School reform and mental health services for students with emotional disturbances educated in urban schools.
Article Type:
Health care reform (Psychological aspects)
Educational reform (Psychological aspects)
High schools (Psychological aspects)
Special needs students (Psychological aspects)
Psychiatric services (Psychological aspects)
Special education (Psychological aspects)
Education (Finance)
Education (Psychological aspects)
Duchnowski, A.J.
Kutash, K.
Pub Date:
Name: Education & Treatment of Children Publisher: West Virginia University Press, University of West Virginia Audience: Professional Format: Magazine/Journal Subject: Education; Family and marriage; Social sciences Copyright: COPYRIGHT 2011 West Virginia University Press, University of West Virginia ISSN: 0748-8491
Date: August, 2011 Source Volume: 34 Source Issue: 3
Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs; 8294000 Education of Handicapped; 9105115 Special Education Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs; 61111 Elementary and Secondary Schools; 92311 Administration of Education Programs SIC Code: 8211 Elementary and secondary schools
Government Agency: United States. Department of Health and Human Services Organization: National Association of State Directors of Special Education

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Full Text:
Outcomes for students in special education continue to be disappointing and those having emotional disturbances (ED) continue to lag behind the other disability groups. In this study, school reform activities and the effects on students who are educated in special education programs for students who have ED were examined. Demographically similar elementary, middle, and high schools in urban communities were classified as either actively engaged in (HI) or not very engaged in (LO) reform activities. Findings indicated students with ED in the HI schools spent more time in academic general education classes with non-handicapped peers; had significantly higher achievement scores in math; and were more likely to receive mental health services from community agencies compared to students in the LO schools. Implications are discussed in terms of current developments in the school-based mental health services research and provider communities to refocus interventions on learning, the core function of schools.

KEYWORDS: Emotional disturbance, school reform, mental health service use, urban, special education

Although there is concern about improving the achievement and functioning of all students who have disabilities, a review of the literature reveals the critical need to focus on youth who have emotional disturbances (ED). For example, in a series of studies beginning in the late 1990s and continuing to the present, Wagner and her colleagues (Blackorby & Wagner, 1996; Wagner, Kutash, Duchnowski, Epstein, & Sumi, 2005; Wagner et al., 2006) concluded that outcomes for students who have ED were the poorest compared to the other disability groups. Results from Wagner's studies revealed average academic achievement for these students was below the 25th percentile; they had the highest dropout rate compared to all disability groups; and half of these students were involved with the justice system two years after separating from school. In spite of their disabilities, students with ED received minimal amounts of psycho-social support, scant support for their families, little in the way of accommodations in instruction, and spent the least amount of time with non-handicapped peers compared to students who had other types of disabilities (Wagner et al, 2006). Students who have ED and are placed in special education programs may be considered a top priority for school reform efforts targeting special education programs for improvement and increasing mental health support services.

Better integration of the education and mental health systems has the potential to increase the capacity for school based mental health services for children with ED (Kutash, Duchnowski, & Lynn, 2006; U.S. Department of Education, 2002; U.S. Department of Health and Human Services, 2003; 1999). However, many barriers to system collaboration have been identified, including different theoretical foundations and training, different language, different goals (academic vs. emotional functioning), different methods of assessment, and a limited empirical base to guide practice (Atkins et al., 2010; Kutash et al, 2006; Hoagwood & Erwin, 1997; Rones & Hoagwood, 2000).

A re-examination of the models and procedures that guide systems integration and service delivery may contribute to increasing the capacity for the provision of school-based mental health services and improved student outcomes. For example, the special education system needs to develop more effective procedures that would provide needed mental health services to students who have ED, as only one-third of students receive needed services (Wagner et al., 2006). In an attempt to understand the lack of related services for these students, Minow (2001) concluded that "many school systems resist the provision of related services on the theory that they are not educational but medical or psychological, even though these services are required under the act (i.e., IDEA) where necessary to enable the student's free, appropriate education. Provision of related services often fails when school districts and other agencies disagree over who should provide and pay for them" (p. 4).

From the mental health perspective, the relationship between effective related services and improved academics has not always been clearly articulated. This issue is being addressed by proposing models that will refocus school-based mental health services on the core function of schools to promote learning. Adelman and Taylor (2006) have proposed that interventions to remove the psycho-social barriers to learning must become part of a school's comprehensive effort at reform and improvement. Atkins and colleagues (2010) foresee a paradigm shift in which mental health professionals become "educational enhancers" providing support to teachers in effective instruction and classroom management. Recognizing the inherent capacity of schools to bridge school, home, and neighborhood, Cappella and colleagues (2008) have proposed an ecological model that aligns mental health intervention goals with school goals through the development of partnerships with professionals and parents.

