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Improving Access to Mental Health Services for Adolescents in Middle and High Schools in Virginia, USA

Stanley Belgarde, Kyrah Coone, Krisan Fragata, Colleen Illsley & Mary Munitz

Virginia Commonwealth University

NURS 607: Epidemiology and Population Health

Dr. Jane Chung and Dr. Leigh Ann Breckenridge

May 1, 2023

Improving Access to Mental Health Services for Adolescents in Middle and High Schools in Virginia, USA

With the many daily societal and behavioral pressures and challenges adolescents face, exacerbated by the COVID-19 pandemic, emotional and behavioral disorders are the most prevalent and costly chronic illnesses for the youth. Billions of dollars each year are spent on treating mental disorders in adolescents, representing one of the highest healthcare expenditures. According to the Centers for Disease Control and Prevention (2023), about 1 in 5 youth experience having a mental, emotional, or behavioral disorder such as anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or a disruptive behavior disorder. These mental health problems contribute to suicide, the second leading cause of death among adolescents in the United States (Twenge, 2020). A study revealed that 75–80 % of youth needing mental health services do not receive services (Miller et al., 2012).

Access to mental health is critical as mental health problems in the youth negatively impact their social functioning, educational, occupational, and overall quality of life. Mental health disorder experiences and thoughts of suicide in childhood and adolescence are related to a wide range of detrimental health outcomes in adulthood (Brådvik, 2018). Effective treatments for these mental health problems are available; however, gaps and disparities continue to exist between the prevalence and treatment rates among youth with access to mental health care caused by social determinants of health such as poverty, geographic location, and poverty (O’Brien et al., 2016). Therefore, it is vital to develop efficient and effective strategies to improve access to mental health services for the youth in Virginia, United States, given the estimated pervasiveness of emotional and behavioral disorders, the limited access to appropriate services, and the costs associated with these conditions.

Background and Significance

Adolescents experience mental health concerns such as depression and anxiety. Suicide rates vary by age, race, ethnicity, and demographics (Twenge, 2020). Suicide causes severe physical, emotional, and economic impacts. People who have survived suicide attempts may experience serious injuries resulting in long-term physical and mental health effects. Suicide affects the health and well-being of families, friends, and the community. When people die by suicide, their surviving families and friends may experience guilt, anger, shock, and symptoms of anxiety or depression (Curtin, 2020). Despite the far-reaching effects of suicide and suicidal attempts, mental health-seeking behavior among adolescents remains low due to various factors, with a lack of resources leading.

Notably, two-thirds percent of the people dying from suicide have not received the help of mental health professionals. Poor access to mental health services has become a severe obstacle to preventing suicide among adolescents. Also, some of the reasons why most adolescents do not receive the help of mental health professionals are a lack of resources. Reinert et al. (2022) state that access to suicide prevention programs and mental health services has successfully lowered suicide rates. However, these resources are not readily available for most adolescents due to the shortage of critical mental health professionals, the lack of mental health specialists in their area, and the lack of support in addressing suicide crisis-intervention issues. In addition, the high costs of mental health services and lack of insurance coverage may make it challenging for adolescents to access them (Reinert et al., 2022). As a result, most adolescents who do not rely primarily on the healthcare delivery systems to address their mental health needs do not have easy access to critical crisis intervention services.

Characteristics of the Target Population

Theoretically, this program aims to give adolescents more accessible, more reliable access to mental health resources at an affordable cost. In order to provide this support to our adolescent population, the program will be implemented directly in middle and high schools in Virginia; therefore, students have access to specific resources without having to worry about transportation, distance to mental health offices, or lack of time and money to obtain mental health treatment. According to the National Association of Secondary School Principals (2022), in the 2014–15 school year, there was one school counselor for every 482 students. However, the recommended ratio by the American School Counseling Association is one school counselor for every 250 students. Therefore, implementing this program in middle and high schools will also help take much of the burden off school staff members and allow the adolescents to be seen and treated in a timely manner (Randi & Gould, 2022). Ultimately, the goal is to have one “team” for each school district in Virginia, including a psychiatrist, psychologist, mental health counselor, guidance counselor, and social worker. This team would travel to different schools within their district each day and provide support to those who would like assistance addressing their mental health concerns. For example, there would be a team for Richmond City Public Schools, one for Portsmouth City Public Schools, Suffolk County Public Schools, and so forth.

When considering demographics, there is a wide range of cultural and social factors that must be taken into consideration. Specific considerations include the language barrier in certain districts of Virginia. For example, the Modern Language Association (MLA) Language Map Data Center (2023) recorded in 2010 that, in Arlington County, only 70.97% of the population speaks English as their first language, whereas, in Richmond, 90.36% of people speak English as their first language. Therefore, an important consideration is whether a translator or a translation system is needed in the program. While this program provides free mental health services, finances need to be considered as well. If deemed necessary that a student needs psychiatric medications or potential hospitalization, will he or she have the insurance or financial capability to afford them? In addition, because the population involves adolescents, is it necessary to contact parents regarding potential care a student might receive? Given the adolescent population, the concerns above regarding specific demographics will be taken into consideration when establishing this program.

