School Based Mental Health: A Maryland Case Study
The following testimony was given last June by Dr. Larry Epp, Ed.D., L.C.P.C to the Kirwan Commission, an initiative started in 2016 to radically improve Maryland Public schools.
Dr. Epp is the Director of School Mental Health Services for Family Services, Inc. of Gaithersburg, Maryland, and the Past President of the Licensed Clinical Professional Counselors of Maryland. He is also a past president of the District of Columbia Chapter of AMHCA and the Maryland Association for Multicultural Counseling and Development. Dr. Epp was recently appointed the Vice Chair of the Montgomery County Mental Health Advisory Committee, which provides guidance to the County Government on mental health issues.
“Thank you for the opportunity to share the lessons of my 25 years of working in the trenches of school mental health in three Maryland counties. My name is Larry Epp, Director of School Mental Health Services for Family Services, Inc., part of the Sheppard Pratt Health System.
Twenty-five years ago, I was offered a position as a School Mental Health Therapist in the East Baltimore Mental Health Partnership at Johns Hopkins Hospital. I was assigned to Paul Laurence Dunbar High School.
I will never forget the commute to my first day of work. I saw rows of boarded up homes deteriorating and in shambles; youth frequenting the corners seemingly engaged in drug distribution; and trash and debris strewn in the streets. I sensed that this community was neglected, unloved, and abandoned by our society. I learned that its children were exposed to as much violence as those in a war zone; and few, after having lived in this harsh environment, were able to climb out of poverty.
There are many such ravaged communities in Maryland; and the trauma of poverty, child abuse, neglect, community and domestic violence are among the forces contributing to increases in mental health challenges among our youth and the ultimate source of the achievement gap in Maryland.
Need for and Value of School Mental Health Programs
The Center for Disease Control recently released a report describing an increase in suicide rates across our country (1). This is true in Maryland as well. For the last decade, suicide has ranked as the third leading cause of death for ages 15 to 24, while climbing to fourth place for ages 25 to 44 (2). Combined with the Opioid Epidemic, death rates for youth and young adults are climbing so dramatically that the U.S. has seen an unprecedented drop in its overall life expectancy (3).
It is not just teenagers and adults wanting to take their own lives. We are seeing an increase in elementary aged students with suicidal ideation. My professors at Johns Hopkins erroneously told me 25 years ago I would rarely see an elementary aged child desiring to take his or her own life. Today, every fifth child referred to our Langley Park school mental health program has suicidal ideation.
The 2017 Maryland Youth Risk Behavior Survey revealed a disturbing truth about suicidal thinking in Maryland. 17.3% of our high school youth considered suicide, and 14.4% made a plan to carry it out. SAMHSA’s Behavioral Health Barometer of 2014 revealed that 52,000 Maryland youth suffered from major depression – but sadly only 44% ever received treatment for it. Depression and suicidal ideation can be the products of psychological trauma. In February 2016, the Baltimore Sun published a survey of two schools in West Baltimore. 43% of the children witnessed physical violence 1-3 times per week, and 37% said they knew someone killed before their 19th birthday. In 2015, the Child Welfare League reported that there were over 51,000 reports of child abuse in Maryland. That means 10,000 more youth were abused that year than attended the University of Maryland at College Park.
We know from the best national projections that between 14 and 20% of Maryland youth will need mental health services each year, but we know from bitter experience that more than half will never receive the services they need. The School Mental Health Movement developed to address the stigma and obstacles that kept many youth from accessing mental health services. Today, if a child or adolescent receives mental health services, they most likely receive them in their school.
Research indicates that school mental health programs decrease suicide risk and substance use among at-risk adolescents (4). School mental health programs across Maryland can also demonstrate that their services reduce school suspensions, prevent out-of-school placement, and accrue budget savings to Maryland schools.
Children cannot be present for learning if they feel psychologically unsafe; they cannot listen to a teacher if depressed or anxious; a spelling test is not a child’s greatest priority if his or her home is filled violence or gunshots ring outside the door. If we want to come face-to-face with the ultimate cause of the achievement gap in Maryland, we will not find it in disparities in curricula or teaching strategies, but in the hearts of our state’s children who have been scarred by trauma through living in communities that we have allowed to languish in poverty for decades.
Identifying youth in need of mental health services is a critical priority. Most school systems are unaware how many children come to school each day psychologically wounded. They do not train their teachers to identify children with mental health disorders, nor do they routinely screen children for these conditions when exhibiting multiple suspensions, truancy, or office referrals.
Limitations of Current Funding Model
Funding for school mental health over the last 25 years has been inconsistent and hardly robust. Currently, school mental health programs are largely funded through Medicaid reimbursement. When it works well, this fee-for-service model allows children and families to access clinical services like psychiatry, individual, family, and group therapy, as well as psychiatric rehabilitation programs (PRP) that build coping skills for children with a higher level of need.
However, the Medicaid fee for service model is woefully inadequate. Reimbursement rates for Medicaid services have stagnated for many years.
Reimbursement that doesn’t keep up with inflation means our staff salaries are inadequate. I will lose half of my Prince Georges County school-based fee for service staff as a result of inadequate pay; and I cannot offer any of them an independent living wage for the community which they call home. Often the school mental health professional is the lowest paid employee of the school.
Inadequate reimbursement also means that clinicians need to be highly productive – engaging in as many billable services as possible. Fee for service clinicians based in schools are not fully able to lend their knowledge and expertise in student support meetings, or as supporting consultants to teachers and administrators.
However, Montgomery County has found a formula for offering generous grant support to school mental health programs--supplemented by Medicaid reimbursement--and this is the model we should follow throughout the state. It allows a mental health therapist to engage in both prevention and treatment activities and to offer equal support to all children, irrespective of their insurance or immigration status.
It is critical for this Commission to understand and support a strong publicly-funded behavioral health system with school mental health programs as a critical component. All community mental health programs, both clinic and school based, support the mental health of children, work to stabilize their families, and connect them to essential resources. Medicaid funding must be strengthened if this system is to make a difference. We can no longer pretend that mental health services are peripheral to education. They must be central to educating the whole child, or we will not reach the many children caught in the throes of trauma and mental illness.
Maryland should also hold commercial insurers accountable for covering school mental health services. Too often, private insurance coverage does not translate into access to mental health services, particularly in school settings.
Conclusion
What the children of Maryland ultimately need is unrestricted access to mental health services in their schools and communities, irrespective of their insurance, immigration status, or income level. No child wishes to fail, no school wishes to fail its children, but children fail and schools fail when we are indifferent and oblivious to the traumas of individual children and the adverse social circumstances that make trauma prevalent in many Maryland communities.
There is hope. Because what school mental health services ultimately offer, when you strip them of the façade of a medical intervention, is a caring relationship between an adult counselor and a child. It is this therapeutic bond of inspiration and compassion, one child at a time, where trauma is healed and the achievement gap will end.”
CDC: U.S. Suicide Rates Have Climbed Dramatically, Nell Greenfieldboyce, National Public Radio (June 7, 2018).
Maryland Vital Statistics Annual Report, Maryland Department of Health, Table 43A, page 151 (2006); Maryland Vital Statistics Annual Report, Maryland Department of Health, Table 43A, page 153 (2016);
Here’s Why Life Expectancy in the U.S. Dropped Again This Year, Grace Donnelly, Fortune (Feb. 9, 2018).
School-Based Mental Health Services and Suicide Risk, Suicide Prevention Resource Center (Feb. 16, 2018)