Implementing and maintaining school-based mental health services in a large, urban school district

The Dallas (Texas) Public Schools established the first school-based health center in the United States in 1969. In 1993 a partnership between two school principals, a school mental health professional, and the medical director of the county mental health center was the impetus for the first comprehensive school-based mental health center in Texas. In 1995 the programs joined together as Youth and Family Centers (YFCs) to provide physical health, mental health, and other support services to students and their families. The 10 strategically located school-based centers are directed by licensed mental health professionals employed by the district who lead a multidisciplinary team of physical health and mental health providers. Students served by the YFCs have fewer discipline problems, course failures, and school absences.     

Challenges to collaboration in school mental health and strategies for overcoming them

BACKGROUND: This article reviews challenges to collaboration in school mental health (SMH) and presents practical strategies for overcoming them. METHODS: The importance of collaboration to the success of SMH programs is reviewed, with a particular focus on collaboration between school‐ and community‐employed professionals. Challenges to effective collaboration between school‐ and community‐employed professionals in SMH are considered. Strategies for overcoming challenges to effective collaboration are presented. RESULTS: Marginalization of the SMH agenda, limited interdisciplinary teamwork, restricted coordination mechanisms, confidentiality concerns, and resource and funding issues are key challenges to collaboration. Strategies targeted toward each of these challenges may help improve the effectiveness of SMH programs and ultimately student outcomes. CONCLUSIONS: Collaboration between school‐ and community‐employed professionals is critical to the success of SMH programs. Despite its promise, the success of SMH programs can be jeopardized by ineffective collaboration between school‐ and community‐employed professionals. Strategies to overcome marginalization, promote authentic interdisciplinary teamwork, build effective coordination mechanisms, protect student and family confidentiality, and promote policy change and resource enhancements should be addressed in SMH improvement planning.     

School-Based Health Centers and School Nurses: Cementing the Collaboration

ABSTRACT: As school health personnel respond to the changing needs of children, new models are being developed and traditional models are being reexamined. The role of the school nurse is expanding at the same time as school-based health centers are increasing in number. Partnerships between school-based health centers and school nurses are critical for the success of school-based health centers, and partnerships will enhance and expand roles for school nurses. This paper clarifies the role of each in three areas: collaboration, communication, and cooperation. In addition, obstacles to partnerships are examined. The goal of this collaboration is a shared vision for the continuum of school health services in which school nurse and school health center serve integral roles. Elements for successful collaboration between nurse and health center are reviewed, including clarifying roles, shared leadership and program ownership, cooperative training and continuing education, negotiating conflict, and most importantly, maintaining mutual support and respect.     

Addressing students' social and emotional needs: the role of mental health teams in schools

Children in today's society face many stresses from a variety of sources that have a major impact on thier psychosocial adjustment and academic performance in school. These stressful events and thier consequences on the quality of life and academic success are particularly significant among low-income and ethnic minority students in American society. Many schools have adopted strategies to help students who are impacted by stressful life events to deal affectively with their problems in an attempt to reduce school failure and school dropout rates among these students. Most notable among these strategies are school-based mental health programs including the establishment of school-based mental health teams which seek to proactively address individual student concerns while improving the general climate of schools. The evidence seems to support the claim that these school-based services have a positive impact on students' social and emotional well-being as well as on their academic achievements. However, with more careful monitoring and much more consistent support from administrators and policy makers, these school-based approaches can more fully realize their potential to enhance the quality of life and to positively impact the future of many poor and ethnic minority students.     

