From Addressing Barriers to Learning,
Vol. 2 (1), Winter 1997

Comprehensive Approaches & Mental Health in Schools

To address the needs of troubling and troubled youth, schools tend to over rely on narrowly focused and time intensive interventions. Given sparse resources, this means serving a small proportion of the many students who require assistance and doing so in a limited way. The deficiencies of prevailing approaches lead to calls for comprehensiveness -- both to better address the needs of those served and to serve greater numbers.

Comprehensiveness: A Term with Wide Appeal

Comprehensiveness is becoming a buzzword. Health providers pursue comprehensive systems of care; states establish initiatives for comprehensive school-linked services; school-based clinics aspire to become comprehensive health centers; and there is talk of comprehensive school health programs. Widespread use of the term masks the fact that comprehension is a vision for the future -- not a reality of the day.

Comprehensiveness requires developmental and holistic perspectives that are translated into an extensive continuum of programs focused on individuals, families, and the environment. Such a continuum ranges from primary prevention and early-age intervention -- through approaches for treating problems soon after onset -- to treatment for severe and chronic problems. Included are programs designed to promote and maintain safety at home and at school, programs to promote and maintain physical and mental health, preschool and early school adjustment programs, programs to improve and augment ongoing social and academic supports, programs to intervene prior to referral, and programs providing intensive treatment. This scope of activity underscores why mechanisms for ongoing interprogram collaboration are essential.

Schools are the focus of several initiatives aspiring to comprehensiveness. Key examples are (1) moves toward school-based health centers and full service schools and (2) the model for comprehensive school health.

Comprehensive School-Based Health Centers and Full Service Schools


 Many of the over 700 school-based or linked health clinics are described as comprehensive centers. This reflects the fact that a large number of students want not only the medical services, but help with personal adjustment and peer/family relationship problems, emotional distress, problems related to physical and sexual abuse, and concerns stemming from use of alcohol and other drugs. Indeed, data indicate that up to 50% of clinic visits are for nonmedical concerns. Given the limited number of staff at such clinics, it is not surprising that the demand for psychosocial and mental health interventions quickly outstrips available resources. School-based and linked health clinics can provide only a restricted range of interventions to a limited number of students. Thus, the desire of such clinics to be comprehensive centers in the full sense of the term remains thwarted.

Joy Dryfoos encompasses the trend to develop school-based health clinics, youth service programs, community schools, and other similar activity under the rubric of full service schools. To date, the reality of this desire for comprehensiveness remains mostly a vision. And, as long as the vision is anchored in the school-linked services model (i.e., initiatives to restructure community health and human services), it is likely that resources will remain too limited to allow for a comprehensive continuum of programs.

Comprehensive School Health

Up until the 1980s, school health programs were seen as encompassing health education, health services, and health environments. Over the last decade, an eight component model for a comprehensive focus on health in schools has been advocated. The components are (1) health education, (2) health services, (3) biophysical and psychosocial environments, (4) counseling, psychological, and social services, (5) integrated efforts of schools and communities to improve health, (6) food service, (7) physical education and physical activity, and (8) health programs for staff.

To develop each states' capacity to move toward comprehensive school health programming, the Centers for Disease Control and Prevention (CDC) set in motion an initiative designed to increase state-level interagency coordination. Relatedly, the Educational Development Center with funding from CDC is in the midst of a project to clarify how national organizations and state and local education and health agencies can advance school health programs.

The focus on comprehensive school health is admirable. It is not, of course, a comprehensive approach for addressing a full range of barriers interfering with learning -- nor does it profess to be. Unfortunately, it's restricted emphasis on health tends to engender resistance from school policy makers who do not understand how they can afford a comprehend-sive focus on health and still accomplish their primary mission to educate students. Reform-minded policy makers may be more open to proposals encompassing a broad range of programs to enhance healthy devel-opment if such programs are part of a comprehensive approach for addressing barriers to learning. 

With respect to addressing barriers to learning, comprehensiveness
 requires more than outreach to link with community resources, more
 than coordination of school-owned services, and more than 
coordination 
of school and community services.  Moving toward comprehensiveness
 encompasses restructuring and enhancing (1) school-owned programs 
and services and (2) community resources; in the process, it is
 essential to (3) weave school and community resources together.  
The result is not simply a reallocation or relocation of resources; 
it is a total transformation of the approach to intervention.





Toward a Comprehensive, Integrated Approach


Policy makers and reformers have not come to grips with the 
realities of addressing barriers to learning and fostering 
healthy development. A few preliminary steps have been 
taken toward reform, such as more flexibility in the use 
of categorical funds and waivers from regulatory restrictions.
 There also is renewed interest in cross-disciplinary and 
interprofessional collaboration training programs.


As our Center's 1996 policy report stresses, however:


	

For school reform to produce desired student outcomes,
 school and community reformers must expand their vision beyond 
restructuring instructional and management functions and recognize
 that there is a third primary and essential set of functions involved 
in enabling teaching and learning.  


