Abstract
The coronavirus disease 2019 pandemic accelerated the impending youth mental health crisis in the United States, necessitating a comprehensive approach to providing mental health education and interventions. School-based occupational therapy practitioners’ scope of practice includes wellness promotion, early detection, and evidence-based interventions for mental health challenges. Given the rise of school-based wellness programs, the growing legislation supporting the formation of such programs, and the burgeoning burden of pediatric mental health concerns, occupational therapy practitioners are uniquely positioned to create and implement interventions to support student access to the general education curriculum and can do so by using both prepandemic funding sources and pandemic response funds. This Health Policy Perspectives column is a call to action to refocus the occupational therapy practitioner’s role in school settings to include providing high-quality, evidence-based preventive mental health education and interventions. In this column, we examine prevention-based occupational therapy services in Mason City Schools, Mason, Ohio, as a model of success in the execution of this vision for school-based practice. In addition, we outline the importance of expanding the role of occupational therapy practitioners in schools, which will in turn increase the visibility and relevancy of the profession and broaden its impact on mitigating the youth mental health crisis.
This Health Policy Perspectives column is a call to action to refocus the occupational therapy practitioner’s role in school settings to include providing high-quality, evidence-based preventive mental health education and interventions.
Although comprehensive data reflecting the far-reaching impact of the coronavirus disease 2019 (COVID-19) pandemic on U.S. mental health are still emerging, preliminary research has demonstrated the deleterious impact of the pandemic on people’s physical health and well-being. In its 2021 report COVID-19 and Mental Health: A Growing Crisis, Mental Health America (MHA; 2020) noted that “more people are reporting frequent thoughts of suicide and self-harm than have ever been recorded in the MHA Screening program since its launch in 2014” (p. 2) and observed that, during the data collection period of the study the group conducted, young people (ages 11–17) were experiencing the highest ever rates of suicidal ideation. After the onset of the pandemic, diagnosable behavioral and conduct concerns have increased significantly year after year, as unmet health care needs in the youth population have increased (Lebrun-Harris et al., 2022). The proportion of children’s mental health–related emergency room visits has also increased; from March 2020 to October 2020 there was a 24% increase in mental health–related emergency room visits among children ages 5 to 11 yr and a 31% increase among adolescents ages 12 to 17 yr, compared with the same time frame in 2019 (Leeb et al., 2020). However, even before the pandemic it was clear that youth across the country were showing signs of an impending mental health crisis (Lebrun-Harris et al., 2022). From 2016 to 2019, there was a 27% increase in diagnosed anxiety disorders and a 24% increase in diagnoses of depression in children, and this uptick continued through 2020 (Leeb et al., 2020). It appears that the COVID-19 pandemic served only to accelerate an already-growing mental health crisis.
Before, and in response to, this national crisis, a growing body of legislation focusing on student mental health emerged, with an emphasis on using mental health curricula to demonstrate the link between mental and physical health (Rivera, 2023). The Elementary and Secondary School Emergency Relief (ESSER) Fund, created by the Coronavirus Aid, Relief, and Economic Security Act (2020; Pub. L. 116-136), is intended to support initiatives that “prevent, prepare for, or respond to the COVID-19 pandemic” (U.S. Department of Education, 2021, p. 9), which includes “providing mental health services and supports, including through the implementation of evidence based full-service community schools” (U.S. Department of Education, 2021, p. 11). Numerous states, including Maine, South Carolina, and California, have enacted bills related to mental health curriculum requirements, and others, such as Tennessee and Utah, have passed bills that provide language and guidance in the support of mental health screening in schools (Rivera, 2023). Still more states have formed work groups, pilot programs, and commissions with a focus on policy and program development in regard to mental health programming for students (National Center for Youth Law, 2022; Rivera, 2023). It is evident that policymakers at both the local and national levels have recognized the severity of the mental health crisis and are working to rectify the shortcomings and advocate for a more comprehensive approach to mental health education in schools.
