al., 1989; Millstein, 1988). Other alternatives include the provision of health and mental health services through "street-based" clinics and community-based youth development programs (see Chapter 10). Unfortunately, exposure of adolescents to these new services is often a matter of chance, social class, or area of residence, rather than need.

Approximately 25 percent of all adolescents are diagnosed with significant forms of emotional distress. Yet, as with the health system generally, it is misleading to speak of a mental health "system" for adolescents. Services are provided through special education in schools, community mental health centers, and inpatient facilities, but these components are poorly integrated and often unavailable to many youths who need them. Consequently, the mental health system meets the needs of a minority of adolescents, with some estimates indicating that up to three-quarters of adolescents with a diagnosable mental disorder do not have any contact with a mental health provider (Joint Commission on Mental Health of Children, 1969; President's Commission on Mental Health, 1978; Knitzer, 1982; U.S. Office of Technology Assessment, 1991b). Moreover, low-income and minority adolescents are the most likely to be denied access or to receive low-quality services (U.S. Office of Technology Assessment, 1991a; Cross et al., 1989; Berlin, 1983; Padilla et al., 1975).

Mental health services have traditionally focused on treatment rather than prevention of illness or the promotion of emotional stability. The difficulties of this approach are well known. Affordability and access are both problems. Even for those young people for whom insurance is available, mental health treatment is offered only on a short-term basis, and often in restrictive inpatient settings. For example, anorexia nervosa, a growing problem among adolescent girls, is rarely covered by insurance programs, and the limit on payments for emotional illness is so low that institutions often cannot afford to deal with adolescents with these problems (see below). Within schools, less than one-third of all students in special education receive psychological, social work, or counseling services. There is only one school psychologist per 2,500 students nationwide, and only about 2 percent of all adolescents receive service from school psychologists (Meyers, 1989; Tremper, 1991). When preventive services are offered, they have been focused on the behavioral problems seen as being reflective