The essential third facet of school and community restructuring
 encompasses integration of enabling programs and services 
with instructional and management components. For a cohesive 
"enabling component" to emerge requires (a) weaving together 
school-owned resources and (b) enhancing programs by integrating 
school and community resources (including increasing access to 
community programs and services by linking as many as feasible to 
programs at the school). This comprehensive, integrated approach 
is meant to transform how communities and their schools address
 barriers to learning and enhance healthy development.


The concept of an enabling component provides a unifying focus
 around which to formulate new policy.  Adoption of an inclusive 
unifying concept is seen as pivotal in convincing policy makers 
to move to a position that recognizes enabling activity as 
essential if schools are to attain their goals.
 

Operationalizing an enabling component requires formulating 
a carefully delimited framework of basic programmatic areas 
and creating an infrastructure for restructuring enabling 
activity. Based on analyses of extant school and
 community activity, enabling activity can be clustered into 
six basic programmatic areas that address barriers to learning 
and enhance healthy development (all of which includes a focus 
on mental health). 


The six areas encompass interventions to: 





The following diagram highlights the rationale for and nature of an enabling component.

NEEDED: A COMPREHENSIVE INTEGRATED PROGRAMMATIC APPROACH:




To clarify each area a bit.



(1) Classroom focused enabling. 

In this area, the idea is to enhance
 classroom-based efforts to enable learning and productive classroom 
functioning by increasing teacher effectiveness for preventing and 
handling problems. This is done by providing personalized professional 
development and enhanced resources to expand a teacher's array of
 strategies for working with a wider range of individual differences. 
For example, teachers learn to use peer tutoring and volunteers (as 
well as home involvement) to enhance social and academic support; they 
learn to increase their accommodative strategies and their ability to 
teach students compensatory strategies; and as appropriate, they are
 provided support in the classroom by resource teachers and counselors.
 Only when necessary is temporary out of class help provided. In 
addition, programs are directed at developing the capabilities of aides,
 volunteers, and any others helping in classrooms or working with 
teachers to enable learning. To further prevent learning, behavior, 
emotional, and health problems, there is also an effort to enhance facets 
of classroom curricula designed to foster socio-emotional and physical
 development.


(2) Student and family assistance.

 Some problems cannot be 
handled without a few special interventions; thus the need for student 
and family assistance. The emphasis is on providing ancillary
 services in a personalized way to assist with a broad-range of needs. 
To begin with, available social, physical and mental health programs 
in the school and community are used. As community outreach brings 
in other resources, they are linked to existing activity in an 
integrated manner. Particular attention is paid to enhancing systems
 for prereferral intervention, triage, case and resource management, 
direct services to meet immediate needs, and referral for special
 services and special education resources and placements as 
appropriate. Ongoing efforts are made to expand and enhance resources. 


(3) Crisis assistance and prevention. 

The intent is to respond 
to, minimize the impact of, and prevent crises. This requires systems 
and programs for emergency/crisis response at a site, throughout a 
school complex, and community-wide (including a program to ensure 
follow-up care); it also encompasses prevention programs for school 
and community to address school safety and violence reduction, suicide, 
child abuse, and so forth. Crisis assistance includes ensuring immediate 
emergency and follow-up care is provided so students are able to resume 
learning without undue delay. Prevention activity creates a safe and
 productive environment and develops the type of attitudes and capacities 
that students and their families need to deal with violence and other 
threats to safety.	


(4) Support for transitions. 

This area involves a programmatic
 focus on the many transition concerns confronting students and their 
families. Such efforts aim at reducing alienation and increasing positive 
attitudes and involvement related to school and various learning 
activities. Examples of interventions include (a) programs to establish 
a welcoming and socially supportive school community, especially for new 
arrivals, (b) 
counseling and articulation programs to support grade-to-grade 
and school-to-school transitions, moving to and from special 
education, going to college, moving to post school living and 
work, and (c) programs for before and after-school and intersession 
to enrich learning and provide recreation in a safe environment.


(5) Home involvement in schooling.

 Efforts to enhance home 
involvement must range from programs to address specific learning 
and support needs of adults in the home to approaches that empower 
sanctioned parent representatives to become full partners in governance.
 Examples include (a) programs to address adult learning and support 
needs, such as ESL classes and mutual support groups, (b) helping those 
in the home meet their basic obligations to the student, such as programs
 on parenting and helping with schoolwork, (c) systems to improve 
communication about matters essential to student and family, (d)
 programs to enhance the home-school connection and sense of community, 
(e) interventions to enhance participation in decisions essential to the 
student, (f) programs to enhance home support for student's basic 
learning and development, (g) interventions to mobilize those at home 
to problem solve related to student needs, and (h) intervention to elicit
 help (support, collaborations, and partnerships) from those at home in 
order to meet classroom, school, and community needs. The context for 
some of this activity may be a parent center (which may be part of a
 Family Service Center facility if one has been established at the site).


(6) Community outreach for involvement and support (including a 
focus on volunteers). 

