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Schools and Health: Our Nation's Investment (1997)

Chapter: Appendix D

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Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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.

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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):

  1. 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;

  2. individual, family, or group counseling services for students who are using alcohol or drugs disfunctionally; (referral to community treatment program if available);

  3. counseling services for students who exhibit poor school performance (and are therefore at high risk for alcohol or drug abuse); and

  4. 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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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,

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

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-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

necticut, incorporates a large medical suite, with one of its offices equipped and used solely for dentistry.

In what may be the most exemplary dental program in the nation, the Board of Health in the city of Beverly, Massachusetts, has maintained a school-based dental clinic for underprivileged children for 76 years. Each child is expected to pay 10 cents a visit. If the clinic exam reveals more complex needs (extractions, orthodontia), the student is referred to local dentists who complete the work for free or at a reduced fee. The clinic also supports dental health education presented by a dental hygienist who visits 135 classrooms annually. The clinic has a singing group called "The Merry Molar Singers" and a "Clean Tooth Club."

A 1992 survey conducted by the National School Boards Association of 87 school districts selected as models for comprehensive health programs revealed that about half provided some type of dental services (Poehlman, 1992). A follow-up survey (with a 35 percent response rate) showed that most of the programs were located in elementary schools. Some three-fourths of those with dental services provided screening on school sites; about one-fourth also offered teeth cleaning, and one in ten gave fluoride rinses or sealants for prevention of tooth decay. Actual treatment was provided in more than one-third of the schools with dental programs: education for dental health was offered in two-thirds. Toothbrushes and toothpaste were distributed in several schools. Local dentists gave presentations, contributed their services at schools, or accepted referrals at low or no fee. In some communities, the Kiwanis Club was active in providing funds.

Mental Health Centers

When school-based clinic providers are asked what the largest unmet need is among their clients, they most frequently mention mental health counseling. Students come to the medical clinics with a litany of complaints about stress and depression, their typical adolescent problems exacerbated seriously by the deteriorating and unsafe social environment in which they live. The demand for mental health counseling has led to the development of school clinics that have a primary function of screening and treating for psychosocial problems, but mental health interventions in schools take many forms. In some communities, a mental health worker, either a psychologist or a social worker, is placed in a school by a community agency. A number of universities have collaborative arrangements with schools for internship experiences with mental health counseling. Within a broader framework of training young people to enhance their social skills, many university-based social psychologists have been busy designing and implementing school-based curricula.

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

A mental health center in a school transfers the functions of a community mental health center to a school building. In this model, a room or group of rooms in a school building is designated as a services center. This center is not usually labeled a "mental health" facility but rather is presented as a place where students can go for all kinds of support and remediation. The staff typically includes clinical psychologists and social workers. Depending on the range of additional services, other staff might be youth workers, tutors, and mentors. The goals of school-based mental health centers are to improve the social adjustment of students and to help them deal with personal and family crises.

A network of school-based mental health programs has been organized by the School Mental Health Project at the University of California at Los Angeles, a national clearinghouse that offers training, research, and technical assistance (Adelman and Taylor, 1991). This project works in conjunction with the Los Angeles Unified School District's School Mental Health Center. Based on this experience, the project is in the process of developing a guidebook for practitioners who want to follow a mental health model. Howard Adelman and Linda Taylor, directors of the project, believe that the major challenge for school-based mental health centers is to identify and collaborate with programs that are already going on in the school district. Many schools have programs focused on substance abuse and teen pregnancy prevention, crisis intervention (suicide), violence reduction, self-esteem enhancement, and other kinds of support groups. However, these efforts lack cohesiveness in theory and implementation, often stigmatize students by targeting them, and suffer from the common bureaucratic problem of poor coordination between programs. One of the most demanding roles for the mental health center is to establish working relationships with key school staff members.

The oldest mental health center in a school appears to have been operating within the Memphis City Schools since 1970. The Memphis City Schools Mental Health Center (MCSMHC) is a private, nonprofit corporation that also acts as an administrative arm of the school system. It is funded largely through contracts with the Tennessee Department of Human Services, the Department of Health, and a grant from Drug Free Schools and Communities. MCSMHC is a state-licensed center with a staff of 161, including psychologists, social workers, alcohol and drug counselors, and homemakers. The programs focus is to provide the overall school environment with many different components that have powerful preventive interventions affecting all children and their families, rather than to concentrate on providing specific services for individuals. The core program consists of 36 mental health teams that are housed in two school centers and rotate through all 160 schools, providing assessments, consultation, faculty inservice, crisis intervention, and counseling.

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

The teams work closely with School Support Teams, which make sure that interventions are actually carried out in the classroom, with families, and with individual students. The center organizes prevention groups in such areas as social skills, divorced families, grief issues, and anger control. In 1992–1993, the teams provided more than 9,000 hours of treatment to students and their families and 7,500 hours of consultation.

The Mental Health Center also takes responsibility for implementing drug abuse prevention, including training teachers in a K–12 curriculum. MCSMHC counselors are assigned to the schools and coordinate the programs, including Student Leadership Training, Just Say No clubs, and Parent to Parent Training. The mental health staff train school teams to work with community groups to address neighborhood issues. A Student Assistance Program specially trains teachers to identify high-risk students. School students suspended for a drug incident are required to attend nine sessions as part of an Early Intervention Group, a requirement that has resulted in a decline in school problems.

The center's most recent initiatives have sought to reduce conflict and violence. Its staff members have organized prevention groups in conflict resolution, using officers from the Memphis police department as co-facilitators. One school is involved in a firearms eradication program. Students and their parents who have received firearms suspensions are seen by a center psychologist and receive more in-depth services if appropriate. One mental health team is located at the Adolescent Parenting Program and works on this issue throughout the school system. Counseling is available, and workshops are offered on stress management, personal goal setting, and African-American issues. MCSMHC also offers services for abused and neglected children, including a Homemaker Program for families that have experienced abuse problems.

An exemplary school-based mental health program was initiated in New Brunswick, New Jersey, in 1988, funded by the New Jersey School-Based Youth Services Program (Reynolds, personal communication). It is operated in the high school and five elementary schools by the local Community Mental Health Center of the University of Medicine and Dentistry of New Jersey. Grantees of the New Jersey School-Based Youth Services Program receive $250,000 to $400,000 per year through the state's Department of Human Resources. The New Brunswick program is funded at the higher end because it covers more than one school. The program has ten full-time core staff members, including eight clinicians (psychologists and social workers), one of whom serves as the director. Staff members conduct individual, group, and family therapy and serve as consultants to school personnel and other agencies involved with adolescents. An activities or outreach worker plans and supervises recreational activities and contacts at the high school. Specialized part-time staff include a preg-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
×

nancy or parenting counselor, substance abuse counselor, and consultants in suicide prevention, ''social problems," and medical care.

The facility at New Brunswick High School is located in the old band room, which has been fixed up to resemble a game room in a settlement house, with television, Ping-Pong and other active games, comfortable furniture, and books and tapes on loan. The center offers tutoring, mentoring, group activities, recreational outings, and educational trips. A number of "therapeutic" groups have been organized in such areas as problem-solving, substance abuse, children of alcoholics, and coping skills for the gifted and talented. Students are referred and provided with transportation to the local neighborhood health center for health services and treatment. During the past two years, one in four of the enrolled students has been involved in active mental health counseling with a clinician. According to Gail Reynolds, the program director, the demand for services is overwhelming, requiring immediate and time-consuming interventions with the family, school, and other social agencies.

