Promising Practices for School Organization of Mental Health Supports

#Counseling, #Stress and coping, #Student supports

This brief synthesizes research insights to examine how schools can better organize mental health supports to meet growing student needs. It highlights why schools have become the primary access point for youth mental health care, the systemic barriers that limit effective support, and the equity implications of current approaches. Drawing on evidence-based and promising practices, the brief outlines strategies that help schools move from reactive, crisis-driven responses toward coordinated, preventive systems—such as embedding services in schools, partnering with community providers, using universal screening, and leveraging educators as key implementers—while also identifying common practices that can unintentionally exacerbate disparities or undermine student well-being.

We gratefully acknowledge the EdResearch for Action Advisory Board members— Abby Quirk, Jill Gurtner, Karissa Sullivan, Sarah Chin, Shannon Garfield —whose expertise as education leaders brought critical, practice-driven insights to guide this brief.

Jennifer Greif Green | Boston University

Joni Williams Splett | University of Florida

January 2026 | Brief No. 38

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Central Question

How can schools effectively leverage resources to meet students’ mental health needs?

Key Insights

BREAKING DOWN THE ISSUE

Youth depression, anxiety, and suicide have risen over the past decade.
Students with mental health challenges are less likely to graduate on time and more likely to miss school and struggle academically.
Over half of youth in need of mental health services do not receive them, especially in underserved communities facing provider shortages and financial barriers.
Schools are the primary source of mental health care for children, yet only 56% of school leaders believe their schools can effectively provide mental health services to all students in need.
The primary barriers to providing mental health care in schools are: (1) staff and provider shortages, (2) funding and resource constraints, (3) challenges in identifying student needs and bias, and (4) misaligned roles and focus on reactive rather than preventative activities.

EVIDENCE-BASED PRACTICES

Locating mental health services within schools significantly increases service uptake and improves mental health outcomes for students.
Effective collaboration between school leaders, school-based mental health professionals, and community mental health providers expands available services and improves student access to mental health supports.
Schools that provide a continuum of supports and services (including school-wide programming and targeted supports for students with greater need) use resources more efficiently and are better prepared to address student needs.
Universal mental health screenings are linked to higher rates of mental health service use among students with mild to moderate disorders.
Educators are critical to effective school-based mental health support, not only in delivering targeted, evidence-based practices, but also in influencing peers to adopt them.
When schools implement practices that are grounded in students’ lived experiences, family norms, and community contexts, students are more likely to trust providers, engage in services, and benefit from interventions.

PRACTICES TO AVOID

Reliance on disciplinary actions and emergency services to address student mental health needs can escalate crises and disproportionately impact marginalized students.
When school-based mental health providers are assigned non-mental health tasks, schools underuse their expertise, and students may not receive adequate support.
When schools treat academics and mental health as a zero-sum game, they will miss opportunities to effectively support students with the highest needs who are often struggling in both areas.

Breaking Down the Issue

What is mental health?

Mental health refers to the emotional, psychological, and social well-being of individuals that affects their ability to cope with daily life, learning, and their community.

Youth depression, anxiety, and suicide have risen over the past decade.

Survey results from 2023 show that 40% of high school students reported experiencing persistent feelings of sadness or hopelessness in the past year, an increase from 30% in 2013. This percentage was higher for females than males, with over half (53%) of female students reporting these feelings in 2023.
Nearly 20% of children in the U.S. experience a diagnosable mental, emotional, or behavioral disorder, such as anxiety, depression, or ADHD, in a given year.
The COVID-19 pandemic caused a sharp rise in youth mental health challenges, especially in communities hardest hit by the crisis.
In 2023, suicide was the third leading cause of death for 15–19-year-olds, with rates rising faster among LGBTQ+ and Black students compared to their peers. In 2023, 20% of teens said they seriously considered attempting suicide in the past year.

Students with mental health challenges are less likely to graduate on time and more likely to miss school and struggle academically.

