Mental Health
The public school system is a practical location to provide mental health services
to youth (Soleimanpour et al., 2010). Schools increasingly expected to provide research-
based interventions to students who are struggling in the schools setting, including those
who have emotional needs (Zigmond, Kloo, and Volonino, 2009). Early identification of
students with emotional and behavioral problems through mental health screening can be
an effective way of identifying students with mental health needs (Kuo, Vander Stoep,
McCauley, and Kernic, 2009). However, the number of school employed mental health
providers is not sufficient to meet the needs within the school setting, and collaborative
relationships with community providers is limited (Brener et al., 2007).
While two-thirds of schools reported that they employed school psychologists
(Brener et al., 2007), these school support staff report that there are significant barriers to
36
being able to meet the mental health needs of students. These barriers have to do with
their primary role in the school setting, problems with using the school to deliver
services, lack of support of school faculty, and administrators, and inadequate training in
mental health service delivery (Suldo et al., 2010). Given that one in five students may
meet the criteria for emotional and behavioral disorders, increased collaboration between
school and community-based mental health services is needed.
Effectiveness of School-Based Services
According to Slade (2002), schools that have counseling available increase access
to and use of services. This increase occurred across race/ethnic groups. Interestingly,
school-based service use did not appear to replace the use of community-based services,
except among students with special education classification. Similarly, Cummings, Ponce
and Mays (2010) found no differences related to race/ethnicity in service use in the
school setting. In contrast, racial and ethnic differences in service use in community
settings were noted (Cummings et al., 2010). Schools appear to be in a position to reduce
racial and ethnic disparities in access to mental health services.
The trend towards considering the school setting as a location for mental health
service delivery appears to be occurring worldwide. This trend is being observed in the
United Kingdom (Rait, Monsen, & Squires, 2010), in Scotland (Lauder, Burton,
Roxburgh, Themessl-Huber, O’Neill, & Abubakari, 2008), and in India (Srikala &
Kishore, 2010). Efforts to improve measurement of students’ psychosocial health, and to
identify therapeutic techniques for use in schools to increase resilience and improve
coping skills, social skills, self-esteem and adjustment issues, have been reported.
37
In the U.S., schools that implemented focused learning lessons to improve social
and emotional learning had fewer problems with externalizing or internalizing student
behavior and improved achievement test performance (Durlak, Weissberg, Dymnicki,
Taylor, & Schellinger, 2011).
Barriers to School-Based Services
Despite their willingness to engage in mental health service delivery, school
counselors, school social workers and school psychologists face barriers (Burton, 2013).
Brown et al. (2006) surveyed school counselors about their perspectives on collaboration
with non-school mental health providers to meet student mental health needs. Most
school counselors agreed that collaborative efforts could help to provide services to
students. The number of students needing support in comparison to the number of
counselors, misunderstandings by administrators about their training in mental health
service delivery, and role strain due to their other duties interfere with schools taking on
mental health service delivery (Brown et al., 2006). School counselors, who view their
role as a guidance counselor rather than a mental health professional, are less likely to
provide mental health services in the schools (Beckles, 2009). Cross (2013) found that
about half of school psychologists indicated that they were qualified to identify and
counsel students with behavior and mood issues in both elementary and secondary. They
were also more likely to use evidence-based cognitive behavior therapy and solution
focused therapy than other types of therapy with students (Cross, 2013). Although
substance use in youth predicts learning, and behavior problems, school mental health
professionals frequently reported that they were unfamiliar with evidence-based
38
interventions (Evans, Koch, Brady, Meszaros, & Sadler, 2012). Training issues impact
school-based professional’s ability to provide needed services.
Training alone does not result in the successful implementation of mental health
services. Although a number of school sites received training for delivering a school
trauma intervention, many of the schools did not implement the intervention when school
trauma was present (Langley et al., 2010). Factors that facilitated implementation
included, organizational structure for delivering school-based services, a social network
of clinicians implementing the program, and administrative support. Grant funding or
funding set aside by the administration was more likely in the schools where
implementation was successful. Barriers were similar for schools that were successful in
the implementation and those who were not successful. For those who did not implement
the program, competing job responsibilities were cited as the primary barrier. Lack of
parent engagement, logistical barriers (e.g. scheduling problems), and lack of support
from school administrators and teachers, did follow. Those who successfully
implemented the program were most likely to cite lack of parent engagement as the
primary barrier. Competing responsibilities, logistical barriers, and lack of support from
school administrators and teachers, followed (Langley et al., 2010).
School mental health providers’ job responsibilities are largely determined by
finances (Bailey, 2005). When schools make referrals to community-based services,
schools can become financially responsible for those services. Special education
categories of eligibility do not align with DSM categories that allow for billing and
insurance reimbursement. Schools located in poorer areas may have fewer financial
39
resources. Children with more severe symptoms and needs were more likely to be
serviced by non-school employed providers, with less experience, working for less
money (Bailey, 2005).
For a school system to consider expanding school-based mental health services,
school administrators must understand the need to allocate funding for this purpose.
School administrators do not appear to be well informed of the problems with children's
mental health and need for school mental health services to improve academic
performance (Caparelli, 2012). Lack of information and training among administrators is
a barrier to children having access to mental health services in schools (Caparelli, 2012).
Schools have the responsibility to provide mental health services to children who
need them. Although the costs associated with having a greater number of mental health
providers present in school are a consideration, so should be the costs related to educating
children with emotional and behavioral problems. School-based services are effective and
provide opportunities for students from lower income and minority race/ethnic groups to
increase use of services. Schools are an appropriate place for services in the U.S. and
worldwide. Barriers to school-based services include inadequate training, competing
responsibilities, logistical barriers (e.g. scheduling), and lack of support by administrators
(e.g. lack of understanding, funding).
Improving interprofessional collaboration between school and community based
mental health providers has the potential to alleviate barriers to mental health services for
children. Partnerships between schools and community organizations can improve
identification and referrals for early intervention. When schools allocate the necessary
40
funding, space, and time for mental health services, many barriers to traditional
community- and school-based services can be eliminated.
Interprofessional Collaboration in Children’s Mental Health
Support for collaboration in children’s mental health has grown in recent years.
The CMHS, SAMHSA, and DHHS (2013) organized the Children's Mental Health
Initiative. Using the Systems of Care Philosophy, the Children’s Mental Health Initiative
emphasizes the need for systems surrounding children to come together to provide
coordinated care though interprofessional collaboration (CMHS, SAMHSA, & DHHS,
2013). Outcome data suggested that the Children's Mental Health Initiative improved
access to services for underserved children and youth (CMHS, SAMHSA, & DHHS,
2013). However, in a large multisite analysis of funded programs, interprofessional
collaboration was one of the most difficult aspects of the Children’s Mental Health
Initiative to achieve (Brannan et al., 2012). Few services were available as part of a
collaborative, multi-agency initiative (Brannan, et al., 2012).
With improved interprofessional collaboration among service sectors in meeting
children’s mental health needs, reduced costs, and increased availability of services to
children have been noted. Sebian et al. (2007) reviewed the research on the systems of
care approach and reported that it resulted in reduced costs, fewer inpatient days, reduced
number of arrests, sustained mental health improvements, decreased suicide-related
behaviors, improved school attendance, improved school achievement, and reductions in
juvenile detention. Sebian et al. (2007) emphasized the need for a school component to
improve the coordinated care model and also noted the need to enhance communication
41
and collaboration, identify stakeholders, and increase technical resources to improve
collecting and sharing information across systems.
In contrast, Hamner, Lambert, and Bickman (1997) and Bickman, Lambert,
Andreade, and Penaloza (2000) found the coordinated care model to increase costs with
no apparent benefit to children over the traditional approach. The Fort Bragg
demonstration was an interdisciplinary effort to provide mental health services to
children at Fort Bragg (Hamner et al., 1997). Outcomes were compared with two other
US. Army locations who received traditionally delivered services at 18 months and 5
years. Compared to traditional outpatient treatment, they found the continuum of model
to be more expensive with similar outcomes (Hamner et al., 1997; Bickman et al., 2000).
No information was presented on the identification and referral processes for program
candidates so it is not clear how children were identified for participation. Attrition was
reported to be high for both traditional and coordinated services.
What is not known is how the population being served, military families, differs
in their likelihood to seek treatment for their troubled children. A quasi-experimental
design was employed and random assignment was not used for placement in either the
continuum of care or traditional outpatient therapy (Hamner et al., 1997). Information on
the traditional services provided in the comparison group was also not available as part of
the report. Finally, no school-based component was offered in this continuum of care
model (Hamner et al., 1997). The literature demonstrates lower levels of attrition when
services are available in the school setting (Armbruster & Lictman, 1999; Husky et al.,
2011). Children participating in the Fort Bragg model were reported to have increased
42
access to services, which was one of the primary goals. They also had a greater number
of services, adding to the cost of treatment (Hamner et al., 1997; Bickman et al., 2000).
DHHS (2000) created a national action agenda to address children’s mental health
needs. Overarching goals of this agenda were to increase children’s access to services and
to reduce costs by coordinating services through the collaborative efforts of multiple
agencies (DHHS, 2000). Several objectives were identified. Training frontline
providers to recognize and manage mental health issues, promoting awareness of
children’s mental health issues, reducing the stigma associated with children’s mental
health, and help-seeking behavior, eliminating racial and ethnic disparities in accessing
mental health care, increasing interprofessional collaboration, improving assessment, and
identification of children’s mental health needs, providing evidence-based prevention,
and intervention strategies, (DHHS, 2000). The final goal was to engage in ongoing
monitoring of access to treatment and the coordination of care (DHHS, 2000). Schools
are on the frontlines and as noted in several places within this review, have the potential
to collaborate with community mental health to identify and provide access to treatment
for children with unmet mental health needs.
Tegethoff et al. (2014) found that the link between school and community-based
mental health service utilization was not significant. Traditional separation of practices
in children’s mental health most often does not result in referrals, or follow-through with
referrals, from school to community-based services. Yet schools alone have not been able
to meet the needs of all or even most children. Building partnerships with mental health
service providers could streamline services and may avoid unnecessary duplication of
43
services. Utilizing the school as a primary location for service delivery has been
demonstrated to reduce attrition and stigma (Armbruster & Lictman, 1999). Limited
information exists as to the factors that improve the initiation of interprofessional
collaboration between school and community agencies. However, there is research that
identifies factors that are important to collaborative relationships, generally, and in
mental health service delivery specifically.
Factors In Interprofessional Collaboration
Interprofessional collaboration has many names. It has been referred to as
integrated care, multiagency, multidisciplinary, interdisciplinary, cross-disciplinary, or
interagency collaboration (Odegard & Strype, 2009). Team members from multiple
mental health organizations or professions work together to meet children mental health
needs (Odegard & Strype, 2009). Improved interprofessional collaboration among mental
health service providers in school and community settings may increase children’s access
to mental health services and to reduce the pressure on school mental health professionals
to carry the burden of meeting the mental health needs of children.
Studies of interprofessional collaboration tend to focus on specific program
evaluation and the factors necessary to improve collaborative experiences once they have
been established. Mattessich and Monsey (1992) surveyed the research literature and
identified factors that were found to sustain collaborative relationships. Six categories of
factors were identified as important to collaborative relationships; environment,
membership, process/structure, communications, purpose, and resources (Mattessich &
Monsey, 1992). Factors that related to the environment included; having a history of
44
collaboration in the community, having a leadership role in the community, and the
favorability of the political or social climate for the collaborative efforts. Factors related
to membership characteristics in collaborative efforts included; mutual respect,
understanding, and trust; appropriate stakeholders chosen for membership; members
believe benefits outweigh costs; and having the ability to compromise. Factors related to
process/structure included; members share stake in the process and outcome, a need for
multiple layers of decision making, the collaborative group is flexible, and adaptable,
although clear roles and policies should be developed. Factors related to communication
included the need for frequent and open communication, and both informal and formal
communication links. Factors related to purpose included having concrete goals and
objectives, a shared vision, and a unique purpose. Finally, collaboration issues related to
resources included having sufficient funds to support its operations, and having a skilled
leader (Mattessich & Monsey, 1992).
Studies of interprofessional collaboration have often been conducted as part of
specific program evaluation or team participation. Interprofessional team experiences in
healthcare were examined. Interprofessional teams in Sweden were interviewed about
their experiences with working in collaborative teams to meet patient needs.
Participating health care team members included occupational therapist, registered nurse,
physiotherapist, medical social worker, administrative assistant, physician, practical
nurse, psychologist, and speech therapist (Kvarnstrom, 2008). Difficulties were generally
related to the team dynamic, the contribution of knowledge by professionals and the
influence of organizational variables (Kvarnstrom, 2008). Problems with role conflict,
45
unequal responsibility for making decisions, value or usefulness to the team, lack of
consensus, unequal knowledge, hierarchical valuations, changes in organization or
setting, and lack of correct resources (i.e., wrong professionals on the team) (Kvarnstrom,
2008). In some cases, teams reported that they were able to discuss and/or resolve some
of the issues, but often times they were not able to either discuss or resolve the issues
(Kvarnstrom, 2008).
Related to children, interprofessional collaboration has been assessed to measure
perceptions of interagency relationships when providing services to children. Child
protection workers and mental health workers were surveyed regarding their perceptions
of one another and inteprofessional collaboration (Darlington, Feeney & Rixon, 2005).
Several factors were noted. Mental health providers and child protection workers have
positive regard for one another and do not mistrust one another but perceive lack of
training in one another's disciplines as being a barrier (Darlington et al., 2005). Barriers
to collaboration were reported to include inadequate resources, issues related to
confidentiality and interagency processes, unrealistic expectations, and professional
boundary issues (Darlington et al., 2005).
On a larger scale, the interprofessional collaboration of community development
teams that were part of a randomized controlled trial the Cal-40 study aimed at improving
the treatment of children in foster care revealed several factors, were measured for
relevant factors (Palinkas et al., 2014). Factors found relevant for collaboration were
classified as external; availability of funding, county size, shared clients, and government
mandates (Palinkas et al., 2014). Factors classified as internal related to participating
46
organizations included common language, common recognition of the problem,
commitment, accountability, or individual characteristics such as interpersonal
relationships and social ties, collaboration facilitator, supportive leadership, and personal
qualities (honesty, credibility, trust and respect) (Palinkas et al., 2014). Collaboration
characteristics that facilitated collaboration included having a broader focus, less
formality, and greater frequency of interaction. The function of the collaboration was
also important. Examples of function include information exchange, pooling of resources,
service delivery (Palinkas et al., 2014).