With this increased focus on creating and administering mental health curricula for both students and school communities, one might wonder who will be tasked with this monumental project. The intuitive answer would seem to be teachers and school counselors but, concurrent with the youth mental health crisis, the United States is also experiencing a great resignation in education—a degree of departure so sweeping that Becky Pringle, president of the National Education Association, called it a “five alarm crisis” (Rahman, 2022). The American School Counselor Association (2022) recommends a student-to- counselor ratio of 250:1, but the national average ratio in schools for the 2020–2021 school year, which was arguably the year when students most needed school counseling intervention, was 415:1. The high caseload numbers and nationwide counselor shortage, along with the increased need for school-based mental health intervention, make it impossible for school counselors to shoulder the entire burden of the current mental health crisis (U.S. Department of Education, 2021). In this column, we assert the importance of occupational therapy practitioners stepping up to fill the gap in mental health service provision by forging a path for the profession in the areas of prevention, wellness, and mental health education in schools.
Background and Context
In school districts across the country, occupational therapy practitioners have long been part of the educational team. Defined as a related service provider in the Individuals With Disabilities Education Act of 1990 (Pub. L. 101–476; 20 USC §1401[26; A]) and as specialized instructional support personnel (SISP) in the Every Student Succeeds Act (ESSA; 2015, Pub. L. 114–95; 20 USC §8002 [42]), they are qualified to provide support to all students. However, their services are most often underused in the provision of specialized therapeutic support for students with disabilities because educators and district administrators often lack a clear understanding of their vast skill set beyond the scope of special education and the distinct value they can bring to all students (Bolton & Plattner, 2020). Given the rising mental health concerns of school-age youth (Lebrun-Harris et al., 2022; Leeb et al., 2020) and the need for qualified mental and behavioral health providers (Long et al., 2022; Substance Abuse and Mental Health Services Administration, 2015), school districts should use ESSER funds and the current legislative momentum to support the hiring of additional occupational therapy practitioners so that the mental health and wellness needs of all students can be addressed. Drawing on emerging data regarding the current youth mental health crisis and our examination of a successful model of prevention-based occupational therapy services in Mason City Schools, Ohio, we demonstrate not only how occupational therapy practitioners can provide services within multitiered systems of support to meet the mental health needs of all students but also why they are uniquely qualified to do this work. This multitiered prevention model can serve as an example for school districts using ESSER funds to address the mental health and wellness needs of all students.
State Example: Mason City Schools, Ohio
Like many schools across the country, Mason City Schools, a suburban district in southwest Ohio, began to see a considerable increase in the need for behavioral and mental health support before the COVID-19 pandemic. The increased need for specialized instructional support within the general education environment became the catalyst for innovation about how public schools could refocus therapeutic services to meet the needs of all learners. As the district began to invest in this work, it became evident that advocacy and community support were needed to make the shift from a traditional educational model, whereby students with identified special needs receive services, to a public health approach—defined as a strengths-based, universal way to manage mental health education (American Occupational Therapy Association, 2017). District leaders intentionally sought input from stakeholders within the district and around the region (e.g., students, parents, community leaders, health care providers) to create a system of support that focused on the whole child and allowed all students to access nonacademic resources as a means of increasing learning and engagement.
Multitiered Systems of Support
District staff knew that to be successful they would have to refocus and expand the role of existing professionals on the team and foster a “paradigm shift to better prepare all school personnel (e.g., teachers, administrators, psychologists, social workers, related services providers) to proactively address the mental health needs of all students” (American Occupational Therapy Association, 2017, p. 2). District staff conducted a 3-yr pilot program at an early childhood center, using a service delivery model based on multitiered systems of support. As a result, occupational therapy practitioners were more involved in educational decision making, which contrasted their previous involvement with only Tier 2 (students identified as at risk for social–emotional difficulties) and Tier 3 (students identified as at greater risk or who already have some social–emotional difficulties).
The pilot program allowed occupational therapy practitioners to lead programming that focused on addressing the needs of the whole school or classroom (Tier 1), working as part of an interdisciplinary model to provide interventions at all tiers and work toward specific outcomes (Table 1). To be specific, the role of the occupational therapist in the interdisciplinary model was to collaborate with team members to ensure that programs included developmentally appropriate and trauma-sensitive interventions, incorporating sensory stimulation and experiences to help students remain successful in the general education environment. The program focused on developing students’ social–emotional skills using a multisensory approach facilitated by the interdisciplinary team. Students attended a group each day that was run by a specialist (e.g., speech-language therapist, physical therapist, counselor, school psychologist, mental health therapist). In addition, students had daily time built in for direct instruction focused on individual goal setting, coping strategies, and behavioral modification. The team also proactively scheduled each student in a multisensory environment as a way to address and minimize disruptive behavior in the classroom.