The South Tama County (Iowa) Partnership Center is an example of a rural school-linked mental health program focused on dropout and substance use prevention (STC Partnership Center, 1994). Located in a rented building in "downtown" Tama, this school-operated center contracts with 14 public and nonprofit agencies, including the local mental health clinic, public health department, juvenile court, and Job Corps. School buses provide transportation for students and their families to the center, where they receive a variety of human services, employment services, education, and recreation. Full-time staff include a social worker and an employment specialist. This program has been funded until recently by a state grant of $200,000 and an in-kind matching grant of $50,000. The current budget is approximately $150,000, which is obtained from various categorical sources.

Family Resource Centers

An unknown number of Family Resource Centers (FRCs) are located in school buildings, while other FRCs are community-based. A few states, including California, Connecticut, Florida, Kentucky, North Carolina, and Wisconsin, have passed legislation that appropriates funds for FRCs (Kagan, 1991). Kentucky's legislation mandates that every elementary school with more than 20 percent of its students eligible for free lunch must have a Family Service Center (Illback, 1993). These programs offer parent education and refer parents to infant and child care, health services, and other community agencies. Grants average $75,000, a minimal amount to cover the cost of a full-time coordinator and other part-time staff. In other states, FRCs supported various state initiatives and federal

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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grants to deliver comprehensive services on school sites, including parent education, child care, counseling, health services, home visiting, and career training. The Chicago-based Family Resources Coalition acts as a clearinghouse for the development of family support programs that can deliver preventive, coordinated, community-based services. Nationwide, some 2,000 programs have been identified that provide the three "Rs": resources, referrals, and relationships. Many of these family and child centers are located in school buildings.

The Family Resource Center in Gainesville, Florida, consists of seven portable units situated between an elementary and a middle school. This program includes a health clinic, experimental nursery, parent education, GED (General Educational Development) preparation and literacy classes, case management, economic services (Aid for Dependent Children, Medicaid, and Food Stamps eligibility establishment), job training and computer education, toy lending library, and family liaison. In a pattern that is typical of multiservice programs, the funding for this effort derives from many sources, including a state Full-Service Schools grant, Chapter I, College of Nursing and Medicine, Even Start, Head Start, Community College, Mental Health Services, School Board, state health grants, and Medicaid reimbursements. The state has awarded the program $2.5 million to build a new center that will have 2,500 square feet of space (currently it has 750 square feet).

Nashville, Tennessee, has a project called "One-Stop-Shopping in a Northeast Nashville Community," which consists of a family resource center and clinic located at a school devoted to serving preschool and kindergarten children. Regular services include home visiting, case management, GED classes, a family literacy program, help with welfare eligibility, year-round school nursing, counseling, job training, and referral. "The unique nature and effectiveness of the project is evidenced by the cooperative relationship in one location of state and local social services, health, literacy, housing and transportation, job training, and public education" (Maternal and Child Health Bureau, 1993). The annual budget is $675,000, which is obtained from local government funds, United Way, MCH Sprans grants, and general state funds.

Case Management

Another variant of school-based health or social services places social workers from community agencies into schools to act as case managers. Cities in Schools (CIS), a national nonprofit organization founded by William Milliken in Washington, D.C., has promulgated this model for prevention of school dropout. CIS operates in more than 122 communities with 384 school sites to facilitate a process of collaboration to bring health,

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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social, and employment services into schools to help high-risk youngsters (Leonard, 1992). Each local entity has its own version but, in general, the program involves "brokering" community social service agencies to provide case management services within the school building. Local businesses are involved in arranging for mentoring and apprenticeship experiences (Cities in Schools, 1988).

In most CIS programs, a case manager is assigned to each high-risk child. Communities vary in program design; some operate alternative schools, and some offer special life skills classes and other forms of remediation and tutoring. A wide array of partnerships has been established through the CIS processes; these include involving Girls and Boys Clubs of America, VISTA, United Way, and Junior League. Several CIS programs have achieved national prominence. For example, Rich's Academy in Atlanta (one of six CIS schools in that community) is an alternative school created in partnership with a department store. CIS has joined with the Iacocca Institute and the Lehigh University College of Education in Pennsylvania to create the National Center for Partnership Development, designed to address the dropout problem by meeting the multiple needs of youth. The CIS strategy has been translated into formal curriculum and training materials and uses computer-based interactive multimedia sessions.

One CIS spin-off is the Pinal County (Arizona) Prevention Partnership, which involves 13 middle and high schools in a collaborative effort of the Department of Human Services, the county school superintendent's office, and a nonprofit agency (Pinal County Human Services, 1990). According to director Charles Teagarden, the strategy calls for "a school-based, integrated delivery system of networking service providers connecting at-risk youths through diligent case management to targeted prevention programs, then to job and career opportunities created by economic development, all monitored by a data system evaluation." More than 100 different human service providers are brought into the schools to conduct these activities, or referrals are arranged. Family Resource Centers in eight of the schools allow parents to interact and work in support groups.

CIS has developed a concept paper calling for schools to create a Teen Health Corps. These programs would include peer education and leadership training centered around preventive health issues, starting with STDs and HIV (Human Immunodeficiency Virus). School-based activities, such as health fairs and class presentations to lower grades, will be organized with involvement by local health department staff (Teen Health Corps Project, undated).

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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School-Based Youth Service Centers

Some school-based centers focus more on coordination and referral than on providing services in schools. Kentucky's major school reform initiative in 1988 called for the development of youth service centers in high schools that have more than 20 percent of their students eligible for free school meals. In this case, small grants (under $75,000) were given to school systems to set up a designated room in the school and to appoint a full-time coordinator to oversee referrals to community agencies for health and social services and to provide on-site counseling related to employment, substance abuse, and mental health.

In New York City, the Beacons Program, created by the city youth agency, supports community-based agencies to develop "lighted school houses" that are open from early morning until late at night, as well as on weekends and during the summer. These "Beacons" offer a wide range of activities depending on neighborhood needs; the activities include after-school recreation, educational remediation, community events, and health services. Grants are in the $300,000 range. Beacons were used as the prototype for the Family and Community Endeavors part of the 1994 Crime Bill, based on the belief that offering after-school activities in high-risk communities would help prevent delinquency.

Comprehensive Multicomponent Programs

A number of school-based interventions have been initiated that address an array of interrelated issues, based on the observation that prevention approaches must be more holistic if they are to be successful. Many of the components discussed above are integrated into these efforts. These programs are put together by an outside organization that provides a full-time coordinator and other services to the school in order to implement all the separate pieces of the package.

The Walbridge Caring Community (Missouri) is one of the most sophisticated models that includes many components and many agencies. An initiative of the Missouri Department of Mental Health, this effort brings together the St. Louis City Public Schools and the Danforth Foundation in a collaborative effort with the state's Departments of Health, Social Services, and Education (Mathtech and Policy Studies Associates, 1991). The center created in this program provides an array of intensive services to the children and families of the Walbridge Elementary School; the center is also open to other community residents. Services include family counseling, case management, substance abuse counseling, student assistance, parenting education, before- and after-school activities, youth programs, health screening, and pre-employment skills. The family

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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counseling and case management component, directed at the families at highest risk, may involve a home therapist. Most of the funding for the intensive individual services (for 14 positions) is provided by the state's Department of Mental Health, while the Department of Social Services supports the after-school program (5 positions). Health services are provided by a school nurse, and the state's Department of Health supports the activities of a home health visitor and a clerical assistant. Funds from the Danforth Foundation and the state offices jointly support the director. One of the unique qualities of this program is its use of an Afrocentric concept in developing self-help, community empowerment, and rites-of-passage ceremonies.

