APPENDIX D
New Approaches to the Organization of Health and Social Services in Schools

Joy Dryfoos, M.A.

SUMMARY

The current state of organization of health and social services in schools does not lend itself to orderly description. In any given school, one might find a complex program that includes a mental health team, a school-based clinic, case management, and a family resource center. In another school a nurse may be carrying the full responsibility with only part-time visits from a school district social worker, counselor, and/or psychologist. Out of this broad landscape, several major trends are discernible. In many communities where the school system serves primarily disadvantaged students who lack access to health services, community agencies are relocating their services into schools to augment the work of school staff. In a few places, school health efforts have been integrated with school reform initiatives to create a completely different kind of community or full-service school that is responsive to the needs of the local population. Both school systems and community agencies are open to making new administrative arrangements that will improve the status of child and family health.

Research and evaluation findings demonstrate that low-income families and their children do indeed gain access to needed health services through school-based programs. Among adolescents, those with the greatest needs (measured by high-risk behaviors) are using the services the most. Users of school-based health services are less likely than others to have health insurance. Mental health and dental services are particularly



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School & Health: Our Nation's Investment APPENDIX D New Approaches to the Organization of Health and Social Services in Schools Joy Dryfoos, M.A. SUMMARY The current state of organization of health and social services in schools does not lend itself to orderly description. In any given school, one might find a complex program that includes a mental health team, a school-based clinic, case management, and a family resource center. In another school a nurse may be carrying the full responsibility with only part-time visits from a school district social worker, counselor, and/or psychologist. Out of this broad landscape, several major trends are discernible. In many communities where the school system serves primarily disadvantaged students who lack access to health services, community agencies are relocating their services into schools to augment the work of school staff. In a few places, school health efforts have been integrated with school reform initiatives to create a completely different kind of community or full-service school that is responsive to the needs of the local population. Both school systems and community agencies are open to making new administrative arrangements that will improve the status of child and family health. Research and evaluation findings demonstrate that low-income families and their children do indeed gain access to needed health services through school-based programs. Among adolescents, those with the greatest needs (measured by high-risk behaviors) are using the services the most. Users of school-based health services are less likely than others to have health insurance. Mental health and dental services are particularly

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School & Health: Our Nation's Investment in demand in communities with marginal resources; however, clinics in schools are also finding many previously undocumented cases of chronic diseases (asthma, heart problems) and illnesses. Use of hospitals and emergency rooms has declined in a few places with school-based health services. It has been more difficult to document the impact of these school-based services on high-risk behaviors, such as substance abuse, unprotected sexual intercourse, or violence. School attendance and achievement have improved in some schools with support programs. The data suggest that intense and targeted programs produce the most measurable effects. Broad replication of comprehensive health and social service programs in schools will require many systemic changes in both the educational establishment and community agencies that supply the services. A number of issues must be addressed, such as financing, governance, turf, staffing, controversy, community input, and parent involvement. A strong movement is under way to create new kinds of arrangements for the delivery of primary health care and social services in schools in conjunction with upgrading the quality of education. States and foundations have taken the lead and will probably have to continue to do so. Leadership at the federal level, as well as opportunities for technical assistance in planning, training, evaluation, and research, would contribute to the growth of this emerging field. ORGANIZATION OF SERVICES IN SCHOOLS Traditionally, when we think of school health services, we remember the school nurse who was on hand to take temperatures of sick children, call their families, and keep reports on absences. The nurse also measured students' heights and weights every year and examined their posture for signs of scoliosis. Today's picture of school health services is vastly changed. First of all, the domain of "health" has stretched to include mental health, social services, and social competence—whatever is needed to enhance the lives of children and families. As a result, the number of different health, mental health, and social services available on school property has greatly increased and the organizational arrangements have become much more complex. Tyack (1992) has shown that despite the growing shift toward academic concerns in recent years, the proportion of school staff who are not teachers has grown significantly, from 30 percent in the 1950s to 48 percent in 1986. He believes that schools are increasingly becoming "multipurpose agencies" despite the push toward academic testing and standards. Just how complex this picture of school health services has become can be seen in the vast array of issues that are being addressed by differ-

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School & Health: Our Nation's Investment ent kinds of interventions. Table D-1 displays the diverse goals and components of current programs based in schools. Table D-2 reveals that at least 40 types of personnel enter into schools to provide services; some are employed by the school districts, others by community agencies. Table D-3 presents the assortment of organizations that bring services into schools, including local public health departments, voluntary agencies, businesses, and foundations. TABLE D-1 Goals and Components of School-Based Programs Categorical (single) Goals Improve school readiness Improve academic achievement Improve attendance Improve classroom behavior Improve graduation rate Improve health and nutrition Prevent depression and suicide Prevent substance abuse Prevent teen pregnancy Prevent violence Special Target Groups Physically handicapped Behavioral problems Language problems, immigrants Children of alcoholics Children of divorced parents Depressed or stressed "At-risk" students (many definitions) Pregnant and parenting teens African-American males Hispanics Asians Rural or isolated populations Program Components Parent involvement, leadership training, literacy Case management, home visiting Crisis intervention Social skills, resistance, assertiveness "Self-esteem", self-efficacy, competency, life skills Basic cognitive skills Job skills or placement Counseling: psychosocial, alcohol and drugs Community outreach Transportation Food, clothes, housing Health and mental health care, immunization, dental care Family planning, condom distribution AIDS education, information, testing After-school recreation, culture Head Start, childcare Eligibility establishment, immigration services Hot line Incentives Comprehensive (multiple) Goals Collaborative dropout, substance use, teen pregnancy, depression prevention Comprehensive services to pregnant and parenting teens Alternative schools School reorganization "One-stop" services for children, youth and families Full-service school

