Locating students who could benefit from mental health
intervention is a process involving SBHC and school staff that utilizes
both aggregate and individual screening methods.*
Conditions differ by grade level. At the elementary
level, note students with:
- Behavioral problems (disruptive, acting out)
- Academic problems
- Symptoms of :
-Depression
-Anxiety
-Abuse
At the secondary level, note students with:
- Symptoms of depression or anxiety
- Major traumatic events/suicidal ideation or behavior
- A history of
- Involvement with court system
- Abuse
- Poor academic performance
- Issues of sexuality/pregnancy or parenting
At both levels, note students who are:
- Undergoing transitions (new grade, new to school, recent immigrant)
- Truant or have been suspended
- Demonstrating marked social withdrawal or isolation
- Excessively absent in general or due to an acute or chronic
medical illness
Additional issues or concerns: An important caution is warranted.
Both pragmatic and ethical constraints require that careful consideration
of the outcome of such outreach efforts be carefully considered.
If the number of students identified as requiring services exceeds
the capacity of the SBHC to provide those services, either adequate
referral measures must be in place, or the scope of the screening
mechanisms should be reconsidered.
Note also the obstacles to early identification efforts: language
and cultural barriers, lack of knowledge of SBHCs, staff and student
turnover, and lack of support from the school principal and PTA
president.
*Aggregate level screening refers to broad-based efforts
to locate students in one of the following groups:
- the school-wide population
- the body of students enrolled in the SBHC
- high-risk populations
*Individual level screening is the responsibility of the mental
health provider on the SBHC team. Working collaboratively within
the team, and between the team and school personnel, the mental
health provider offers consultation and education to promote
- sensitivity and awareness regarding emotional and behavioral
problems in students presenting with medical or other complaints
- increased awareness of mental health risk factors and
early signs of mental health problems.
ASSESSMENT & EVALUATION
Definition and Standards of Practice
Definition
The first contact a student has with the SBHC should include medical
as well as mental health screening. This will determine whether
"wait-and-see" and "supportive/holding" activities,
followed by periodic team re-evaluation, or a full
mental health intake is required.
A mental health intake/diagnostic evaluation should be done
by the mental health worker, following the guidelines of a diagnostic
evaluation using DSM-4 criteria.
Standards of Practice
Mental health treatment requires careful treatment planning which
is predicated on thorough diagnostic evaluation resulting in a clear
understanding of problems, symptoms, choice(s) of treatment and
treatment goals.
Prerequisites
- Time for interdisciplinary case conferences (minimum bimonthly recommended)
and discussion of initial client assessment, mental health diagnostic
evaluation, and follow-up and periodic status review as needed.
- Standardized assessment and evaluation forms.
- Standards for completing assessments and specific chart forms prior
to a diagnostic evaluation.
- Appropriate use of DSM-4 terminology and diagnostic procedures.
- DSM-4-based diagnostic evaluation when psychiatric illness is suspected
(either on-site or at an appropriate mental health facility.)
Strategies and Tools
- The initial screening/assessment should include questions regarding
mental health issues that determine if a mental health problem may
be present. This can take the form of a simple intake form (name,
address, "why are you here?") or a fuller questionnaire
filled out by the student or provider. The assessment procedure must
be uniform and organized.
- The mental health intake/evaluation should have a structured questionnaire,
which identifies the presence of a mental illness based on the DSM-4.
This may take the form of a psychosocial assessment and a mental status
exam.
- Combine "core" SBHC and specialist staff as needed for
effective, periodic case conferences. Similarly, use opportunities
for presentation of SBHC cases at sponsoring or host agency’s case
conferences.
- A mechanism is recommended.for evaluation of the family, which may
include completion of a family map or genogram.
- Standardized evaluation tools such as the Connors or Beck can be
used where appropriate.
Target Populations (condition, age, etc.)
- Assessment, which includes screening for mental health problems,
should be done on all students who enter the SBHC for any reason.
- A complete intake is used with those students who demonstrate
mental health problems.
Additional issues or concerns: Lack of time may create a
tendency to neglect case conferencing. Addressing this ever-present
obstacle is necessary if the benefits of periodic case review is
to be realized. Similarly, ongoing communication, collaboration
and support among staff are essential, given the likelihood that
youth, especially at the secondary level, may approach SBHC staff
with whom they are most comfortable (irrespective of assigned staff/clinician).