Tiered Services Provided by Occupational Therapists
The positive results of the pilot program led to the investment in a prevention-and-wellness team, which started with four interdisciplinary team members (two occupational therapists, a special education teacher, and a social worker) and has since expanded to include one supervisor of prevention and wellness (an occupational therapy practitioner), 21 school counselors, one prevention-and-wellness coordinator, four prevention-and-wellness designers (including one occupational therapy practitioner), two resource coordinators, 13 school-based mental health therapists, one nurse practitioner, a community liaison, and six therapy dogs, all focused on providing consistent wrap-around supports to students and families as a means of ensuring a well-rounded and successful academic experience.
Outcomes
During the first 3 yr of the pilot program, the district has increased mental health intervention from 2,500 hr/yr to more than 13,000 hr/yr, has seen an 85% increase in students who have been able to de-escalate problematic behavior and remain in the educational setting, has completed more than 400 risk assessments, and has been able to maintain an average of 80% access to care for mental health services. The outcomes achieved during the 3-yr pilot of the social–emotional programming at the early childhood center justified an increase in interdisciplinary mental health supports (individual and small-group intervention, therapeutic support provided on a walk-in basis, access to clinical mental health services within the school environment, etc.), and student-led advocacy, collaborative partnerships with community agencies, and reallocation and redesign of current district resources further solidified the plans to invest in a prevention-and-wellness team that would support the mental health of all students, staff, and community members. As the work has expanded, the team continues to function in a collaborative model, led by an occupational therapy practitioner, using the unique strengths of all ESSA-recognized SISP to enhance whole-child learning within the school setting.
The outcomes of the occupational therapy practitioner–led pilot program supported the district’s vision of addressing student mental health concerns and the occupational therapists’ vision of ensuring that all students were engaged in meaningful occupations fostered through positive adult relationships, supportive services, an inclusive culture, and a mentally healthy learning environment for all. The district’s approach to student well-being exemplified an innovation that expanded access and awareness of best practices for the school community, a funding priority outlined by the ESSER Fund. Mason City School’s pilot program epitomizes the mission and vision of ESSA to “provide all children significant opportunity to receive a fair, equitable, and high-quality education, and to close educational achievement gaps” (20 USC §6301) and further support the notion of occupational justice, whereby every individual has a right to equal opportunities and life chances to reach their potential (Wilcock & Townsend, 2009).
Conclusion
As members of interdisciplinary prevention and wellness efforts, occupational therapy practitioners have an increased value to schools. A growing number of youth are being diagnosed with mental health conditions and require interventions (Lebrun-Harris et al., 2022). Occupational therapy practitioners are recognized as SISP under ESSA and can help address the current shortage of qualified personnel needed to manage the mental health crisis that is affecting schools across the country. Given the urgent need for school-based prevention and wellness programs, and the reallocation of ESSER funds, school districts should adopt innovative and interdisciplinary models to address student mental health by using SISP as part of school-based mental health teams. Occupational therapy practitioners are uniquely positioned to lead the way by creating and implementing interventions and programs that support the whole child by increasing access to mental health interventions within the general education environment.
Nearly a decade after the reauthorization of ESSA in 2015, and in the wake of pandemic-responsive mental health legislation, schools across the country are only now starting to imagine what is possible. The example of Mason City Schools demonstrates how one district has expanded its capacity and used occupational therapy practitioner–led teams to provide a comprehensive approach to mental health education and intervention. As health care professionals with the skills to “bridge the therapeutic nature of mental and behavioral health services with . . . life skills development[,] and personal interactions while balancing those with client’s needs” (Wilburn et al., 2021, p. 1), occupational therapy practitioners have the capability to play a key role in school-based prevention and wellness programming that encompasses training professional educators and school-based staff in the area of mental health, including but not limited to trauma, behavioral regulation, and sensory integration (Blackwell & Bilics, 2018; Cahill et al., 2020; Fraser et al., 2019).
Footnotes
Acknowledgments
We extend our gratitude to Susan Cahill for her support in writing this article. Her endless guidance and her insightful feedback were instrumental in crafting this piece. In addition, we thank the American Occupational Therapy Association’s Policy Team for their expert knowledge of federal policy and continued advocacy for the implementation of federally funded wellness programs in education.