To measure perceptions of collaboration in collaborative school teams, Mellin et
al. (2010) surveyed school professionals participating in interprofessional school teams.
Participants included members of interprofessional school teams across the U.S..
Responses were based on the type of team in which they collaborated. Most often these
included school mental health teams, individual education program (IEP) teams, and
student support teams (Mellin et al, 2010). A survey was developed to measure elements
of interprofessional teams. This survey assessed team interdependence, newly created
professional activities, flexibility, collective ownership of goals, and reflection on process
(Mellin et al, 2010). Through factor analysis, four factors emerged; need for reflection
on the collaborative process, need for flexibility in the professional role, creation of new
professional activities needed for better program functioning, and interdependence among
team members (Mellin et al, 2010).
Specific to the mental health needs of children, Mendenhall and Frauenholtz
(2014) evaluated the process of implementing a large-scale community-based
47
comprehensive system of care to support mental health for children with serious
emotional and behavioral disorders. Collaboration between various systems was
necessary for program implementation to be successful. Despite support at the systems
level, several barriers were discussed through the implementation process. A lack of
knowledge between systems as to how each system worked resulted in communication
issues (Mendenhall & Frauenholtz, 2014). Additionally, resentment, resistance, and
power imbalances resulted when relevant stakeholders were excluded from the planning
and implementation process. Stakeholders also had difficulty reaching consensus and
some issues were not resolved (Mendenhall & Frauenholtz, 2014). Including a
representative from the agencies involved as well as state and family representatives were
found to be an important step toward improving collaboration (Mendenhall &
Frauenholtz, 2014). There were also many benefits of collaboration. Having members of
various systems work together led to improved sense of trust and willingness to help.
They developed creative ways to ensure communication such as video conferences for
meetings to reduce the need for travel (Mendenhall & Frauenholtz, 2014).
Many studies have looked at interprofessional collaboration through specific
program evaluation and looking at how groups of professionals perceive their
experiences with collaboration. Factors that are relevant to collaboration can be external,
such as the political climate and funding, internal, such as organizational characteristics
and personal characteristics, or they can be related to the process of collaboration. Little
attention has been given to the initiation of collaborative efforts outside of program
48
mandates. However, several studies have evaluated collaboration among school- and
community-based mental health providers.
Collaboration Between School and Community-Based Mental Health Providers
Several studies have looked at the issues involved in school-community
relationships in the treatment of children’s mental health. Related specifically to the
collaborative efforts of school and community mental health professionals, Odegard
(2006) used surveys to examine collaboration among Norwegian school and community
professionals. When Odegard (2006) assessed their perceptions of interprofessional
collaboration across individual, group, and organizational aspects of the collaborative
process, six factors emerged. These factors included; the interprofessional climate, the
cultures of both organizations, the goals of the organizations; professional power, the
leadership of the group, and the motivation to engage in interprofessional collaboration.
An investigation of the perceptions of interprofessional collaboration among school and
community mental health professionals located within the U.S. is needed to identify ways
to improve collaborative efforts and improve mental health services for children
Establishing partnerships with community agencies can help to meet the
emotional needs of children. Duchnowski and Kutash (2011) assessed the effectiveness
of schools in the delivery of supports for students with Emotional Disturbance.
Participants were recruited from 37 schools in 13 states and whittled down to seven
schools meeting study requirements for having a sufficient number students with
emotional disabilities, having established high levels of reform for meeting student
emotional needs, and having diverse student bodies (Duchnowski & Kutash, 2011).
49
Seven comparison schools with low levels of reform were identified within the school
districts serving the seven schools identified. Surveys were given to assess school reform.
Parents reported on student demographics and answered surveys about their child's
mental health service use (Duchnowski & Kutash, 2011). Student functioning was
measured through achievement tests, and behavior rating scales. Parent involvement was
also measured through survey data. Schools embracing the collaboration between
education and mental health systems were identified as high-reform schools while low-
reform schools were those with little collaboration. Schools with high-reform had more
direct instruction for students with emotional disturbances to promote reading and math
and had a proactive approach to discipline rather than a punitive approach. They spent
more time in the general education setting and improved overall math performance
(Duchnowski & Kutash, 2011). Additionally, procedures were put in place to include
more stakeholders in planning and monitoring objectives and goals. Mental health
services were provided equally as often in both the high and low reform schools.
However, services were more frequently provided by community agency personnel with
services delivered in the school setting in high reform schools (Duchnowski & Kutash,
2011). Collaborative efforts were more frequent in high-reform schools to increase
capacity to provide mental health services. Although schools did not report differences in
parent involvement, parents in the high-reform schools reported lower levels of
participation than those in low-reform schools (Duchnowski & Kutash, 2011).
Administrators reported that parent time spent in low-reform schools was typically
50
negative as a result of their student's problems and discipline issues (Duchnowski &
Kutash, 2011).
Program evaluation has been done with regard to community-based mental health
staff providing services within the school setting. Douglas (2001) investigated
collaborative efforts among agency-employed and school-employed providers working
together within the public school setting. School employed personnel were less
supportive of collaboration than agency staff and expressed a desire to have more school-
based mental health professionals (Douglas, 2001). Both school and agency employed
mental health providers expressed concern about the number of mental health providers
being too few. They also expressed concern about the need for more support by the
school administrators and governing boards to increase the number of mental health
providers available to help students (Douglas, 2001). Agency-employed staff reported
that teachers were often reluctant to allow students to leave instruction to receive
intervention services. There were also issues with funding. Administrators acknowledged
that collaborative efforts were affordable but expressed concerns about agency-employed
staff and their understanding of the school culture and adherence to agreements made
about service delivery (Douglas, 2001). School and agency employed providers reported
the need for relationship building and planning in the referral process and for the
provision of services. Benefits of collaboration included aiding families in accessing
mental health services (Douglas, 2001). Similarly, Kindall (2009) found that school
districts could save money by contracting agencies to provide school-based mental health
services. However, school district personnel were more satisfied with district employed
51
mental health staff. Additionally, agency employees reported spending more time
engaged in indirect services than school employees (Kindall, 2009).
Many problems with collaboration seem to have to do with communication and
building cooperative relationships. Massey et al. (2005) completed a qualitative analysis
of collaboration as part of a program evaluation of several prevention/intervention
programs that focused on reducing violence in schools. Both community-based and
school-based implementation of prevention and intervention programs occurred.
Program members from twelve programs were part of focus groups to gain an
understanding of the issues related to comprehensive program implementation (Massey et
al., 2005). Service providers, senior program supervisors, social workers, counselors, and
school psychologists were included in the focus groups (Massey et al., 2005). They
reported several themes regarding the implementation process that are relevant to
interprofessional collaboration. Community-based practitioners reported concerns about
feeling accepted in schools and recalled difficulties building relationships with school
people. In contrast, having a good relationship with school administrators aided in
community providers integrating with school personnel (Massey et al., 2005).
Communication problems were noted by both school and community-based providers.
Another concern conveyed by the external service providers surrounded parental consent
and confidentiality. Community-based providers felt limited in discussing children with
teachers and other school personnel without obtaining parental consent to share
information (Massey et al., 2005). Teachers and other school personnel were said to have
little understanding of those limitations. Community-based providers also felt that the
52
task of sustaining the program by seeking additional funding fell on them and often did
not feel that the school districts were working to keep programs going (Massey et al.,
2005).
Opinions about interprofessional collaboration were gathered from a small sample
of school counselors and the principles/vice principals involved in hiring staff to
understand their perceptions of contracting community mental health professionals to
provide mental health services, their views on interprofessional collaboration among
school counselors, and community mental health professionals as well as their thoughts
about the school counselors' role (Brown et al., 2006). Survey questions were developed
and four open-ended questions were posed. School counselors largely reported that they
were trained to provide counseling, that they could identify students in need of
counseling, and that they considered themselves to be mental health professionals (Brown
et al., 2006). Administrators were less likely to report that their school counselors were
competent in these areas. Many counselors and administrators agreed with contracting
community mental health professionals. Counselors noted the greater student need,
school counselor's role, competing responsibilities in schools, and low counselor to
student staffing ratios (Brown et al., 2006). Administrators noted the growing
responsibility for schools to meet children's mental health needs. Counselors who had
reservations or disagreed with hiring community mental health professionals reported
concerns about the qualifications of community mental health professionals and their
frustration over having clerical duties that interfered with their own ability to deliver
services (Brown et al., 2006). Administrators with reservations or who disagreed with
53
hiring community mental health providers indicated that the outside providers would
need to have an understanding of school operations, or that it was simply not affordable
to consider (Brown et al., 2006).
Walsh (2013) conducted a national survey of school psychologists and found that
all respondents reported communicating with community-based mental health providers
(psychiatrists, pediatricians, neurologists, psychologists, social workers,
counselors/therapists, or case managers). With regard to collaboration, nearly 20%
reported collaboration with community mental health providers at more than once a
month. Nearly half of respondents reported less than 10 instances of collaboration in the
previous school year, while almost a quarter reported no collaboration at all.
Most school psychologist reported benefits to collaborative efforts such as
improving student mental health, behavioral or academic outcomes for students were
improved (Walsh, 2013). Many reported that it provided an opportunity for cross-
disciplinary problem solving. A little over half of respondents reported that collaboration
would help with assessing student progress across settings, would increase parent
involvement, and would provide a chance to share resources. Just under half perceived
that it would be beneficial in avoiding duplication of resources. About a third believed
that it would provide an opportunity to learn different methodology and techniques.
About a quarter thought they would feel valued for their expertise to other professionals,
or it would improve a student's physical health. Less than 1% reported no benefit to
collaboration (Walsh, 2013). Barriers to collaboration were reported as time constraints,
accessibility of community providers, obtaining parent permission to collaborate with
54
community providers, turnover in the community, and some reported that they did not
have information about providers that were working with students (Walsh, 2013). Some
respondents indicated that they thought that views on mental health services and child
development were too different. Almost 5% reported no barriers to collaboration.
Professional development in mental health was a significant predictor of
collaboration (Walsh, 2013). For those who had over 10 hours of training in youth mental
health, the amount of communication and collaboration with community-based providers
increased. The primary role of the school psychologist was also a factor in collaboration.
For school psychologists whose primary role was student-focused or system focused
consultation, collaboration was significantly higher than those who saw their primary role
as special education evaluation. Collaboration was also lower for those who saw their
primary role as intervention planning and implementation. School factors such as the
number of students served by the school psychologist and the socioeconomic status of the
school were not significant predictors of the amount of collaboration (Walsh, 2013).
Outcome data appear to support collaborative school/community endeavors.
When implemented in conjunction with school systems, the systems of care approach has
resulted in reduced costs, fewer inpatient days, reduced number of arrests, sustained
mental health improvements, decreased suicide-related behaviors, improved school
attendance, improved school achievement, and reduced juvenile detention (Sebian et al.,
2007). Expanded School Mental Health in the Minneapolis Public Schools is a
collaborative effort that utilizes collaboration with private non-profit agencies to place
mental health providers in school settings. In four years, there was a reduction in the
55
number of mental health systems, and an increase in access to mental health services for
low-income and minority populations. Increasing access to mental health services
reduced suspension rates (Everts. 2011). When family members participated in
therapeutic efforts, teachers tended to have more positive ratings of student symptoms,
and reading scores were higher.
Similarly, Mancoske (2013) assessed children's outcomes while involved in a
comprehensive system of care model after six months to 1 year of services in a low-
income, primarily African American sample. Outcome data suggested less substance use,
depression, and anxiety were evident when treatment was in place. Additionally,
increased school attendance, fewer disciplinary actions at school (suspensions,
expulsions) and better grades were noted. Cultural competencies have also been found to
be important. Providers that demonstrate an understanding family cultural values and
beliefs, understand family beliefs about mental health, religion and family needs, speak
the family's primary language, or know when an interpreter was needed, were more
effective. When service providers were viewed as more culturally competent, outcomes
were statistically better than when service providers were not rated as culturally
competent (Mancoske, 2013).
Despite the potential value of collaboration, efforts to implement comprehensive
interprofessional collaboration have not become the norm. It is necessary to investigate
the phenomenon of interprofessional collaboration and the factors that facilitate and limit
school and community collaboration in the provision of children’s mental health services.
Most mental health professionals see the value in collaborating with community-based
56
mental health providers, yet there are significant barriers that reduce collaborative efforts.
Barriers to collaboration between school and community mental health most often
reported in the literature include; time constraints, role strain, role differences between
school and community mental health providers, acceptance of community providers in
the school setting, and communication difficulties. For school psychologists, increased
training in mental illness was related to a greater collaboration with community mental
health providers.
Although these efforts to identify issues related to collaboration between school
and community-based providers are a good start, it is necessary to understand the
experiences of school-based mental health providers and community-based mental health
in collaboration. The information that is obtained through the use of focus groups and
interviews will be used to determine strategies for improving school and community
collaboration in meeting children’s mental health services. In contrast to previous studies
that tend to identify issues presented as part of particular program evaluations or that
focus on particular groups separately (e.g., school psychologists, community providers,
school counselors), this study proposes to include both school and community-based
mental health providers with various levels of experience in collaboration. Given that
most mental health professionals see the value of collaboration, it is necessary to gain
their perspective on what factors are involved in facilitating collaborative efforts.
Summary
Roughly two-thirds of children who have mental health needs do not access
mental health services. There is a need for a comprehensive and collaborative approach
57
to children's mental health treatment. Children's mental health problems significantly
impact lifelong outcomes. At-risk and vulnerable children are more likely to have school
problems, lower educational attainment, anxiety, depression, substance abuse, and
suicidal thoughts or actions.
Community-based mental health services have not been sufficient to meet the
demands of children's mental health problems. School-based mental health services have
also not been sufficient to meet children’s mental health needs. Comprehensive and
collaborative approaches to mental health care have resulted in improving children's
access to services and building long-term success. School and community collaborations
lead to improvement in student outcomes. Many factors are known about collaborative
relationships generally, and about school and community collaborations specifically;
however, two little collaboration occurs to meet the mental health needs of children.
