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State lags in on-campus mental health care for kids

by Emily Walkenhorst | November 15, 2020 at 3:27 a.m.
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At least one of every 13 students in Arkansas public schools uses on-campus mental health services in a given year, according to state Medicaid data.

That translates to at least 35,000 Medicaid-eligible students a year, according to the data.

The ratio is assuredly higher if students with private insurance who use campus services are considered, but no public data is available on those numbers.

In 2011, the earliest year for which Medicaid data are available, 15,570 students filed claims for mental health services at school, totaling $32.8 million in claims paid. In 2018, 37,474 students filed Medicaid claims, totaling $75.5 million in paid claims. More recent data are unavailable because of changes in Medicaid reporting procedures that obscure information on services at schools.

Between fiscal 2011 and fiscal 2018, the state spent about $517 million on school-based mental health services, records from the state Department of Human Services show. Figures for the past two fiscal years show that at least another $97.6 million in taxpayer dollars funded those services, but the department no longer sends some of that money directly to providers, making it harder to determine exact amounts.

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Still, there's no doubt that the need continues to grow, and the coronavirus pandemic has challenged the system of delivering services to schoolchildren.

Pandemic or not, the type and quality of help students receive depend on where a student attends school.

Arkansas lags behind most neighboring states in the ratios of school-employed psychological staff members and social workers to students. The state's ratio of school counselors to students, 364-to-1 for the 2019-20 academic year, is well above the American School Counselor Association's recommended ratio of 250-to-1.

Officials acknowledge the need for more and better services in light of increases in youth suicides, the growing demand for existing services, and research that points to the importance of addressing childhood trauma and toxic stress before they warp human potential.

"I do think this is a national crisis we are seeing," said Betsy Kindall, director of Arkansas Advancing Wellness And Resiliency in Education (AWARE) at the state Department of Education. "I do not know the answer but only that we have to step up our game in meeting the growing demand of kids' needs within the school setting. Those needs have changed so much just in the last three years. We are in crisis."

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Schools have become a major source for child mental health care, both in services and in social-emotional learning practices used in classrooms. Mental health care has helped students improve in their studies and behave better, leaders say, although there's a lot of work to be done.

Like school-based health centers, free and reduced-price lunches and school breakfast programs, mental health services are a way schools can address societal shortcomings outside of the classroom by helping students while they're in the classroom.

Public dollars spent toward mental health services at schools made up about a third ($78.5 million compared with $225.2 million) of the public dollars allocated for free and reduced-price lunches in 2017, according to Arkansas Department of Human Services data and a report from the Arkansas Bureau of Legislative Research from that year.

Mental health services make it easier and less disruptive for children to see therapists. School-based services usually don't include specialized therapies or psychiatry, but many students and parents say having access to professionals on campus has made an incalculable difference in their lives.

One Springdale student told the Arkansas Democrat-Gazette that she ended up getting the help she needed after telling a teacher she was thinking about suicide.

That was easier, in her mind, than telling her mother or a friend.

"It's personal, but in a different sense," she said.

Telling school officials about her suicide ideations eventually led to the first of several hospitalizations. Her mother credits those hospitalizations with potentially saving her daughter's life.

Mental health care providers first flooded Arkansas schools in the early 2000s. By the mid-2000s, their presence and incorporation into the state's schools remained, as one superintendent put it, the "Wild West." They kept growing with little oversight.

Medicaid changes that began in 2019 were prompted in part by corruption charges against some of the biggest providers of mental health services in schools.

The corruption scandal extended beyond school mental health care providers, embroiling several state lawmakers and a prominent lobbyist.

In one case, Preferred Family Healthcare, once the largest provider of school mental health services, recently agreed to pay $6.5 million to Arkansas and U.S. governments for fraudulently billing taxpayers. From 2011-18, the period for which the newspaper could obtain data, the company collected $76.5 million, 14.8% of the $517 million in mental health claims paid out during that time. That also represented about a third of the Medicaid payments to Preferred Family and its affiliates during that period.

The Medicaid changes have added steps to get certain services covered and raised reimbursement rates for schools and individual practitioners to equal those that provider organizations had been receiving for years. One district, Fouke, hired two mental health professionals in response to the rate increases.

Still, few school districts employ therapists and few districts are approved Medicaid providers. Schools still must provide a 30% Medicaid match if they hire their own therapists, unlike provider organizations and individual practitioners.


Since 1975, special education was intended to help students with disabilities, including mental health issues, that interfered with their learning.

That safeguard is still law.

But Arkansas for years has had one of the lowest rates of serving children under the mental health designation in special education.

The state's rate is less than a third of the national one, potentially indicating thousands of children left out of special education in Arkansas.

Exactly how many Arkansas kids are being left out of special education is unclear.

Educators may be skirting special education to save money, some say. Or, as state Education Department officials assert and local school leaders admit to the newspaper, educators may be labeling children under different special-education designations to avoid any stigma associated with mental health labels.

Under federal special-education law, a student's unique needs must be addressed, regardless of the student's designation.

The discrepancy with the national rate has been noted many times, in reports to state legislators and by advocacy groups.

In a 2016 report evaluating special education in the state, Arkansas Advocates for Children and Families noted the "gaps in identifying students who have emotional disabilities."

Experts estimate that 3% to 6% of children would qualify for the services under Arkansas' definition. But behavioral specialists' caseloads are high, according to the report.

"There aren't enough people qualified to work with students with emotional disturbances, so if more students were identified with emotional disturbance challenges, schools would be overwhelmed," the report concludes.

Arkansas has a relatively average percentage of students enrolled in special education overall, a proportion that has been rising for the past several years, to nearly 13%.

The number of Arkansas students receiving special education for "emotional disturbance" -- the mental health category -- has been rising steadily.

But if Arkansas had served the national average of students under the special-education designation in the 2017-18 school year -- 0.63%, according to the latest data of this type available -- roughly 3,100 youths ages 6-21 would have received the services.

Instead, Arkansas served 0.2% that school year, or 988 children.

Many mental health care officials say the lack of services comes down to money. Providing therapy as a part of special education isn't the same as signing an agreement with a mental health care provider to see any kid on campus.

Under those agreements, the providers can bill a student's Medicaid or, in some cases, their private insurance for sessions provided at school, at no cost to the school. Under special education, the school has to pay for everything. The school would have to be a Medicaid provider to be able to bill Medicaid, and outside clinics would be unable to bill Medicaid directly for anything.

When it comes to school mental health, government alone won't solve this "major" campus issue, Arkansas Secretary of Education Johnny Key said in a statement to the Arkansas Democrat-Gazette. But state agencies can look at ways to work together to address it, he said.

"It is a complex, multifaceted issue that will continue to grow if we don't come up with solutions," he said.


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