Association of School-Based Health Center Availability With Child Mental Health Outcomes

To estimate changes in student mental health outcomes after the adoption of a school-based health center (SBHC).

Using a retrospective, quasi-experimental design, this study compared changes in mental health diagnoses and healthcare utilization among students in school districts that adopted an SBHC to students in districts that did not adopt an SBHC, before and after adoption. A stacked difference-in-differences estimator was used to address the staggered adoption of SBHCs and the potential for heterogeneous treatment effects. Health conditions (measured via diagnosis codes) and health care use (measured via procedure codes and place-of-service codes) were obtained from Medicaid inpatient, outpatient, physician, and pharmacy claims.

Information on the availability of SBHCs was obtained via census of 142 of Tennessee's 147 public school districts. Using secondary data from administrative health and education records, we probabilistically linked Tennessee students enrolled in Medicaid to public-school records from 2006 to 2021. We linked approximately 70% of students enrolled in a Tennessee public school to Medicaid records.

We identified 41 districts with an SBHC between 2007 and 2019. After the adoption of an SBHC, districts with an SBHC had a 0.5 (95% CI: -0.9, -0.2) percentage point decline in the proportion of students with any mental health diagnosis, which corresponds to a 6.6% relative decline. This was driven by a decrease in the diagnosis of depression, anxiety, and attention deficit and hyperactivity disorder (ADHD). We also found a significant increase in outpatient mental health care visits and a decrease in emergency department visits for mental health conditions after the adoption of an SBHC.

SBHCs are one mechanism through which the mental health needs of school-aged children are met. Timely and adequate resources are needed to ensure SBHCs can sustain their services in this time of need.