Impact of school-based and out-of-school mental health services on reducing school absence and school suspension among children with psychiatric disorders

Abstract

School-based mental health services are as effective as traditional outpatient clinic services in improving clinical outcomes (Armbruster & Lichtman, 1999; Hussey & Guo, 2003; Owens & Murphy, 2008), do a better job of engaging and retaining families (Atkins, Frazier, Birman, Adil, Jackson, et al., 2006) and are associated with reduced stigma (Taras, Frankowski, & McGrath, 2004). In addition to improving clinical outcomes, school-based programs have the advantage of being able to explicitly target behaviors and symptoms that affect school functioning, thereby improving academic outcomes (Lyon, Borntrager, Nakamura, & Higa-McMillan, 2013). It is important to demonstrate whether school-based mental health programs improve academic outcomes. Academic outcomes are the ones in which school personnel are most invested; if mental health services address those goals, it can increase the perceived value and fit of mental health programs (Atkins, Rusch, Mehta, & Lakind, 2015). Absenteeism is an important example of academic outcomes that mental health programs can address. Nationally, 10–15% of students are chronically absent from school (Balfanz & Byrnes, 2012). Absences increase in fifth grade and middle school, particularly among economically disadvantaged children (Balfanz & Byrnes, 2013). Greater absenteeism in sixth grade is associated with higher risk for high school dropout (Balfanz, Herzog, & Maclver, 2007). School suspensions represent another school outcome that mental health programs can address. Suspensions are associated with school dropout, delinquency and drug use (Sheryl, Stephanie, Herrenkohl, Toumbourou, & Catalano, 2014). Preliminary evidence supports the effectiveness of school-based mental health services in improving school absences and/or suspensions. For example, Positive Action, a school-based social-emotional and character development program implemented in low-income Chicago schools, has significantly reduced students’ school absences (Bavarian, Lewis, Dubois, Accok, & Vuchinich, 2013). The Rochester Resilience Project, which was tested in a randomized controlled trial for urban children with behavioral and emotional problems, significantly decreased mean school suspension (Wyman, Cross, Brown, Yu, & Tu, 2010). Other studies have found that school-based programs reduce suspensions (Flay, Allred, & Ordway, 2001; Kang-Yi, Mandell, & Hadley, 2013). While these studies provide preliminary evidence that school-based mental health interventions can improve school absence and suspension, the association between these programs and outcomes has not been extensively studied. Even fewer studies have examined school-based mental health programs implemented by community practitioners in real-world settings. None to our knowledge has examined the role of school-based mental health services on children’s use of community mental health services outside the school and more importantly, the impact of using these services on children’s academic outcomes. Previous research has identified that parents’ perception of children’s functional impairment significantly affects children’s use of school-based and out-of-school community mental health services (i.e., Langer, Wood, Wood, Garland, Landsverk, et al., 2016). The finding suggests that children’s use of community mental health services outside their school will decrease if their parents perceive the school-based mental health services as improving their children’s behavioral functioning. Findings regarding the relative impact of mental health services delivered inside and outside of school on children’s academic outcomes will inform policymakers of the most effective settings for delivering mental health services. For example, Philadelphia relies on teams from publicly-funded community mental health agencies to provide school-based mental health care to youth in selected kindergarten through 8th grade Philadelphia public schools. This program model is not unique to Philadelphia; other counties and states such as Baltimore, New York City and Florida also provide Medicaid-funded mental health support including individual therapy and/or group therapy in schools (Cammack, Brandt, Slade, Lever, & Stephan, 2014). Starting in 2007, School Therapeutic Services (STS) teams were deployed to better integrate mental health services in Philadelphia schools. STS was developed in response to the increasing need for integrated mental health services in Philadelphia elementary and middle schools (City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2006). The goals of STS include providing youth with therapy and in-class support (when indicated) in school to address emotional and behavioral concerns, promote social and emotional development, and reduce school absences and suspensions, among other outcomes. The present study examined the impact of STS on children’s academic outcomes and use of out-of-school mental health services. Specifically, we examined the impact of both STS and out-of-school mental health services on children’s school absence and in- and out-of-school suspension. We also investigated whether STS affected children’s supplementary community-based mental health service use. We hypothesized, based on stated STS goals, that school absences and suspensions of the children who receive STS would decrease over time. We also hypothesized that out-of-school services would have a smaller effect than STS on absences and suspensions, and that more use of STS would be associated with less use of out-of-school community mental health services.