The current study proposes to identify those factors that are related to initiation of
sustained collaboration between school and community mental health providers. Much of
the information obtained about the factors that limit and facilitate collaboration among
this group has been obtained through program evaluation based on specific or established
collaborative relationships, or through surveys of individual groups of providers. Efforts
to obtain qualitative information about the factors important to initiating collaborations
from the perspective of both school-based and community-based mental health providers
do not currently exist. An effort to understand the experience of collaboration through
school and community mental health professionals is necessary in order to improve the
likelihood that these groups will engage in collaboration and to identify the reasons they
58
may avoid these types of interactions. This study proposes to obtain information from
both school-based, and community-based mental health providers as well as
administrators in schools and mental health agencies. Collaborative focus groups
consisting of members of the community and the school will be utilized to optimize the
exploration of these factors from both perspectives.
59
Chapter 3: Research Method
Introduction
The previous chapters have provided a detailed discussion of the unmet mental
health needs of children, the barriers to both community-based and school-based mental
health services for children, and the current state of collaboration between mental health
providers in community and school settings. Children may experience negative outcomes
as a result of having unmet mental health needs. Problems with school discipline, school
achievement, peer relationships, and mental illness can be overcome with access to
mental health services. Even children who are not experiencing significant mental health
problems but who do not identify aspects of well-being or flourishing have lower
engagement and achievement and are at greater risk for negative outcomes. Improved
collaboration and partnerships between school and community mental health providers
may increase children's access to mental health services. However, limited collaboration
exists at this time.
Collaborative efforts between community agencies and school-community
partnerships have yielded some assessment of the factors that limit and facilitate
collaboration. An assessment of factors important to interprofessional collaboration
between school and community mental health professionals in Norway indicated several
important aspects of their collaborative experiences (Odegard, 2006). Individual factors
included motivation, role expectations, personality style, and professional power. Group
factors included group leadership, coping, communication, and social support.
Organizational factors included organizational culture, organizational goals,
60
organizational domain, and organizational environment (Odegard, 2006). Leadership,
social support, motivation, and organizational culture were identified as the most
important (Odegard & Strype, 2009). In the U.S., there have been efforts to examine
interprofessional collaboration in relation to specific programs and initiatives, or with
specific groups regarding the amount of collaboration they engage in and/or their feelings
about the need for collaboration. To date, there has been no attempt to understand the
experiences of both school and community mental health professionals with varying
levels of experience with collaboration to identify the specific factors that increase the
likelihood of initiating collaborative relationships outside of program mandates.
This chapter outlines the qualitative method and design that were used to assist in
understanding this phenomenon from the perspectives of both school and community
mental health providers. It includes the profile of prospective participants and how they
were recruited for the study. Specific information is provided as to the procedures were
used and how the ethical protection of participants was ensured. The procedures are listed
as to how the data were collected and analyzed and how the verification of findings was
handled.
Research Methodology
This topic can best be explored through qualitative methodology. Although some
information on this topic has been gleaned as part of other studies, the specific factors
that are necessary for initiating collaboration between school and community mental
health providers, outside of program mandates, have not yet been fully explored,
requiring a qualitative method of inquiry (Creswell, 2013). This study explored the
61
phenomenon of interprofessional collaboration through the experiences of school and
community mental health providers. This study was primarily phenomenological and
was necessary to study the experiences of mental health professionals in collaborative
efforts. Participants’ experiences were described and analyzed using Moustakas’s (1994)
transcendental phenomenology. In transcendental phenomenology, knowledge of a
phenomenon can only be perceived through human experiences. In order to look at the
problem with minimal bias, the researcher must set aside his or her own perception of the
problem and look at the problem anew through the eyes of the study participants
(Mustakas, 1994). This strategy was employed.
This investigation was justified by the theoretical framework, in which the
development of children’s mental health was seen through an ecological perspective.
Proponents of Bronfenbrenner's ecology of human development view children through
their interactions with the multiple systems and contexts in which they come in contact
(Bronfenbrenner, 1979). This study was primarily concerned with the mesosystem, which
involves the interaction of systems in the child's microsystem or immediate environment
(e.g., school and community). To a lesser degree, the exosystem, which involves the
surrounding environment (local services, school board, political arena); the macrosystem
(cultural values); and the chronosystem (passing time and historical events;
Bronfenbrenner, 1994) were also considered. As goals align within and between these
systems, child development occurs with less disruption.
Ensuring that children have access to comprehensive systems of mental health
care when it is needed can improve children’s ability to reach a state of mental well-
62
being. The key principles of the systems of care philosophy require that a child have
access to early identification and intervention, as well as individualized, culturally
sensitive, nondiscriminatory, and comprehensive treatment in the least restrictive
environment, with case managers serving as advocates who ensure collaboration among
service sectors or agencies and families for the planning of services and transition to adult
services as needed (Miller et al., 2012; Pumariega et al., 2003).
Research Design
In transcendental phenomenology, it is necessary to understand the essence of the
human experience of a phenomenon (Moustakas, 1994). To do this requires the
researcher to identify and set aside personal biases about the phenomenon in order to see
the information anew. This was explained by Moustakas (1994) as Husserl’s concept of
Epoche or bracketing. One method that Moustakas described involves using reflective
meditation in which preconceptions are allowed to enter and leave consciousness and are
eventually written out. The list is then reviewed and released from consciousness until
the researcher is receptive to new experiences of the phenomenon (Moustakas, 1994).
Creswell (2013) described a procedure in which the researcher presents his or her own
personal experiences with the phenomenon in the methods section under the “role of the
researcher” (p. 82). This strategy was employed.
Phenomenological investigation is typically associated with in-depth interviews
with individuals who have experienced the phenomenon of interest (Creswell, 2013). In
this case, focus groups were used to help uncover factors that influence interprofessional
collaboration. Bradbury-Jones, Sambrook, and Irvine (2009) concluded that focus groups
63
can be advantageous for understanding the essence of a phenomenon because they may
help a researcher to bracket preconceptions as they are challenged by group members. A
focus group study is a series of discussions conducted with groups of 4 to 12 people with
some commonality (Krueger & Casey, 2015). Focus groups, when conducted in a
relaxed, nonthreatening environment, promote self-disclosure through the use of group
processes (Krueger & Casey, 2015). Because focus groups consisted of both school and
community mental health providers, there was the possibility that the discussion would
be enriched and that participants would be able to identify additional factors. In-depth
interviews were used to supplement focus group discussions. This helped with
verification of results through triangulation of data, which involves making use of
multiple sources of data, multiple methods, and/or multiple investigators, or using
theories to provide corroborating evidence (Creswell, 2013). Data were analyzed using
Moustakas’s method of data analysis (described under Data Analysis, below) and the
meaning or essence of participants’ experiences was formed.
The purpose of this study was to identify the factors that facilitate collaboration
between school and community mental health professionals. It was necessary for
participants to have had some experience with collaboration, communication, or
consultation with other mental health professionals. School professionals must have had
some experience working with community professionals. Community professionals must
have had some experience working with school-based professionals. It was not necessary
for the participants to be involved in active or sustained collaborative relationships.
Participants took part in focus groups that were led with a semistructured set of interview
64
questions (Appendix B; p. 87). Focus groups were videotaped and audiotaped for later
analysis. The broad research questions are listed below.
Participants
Focus groups consisted of at least 4 or 5 but no more than 10 members. Large
groups with more than 10 participants can be difficult to control (Krueger & Casey,
2015). Groups that are too large can also limit individuals’ opportunities to share
experiences (Krueger & Casey, 2015). At least three groups were planned. Additional
interviews with group participants were added to ensure saturation had been reached.
Groups consisted of school psychologists and school counselors, as well as community-
based counselors and social workers. Administrators who oversaw the provision of
mental health services were also invited to participate.
Participants were recruited from local school districts and community agencies or
private practice in the greater Phoenix, AZ area. A letter describing the proposed study
was sent to local school districts and community agencies/providers to recruit potential
volunteers. Additionally, nominations were be taken from neutral parties or from other
nominees. Letters are included in Appendix A (pp. 85-86).
Research Questions
The research questions were as follows:
• What are the factors that may facilitate the initiation of collaborative
relationships, outside of program requirements or mandates in the provision of
services to children?
65
• How can the known barriers to collaboration be overcome to increase the
development of collaborative relationships?
• What differences exist between school- and community-based mental health
service providers in their view of collaboration in serving children with
mental health needs?
• What differences exist between service providers and administrators in how
they view collaboration in serving children with mental health needs?
Ethical Protection of Participants
The participants were adult male and female mental health professionals. They
participated on a voluntary basis. In transcendental phenomenology, participants are
thought of as coresearchers and are fully informed of the true nature of the study
(Mustakas, 1994). Given this, there was no expectation of harm related to participants’
involvement in this study. Had any of the participants experienced harm related to their
participation in this study, a referral would have been made to local services. This was
not necessary. Each participant signed consent for participation. Confidentiality was
maintained by storing all files, audiotapes, and transcripts in a locked cabinet in my home
office.
Procedures
In order to recruit study participants, local school districts, community mental
health agencies, and professionals in private practice were contacted by phone to provide
information about the study. Follow-up letters were sent to these organizations to
provide details about the study and request assistance in recruiting school and
66
community-based mental health providers. Once potential participants were identified,
in-person or phone meetings with school and community-based mental health providers
were scheduled in order to describe the study and screen candidates. Letters were sent to
provide details about the study. Viable candidates were those who had experienced the
phenomenon of collaboration between home and community mental health. Candidates
were contacted to schedule participation in focus groups. The consent form was sent for
participant review prior to participation in the focus group.
During focus groups, each participant were provided with an informational letter
describing the study, and participants were asked to sign the consent form. A set of
questions were used to guide the discussion in the focus group (Appendix B; p. 87).
Videotapes and audiotapes were transcribed verbatim and analyzed as described later in
the chapter.
Once the qualitative data had been initially analyzed, participants were contacted
to assist in validating themes extracted from transcripts of their focus group. Participants
were sent a summary of the thematic analysis. Participants were asked to examine the
themes and provide any additions or corrections. A follow-up meeting or phone call was
scheduled individually with those who responded to review the themes and any concerns
the participant had about the thematic analysis.
The Researcher's Role
As the human instrument of data collection, I reflected on personal experiences so
that personal biases could be examined. As a school psychologist, I found that personal
experiences had engendered strong positive perceptions about interprofessional
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collaboration between school and community mental health providers and the need for it.
Preconceptions about the barriers to school-community collaboration were also held. It
was necessary to bring all of these biases to light so that the phenomenon could be seen
from a fresh perspective. Additionally, member checks were used to give participants an
opportunity to reflect on any potential biases that resulted from my experiences during
the analysis. Member checking occurs when a researcher takes the findings of research
to the participants, giving them an opportunity to make corrections or additions
(Creswell, 2013).
Data Collection
Data were collected primarily through the use of focus groups. Focus groups are
essentially group interviews that allow for interaction and have the potential to provide a
safe environment and a sense of cohesion among group members (Sim, 1998). Several
qualitative studies of interprofessional collaboration have successfully used focus groups
to identify factors important to collaborative efforts. Focus groups have been used to
look at collaboration in health and social care (Hudson, 2002; King & Ross, 2003) and to
examine the experiences of healthcare team members (Kvarnstrom, 2008; Sargeant,
Loney, & Murphy, 2008), and intensive care unit teams (Lingard, Espin, Evans, &
Hwryluck, 2004). They have been used to look at barriers to collaboration among
community pharmacists and general practitioners (Hughes & McCann, 2003) and in
evaluating collaborative experiences in school mental health (Massey et al., 2005).
McLafferty (2004) evaluated the use of focus group interviews as a method for collecting
qualitative data in healthcare and determined that although focus groups that include
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strangers require a greater degree of moderator interaction, focus groups are dynamic and
can be an efficient way of collecting rich data. Focus groups were interviewed using the
interview guide (Appendix B; p. 87) and were videotaped and audiotaped to aid in
phenomenological analysis. Group interviews were transcribed for subsequent analysis.
Interviews were used to supplement and verify the data collected in the focus
groups. Participants were interviewed at a time and location that was convenient for them
or by phone using the interview guide. Interviews were transcribed to use in data
analysis.
Data Analysis
Data were analyzed using Moustakas’s (1994) procedures with the adaptation
recommended by Creswell (2013) to bracket out personal biases at the outset. Once
biases had been set aside (Epoche) and data had been collected and transcribed,
phenomenological reduction was applied. In this step, significant statements were
identified to build an understanding of how the participant experienced the phenomenon.
In the process of horizontalization, statements have the same value unless they are
identified as repeated ideas or as being irrelevant to the individual’s experience of the
phenomenon (Moustakas, 1994). Overarching clusters or themes were identified from
the horizons. Textural descriptions of the participants’ experiences were written based on
the statements and themes identified.
Moustakas’s (1994) next step, imaginative variation, requires the researcher to
consider the conditions surrounding the experience of the phenomenon. Structural themes
were considered in terms of time, space, causality, etc., and structural descriptions of the
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context of the phenomenon were written. In the final step, the textural and structural
descriptions were used to identify the essence of the experiences of the participants. The
collective perceptions of the participants were synthesized.
Verification of Findings
Verification of research findings in qualitative research is completed as a
validation process to ensure the trustworthiness and credibility of the findings (Creswell,
2013). Of the eight methods that Creswell proposed, clarifying researcher bias,
triangulation and member checks were used.
Clarifying Researcher Bias
As part of the process of transcendental phenomenology, I must set aside
preconceptions and biases. This was done prior to the collection and analysis of data and
was presented under the heading The Researcher’s Role. Personal experiences and biases
that are relevant to the study and the analysis of data collected in the study were
explained. My experiences as a school psychologist and with interprofessional
collaboration between school-community mental health providers are relevant because
my strong positive feelings about collaborative mental health and the need for more
frequent efforts to collaborate have been shaped through my experiences. I have strong
presuppositions about the reasons that collaborative efforts are difficult from the
perspective of school-employed staff. Time constraints, role strain and a lack of support
from school administrators are among those preconceptions. These experiences were
bracketed and set aside to reduce the likelihood of bias in interpretation.