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School & Health: Our Nation's Investment TABLE D-2 Personnel Involved in School-Based Programs Registered nurse Nurse practitioner Physician Physician's assistant Health aide Dentist Dental hygienist Optometrist Audiometrist Social worker Case manager Psychologist Psychosocial counselor Substance abuse counselor Parent advocate Community worker Outreach worker Tutor or mentor Resource teacher Classroom aide Mediation trainer (nonviolence) Program coordinator General youth worker General family worker Eligibility worker Job trainer Legal adviser Recreation specialist Arts and culture specialist Volunteer Parent Senior citizen Business mentor College student University researchers Psychology Education Health or Medicine Justice Police Law professors Court officers Clergy This section reviews the various ways in which health and other services are made available in schools, ranging from the simplest categorical models to quite complex comprehensive delivery systems (Dryfoos, 1994a, 1994b, 1994c). As the models become more complicated, personnel from outside the school system enter the picture (and the school building), bringing their protocols, liability coverage, and financing with them. In the many source documents that report on school-based services, no two models are alike in regard to organizational framework. According to a discussion of school-based or school-linked service models in Maryland, "recognizing the diversity of communities and school systems across the state, it is important to realize that each service model may look different in terms of selected location and management style. The determination of which model will work better in a given situation must be a local decision based on an analysis of that community" (State of Maryland, 1994). The section starts with a description of programs and models and provides examples (and costs where known). It also includes a summary of major findings from research and evaluation, and discusses major issues as they apply to organizing comprehensive school health programs.

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School & Health: Our Nation's Investment TABLE D-3 Organizations That Bring Services into Schools Local County-city government Mayor's office County administrator Youth bureau Local education agency (school board) Public health department Mental health department City or County hospital Community health center Public welfare department Department of human resources Police department Probation office Court office Extension service Parks and recreation Child protective services, foster care Private or nonprofit Hospital, medical or nursing school Health maintenance organization Medical or dental society Mental health center Women's health center, Planned Parenthood Community-based neighborhood organization Cities in Schools Senior citizen group Service club (Kiwanis, Elks, Lions) United Way, local planning councils Youth council Youth organization (Girls, Inc.; Girls and Boys Clubs; 4H; YWCA and YMCA) Social services agency Colleges and universities Education, graduate school Social work Psychology Public health Medical and nursing school College (general) Community college Specialized research center Business Labor union Bar association Local foundations State Governors office initiative Legislative initiative Health department Education department Human resources department National Special governmental initiatives Center for Substance Abuse Prevention Maternal and Child Health Adolescent Initiative Division of School and Adolescent Chapter 1 Drug Free Schools Foundation initiative ''Think tank" research and development organizations

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School & Health: Our Nation's Investment The following typology has been used here: pupil personnel teams, student assistance programs, school-based health centers, school-based dental clinics, mental health centers, family resource centers, case management and cities in schools, school-based youth service centers, teen parent programs, comprehensive multicomponent programs, school reorganization, and community or full-service schools. Pupil Personnel Teams Many schools organize their pupil personnel staff by teams with various configurations. The school social worker, guidance counselor, nurse, and psychologist meet with the principal and selected teachers. Team members review "cases" and work together to make sure that the needs of the students and their families are being met. The major pupil personnel agencies have joined together to form the National Alliance of Pupil Services Organizations (NAPSO), with a mission of promoting interdisciplinary approaches to their professions and supporting integrated service delivery processes (National Alliance of Pupil Services Organizations, 1992). The group's statement spells out significant roles for its 2.5 million professional constituents: "School-based pupil services personnel, who are responsible for delivering education, health, mental health, and social services within school systems, comprise a critical element which forms a natural bridge between educators and community personnel who enter schools to provide services. They are of the schools as well as in the schools. They can serve to mediate, interpret, and negotiate between other school personnel and persons entering the school from the outside." Taylor and Adelman promote the creation of a resource coordinating team that would focus on identifying resources rather than on individual cases. Such a team "provides a necessary mechanism for enhancing systems for coordination, integration, and development of intervention … ensures that effective referral and case management systems are in place, [works on] communication among school staff and with the home, … [and] explores ways to develop additional resources" (Taylor and Adelman, in press). The resource coordinating team reaches beyond pupil personnel and adds special education and bilingual teachers, dropout

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School & Health: Our Nation's Investment counselors, and representatives from any community agency that is involved at the school. In actual practice, many school systems do not have the funds to employ pupil personnel staff. Budget cuts, particularly in disadvantaged communities, have made huge dents in these categories. If social workers and psychologists are employed by school systems, they are often shared between schools and cannot possibly work in teams because of the demands on their time. One solution to this problem in needy areas has been for outside agencies to put together teams and relocate them in schools. In Catawba County, North Carolina, the county government has assumed responsibility for providing school services through a team. The Public Health Department contributes a nurse, the Department of Social Services provides a social worker, and the Department of Mental Health supplies a psychologist (Moore, 1992). Placed in an office in a school, this team serves elementary, middle, and high schools. A second team has been organized to serve three elementary schools and one middle school. The lead team member is the psychologist; the team does intensive work with individual children, conducts home visits, follows up on attendance problems, refers students to the health department for medical care, and works closely with teachers singly and in groups. The program is managed by the Public Health Department, which acts as the home base where records are kept, supervision is maintained, and a health clinic is located. This program was created jointly by the county manager and the school superintendent and is supported by county tax dollars. Its success has been attributed to starting with what the school system perceived as the problem—in this case, head lice. The first component was the implementation of a "no-nit" policy whereby health department staffs screened and treated all students. After that, the team was free to work on other problems identified by the school staff, particularly teen pregnancy, truancy, and smoking. The Travis County (Texas) Health Department, in conjunction with the Austin City School District, has organized a school services team in high-risk elementary schools: the team consists of a nurse, mental health counselor, social worker, and community outreach worker (Maternal and Child Health Bureau, 1993). The team provides screenings, case management, home visits, and health promotion activities. Initial agency—school communication problems were overcome by inviting the principals and counselors in the pilot schools to be part of the interview team and involved hiring decisions. The annual cost is $150,000 per school, which is provided by city and county funds (EPSDT [Early Periodic Screening, Detection, and Treatment] funding is being accessed). In Florida, an analysis of data from sites supported by the Supple-

