Meeting Mandates: Necessary...but Insufficient and Often Unsatisfying

The following are some of the typical tasks assigned to school nurses, psychologists, social workers, counselors, and other specialists:

• appraisal of new enrollees
  
• physical health, dental, and vision screening as mandated
  
• assessment of students referred for special education placement
  
• screening and reporting for suspected child abuse
  
• screening and referral for suspected substance abuse
  
• assessment and follow-up to control communicable (including sexually transmitted) diseases
  
• physical and mental health education
  
• emergency care when major physical or mental health problems arise
  
• participation in emergency and crisis planning (e.g., planning for how the school should respond to fires, floods, earthquakes, acts of violence and their aftermath)
  

And of course the ever present "Other tasks as assigned."

These tasks require use of assessment, counseling, referral, consultation, monitoring, follow-up, information dissemination, and clerical skills related to remedial and preventive health concerns. They involve interactions with students, families, school staff, and professionals in the community.

Anyone seeing a school "support" staff in action as they pursue their many tasks knows they are more than busy.

Anyone who talks with enough school support staff also knows that they are inundated with referrals for students whose problems stem from a variety of physical and mental health concerns.

Many school support staff want to redesign their roles so that much of the clerical and assessment activity related to "mandates" can be streamlined. This would allow them to perform an array of other functions that their training and expertise indicate they are capable of doing. It would allow them to work more intensively with others at a school site to maximize the impact schools have on addressing the most profound barriers causing students to fall by the wayside. And all this has the potential not only to enhance the success of a great many more students, but also should prove more satisfying to the professionals involved.

How can this be done? "Not by working harder, but by working smarter."

One essential element in working smarter is to have an enhanced conceptual base that can increase effectiveness. And one of the essential elements of such a conceptual base is accounting for a full range of factors that cause students to have problems.

Understanding What Causes Different Types of Problems

Before the 1920s, the tendency was to view human behavior as determined primarily by something within the person, especially inborn characteristics. As the psychological school of thought known as behaviorism gained in influence, a strong competing view arose. Behavior was seen as shaped by environmental influences, particularly the stimuli and reinforcers one encounters.

Today, human functioning is viewed in transactional terms -- as the product of a reciprocal interplay between person and environment. However, prevailing approaches to labeling and addressing human problems still create the impression that problems are determined by either person or environment variables.

This is both unfortunate and unnecessary -- unfortunate because such a view limits progress in practice and research, unnecessary because a transactional view encompasses the position that problems may be caused by person, environment, or both. This broad paradigm encourages a comprehensive perspective of cause and correction.

The following is a way to think about the implications of a broad framework for understanding the causes of students' problems.

This way of thinking offers a useful starting place for classifying behavioral, emotional, and learning problems and helps avoid overdiagnosing internal pathology.

As illustrated below, such problems can be differentiated along a continuum that separates those caused by internal factors, environmental variables, or a combination of both.

To highlight a few points about the illustration:

Problems caused by the environment are placed at one end of the continuum and referred to as Type I problems.

At the other end are problems caused primarily by pathology within the person; these are designated as Type III problems.

In the middle are problems stemming from a relatively equal contribution of environmental and person sources, labelled Type II problems.

Also note that in this scheme, diagnostic labels denoting extremely dysfunctional problems caused by pathological conditions within a person are reserved for individuals who fit the Type III category.

Obviously, some problems caused by pathological conditions within a person are not manifested in severe, pervasive ways, and there are persons without such pathology whose problems do become severe and pervasive. The intent is not to ignore these individuals. As a first categorization step, however, it is essential they not be confused with those seen as having Type III problems.

At the other end of the continuum are individuals with problems arising from factors outside the person (i.e., Type I problems). Many people grow up in impoverished and hostile environmental circumstances. Such conditions should be considered first in hypothesizing what initially caused the individual's behavioral, emotional, and learning problems. (After environmental causes are ruled out, hypotheses about internal pathology become more viable.)

To provide a reference point in the middle of the continuum, a Type II category is used. This group consists of persons who do not function well in situations where their individual differences and minor vulnerabilities are poorly accommodated or are responded to hostilely. The problems of an individual in this group are a relatively equal product of person characteristics and failure of the environment to accommodate that individual.

