School-Based Mental Health Services

School-Based Mental Health Services
June 4, 2021 No Comments Vision of Justice Cece R. '23

A School’s Responsibility in Providing Mental Health Support

By Cece Reali

Exploring the benefits of mental health services through a public health perspective, this paper addresses a school’s responsibility to provide mental health treatment services and asks larger questions such as, “How can/should schools provide and distribute resources like mental health services to those who truly need them?” 

Table of Contents


Mental health disparities among children are on the rise across America, and the lack of resources to help is astonishing. Minorities and low-socioeconomic students are impacted the most, and yet schools do not have the resources to provide adequate care. Access to school-based mental health treatment services has become a concern of justice and inequity as funding is a main factor for this resource. One in five children experience mental health issues during their school years, yet 60% of those students do not get the treatment they need (NASP). Inequity, highlighted by selective access to resources such as mental health treatment, is what widens the gap between schools with different budgets, making this issue far bigger than it might first appear. Although there are several organizations that provide resources for improving student mental health like the National Center for School Mental Health (NCSMH), more needs to be done for a wider variety of schools. This is also an extremely relevant issue today, as a pandemic highlights these issues by forcing schools to close down and mental health disparities continue to develop.

This paper focuses on children’s mental health disparities while also discussing potential issues with the existing system of programs and funding for school-based mental health programs. The current five main models are services provided by the district, mental health units within a school health clinic, co-located community services in schools, mental health integrated into the curriculum, and a full prevention intervention and treatment program. For this paper, I will be focusing more specifically on anxiety and depression in students–a group that seems to be at the center of today’s mental health crisis. 

Prevalence of Mental Health Conditions

Mental health conditions among children, specifically anxiety and depression, have drastically increased in recent years. The Center for Mental Health Services (CMHS) defines mental health conditions  as “problems that affect one’s thoughts, body, feelings, and behavior.” 1 in 5 children experience a mental health problem in school but an estimated 60% of students do not receive the treatment they need (U.S. Department of Health and Human Services). 

Blue Cross Blue Shield collected patient data from 2013 and 2016, and found a dramatic increase in major depressive disorder. Although the disorder rose in each age category, depression in children ages 12-17 increased the most at 63% (Fox). 

Image by 1388843 from Pixabay

Anxiety is a mental health disorder that causes intense stress, worry, or fear in a patient, disrupting everyday activities. Having difficulty controlling worry, restlessness, and panic attacks are all symptoms of an anxiety disorder. Nearly one-half of patients suffering from an anxiety disorder are also diagnosed with depression, which creates feelings of sadness and typically results in the loss of interest in both daily activities and hobbies (NIMH). Changes in diet, feeling worthless, and thoughts of suicide are common symptoms of major depressive disorder (APA). It is important to note that both anxiety and depression can be genetic, but can also be cultural in origin. Factors such as family issues, life events, and stressful school environments are proven to increase the risk of developing anxiety or depression (ADAA). Risk factors of mental health include “…poverty, physical abuse, emotional abuse or neglect, harmful stress, discrimination, loss of a loved one, frequent moving, alcohol and drug use, trauma, and exposure to violence” (Rogers).

Today, as COVID-19 has forced schools to shut down and kids are isolated from peers, there are increased rates of anxiety disorder and depressive disorder among students (Syed and Zhou, 2020).

From conducting a study on young adults under the age of 25, it was concluded that “In May, these populations were experiencing higher rates of anxiety and depression than any other single age group” (Mental Health America). Higher levels of mental health conditions have had a severe impact on students, especially as disparities in mental health and access to support arise.