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School & Health: Our Nation's Investment mental School Health Program reported that the team approach cost $55 per student (Eimhovich and Herrington, 1993). Student Assistance Programs Student assistance programs (SAPs) are another genre of school-based programs that tend to be categorical in that they are aimed at specific behaviors, but they also provide services that are more comprehensive than the categorical classroom-based prevention programs. One example is the Student Assistance Model developed and implemented in Westchester County (New York) almost a decade ago. This program brings full-time professional counselors (social workers) into schools to provide alcohol and drug abuse intervention and prevention services targeted at students and their families. This program, one of five selected by the National Institute of Alcohol Abuse and Alcoholism as a model, has four basic components (National Institute of Alcohol Abuse and Alcoholism, 1984): group counseling sessions (eight to 20 sessions) for students with alcoholic parents, focusing on increased self-efficacy and improved academic, behavioral, social, and emotional functioning; individual, family, or group counseling services for students who are using alcohol or drugs disfunctionally; (referral to community treatment program if available); counseling services for students who exhibit poor school performance (and are therefore at high risk for alcohol or drug abuse); and collaboration with parent and community groups to develop ways of dealing with substance abuse problems. Although based in schools, the counselors are all employed and supervised by, and receive intensive training from, an outside corporation, such as a county mental health department, and therefore do not operate under the same constraints as school guidance counselors (e.g., they can maintain confidentiality, and they have more time for individual attention). However, schools and their principals must be heavily committed to the program and provide space, equipment, open communication with the staff, and other supportive policies. An important aspect of this program is training teachers, parents, and other gatekeepers to be sensitive to student problems and to refer the students appropriately to counselors. Mandatory referral is required if students are found under the influence of alcohol or drugs on school grounds. Teen Choice is another targeted program operated by outside professionals in public schools, this one focused on pregnancy prevention. It is

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School & Health: Our Nation's Investment operated by Inwood House, a voluntary social service agency, in the New York City public schools (Inwood House, 1987). Specially trained professional social workers staff three components: small groups, individual counseling and referral, and classroom dialogues. The small groups meet once a week for a semester and cover issues of sexuality, birth control, values clarification, peer pressure, and similar issues. The workers are assigned to a school and are on-site three to five days per week in seven schools. The most common problems that arise in counseling sessions include pregnancy scares (25 percent of cases), birth control, relationship and family issues, and general mental health evaluation. School-Based Health Centers One response to the growing health needs of students has been the development of school-based health centers (SBHC), most frequently in inner city high schools but increasingly in middle and elementary schools (Lear et al., 1991). No one knows exactly how many SBHCs are up and running. My own estimate is that there are about 650 SBHCs, and they operate in almost all parts of the country. However, the recent School Health Policies and Programs Study states that 11.5 percent of school districts reported at least one school-based clinic. Applying this proportion to the 13,169 school districts yields an estimate of more than 1,400 school-based clinics, twice the number usually given (Small et al., 1995). A school-based health center is defined here as one or more rooms located within a school building or on school property and designated as a place where students can go to receive primary health services. This center or clinic is more than a school nursing station; students are also able to receive health services not generally available in school, such as physical examinations, treatment for minor injuries and illnesses, screening for sexually transmitted diseases, pregnancy tests, and psychosocial counseling. Services are provided by nurse practitioners, health aides, outreach workers, social workers, and physicians. Most of these practitioners are employed by one or more local agencies, such as health departments, hospitals, medical schools, or social service agencies. Most SBHCs also provide health education and health promotion in the clinic, the classroom, for staff, and even for the community; 86 percent of providers offer health education in classrooms in clinic schools (Hauser-McKinney and Peak, 1995). Most run group counseling sessions in reproductive health care, family problems, asthma control, depression, and other relevant subjects. In some communities, a school-based health services program provides care for more than one school. A mobile van is equipped to go from school to school, allowing workers to provide physical examinations,

