Background: This study examined the impact of school-based mental health programs on children's school outcomes and the utilization of acute mental health services. Methods: The study sample included 468 Medicaid-enrolled children aged 6 to 17 years who were enrolled 1 of 2 school-based mental health programs (SBMHs) in a metropolitan area sometime during school year 2006-2007. A multilevel analysis examined the relative effects of SBMHs on children's absence, suspension, grade promotion, use of acute mental health services, as well as the association of child and school-level factors on the outcomes of interest. Results: Little change in average number of days absent per month and no significant change in the use of acute mental health services were found. The mean number of days suspended per month out-of-school decreased from 0.100 to 0.003 days (p less than 0.001). The percentage of children promoted to the next grade increased almost 13% after program enrollment (p less than 0.01). Program type did not predict outcome changes except grade promotion. Conclusions: Despite the positive effect of school-based mental health programs on some school outcomes, the lack of difference between programs suggests the need to identify active mechanisms associated with outcome to make the delivery of care more efficient. (Contains 5 tables.)