The Schools of the Future Project is a large-scale foundation effort to help schools evolve into primary neighborhood institutions for promoting child and family development (Holtzman, 1992). The Texas-based Hogg Foundation for Mental Health is supporting major programs in four cities (Austin, Dallas, Houston, and San Antonio) by providing five-year grants of $50,000 per year to use elementary and middle schools as the locus of delivery of services. An equal amount of funding has been set aside for evaluation and monitoring. The foundation is interested in creating and testing an intervention that combines the latest models, including the Comer School Development Program, Zigler's Schools of the 21st Century, school-based clinics, programs for community renewal, and family preservation. Each program has a full-time project coordinator (a social worker) to establish links and partnerships between the schools and the providers of health and human services and to involve parents and teachers in program activities. For example, at San Antonio's three school sites, 11 graduate student interns were providing family, group, and individual therapy and 10 graduate social worker students were providing crisis intervention, home visits, and AFDC (Aid to Families with Dependent Children) and Food Stamp certifications, and were working with child protective services. Parent education, parent volunteer activities, after-school recreation, gang prevention programs, and other efforts were developed that involve many local organizations.

San Diego's New Beginnings is frequently cited as a model for providing integrated services in a nonfragmented services. Located in an inner city middle school, this program grew out of a partnership formed by the City (police, parks, recreation) and the County (health, social services, and probation) of San Diego, the school district, the community college, and the San Diego Housing Commission. These collaborators spent two years planning a school-based center to house a score of local agencies who were "expected to leave behind their parochial origins and become family service advocates" (Melaville and Blank, 1993). Workers relocated from the participant agencies (family service advocates) serve

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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all families with children between the ages of 5 and 12 who attend that school. Services include case management; preventive health care, screening, and immunizations; drug, alcohol, and mental health treatment; adult education and school tutoring; and other community services as needed, such as day care, translation, transportation, and extended library and park hours. In order to link school and center staff, a Task Force was formed of administrative, clerical, and front-line workers to iron out the difficult process of changing roles and relationships. The New Beginnings model is being replicated in other communities and schools, with the stated mission being "a tearing down of barriers, a giving up of turf, and a new way of doing business."

Teen Parent Programs

Not so many years ago, schools were permitted to expel students who were pregnant. Since 1975, however, with the implementation Title IX of the Education Amendments, publicly supported educational programs have been prohibited from discriminating on the basis of pregnancy status. Schools are required to provide equal educational opportunities to pregnant teens and young parents, though not necessarily in the same building as the other students. In a number of communities, alternative schools for teen parents have been organized with funding from foundations and government grants. The model that has been used builds on concepts of comprehensive services, putting together an array of health services, social services, educational remediation, childcare components, and a lot of individual attention.

The New Futures School, Inc., in Albuquerque, New Mexico, is an alternative school run by the local school system in conjunction with a community-based organization (Goetz, 1992). It offers educational, health, counseling, vocational, and childcare services to pregnant adolescents and adolescent parents, including young fathers. Over the past 21 years, 5,000 parents have received services from this school. New Futures is one of four program models used as a basis for federal legislation on adolescent pregnancy and has been widely replicated throughout the United States. Its operating budget is about $1.1 million, 79 percent of which comes from the school system and the rest from state and federal grants and private sources.

The New Vistas High School is an alternative program for pregnant teens and teen mothers in the Minneapolis (Minnesota) public school system. The facility is located in the headquarters of the Honeywell Corporation (Rigden, 1992). The corporation provides the facility as well as funds for equipment and special projects, food, a staff liaison, and volunteers and mentors. The Minneapolis school system provides academic

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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instruction and support services. Other corporations have donated computers and software. Health services are provided on-site by the Minneapolis Children's Medical Center and the Health Department. A fully equipped day care center is located next door and staffed by County Community Services, and a social worker is supported by the Big Brothers/Big Sisters organization.

School Reorganization

Many of the examples discussed so far are aimed at categorical problems: that is, they are single-component programs that attempt to prevent substance abuse, delinquency, teen pregnancy, or school dropout, or they are multicomponent programs that put together packages of health and social services. Yet many authorities believe that these separate programs serve only to "patch up" a few of a child's and a family's problems, and that what young people need in order to succeed requires making more sweeping changes in the way children are educated. In the educational domain, this means altering the ways in which children are taught and designing schools that are responsive to the needs of contemporary families and students. School quality is perceived as the ultimate intervention to ensure the long-term "health" of the child.

Several major authorities have emerged, each with a different view of what has to be done to change the environment in schools. None of these educational leaders is currently attached to a school system, but all of them are heavily involved in shaping school systems of the future through their academic centers. Henry Levin, of Stanford University, has proposed "accelerated schools" in reaction to the continuing failure of the schools to educate high-risk children. "The premises of the remediation approach are demonstrably false," according to Levin, "and the consequences are debilitating" (Colvin, 1988). Levin's group has initiated elementary school demonstration projects that are rich in curriculum content relevant to students' lives. The goal is to accelerate learning prior to sixth grade so that disadvantaged students catch up while they still can. Children are exposed to literature, problem-solving, and a range of cultural experiences, rather than simply being exposed to drill lessons. Techniques such as cooperative learning, peer tutoring, and community outreach are incorporated. Parents, staff, and students enter into contractual relationships that define the obligations of each party.

The School Development Program, a school-based management approach to making school a more productive environment for poor minority children, is an important example of how outside expertise can be utilized to influence the total school environment (Comer, 1984). This process, developed by James Comer from the Yale University Child Study

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Center, has been implemented successfully in several inner city elementary schools in New Haven and is being replicated in at least 165 schools throughout the country. The program attempts to strengthen and redefine the relationships among principals, teachers, parents, and students. Representative management and governance is implemented through an elected School Advisory Council that includes the principal, teachers, teacher aides, and parents. A Mental Health Team that include the school psychologist and other support personnel provides direct services to children and advises school staff and parents. An innovative Parent Participation Program calls for a parent to work in each classroom on a part-time basis. In addition to serving as representatives to the Advisory Council, parents are encouraged to volunteer as teacher aides and librarians, publish newsletters, and organize social activities. A social skills curriculum has been developed that integrates the teaching of basic skills with the teaching of "mainstream" (middle-class) arts and social skills. According to Comer, the strength of this project is its focus on the entire school rather than on any one particular aspect and its attention to institutional rather than individual change. This is one of the few models that has successfully engaged parents in school programs.

Success for All is a demonstration program for elementary schools that was initiated by Robert Slavin and colleagues at the Johns Hopkins University Center for Research on Elementary and Middle Schools (Center for Research on Elementary and Middle Schools, 1989). The program restructures the entire school to do "everything" necessary to ensure that all students will be performing at grade level by the end of the third grade. Interventions include a half-day preschool and full-day kindergarten, a Family Support Team, an effective reading program, reading tutors, individual academic plans based on frequent assessments, a full-time program facilitator and coordinator, training and support for teachers, and a school advisory committee that meets weekly. The Family Support Team works full-time in each school and consists of social workers, attendance workers, and a parent-liaison worker. The team provides parenting education and support assistance for day-to-day problems, such as nutrition, getting glasses, attendance, and problem behaviors. Family Support Teams are responsible for developing linkages with community resources. Success for All is currently being replicated in seven schools in Baltimore and one school in Philadelphia. One program has a public health nurse practitioner who provides on-site medical care, while another school is connected with a family counseling agency that provides some school-based services. One Success for All school has worked with a community agency to have a food distribution center at the school, and another houses a clothes bank.

