Multidisciplinary school-based programs may include a staff of school counselors, psychologists, social workers, nurses, nurse practitioners, physicians, and other specialized professionals.^6,7 School nurses and school counselors can provide early assessment, intervention, planning, and follow-up of students in need of mental health services. School nurses are often the first to identify students that may be experiencing mental health issues and advocate for their care; they also connect them with school counselors.¹⁰ Schools can also refer students to community-based mental health services and help provide additional care and follow-up when needed.^11,12 Schools may provide services in a school-based health center (SBHC) and provide different levels of service based on the severity of mental health issues experienced at the school.⁶ Schools may also establish student support teams, crisis response teams, and other multidisciplinary teams to assist students with mental health concerns.^6,7

It is important to ensure that school staff working on mental health and social services have the necessary knowledge, skills, and attitudes to perform in their roles and are involved in continued professional development.¹³ To facilitate this, schools may ensure they (1) employ sufficient staff, including a sufficient number who have needed licenses/credentials, to address the school’s comprehensive needs and (2) provide ongoing opportunities for staff to participate in relevant, effective learning experiences, including cross-disciplinary, cross-role, and cross-agency learning.¹³

Using data from the School Health Policies and Practices Study (SHPPS), previous studies have found some variations in school health policies and practices, including some mental health and social service policies and practices, by school demographic characteristics.^14,15 Aside from these earlier SHPPS analyses, no other studies were identified that examined differences in a variety of school mental health and social service policies by demographics. This analysis therefore builds upon this previous work by using SHPPS 2012 data to examine multiple district-level school health policies related to mental health and social services to determine if they varied by school district region, metropolitan status, affluence, percentage of students receiving free or reduced price lunch, and percentage of minority students. Compared to previous publications, this analysis focused on school districts rather than schools and included additional variables, such as geographic region and several school mental health and social services topics. This work also has the potential to identify persistent and new patterns in associations between district characteristics and policies since the previous studies used data from 2000 and 2006.

SHPPS 2012 was conducted by the Centers for Disease Control and Prevention (CDC) during October 2011–August 2012. SHPPS 2012 examined eight components of school health at the state and district levels: health education, physical education and activity, health services, mental health and social services, nutrition services, healthy and safe school environment, faculty and staff health promotion, and family and community involvement. A detailed description of the SHPPS 2012 methods has been published previously.¹⁶ Although SHPPS 2012 collected data at the state and district levels, this analysis uses district-level data only, as the state-level survey did not collect information on state-level policies.

District-level demographic characteristics are shown in Table 1. Table 2 presents the percentage of districts that adopted policies regarding specific school mental health or social services topics related to staffing and staff qualifications and student support services.

Table 3 shows the associations between district-level characteristics and district policies related to school mental health and social services. Having a policy stating that each school will have someone to oversee or coordinate mental health or social services at the school significantly varied by affluence. That is, low/below average affluence districts had significantly higher odds of having such a policy as compared to average affluence districts (OR=2.30, 95% CI=1.36, 3.88). Specifically, 49.1% of low/below average affluence districts had this policy as compared to 33.0% of average affluence districts (data not shown).

Results regarding counselor-to-student ratios were similar by school level. For all school levels, having a policy stating that each school will have a specified ratio of counselors to students significantly differed by region. That is, districts in the South had higher odds of having such as policy as compared to districts in the Northeast (elementary: OR=7.88, 95% CI= 3.17, 19.60; middle: OR=8.56, 95% CI=3.46, 21.23, high: OR= 7.21, 95% CI= 3.00, 17.36). For high schools, the odds were also higher among districts in the Midwest as compared to districts in the Northeast. For middle schools and high schools, there was also a significant difference by affluence. The odds were higher among low/below average affluence schools as compared to average affluence schools (middle: OR=1.77, 95% CI=1.02, 3.06; high: OR=2.43, 95% CI=1.33, 4.46).