Current Systems and Stakeholders

When discussing current school-based mental health systems, it is important to define the role of stakeholders as well as a school’s role in treating vs. identifying conditions. School counselors provide counseling for the general population of the school, while school psychologists specialize in conditions and work more closely with individual students. Psychologists administer tests and often help create individualized education plans but are also more costly for a school. For schools that can’t afford these options, some might ask if a school nurse might be qualified to support student mental health. While a school nurse can work with psychologists to aid a student’s mental health problems, it is not a part of their job and they should not be substitutes for professionals trained in the psychology field. School nurses might be helpful in identifying conditions but cannot be expected to treat a student. In fact, while students receiving treatment from a school is ideal, I recognize that this may not be realistic for many schools right now. Identifying conditions should be expected but the ultimate goal is in-school treatment by trained professionals. 

Disparities in Care

Mental health disparities can be defined as higher levels of mental health issues among minorities, such as those of lower economic status and racial minorities (Bischoff, Springer, & Taylor, 2017). Barriers to access to mental health care deepen these disparities, continuing a cycle of deepening vulnerability that raises ethical concerns. 

Many children who are part of low-SES families share common experiences of financial stress, substance abuse, and violence in their neighborhood–all factors that contribute to poor mental health. Yet, people of lower economic status don’t have the access to mental health care that many wealthier citizens take for granted. Cost, in general, has proven to be a larger struggle:

Forty-two percent of the population saw cost and poor insurance coverage as the top barriers for accessing mental health care (National Council for Behavioral Health).

One in four Americans reported having to choose between getting mental health treatment and paying for daily necessities (National Council for Mental Wellbeing). Health care plans lack in-network providers and have unreasonable criteria for insurance. Because of this, many insurance companies don’t cover mental health despite the mental health parity laws established (Bogusz). Financial barriers such as these further polarize contrasting economic groups and will eventually lead to mental wellness being a privilege for some, instead of a right for all. 

Racial minorities, another group disadvantaged by lack of access to mental health care, also face bias in the psychology field as well as increased levels of mental health disorders. In the 1800s, psychiatrists and scientists claimed that slavery was acceptable because black men suffered from mental illnesses (Office of the Surgeon General (US)). Drapetomania was said to be a mental illness present in freed slaves and was listed in the Practical Medical Dictionary until 1914. In the 1960s, as the civil rights movement took off, schizophrenia became the diagnosis to describe black men, writing off their anger and violence as “delusional anti-whiteness.” Looking at this history helps us understand the existing racism resulting in mental health disparities among black people and other racial minorities today.

Black adolescents are often diagnosed with schizophrenia more than the more accurate diagnosis of a depressive disorder, in part due to differential symptoms and clinician bias (Cokley).

Studies show that at least two-thirds of health providers hold some form of implicit bias against marginalized groups (Merino et al.). The role of implicit bias, unconscious stereotyping, manifests often in the psychology field and limits access to medical care for racial minorities. These groups are also at higher risk of developing mental health conditions because of the impact microaggressions, bias, and prejudice have on the psyche. “‘Racial battle fatigue’ is the burden that results from regular exposure to prejudiced information; prodding from people regarding racial events or wanting to become educated or allies; and people invalidating their experiences,” Helen Neville, a professor of educational psychology explained. She mentions that Asian Americans face discrimination for looks, language, culture, and recently, the pandemic–all having an extremely negative impact on mental health. Clinician Richelle Concepcion raises the point that they also face great amounts of family and social stress by having to represent their family well and embody two cultures: that of their heritage and “American” in the US (Rogers). 

In addition to economic and racial barriers, the average person also experiences stigma around mental health, further limiting the availability of mental health support. Nearly one-third of Americans, or 31%, have worried about others judging them when they told them they have sought mental health services, and over a fifth of the population have lied to avoid telling people they were seeking mental health services (National Council for Behavioral Health). Additionally, focus groups with African Americans in rural locations revealed the higher levels of stigma in smaller communities, participants explaining that private information spreads fast and that they would be judged for their mental health conditions. Stigma like this prevents those at risk from getting help, as one participant realized when he “happened to visit a friend who had just taken pills in an attempt to take his own life” (SAMHSA).

