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Adolescent Psychiatry

A program of comprehensive school-based mental health services in a large urban public school district: The Dallas model

A program of comprehensive school-based mental health services in a large urban public school district: The Dallas model

Pearson, Glen

The long history of the relationship between adolescent psychiatry and public education is marked by a kind of reciprocal ambivalence, varying in intensity over time, from mutual neglect to territorial conflict. Over the past 30 years, educators and psychiatrists as professional groups have experienced many changes in the scientific, social, legal, economic, and political environments in which each must carry out its mission. Psychiatry has weathered the community mental health and patient advocacy movements, a nosological revolution, an explosion of knowledge in neuroscience and psychopharmacology, the rise and fall of proprietary psychiatric hospitals, deinstitutionalization of the seriously and persistently mentally ill, and, not least of all, the headlong implementation of managed care currently under way. Public education has borne the brunt of the burden of regressive social anomie in our inner cities-poverty, racial conflict, high crime rates, alcoholism, drug addiction, and family and youth violence-while enduring unendingly shifting pressures for change, including such trends as site-based school management, school improvement modeling, mental health and substance abuse curricula, community services programs, and federally mandated special education services to disabled or handicapped children. Although psychiatrists and educators have always been invested in producing healthy, well-educated, productive citizens, both have usually been too preoccupied with the vicissitudes of their own professional domains to see the larger picture of their shared common purpose, let alone come together and work synergistically in its service.

In 1993, in response to a request by two school principals, Dallas’s public mental health agency helped the school staff to initiate a collaborative mental health clinic using existing resources and personnel along with a child and adolescent psychiatrist. In the 5 years that followed, this model matured, developed, and grew into a district-wide program of health, comprehensive mental health, and youth and family services in 10 sites serving all 160,000 students in more than 200 schools. In this chapter, we review the literature on school-based mental health services, trace the development of the Dallas service delivery model to its present configuration, and report the results of its program evaluation. We also discuss some of the advantages we have discovered, as well as the challenges that we have faced and those which still confront us.

Review of the Literature

Healthcare services have been provided in schools since the late 19th century, when doctors monitored outbreaks of infectious diseases such as tuberculosis and diphtheria. Even then, programs were plagued with funding problems, arguments over service responsibilities, and difficulty establishing and maintaining collaborative agreements (Dryfoos and Klerman, 1988). Although lacking in organization, services survived and even began to proliferate when the issue of teen pregnancy surfaced (Balassone, Bell, and Peterfreund, 1991). The social, psychological, and health problems of children necessitate a comprehensive approach (Halfon, Inkelas, and Wood, 1995). This has been especially true for teenagers, who have their own set of health issues due to risk-taking behaviors, difficulty accessing care, confidentiality, and the emotional upheaval that often characterizes adolescence (Brindis and Sanghvi, 1997). Schools have proved to be a vitally important site for the establishment of mental health services for children, as other existing community resources too often cannot meet this need (Flaherty, Weist, and Warner, 1996).

Historically, healthcare services and mental health services have been seen as separate and distinct-a dichotomy maintained over the years by such influences as the stigma associated with mental illness, the lack of hard medical evidence of the effectiveness of psychiatric treatment, the resistance of the profession to change, and financial barriers to accessing mental health services. Over the past 20 years, however, a revolution in neuroscience and the rapid development of effective biological therapies has helped reestablish the link between psychiatry and medicine. The partnering of health, mental health, and schools has brought about its own set of conflicts: turfism, funding issues, differences in eligibility for services, paperwork, accountability, and colocation issues (Hacker et al., 1994). Relationships between mental health providers and school personnel have often been awkward, even competitive, with differing ideologies regarding what is best for the child.

Successful integration of services requires interorganizational cooperation: interdependence, mutual benefit, common modes of communication, and complementary technologies (Goldman, 1982). Gottlieb and Kotch (1984) have suggested guidelines for developing school-based services: convening a network of partners, assessing healthcare needs and resources, deciding what services to offer, delineating gaps and duplications, choosing a site, and developing and monitoring implementation. A well-designed health services program, combined with comprehensive health education, can significantly advance the health of the nation’s children. Once services are in place, students, parents, and school staff must know of their existence. Walter et al. (1995) found that referral sources in a large urban school clinic system consisted of clinic outreach (48%), self-referral (44%), and school staff referral (8%). Despite efforts to spread information, knowledge of available services is sometimes lacking. Reasons for nonuse by students include lack of parental permission, feelings that the clinic would not be able to help them, concerns about confidentiality, and no knowledge that the services existed (Balassone et al., 1991); others have reported not being able to leave class for appointments (Keyl et al., 1996); still others have complained of a lack of communication among school, parents, and health providers regarding needs and services available to meet them (Fox, Rankin, and Salmon, 1991).