Students experiencing mental health problems are less likely to graduate high school on time and have lower educational attainment than their peers. Within school, students with mental health problems tend to have lower achievement scores and higher rates of persistent absenteeism.
Students with anxiety and depressive symptoms report higher rates of suspensions and expulsions than their peers.

Over half of youth in need of mental health services do not receive them, especially in underserved communities facing provider shortages and financial barriers.

On average, most youth who meet with a mental health provider attend only 1-2 sessions, which means that even when youth do meet with a mental health provider, they often do not receive regular, ongoing care necessary for effectiveness.
There are substantial racial/ethnic, socio-economic, and geographic disparities in access to mental health services in community/outpatient settings. For example, studies consistently show that White youth more often receive mental health services in community settings than Black and Latino/a youth. Families living in poverty are also less likely to access mental health services, due to a combination of factors including affordability, accessibility, and stigma.

Schools are the primary source of mental health care for children, yet only 56% of school leaders believe their schools can effectively provide mental health services to all students in need.

Schools are the top location where youth receive mental health services, closely followed by outpatient settings. Almost all public schools (96%) report providing some mental health services to their students. The most commonly offered services are one-on-one counseling or therapy (84%), case management or coordination of services (70%), and referrals to providers in the community (66%).

The primary barriers to providing mental health care in schools are:

1. Staff and provider shortages:
- Insufficient staffing is the most frequently cited barrier to providing care.
- Even when funding is available, many positions go unfilled due to low graduation rates from regional programs.
2. Funding and resource constraints:
- Lack of sustainable funding (for staff salaries, program materials, training, support services) is a frequent barrier.
- Many schools lack the capacity to offer key services like mental health assessments—only 55% of public schools provided these in 2019–20.
3. Challenges in identifying student needs and bias:
- Schools often struggle to accurately identify which students need mental health support. Referral processes can be influenced by implicit bias, cultural misunderstandings, and inconsistent criteria, leading to over-identification of some groups (e.g., Black boys for behavioral concerns) and under-identification of others (e.g., multilingual learners, or students from cultures that stigmatize mental health).
- Educators are often more likely to notice and be concerned with visible behavior issues than challenges youth may experience internally, like anxiety or depression. Further, students with visible behavioral issues are more likely to be identified for services than those with less easily observable challenges.
- In youth, visible behaviors are also often manifestations of internalizing challenges. For example, anxiety often shows up externally as behaviors that can be misinterpreted as irritability, rudeness, or anger. At the same time, school staff sometimes hold biases, whether consciously or not, associating aggression and anger more with Black youths than their White peers. These visible behaviors can lead to disciplinary referrals, with Black students being disproportionately disciplined for behaviors like aggression, anger, and disrespect than White students. Together, these patterns suggest that systemic mechanisms and implicit racial bias may lead school staff to interpret Black students’ behavior as misconduct rather than an underlying mental health need.
4. Misaligned roles and focus on reactive rather than preventative activities:
- School mental health providers are often overwhelmed with crisis response and high-need cases, leaving little time for preventive programs like social-emotional learning and universal screening. There is evidence that prevention-focused activities, like universal screening, lead to students being identified and connected with services more quickly, thereby reducing the need for crisis response.
- Role ambiguity can result in mental health staff taking on non-mental health responsibilities, such as serving as a testing coordinator, further limiting their ability to implement preventive programming and comprehensive interventions.

Evidence-Based and Promising Practices

Multiple models of school-based mental health service delivery have been designed to address challenges to providing preventive and comprehensive support to students. These models generally include the following five research-backed strategies: locating mental health services within schools, collaborating with community mental health providers, providing a comprehensive continuum of services, using universal screenings, and leveraging existing staff and resources.

Locating mental health services within schools significantly increases service uptake and improves mental health outcomes for students.