The Coalition of Essential Schools is a consortium of schools that have

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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reorganized to incorporate the principles derived from the work of Theodore Sizer of Brown University (Sizer, 1984). Based on his experience studying American high schools, he has concluded that the most important task for schools is to teach students mastery of their school work. Sizer believes that it is more important for children to learn a few important ideas "deeply" than to be exposed to fragmented and ineffectual teaching. In a model Coalition school, Central Park East in New York City, Principal Deborah Meier intensely exposes students in grades 7 through 10 to a classical curriculum in the arts, sciences, and humanities. The last two years of high school serve as an "institute," with each student following individual program—such as courses in other places, field work, and projects. Teachers act as coaches and counselors for the students; each day begins with a meeting of an advisory group of 15 students, at which time any subject may be brought up and shared with other students.

Community or Full-Service Schools

In the past, the phrase "community school" has been applied mainly to adult education classes held in school buildings. The new generation of community schools begins to follow the broader construct of full-service schools and includes the integration of quality education with support services (see Table D-4). Several schools have been identified as potential models (IS 218, PS 5, and Children's Aid Society in New York City; Robertson and Hanshaw in Modesta, California; Farrell School System in Pennsylvania; Turner School in Philadelphia). What these community schools have in common are restructured academic programs integrated with parent involvement and services for parents; health centers and family resource rooms; after-school activities; cultural and community activities; and around-the-clock operation. Mental health services are provided by contract with community mental health agencies and by using interns from schools of social work. Each of these community schools is striving (in different ways) to become a village hub; by combining in joint efforts with community agencies to create as rich an environment as possible for children and their families.

IS 218, a middle school in Washington Heights, New York, was created through a partnership between the school system and the nonprofit Children's Aid Society (CAS) (Peder Zane, 1992). With this unique arrangement, CAS has created a "settlement house" in a school, located in a new building with air-conditioning for summer programs, outside lights on the playground, and an unusually attractive setting indicative of a different kind of school. It offers students a choice of five self-contained "academies": Business; Community Service; Expressive Arts; Ethics and

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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TABLE D-4 Full-Service Schools: One-Stop, Unfragmented Collaborative Institutions

Quality Education Provided by Schools

Effective basic skills

Individualized instruction

Team teaching

Cooperative learning

School-based management

Healthy school climate

Alternatives to tracking

Parent involvement

Effective discipline

Services Provided by Schools or Community Agencies

Comprehensive health education

Health promotion

Social skills training

Preparation for the world of work (life planning)

Support Services Provided by Community Agencies

Primary health services

Health screening

Immunizations

Dental services

Family planning

Individual counseling

Group counseling

Substance abuse treatment

Mental health services

Nutrition or weight management

Referral with follow-up

Basic services: housing, food, clothes

Recreation, sports, culture

Mentoring

Family welfare services

Parent education, literacy

Child care

Employment training or jobs

Case management

Crisis intervention

Community policing

Legal aid

Laundry

Law; or Mathematics, Science and Technology. The school opens at 7:00 a.m. for breakfast and classes in dance, Latin band, and sports, and stays open after school for educational enrichment, mentoring, sports, computer lab, music, arts, trips, and entrepreneurial workshops. In the evening, teenagers are welcome to use the sports and arts facilities and to take classes along with adults who come for English, computer work, parenting skills, and other workshops. A Family Resource Center provides parents with social services such as immigration, employment, and housing consultations. Twenty-five mothers have been recruited to work in the center as family advocates; they receive a small stipend for their services. A primary health and dental clinic run by the Visiting Nurses Association is also located in the lobby of the school. Services include food and nutrition programs, health screening, dental care, treatment and specialist referrals, drug and teen pregnancy prevention, immunization, and developmental testing. School-supported and CAS-supported social

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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workers and mental health counselors work together to serve students and families. The school stays open weekends and summers, offering the Dominican community many opportunities for cultural enrichment and family participation. This full-service program adds about $1,000 per student to the budget (over and above the average amount of $6,500 spent in New York City). These additional costs are paid by Medicaid reimbursements and grants to the Children's Aid Society from foundations.

RESEARCH FINDINGS ON SCHOOL SERVICES MODELS

Research on the utilization of school-based health and social services has advanced well, and has documented the use of services by needy and high-risk youth. Conducting impact studies has been more problematic because of the difficulties of surveying, tracking, and establishing control groups for school populations (Gomby, 1993; Support Center for School-Based and School-Linked Health Care, 1995). Over the past decade, a few significant studies of school-based clinics have been conducted. Several recent summaries of these studies have confirmed the consistent finding that clinics could be implemented successfully in schools, enrolling substantial percentages of students (Dryfoos et al., in press; Kirby, 1994). Clinic users were reported to have received adequate care that was provided in a cost-effective manner and to be very satisfied with both the quality of the services and the caregivers.

Utilization Studies

This section focuses on studies that have been conducted since 1990. In general, the studies offer further evidence of high utilization rates.

Enrollment

A basic measure of program utilization is how many of the students in a school enroll in the clinic. Typically, enrollment involves the submission of a form indicating parental consent. Non-enrolled students can be treated for emergencies, but they must then go through the enrollment process. Clinics start out with low enrollments and gradually build over the years, with a high proportion of the students eventually signing up. A related measure is the percentage of enrollees who actually use the facility.

Advocates for Youth (AFY) reports that in 1993, about two-thirds of the students in respondent schools were enrolled in their school-based health centers and 75 percent of them utilized the program over the reporting year (Hauser-McKinney and Peak, 1995). A survey of 19 schools

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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supported by the Robert Wood Johnson (RWJ) Foundation showed identical proportions (Kisker et al., 1994).

A study of a sample of students from nine Baltimore school-based clinics compared enrollees with non-enrollees and found that those who enrolled are significantly more likely to have had health problems, are in families receiving medical assistance (Medicaid), are in special education, and are African American. Those who did not enroll in the clinic reported a variety of reasons, primarily being satisfied with their current provider (Santelli et al., in press).

Client Characteristics

Among the respondents to the AFY survey, clinics reported that about 60 percent of enrolled students were female. One-third of the enrollees were African American, one-third white, 20 percent Latino, and the rest were Asian, Native-American, and other (Hauser-McKinney and Peak, 1995). Most reports show that although clinic users tend to mirror the student population in regard to race and ethnicity, females are more likely to use clinics (especially if reproductive health care is offered). However, the fact that 40 percent of the users are male is significant and demonstrates that when services are conveniently located, young men will use them.

Enrollees show very different patterns of use. In one school-based clinic in Los Angeles, within a one-year period, 5 percent of enrollees had made no visits, 41 percent had visited once, 39 percent had made two to five visits, 8 percent made six to ten visits, and 6 percent had used the clinic more than ten times (Adelman et al., 1993). Users reported ease of access as the most important reason for using the facility in the school, and they perceived the care provided as helpful and confidential. Nonusers stated that they did not use the clinic because they did not need it or they were concerned about lack of confidentiality. In this sample, frequent clinic users were more likely to score high on indices of psychological stress. The authors concluded that ''an on-campus clinic can attract a significant number of students who otherwise would not have sought out or received such help."