In this paper we present a brief description of comprehensive school reform in order to establish a context for an exploratory study examining the relationship between school reform activities, outcomes, and mental health services for students who are identified as having ED and placed in special education programs. We present the results of a study comparing schools that are highly engaged versus schools that are less engaged in reform activities, and the academic and emotional functioning of their students who have ED. We also discuss implications for the integration of education and mental health systems in schools.

The Current Context of Schools: Comprehensive School Reform

With the re-authorization of the Elementary and Secondary Education Act (ESEA) in 2002 as the No Child Left Behind Act (NCLB), major changes in federal policy occurred. For example, Title I of ESEA was transformed from a supplemental remedial reading program to a major influence in the standards-based school reform movement. With the passage of NCLB, federal policy was extended to support Comprehensive School Reform Programs (CSRP) to improve low-performing, high-poverty schools (Borman et al., 2002). The federal CSRP initiative has promoted, through a large grant program, the adoption of externally developed school-wide reform programs or models that are considered to be scientifically-based and meet federally developed criteria for a school-wide model (Borman, et al., 2002). Borman and his colleagues (2002) have conducted an extensive meta-analysis of 29 CSRPs, identifying three promising programs: Direct Instruction (e.g., Gersten & Keating, 1987); Comer School Development Program (e.g. Comer, 1987); and Success for All (e.g., Slavin & Madden, 2000).

Briefly, Direct Instruction encompasses methods developed by Siegfried Engelmann and his colleagues (e.g., Adams & Engelmann, 1996) aimed at promoting reading and math competencies in elementary age students. A strong evidence base supports the use of techniques such as homogeneous grouping, planned sequences of activities, scripted lessons, and a fast pace of instruction in order to increase the active engagement of learners and to keep them focused. The "Comer Process" is a K-12 system of managing, organizing, coordinating and integrating the components of a comprehensive school plan by three teams. The School Planning and Management Team is comprised of parents/families, teachers, administrators and support staff (and middle and high school students); this team develops the comprehensive school plan and evaluates and modifies strategies every quarter. The Student and Staff Support Team, comprised of staff who have expertise in child development and mental health, coordinates and integrates mental health support for students through individual therapy or with groups. The Parent/Family Team is comprised of parents and other family members, and develops activities that enable them to support the overall development of all the children in the school. The Comer Process uses collaboration, consensus decision-making, and no-fault, no blame problem solving with extensive communication between teams to achieve the goals of the school plan. Success for All is a series of standards-based curricula that include reading, writing, and oral language for students in pre-K to eighth grade. Students are grouped by reading ability and receive instruction in 90-minute reading blocks. Certified teachers serve as tutors for students who are having difficulties. The program aims to emphasize early intervention in order to prevent failure.

While no exact number is available, it is estimated that perhaps as many as three to four thousand schools are engaged in implementing a CSRP (Borman et al., 2002), a fraction of the approximate 100,000 schools in the country. The majority of schools are in engaged in reform activities that have been developed internally at the school or district level. Examples of these locally developed efforts include the following: site-based management strategies (Cawelti, 1994, Malen, 1994); increasing the use of scientifically supported curriculum and instruction (Borman, 2000; Wong & Meyer, 1998); increasing parent involvement (Jeynes, 2005; 2007); and the inclusion of all students, including those students who have disabilities, in reform activities (Sailor, 1991). Locally developed reform activities are the focus of the present study.

Purpose of the Present Study and Focus on Students Who Have ED

The purpose of the present study is to examine school improvement activities in urban communities, determine if there are meaningful differences in the amount of reform activities operating in schools and examine how these activities affect the academic and emotional functioning of students who have ED, their educational program, and the mental health services they receive. Urban schools were chosen to participate in this study because they typically serve children whose families are from diverse ethnic and cultural backgrounds and have high instances of poverty, factors that present some of the greatest challenges facing schools in their efforts to improve student outcomes (Kutash & Duchnowski, 2004).

The specific research questions in the study were: (1) Can schools be classified in terms of their level of engagement in reform activities?; (2) Are greater levels of school reform activity related to improved functioning for students with ED?; (3) Is parent involvement related to the level of school reform in their child's school?; and (4) Are school reform activities related to the amount of mental health services received by students who have ED?



