June 22, 2021
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Behavioral health is a broad term used in both medical and educational settings. It encompasses mental health, mental health disorders, and substance use disorders. Behavioral health disorders can interfere with the way a person thinks, feels and acts. Because many students need supports in these areas, the topic of behavioral health is important to address. Two recent surveys found mental health and substance use disorders were more common among Washington youth than the national average.
National education and healthcare organizations recommend schools address student behavioral health in addition to physical health. Historically, schools have not provided these services. In Washington, the behavioral health and education systems operate separately. Here, the Health Care Authority (HCA) and Office of Superintendent of Public Instruction (OSPI) both play significant but distinct roles, as do local school districts and regional educational service districts.
This audit sought opportunities to improve students’ access to needed supports and services. It looked at two areas:
- How public K-12 school districts are addressing student behavioral health prevention and early intervention
- The larger state system in place to coordinate and support these services
Read a two-page summary of the report.
Report Number 1028626
State Auditor’s Office contacts
State Auditor Pat McCarthy
Scott Frank – Director of Performance and IT Audit
Christopher Cortines, CPA – Assistant Director for Performance Audit
Tania Fleming – Principal Performance Auditor
Carolyn Cato – Senior Performance Auditor
Brenton Clark, Performance Auditor
Nancy Patiño – Performance Auditor
Leading practices recommend that effective school-based behavioral health systems include a full continuum of student supports. However, our survey of selected schools statewide found that relatively few said they had adopted all recommended core elements.
Furthermore, the state’s current approach is fragmented, with roles and responsibilities assigned across several local and state agencies. This decentralized approach has relied on school districts to develop behavioral health plans without oversight. Gaps in the current oversight and guidance structure requires improved state-level coordination, as insufficient state-level direction and oversight have led to uneven access to behavioral health supports.
Truly fixing the system for prevention and early intervention efforts will be no small undertaking. It will require structural changes to place someone in charge of the system. Schools, school districts, and the educational service districts that help support them, will need additional resources.
This audit also highlights some steps the state and schools could take to make incremental improvements. Notwithstanding those steps, the state’s long-term goal should be developing a coherent system to give Washington’s youth the supports they need to address behavioral health concerns early on.
Nearly half of all people with mental health disorders begin exhibiting symptoms by the time they start high school. Students whose needs for behavioral health supports go unmet can suffer from short- and long-term consequences. The former include poor academic performance, school violence, criminal activity and dropping out of school. Left unaddressed, these disorders can lead to lifelong problems. Examples of long-term consequences include homelessness, incarceration and, in some cases, even death by suicide. Even before the start of the pandemic, Washington students experienced these issues at a higher rate than national averages. The disruption and social isolation of the pandemic have only made the problem more intense.
National experts recognize that schools are a natural setting to promote student well-being, identify behavioral health concerns and offer necessary interventions. Students spend a large portion of their days at school, so teachers and other school staff play an integral role in identifying and supporting students with behavioral health needs.
But in order to help students, schools must screen them to identify those who need supportive services. Schools and districts must be able to offer a seamless continuum of supports and services. The continuum spans activities around prevention, early intervention and referrals for treatment. Examples of activities include educational programs to increase students’ awareness of mental health issues and help them build healthy coping skills.
Experiences of schools
Audit work included a survey of selected Washington schools in 50 districts statewide. Nearly 400 schools responded. We learned that while most schools have not implemented the full continuum of supports, many provide at least some services.
Nearly all schools trained their employees to recognize and respond to student behavioral health concerns. Nearly all also had dedicated staff to respond to behavioral health concerns. Most schools monitored student data, such as disciplinary referrals and attendance. Such information helps school staff identify possible student behavioral health concerns. It also helps administrators make informed decisions about resource allocation and staffing. Few schools systematically screened all students. This gap in screening means it is possible that some children who need help do not receive it.
School officials told auditors about two key barriers that prevent students from accessing services. First, and most pressing, was the limited number of nearby and available mental health providers. Second, the lack of transportation made it more difficult for schools to connect students to a provider to receive services.