The Mental Health Needs of Elementary Schoolchildren

More than 500 elementary school personnel from a large Colorado school district provided perceptions of the unmet mental health needs of their students, the likely causes of the needs, and suggestions about solutions or programs to meet the needs. The district's definition of "mental health"--positive self-image, healthy interrelationships with peers and adults, and acquisition of school skills and competencies--guided the questionnaire design. Respondents perceived numerous unmet mental health needs, most involving about 15% of the student population. The most frequently perceived problems were poor decision-making and problem-solving skills, poor self-image, low self-confidence, inability to resolve interpersonal conflicts, depression/unhappiness, low motivation, and various conduct disorders. Further, most respondents believed children's unmet mental health needs are increasing, and the causes for most problems are family-and home-related, but most suggested solutions were school-based. Recommendations include increasing the involvement of school nurses in programs aimed at improving children's mental health.     

Mental health prevention through affective education in schools

There has been increasing interest in the prevention of mental disorders and promotion of emotional strengths through school experiences emphasizing the affective domain. School professionals are being called upon to participate in the conception, planning, and implementation of affective education programs in schools. This paper examines the field of affective education. It addresses the field as a juxtaposition of education and mental health, and as a school-based mental health prevention strategy. Mental health prevention through affective education spans a range of intervention modes from individually centered to those dealing with whole classrooms and schools.     

Guidelines for School Health Programs to Promote Lifelong Healthy Eating

ABSTRACT: Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke. School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors. This report summarizes strategies most likely to be effective in promoting healthy eating among school-age youths and provides nutrition education guidelines for a comprehensive school health program. These guidelines are based on a review of research, theory, and current practice, and they were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies. The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, coordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training, family and community involvement, and program evaluation.     

Guidelines for School Health Programs to Prevent Tobacco Use and Addiction

ABSTRACT: Tobacco use is the leading cause of preventable death in the U.S. Most daily smokers (82%) began smoking before age 18, and more than 3,000 young persons begin smoking each day. School programs designed to prevent tobacco use could become one of the most effective strategies available to reduce U.S. tobacco use. The following guidelines summarize school-based strategies most likely to be effective in preventing tobacco use among youth. They were developed by CDC in collaboration with experts from 29 national, federal, and voluntary agencies and with other leading tobacco-use prevention authorities to help school personnel implement effective tobacco-use prevention programs. These guidelines are based on an in-depth review of research, theory, and current practice in school-based tobacco-use prevention. The guidelines recommend that all schools: a) develop and enforce a school policy on tobacco use, b) provide instruction about the short-term and long-term negative physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills, c) provide K-12 tobacco-use prevention education, d) provide program-specific training for teachers, e) involve parents or families in support of school-based programs to prevent tobacco use, f) support cessation efforts among students and all school staff who use tobacco, and g) assess the tobacco-use prevention program at regular intervals. (J Sch Health. 1994; 64(9): 353–360)     

Asian-American Adolescent Immigrants: The New York City Schools Experience

ABSTRACT: This article describes development and implementation of a school-based vaccination program that targeted Asian-American adolescents. The program was implemented by the Chinatown Health Clinic in New York City in two high schools and a junior high school in Lower Manhattan. The article examines strategies effective in vaccinating this varied group of adolescents. Rates of completion for the three-dose hepatitis B vaccine are compared between schools. Optional serology testing for hepatitis B infection was conducted as part of the school program and rates of infection in this population are presented. The article discusses the importance and effectiveness of school-based programs in providing essential health services to this group of adolescents.     

A Nationwide Survey of School Health Services Delivery in Urban Schools

ABSTRACT: To understand school health service delivery models, and to plan for reorganization of a local school health service, a telephone survey of school-based health programs from around the country was conducted in 1992. Responses were elicited from 33 school departments in some of the largest American cities. Respondents described their current programs, obstacles they face, and approaches they have chosen to address the needs of urban schoolchildren. City size did affect amount of services provided overall, but a clear relationship existed between number of providers employed, and the number/amount of screening services available. Cities employed a range of strategies to enhance services, including collaboration with local health authorities, creation of school clinics, and billing for services.     

