From Addressing Barriers to Learning,
Vol. 1 (1), Winter 1996

Mental Health in Schools: Emerging Trends

It is widely recognized that social, emotional, and physical health deficits and other persistent barriers to learning must be addressed if students are to benefit appropriately from their schooling (see Table 1). Many professionals struggle to ease problems, increase opportunities, and enhance the well-being of students, families, and school staff. While all can benefit from interventions to enhance social and emotional development, such activity is essential for students manifesting severe and pervasive problems.

Table 1

Nature and Scope of Student Needs that Must be Addressed

I. Barriers to learning/parenting/teaching (beyond medical/dental needs)
A. Deficiencies in basic living resources and opportunities for development
  • dearth of food in the home
  • inadequate clothing
  • substandard housing (incl. being homeless)
  • lack of transportation
  • income at or below the poverty level (e.g., due to unemployment or welfare status)
  • lack of after-school supervision for child
  • immigration-related concerns (e.g., limited English Proficiency, legal status)
  • B. Observable problems
  • school adjustment problems (incl. prevention of truancy, pregnancy, and dropouts)
  • relationship difficulties (incl. dysfunctional family situations, insensitivity to others)
  • language difficulties
  • abuse by others (physical and sexual)
  • substance abuse
  • emotional upset
  • delinquency (incl. gang-related problems and community violence)
  • psychosocial concerns stemming from sexual activity (e.g., prevention of and reactions to pregnancy or STDs)
  • psychopathology
  • C. General stressors and underlying psychological problems associated with
  • external stressors (objective and perceived) and deficits in support systems
  • competence deficits (low self-efficacy/self-esteem, skill deficits)
  • threats to self-determination/autonomy/control
  • feeling unrelated to others or perceiving threats to valued relationships
  • personality disorders or psychopathology
  • D. Crises and emergencies
  • personal/familial (incl. home violence)
  • subgroup (e.g., death of a classmate or close colleague)
  • school-wide (e.g., earthquake, floods, shooting on campus)
  • E. Difficult transitions
  • associated with stages of schooling (e.g., entry, leaving)
  • associated with stages of life (e.g., puberty, job and career concerns)
  • associated with changes in life circumstances (e.g., moving, death in the family)

  • II. Severity and pervasiveness of problems addressed
    A. Mild-moderate-severe
    B. Narrow-pervasive

    III. Areas of focus in enhancing healthy psychosocial development

    A. Responsibility and integrity
    (e.g., understanding and valuing of societal expectations and moral courses of action)

    B. Self-esteem
    (e.g., feelings of competence, self-determination, and being connected to others)

    C. Social and working relationships
    (e.g., social awareness, empathy, respect, communication, interpersonal cooperation and problem solving, critical thinking, judgement, and decision making)

    D. Self-evaluation and self-direction/regulation
    (e.g., understanding of self and impact on others, development of personal goals, initiative, and functional autonomy)

    E. Temperament
    (e.g., emotional stability and responsiveness)

    F. Personal safety and safe behavior
    (e.g., understanding and valuing of ways to maintain safety, avoid violence, resist drug abuse, and prevent sexual abuse)

    G. Health maintenance
    (e.g., understanding and valuing of ways to maintain physical and mental health)

    H. Effective physical functioning
    (e.g., understanding and valuing of how to develop and maintain physical fitness)

    I. Careers and life roles
    (e.g., awareness of vocational options, changing nature of sex roles, stress management)

    J. Creativity
    (e.g., breaking set)

    Table 2 below outlines an array of interveners
    involved in schools who are concerned with these matters.