These economic, racial, and stigma-related barriers explain how 64% of those who have tried to get mental health treatment agreed that the US government needs to be doing more to improve access, especially because these categories are all interconnected and impacted by each other (National Council for Behavioral Health). A study comparing mental health stigma in different racial groups found that racial minorities showed more stigma than racial majorities. In addition to stigma barriers, the mental health of racial minorities is more affected by financial issues: analysis of U.S. Census Bureau data shows that in 2005, African Americans were 7.3 times more likely to live in high poverty neighborhoods with limited to no access to mental health services (Denton & Anderson, 2005), continuing a cycle of poverty and discrimination. Additionally, Black and African American people living below poverty are twice as likely to report serious psychological distress than those living over 2x the poverty level (Mental Health America). This proves that the lack of mental health access connects to systemic issues and, additionally, suggests the importance of reducing racial and economic stressors and strengthening mental health education to combat stigma. 

The symbiotic relationship between these categories displays the importance of fairly distributing resources like mental health care. However, there are many examples in our society where the poor are further disadvantaged by the system. Absolute equality is impossible to achieve, and inequality can be considered inevitable–so why would directing resources like mental health care towards middle and upper classes be unethical, especially when funding and psychologists are limited even for more affluent communities, some might ask? In my view, total equitable distribution of mental health services may be unrealistic but is an ideal to work towards for our society. The value of fairness would ensure equitable access to mental health services, no matter the age, race, or SES. Adding mental health support, in turn, would improve levels of fairness among different populations. A fair society supports the underprivileged while working towards balance and this idea of “leveling the playing field” is imperative in improving a system that disproportionately disadvantages groups who are already vulnerable. As stated by Thomas Scanlon in his paper on equality, “…the idea of equality of opportunity–as expressed in the familiar metaphors of a “fair race” or a “level playing field”–provides a familiar example of this …reason for objecting to inequality: inequalities are objectionable when they undermine the fairness of important institutions.” Fairness is a principal value for our society and the case for developing mental health support to improve the quality of life for the disadvantaged and serve the community as a whole. 

After thoroughly researching this topic and funding aspects, I have found that implementing new or increased mental health support is not simple. The pandemic is a factor that has further complicated ethical issues and equitable access to mental health care while deepening disparities. 

Equitable Care, From a Distance

Students of color living in poverty are disadvantaged during the pandemic primarily due to two different factors, on which this paper will focus. First, they are the group most at risk for developing mental health issues because of environmental components and the pandemic. Secondly, online mental health care is even more limited for minorities. The value of justice is extremely pertinent in this topic; the lack of justice in who is receiving health care in general, but also during a pandemic, is one of the principal issues faced by many today. 

The story of Leslie Keiser, a 16-year-old girl living on a Montana reservation who committed suicide, is sadly far too common. In a typical year, rates of suicide among indigenous teens like Leslie are twice the rate of white teens (Reardon). COVID-19 has increased disparities between these two groups and has resulted in a rise of suicides like Leslie Keiser. This is just one example, displaying the disastrous mental health effects of combining previous discrimination and struggle of being a minority with isolation and the death toll of a pandemic. Suicide often involves complex biological and environmental risk factors, but child psychologists have warned that the pandemic might be causing a spike in suicide. It is important to note that many psychologist appointments had to be canceled earlier in the pandemic. To deepen these disparities, therapy is not an option for many people on rural reservations who don’t have computers or reliable internet access. And Maria Vega, a member of the Fort Peck Indian Tribes, points out that the therapists who offer telehealth services often have long waitlists (Reardon). 

Both remote learning and online care have produced inequalities among students and proved to be an extra challenge for everyday citizens. Online care is in general is more critical than ever during COVID-19 but simultaneously generates more obstacles.

86 percent of white Americans own a computer or laptop compared to just 58 percent for blacks and 57 percent for Hispanics (Pulliam, 2020).

And although many mental health centers switched to online easily, mental health care online brings its own problems of confidentiality, cybersecurity, and quality of care. 