TREATMENT - INDIVIDUAL, GROUP, FAMILY
Definition and Standards of Practice
Definition:
Treatment is the use of a systematic response to an articulated
mental health problem in which there is an attempt to:
- define the mental health problem
- create a well-defined treatment plan which is regularly revised
- apply accepted tools of clinical practice
- regularly assess, revise and re-evaluate the plan
There is a distinction between treatment and outreach or alliance-building.
Although the latter is essential for community-based mental health
work and may create a milieu for treatment, it is not treatment
per se.
Standards of Practice:
- Mental health treatment services should not be confined to long-term,
individual, insight-oriented therapy as this is not the most effective,
efficient or appropriate treatment methodology for many child and
adolescent problems.
- Treatment modality (e.g., individual, family, group, psychopharmacology
etc.) and content should be determined by the needs of the individual
student/client, and drawn from evidence-based practice.
- "It is recommended that physical and mental health providers
have a shared vision regarding reaching students in need and a willingness
to collaborate on specific cases." (Weist, Mark D. et. al., (2001),
Addressing Mental Health Issues within School-Based Health Centers
, p. 5. Such a vision necessitates flexibility in roles and boundaries.
In such a system, the treatment of emotional and behavioral issues
should not be the sole purview of a particular provider but of the
SBHC staff as a whole.
- Since the termination of the therapeutic relationship is especially
difficult for children and youth, therapists must work to minimize
the impact of transitions, anticipate them occurring and provide appropriate
planning and support.
Prerequisites
- Policies regarding the total number of cases permitted in one provider’s
active caseload as well as the total number of cases in supportive
management.
- Policy regarding the triage of cases which assures that every case
is assigned to treatment with:
a. a specific plan.
b. a specified time period after which progress is reviewed.
- an articulated decision-tree for re-assigning a case to an alternate
level of care, i.e., individual, group or family treatment, supportive
maintenance or outside referral.
Strategies and Tools
- Utilize accepted short-term, goal-directed, and outcome-based
models of treatment, including groups for individuals who share
a common problem, multiple family group work, and brief family
counseling, as appropriate.
- Support other essential relationships with a positive impact
on the student/client’s life.
- Utilize informal means of maintaining connection with student/clients
through such mechanisms as Drop-In Centers, discussion groups
and flexible scheduling of appointments. Collaborate in these
efforts with school guidance and mental health staff as well as
peer educators, adult mentors, and community services.
- Utilize reviews of standard, evidence-based treatment practices
for child and adolescent mental health found in the publications
of such professional organizations as the American Psychological
Association, the National Association of Social Workers, the National
Association of School Nurses, the National Assembly on School-Based
Health Care, and the Academy of Child and Adolescent Psychiatry.
- Employ published treatment protocols or practice parameters,
such as:
McDermott, John F. Jr. et al., (October, 1997). 1997 Supplement
to the Journal of the American Academy of Child and Adolescent
Psychiatry, Practice Parameters. Vol. 36, No. 10. Pp. 1S-202S.
Dulcan, Mina K. (December, 1999). 1999 Supplement to the Journal
of the American Academy of Child and Adolescent Psychiatry, Practice
Parameters. Vol. 38, No. 12. pp. 82S.
- Utilize materials developed by the two national centers on school
mental health: the UCLA School Mental Health Project/Center for
Mental Health in Schools and the University of Maryland Center
for School Mental Health Assistance.
Target Populations (condition, age, etc.)
Students exhibiting:
- Aggressive behavior
- School refusal
- Depression
- Anxiety
- PTSD
- Separation anxiety
- Conversion disorder
- Parent-child conflict
- Disruptive Behavior Disorders
- AD/HD
- ODD
- Conduct Disorder
- Symptoms of grief or loss
Families in need of support, through after-school hours presentations
and discussions; developing the school as a family-oriented community
center, referral to outside counseling. NB Judy, I can’t get
the family piece above to list the three items after "families
in need of support" by numbers, as per the 8 items under students.
Can you??