    Table 2

    Types of interveners who might play primary or secondary roles in counseling, psychological, and social service activity

    Instructional professionals
    (e.g., regular classroom teachers, special education staff, health educators, classroom resource staff and consultants)

    Health office professionals
    (e.g., nurses, physicians, health educators, consultants)

    Counseling, psychological, and social work professionals
    (e.g., counselors, health educators, psychologists, psychiatrists, psychiatric nurses, social workers, consultants)

    Itinerant therapists
    (e.g., art, dance, occupational, physical, speech-language-hearing, music, and recreation therapists; psychodramatists)

    Personnel-in-training for the above roles
  • Aides
  • Classified staff (e.g., clerical and cafeteria staff, custodians, bus drivers)
  • Paraprofessionals
  • Peers (e.g., peer/cross-age counselors and tutors, mutual support and self-help groups)
  • Recreation personnel
  • Volunteers (professional/paraprofessional/nonprofessional)

  • All schools have and benefit from the activity of such interveners (see below).

    Types of functions provided

    Direct services and instruction
    (based on prevailing standards of practice and informed by research)
  • Crisis intervention and emergency assistance (e.g., psychological first-aid and follow-up; suicide prevention; emergency services, such as food, clothing, transportation)
  • Assessment (individuals, groups, classroom, school, and home environments)
  • Treatment, remediation, rehabilitation (incl. secondary prevention)
  • Transition and follow-up (e.g., orientations, social support for newcomers, follow-thru)
  • Primary prevention through protection, mediation, promoting and fostering opportunities, positive development, and wellness (e.g., guidance counseling; contributing to development and implementation of health and violence reduction curricula; placement assistance; advocacy; liaison between school and home; gang, delinquency, and safe-school programs; conflict resolution)
  • Increasing the amount of direct service impact through multidisciplinary teamwork, consultation, training, and supervision
  • Coordination, development, and leadership for programs, services, resources, systems
  • Needs assessment, gatekeeping, referral, triage, and case monitoring/management (e.g., participating on student study/assistance teams; facilitating communication among all concerned parties)
  • Coordinating activities (across disciplines and components; with regular, special, and compensatory educ.; in and out of school)
  • Mapping and enhancing resources and systems
  • Developing new approaches (incl. facilitating systemic changes)
  • Monitoring and evaluating intervention for quality improvement, cost-benefit accountability, research
  • Advocacy for programs and services and for standards of care in the schools
  • Pursuing strategies for public relations and for enhancing financial resources
  • Enhancing connections with community resources
  • Strategies to increase responsiveness to referrals from the school
  • Strategies to create formal linkages among programs and services

  • Data on diagnosable mental disorders (based on community samples) suggest that from 12% to 22% of all children suffer from mental, emotional or behavioral disorders, and relatively few receive mental health services. The picture is even bleaker when expanded beyond the limited perspective of diagnosable mental disorders to include all young people experiencing psychosocial problems and who Joy Dryfoos defines as "at risk of not maturing into responsible adults." The number "at risk" in many schools serving low-income populations has climbed over the 50% mark. Harold Hodgkinson, director of the Center for Demographic Policy, estimates across the nation 40% of students are in "very bad educational shape" and "at risk of failing to fulfill their physical and mental promise." Because so many live in inner cities and impoverished rural areas and are recently arrived immigrants, he attributes their school problems mainly to conditions they bring with them when they enter kindergarten. These are conditions associated with poverty, difficult and extremely diverse family circumstance, lack of English language skills, violent neighborhoods, physical and emotional problems, and lack of health care. One impact is that at least 12% fail to complete high school, which leads to extensive consequences for them, their families, and society.

    Few schools, of course, can afford the entire array of personnel and activity outlined above. And, because so many young people experience serious problems that interfere with learning and performing in school, most schools indicate that they need much more than they have.

