Factors Instigating Emotional, Behavioral, and Learning Problems

Environment (E)
Type I Problem

Person (P)
Type II Problems

Interactions and Transactions
Between E & P*
Type II Problems

1. Insufficient stimuli (e.g., prolonged periods in impoverished environments; deprivation of learning opportunities at homes or school such as lack of play and practice situations and poor instruction; inadequate diet)
1. Physiological insult (e.g., cerebral trauma, such as accident or stroke, endocrine dysfunctions and chemical imbalances; illness affecting brain or sensory functioning)
1. Severe to moderate personal vulnerabilities and environmental defects and deference (e.g., person with extremely slow development in a highly demanding environment, all of which simultaneously and equally instigate the problem)
2. Excessive stimuli
(e.g., overly demanding home, school, or work experiences, such as overwhelming pressure to achieve and cameralistic expectations; overcrowding)
2. Genetic anomaly
(e.g., genes which limit, slow down, or lead to any atypical development)
2. Minor personal vulnerabilities not accommodated by the situation
(e.g., person with minimal CNS disorders resulting in auditory perceptual disability trying to do auditory-loaded tasks; very active person forced into situations at home, school, or work that does not tolerate this level of activity)
3. Intrusive and hostile stimuli
(e.g., medical practices, especially at birth, leading to physiological impairment; contaminated environments; conflict in home, school, work place; faulty child-rearing practices, such as long standing abuse and reject
3. Cognitive activity and affective states experienced by self as deviant (e.g., lack of knowledge or skills such as basic cognitive strategies; lack of ability to cope effectively with emotions, such as low self-esteem)
3. Minor environmental defects and differences not accommodated by the individual
(e.g., person is in the minority racially or culturally and is not participating in many social activities because he or she thinks others may be unreceptive)
4. Physical characteristics shaping contact with environment and/or experiences by self an deviant
(e.g., visual, auditory, or motoric deficits; secession or reduced sensitivity to stimuli; easily fatigues; factors such as race. sex. age, or unusual a
5. Deviant actions of the individual
(e.g., performance problems, such as excessive errors in performing; high or low levels of activity)

*May involve only one (P) and one (E) variable or mayinvolve multiple combinations.

From: H.S. Adelman and L. Taylor (1993). Learning Problems and learning disabilities: Moving forward. Pacific Grove, CA: Brooks/Cole. Reprinted with permission.

Return to
Section C Contents of All Three Units
Unit I Main Menu

The school-based clinic movement was created in response to concerns about teen pregnancy and a desire to enhance access to physical health care for underserved youth. Soon after opening, most clinics find it essential also to address mental health and psychosocial concerns. The need to do so reflects two basic realities. One, some students' physical complaints are psychogenic, and thus, treatment of various medical problems is aided by psychological intervention. Two, in a large number of cases, students come to clinics primarily for help with no medical problems, such as personal adjustment and peer and family relationship problems, emotional distress, problems related to physical and sexual abuse, and concerns stemming from use of alcohol and other drugs. Indeed, up to 50% of clinic visits are for nonmedical concerns (Adelman, Barker, & Nelson, 1993; Center for Reproductive Health Policy Research, 1989; Robert Wood Johnson Foundation, 1989).

Thus, as these clinics evolve, so does the provision of counseling, psychological, and social services in the schools. At the same time, given the limited number of staff at such clinics, it is not surprising that the demand for psychosocial interventions quickly outstrips the resources available.

Without a massive infusion of money, 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.

Return to
Section C
Contents of All Three Units
Unit I Main Menu

Establishing a comprehensive, integrated approach is excruciatingly hard. Efforts to do so are handicapped by the way interventions are conceived and organized and the way professionals understand their functions. Conceptually, intervention rarely is envisioned comprehensively. Organizationally, the tendency is for policy makers to mandate and planners and developers to focus on specific programs. Functionally, most practitioners and researchers spend most of their time working directly with specific interventions and samples and give little thought or time to comprehensive models or mechanisms for program development and collaboration. Consequently, programs to address physical, mental health, and psychosocial problems rarely are coordinated with each other or with educational programs.

