United States Government Accountability Office

Washington, DC 20548 

October 5, 2007 

The Honorable Edward M. Kennedy 

Chairman 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

Dear Mr. Chairman: 

Subject: School Mental Health: Role of the Substance Abuse and Mental Health Services 

Administration and Factors Affecting Service Provision

The U.S. Surgeon General reported in 1999 that about one in five children in the United States 

suffers from a mental health problem that could impair their ability to function at school or in 

the community. Yet many children receive no mental health services. While many of the 

existing mental health services for children are provided in schools, the extent and manner of 

school mental health service delivery vary across the country and within school districts.1

Federally led initiatives have identified schools as a potentially promising location for

beginning to address the mental health needs of children. Both the report of the Surgeon 

General’s Conference on Children’s Mental Health and the 2003 report of the President’s New 

Freedom Commission on Mental Health—Achieving the Promise: Transforming Mental 

Health Care in America—identified school mental health services as a means of improving 

children’s mental and emotional well-being.2

At the federal level, the Department of Health and Human Services’ (HHS) Substance Abuse 

and Mental Health Services Administration (SAMHSA) has a stated mission of building 

resilience and facilitating recovery for people—including children at risk for mental health 

problems. Although SAMHSA is the federal government’s lead agency for mental health

services, other federal agencies and departments, such as HHS’s Centers for Disease Control 

and Prevention (CDC) and the Department of Education (Education), engage in, or 

 1

For the purposes of this report, we use the term “school mental health services” to refer to both

school-based services, i.e., services provided in the school, and school-linked services, i.e., services

provided by a community provider through a link with the school. Throughout this report, the term 

school is used to refer to elementary and secondary education, i.e., kindergarten through 12th grade. 

2

U.S. Public Health Service, Report of the Surgeon General’s Conference on Children’s Mental Health: 

A National Action Agenda, Department of Health and Human Services (Washington, D.C.: Sept. 18-19,

2000) and New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental 

Health Care in America: Final Report, Department of Health and Human Services (Rockville, Md.: 

July 22, 2003).

 GAO-08-19R School Mental Health Services 
coordinate,3

 activities related to school mental health services in various ways. SAMHSA 

works to achieve its mission chiefly by providing grants and technical assistance.4

 For 

example, the agency uses grant funds and technical assistance to support the expansion of 

mental health service capacity and the use of evidence-based practices in mental health 

services. Typically, efforts that have been validated by some form of documented scientific 

data are referred to as evidence-based. 

You asked us to provide information on school mental health services and the role of 

SAMHSA in this area. In this report, we describe (1) SAMHSA’s coordination with other 

federal departments and agencies to support mental health services in schools, (2) the efforts 

SAMHSA has made to identify and support evidence-based school mental health services and 

best practices for service delivery, and (3) factors that affect the provision of mental health 

services in schools. 

To address these objectives, we reviewed materials related to SAMHSA’s efforts to 

coordinate activities related to school mental health services with other federal departments 

and agencies. We also reviewed materials related to SAMHSA’s efforts to identify and support 

the use of evidence-based interventions. These materials included program descriptions and 

grant announcements related to federal programs that support school mental health services, 

as well as agendas and summary documents from interagency meetings related to children’s 

mental health. We conducted interviews with SAMHSA staff, as well as staff from other HHS 

agencies who interact with SAMHSA or conduct activities related to school mental health 

services. In addition, we interviewed staff from Education’s Office of Safe and Drug-Free 

Schools and the Department of Justice’s (DOJ) Office of Justice Programs, which participate 

in activities related to mental health services and violence prevention programs in schools. 

We also interviewed experts in the field of mental health services and representatives of 

mental health provider groups and school administration associations. Information on mental 

health services provided to students who qualify for special education services through the 

Individuals with Disabilities Education Act (IDEA) was outside the scope of our work.5

To provide information on factors that affect the provision of school mental health services, 

we conducted interviews with representatives from seven selected sites—schools and school 

districts—and reviewed documents, including their program descriptions, training materials, 

 3

Coordination can be broadly defined as any joint activity by two or more organizations that is 

intended to produce more public value than could be produced when organizations act alone. For the 

purposes of this report, we use the term “coordination” to include activities variously described as

“cooperation,” “collaboration,” “integration,” and “networking.” See GAO, Results-Oriented 

Government: Practices That Can Help Enhance and Sustain Collaboration among Federal Agencies, 

GAO-06-15 (Washington, D.C.: October 2005).

4

In this report, we use the term grants to include both grants and cooperative agreements, except 

where otherwise indicated. The distinction between a grant and a cooperative agreement is the degree

of federal involvement. A cooperative agreement is used when substantial involvement is expected

between an agency and the funding recipient, whereas a grant is used when substantial involvement is

not expected between an agency and the funding recipient. In addition, for the purposes of this report, 

we use the term technical assistance to refer to support provided to organizations receiving federal 

funding to help them with the implementation of their program, such as assistance with strategic 

planning or program evaluation. 

5

IDEA provides funding to support free, appropriate public educational services to children with 

disabilities, including disabilities related to mental health. 20 U.S.C. § 1400 et seq. 

2 GAO-08-19R School Mental Health Services
and evaluation reports. We conducted interviews on site at five locations, two in Connecticut 

and three in Ohio; and by telephone with two locations, one in Florida and one in North 

Carolina. 

To select our seven sites we 

• Interviewed officials from federal agencies and associations, as well as experts in the area 

of school mental health, to identify states, localities, school districts, and specific schools 

considered to be active in the area of school mental health services. 

• Selected a sample of 7 sites from approximately 53 identified locations based on the 

following criteria: The sites selected were to include a mix of urban and rural settings, 

settings with school-based health centers, and at least 1 site currently receiving funds 

through the federal Safe Schools/Healthy Students (SS/HS) and Grants for the Integration 

of Schools and Mental Health Systems Programs. 

Because we used a nongeneralizable sample to select our sites, the information provided 

cannot be used to make inferences about other programs. In addition, the information 

provided by program officials does not reflect all efforts under way in their locations related 

to school mental health services. (For additional information on our methodology, see encl. I. 

For more information on sites in our review, see encl. II.) 

We conducted our work from March 2007 through September 2007 in accordance with 

generally accepted government auditing standards. 

Results in Brief 

SAMHSA coordinates formally and informally with other federal departments and agencies 

on school mental health services. The agency currently maintains two formal coordination 

efforts for school mental health services. It coordinates with (1) Education and DOJ for the 

SS/HS initiative, a key federal effort to directly support mental health services in schools; and 

(2) several federal departments and agencies serving children, including Education and DOJ, 

for the Federal/National Partnership, an effort designed to promote coordination related to 

children’s mental health and substance use prevention. In addition to formal coordination 

efforts, SAMHSA officials maintain multiple informal or episodic coordination efforts with 

other federal departments and agencies, such as Education, CDC, and the Health Resources 

and Services Administration (HRSA), on a variety of activities related to school mental health 

services; these are based largely on personal relationships among agency staff. 

SAMHSA both identifies and supports the use of evidence-based school mental health

interventions. To identify evidence-based interventions, SAMHSA uses the National Registry 

of Evidence-based Programs and Practices (NREPP). This searchable registry assists 

interested parties, including school and school district staff members, in identifying 

interventions to provide mental health services for children in schools. As of August 2007, 

slightly more than one-fourth of the interventions listed on NREPP were related to school 

mental health, including interventions designed to address aggressive behavior, depression, 

or school violence. SAMHSA also supports the use of evidence-based school mental health 

interventions through grant programs, including the SS/HS program. SS/HS requires grantees 

to use evidence-based interventions and provides technical assistance for the implementation 

of these interventions. SAMHSA also awards grants to support the use of evidence-based 

interventions through other programs not specifically designed for the school setting.

3 GAO-08-19R School Mental Health Services
Officials from the seven sites in our review identified coordination and close working 

relationships, support from “program champions”—advocates for the program—and school 

leadership, and sustainable funding and staffing as factors that can affect the provision of 

school mental health services. Because mental health professionals focus on students’ 

emotional health and education professionals focus on academic achievement, coordination 

between these differing missions can enhance the provision of school mental health services. 

School officials from sites in our review recognized that addressing students’ mental health 

needs can improve their academic achievement. Site officials told us that, in addition to being 

aware of a school’s academic mission, mental health providers need to be cognizant of 

students’ academic schedules and responsibilities. For example, sites avoided providing 

services during testing periods. Coordination between sites and external stakeholders, such 

as community mental health or social service agencies, can also enhance the provision of 

school mental health services by allowing schools to build relationships with other agencies 

that influence the lives of students. Sites also emphasized the importance of working closely 

with existing school health and mental health staff. By doing this, sites can avoid overlap in 

services provided to students. Site officials stressed that one or more program champions 

and support from school leaders can play a role in implementing school mental health 

services; conversely, the loss of either of these can threaten program continuity. Finally, site 

officials noted that difficulties securing and sustaining both funding and mental health 

service provider staff have affected the ability to implement school mental health services. 

