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
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:
- enhance classroom-based efforts to enable learning
- provide prescribed student and family assistance
- respond to and prevent crises
- support transitions
- increase home involvement in schooling
- outreach for greater community involvement and support -- including recruitment of volunteers.
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
(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
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,
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
||Enabling Component Areas|
(1) Health Education
The curricular facets of this CDC component fit into
(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
(8) Integrated School/Community
School Mental Health Project-UCLA
WebMaster: Perry Nelson (firstname.lastname@example.org)