Many children and adolescents are experiencing poor mental and emotional health, which in some cases may be linked to negative impacts from the COVID-19 pandemic and exposure to gun violence, among other factors. In recognition of growing mental health concerns among children, recent policy measures, including the Bipartisan Safer Communities Act and the American Rescue Plan Act, provide pathways to support school-based mental health services for students. These policy actions aim to expand mental health care in schools – a setting that is more easily accessible by children and adolescents.
In this analysis, we explore the landscape of mental health services in schools during the 2021-2022 school year, barriers to offering services, and how recent policies facilitate the expansion of school-based mental health care. We draw upon data from the new 2022 School Pulse Panel, a study by the National Center for Education Statistics and the U.S. Census Bureau that surveys staff of public primary, middle, high, and combined-grade schools monthly on a variety of topics, including school mental health services.
School-based mental health services can improve access to care, allow for early identification and treatment of mental health issues, and may be linked to reduced absenteeism and better mental health outcomes. School-based services can also reduce access barriers for underserved populations, including children from low-income households and children of color.
The delivery of mental health services in schools has evolved over time and continues to vary across schools. Some students access in-person mental health services at schools or near campus while others access services through telehealth. Service delivery can range from a single provider (who is not necessarily a licensed mental health professional) to a team of providers, including psychologists, social workers, and academic or guidance counselors. A growing number of schools have also integrated social and emotional learning and other mental health literacy programs into their curriculum.
Despite the growth of school-based mental health services, challenges persist, including mental health provider shortages and inadequate funding.
Landscape of School-Based Mental Health Services
Most public schools offer mental health services to students, although utilization remains unclear. In the 2021-2022 school year, 96% of public schools reported offering at least one type of mental health service to their students. As shown in Figure 1, the most frequently offered services are:
- Individual-based interventions like one-on-one counseling or therapy (84% of public schools),
- Case management or coordinating mental health services (70%), and
- Referrals for care outside of the school (66%).
Only one-third (34%) of schools provide outreach services, which includes mental health screenings for all students. These universal behavioral health screenings are considered a best practice and allow for schools to better identify all students with needs and tailor services to their specific student population. However, many schools do not offer these screenings often due to a lack of resources or difficulty accessing providers to conduct screenings, burden of collecting and maintaining data, and/or a lack of buy-in from school administrators.
Approximately one out of five schools (17%) reported offering mental health services through telehealth during the 2021-2022 school year. While telehealth became a more widely used pathway to delivering health care during the pandemic, a growing number of schools already began providing care through telehealth prior to the pandemic. The utilization of telehealth in all school-based health care is more common in rural areas – where provider shortages and transportation issues are more prevalent – and can reduce barriers to care for underserved students.
Staffing models for school-based mental health care can vary across schools. Sixty-eight percent of public schools have a school or district-employed licensed mental health professional on staff and 51% employ an external mental health provider (Figure 1). While general or academic school counselors can provide mental health services to students as well, they typically focus on short-term and preventive services and are not equipped to offer long-term care. The School Pulse Panel does not include information on the number of mental health providers on staff; however, other research indicates that most schools do not meet the recommended ratios of counselors and/or psychologists to students.
Other school staff, particularly teachers, often play a role in identifying students with mental health needs and linking them to care. However, research prior to the pandemic found that many teachers did not receive adequate training to identify and provide support to students with mental health needs. Since the pandemic began, nearly three out of four schools (73%) have reported providing trainings and professional development to staff in order to help them identify growing mental health concerns among school students. However, data on the impact of these trainings is unavailable and it is unclear what share of schools were providing trainings prior to the pandemic.
School mental health services are supported through multiple sources of funding at the national, state, and local level. As shown in Figure 1, in the 2021-2022 school year, just over half of schools reported receiving funding for mental health services from district or school funds (57%) or federal grants or programs (52%), while smaller shares of schools reported funding from partnerships with organizations (37%) or state programs (32%). At the federal level, many schools receive support through the Department of Education – including grant programs and the Every Student Succeeds Act – and the Department of Health and Human Services (HHS). Schools may receive funds through Medicaid in several ways, including reimbursement for medically necessary services that are part of a student’s Individualized Education Plan (IEP),reimbursement for eligible health services for students with Medicaid coverage and for some administrative services. Additionally, many state budgets appropriate funds toward mental health services while fewer states allocate funds directly in their school funding models.
CHANGES DUE TO THE PANDEMIC
In response to growing mental health concerns during the pandemic, 67% of schools reported increasing mental health services offered to students (Figure 2). However, fewer than half of schools (41%) reported hiring new staff to focus on students’ mental health and well-being since the pandemic began (Figure 2). The inability of some schools to staff up despite growing mental health challenges may be due to budget constraints coupled with limited availability of mental health professionals.
In light of the pandemic, 27% of schools added classes for their students on social, emotional, and mental well-being since March 2020 (Figure 2). Additionally, for the 2021-2022 school year, 28% of schools made changes to their academic calendar to address mental health concerns for both staff and students. Examples of these changes include providing additional days off and allocating time to focus on mental wellness during the school day. Several states have introduced or passed measures allowing students excused absences related to mental health.