Bringing mental health professionals into schools through models such as school-based health centers and Expanded School Mental Health programs significantly increases access and service use.
When mental health services are available at school, students are more likely to use them, and racial and ethnic disparities in access shrink or disappear altogether as barriers like cost and transportation are reduced.
Evidence from multiple states underscores the benefits. In Oregon, students attending schools with health centers reported lower rates of depressive episodes, suicidal ideation, and suicide attempts across all demographic groups. In Tennessee, districts that introduced school-based health centers saw a 7% reduction in diagnosed mental health conditions among low-income students compared to similar districts without these supports.
When implemented effectively, Expanded School Mental Health models improve care coordination, increase service uptake (by nearly 17% compared to community referrals), and reduce special education referrals for emotional and behavioral issues.

Effective collaboration between school leaders, school-based mental health professionals, and community mental health providers expands available services and improves student access to mental health supports.

The Interconnected Systems Framework (ISF) helps schools and community providers coordinate mental health and behavioral supports more effectively, leading to more students receiving services, fewer disciplinary incidents, and improved student engagement.
Clear delineation of roles and responsibilities is critical for effective partnerships. A Memorandum of Understanding (MOU) can increase the effectiveness and transparency of these partnerships, clarify the financial model, and resolve logistical issues that often arise (e.g., space needs, referral protocols, access to wifi).
Clear referral processes for community-based services help staff understand which community services are available and how to connect students to them. This requires mapping local resources to school needs, documenting access factors (e.g., language, cost), and forming district-community leadership teams to support collaboration.
For high-need students receiving services across sectors, coordinated care is essential to avoid conflicting recommendations and ensure consistent support. Case studies and lessons learned from partnerships can provide examples for school districts seeking to bolster their care coordination.

Schools that provide a continuum of supports and services (including school-wide programming and targeted supports for students with greater need) use resources more efficiently and are better prepared to address student needs.

Simply hiring more mental health staff is not enough to improve student support. This study found that the student-to-provider ratio in schools was less important in determining whether students received mental health services than how providers used their time (e.g., providing early intervention services).

Schools implementing universal social-emotional learning (SEL) programs show significant improvements in students’ social-emotional competencies and increases in academic performance.
Early identification and low-intensity interventions (e.g., check-in/check-out, small group counseling) have been linked to improved student behavior and reduced referrals for special education or disciplinary action.
Students in schools with integrated mental health supports are more likely to access services before symptoms become severe, leading to better long-term mental health outcomes. The ISF integrates mental health practices and professionals into schools’ existing multi-tiered support systems, including Positive Behavioral Interventions and Supports (PBIS). At Tier 1, ISF aligns behavioral expectations with social-emotional learning for all students. At Tiers 2 and 3, it combines mental health screening and discipline data to identify students in need and provide targeted, low-resource interventions like check-in/check-out systems, small group counseling, and mentoring programs. ISF also improves coordination among providers, reducing duplication and increasing efficiency.
Cost-benefit analyses show that prevention-oriented school mental health programs can yield long-term savings by reducing the need for more intensive clinical or special education services.

Universal mental health screenings are linked to higher rates of mental health service use among students with mild to moderate disorders.

Research-based mental health screeners help schools proactively identify students who may need support before issues escalate. Screeners help schools move beyond relying solely on teacher referrals or visible behavior, which can be inconsistent or biased, and ensure all students, not just those who act out or are already receiving attention, are considered for support.
Dual-factor screeners assess both students’ challenges and strengths, helping schools focus on promoting positive mental health, not just reducing symptoms.
Schools do not need to screen every student annually; many use targeted screenings at key grade levels or transition points (e.g., 3rd, 5th, and 7th grade) to monitor changes.
Successful implementation of screening requires the following:
- Collecting and storing screening data securely and ensuring access to data is only provided to trained personnel.
- Communicating with families to explain the purpose and process of screenings, as well as their rights in the process, helps build trust and reduces misunderstandings or concerns about how data will be used. Including and prioritizing family, community, and student voice is a key component of equity-focused mental health screening.
- Using multiple informants improves the accuracy of screening results. Teacher-completed screeners tend to be more reliable for assessing externalizing symptoms, like acting-out behaviors. For internalizing symptoms like anxiety or depression that may not be as visible to adults, self-report measures are recommended.
- Establishing clear systems for promptly reviewing screening results and connecting students to appropriate interventions helps ensure timely support. Implementation guidelines and materials can be found here and here.
Piloting the screening process on a small scale allows schools to troubleshoot logistics, train staff, and build trust with families before expanding the effort system-wide.