The value of equity tells us that we don’t need to increase mental health care for all–many wealthier schools already have it. Equity means that an individual may need to experience or receive something different (not equal) in order to maintain fairness and access. Discussion surrounding the need for equity has also become increasingly relevant as the debate between in-person learning and remote learning grows. Lack of motivation and tiredness due to remote learning are common behaviors that students and parents have reported. Districts have to choose to risk higher infection rates or risk inferior education and poor student mental health. Making this decision for districts with high numbers of children from racial minority and high poverty households adds another layer of complexity–these populations also tend to be the most vulnerable to contracting the virus because of crowded living conditions, access to healthcare, and fewer testing options. Furthermore, low-funded districts typically do not have the resources to transfer back to in-person learning, while most private schools and affluent districts do. Wealthier private schools have the money to purchase materials like plexiglass and provide testing but they also have smaller class sizes and because of this, it is much easier to identify and isolate cases. However, low-SES students and racial minorities in public schools do not have this advantage and, at the same time, are also are the largest group that depends on in-person school mental health services. Different education plans in response to the pandemic widen the equity gap between schools and will impact not only the quality of learning for students but mental health. Ensuring mental health care services for all means creating equitable access and schools, especially during the pandemic. Surprisingly, the disparities in health equity are not a large motivator for states to improve access, but “with a collective and newly heightened awareness of systemic inequity, it may emerge as a motivator for other states considering this change” (Child Trends).

Improving mental health access online is key to help slow the rise of mental health conditions while students continue to attend school online and are isolated from their peers. The balance of equity requires more focus on the underprivileged, which is why allocating mental health care funds specifically to underprivileged schools would be wise. 

Positive Effects and Consequentialism

Ideally, the positive effects of mental health treatment should cause schools to take a utilitarian/consequentialist approach where the cost of implementing mental health services is justified by the greater good. To understand the impact of mental health crisis and why it is important, the results of increasing school-based mental health care must be discussed. 

Mental health problems impact more than just the diagnosed individual as these issues extend into larger public systems. As many as two-thirds of youths in the juvenile justice system have a diagnosable mental health problem (Meservey and Skowyra 2015). Economic loss for a community comes from the cost of care, but more from the consequences of widespread poor mental health, resulting in an estimated $193 billion in lost earnings. Many children suffering from mental health issues are misdiagnosed and placed into special education programs, costing a significant amount of money and increasing the chances of the child dropping out. One study found that five percent of students do not finish their education due to psychiatric disorders and estimated that 4.29 million people would have graduated from college had they not been suffering from these disorders (SAMHSA).  

Due to these grave consequences, poor mental health is a public health issue and the consequences extend beyond those directly diagnosed. The current negative ramifications of economic loss, increased incarceration and worsened school behavior joined with the opportunity for positive impact should rationalize adding more mental health support in schools. Additionally, there is a considerable psychological cost for friends and family of mental health patients: people involved report that supporting a person with mental health problems is taxing. In this case, utilitarian and consequentialist frameworks are closely connected. The consequences of adequate or deficient care largely impact individuals and whole communities, calling for a utilitarian approach that would benefit the greater good.

Factors of Responsibility

The responsibility to address mental health and well-being has been shuffled from hospitals, families, and more recently, to schools. Products of a flawed healthcare system, school-based health centers came out of a need for care, including appropriate mental health resources for children. But why should schools be responsible for mental health, when the main goal is education?

Mental health treatment being out of a schools’ jurisdiction is a belief often argued.

“Schools are in the business of providing education — they are not in the business of providing medical services” (Gorman).

– Jessica Shubel, from Center on Budget and Policy Priorities

Under this lens, schools being the “de facto” provider for mental health care shouldn’t be a priority when basic education is struggling. Mental health care takes away resources from the primary need and goal, education. With 32% of this country’s 4th graders not at the basic reading level, the focus needs to be on learning (The National Children’s Book and Literacy Alliance). 