Students who report higher rates of high-risk behaviors, such as substance abuse and early initiation of sexual intercourse, appear to be more likely than other students to use school-based clinics. A study of students in four schools in Oregon showed a consistent and significant association between number of clinic visits and number of preexisting high-risk health behaviors (Stout, 1991). Only one-third of those students who reported no risk behaviors used the clinics, as compared to more than two-thirds of the highest-risk students. Frequent users (three or more times) of School

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Wellness Centers in Delaware were more likely than nonusers to report having engaged in such high-risk behaviors as suicide attempts, substance abuse, unprotected sexual activity, and eating-related purging (National Adolescent Health Resource Center, 1993).

Users of Denver's three high school clinics made an average of three visits per year (Wolk and Kaplan, 1993). However, a small number of students (11 percent) made 15 or more visits per year, accounting for 40 percent of all patient visits. These frequent visitors were significantly more likely to be females and to have lower grade point averages. Some 23 percent of the frequent visitors were diagnosed with mental health problems at the time of their initial visit, compared to 4 percent of the average users. By the end of the school year, 61 percent of all visits by frequent users were for mental health-related issues, compared to 10 percent of all visits by the average users. High-risk behaviors were significantly more prevalent among frequent users, particularly unprotected sexual activity and use of alcohol and drugs (but not tobacco). It is of some consequence that most of the frequent users initially presented acute medical problems, at which time they were identified as students in need of mental health counseling. Many practitioners believe that the provision of comprehensive services offers a means for troubled students to enter into counseling and treatment for psychosocial problems. Youth are concerned about the stigma of attending a program specifically labeled mental health.

Surveys in Florida schools with school-based services showed that students who engaged in high-risk behaviors were more likely to visit the health room than were other students. Students reported high levels of satisfaction with the program, as did school administrators and parents. "Principals seemed very accommodating [of school based health services staff] because their presence relieved other staff from dealing with students with various health needs: calling parents for pick up, delivering first aid, and at least in one site, delivering a baby in the school parking lot" (Eimhovich and Herrington, 1993).

The Robert Wood Johnson Foundation evaluation describes the characteristics of the population of students in schools with SBCHCs (rather than of students who used the clinics) (Kisker et al., 1994). In these 19 schools, 15 percent of students were non-Hispanic white, 44 percent were Hispanic, and one-third were African American. One-fourth of the youths stated that their parents had not completed high school and another third said their parents had no post-secondary education. One in five families was on welfare, and one-third received free or reduced-price school lunches. In the 1992 follow-up survey, 30 percent of the health center school students reported that their families had no health insurance, 20 percent were covered by Medicaid, 31 percent had private insurance or

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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belonged to a health maintenance organization (HMO), and the remaining 19 percent did not know what type of coverage they had. As would be expected, health insurance coverage varied widely by school, ranging from 1 percent to 48 percent for families that had no coverage at all.

Brindis and coworkers (1995) found in a study of three urban schools that students with private insurance or HMO coverage had the highest rates of SBHC utilization (67 and 66 percent, respectively) and students without insurance or with Medicaid had the lowest (57 and 59 percent, respectively). Use of medical services did not differ by insurance status; however, clinic-enrolled students with Medicaid coverage were more likely to use SBHC mental health services than were others (30 percent compared to 22 percent).

Outcome Data

In the early 1980s, interest in incorporating school-based clinics as an important part of a strategy for pregnancy prevention was stimulated by the publication of data from St. Paul, Minnesota, that showed a decline in pregnancy rates in schools with clinics (Edwards et al., 1980). However, a later examination of birth rates showed that there were large year-to-year fluctuations and that the clinics had little or no impact (Kirby et al., 1993). In fact, a review of the earlier studies showed mixed results for an array of behavioral impact measures (Kirby, 1994). Studies that found positive effects on high-risk behaviors were offset by those that found negative effects or more likely, no effects. Recent studies also contain a mix of results.

Pregnancy-Related Outcomes

Pregnancy-related outcomes include delaying the onset of intercourse, consistent use of contraception among those who are sexually active, lower birth rates, and lower pregnancy rates. In general, studies have confirmed that the presence of a school-based clinic has no effect on the rate of sexual intercourse and has little effect on contraceptive use unless the clinic offers a pregnancy prevention program. A study of two schools with clinics that dispensed contraceptives on-site found few differences in contraceptive use compared to two schools where contraceptives were prescribed and not dispensed. The only significant variable related to use was the higher number of contacts that the students had with the clinic staff (Brindis et al., 1994).

When Florida created a Supplemental School Health Services Program, the legislation mandated evaluation to study how effectively the program met its objectives of pregnancy prevention and the promotion of

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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student health (Emihovich and Herrington, 1993). The report on the first year, produced by Florida State University, was based on student surveys and site visits to 12 counties. All of the grantees had a designated health room in the school and the evaluation found heavy utilization rates, primarily for physical complaints, physical examinations, and minor injuries. The evaluation also stated that school-reported pregnancy rates had declined in some of the schools, but the data presented appeared to be estimates and were not validated. However, one comment from the report is interesting: "The most dramatic shift occurred at Glades Central High School in Palm Beach where the pregnancy rate dropped almost 73 percent. This project is also the only one where students can obtain prescriptions for contraceptives at the school and where there is a family practice physician available three days a week" (Emihovich and Herrington, 1993).

The first evaluation of the California Healthy Start initiative presents data on 40 different grantees, including eight youth service programs, five of which are school-based clinics. The report showed that adolescent clients of programs with the explicit goal of reducing teen pregnancy had significant reductions in the rate of initiation of sexually activity and an increase in the rate of reliable contraceptive use (Wagner et al., 1994). Among teenagers in pregnancy prevention programs, about 45 percent were sexually active at the end of the first six-month follow-up period, a significant 23 percent decrease from the proportion at intake (77 percent). Youth service programs showed large gains in linking clients to sources of health care.

An evaluation of the Teen Choice program showed that students were generally at high risk of pregnancy (Inwood House, 1987). In addition to demonstrating positive changes in knowledge and attitudes, participants were shown to have significantly improved their use of contraception following their group experiences and to have maintained these practices over time. Strengths of the program cited by the evaluators included that the program was convenient, students are respected, and although abstinence is encouraged, contraceptive use is recommended for those who choose not to abstain.

Other High-Risk Behaviors

At Lincoln High School in Denver, Colorado, a student who commits a drug offense can enter into a treatment contract for seven sessions at the school-based clinic rather than be suspended from the school. This component has resulted in an 80 percent reduction in suspensions (Bureau of Primary Health Care, 1993).

The Healthy Start data from California showed that in school-based

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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youth programs aimed at reducing violence, a significant reduction in gang activity was reported at the six-month follow-up (from 7 to 2 percent) (Wagner et al., 1994).

The Student Assistance Program, a school-based substance abuse program, was evaluated by an outside contractor in the early years of the program (Moberg, 1988). The summary report stated that the program was very effective in preventing nonuser students from taking up alcohol and marijuana use and in reducing or stopping the prevalence among users. Alcohol users improved their attendance at school. There was some evidence that the larger the number of individual counseling sessions, the greater the success. No effect was shown for users of hard drugs. This evaluation did not include data from control schools.