Schools. A national recruitment effort was undertaken to identify schools whose staff believed they were excelling in their efforts to implement school improvement activities. This multi-step process began with an invitation mailed to approximately 200 members of various child-serving organizations (e.g., National Association of State Directors of Special Education, Federation of Families for Children's Mental Health, National Association of State Mental Health Program Directors) asking for nominations of any school perceived as actively engaged in restructuring efforts to better serve children and youth with serious emotional disturbances. This process resulted in the nomination of 37 schools located in 13 states. During the next step, all nominated schools were asked to complete a questionnaire about their school, including enrollment demographics, type of setting (urban, suburban, rural), number of students receiving free or reduced lunch (a commonly used proxy for SES), the school's current restructuring activities, and the school's relationship with community agencies. Schools continued in the process by completing a follow-up questionnaire if they met the following criteria: a) they served students formally identified as having emotional and behavioral disabilities, b) they were located in an urban area (as defined by the National Center for Education Statistics), c) they were identified as a regular public school as opposed to a special education center or day treatment facility, and d) they served at least 40% of its student body from ethnically and culturally diverse backgrounds. Additionally, these schools had to e) describe evidence of involvement of parents who have children with ED, and f) have been involved in school reform activities for a minimum of 2 years. Fifteen schools completed and returned the first questionnaire and of those, nine schools met study criteria and were sent the follow-up survey designed to gather more complete information on the nature of restructuring and reform activities taking place in the schools. Seven schools returned the follow-up survey and were deemed eligible for site visits from study personnel. Site visits by study staff were conducted with district personnel and building administrators to finalize participation in the study.

In an effort to include comparison schools, study staff interviewed district staff using a structured screener to identify schools in the same district that were demographically similar to nominated schools, and were perceived as less engaged in school improvement activities. District staff supplied the same information for these comparison schools that was collected on the schools nominated as being highly engaged in reform activities. As a result of this process, a total of seven nominated schools (three elementary, two middle and two high schools) were paired with seven comparison schools serving demographically similar (e.g., age, race/ethnicity, free/reduced lunch) Students, for a total of 14 participating schools. Using census data descriptors, these schools were located in four mid-size urban communities in four states (Missouri, Florida, Ohio, and Maryland). All 14 schools completed the School Improvement Index (Duchnowski, Kutash, and Oliveira, 2004), described below, in order to confirm their level of engagement in reform activities.

Students and parents. To ensure that the participating schools were serving similar students, data were collected from parents and students with ED regarding the students' current level of impairment and emotional and academic functioning. The protocol for recruiting parents involved designating a liaison staff member from each participating school who identified potential student participants for the study based on the following eligibility criteria: (a) the student was formally identified as having an emotional or behavioral disability and served in special education, (b) the student was over 4 years of age, (c) the student had been actively attending school for the 30-day period prior to data collection, (d) the student had been enrolled in the school for a minimum of half the school year, and (e) the student and parent spoke English or Spanish. The school liaison invited the parents/caregivers of eligible students to attend an information meeting about the study or parents were sent information about the study to their homes. Parents/caregivers interested in participating in the study were interviewed either at the information meeting or at a time and place convenient for them and given a stipend of $50 for their time.

Overall, 328 student-parent/caretaker dyads from 14 schools were eligible for participation and 199 consented to participate, for a 61 % participation rate. Student participants (n = 199) and eligible non-participants (n = 129) did not significantly differ on gender [[x.sup.2](l/ 328) = 0.05, p =.82] or race [[x.sup.2](l, 328) = 0.30, p =.58]. Participants did differ from non-participants on age [t(326) = -2.67, p<.01 ] and on lunch status [[x.sup.2](l, 328) = 4.46, p<.05]. These findings suggest that student participants (M = 12.5 years old, SD = 3.2) were significantly older than non-participants (M = 11.5 years old, SD = 3.3) and had higher family incomes.


School reform activities. The School Improvement Index (SII) (Duchnowski et al., 2004) was used to evaluate the degree to which schools engaged in reform activities. The SII has demonstrated reliability in classifying schools along a continuum of engagement in school reform and improvement activities. The SII measures constructs that are consistent with criteria proposed in the federal CSRP. These include site-based management the use of scientifically supported curriculum and instruction, parent involvement, and the inclusion of all children in reform activities (Borman et al., 2002).

The SII requires a minimum of five school staff members (i.e., principal, special education teacher, general education teacher, school advisory committee member, and key informant) to rate the school on the following six areas that are supported by the literature as describing school reform and improvement activities: (1) Governance: how the school is managed and governed (Cawalti, 1994; Newman, King, & Rigdon, 1996); (2) Accountability: how academic results are used to inform instruction (NCLB, 2002; Rothman, 1995); (3) Curriculum and Instruction: the use of innovative curriculum and instructional techniques (Bybee,1997; Corcoran & Goertz, 1995; NCLB, 2002); (4) Includedness: the availability of an array of environments to meet the needs of students with special needs (Hocutt & McKinney, 1995; Sailor 1991); (5) Parent Involvement: the amount and type of parent involvement (Jeynes, 2005; 2007; Turnbull & Turnbull, 1997); and (6) Pro-Social Discipline: whether discipline incidents are handled in a pro-active educational manner (Adelman & Taylor, 2006; Carr et al., 2002). Each of the six topic areas is composed of four parts or indicators for a total of 24 indicators (items). Each of these indicators ranges from -3 to +3. Total scores on the SII can range from a high of +72, indicating greater levels of school reform activity, to a low of -72, indicating lower levels of school reform efforts. The SII has been shown to be a reliable and valid measure of the degree to which a school is engaged in reform and improvement activities. Intraclass correlation coefficients are above the desirable level of.80 (Landis & Koch, 1977). In addition, test-retest reliability was evidenced by ratings remaining relatively unchanged after a 6-month delay. Discriminate validity was established by determining that the SII could differentiate between schools active in reform efforts and those schools less active in reform efforts (Duchnowski et al., 2004).