Limited efficacy seems inevitable as long as the full continuum of necessary programs is unavailable; limited cost effectiveness seems inevitable as long as related interventions are carried out in isolation of each other. Given all this, it is not surprising that many in the field doubt that major breakthroughs can occur without a comprehensive and integrated programmatic thrust. Such views have added impetus to major initiatives are underway designed to restructure community health and human services and the way schools operate (Adelman, 1996; Adler & Gardner, 1994; Center for the Future of Children Staff, 1992; Hodgkinson, 1989; Taylor & Adelman, 1996).

Return to
Section C
Contents of All Three Units
Unit I Main Menu

Here's what one school-based psychiatrist has to say. Do you agree or disagree with him?
It happens several times a week in my practice of community child and adolescent psychiatry: Our society's overwhelming belief in medically controlling our kids' behavior finds expression in ever more Huxleyesque demands on the psychiatrist to prescribe. This week's winners are the school district, the juvenile court, and a religious shelter for homeless families with children. Their respective would-be victims are LaShondra, Trevor, and Jimmy.

Jimmy is a 9 year old boy with a long history of treatment for severe emotional disturbance. He's in a school-based day treatment program and seems to be making terrific progress on self-managing his behavior. This turnaround has occurred just in the past few weeks, following an acute psychiatric hospital stay during which the many psychotropic medications he'd been taking without apparent benefit were tapered and discontinued. He was discharged to the day treatment facility and is receiving case management and therapeutic services at home in the community. Unfortunately, the grandmother with whom he lives has been evicted from her residence, and has applied for assistance to a homeless family program. She and Jimmy are scheduled to be admitted to a shelter program next week, but the shelter has made it a condition of receiving services that Jimmy be on medication.

LaShondra is 14. She is in special education classes at her junior high school because of mild mental retardation and emotional disturbance. She bears both physical and psychic scars of early prolonged abuse, and has symptoms of borderline personality pathology and PTSD. She likes school and wants to learn, but keeps getting expelled for behavioral outbursts. The school, too, has made it a condition of her readmittance to classes that she be on medication. LaShondra experiences psychotropic medication as inimical to her emerging adolescent autonomy, and has had negative therapeutic effects during past trials of treatment.

Trevor, at 15, is incarcerated in the Juvenile Detention Center, awaiting a hearing on certification to stand trial as an adult on two charges of capital murder. We have evaluated him for fitness to proceed and determined that he's not mentally ill, but are involved in providing services to Trevor in consultation with the juvenile authorities because he is persistently threatening suicide. We think the best plan is to keep him closely supervised in detention, but the juvenile department is concerned about their liability and petition the court to transfer him to a psychiatric hospital. Two hearings are held on the same day. At the first hearing Trevor is committed to a private facility, on condition that the facility accepts the admission. The facility refuses. At the second hearing, Trevor is committed to the state hospital on condition that the hospital certifies that they can guarantee security. The hospital can't. The Court then orders that Trevor be involuntarily administered unspecified psychotropic agents by injection.

I am not making these things up. These three cases have so far occupied the last three days of my week, and I'm telling you about them not to garner sympathy for the kids (only two of whom have any sympathy coming in any case), or for me (despite my clearly deserving some), but to focus attention on the astonishing degree to which everyone in our society has come to believe in the prescribing of psychotropic medication as a cure, or at least a control, for disturbing behavior in kids.

How did we arrive at this state of affairs? Though a very complex interaction among a myriad of scientific, social, and historical factors, of which I want to mention just two of the scientific ones: progress in psychiatric nosology, and progress in biological psychiatry.

Since 1980, we've trained a generation or two of psychiatrists in the phenomenological approach to diagnosis. The last three editions of the DSM (III-R, and IV) are determinedly atheoretical and empirical in their approach (the majority of members of the Work Groups on Child and Adolescent Disorders for the last three DSM's have been pediatric psychopharmacology researchers), and I think we have long since abandoned trying to teach residents to think about the meanings of symptoms to patients (and ourselves), about the dynamics of intrapsychic structure and interpersonal process. During the same time, the explosive growth of neuroscience and pharmacology has given us many new tools with which to work (if only we knew how: my friend and teacher Bob Beavers used to say, "if the only tool you have is a hammer, everything looks like a nail to you!").