Mental Health

The evaluation of California's Healthy Start clients included examining families as well as students. Six months after the initiation of the program, the proportion of core clients who reported some level of depression dropped from 28 to 22 percent, and when depression did occur, it was significantly less likely to be reported as a major problem at follow-up (32 versus 23 percent of those who were depressed) (Wagner et al., 1994).

Health System Related

Students attending the nine school-based clinics in Baltimore were compared with students in four matched schools in regard to their access to medical and social services and their hospitalizations and use of emergency rooms (Santelli et al., in press). Students in schools with health clinics were more likely to report seeing a social worker (11 percent) than were students in schools without clinics (8 percent). Those in schools with clinics were more likely to have received specific health services (physicals, acute health care, family planning, counseling) and reported significantly lower rates of hospitalization. In regard to use of emergency rooms, rates were reduced only for those students who had been enrolled in the schools with clinics for more than a year.

Decreases in the use of emergency rooms by students in schools with clinics were reported in San Francisco (from 12 to 4 percent over two years) and San Jose (from 9 to 4 percent). At the same time, significant increases were shown in the percentage of students who said that they were able to access health services when needed, presumably through the school-based clinics (Center for Reproductive Health and Policy Research, 1993). The school-based clinic in San Fernando, California, specifically

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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targets students with little or no access to health care—93 percent of its enrollees report no other source of medical care and no health insurance (Bureau of Primary Health Care, 1993). A unique finding was the high level of use of mental health services in school-based clinics among students with HMO and private insurance. According to the Center for Reproductive Health and Policy Research (1993), the extensive use of the school clinic by students with other health care options "implies that the clinic is able to provide mental health services in a manner that is more acceptable to the adolescents, and that the integration of this service with a comprehensive array of health services may help diminish the stigma often associated with this kind of service … (it) may also reflect the relative unavailability … of these services as provided through HMO or private insurance coverage" (Center for Reproductive Health and Policy Research, 1993).

In a survey of 500 users of school-linked Teen Health Centers in Michigan, 21 percent of the respondents indicated that they would not have received health care if the centers did not exist (Anthony, 1991). The main reasons given were lack of transportation and lack of a family physician. Some 38 percent reported learning of new health problems during the visit (the problems included cancer symptoms, penicillin allergy, ear trouble, and high cholesterol), and 65 percent indicated that their behavior had changed as a result of their contact with the Teen Health Centers.

The RWJ evaluation found that students in schools with health centers received significantly more health care during the year before the follow-up survey and were more likely to have a usual place of health care than they would have if their health care use had followed the same pattern as that of urban youths nationally (Kisker et al., 1994). Students in schools with SBHCs reported greater increases in treatment for illnesses and injuries. Students who used the Healthy Start youth service programs reported significant gains in access to medical care and a marked improvement in having a regular source of care.

School-based health centers have been shown to identify students with serious physical or mental health problems. The survey of students in two Delaware schools with Wellness Centers in showed that during a year, center users were more likely than nonusers to have had physical exams (72 versus 55 percent) gynecological exams (24 versus 19 percent), psychological counseling (21 versus 14 percent), and eye exams (73 percent versus 60 percent). Little difference between users and nonusers was shown in whether they had their hearing checked or whether they had seen a health provider at least once (National Adolescent Health Resource Center, 1993). Users of the centers were more likely to have sought a health professional for advice about friends or family members. Students who did not use the centers reported that they had been healthy and did

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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not need any services or had another source of care. Students who used the services cited convenience in scheduling, transportation, and confidentiality as their main reasons.

The recent focus on immunization suggests another important role for school-based clinics—the ability to respond rapidly to epidemics and crises in the health system. The New York State Department of Health recently created a pilot immunization project involving outreach efforts by three state-funded school health centers in New York City elementary schools (Bosker, 1992). Many immunizations were provided at low cost, not only to school children but also to their younger siblings. However, the highest-risk families failed to respond, which prompted the providers to recommend a better-orchestrated annual immunization campaign, more appropriate educational materials, and central coordination and support.

When the California Healthy Start evaluation looked at all clients, including adults, it found an increase from 19 to 26 percent in the number of core families who had children participating in the California Health and Disability Program within six months of enrolling in a Healthy Start intervention (Wagner et al., 1994). A reduction in health care due to illness or injury (from 36 to 29 percent) was also reported.

Parents at the Walbridge Caring Community school reported fewer problems with health care access. They also were more likely than parents in a comparison school to report that it was easy for students to get help with health problems (96 versus 59 percent) and that the school helped a lot with their own health care needs (47 versus 25 percent) (Philliber Research Associates, 1994).

School Related

Advocates of SBHCs assert that achievement and graduation rates should increase when health services are made accessible. Washington Senator Brock Adams claimed at a Senate hearing that a school clinic in Seattle's Ranier Beach High School "prevented 40 students from dropping out of school and significantly reduced the number of youth sent home from school" (Adams, 1992). In the San Fernando (California) High School, school-based clinic users were half as likely to drop out of school as were nonusers (9 versus 18 percent) (Bureau of Primary Health Care, 1993). A study of a clinic located in an alternative school and run by a health department is a unique example of an evaluation that focuses entirely on school performance (McCord et al., 1993). Students who used the clinic were twice as likely to stay in school and nearly twice as likely to graduate or be promoted than non-registered students. The more visits that students made to the clinic, the higher their graduation or promotion

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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rates. The researchers found this relationship "particularly striking" among black males and attributed these successful outcomes to the trust and support provided by the clinic staff to help students function better in school.

Results from California's Healthy Start program showed that children who received intensive services in school-based programs made a significant improvement in grade point average, particularly among younger students and those who were performing least well before participating in the programs (Wagner et al., 1994). Teacher ratings of student behavior also improved significantly for those who received intensive services.

Evaluation of the Walbridge Caring Community program showed that students who received intensive services had a 27 percent increase in how their teacher rated their work habits, a 16 percent improvement in their social-emotional growth, and a 23 percent improvement in grade point average (Philliber Research Associates, 1994).

The Children's Aid Society reported "overwhelmingly positive results" after the first two years that IS 218 Community School had been opened: "student scores are up 15 points in both math and reading, attendance is the highest in the district; there has been no incidence of violence … [and] no destruction of property or even graffiti" (Children's Aid Society, 1994). At least 1,000 parents have been involved and the schools have become a central meeting place in the community.

The Partnership Center in Tama, Iowa, claims an increase in attendance and grade point averages as a result of its program, but the center cites no significant decreases in dropout rates (STC Partnership Center, 1994).

The study of school-based health programs in Florida showed a high percentage of students who were returned to class after being seen in the health room (Eimhovich and Herrington, 1993). Only 10 percent of elementary students and 18 percent of high school students were unable to return, much lower rates than those typically found in routine school nursing practices. In the Baltimore study, absenteeism because of illness was not significantly different between schools with SBHCs and other schools, where 51 percent of the sample of students reported having been absent in the past 30 days (Santelli et al., in press).