Student demographic and mental health service use. Parents were asked to report their income, their child's age when problems related to his/her disability were first noticed, when their child first received professional help for his/her disability, and when their child first began a special education program for students with ED. Data collected from school files included student age, gender, free/reduced lunch status, the amount of time each student spent in special education settings per day, and any mental health services the student received at school from either school personnel or community agency personnel during the school day. These services included individual or group counseling, case management, medication management, or other services designed to help the student with his or her behavioral or emotional functioning.

In order to capture any mental health services the student received outside the school, parents completed the parent version of the Service Assessment for Children and Adolescents (SACA) (Stiffman et al., 2000). This questionnaire is designed to assess the utilization of mental health services by children and adolescents. Service utilization is examined by the SACA across two service categories: inpatient (e.g., psychiatric hospital, residential treatment center) and outpatient (e.g., community mental health centers, day treatment facilities). The SACA provides information on service utilization during the youth's lifetime (including age when services were received) as well as recent use of services. This instrument has excellent test-retest reliability for both lifetime and previous 12-month service use (Stiffman et al., 2000).

Student functioning. To document student academic functioning, an academic achievement assessment was administered to all students by study staff. The Wide Range Achievement Test-3 (WRAT3; Wilkinson, 1993) was administered to each student participant at the end of the school year to measure achievement levels in reading and mathematics. The psychometric properties of the WRAT-III have been well established (Smith, Smith, & Smithson, 1995; Wilkinson, 1993).

In order to capture the emotional functioning and level of impairment experienced by the students, the Child Behavior Checklist (CBCL; Achenbach, 1991) was completed by parents. The CBCL is a widely used instrument designed to measure behavioral and emotional problems for youth ages 4 to 18 years and yields total, internalizing, and externalizing behavior problem T-scores. The psychometric properties of the CBCL have been supported in several studies (e.g., Achenbach, 1991).

The Columbia Impairment Scale (CIS; Bird et al., 1993) was also completed by parents and provides a global assessment of functional impairment across four major functional areas: interpersonal relations, certain broad areas of psychopathology, functioning at school, and use of leisure time. The CIS yields a total impairment score that can range from 0 to 52. A score of 16 or above is considered to be in the clinical range of impairment. Psychometric properties have been validated in several studies (Bird et al., 1993; Bird et al, 1996).

Parent involvement. The Parent Involvement Opinionnaire was developed specifically for this study and asks parents to assess the degree of parental involvement for all parents at the school, as well as their own personal level of school involvement. The measure assessing perceived involvement of all parents includes 3 questions on a scale from 1 (low parental involvement) to 5 (high parental involvement). The measure assessing personal parental involvement includes eight questions on a scale from 1 (no involvement) to 5 (high involvement). Internal consistency reliability for both parent involvement measures, perceived involvement of all parents and personal involvement, was acceptable (Cronbach's alpha=0.81 and 0.71). Items from both measures were summed individually to provide a score for the perceived involvement of all parents and a score for personal parental involvement. Parent involvement scores for all parents can range from 3 (indicating low parental involvement) to 15 (indicating high parental involvement). Personal parental involvement scores can range from 8 (low parental involvement) to 40 (high parental involvement).


School Reform

The first topic addressed by this study was the varying amount of school reform operating in each school. The SII Total Scores for the fourteen schools participating in this study ranged from -12,2 to 38.8. When schools were rank ordered, the six schools scoring the highest on the SII were categorized into the group that was highly engaged in reform (HI) and the six schools scoring the lowest were categorized into the group not very engaged in reform (LO). The remaining two schools scored in the middle of the scale, indicating neither high nor low engagement in reform activities, and were eliminated from subsequent analyses. The HI and LO schools were equivalent in terms of grade levels. There were two high schools, two middle schools, and two elementary schools in each group. The two schools that scored in the middle range of the scale and not included in the data analysis were both elementary schools.

The SII Total Scores for the top six performing schools ranged from 23.6 to 38.8, and the SII Total Scores for the bottom six performing schools ranged from -12.2 to 12.8, indicating variability between the two groups in the amount of school reform activities. While the SII has not been developed to the point where an absolute cutoff score can be used to indicate reform activity, there was evidence supporting reform for an average of 40% of the indicators for the HI schools and only 4% for the LO schools. Of the six indicators of reform activity on the SII, three showed the greatest difference between the HI schools and the LO schools: Curriculum and Instruction (the use of innovative, evidence-based curriculum and instructional techniques); Includedness (the availability of an array of environments to meet the needs of students with special needs); and Pro-Social Discipline (whether discipline incidents were handled in a pro-active educational manner), see Table 1.

