The Trajectory of Mental Health Services

Tegethoff, M., Stalujanis, E., Belardi, A., & Meinlschmidt, G. (2014). School Mental Health Services: Signpost for Out-of-School Service Utilization in Adolescents with Mental Disorders? A Nationally Representative United States Cohort. PloS One, 9(6), e99675. doi:10.1371/journal.pone.0099675


This article, “School Mental Health Services: Signpost for Out-of-School Service Utilization in Adolescents with Mental Disorders? A Nationally Representative United States Cohort”, looked at how school mental health service providers, such as school psychologists, serve as a guide to out-of-school medical or mental health providers (Tegethoff, Stalujanis, Belardi, & Meinlschmidt, 2014). They used data collected from the National Comorbidity Survey Replication Adolescent Supplement (NCS- A), which is an incredibly in-depth study of children and adolescents with mental illnesses completed between 2001 and 2004. The NCS-A study included data from interviews with the child/adolescent, rating forms completed by the child/adolescent and a parent/guardian, and detailed demographic information. This data is available for other researchers to use to complete their own research. For this study, lots and lots of statistical analyses were used by the authors on the data collected in the NCS-A study order to make their final conclusions.  Overall, the researchers found that school-based mental health services due typically guide families to out-of-school medical service providers, such as pediatricians or emergency rooms. Less often, school-based mental health services guide families to mental health specialists, such as psychiatrists or outpatient mental health clinics.

What was interesting to me, and what I’m still having a hard time understanding, was the “hazard ratios” computed by the researchers. I was able to learn that a hazard ratio is a statistical analysis that tells the amount of time between Situation A and Situation B happening. The statistical analysis did not necessarily look at whether or not (for example) school psychologists encouraged parents to go to the pediatrician or psychiatrist, but how long it took before the family sought those services. (At least, I think that’s what it was saying!) Also, despite my cursory knowledge of statistics and research on hazard ratios, I was unable to understand what a hazard ratio (HR) of 1.17 or 3.15 really meant. I did figure out that HR=3.15 takes about 3 times longer than HR= 1.17, but I can’t turn that into raw numbers. (I mean… three times longer than what? What does 1 equal? A week? A month? Some theoretical amount of time that is never really determined? Argh!)  The article doesn’t really explain it, though it may be because their usual audience would already know.

The authors organized the article in an easy-to-read format, and I really appreciated that the tables were embedded into the article instead of attached as appendices. I think it just makes it a lot easier to read that way. I enjoyed how they used end notes and not parentheticals, too – I know it’s just a personal preference (and I have made my peace with APA style, since that’s the preferred format for educational research), but I do think end notes allow for more fluid reading. There was not a specific literature review included, though the authors did reference many studies previously conducted to support their reasons and findings along the way.

Some of the data reported in the tables was interesting, but I’m not sure how necessary or useful it was. For example, I found it really interesting to see that nearly 50% of the children and adolescents in the total sample cited 3 or more siblings, and that over 35% of the total sample were first-borns. Though I am not a fan of birth-order theories, I had a mental jaunt about this. Does a bigger family simply increase your chances of at least one child having a mental illness? Are first-borns more susceptible to mental illness? Or is it just that parents need more support recognizing mental illness in their first-born, and are more likely to seek outside services for later children without the school initially intervening? Interesting questions – right?? Well, they are to me. But even though this information is given in the article, it was not referenced anywhere in the text. I’m a fan of visuals, but only when the pertinent information is provided and explained within the article. Otherwise, it just appears to be fluff and can overwhelm the reader.

According to the article, “this is the first comprehensive study of the role of the school mental health sector as a guide to mental health care in out-of-school sectors” (Tegethoff, Stalujanis, Belardi, & Meinlschmidt, 20149, p. 6). It did not explore whether school mental health providers caused students to seek outside mental health support, but did look for a temporal relationship (i.e. that the school-based referral came before seeking outside help). The next step would be to look at causality. The authors note that this will be really difficult to do, though, because of the size of the sample needed to make it representative of the entire population.

In some ways, I was pretty bummed to realize this article didn’t explore causality. I mean – was this really necessary to prove? Did anyone NOT think the school-based referrals came first?? But then I remembered one of the basic tenets of research the way it exists in the world: if it hasn’t been proven, then it can’t be used to support your theory. I also thought about how a handful of my students who I don’t realize have any mental illnesses until their psychiatrist sends a script requesting testing or a 504 Plan. So there are times that the school is not the first one to find a problem.

Additionally, even though this information cannot be used to show causality, it did have interesting findings. It implies that school psychologists and other school-based mental health professionals are doing well at referring to pediatricians and emergency rooms, but less well at connecting directly with community-based mental health service providers such as psychiatrists and therapists. I would say I find that to be true in my district. We (school psychologists) shy away from making recommendations about medical diagnoses because we are not doctors. I think it’s because of this that we are also wary of sending parents to mental health providers and instead suggest they check our results with their primary care physician first. And when we have a child in extreme crisis, we tend to recommend the emergency room to families and not the psych ward. I’m not sure how much is due to our desire to be “PC,” how much is due to a hesitancy to suggest medical diagnoses, and how much is pragmatically due to insurance requirements (i.e. many insurances need a formal referral from a primary care physician before paying for specialist services like a psychiatrist).

As I’ve mentioned before, I would love to see school-based mental health service providers working together with medical professionals. I would love to have wrap-around services provided within the school, including access to fully licensed psychiatrists and therapists. I think school psychologists have more training and expertise than we sometimes give ourselves credit for, and I want us to be part of a system that supports us using that expertise. This article helps clarify where we  land in the overall mental health trajectory for students, and I think it can speak to what our next steps should be (better awareness and better connections with outside providers).

Finally, on a completely separate note, I have recently read many articles about “outsiders” doing research on a particular culture or society, and how that framework is inappropriate. I have struggled to really understand the problem with it, because the “outsiders” have primarily been people who I identify with. But this study was completed by Swiss and German researchers on U.S. children and adolescents. Why? Why wouldn’t they study their own countries’ mental health trajectories (especially since they probably have a very different medical system than the U.S., so results would not be generalized to their countries)? Why wouldn’t U.S. researchers have been the ones to spearhead this study, or at least be involved?? Overall, I don’t see anything in the results that seems like they would be tainted by the nationality of the researchers, but I still questioned why. Ah… perhaps this is a small example of what those indigenous cultures have experienced!

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Lead School Psychologist at Peoria Unified School District

Janine Fischer is the lead school psychologist for the Peoria Unified School District. She is currently pursuing her Educational Doctorate degree in Educational Leadership and Innovation through Arizona State University. Her passions in life are kids, mental health, and changing the world by making kids’ lives better.

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