COMMITMENT • INTEGRITY • LEADERSHIP	View full PDF report View Selected Abbreviations
Youth Suicide Prevention Local Educational Agencies Lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self‑Harm Report Number: 2019-125

Audit Results

None of the Six LEAs We Reviewed Have Adopted Adequate Youth Suicide Prevention Policies

To ensure that LEAs take the actions necessary to prevent youth suicides, the State has established suicide prevention policy requirements and identified best practices. However, none of the six LEAs we reviewed have adopted policies that fully met these requirements and best practices. State law required that before the beginning of the 2017–18 academic year, all California LEAs that serve pupils in grades 7 through 12 adopt suicide prevention policies that address certain key topics, including suicide intervention and prevention. In addition, state law required that the LEAs consult with school and community stakeholders, school‑employed mental health professionals, and suicide prevention experts when adopting these policies. At the Legislature’s direction, Education published a model policy in May 2017 for the LEAs’ use. This model policy highlights best practices that suicide prevention organizations recommend, such as identifying primary and secondary liaisons to whom staff report known or suspected suicidal intentions and providing students with education about mental health challenges.

Although state law does not require LEAs to adopt Education’s model policy, the model policy contains numerous best practices, and therefore we expected the LEAs to have incorporated the concepts it contains into their own policies. Nonetheless, all six of the LEAs we reviewed lacked suicide prevention policy elements that either state law or the model policy identify. As Table 1 shows, these missing elements include the appointment of a suicide prevention point of contact and establishment of a response team—also known as a postvention team—to convene after a suicide. Without these elements, the LEAs may be unprepared to identify warning signs or provide resources for students at risk. For example, the establishment of a response team is important because the suicidal behavior of one student may reduce other students’ inhibitions against suicide. A systematic response can reduce the likelihood of clusters of suicides by providing at‑risk students with support and guidance.

Table 1
The LEA Suicide Prevention Policies We Reviewed Lacked Crucial Elements

Requirement or Best Practice	San Francisco Unified	Ukiah Unified	Kern High School District*	Gateway Charter	Redwoods Charter*	Heartland Charter*
Requirements in State Law
Addresses suicide prevention, intervention, and postvention procedures	YES	YES	YES	YES	NO	YES
Addresses needs of at‑risk groups, such as LGBTQ youth and youth in foster care	YES	YES	YES	NO	NO	YES
Constructed in consultation with community stakeholders	NO	NO	NO	NO	YES	NO
Education’s Best Practices
Includes provision to share policy and other information with parents, guardians, and caregivers	YES	YES	YES	YES	NO	NO
Appoints an individual or team to serve as a suicide prevention point of contact to assist other staff	NO	NO	YES	YES	NO	YES
Identifies a primary and secondary suicide prevention liaison to whom staff should report a student’s known or suspected suicidal intentions	YES	YES	YES	YES	NO	NO
Requires annual professional development training related to suicide prevention for staff	YES	NO	YES	YES	NO	YES
Outlines how suicide prevention education will be provided to students	YES	YES	YES	YES	NO	NO
Requires establishment of a postvention response team	YES	NO	YES	YES	NO	NO
Includes an action plan for in‑school suicide attempts	YES	YES	YES	YES	NO	†
Includes an action plan for out‑of‑school suicide attempts	NO	NO	NO	YES	NO	YES

Source: State law, suicide prevention materials from Education, and LEA policies.

Note: Education’s model policy is located at https://tinyurl.com/suicidepreventionCA.

* We reviewed suicide prevention policies that were in effect during the 2019–20 academic year. After we notified the LEAs of the deficiencies we identified, they indicated that they had updated their policies to address some of our concerns.

^† Heartland Charter is a home‑study school and does not have protocols for in‑school suicide attempts.

When we discussed these deficiencies with the LEAs, they offered a number of different reasons for deviating from Education’s model. The three charter schools acknowledged the gaps we identified, and their administrators stated they would update their policies as necessary. The three school districts explained that their policies were based on a model that the California School Boards Association (School Boards Association) published in March 2017, two months before Education introduced its model policy. The School Boards Association is a nonprofit organization that provides districts with sample policies and administrative procedures, among other services. The director of instruction at Kern High School District indicated that the district began developing its policy before Education released its model but would update its policy to include the missing elements. Staff at both Ukiah Unified and San Francisco Unified stated that some of the required elements missing from their policies exist in other documents and processes. Although incorporating materials into a policy by reference to other documents is reasonable, their suicide prevention policies did not contain references to those relevant documents.

Although Education’s program consultant for mental health services (program consultant) believes that the School Boards Association’s policy is sufficient for compliance with state law, the policy omits several best practices that Education’s model includes. For example, the School Boards Association’s policy discussed suicide prevention training but did not recommend that LEAs provide it annually as the model does. In addition, the policy did not address creating an action plan for incidents of suicide or self‑harm that occur outside of school. According to the program consultant, LEAs should adopt robust policies to ensure that the schools have adequate processes and training in place to respond to mental health crises. Nonetheless, an assistant executive director at the School Boards Association stated that most of the State’s school districts and county offices of education have access to the School Boards Association’s model, and many may have relied on it when developing their suicide prevention policies. Widespread reliance on a policy that does not include many best practices may mean that numerous LEAs do not have the best tools available to prevent youth suicide.

According to one of Education's program consultants, the School Boards Association developed its model without collaborating with Education. Although the program consultant was aware of the alternative policy, Education has not contacted the School Boards Association to ensure that the policy contains necessary requirements and sufficient detail. The program consultant acknowledged that increased coordination could have benefited both entities’ model policies. She asserted that Education intends to contact the association in the future but did not have time to do so before the 2017–18 academic year when state law required the policies to take effect.

In addition, none of the LEAs we reviewed could demonstrate that they obtained feedback from all of the relevant stakeholders when constructing their policies. As the text box shows, state law and Education’s model policy identify the groups that LEAs must or should involve when developing suicide prevention policies. However, we found that the actual stakeholders and experts that LEAs involved varied. For example, Kern High School District convened a suicide prevention committee that included mental health professionals, school district law enforcement representatives, school administrators, and other school staff. In contrast, Ukiah Unified’s superintendent explained that the LEA primarily relied on its board and school counselors to approve and update its policy. In particular, we noted that the LEAs generally did not involve community stakeholders or suicide prevention experts. Only Redwoods Charter was able to demonstrate that it involved a representative from a community organization.

