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All of our reportsare available on the web:

www.nhpolicy.org

New Hampshire Center New Hampshire Center for Public Policy Studiesfor Public Policy Studies

“…to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire’s future.”

Board of DirectorsDonna Sytek, Chair

John B. Andrews

John D. Crosier, Sr.

William H. Dunlap

Sheila T. Francoeur

Chuck Morse

Todd I. Selig

Stuart V. Smith, Jr.

James E. Tibbetts

Brian F. Walsh

Kimon S. Zachos

Martin L. Gross, Chair Emeritus

StaffSteve Norton, Executive Director

Ryan Tappin

Cathy Arredondo

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Mental Health in New Hampshire’s Schools

CMH Community of Practice and NHASEA

June 12, 2009

Ryan Tappin, Research Associate

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Why look at mental health and schools?

4

Top 20 providers of MH services for children

Total Expenditures for Mental Health Services for Medicaid Enrolled Children Up to age 19 for the Top 20 Providers

Provider Total Expenditures Service Count

RIVERBEND COMMUNITYMENTAL HEALTH $3,840,202 22,205

THE MENTAL HEALTH CENTER OF GREATER MANCHESTER $3,426,685 18,817

LAKES REGION MENTAL HEALTH $3,013,125 15,118

WEST CENTRAL BEHAVIORAL HEALTH $2,674,982 18,875

MONADNOCK FAMILY SERVICES $2,602,120 15,333

SEACOAST MENTAL HEALTH CENTER $2,487,523 12,907

MOUNT PROSPECT ACADEMY INC $2,444,888 1,632

COMMUNITY COUNCIL OF NASHUA $2,201,147 14,849

ODYSSEY HOUSE INC $1,683,859 647

BEHAVIORAL HEALTH SERVICES $1,586,829 9,558

NASHUA CHILDREN'S HOME $1,527,389 1,103

CLM BEHAVIORAL HEALTH SYSTEMS $1,506,753 9,288

EASTER SEALS NH $1,487,099 887

EASTER SEALS NH INC - ZACHARY RD $1,393,243 550

NEW HAMPSHIRE HOSPITAL $1,354,952 251

LUTHERAN COMMUNITY SERVICES OF NORTHERN NEW ENGLAND $1,030,063 838

ECKERD FAMILY YOUTH ALTERNATIVE $960,273 385

MANCHESTER SCHOOL DISTRICT $904,534 18,897

EASTER SEAL SOCIETY OF NH INC $895,072 436

NASHUA SCHOOL DISTRICT $852,734 22,967

Interesting!

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Schools provided $13.5 million in

Medicaid funded MH services in 2005

Total Expenditures for Mental Health Services for Medicaid Enrolled Children Up to age 19 by Provider Type

Provider TypeTotal

ExpendituresService Count

Total Children

Average Costper Child

Average Cost

per Service

Average Number of Services per

Child

Mental Health Clinic $25,191,173 148,927 6,544 $3,850 $169 23

Private Non-Medical Institution $21,548,382 13,270 1,251 $17,225 $1,624 11

School Health Services $13,525,760 253,390 4,680 $2,890 $53 54

Home and Community Based Care $4,951,315 20,587 638 $7,761 $241 32

Day Rehabilitation Center $4,382,659 19,460 1,402 $3,126 $225 14

DCYF Services $4,061,514 4,139 207 $19,621 $981 20

Psychologist $2,538,164 36,305 3,559 $713 $70 10

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Which schools are providing the most services?

Total Expenditures for Mental Health Services for Medicaid Enrolled Children Up to age 19 for the Top 20 School Districts

