Think earaches, sore throats or runny noses top the list of reasons children visit the nation's 1,700 school-based health centers? Try depression, anxiety and trauma.
In fact, mental health services are the fastest-growing component of school-based health care. In the last 10 years, the number of school-based health centers with mental health professionals on staff has more than doubled.
"You will hear people say at school-based health care meetings that if there has to be a choice between a full-time nurse practitioner and a full-time mental health provider, that they'll take the mental health provider because the unmet need is that great," says Julia Lear, PhD, of George Washington University's Center for Health and Health Care in Schools.
School-based health centers are also increasingly popular among parents, teachers and school administrators because they deliver low- or no-cost health and mental health care. A 2003 survey conducted by Lear's center found that 83 percent of parents support health-care delivery in schools. A 2007 survey by the W.K. Kellogg Foundation found that two-thirds of voters support them.
Such centers are also growing in number: 152 opened between 2001 and 2005, and Congress is considering two bills that would expand that number.
Yet some school mental health experts say that school-based health centers are an inefficient use of public funds, especially in urban areas that have untapped community mental health services. School clinics, they maintain, aren't always cost-effective for long-term mental health disorders and can become a low priority if funding dries up.
"Education is the mission of schools, and school policymakers are quick to point this out when asked to do more, especially with respect to mental health," says Howard Adelman, PhD, of UCLA's Center for Mental Health in Schools. Meanwhile, funding is also a major concern of those working to keep such programs afloat.
"You constantly have to prove your worth," says school health center veteran Beth Warner, PhD, of the University of Maryland, College Park. "Every year you have to re-apply for funding and you wait on the edge of your seat to see what will happen."
Care right there
Many of today's school-based health centers offer services far beyond the part-time nurse with no back-up model. They offer immunizations, physicals, dental care, nutrition counseling, reproductive health care, and asthma and diabetes management.
On the mental health front, they may offer individual, group and family therapy, crisis counseling, mental health screenings, assessment and substance abuse counseling and prevention.
Demand for these centers is up in part because research suggests they work. A 2007 study in Pediatrics (Vol. 120, No. 4) found that low-income and uninsured adolescents who used school-based health centers were more likely to have had regular checkups, flu and tetanus shots and less likely to visit emergency rooms than adolescents who were tapped community clinics. A 2006 study in the American Journal of Public Health (Vol. 96, No. 9) found that teen pregnancy rates dropped significantly among black adolescents attending high schools with school-based health clinics. And a 2003 study in the Journal of Adolescent Health (Vol. 32, No. 6) found that students were 21 times more likely to make mental health-related visits to school-based health centers than to community health clinics.
Psychologists on the front lines in these centers agree that setting up shop on school grounds is the best way to reach children.
"Not only can you observe them in their social context, you are setting up an environment where they feel they are on their own terms and on their own turf," says Laura Hurwitz, who directs school mental health programs at the National Assembly on School-Based Health Care.
Plus, today's time-strapped parents often have trouble getting children to after-school appointments at offsite clinics.
"You reduce two barriers by being in the school," says Hurwitz. "You reduce the stigma of the traditional mental health setting and the barrier of having to get there."
Being in schools also enables mental health professionals to guide teachers on ways to follow up on a child's therapy in the classroom. Psychology practitioner Christine Cheng, PhD, for example, recently worked with a first-grade teacher whose student was so attached to him, he worried the boy wouldn't come to school the week he'd be on vacation. Cheng, who works at the Montefiore Medical Center School Health Clinic at P.S. 105 in the Bronx, told the teacher to give the boy something of his to keep all week. The boy not only made it through the week with few tears, he gained confidence in the classroom.
"He's doing better academically, he's speaking up more ... he even went on stage for a school performance," says Cheng.
School-based health centers are also an additional mental health resource for teachers who are faced with challenging student behaviors or who may struggle with job-related stress, says psychologist Gary Blau, PhD, who worked in school-based health centers and now runs the Child, Adolescent and Family branch of the Center for Mental Health Services at SAMHSA.
"If a teacher has trouble managing a child, extra consultation may be readily available to them," says Blau. "It's also an opportunity to educate teachers and administrators about how their mental health impacts their ability to teach and function."
Bang for the buck?
While Cheng works full time at P.S. 105, not every clinic has a 40-hour-per-week mental health professional. Many psychologists work in these centers part time or are split across several schools. Education backgrounds also vary: Although 80 percent of the nation's school-based health centers employ mental health professionals, only 19 percent are PhD-level clinical or counseling psychologists; most are clinical social workers.
Funding for the centers is often tenuous. The centers receive limited federal funding; the money to pay for them generally comes from state grants, partnerships with local hospitals or public health departments, or grants from nonprofits, such as the W.K. Kellogg Foundation and the Robert Wood Johnson Foundation, which has funded more than 80 centers.
A lack of steady funding is one reason these centers haven't caught on in Boston, says Boston College's Mary Walsh, PhD, who conducts research on mental health delivery in schools. She recommends that schools tap community mental health services, especially in urban areas.
"It doesn't make sense for schools to try to duplicate services in resource-rich areas," she says. "It does make sense to try to make effective links."
That instability can also create too much competition for resources within schools that must keep student achievement at the fore, adds UCLA's Adelman.
"Prevailing school accountability pressures increasingly have concentrated on instructional practices—to the detriment of all matters not seen as directly related to raising achievement test scores," he says. Adelman and his colleagues at the Center for Mental Health in Schools at UCLA pursue research and advocacy on the best ways to enhance mental health in schools by working within the schools' education missions and creating mental health interventions and promotion programs that "braid together the resources of schools and communities," he says.
School-based health centers can also be highly controversial in some communities, especially in high schools, where some view them as pregnancy clinics that push the use of birth control. But contraception is dispensed in fewer than a quarter of the centers, according to NASBHC, and pregnancy screening and abstinence counseling represent only a small slice of the health services such centers offer.
Yet more school-based centers may soon be on their way. Congress is considering the School-Based Health Clinic Establishment Act (S. 600) and the School-Based Health Clinic Act of 2007 (H.R. 4230), to expand federal funding for school-based health care, including mental health. APA supports the bills, noting that the centers connect underserved children with health and mental health care and boost schools by promoting health and reducing absenteeism, says Annie Toro, JD, associate executive director of APA's Public Interest Government Relations Office.
APA's Practice Directorate is working with NASBHC to expand psychology's role in school-based health centers, such as through supervisory roles and part-time roles at centers that can't fund full-time psychologists.
Meanwhile, other facets of psychology are looking for ways to fine-tune mental health screening at school-based health centers. Mark Weist, PhD, and Sharon Hoover Stephan, PhD, of the University of Maryland's Center for School Mental Health, trained professionals from 19 school-based health centers on how medical and mental health staff can collaborate more closely on diagnoses and treatments. They then surveyed the trainees and found a significant increase in the number of mental health screenings and assessments at their sites and a more team-oriented approach.
The findings are encouraging to Stephan, who saw firsthand how much these centers offer children during the two years she worked in Baltimore's school health centers.
"Far more children actually get the services they need where there is a center on site, especially one that includes mental health services," says Stephan. "And we're constantly hearing, 'How can we get more of these centers?'"