Predictors of Disparities in Access and Retention in School-Based Mental Health Services

Introduction: Over 18 million children and adolescents experience mental health problems, yet only a third of those youth receive treatment (Merikangas et al., 2011). Youth of color are significantly less likely to access mental health care than their white peers despite similar levels of need for services (Garland et al., 2005; Snowden & Yamada, 2005). Research indicates that even when youth of color initiate mental health services they are more likely to terminate prematurely (Haan et al 2014; Wolf et al., 2014). Disparities in unmet mental health needs contribute to a range of negative outcomes that occur disproportionately for low-income youth and youth of color, such as school dropout, youth violence, and juvenile justice involvement.

Schools provide convenient access points for mental health services, reducing barriers to treatment that plague traditional outpatient settings, such as transportation, health insurance, and parental involvement. Despite promising evidence that school mental health (SMH) services can reduce disparities in access to mental health care, little is known about what predicts retention in SMH services. The objective of this study was to determine which factors contribute to disparities in access and retention of SMH services.

Methods: Existing data were analyzed for 17,348 students (2,205 who received SMH services) who attended 17 middle and high schools in an urban school district. Student-level predictors included sex, race/ethnicity, and mental health need at intake. School-level predictors included grade level (middle vs. high school), student/teacher ratio, percent white students, and percent of students receiving free or reduced lunch. Hierarchical generalized linear modeling was used to examine the association between student- and school-level variables and retention in care.

Results: White, Latino, and Asian students were less likely to access SMH services; Multi-racial and Native American students were more likely to access services, and African American students were no more or less likely. Hierarchical models found that retention in services was more likely for female students, those who presented with social/educational problems, internalizing problems, and trauma/abuse/neglect, and less likely for Asian students. Retention was also more likely for students in middle schools, schools with a lower student/teacher ratio, and schools with a smaller percentage of students eligible for free or reduced lunch.

Conclusions: While SMH services show promise in increasing access for underserved groups, ensuring equitable retention of students in care will likely require concerted effort focused on consistently engaging students and ensuring quality of care.