Journal of Youth and Adolescence, Vol. 34, No. 1, February 2005, pp. 3–6 ( C© 2005)DOI: 10.1007/s10964-005-1330-2

Expanded School Mental Health: Challengesand Opportunities in an Emerging Field

Mark D. Weist1 and Steven W. Evans2

Reviews the need for and development of expanded school mental health (ESMH) programs, whichprovide a continuum of mental health promotion and intervention through school–community part-nerships. Since ESMH is a relatively new, but increasingly prominent field, countless issues are beingaddressed in practice and research and in efforts to bridge practice and research. We review particu-lar content and context dimensions of ESMH in need of development including quality assessmentand improvement, empirically supported practice, improving assessment and outcome evaluation,involving educators in the work, understanding school environments, and tailoring programs throughqualitative research. Summaries of articles that amplify these themes are provided.

KEY WORDS: expanded school mental health; health care; quality assessment and improvement.

In the United States (U.S.) the mental health systemfor children and adolescents is acknowledged to be bro-ken (New Freedom Commission on Mental Health, 2003)with less than a third of youth with serious mental healthissues receiving any care and the percent of youth who re-ceive effective care likely less than 10% (see U.S. PublicHealth Service, 2000). In the former Surgeon General’sreport on Children’s Mental Health (U.S. Public HealthService, 2000), and more recently, in the report releasedby the President’s New Freedom Commission on MentalHealth (2003), schools are recognized as the major settingfor providing mental health care to youth and are critical inenhancing service utilization (Adelman and Taylor, 1999).Although schools have been described as the “de facto”provider of mental health services to children, in actu-ality, mental health services may be quite limited withinthem. (Weist et al., 2003). Problems related to access tomental health services are even more severe in other childserving systems such as child welfare and juvenile jus-tice (Osher and Hanley, 2001). Across all systems, childmental health efforts are plagued by extremely limited

1University of Maryland School of Medicine, Baltimore, Maryland.To whom correspondence should be addressed at the Center forSchool Mental Health Assistance, University of Maryland School ofMedicine, 737 West Lombard Street, 4th Floor, Baltimore, MD 21201;mweist@psych.umaryland.edu.

2James Madison University, Harrisonburg, Virginia.

resources, evaluation, training, and technical assistance,leading to questionable quality and effectiveness of ser-vices that are being delivered (Greenberg et al., 1999; U.S.Public Health Service, 2000).

We use the term expanded school mental health(ESMH) to refer to partnerships between schools andcommunity programs and agencies (under the guidanceof families) that provide mental health promotion and in-tervention to youth in general and special education. Thisapproach contrasts with a more traditional approach ofschools providing limited assessment, consultation, andtreatment services for youth in or being referred intospecial education (Weist, 1997). The ESMH approach,while discussed in the 1950s did not really begin to gainmomentum until the late 1980s, with a number of fac-tors contributing to the field’s development, including:the systems of care initiative, the growth of school-basedhealth centers, increasing recognition of problems in tra-ditional community mental health, and so on (see Flahertyand Osher, 2003; Weist et al., 2003). There are many is-sues in need of attention as the ESMH field develops. Aprominent theme involves the integration of empiricallysupported interventions into schools with an emphasis oncontinuous quality improvement. A number of the arti-cles in this special issue address this critically importanttheme. In order to implement effective mental health pro-motion and intervention in schools a second major theme

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of this special issue reflects the need to understand theschool context. There are considerable differences be-tween providing mental health care in traditional settingssuch as community mental health centers and private of-fices and schools, and in order to be effective programsand staff need to understand and connect to critical di-mensions of the school context. Thus, the papers in thisspecial issue reflect key content dimensions such as ensur-ing practices are empirically supported, and key contextdimensions such as integrating a range of services intothe various environments of schools (see Ringeisen et al.,2003).

In child and adolescent mental health research, therehas been an increasing emphasis on improving the con-tent of care by focusing on the development, evaluation,and dissemination of empirically supported treatments(Herschell et al., 2004; Ollendick and Davis, 2004). Thisfocus on content of care is critical; for example, the re-sults of the Fort Bragg Project demonstrated that even themost progressive models of delivering and coordinatingservices provide little to no benefit over traditional mod-els when the content of care provided is not controlled(Bickman et al., 2000). In fact, Weiss and colleaguescompared tutoring with school-based mental health with-out controlling for the type or quality of school mentalhealth care provided and results indicated no differences inoutcomes between the interventions (Weiss et al., 1999).These studies indicate that simply adopting the ESMH ap-proach without ensuring that mental health promotion andintervention efforts are empirically supported is likely toprovide little to no benefit to students and schools (Evansand Weist, 2004; School Mental Health Alliance, 2004).

Furthermore, even when providing empirically sup-ported treatments in well-designed and supported ESMHprograms, it is important to include appropriate evalua-tion strategies and tools to ensure that services are in factleading to improved outcomes, another very large agenda(Weist et al., 2000). Here, a critical issue is to capital-ize on assessment opportunities within the school settingsuch as collecting ratings of child functioning from teach-ers. However, problems with the reliability and validityof teacher report and changing school environments frompreschool through high school present serious obstaclesto interpreting assessment data (Evans et al., in press). Athird major theme in this special issue focuses on capital-izing on evaluation opportunities and overcoming evalu-ation challenges in schools.