However, the responsibility to contribute positively to society as well as the responsibility to support student well-being is part of a school’s duty, therefore, so is student mental health. Under the principle of beneficence, they have a responsibility to make a positive contribution to society by providing education and a safe environment for children. Schools do have a responsibility to be morally right and act for the good of students, but when does that become unexpected? It may be unrealistic to consider public schools having a moral obligation and acting out of pure goodness but this ideal should not be completely forgotten. With this ideal, schools have some form of responsibility to the public, and as stated by Christy Oslund in her book, Supporting College and University Students with Invisible Disabilities, “Society is best served by assisting all of us in maintaining mental health, rather than trying to foresee which of us is most likely to act out when mental health support is not readily available.”

Another factor in deciding a school’s responsibility to provide mental health care is the worry that the duty of providing quality education is interrupted by poor mental health among students:

“Studies of young people have found that health-risk behaviors negatively affect: (1) education outcomes, including graduation rates, class grades, and performance on standardized tests;(2) education behaviors, including attendance, dropout rates, behavioral problems, and degree of involvement in school activities such as homework and extracurricular pursuits; and (3) student attitudes, including aspirations for postsecondary education, feelings about safety at school, and positive personal attitudes.”

– Olsen and Allensworth, Page 1003

Both anxiety and depression affect working memory, making it hard to learn new information and retain old information. To fulfill the U.S Department of Education’s mission statement “to promote student achievement and preparation for global competitiveness,” schools must expand and add mental health support. 

One aspect contributing to a school’s responsibility is the appropriateness of school as a resource; accessibility for mental health care is an issue made easier if the resource was in school. Transportation and insurance issues are eliminated when mental health is integrated into schools, where students spend over half their day. A 2003 study in the Journal of Adolescent Health found that students were 21 times more likely to make mental health-related visits to school-based health centers than to community health clinics. The convenience of a task does not automatically give a person or organization the responsibility of doing it; this can be applied to the school’s responsibility as well, but it also must be considered as a fact that contributes to the support for school-based mental health services.  

Schools should have student’s best interests as one of their priorities: not only is it the “right thing to do,” but also their job and duty.

“I do believe it is the school’s responsibility to advocate for mental health care in the community and to incorporate mental health care in their annual budgets for taxpayer approval; and with that approval hire qualified mental health providers to assist students and their families.”

– Dr. D’Elia, Assistant Superintendent of Chatham Support Services

In this way, a deontological framework can be applied to support the perspective of schools having an ethical duty or obligation to provide mental health care. Even removing the considerations of possible consequences, schools have a job to protect study well-being. Convenience, quality of education, and a possible moral obligation speak for school-based mental health, but several blurred lines arise with this conclusion.

Unresolved Concerns of Responsibility

School responsibility brings up discussion around a few unknowns regarding boundaries of privacy, the school’s negative impact on mental health, and the possibility of a slippery slope. 

Blurred lines concerning privacy have been a debate in both schools and health care for a while, and the intersection of these two categories proves to be even more difficult to break down. Critics argue that school-based health services “threaten to undermine parental authority and invade families’ and children’s privacy,” (Rogers et al.) but when does safety outweigh this? This can be hard to determine, as privacy is subjective–the amount of privacy wanted varies per person and these boundaries may be different for every family. A general question to ask is if the school is crossing boundaries by “playing the role” of a parent. However, it must be considered that many parents don’t have the resources to provide mental health support for their children while some families simply ignore it. 

When should parents take responsibility for their child’s mental health issues, and what should a school do if the parent is not fulfilling that role? This may vary for every district, as do the guidelines and limitations of a school psychologist. How far can a counselor question/hear about a student’s personal life or relationship with parents? And, on the flip side, should a school counselor tell parents information about a student’s mental health? Mental health is a private issue to many students, maybe in part due to the stigma. Do teachers have a responsibility to tell parents or counselors if they notice symptoms of a mental health disorder in a student, even if it is opposing a student’s wishes–would this be considered a violation of privacy? 