Schools that were more actively engaged in reform (HI) appeared committed to shared decision making by a more diverse group of stakeholders. There were specific procedures in place for a formal School Improvement Team to develop a plan and monitor the achievement of short term objectives and goals. All schools in the study were in states that required all students to take annual statewide achievement tests, consequently there was no variability on this factor. However, there were differences between schools in how they used achievement data. In the HI schools, there were more instances of teams disaggregating the data and identifying low performing students who needed extra help. At the elementary level, the two HI schools used a direct instruction program for reading and students who had ED were included in this type of reading instruction. The LO schools used district selected commercial reading programs that did not use a direct instruction approach.

At the middle school level, the two HI schools had evidence of planning and input from stakeholder groups through the School Improvement Teams resulting in a Team Teaching approach. Students were divided into groups for the core subjects: language arts, math, science and social studies. The four teachers of each of these subjects served as a team for the students in each group, with common planning periods enabling attention to individual students. This mechanism was helpful in monitoring ED students who were placed in these academic classes. In the LO middle schools, the traditional seven period day was used. The HI high schools also re-organized the instructional day. They used a block-schedule approach that provided 90 minute periods three times each week for the core subjects of language arts, math, science, and social studies. This approach is based on the premise that teachers can develop learning themes with more depth given a longer time span. Such a program requires a large commitment by administrators and staff to make it work. In the HI schools we found evidence of school-wide, grade level, and subject department level input to the School Improvement Team to make block scheduling work. At the two LO high schools the traditional seven period day schedules was used.

In summary, the schools in this study were all governed by state and district level mandates and procedures. However, as depicted in Table 1, they varied in the degree to which they engaged in core activities aimed at school improvement.

Relationship between School Reform Activities and Study Variables

Demographics and background. The students participating in the study were generally male (85.0%), Black (78.7%), around 14 years of age (M = 14.0, SD = 2.9) and in the seventh grade (M = 7.4, SD = 2.7). Eighty-three percent of these students were enrolled in the free/reduced price lunch program. According to parents, nearly half of all participants lived below the poverty level, with an average income of $25,060 (Mdn = $20,000). Parents reported first noticing a problem related to their child's disability at about age six (M = 5.9, SD = 2.6), and that their child first received professional help for his/her disability at around eight years of age (M = 7.5, SD = 2.6). Parents also reported that their child first received outpatient mental health services at age eight (M = 8.3, SD = 3.0) and inpatient services one year later at age nine (M = 9.0, SD = 3.0). In addition, parents reported that their child spent on average 61% of their entire school career in a special education program for students with ED (M = 60.9, SD = 28.8).

Independent-samples t-tests and Pearson chi-square tests were conducted to compare the demographic characteristics between students in the HI schools and in the LO schools. Overall, the groups were quite similar. There were no significant differences between the two groups in student age [t(148) = -0.15, p =.88], gender [[x.sup.2] (1, 150) = 3.16, p =.08], race [[x.sup.2] (h 150) = 0.69, p =.41], income [t(140) = -1.59, p =.11], free/reduced lunch status [[x.sup.2] (l, 150) = 4.29, p =.12], or poverty level [[x.sup.2] (l/142) = 0.49, p =.49]. No significant differences were seen in the age parents first noticed a problem with their child [t(143) = 0.06, p =.95], the age in which the child first received professional help [t(138) = -0.35, p =.72], the child's age when first received outpatient services [t(94) = -0.78, p =.44], or the child's age when first received inpatient help [t(44) = -1,35, p =.19]. No significant differences were found between the two groups for the percentage of their school career spent in a special education program for students with EBD [t(141) = -0.94, p-.35].

Academic and emotional functioning. Results from the administration of standardized assessments revealed that the majority of parents from both HI and LO schools rated student functioning in the clinical range, or above a score of 63.0 (M = 66.7, SD = 9.0), on the Total Problems score of the CBCL. Students scored in the clinical range of the Externalizing Behaviors score (M = 66.9, SD = 9.4) and in the borderline range (scores of 60 - 63) of the Internalizing Behaviors score (M = 62.0, SD = 11.2). The majority of students also scored in the clinical range of impairment on the CIS, or a score of 16 or higher, indicating significant levels of emotional and behavioral impairment. There were no significant differences between the students in the HI vs. LO schools on measures of child emotional impairment as measured by the CBCL ft(148) =.90, p =.37, ES =.18], or CIS [ t(148) =.91, p =.36, ES =.15], see Table 2.