In commenting on a draft of this report, HHS agreed with our characterization of SAMHSA’s 

efforts related to school mental health services and stressed the importance of schools as a 

venue for the delivery of mental health prevention and treatment programs, services, and 

supports. Education told us it had no comments on the draft. 

Background 

Multiple federal agencies are involved to varying degrees in school mental health services at 

the elementary and secondary level, including through grants and technical assistance. While 

school mental health services vary from location to location, most schools have some efforts 

in place to address students’ mental health needs, which can be provided by a variety of 

mental health professionals. 

Federal Role in Education and Mental Health Services for Children

Elementary and secondary education is primarily a responsibility of states and localities. 

During the 2003-2004 school year, Education reported that the state and local share of total 

revenues related to elementary and secondary education equaled 91 percent—just over $420 

billion. While state and local agencies take the lead in elementary and secondary education, a 

variety of federal departments and agencies are involved in supporting or promoting mental 

health in schools. 

SAMHSA has primary federal responsibility for issues related to children’s mental health 

services.6

 SAMHSA’s Center for Mental Health Services supports mental health services that 

are evidence-based, provided in community settings, and designed to promote recovery for 

people with, or at risk for, mental health disorders. The center provides this support through 

 6

SAMHSA’s total fiscal year 2007 budget was about $3.2 billion. 

4 GAO-08-19R School Mental Health Services
grants and technical assistance, and acts as SAMHSA’s lead in the SS/HS program, an effort 

that directly supports mental health services in schools. Since its creation in 1999, the SS/HS 

grant program, a joint effort of SAMHSA, Education, and DOJ, has awarded more than 

$1 billion to support school mental health services and related activities. The program is 

designed to promote safe, drug-free schools and healthy childhood development and includes 

efforts to promote positive student behavior and early identification and treatment of mental 

health problems. (See encl. III for more information on the SS/HS program.) SAMHSA funds 

other programs related to children’s mental health that, while not focused on schools, relate 

to school programs or efforts in the area of school mental health. 

In addition to SAMHSA, other agencies within HHS have roles related to school mental health 

services. For example, 

• HRSA funds the Mental Health in Schools Program to support two centers related to 

school mental health.

7

 These centers currently focus on analysis of school mental health 

policies and programs and have also provided training and technical assistance. Fiscal

year 2007 funding for this program was $900,000. HRSA’s Health Center Program, funded 

at approximately $1.78 million in fiscal year 2006, supports community health centers, 

including centers designed to provide services to specific populations such as migrant 

workers, residents of public housing, and at-risk school students. Services to students can 

be provided through school-based health centers, which may provide mental health 

services such as case management or therapy. 

• CDC has developed the Coordinated School Health Program model, made up of eight

interrelated components addressing student health, one of which is counseling and 

psychological services. CDC also has a cooperative agreement with the National Assembly 

on School-Based Health Care, an organization whose mission is to support school-based 

health centers, for a 5-year “School Mental Health Capacity Building Partnership” 

initiative. This initiative, which according to CDC officials is funded at $175,000 per year, 

is designed to strengthen efforts to improve school mental health services and synthesize 

information on state and local efforts in this area. CDC surveys, including student surveys 

and surveys of school and school district staff, also collect information directly or 

indirectly related to school mental health services. 

• The National Institutes of Health’s National Institute of Mental Health (NIMH) funds 

research on school mental health services and service delivery models. 

• The Centers for Medicare and Medicaid Services’ Medicaid program, a joint federal-state 

program to finance health care coverage for certain categories of low-income individuals, 

can in some cases be used to pay for specific school mental health services. For example, 

in some states, Medicaid may pay for diagnosis of mental health issues or therapy 

provided in a school setting for students enrolled in Medicaid.

 7

These centers are the Center for Mental Health in Schools at the University of California, Los Angeles 

and the Center for School Mental Health Analysis and Action at the University of Maryland, Baltimore.

5 GAO-08-19R School Mental Health Services
Other federal departments also support programs related to school mental health services. 

For example, 

• Education’s Office of Safe and Drug-Free Schools participates in the SS/HS program. In 

addition, it funds both the Grants for the Integration of Schools and Mental Health 

Systems program, a grant program designed to help school systems develop connections 

with local mental health systems, and the Elementary and Secondary School Counseling 

program, which provides funding to school systems to establish or expand elementary

and secondary school counseling programs.8

 Grants for these two programs totaled just 

under $40 million in fiscal year 2007. Education also supports Project School Emergency 

Response to Violence (Project SERV), a grant program that funds short-term and longterm education-related services, including mental health assessments, referrals, and 

counseling services, to school systems in which the learning environment has been 

affected by a violent or traumatic event. In fiscal year 2007, Project SERV was funded at 

$3 million.9

• DOJ also participates in the SS/HS program. In addition, the Office of Justice Programs 

has funded efforts to develop resources related to youth violence and truancy prevention, 

which may involve mental health programs in school settings. Through the Antiterrorism 

and Emergency Assistance Program for Terrorism and Mass Violence, the Office for 

Victims of Crime (OVC) provides funds to states and localities, including schools, to 

address issues, including mental health needs, stemming from intentional acts of criminal 

mass violence. For example, OVC officials reported that the program provided funds 

following the September 2006 shooting at Platte Canyon High School in Bailey, Colorado. 

Delivery of School Mental Health Services to Children

Because decisions related to schools are typically made at the local level, school mental 

health service delivery varies from district to district, and can vary from school to school 

within the same district. A variety of services can be provided, including prevention activities, 

assessment, crisis intervention, case management, and counseling. Efforts can focus on a 

wide range of problems, including specific mental health diagnoses, bullying, violence, and 

discipline issues. 

Studies indicate that most of the approximately 90,000 public schools nationwide have 

various efforts in place to address the mental health needs of their students.10 While the 

mechanisms for delivering school mental health services vary greatly from location to

location, several general delivery mechanisms have been identified:11

• School student support services: Services provided by school-employed staff such as 

counselors or psychologists. 

 8

Funding can be awarded to secondary schools only if grant funds exceed $40 million. 

9

Funds appropriated for Project SERV remain available for awards in subsequent years if not used. 

10S. Foster et al., School Mental Health Services in the United States, 2002-2003 (Rockville, Md.: 

Center for Mental Health Services, SAMHSA, 2005). 

11These mechanisms are not mutually exclusive. For more information, see Center for Mental Health in 

Schools, The Current Status of Mental Health in Schools: A Policy and Practice Analysis (Los

Angeles, Calif.: 2006). 

6 GAO-08-19R School Mental Health Services
• School-district mental health units: Services provided to students through a districtoperated mental health unit or clinic.

• Agreements for services with community providers: Services provided through an 

agreement between the schools and a community provider, such as a school-based health 

center run by an entity other than the school or school district. 

• Classroom-based curricula: Services provided through curricula in classrooms or as 

special programs, such as activities to promote healthy emotional behavior and prevent 

behavioral problems. 

• Comprehensive, multifaceted, and integrated approaches: Services provided through 

comprehensive systems that bring together resources from both schools and communities 

in an integrated fashion to promote student mental health. 

According to a 2005 SAMHSA report, during the 2002-2003 school year about one-third of 

school districts surveyed provided mental health services using only school or school district 

employees.12 More than half of the schools surveyed reported that they contracted with one 

or more community organizations or individual providers for mental health services. Almost 

30 percent of these schools reported that they contracted with their local mental health

agency, while others reported contracting with a variety of public and private providers. Six 

percent and 4 percent of schools, respectively, reported contracting with hospitals or faithbased organizations. 

Regardless of the mechanism used, services generally fall into three categories—universal, 

selective, or indicated:13

• Universal: Services intended for all children, including services related to creating a 

positive school environment or improving students’ social skills. These services may focus 

on decreasing risk factors for future mental health problems and increasing resilience by 

promoting positive school environments and ensuring that students have access to 

appropriate supports to allow healthy emotional development. 

• Selective: Services targeting a smaller subset of the population, usually those children 

identified as at-risk for developing mental health problems or with identified mental 

health needs. Services at this level may include targeted violence-, suicide-, or dropoutprevention programs or group therapy. 

• Indicated: Services targeting children with the greatest need for support, which could

include intensive services such as one-on-one therapy. 

 12S. Foster et al. 

13Other models for these categories exist. For more information on various models, see K. Kutash, A.J.

Duchnowski, and N. Lynn, School-Based Mental Health: An Empirical Guide for Decision-Makers 

(Tampa, Fla.: University of South Florida, 2006). 