Theoretical basis and program design of a school-based mental health intervention for traumatized immigrant children: a collaborative research partnership

This article describes a collaborative research model for school-based mental health services that targets children who are recent immigrants with violence-related mental health symptoms. The model describes a conceptual framework used in the establishment of an academic-community partnership during the development, evaluation, and implementation of the Mental Health for Immigrants Program (MHIP), a school-based mental health intervention. The article discusses the challenges that occurred and provides specific examples of how a participatory research partnership may work together through all program phases—design through implementation and program evaluation—to meet a specific community's needs and produce generalizable knowledge. The challenges and limitations of collaborative research approaches also are discussed, with particular emphasis on the role of participatory research in the development and evaluation of school-based mental health programs.     

Working With Non-Dental Groups to Influence Adoption of Self-Applied Fluoride Programs in Schools: One Approach

Although the use of self-applied fluorides in schools has been proven safe and effective, thousands of children are not benefiting from these procedures. This paper describes a dual promotional approach designed to increase the awareness of the need for school-based self-applied fluoride programs. A manned exhibit providing consultation and educational materials was displayed during the entire meeting of a state PTA and was supplemented by a presentation scheduled on the formal program. The workshop participants were parents of school-age children; most held decision-making positions in their local PTAs. Results of the workshop to date include: one participant prevented the demise of an established fluoride mouthrinsing program in her community; and the workshop leaders presented the merits of school-based self-applied fluoride programs to a local PTA and a county school health council. The same programs were described in a county PTA newsletter. These actions suggest that, given the appropriate information and assistance, parents of school children through their PTA can influence adoption of school-based fluoride programs. Furthermore, strategies directed toward members of other groups with an interest and decision-making role in children's health may be effective methods of influencing adoption of school-based self-applied fluoride programs and ultimately promoting children's oral health.     

The contribution of school health education to community health promotion: what can we reasonably expect?

Evaluative studies of outcomes of traditional school health education programs have shown that they are very effective in increasing knowledge, somewhat effective in improving attitudes, and, with few notable exceptions, generally ineffective in changing health practices. This paper discusses the previous reviews of the literature of outcomes of school health education programs, and discusses the constraints inherent in school-based activities; an emphasis on cognitive learning, lecture-oriented teaching methods, inadequate pupil assessment procedures, a captive audience, competing subject areas, competing behavioral influences, behavior change attempts directed at ingrained health habits, inadequate coordination with community resources, and lack of consensus regarding educational goals. The paper then examines several recent successful school health education programs emphasizing non-traditional approaches in self-initiated care, pregnancy prevention, smoking prevention, and nutrition. It is concluded that school-based health education programs have three important roles in community health promotion: 1. the provision of a fundamental understanding of health and disease concepts to large segments of the population; 2. the reinforcement of positive health attitudes; and 3. the alteration of concurrent health behaviors for significant health problems. Although school health education may be helpful in enhancing decision-making and social interaction skills, little empirical evidence exists at this time to support this conclusion.     

Expanded school mental health programs: advancing reform and closing the gap between research and practice

Expanded school mental health (ESMH) programs provide a range of mental health services to youth in special and regular education including prevention, assessment, treatment, and case management. Despite the rapid growth of ESMH programs in the United States and elsewhere, many communities still do not have ESMH programs and those that do exist often fail to implement empirically validated intervention and treatment strategies. Systematic prevention efforts remain a lauded, yet illusive goal. For ESMH programs to fulfill their promise of improved access, increased productivity and improved behavioral outcomes, researchers, school-based mental health service providers, and educators must work together to move child mental health programs beyond limiting constructs and approaches. These issues are reviewed and an example of an "ideal" approach to implement best practices in schools and close the gap between research and practice is offered.     