Image by mohamed Hassan from Pixabay

In a crisis, safety is prioritized over privacy but it can be hard to determine exactly when a student’s mental health fits into the crisis standards. Because mental health is a very private issue, it is hard for outsiders to notice symptoms of depression or anxiety that can sometimes lead to attempts of suicide. Teachers should work with school counselors to understand when a student might be struggling to prevent this; they are in a position where they can spot mental health trouble if properly trained. This guideline may even be a part of their job–the role of an educator includes helping students develop academically, but also as an individual. However, many teachers aren’t even properly trained to respond to or recognize mental health issues, another underlying issue included in school mental health support. Although a majority of teachers have expressed that they feel unprepared to identify and support mental health problems, mental health training programs like the commonly used Mental Health First Aid are often shortened or rushed to save time and money (Fulks et al.).

As training is increased, we have to ask what is fair to expect from teachers, especially as identifying these issues is difficult and can’t be taught in brief training sessions. Regardless, schools should do the best they can to provide basic training, a point that  Dr. D’Elia agrees with as he says,

“It is also the responsibility of a school to educate staff on signs and symptoms of mental health problems so that students can be identified and provided with mental health services as needed.” 

– Dr. D’Elia, Assistant Superintendent of Chatham Support Services

Does school responsibility grow when the impact of a negative environment in schools is considered? Schools are not the main factor in increased mental health concerns, but research does show that long-term stress from school creates a higher likelihood of depression and anxiety. This consideration ties back to a larger issue of poor public school systems. The quality of teachers, levels of violence, and materials of each school vary to a great extent. Among this variability, alarming facts remain; only 59% of students reported that they felt safe at school in 2019 (YouthTruth Student Survey), and the quality of education is often sacrificed as few high-poverty schools have advanced coursework. Younger kids frequently go without recess or have limited time for lunch, and bullying rose by more than 35% from 2016-2019 (Patchin). Schools not meeting the essential needs of students is a relevant issue that has more of an impact on mental health than many might assume. Poor school environments like these raise mental health issues, but these low-funded districts also are the ones who struggle to receive funding to assist. 

If schools have some level of responsibility to medically care for students, where does the line need to be drawn so schools don’t end up providing support for more and more medical issues? School-based health centers (SBHCs) provide mental health services in addition to other health services. Many schools are already offering services that you could find in a doctor’s office–physicals, reproductive health care, and nutritional education. Recently, the argument for providing vaccines in schools has grown under the need for expanding availability and affordability. Mental health screening is also gaining popularity and is even mandatory in some locations, sparking many possible privacy-related discussions. Increased healthcare in school is undoubtedly a slippery slope, and at a certain point, not all of that would be a school’s responsibility. How would schools decide what to treat and what not to, without excluding or discriminating against certain mental illnesses or disabilities? Would schools have to diagnose mental health, not just treat it? What illnesses would be excluded? The extreme growth of health care in schools is far in the future, but it is a slippery slope that can’t be ignored. With the school’s responsibility of care, it is imperative that boundaries are maintained to continue a safe and organized system. 

The discussion around these boundaries is extremely pertinent and needs to be addressed before implementing more mental health support. However, it is also hard to determine what stakeholders should be involved in these conversations as the funding aspects of school-based mental health services affect a larger group of people. 

Funding Allocation and Conflict

While funding is not the sole solution to this issue, it is clear that it is one of the first challenges of school-mental health support that needs to be addressed. With the struggle of increasing budgeting comes issues of taxes and liabilities that ask whether school-based mental health services would really ensure justice and better school environments.

Obtaining money to support mental health services is an issue prevalent in many schools, but financial issues and guidelines vary greatly per district. Currently, there is an average of 1,401 students per one school psychologist–a ratio far from the recommended 500-700 students per psychologist (National Association of School Psychologists). The shortage of psychologists is one of the losses that comes with under-funded school mental health programs. More affluent school districts can offer higher-paying jobs to these psychologists, leaving the economically disadvantaged schools with even more scarcity of staff. 

“The centers receive limited federal funding; the money to pay for them generally comes from state grants, partnerships with local hospitals or public health departments, or grants from nonprofits…” (Chamberlin).

