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:

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

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


(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


(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


(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


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