This is a literature review that examines House Bill 9 and the impact of the implementation of telehealth to address behavioral and mental health issues in public schools. This literature review examines families and individuals in societal contexts as I discuss the internal dynamics of family and the role that parents and communities can play to support adolescent mental health. I address family resource management and how goal setting can be used to educate and train parents to fulfill their responsibilities. I also address public policy and how House Bill 9 can be used to holistically address community, family, and individual well-being. To address these content areas I utilized competencies such as evaluating programs, corresponding with others, prioritizing community responsibilities, modifying existing policy, developing goals, and collecting information.

1. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 1
Telehealth Impact on Middle School Mental Health
Jenna Buggs
University of Georgia
HDFS 4130/6130
Dr. Melissa Kozak
April 4, 2021

2. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 2
Abstract
This article is an examination of House Bill 9 and the implications of utilizing telehealth services
in public schools to address adolescent mental health. The historical development of mental
health policy has led to an increased emphasis on family involvement to promote individual
well-being. However, there is still a significant gap in parental and school staff education on
mental and behavioral health issues. This article examines literature to see the historical trend in
policy and suggests ways that policymakers can use House Bill 9 to increase adolescent mental
health awareness and prevention. Furthermore, this article examines previous research on the risk
factors and protective factors of telehealth implementation. Additionally, since House Bill 9 did
not crossover from the Georgia House of Representatives to the Senate, the article suggests ways
to edit the bill to be more holistic and efficient. This article contains a background briefing report
and a 2-page fact sheet with discussion questions.
Keywords: House Bill 9, mental health, middle school, telehealth

3. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 3
Telehealth Impact on Middle School Mental Health
Topic Overview
Mental health issues are incredibly prevalent today, with one in six children diagnosed
with behavioral, cognitive, or developmental disorders (Georgia Voices, 2020a). Furthermore,
fifty percent of lifetime mental health illness onset occurs in individuals aged 14 years old (Sung
et al., 2021). Considering these statistics on the vastness of youth mental health problems, two in
five children have difficulty accessing the mental health treatment they need (Georgia Voices,
2020a). This situation of increased youth mental issues and the lack of resources to cope with
them creates a dilemma. To address this lack of treatment, the Georgia House of Representatives
proposed House Bill 9 to develop guidelines to use telehealth services in public schools for
mental and behavioral health services (HB 9, 2021). Policymakers define telehealth as the health
services provided by a health care provider through technologies such as telephones or remote
patient monitoring devices to facilitate the diagnosis, education, and treatment of a student’s
health care (HB 9, 2021). While this house bill may seem to focus on individual needs, it does
impact families, and analyzing this issue with a Family Impact Lens can provide context for
addressing this important issue.
Specifically, family policy is defined as policy that seeks to promote and strengthen
families by addressing family functions such as family formation, partner relationships,
economic support, childrearing, and caregiving (Bogenschneider, 2016). House Bill 9 defines
family mainly in terms of function as it emphasizes the purpose of families in sharing resources
and caring for the young (Bogenschneider, 2016). House Bill 9 addresses the functions of family
formation, economic support, and caregiving. Furthermore, considering family structure, this

4. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 4
policy aims at achieving individual health while also striving to educate families and provide
them with services in the larger community.
Because children's emotional health is primarily shaped by their experience at home with
their families, parental engagement is essential in improving health services delivery (Georgia
Division of Mental Health, 1965). Consequently, instead of merely responding to specific
individual needs, this policy provides a comprehensive vision for families (Bogenschneider,
2016). Therefore, this policy and its goal of implementing telehealth in public schools could
significantly impact mental health intervention in middle schools.
Review of Literature
Political Trends
The field of family policy was not even formed until the 1970s, so approaches prior to
this were highly individualistic (Bogenschneider, 2016). Even today, we live in a highly
individualistic society that often places individual needs over family needs (Bogenschneider,
2016). Despite this, policymakers began using the family impact lens to discover how families
are affected by an issue, how they may have contributed to a problem, and whether involving
families could result in a more effective policy (Bogenschneider, 2016).
Consequently, policy began to incorporate parental involvement in children's lives in the
1990s with the Educate America Act. Furthermore, in 2000, the Children's Health Act was
passed to improve childcare centers' health and safety. Over the past 20 years, policymakers have
passed various policies to coordinate family preservation and promote child well-being.
Furthermore, policies such as the Patient Protection and Affordable Care Act were enacted to
increase access to affordable health care and improve healthcare quality (Bogenschneider, 2016).
Therefore, policies have continued to move toward collaboration in schools, communities, and

5. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 5
families to ensure students access to affordable and quality health services (Georgia Middle
Grades Task Force, 1993). This correlates to the ecological family systems theory which depicts
how families influence individual development and how the community and policy impact
family functioning (Bogenschneider, 2016). For example, how well families function is
determined by the emotional, economic, and social support they receive (Bogenschneider, 2016).
Therefore, the use of telehealth in schools could improve the stability and commitment of family
members to one another which improves the quality of relationships with one another and overall
well-being.
Throughout history, mental health policy has aimed at re-engaging families through
effective communication and youth adolescents' education (Georgia Middle Grades Task Force,
1993). This engagement relates to telehealth as its purpose is to use communications
technologies at school related functions to enhance care management and create a middle school
climate of warmth, caring, respect, and a sense of family (Georgia Middle Grades Task Force,
1993). Consequently, policy concerning mental health must be organized around the student’s
needs, and schools must play a larger role in improving access to adolescent health resources
(Georgia Middle Grades Task Force, 1993).
Social Trends
In addition to the political trends that have impacted this policy, social factors have also
played a significant role in mental health policy. Schools have the unique opportunity to mold
attitudes and shape adults' opinions about mental health (Georgia Division of Mental Health,
1965). Sadly, mental and behavioral health services receive negative attitudes from the public
(Georgia Division of Mental Health, 1965). In 1965, only fifty percent of companies that offered
health and accident coverage included coverage for mental illnesses (Georgia Division of Mental

6. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 6
Health, 1965). This discrepancy points to the idea that the public and government often view
mental health as lesser than physical health. However, today, parity exists legally recognizing
mental health conditions as equal to physical illness (Kozak, 2021). This recognition begins with
schools normalizing this help-seeking behavior and encouraging students to seek counseling
(Dameron & Curtis, 2020).
Because students spend six to seven hours a day for about 180 days a year at school
(Georgia Department of Public Health, 2014), schools have the unique position of observing,
evaluating, and guiding the child throughout their school life (Georgia Division of Mental
Health, 1965). However, only 72% of middle schools have a link to health services in the
community (Georgia Department of Public Health, 2014). Meanwhile, 31% of middle schools
engage in health policies and programs, while 42% facilitate access to social and mental health
services (Georgia Department of Public Health, 2014). Therefore, despite the overwhelming
statistics of youth mental health issues, schools often do not engage in community resources.
Consequently, parents' knowledge about health care is limited (Georgia Division of Mental
Health, 1965). This lack of resources and education is further multiplied when considering that
63 counties in Georgia do not have a pediatrician, and there is insufficient training or staff
capacity limiting implementation (Georgia Voices, 2020b).
Considering this poor fit of interventions, House Bill 9 offers an opportunity of
improving access to health care for children (Bynum et al., 2011) and advancing the use of
effective, sustainable treatments (Bearman, n.d.). Youth mental health issues pose several risk
factors, but House Bill 9 and mental telehealth services offer protective factors to promote
student, parent, and school staff adaptation and competence.
Risk Factors

7. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 7
Adolescence is a time characterized by physical, cognitive, and socioemotional changes
that can contribute to mental health turmoil (Dameron & Curtis, 2020). Physically, as puberty
begins, adolescents have heavier bodies that limit their level of strength, endurance, and
flexibility (Georgia Middle Grades Task Force, 1993). Cognitively, they have widely varying
moods, are more likely to be self-conscious, and lack self-esteem, while also feeling that their
experiences are unique to themselves (Georgia Middle Grades Task Force, 1993). Socially, they
feel inadequate as they encounter differences between themselves and others, are trying on new
identities, and have a strong need to be a part of a group (Georgia Middle Grades Task Force,
1993). These changes can lead to unhealthy behaviors in which teenagers feel alienated and
uncared for (Georgia Middle Grades Task Force, 1993). As a result, these individual problems
can contribute to mental health impairment, leading to a wide range of risk factors.
Several studies have indicated that depressed teens are more likely to experience
impairment in family, peer, and academic functioning (Dameron & Curtis, 2020). Furthermore,
they are more likely to engage in substance abuse, aggression, inattention, and anxiety (Dameron
& Curtis, 2020). These negative behaviors all lead to lower academic engagement levels,
educational efficacy, and grade point average (Dameron & Curtis, 2020).
Unfortunately, many barriers exist that prevent children from receiving essential health
care services. For example, extreme poverty, lack of transportation, and a shortage of health
professionals all limit children's access to mental health services that they may need (Bynum et
al., 2011). Since mental health conditions are the costliest condition in the United States, they
often create economic and emotional burdens for individuals with mental health issues.
Consequently, the lack of funding prevents individuals from receiving proper treatment
contributing to the vulnerability to future adverse developmental outcomes (Sung et al., 2021).

8. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 8
Protective Factors
Considering the barriers of access to mental health care services and the consequences of
not treating youth mental health, telehealth offers a safeguard to enhance individual and family
well-being. For example, school telehealth can reach a larger number of children by improving
access to medical care and health education (Bynum et al., 2011). Specifically, telehealth can
reduce barriers related to distance and travel (Bynum et al., 2011). However, incorporating the
family in this treatment is essential for program success. Unfortunately, two-thirds of parents do
not have contact or guidance from public school professionals (Stormshak et al., 2019).
To solve this dilemma, schools must offer parenting skills training and support for
families to improve long-term child behavioral outcomes across development (Stormshak et al.,
2019). By engaging parents and caretakers, students are less likely to engage in delinquent
behaviors, including smoking, drinking alcohol, being physical aggressive, or skipping school
(Georgia Department of Mental Health, 2014).
In addition to parent and caretaker involvement, school-based mental health must
increase school connectedness. Therefore, staff must engage in professional development
training to consistently promote cooperation between parents, teachers, and administrators
(Georgia Department of Mental Health, 2014). Furthermore, the school telehealth nurse must
demonstrate effective communication with parents, children, and teachers to promote a healthy
and safe school environment (Bynum et al., 2011). This increased connectedness serves to
decrease substance abuse, early sexual initiation, violence, and risky behavior (Georgia
Department of Mental Health, 2014). This connectedness aligns with the ecological family
systems theory in which policy impacts community resources by utilizing social services and
public health nurses to provide economic and social support to promote family stability leading

9. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 9
to enhanced individual cognitive and physical abilities (Bogenschneider, 2016). Therefore, the
mental health services provided through telehealth proposed in House Bill 9 can reduce
individual risk factors and provide social and physical support to families.
Telehealth Outcomes
Considering the risk factors associated with youth mental health and the protective
factors that House Bill 9 could provide, it seems that telehealth implementation in public schools
could make a significant impact. School nurses and counselors often serve as children's primary
healthcare ("Needwood Middle School," 2016). However, counselors are burdened with various
roles, competing demands, and they can often only provide short-term service (Dameron &
Curtis, 2020). Also, researchers have found that teacher-delivered interventions have little impact
on student externalizing behaviors (Morgan-Lopez et al., 2020). Therefore, counselors may
utilize indirect services to refer students to community resources that treat mental health issues
(Dameron & Curtis, 2020). However, since 63 counties do not have a pediatrician (Georgia
Voices, 2020b), schools can use telehealth to expand practitioner-delivered mental health
services (Morgan-Lopez et al., 2020).
Specifically, schools that have administered telehealth projects have found improved
patient adherence to clinical outcomes, a decline in school absences, and improved cost savings
for medical care Bynum et al., 2011). Furthermore, the use of telehealth to improve student
mental health can also allow different levels of assistance based on students' diverse needs
(Morgan-Lopez et al., 2020). This diversity in treatment and broad accessibility could
significantly impact the school environment (Morgan-Lopez et al., 2020). Thus, when student's
health is managed effectively, they learn most effectively ("Needwood Middle School," 2016).
Conclusion

10. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 10
Overall, mental and behavioral health issues are very prevalent in middle schools today.
However, counselors and school staff lack sufficient resources to deliver mental health services
to students. The House proposed House Bill 9 to address this issue and require public schools to
utilize telehealth services for mental and behavioral health. Throughout history, there have been
political and social trends in shifting policy to be more family-centered and increase the quality
and accessibility of health care. Nonetheless, many barriers exist to implementing mental health,
such as a shortage of staff (Stormshak et al., 2019), a lack of funding (Sung et al., 2021), and the
lack of transportation to mental health services (Bynum et al., 2011). Therefore, public schools
can utilize telehealth to reduce delivery and training costs while also increasing mental health
services (Stormshak et al., 2019). This policy could promote equity and access for all students
(Dameron & Curtis, 2020), to foster a beneficial school setting (Morgan-Lopez et al., 2020).
In conclusion, House Bill 9 can offer intended results such as increased access,
flexibility, and quality of mental health care for youth (Bearman, n.d.). However, this policy may
create unintended consequences of being too individualistic. With regards to the ecological
systems model, parental and community involvement in such services is critical to achieving
maximum effectiveness (Georgia Middle Grades Task Force, 1993), and their presence can
improve the delivery of health services (Georgia Department of Public Health, 2014). Since
House Bill 9 did not pass crossover, I recommend that it be picked up by legislation and edited to
enhance family engagement by cooperating with other community agencies and administering
health education programs for adults (Georgia Division of Mental Health, 1965). Despite some
unintended consequences, House Bill 9 has the potential of creating long-term change for youth
experiencing mental health issues, and it could play a fundamental role in enhancing family
functioning and well-being.

11. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 11
References
Bearman, Sarah K. (n.d.). Partnering with School Providers to Codesign Mental Health
Interventions: An Open Trial of Act & Adapt in Urban Public Middle Schools.
Psychology in the Schools., 57(11), 1689–1709.
Bogenschneider, K. (2014). Family policy matters: How policymaking affects families and what
professionals can do, 3rd Ed. New York, NY: Routledge
Bynum, A. B., Irwin, C. A., Burke, B. L., Hadleys, M. V., Vogels, R., Evans, P., Ragland, D., &
Johnson, T. (2011). Impact of School Telehealth on Access to Medical Care, Clinical
Outcomes, and Cost Savings among Children in Rural Arkansas. Journal of Education
Research, 5(2), 99–117.
Dameron, M. L., & Curtis, R. (2020). Hope for the Hurting: Strategies for School Counselors
Working with Heartbroken Students. Journal of School Counseling, 18(4).
Georgia Department of Public Health (2014). Georgia middle and high school safe and
supportive school environment data summary. Retrieved from
http://dlg.galileo.usg.edu/do:dlg_ggpd_s-ga-bp780-b-pm1-b2015-bs2-belec-p-btext
Georgia Division of Mental Health (1965). A comprehensive mental health plan for Georgia.
Retrieved from http://dlg.galileo.usg.edu/do:dlg_ggpd_s-ga-bh700-pm4-bm1-b1965-bc6
Georgia Middle Grades Task Force (1993). Linking services for Georgia's young adolescents.
Retrieved from http://dlg.galileo.usg.edu/do:dlg_ggpd_s-ga-be300-pi5-bm1-b1993-ba3
Georgia Voices (2020a). School-Based Mental Health Programs: how they work and succeed.
Voices for Georgia's Children.

12. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 12
https://georgiavoices.org/wp-content/uploads/2021/01/SBMH-Programs-How-They-
Work-and-Succeed.pdf?9d7bd4&9d7bd4
Georgia Voices (2020b). School-Based Telehealth in Georgia. Voices for Georgia’s Children.
https://georgiavoices.org/wp-content/uploads/2021/01/SBTH-in-
Georgia.pdf?9d7bd4&9d7bd4
HB 9: Education, Department of; develop guidelines for use of telehealth services in public
schools. (2021). Georgia General Assembly. https://www.legis.ga.gov/legislation/58794
Kozak, M. (2021). Mental health [PDF document]. Retrieved from Lecture Notes.
Morgan-Lopez, A. A., Saavedra, L. M., Yaros, A. C., Trudeau, J. V., & Buben, A. (2020). The
Effects of Practitioner-Delivered School-Based Mental Health on Aggression and
Violence Victimization in Middle Schoolers. School Mental Health, 12(2), 417–427.
Needwood Middle School pilots telehealth service (2016). Brunswick News
[Brunswick, GA].
https://link.gale.com/apps/doc/A462774925/ITOF?u=uga&sid=ITOF&xid=cc9a055d
Stormshak, E. A., Seeley, J. R., Caruthers, A. S., Cardenas, L., Moore, K. J., Tyler, M. S.,
Fleming, C. M., Gau, J., & Danaher, B. (2019). Evaluating the Efficacy of the Family
Check-Up Online: A School-Based, eHealth Model for the Prevention of Problem
Behavior during the Middle School Years. In Grantee Submission. Grantee Submission.
Sung, J. Y., Kacmarek, C. N., & Schleider, J. L. (2021). Economic Evaluations of Mental Health
Programs for Children and Adolescents in the United States: A Systematic
Review. Clinical Child & Family Psychology Review, 24(1), 1–19.
https://doi.org/10.1007/s10567-020-00333-1

13. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 13
Fact Sheet and Discussion Questions
Literature Facts
In the past, mental health awareness in schools mostly emphasized teachers'
responsibility to foster normal growth and development (Georgia Division of Mental Health,
1965). Furthermore, schools were seen as an environment to educate students on mental health
and mold their attitudes (Georgia Division of Mental Health, 1965). Since then, research has
found that teacher-based intervention has little impact on externalizing behaviors (Morgan-Lopez
et al., 2020). Despite this, school nurses and counselors are many children's primary health care
("Needwood Middle School," 2016). Therefore, public schools offering telehealth services for
mental and behavioral health resources can increase children and family access to health
education, reduce barriers to healthcare access, and reduce absenteeism (Georgia Voices, 2020b).
Promising Policies and Practice
The most promising practices of House Bill 9 involve incorporating family-centered
prevention that provides training in parenting skills and support to improve long-term behavioral
outcomes for youth (Stormshak et al., 2019). When schools partner with mental health agencies,
families, staff, and students, they can improve individual well-being and enhance the school
environment (Morgan-Lopez et al., 2020). Furthermore, telehealth's unique online format for
mental health services can counter the risk factors of limited staffing and resources that many
schools face (Stormshak et al., 2019).
Questions for Audience

14. TELEHEALTH IMPACT ON MIDDLE SCHOOL MENTAL HEALTH 14
1. What is the purpose of House Bill 9?
2. What is the importance of incorporating family in policymaking?
3. Why do schools have the unique opportunity to deliver mental health services?
4. Why are middle schoolers more prone to mental health issues?
5. What are some barriers to families receiving mental health services?
6. In what ways can Telehealth overcome some of these barriers?
7. What has previous research on implementing Telehealth revealed?
8. How can House Bill 9 be edited to address families more holistically?
9. How does the bill provide community supports to influence family stability?
10. How does family stability impact individual well-being?
11. What are the benefits of including families in delivering school-based Telehealth services
for mental and behavioral health?