The LEAs gave different reasons for not including all required stakeholders. Heartland Charter’s executive director explained that the charter school organization to which it previously belonged provided the suicide prevention policy and that Heartland Charter was unaware of the requirements to consult stakeholders. San Francisco Unified’s director of safety and wellness explained that although the district did consult with local community organizations and the county's department of public health, it did not keep records of the meetings. Administrators at Gateway Charter, Kern High School District, and Ukiah Unified all asserted that they involved the groups necessary for creating an effective policy. However, the LEAs’ consistent failure to include community groups suggests that they may not fully recognize the benefits of doing so. For example, individuals in certain groups at higher risk of suicide can benefit from policies, procedures, and resources specifically tailored to their needs. The lack of outside stakeholder involvement may result in some LEAs’ policies failing to meet the specific needs of their communities.

Some LEAs We Reviewed Have Not Provided Adequate Training to Their Faculty, Staff, and Students on Preventing Suicide

The LEAs’ inadequate training programs may limit the effectiveness of their suicide prevention efforts. Although the State does not mandate training for school personnel, state law does outline which elements such training must include if LEAs provide it—such as identifying school‑based mental health services and how to refer students to them. In addition, a number of organizations recommend suicide prevention training for all personnel. However, only one of the six LEAs provided training to their faculty and staff that included all the legally required elements we reviewed. Compounding these deficiencies, some LEAs did not provide training to all staff or they provided training months after the school year began. Further, some LEAs provided only limited education to students regarding suicide prevention, even though studies have identified positive associations between providing students with suicide education and improvements in factors related to reducing suicide rates. The LEAs’ failure to adequately educate their faculty and staff about suicide prevention is likely due in part to the costs associated with effective training.

Some of the LEAs We Reviewed Did Not Fully Train Staff on Identifying and Assisting Students at Risk of Suicide

Because school personnel are in an ideal position to observe student behavior and to recognize and respond to signs of crises, a coalition of organizations engaged in suicide prevention efforts, including the American Foundation for Suicide Prevention, recommends providing all school personnel with training regarding youth suicide prevention. Similarly, Education’s model policy recommends that LEAs train staff to recognize suicide warning factors and risk factors and that LEAs identify local populations of students who are at an elevated risk for suicide, including LGBTQ youth. Although state law does not mandate training on suicide prevention, it does require that if LEAs conduct such training, the training materials must include information on how to identify appropriate mental health services—both at the school site and within the larger community—and when and how to refer youth and their families to those services.

Although all six LEAs we reviewed provided suicide prevention training during the 2019–20 academic year, each failed to include one or more of the elements in state law or Education’s model policy. These deficiencies may leave teachers and staff unprepared to identify and assist students at risk of self‑harm and suicide. Of the six LEAs we reviewed, five did not include components mandated by state law for training their teachers and staff. For example, as we show in Table 2, Gateway Charter, Kern High School District, Heartland Charter, and Ukiah Unified used training materials that did not include information on community‑based mental health services and procedures for referring students to them. In contrast, San Francisco Unified’s training materials included simple flowcharts identifying whom staff should contact for assessing students who are at risk of harming themselves or others, as well as alternatives if the initial contact is not readily available. These flowcharts also emphasize the importance of an immediate referral and describe the mental health resources available both on‑site and off‑site.

Table 2
In Academic Year 2019–20, None of the LEAs’ Trainings We Reviewed Included All of the Elements Identified in State Law and Education’s Best Practices

	San Francisco Unified	Ukiah Unified	Kern High School District	Gateway Charter	Redwoods Charter	Heartland Charter
State law requires training to:
Identify school‑based mental health services and when and how to refer students to them	YES	NO	NO	YES	NO	NO
Identify community‑based mental health services and when and how to refer students to them	YES	NO	NO	NO	YES	NO
Education recommends training to:
Discuss high‑risk groups	YES	NO	YES	NO	NO	YES
Discuss all three elements of suicide identification: risk factors, warning factors, and protective factors	NO	NO	YES	NO	YES	YES
Discuss trends identified in data on self‑harm incidents and suicides within the LEA’s region	YES	NO	NO	NO	NO	NO

Source: Analysis of state law, Education’s suicide prevention model policy, interviews with Education personnel, and academic year 2019–20 training materials at the six LEAs.

In addition, all of the LEA training programs we reviewed lacked one or more of the suicide prevention training and education elements that Education describes in its model policy. Specifically, Education recommends that suicide prevention training include discussion of suicide risk factors, warning factors, and protective factors, as Table 3 indicates. However, as Table 2 shows, three of the LEAs did not train teachers and staff on all three elements. Youth who are contemplating suicide frequently exhibit signs of their distress, and teachers and staff trained to identify these warning signs are in key positions to obtain help and prevent suicide attempts.

Table 3
Education Recommends That Suicide Prevention Training Include Specific Elements

Key Elements	Description	Examples	Impact of Training
Risk factors	Characteristics of a student that increase the likelihood of suicide.	• Prior suicide attempt(s)	Staff are aware of students experiencing risk factors and can keep watch for changes in their behavior.
		• Mental disorder(s)
		• Access to lethal means of harm
Warning factors	Behaviors that indicate immediate risk for suicide.	• Giving away prized possessions	Staff can more effectively identify students who show signs of suicidal thinking and can take immediate steps to help.
		• Searching online for methods to end life
		• Showing rage or displaying extreme mood swings
Protective factors	Characteristics that help protect a student from suicide.	• Effective behavioral health care	Staff can create an environment that enhances protective factors and reduces likelihood of suicide attempts.
		• Connectedness to family and community

Source: Education’s model policy, HEARD Alliance’s Toolkit for Mental Health Promotion and Suicide Prevention, Suicide Prevention Resource Center’s website, and American Foundation for Suicide Prevention website.