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Triangulation
A second strategy that will be employed for validation will be triangulation. Use
of multiple sources of information can help to corroborate findings (Creswell, 2013). In
this study, there was an opportunity to compare data obtained from participants based in
the community setting with those based in the school setting. Additionally, both focus
groups and in-depth interviews were used to compare the responses of members in a
group as compared with their responses in an individual setting. During a focus group
study, the opinions of more dominant and outspoken members of the group may
overshadow the opinions of more reserved participants and their voices may not be heard
in this forum (Krueger & Casey, 2015). In-depth interviews were held in addition to
participation in the focus groups when possible to ensure that all members had an
opportunity to share their experiences with facilitate school-community collaboration.
Member Checks
Participants were contacted to review the study findings and to correct or add to
the analysis of the data. This was done by contacting participants individually and
conducting the check by phone or in person.
Summary and Conclusions
Children spend a large portion of their day within the school setting. Often,
schools are the first and only location in which children seek mental health services, yet
school professionals are limited in their training and the time they have to engage in
providing mental health services. Although collaborative efforts between community
agencies and between schools and communities have had a positive impact on children’s
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mental health and well-being, barriers to interprofessional collaboration reduce the
likelihood that these types of collaborations will occur. Studies published previously
have surveyed or interviewed mental health providers who have participated in specific
programs or have focused on the experiences of one group or another (e.g., social
workers, school psychologists, school social workers, etc.).
This study proposes to gather information based on the experiences of both school
and community based social workers, counselors and psychologists, outside of
participation in specific programs that focus on interprofessional collaboration. Learning
about the experiences of mental health professionals in this way allowed for the
development of new insights as to why interprofessional collaboration is limited and what
may be necessary to encourage mental health professionals to seek these types of
collaborations.
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Chapter 4: Results
Introduction
Collaborative relationships between schools and community-based mental health
services have become an ideal way to meet children’s mental health needs, yet these
collaborative relationships too often remain the ideal and do not translate into practice.
Many barriers exist to initiating and sustaining collaborative relationships; however, few
studies have reflected on how mental health providers believe that these barriers can be
overcome. This study fills a void in the literature by facilitating a better understanding of
the collaborative experiences of mental health providers in both settings and how they
believe that known barriers can be overcome. In this study, focus groups were used to
interview mental health providers working both inside and outside the school setting
regarding their experiences. This chapter details how participants were recruited; the
profile of each participant; how data were collected, stored, and analyzed; verification
procedures; and themes identified.
Recruitment
Participants were recruited by word of mouth in day-to-day interactions within the
professional helping community, by email invitation, and through calls to local schools
and community mental health organizations. Participants were part of school and
community organizations that had experience with collaborating to support children’s
mental health needs. Emails to organizations largely went unanswered or were rejected
by members of the organizations. For example, a local mental health organization sent
the following rejection via email: “We don't do this kind of work. I'm sorry but we can't
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help you.” In other instances, a gatekeeper, such as a secretary or even a director of clinical
programming and education for the organization, responded that he or she would pass along
information about the study. However, future attempts to follow up with the organization were
met with no response. School-based mental health providers were much easier to recruit and
were much more likely to respond and be interested in participating. In-person and word-of-
mouth recruitment efforts were most effective for both community-based providers and school-
based providers.
Of the 20 participants recruited, 13 were found in schools, one was found in an institute
of higher learning where she was my fellow adjunct faculty member, one was referred by another
participant, and five volunteered after being given a recruitment letter (Appendix A) by a
program director recruited by word of mouth. Of those found in schools, three were certified
school psychologists, one was a lead school psychologist, and nine were school guidance
counselors. The participant recruited from an institute of higher learning was a licensed clinical
psychologist. Six of the participants were part of a community behavioral health organization.
Two of them were program directors, and the other four were master’s or doctoral level school-
based clinicians in partnerships with local education agencies. Eighteen participants were
women, and two were men.
Participant Profiles
Participant 1, “Sara,” was a 25-year-old Caucasian woman. She was a master’s-
level behavioral health professional who had been working as a school-based clinician for
a local behavioral health organization for 2 years. She was placed within the school
setting and delivered therapeutic services in a school-based model.
Participant 2, “Lynn,” was a 38-year-old Caucasian woman who was a master’s-
level behavioral health professional with 9 years of experience. She was employed by a
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local behavioral health organization and had been working as part of a school-based
model of service delivery for 2 ½ years.
Participant 3, “Jenny,” was a 39-year-old Hispanic woman who was the program
director for a local behavioral health agency. She initiated a school-based therapy
program that had been in place for the past 4 years.
Participant 4, “Chrissy,” was a 40-year-old Caucasian woman who was a school
psychologist. She had 13 years of experience working in both elementary and high
schools in public school settings. She was currently employed by a contract company
and placed in the public school setting.
Participant 5, “Maria,” was a 29-year-old Caucasian woman who was employed
as a behavioral health professional for a local behavioral health organization. She was
currently placed in a school setting where she was working in a school-based model of
mental health service delivery.
Participant 6, “Jan,” was a 42-year-old Caucasian woman who was a program
director for a local behavioral health agency. She led the school-based therapy program
for the eastern part of the area.
Participant 7, “Gloria,” was a 29-year-old Hispanic woman who was a behavioral
health professional for a local behavioral health organization. She had been placed in the
school-based program for 2 years.
Participant 8, “Tara,” was a 40-year-old Caucasian woman who was the lead
school psychologist for a local public school. She had 12 years of experience as a school
psychologist.
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Participant 9, “Yolanda,” was a 35-year-old Hispanic woman. She was a licensed
clinical psychologist and was employed in a local school district. She had 9 years of
experience as a psychologist.
Participant 10, “Mabel,” was a 38-year-old Caucasian woman. She was a certified
school counselor working in a local high school, where she had been a counselor for 4
years.
Participant 11, “Megan,” was a 35-year-old Caucasian woman who worked as a
school psychologist in a local high school. She had 5 years of experience.
Participant 12, “John,” was a 35-year-old Caucasian man. He was a certified
school counselor working in a local high school. He had 5 years of experience in his
position.
Participant 13, “Marletta,” was a 48-year-old African American woman. She was
a certified school counselor and had 20 years of experience. She was employed by a local
school district where she was a high school guidance counselor.
Participant 14, “Rita,” was a 53-year-old Hispanic woman. She was a certified
school counselor working in a local high school. She had 20 years of experience.
Participant 15, “Genevieve,” was a 30-year-old Caucasian woman. She was a
certified school counselor for a local high school. She had 1 year of experience.
Participant 16, “Tom,” was a 45-year-old Caucasian man. He was a certified
guidance counselor with 13 years of experience.
Participant 17, “Nicole,” was a 35-year-old Hispanic woman. She was a certified
high school guidance counselor with 9 years of experience.
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Participant 18, “Donna,” was a 45-year-old Caucasian woman. She was a certified
guidance counselor with 8 years of experience.
Participant 19, “Riley,” was a 32-year-old Caucasian woman. She was a certified
school psychologist with 4 years of experience.
Participant 20, “Stella,” was a 50-year-old Caucasian woman. She was a certified
guidance counselor with 4 years of experience.
Data Collection and Storage
All participants were part of in-person focus groups, as described in Chapter 3. A
total of three focus groups were formed. Two focus groups were held at participants’
high school work settings and were composed of school-based mental health
professionals. One of these groups contained six participants; the other had five. One
focus group, with nine participants, was held at a local behavioral health organization and
was composed of a mix of school and community mental health professionals. Focus
groups lasted between 1 hour and 1 ½ hours. Consent forms were reviewed at the
beginning of each focus group, and each participant was offered a copy to keep.
Interviews were recorded using a digital video recorder. Recordings have been filed and
saved in a secure database on my personal computer. I transcribed each focus group and
stored these documents in a password-protected document on my home computer.
Identifying information was removed from transcripts.
Data Analysis
Data were analyzed using Moustakas’s (1994) procedures, with the adaptation
recommended by Creswell (2013) to bracket out personal biases at the outset.
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Transcripts were read, and significant statements were identified to build an
understanding of how each participant experienced collaboration. Analysis was first
completed in relation to each participant to better understand each individual’s
experiences. Analysis was then completed in relation to each of the research questions.
Overarching clusters or themes were identified. Contextual factors including job
description were considered, along with participants’ experiences, to identify individual
and group descriptions of participants’ experiences.
Data Verification
Data verification procedures were completed following individual analyses.
Interviews were transcribed and analyzed. Three techniques were used: clarifying
researcher bias, triangulation, and member checks.
Clarifying Researcher Bias
As discussed in Chapter 3, researcher bias and assumptions can affect data
collection and analysis. Researcher bias was identified at the outset to guard against bias
during the analysis of the data. I expected to find that both school- and community-based
mental health providers would have generally positive feelings regarding collaboration
and would express a desire for greater collaboration. Participants were aware of my
biases and experiences with collaboration as a school psychologist and were invited to
challenge my assumptions and address concerns about potential risks associated with
collaboration both during the initial focus group and during member checks.
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Triangulation
Data were collected through two methods to corroborate the information obtained
through each method. Focus groups were held, and follow-up interviews were conducted
with those participants who agreed to take part to share their experiences. During follow-
up interviews, participants were offered an opportunity to add to or change their initial
responses. There were some participants who had been very quiet during the focus
groups who were able to answer more freely in the individual interviews.
Data were analyzed in three ways. Data were coded and statements were
analyzed to identify overarching themes. Data were also analyzed by research question.
Finally, data were analyzed in relation to participants’ job descriptions to determine
whether similarities in experiences and views were held in relation to participants’ roles
as community-based administrators or mental health providers, school psychologists,
school counselors, or school-based administrators.
Member Checks
Following analysis of each participant’s statements, participants were contacted in
person, by phone, or by email. Eleven participants responded, participated in member
checks, and were provided with my conclusions about their statements. Each
participating member was given an opportunity to correct or expand upon the
interpretation of their statements. The remaining participants did not respond to attempts
to schedule checks. Subsequently, they were emailed a statement containing the themes
identified through the analysis and were provided an opportunity to respond. Each
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document was protected with a password. Passwords were sent to the participants in a
separate email so that they could unlock and open the document.
Themes Identified
Benefits of Collaboration
Study participants were largely in favor of collaboration between school and
community mental health. This was likely because they self-selected for participation
because they were interested in or believed in the idea already. They were able to present
many benefits of collaboration, particularly pertaining to cases in which community
mental health providers are able to provide services at schools.
Accessibility. Participants noted that when community mental health has a
presence on a school campus, barriers preventing children from receiving mental health
services may be eliminated. Families do not have to worry about transportation, money,
or taking time off work to take their children to a facility. Participants felt that this type
of collaboration improves accessibility. Jan, a community agency program director, said,
It’s an accessibility piece. We’re supporting a model that allows children to be
seen very, very frequently. There’s collaboration with the family and there’s
collaboration with the school and we’re all coming together. Families don’t have
to worry about taking an hour out of work or driving to pick up their child, going
to an appointment; doing all that first if they have childcare issues, transportation
issues or financial issues. That outpatient appointment can become very stressful
and may become less of a priority. Being on school campuses, neighborhood
school is usually within walking distance or relatively short drive. That’s a
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significant accessibility piece and I think that does help to manage the risk. It’s
that wrap-around model, very supportive-type collaboration.
Several participants, like Yolanda, a school-employed licensed clinical psychologist,
noted that stigma can be reduced by having programs available at school. Yolanda
explained,
If I’m going to the school to get mental health services, I’m not going to a clinic
or hospital, so it’s a lot safer if we’re working with diverse students or just
students who don’t want that stigma. If I go the psychiatrist today, people are
going to think that I’m going to leave because I am mentally ill, as opposed to I
just need some extra support.
The theme of safety and reduced stigma came up several times in relation to
having services available at school. Jan felt that parents may be more willing to accept
services if they are available in the school setting: “Parents often see their neighborhood
school as a safe place. They’re more likely to accept mental health services if they have a
connection with somebody on a school campus.”
Improved student mental health. Some participants thought that having
collaborative relationships between school and community mental health professionals
can help to meet students’ needs before they get to the point of crisis. There was also
some discussion that suggested that when community mental health is available in the
school, it can help to manage the level of risk and the costs associated with helping
higher need students. Participants thought that community mental health services in
schools might lead to a decline in depression and suicidality. With services available,
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students’ problems might not have to escalate to that level before mental health services
were accessible to students. Jenny, a community agency program director, suggested that
collaborative relationships that include having a community mental health staff member
located on a school campus can improve outcomes for students.
We have the highest percentage of reliable change with our services. The model
works and we have the data as an organization. We are more effective than any
other program in the agency and that says a lot about what we’re doing with
schools.
Improved relationships. The idea that collaboration can improve relationships
between school and families was also mentioned. Sara said,
Benefits of working in the school are that it can help change a family’s
relationship with the school. If you have a family that might think the school is
always against them or just giving them a lot of resistance, Community Mental
health can be a great bridge to help build those relationships. They are getting
everyone to the table for CFTs and working more closely with teachers.
Education, training, and sharing of resources. Yet another perceived benefit to
collaboration was that community mental health could provide training to teachers and
help them to better understand and work with students who have mental health problems.
Lynn mentioned that she can go over with teachers what she is working with on students
and a lot of times they take the strategies and use them with other kids. She said that they
can also help teachers and staff to accept new approaches to working with difficult
students and that this may change the future for the student.
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We have a role in the trajectory of success of that child. Oh, that kiddo, he has
been a terror for 10 years, or that’s the reputation and so with us being in the
school introducing new language about the child and maybe what’s going on with
those behaviors and helping the school understand, accept and embrace maybe a
new approach and that child no longer becomes the terror passing from third to
fourth grade and from fifth to sixth grade.
Collaboration was said to help administrators, staff and parents better understand how
providing mental health services to children in schools can help to improve academic
outcomes that schools care about, like academic performance and attendance. This is
welcomed by overwhelmed, school-employed, mental health staff, like school
psychologists and counselors who don’t feel that they have the time or training to address
student needs on a regular basis. John said that when children have immediate mental
health needs he does what he needs to do to respond but that he is not prepared to treat
mental health problems.
I’m triaging the severity, referring out and notifying parents. It’s the confidence I
have in my skills in that area. I don’t feel confident in my skills. I’m not a
mental health professional. With more collaboration, we could have resources
available on campus.
There was also some ambivalence that came from school guidance counselors
with regard to the benefit and need for collaboration. Although they were glad to know
that certain students were receiving services, they were not sure if they should be
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engaged in a more collaborative relationship in some cases, but wanted it in others.