Outreach to the community is used to build 
linkages and collaborations, develop greater involvement in schooling, 
and enhance 
support for efforts to enable learning. Outreach is made to public and 
private community agencies, universities, colleges, organizations, and 
facilities; businesses and professional organizations and groups; and 
volunteer service programs, organizations, and clubs. Examples of 
activity include (a) programs to recruit community involvement and 
support (e.g., linkages and integration with community health and 
social services; volunteers, mentors, and individuals with expertise and 
resources; local businesses to adopt-a-school and provide resources, 
awards, incentives, and jobs; formal partnership arrangements), (b) 
systems and programs designed to train, screen, and maintain volunteer 
parents, college students, senior citizens, peer and cross-age tutors 
and counselors, and professionals-in-training who then provide direct 
help for staff and students -- especially targeted students, (c) programs
 outreaching to hard to involve students and families (those who don't 
come to school regularly -- including truants and dropouts), and (d) 
programs to enhance community-school connections and sense of community 
(e.g., orientations, open houses, performances and cultural and sports 
events, festivals and celebrations, workshops and fairs).


Ultimately, a comprehensive set of programs to address barriers and 
enhance healthy development must be woven into the fabric of every 
school. In addition, feeder schools need to link together to maximize 
use of limited school and community resources. By working to develop 
a comprehensive, integrated approach, every school can be seen, once
 more, as a key element of its community. When schools are seen as a
 valued and integrated part of every community, talk of school and 
community as separate entities can cease; talk of education as if it 
were the sole function of schools should end; and the major role schools 
can play in enhancing healthy development may be appreciated.  



Encompassing the Concept of Comprehensive School Health into a
 Comprehensive Approach to Address Barriers to Student Learning 




It has been our experience that schools respond better when proposals 
emphasize a comprehensive approach to addressing barriers to learning, 
rather than recommending a focus on specifically on physical and mental 
health. Given the thrust to enhance Comprehensive School Health in
 general and the eight "component" Comprehensive School Health model 
in particular, it is important to understand that the concept of the 
Enabling Component readily encompasses the eight components of 
comprehensive school health. That is, these eight components fit
 readily into the six areas of the Enabling Component with some of the 
eight components best understood as fitting more than one cluster of 
Enabling Component programming (see the Exhibit on the next page.)


Some Relevant References


Adelman, H.S. (1996).  Restructuring support services:Toward 
a comprehensive approach.  Kent, OH: American School Health Association.


Adelman, H.S. (1996).  Restructuring education support services 
and integrating community resources: Beyond the full service school 
model.  School Psychology Review, 25, 431-445.


Adelman, H.S. & Taylor, L. (in press). System reform to address 
barriers to learning. Beyond school-linked services and full 
service schools. American Journal of Orthopsychiatry.


Dryfoos, J.G. (1994).  Full-service schools:  A revolution in 
health and social services for children, youth, and families.  
San Francisco: Jossey-Bass.


Knapp, M.S. (1995).  How shall we study comprehensive collaborative 
services for children and families? 
Educational Researcher, 24, 5-16.


Kolbe, L. (1993). An essential strategy to improve the health 
and education of Americans.  Preventive Medicine, 22, 544-560.


Taylor, L., & Adelman, H.S. (1996), Mental health in the 
schools:  Promising directions for practice.  Adolescent 
Medicine: State of the Art Reviews, 7, 303-317.













Linking Models to Present a Unifying Approach for Policy Making




CDC "components"		   	

Enabling Component Areas




(1) Health Education
			

The curricular facets of this CDC component fit into
 					CLASSROOM-FOCUSED ENABLING.



(2) Health Services
			

Fits into STUDENT AND FAMILY ASSISTANCE.
	


(3) Biophysical/ psychosocial Environments	
	
Enhancing the environment emerges from the total
      		programmatic effort (in all 6 areas) to address barriers to
					learning -- as integrated with the Instructional and
					Management Components at a school site. The resultant
					comprehensive and cohesive approach produces the type of
					structure that is essential for evolving and creating a healthy
					psychosocial and biophysical environment.



(4) Counseling, Psychological, & Social Services

Fits into STUDENT AND FAMILY ASSISTANCE.

      


(5)  Food Services			

We want to reconceptualize school breakfast and lunch 
					services as another opportunity to offer essential programs
					providing SUPPORT FOR TRANSITIONS.  In this respect,
		 			schools could pair breakfast time with structured before school
 					recreation opportunities as ways to counter tardiness and
 					enhance student readiness for the school day. The same goes for
	 				lunch and after school. Also fits in with programs related to
 					HOME INVOLVEMENT IN SCHOOLING.



(6) P.E. and physical activity		

Fits in SUPPORT FOR TRANSITIONS and also can play
					a role related to CLASSROOM-FOCUSED ENABLING
					and HOME INVOLVEMENT IN SCHOOLING.



(7) Health Programs for Faculty	& Staff

In terms of providing direct health support to faculty and
      				staff, schools will need to expand STUDENT AND FAMILY
					ASSISTANCE. Some of the best health benefits for faculty and
					staff would be related to enhancing the effectiveness of schools
					in Addressing Barriers to Student Learning by establishing the
					type of comprehensive, integrated approach called for by the
					Enabling Component concept. This will reduce degrees of stress
					and burnout.



(8) Integrated School/Community		

COMMUNITY OUTREACH 










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