7 GAO-08-19R School Mental Health Services
Staffing of Mental Health Service Provision in Schools

Providers of various types—school counselors, psychologists, social workers, nurses, 

marriage and family therapists, and others—can address students’ mental health needs in 

schools. The roles of these professionals overlap to some extent, but each has particular 

areas of expertise. (See table 1.) 

Table 1: Selected Professions That May Provide School Mental Health Services 

Provider type Provider description 

Provider association’s 

recommended providerto-student ratioa

Provider association’s 

recommended training

levela

School 

counselors 

Provide services designed to 

address students’ academic, 

career, and personal/social

development. These services can 

include individual or group 

counseling, consultation with 

parents and teachers, and referrals 

to other school or community 

resources. 

1 school counselor to 

every 250 students 

Master’s level

School 

psychologists 

Assess students’ psychological

functioning and needs, and provide 

consultation to parents and school 

staff on students’ behavioral, social, 

emotional, and instructional needs. 

May provide some prevention and 

direct intervention services. May 

focus on assessment of the special 

education population. 

1 school psychologist to 

every 1,000 students 

Post-master’s specialistlevel degree program 

School social

workers 

Provide services designed to create 

linkages among the school, family, 

and community, including case

management, support groups, 

crisis intervention, and home visits. 

1 school social worker to 

every 400 students 

Master’s level

School nurses Implement school health services, 

including mental health, for all

students. Can provide services 

including chronic care, general

health education and promotion 

activities, and teacher education. 

May also act as a contact within 

the school for a family. 

1 school nurse to every 

750 students 

Licensure as a registered 

nurse and a baccalaureate 

degree 

Marriage and 

family therapists

Diagnose and treat mental and

emotional disorders within the 

context of marriage, couples, and 

family systems. While not exclusive 

to schools, some work in school 

settings. 

No recommended ratio Master’s level

Source: GAO analysis of information from HRSA and provider associations. 

a

Recommended by the relevant provider association: American School Counselor Association, National Association of School 

Psychologists, School Social Work Association of America, National Association of School Nurses, and the American

Association for Marriage and Family Therapy. 

SAMHSA’s 2005 report identified school counselors as the most common type of school 

mental health provider, followed by school psychologists and school social workers. The 

study also found that school nurses, with broad responsibility for student health needs, spend 

one-third of their time providing mental health services. In addition to the credentials 

8 GAO-08-19R School Mental Health Services
recommended by provider associations, a 2000 study found that most states and school 

districts have developed minimum education and certification requirements for school staff 

who provide mental health services.14 Of states with minimum educational requirements, 

most required a master’s degree for counselors and psychologists, while fewer than half 

required a master’s degree for social workers.15

SAMHSA Coordinates Formally and Informally at the Federal Level on School 

Mental Health Services 

SAMHSA coordinates with other federal departments and agencies on school mental health 

services. SAMHSA currently maintains two formal coordination efforts for school mental 

health services—it coordinates with (1) Education and DOJ for the SS/HS initiative and 

(2) several federal departments and agencies serving children for the Federal/National 

Partnership, an effort designed to promote collaboration related to children’s mental health 

and substance use prevention. In addition to formal coordination efforts, SAMHSA officials 

maintain multiple informal or episodic coordination efforts at the federal level related to 

school mental health services. 

SAMHSA Formally Coordinates with Federal Departments and Agencies on an Ongoing Basis

SAMHSA, Education, and DOJ have coordinated on SS/HS by contributing financial, 

technical, and administrative support through a collaborative agreement.16 SAMHSA’s funds 

are used for mental health promotion, prevention, early identification, and treatment services 

and supports for students and their families. These activities can include early identification 

and assessment in the school setting, and early childhood development programs, such as 

nurse home visits for young children who demonstrate behavior problems. The funds 

contributed by Education and DOJ have been used for alcohol, drug, and violence prevention 

and early intervention programs, as well as efforts to address student behavioral, social, and 

emotional supports.17

 14N.D. Brener, J. Martindale, and M.D. Weist, “Mental Health and Social Services: Results from the 

School Health Policies and Programs Study 2000,” Journal of School Health (2001): 305-312. The 2000

School Health Policies and Programs Study provides the most recent data available and is based on 

data from the 50 states plus the District of Columbia and a nationally representative sample of school 

districts. CDC officials anticipate that new data from the study will be available in fall 2007. 

15The study does not collect information regarding marriage and family therapists or other provider

types.

16While the collaborative agreement that guides the SS/HS program has not changed, DOJ has not

contributed funds since fiscal year 2003 and does not currently have staff assigned to the SS/HS 

program. However, the agency still participates in making programmatic decisions, including grant 

decisions, under the collaborative agreement.

17Although Education’s SS/HS funds can be used for prevention and early intervention programs, 

Education cannot use these funds for medical services (including mental health treatment) or drug

treatment or rehabilitation, except for pupil services or referral to treatment for students who are

victims of, or witnesses to, crime or who illegally use drugs. 20 U.S.C. § 7164. 

9 GAO-08-19R School Mental Health Services
SAMHSA and DOJ have made funds available to Education, which also contributes funds. 

Education acts as fiscal agent of the program and issues grant awards. In addition, the 

agencies have coordinated peer reviews of SS/HS grant applications,18 while Education 

collects and maintains final grantee progress and financial reports. SAMHSA also has a 

cooperative agreement with a national organization to provide technical assistance to SS/HS 

grantees. According to SAMHSA officials, the agency coordination effort for SS/HS is 

organized into two teams, which meet to discuss issues related to the program: (1) an 

interagency policy team made up of high-level representatives from each agency, and (2) a 

supervisory team consisting of agency staff who discuss day-to-day management issues, 

including staff assignments and scheduling. In addition, program officers from SAMHSA and 

Education—nine in total—monitor and manage from 11 to 18 grants each and meet monthly 

to discuss issues related to the program. Experts in school mental health services told us that 

the SS/HS is a good example of effective coordination at the federal level. 

SAMHSA’s coordination with Education and DOJ for the SS/HS program includes key 

practices that we have identified as helping to enhance and sustain coordination among 

federal agencies.19 To define and articulate a common program outcome, the agencies

overcame the differences in agency missions by identifying a common mission—to create 

safe school environments and healthy students. This effort to identify a common mission was 

designed to create a seamless program for grantees at the local level. To establish mutually 

reinforcing or joint strategies for the program, agency leadership at the three agencies vested 

decision-making authority in officials such as division directors and branch chiefs, who 

assigned their staff to the SS/HS effort. The agencies established compatible policies, 

procedures, and other means to operate across agency boundaries and agreed on each 

agency’s roles and responsibilities. For example, because each agency had different program 

monitoring policies, officials created a program monitoring system that was consistent across 

all three agencies.20 To develop mechanisms to monitor, evaluate, and report on results, the 

agencies built an evaluation component into the SS/HS program at the federal and local 

levels—grantees are required to conduct local evaluations, and the federal agencies are 

conducting a national evaluation for SS/HS.21

 18Grant applications are screened by federal SS/HS staff and then forwarded to a contractor for peer

review. The peer review panel is organized by the contractor and is made up of three independent

reviewers, with a federal program officer acting as a discussion facilitator. The list of applications 

ranked by reviewers’ scores is provided to SAMHSA, Education, and DOJ for review prior to final grant

awards. In fiscal year 2007, 27 new grants were awarded.

19These key practices are (1) defining and articulating a common outcome; (2) establishing mutually 

reinforcing or joint strategies; (3) identifying and addressing needs by leveraging resources; 

(4) agreeing on roles and responsibilities; (5) establishing compatible policies, procedures, and other 

means to operate across agency boundaries; (6) developing mechanisms to monitor, evaluate, and 

report on results; (7) reinforcing agency accountability for collaborative efforts through agency plans 

and reports; and (8) reinforcing individual accountability for collaborative efforts through 

performance management systems. See GAO-06-15. 

20An official from DOJ noted that when creating this system, all the agencies agreed that if they could 

not reach consensus, they would use Education’s policy or procedure, because of Education’s role as 

fiscal agent for the grant. However, SAMHSA officials noted this has not been necessary as the 

agencies have been able to reach consensus. 

21SAMHSA and NIMH also co-sponsor a program announcement for SS/HS grantee sites to participate 

in research opportunities unrelated to the national and local evaluations. 

10 GAO-08-19R School Mental Health Services
SAMHSA’s other formal coordination effort is the Federal/National Partnership, formed in 

2004 with SAMHSA designated as the lead agency.22 The purpose of this partnership is to 

promote collaboration among federal agencies to transform children’s mental health and 

substance abuse delivery systems nationally. The partnership includes representatives from 

key federal agencies that serve children, national organizations, and family and youth

organizations.

23 During its first meeting in November 2004, the partnership established three 

workgroups focused on children’s mental health issues, one of which is the Integration of 

Mental Health and Education Workgroup, which is focused on school mental health 

services.24 The purpose of this workgroup is to develop a coordinated federal process to 

support integration of school mental health services. 