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School & Health: Our Nation's Investment ambulatory services, immunizations, and referrals for more comprehensive medical and dental care. These functions can also be provided on-site if a room can be appropriately equipped and privacy ensured. The average expenditure reported by school-based clinics in 1993 was about $150,000, plus about $30,000 in in-kind or matching funds (Hauser-McKinney and Peak, 1995). State public health-sponsored clinics reported the lowest budgets (about $100,000) and mental health agencies the highest (more than $200,000). In 1994, states reported that they provided $37 million for SBHCs: $25 million in state initiatives and $12 million from Maternal and Child Health (MCH) block grants. Also, some funds are received from Medicaid, Title XX (social services), Drug Free Schools, and Title X (family planning). A few states (Colorado, Delaware, Florida, Illinois, Louisiana, Massachusetts, Michigan, New York, and Texas) account for most state funds. It is estimated that about $100 million is currently being spent on SBHCs—half from states, a small amount from federal sources, some from foundations, lots of in-kind contributions, and very little coming directly from education budgets. Although many students are eligible for Medicaid, only about 7 percent of costs for school-based primary care is being reimbursed by this source. Practitioners from across the country have recently organized a National Assembly for School-Based Health Care to promote this model and encourage the provision of high-quality care. State coalitions of providers in New York, California, and Connecticut are actively involved in working on such issues as managed care and information systems. The Robert Wood Johnson Foundation has given grants to 10 states to develop coordination mechanisms at the state level and create model district-wide school-based health care demonstrations. The Jackson-Hinds Comprehensive Health Center in Jackson, Mississippi, currently operates school-based health services in four high schools, three middle schools, and one elementary school. In 1979, when the program was first initiated at Lanier High School, the staff found many conditions that demonstrated the extensive unmet needs of the students, including urinary tract infections, anemia, heart murmurs, and psychosocial problems. In a student body of 960, more than 90 girls either were pregnant or already had a child. Some 25 percent of the pregnancies had occurred while the youngsters were in junior high, which prompted the program to extend resources to an inner city junior high school and to a second high school the following year. The other clinics were added in the late 1980s. Clinics are located in whatever rooms schools can make available. At Lanier High School, two small rooms near the principal's office are equipped as clinics. Group counseling and health education classes are provided in a large classroom that has been outfitted with private offices

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School & Health: Our Nation's Investment for individual counseling. The infant care center is located in a mobile unit attached to the school. The staff includes a physician, nurse practitioner, licensed practical nurse, two nurse assistants, and an educator or counselor, all part-time workers. The school-based clinic protocol includes a medical history and routine lab tests of hematocrit, hemoglobin, and urinalysis. Each enrolled student completes a psychosocial assessment to provide information about risk levels for substance abuse, violence, suicide, pregnancy, sexually transmitted diseases (STDs), accidents, and family conflict. Depending on indications from the health history and the assessment tool, the student is scheduled for a visit with the physician and/or counselor. However, the clinic is always open from 8:00 a.m. to 5:00 p.m. for walk-in visits for emergency care and crisis intervention. Clinic staff conduct individual and group counseling sessions. Students who are sexually active are given birth control methods, including condoms, and are followed up bimonthly. Staff members also dispense formal health instruction about such specific issues as compliance with medication protocols or treatment of acne, and conduct informal "rap sessions" on parenting, the reproductive health system, birth control methods, sexual values, STDs, and substance abuse. The counseling and clinic services are closely coordinated. Enrollees in the school clinic are referred to the primary community health center for routine dental screening, cleaning, and fluoride application. This facility is always open to students after school hours, on weekends, and on holidays. Arrangements for early prenatal care are made through the obstetrical department of the health center. Teen mothers are carefully monitored throughout their pregnancies, with special attention paid to keeping the young women in school as long as possible and getting them back within a month after delivery. Day care is provided at the school. Young mothers are counseled and instructed about child development and parenting skills. The day care center is also used for teaching child psychology to high school students. School-Affiliated Dental Services Earlier in the century, many schools had established dental clinics, but very few such clinics remain in existence. Yet school-based health staff frequently report dental health needs as pressing; many disadvantaged youth have no access to a family dentist. A few school-based clinics have added dental services to their protocols. The clinic in Pinkston High School in Dallas, Texas, incorporates a fully equipped dental suite and a full-time dentist on staff. A new elementary school in Bridgeport, Con-

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School & Health: Our Nation's Investment managed care contracts to fund these programs. Although financing is a barrier to the expansion of full-service schools, it is not the only hurdle faced by program developers. Other factors such as governance, turf, responsiveness to the community, staffing and training, and controversy must also be addressed. Governance Much of the rhetoric in support of developing health and social services in schools has been presented in the language of systems change, calling for radical reform of the way educational, health, and welfare agencies provide services (Knitzer, 1989; Melaville and Blank, 1993). Consensus has formed around the goals of one-stop, seamless, service provision, whether in a school or in a community-based agency, along with empowerment of the "target population." A review of current models reveals that little systems change has taken effect. Most of the new wave of 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 arrangement, 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. Yet 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. Partners—schools and community agencies—have agreed on goals and signed contracts or memoranda of understanding that leave the status quo of the organizations entirely intact. The agreements may specify policies regarding fiscal responsibility, client–student data collection, confidentiality, and other administrative issues. The first evaluation of New Beginnings in San Diego, a multiagency program that operates a family resource center in Hamilton School, warns that it is "difficult to overestimate the amount of time collaboration takes" (Barfield et al., 1994). The participants discovered that it was easier to get agencies to make "deals" (sign contracts to relocate workers) than to achieve major changes in delivery systems. Staff turnover, family mobility, fiscal problems, and personality issues were cited as some of the barriers to change. Most school-based health centers are funded by grants made directly from state health departments to local health agencies, which then contract with school systems to provide services. This is a matter of policy for some state health departments and foundations, which believe that the school system should not be burdened with the responsi-