Regarding academic functioning, students scored an average of 75.5 (SD = 13.0) on math achievement and 77.5 (SD = 17.6) on reading achievement. Students in the HI schools had significantly higher math scores than students in the LO schools, t(148) = -2.33, p = .02, ES = .38. There was not a significant difference in the reading achievement scores, t(148) = -1.56, p =.12, ES.25.

Time in special education settings. In the current school year, students spent on average 36% of their week in general education settings (M = 36.2%, SD = 27.6%) and 8% of their school week in academic general education settings (M = 7.9%, SD = 17.2%). Students in the HI schools spent significantly more of their week in general education settings than their counterparts in the LO schools, t(148) = -3.48, p =.00, ES =.57. Students in the HI schools also spent more of their school week in academic general education settings than students in the LO schools, t(133.5) = -3.16, p =.00, ES -.49, see Table 2.

Parent involvement. Parents rated two types of parental involvement: their perceived involvement of all parents at their child's school and their own personal involvement at their child's school. The average score for parents' perceived involvement of all parents at the school was 8.3 (SD = 3.4) on a scale ranging from 3-15, with higher scores indicating greater involvement. Parents rated their own personal involvement with an average score of 23.9 (SD = 7.0) on a scale ranging from, 8-40, with higher scores again indicating greater involvement. When reporting on the involvement of all parents at their child's school, no significant differences were seen between the groups, t(110) = 1.66, p =.10, ES =.32. However, parents of students in the HI schools rated their individual involvement levels as significantly lower than parents of students in the LO schools, t(146) = 2.70, p =.01, ES =.45, see Table 2.

Mental health services. Data were collected on the amount of services provided in schools and who provided the services. Mental health services provided in the schools were classified as being provided by either school personnel (employed by the school) or community agency personnel (contracted by the school to provide services in the school). Overall, 56.0% of students participating in the study received services from either school providers, community agency personnel, or both. Of those students who received services, 46.4% received services solely from school personnel; 22.6% received services solely from community agency personnel operating in the schools; and 31.0% received services from both types of providers.

The percentage of students receiving mental health services in the HI and LO schools did not differ, % (1, N = 150) = 2.20, p =.14, OR =.61. However, more students in the LO schools received services solely from school providers than students in the HI schools, [x.2.sup] (1, N = 84) = 10.77, p<.01, OR= 4.50. Conversely, significantly more students in the HI schools received services solely from community agency personnel operating in the schools than students in the LO schools, [x.2.sup] (l, N = 84) = 19.66, p<.01, OR = 30.75, see Table 3.

Mental health service use was also examined in terms of service units received per month. A service unit was defined as an occurrence of any mental health service provided to a student, and could include group or individual counseling, medication management, or case management. Overall, students received an average of 17.7 service units per month from either school personnel, community agency personnel, or both. Among students who received services, students received an average 14 service units per month (M = 14.1, SD = 9.6) from school personnel and 18 service units per month (M = 18.1, SD = 7.5) from community agency personnel operating in the schools.

There were no significant differences in the service units received per month from any source between the HI and LO schools t(77) = -79, p =.43, ES =.17. In addition, the two groups did not differ in services received solely from school personnel, t(37) = 0.99, p =.33, ES =.34, However, of students who received services solely from community agency personnel operating in the schools, students in the HI schools received 19 service units per month while only one student in the LO schools was included in this category and that student received less than 1 service unit per month (see Table 3).


In this study we described locally developed school reform activities, their relationship to the inclusion of students who have ED in the general education environment, and associations between these strategies and levels of academic and emotional functioning for students who have ED. Urban school districts were targeted for participation in the study as students who have ED in such districts have been identified as having serious academic and behavioral challenges requiring schools to develop specific strategies to meet student needs (e.g., Kutash & Duchnowski, 2004).

Schools were classified along a continuum of their engagement in school reform and improvement activities. The reform used in these schools was internally developed as opposed to external models supported in the federal CSRP. However, these schools reported activities aimed at achieving factors such as decentralized site-based management, the use of scientifically supported curriculum, and parent involvement, which are consistent with the criteria proposed by the federal CSRP (Borman, et al., 2002).

On measures of emotional functioning of youth, the CBCL and the CIS, the average scores of study participants were well in the clinical range. In addition, the students have had their emotional and behavioral problems for a long time. Although the average age of the participants was 14, parents reported first noticing a problem before age six. On average, students received outpatient therapy started at age 8 years and inpatient service occurred at age 9 years. In addition, they spent 61% of their school careers in special education. Currently, 63% of their day was being spent in special education classes and only 8% percent in a general education academic class.