Students use school-based clinics to meet a variety of healthcare needs, ranging from basic health education and screening to chronic psychosocial problems, and school sites have evolved to meet the everchanging challenges of the youth they serve. Igoe and Goodwin ( 1991 ) note that the school is a likely site to target such tasks as properly immunizing the nation’s pediatric population. A majority of clinics provides an array of services, including assessment and referral, treatment of minor injuries, routine health screening, sports physicals, nutrition information, laboratory services, birth control and pregnancy information, and mental health services (Balassone et al., 1991). Ryan, Jones, and Weitzman (1996) have underscored the importance of these services with their finding that urban junior high school students who used the school-based clinics were more likely to be involved in risktaking behaviors (e.g., unprotected sex, physical violence, and substance abuse) and were also performing more poorly academically.

Although school-based health services have been in place for almost a century, the integration of mental health services is relatively new (Flaherty et al., 1996). A wide range of estimates of the prevalence of mental health issues in the help-seeking student population has been reported. Balassone et al. (1991) have reported that the most frequent visits were for general illness and sports physicals, but 20% were for mental health services. Others have found that as many as 50% of clinic visits are for such nonmedical reasons as peer and family issues, emotional problems, and substance abuse (Adelman and Taylor, 1996). Many physical complaints have psychogenic origins, and the treatment of many other health problems is enhanced by mental health services. Whatever their stated reason for a clinic visit, students often have other physical and mental health needs (Harold and Harold, 1993). A survey of Texas school nurses found that a significant amount of time is spent caring for students with special health needs; chronic medical problems were foremost among these, but attention deficit hyperactivity disorder ranked second only to asthma as a reason for nursing involvement.

In a survey of Colorado school personnel, Goodwin, Goodwin, and Cantrill (1988) found that poor decision-making skills, poor self-image, inability to resolve interpersonal conflict, depression, and conduct problems were the principal unmet mental health needs of students. Elementary-age users of school mental health services were reported to have more critical life events, more signs of familial disruption, and more involvement in special services (Cowen, Weissberg, and Guare, 1984). Gaps in and duplications of services can be eliminated (Gottlieb and Kotch,1984). Consumers using the school-based clinics are as economically disadvantaged and as psychiatrically impaired as community clinic users but do not have easy access to the community clinics (Armbruster, Gerstein, and Fallon, 1997). Most needed services can be provided on site (Walter et al., 1995), and students frequently make return visits to the clinic (Ryan et al., 1996).

School-based health centers are now providing care to high-risk youth who may not receive it elsewhere. These clinics are targeting many of the 1990 “Health Objectives for the Nation”: general health screening, improved pregnancy outcomes for adolescent mothers, decreased substance abuse, better control of stress, less suicidal ideation, improved nutrition, and more immediate treatment of accidents and injuries (Dryfoos and Klerman, 1988).

School clinic users have greater access to needed services than their nonusing peers. They report high ratings of clinic staff and services (Balassone et al., 1991) and demonstrate a higher rate of utilization of services of all kinds. Student self-reports show a significant decline in rates of depression and significant improvement in self-concept (Weist et al., 1996). Nonusers of services are more socially withdrawn than peers who take advantage of services; they have more total absences and lower grades (Weist et al., 1995).

Although further studies monitoring the outcomes of these programs are certainly needed, the evidence already available clearly shows that the integration of health and mental health services through partnership with the schools can only improve our ability to provide care to the nation’s youth.