School DistrictTotal

Expenditures

Percent of All School Service

Expenditures

Service Count

Percent of AllServices

Provided

MANCHESTER SCHOOL DISTRICT $904,534 7% 18,897 7%

NASHUA SCHOOL DISTRICT $852,734 6% 22,967 9%

MERRIMACK SCHOOL DISTRICT $661,437 5% 9,922 4%

CONVAL SCHOOL DISTRICT $377,535 3% 4,391 2%

MONADNOCK REGIONAL SCHOOL $352,681 3% 6,316 2%

TIMBERLANE REGIONAL SCHOOL DISTRICT $319,151 2% 6,097 2%

JAFFREY/RINDGE SCHOOLS $311,111 2% 95 0%

HAVERHILL COOPERATIVE $299,162 2% 2,651 1%

FALL MOUNTAIN REGIONAL SCHOOL $290,006 2% 5,373 2%

ROCHESTER SCHOOL DISTRICT $286,190 2% 3,234 1%

CONCORD SCHOOL DISTRICT $258,594 2% 1,278 1%

DERRY COOPERATIVE $255,921 2% 339 0%

THE EXETER REGION COOPERATIVE $245,518 2% 2,870 1%

LACONIA SCHOOL DISTRICT $236,603 2% 4,312 2%

PORTSMOUTH SCHOOL DISTRICT $234,351 2% 4,957 2%

CLAREMONT SCHOOL DISTRICT $229,291 2% 4,337 2%

DOVER SCHOOL DISTRICT $224,376 2% 7,266 3%

LONDONDERRY SCHOOL DISTRICT $200,426 1% 8,006 3%

SALEM SCHOOL DISTRICT $184,833 1% 4,066 2%

CONWAY SCHOOL DISTRICT $181,819 1% 2,973 1%

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What services are schools providing?

Total Expenditures for Mental Health Services for Medicaid Enrolled Children up to 19by CPT Code

CPT Code DescriptionTotal

ExpendituresService Count

90810

Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approx. 20 to 30 min. face-to-face with the patient $202,476 5,975

H0046 Mental health services, not otherwise specified $558,003 25,275

H2017 Psychosocial rehabilitation services, per 15 min. $12,765,281 222,140

   

Total   $13,525,759 243,664

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What we wanted to find out

• More specifically, what services are schools providing?

• How are schools supporting these services and how is funding administered?

• Who are the practitioners providing those services?

• What mental health issues are most commonly seen in the school setting?

• What barriers exist to providing school-based mental health services?

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What we did – Part 1

• Fielded 2 surveys taken from a national survey of school-based mental health, conducted nationally by SAMHSA in 2002

• Sent survey to all districts and all schools to eliminate sampling bias

• Response rate – 19% of schools and 31% of districts

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What we did - Part 2

• Interviews with Children’s Directors at the Community Mental Health Centers.

• Discussions focused around:– The arrangements of formal agreements with schools

districts.– The existence and structure of informal agreements

for services and other informal relationships between CMHCs and schools.

– Advantages, disadvantages, successes, and barriers in providing mental health services in schools.

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Survey Results

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Administration and Funding

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Who receives services?

Students Receiving Mental Health Services

All Students, 86%

Special Ed Students Only,

9%

Not Available, 5%

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Who has the administrative responsibility?

Administrative Responsibilty for Mental Health Services

School 28%

Administrative Responsibility at

the School District72%

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What is the relationship between MH and SPED?

Administration of Special Education and Mental Health Services

Together68%

Separately32%

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How are MH services budgeted?

Mental Health Services Budgeted Separately from Other Education Expenditures

Mental Health Budgeted Separately

48%

Not Separately Budgeted

52%

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Funding for School Mental Health

Percent of School Districts Indicating Each as a Source of Funds for Mental Health Services

84%

80%

76%

64%

64%

28%

16%

16%

12%

12%

8%

4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Local Funds

Medicaid

IDEA

Title IV

State Special Ed

Third Party

Community Health Services BlockGrant

General Fund

Title 1

Safe Schools Initiative

Self-Pay

Private Foundation

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Has funding for MH changed over the past year?

Changes in Funding Level for Mental Health Services for Students

Decreased24%

Remained the same48%

Increased24%

Not Available4%

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Mental Health Issues in Schools

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What MH issues are school services treating?

Percentage of NH Schools that Ranked the Following Mental Health Problems as Among their Top Three Problems for Male and Female Students, 2007-2008

69%

61%

43%

22%

29%

17%

80%

19%16%

28%

54%

27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

SocialInterpersonal

Or Family

AggressiveDisruptiveBehavior

Behaviorproblems assoc

with neuro

AdjustmentIssues

Anxiety stressschool phobia

Depression

MalesFemales

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What MH issues are school services treating?