In short, I think we've unwittingly relinquished our most powerful and proven tool: appropriately affectionate, professionally respectful, intimate personal engagement of the patient in mutual exploration of inner meanings. We're frittering our therapeutic potency away on serial trials of psychotropic drugs, and we're prescribing for patients when we don't know the person. There are too many kids on too many drugs, and many of the kids have been given medication as a substitute for engagement and exploration of personal issues.

The point I'm trying to make is that every sector of today's society contributes to this pressure to prescribe. Parents believe medication will cure, schools believe it, courts believe it. even nonpsychiatric mental health professionals believe it. Well, I don't believe it, and it's been my experience with ASAP that most of our members don't believe it either. And, if not only do we not believe that medicine cures, but also we do believe that we have a more powerful and effective treatment which provides an essential context for medication to be helpful, let's stand up and say so. I look forward to hearing from y'all: agree or disagree.

Psychiatrist Glen Pearson is president of the American Society for Adolescent Psychiatry (ASAP).
Reprinted with permission.

Return to
Section C
Contents of All Three Units
Unit I Main Menu

Unit I Section C Continued

           From Primary Prevention to Treatment of Serious Problems:  
        A Continuum of Community-School Programs to Address Barriers to 
                  Learning and Enhance Healthy Development

   Intervention				Examples of Focus and Types of Intervention
    Continuum			(Programs and services aimed at system changes and individual needs)

Primary prevention 	1.  Public health protection, promotion, and maintenance to foster opportunities,
 	|		     positive development, and wellness
	|	  		• economic enhancement of those living in poverty (e.g., work/welfare programs)
	|	  		• safety (e.g., instruction, regulations, lead abatement programs)
	|			• physical and mental health (incl. healthy start initiatives, immunizations, dental
	|			  care, substance abuse prevention, violence prevention, health/mental health
	|			  education, sex education and family planning, recreation, social services to access
	|			  basic living resources, and so forth)
	|	 	2.  Preschool-age support and assistance to enhance health and psychosocial
 	|		     development
	|			• systems' enhancement through multidisciplinary team work, consultation, and
 	|			   staff development
	|			• education and social support for parents of preschoolers
 	|			• quality day care
	|			• quality early education
 Early-after-onset		• appropriate screening and amelioration of physical and mental health and
    intervention		  psychosocial problems
	|		3.  Early-schooling targeted interventions
	|		 	• orientations, welcoming and transition support into school and community life for
 	|	  	     	  students and their families (especially immigrants)
	|			• support and guidance to ameliorate school adjustment problems
	|		     	• personalized instruction in the primary grades
 	|		     	• additional support to address specific learning problems
   	|		     	• parent involvement in problem solving
	|		     	• comprehensive and accessible psychosocial and physical and mental health
	|	  	          programs (incl. a focus on community and home violence and other problems
 	|	 	          identified through community needs assessment)
 	|	  	4.  Improvement and augmentation of ongoing regular support
	|			• enhance systems through multidisciplinary team work, consultation, and staff
 	|	  	  	  development
	|		     	• preparation and support for school and life transitions 
	|		     	• teaching "basics" of support and remediation to regular teachers (incl. use of
	|	  	          available resource personnel, peer and volunteer support)
	|		     	• parent involvement in problem solving  
	|	 	     	• resource support for parents-in-need (incl. assistance in finding work, legal aid,
	|	  	          ESL and citizenship classes, and so forth) 
	|		     	• comprehensive and accessible psychosocial and physical and mental health
 	|		          interventions (incl. health and physical education, recreation, violence reduction
 	|		          programs, and so forth)
	|		     	• Academic guidance and assistance
	|		     	• Emergency and crisis prevention and response mechanisms
	|	     	5.  Other interventions prior to referral for intensive and ongoing targeted treatments
	|			• enhance systems through multidisciplinary team work, consultation, and staff
 	|		          development
  	|		     	• short-term specialized interventions (including resource teacher instruction
	|		          and family mobilization; programs for suicide prevention, pregnant minors,
	|		          substance abusers, gang members, and other potential dropouts)
  Treatment for	  	6.  Intensive treatments 
  severe/chronic 	        • referral, triage, placement guidance and assistance, case management, and 
     problems		    	  resource coordination 
			        • family preservation programs and services
		   	        • special education and rehabilitation
			        • dropout recovery and follow-up support
		  	        • services for severe-chronic psychosocial/mental/physical health problems

Return to Unit I Section C Contents


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

  • Adelman, H.S., Barker, L. A., & Nelson, P. (1993). A study of a school-based clinic: Who uses it and who doesn't? Journal of Clinical Child Psychology, 22, 52-59.