Donna explained,
To be able to call and have a [crisis] team come out who does know what they’re
doing and they can talk [to the student] and determine what needs to happen. That
is huge for us. So, I’ve been a part of that multiple times. I have had a student
who had a counselor come meet with her here [at school] but I was completely
unaware of that. The only reason I knew was that because she was getting pulled
into the library and I happened to see her. So, there was no collaboration and I’m
OK with that because I’m her guidance counselor and I’ll support her whenever
she wants to share with me but if she’s receiving that counseling for a personal
reason I think that’s appropriate for it to stay separate but just knowing that she
was receiving that was comforting to me because I can’t provide that for her. The
struggle we have if the kid goes to [the hospital] for a week or whatever and then
returns to school its super difficult to get any kind of information. Our assistant
principal wants like a safety plan or something like that and you can’t get really
anything if a parent doesn’t bring it in. So that does not really feel collaborative.
Risks of Collaboration
There were some risks presented to collaboration. The main risks identified were
related to liability, adversarial relationships, confidentiality and consent, eligibility for
services, and privatization of public school funds.
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Liability. Another concern was the idea presented by some school counselors that
the school may not want to get involved in the liability that they might take on if they
begin to provide mental health services. Tom said,
I’m not so sure that it isn’t … the expense of it. There’s other districts that are
pretty close to us like [school district] has social workers. I talked to a coach
whose wife was one on campus. I don’t know for sure but I’m not sure our
district is not OK with those things being separate there’s a liability that comes
with it when you start getting involved in those areas and I think that’s one of
those things for us as guidance counselors. And that’s where collaboration is
tough because we can get a lot of information from outside resource about a
student but to be quite honest, our supports are going to be what we’re trained in,
what we feel skilled in, because the minute you step out of your area… Let’s be
honest if we step out of an area and we start counseling, that’s not what we’re
trained to do. Our employers know that’s not what we’re trained to do. If it ever
went to litigation or anything like that were going to be standing our own. So, you
have to be very cautious, fully knowing that you may not be supported on that
other end.
Another concern about the liability had to do with the trust that families have in the
school staff and guidance counselors and worry about the services being provided by the
outside agency and that if the community agency was not providing the kinds of services
or supports that the child needed that the parent might stay with that agency based upon
the word of the school counselor. Stella said,
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I would worry if it were my responsibility to set up the connections, is it really
reputable? Are they doing justice with my kids? I send them to good hands am
not sure their qualified and I don’t have time to vet then ahead of time that a time
that would be my fear.
Tom added,
To some parents our word is golden. As a parent, I am aware that if something
doesn’t work for my child, I’m gonna keep trying. And it’s scary that your
opinions are held in that prestige that, my gosh, they may stay in that situation and
it’s not working. And that would break my heart.
Adversarial relationships. Although some of the participants suggested that
improving relationships with families was a potential benefit, there was some dissent.
Cindy was concerned that there could be times when community providers may be more
of a support to the parent and may not help them to understand the school’s position. She
said, “Sometimes they (community providers) can become adversarial. We're trying to
prepare students to stand on their own feet, expand their comfort zone. Sometimes
parents and advocates view that as being disrespectful of their disability.”
Service eligibility. Another concern that was mentioned had to do with student’s
eligibility for services. One school psychologist explained that the alternative school she
works with had decided not to collaborate with a community agency because they would
only see students who were Medicaid eligible or who agreed to private pay. The school
was not willing to fund services for students with private insurance who could not afford
to pay for services. She also felt that in this case it would be appropriate for her school to
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hire a school social worker to provide the services to students. In describing her
experiences, Riley said,
One of the reasons we’re not doing the [community organization] thing is because
I told our K12 [administrator] that I don’t think it’s appropriate for us to be
denying service to some kids. I’ve been in meetings with people talking about
mental health support at [the campus] and I am used working in residential
treatment facilities and working in an alternative school. If really, it’s going to be
an alternative school, it’s missing a key component; Mental Health Service.
There’s nothing there. And no matter how much we keep knocking on that
door… they tried to get us a .5 nurse. It’s like, NO not a nurse! I just don’t
understand it. Maybe they’re afraid to bring them because they’re like if one
school has a social worker, that all the schools are going to want a social worker.
Privatization of public school funds. Some participants were concerned about
the costs that may be associated with collaborative partnerships with community mental
health and the appropriateness of using public school funds to pay for services from for
profit agencies. Riley stated, “I think that we’re getting so focused on bringing in private
for profit companies into education and it really could have lasting harmful
effects…Since being here I have been surprised that the amount of privatization that goes
on in public education.”
Confidentiality and consent. There was some concern about parental consent
and confidentiality issues. Donna was concerned that a parent may not allow a student to
access needed services. She said,
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I wonder how much of a barrier mental support would be even if we did bring it
to the school because of the stigma. The kids who need it, their parents may say I
don’t want my kid to be that kid and not want the school to know what’s going
on. I wonder how many of those kids we want to receive the services would be
denied because their minors. I can think of some family that would say, “Nope,
there’s nothing wrong with him.”
Similarly, Tara said that as a school psychologist, she had difficulty figuring out how
much collaboration about a student was appropriate without parental permission. She
said, “I could see we run into it a little bit not so much not wanting to collaborate but
figuring out how much we can collaborate; how much information can we share? Where
is that line of what is OK without specific permission?”
Barriers to Collaboration
Study participants identified several barriers to initiating and sustaining
collaborative relationships. They identified barriers related to time, communication,
funding, and different agendas.
Time. Study participants from both school and community-employed settings
shared concerns about time as a major barrier to collaboration. Lynn explained that high
caseloads can make it difficult to take advantage of opportunities to collaborate.
I think it’s harder when the problems are the lower level. When you have
someone with a lot of needs, big crisis, its collaborative and they have smaller
caseloads and are mobile and they can be more involved with schools, have the
time and energy to devote. But if you have lower level kids on your caseload
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with small problems they could become facility based. People have a caseload
that bigger. If I go to a school, then that’s like 3 times for kids that I am missing
for one child so I don’t have the time to do it. There becomes a disconnect
between facility based services and schools. Yes, I understand that you’re the
teacher but there’s no relationship. Maybe you send me a copy of the IEP, if I
have an ROI (release of information). It’s the constraints of having a big caseload.
With a smaller caseload, there is the time and opportunity to create those
relationships.
School-employed participants agreed that in schools, time constraints and high caseloads
may result in collaboration being most likely to occur for higher needs students.
Chrissy said,
In the schools, my experience has been that our higher needs students, we do a
really amazing job with that collaboration piece, but that’s exactly it. The mid-
level, low-level need, fall back. The students that do best in that situation are the
students that have parents that are good advocators and are informed.
Marletta was also concerned about the amount of time needed to spend with those
students whose needs were the highest, “We just pour, pour, pour into them. It goes back
to the bigger mental health picture. We can only do so much. We don’t have the
resources here.”
Communication. Participants reported difficulty initiating and sustaining
communication. It can be difficult know who to contact and what information can be
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shared, legally. From Yolanda’s perspective, communication is vital, but it is necessary
to have parent permission to release information.
I don’t know maybe in an idealic society we could have a mutual or an Ongoing
release of information where if they are working we can share information easily.
I think that’s a barrier. You have to get parent permission not only to sign the
HIPPA form for the community mental health but then the FERPA form and not
only is it one way but you have to have two FERPA forms to have, you can talk to
me but I might not be able to talk back until you sign the second form. If there
were a universal release of information to talk with community mental health,
again in a utopian society, is it ever gonna happen? But that communication is so
vital.
Following from a previous discussion about the importance of school people to be
involved in Child Family Team (CFT) meetings with community organizations, Yolanda
shared,
I have never been invited to a CFT and I don't know what students have one. And
so, a lot of times its, ‘well we had this meeting and now we are going to need this
from the school.’ It’s like it would have been nice to know and parents may not
share that information.
Megan shared her experiences trying to connect to community organizations to
get information she might be able to share with children and families. She expressed a
desire to have regular contact with community organizations.
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Last year I spent one or two days contacting places that I saw in the community.
When I actually got to talk to someone they were more than willing to send me
some things for sure. And then someone called us last year and said I’m your
liaison to your, you know, organization. I’m just calling to see if you have any
needs or whatever and actually did help me with a student here who had been
depressed or whatever. And then after that they never called again. They
disappeared. They were probably overworked and underpaid and just didn’t have
the resources. I think that it would take not just that person calling monthly but
setting foot on campus and scheduling an hour here and there to speak to you
know school mental health people on the campus to check in. And if they were
doing that regularly, if we can get someone on campus to do that, that would be
huge bridge to services.
Inconsistency in community mental health was shared by several school mental health
professionals in terms of turnover. Marletta suggested, "I think its turnover. I mean you
make a relationship, you know you make a connection with someone and it’s like 'Hi, I
remember working with [name]...' and 'Oh, she's no longer here.'” Riley also expressed
concern about this, "I feel like there is so much turnover that the kid will get established
with someone and then they'll leave so there's not really any consistency."
Funding. Several participants raised concerns about how funding can be barrier
to collaborative relationships. There were concerns about how schools could attract
mental health organizations and how the community agencies may not find schools to be
a profitable market. Mabel wondered,
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How are they going to be compensated for their efforts? You have to make a
dollar and the district is probably not going to fund, am I wrong in assuming
they’re not going to fund something like this? It has to be lucrative. If there were
a lucrative market, there would be people who were starting to build up a
clientele, tapping into a market that’s not been tapped into. It’s not lucrative
because there is no money here.
John agreed that it was unlikely that the school board would be willing to fund a
collaborative program that placed mental health professionals from the community on
school campuses.
What kind of federal grants are out there for stuff like this? Everything that takes
place outside of straight education and even within straight education, any service
that is research based that indicates increased academic performance does not
typically come on the local taxpayer’s dime. Free/reduced lunch, title 1 after
school intervention, so I think the extent to which those opportunities could be
thought out, researched and utilized. you took the words out of my mouth earlier
you're not going to convince the board elected from a primarily like wealthy
District that this is like most parents want to do it they're going to go out and see a
therapist. That’s just not gonna compute. If you look at the way we fund
education it would just be asinine that we would help support someone. On paper,
a billable hour for mental health, that’s insane, it’s just so off the charts of what
we, how much we value each kid per dollar. And the staff members that work
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with them all the time, it’s totally inverted so it would have to be some kind of
outside funding and compensation, which I know is not a surprise I’m sure but …
The sustainability of programs was also questioned by Chrissy,
I am in a position now that I am in a district now that values mental health
services that are school-based and are employed by the district. That has not been
my experience up to this point. It’s that financial piece. Schools face a lot of
pressure financially. When we go through these budget decisions, mental health is
one of those things that seems to go.
Similarly, Marletta discussed cutbacks that had eliminated her job as an intervention
specialist on an elementary school campus. Due to budget cuts, she felt that they just
kept “peeling back” layers of support for students until the “bridges kind of collapse”.
Different agendas. Differences also emerged in how school and community
mental health professionals view student problems. Schools and community
organizations may have a different focus and may be working on different goals with the
student. There is a perception from school staff members that community agencies may
be working to appease the parent and may not understand the role of the school, and the
process by which services become eligible for special education services. There is a
perception from community staff that their role may not be valued by the school. Rita
said of community providers that they don’t necessarily think that the school understands
the child’s disability.
They’re just looking at this IEP meeting. They’re not thinking long term. I’m
always thinking long-term and I have no problem saying that might work for
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today but how are we going to get them through to the end where they leave us
and they can function?
Along those same lines, Yolanda felt that there was a lot of confusion about what an IEP
is for on the part of community mental health. She felt that parents can sometimes be
misinformed by community health who may not understand specially designed
instruction, “kids are resilient, they might not show these behaviors at school”.
Many of the school-based providers indicated that they thought there may be a
misperception about what they were doing with students in terms of therapy. Megan was
concerned that community mental health providers may not understand that schools are
not doing therapy. “School mental health providers are helping students access the
curriculum, not creating a therapeutic relationship.” Similarly, Rita was concerned that
parents do not understand the difference between what they do and what a community
mental health professional does: “When the Spanish-speaking parents come in and hear,
‘consejero,’ the Spanish word for counselor, and they’re like, ‘yeah’ and I’m like, ‘no,
not that kind. I don’t do therapy.’”
John was concerned that there may be questions about who is in charge and that
the community organization may have a different agenda from the school. Tom was
more concerned about what his role should be as a school counselor and was conflicted
about the academic goals of education for students struggling with mental health issues.
Tom said,
I think maybe it’s just the way you look at education in general and what our role
is because we catch so many different things coming down the pipe how to
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educate kids in and we’re doing a poor job of educating kids. I mean you hear
about it in the news all the time and the things that were talking about now about
the support and the mental health issues, they’re really not prioritized. We really
need to find the balance and reestablish what the role is because I’m torn in two
worlds. I mean I have a heart for people. And my heart gets broken when I see
people like the young lady that we talked about and we all have them….It gets
frustrating I guess my point on that is that they need to work together somehow.
That you have to reestablish what education’s role is that is because again what
we’ve been dealing with when she’s [a student] missed fifth hour every day the
last week and she goes into this mode and she comes to visit with me and she
finds a safe haven in the nurse’s office and again education’s not getting done
here. It’s almost like they need to bring the organizations in but they still need to
be two separate entities. Right now, we’re dabbling into too many things and not
doing one thing very well it seems like sometimes.
Sara suggested that community mental health understands how important a role the
school plays in the Child Family Team (CFT) process but schools do not always
understand how big of a role they play: “Those that get it are trying to teach everyone,
but if you don’t have someone in the district and the school it’s difficult to get their buy-
in.”
Overcoming Barriers to Collaboration
Study participants had many suggestions for overcoming the barriers to
collaboration. Problems addressed included initiating relationships, funding problems,
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leadership and communication issues, accessibility issues, and sustaining collaborative
relationships were all addressed by the participants.
Initiating collaborative relationships. Participants suggested several
possibilities for facilitating collaboration; needs assessments to demonstrate the need for
services, program initiatives at the state or district level, word of mouth from school to
school about partnerships, and getting administrator buy in. The idea that schools needed
a school social worker or someone whose job it was to manage those collaborative
relationships.
Several participants felt that a top-down approach to collaboration would be most
effective. Community-employed providers working in the schools found that they had
the most success when their role was understood and welcomed by the building or district
level administrators. Lynn suggested that the statewide behavior health leaders should
meet with the department of education should work together to expand collaborative
efforts.
The way to facilitate would be at the top. Mercy Maricopa and the Department of
Education sitting down and talking about it, and have a trickledown effect so that
the Department of Education can go to all the districts and say, ‘this is an
availability,’ and identifying organizations under Mercy Maricopa, and creating
those partnerships.
Jenny agreed that top down coming from the district level was beneficial. She
also thought word of mouth was important:
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It’s really word of mouth, having a champion in the district. I never would have
developed a partnership with [school district] had a principal from another district
not met the principal at [school district] at a conference. They’re talking sand she
says, ‘Oh my God, you have what at your school? And that led her to call me and
so when we have school administrators and staff who are really in tune to wanting
support on their campus they’re very, very motivated.”
Educating decision makers was also proposed as a way to help facilitate the
development of collaborative relationships. Chrissy said,
Educating our administrators as to what this is, a lot of these decisions are made
by the [school] board and they’re just regular people who don’t know. Your
board, as you know, those people are doing it because they care and they can only
work with the information they have, so making sure that they have the
information. If they don’t know what we do and how important it is bring it back
to the student performance and attendance and things that make people
understand that it is important.
Funding. Another theme for overcoming barriers was the idea that costs can be
decreased in other areas by building and funding partnerships like these. Jenny felt that
risk management was a compelling argument and could persuade school districts that
funding partnerships could save money in other places.
We tend not to have as many high needs kids in the school setting because we’re
able to work with the school to manage the level of risk and need. It costs more
money to have the high needs kids. It’s beneficial for both. Having a high-risk
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student, it costs more money to have these kids… We can manage those risks by
establishing these partnerships.
The idea that building partnerships could reduce costs by minimizing risks was
popular, but difficult to demonstrate what the benefits would be on a day to day basis.
Chrissy said,
Schools may think about the threat of lawsuit. What happens if we don’t do it- to
the extreme? But I think benefitting us day to day; I think it is hard for schools to
see. I would also be interested in finding ways to better demonstrate how
important what you all do for our kids is.
The possibility of looking for grants was also considered, but there was concern
about what happens to programs once the grant funding is gone. There was consensus
that convincing decision makers would take presenting information on outcomes to help
them understand and support collaborative partnerships. Jenny said,
We talked to our supervisor recently and you inspired me to look at the
organization doing a Needs Assessment in schools that we are currently in, doing
focus groups, doing informant interviews and looking at those outcome data and
presenting that as a tool to Mercy Maricopa because we have been meeting with
them to expose the work we’ve been doing in school, but also then taking that
data to school districts so that they know that they need partnerships like this.
School services in a community-based organization and the thing that we’re doing
together this is something that could be really powerful for future collaborations.
We’re kind of excited, very preliminary conversation.
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Cost savings was another potential source of funding. Specifically, participants
suggested that savings on the school side could be as simple as reducing outplacements.
In order to hire a school social worker, for example, Riley suggested,
And if it’s a cost thing, because I have been working a lot with [school] in terms
of let’s conceptualize what why are they doing this that you know I mean not
sending one kid to [private placement] covers the cost of that person.
Additionally, managing risk and need was identified as a measure of potential cost
savings. Jenny noted,
We tend not to have as many high needs kids in the school setting because we're
able to work with the school to manage the level of risk and need. It costs more
money to have the high needs kids. It's beneficial for both. Having a high-risk
student, it cost more money to have these kids, and more insurance and expenses.
It's beneficial to both. They work with the school’s school psychologist
administrators and assess risk. It's a huge responsibility...We can manage those
risks by establishing these partnerships.
Seeking federal grants for funding was also suggested.
Leadership/communication. With regard to leadership and communication
schools felt that it would be important to hire a professional like a social worker to be in
the role of leading collaborations. Donna said,
We first need someone on our campus who is not the school psychologist who is
trained in some of those techniques. Because you can tell me what’s going on or
while you’re working with the kid on but I still am not trained to be able to add
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anything to that other than, "Keep it up. Good job." So I think having someone
here who could work with those outside agencies in supporting the kids. With our
caseload and the number of students we have the number of IEPs the number of
504s the testing all of these things that is just not something I mean that’s a time
consuming thing you have the kid going through and I mean there’s a lot of hours
that you’re talking about for those kids and it’s just not a priority in our district
that’s for sure. Not when you’re cutting counselors and increasing caseloads and
responsibilities. You would have to have another staff member who was role that
was.
Riley added,
And I know we fought really hard to get a behavior interventionist on our campus.
It was just me doing a lot of work and we’d have someone come for a day here
and a day at [school] then we got one fulltime. Don’t get me wrong I love that we
have a Full-Time BI but I think that we could have a social worker doing what she
does with the kids and then taking on those extra things. The amount of kids are
being seen are able to be covered in about three days and then there’s two days of
doing other things like meeting with kids that aren’t scheduled on things like that
were crisis management or whatever but the skill set that you need for the BI
would be encompassed in a social worker so I just don’t really understand why
they’re not behind doing that.
Agenda. To overcome concerns about having different goals within each
organization, it was indicated by participants that developing a common agenda with
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common goals was important. School psychologists did not see the goals as all the
different and also felt there was an adequate understanding by community mental health
about what was happening in the schools. Megan said,
I feel like I've had a good experience with mental health professionals from the
community. They're usually an agreement and it's extremely helpful to have them
there because they know what they're really targeting out there. Or when they call
and they're asking about a student check in more tell me more. We're not really
doing therapy here we're trying to ask to help them access their curriculum.
Therapeutic environment is very different than what we're doing in school. I feel
like I don't know if it's a misconception but I feel like I'm desperate for that. I
want them to be here I want them to be involved and I feel like maybe they have
so much business out there they don't need that.
Community mental health providers felt that building a common understanding alleviated
issues related to agenda. Gloria said,
Talking about schools really getting it I've had a completely different experience
in the school I'm in where the administration truly does understand my role. It's
really effective to where we're starting to get the referrals from the staff after they
do their interventions first and if they're not effective they refer them to me.
Gloria also mentioned the importance of demonstrating an understanding of the school’s
role. She said,
Being respectful of teachers and their time plays a big role in it. Explain to them
how the process will be when do they want to work with your 7th and 8th graders.
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They're doing testing, there are certain times to avoid they're very clear about that,
but they realize that if there's an emergency situation. it's whatever time it's
necessary to be effective so I think that's it helpful and they work with you better.
Accessibility. Participants working for community agencies who delivered
services to students in a school-based model made the case for school-based service
delivery as a way to overcome barriers and increase collaboration. Having staff present
in school allowed opportunities for greater collaboration. According to Maria,
“integrating yourself into the school environment” provides opportunities for school staff
to approach community professionals about possible referrals. Having community
providers in schools reduces the concerns about time for collaboration and provides more
opportunities for communication. Lynn expressed how much easier communication is in
this model.
We play so much of a role within the school. I can run over to Sean’s classroom
and talk to his teacher and we can go over those coping skills that he learned. And
the teacher, things I was working on with an individual kiddo, the teacher brings
in her own and is using them in the classroom for all students.
Jan also explained how the school-based model can improve collaboration. She
also noted that this model may not work for every therapist.
Our model eliminates the barriers. It is in our procedures that we will talk to
teachers and administrators as part of the collaborative team. Ongoing
collaboration is happening all the time in this model. Not every clinician can be a
school-based clinician. You have to be willing to go to the classroom and talk to
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teachers and share information. Same with school psychologists, and bring
parents and teachers together.
Sustaining collaboration. Jenny, a program director, suggested that looking at
outcome data and presenting that information could help support collaborative efforts in
the long term. She said,
We talked to our supervisor recently and you inspired me to look at the
organization doing a needs assessment in schools that we're currently in. Doing
focus groups, doing informant interviews and looking at those outcome data and
presenting that as a tool to [state organization] because we've been meeting with
them to expose the work we've been doing in school. But also then taking that
data to school district. so that they know they need partnerships like this, school
service in a community-based organization and the thing that we're doing
together. And this is something that could be really powerful for future
collaborations. We're kind of excited very preliminary conversation.
Summary
Analysis of these qualitative data was completed to identify benefits and risks
associated with collaboration between school and community mental health providers,
and to identify factors that facilitate collaboration, barriers to collaboration, and ways that
barriers may be overcome. Benefits of collaboration included; removing barriers to
services for children, increasing accessibility of services, particularly if services were
available as a school-based model, improved student mental health, and improved
relationships between school and families. Mutual benefits to collaboration included;
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education, training, and sharing of resources that have the potential to reduce costs.
Risks of collaboration included; the liability the school may take on by getting involved
in children's mental health, relationships with families and community agencies that may
become adversarial, problems with parental consent, and confidentiality. Barriers to
collaboration were related to time, communication, funding, and differing agendas of the
school and community organization. Most school-based professionals believed that it was
necessary to employ a mental health professional such as a social worker, whose job it
was to establish and maintain collaborative relationships. Both school and community
mental health providers indicated that establishing relationships was a process that
worked best from the top down. Participants proposed ideas for funding that included;
cutting costs, reducing risks, and finding grants. Jointly developing procedures,
increasing accessibility by having services available within the school setting, and
collecting outcome data regularly to share with stakeholders, were discussed.
Understanding the experiences of collaboration among school and community mental
health providers has the potential to help schools and community agencies overcome
barriers to collaboration, and improve the coordination of services for children with
unmet mental health needs.
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Chapter 5: Interpretations and Conclusions
Introduction
As many as one quarter of children have mental health needs, yet only about a
third of them receive mental health services (Merikangas et al., 2010; Merikangas et al.,
2011). Community- and school-based mental health services, independently, have not
been sufficient to meet children’s mental health needs. Most students with mental health
needs initiate services in the educational setting (Farmer et al., 2003). However, there is
little evidence to support that services carry over from school to community-based mental
health or vice versa.
Barriers to community-based services disproportionately impact children from
lower socioeconomic levels and from minority ethnic backgrounds (Alegria et al., 2012;
DeRigne, 2010; Kodjo & Auinger, 2004). In schools, services are impacted by too few
providers, role strain, and inadequate training (Suldo, Friedrich, & Michalowski, 2010).
Increasing collaboration between school- and community-based mental health
professionals may allow school and community organizations to share the responsibility
of meeting children’s mental health needs.
Recent legislative updates to the Elementary and Secondary Education Act of
1965, known as the Every Student Succeeds Act (ESSA, 2015), require schools to
address the mental health needs of students, including early identification of mental
health problems, coordination of services, and the use of partnerships to expand access to
or coordinate services for students in order to improve school safety and increase the
likelihood that at-risk students will complete their education. Barriers to collaboration
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have been identified, but little information is available to determine how school and
community mental health providers can initiate and sustain collaborative relationships or
how they may overcome barriers to collaboration to meet children’s mental health needs.
A phenomenological approach to this inquiry was used to understand the
experiences of school and community mental health providers with varying levels of
involvement in collaborative relationships. This method was chosen to capture the lived
experiences of mental health service providers with initiating and sustaining collaboration
in the provision of mental health services for children. Understanding their experiences
can help in the effort to identify ways in which barriers may be overcome for
collaborative relationships to flourish.
The findings from the focus groups and interviews revealed that participants’
views of collaboration were generally positive, but school-based providers
overwhelmingly suggested that it was difficult to initiate and maintain collaborative
relationships at the level of the mental health provider. A few providers also noted risks
related to collaboration. Benefits of collaboration included the ability to remove barriers
and to increase accessibility of services, particularly if services were available within a
school-based model, as well as improvements in student mental health and relationships
between schools and families. Further, mutual benefits included education, training, and
sharing of resources, which had the potential to reduce costs. Risks of collaboration
included concerns about the liability the school might take on by getting involved in
children's mental health, especially if some students with needs were not eligible for
services through the community mental health agency; concerns that relationships
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between families and community agencies might become adversarial; and problems with
parental consent and confidentiality.
Barriers to collaboration were related to time, communication, funding, and
differing agendas of the school and community organization. Ideas for overcoming
barriers to collaboration included initiating collaborative relationships with a top-down
approach, identifying a leader who could be responsible for maintaining communication,
developing common goals and a common agenda by increasing parental involvement,
respecting teachers’ time and establishing a culture of collaboration, increasing
accessibility by providing services through a school-based model, and sustaining
collaboration by collecting outcome data to educate administrators and school boards as
to the effectiveness of the collaborative efforts and reductions in costs associated with
risk management and outplacements. A consensus of the school-based professionals was
that it would be most beneficial for schools to have a person, such as a school social
worker, who could take on the responsibility for leading collaborative efforts on the
school side.
Interpretations
The intent of this study was to provide insight into the experiences of school and
community mental health providers in collaborative relationships to support children’s
mental health needs. The results of this study suggest that mental health professionals on
both sides do see the benefits of a collaborative relationship, but, especially among
school professionals, do not feel that there is much that they as professionals can do to
initiate and maintain such relationships. Despite feeling that they had limited control
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over establishing collaborative relationships, they could identify barriers as well as ways
in which those barriers could be overcome. Professional experiences related to the
benefits and risks of collaboration, the barriers to collaboration, and overcoming those
barriers were identified. The position of the mental health provider as a school- or
community-employed professional, is a point of consideration when interpreting the
findings of this study, particularly given the low number of community mental health
professionals who agreed to participate in this study. Additionally, few participants
identified themselves as administrators.
Facilitating Collaboration and Overcoming Barriers
Study participants identified benefits and risks for initiating and sustaining
collaboration. Issues related to initiating collaboration included improving accessibility,
navigating confidentiality and consent, dealing with family relationships, managing
district risks and liabilities for student outcomes, and improving training, education and
sharing of resources. Sustaining collaboration was associated with overcoming barriers
related to time and role conflict, identifying leadership to manage the collaborative
relationship, building a common agenda, and identifying sources for sustained funding.
Benefits, risks, barriers, and ways to overcome these barriers are discussed in greater
detail below as the two primary goals of this study, initiating and sustaining
collaboration.