Even though Education’s model policy indicates that training should include additional information regarding high‑risk groups of students, such as LGBTQ youth, three LEAs that provided training did not follow this best practice. According to the 2012 National Strategy for Suicide Prevention produced by the Office of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention, some risk and protective factors may be more important to one group than another. For example, San Francisco Unified’s training material includes statistics on the demographics of its students who have attempted or have considered suicide categorized by gender, sexual orientation, and race. When San Francisco Unified found that a higher than average percentage of its Filipino middle school population had seriously considered suicide, it developed additional training specific to this group and identified culturally appropriate resources. In contrast, when LEAs do not identify and provide training related to high‑risk groups, teachers and staff may not be aware of the relevant warning signs, risk factors, and resources, which may impede their ability to reduce suicide risk in the populations that most need the help.

Some LEAs appear to have prioritized convenience over compliance with state law and Education’s best practices when selecting suicide prevention training materials. For example, according to the charter school organization to which it previously belonged, Heartland Charter selected the training video it uses from a list of options preapproved by its insurance plan, without its staff reviewing any of the other options. Kern High School District’s human resources administrator stated that it chose its online training program—even though it lacked certain elements—because it allowed employees to easily complete a number of required trainings before the start of the academic year. When we discussed missing elements in their training material, staff at both San Francisco Unified and Ukiah Unified referenced other efforts that they believed addressed the missing concepts. However, because this information was not included in the training, it is not clear if it was provided to all faculty and staff. When LEAs do not proactively work to ensure that their trainings meet requirements in state law and best practices, teachers and staff may not have all the knowledge or confidence necessary to respond appropriately when students are at risk of suicide.

Some of the LEAs We Reviewed Did Not Provide Training to All Teachers and Staff in a Timely Manner

Only four of the six LEAs provided training to both teachers and staff, even though Education recommends that training be provided to all adults at school sites at least annually. We reviewed the training provided by one school overseen by each of the six LEAs, and only four provided suicide prevention training to both teachers and staff, as Table 4 shows. According to Gateway Charter’s assistant principal, the school does not require some staff members in nonteaching and support positions, such as coaches, security guards, and secretaries, to receive suicide prevention training because they are needed to supervise the students while teachers are attending the training. Ukiah Unified’s director of alternative education, on the other hand, stated that by providing training to teachers, the district’s policy exceeds the State’s requirements. Although providing suicide prevention training to all staff may present challenges, many different individuals at a school communicate with its students throughout the day. In acknowledgement of this, a 2019 report on mental health services in public schools suggested that school districts should teach everyone who works with students—including teachers, staff, bus drivers, and cafeteria workers—how to identify and respond to a student in crisis and what resources are available.

Table 4
Only Four of the LEAs We Reviewed Provided Suicide Prevention Training to Both Teachers and Other Staff During Academic Year 2019–20

	San Francisco Unified	Ukiah Unified	Kern High School District	Gateway Charter	Redwoods Charter	Heartland Charter
	Civic Center  Secondary School Grades 7–12	Ukiah High School Grades 9–12	Bakersfield High School Grades 9–12	Gateway Public High School Grades 9–12	Accelerated Achievement Academy Grades 4–12	Heartland Charter School Grades K–12
Provided suicide prevention training to teachers	YES	YES	YES	YES	YES	YES
Provided suicide prevention training to other staff	YES	NO	YES	NO	YES	YES
Provided training within three months of students beginning classes	NO	NO	YES	YES	YES	YES

Source: Auditor analysis of attendance records and staffing information at all six LEAs we reviewed for academic year 2019–20.

Note: We selected one school for review from each LEA we visited.

Some LEAs we reviewed also did not ensure that teachers and staff members obtained suicide prevention training in a timely manner, which may have limited the impact of the training. Our analysis of Public Health’s suicide data from 2009 through 2018 indicated that the number of youth suicides increased by 16 percent during the first three months of the academic year. The HEARD Alliance suggests educating teachers and key staff before the school year begins or during staff development days. However, two of the six LEAs did not conduct their training within the first three months of their school years. For example, Ukiah High School did not provide training until more than five months after students began attending classes. According to Ukiah Unified’s superintendent, the school held other staff trainings before providing the suicide prevention training because state law does not require the suicide prevention training to be held by a particular date. The social worker responsible for providing the suicide prevention training at San Francisco Unified’s Civic Center Secondary School stated that he did not provide the training until six months after students began attending classes because he did not have the time to effectively do so. However, if teachers, school counselors, and others who work closely with students do not receive training in a timely fashion, they may be ill‑equipped to spot the signs of a student in distress during a period when the rate of youth suicide has historically increased.

Some of the LEAs We Reviewed Are Not Educating Students on Suicide Awareness and Prevention

LEAs can bolster their suicide prevention efforts by providing students with comprehensive suicide awareness and prevention education. Multiple studies have identified positive associations between providing student suicide education and improvements in factors related to reducing suicide rates. For example, a 2015 study of Connecticut high school students found that a program intended to increase the students’ abilities to identify warning signs of suicide and depression and to understand the importance of seeking help resulted in significantly fewer self‑reported suicide attempts over the following three months. It also resulted in more favorable student attitudes toward seeking help for themselves and friends. Education recommends that LEAs provide developmentally appropriate curriculum to students about the warning signs of mental health issues, including suicide. Although such a curriculum encourages students to seek and receive potentially lifesaving services, state law does not currently require LEA suicide prevention policies to address self‑harm or suicide prevention education for students.

The LEAs we reviewed have taken different approaches toward educating students about suicide prevention. Gateway Charter, Kern High School District, and San Francisco Unified incorporate suicide prevention lessons into student curricula. In contrast, although Ukiah Unified’s suicide prevention policy requires the provision of suicide prevention education as part of its health curriculum, its director of alternative education admitted that in practice it is not consistently provided. Meanwhile, Redwoods Charter explained that it does not require any suicide‑related lessons before students’ senior year. Redwoods Charter’s codirector explained that while the school’s policies do not require student suicide prevention lessons, it does offer occasional mental health outreach activities, such as student‑organized compilations of mental health resources that resulted in teacher‑led discussions. However, we question the value of this approach because ensuring that students receive comprehensive suicide prevention education in accordance with Education’s best practices may help reduce the stigma associated with seeking help and increase the number of students who seek assistance.

We also have concerns about the approach that Heartland Charter used. As the Introduction describes, Heartland Charter conducts much of its instruction through distance learning. Because of the limited in‑person interaction between instructors and students, we expected Heartland Charter to provide a robust student education suicide prevention program to ensure that its students are comfortable contacting an adult if they are experiencing a mental health crisis. However, Heartland Charter did not provide any suicide prevention education to its students when we initially spoke to school representatives. According to Heartland Charter’s executive director, it generally does not provide standard curricula to all its students because doing so would be contrary to its structure as a home‑study school. After discussing this issue with the audit team, the executive director indicated that she would explore adding curriculum elements related to suicide prevention, and Heartland Charter subsequently distributed activity plans and resources on this subject to parents.

We are concerned that such omissions may occur in other distance learning environments, particularly as many of the State’s LEAs have transitioned to distance learning recently because of the COVID‑19 pandemic. Education’s program consultant stated that Education is in the process of creating information regarding suicide prevention to distribute to educators and parents, but as of July 2020, it had not finalized a plan. Without appropriate guidance and resources, the lack of suicide prevention education we identified at Heartland Charter may be present at other LEAs conducting instruction through distance learning.

Education and the San Diego County Office of Education Have Provided an Online Suicide Prevention Training Program, but Few LEAs Will Have Access to It

According to Education’s program consultant, many LEAs struggle to provide suicide prevention training for their teachers and staff because of a lack of funding. For example, Redwoods Charter’s principal explained that because of a lack of funding and difficulties in identifying available training in the Ukiah area, the school encourages its teachers to attend a training that the Mendocino County Office of Education provides at no cost to Redwoods Charter. The Mendocino County Office of Education’s special projects manager pointed out that although some LEAs rely on that free training, others do not take advantage of it because of the limited availability of substitute teachers and the costs associated with hiring them while their teachers are at the training. She also stated that this training is not specific to suicide prevention but rather is designed to teach participants how to help adolescents experiencing mental health or addiction challenges. Education’s program consultant explained that the training in question is basic in nature, does not incorporate all of the best practices identified in Education’s model policy, and should not be used as an LEA’s annual suicide prevention training.

The struggle to establish and provide adequate suicide prevention training extends beyond the LEAs in Mendocino County. According to the program consultant at Education, many LEAs, including some in rural counties such as Trinity and Mendocino counties, as well as others in urban counties such as Los Angeles, Orange, and Contra Costa, do not have the resources to establish their own training or to pay for their staff’s time to take the training. A 2012 study shows that suicide prevention training increases school personnel’s perceived knowledge about and confidence in responding to distressed youth. Without adequate training, LEAs reduce the likelihood that their faculty and staff will respond appropriately to students at risk of self‑harm and suicide.

The Legislature provided Education with an opportunity to facilitate statewide suicide prevention training. In 2018 it passed a state law requiring Education to identify an online training program that LEAs could use to train both staff and students on suicide awareness and prevention. The law required Education to provide funding to a county office of education to acquire and disseminate the program to other LEAs statewide, and the Legislature appropriated a one‑time amount of $1.7 million for these purposes. In October 2019, Education selected the San Diego County Office of Education (SDCOE) to provide and promote the online suicide prevention training program. SDCOE entered into a $1.3 million contract with a vendor to create an online suicide prevention training. The vendor supplied its preexisting online training and agreed to provide it to a total of 66,000 school personnel and students. According to Education, the funding the Legislature appropriated could not meet the training needs of all middle and high school staff and students in California, but it is advocating for the State to continue funding the training program in subsequent years. However, we question whether this is a cost‑effective approach to providing such training. At the rate the vendor charged for the licenses, it will cost more than $13.5 million per year to provide this training to every LEA teacher and staff member throughout the State.

The training Education has selected will currently be provided to a small proportion of the State’s teachers and staff—only 600 individuals in each county—with the remainder allocated to students. Consequently, many LEAs must continue to rely on their current trainings. Further, Education’s program consultant stated that many LEAs may not be interested because they offer their own training already or contract through a vendor, and Education will consider the program a success if all 66,000 licenses are used. As we describe previously, each of the suicide prevention trainings provided by the LEAs we reviewed lacked one or more of the elements described in state law or Education’s best practices. However, because none of the LEAs we reviewed incorporated all of the elements in their trainings, it is likely that many other LEAs throughout the State are also providing training that lacks one or more of the elements that the law requires. To ensure that these trainings adequately address the needs of at‑risk students, Education should reach out to LEAs throughout the State to encourage them to adopt the legally required elements.

None of the State’s LEAs Employ the Recommended Number of Mental Health Professionals

None of the State’s LEAs employ the recommended number of each type of mental health professional even though research indicates that access to mental health professionals decreases the likelihood of youth suicide. Mental health professionals provide academic, career, and psychological counseling to students, as well as social development and physical health services. In 2001 the Legislature required Education to perform a comprehensive study to determine the appropriate ratios of school counselors and other student support service personnel to students in California schools. Based on recommendations from professional associations, Education’s study established recommended mental health professional‑to‑student ratios for the four positions the text box describes.

Research indicates that access to mental health professionals decreases the likelihood of youth suicide. One study that examined the use of health and mental health care services among youth who died by suicide and comparable youth who did not found that the likelihood of suicide significantly decreased when youth had more frequent mental health visits. Moreover, research has shown that school counselors—one type of mental health professional—can improve academic outcomes while also helping to reduce the risk factors associated with higher rates of suicide, such as impulsive or aggressive tendencies, isolation, and a history of alcohol or substance abuse. In fact, studies have found that better student‑to‑counselor ratios were associated with improved discipline, attendance, and graduation rates. Further, according to a 2010 study, increased funding for school counselors or adopting a minimum counselor‑to‑student ratio in elementary schools resulted in fewer teachers reporting problems with students fighting, cutting class, and using drugs.

Despite the importance of these support staff, many of the LEAs in the State reported that they did not employ the recommended number of mental health professionals in even a single category during the 2018–19 academic year. Education requires LEAs to submit staffing data, and we used those data to determine whether they met Education’s recommended ratios. We found that none of the 1,034 LEAs that reported staffing information met Education’s recommended ratios in all four of the mental health professional categories. In fact, 25 percent of the LEAs reported they did not have mental health professionals in any of the four categories. Further, fewer than 5 percent reported having the recommended number of mental health professionals in the individual categories of school counselors, school nurses, and school social workers, as Table 5 shows. To account for schools with a surplus of certain types of mental health professionals and deficiencies in others, we also standardized the four ratios into one and analyzed the data using this broader combined ratio. Even so, only 3 percent of LEAs met this combined ratio.

Table 5
The State’s LEAs Reported Employing Fewer Than the Recommended Number of Mental Health Professionals During the 2018–19 Academic Year

Type	Recommended Professional‑to­‑student ratio	Number of the 1034 LEAs that met the recommended ratio	Percentage of LEAs that met the recommended ratio	Number of the 1034 LEAs with no professionals	Percentage of LEAs with no professionals
School counselors	1:250	33	3%	350	34%
School nurses	1:750	28	3	547	53
School social workers	1:800	11	1	937	91
School psychologists	1:1000	248	24	433	42
Met all four ratios		0	0	260	25
Combined ratio*	15:2000*	35	3	NA

Source: Education’s 2003 Study of Pupil Personnel Ratios, Services, and Programs, and analysis of Education’s staffing and enrollment data.

* For every 2,000 students, LEAs should employ a combined total of 15 school counselors, school nurses, school social workers, and school psychologists.

When we asked Education why so few LEAs met the recommended ratios, one of its program consultants stated that budgetary constraints limit LEAs’ ability to hire and retain mental health professionals. In addition, he said that LEAs face pressure to increase salaries for faculty and staff, and that LEAs have little leverage to earmark funds to hire and retain mental health professionals because state funds are not restricted for specific purposes. Nonetheless, given that the State’s rate of youth suicide has continued to rise, we are concerned that LEAs are consistently prioritizing other expenditures.

Much like LEAs in the rest of the State, the six LEAs we reviewed did not employ the recommended number of mental health professionals. According to their payroll data for fiscal year 2018–19, none employed the recommended number of mental health professionals in every category, as Table 6 shows. For example, San Francisco Unified met only two of the four ratios, even though its staffing levels were, on average, the closest to the recommended ratios of the six LEAs we reviewed. In contrast, Kern High School District employed only 21 percent of the school nurses and 53 percent of the school psychologists required to meet the recommended ratios. Even more concerning, each of the three charter schools employed only one of the four types of mental health professionals. Gateway Charter and Redwoods Charter indicated that they want to increase mental health services but that they currently lack funding to do so. Heartland Charter’s executive director indicated that Heartland Charter has increased its staffing since the 2018–19 school year and that she believes it is meeting its students’ needs. However, even with the increase she described, Heartland Charter would be employing only 44 percent of the school nurses, 15 percent of the school counselors, and none of the school social workers required to meet Education’s recommended standards. Consequently, students attending these schools do not have access to the recommended level of mental health professionals, despite the fact that the suicide rates in Kern and Mendocino counties exceed those of the majority of the counties in the State.

Table 6
The Six LEAs Failed to Meet Most of Education’s Recommended Ratios for Mental Health Professionals During Fiscal Year 2018–19

		Staffing level met
Professional‑to‑student ratio		San Francisco Unified	Ukiah Unified	Kern High School District	Gateway Charter	Redwoods Charter	Heartland Charter
School counselors	1:250	106%	115%	84%	127%	84%	*
School nurses	1:750	76	47	21	0	0	*
School psychologists	1:1000	102	163	53	*	0	59*
School social workers	1:800	95*	0	64	0	0	0

Source: Analysis of Education’s enrollment data, documentation from Gateway Charter and Heartland Charter, and payroll data from Heartland Charter, Kern High School District, Redwoods Charter, San Francisco Unified, and Ukiah Unified.

Note: In the categories above, we included individuals whose position descriptions indicated they provided mental health services to students, regardless of their educational attainment or certification status.

* The LEA informed us that there were individuals providing services in this category of mental health professional; however, they were unable to quantify the time these individuals spent providing services. Therefore, we did not include them in our analysis.

Education’s program consultant acknowledged the undeniable need for student service staff and student support programs to prevent youth suicide. However, he asserted that a statewide program to fund mental health professionals at LEAs is unlikely because of the State’s current focus on local control of education spending. Nonetheless, ensuring that youth have access to mental health services is crucial to addressing the State’s rising suicide rates.

School‑Based Health Centers Could Effectively Provide Mental Health Services to Students

Our review of effective suicide prevention practices found that school‑based health centers (school health centers) that provide mental health services can help offset school staffing shortages by leveraging other funding sources. School health centers are located on or very near school grounds and, depending on the health professionals they employ, may provide a variety of physical and mental health services, such as mental health care, immunizations, substance abuse counseling, oral health care, and nutrition education. Other entities, such as community health centers or local health departments, often support school health center operations and may employ the physicians, nurse practitioners, mental health professionals, and other medical support staff. Our review found that both the state of Oregon and San Francisco Unified have successfully established school health centers that provide positive outcomes for students. The State attempted to address this issue in 2007 when it required Public Health’s predecessor to establish a program to support the development of health centers, a responsibility it later assigned to Public Health. However, as we discuss later, Public Health never developed the program, and at present, school health centers only serve a small proportion of California’s students.

Oregon and San Francisco Unified’s School Health Centers Increase Access to Mental Health Care

Research has consistently demonstrated that school health centers increase youth access to mental health care, which is associated with a reduction in the factors that lead to youth suicides and self‑harm. For example, a 2003 comparison of high school students’ use of school health centers and of community health clinics found that a significantly higher percentage of visits to the school health centers were for mental health reasons, leading the authors to conclude that these centers have a unique role in increasing youths’ use of mental health services. A 2018 review of studies on school health centers concluded that they increase access to health care, decrease the cost of care, and are well positioned to provide mental health services. These studies suggest that students use school health centers when they are available and that school health centers can provide the mental health services that serve as protective factors against suicide.