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School & Health: Our Nation's Investment bility for providing primary health and social services to the students. At the same time, the local education agencies are the grant recipients for the largest state programs (California, Florida, and Kentucky), and these systems may either provide services themselves or, more typically, contract them out. Although few school services models have been able to overcome the barriers to the formation of new kinds of governance, this should not be perceived as a deterrent to further service integration efforts. Past attempts at systems reform have shown that it is much more difficult to alter the way in which entrenched administrators operate across agencies than it is to make incremental changes in the existing systems they run. The movement toward service integration as exemplified in full-service schools has clearly had an effect on cutting red tape in some programs, but practitioners are still confronted with the conflicting eligibility criteria and restrictions that go along with categorical programs. Turf Bringing outside health or social services into a school building under the auspices of an outside agency is an invitation to turf wars. Two or more different staffs operate under separate jurisdictions in terms of unions, policies, pay schedules, hours of work, and direction. Without careful planning and negotiation, the school staff can be very threatened by the appearance of a new group of workers. School nurses have been particularly vulnerable because they feel replaced by a differently trained nurse (nurse practitioner), who is allowed to conduct complete physical examinations, prescribe and administer medication, suture wounds, and perform other hands-on activities. However, school social workers, psychologists, and guidance counselors often have similar initial negative responses. Who is responsible for the children and their families? Some teachers oppose school-based services if students leave their classes for clinic appointments. Custodians resent keeping buildings open so families can use them. A significant area for potential conflict is discipline. The school has its own practices, such as suspension and other forms of punishment, that may be antithetic to the ethos of the newcomers. Competition between community agencies can also arise in the development of full-service schools. Agencies begin vying for scarce resources when states or foundations issue requests for proposals (RFPs) that call for proposals that stress collaboration. Who represents the "community"? One key to successfully overcoming these situations appears to be a sensitive principal who, right from the planning stage, involves his school personnel along with outside personnel in creating a team approach. Serious and ongoing in-service training involving both the existing staff and

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School & Health: Our Nation's Investment the staff of the outside agency will be needed to negotiate areas of tension and to learn to understand where each side is "coming from." Experience shows that within a short period of time, most schools find more than enough crises to go around. School personnel become major supporters of school-based services when attendance improves and behavioral problems are addressed by practitioners. For their part, practitioners come to recognize how difficult it is to maintain order in today's schools. Initial planning that anticipates school–agency friction is more successful. In a new elementary school in Bridgeport, Connecticut, which has a built-in public health department-sponsored clinic, the school nurse (paid school funds) was placed in the central position in the clinic as traffic director, to screen all students and direct them to the appropriate clinic staff member—nurse practitioner, dentist, outreach worker, or counselor. In restructured middle schools, outside social workers have been assigned to houses or academies, in keeping with the new design of the school. Clinic coordinators from around the country report that when the principal expresses ownership and refers to "My clinic," the staff know that they have it made. School-Based Versus Community-Based Questions have also been raised about placing the locus of full-service programs in schools in communities that are distrustful of the educational establishment (Chaskin and Richman, 1992). In some locations, community leaders feel that the school systems are to resistant to change that the leaders have little confidence that the quality education component of the full-service vision will ever materialize. Human resource planners have proposed an alternative model that places services in buildings run by community-based organizations, in which families feel comfortable and are assured of greater roles in decisionmaking. This service integration theory still holds, but the locus of services is placed firmly in the neighborhood, with the services operated directly under local control. The school board has no place in this model, obviating the difficult negotiations that can be stressful and time-consuming. Michigan's experience with its 19 teen health centers (11 school based or school linked and 8 in the community) suggested that community-based centers had greater flexibility, especially in regard to the provision of family planning; could more easily ensure confidentiality; could serve more dropouts; were free to set their own parental consent protocols; and avoided the (unfounded) suspicion that school funds were being used for nonacademic services. However, the school-based centers were found to have reduced the necessity for outreach; they more readily involved school personnel, could serve students on-site, were perceived to have more direct access to teens;

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School & Health: Our Nation's Investment were more likely to obtain foundation support; took on the function of health promotion in the schools; and were able to garner in-kind resources from the school system, such as space, maintenance, utilities, and supplies. Concern has been raised about the viability of full-service schools as sites for dealing with young people who no longer attend school. Some of the existing school-based centers do serve out-of-school youth as well as siblings and parents of current students. Others do not. For two major youth-serving organizations in New York City (El Puente and the Door), the transformation into full-service schools started with community organizations that added basic educational components to their rosters of services and obtained certification as part of the public school system. This community youth center–school model offers an approach for working with school dropouts who are often youth agency clients. The disaffected youth are drawn back into the school system through the efforts of trusted youth service agency staff. Transportation Program reviews in both Florida and Kentucky cited transportation as a major issue for people who used their centers. Those who relied on school-linked services found that referrals to community agencies were not carried out because the students and families were not able to get to those places. School-based models that were open after school hours or wanted to bring parents into school during school hours also encountered transportation problems. School buses are usually run by contractors with inflexible schedules. Few programs have the necessary resources to offer van service to families, particularly those that live in outlying rural areas. Issues such as transportation can be dealt with through the planning process. School systems may be willing to alter contracts with bus companies or negotiate with their own bus driver unions to schedule but runs for the convenience of the families rather than the convenience of the system. Buses can be scheduled for late afternoons, evenings, and weekends. In many places, the precedent exists if the destination involves a competitive athletic event. Staffing and Training If programs are already experiencing difficulty hiring nurse practitioners and social workers, where will the staff for 16,000 full-service schools come from? If the concept catches on and schools are seen as the locus for new kinds of institutional arrangements that cut across categorical lines, almost every category of professional worker will need to be retrained

