Mental Health Research in Tennessee Schools

About the Study

Mental health disorders among children have been steadily rising since the early 2000s. About 1 in 5 children are diagnosed with a mental health disorder each year, and about 2 in 5 children will meet criteria for a mental health disorder before they turn age 18. The COVID-19 pandemic accelerated the rates of children experiencing mental health conditions, with a doubling of the prevalence of depression and anxiety symptoms, at the same time that they were encountering deteriorating access to health care.

Schools are frequently firsthand observers of children’s emerging or existing mental health issues, and school-based health centers (SBHCs) can serve as an important source of regular care for their needs. We are funded by the National Institutes of Mental Health (1R01MH132686 – 01) to generate timely, generalizable knowledge on the implementation and impact of school-based health interventions for improving children’s mental health and education outcomes. We are advancing our understanding of the efficacy of SBHCs and other school-based supports by:

Analyzing longitudinal, linked health and education data on Tennessee children
Examining in-depth the organization and implementation of SBHCs and other school-based supports and how they are serving disadvantaged or underserved subgroups of children.

Research Objectives

While U.S. public schools are the most common institutional entry point to mental health services for children, there are significant gaps in our understanding of the effectiveness of school-based or school-linked health services and the extent to which they are reaching underserved subgroups of children. Few studies examine their effectiveness over time or in-depth, including the mechanisms by which school-based interventions and supports have the potential to improve children’s mental health outcomes.

We aim to fill these critical gaps in research and generate new knowledge on program and policy levers that schools can deploy to increase the effectiveness of their interventions and reduce inequities in children’s health and education outcomes. A key innovation of our research is our use of a high-quality, linked health and education dataset that includes the population of children in Tennessee who have a Medicaid record at any point in time since 2006. We are using these data to compare children in schools with and without access to SBHCs (and other similar interventions) to understand SBHC impacts on children’s mental health and educational outcomes over time and across place.

We will also generate timely new information on how SBHCs adapted their service delivery approaches during the COVID-19 pandemic and the extent to which disruptions in children’s access to mental and behavioral health services may have disproportionately affected disadvantaged children.

Research Methods and Materials

Methods Overview: We use variation in the presence of SBHCs and other resources such as Advancing Wellness and Resiliency in Education (AWARE) grants to estimate changes in children’s health and education outcomes before and after their introduction. In our empirical analyses, we are employing difference-in-differences and event-study-type estimation approaches to understand how the effects of SBHCs and AWARE grants may vary by factors such as the length of time they are operating, their structure and types of school-based health services provided, mental health staffing, and subgroups of children served.

We are also conducting interviews and site visits to document the resources available in school districts with an SBHC or AWARE grant, as well as a comparison sample of school districts without these resources, to better understand the landscape of mental health services for children across Tennessee. The information we are collecting allows for probing of the types of services that are being provided and to whom; how various resources and staffing have affected school district capacities for serving children’s mental health needs; and the sustainability of services and supports over time. We are also identifying “best practices” that could be more widely adopted in Tennessee and other states.

Data Overview: The high-quality, longitudinal, linked health and education dataset—encompassing the population of children in Tennessee enrolled in TennCare at any point since 2006—includes statewide administrative education data, Medicaid enrollment and claims data, hospital discharge data, and vital statistics. The linked data currently include approximately 1.7 million unique, low-income Tennessee children. The health and education measures we constructing with these data are described in this data brief.

This research article describes an algorithm we developed using the health insurance claims and enrollment data to measure adverse childhood experiences (ADM-ACE): https://pubmed.ncbi.nlm.nih.gov/35275403/.

We are currently linking additional years of data using a sophisticated probabilistic approach to generate the data files, where each student in the education data is linked to a likely case in the Medicaid enrollment data.

Research Team and Partners

Principal Investigators

Carolyn Heinrich, Vanderbilt University
Melinda Buntin, Johns Hopkins University

Co-investigator

Carrie Fry, Vanderbilt University Medical Center

Research staff

Daphne Penn, Assistant Professor, Vanderbilt University
Jennifer Russell, Professor, Vanderbilt University
Sunil Kripalani, Professor of Medicine, Vanderbilt University Medical Center

Laura Booker, Director, Tennessee Education Research Alliance (TERA)
Kaitlin Binsted, project coordinator, Tennessee Education Research Alliance
Dawn Schwartz, project assistant, Vanderbilt University School of Medicine

Yixuan Li, research associate, Vanderbilt University Medical Center

Huiping Sheng, research and programming support, Vanderbilt University Medical Center

Mason Shero, Visiting Assistant Professor, Denison University

Liliane Nienstedt, PhD student, Vanderbilt University
Kathryn Enriquez, PhD student, Vanderbilt University

Sara White, PhD student, Vanderbilt University

Kathryn Enriquez, PhD student, Vanderbilt University

Jason Sell, PhD student, Vanderbilt University Medical Center

Tatum Watson, PhD student, Vanderbilt University Medical Center

Audrey Kim, undergraduate student, Vanderbilt University

George Adae-Mensah, undergraduate student, Vanderbilt University

Isabelle Burg, undergraduate student, Vanderbilt University Medical Center

State of Tennessee Partners:

Tennessee Department of Education

Tennessee Department of Health

TennCare

Tennessee Department of Mental Health and Substance Abuse Services

Research Products

We aim to actively disseminate our study findings to ensure that they inform program strategies, policies, and evaluation tools for improving the efficacy of school-based health interventions for children.

NEW RELEASES!

Tennessee Education Research Alliance (TERA) brief: Examining the Role of School-Based Health Centers in Improving Mental Health Outcomes for Tennessee Students

Policy brief: Investments in Tennessee’s School-Based Mental Health Care Should Be Expanded, Funded to Meet Rising Need

Review Article

Children and Youth Services Review, 2023: Minding the gap: Evidence, implementation and funding gaps in mental health services delivery for school-aged children

2024 Research Presentations

Tennessee Coordinated School Health Institute, February 2024: How Tennessee Schools are Working to Improve Children’s Mental Health

Association for Education Finance and Policy Conference, March 2024: