Audit Highlights . . .
Our audit of the role and effectiveness of LEAs in preventing youth suicide highlights the following:
- » The six LEAs we reviewed have not adopted adequate youth suicide prevention policies and training.
- Given proper policies and training, school personnel who regularly interact with students are well positioned to recognize the warning signs of suicide and assist students at risk of self-harm and suicide.
- None of the six LEAs we audited had implemented suicide prevention policies and training that fully addressed statutory requirements and the best practices that Education recommends.
- » LEAs need more mental health professionals to help prevent youth suicide.
- No LEA in the State reported employing the recommended number of school counselors, school nurses, school social workers, and school psychologists; and 25 percent did not employ even one such resource.
- » School-based health centers could provide students with better access to mental health professionals.
- Despite the demonstrated benefits that such centers offer, the State has done little to foster their implementation.
- Even with a statutory mandate to do so, Public Health had not established a support program that would help LEAs establish, retain, and expand school‑based health centers.
- » LEAs should seek local and federal funding to help increase the number of mental health professionals on school campuses.
- Five of the six LEAs we reviewed were not aware that the Mental Health Services Act makes funding available to them through their local counties.
- Education and Health Care Services have not taken steps to ensure that all LEAs are aware of ways to decrease the administrative burden of obtaining reimbursement for some of the mental health services they provide.
Results in Brief
Youth suicide is a growing health crisis in California. The annual number of suicides of youth ages 12 to 19 increased by 15 percent statewide from 2009 to 2018. In addition, instances of youth committing acts of self‑harm—behavior that is self‑directed and deliberately results in injury—increased by 50 percent during the same period. Because students spend a significant amount of time in school, school personnel are well positioned to recognize the warning signs of suicide risk and to make the appropriate referrals for help. Schools can more effectively assist students if they have appropriate suicide prevention policies in place, if they train their faculty and staff to recognize and respond to youth who are at risk of suicide or self‑harm, and if they employ an adequate number of professionals, such as school counselors, who provide mental health services. The deficiencies we found in these areas during our review suggest that many county offices of education, school districts, and charter schools—known collectively as local educational agencies (LEAs)—could do more to address youth suicide and self‑harm.
In 2016 the Legislature passed a law requiring LEAs that serve students in grades 7 to 12 to adopt suicide prevention policies. However, the six LEAs we reviewed—three school districts and three charter schools—have not adopted policies that fully address the statutory requirements and the best practices that the California Department of Education (Education) recommends in the model policy it created in response to the 2016 law. For example, some of the LEAs’ policies did not establish response teams that convene after a student dies by suicide. A systematic and timely response to such incidents can reduce the likelihood of clusters of suicides. Until LEAs create clear policies that meet both legal requirements and Education’s recommended best practices, they are depriving staff of a useful reference for effectively implementing suicide prevention processes and quickly reacting to crises.
In addition, the LEAs we reviewed conducted trainings that were missing elements that help school personnel identify warning signs and help prevent suicide. Although state law does not mandate suicide prevention training, it does require that if LEAs conduct such training, the materials must include information on when and how to refer youth and their families to appropriate mental health services. Although all six of the LEAs we reviewed provided suicide prevention training during the 2019–20 academic year, each failed to include one or more of the elements identified in state law or in Education’s model policy. When selecting their suicide prevention trainings, some LEAs did not prioritize complying with state law and Education’s best practices, while others contended that their trainings were sufficient and referenced other efforts that they believed had addressed the pertinent issues. However, when trainings do not meet statutory requirements and best practices, teachers and staff may not have all the knowledge or confidence necessary to respond appropriately to students who are at risk.
We also found that of the 1,034 LEAs that submitted personnel information to Education for the 2018–19 academic year, none employed Education’s recommended number of school counselors, school nurses, school social workers, and school psychologists, which we collectively refer to as mental health professionals. Mental health professionals provide academic, career, and psychological counseling to students, as well as social development services and physical health services. Although these mental health professionals play a critical role in helping to reduce youth suicide, few of the State’s LEAs reported employing the recommended number of even one of the four types of professionals during the 2018–19 academic year. In fact, 260 LEAs—or 25 percent of the 1,034 LEAs reporting data to Education in academic year 2018–19—did not employ a single mental health professional. According to one of Education’s program consultants, a statewide program to fund mental health professionals is unlikely because of the State’s current focus on local control of education funding. Nonetheless, as the State’s rates of youth suicide and self‑harm rise, these key positions remain understaffed.
One best practice for increasing students’ access to mental health professionals is the establishment of school‑based health centers (school health centers). School health centers are clinics located on or near school grounds that may provide a variety of physical and mental health services, such as immunizations, substance abuse counseling, and mental health care. Community health centers or local health departments often support school health center operations and may employ the health professionals who work at them. Research has consistently demonstrated that school health centers increase youth access to mental health care. Further, they allow LEAs to leverage other sources of funding, including public and private health insurance, to pay for mental health services for students. Although both San Francisco Unified School District and the state of Oregon have used school health centers to successfully provide students with mental health services, as of 2019, only 4 percent of California’s kindergarten‑through‑grade 12 students attended a school with a school health center.
Despite the demonstrated benefits that school health centers offer, the State has done little to foster their implementation. In 2007 the Legislature required the California Department of Public Health (Public Health) to establish a program to support the development of school health centers (support program). However, as of July 2020, Public Health had not yet done so. Public Health’s Center for Healthy Communities’ deputy director stated that the $1.2 million the Legislature provided to Public Health for the support program across two fiscal years—2016–17 and 2017–18—was not adequate to establish a full program; however, she also stated that Public Health has not requested additional funding. Given the Legislature’s mandate, it is unclear why Public Health has taken so little action to create and administer the support program for the past 13 years, including requesting adequate funding. A robust support program could assist LEAs in creating school health centers and enable them to better leverage available funding to improve student access to mental health services.
Although several of the LEAs we reviewed relied solely on state funding to pay their mental health professionals, others took advantage of local and federal funds for this purpose. The LEAs that used additional sources of funding spent more per student on mental health professionals and met more of the staffing levels for these professionals that Education recommends. In addition to local funds, such as those available through the Mental Health Services Act, LEAs may seek federal reimbursement of up to 50 percent of the costs of certain health‑related services they have provided to students who are eligible for Medi‑Cal through what is known as the billing option program. Although some LEAs consider the billing option program to be administratively burdensome, they can partner with their county offices of education to centralize the program’s administrative costs and responsibilities. However, the Department of Health Care Services—which administers the billing option program—and Education have not done enough to ensure that all LEAs are aware of the opportunity to partner with their county offices of education, which has likely reduced the impact this program has had on increasing students’ access to mental health care.
Summary of Recommendations
To promote the adoption of the suicide prevention best practices that it has identified, Education should annually remind LEAs of the elements in its model policy.
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. Public Health should use the support program to assist LEAs in establishing school health centers and in identifying and applying for available funding as authorized by law, such as Medi‑Cal reimbursements.
Health Care Services
To ensure that LEAs take full advantage of Medi‑Cal funds, Health Care Services should work with Education to inform LEAs that they can partner with their county offices of education to centralize the administrative responsibilities necessary to obtain reimbursement through the billing option program.
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.
Education and Health Care Services stated they would implement our recommendations. Public Health said that it would evaluate the resources necessary to establish the support program required by law. Several of the six LEAs described how they believe their suicide prevention efforts address the shortcomings we identified in their policies, but most stated that they would also update their policies to address those shortcomings.