Initiating Collaboration
School and community providers agreed that initiating collaboration was most
likely to occur with program initiative, beginning at the state or district level. This was
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felt to provide the best understanding by both organizations as to what the expectations of
the collaboration would be. Participants suggested that the “top-down” approach is
needed in order for administrators to buy into and support the program. Another
suggestion was to conduct an assessment to document student needs. Finally, word of
mouth was identified as a way to gain acceptance for collaborative models, particularly
from administrator to administrator. A tool that has the potential to assess readiness for
collaboration at the school level is the Expanded School Mental Health Collaboration
Instrument (School Version). The scale addresses several factors related to collaboration,
including interpersonal processes, buy-in, outreach by community agencies, school
environment, and administrative support (Mellin, Taylor, & Weist, 2013). Three main
factors related to collaboration were types of, influences on, and benefits of collaboration
(Mellin et al., 2013). From a planning perspective, the results of this type of school- or
district-wide assessment may help school professionals better understand what needs to
be done to prepare for coordinated and collaborative relationships with community
mental health.
Accessibility. There was a lot of support among participants for the idea that
collaboration between school and community mental health providers could improve
access to mental health services for students, particularly when services were delivered as
part of a school-based model. Participants also expressed concerns about whether parents
would follow through on referrals. Accessibility and availability of services in terms of
time and location have been identified as significant barriers to children receiving needed
mental health services (Cummings et al., 2013; DeRigne, 2010). Problems have also
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been noted by school mental health providers regarding accessibility of community
mental health providers for collaboration (Walsh, 2013). Housing community mental
health providers within the school building can help to eliminate this barrier. Community
providers in this study working within the school setting reported improved accessibility,
both in terms of children accessing services and in terms of school personnel accessing
clinicians. Jenny and Jan, program directors for a school-based program in a community
agency, shared that having clinicians located within the school works. Jenny stated, “We
have the highest percentage of reliable change with our services,” and Jan said, “Our
model eliminates the barriers.” This is an important consideration for ways in which
barriers to services can be overcome. Students are able to be seen more frequently, and
communication and collaboration between community and school staff are built into the
model.
Consent and confidentiality. Some participants shared concerns about sharing
too much information with collaborative partners without specific permission, and others
were concerned that parents might not consent for their children to receive services due to
stigma. School and community mental health partnerships are required to abide by the
Family Educational Rights and Privacy Act (FERPA) and the Health Insurance
Portability and Accountability Act (HIPAA) to protect the confidentiality and privacy of
children (Klontz, Bivens, Michels, DeLeon, & Tom, 2015). FERPA allows for disclosure
of mental health records to health care professionals providing treatment to the student
with the student’s permission, or with the guardian’s permission if the student is a minor
(U.S. Department of Health and Human Services [DHHS] & U.S. Department of
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Education [DOE], 2008). Once the record is in possession by the healthcare
organization, the healthcare organization is required to protect the information according
to HIPAA privacy rules. At that point, the mental health record can be disclosed to
prevent an immediate threat to health or safety (for the patient or another party) or to
lessen the threat, including to law enforcement, the target of the threat, family, or others
who might lessen the threat. Otherwise, consent by the patient or guardian (for a minor
child) is necessary (DHHS & DOE, 2008). The key to maintaining appropriate privacy
and confidentiality is to develop procedures for how these issues will be managed
(Klontz et al., 2015). Consent forms should be used for evaluation and treatment that
satisfy both FERPA and HIPAA requirements, permission should be obtained early in the
process, and it should be identified as part of the procedure how records will be stored
and managed (Klontz et al., 2015).
Family relationships. Study results suggested that some school-employed staff
felt that relationships with families could become adversarial if the community provider
did not understand the school's agenda. On the other hand, many school- and
community-based providers felt that working collaboratively with community mental
health could help to improve family relationships as grades or discipline improved and
school staff gained a better understanding of children’s struggles. Schools and families
may have issues that include distrust or disconnection, especially when cultural
differences are perceived between teachers and students (Mellin, Belknap, Brodie, &
Sholes, 2015). Families may not be available to be involved in the way that schools
would like, due to long work hours or feeling unwelcome in school (Mellin et al., 2015).
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This can extend to mistrust by schools of community organizations or mistrust in families
concerning community organizations (Mellin et al., 2015). In contrast, when school-
family relationships are strong, they may facilitate trust (Bryan & Henry, 2012).
Establishing partners with organizations that are also trustworthy may help to facilitate
the likelihood that families will follow through with mental health referrals for services.
Participants also thought that these types of collaboration could improve
relationships between schools and families. When providers understand social and
cultural family values and beliefs, improvements for children are greater (Mancoske,
2013). Additionally, when discipline problems negatively impact their children, parents
often find the time that they spend at school to be negative due to these problems
(Duchnowski & Kutash, 2011). Community providers felt that once they became
involved, the school had a better understanding of students’ problems, children showed
improvements academically or in relation to discipline, and families experienced relief,
helping to improve family-school relationships (Duchnowski & Kutash, 2011).
Student outcomes. Another theme identified was improved student mental
health. Administrators from the community agency reported that their program was more
effective than center-based programs without school collaboration within the same
organization. Community providers also indicated that they could see students more
frequently and when problems were present at a lower level. Children who receive
services under a coordinated systems of care approach demonstrate improved
relationships, emotions, school functioning (improved attendance, fewer discipline
referrals, better grades), and functioning at home, as well as decreased substance abuse,
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depression, anxiety, and suicidal thoughts and attempts (CMHS, SAMHSA, & DHHS,
2015; Mancoske, 2013). Under the current version of ESSA (2015), schools are
responsible for identifying and coordinating services for students with mental health
problems.
Training and sharing of resources. The idea of that collaboration could result in
more training opportunities for teachers and school staff and that collaboration results in
a sharing of resources and responsibilities was identified. Some concerns were also noted.
All school counselors indicated that they felt that they were not trained to provide mental
health services. Interdisciplinary collaboration is associated with an array of
competencies (communication skills, collaboration skills, relationship-building skills,
team participation skills, consultation skills, group process skills, identifying and
understanding roles and responsibilities, collaborating effectively across systems, values
input from stakeholders, participating in planning, needs assessment and resource
mapping, knowledge of available community supports and when they are needed, etc.)
that must be learned and practiced in order to support collaborative relationships
(Michael, Bernstein, Owens, Albright, & Anderson-Butcher, 2014). School and
community mental health professionals can use effective relationships to provide training
opportunities to one another and to create an understanding of the goals of each system to
more effectively coordinate care for students.
Several participants suggested that educating teachers to better understand and
respond to children’s mental health problems could have a positive impact not just on
students in service, but on other students as well. All states require some level of mental
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health training in teacher preparation programs (Ball et al., 2016), and teachers have
reported concern for student mental health (Moon, Williford, & Mendenhall, 2017).
However, teachers have also reported a need for further mental health training (Moon et
al., 2017). Compared with school mental health professionals and administrators,
teachers are less likely to believe that addressing mental health issues is part of their job
(Moon et al., 2017).
Collaborative relationships provide additional sources for ongoing professional
development that can be beneficial to key collaborators including teachers and other
school support staff who work with students from day to day. Mental health first aid
training can improve teachers’ knowledge and beliefs about treatment, but it may not
result in any significant change in their efforts to support individual students (Jorm,
Kitchener, Sawyer, Scales, & Cvetkovski, 2010). Collaborative partnerships may
improve teachers’ ability to address mental health needs by providing an opportunity for
teachers to learn through training, collaboration, and interactions with community and
school mental health providers. Feedback and training can improve the delivery of
interventions at earlier stages and may reduce the need for more intensive supports.
Risk management. Results from this study suggest that some school-based
professionals were concerned that by initiating collaboration, the district would become
liable for student outcomes. Other school-based providers were concerned that parents
held their recommendations in too high regard, which they felt could be a problem if the
organization was not properly vetted. Several community and school professionals felt
that, in contrast, having mental health services available could manage the risks
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associated with children’s mental health problems by establishing partnerships. As was
reported by participants in this study, school counselors and school psychologists may
not have needed time or training and are often not set up with student-to-provider ratios
for diagnosing and treating mental illness (LaFee, 2013). Lafee (2013) recommended
coordinating collaborative services in the form of mental health clinics on campus. The
argument for this is that when the school takes on the task of mental health diagnosis and
treatment, it also takes on liability risks. By implementing mental health procedures and
collaborating with community mental health, schools can build connections with external
mental health providers while protecting themselves from liability risks they would face
if they were to diagnose and treat students themselves or if they were to do nothing
(LaFee, 2013).
Sustaining Collaboration
Ideas for sustained collaboration included minimizing barriers to collaboration
including time and role strain by; increasing training in mental health, hiring school staff
to lead and manage collaborative relationships, building a common agenda by setting
clear rules and boundaries, developing common goals and common language,
establishing a referral process, frequent meetings, and evaluation of collaborative efforts.
Conducting assessments to document student need, and collecting outcome data to share
with educators, administrators, schoolboards, and state organizations may help to justify
financial needs to potential sources of funding. Completing a cost benefit analysis and
demonstrating how costs can be reduced across several systems may help to make the
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case that paying for some services are affordable. Strategies are discussed in greater
detail below.
Time and role strain. Time was identified by most of the participants employed
by schools as a major issue. Mental health professionals in schools and in the
community, each felt that high caseloads left little time for collaboration. Participants
also felt that high needs students received the most support; with community-based
mental health professionals and school psychologists indicating that collaboration was
better with these students. School counselors reported that the high needs students took
most of their time, but often they did not feel that the time was a good investment.
Students fell behind in their school work and sometimes left without school counselors
feeling that they had made a difference. Time constraints and heavy workloads are noted
as barriers within the literature (Odegard, 2005; Walsh, 2013).
Additionally, school counselors expressed difficulty identifying themselves as
mental health professionals. They expressed concern about parents thinking they could
provide ongoing therapeutic counseling and they reported that they lacked the necessary
training to act in the capacity of a counselor. One group member said she felt that the
word counselor should be removed from her job title. This is consistent with the research
literature suggesting that those who identify primarily as a guidance counselor are less
likely to provide mental health services (Beckles, 2009). School psychologists in this
study indicated that their training supported them in the role of mental health provider but
that time constraints were the major barrier. Walsh (2013) found that school
psychologists whose primary role was evaluation for special education eligibility,
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engaged in less collaboration. For school psychologists, number of professional
development hours in mental health was related to amount of time in collaboration
(Walsh, 2013). For those with more than 10 hours of training, both communication and
collaboration with community mental health increased. Increasing training opportunities
for school professionals in youth mental health may be a way to increase collaboration.
Additionally, school professionals suggested schools hire a school social worker whose
job it would be to lead and manage these types of relationships (discussed further below).
Identifying leadership. Many school-based providers felt that leadership and
communication issues could be addressed by hiring someone whose primary role it is to
initiate and maintain collaboration and communication. School mental health providers
suggested hiring a social worker at the school to manage the relationships with
community organizations. Identifying leadership in the community may also help to
avoid confusion given that school mental health professionals indicated that high levels
of turnover within community mental health are a significant barrier to collaboration and
communication. Concern about high turnover in community mental health is consistent
with previous research (Mellin & Weist, 2011). Community organizations involved in
collaborative partnerships may also look at improving retention by providing incentives
for continuing with the organization to ensure that there is investment in school-
community relations (Mellin & Weist, 2011). When changes are expected,
communication about these changes from the community-based leader may help to
support efforts to sustain relations.
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Building a common agenda. Creating specific procedures and outlining a
common agenda was identified by school-based providers as a way to ensure that schools
and community organizations established rules and common goals. They also felt that it
would be necessary to provide training to staff and establishing a culture of collaboration.
One school counselor suggested that when community mental health providers come to
school meetings they don't understand the role of the school and the focus on academics
and educational issues, while another school counselor felt that for some students there
was a conflict between academic goals and mental health goals. Community-employed
therapists, in contrast, suggested that collaboration, whether they attend an IEP meeting
or schools staff attend a CFT, was beneficial. They felt that it could be difficult to get
school buy-in. School psychologists did not see the goals of school and community
mental health as being very different while community mental health providers felt it was
important to build common understanding and goals so that admin and school staff
understood their role and could aid in making referrals for services. Community mental
health providers also felt it was important for them to demonstrate understanding of the
school's role. Specifically, they suggested having clear guidelines about when to see
students and how to be respectful of teachers when pulling students. Developing a
positive attitude toward one another's roles and a common understanding of the child's
problems can help to facilitate collaboration (Odegard, 2005). Having a common
language, a sense of commitment and accountability and greater interaction were also
found to facilitate collaboration (Palinkas et al., 2014). Frequent meetings and ongoing
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assessment of the collaborative process may help to keep community and school staff
engaged.
Funding. Another concern noted by participants was that some children may be
denied services that they need due to funding issues. Community providers in this study
responded to concerns about denying children needed services and indicated that
community organizations may be able to provide services on a sliding scale or lower fees
for children who were not eligible for Medicaid. Funding to sustain mental health
collaborative partnerships can come from Medicaid, private insurance, state health
departments, fee-for services, nonprofit companies, community coalitions, grants, social
services or mental health government organizations, and community funding sources
(Klotz et al., 2015). Additionally, use of volunteers or use of interns through partnerships
with university programs may help to sustain mental health service accessibility for
students (Klontz et al., 2015).
Local funding sources are also an option. Sources may include child welfare,
juvenile justice, health organizations, and school districts (Weist et al., 2003). However,
one participant shared concerns that if schools and other public organization fund
services in partnerships with private, for-profit agencies, that the effects could be
harmful. Exogenous privatization utilizes the private, for-profit, sector to provide
education services (Ball & Youdell, 2007). Contracting services for transportation,
cleaning, food services and building maintenance are common practice for schools (Ball
& Youdell, 2007). Most participants in this study felt that benefits outweighed the risks
and that it was possible to put procedures in place to ward off any ill effects of such
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relationships. Recently, federal, state and local governments have enacted policies that
provide funding for charter schools, voucher programs and open enrollment to foster
competition and innovation in academically underperforming areas (Roda & Wells,
2013). These policies can result in increased racial/ethnic segregation (Roda & Wells,
2013) and change the way education is managed, how curriculum is delivered and how
performance is measured (Ball & Youdell, 2007). Identifying the benefits and risks of the
specific policies and how they are implemented should be considered when analyzing
outcomes of such policies.