SAMHSA convened a meeting in August 2006 to begin planning the Integration of Mental 

Health and Education Workgroup. At the August 2006 meeting, a variety of organizations that 

provide technical assistance related to children’s mental health were brought together and a 

core group of participants identified. As of July 2007, some tasks identified at the August 2006 

meeting had been completed. For example, SAMHSA has compiled a list of programs by topic 

area, which can be found on the agency’s Web site. Program topics include school mental 

health, suicide prevention, youth violence prevention, and other programs related to mental 

health and substance abuse issues for children and families. SAMHSA also organized events 

for National Children’s Mental Health Awareness Day in May 2007, which focused on school 

mental health services. Other tasks are in progress. For example, a logic model—a model that 

describes how an initiative should work and anticipated outcomes—for the integration of 

education and mental health in schools is being developed. SAMHSA officials expect to 

convene the first workgroup meeting in fall 2007 and plan to include participation by 

education professionals and other federal agencies. The agency also plans to invite 

participation from representatives of community-based organizations and school-employed 

providers. 

SAMHSA Officials Coordinate with Federal Departments and Agencies on an Informal or 

Episodic Basis

SAMHSA officials maintain informal or episodic coordination efforts on issues related to 

school mental health services with Education and other HHS agencies such as HRSA, CDC, 

and NIMH;25 these are based largely on personal relationships between agency staff. For 

 22The Federal/National Partnership is organized as part of the Federal Partners Senior Workgroup, 

made up of senior representatives of more than 20 federal agencies and offices. This Senior

Workgroup is responsible for implementing the Federal Action Agenda, which focuses on efforts at the 

federal level to transform the mental health system. The Federal Action Agenda was developed in

response to the 2003 report from the President’s New Freedom Commission. 

23The federal partners include SAMHSA and other departments and agencies, such as Education, the 

Department of Housing and Urban Development, DOJ, the Department of Labor, the Department of

Veterans Affairs, and the Social Security Administration. This partnership also includes other

nongovernmental organizations working in the area of school mental health services. 

24The Integration of Mental Health and Education Workgroup is also known as the School-Based 

Mental Health Services Workgroup. The two other workgroups are the Youth-Guided Policies and 

Services Workgroup and the Early Identification Workgroup. 

25SAMHSA officials also maintain informal coordination efforts with HHS’s Indian Health Service and 

Administration for Children and Families. 

11 GAO-08-19R School Mental Health Services
example, at the request of Education staff, SAMHSA staff reviewed and commented on the 

Grants for the Integration of Schools and Mental Health Systems application before its public 

release.26 SAMHSA and Education officials told us they work on an as-needed basis to ensure 

that their respective agencies are not awarding funding to the same grantees for the same 

activities. SAMHSA officials told us that personnel from the two agencies also communicate 

with each other almost daily about the SS/HS program. 

While SAMHSA and HRSA had a formal cooperative agreement in the past to co-fund two 

technical assistance centers for school mental health services, SAMHSA officials told us that 

SAMHSA is no longer providing funds for this effort, although HRSA continues to do so.27

However, the two agencies continue to have some informal interaction about the two 

centers. For example, SAMHSA presents an award recognizing programs that promote school 

mental health services at a conference hosted annually by one of these centers. In addition to 

this interaction, SAMHSA and HRSA staff meet on an ongoing basis to discuss how they can 

collaborate to assist states with efforts to integrate health, mental health, and education. For 

example, staff from the two agencies have met to discuss a HRSA initiative that provides 

funds to states to promote availability and quality of services focused on healthy child 

development and school readiness. The two agencies are also working together to 

incorporate information on the warning signs of mental health problems into an existing 

SAMHSA program designed to serve children with serious emotional disturbances. 

SAMHSA and CDC officials also work together on an informal and episodic basis. For 

example, a SAMHSA official participated on an expert panel about 3 years ago to help CDC’s 

Division of Adolescent and School Health consider how to identify possible opportunities for 

the division to promote and enhance the mental health component of the Coordinated School 

Health Program. According to CDC officials, because the agency does not have a strong focus 

on school mental health services, it reaches out to SAMHSA for guidance in this area. For 

example, CDC directs its grantees to SAMHSA’s NREPP database to find appropriate 

interventions to implement at the local level. 

SAMHSA and NIMH officials have had informal discussions on the recent redesign of

SAMHSA’s NREPP, and NIMH suggested researchers who could review interventions for this 

registry of evidence-based programs and practices. In some cases, NIMH encouraged its 

grantees to submit evidence-based interventions to NREPP. Staff members from the two 

agencies have discussed how research can be transferred into community practice, and 

NIMH staff have also consulted with, and provided technical assistance to, SAMHSA 

grantees. 

SAMHSA Identifies and Supports Evidence-Based Interventions, Some of Which 

Target School Mental Health Services 

SAMHSA identifies evidence-based mental health interventions, including some that can be

used in school settings, and supports their use. To identify evidence-based mental health 

 26The Grants for the Integration of Schools and Mental Health Systems program provides grants to 

state and local education agencies and tribes for the purpose of developing linkages between school 

systems and local mental health systems to increase student access to quality mental health care. 

27In fiscal year 2006, HRSA contributed $600,000 to these centers, part of the Mental Health in Schools 

Program, while SAMHSA contributed $300,000. HRSA contributed $900,000 in fiscal year 2007, but the

agency has limited fiscal year 2008 funds for the program to $600,000. 

12 GAO-08-19R School Mental Health Services
interventions, SAMHSA uses its NREPP database; as of August 2007, slightly more than onefourth of the interventions on NREPP were mental health services based in schools. SAMHSA

also supports the initial implementation and ongoing administration of evidence-based

interventions in the school setting through grant programs, such as the SS/HS grant program. 

This program awards grants for evidence-based interventions and provides technical 

assistance for the implementation of these interventions. SAMHSA also supports the use of 

evidence-based interventions through other grant programs that may be used in schools but 

are not specifically designed for the school setting. 

SAMHSA Uses a National Registry to Identify Evidence-Based Interventions, and Some Are 

for Use in School Settings

SAMHSA uses NREPP, a searchable online database, to help interested parties, including 

school officials, in identifying evidence-based interventions.28 The purpose of NREPP, which 

was initially designed in 1997 and redesigned in March 2007, is to help interested parties in 

identifying evidence-based approaches to preventing and treating mental illness and 

substance abuse. NREPP is funded by SAMHSA and is a core component of the agency’s 

Science to Service Initiative, which seeks to promote broader adoption of effective, evidencebased interventions within routine clinical and community-based settings. Because there is 

no universally accepted definition for what constitutes evidence, SAMHSA has stated that 

NREPP was not designed to serve as a single authoritative source for evidence-based 

interventions.29 Rather, SAMHSA acknowledges that there are multiple ways of establishing 

and assessing the strength of an intervention’s evidence, such as research methods that 

include pre- and posttest studies and controlled clinical studies. Agency officials characterize 

NREPP as one of many tools for identifying and assessing evidence-based interventions. 

In order to update NREPP, SAMHSA anticipates publishing annual notices in the Federal 

Register soliciting evidence-based interventions that may be selected for review and 

placement on the registry. Interventions, submitted by those seeking placement on the 

NREPP registry, are evaluated through a standard process, which involves both a submission 

of materials and an independent review process. (See fig. 1.) The submission process is used 

to determine whether interventions submitted for review meet NREPP’s three minimum 

requirements: (1) the intervention must demonstrate one or more positive outcomes, (2) the 

research findings related to the intervention must have been published in a comprehensive 

evaluation report or peer-reviewed publication, and (3) dissemination materials must be 

available.30

 28SAMHSA redesigned NREPP (http://www.nrepp.samhsa.gov) in order to make it more

comprehensive and interactive. 

29See Changes to the National Registry of Evidence-based Programs and Practices, Notice, 71 Fed. 

Reg. (Mar. 14, 2006), and SAMHSA, “National Registry of Evidence-based Programs and Practices

(NREPP): An Important Note for NREPP Users,” 2007, http://www.nrepp.samhsa.gov/about-note.htm

(accessed Apr. 20, 2007). 

30The positive program outcomes must be statistically significant at a level of 95 percent confidence. 

Dissemination materials could include items such as program manuals, program process guides, and 

training materials. 

13 GAO-08-19R School Mental Health Services
Figure 1: NREPP Review Process 

Source: GAO analysis of SAMHSA documents.