Program Development

The first school-based mental health services in Dallas were established by voluntary agreement between two local campus principals and the Dallas Mental Health/Mental Retardation Center (MH/MRC), facilitated by school psychology personnel who mediated the relationship. One child psychiatrist and one adolescent psychiatrist from the MH/MRC medical staff provided one half-day of direct services and consultation per week and was allowed to partner with campus-based school personnel to form a team. The school had considerable resources that could be coopted to develop services: one full-time advanced nurse practitioner, two school psychologists, one social worker, one counselor, and one parent ombudsman. All of these educational professionals brought considerable enthusiasm and dedication to the development of a collaborative, multidisciplinary mental health treatment team under the leadership of the child/adolescent psychiatrist. The process of development was made possible by the full support of the founding principals and their staffs, and it was the principals and their assistant administrators who generated the majority of early referrals to the program.

Initially, four hours of psychiatrist time were scheduled each week, from 2:00 p.m. to 6:00 p.m., in order to afford the opportunity for inclassroom consultation as well as after-school and after-work family appointments. (This scheduling paradigm has stood the test of time and continues to be the model for utilization of psychiatrist time most desired by families and staff.) The MH/MRC’s interest at this point was primarily heuristic, around issues of case finding, needs assessment, and experimental service delivery redesign, with particular emphasis on improving accessibility. Among the many important discoveries of this early phase in the program’s evolution were the following: Children and families who would not seek services from a public mental health clinic will accept them gladly if they are offered in a familiar, userfriendly, close-to-home setting; accessibility for patients translates into productivity for providers (as appointment compliance rates approach 100%); although there continues to be a need for traditional school consultation, the crying need articulated by school staff and families is for direct treatment services; and there already exists within the public schools a wealth of social and clinical service resources that can be pulled together from within if only a broad-enough vision is applied from without, given administrative encouragement and support.

The experimental program involving the first two campuses was so successful that word spread rapidly throughout the district, resulting in an almost immediate demand for the establishment of similar services; within six months, the model had expanded to serving 14 campuses in six additional sites. During this early expansion, new service sites were implemented in the same entrepreneurial fashion that had characterized the first pilot: Interested principals and school communities approached either MH/MRC or the district employees who were working within the informal collaborative and offered space and other resources in exchange for psychiatric and social services. Subsequent expansion efforts were influenced by three factors that surfaced unexpectedly in the 1994-1995 school year: (a) The school district’s Health and Human Services division became concerned about issues of equity if the informal collaboration were allowed to continue expanding entrepreneurially. driven by local campus demand; (b) a politically powerful group of local elected officials and business leaders, which had been attempting, unsuccessfully, to drive the development of a student support program (from the top down) for several years, noticed the successful emergence of the grass-roots, bottom-up services program and began maneuvering to get in front of and coopt it; and (c) the rapid expansion of the mental health service program resulted in its encountering the pioneering initiative of the Parkland Health and Hospital System, which had already established and maintained healthcare services within the Dallas Public Schools for more than 20 years. All three converging issues were resolved in a bold stroke by the school district, whose Health/Human Services administrator-herself a mental health professional, a respected advocate for children’s mental health, and an established friend of the mental health provider community-moved to consolidate the informal collaborative with the business leaders’ and elected officials’ initiative, under the aegis of the school district, and invite both Parkland and Dallas MH/MRC as partners to provide services together, under the title of Youth and Family Centers (YFCs). The school district also was able to provide infrastructure funding for the project, including facilities, management, support, and suppliesallowing the provider partners to concentrate on their missions of health and mental health service delivery. The YFCs have operated under this paradigm for almost three years; only now, the partners are in the process of legally structuralizing their interrelationships with formal memoranda of agreement. The trade-off of price paid (loss of entrepreneurial spirit and local community control) for value received (broadness of reach and equity) is discussed later, in the “Advantages” and Challenges” sections.

Program Description: Dallas Youth and Family Centers

STRUCTURE

In the fall of 1993, two Dallas Public Schools campuses joined with Dallas MH/MRC and established the first intensive school-based mental health center. Within six months, the program expanded to 14 additional campuses. School-based centers experienced dramatic further growth until the fall of 1995, when Parkland Health and Hospital System, Dallas Public Schools, and Dallas MH/MRC formed a collaboration establishing the YFCs to provide integrated physical and mental health care in school-based settings.

UNIQUE PROGRAM FEATURES

Each of the 10 YFCs is geographically located to serve 20 to 25 school campuses. Each “family of schools” (Adelman and Taylor, 1996) includes a few high schools and all of their feeder elementary and middle schools. Each school campus provides a member of its student support team as liaison to the YFC in order to facilitate referral and implement the school service part of the child’s treatment plan.