Soliciting funds from private donors and private foundations may also be an
option (Cammack, Brandt, Slade, Lever & Stephan, 2014). Coordinated care has been
associated with reduced inpatient services by 42%, ER visits by 57%, juvenile arrests by
38%, retention rates, school dropout rates, and parent absences from work and increased
parental employment (Stroul, Pires, Boyce, Krivelyova, & Walrath, 2014). One study
participant noted that cost savings could be found in schools through fewer
outplacements. Cost-benefit analyses across multiple systems can help support the need
for integrated collaborative approaches to children's mental health.
Schools and communities may have to become increasingly creative in how they
find and allocate financial resources in the current political climate where the Affordable
Care Act is in danger of being repealed and replaced with a healthcare bill that
significantly reduces funding to Medicaid and leaves mental health care benefits up to
each state to decide (Grayson, Hurt, & Kodjak, 2017). Proposed changes in federal
funding for education, expanding school choice, may result in decreased funding for
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public schools in favor of public and private charter schools (U.S. DOE, 2017). Finally,
the U.S. DHHS (2017) is anticipating $374,000,000 budget decrease, with reduced
funding in community mental health, certain mental health programs, substance abuse
prevention, health surveillance and program support. While children's service funding is
proposed to remain unchanged, reduced funding for mental health services, substance
abuse prevention, program support and monitoring of mental health needs is likely to
have a negative impact on children and their families.
Collecting and sharing outcomes. Although it continues to be reported that the
literature is scant in terms of student outcomes related to collaboration, the information
that exists suggests that coordinating systems has been effective in improving school
attendance and grades, decreasing emotional and behavioral problems, decreasing
suicidality, lowering rates of substance abuse and reducing involvement with the juvenile
justice system (Stroul et al., 2014). In low income, African-American populations,
coordinated care was associated with better attendance and grades, fewer disciplinary
referrals, less substance use, and reduced mental health symptoms (Mancoske, 2013).
When at risk students access available mental health services in a school setting,
academic outcomes improve (Walker et al., 2010). Community-based mental health
directors in this study have identified the importance of collecting and sharing outcome
data in order to continue to build relationships with school. They indicated a desire to
conduct needs assessments, interview focus groups, use informant interviews and collect
information on therapeutic and educational outcomes. These participants identified
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sharing this information with state departments of mental health and education and local
school districts as crucial for expanding their school-based program.
Theoretical Considerations
The systems of care model developed by SAMHSA out of a need to improve
mental health services for children (Pumariega, Winters, & Huffine, 2003) continues to
support collaboration as a worthwhile initiative. The establishment of the children’s
mental health initiative endeavored to improve access and comprehensive mental health
treatment to children in need. Outcomes assessed as of 2013 suggest that children with
services delivered under a systems of care approach improved their ability to develop
relationships, manage emotions, improve functioning in schools (fewer suspensions and
better grades) and at home, improved anxiety, and decreased suicide attempts and
ideation (CMHS, SAMHSA, & DHHS, 2015).
Bronfenbrenner’s ecology of human development is discussed earlier in this
review and reappears here as a way of looking at how interactions between systems can
affect the developing child (Bronfenbrenner, 1979; 1994). Adding to this, resilience is a
theoretical construct from which collaboration in mental health can be viewed. Ungar,
Ghazinour & Richter (2013) analyzed resilience in the context of Bronfenbrenner’s
ecology of human development and found it fitting. A social-ecological view of
resilience emphasizes the role of systems in facilitating positive child development. This
view looks at the adaptations needed in each system to support desired outcomes. At the
micro level resilience is impacted by individual factors including; biology, personality,
and temperament, but also the family, the neighborhood, school, and religious
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organizations, of which the child is a part (Ungar et al., 2013). Making changes in any of
these systems can affect the child’s development and can impact the child’s ability to be
resilient. At the level of the mesosystem, resilience is an outcome of interactions
between the microsystems to which the student belongs. When microsystems form
complex interactions, they can exchange resources that enhance the growth of the child
(Ungar et al., 2013). Little research has been done to examine the effect of intervention
at this level on resilience. The exosystem is the social networks that indirectly affect the
child, but that affect those in the child’s microsystem or mesosystem (Bronfenbrenner,
1994; Ungar et al., 2013). Thus, increasing supports for parents; social supports, parent
training, and support for working parents can positively impact children. Similarly,
increasing supports for teachers; training in mental health, social supports, team building
activities, supportive administrators, and well-trained support staff, can also have a
positive impact on children’s ability to be resilient. In the school system, having a well-
developed character education plan and integrated collaborative mental health supports
can positively affect not only the child but the other students who can affect the resilience
of the child (Bronfenbrenner, 1994; Ungar et al., 2013). The macrosystem includes
cultural factors and values that affect child development. This can include the impact of
values transmission that occurs in subcultures. Thus, as criminal behavior or drug use is
normative within the subculture, this can have an impact on the child’s resilience.
Families that reinforce adherence to the majority culture standards have children who are
less likely to have problems with criminal behavior or drug use (Ungar et al., 2013).
Finally, the chronosystem includes the impact of historical events and time on resilience.
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Events such as the attacks on the World Trade Center and the Capital building on
September 11, 2011 have a lasting impact on the macrosystem due to changes in public
policies, legal and political platforms that in turn affect the exosystem, the mesosystem,
and the microsystem, to impact resilience.
Finally, the current view of mental health is that mental health is not merely the
absence of mental illness, but a positive sense of mental well-being (Antaramian et al.,
2010; Herrman et al., 2005). Flourishing involves accentuating the positive by increasing
positive emotions, improving emotional well-being, and increasing satisfaction and
success in life (Keyes, 2007). Keyes (2007) noted that it was important that people have a
sense of belonging and comfort within their community, that they engage in activities that
are valued by others, and that they accept others. For teens, the indicators of flourishing
include; psychological and social well-being, autonomy, environmental success, self-
acceptance, personal growth, life purpose, and positive relationships (Keyes, 2006).
Moderately mentally healthy teens have few mental problems but do not have
characteristics of flourishing, while those who are languishing have mental health
problems (Keyes, 2006). It is imperative to have systems in place for the identification of
students with mental health problems as well as to identify those who are not flourishing,
and therefore at-risk. Providing interventions for these children can improve their
opportunity to thrive, improving lifelong outcomes. Mental health services may improve
children’s opportunity to achieve a state of well-being.
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Implications for Social Change
Hess, Pearrow, Hazel, Sander, & Wille (2017) made the argument that school
mental health is a public health issue and deserves the attention of the larger healthcare
system. Healthcare has long been provided in the school system, yet this has gone
unrecognized, despite carrying a price tag greater than $10 billion annually (Hess et al.,
2017). In fact, mental health treatment is most often initiated in the school setting
(Farmer et al., 2003). Efforts to expand mental health services in schools and to establish
collaborative relationships with community mental health agencies can best be construed
as a cry for help. Approaches to public health emphasize prevention, positive practices,
widespread assessment, intervention, and comprehensive service delivery, which
coincides well with a multitiered system of supports. Tier 1 of a multitiered system of
support involves universal strategies appropriate for all students (Desrochers, 2014). Tier
2 includes targeted interventions for students at risk of mental health problems. Finally,
Tier 3 involves intensive intervention for student currently experiencing mental health
problems (Desrochers, 2014).
School psychologists, school counselors and school social workers are in a
position to garner support for improved mental health support from school district and
school building administrators. Universal, school-wide strategies and social emotional
learning can be taught and implemented by teachers and school staff. When used as part
of a multitiered system of support teachers implementing social emotional learning
curricula to teach class wide strategies for social competence and resilience and positive
behavioral interventions and supports, a schoolwide approach to teaching, modeling,
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cueing, and reinforcing appropriate behavior either individually or together, resulted in
improvements in student mental health functioning when compared with business as
usual (Cook et al., 2015). For students at Tier 2, consultation and collaboration between
school and community mental health providers can provide opportunities for more
focused and targeted interventions for at-risk students, preventing more significant school
and mental health problems from developing, while students at Tier 3 are likely to require
more intensive behavior health supports (Hess et al., 2017). Within this model,
collaborative relationships between school and community mental health are not just
ideal, but necessary to provide the supports needed. A greater understanding of school
mental health as a public mental health problems is needed.
Data obtained through this qualitative inquiry corroborates and extends previous
research on collaboration. Problems with initiating and sustaining collaborative
relationships among school and community mental health professionals continue to
prevent worthwhile partnerships from improving children’s ability to receive needed
mental health services, despite a recognition of the benefits that these types of
relationships. New information garnered from this study suggests that support for
collaborative partnerships is expected to have the greatest effect when high level
administrators at state departments of education and mental health and school district
leadership champion the cause, implementing collaborative practices from a top-down
approach. Additionally, many participants suggested that providing community mental
health services within the school setting could eliminate barriers, improve access to
services, and improve children’s ability to build resilience to mental illness. By
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intervening at the lowest levels of need, within the school setting, where children spend
much of the day, it is possible to affect outcomes and improve children’s wellbeing.
School and community mental health professionals involved in collaborative
relationships are in a position to advocate for policies that can help to sustain
collaborative practices. Eliminating barriers at the school level to reduce time constraints
and role strain by identifying leaders to manage collaborative partnerships may help to
improve the ability to apply school mental health in a multitiered system of support.
School and community mental health professionals can help to conduct needs
assessments and collect student outcome data to share with state and school level officials
to identify and secure sources of funding. Resilience can be achieved in an ecological
model when public policy changes encourage interaction among the systems to support
children’s mental health needs.
Limitations
The limitations for this study include difficulty with recruitment of community
mental health providers. Although many community mental health agencies were
contacted and offered the opportunity to participate in focus group or interviews, many
these organizations and providers did not engage in collaboration with schools and did
not feel that they had anything they could add to the discussion. Others indicated that
they did not have time or were not willing to make time to participate in this research.
Just six of the twenty participants were community-based mental health providers, and
two of those participants were in a supervisory role and were not providing direct
services to children. Two of the community participants were willing to participate in
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more in depth follow up to ensure that as much information as possible could be obtained
from the perspective of community-based mental health providers. It does appear that the
information collected is sufficient for making some general interpretations.
A limitation among the school-based providers was recruiting participants in an
administrative role. Only one of the fourteen school-employed mental health providers
interviewed was in a supervisory role. School administrators contacted did not feel that
they had enough experience with school-community collaboration, were not available to
participate in focus groups, or were not interested in participating in the study.
Another possible limitation was gender. Of the twenty participants in this study,
only 2 (10%) were male. None of the community-based providers were men. Women do
tend to dominate the fields of community and school mental health. About 77% of school
psychologists are women (Castillo, Curtis, & Gelley, 2013), 73% of counselors are
women (Evans, 2010), and 77% of school counselors are women (Bridgeland & Bruce,
2011). A somewhat smaller percent of males participated in this study than is observed
in these fields.
Another limitation is the somewhat small sample. Recruiting school-based
mental health providers was relatively easy and they were generally willing to participate.
Given the limited number of community-based mental health providers, it was
determined that continuing to recruit school-based participants would skew the results.
Additionally, when analyzing data, it became clear that saturation of the data had been
reached. Participants’ descriptions became repetitive and confirmed previously collected
data.
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Recommendations
School district and state mental health agencies should consider the results of this
study. School professionals experience stress related to their inability to meet children’s
mental health needs. Community agencies in partnership with schools can identify needs
early and reduce the level of risk management needed in the school setting. Reducing
outplacements by minimizing children’s level of behavioral difficulty can reduce costs
and provide a source of funding for school districts to hire support staff whose role it is to
initiate and sustain collaborative relationships. Adequate planning for early intervention
at the highest levels can reduce costs for high needs students by eliminating the costs
involved in high needs case management and reduce the need for services in multiple
sectors.
Conclusions
Viewing school mental health as a public mental health issue and utilizing a
multitiered systems of support approach to support the need for collaboration between
school and community mental health may result in a program with an emphasis on
prevention and promoting resilience. A systems of care approach to meet children’s
unmet mental health needs can be viewed through an ecological model of resiliency.
According to Zimmerman (2013), a strengths-based approach to intervention supported
by resiliency theory may be best to promote mental health in adolescents. Promotive
factors include; individual factors or assets and supportive resources, including parents,
other adults, and programs for learning and practicing skills (Zimmerman, 2013).
Promotive factors or assets can mitigate the risk factors present in the adolescent's life.
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As noted in the experiences of participants in this study, Lee et al. (2013) found that
collaboration between systems for children with emotional disturbance helped to reduce
the severity of problems and improved the child's ability to function. Parents also
demonstrated increased competence in handling their child when systems collaborated
with one another to support children (Lee et al., 2013). Weist et al. (2012) noted that
mental health initiatives often get lost within the schools. Schools are held accountable
for academic rather than mental health outcomes. Recognizing that barriers to student
learning can be academic and nonacademic can be reduced by promoting student
wellness can help mental health and wellness initiatives survive (Weist et al., 2012).
Developing relationships among school and community professionals to support
children's mental health is necessary in order to understand the resources available within
the community and to develop partnerships to increase the coordination of services.
Within the literature are numerous suggestions for improving the process of
collaboration. The results of this study are consistent with those recommendations. To
increase coordination of services among school and community mental health
professionals, organizational supports may be needed. IEP team meetings, CST meetings
and CFT meetings are effective ways to stay in communication and to coordinate care
(Weist et al., 2012). Collaborative team member should include school and community
employed mental health staff, educators, health staff (school and community), family
members and family advocates (Weist et al., 2012). They should meet regularly and
choose a leader to facilitate meetings. Evaluating the team's work should occur regularly.
Policies and procedures and services offered should be outlined in a written agreement
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(Weist et al., 2012). Community mental health staff involve parents as much as possible
in the child's mental health services. Approaches to resilience that strengthen the family
can be very effective in improving the functioning of individual and the family (Walsh,
2002). Community mental health staff may be able to help promote resilience not just
within the student, but for the entire family (Walsh, 2002).
Browne, Gafni, Roberts, Byrne, & Majumdar (2004) concluded that that school-
based services provide easy access and encourage participation while community
programs provide a greater opportunity for confidentiality but reach a smaller number of
children. Confidentiality issues can be reduced by obtaining a release of information
from the family (Weist, et al, 2012). When mental health services are available in a
school health center, accessibility is improved and barriers to services are eliminated
(Bains & Diallo, 2016). Building collaborative partnerships in which community mental
health services are available within the school setting, as part of a multitiered system of
support, within a larger public health model is necessary to promote resilience, and is
achievable when adequate supports for the collaborative process are in place.