There are, of course, variations along the continuum that do not precisely fit a category. That is, at each point between the extreme ends, environment-person transactions are the cause, but the degree to which each contributes to the problem varies. Toward the environment end of the continuum, environmental factors play a bigger role (represented as E<--->p). Toward the other end, person variables account for more of the problem (thus e<--->P).

Clearly, a simple continuum cannot do justice to the complexities associated with labeling and differentiating psychopathology and psychosocial problems.

Furthermore, some problems are not easily assessed or do not fall readily into a group due to a lack of information and comorbidity.

Starting with a broad model of cause, however, helps practitioners counter tendencies to prematurely conclude that a problem is caused by pathology within the individual and thus helps avoid blaming the victim (Ryan, 1971).

It also helps highlight the notion that improving the way the environment accommodates individual differences may be a sufficient intervention strategy.

Clinical Approaches at School Sites

All schools have and benefit from counseling, psychological, and social service interventions and want more.

Some of the services are provided by nurses and other student services professionals hired by the school district.

In addition, a few community services are appearing on campuses as part of the effort to base some of these at school sites.

For many years, clinical approaches in school settings were offered in a practitioner's office and carried out in relative isolation of other interventions aimed at a student and her or his family.

Recently, efforts to increase the range of services
at school sites and to coordinate such
efforts has led to an expanded number of
school-based health centers and family service centers.

School-Based Health Centers

Many of the now over 1,000 school-based or linked health clinics are described as comprehensive centers (Advocates for Youth, 1994; Dryfoos, 1994; Robert Wood Johnson Foundation, 1993; Schlitt, Rickett, Montgomery, & Lear, 1994). This reflects the fact that the problems students bring to such clinics require much more than medical intervention.

Family Service Centers and Full Service Schools

Dryfoos (1994, 1995) encompasses the trend to develop school-based primary health clinics, youth service programs, community schools, and other similar activity under the rubric of full service schools. (She credits the term to Florida's comprehensive school-based legislation.)

As she notes in her review:

Much of the rhetoric in support of the full service schools concept has been presented in the language of systems change, calling for radical reform of the way educational, health, and welfare agencies provide services. Consensus has formed around the goals of one stop, seamless service provision, whether in a school- or community-based agency, along with empowerment of the target population. ... most of the programs have moved services from one place to another; for example, a medical unit from a hospital or health department relocates into a school through a contractual agreement, or staff of a community mental health center is reassigned to a school, or a grant to a school creates a coordinator in a center. As the program expands, the center staff work with the school to draw in additional services, fostering more contracts between the schools and community agencies. But few of the school systems or the agencies have changed their governance. The outside agency is not involved in school restructuring or school policy, nor is the school system involved in the governance of the provider agency. The result is not yet a new organizational entity, but the school is an improved institution and on the path to becoming a different kind of institution that is significantly responsive to the needs of the community (p. 169).

Full service schools reflect the desire for comprehensiveness; the reality remains much less than the vision. As long as such efforts are shaped primarily by a school-linked services model (i.e., initiatives to restructure to community health and human services), resources will remain too limited to allow for a comprehensive continuum of programs.

And in their struggle to find ways to finance programs for troubled and troubling youth,community agencies and schools are forced to tap into resources that require assigning youngsters labels that convey severe pathology. Reimbursement for mental health and special education interventions is tied to such diagnoses. This fact dramatically illustrates how social policy shapes decisions about who receives assistance and the ways in which problems are addressed. It also represents a major ethical dilemma for practitioners. That dilemma is not whether to use labels, but rather how to resist the pressure to inappropriately use those labels that yield reimbursement from third party payers.

Programmatic Approaches:
Going Beyond Clinical Interventions to Address the Full Range of Problems

A large number of young people are unhappy and emotionally upset; only a small percent are clinically depressed. A large number of youngsters behave in ways that distress others; only a small percent have ADHD or a conduct disorder. In some schools, the majority of students have garden variety learning problems; only a few have learning disabilities. Thankfully, those suffering from true internal pathology (those referred to here as Type III problems) represent a relatively small segment of the population. Society must never stop providing the best services it can for such individuals and doing so means taking great care not to misdiagnose others whose "symptoms" may be similar but are caused to a significant degree by factors other than internal pathology (those referred to above as Type I and II problems). Such misdiagnoses lead to policies and practices that exhaust available resources in serving a relatively small percent of those in need. That is a major reason why there are so few resources to address the barriers interfering with the education and healthy development of so many youngsters who are seen as troubled and troubling.