    The problem of at risk students has grown so great that educators find they must hold special national summits where the emphasis is not only on the academic plight of students, but also on how to make schools safe. Keith Geiger, President of the National Education Association, reflecting on the association's 1995 "Safe Schools Summit," laments:

    How does a history teacher explain the relevance of the Emancipation Proclamation to students who feel enslaved by fear? How does a guidance counselor persuade a boy to study hard and aim for college if that boy, in his gut, doesn't expect to live past his 20th birthday?
    Am I exaggerating? David Sachter, director of the U.S. Centers for Disease Control and Prevention, told the summit about a major new CDC survey of 16,000 students, grades 9 through 12 in both public and private schools.
    Nearly 22 percent of those surveyed said they had carried a weapon in the previous month. Nearly one quarter (24.1%) of students had seriously considered attempting suicide in the previous 12 months; 8.6 percent had actually attempted suicide in that period. This study follows an earlier CDC finding that violence among young people has reached "epidemic" proportions (p. 14).

    There is growing consensus about the crisis nature of the situation. And it is widely recognized that failure to address the problems of children and schools can only exacerbate the health and economic consequences for society. The literature on mental health related interventions in schools encompasses an enormous array of specific practices and issues. In this limited space, we will simply outline the state of the art and a few emerging reforms that are reshaping the work of mental health professionals in the schools.

    New directions call for functions that go beyond direct service and traditional consultation. All who work in the schools must be prepared not only to provide direct help but to act as advocates, catalysts, brokers, and facilitators of systemic reform. Particularly needed are efforts to improve intervention efficacy through integrating physical and mental health and social services. More extensively, the need is for systemic restructuring of all support programs and services into a comprehensive and cohesive set of programs.

    State of the Art

    Comprehensive approaches recognize the role school, home, and community life play in creating and correcting young people's problems. From such a perspective, schools must provide interventions that address individual problems and system changes. It is widely recognized that social, emotional, and physical health problems and other barriers to learning must be addressed if students are to learn in ways that allow schools to accomplish their educational mission (Dryfoos, 1994; Tyack, 1992). In this regard, there is renewed interest in the notion that school-based and linked services increase access to underserved and hard-to-reach populations.

    An extensive literature reports positive outcomes for psychosocial interventions available to schools.

    This research can be characterized as promising, albeit restricted in scope. It provides a menu of "best practices." Many of the reports are from narrowly focused brief demonstrations that by their very nature could only produce limited outcomes. Still, a significant number of appropriately developed and implemented programs have demonstrated benefits not only for schools (e.g., better student functioning, increased attendance, less teacher frustration), but for society (e.g., reduced costs related to welfare, unemployment, and use of emergency and adult services). Thus, the literature is encouraging and also emphasizes that the search for better practices remains a high priority and must reflect the diverse demographics and conditions of a changing society.

    School professionals are engaged in an increasingly wide array of activity, Including promotion of social and emotional development, direct services, outreach to families, and various forms of support for teachers and other school personnel. There is enhanced emphasis on coordination and collaboration within a school and with community agencies to provide the "network of care" necessary to deal with complex problems over time. As this article highlights, counseling, psychological, and social services in schools are expanding and changing rapidly. Schools' efforts to address psychosocial problems encompass (a) prevention and prereferral interventions for mild problems, (b) high visibility programs for high-frequency psychosocial problems, and (c) strategies to address severe and pervasive mental health problems.

    Emerging Trends

    Proliferation of psychosocial programs in schools tends to occur with little coordination of planning and implementation. As awareness of deficiencies has increased, major systemic changes have been proposed. Four emerging trends are

    Each trend has implications for what goes on in schools and for the ways in which our Center will operate.

    New Roles for Mental Health Professionals

    Based on our analysis of emerging trends, the range of functions mental health specialists should perform for schools are

    The relatively small number of mental health personnel available to schools cannot provide much in the way of direct services. The more their expertise is used at the level of program organization, development, and maintenance, the more students they can help.