Barriers to School-Based Mental Health Services
During the 2021-2022 school year, approximately half of schools reported they strongly (12%) or moderately agreed (44%) they could effectively provide mental health services to all students in need. Meanwhile, a third of schools reported they strongly (10%) or moderately disagreed (23%) that they could effectively provide mental health services and 11% neither agreed or disagreed. Among the 88% of schools that did not strongly believe they could effectively provide mental health services to students in need, the most reported limitations involved mental health provider shortages – 61% cited insufficient staff coverage and 57% cited a lack of access to providers (Figure 3). Schools have faced provider shortages for years, but this issue has recently received more attention in light of growing mental health concerns among children. Many schools do not meet recommended ratios for psychologists to students (500:1) or counselors to students (250:1). Going into the 2022-2023 school year, 19% of public schools have vacancies for mental health professionals. Among schools with these vacancies, 84% reported it will be somewhat or very difficult to fill these mental health positions.
Among school staff that did not strongly believe they could provide mental health services to all students in need during the 2021-2022 school year, 48% cited inadequate funding as a barrier (Figure 3). Funding challenges for school mental health services have long existed. In order to provide and sustain services, many schools use funding from multiple sources, including at the national, state, and local levels, as previously mentioned. However, this presents several challenges as schools navigate varying specifications of how to utilize funds based on the source and changes to funding streams over time.
How Have Recent Policies Addressed School-Based Mental Health Services?
The American Rescue Plan Act and recent state policies have provided pathways to expand mental health and wellness services in schools. In 2021, the American Rescue Plan Act (ARPA) was passed and designed to provide relief from the continued impacts of the pandemic. A portion of funds from the ARPA ($122.8 billion) were allocated for the Elementary and Secondary School Emergency Relief (ESSER), and many states are using some of these funds to support school-based mental health care. Some ways states and schools are using these funds include growing the school mental health provider workforce (e.g. funding positions for mental health counselors and social workers in schools), partnering with community-based mental health agencies to expand access to care for students, providing trainings for school staff, and providing technical assistance for school mental health programs. However, one study has also found that lower-income schools and schools in rural areas are less likely to use ARPA funds toward school-based mental health services than their counterparts. Some schools (22%) reported using ARPA funds to create new staff positions during the 2021-2022 school year, although a large share of schools did not know (37%) if funds were used for these purposes. Among the schools that did use ARPA funds toward new staffing, 35% reported using a portion of these funds for school mental health professionals (e.g. psychologists and social workers). The ARPA also included funding to support students with disabilities and youth experiencing homelessness. Separately, some states have passed legislation to address growing mental health concerns, including the implementation of suicide prevention programs and mental health screening programs.
The recently passed Bipartisan Safer Communities Act also allocates funds to support school-based mental health services. In response to increasing gun violence and mass shootings, the Bipartisan Safer Communities Act was signed into law in June 2022. This legislation focuses on both gun reform and youth mental health, including provisions to support and expand school-based mental health services, highlighted below.
|Expansion of School-Based Health Care Through Medicaid||Requires the Centers for Medicare and Medicaid Services (CMS) to provide states with resources and guidance on how to support and expand school-based health care, including mental health services. Guidance may include best practices for payment and reimbursement of school-based services and utilization of telehealth. These provisions include $50 million in planning grants for states.|
|Expansion of School-Based Mental Health Providers||Allocates $500 million each for the School Based Mental Health Services Grant Program and the Mental Health Services Professional Demonstration Grant Program. These grant programs will allow for school districts with demonstrated need to increase the number of mental health providers in schools and provide training. A portion of these funds will be disbursed beginning in August 2022.|
|Improving School Climate||Allocates $1 billion towards keeping students healthy and safe through a number of programs, including crisis intervention, suicide prevention, mentoring, and drug and violence prevention.|
|School Safety||Allocates $300 million over 5 years through the STOP School Violence Act. Funds should be used toward school violence prevention and providing training to school staff. Funds cannot be used for training or providing school personnel with dangerous weapons.|
|Trauma Support||Allocates $28 million over 4 years for schools to provide trauma care to students in need. Care will be provided through Project Aware.|
|Other Youth Mental Health Provisions||Additional provisions that address children’s mental health but are separate from school-based care include improving the implementation of Medicaid’s Early and Periodic Screening, Diagnostic and Treatment benefit across states, increasing access to behavioral health services through telehealth under Medicaid/CHIP, mental health training for pediatric providers, and increasing access to community-based mental health services.|
Despite recent increased attention and resources for school-based mental health services, challenges remain. In May 2022, large shares of public school staff reported that they strongly agree the pandemic has negatively impacted students’ behavioral development (39%) and socioemotional development (45%). It is unclear how schools will adequately address these impacts as they continue to face challenges, including mental health provider shortages, burnout among school staff, disparities by race and ethnicity in access to school services, and long-term sustainability issues. Addressing these challenges and improving access to school-based mental health services may help mitigate rising mental health concerns among youth.
This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.