Educators are critical to effective school-based mental health support, not only in delivering targeted, evidence-based practices, but also in influencing peers to adopt them.

A meta-analysis found that interventions delivered by school staff are most effective when they are focused on delivery to the students who need them the most, use clear strategies to promote positive behavior, are integrated into academics, occur frequently, and focus on externalizing behaviors like disruption, aggression, or noncompliance.
Teachers are more likely to use recommended classroom strategies when their trusted teacher peers (not just outside mental health professionals) encourage and model them. In this study, teachers identified as opinion leaders had a bigger influence on their colleagues than mental health providers alone, showing that peer leadership can play a powerful role in spreading effective practices in schools.

When schools implement practices that are grounded in students’ lived experiences, family norms, and community contexts, students are more likely to trust providers, engage in services, and benefit from interventions.

Existing frameworks, such as the culturally responsive, antiracist, and equitable (CARE) approach, provide foundations for schools to center equity in their MTSS models and provision of mental health services, which include building family-school-community partnerships for minoritized communities and supporting and training the workforce.

While it is important for all school mental health professionals to provide culturally and linguistically sustaining services, a diverse, representative workforce improves communication, builds trust, and leads to more equitable identification and support of students’ mental health needs.

Practices to Avoid

Reliance on disciplinary actions and emergency services to address student mental health needs can escalate crises and disproportionately impact marginalized students.

Exclusionary discipline practices predict worsening student mental health, yet students with mental health needs are more likely to be suspended or expelled than their peers. However, this does not mean that every disciplinary action reflects an inappropriate response to a mental health issue. If a disciplinary action is necessary, it should be paired with follow-up supports that address the student’s underlying needs rather than treating discipline as the primary intervention.
Black students and students with disabilities are disproportionately affected by exclusionary discipline.
Police are frequently called upon to respond to mental health crises in schools despite the fact that these situations rarely require law enforcement action or result in contact with the criminal justice system. This raises questions about whether police are the most appropriate responders. Further, contact with police in schools is associated with heightened symptoms of depression.

When school-based mental health providers are assigned non-mental health tasks, schools underuse their expertise, and students may not receive adequate support.

Mental health providers in schools report spending large portions of their time on administrative tasks, testing, supervision, or discipline-related duties that fall outside their mental health expertise. This misalignment reduces their capacity to deliver preventive care, provide counseling, support crisis response, or collaborate with teachers and families to address student needs.
When school mental health teams don’t have clearly defined roles, staff may duplicate efforts, miss critical tasks, or be pulled into duties outside their expertise, leading to confusion and inefficiency. By clarifying each team member’s role and leveraging their specific strengths, schools can better coordinate efforts and ensure that providers have the time and focus to deliver preventive care and early intervention.

When schools treat academics and mental health as a zero-sum game, they will miss opportunities to effectively support students with the highest needs who are often struggling in both areas.

Research is clear that improved mental health and well-being are associated with improved academic functioning. Both can and should be prioritized in school settings.
Teacher preparation can set the tone for integrating mental health and well-being in teachers’ conceptualization of their professional role. Just as early childhood and elementary educators often focus on whole-child wellbeing, extending this practice through adolescence acknowledges the many youth who concurrently struggle academically and emotionally.

This EdResearch for Action Project brief is a collaboration among:

Funding for this research was provided by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the foundation.