A major aim of this study was to contribute information about current school reform activities and potential effects on students in special education programs who were identified as having ED. Although results of the study are mixed, some encouraging results emerged. First, the S1I was verified as able to cluster the schools into two distinct groups that clearly differed in the amount of school reform and improvement activity that was reported in the interviews. While there was a range of scores within each group, the average for HI schools was 28.9 and the average for LO schools was 2.8. Further, the lowest score for HI schools was 23.6 and the highest score for LO schools was 12.8, indicating that schools may be identified in terms of their level of engagement in reform activities. Our results suggest that schools engaging in higher levels of school reform may also be collaborating more frequently with community agencies to increase the capacity to provide mental health services for students who have ED, Mental health service providers may increase their opportunities for establishing partnerships with schools by becoming familiar with reform activities and supporting them where possible. For example, agency staff can volunteer to serve on School Improvement Teams that are part of the shared decision making process. Agency staff can offer school staff professional development opportunities with evidence-based practices focused on challenging behavior and other pro-social discipline strategies. Finally, provider agencies could provide parent support programs. All of these activities are consistent with reform goals identified in this study.

The demographic characteristics of the students in each group did not differ and neither did their scores on the CBCL and the CIS, indicating comparable levels of emotional functioning. There were, however, differences in measures of academic characteristics. Students who had ED in the HI schools spent significantly more time in general education classes with peers who did not have disabilities. They also spent a significantly greater time in academic general education classes than students with ED in the LO schools. The math scores for the HI schools were significantly higher than for the LO schools, though both were still below expected grade level. Reading scores were in the same direction, but not statistically significant.

The results of the measures of parent involvement were not consistent and are indicative of the complexity of parent involvement and the need for more comprehensive measure of this construct. For example, some of the questions about parent involvement concerned attending meetings in school. Debriefing with principals suggested that most of the meetings with parents were negative and concerned discipline issues. It may be that with no differentiation of the content of the meetings, parents in the LO schools reported attending more meetings than parents in the HI schools, and thus received a higher score on the involvement domain.

There were differences in mental health services between the two groups. The LO schools received more mental health services from school staff, while the HI schools received more services from community agency staff who delivered services in school during the school day. Importantly, students in the HI schools who received services from outside agencies received an average of 19.0 mental health service units per month, while students in the LO schools received 0.4 service units per month, less than once a week. It may be that pupil services staff in both sets of schools are typically understaffed, and therefore have to provide many ancillary services that are not directly aimed at psycho-social support and intervention, leaving less time to provide mental health services. However, schools engaged in more reform may have greater interaction with members of the community, facilitating the development of inter-agency agreements and increasing the units of mental health services their students receive with the addition of agency personnel.

The potential relationship between school reform and mental health services for students is important because as noted, there is interest in and research on refocusing mental health services to be more compatible with primary school goals (Adleman & Taylor, 2006; Atkins et al., 2010; Cappella, et al., 2008; Weist, 2005). School administrators are beginning to realize the link between psychosocial barriers to learning and scores on achievement tests (Adelman & Taylor, 2006). If mental health services researchers and providers develop a more in-depth understanding of school reform, they may be more effective in facilitating the provision of school-based mental health services, especially for students who have ED and who are served in special education programs. In the emerging role of "educational enhancers," mental health service providers need to become more focused on supporting teachers, both general education and special education, in providing effective instruction to students and effectively managing classroom discipline. Strategies to engage families, especially those who have a child with ED, are needed and are a natural area for mental health professionals to serve as a bridge between school and home.


Although the results of this study may be encouraging to the practice field and informative to researchers who are investigating school-based mental services, there are several factors that narrow the overall impact of the study findings. First, the small sample of convenience limits the generalizability of results; although it should be noted that demographic characteristics of the students are very similar to those in studies that have used nationally representative samples of participants. Second, the design employs a case study approach and there are no causal inferences possible from the results. Third, the SI1 is an instrument that classifies schools at a very broad level. As Borman, et al. (2002) point out, there is much variability found when investigating school reform. There are unknown school specific and program specific factors operating in the sample under investigation. A particular challenge in studies such as the current study is the possibility that results can be nested as a result of unknown school factors. When the student is used as the unit of analysis and multiple schools are examined, violation of the independence of error assumption may occur (Kutash, Banks, Duchnowski, & Lynn, 2007). Kutash and her colleagues found that variables focusing on emotional disturbance are less affected by nesting but school-related variables such as academic functioning are more affected. Since studies of school reform investigate student outcomes that vary across schools, it is important to identify these factors and to measure the fidelity of program implementation. In addition, we do not know the quality of the mental health services implemented in the schools and the degree to which they were evidence-based.

Nevertheless, the current study has identified a relatively low cost instrument, the SII, which may be a potential asset in studies of school reform. We have also produced results that offer some cause for optimism to those involved in educating students with ED. Characteristics of schools that are considered to be more engaged in the reform and improvement process appear to be related to more positive academic functioning for students with ED. Given the long history of poor progress for these students and the paucity of research that directly focuses on outcomes of students who have ED and their experience with the general education curriculum (Simpson, 2004), this study is a note of hope for this under-served and ineffectively served group of youth with disabilities.