Oregon’s school health centers illustrate how California could increase the provision of mental health services to students. According to a 2018 study, Oregon students at schools with health centers offering additional mental health services were less likely to think about or attempt suicide. In addition, annual reports from the Oregon Health Authority (Oregon Health) on its school health centers indicate that the centers provide mental health services to students who might not otherwise have access to them. In 2020 Oregon Health reported that all 79 certified school health centers in the state employed on‑site behavioral health providers, a category that encompasses mental health and substance abuse services, and that 42 percent of all visits from clients of ages 5 through 21 during the 2018–19 academic year were for behavioral health reasons. Further, 67 percent of the school health centers were located in health professional shortage areas, a federal designation for defined geographic areas that have a shortage of primary care, dental, or mental health providers relative to the local population. California has a large number of such areas; in fact, in 2020 there were 1,623 health professional shortage areas in the State. Oregon’s example illustrates how California could use school health centers to increase the provision of mental health services to students and thus decrease the likelihood of suicide attempts in areas with limited access to care.

In addition to state appropriations, Oregon’s health centers rely on a number of sources of revenue, including grants, health insurance billing, and donations. Oregon provided counties with about $60,000 per school health center each year from 2017 through 2019. According to Oregon Health, currently the total cost to the state for the health center program—including staff at the state level—is $18.5 million. However, for every dollar of state public health funding, school health centers obtain more than three and a half dollars from other sources, such as federal Medicaid funds. About 59 percent of the individuals receiving services from the school health centers were insured through public programs, and another 21 percent were covered through private insurance. Thus, school health centers are able to draw on other funding sources for a significant portion of the services they provide. We discuss opportunities for California’s LEAs to take similar advantage of federal funding later in this report.

San Francisco Unified’s wellness initiative (wellness program), which includes 18 school health centers, has also reduced barriers to students’ obtaining mental health services. From 2009 through 2018, San Francisco County had one of the lowest youth suicide and self‑harm rates of California’s counties. San Francisco Unified initiated its wellness program in 2000 with two pilot school health centers and has since expanded it to include centers at all of its high schools. School health centers such as these reduce barriers to care, such as cost and transportation, by offering services on campus at no cost to students or their families. According to the vendor that maintains San Francisco Unified’s health care service database, the wellness program has consistently served more than half of the student population.

San Francisco Unified collaborates with a number of other organizations to provide the wellness program, and several factors have contributed to the program’s success. According to its safety and wellness director, its partnerships with two county agencies—the Department of Children, Youth and Their Families and the San Francisco Department of Public Health—allow the district to leverage existing resources. Specifically, these resources include a mixture of local, state, and federal funds that are used to support the wellness program. He also stated that San Francisco Unified’s partnership with a local nonprofit organization, Richmond Area Multi‑Services, Inc. (RAMS), has allowed the district to expand its provision of mental health services.

Public Health Has Not Established a School Health Center Support Program as the Law Requires

More than a decade ago, the Legislature took steps to support the creation of additional school health centers, but Public Health’s inaction has impeded these efforts. In 2007 a state law required Public Health’s predecessor, the Department of Health Services, to establish the Public School Health Center Support Program (support program) to provide assistance to LEAs in establishing, maintaining, and expanding school health centers. It also directed the support program to provide LEAs—including charter schools—with technical assistance, which may include identifying sources of funding, such as local grants and federal Medi‑Cal reimbursement programs, to create new school health centers or expand those already in place. The then‑governor stated that this law was a step toward his goal of creating 500 school health centers. In 2009 the Legislature added a grant component—which is contingent on funding—to the support program law authorizing Public Health to provide grants to improve existing health centers or to develop new health centers.

However, as of July 2020, Public Health had not established the support program, thus depriving LEAs of the assistance in establishing, retaining, and expanding school health centers that such a program would provide. According to Public Health’s Center for Healthy Communities deputy director (deputy director), Public Health has not put into place activities to assist schools because of a lack of staff and resources. Nonetheless, it received a total of $1.2 million across two fiscal years—2016–17 and 2017–18—which she acknowledged was for the support program. She stated that these funds were not enough to sustain a full support program; however, she also stated that Public Health has not requested additional funds. The Legislature mandated that Public Health create and administer the support program, and it provided Public Health with more than $1 million with which it could have done so. Thus, we expected Public Health to have created the support program and, if unable to do so, to have requested any necessary additional funding.

Although Public Health has not met the statutory requirement to create the support program, it has gathered some information that could inform the development of such a program. Specifically, it used portions of the $1.2 million that the Legislature appropriated to complete two reports in 2018. These reports provide information on how other states fund and staff similar programs, as well as the results of school health center administrator surveys describing school health center needs, services, challenges, and funding sources. In addition, Public Health established a work group that includes representatives of Education and the California School‑Based Health Alliance (CSHA).

Public Health’s deputy director also stated that it has no formal plans to establish the support program because it has not identified a sustainable funding source. As we previously describe, none of the six LEAs we reviewed—or any of the other 1,034 LEAs reporting staffing information to Education—employed the recommended number of mental health professionals in all four categories during the 2018–19 academic year. Further, according to CSHA, fewer than 280 school health centers had been established across the State as of 2019—as Figure 7 shows—and these school health centers provide access to services for just 4 percent of the total number of students enrolled in kindergarten through grade 12. A robust support program could assist LEAs in creating additional school health centers and leveraging existing MHSA and Medi‑Cal funds to improve mental health professional‑to‑student ratios.

Figure 7
As of 2019, Few School Health Centers Existed in the State

Legislative funding for the grant component established in 2009 could facilitate the creation of school health centers in underserved counties with high rates of suicide and self‑harm. For example, Mendocino County—which has a higher‑than‑average rate of youth suicide—has nine schools that each serve more than 100 high school students. Using Oregon’s school health center funding formulas for state assistance, establishing nine school health centers would cost about $855,000 in planning costs and an additional $504,000 annually for operating costs. State law requires the support program to provide assistance to LEAs, which may include identifying additional funds, such as federal and local grants, to cover the additional costs and would require grantees receiving funds for operating costs to become Medi‑Cal providers.

Given the demonstrated benefits that school health centers offer, it is unclear why the State has not done more to ensure their implementation, particularly in its underserved areas. In the absence of adequate mental health professional staffing, the State’s rates of suicide and self‑harm have continued to climb. Had the support program been established, it would have required grantees to provide or have a plan for providing a variety of services in response to community needs, including mental health services.

