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Research on a model mental health program serving the majority of public schools in Dallas County shows that students referred mainly for behavioral and emotional problems were less disruptive and improved academically after receiving services.
There were 42 percent fewer referrals to the principals' offices for disciplinary problems and 32 percent fewer course failures at the end of the 1995-96 school year. In contrast, students receiving physical health services experienced only a 11 percent decline in both areas at year end.
Students receiving mental health services also experienced fewer absences (22 percent) and visits to the school nurse (18 percent) by year end than students receiving physical health services (21 and 15 percent, respectively).
"I expected mental health services to [yield] greater improvements in these areas because of our focus on specific symptomatic behaviors," said Glenn Pearson, M.D., director of child and adolescent services for the Dallas County Mental Health/Mental Retardation (MHMR) Department. Pearson is president-elect of the American Society for Adolescent Psychiatry.
The results reflect the mental health program's first year as a collaborative partnership between Pearson's agency, the Dallas Public Schools, and the Dallas County hospital district. Comprehensive mental and physical health services are provided to 204 schools with approximately 150,000 students through nine school-based Youth and Family Centers.
A total of 2,677 mental health visits were logged for 670 students at the centers during the 1995-96 academic year. About 50 percent of the presenting problems were behavioral; the remainder were emotional (29 percent), family related (14 percent), health related (6 percent), and academic (3 percent).
The primary diagnoses were behavioral and mood disorders.
Treatment provided in order of frequency was individual therapy (34 percent), family therapy (24 percent), school interventions (20 percent), and medication (11 percent). Family therapy was used first and then combined with individual therapy and other interventions when necessary.
Support groups made up 12 percent of treatment and parental training made up 10 percent.
Mark Weist, Ph.D., director of the national Center for School Mental Health Assistance in Baltimore, told Psychiatric News that the Dallas school-based program is "one of the more comprehensive and effective programs in the country."
Weist has directed the program since late 1995, when he received a federal grant to establish a national resource and technical assistance center (see article below). Prior to that, he directed a model school-based mental health program.
Each Youth and Family Center in Dallas is staffed with mental health professionals including a full-time licensed professional counselor and part-time child and adolescent psychiatrists, licensed professional counselors, and school psychologists. Marriage and family therapists, social workers, nurses, and parent educators are also part-time staff.
Pearson noted, "A typical student mental health consultation involves the teacher, principal, family, and professional counselor to evaluate every element that impinges upon a child's daily life. A collaborative action plan is developed and implemented in the school, home, and community," he said.
Patient compliance with appointments at the centers is 100 percent, which is double the compliance rate at community mental health centers in Dallas County, noted Pearson.
"We have more people coming here than we can see. There is no comparison in terms of our productivity."
Pearson observed that students and families tend to associate less stigma with a school setting than a community mental health center. Services are accessible with flexible hours and 24-hour back-up, including an emergency hotline and mobile crisis team.
Family satisfaction with the services has been high, according to a survey of 273 family members who used the services in the 1995-96 school year. The majority of respondents were pleased with the amount of time the professional staff spent with them and thought they were helpful.
Ninety-four percent of family members said they were always or frequently involved in the child's evaluation and follow-up. Most respondents (85 percent) said the student improved after treatment.
High school principals gave the centers high marks for quality and value of services, accessibility to families, professional staff, and prompt delivery of services. Complaints by the principals included a lack of transportation, students placed on a waiting list for services, and a shortage of personnel.
Pearson and colleague Jenni Jennings, clinical supervisor of psychological services in Dallas Public Schools, established the first school-based mental health clinic in Dallas County in 1993 at a principal's request. Within six months, several principals had made similar requests, leading to the program's expansion to 14 public schools.
The program's popularity drew the attention of district school officials, who wanted to maintain oversight, said Pearson.
He commented that an advantage of partnering with the school district has been that "the district funds the program's infrastructure, allowing the various agencies to perform their services. A disadvantage has been that the district has a standardized approach to schools leaving little room to tailor services to the needs of diverse communities."
Pearson also discovered turf issues among public school health professionals from various disciplines that made developing interdisciplinary teams a challenge.
Nonetheless, Pearson and his colleagues eventually persuaded staff members that teamwork is more beneficial than not communicating with each other.
Pearson also would like to pool funding resources for state agencies serving children to expand services.
"The biggest barrier is [that] state rules prohibit this practice because federal funding is involved so each agency competes with each other for funding," said Pearson.
At present, funding for the mental health program comes from public agency partners, nonprofit organizations, and private and governmental grants. Part-time child and adolescent psychiatrists are salaried or paid on an hourly basis by Pearson's department.
Pearson added that he hopes to bill Medicaid for mental health services provided at the centers in the future because the vast majority of patients are indigent and uninsured.
Two national centers, both funded by the Maternal and Child Health Bureau of the Department of Health and Human Services (DHHS), are providing a variety of services to develop and expand school-based mental health programs.
Mark Weist, Ph.D., director of the center at the University of Maryland in Baltimore (UMB), told Psychiatric News, "We provide technical support and assistance to existing programs to improve and expand their mental health services and schools interested in creating such services."
He noted there is a growing national movement to develop comprehensive mental health services for youth in schools. Historically, school mental health services meant referrals to special education for assessments, said Weist.
"This created a large void in the treatment services available to children in general education." Moreover, said Weist, "there are many barriers to children receiving services through the community mental health system. We hope to merge the two systems to provide better services to children."
He noted that the Baltimore Center for School Mental Health Assistance and the University of California at Los Angeles Mental Health in Schools Center both provide training and technical assistance to schools, school districts, and local governments. The UMB center is focusing specifically on the role of the practitioner, while the UCLA center is examining policy and practice issues.
The UMB center offers consultation to school health, mental health, and education personnel to address the full range of administrative, clinical, and systems issues. The center has a resource library and a clearinghouse, offers training programs (including a national annual conference to be held September 12 and 13 in New Orleans), and convenes expert panels to develop recommendations in critical areas, said Weist.
The UCLA center is addressing broad systemic issues including helping communities develop and maintain mental health service programs and addressing the barriers that affect children's ability to learn.
According to codirector Howard Adelman, the center plans to develop strategies that counter service fragmentation and enhance school and community programs. Currently a survey of state mental health and education agencies is being conducted, and the center is sponsoring regional meetings for agency officials to foster collaboration. Other efforts include developing a volunteer consultation team and a newsletter.
More information is available from the UCLA center's Web site at (Psychiatric News, May 16, 1997)