Percentage of NH Schools that Ranked the Following Mental Health Problems as Among their Top Three Problems for Male and Female Students, 2007-2008

69%

61%

43%

22%

29%

17%

80%

19%16%

28%

54%

27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

SocialInterpersonal

Or Family

AggressiveDisruptiveBehavior

Behaviorproblems assoc

with neuro

AdjustmentIssues

Anxiety stressschool phobia

Depression

MalesFemales

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Social, interpersonal, and family issues are most common

Problems Which Use Most of NH School's Mental Health Resources

Aggressive/disruptive behavior, bullying

15%

Behavior problems assoc w neurological disorders

13%

Anxiety, stress, school phobia

8%

Adjustment issues1%

Alcohol/drug problems1%

Major psychiatric or developmental disorders

4%

NA7%

Depression, grief reactions2%

Suicidal or homicidal thoughts or behavior

1%

Social, interpersonal or family problems

48%

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High schools tend to have different needs

Mental Health or Psychosocial Problems Using Most of the Resources

0%

10%

20%

30%

40%

50%

60%

Social, interpersonalor family problems

Aggressive/disruptivebehavior, bullying

Behavior problemsassoc w neurological

disorders

Anxiety, stress,school phobia

Other

High SchoolMiddle SchoolElementary

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Mental Health Services Provided

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What services are school MH programs providing?

Percentage of Schools Providing Various Mental Health Services, 2007-2008

83% 84%

76%80%

75%73%

70%

39%

32%

41%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Assessment BehaviorManagementConsultation

CaseManagement

Referral toSpecializedPrograms

CrisisIntervention

IndividualCounseling

GroupCounseling

SubstanceAbuse

Medication forEmotional orBehavioral

Referral forMedication

Management

FamilySupport

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NH is not unlike the rest of the nation

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Few schools are providing screening….

Percent of Schools with School-wide Screening for Behavioral or Emotional Problems

36%

42%

51%

39%

33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Kindergarten Screening forSocial-Emotional Problems

Health Class Inventory My Voice StudentAspiration Survey

Systemic Screening forBehavioral Disorders

Youth Risk Behavior

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…and prevention services

Percent of Schools Offering Prevention and Early Intervention Programs and Services

25%

50%

41%

37% 38%

42%

46%

0%

10%

20%

30%

40%

50%

60%

PBIS Responsive Classroom Safe Schools/HealthStudents

Alcohol/Tobacco/DrugUse Prevention

Prevention and Pre-Referral

Outreach to Parents PeerCounseling/Mediation

30

Many barriers to providing services in schools exist…

Percentage of Schools Reporting Extent to Which Various Factors are Barriers to Providing Mental Health Services, 2007-2008

0%

10%

20%

30%

40%

50%

60%

70%

FinancialConstraints of

Families

TransportationDifficulties

CommunityMental Health

ResourcesInadequate

InadequateResources

(e.g. waitinglists)

CompetingPriorities

GainingParental

Cooperationand Consent

Stigma InadequateCoordination

betweenschool andcommunity

Language andCulturalBarriers

ProtectingStudent

Confidentiality

NH

SAMSHA

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…creating difficulty in providing services

Percent of Schools Indicating Service is Difficult to Provide

21%

13% 13%

32%

21%20%

26% 27%

45%

37% 37%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Assessment BehaviorManagementConsultation

CaseManagement

Referral toSpecializedPrograms

CrisisIntervention

IndividualCounseling

GroupCounseling

SubstanceAbuse

Medication forEmotional orBehavioral

Referral forMedication

Management

Family Support

32

Schools with higher poverty levels find more difficulty in providing

servicesPercent of Schools Indicating Difficulty in

Providing Services by Enrollment in Free and Reduced Lunch Programs

0%

10%

20%

30%

40%

50%

60%

Assessment BehaviorManagementConsultation

Case Management Referral toSpecializedPrograms

Crisis Intervention IndividualCounseling

Group Counseling Substance Abuse Medication forEmotional orBehavioral

Referral forMedication

Management

Family Support

Above State Average with FreeLunchBelow State Average Percentwith Free Lunch

33

Staffing Mental Health Services

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The majority of MH services are provided by internal staff