The first two articles discuss issues related to effec-tive practice in schools. In the opening article, Weist andcolleagues describe the development of a set of princi-ples for best practice in ESMH that provides a frameworkfor developing much needed quality assessment and im-

provement efforts (QAI). QAI represents the intersectionof science and practice and subsumes empirically sup-ported practice. However, up to the present QAI effortsin the ESMH field have been very limited (Weist et al.,2002). The article provides a needed example of the de-velopment of a systematic QAI strategy for school mentalhealth. Schaeffer and colleagues then report on their ef-fort through a national center for mental health in schoolsto identify empirically supported programs that can beimplemented by clinicians in ESMH programs. Throughexperiences of clinicians working in a program in 22Baltimore schools, challenges to empirically supportedpractice and strategies to overcome these challenges arepresented.

The next two articles address the important assess-ment and evaluation issues described above. First, Brunsand colleagues report on an effort to improve school-widedata collection systems in order to assess a potentiallyimportant outcome of school mental health—school sus-pensions. While findings did not support a reduction inschool suspensions, important directions for program de-velopment, improving data systems, data analysis, andconnecting findings to influence policy are presented.Then, Anthony and colleagues report on a study of teacherratings of child emotional and behavioral problems inpreschool students. The study documents the importanceof extending the school mental health research agendadown to include preschool students, and underscores thecritical role of classrooms in influencing perceptions ofchild behavior. Clearly, a large agenda in the paradigmaticchange of school mental health is to extend assessmentmethodologies to capture critical contextual influences onchildren.

The ESMH approach presents difficult challenges tothe application of QAI, empirically supported practicesand outcome measurement because the school setting is amuch more diverse and complicated environment than amental health center. Schools are a reflection of the com-munities in which they exist and exemplify the racial,cultural, economic, safety, and other characteristics oftheir communities. In addition, the school environmentis managed by educators for the primary purpose of edu-cating students. The role of mental health and well-beingin this agenda varies dramatically by school and commu-nity. In order for ESMH services to be successful, mentalhealth staff implementing this agenda must be respect-ful of that priority and actively collaborate with teach-ers, administrators, and school-employed mental healthprofessionals.

The final two articles in this special issue addresssome of these contextual factors. Paternite and Johnstonfocus on educator–mental health provider collaboration

Expanded School Mental Health 5

issues and demonstrate the necessity and value of thesepartnerships. They provide specific examples of educator–mental health partnerships and ideas for integrating train-ing, research, and practice. Finally, Evans and colleaguesreport on an effort to evaluate the Australian MindMatterswhole school mental health promotion approach for ap-plication in the United States. The report emphasizes theneed to study the feasibility of promising approaches innew settings and cultures, and highlights the promise ofinternational models of school mental health promotion.The MindMatters program is a universal intervention andaddresses many of the contextual issues that could facili-tate or obstruct the development of ESMH.

While there are many obstacles remaining beforeESMH achieves its promise to improve the well-beingand school and life success of children and adolescentsmore broadly, there are many signs that we are makingimportant strides. Dedicated interdisciplinary groups ofprofessionals are joining forces with parents to move to-ward a full continuum of school-based mental health pro-motion and intervention for all youth, including universalapproaches to prevent problems, early identification andintervention efforts, and treatment (School Mental HealthAlliance, 2004). ESMH augments the mental health pro-grams and staff working in schools (e.g., school psychol-ogists, counselors, and social workers). Many advantagesof the ESMH approach have been described, includingsignificant enhancements in access to services (Catronet al., 1998; Weist et al., 1999), improved generaliza-tion of treatment gains (Evans et al., 2003a,b), expandedpreventive services (Tashman et al., 2000), and the fa-cilitation of systems of care development (Hodges et al.,1998). In addition, early evaluation data suggest that whendone well, ESMH programs can lead to improved student,school, and system outcomes (Armbruster and Lichtman,1999; Bruns et al., 2004; Evans et al., 2004; Illback et al.,1997; Nabors et al., 2000).

However, the ESMH field is also confronting manychallenges as it moves from very tenuous (even nonex-istent) support in many communities to build advocacyagendas, influence policy, enhance resources, developprograms strategically, and involve major stakeholdergroups (e.g., youth, families, teachers, communities lead-ers) in all aspects of the work (Lever et al., 2003). Further,assumptions about advantages of school mental healthand obstacles to dissemination need extensive researchand evaluation. ESMH is a relatively new and growingfield with activities occurring along many critical dimen-sions. Articles in this special issue cover but a few ofthese dimensions; nevertheless, they do address some ofthe critical issues related to content and context that willshape the field in the near future.

ACKNOWLEDGMENTS

Supported by cooperative agreement U45 MC00174-10-0 from the Office of Adolescent Health,Maternal and Child Health Bureau (Title V, Social Secu-rity Act), Health Resources and Services Administration,with co-funding by the Center for Mental Health Ser-vices, Substance Abuse and Mental Health ServicesAdministration.

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