Applicant submits

intervention to SAMHSA 

for placement on NREPP

Intervention is not 

placed on NREPP

Intervention summary and 

ratings are placed on 

NREPP Web site 

SAMHSA and applicant 

prepare necessary 

documentation for review 

Meets minimum

requirements and

SAMHSA approves

for review

Does not meet

requirements

No

agreement

Agreement

Ratings and

intervention summaries

are submitted to the applicant to

obtain agreement on the

content of the NREPP

postinga

The application

is evaluated by SAMHSA

to determine if the intervention

meets NREPP’s minimum

requirements

The intervention is reviewed 

and quality-of-research and 

readiness-for-dissemination 

ratings are given by 

independent reviewers

a

SAMHSA provides applicants with the opportunity to approve the summary information before it is published on the Web site. 

However, NREPP will not change the intervention’s ratings unless new information is provided by the applicant. If the applicant

and SAMHSA do not agree on the Web posting (i.e., intervention summary and ratings), then the intervention will not be placed 

on NREPP. 

Once it is determined that an intervention meets all three minimum requirements and a 

senior SAMHSA official approves the intervention for review, the intervention is reviewed by 

a panel of independent reviewers with special knowledge in the subject area. These 

reviewers rate the quality of the research on the intervention and its readiness for 

dissemination on a zero-to-four point scale.31 The quality-of-research rating is obtained by 

using six criteria to score the strength of the research supporting the intervention’s stated 

 31Independent reviewers are not employed by SAMHSA; rather, they work as agency consultants to the 

agency’s NREPP contractor. SAMHSA recruits two types of reviewers to rate each program’s quality of 

research and readiness for dissemination. Quality-of-research reviewers must have a doctoral-level

degree and, if possible, possess experience evaluating prevention and treatment programs. Readinessfor-dissemination reviewers can include consumers of services, service providers, and experts in

program implementation. Both types of reviewers must possess knowledge of mental health and/or

substance use prevention or treatment content areas.

14 GAO-08-19R School Mental Health Services
outcomes, and then averaging the six ratings.32 The readiness-for-dissemination rating is

achieved by evaluating the dissemination materials using three criteria and averaging the 

ratings of these criteria.33 A final rating for the intervention’s quality of research and readiness 

for dissemination is achieved by reaching reviewer consensus if there are significant 

differences in their ratings. SAMHSA posts the intervention’s ratings on its Web site along 

with additional descriptive information on the intervention.34 (See fig. 2 for a sample NREPP 

rating.) 

Figure 2: Sample NREPP Rating 

Outcome 1: School disciplinary

 code violations 1.0 2.5 2.3 2.0 2.3 3.5 2.3

Outcome 2: Violent/aggressive

behavior−self-reports 2.5 2.5 2.3 2.0 2.3 3.5 2.5

Outcome 3: Victimization 2.5 2.5 2.0 2.0 2.5 3.5 2.5

Outcome 4: Peer provocation 2.5 2.5 2.0 2.0 2.3 3.3 2.4

Outcome 5: Life satisfaction 2.5 2.5 2.0 2.0 2.5 3.5 2.5

Reliability

Validity

Fidelity

Missing

 data/attrition

Confounding

 variables

Data analysisOverall rating

Quality-of-research ratings by criteria (0.0–4.0 scale)

Outcome

Readiness-for-dissemination

rating for intervention 3.0 3.8 2.0 2.9

Implementation

 materials

Training and

support

Quality

 assurance

Overall rating

Readiness-for-dissemination ratings by criteria (0.0–4.0 scale)

Readiness for dissemination

Source: NREPP.

Note: Listed outcomes are examples. 

 32Each program outcome is evaluated by reviewing the following six “quality-of-research” criteria: 

(1) reliability of the outcome measures, (2) validity of the outcome measures, (3) intervention 

fidelity—the “experimental” intervention was implemented as designed, (4) missing data and attrition,

(5) potential confounding variables, and (6) appropriateness of the analysis. 

33The three “readiness-for-dissemination” criteria are evaluated by reviewing the amount and adequacy

of the intervention’s (1) implementation materials, (2) training supports, and (3) quality improvement 

materials, such as manuals on how to provide quality improvement feedback. 

34Prior to the 2007 redesign of NREPP, programs were rated in their entirety by placing them into three 

categories of effectiveness: model, effective, and promising. According to SAMHSA officials, the 

agency chose to eliminate these categories because they appeared arbitrary to some users and 

distinctions between them were unclear. The agency plans to advertise these changes through several

efforts, such as e-mail alerts to notify users when new programs have been added to the registry.

15 GAO-08-19R School Mental Health Services
Some interventions listed on NREPP were designed for use in the school setting. Specifically, 

as of August 2007, 13 of NREPP’s 46 interventions were identified as school mental health 

interventions, including those designed to address aggressive behavior, depression, or school 

violence. Other settings for interventions listed on NREPP include correctional facilities, 

residential settings, and the workplace. SAMHSA is in the process of adding interventions to 

the registry and, according to a SAMHSA official, approximately half of the intervention

applications submitted in fiscal year 2007 were mental health or substance abuse 

interventions that could be appropriate for use in schools. 

SAMHSA Supports Evidence-Based Mental Health Interventions That Can Be Used in School 

Settings

SAMHSA supports the use of evidence-based interventions in the school setting in the SS/HS 

grant program. SS/HS program policy requires that grantees implement and administer 

evidence-based interventions, but does not require its grantees to use a specific method of 

selecting those interventions.35 The program’s grant application provides potential grantees 

with guidance on how to choose an evidence-based intervention and with a list of online 

resources, including NREPP. To help current grantees identify and implement evidencebased interventions, the National Center for Mental Health Promotion and Youth Violence 

Prevention provides technical assistance to all active SS/HS grantees through a cooperative 

agreement with SAMHSA. The National Center also provides current grantees with additional 

technical assistance, such as support in implementing culturally appropriate programs or 

designing and implementing program evaluation tools. 

SAMHSA also supports the use of evidence-based mental health interventions when funding 

other programs that may be used in schools or community settings. SAMHSA’s Child Mental 

Health Initiative provides federal funds, through cooperative agreements with state and local 

governments and tribal organizations, to develop and sustain an effective system of care for 

children with serious emotional disturbances. The funding recipients are required to 

collaborate with other entities that serve children, such as local child welfare and juvenile 

justice agencies. In fiscal years 2005 and 2006, most federal funding for the program was 

directly provided to, and managed by, state and local governments. Child Mental Health 

Initiative recipients may use the funds to provide mental health interventions in schools and 

are required by SAMHSA policy to implement at least one evidence-based intervention. 

However, according to a SAMHSA official, funding recipients have noted that it can be 

challenging for those outside schools to work within a school setting. Another program, 

SAMHSA’s State/Tribal Youth Suicide Prevention Grant Program, provides funds through 

cooperative agreements with states, tribal communities, and public or nonprofit 

organizations to support the development and implementation of statewide or tribal youth 

suicide prevention and intervention strategies. Preference is given to program participants 

that collaborate with institutions that serve youth, which could include schools, and SAMHSA 

policy requires program participants to report the number of evidence-based interventions 

used. 

 35The SS/HS program defines an evidence-based intervention as one that is supported by scientific data 

to indicate its effectiveness. The statutes authorizing SAMHSA, Education, and DOJ’s programs do not 

require that grantees implement evidence-based programs. 20 U.S.C. § 7131; 42 U.S.C. §§ 290hh, 5614.

The requirement is set forth in program selection criteria developed by the agencies responsible for 

the SS/HS program and published as a Notice of Final Priorities, Requirements, Selection Criteria, 

and Definitions in the Federal Register. 

16 GAO-08-19R School Mental Health Services
Multiple Factors Affect the Provision of School Mental Health Services 

Officials in the seven schools and school districts in our review told us that coordination and 

close working relationships, support from program champions—advocates for a program—

and school leadership, and resources are factors that can affect the provision of school 

mental health services. Because the missions of mental health and education professionals 

differ, coordination between them can enhance the provision of school mental health 

services. Coordination with external stakeholders (such as community mental health 

providers) and among internal stakeholders (such as teachers and health care professionals) 

can also affect the provision of school mental health services. Site officials stressed that one 

or more program champions and support from school leaders can play a significant role in 

implementing school mental health services; conversely, the loss of either of these can

threaten program continuity. Site officials also noted that difficulties securing and sustaining 

both funding and staffing have affected the ability to implement school mental health

services. 

Differing Missions and Coordination of Efforts Affect Service Provision

Because the missions of mental health and education professionals differ, coordination

between them can enhance the provision of school mental health services, according to

experts and school staff. While mental health providers typically focus on the emotional 

health of students, the primary focus of schools is students’ academic achievement. By 

framing student mental health as a means of improving student academic achievement, 

experts told us that mental health providers may improve the likelihood of being able to

implement a school program. School officials we interviewed, including principals and 

teachers, said they recognized that addressing students’ social, emotional, and behavioral 

health needs can improve their ability to focus on academics. The principal of one school 

reported that, in the past, her teachers spent a large amount of their time dealing with

nonacademic issues, including behavioral problems, in the classroom. This school now 

provides universal mental health services for all students and selective services for a smaller 

subset of students. For example, the school offers a schoolwide program to reduce student 

aggression and behavior problems, and also works with community mental health providers 

to obtain services for children with more serious needs. Teachers said that because of these 

efforts, disruptions associated with students’ behavioral issues have been reduced and they 

are better able to focus on academics. 