The audit showed that the system to both support and hold school districts accountable for their efforts is highly fragmented.
- State law does not assign responsibility for ensuring that school districts provide a baseline of behavioral health support in schools.
- Nor does it make one agency responsible for giving districts broad strategic direction on how to meet the state’s expectations.
This lack of comprehensive state direction resulted in a system in which schools vary considerably the support they can give students. The decentralized approach has relied on school districts to develop behavioral health plans without adequate guidance from state-level authorities.
Other factors contribute to the challenges in the system, including insufficient guidance, monitoring and training. For example, OSPI’s model plan does not address all legal requirements. In addition, OSPI has yet to review districts’ behavioral health plans. This means districts lack guidance on what improvements they must make to ensure plans meet state requirements.
Neither HCA nor OSPI is able to provide programming and resources sufficient to help schools and districts actually implement comprehensive behavioral health systems that address the full continuum of services and supports. The audit also found that educational service districts could provide only limited support to school districts, because they lacked funding to do more.
Although Washington does have a workgroup dedicated to student behavioral health services, its authority is limited. It acts primarily to make recommendations to the Legislature. It can neither fund nor direct districts’ activities. Leading practices suggest state-level direction and coordination can help schools and districts better address students’ needs.
Taking the lead
The consequence of Washington’s fragmented system is uneven and often inadequate availability of services for students. Leading practices suggest that state-level coordination is key to successfully promoting engagement and goal setting across education and health agencies.
The National Center for School Mental Health recommends that states consider convening an advisory council made up of relevant parties in the behavioral health and education systems. Such councils ideally work closely and collaboratively with their state’s designated lead agency. Their joint goal: To help school districts establish more consistent prevention through early intervention services across the state.
Washington lacks one agency tasked with leading the state’s efforts. This lead agency would be responsible for coordinating strategic direction and local activities with representatives from HCA, OSPI, service districts and other key partners such as managed care organizations. It would also be responsible for providing key technical support to school districts for program implementation. Finally, it would report outcomes of school-based behavioral health programs to the Legislature. The two strongest candidates for the role of lead agency are:
- HCA, because it is the state’s behavioral health authority and has the greater depth of resources in this field
- OSPI, because it is the lead agency on K-12 education and has direct relationships with schools and districts
The Legislature can promote improvements by establishing a lead agency and an advisory council. In addition, it will need to address resource constraints.
The state allocates funding to help education agencies and HCA implement behavioral health prevention and early intervention activities. Current funding appears inadequate to meet the needs of all Washington students. Many representatives from HCA, OSPI, educational service districts and school districts said that they wanted to provide greater behavioral health supports for students. However, limited resources constrained their ability to do so.
For example, the state’s school funding formula – used to calculate resource funding for schools – requires a large number of students in order to fund behavioral health personnel. The audit noted that a district must serve around 23,500 elementary students to receive funding for one school psychologist. It must serve around 9,500 elementary students to receive funding for a single school social worker.
Addressing the broader issue of behavioral health disorders goes beyond what schools can reasonably solve. Nonetheless, schools are a hub for the vast majority of children who might begin to exhibit symptoms. They are a natural setting for prevention and early intervention efforts. The audit noted some ways other states help education agencies with coordination, guidance and financial support.
For example, Medicaid allows education agencies to become providers and deliver behavioral health services in schools. As the state’s Medicaid agency, HCA is positioned to help education agencies with challenges they face when contracting with the state’s managed care organizations. HCA could provide better guidance around reimbursable services as well as contracting and billing with managed care organizations.
We made recommendations to the Legislature to address fragmentation in the existing structure. The audit suggested ways it could provide greater state-level coordination and direction.
We also made a series of recommendations to HCA to improve the existing state system’s ability to connect students with behavioral health prevention and early intervention services. In addition, we made a recommendation to OSPI to address the shortcomings of its model plan.