Although it is difficult to locate evaluations that specifically look at the effect of the provision of medical services on long-term outcomes, some success stories are emerging from an array of other kinds of school-based interventions. Several of the Success for All elementary schools in Baltimore that included Family Support Teams (social worker, school nurse, facilitator) and Integrated Human Services (on-site health clinic run by the health department or services from family counseling or men-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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tal health agency) showed significant improvements in attendance and reductions in the numbers of students retained (left back) to close to zero (Dolan and Haxby, 1992). A strong school-based case management program in Fresno, California, conducted in conjunction with the county department of social services, showed a 40 percent reduction in unexcused absences, a decrease of 70 percent in referrals for misbehavior, and a substantial increase in parental involvement (Center for Future of Children, 1992).

The Metropolitan Health Department of Nashville, Davidson County, Tennessee, reported that its One Stop Shopping Family Resource Center provided easier access to prenatal care, pediatric services, and school health (Maternal and Child Health Bureau, 1993). The immunization rate for enrolled 4- to 5-year-olds was 98 percent in 1993, and 150 families were in intensive case management.

Organizational Research

A few studies have been conducted to document the design and implementation of SBHCs. A unique survey of 90 clinics in 1991 focused on planning strategies and barriers to implementation (Rienzo, 1994). Key variables that influenced the capacity of SBHCs to offer comprehensive services (number of clinical and outreach services provided) included the presence of a strong coordinator, the use of information such as needs assessments for gaining support in the community, and obtaining funding from national sources, particularly foundations. The ideal coordinator was described as a "workaholic," with the ability to acquire funding and expertise in adolescent care. The more successful programs carefully organized planning committees and community advisory boards, and relied on committed school administrators to facilitate "navigation" through the approval process. Barriers to implementation included insufficient funding (66 percent) and problems with staff training and turnover (33 percent), issues that are related at least in part to the matter of funding. Many programs initially confronted organized opposition and dealt with controversy through public hearings. As a result, several changed their policies in regard to birth control and abortion counseling; birth control was limited in 28 percent of the cases and abortion counseling proscribed in 9 percent.

One study documented the importance of providing services on school property (school based) rather than nearby (school linked). A health center was removed from school grounds in Quincy, Florida, during the tenure of a conservative governor, who refused to allow public funds to be used for school-based clinics (Center for Human Services Policy and Administration, 1990). The level of service activity declined

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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immediately, with a drop of 30 percent during the year, particularly among males and younger students. The largest decline (66 percent) was in students using the clinic for first aid. According to the staff, the implementation of more complicated, less private procedures for obtaining permission to visit the center during the school day tended to reinforce the negative effect of the relocation. Students had to go through the central office in order to leave the campus and walk across the street to the clinic. Almost the first act of the new governor, Lawton Chiles, in 1990 was to inform county officials of his intent to return the center to the school grounds. A new building was dedicated in early 1991 on the campus, and utilization immediately climbed back to its previous level.

The RWJ evaluation attempted to conduct a "dose-response" analysis to determine the effect of "stronger" health centers versus "weaker" ones. The 19 sites were scored on a composite index that included staffing, turnover, location, integration into school, and relationship to school establishment (Kisker et al., 1994). "Erratic results" were reported. Only a few significant findings were plausible: stronger SBHCs, particularly those that were well staffed, did produce higher enrollment and visit rates.

Research has shown that although the emerging school-based models—centers, community schools, clinics—have many differences, there are a number of common components of successful programs, as measured by utilization. Key factors include the following:

  • School and community people join together to develop a shared vision of new institutional arrangements. Open communication is essential at every stage. The planning process starts with a needs assessment to ensure that the design is responsive to the requirements of the students and their families. An advisory board includes school and agency personnel, parents, and community leaders (and, in some places, students). Parental consent is required for receipt of services.

  • The principal is instrumental in the implementation and smooth operation of school-based programs. Schools provide space, maintenance, and security. School doors are open before and after school, on weekends, and during the summer. Classrooms, gyms, playgrounds, music rooms, and computer facilities are open for community use.

  • A special space is designated within the school as a center for individual and group counseling, parent education, career information, offices for case managers, kitchen, play space, clothes or food distribution, and arrangements for referrals. If primary health care is provided, adequate space is designated in or near a school for a medical clinic with examining rooms, a lab, an area for confidential counseling, and arrangements for recordkeeping and referrals.

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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  • The configuration of services brought in by community agencies depends on what already exists in the school. School personnel have to participate in the process from the beginning.

  • A full-time coordinator or program director runs the support services in conjunction with school and community agencies. Personnel are trained to be sensitive to issues related to youth development, cultural diversity, and community empowerment.

  • Staff recruitment requires time and attention. It is difficult to locate certified youth workers with appropriate language skills (Spanish, Asian, etc.) in many areas.

  • Parents are involved at many program levels, as users of services, volunteer aides, paid program workers, and advisory board members.

  • A data system is in place, preferably a computerized management information system that can process records, update needs assessments, and be used for evaluation.

  • The process of program development is greatly enhanced by the availability of technical assistance. State and foundation staffs have played a major role in extending these models, especially in rural areas.

  • A designated space, such as a center in a school, acts as an anchor for bringing in other services from the community.

Cost–Benefit Studies

Several studies have estimated costs and benefits. One study estimated that if young people in New York State received early preventive care through school clinics, $327 million could be saved annually in hospitalizations for delivery of teen pregnancies, low-birthweight babies, and chronic diseases such as asthma (New York State Department of Health, 1994). A cost–benefit analysis of three California school-based clinics compared the costs for the school services with the estimated cost in the absence of the school clinic (Center for Reproductive Health and Policy Research, 1993). Variables used included reduced emergency room use, pregnancies avoided, early pregnancy detection, and detection and treatment of chlamydia, a prevalent sexually transmitted disease. The ratios of savings to costs ranged from $1.38 to $2.00 in savings per $1.00 in costs, suggesting that the school clinic services were a good investment for the health system.

Igoe and Giordano (1992) reported that ''cumulative evidence over the past decade shows that nurses have delivered cost-effective care (in school clinics) that can be substituted for physician's services in many situations (with) outcomes as good as or better than those physicians achieve in primary care—and at lower cost."

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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DISCUSSION

What's Going on Here?

This paper has reviewed a number of examples of service delivery arrangements that bring health, mental health, and social services to young people in schools. Preliminary research on utilization and outcomes has been summarized, showing great gains in access for high-risk students but only scattered returns in regard to outcomes. During the past decade, we have clearly experienced a significant movement of personnel into schools from outside agencies to assist the schools' personnel in dealing with growing demands for services. The new programs appear to be more complex, creative, and innovative than in the recent past. Many of the new interventions are based on contemporary research on child and adolescent behaviors, and they represent an attempt to design more effective programs. As a result, school-based efforts are more comprehensive and holistic, and are framed to approach the total needs of the child and the family in the context of the community. Many components have been put together that have proven impact in the prevention field; these components include individual attention, sustained attention, respect for confidentiality, and outreach and home visiting to involve parents (Dryfoos, 1990).

What's Driving All This Activity?