Medicaid is a federal-state program that provides health care for people with lower incomes and resources and annually spends $4 billion on schools–a small portion compared to the overall $400 billion budget (Webb). For each state, the distribution of this money differs but “As of Fall 2020, more than half of all states and the District of Columbia (i.e. 26 jurisdictions) had barriers inhibiting schools from utilizing Medicaid to support free school-based health services.” The federal government reimburses states (on average, 57%) for health expenditures, which means that Medicaid does require a state investment. More than half of the states are limited to spending Medicaid only for students with IEPs (Individualized Education Plan), IFSP (Individualized Family Service Plan), or under the Individuals with Disabilities Education Act (IDEA). The states of Georgia and Maryland do not reimburse for school health services that aren’t under an IEP or IFSP, while 24 states require that school-based health services be documented in an IEP or IFSP (Wilkinson et al.). Even requiring the services in an IEP is a barrier because these processes take time and are often difficult to work through, and many students with mental health issues may not have access to the resources required to obtain an IEP or IFSP. 

On an individual school level, district school administrators develop an annual budget for their school/department and then incorporate the top needs by prioritization. These schools must stay within a fixed budget established by the taxpayers and state aid. After staff salaries, transportation, building maintenance, and special education, the small remainder of the budget is is used to address curriculum, unfunded mandates, and new initiatives. The decision on how the funding is allocated is determined by the Superintendent who makes that recommendation to the Board of Education, who then presents the budget to the community. A district can ask the local residents to approve additional funding if they want to exceed their annual budget cap. If the budget is within the 2% cap requirement, community approval is not needed. As Dr. D’Elia, Assistant Superintendent of Chatham Student Support Services says, “It is important to keep in mind that each district has its own Boards of Education, Superintendent, and culture, so this process varies for each situation,” but one common theme can be seen across the board: prioritizing funding for mental health is a struggle.

To solve some of these funding issues for the most vulnerable and endangered districts, Mary Walsh, who conducts research on mental health delivery in schools, recommends that schools “tap community mental health services, especially in urban areas” (Chamberlin). Is it ethical to redistribute resources and money from affluent locations to rural or lower-funded schools? Is this supporting “American” values of equality and equal opportunity, or contradicting what many believe are this country’s values by taking away resources from citizens? Furthermore, these citizens paid for those resources–so don’t they have the right to say where their money goes? This connects to the idea that larger businesses or wealthier people might have a larger responsibility to society. With privilege comes greater responsibility; applying this idea to schools would support redistribution of resources from affluent to lower-funded districts.

One concern is that increased funding will create a domino effect, increasing taxes and, in turn, affecting affordability–this is a concern that also varies per district. There is a fear of economic consequences in implementing school-based mental health programs, a severe ramification, particularly for low-income communities. Although the risk of losing money isn’t too substantial, evidence of school-based mental health programs being cost-effective in high-poverty areas is not fully developed yet. Because of this, it is challenging to weigh the risks and benefits but this does fit the argument that mental health is a family responsibility, not a taxpayers.

When discussing financial conflicts surrounding mental health centers, liabilities for the school district must also be taken into account. As one tragic case study points out, “If a tragic event such as suicide were to occur, the therapist may be covered by malpractice insurance, but the school district could be sued for poor supervision of the therapist…Coverage for the school district would pivot on the question of whether the supervision of mental health treatment professionals is considered an appropriate activity of a school district” (Underwood et al.). In this case, students reported to the school counselor that D.B. (an 8th-grade student) was cutting himself and threatened suicide. The counselor responded by suggesting therapy to D.B. and his parents, and his father took him to the doctor, who concluded that he was not suicidal. Two weeks later, the counselor was notified that D.B. had been texting his friend, threatening suicide. The counselor did not take action and D.B. died by suicide a few days later, prompting D.B.’s father to sue the school district and school counselor. The school district was protected by qualified immunity but the case against the counselor went to trial (Baab v. Medina City Schools Bd. of Edn., 2019-Ohio-510).