Site officials told us that to provide services in the school setting, mental health professionals 

need to be cognizant not only of a school’s academic mission, but also of students’ academic 

schedules and responsibilities. Staff members at one site reported that they avoided 

scheduling appointments for services during school testing periods, while staff from another 

reported that they tried to provide as many services as possible during nonacademic times, 

such as lunch. Some school officials noted that working with external providers could pose 

difficulties because these providers might not recognize the priority of the school’s academic 

schedule. An official from one site with multiple school-based health centers stated that a 

past contract it had with a community provider to run one of its centers was terminated 

because the provider was not able to work within the schedule constraints of the school. 

Site officials told us that coordinating with external stakeholders—local government 

agencies, providers, or community organizations—is important when implementing school 

mental health services. Two sites in one state partner with county councils made up of 

17 GAO-08-19R School Mental Health Services
multiple local agencies serving children and families.36 Staff from these two sites reported 

that the partnership helped them establish a relationship with other agencies, such as 

juvenile justice or job and family service agencies, that may influence the lives of their 

students. A representative from one of the county councils stated that prior to the council’s 

work with school officials, agencies in the county had been interested in working with 

schools but did not know how to bring that about. Officials at some sites told us they also 

had developed relationships with local religious organizations. At one site, officials reported 

that this resulted in the organizations’ supporting after-school and summer activities and 

acting as a source of volunteers to help organize these events when needed. Officials from 

sites in our review also told us that family involvement in the services provided to children 

was an important factor and that they typically required parental consent for students to 

receive services. 

In addition, staff at sites in our review emphasized the importance of working closely with 

existing school health and mental health staff—including counselors, social workers, 

psychologists, and nurses—to ensure the success of school mental health services. They 

noted that it was particularly important to work together when implementing initiatives, in 

order to reduce service overlap or potential conflict between providers. In schools with a 

school-based health center, officials reported that the school nurse often worked in 

collaboration with the centers, providing care to students not enrolled in the center or 

identifying enrolled students in need of services.37 In one school without a school-based 

health center, the school nurse and the school social worker who coordinates the universal 

mental health programs meet regularly to discuss students referred for physical and mental 

health problems. Officials at sites in our review also noted that school nurses may help 

identify when students who come in for physical health reasons may have symptoms related 

to mental health issues. Officials told us that, in some cases, failure to recognize the roles of 

existing school staff members had created tension. 

Sites also work to include teachers and administrative staff in their school or school district 

programs and to provide teachers with training or materials on mental health issues. Two 

sites have developed multidisciplinary teams, including teachers and school administrators 

as well as mental health professionals, that meet to identify and coordinate services for 

students showing signs of mental health problems. By including teachers and school 

administrators in efforts, sites try to ensure that all staff members are involved in the 

program. Officials from one of these sites also reported providing training to teachers on a 

variety of issues, including understanding mental health diagnoses, the impact of trauma on 

children, and nonacademic barriers to learning, such as issues related to poverty. Staff 

members at a third site have created documents for teachers, including handouts providing 

information on when to refer students for mental health services, the protocol for referrals, 

and the role of case managers. 

 36This state has developed an initiative that includes both state- and county-level partnerships focused

on improving the well-being of children and their families. The partnerships are composed of 

government agencies, and, at the county level, also include community organizations. County-level 

councils, formed by the county board of commissioners, must include representation from families, 

schools, and multiple agencies, including alcohol, drug addiction, mental health, and job and family 

services. 

37Eligible students who wish to receive services through the school-based health center at the sites we 

reviewed are required to join the center by enrolling.

18 GAO-08-19R School Mental Health Services
Program Champions and School Leadership Affect Provision of Services

Officials at sites in our review stressed the importance of having a program champion and the 

support of school and school district leadership when implementing programs. At one site, 

officials stated that their effort to introduce a school mental health services program had 

multiple champions, including staff from the local educational service center38 and local

mental health providers. Officials at this site reported bringing together community agencies 

that work with children, including local school districts, and said that they were able to hire a 

program director who, according to site staff, had the “passion” to run the program. The staff 

from the multiple agencies involved believed that without this program director to further 

champion the program, they would not have been able to continue to dedicate sufficient 

attention to the program to keep it moving forward. At another site, officials told us that the 

principal was the champion for mental health services at the school and provided the school 

leadership needed to implement programs. Because of the success of efforts at that school, 

the superintendent of the district asked this principal to examine how services could be 

expanded to another district school. 

Officials we spoke with told us, however, that initiatives may become dependent on the 

program champion and expressed concern that such initiatives might not be able to survive 

the champion’s departure. Similarly, officials told us that wavering support at the 

administrative level or a change in leadership—particularly principals and superintendents—

could raise concerns for program sustainability. In one school district, staff told us that while 

the indicated mental health services provided through their school-based health centers were 

well established, the universal mental health initiatives they had implemented, such as a 

classroom-based violence prevention program, would not have existed without the 

leadership of one particular staff member. The person identified as the program champion 

told us that she would like to train a successor but, because of budget constraints, it would 

be difficult to hire a new staff person to train while she was still in her position. Officials at 

another site told us their program champion was the school principal, who planned to retire 

in 3 years. To ensure that the existing mental health initiatives continue, the principal was 

working to fully train school staff, including teachers, to maintain and advocate for these 

initiatives. Because staff from this school will be involved in the process of hiring a 

replacement, the current principal hopes that they will be in a position to identify a potential 

replacement who will continue the initiatives. 

Securing and Sustaining Funding and Appropriate Staff for School Mental Health Services 

Affect Service Provision

Site officials told us that difficulty securing and sustaining funding and mental health service 

provider staff had affected their ability to implement school mental health services. 

According to experts, no single funding stream specifically focuses on school mental health 

services, and sites reported piecing together multiple funding streams to support their 

programs. For example, officials at one site reported combining funds from at least four 

different sources, including private grants, the state Department of Education, and federal 

 38This center provides services, including technical and operational assistance, professional 

development, and curriculum services, to the eight school districts within its area. 

19 GAO-08-19R School Mental Health Services
sources, to support its mental health services.39 Officials at this site said that while their 

school district provided space for service delivery, it provided no monetary support for the 

site’s programs. Funding streams that staff identified often came with restrictions on use. For 

example, one site provided case management services to students, but because of funding 

restrictions, these services could be provided only to elementary students who qualified for 

free and reduced lunches.40 Officials stated that Medicaid, while a possible funding source for 

some services, was difficult to use. In particular, they expressed concerns related to 

Medicaid’s paperwork, reimbursement rates, and enrollment of eligible students in the 

Medicaid program. In addition, changes in funding priorities can affect sites’ funding for 

programs. At the time of our site visits, two sites in one state told us they had just been 

notified that state-level funding priorities had shifted. As a result, these sites anticipated 

laying off, or cutting the hours of, case management or mental health staff.

41

Officials at the sites in our review said they appreciated the flexibility of grant funding, but 

said that grants might not last long enough to allow a program to stabilize and that other 

funds to sustain initiatives were not always available.42 Officials from one site, located in a 

town surrounded by rural counties, noted that while grants often required them to consider 

sustainability when applying for funds, the school district and county had no funds to support 

initiatives started through grants and they were not aware of local foundations or 

organizations that might be able to provide additional funds. 

While officials indicated that it was difficult to secure funding, some reported that by 

coordinating the efforts of multiple local agencies or securing the support of the school 

administrator, they were able to identify resources to support their programs. By partnering 

with local government agencies and other stakeholders, staff from one site were able to use 

resources available to those organizations, including resources that might not otherwise be 

available to schools. In addition, relationships with external agencies helped create 

advocates in the community for another school district’s program, according to officials. At 

another site, officials reported that while they had not formally secured funding for the staff 

needed to continue a grant program, the principals of some schools participating in the 

program said they were willing to include the salary of the schools’ program staff members in 

 39The federal funds came from Medicaid and the Temporary Assistance for Needy Families (TANF) 

program, which provides funds to states to provide assistance and work opportunities to needy 

families. Both federal and state governments contribute to Medicaid and TANF. 

40For elementary students who did not qualify for services, this site used its prevention coordinator—a 

grant-funded contractor responsible for schoolwide prevention activities—to provide limited

individual assistance. However, an official at this site noted that restrictions limiting services to only

certain populations, such as students in certain grades or at certain income levels, could lead to 

resentment over services not being available to all students. 