Some LEAs Have Not Sought Local and Federal Funding That Could Increase Students’ Access to Mental Health Professionals

All of the LEAs we reviewed rely on state funding for the majority of their spending on mental health professionals. However, by seeking federal and local funding, they could increase the number of mental health professionals they employ and thus better ensure that students have adequate access to mental health care. For example, the San Francisco County Department of Public Health uses MHSA funding to pay for mental health professionals on San Francisco Unified's campuses. In addition, the State’s billing option program—which we describe in the Introduction—allows LEAs to receive federal reimbursement for 50 percent of the costs of certain health‑related services. Although some LEAs consider the administration of the billing option program to be overly burdensome, they can partner with their county offices of education to centralize administrative responsibilities. However, Education and Health Care Services—the agency that administers the program for the State—have not adequately ensured that all LEAs are aware of the opportunity to partner with their county offices of education.

Some LEAs Have Not Pursued MHSA Funding for On‑Campus Mental Health Care

According to Education’s program consultant, because state law does not mandate specific levels of spending or staffing, LEAs decide how much to spend on mental health services. Not surprisingly, the LEAs we reviewed spent significantly different amounts per student on mental health care, as Table 7 shows. For example, San Francisco Unified’s total spending per student on mental health professionals exceeded $800 per student, whereas Kern High School District spent $511 per student. The LEAs that spent the most per student on mental health professionals—San Francisco Unified and Ukiah Unified—met more of the staffing ratios Education recommends, as we previously describe.

Table 7
The Six LEAs’ Spending on Mental Health Professionals Differed Substantially During Fiscal Year 2018–19

	San Francisco Unified*	Ukiah Unified	Kern High School District	Gateway Charter	Redwoods Charter	Heartland Charter
Total spending on mental health professionals	$20,858,000	$2,371,000	$20,393,000	$360,000	$92,000	$237,000
Number of students enrolled at middle and high schools	25,320	3,164	39,884	788	297	3,396
Mental health professional spending per student	$824	$749	$511	$457	$310	$70
	School Districts	Charter Schools
Average mental health professional spending per student	$695	$279

Source: Analysis of Education’s enrollment data, documentation from Gateway Charter and Heartland Charter, and payroll data from Heartland Charter, Kern High School District, Redwoods Charter, San Francisco Unified, and Ukiah Unified.

* San Francisco Unified’s mental health spending includes the cost of a contract with RAMS to provide mental health professionals in its school health centers that is paid by the San Francisco Department of Public Health.

Although on average the three school districts we reviewed spent considerably more on mental health professionals per student than the three charter schools—$695 and $279, respectively—the charter schools stated that they leveraged resources from other entities to provide some additional mental health services. For example, Gateway Charter administrators indicated that two San Francisco Unified school psychologists work at Gateway Charter two or three days per week and that Gateway Charter does not pay for these positions. Heartland Charter’s deputy executive director explained that mental health professionals from the charter school organization to which it belonged at the time provided services to it and other charter schools. Finally, Redwoods Charter’s chief financial officer stated that staff refer students with mental health issues to community organizations that provide services at no cost. Because we could not quantify the services that these other entities provided to the charter schools, they are not reflected in our analysis. However, even under a generous interpretation of the additional capacity represented by these other resources, the three charters did not provide sufficient numbers of mental health professionals to meet Education’s recommended staffing ratios. 

The LEAs that spent the most per student were able to do so in part because they obtained funds from other sources to augment what they spent from their state appropriations. As Table 8 shows, all of the LEAs we reviewed relied on state funding for more than half of their budgets for mental health professionals. Moreover, two of the charter schools relied on state funding for 100 percent of these expenditures. However, state funds represented only 56 percent of mental health professional expenditures at San Francisco Unified, which came the closest to meeting Education’s staffing ratios. Similarly, Ukiah Unified’s percentage of state spending for mental health professionals represented 74 percent, and it was also the second closest to meeting the recommended staffing ratios.

Table 8
LEAs Relied on State Funds for the Majority of Mental Health Professional Spending in Fiscal Year 2018–19

	San Francisco Unified	Ukiah Unified	Kern High School District	Gateway Charter*	Redwoods Charter	Heartland Charter
Total mental health professional spending†	$20,858,000	$2,371,000	$20,393,000	$360,000	$92,000	$237,000
Percent of mental health professional spending from federal sources	6%	24%	7%	0%	26%	0%
Percent of mental health professional spending from state sources	56	74	93	100	74	100
Percent of mental health professional spending from local sources	38	2	0	0	0	0

Source: Analysis of documentation from Gateway Charter and payroll data from Heartland Charter, Kern High School District, Redwoods Charter, San Francisco Unified, and Ukiah Unified.

* Gateway Charter indicated all of its funding came from state sources; however, because Gateway Charter does not actively track how it uses specific funding sources, we could not confirm the sources of the funds it used for mental health services.

^† Mental health costs consist of salary and benefit costs associated with personnel providing services directly to students. We excluded administrative positions.

Although augmenting state funds with funding from other sources appears to be crucial to improving staffing ratios, five of the six LEAs we reviewed were not even aware of one of these other sources of funding—local MHSA funds from their respective counties. As the Introduction describes, the State passed the MHSA in 2004 in part to expand mental health care services for children with a focus on prevention and early intervention services. Nonetheless, only San Francisco Unified used MHSA funds to employ mental health professionals. Specifically, the San Francisco Department of Public Health uses some MHSA funds, in addition to local and federal funds, to pay for the services that RAMS provides to San Francisco Unified. Representatives from the other five LEAs we reviewed indicated that they were unaware of MHSA funds.

LEAs Have Not Consistently Used the Billing Option Program to Obtain Federal Reimbursement for Providing Mental Health Services

Health Care Services oversees the billing option program, which allows LEAs to seek federal reimbursement for 50 percent of their costs to provide medically necessary health‑related services to Medi‑Cal‑eligible students by qualified medical practitioners. During fiscal year 2017–18, LEAs received nearly $134 million through the billing option program. In late April 2020, Health Care Services received approval to expand access to Medi‑Cal reimbursement through the program. Before 2020, reimbursement for Medi‑Cal‑eligible students without an individualized education program (IEP) was limited. An IEP is a plan created for those students with a learning disability or health impairment. For example, a student without an IEP was limited to six hours of counseling per fiscal year; however, the program’s expansion in 2020 eliminated this restriction. Additionally, CMS made this approval effective July 2015, allowing LEAs to claim reimbursement for services they had already provided. Based on the California Health and Human Services Agency’s data, more than 49 percent of the State’s population under the age of 20, or more than five million individuals, were eligible for Medi‑Cal as of July 2019.

