Mental Health Supports in Schools: Pediatrician Perspectives and Policy Prescriptions for Improving Equitable Access

Despite rising rates of youth mental illness, over 60% of youth receive no treatment, and minority and low income youth are disproportionately impacted by mental illness. The AAP recommends depression screening for all youth ages 12+; however, connecting youth to follow-up after a positive depression screen is often difficult. Schools are an underutilized and equity-promoting setting for mental health services that minimizes transportation barriers. Youth are 6 times more likely to complete school-based vs community-based therapy, though health insurance reimbursement for school-based services can be a barrier. To investigate the current landscape of mental health screening and follow-up in pediatric primary care and in schools, we aimed to 1) Identify barriers and facilitators for pediatricians to screen for depression and develop follow-up plans and 2) Examine policies affecting reimbursement and access to behavioral health supports in schools. Using the Consolidated Framework for Implementation Research, we examined the internal context by analyzing 11 semi-structured interviews with pediatricians on screening for and managing depression. To investigate the external context, we conducted a landscape policy analysis that examined funding mechanisms for school-based mental health services, including through Medicaid reimbursement, grants, and other revenue sources. Pediatricians identified fewer barriers to screening than in referring to follow-up services. Barriers to follow-up included lack of available mental health providers co-located in clinics or in the community, inadequate mental health insurance coverage, and absence standardized policies for pediatric mental health follow-ups. In the landscape analysis across states, 18 states expanded Medicaid coverage in schools to students with any type of individualized care plan (not only an individualized education plan, IEP). Of these states, 12 cover school behavioral health services delivered via telehealth for all students, 13 reimburse services through the Random Moment Time Study payment model, and 17 reimburse at least three types of behavioral health staff. Based on our findings, the following are likely to improve access to mental health services in schools: 1. Expand sustainable funding for school behavioral health services through health insurance coverage 2. Create new external funding mechanisms for school-based behavioral health services 3. Implement comprehensive and tiered systems of supports for behavioral health in schools 4. Decrease the administrative burden for schools to be reimbursed for behavioral health services in schools Strengthening behavioral health services in schools is an approach that pediatric providers and policymakers could leverage to increase access to follow-up supports for children who screen positive for mental health issues. Policy changes that facilitate reimbursement of school-based mental health services can improve health outcomes and advance equity.