    This fact is the basis for suggesting that the three areas of function listed above be prioritized so school-based mental health professionals can use their time to produce the broadest impact (Adelman & Taylor, 1991). Used properly, such personnel can play a potent role in creating a comprehensive, integrated approach to meeting the needs of the young by interweaving what schools can do with what the community offers. School mental health professionals bring specialized understanding of cause (e.g., psychosocial factors and pathology) and intervention (e.g., approaching problem amelioration through attitude and motivation change and system strategies). This knowledge can have many benefits. For instance, mental health perspectives of "best fit" and "least intervention needed" strategies can contribute to reduced referrals and increased efficacy of mainstream and special education programs. With respect to pre and inservice staff development, such perspectives can expand educators' views of how to help students with everyday upsets as well as with crises and other serious problems -- in ways that contribute to positive growth. Specialized mental health understanding also can be translated into programs for targeted problems (e.g., depression, dropout prevention, drug abuse, gang activity, teen pregnancy).

    Despite the range of knowledge and skills they bring to a setting, mental health professionals usually find their overwhelming caseload of students restricts them to providing direct services. Even then, they see a small proportion of the many students, families, and school staff who could benefit from their efforts. This is not surprising given the relatively limited cadre of specialists school districts employ.

    This lamentable state of affairs raises several points for discussion. One often discussed idea is that greater dividends (in terms of helping more people) might be forthcoming if such personnel devoted their talents more to prevention. At an even more fundamental level, it seems likely that larger numbers would benefit if these professionals devoted a greater portion of their expertise to creating a comprehensive, integrated approach for addressing barriers to learning and enhancing healthy development. For this to happen, however, there must be a shift in priorities with respect to how they use their time. Specifically, this involves redeploying time to focus more on functions related to

    (a) coordination, development, and leadership (e.g., to evolve and maintain resource integration) and
    (b) evolving long-lasting collaborations with community resources.

    Used properly, such personnel can contribute greatly to creation of a comprehensive, integrated approach.

    Concluding Comments

    Emerging trends are reshaping the work of mental health professionals in schools. New directions call for going beyond direct service and beyond traditional consultation. All who work in schools must be prepared not only to provide direct help but to act as advocates, catalysts, brokers, and facilitators of systemic reform. Particularly needed are efforts to improve intervention outcomes by integrating physical and mental health and social services. More comprehensively, the need is for systemic restructuring of all education support programs and services to improve the state of the art and provide a safety net of care for generations to come. We will have more to say about this in the next issue.


    Adelman, H.S., & Taylor, L. (1993). School-based mental health: Toward a comprehensive approach. Journal of Mental Health Administration, 20, 32-45.
    Costello, E.J. (1989). Developments in child psychiatric epidemiology. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 836-841.
    Dryfoos, J.G. (1990). Adolescents at risk: Prevalence and prevention. London: Oxford Press.
    Dryfoos, J.G. (1994). Full-service schools: A revolution in health and social services for children, youth, and families. San Francisco: Jossey-Bass.
    Geiger, K. (1995). L.A.'s Kids Courageous. United Teacher, XXVI, 14 & 19.
    Hoagwood, K. (1995). Issues in Designing and implementing studies of non-mental health care sectors. Journal of Clinical Child Psychology, 23, 114-120.
    Hodgkinson, H.L. (1993). American education: The good the bad, and the task. Phi Delta Kappan, 74, 619-623.
    Knitzer, J., Steinberg, Z., & Fleisch, B. (1990). At the schoolhouse door: An examination of programs and policies for children with behavioral and emotional problems. NY: Bank Street.
    National Education Goals Panel (1994). Data for the National Education Goals Report. Volume One: National data. Washington ,D.C.: U.S. GPO.
    Tyack, D.B., (1992). Health and social services in public schools: Historical perspectives. The Future of Children, 2, 19-31.

    Note: a fuller discussion of this topic will be published later this year. See L. Taylor & H.S. Adelman (in press), Mental health in the schools: Promising directions for practice. In L. Juszcak & M. Fisher (Eds.) Health care in schools. A special edition of Adolescent Medicine: State of the Art Reviews. Also, see H.S. Adelman (1995), Clinical psychology: Beyond psychopathology and clinical interventions. Clinical Psychology: Science and Practice, 2, 28-44.

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