Because behavior, emotional, and learning problems usually are labelled in ways that overemphasize internal pathology, it is not surprising that helping strategies take the form of clinical/remedial intervention. And for the most part, such interventions are developed and function in relative isolation of each other.

Thus, they represent another instance of using piecemeal and fragmented strategies to address complex problems.

One result is that an individual identified as having several problems may be involved in programs with several professionals working independently of each other. Similarly, a youngster identified and treated in special infant and pre-school programs who still requires special support may cease to receive appropriate help upon entering school. And so forth.

Dealing with the full continuum of Type I, II, and III problems requires a comprehensive and integrated programmatic approach. Such an approach may require one or more mental health, physical health, and social services. That is, any one of the problems may require the efforts of several programs, concurrently and over time. This is even more likely to be the case when an individual has more than one problem. And, in any instance where more than one program is indicated, it is evident that interventions should be coordinated and, if feasible, integrated.

Needed: A Full Continuum of Programs and Services

School health programs always have been concerned with more than offering clinical services. And over the last decade, leaders in the field have advocated for an eight component model to ensure schools have a comprehensive focus on health (Allensworth & Kolbe, 1987; Kolbe, 1986). 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 faculty and staff.

The focus on comprehensive school health is admirable. It is not, of course, a comprehensive approach for addressing a full range of barriers to learning -- nor does it profess to be. Moreover, its restricted emphasis on health tends to engender resistance from school policy makers who do not think they can afford a comprehensive 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 development if such programs are part of a comprehensive approach for addressing barriers to learning.

Some are suggesting that the school-linked services movement, especially in the form of full service schools is the answer. And each day brings additional reports from projects such as New Jersey's School-Based Youth Services Program, the Healthy Start Initiative in California, the Beacons Schools in New York, Cities-in-Schools, and the New Futures Initiative.

A review by Michael Knapp (1995) underscores the fact that the literature on school-linked services is heavy on advocacy and prescription and light on findings. Not surprisingly, findings primarily reflect how hard it is to institutionalize such approaches. 

Keeping the difficulties in mind, a reasonable inference from available data is that school-community collaborations can be successful and cost effective over the long-run.

Outstationing community agency staff at schools allows easier access for students and families -- especially in areas with underserved and hard to reach populations. Such efforts not only provide services, they seem to encourage schools to open their doors in ways that enhance family involvement. Analyses suggest better outcomes are associated with empowering children and families and having the capability to address diverse constituencies and contexts. Families using school-based centers are described as becoming interested in contributing to school and community by providing social support networks for new students and families, teaching each other coping skills, participating in school governance, and helping create a psychological sense of community.

At the same time, it is clear that initiatives for school-linked services produce tension between school district pupil services personnel and their counterparts in community-based organizations.

When "outside" professionals are brought in, school specialist staff often view the move as discounting their skills and threatening their jobs. These concerns are aggravated whenever policy makers appear to overestimate the promise of school-linked services with regard to addressing the full range of barriers to learning. And, ironically, by downplaying school-owned resources, the school-linked services movement has allowed educators to ignore the need for restructuring the various education support programs and services that schools own and operate.

A continuum is outlined on the following page to illustrate the comprehensive range of programs needed to address Type I, II, and III problems.

As can be seen, the continuum ranges from programs for primary prevention (including the promotion of mental health) and early-age intervention --through those for addressing problems soon after onset-- on to treatments for severe and chronic problems.

In doing so, it encompasses prevention and prereferral interventions for mild problems, high visibility programs for high-frequency psychosocial problems, and strategies to assist with severe and pervasive mental health problems.

Such an approach recognizes the role school, home, and community life play in creating and correcting young people's problems, especially those who are under-served and hard-to-reach.

With respect to comprehensiveness, the programs outlined highlight that many problems must be addressed developmentally and with a range of programs -- some focused on individuals and some on environmental systems, some focused on mental health and some on physical health, education, and social services. With respect to concerns about integrating programs, the continuum underscores the need for concurrent interprogram linkages and for linkages over extended periods of time.

From such a perspective, schools must provide interventions that address individual problems and system changes. At the same time, schools must continue to explore formal and informal ways to link with public and private community agencies.