STAFFING

The school district employs a licensed mental health professional as YFC manager at each site. YFC managers lead and coordinate the activities of a team of health professionals from Parkland, a team of mental health professionals from Dallas MH/MRC, and several parttime school staff. Health team members include pediatricians, nurse practitioners, physician assistants, and social workers. Mental health professionals include child and adolescent psychiatrists, intake/assessment workers, and nonpsychiatric clinical service providers. School district employees who work part-time in the YFC programs include school psychologists, social workers, counselors, nurses, marriage and family therapists, and parent educators. Dallas MH/MRC provides 24hour crisis response capability and physician on-call services.

TRAINING

Both pre-service and in-service training are integral parts of the YFC program. Predoctoral internships in psychology and social work are offered in collaboration with the graduate schools of several area universities. General psychiatry residents and child/adolescent psychiatry fellows at the University of Texas Southwestern Medical School are routinely assigned to rotations in the YFCs. Two semesters annually of child development training are provided to YFC staff members by volunteer faculty from the Dallas Psychoanalytic Institute, and all three partner agencies participate in a monthly school-based clinic grand rounds in which cases and current scientific topics are presented and discussed.

GUIDING PRINCIPLES

An integrated, holistic approach to addressing children’s needs, particularly those of at-risk children, requires coordinated, family-focused, prevention-oriented, community-centered programming, developed in response to the self-identified needs of local school communities. Some of the principles that inform the operation of YFCs are belief in a holistic approach to addressing children’s developmental needs; belief in family-focused and prevention-oriented services; and beliefs that health and mental health services should be available to all children and families, that schools play a central role in the lives of children and adolescents, that a child’s well-being affects his or her academic performance, and that all families have strengths and resources and must be empowered to participate in their children’s education, growth, and development. It is our intent that every aspect of our program should reflect these beliefs.

The YFC partners believe that valuing and empowering families and friends produces positive changes for the school and community and creates opportunities for parents and families to participate fully in their children’s education.

SERVICE DELIVERY PROCESS

Referral

Referrals to the YFCs are initiated by several sources: parents, school staff, and community agencies. School student support teams (SSTs), trained by YFC staff, screen student referrals and request YFC services in one or more of five major components: intensive mental health care, physical health care, counseling, family/home involvement, and youth development activities.

The major student referral categories for intensive mental health services are behavioral/emotional issues, family/home issues, and delinquent behavior. Behavioral issues include such symptoms as hyperactivity, impulsivity, aggressive behavior, conflict with teachers, and peer relationship difficulties; emotional issues include depression, anxiety, social withdrawal, and somatic complaints; family/home referrals may reflect issues relating to divorce, separation, marital conflict, abuse, or neglect; and referrals for delinquent behavior are characterized by truancy, stealing, assault, or gang involvement.

Service Prototype

The YFC program provides a collaborative multidisciplinary mental health treatment team, co-led by the child and adolescent psychiatrist and the YFC manager (licensed mental health professional). The team approach is reflected in every phase of service delivery: intake, evaluation/assessment, treatment, and follow-up. Concomitant with the multidisciplinary professional teamwork, the school staff participates in the child-centered plan of treatment and related service, which is developed and implemented across the contexts of school, home, and community; successful outcomes depend on the involvement of adults in all these sectors who touch the students’ lives.

Upon enrollment in a YFC, a child can expect to receive services throughout his or her school life, from preschool through Grade 12. School success indicators for each student are tracked each school year, and aggregate data on these indicators are reported as feedback to YFC staff and sponsoring partner agency administrators and boards of trustees.

YFCs are open 5 days a week, with extended evening hours (until 8 or 9 p.m.) available Monday through Thursday. Twenty-four-hour, 7-day backup crisis services including emergency room and hospital care are provided by Parkland and Dallas MH/MRC.

Procedures

Mental health service delivery occurs in several steps, with full family participation expected throughout the process.

Step 1. The school campus SST compiles school data (records of grades, attendance, disciplinary referrals, special education services) on the referred student. The SST member interviews the student and family, observes the student in class, completes the Teacher Report Form of the Child Behavior Check List (CBCL; Achenbach and Edelbrock, 1986), and obtains parent permission for the child to receive YFC services. The compiled student data are forwarded to the YFC with a one-page summary referral form. Frequently, the school’s campus liaison will consult with the YFC manager about the referred student.

