A Bronx, N.Y., fourth-grader complains of dizziness and has trouble catching his breath. In another school, such a child might immediately be sent home, but this student's school houses a health center, supported by Children's Hospital at Montefiore. As a result, the teacher refers him to the center's physician, who conducts a thorough medical exam and interviews the boy about his home life, peers and academic workload.
In just one visit, the provider pinpoints the problem: The child is anxious about upcoming standardized tests. The physician refers him to the center's onsite mental health provider, who recommends that he participate in an anxiety-reduction group, where he learns ways to calm his fears. His teacher is involved in his treatment and reinforces the relaxation techniques in class.
In the end, the child passes the exam that triggered his anxiety. But more importantly, he is better equipped to deal with future anxieties--and a student who might have been caught in a downward spiral of falling grades and poor attendance is back on track.
More schools are providing such safety nets for children through school-based health centers, which offer a one-stop source of primary and preventive health and mental care. Though still relatively scarce in the nation's 90,000 public schools, the number of school-based health centers has increased from 120 sites in 1988 to more than 1,500 today, according to the National Assembly on School-Based Health Care (NASBHC), an advocacy organization that promotes the model to policy-makers.
"More school-based health centers are opening as local, state and federal governments realize that physical and mental health go hand-in-hand," says Ron Palomares, PhD, associate executive director for policy and advocacy in the schools in APA's Practice Directorate. "The centers and their supporters have been broadcasting their successes and showing how physical and mental health problems are manifested in the classroom, and the toll they take on student achievement."
The centers are sponsored by a combination of funding from hospitals, health departments, federal grants, patient revenue and sometimes universities and private foundations. They provide a range of services depending on their size and budgets, from only health screenings and assessments to a full complement of care, including acute illness treatment, immunizations, laboratory tests, health education, psychological assessments and referrals, and individual and family therapy--all on the school grounds.
"That's one of the many pluses of having a school-based health center," says psychologist Kari Collins, PhD, director of mental health services at the Montefiore program. "We are where the kids are, so children are more likely to follow through with their appointments."
Not only do the children miss very little class, but their parents don't have to take time off from work to take them to a physical or mental health provider. That's a tremendous service for families, says Susan Dorsaneo, PhD, a supervisor in the Dallas public schools-based health-care system.
"We serve a lot of working poor and immigrant families who would not have the time--or even the idea--to see a psychologist otherwise," she explains. "They may not even realize that their child's behavior represents something else."
Some "clinics" are actually traveling teams that set up shop in a school nurse's office to provide a half day of services. Other centers, like those in the Bronx program, operate like small community health centers. That system--the largest comprehensive school health program in the country--runs 12 centers, each staffed at minimum with a full-time medical provider, licensed practical nurse, mental health provider (a psychologist or social worker) and office manager. They even offer dental services.
"We are trying to actualize a fairly broad model of primary care, which includes a full-blown mental, physical, oral and community health program, all integrated into one," says David K. Appel, MD, the program's director. The most common mental health problems treated by the Bronx centers are mood disorders, adjustment problems, attention disorders, anxiety and disruptive behaviors.
The need for such centers was recently underscored with the July release of the first-ever national survey of mental health services in the nation's public schools, commissioned by the Substance Abuse and Mental Health Services Administration.
The study found that more children are struggling with mental health problems, but the resources to meet those needs are inadequate. The good news is that more money is trickling, albeit slowly, to school-based health care. For example, the centers are included as part of the growth of community health programs under President Bush's Primary Care Access initiative, according to John Schlitt, NASBHC's executive director.
In addition, language friendly to school-based health centers appears in President Bush's New Freedom initiative (see page 28), the No Child Left Behind legislation and the reauthorization of the Individuals with Disabilities Education Improvement Act, according to Mark Weist, PhD, of the Center for School Mental Health Assistance at the University of Maryland Medical Center, which offers training and technical assistance to school-based centers.
"The federal government is providing noteworthy leadership in advancing school mental health," says Weist.
Meanwhile, a handful of states are striving to enhance their school-based care, adds Schlitt. Michigan, for example, hopes to launch centers in more than 20 communities, and New Mexico's governor has pledged to double that state's centers.
Advocates hope that documenting the success of school-based centers will boost funding. Montefiore's Appel, for example, is on a team of investigators who examined whether school-based health centers improved care for elementary school asthmatics. The team found that access to school-based health centers was associated with a reduction in the rate of hospitalization and a gain of three school days for children with asthma.
Another vein of research finds that hard-to-reach populations, especially minorities and males, are more likely to go to a school-based health center than to a community health center or a health maintenance organization. More such research is under way.
A fulfilling setting for psychologists
About 12 percent of the mental health providers in school-based settings are psychologists, according to the NASBHC. Other psychologists in the centers serve as consultants or in administrative roles, such as clinical directors and supervisors. They emphasize that the school-based model seeks to build on--not supplant--the work already being done by school psychologists, guidance counselors and other school staff.
"The idea is to move toward a full continuum of health and mental health promotion and treatment by partnering with the schools and the community," Weist explains.
In addition to providing a variety of services for many different clients, psychologists say they relish the chance to interact with different people and families.
"You're able to interface more directly with health-care professionals and others than you would in an outpatient setting," says Collins. "You're able to do a classroom evaluation of a child and sit down with a teacher and really talk with them."
Such collaboration, says Phyllis Green, a Dallas clinical supervisor, creates a more thorough system of care. "Too often, mental health professionals categorize or pathologize a child's behavior," she says. "But instead of letting a problem cause a major disruption in a child's education, we work with the school. We're about helping children find their strengths to be more successful in school."Sara Martin is a writer and editor in Washington, D.C.
Webber, M.P., Carpiniello, K.E., Oruwariye, T., Lo, Y., Burton, W.B., & Appel, D.K. (2003). Do school-based health centers make a difference? Archives of Pediatrics and Adolescent Medicine, 157, 125-129.
Juszczak, L., Melinkovich, P., & Kaplan, D. (2003). Use of health and mental health services by adolescents across multiple delivery sites. Journal of Adolescent Health, 32 (Suppl. 6), 108-118.
Kaplan, D.W., Calonge, B.N., Guernsey, B.P., & Hanrahan, M.B. (1998). Managed care and SBHCs. Use of health services. Archives of Pediatrics and Adolescent Medicine, 152, 25-33.
Nastasi, B.K., Moore, R.B., & Varjas, K.M. (2004). School-based mental health services: Creating comprehensive and culturally specific programs. Washington, DC: American Psychological Association.
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