In this era of high stakes testing and mandated school improvement, individual schools and school districts continue to anxiously engage in school improvement activities. This may offer an opportunity for the mental health system to contribute to improving outcomes for students by being cognizant of the requirements and mechanisms of school reform. Students who have disabilities and who are educated in special education programs present a new source of concern for school administrators as NCLB requires all students to take part in testing and all scores are calculated in a school's report card. Increasing access to mental health services for their students continues to be a challenge for schools. Effective school reform activities may provide an important facilitator of improved collaboration between the education and mental health systems, resulting in improved outcomes for students if effective interventions are used. As the role of mental health services becomes refocused on the core function of school, mental health professionals need to understand how factors related to school reform such as evidence-based instruction, effective classroom management and pro-social discipline can be supported through their expertise. A research agenda is needed that will support the development of this new role for school-based mental health services. As schools face continued awareness of the need to address psychosocial barriers to learning in their students, effective collaborative programs with community-based mental health service providers can provide a welcome support.


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A. J. Duchnowski and K. Kutash University of South Florida

Correspondence to Albert J. Duchnowski, Ph.D., University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612; e-mail:

This study was funded in part by Grant H133B990022 from the National Institute for Disability and Rehabilitation Research and the Substance Abuse and Mental Health Services Administration.
Table 1 Mean, Standard Deviation, and range for Total SII
Score and Scale Scores for schools classified as engaged
in greater levels of reform (HI) and schools with low
(LO) levels of reform efforts.

         Total  Governance  Accountability  Curriculum   Includedness
          SII                                   and
         Score                              Instruction

HI Schools

Mean      28.9         3.6             5.6          7.2           3.8

SD         5.9         1.4             3.6          2.0           4.2

Range     23.6  1.4 to 5.0     1.2 to 10.4   3.2 to 8.8   -2.0 to 9.0

LO Schools

Mean       2.6         2.7             2.7         -1.0          -3.1

SD         9.1         2.9             3.2          1.7           3.5

         -12.2     -2.8 to     -1.2 to 6.6  -2.8 to 1.2   -9.4 to 1.0
            to         4.6

           Parent     Pro-Social
         Involvement  Discipline

HI Schools

Mean             1.4         6.1

SD               2.8         2.3

Range    -1.2 to 4.8  3.2 to 9.2

LO Schools

Mean             0.3         1.1

SD               3.5         4.0

         -9.4 to 1.0     -4.0 to

Note: Scale scores on the SII can range from -12 to 12. Total
scores on the SII can range from a high of +72, indicating
greater levels of school reform activity/ to a low of -72,
indicating lower levels of school reform efforts.

Table 2 Academic and emotional functioning, time spent in general
education settings, and parent involvement for students in LO
schools and HI schools

Academic     LO Schools  HI Schools  Significance  Effect
and                                                 Size
Emotional      M(SD)       M (SD)

CBCL Total         62.4  57.8(26.1)        p=0.29  g=0,18
Score            (26.3)
                   n=67        n=83

CIS Score    19.0 (9.7)  17.5 (9.9)        p=0.36  g=0.15
                   n=67        n=83

WRAT Math    72.8(11.8)  77.7(13.6)         p=.02  g=0.38
Standard           n=67        n=83

WRAT               75.0  79.5(18.4)         p=.12  g=0.25
Reading          (16.3)
Standard           n=67        n=83

Percent of Week in General Education

Any genera]       27.8%       43.0%         p=.00  g=0.57
education       (21.9%)     (29.9%)
setting            n=67        n=83

Academic           3.4%       11.6%       p=.0()2  g=0.49
general         (11.3%)     (20.1%)
education          n=67        n=83

Parent involvement

Involvement   9.0 (3.5)   7.9 (3.4)          p=10  g=0.32
of all             n=48        n=64

Individual   26.6 (6.7)  22.6 (7.0)        p=.008  g=0.45
involvement        n=66        n=82

Table 3 Percentage of students who received mental health
services by provider type and number of service units
received per month for students in LO schools and HI schools

% of          LO         HI                     Effect
Students   Schools   Schools    Significance   Size

From any    62.7%    50.6%       p=0.14        OR=0.61
source     (n=67)   (n=83)

From        64.3%    28.6%        p<.01        OR=4.50
school     (n=42)   (n=42)

From        2.4%     42.9%        p<.01       OR=30.75
agency    (n=42)    (n=42)

Number of   M (SD)   M (SD)
Per Month

Service     16.7      18.8        p=.43         g=0.17
units     (10.4)    (13.3)
from        n=42      n=42

Service     15.1      11.8        p=.33         g=0.34
units      (8.6)    (11.7)
from        n=27      n=12

Service     0.4       19.0           NA             NA
units      (NA)      (6.4)
from        n=l       n=18
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