Needs Assessment

Conducting a mental health needs assessment for adolescents should be done in a way that is easy for adolescents to participate in. The assessment should include a questionnaire that highlights critical psychological disorders that adolescents can be vulnerable to, such as anxiety, depression, and suicide, but also helps narrow in on adolescents in need in regard to sample size based on the number of submissions (Substance Abuse and Mental Health Services Administration, 2022). It should also feature questions that assess suicide risk, which could aid in prioritizing adolescents with safety risks. The assessment should also highlight financial needs if psychiatric resources are needed and financial barriers do not impede the adolescent. According to the National Academy for State Health Policy (2022), states have already passed policies providing improved resources for assisting with mental health. Virginia is among those states to provide funding and initiate development on designing a mental health task force. However, there should be another assessment for school counselors to complete to help identify specific needs for the school they operate in. Lastly, the questionnaire should also be presented so adolescents can submit mental health information without fear of information disclosure.

In terms of a model in which the mental health needs assessment could be presented, a secured online survey would be the best method to appeal to adolescents. Even if an adolescent cannot access a smartphone or smart device to submit a mental health needs assessment, it could be done from the online resources available in school or a library. The survey would have key depression questions from the PHQ-9 questionnaire, the GAD-7 questionnaire for anxiety, and the Young Mania Rating Scale for bipolar disorder, for example (Infectious Diseases Education & Assessment, 2023). The survey could be submitted to a school counselor or a behavioral health team via secure messaging for prompt follow-up with the adolescent and his or her family. The survey would not be a means for mental health diagnosis but a method for early intervention for mental health crises in the adolescent population.

Mission Statement

To be committed to enhancing mental health awareness, promoting wellness of the individual, family, and community, and increasing equitable access to treatment and services for the youth.

To assist adolescents in middle and high school students in Virginia experiencing mental health problems by serving mental health education and support through prevention, intervention, treatment, and education.

Goals/Objectives

This program’s ultimate overarching goal is to improve access to mental health services for adolescents and reduce the number of adolescents suffering from mental illnesses. A program must be curated to achieve this goal and describe the implementation steps. When creating the goals and objectives, the priority was considering the target population and how they could be reached most effectively. One goal for the program is to eventually integrate a mental health support “team” into every school district, allowing students convenient access to mental health treatment. Furthermore, with the implementation and integration of this program into middle and high schools, another goal is to raise awareness and reduce the stigma surrounding mental illness by using this program to educate and familiarize students with the signs and symptoms of mental illnesses and when to seek treatment. This can be achieved by engaging students in educational learning and encouraging them to ask questions about mental illness. Providing adolescents with the support and resources they need to combat the mental illness they may be dealing with is also one of the goals. These resources include possible referrals to a specific therapy, potential medical prescription, or education one of the team members provided on coping with specific mental struggles. These program goals will reduce the number of adolescents with mental health illnesses, and an improvement in the overall health status of adolescents is expected to be seen in the future.

Program Description

The program to be implemented will comprise a team of professionals, including a psychiatrist, psychologist, mental health counselor, guidance counselor, and social worker. This team will go into each middle and high school in a district quarterly to provide mental health education and support services, meet with staff guidance counselors, and provide insight into resources available to adolescents who struggle with mental health. The day will include time for different areas for each member to support students and staff in each school.

To start the day, the team will provide individual education sessions to each grade or as a general assembly. They will discuss mental health, who is at a higher risk for developing mental health illnesses, specific areas that adolescents may see these illnesses presenting (such as the inability to concentrate with ADHD), and generalized coping mechanisms that can be applied to various areas (National Institute of Mental Health, 2021). The students and staff will have an opportunity to ask questions and engage. Educational material will be given out, as well as QR codes for apps that are available for mental health support. Following this educational session, the team will have the opportunity to come to speak to classes and talk to students individually if the student requests. This information is documented and is passed along to guidance counselors who are staffed at the school so that they can follow up further with students who have been identified as ones who may be struggling with mental health or at high risk. During the education sessions, information will be shared with students to shed light on the available resources in times of crisis or attempted suicide.

One of the primary resources this team will share with students is using the 988 Suicide and Crisis Lifeline. When dialed, this number provides 24/7 free emotional and mental support to people in suicide or mental health crisis. The students can access this lifeline by call or text. According to the program’s website, this program has answered over 23 million calls since 2005 from people in a mental health crisis. The program can dispatch a mental health professional to the scene if needed (Substance Abuse and Mental Health Services Administration, 2023). The goal of promoting this resource to adolescents would be to assist them in mental health crises to prevent attempted suicide ultimately.