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School & Health: Our Nation's Investment and new professionals will need to be cross-trained. Educators will have to better understand youth and family development issues, become more culturally sensitive, and further master their own specialties. Human service workers will have to learn how to function in schools and understand the culture of educational institutions. New types of coordinators and directors for school-based services will have to be able to interrelate with both schools and community agencies and help everyone bridge the gap. In addition, they will need strong fiscal management skills to handle the complexities that go along with multiple funding sources and accountability. Even when staff can be identified, turnover rates are often high. Working with disadvantaged children and families is labor intensive and can lead to burn out if the management does not address personnel issues with care and grace. In addition, practitioners in some areas report that the greatest difficulty is recruiting trained professionals who are bilingual. The need for appropriately trained personnel stands as a major barrier to replication. This issue is already being addressed on a small scale in a few university settings, where there are efforts to change curricular offerings and coordinate master's level requirements. The major professional organizations for pupil personnel services (school nurses, school psychologists, school social workers, guidance counselors) are already working together to define the roles of their constituencies in new program models. Controversy It has been observed that the phrase "school-based clinic" is like a red flag for those waiting to raise community tensions over sexuality issues. The most highly publicized school-based health programs in the early 1980s were heralded as pregnancy prevention programs, leading to attacks from the opposition that schools were opening "sex clinics" and "abortion mills." When later replications of these models were shown to have little effect on pregnancy rates because they did not include family planning services, the attack shifted and the opposition organized against bringing any kind of services into school buildings, even elementary schools. For example, at the time that the Kentucky Youth and Family Centers were first proposed, the Eagle Forum put out brochures referring to the proponents as "child snatchers." In reality, few programs have been stopped in their tracks because of organized opposition. Accounts of these events are elucidating. Parents invariably surface as the most articulate and credible advocates for school-based services. National and local polls have documented the high level

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School & Health: Our Nation's Investment of support for these concepts. The 1992 Gallup Poll reported that 77 percent of respondents favored using public school buildings in their communities to provide health and social services to students, administered and coordinated by various government agencies. A majority of respondents (68 percent) approved of condom distribution in their local public schools, although one in four of them would require parental consent (Elam et al., 1992). A 1993 sample survey of North Carolina registered voters showed that 73 percent believed that health care centers offering prevention services should be located at high schools. There were no differences by gender, religion, or parental status, although the strongest support came from African Americans between the ages of 18 and 34. More than 60 percent favored providing birth control at the centers. Many state programs were authorized by legislation that prohibited the distribution of contraceptives and referral for abortions on school premises. Other ''comprehensive" programs developed during the school–community planning process omitted the distribution of birth control, suggesting that the expectation of controversy has a cooling effect on service provision. State officials have also been articulate on these issues. When Joycelyn Elders (former Surgeon General of the United States) was Director of Health in Arkansas, she strongly supported the concept of school-based services, always emphasizing that the decision about how to provide family planning was strictly up to the local school and community. Several local school boards voted to provide contraception when given the option. In recent years, school systems have been changing such policies to allow the distribution of condoms in schools, as long as parents do not object. Typically, the local health department comes into the school to hand out the condoms, relieving the school system of the responsibility. State initiatives offering grants to communities that develop collaborative projects have engendered some negative responses from local practitioners. One group of representatives from a remote rural area expressed concern about "Big Brother." The group did not want the state to tell its members how to organize services in their community. It feared that a school-based collaborative project that placed social services along with health and child protective services might "inflict help" on people who didn't want it. Concern was expressed that one-stop services might make families more dependent, rather than empowering them to act for themselves. In some communities, objections have been raised to the provision of mental health services and substance abuse counseling in the schools because they are too "personal." Experience across the nation has shown that the response to requests for proposals from state governments and foundations has been overwhelming. Fear of controversy appears to be secondary to the need for

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School & Health: Our Nation's Investment support for innovative services in schools. The media could play a more positive role in emphasizing the comprehensive scope of full-service schools and their potential to create better institutions for children and families. Too Little, Too Late Perhaps the most powerful argument that can be made, however, is that all of this program development will not make much difference in the lives of disadvantaged youth. Many very troubled young people, no matter what goes on behind the schoolhouse door, must still return to dangerous households or the streets after school. Few would quarrel with the point that early intervention is essential, but this should not be used as a justification for ignoring the millions of teenagers who can still be assisted. At the same time, in communities with school-based services, attention is turning toward the development of more sites in elementary schools. The preferred arrangement is the "cluster," tracking youngsters from kindergarten (or even preschool) through high school and providing related support services at each school along the way. In the new RWJ initiative, states are being asked to support school districts with the capacity for creating district-wide plans for comprehensive school-based health and social services. The development of new forms of organizational arrangements to enhance delivery systems and improve educational experiences is an optimistic enterprise. It represents the aggregate energies of hundreds of practitioners, youth workers, educators, and advocates who plow ahead despite the obstacles to try to create more responsive institutions for the twenty-first century. Indisputably, the budget crisis is having a cooling effect. Yet this movement will continue to expand because it fits with the times, is certainly needed, uses resources rationally, puts significant program components together, and is enthusiastically supported by both the consumers and the providers. REFERENCES Adams, B. (Senator) 1992. Washington in helping America's youth in crisis. Testimony presented at Hearing of the Committee on Labor and Human Resources, U.S. Senate, Washington, D.C. July 28. Adelman, H., and Taylor, L. 1991. Mental health facets of the school-based health center movement: Need and opportunity for research and development." Journal of Mental Health Administration 18:272–283. Adelman, H., Barker, L., and Nelson, P. 1993. A study of a school-based clinic: Who uses it and who doesn't? Journal of Clinical Child Psychology 22(I):52–59.