Having a policy that required newly hired school counselors to have a master’s degree in counseling significantly differed by region. That is, districts in the West had lower odds of having such a policy as compared to districts in the Northeast (OR=0.47; 95% CI=0.23, 0.97). Specifically, 56.4% of districts in the West had this policy as compared to 71.4% of districts in the Northeast (data not shown). Having a policy that required newly hired school counselors to be licensed, certified, or credentialed by a state agency or board significantly differed by region and metropolitan status. Districts in the West had lower odds of having such a policy as compared to districts in the Northeast (OR=0.39, 95% CI=0.17, 0.92) and rural districts had lower odds as compared to urban districts (OR=0.56, 95% CI=0.32, 0.96).

There were no demographic differences regarding policies requiring newly hired school psychologists to have a master’s degree in psychology. However, there was a difference by metropolitan status in whether districts required newly hired school psychologists to be licensed, certified, or credentialed by a state agency or board. Rural districts had significantly lower odds as compared to urban districts (OR=0.31; 95% CI=0.17, 0.57).

Demographic differences regarding policies requiring newly hired school social workers to (1) have a master’s degree in social work and (2) be licensed, certified, or credentialed by a state agency or board were similar. Both policies differed by region, metropolitan status, affluence, and majority minority status. Districts in the Midwest, South, and West had lower odds of having such policies as compared to districts in the Northeast; rural districts had lower odds as compared to urban districts; above average/high affluence districts had higher odds as compared to average affluence districts; and majority minority districts had higher odds as compared to majority Caucasian districts. In addition, districts with a low percentage of students receiving free or reduced-priced lunch had significantly lower odds of requiring newly hired school social workers to be licensed, certified, or credentialed by a state agency or board as compared to districts with a medium percentage (OR=0.46; 95% CI=0.23, 0.92).

Having a policy stating that school mental health or social services staff are required to earn continuing education credits on mental health or social services topics significantly differed by region and metropolitan status. That is, districts in the West had lower odds of having such a policy as compared to districts in the Northeast (OR=0.34; 95% CI=0.18, 0.64) and rural districts had lower odds as compared to urban districts (OR=0.57; 95% CI=0.38, 0.85).

Having a policy that student assistance programs will be offered to all students significantly differed only by affluence. Low/below average affluence schools had higher odds of having this policy as compared to average affluence schools (OR=2.39; 95% CI=1.29, 4.44). Having a policy stating that schools will create and maintain student support teams did not differ by any of the district-level demographic characteristics included in this analysis.

This analysis examined the odds of prevalence of policies and practices in school districts relative to one another. Some patterns emerged regarding the association between district-level demographic characteristics and school mental health and social services policies. In general, Southern and low affluence districts were more likely to have policies requiring counselor-to-student ratios. The American School Counselors Association (ASCA) recommends a counselor-to-student ratio of 1:250.¹¹ SHPPS does not ascertain the actual ratio of counselors to students, but having a district-level policy establishing a specified ratio demonstrates support for sufficient counselors. Southern and low affluence districts may be more likely to have policies requiring counselor-to-student ratios because of a greater need for counselors in these districts and/or lower availability of school counselors in these areas. A report of school counselors found that the average caseload were highest for counselors in the South as compared to other regions.¹⁸ Further, low income students tend to have more mental health issues.² Therefore, these districts may make establishing counselor-to-student ratios a priority.

Northeastern and urban districts were generally more likely to have staff education and credentialing requirements. Perhaps there is a greater pool of potential candidates in these types of districts, so they can set requirements that allow them to be more selective in their hiring. School psychologist salaries tend to be higher in the Northeast as compared to other regions which may drive psychologists to that region.¹⁹ In addition, there is a lack of highly trained school psychologists in rural areas.²⁰ Regardless, it is important for districts to set high standards for staff education and credentialing. Mental health and social services staff must be prepared to develop student-focused initiatives within a changing climate and new information. The growing knowledge base in various disciplines and fields of practice and initiatives can help change and restructure educational efforts.¹³ Further, the American Academy of Pediatrics recommends that school mental health professionals have training specific to child and adolescent mental health and are competent to provide mental health services in the school setting.⁶ Educational requirements and state credentialing can play a major role in determining that individuals are prepared for school mental health work. Professional organizations for school counselors, school psychologists, and school social workers each recommend some graduate training, if not a completed master’s degree, for professionals in their field. They also recommend certain credentialing, licensure, or qualification standards.^11,21,22 The most consistent associations with district-level demographics occurred for school social worker requirements. This may be due to the fact that, compared to the need for school counselors or psychologists, the need for school social workers is more dependent on factors related to the income of students because social workers help access resources that students with lower incomes are more likely to need.