While schools are not directly responsible for suicide, they can be legally liable for creating a special danger of suicide or “acting recklessly in carrying out their responsibilities to the student” (Underwood et al.). Litigations against the schools are  principal factors in shaping a strong idea of what a school to parent relationship should look like. The in loco parentis doctrine refers to an obligation for a person or organization, in this case a school, to take on duties typical of a parent. To many, this old doctrine seems outdated with a troublesome past.

 Until the 19th century, public schools had similar legal responsibilities for students as parents, with the in loco parentis concept excusing harsh disciplinary action against students. In the 1960s, this doctrine resulted in restrictions on student freedoms and rights, leading to the eradication of the theory. However, many aspects of the in loco parentis doctrine have returned and been transformed, fitting the logic of the need for school-based mental health services. The doctrine has shifted from excusing disciplinary action to protection and student safety. 

An updated look at this theory surfaces pertinent questions about the degree to which it should be applied.

Parents give schools the responsibility to care for a child, but to what extent?

Is mental health included under the responsibility to provide safety? When parents entrust schools with their children, they expect a school to provide protection from immediate danger. However, giving the school “too much trust” in the name of in loco parentis can be harmful to both students and the school. Some worry that the revival of laws like these may cause schools to be less likely to admit students with mental health disorders in order to avoid lawsuits, while many argue that citing anti-discrimination policies can prevent this. The modern-day version of this traditional belief is centered around the “best interest” of the child, a subjective term that can give rise to controversy between the parent and school. However, parents still have the ultimate power regarding their child’s mental health, and so the in loco parentis doctrine can cause more liabilities for a school, especially regarding mental health.

Legal aspects are not the only complicating factors in incorporating mental health services in public schools: funding can add an additional layer of complexity as well. It is hard to imagine prioritizing funding for certain critical care, particularly when seeing the considerable need for educational resources for children like teacher development and curriculum. Consequently, many people feel this valuable money might be more useful allocated towards larger and “more pressing” public health concerns. Prioritizing public health issues has benefits under a utilitarian lens but can ultimately lead to a slippery slope of continually leaving smaller concerns behind. In fact, misjudging the importance of mental health and brushing it aside has been a main contributor to such a rise of anxiety and depression. Additionally, the evidence of positive impacts discussed above should be enough to argue that mental health services are important.


Programs like the National Center for School Mental Health (NCSMH) have provided resources for improving mental health services in schools, with additional information for COVID-19 and mental health screening. This website contains articles on specific topics of white supremacy, racism, bias, and how they are connected to mental health. Substance Abuse and Mental Health Services Administration (SAMHSA) also includes similar resources and has released many reports on the impact of mental health. But while these resources have been extremely important for education and increasing mental health support, they have not and will not single-handedly solve the issue. 

Research suggests partnering school staff with community counselors as partnerships can “serve to strengthen, support, and even transform individual partners, resulting in improved program quality, more efficient use of resources, and better alignment of goals and curricula” (Harvard Family Research Project, 2010). Inclusion of school-based mental health support in governmental COVID-19 aid packages is also essential because of the impact of COVID-19 on mental health. However, to provide any long-term solution, there must be an increase in licensed health professionals. 

I started this paper with a strong opinion in mind, but after researching, I have started to understand how complex and multi-faceted school-based mental health support is. One of my main takeaways is understanding the clear connection between funding for schools and mental health support. Due to the importance of collaboration, I end this paper by supporting a multitiered system of supports (MTSS) approach where the school-employed psychologist works with parents and teachers to provide the best possible care for a student based on need.

School-based mental health services are critical, especially to low SES and minority communities. I believe that schools do have a responsibility to provide mental health treatment because of mental health’s role in student well-being, lack of accessibility otherwise, fairness, and beneficence. Improving funding and access, although a difficult and unrealistic process for many schools, will improve public health and is important in maintaining a fair, just, and equitable society. 

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