41Officials in one of these school districts reported that with 2 weeks left before the end of the school

year, they had not been told whether they would have funds to retain their case management staff for 

the upcoming school year. As of August 2007, all case management positions had been eliminated, and 

this site was no longer offering case management services.

42An official from one site also told us that funding streams may not be consistent, noting that funding 

that may have been available 2 or 3 years before may no longer be available. 

20 GAO-08-19R School Mental Health Services
their general school budgets for the upcoming year. One principal told us that she was willing 

to do this because the program was an asset to the school.43

Site officials told us that, in addition to securing and sustaining funding, it could be difficult 

to hire and retain mental health professionals to provide school services, particularly in small 

towns and rural areas. Providers at one site noted that the site’s program could expand only 

to a limited degree because there were no more available mental health providers in the 

area.44 Staff reported difficulty recruiting providers to the area, a town located about 1 hour 

from a metropolitan area where mental health providers are paid significantly more. Staff 

members from a rural school district similarly told us that they had been trying to hire a 

behavioral health specialist since October 2006 but had not been able to find one willing to 

move to their district until June 2007.

Contrary to the experience of some sites, schools and school districts located near 

universities reported having better access to providers. Officials from one urban school 

district reported working with local universities to offer internship opportunities, which 

allowed it to attract former interns to positions as permanent staff. At another site, which has 

had difficulties attracting mental health staff, providers involved in the program are working 

with a local university to expand the university’s social work program, and hope this 

expansion will be a source of future mental health staff. 

Agency Comments 

We provided a draft of this report to HHS and Education for comment. HHS provided written 

comments on the draft of this report, which are provided in enclosure IV. HHS also provided 

technical comments, which we incorporated where appropriate. HHS indicated that the 

report accurately reflects SAMHSA’s efforts regarding school mental health services. The 

agency also stressed the importance of schools as a venue for the delivery of mental health 

prevention and treatment programs, services, and supports. Education told us it had no 

comments on the draft. 

- - - - - 

As we agreed with your office, unless you publicly announce the contents of this report 

earlier, we plan no further distribution of this letter until 30 days after the date of this letter. 

At that time, we will send copies to the Administrator of SAMHSA, appropriate congressional 

committees, and other interested parties. In addition, the report will be available at no charge 

on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this 

report, please contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for our 

 43School officials noted that these individual school budgets require approval at the superintendent 

level, so these positions could still be cut. As of June 2007, staff and school officials did not know 

whether these positions would be approved for the 2007-2008 school year. 

44Staff at this site told us that they were willing to use a variety of mental health provider types,

although they preferred to use master’s-level counselors. Officials from other sites also indicated that

they were willing to use, and had used, a variety of mental health provider types including social

workers, counselors, and marriage and family therapists. 

21 GAO-08-19R School Mental Health Services
Offices of Congressional Relations and Public Affairs may be found on the last page of this 

report. GAO staff who made major contributions to this report are listed in enclosure V. 

Sincerely yours, 

Cynthia A. Bascetta 

Director, Health Care 

22 GAO-08-19R School Mental Health Services
Enclosure I 

 

Scope and Methodology 

We examined the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 

efforts to coordinate with federal departments and agencies to support school mental health 

services and to identify and support evidence-based school mental health services.45 To do 

this, we reviewed multiple documents, including a collaborative agreement related to federal 

school mental health funding, interagency meeting minutes, documents describing changes in 

the National Registry of Evidence-based Programs and Practices (NREPP), and Federal 

Register notices. We interviewed staff at SAMHSA, including program staff charged with 

implementing interagency programs related to children’s mental health and developing and 

implementing NREPP. We also interviewed staff from the Department of Health and Human 

Services’ Health Resources and Services Administration, Centers for Disease Control and 

Prevention, and National Institutes of Health. We spoke with staff from the Department of 

Justice and the Department of Education who interact with SAMHSA with regard to school 

mental health. 

To describe factors that have affected the provision of school mental health services, we 

reviewed relevant research and interviewed experts working in the area of school mental 

health, including representatives of the Center for Health and Health Care in Schools, Center 

for Mental Health in Schools, Center for School Mental Health Analysis and Action, Center 

for School-Based Mental Health Programs, Research and Training Center for Children’s 

Mental Health, and National Assembly on School-Based Health Care. To obtain information 

on their constituents’ roles in school settings, we also reviewed documents and interviewed 

representatives from professional associations whose members provide school mental health 

services, including the National Association of School Psychologists, American School

Counselor Association, School Social Work Association of America, National Association of 

School Nurses, and the American Association for Marriage and Family Therapy. In addition, 

we interviewed officials with associations representing education service providers, such as 

the American Association of School Administrators and the National School Boards 

Association. 

To provide information on factors that selected sites considered important when providing 

school mental health services, we conducted interviews with representatives from seven 

selected schools and school districts. To identify states, localities, specific schools, and 

school districts considered to be active in the area of school mental health services, we 

interviewed officials from federal agencies, experts in the area of school mental health, and 

provider associations. From the approximately 53 locations they identified, we selected a 

judgmental sample of 7 sites: two school districts in Connecticut, one school district in 

Florida, one multidistrict program in North Carolina, and one school district, one school, and 

one multidistrict program in Ohio. These sites were selected because they represented a mix 

of urban and rural settings and settings with and without school-based health centers. We 

also ensured that we included sites that were currently receiving funds through the joint 

SAMHSA, Department of Education, and Department of Justice Safe Schools/Healthy 

Students program and the Department of Education Grants for the Integration of Schools and 

Mental Health Systems program. Because we used a nongeneralizable sample to select our 

sites, the information provided cannot be used to make inferences about other programs. In 

45School mental health services provided to students who qualify for special education services 

through the Individuals with Disabilities Education Act were outside the scope of our work. 

23 GAO-08-19R School Mental Health Services 
Enclosure I 

addition, the information provided by program officials does not reflect all efforts under way 

in their locations related to school mental health services. 

We conducted our work from March 2007 through September 2007 in accordance with 

generally accepted government auditing standards. 

24 GAO-08-19R School Mental Health Services
Enclosure II 

Characteristics of Sites in Our Review 

State 

Location 

characteristics 

School 

district sizea

School or

school 

district 

populationa

Safe 

Schools/

Healthy 

Students

grantee 

Schoolbased

health

center Program description

Connecticut School district

located in an 

urban area 

The school 

district consists

of 41 schools 

22,296 

students in 

the school 

district 

Yes Yes The school district provides 

universal services throughout

the district using an evidencebased program that has been 

in place for several years. This 

school district also provides a

variety of selective and 

indicated services to students

through its multiple schoolbased health centers. 

To assist students in need of 

more intensive support, such 

as therapy services, the district 

works with a community 

mental health provider; through 

the Safe Schools/Healthy 

Students (SS/HS) Initiative, it

has also been able to secure 

funding for a child psychiatrist. 

Students in certain high 

schools also receive services 

through centers, staffed in 

large part by master’s-level 

social work interns, designed

to provide counseling and 

support to students and their 

families. These centers are 

part of the district’s SS/HS 

Initiative. 

Connecticut School district

located in an 

urban area 

The school 

district consists

of 35 schools 

22,264 

students in 

the school 

district 

No Yes Universal mental health 

services, including violence 

and bullying prevention, are 

provided using multiple 

evidence-based programs. 

Mental health services at both 

the selective and the indicated

level are provided to regular 

education students through 

multiple school-based health 

centers. The centers are 

staffed by mental health 

providers, including social

workers. For students needing 

more intensive services or to 

respond to crisis situations, the 

centers also have psychiatric 

staff on call. 

25 GAO-08-19R School Mental Health Services 
Enclosure II 

State 

Location 

characteristics 

School 

district sizea

School or

school 

district 

populationa

Safe 

Schools/

Healthy 

Students

grantee 

Schoolbased

health

center Program description

Florida School district

located in a 

rural county 

The school 

district consists

of 2 schoolsb

1,058

students in 

the school 

districtb

Yes No This school district provides 

universal services, including a 

bullying prevention program, 

after-school activities, and drug

and alcohol prevention 

activities. A counselor is 

available to provide mental 

health services to students 

across the district. The school 

district works with a private 

contractor to provide more 

intensive services, such as 

therapy, to students who need

them. The district also partners 

with the state health 

department and local agencies 

serving children as part of the

SS/HS Initiative. 

North 

Carolina 

Regional 

grouping of 

school districts 

located in 3

rural counties 

The regional 

grouping 

consists of 3

school districts 

with 21 

schoolsc

7,014 

students in 

the combined 

3 school 

districts c

Yes Yes The districts have implemented

universal services for students, 

including a violence and drug

abuse prevention program, 

and are conducting training for 

teachers and administrators on

mental health issues. Using 

funds from the SS/HS 

Initiative, three school districts 

are implementing school 

nurse-school counselor teams 

in schools throughout their 

districts. These teams act as 

the initial contact for students 

in need of selective or 

indicated mental health 

services and work in 

coordination with community 

providers to secure services 

for students. In addition, the 

districts have developed a 

council of key agencies and 

organizations that may impact

students’ lives.