Why the accelerated movement toward comprehensive school-based services? The plight of young people growing up in inner cities or poor rural areas has been well documented. The "new social morbidities"—such adverse effects of the modern age as unsafe sex, drugs, violence, depression, and stress—account for a vast number of youth who will never make it without immediate intervention. These disadvantaged young people live in run-down, resource-poor communities; attend decaying schools; lack nurturing and caring; and cannot overcome the odds unless they receive substantial assistance. Many observers maintain that the existing systems for providing services to disadvantaged families and their children are fragmented and ineffective. Both the human services agencies and the educational system are called upon to respond to these social deficiencies. Thus, the rationale for creating new kinds of institutional arrangements crosses several domains: health, education, and social services integration. Consensus is building among educators about the importance of bringing support services into schools that will strengthen their efforts at restructuring. Service integration—the establishment of linkages between agencies—is a "hardy perennial" that reap-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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pears whenever there are a plethora of categorical programs and overwhelming needs, but little new money to address the problem. The subject is of interest to advocates of school-based programs because of the necessity for welding together fragmented health and social service agencies with educational systems. This is often a challenging experience because of the fragmentation that has resulted from the development of specialized programs to address each category of need as it gains visibility in a very competitive funding and media environment.

The fact that these categorical programs have only limited and short-term effects has fed the demand for "integration" of services, reducing the fragmentation of existing service systems for families. Many of the new "family-centered" programs are being placed in schools to facilitate one-stop-shopping for whatever families and their children need to overcome the enormous odds with which they are confronted in disadvantaged communities. Much of the service integration rhetoric calls for "systems changes," new ways of organizing administrative structures so they will be more responsive to consumers. In this literature, considerable attention is being directed toward the involvement of the community and the importance of a sense of "ownership" by parents and other residents, which recalls the language of the community action programs of the 1960s.

Issues in the Development of Comprehensive School-Based Programs
Funding

Much of the impetus for school-based centers and community-schools has come from state initiatives and foundation demonstration projects. Although the current federal administration has evidenced an interest in adolescent health issues, educational restructuring, and service integration, all that has come through in the way of tangible support for direct services has been a new small grants program in the Bureau of Primary Health Care, along with some new funds for training in the Bureau of Maternal and Child Health. For the first time, about $3 million in grants has been awarded to 27 new school-based clinics around the country. In what some observers see as an era of budget cutting, we cannot anticipate much new action at the federal level, even though the concept of full-service schools has emerged in many different domains, including health reform, revision of Chapter 1 (now Title 1, support for schools with high numbers of disadvantaged youth), welfare reform, crime prevention, and positive youth development.

Until the law changes, all state Medicaid programs were required to cover hospitalization, physician services, laboratory and x-ray services,

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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family planning, and Early and Periodic Screening, Diagnostic, and Treatment services for children under age 21. The EPSDT component of Medicaid was originally designed to provide comprehensive health screening for poor children, as well as subsequent diagnosis and treatment services for conditions found during the screening exams. Comprehensive screening included not only basic health, vision, hearing, and dental components but "anticipatory guidance" that could include counseling services, case management, and health prevention. Although federal law mandated EPSDT services for Medicaid-eligible children and adolescents, states have not provided sufficient outreach and follow-up to ensure that those eligible are actually screened.

The potential of EPSDT as a funding source for school-based services is ambiguous. Currently, Medicaid enrollees are being required to obtain coverage through managed care. Many HMOs and other managed care providers may not include preventive services, mental health services, and health screening as part of the package. In some places, school health service providers may have to negotiate with multiple plans for students in their schools. As Brindis (1995) points out, there are "conflicting priorities of SBHCs which seek to increase access to care and … managed care programs which must find ways to contain costs." Many other barriers stand between SBHCs and this form of health financing, not the least of which is the assurance of confidentiality. One proposal has been to create "school health resource partnerships" between districts, health providers, and other community agencies to address the financial viability of school health service programs in a managed care environment (Brellochs, 1995). States would require that managed care plans participate as a condition of licensure.

The recent revision of Chapter 1 will make it possible for schools to use some of the funds for social services in partnerships with community agencies. The various crime bills called for many millions for Beacon-type programs, but those funds have disappeared. Finally, the Division of Adolescent and School Health (DASH) at the Centers for Disease Control Prevention (CDC) is supporting many state and local HIV prevention initiatives, and recently began funding 12 states to strengthen their offices of health and education to provide more comprehensive schools health services and health education.

In some states, including Florida, California, and Kentucky, competitive grants have been awarded to school districts that must then seek partners in collaboration. In other states, such as New Jersey, a community-based agency may be the lead grantee and seek partnerships with a school. More than $30 million is being spent each year in Florida on the state's innovative full-service schools program, supporting collaborative school-based projects of varying service mixes, including family resource

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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centers, case management, recreational programs, and school-based clinics. The expectation is that all schools will participate in this program in a few years and that child care, vocational education, and mental health services will gradually be phased in.

California's Healthy Start Support Services for Children Act was launched in 1991 with high ideals: "to be a catalyst in a revolution that will fundamentally change for the better the way organizations work together, the way resources are allocated for children and families, the nature and location of services provided, and ultimately, the outcomes experienced by children and families" (Wagner et al., 1994). The $20 million initiative directly funds 40 service projects and 200 planning projects. School districts have created four types of collaborative programs: school site family resource centers, satellite school-linked family service centers, family service coordination teams involving school personnel with project staff, and youth service programs that include school-based clinics. Since 1987, New Jersey's Department of Human Resources has committed more than $6 million annually for its School-Based Youth Services Program.

Foundations have played an important role in creating demonstration projects of many descriptions. In 1987, the Robert Wood Johnson Foundation awarded grants to launch health centers in 24 schools; building on that experience, RWJ has created the Making the Grade initiative, supporting 10 states to create state-level offices for school-based services and model clinics in local school districts. The Carnegie Corporation is supporting states in its Turning Point initiative to help middle schools link students to comprehensive health and social services as one component of middle school reorganization. The Hogg Foundation for Mental Health has been instrumental in creating the Schools of the Future, changing schools into primary neighborhood institutions for promoting child and family development, building on the Comer School Development Program, Zigler's Schools of the 21st Century, school-based clinics, programs for community renewal, and family preservation.

Funding is definitely a major issue in the future development of school-based services. My own estimates call for 16,000 schools to be "full serviced" within the near future (Dryfoos, 1994a). This encompasses one in five schools in the nation, including all of those in which more than half of the students are eligible for free lunches. If start-up costs of $100,000 to $200,000 per school are assumed, the amount of money needed to replicate these models is around $1.6 to $3.2 billion per year, about the same amount being spent for Head Start and half of the appropriation for Chapter 1.

The advent of managed care greatly complicates the fiscal arrangements for providing on-site health care in schools, but practitioners are working hard to overcome the bureaucratic and policy barriers to using

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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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-

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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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

Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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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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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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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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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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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.

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Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Suggested Citation:"Appendix D." Institute of Medicine. 1997. Schools and Health: Our Nation's Investment. Washington, DC: The National Academies Press. doi: 10.17226/5153.
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Schools and Health: Our Nation's Investment Get This Book
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Schools and Health is a readable and well-organized book on comprehensive school health programs (CSHPs) for children in grades K-12. The book explores the needs of today's students and how those needs can be met through CSHP design and development.

The committee provides broad recommendations for CSHPs, with suggestions and guidelines for national, state, and local actions. The volume examines how communities can become involved, explores models for CSHPs, and identifies elements of successful programs. Topics include:

  • The history of and precedents for health programs in schools.
  • The state of the art in physical education, health education, health services, mental health and pupil services, and nutrition and food services.
  • Policies, finances, and other elements of CSHP infrastructure.
  • Research and evaluation challenges.

Schools and Health will be important to policymakers in health and education, school administrators, school physicians and nurses, health educators, social scientists, child advocates, teachers, and parents.

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