Percentage of Schools with Various Types of Staff Who Provide Mental Health Services

(NH=2007-2008, SAMSHA US=2002-2003)

75%

67%

25%21% 21%

17%

6%

77%

69%

12%

44%

16%

9%

2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

StaffCounselors

SchoolPsychologists

SubstanceAbuse

Counselors

School SocialWorkers

Mental HealthCounselors

Clinical/PHDCounselors

Psychiatrists

NHSAMHSA

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Little coordination between MH providers and other school staff exists

Percentage of Schools Meeting Weekly To Coordinate Mental Health Activities and Services Within Schools, (US 2002-2003, NH 2007-2008)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

InterdisciplinaryMeetings among

Mental Health(MH) Staff

MH Staff/Teacher Planning

MH Staff/ SpecialEducationplanning

Share MHResources

InformalCommunication

NHUS

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About half of schools contract with an outside provider

Percent of Schools with a Formal or Contractual Agreement with a Community-Based Organization, 2007-2008

56%

39%

50%47%

0%

10%

20%

30%

40%

50%

60%

High School Middle School Elementary All Schools

37

Individual providers were most reported community partner

Most Frequent Community Partners for Those Schools with Formal or Contractual Relationships with Community-Based Organizations

74%

62%

40%37%

33%

24% 24% 23%

15%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

IndividualProviders

County orCommunity

Mental HealthAgency

Juvenile JusticeSystem

Local Hospital CommunityHealth Center

Child WelfareAgency

CommunityService

Organization

Faith BasedOrganization

School BasedHealth Center

Other

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Collecting Mental Health Services Data

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One-third of schools do not collect data on MH services provided

Collection of Data on Mental Health Services Provided to Students

Collect or Have Access to

Mental Health Services for Special Ed only, 20%

No Data Collected, 34%

Collect or Have Access to MH

Services Provided (All Students)?,

46%

40

Few schools collect data on specific service elements

Share of Schools that Collect Data on ....

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Data Collected onTypes of MH

Problems

Types of SchoolBased Services

Provided

DemographicCharacteristics of

Service Users

Number of Units ofMental Health

Services

Referrals toCommunity Mental

Health

Referrals forStudents onMedication?

Reporting toDistrict or State

Offices?

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Schools and the CMHCs

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Schools and the community mental health centers

• Coordination of services between agencies receiving public support is minimal. This is despite the system relying heavily on public financing.

• This reliance on public financing offers a natural partnership between schools and the CMHCs. However, only about 13% of schools have a formal partnership.

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Although few formal agreements exist, informal relationships are commonplace

• The types of school-based services (and the agreements that govern them) vary greater across the state.– Logistical agreements– Specific services, like IEP related activities and

psycho educational groups– Very rarely do schools pay directly for individual

services with a CMHC

• Schools are often a catalyst for initiating mental health services. Even through informal relationships with community providers.

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Barriers create significant challenges to school/CMHC partnerships

• Many challenges to school-based mental health care exist– Expectations between the systems can create a challenge– Parental engagement can be frustrating to schools and providers– Resources, staff and logistical resources are ongoing challenges

• Coverage and geography are significant barriers– Medicaid – parents are often not covered– Private – does not pay for support services and limits treatment

sessions– Self-pay is rare

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Factors influence success -programs have potential

• Several factors influence whether schools have mental health services available– Buy-in from administration and school boards– Availability of private providers (including CMHCs)– Resources– Stigma

• Open communication is the greatest avenue to success

• Even with challenges, school-based mental health services has the potential to increase access and improve treatment

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Take Aways

• Schools play a large role in providing MH services to children.

• Little information is available to manage the system in place.

• Little formal coordination of services across systems, particularly among the publicly-supported.

• Significant funding is being utilized without coordination of the various funding sources

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Thank You

Questions?Thoughts?

Comments?