SERVICE COORDINATION
Definition and Standards of Practice
Definition
The term service coordination expresses the facilitation and advocacy
roles of the mental health provider. It encompasses coordination
of care with the educational and service community in the school
building as well as service referral, coordination and systems negotiation
with outside service providers.
Standards of Practice
- A thorough referral involves contacting the prospective service
provider, assuring that a connection is made and service or treatment
occurs, and establishing ongoing feedback mechanisms.
- Referrals must be appropriate to both the student and provider/agency.
They should be ethnically sensitive, feasible, relevant to the
needs of the student and family, and within the expertise of the
referral agency.
Prerequisites
- Established referral policy and lines of responsibility for
follow-up. This should include a feedback system to the referring
agent.
- Referral networks in place and regularly reviewed.
- Knowledge of social services and government benefits, including
education, income and health care resources and benefits.
- Access to published and on-line directories of community agencies
and services, as well as the time to establish the reliability
of such information.
Strategies and Tools
- Relationships with/membership on Pupil Personnel and other relevant
school committees.
- Directories of services and programs.
- Liaisons with service delivery agencies.
- Working alliances with other health care/social service providers
within the school.
- Visits and presentations to and from community agencies.
Target Populations (condition, age, etc.)
- Victims of child abuse
- Children with chronic illness
- Children with chronic mental health or behavior disorders
- Any child referred after intake/evaluation
- Pregnant or parenting teenagers
- Children with legal problems
Additional concerns: Although provision of treatment for
substance use is beyond the purview of SBHCs, the contribution of
this issue to health, educational, and mental health problems has
been well documented. Identification of referral routes and advocacy
for appropriate care is recommended.
PREVENTION/EARLY INTERVENTION
Definition and Standards of Practice
Prevention/early intervention refers to interventions, programs
and strategies offered to benefit students showing early, little
or no signs of distress, with the aim of decreasing the likelihood
that symptoms or problems will occur or worsen in the future. Prevention
may target individuals or systems affecting the lives of students,
including school personnel, family members, other adults and the
community-at-large.
Standards of Practice
- Since prevention efforts can greatly decrease the costs and
burden of providing palliative care, significant mental health
provider time should be devoted to these activities.
- Prevention programs and strategies should be utilized if there
is evidence of effectiveness or if their effectiveness is being
tested.
- Prevention activities should be responsive to the needs and
resources of the school and larger community, and should be re-evaluated
periodically.
Prerequisites
- Knowledge of prevention strategies.
- Access to information from the school and community regarding
student risk factors.
- Collaboration and communication between school and SBHC staff
on prevention priorities and efforts.
- Access to materials providing information and "how-to’s"
on evidence-based prevention strategies. Some prevention programs
may require training or certification in specific skills.
- Opportunity to provide professional development programs to
school personnel.
- Attention to appropriate orientation, coordination and supervision
of staff and volunteers involved in prevention activities.
Strategies and Tools
- Effective and accepted prevention activities generally are most
effective when undertaken in collaboration with other school or
community personnel.
- Since working with school staff may be optimal, consider development
of a core leadership group or utilization of an existing school
committee or task force that includes both SBHC and school staff
to plan and track prevention activities.
- Think about ways to extend your reach. For example, it may be
useful to develop volunteers (or to collaborate with existing
organizations willing to provide volunteer personnel, such as
colleges, religious institutions, voluntary associations) to help
plan or implement a particular prevention activity. Similarly,
it is economical to disseminate such information as mental health
warning signs or indicators of ADHD to large and influential constituencies,
such as school faculty, family members, etc.
- Utilize "train-the-trainer" or "turn-key"
models of staff development in which the mental health provider
offers concentrated, time-limited training and consultation to
enable selected school (or other) personnel to replicate and carry
out identified prevention activities.
Target Populations (condition, age, etc.)
- Broad-based prevention efforts may be applied to the entire
school population. This is practical only for interventions that
are time-limited and focused. For example, all students may participate
in a Healthy Minds/Healthy Bodies Week or in such short-term activities
as social skills training.
- Programs that are on-going or require greater staff effort should
start by focusing on appropriate target populations. For example,
conflict resolution or anger management programs may be provided
for those students in specific grades experiencing the most difficulty
with aggression. Similarly, students with a history of court involvement,
suspension, or family stress may be identified for early identification/prevention
efforts.