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School & Health: Our Nation's Investment Anthony D. 1991. Michigan Department of Public Health: Remarks to support center for school-based clinics annual meeting, Dearborn, Michigan, October. Barfield, D., Brindis, C., Guthrie, L., McDonald, W., Philliber, S., and Scott, B. 1994. The evaluation of New Beginnings. First Report. San Francisco: Far West Laboratory. Bosker, I. 1992. A school-based clinic immunization outreach project targeting measles in New York City. Paper presented at the Annual Meeting of the American Public Health Association, Washington, D.C., November. Brellochs, C. 1995. School health services in the United States: A 100-year tradition and a place for innovation. Paper prepared by the School Health Policy Initiative, Montefiore Medical Center, N.Y. Brindis, C., Kapphanhn, C., McCarter, V., and Wolfe, A. 1995. The impact of health insurance status on adolescents' utilization of school-based clinic services: Implications for health reform. Journal of Adolescent Health Care 16:18–25. Brindis, C., Starbuck-Morales, S., Wolfe, A.L., and McCarter V. 1994. Characteristics associated with contraceptive use among adolescent females in school-based family planning program. Family Planning Perspectives 26:160–164. Brindis, C. 1995. Promising approaches for adolescent reproductive health service delivery: The role of school-based health centers in a managed care environment. Western Journal of Medicine 163(Suppl.):50–56. Bureau of Primary Health Care. 1993. School-Based Clinics That Work . Washington D.C.: Division of Special Populations, Health Resources and Services Administration, HRSA 93-248P. Center for the Future of Children. 1992. The Future of Children: School Linked Services 2(1), Appendix A. Center for Human Services Policy and Administration. 1990. Shanks Health Center Evaluation. Final report: Third year of program operation. Tallahassee: Florida State University. Center for Reproductive Health and Policy Research. 1993. Annual Report to the Carnegie Corporation of New York and the Stuart Foundations: July 1, 1991–June 3, 1992. San Francisco: Institute for Health Policy Studies, University of California. Center for Research on Elementary and Middle Schools. 1989. Success for All. CREMS Report. Baltimore: Johns Hopkins University. Chaskin, R., and Richman, H. 1992. Concerns about school-linked services: Institution-based versus community-based models. The Future of Children: School Linked Services. 2(1):107–117. Children's Aid Society. 1994. Handout prepared for the Invitational Conference of the U.S. Department of Education and the American Educational Research Association: School-linked comprehensive services for children and families, Leesburg, Va., September 28 to October 2. Cities in Schools. 1988. "Fact sheet" and "Questions about cities in schools." Washington D.C.: Cities in Schools. Colvin, R. 1988. California researchers "accelerate" activities to replace remediation. Education Week November 30. Comer, J. 1984. Improving American education: Roles for Parents. Hearing before the Select Committee on Children Youth and Families, June 7. Washington D.C.: U.S. Government Printing Office. Dolan, L., and Haxby, A. 1992. The role of family support and integrated human services in achieving success for all in the elementary school. Baltimore: Johns Hopkins University, Center for Research on Effective Schooling for Disadvantaged Students. Report No. 31, April.

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School & Health: Our Nation's Investment Dryfoos, J. 1990. Adolescents-at-Risk: Prevalence and Prevention. New York: Oxford University Press. Dryfoos, J. 1994a. Full-Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families. San Francisco: Jossey-Bass. Dryfoos J. 1994b. Medical clinics in junior high school: Changing the model to meet demands. Journal of Adolescent Health 15(7):549-557. Dryfoos, J. 1994c. School-linked comprehensive services for adolescents. Paper commissioned for the Invitational Conference of the U.S. Department of Education and the American Educational Research Association: School-linked comprehensive services for children and families, Leesburg, Va., September 28 to October 2. Dryfoos, J., Brindis, C., and Kaplan, D. In press. Research and evaluation in school-based health care. In Health Care in Schools, A Special Edition of Adolescent Medicine: State of the Art Reviews, ed. L. Juszak and M. Fisher. Edwards, L.E., Steinman, M.E., Arnold, K.A., and Hakanson, E.Y. 1980. Adolescent pregnancy prevention services in high school clinics. Family Planning Perspectives 12(1):7. Elam, S., Rose, L., and Gallup, A. 1992. The 24th Annual Gallup/Phi Delta Kappa Poll of the public's attitudes toward the public schools. Phi Delta Kappan (Sept. 1992): 41-53. Eimhovich, C., and Herrington, C.D. 1993. Florida's Supplemental School Health Services Projects: An evaluation. Tallahassee: Florida State University. Goetz, K., ed. 1992. Programs to Strengthen Families: a Resource Guide. 3rd ed. Chicago: Family Resource Coalition. Gomby, D.S. 1993. Basics of program evaluation for school-linked service initiatives. Working Paper No. 1932. Los Altos, Calif. David and Lucille Packard Foundation, Center for the Future of Children, February. Hauser-McKinney, D., and Peak, G. 1995. Update 1994. Washington D.C.: Advocates for Youth, Support Center for School-Based and School-Linked Health Care. Holtzman, W. ed. 1992. School of the Future. Austin, Tex.: American Psychological Association and Hogg Foundation for Mental Health. Igoe, J., and Giordano, B. 1992. Expanding School Health Services to Serve Families in the 21st Century. Washington D.C.: American Nurses Publishing. Illback, R. 1993. Formative evaluation of the Kentucky Family Resource and Youth Service Centers: A descriptive analysis of program trends. Louisville: REACH of Lousiville. Inwood House. 1987. Community outreach program: Teen choice. A model program addressing the problem of teenage pregnancy. Summary report. Kagan, S.L. 1991. United We Stand: Collaboration for Child Care and Early Education Services. New York: Teachers College Press. Kirby, D. 1994. Findings from other studies of school-based clinics. Presentation given at meeting on evaluation sponsored by the Robert Wood Johnson Foundation, Washington, D.C., September 23. Kirby, D., Resnick, M.D., and Downes, B. 1993. The effects of school-based health clinics in St. Paul on school-wide birth rates. Family Planning Perspectives 25:12-16. Kisker, E.E., Brown, R.S., and Hill, J. 1994. Healthy Caring: Outcomes of the Robert Wood Johnson Foundation's School-Based Adolescent Health Care Program. Princeton, N.J.: Mathematica Policy Research. Knitzer, J. 1989. Collaborations Between Child Welfare and Mental Health: Emerging Patterns and Challenges. New York: Bank Street College of Education. Lear, J., Gleicher, H., and St. Germaine, A. 1991. Reorganizing health care for adolescents: The experience of the School-Based Adolescent Health Care program. Journal of Adolescent Health 12(6): 450-458. Leonard, W. 1992. Keeping kids in school. Focus (June 4-5).