  • Adelman, H.S. & Taylor, L. (1993). Learning problems and learning disabilities: Moving forward. Pacific Grove, CA: Brooks/Cole.

  • Adler, L., & Gardner, S. (Eds.), (1994). The politics of linking schools and social services. Washington, DC: Falmer Press.

  • Allensworth, D. & Kolbe, L. (1987). The comprehensive school health program: Exploring an expanded concept. Journal of School Health, 57, 409-473.

  • Center for the Future of Children Staff (1992). The future of children, 2, 6-18.

  • Center for Reproductive Health Policy Research (1989). Annual Report: Evaluation of California's comprehensive school-based health centers. San Francisco: Center for Reproductive Health Policy Research, Institute for Health Policy Studies, UCSF.

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

  • Dryfoos, J. (1995). Full service schools: Revolution or fad? Journal of Research on Adolescence, 5, 147-172.

  • Hodgkinson, H.L. (1989). The same client: The demographics of education and service delivery systems. Washington, DC: Institute for educational Leadership. Inc./Center for Demographic Policy.

  • Kolbe, L.J. (1986). Increasing the impact of school health programs: Emerging research perspectives. Health Education, 17, 47-52.

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

  • Robert Wood Johnson Foundation (1993). Making the grade: State and local partnerships to establish school-based health centers. Princeton, NJ: Author.

    Robert Wood Johnson Foundation (1989). Annual Report. Princeton, NJ: Author.

  • Ryan, W. (1991). Blaming the victim. New York: Random House.

  • Schlitt, J.J., Rickett, K.D., Montgomery, L.L., & Lear, J. (1994). State initiatives to support school-based health centers: A national survey. Washington, DC: Making the Grade.

  • Taylor, L., & Adelman, H.S. (1996). Mental health in schools: Promising directions for practice. Adolescent Medicine: State of the Art Reviews, 7, 303-317.
  • Return to
    Return to Unit I Section C Contents

    Test Questions-Unit 1: Section C

    (1) Which of the following are implications of understanding a student's problems in terms of a causal continuum that ranges from internal to external causes?

    ___(a) some problems primarily result from biological or psychological factors
    ___(b) some problems primarily result from environmental causes
    ___(c) some problems are caused by the environment not accommodating individual differences and vulnerabilities
    ___(d) a and b
    ___(e) all of the above
    ___(f) none of the above

    (2) Improving the way the environment accommodates individual differences may be a sufficient intervention strategy.

    _____True _____False

    (3) School-Based Health Centers have come to find it necessary to address mental health and psychosocial concerns because

    ___(a) mental health is more important than physical health
    ___(b) many students physical complaints are psychogenic
    ___(c) mental health services are less costly
    ___(d) many students come to the centers for help with psychosocial problems
    ___(e) a and b
    ___(f) a and c
    ___(g) b and d
    ___(h) all of the above

    4) With respect to addressing barriers to learning, a comprehensive approach requires more than a focus on health and social services.

    _____True _____False

    (5) A comprehensive approach to addressing barriers to learning is achieved by outreaching to link with community resources.

    _____True _____False

    (6) With respect to addressing barriers to learning, a comprehensive approach requires more than coordination of school and community services.

    _____True _____False

    (7) Moving toward comprehensiveness in addressing barriers to learning encompasses restructuring, transforming, and enhancing (a) relevant school-owned programs and services, (b) community resources, and (c) weaving these school and community resources together.

    _____True _____False

    Move on to:
    Unit I Coda

    Return to
    Unit I Main Menu
    Contents of All Three Units