Following education and discussion with the students, the team would then meet with the school guidance counselors on staff to provide support, insight, and other available resources they may need to be made aware of. The team will share at-risk students that have been identified so that the guidance counselors can follow up with these students and provide them with the support and resources they might need.

After the education and discussion sessions, the students will be sent optional online questionnaires to fill out privately if they want to learn about more resources available or feel they need additional mental health support.

Resources and Budget

Improving access to mental health services for adolescents within the state of Virginia requires an immense amount of funding. Establishing a mathematically accurate budget will be an essential aspect of the program as it ensures resource availability, helps prioritize program initiatives, and ultimately estimates current and future expenses for a specific period within the program itself. When creating a budget for this program, financial considerations include the cost of hiring each member of our team of professionals, including a psychiatrist, psychologist, mental health counselor, and social worker. According to the U.S. Bureau of Labor and Statistics, in 2021, the average salary was $50,390 for a social worker, $43,390 for a mental health counselor, $81,040 for a psychologist, and $226,880 for a psychiatrist. After adding up these given salaries, it would cost approximately $401,700 for each public school district to have its own program. Ultimately, the goal is to provide every public school district with one team. This team will travel to each middle and/or high school within their district multiple times throughout the year.

According to the Department of Education, in 2022, Virginia had 135 public school districts. Therefore, after calculating the cost for each team multiplied by each school district, it would be $54.2 million to provide all the middle and high schools in Virginia with a mental health care team. While this does seem like an immense amount of money, according to the Urban Institute, in fiscal year 2017, Virginia spent $6.57 billion on school funding (45 percent of total state and local funding), and districts contributed an additional $8.02 billion. Therefore, when looking at the Virginia Public school funding, this would be a small fraction of the Virginia education system’s budget and spending for the year. In addition to the mental health team, resources needed include educational handouts, access to wifi and computers, and space within the school building to provide therapy and education sessions to the students. While it can be attributed to the budget, this requires very minimal financial contribution. Overall, mental health is a significant illness, specifically in adolescents. Therefore, our financial grants and budgets must be supported to provide children with the resources they need to succeed and combat any obstacles pertaining to mental health.

Timeline

The timeline for the launch of this mental health services program aimed at adolescents would be geared towards formatting the program around the academic school year. The mental health services program would be introduced to the school counselor and instructors during the preparation and orientation week before the first day of school. For example, in the Richmond Public Schools calendar, this would be from August 19th to the 26th. This timeline would be slightly adjusted based on each school district’s calendar start and end dates. During this week, the school counselor and instructors will be introduced to members of the rest of the team, including a psychiatrist, psychologist, mental health counselor, and social worker. School faculty will be informed on how the program’s services can contribute towards the mental health service program’s initiative. Also, this would be an opportunity to describe in detail the implementation of the mental health program so that instructors and the school counselor can introduce the service available to students on the first day of school. The program would run throughout the academic year as can be seen in Figure 1.

Figure 1

Program Timeline for Improving Access to Mental Health Services for Adolescents in Middle and High Schools in Virginia, USA

Program Implementation

Program implementation would first start with making the service known to students throughout the first day of school or class orientation. If students have access to a smartphone or laptop, they can be shown a link to submit mental health concerns and have it saved for easy access. If they do not have access to an electronic device, students can be shown how to access it via the library. Once accessed, students would be able to answer questions that originate from the PHQ-9, GAD-7, and Young Mania Rating Scale to assess for depression, anxiety, and bipolar disorder symptoms. Answer data and student names would be sent to the school counselor and mental health team for follow up with the adolescent and family. Barriers that may exist during program implementation would be limited access or delayed response to staff during school breaks or holidays. Students experiencing a crisis will be referred to the emergency hotline phone number 988.

Program Evaluation

insert program evaluation here

Conclusion

Research has clearly shown that adequate access to mental health resources during school engagements significantly impacts adolescents’ lives. Though many mental health services are found outside of the school setting, these are often underutilized. Collaborating with various professionals in the school setting is an effective way to address the mental health needs of adolescents, as education affects health. Most youths spend much time in schools making schools the ideal environment to provide timely and convenient access to mental health services to help identity, prevent and intervene to avert the escalation of a mental health illness. Providing services at school due to compulsory school attendance is also cost-efficient as it provides good accessibility to various services. Adolescents experiencing depression, anxiety, suicidal ideations, disruptive behavior disorder, or other mental health behavior will now have better access and resources. A team of professionals will work with the students to provide mental health education and support services at the schools.

Schools could use the findings from this program to improve further and implement changes and strategies as needed in the future, which may increase the results through its intended purposes. Investing in school-based mental health program initiatives will connect students to coverage and resources, establish a working group and engage them further to enhance the quality of care they receive. As mental health affects students’ social life and well-being, successful partnership with professionals providing mental health help will enable middle school and high school students to achieve a better learning environment, experience a more positive overall quality of life, and reach an understanding of the mission, vision, and goals of the program.

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