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School & Health: Our Nation's Investment Maternal and Child Health Bureau (MCH). 1993. Briefing sheet from 1993 Urban MCH Leadership Conference Profile. Washington, D.C. Mathtech and Policy Studies Associates. 1991. Selected collaborations in service integration. Report for the U.S. Department of Education and U.S. Department of Health and Human Services, ED Contract LC89089001, February. McCord, M.D., Klein, J.D., Foy, J.M., and Fothergill, K. 1993. School-based clinic use and school performance. Journal of Adolescent Health 14:91-98. Melaville, A.I., and Blank, M.J. 1993. Together We Can: A Guide for Crafting a Profamily System of Education and Human Services. Washington, D.C.: U.S. Government Printing Office. Moberg, D. 1988. Evaluation results for a student assistance program. Paper presented at Annual Meeting of the American Public Health Association, Boston, Mass., November 14. Moore, B. 1992. Maternal and Child Health Nursing Supervisor, Catawba County Health Department. Interview, March. National Adolescent Health Resource Center. 1993. Evaluative review: Findings from a study of selected high school wellness centers in Delaware. University of Minnesota, Division of General Pediatrics and Adolescent Health. National Alliance of Pupil Services Organizations. 1992. Mission Statement. Washington, D.C.: National Alliance of Pupil Services Organizations, December. National Institute on Alcohol Abuse and Alcoholism. 1984. Prevention Plus: Involving Schools, Parents, and the Community in Alcohol and Drug Education. Washington, D.C.: U.S. Department of Health and Human Services. New York State Department of Health. 1994. Unpublished data from School Health Division. Albany, N.Y. Peder Zane, J. 1992. Teacher, doctor, counselor in one. New York Times, February 26, p. B-1. Philliber Research Associates. 1994. An evaluation of the caring communities program at Walbridge Elementary School. Accord, N.Y. Pinal County Human Services. 1990. Pinal County Prevention Partnership, Year End Report FY 1988–1989. Pinal County, Ariz. Poehlman, B. 1992. Comprehensive School Health Programs Project, National School Boards Association. Alexandria, Va.: National School Boards Association. Reynolds, G. Undated. Director of the School Based Youth Services Program, New Brunswick Public Schools. Visits to program and discussion with director. Rienzo, B.A. 1994. Factors in the successful establishment of school-based clinics. Clearinghouse 67(6):356–362. Rigden, D. 1992. Business and the Schools: A Guide to Effective Programs . 2nd ed. New York: Council for Aid to Education. Santelli, J., Kouzis, A., and Newcomer, S. In press. Adolescent student attitudes toward school-based health centers. Journal of Adolescent Health. Sizer, T. 1984. Horace's Compromise. Boston: Houghton-Mifflin. Small, M.L., Majer, L.S., Allensworth, D.D., Farquahar, B.F., Kann, L., and Pateman, B.C. 1995. School health services. Journal of School Health 65(8):319–326. State of Maryland. 1994. Report to the Subcabinet for Children, Youth, and Families from the School-Based/School-Linked Services Committee, May 12. STC Partnership Center. 1994. Handout prepared for the Invitational Conference of the U.S. Department of Education and the American Educational Research Association: school-linked comprehensive services for children and families, Leesburg, Va., September 28 to October 2. Stout, J. 1991. School-based health clinics: Are they addressing the needs of the students? Thesis for Master of Public Health, University of Washington. Support Center for School-Based and School-Linked Health Care. 1995. Assessing and Evaluating School Health Centers, Volume IV:. Washington, D.C.: Advocates for Youth.

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School & Health: Our Nation's Investment Taylor, L., and Adelman, H. In press. Mental health in the schools: Promising directions for practice. Health Care in Schools, A Special Edition of Adolescent Medicine: State of the Art Reviews, L. Juszak and M. Fisher, eds. Teen Health Corps Project. Undated. Concept paper for National Cities in Schools, Inc. Washington, D.C. Tyack, D. 1992. Health and social services in public schools: historical perspective. The Future of Children: School Linked Services. 2(1):107–117. Wagner, M., Golan, S., Shaver, D., Newman, L., Wechsler, M., and Kelley, F. 1994. A healthy start for California's children and families: Early findings from a statewide evaluation of school-linked services. Menlo Park, Calif.: SRI International, June. Wolk, L.I., and Kaplan, D.W. 1993. Frequent school-based clinic utilization: A comparative profile of problems and service needs. Journal of Adolescent Health 14:458–463.