To decrease the administrative burden of the billing option program, LEAs can partner with their county offices of education. According to Health Care Services’ Medi‑Cal Claims and Services Branch Chief (branch chief), LEAs’ participation in the billing option program is voluntary because some do not have the capability to handle the administrative tasks and costs. Ukiah Unified’s director of student services echoed this concern, indicating that submitting claims through the billing option program requires LEAs to either hire additional staff or use existing staff who do not have the time or necessary expertise. However, Ukiah Unified has addressed these constraints by partnering with the Mendocino County Office of Education, which performs all of the administrative tasks necessary to obtain reimbursement. According to the Medi‑Cal manager at Mendocino County Office of Education, this approach centralizes the administrative responsibilities at the county level and reduces the burden to the LEA of obtaining reimbursement for the services it provides. The billing option program allows LEAs to pool resources, such as sharing practitioners' and administrative staff, to provide services. The Health Care Services branch chief identified an additional advantage of centralizing these administrative responsibilities: it decreases the number of LEAs that must register with Health Care Services as Medi‑Cal providers. Of the state’s 58 county offices of education, 54 are already registered through Health Care Services as Medi‑Cal providers.

Although the billing option program represents a significant potential source of funds for LEAs, according to Health Care Services data, only 600 of the State’s 2,400 LEAs participate in the program, including Kern High School District, San Francisco Unified, and—through the Mendocino County Office of Education—Ukiah Unified. Health Care Services was unable to tell us which LEAs were not participating in the program because, like Ukiah Unified, some LEAs participate through their respective county offices of education. Thus, it is unclear how many of the 1,800 LEAs that are not Medi‑Cal providers participate in the billing option program.

Education and Health Care Services could better inform LEAs of the option to partner with their county office of education. By seeking reimbursement for the services they have provided, LEAs could supplement their existing mental health services budgets. State law assigns Health Care Services the responsibility of communicating with LEAs and collaborating with Education to increase LEA participation in the billing option program. Although Health Care Services has conducted some outreach regarding the program’s expansion through in‑person and online trainings, these efforts were primarily focused on existing participants because Health Care Services does not actively send information about the program to nonparticipating LEAs. According to its branch chief, Health Care Services does not have the staff necessary to conduct additional outreach efforts, and it does not actively track which LEAs do not participate in the program; rather, it relies on Education to forward information on the billing option program to nonparticipating LEAs.

Education’s administrator for school health and safety indicated that it has sent some information about the billing option program expansion to all LEAs on behalf of Health Care Services. However, as we describe earlier, it is unclear how many of the 1,800 LEAs across the State that are not Medi‑Cal providers take advantage of this program. Further, according to the branch chief for Health Care Services, it has not informed LEAs of the option to leverage county offices of education to handle the administrative tasks associated with the billing option program. Until Health Care Services and Education take a coordinated approach to informing LEAs about this option, some LEAs are less likely to take advantage of these federal funds, which they could use to improve students’ access to the mental health care they need.

Recommendations

Legislature

To increase students’ access to mental health services, the Legislature should provide funding for Public Health to award grants for a pilot program that would establish school health centers at a selection of LEAs located in counties with high rates of youth suicide and self‑harm. The Legislature should require Public Health to collaborate with Education to collect data on the pilot program and to provide annual reports on the effectiveness and cost of the program. If the school health center program is deemed affordable and effective, the Legislature should consider expanding it to LEAs throughout the State.

Education

To promote the adoption of the best practices that it has identified, Education should remind LEAs of the elements in its model policy. To do so, it should annually send a notice to all LEAs that describes suicide prevention resources, such as the model policy, and encourages their use. Education should also work with external organizations that maintain model policies, including the School Boards Association, to encourage the development of policies that are consistent with state law and best practices by no later than September 2021.

To encourage LEAs to incorporate elements of suicide prevention training that provide teachers and staff with the knowledge necessary to assist students at risk of self‑harm and suicide, Education should remind all LEAs of the statutorily required elements for suicide prevention training.

To support the provision of suicide prevention education to students at LEAs operating through distance learning, Education should complete and issue to LEAs the resources and guidance it is developing on how to conduct suicide prevention education remotely.

Health Care Services

To ensure that LEAs take full advantage of federal funds for Medi‑Cal‑eligible students, Health Care Services should work with Education to inform LEAs that they may partner with their county offices of education to centralize the administrative responsibilities necessary to obtain reimbursement through the billing option program.

Public Health

To support LEAs’ efforts to provide mental health services, Public Health should establish the support program for school health centers as state law requires. If Public Health lacks the funding to do so, it should request additional funds as needed. The support program should assist LEAs in establishing school health centers and in identifying and applying for available funding as authorized by law, such as Medi‑Cal reimbursement and MHSA funds.

LEAs

To ensure that their teachers and staff have the information necessary to respond consistently, promptly, and appropriately to reduce suicide risk, the six LEAs we reviewed should revise their policies by March 2021 to comply with state law and incorporate the best practices in Education’s model policy.

To ensure that their teachers and staff have the knowledge necessary to identify and assist students at risk of self‑harm and suicide, the six LEAs we reviewed should do the following:

• Revise their suicide prevention training materials by June 2021 to align with state law and incorporate the best practices in Education’s model policy.
  
• LEAs that provide suicide prevention training should conduct it at the beginning of the school year.
  

To improve their students’ access to mental health professionals, Kern High School District, Ukiah Unified, Gateway Charter, Redwoods Charter, and Heartland Charter should coordinate with their respective counties to request MHSA funding to employ additional school counselors, school nurses, school social workers, and school psychologists.

We conducted this performance audit under the authority vested in the California State Auditor by Government Code 8543 et seq. and in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

ELAINE M. HOWLE, CPA
California State Auditor

September 29, 2020

Back to top