School-Based Health Centers in the Context of Education Reform

ABSTRACT: The rapid proliferation of school-based health centers is taking place at the same time that school systems are seeking to improve their educational practices. Many different school reform models are being promulgated with modest success. Absence of connections between school reorganization and the provision of human services may lead to failure. The emerging community school model integrates quality education with effective health, mental health, and social services in "one stop" school centers that become student, parent, and community hubs     

The effects of harassment and victimization on self-rated health and mental health among Canadian adolescents

Using 1996/1997 to 2000/2001 data from the Canadian National Longitudinal Survey of Children and Youth, this paper examines the effects of harassment on self-rated and mental health status among Canadian adolescents aged 16-17 years. Forty-six percent of the children experienced harassment and victimization (verbal aggression, threat, and physical harm/assault) at school and 40% outside of school. Harassment at school, rather than otherwise, was associated with poor health status and higher levels of depression even when previous health conditions and socio-demographic variables were held constant. The relationship between harassment and mental health is particularly pronounced among girls, immigrant children and those living in single-parent households. Given the sizable proportion of adolescents as victims of harassment at school and its significant relationship with both health status and depression, the issue warrants serious public health attention through school-based intervention programs.     

Opportunity model of collaboration: a model for assessment instrument development

Collaboration between allied health educators and clinicians has a long history in terms of fieldwork education. Use of collaborative partnerships for practice endeavors and research also has been reported in the literature. Another possible area in which collaboration could be effective is the development of an assessment instrument. Collaboration can have negative and positive results, however, and individuals who plan an instrument development project are cautioned to pay attention to the collaborative nature of the project as well as to the instrument development task itself. This article describes a model for collaboration that evolved out of an instrument development project involving educators from the occupational therapy programs at Utica College and the University of Illinois, Chicago; clinicians in school-based practice; and occupational therapy students. Experiences from the project are used to illustrate concepts of the model.     

MasterMind: Empower Yourself With Mental Health. A program for adolescents

BACKGROUND: Teachers need classroom-based programs to develop and support mental health fitness in adolescents because this age group faces significant challenges to their mental health. There is a paucity of such ready-made programs. This article describes the development and proposed implementation of a low-cost, effective, adaptable, 6-week, classroom-based workshop entitled MasterMind: Empower Yourself With Mental Health. MasterMind provides students with a "toolbox for mental health" by creating a safe environment for discussion of mental health and emotionally charged topics, by increasing student knowledge of mental health issues, and by providing tools to develop and maintain mental health. Instructional materials address topics identified through needs assessments. The program combines instruction and written exercises with "peer-teaching-peer" group activities, individual assignments, and open discussion. Specific methods are included to allow students to ask questions anonymously and to build each other's self-esteem. METHODS: MasterMind was implemented as a pilot program to a Seattle, WA, middle school class of 30 students and addressed self-esteem, media literacy, school resources, relationships, emotions, stress and ways to de-stress, and future goals. RESULTS: The students' enthusiasm and participation increased throughout the program, and they gave high satisfaction ratings to the topics covered. Additionally, the host teacher continued selected program activities after MasterMind was completed. CONCLUSIONS: MasterMind educates all students in a class, not just those with identified emotional problems, and can potentially identify children with mental health needs not already evident. The pilot program implementation of MasterMind shows that such programs have potential for providing adolescents with tools to optimize mental health.     

An ecological model for school-based mental health services for urban low-income aggressive children

An ecological model for school-based mental health services that targets urban low-income aggressive children—a highly vulnerable and underserved population—is presented. The goals of the model are to increase children's and teachers' involvement in the delivery of services and to increase the integration of these services into existing school resources and activities. The model proposes that mental health service providers work in collaboration with teachers to deliver services that (1) can be managed by existing school resources and personnel, (2) are related to empirically based factors associated with reduced aggression and increased social functioning, and (3) are group administered to increase the number of children served and to reduce stigmatization associated with mental health services. The model is individualized and flexible by acknowledging that contexts for aggression differ across classrooms and children and by providing services specific to those contexts. Two studies are presented illustrating the application of this model to decrease aggression and increase academic engagement in low-income urban public schools.Dolores Webster works in a private practice in Philadelphia.