Western and rural districts were less likely to have a policy requiring school mental health or social services staff to earn continuing education credits on mental health or social services topics. Districts in these areas may be less likely to have such requirements because of a lower level of competition for these positions or because they have fewer resources than other districts to support staff training. Schools in the West receive less funding per pupil compared to schools in the Northeast or Midwest,²³ and rural schools must often deal with funding shortfalls.²⁴ It is important for districts to devote resources to professional development for mental health and social services staff, because the possession of certain knowledge, abilities, skills, and attitudes can help school mental health or social services staff be continually prepared for the changing demands of the job.¹¹ Professional development is critical for staff to develop skills, maintain competencies that help students succeed, identify areas for improvement, adopt best practices, address problems.²⁵ Commitment to professional development can help schools develop quality programs and interventions.²⁵

There were few or no associations between demographic characteristics and requiring a mental health or social services coordinator, student assistance programs, or student support teams. Reasons for this consistent lack of association are unknown. School health coordination is key to effective mental health services and involves organizing and managing multiple school health initiatives, such as instruction and environmental changes.²⁶ Coordination connects diverse initiatives designed to reduce health risks and promote health and student achievement. Promotion of coordination of these services at the school level may assist schools in their planning efforts and help schools more efficiently use their resources. However, less than half of districts nationwide had a policy stating that each school will have a mental health or social services coordinator. All types of districts would benefit from striving toward coordinator requirements given the value of these positions. Interest in student assistance programs has increased in most states as it is seen as a promising avenue to help students overcome barriers to learning.²⁷ The Health, Mental Health, and Safety Guidelines for Schools states that schools should have student support teams.⁷ It is a positive finding that more than three-fourths of districts required schools to have student assistance programs and student support teams. However, though many schools may offer these services, expansion of district policies would likely result in more students who are in need of various types of support having access to services and promoting their academic and emotional development.

This study also revealed that some district-level demographic characteristics were not consistently associated with the school mental health and social services policies included in this analysis. The percentage of students receiving free or reduced-price lunch was only associated with school social worker educational requirements and district-level minority concentration was only associated with policies regarding social worker education and credentialing requirements. This finding might be the result of these characteristics being related to other characteristics in the model, such as affluence, which were more strongly associated with the policies. It is encouraging, however, that districts with high percentages of students receiving free or reduced-price lunch or high percentages of minority students do not appear to lack key district-level policies related to mental health and social services. However, since more than half of the districts in this study had medium or high percentages of students qualifying for free or reduced price lunch, this may mean that the tax systems for these schools may not be sufficient to generate needed funds to support ideal mental health and social services programs for all schools. The percentage of schools qualifying for free or reduced price lunch is a marker of poverty status and, in many states, high poverty districts receive less funding.²³

We can compare these results to previous studies that have examined associations between demographic characteristics and mental health and social services policies.^14,15 Two previous manuscripts have reported differences in school-level policies using SHPPS data. Though the variables of interest were different for these studies, there was some overlap. Both studies examined associations of urbanicity and percent white student population with student assistance programs and found no significant associations; this is consistent with our findings. Neither study included an affluence indicator which we found was significantly associated with student assistance programs. Balaji and colleagues also examined free lunch and found no association with student assistance programs.¹⁵ Brener and co-authors examined demographic differences with having a mental health or social services coordinator.¹⁴ Results were not significant by percent white student population or urbanicity, consistent with our findings.

School districts can use the results of this study to help improve their policies and practices, which can in turn help schools develop and sustain environments supportive of student mental health. Some specific examples of actions school districts can take include:

A lack of resources may preclude districts’ ability to take some or all of these actions. However, it is important to use limited resources for school mental health and social services as addressing mental health issues in schools can promote students’ success through improvements in behavior and academics, improve teaching conditions, and reduce societal costs related to untreated mental health conditions.⁸