Step 2. The family makes its first visit to the YFC, where intake staff complete initial assessment and paperwork (required by state funding authorities as part of program evaluation and performance contracting). Intake staff and site-based mental health professionals establish a relationship with the family and begin formulating the case for presentation to the collaborative evaluation team.

Step 3. The next step in service delivery is the collaborative team evaluation at the YFC. Team members always include the child and adolescent psychiatrist, the YFC manager, and such other mental health professionals and school staff members as are indicated by the circumstances. School staff, sometimes including classroom teachers and administrators, are often present; most referrals for mental health care are from school personnel, and the team values their direct participation. The YFC manager presents the case summary to the psychiatrist and team before the referred student and family join the group to be interviewed by the psychiatrist. Data from the interview are combined with observations from school and data from such instruments as the CBCL (parent, teacher, and youth self-report forms), and others required by the Texas Uniform Assessment, to arrive at a preliminary diagnosis, case formulation, and treatment plan.

A basic tenet of the model is the participation of all family members in the assessment and treatment processes: Grandparents and other extended family members often come to the table with their concerns, resources, and recommendations. The voices and visions of family members are highly valued; very often, families find immediate solutions to some of their most pressing problems.

Step 4. Treatment planning occurs at the conclusion of the team evaluation and takes advantage of having all the relevant members of the child’s interlocking systems of family and school present for the process. The emphasis is on being comprehensive and on providing consistent interventions across systems while remaining problem oriented and solution focused. Specific strategies are detailed for both home and school (school service plan).

Step 5. Feedback to the referring school includes a copy of the school service plan, which is sent to the campus liaison at the referring school for implementation and monitoring. Each campus principal signs a contract at the beginning of the school year agreeing to work with the treatment team on recommended interventions.

Step 6. Therapeutic interventions are provided by mental health staff from both Dallas Public Schools and the Dallas MH/MRC. Providers include the psychiatrist, psychologists, social workers, licensed professional counselors, and rehabilitation skills trainers. Therapeutic modalities include individual therapy, group therapy, family therapy, play therapy, and adjunctive psychopharmacology. Bilingual (Spanish/English) services are available. The principles guiding these therapeutic approaches are eclectic and practical, with a predominance of familysystems, psychodynamic, cognitive-behavioral, and interpersonal orientations. School intervention plans often include behavior management plans, further psychometric evaluation, schedule or classroom assignment changes, mediation to resolve teacher-student conflict, and youth development activities. Interventions for the family to carry out at home are also a part of the treatment plan.

Step 7. Follow-up evaluation and treatment plan revisions are completed regularly (30 to 90 days) depending on the needs of each student and family. (The Texas Uniform Assessment requires a complete reassessment every 90 days regardless of the needs of the student.)

PROGRAM EVALUATION

The YFC program is evaluated annually by the Division of Research, Evaluation, and Information Systems of the Dallas Public Schools. Context, process, and outcome evaluation information is included in an annual report, the purpose of which is to review what services are provided, how the program is implemented, and the relationship between services and school success outcome measures. Context evaluation questions center on program goals and priorities, data from the project partners, and a review of literature concerning school-based mental and physical healthcare. Process evaluation questions address how the program is implemented, what quality assurances are in place, and how staff training addresses program needs. Outcome evaluation questions concern customer satisfaction and student school success outcomes (grades, attendance, behavior). Evaluation methodologies include interviews, questionnaires, follow-up data, attendance and discipline referral data, and student grades. Texas MH/MRC program evaluation data are collected and reported separately from the district’s program evaluation; in addition to satisfaction and school success data, the MH/MRC program evaluation reports CBCL score changes, arrest rates, and certain “critical incident” occurrence rates (e.g., running away, placement outside the home).

Program Results

The staff at each YFC enters demographic information, presenting problems, and services received into the database during the traditional school year (August-May). Results reported here are based on the 1996-1997 school year.

