NH Public Policy
New Hampshire Center for Public Policy Studies

Mental Health Services in New Hampshire's Schools

Executive Summary

Date: April 17th, 2009

As the Center has noted previously, as many as 55,756 children, ages 5 to 19, have a diagnosable mental health disorder and almost 14,000 have a serious emotional disturbance. Most of these children are educated in the New Hampshire public school system. Understanding if, and how, public schools manage the behavioral health issues of their students is of obvious public policy significance.

Despite this policy significance, comprehensive information about the role of schools in mental health services in New Hampshire is not available. This work – combining surveys of both school districts and schools and interviews with community mental health centers across the state – is designed to be an initial assessment of how this system is administered and funded, the mental health conditions driving this system, the services that it provides, and the manner in which the system assesses its progress in ensuring the mental well being of its children.

The major findings of this analysis are:

Schools in New Hampshire play a large role in providing mental health services to New Hampshire children.

Nationally, although not all children in need of mental health services receive them, many that do receive them through the school system (Burns et al., 1995). This analysis confirms that significant energy and resources are devoted to providing mental health services to New Hampshire’s children through the schools. According to the Center’s recent analysis of mental health service provision, 25% – or 17,680 children – received services for a mental illness in 2005 through the Medicaid program, and the state’s schools were among the primary providers of those services. The Manchester and Nashua School districts billed the state’s Medicaid program for almost $1 million each for mental health services in 2005.

The schools indicated that they provide a comprehensive, publicly-funded set of mental health service, but there’s little information available about the volume and type of services being provided and the mental health outcomes associated with this care.

When talking about schools providing mental health care, we are talking about something much more comprehensive than guidance counselors providing career help. Schools are providing mental health services to both special education and the general population. Only 9% of schools indicated that they provided mental health services only to special education students. Schools are providing a broad array of mental health services to their students. Slightly more than 50% of schools in New Hampshire provide school-wide screening for behavioral or emotional problems, and 73% of schools provide individual counseling services. Most schools (70-80%) did not note difficulty providing basic mental health services. However, a significantly higher share of schools noted difficulty in providing medication management and referral to specialized services.

Although significant resources are being devoted to mental health services, information on the types of diagnoses, the types of services being provided, and perhaps most important, the outcomes associated with this system are not well documented. Almost 1/3 of schools do not collect any data on services being provided for special education or mental health specific needs.

There is little formal coordination between the various public systems receiving state and local funding to provide mental health services to children.

Like school mental health services, the Community Mental Health Centers (CMHC) are supported primarily by Medicaid – suggesting that potential partnerships between schools and community mental health could maximize resources. In fact, a prior ad hoc survey has found that formal relationships between schools and the Community Mental Health Centers exist across the state, but little was known about the administrative arrangements of these agreements. However, the data show that the community mental health system is not as significant a provider as private providers.

Interviews with the children’s directors at the CMHCs working in the field revealed that, even though many informal relationships exist, relatively few schools have formal agreements with these clinics and that the scope and provisions of these agreements varies widely across the regions of the state. Although schools may not contract with a CMHC for school-based services, the vast majority of schools have informal, yet frequent, contact with them to help facilitate the coordination of mental health treatment for students in need. Practitioners interviewed also were in agreement that school-based services increase access to mental health services to children who otherwise would never be treated, due to several barriers.

Significant resources are being provided to the public schools for the provision of mental health services, yet there appears to be little public policy coordination across the various funding sources.

This public system of mental health care for children is funded by a myriad of sources, with over 80% of schools reporting the use of some local funds for providing mental health services, a significantly higher share than in national surveys of schools. This is not surprising given the state’s historical focus on ‘local control.’

In New Hampshire, the two most prevalent sources of funding are local resources and Medicaid, which is funded by both the state and the federal government. In addition, the state makes a significant contribution to local special education expenditures for those children for whom the cost of an education is significantly higher due to mental or physical disability. Catastrophic Aid – the program in which the state shares in the costs of providing special education services to high acuity children – continues to be one of the primary growth areas in state general fund expenditures.

Despite the fact that significant resources are being expended on these broad school-based mental health services, the issue of children’s mental health is only peripherally included in the major mental health and education policy conversations currently being debated. In the 2007 legislative session, SB 18 increased the dropout age from 16 to 18 years of age. This policy change – which will fundamentally affect the learning plans for students who would have otherwise dropped out – will also have a significant impact on the demand for mental health services, given the demonstrated association between mental health issues and drop-out rates.

While legislation specified information on alternative learning plans for completing an education, it did not in any way address the mental health service needs associated with this major change in policy.

Furthermore, in the following legislative session, the legislature passed a definition of adequacy based on the state’s minimum standards for public school approval. These standards include a series of standards associated with a psychologist program. Those districts that hire a school psychologist must have a comprehensive continuum of services and must, among other things, be able to conduct basic investigations and program evaluations for improvement of services. From these data, while it is clear that significant resources are being devoted to mental health services, the coordination of the various parts of this system and the ability to evaluate and assess this system does not appear to exist.

Finally, there are a series of mental health plans that emerged, one from the Department of Health and Human Services and the other from the mental health commission. Neither one of these documents spends significant time nor resources on the broad system of school-based mental health services that exist.