Ohio Regional

grouping of 

school districts 

in and around a 

small town 

The regional 

grouping 

consists of 8

school districts 

with 43 schools

18,193

students in 

the combined 

8 school 

districts 

No No This regional effort focuses on 

providing services through 

multidisciplinary teams. These 

teams can include school 

administrators and teachers, 

staff from local community 

mental health providers, 

substance abuse 

professionals, and staff from 

the local health department 

and juvenile court. The 

composition of the teams 

varies by school, and others 

may be invited to participate as

needed. 

26 GAO-08-19R School Mental Health Services
Enclosure II 

State 

Location 

characteristics 

School 

district sizea

School or

school 

district 

populationa

Safe 

Schools/

Healthy 

Students

grantee 

Schoolbased

health

center Program description

Ohio 

(cont’d.) 

The teams provide services at

the universal, selective, and 

indicated level. They build a 

complete system of services 

for students and their families 

based in a school setting, and

include an after-school 

component, skill/asset building, 

mentoring, and counseling 

services. 

Ohio Single school

within the 

school district of 

a midsize town

The school is 

part of a school 

district with 12 

schools 

370 students 

in the schoold

No No This elementary school works 

with community partners, 

including local government 

agencies and nonprofits, to 

provide universal, selective, 

and indicated services. It 

provides universal services 

through an evidence-based 

classroom program and uses

the combined services of a 

school nurse and school social 

worker to provide selective 

services to children in need of

additional support. If students 

need intensive services, the 

school works with a local

mental health provider to 

obtain services. This same 

provider also offers case 

management support for the 

school. 

Ohio School district in

a small urban 

jurisdiction colocated with a 

large urban area

The school 

district consists

of 3 schools 

1,098

students in 

the school 

district 

No Yes This school district includes a 

school-based health center 

and provides a variety of 

mental health services to 

elementary and middle school

students. Universal services 

are provided at the district’s 

two elementary schools using 

two evidence-based programs

identified through the 

Substance Abuse and Mental 

Health Services

Administration. One of these 

programs is also used to 

provide services to students at 

the district’s middle school. 

These services are 

implemented by a contracted 

prevention coordinator (a 

licensed mental health 

provider) and a doctoral intern

from an area university. 

27 GAO-08-19R School Mental Health Services
Enclosure II 

State 

Location 

characteristics 

School 

district sizea

School or

school 

district 

populationa

Safe 

Schools/

Healthy 

Students

grantee 

Schoolbased

health

center Program description

Ohio 

(cont’d.) 

Selective and indicated

services, including limited 

therapy and case management 

services, are provided by staff 

from the school-based health 

center and through a contract 

with a community-based 

mental health provider. The 

school-based health center is 

supported by a pediatrician

who can assist in the referral of 

children in need of mental 

health services to outside 

providers. 

Source: GAO analysis of information from sites and U.S. Department of Education.

Note: Universal services are those intended for all children; selective services are those targeting a smaller subset of children, 

usually those identified as at-risk for developing mental health problems; indicated services are those targeting children with

the greatest need of support. 

a

Unless otherwise noted, data are for the 2004-2005 school year for public schools. 

b

Officials at this site reported that the school district also provides services to the one local private school in its district, which 

has about 100 students. 

c

These data are for the 2005-2006 school year for public schools. 

d

The total school district population was 4,994 students. 

28 GAO-08-19R School Mental Health Services
Enclosure III 

Information on the Safe Schools / Healthy Students Grant Program, as of 

August 2007 

Participating 

agencies and 

offices 

Office of Safe and Drug-Free Schools within the Department of Education, Substance 

Abuse and Mental Health Services Administration (SAMHSA) within the Department 

of Health and Human Services (HHS), and Office of Juvenile Justice and 

Delinquency Prevention within the Department of Justice 

Type of assistance Discretionary/Competitive Grant 

Who can apply Local Educational Agencies (LEAs)a

Program description Safe Schools/Healthy Students (SS/HS) grants support LEAs in the development of 

communitywide approaches to creating safe and drug-free schools and promoting 

healthy childhood development. Programs are intended to prevent violence and the 

illegal use of drugs and to promote safety and discipline. LEAs are required to partner 

with local law enforcement, public mental health, and juvenile justice agencies. This 

program has been jointly funded and administered by HHS and the Departments of 

Education and Justice.b Within HHS, SAMHSA has primary responsibility for this 

program. 

Maximum grantee 

awards 

• $2,250,000 per year for 4 years for an LEA with at least 35,000 students 

• $1,500,000 per year for 4 years for an LEA with at least 5,000 students but fewer 

than 35,000 students 

• $750,000 per year for 4 years for an LEA with fewer than 5,000 students 

Education level Kindergarten through 12th gradec

New SS/HS awards, 

by fiscal year

Fiscal year 2007: $37,454,964

Fiscal year 2006: $30,913,344 

Fiscal year 2005: $76,367,807 

Legislative citation Public Health Service Act, as amended, § 581, 42 U.S.C. § 290hh 

Juvenile Justice and Delinquency Prevention Act, as amended, § 204, 42 U.S.C. § 

5614 

Elementary and Secondary Education Act of 1965, as amended, Title IV, Part A, 

Subpart 2, § 4121; 20 U.S.C. § 7131 

Number of new 

awards, by federal 

fiscal year 

Fiscal year 2007: 27 awards 

Fiscal year 2006: 19 awards 

Fiscal year 2005: 40 awards 

Program elements • Safe school environments and violence prevention activities: Support a continuum 

of strategies—including universal prevention, early intervention, and intensive 

activities, curricula, programs, and services—focused on the entire school 

population as well as students with disruptive, destructive, or violent behaviors. 

• Alcohol, tobacco, and other drug prevention activities: Support the prevention or 

reduction of substance use and abuse among youth, in coordination with broader 

environmental strategies that address change at the individual, classroom, school, 

family, and community level. 

• Student behavioral, social, and emotional supports: Support strategies to promote 

positive relationships for youth and meaningful parental and community 

involvement, and to recognize the role of students’ social and emotional needs in 

their development. 

• Mental health services: Support enhanced integration, coordination, and resource 

sharing among education, mental health, and social service providers, including 

early identification and assessment and providing early intervention services for atrisk children and their families, and referral and follow-up with local public mental 

health agencies as needed. Also support school staff training and consultation, 

supportive services to families, and revision of policies and procedures to address 

communication and sharing of information across service systems. 

29 GAO-08-19R School Mental Health Services 
Enclosure III 

Program elements 

(cont’d.)

• Early childhood social and emotional learning programs: Support ways to 

overcome barriers to identifying and serving children and families in need of 

services and to identify and consult appropriate community partners in developing 

services to address early childhood social and emotional learning programs.

Selected grant 

requirements 

• Memorandum of agreement among required partners 

• Logic model of the proposed projectd

• Use of evidence-based programs 

• Local evaluations conducted by grantees 

Source: GAO analysis of documents from SAMHSA and Department of Education. GAO analysis of Department of Education, “Safe Schools/Healthy Students Initiative,” 

2007, http://www.ed.gov/programs/dvpsafeschools/index.html (accessed August 6, 2007).

a

LEAs are public boards of education or other public authorities legally constituted within a state for either administrative control 

or direction of, or to perform a service function for, public elementary or secondary schools in a city, county, township, school 

district, or other political subdivision of a state, or for a combination of school districts or counties that are recognized in a state 

as administrative agencies for their public elementary or secondary schools. 

b

The Department of Justice contributed funding and administrative support to the SS/HS program from 1999 through 2003. 

While the Department of Justice signs the collaborative agreement that guides the program, the agency no longer provides 

funding or administrative support. 

c

The SS/HS program also supports efforts focused on early education for children. 

d

According to the SS/HS Fiscal Year 2007 Application Procedures, a logic model is a graphic presentation of the project in 

chart format that shows, by element: identified needs and gaps, goals, objectives, activities, partners’ roles, outcomes, and 

processes for measuring outcomes. 

30 GAO-08-19R School Mental Health Services
Enclosure IV 

Comments from the Department of Health and Human Services 

31 GAO-08-19R School Mental Health Services 
Enclosure V 

GAO Contact and Staff Acknowledgments 

GAO Contact 

Cynthia A. Bascetta, (202) 512-7114 or bascettac@gao.gov

Acknowledgments 

In addition to the person named above, Helene F. Toiv, Assistant Director; Jennie F. Apter; 

Emily R. Gamble Gardiner; Jeremie C. Greer; Neetha Rao; and Jennifer Whitworth made key 

contributions to this report. 

(290592) 

32 GAO-08-19R School Mental Health Services 
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