SAMPLE CHARACTERISTICS AND INTERVENTIONS

Student and family demographics are shown in Figure 1. One thousand six hundred sixty-two students and their families received intensive mental health services during the school year. The majority of the students were eligible for free or reduced-fee lunch (73%), met poverty guidelines (68%), and were considered at risk for dropping out of school (60%). Additionally, 27% were speakers of other languages, 24% were in special education, and 4% were in special programs for talented and gifted students. The patient group was 66% male, 43% African American, 38% Hispanic, 18% Anglo, and 1% Asian American. Information related to parents’ employment status was collected for 819 families and is reported in Figure 2. Data suggest that these children were from families of working poor, with 79.8% reporting an employed parent or guardian versus 20.2% with no employed parent or guardian. Additionally, 21.7% reported both parents working. Information bearing on family type is summarized in Figure 3. Of the 1,100 families reporting, 42.4% were single-parent, 30.8% were nuclear, 13.3% were blended/married, 8.3% were multigenerational, 2.5% were blended/ unmarried, and 2.7% were of unspecified family type. Finally, as demonstrated in Figure 4, our families were overwhelmingly lacking in private health insurance (97% uninsured).

Presenting problems are summarized in Figure 5. Behavior problems comprised the majority of referral issues (66.4%); 20.2% were referred for emotional problems, 7.5% for family issues, 3.5% for academic problems, and 2.3% for “other” problems. Grade levels of referred students are shown in Figure 6; the referral rates for prekindergarten to Grade 3 (34%), Grade 4 to Grade 6 (24%), Grades 7 and 8 (19%), and Grade 9 to Grade 12 (24%) bear an uncertain relationship to theoretical developmental and academic transition phases, which are the focus of further study and consideration. Diagnostic Groups The official diagnoses our patients have been given since the program opened in 1993 fall into seven general categories, summarized in Figure 7. The most common diagnoses have been disruptive behavior disorders (37%) and mood disorders (22%). Other diagnoses are adjustment disorders (14%), anxiety disorders (9%), personality disorders (7%), and V-codes (8%), with 2% unspecified or unknown. An interesting finding is that, although school staff have a high index of suspicion for disruptive behavior disorders and overwhelmingly list behavior problems (66%) as the presenting problem, after evaluation only about half of the behavior problem children are diagnosed with disruptive behavior disorders. Many cases of apparently disruptive behavior are due to mood, anxiety, or adjustment disorders or to a nonpsychopathological disturbance in significant relationships in family or community.

Primary therapeutic interventions are summarized in Figure 8. Family therapy is the first-line intervention for 42.8% of referred cases. Other treatments include individual psychotherapy (30.9%), school interventions (13.7%), parent training (7.2%), support group (3%), group therapy (2.1%), and other or unspecified intervention (2%). Frequently, the treatments are combined in order to maximize therapeutic effects and to give extra support to the child and family or to the school staff. Prescription of psychopharmacological agents (Figure 9) occurred in 22% of the cases. Medication is never a primary therapeutic intervention; it is always considered an adjunct to one or more of the other modalities.

As previously noted in our guiding principles, all facets (home, school, community) of a child’s environment influence his or her wellbeing (mental health, school performance, physical health); therefore, interventions are always provided across the contexts of home, school, and community.

OUTCOMES

Student Performance Outcomes

Data related to student attendance, grades, and behavior were compiled as baseline in the first or second 6-week term and as posttest follow-up in the sixth or final 6-week term of each of the 2 school years of the evaluation (1995-1996 and 1996-1997). There were fewer absences, course failures, and disciplinary referrals for both school years. Figure 10 shows a summary of results for the 1996-1997 school year. For mental health care, these improvements reflected as much as a 32% decrease in absences, a 31% decrease in course failures, and a 95% decrease in disciplinary referrals. The independent evaluator concluded that effects in all three outcome measures were significant (Bush, 1997), with students who received intensive mental health intervention showing “meaningful decreases” in absences, course failures, and disciplinary referrals.

Student, Family, and School Personnel Satisfaction

Consumer questionnaires were completed by students and family members who received mental health care, and similar questionnaires were completed by school personnel who referred students to the YFCs. Family outcomes were positive, with an excess of 90% reporting that they were involved in their child’s evaluation and treatment, that they would return to YFC for services, and that they were happy with the amount of time spent with them and how they were treated by staff. Student satisfaction was similarly high, with more than 90% reporting satisfaction with the amount of time spent and how they were treated, 90% reporting that they were doing better or much better since they received services, and 80% reporting that their families were doing better or much better since the intervention. As for school personnel, more than 95% reported being satisfied with services. Similarly, high percentages described the services as being of high quality and said that they would recommend YFC services to other schools (Bush, 1996, 1997).

Discussion

What have we learned from our first 5 years of experience providing community mental health services on site in the public schools? That this service delivery model brings many advantages for patients, families, schools, and service providers is now nearly axiomatic; it is also true that attempts to establish and maintain such a service delivery system face many arduous challenges.

ADVANTAGES

For children and families, the advantages of the school-based model are obvious: Services are close to home, accessible, user friendly, and relatively devoid of stigma. For providers and school staff, it is very gratifying to be able to work with and effect change in some of the most crucial environmental variables that affect the child’s functioning (home, school, community); community service providers in traditional models of service delivery have been long accustomed to seeing only a fraction of their appointed clinical service hours, owing to high noncompliance rates; compliance rates approaching 100% are not unheard of in school-based settings. For agency administrators, the most important finding is that improved accessibility for consumers translates directly into vastly improved productivity of agency provider staff. If we take our services to where the kids are, rather than give the kids appointments to come see us, we will experience a great deal less downtime in general and will be helpful to many who otherwise would never have sought our services.

CHALLENGES

As the model has expanded and matured, we have begun to notice that appointment compliance rates, which were initially extremely high, are declining in school-based sites. We attribute this to a kind of satiation in the target population: Now that we are more accessible (but not nearly accessible enough, with each site serving 20 to 25 school campuses), the same public mental health client mentality that pervades our own outpatient clinics has infected our outreach centers. This is a particularly worrisome trend, as mental health agency administrators attempt to plan further allocation of scarce resources in the community.

Political and territorial boundary issues are formidable challenges for a collaboration such as ours. From the beginning, our operational partners have shared a common vision and purpose; we have respected one another and supported one anothers’ missions. During the same period of time, each of our sponsoring governing bodies has experienced severe political vicissitudes of one kind or another, some of which could have been life-threatening to our nascent collaboration-the school’s board of trustees hiring and firing a superintendent and engaging in internecine warfare; the mental health board of trustees hiring and firing an executive director and trying to micromanage YFC operations, until brought up short by a State Auditor’s Office investigation; and the hospital district’s board getting involved in the controversy over the provision of family planning and reproductive healthcare services to adolescents. The providers of clinical and social services to youth, represented by the operational arms of all three agencies, have clung to their mutual respect and support for one another through it all, but maintaining services in such an uncertain and heated political climate remains a questionable proposition.

The advent of managed care in the provision of both healthcare and behavioral healthcare services hangs heavy over all three partners in our enterprise. We are all significant providers of Medicaid-funded services, albeit under differing Medicaid “program options.” Heretofore, the Dallas MH/MRC has been an exclusive provider of rehabilitation option program services; Dallas Public Schools has been the provider of school health and related services, and Parkland has been the provider of early prevention, screening, diagnosis, and treatment services. Under a pending plan by the state of Texas to modify the provision of healthcare and behavioral healthcare services under a new Medicaid 1915(b) waiver, Dallas County and six surrounding counties will come under the supervision of a yet-to-be-appointed local behavioral healthcare authority, which will supervise the administration of services, delivered by competitively secured managed behavioral healthcare organizations (which may or may not include our existing community mental health centers). Under these conditions, our two provider partners must be concerned not only about retaining “market share” but, indeed, about survival. An interesting leitmotif in the prevailing maneuvering among the agencies is the loyalty of the operational divisions of our partners to one another, even as the superordinate organizations compete and, potentially, clash.

Conclusion

Providing integrated health and mental health services in the public schools has advantages for all the stakeholder groups: children and families, school authorities, providers of clinical services, and public agency administrators. Vastly improved accessibility for consumers translates into enhanced productivity for treatment providers. The outcomes of school-based mental health services are promising in terms of clinical symptom reduction, school success indicators, and stakeholder satisfaction.

A multidisciplinary, multiagency interprofessional team approach to service delivery is an effective way of integrating diverse resources and bringing them to bear upon the mental health problems of children and families. Psychiatrists have a key role as leader of the clinical team, provider of psychiatric services, and clinical supervisor of other mental health professionals on the team. The confluence of several current trends in public education and psychiatry makes the present a time ripe with opportunities for collaboration to improve the mental health of our children and their families.

Copyright Analytic Press 1999

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