Providing Mental Health Servies to Youth Where They Are

School and Community Based Approaches

Harinder S. Ghuman, Mark D. Weist, Richard M. Sarles, Harinder S. Ghuman, Mark D. Weist, Richard M. Sarles

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135451721
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Barriers to community mental health centers (such as stigma, waiting lists) prevent youth from receiving necessary services. Providing Mental Health Services to Youth Where They Are, identifies the reform that is needed in children's mental health service. As the issues of systems of mental health care have received increased attention, so has the recognition of the benefits of providing services to youth where they are: that is, in natural settings, such as home or school. Principles to include in systems of mental health care for youth are as equally important as actually reaching the youth: involvement of families, school staff, community leaders, and clergy. The development of programs are matched to the developmental, cultural, and other needs of youth in a community so they mesh with existing services. This book describes how these principles play out in school-, home-, and community-based mental health programs for youth.

PART ONE

School-Based Approaches

CHAPTER ONE

School-Based Mental Health in the United States: An Historical Perspective and Baltimore’s Experience

Yu Ling Han, Ph.D., Kristin V. Christodulu, Ph.D.,
Bernice Rosenthal, M.P.H., Louise Fink, M.Ed.,
and Mark D. Weist, Ph.D.

Since the late 1980s, a full range of mental health services has been progressively developed in schools across the United States. These “expanded” school mental health (ESMH) programs augment assessment and administrative services for youth in special education by offering evaluative and treatment services (e.g., individual, group, and family therapies) to all youth in schools, including those in regular education. A national movement is under way to develop or improve ESMH programs in diverse communities in the United States. This movement has largely been a response to an increasing recognition of the limitations of community mental health centers (CMHCs) and private practitioners in meeting young people’s mental health needs. ESMH programs were designed to overcome many of the barriers constraining the provision of mental health services in these traditional sites (Flaherty, Weist, & Warner, 1996; Weist, 1997).

ESMH programs owe part of their success to the preexisting and more established school-based health centers (SBHCs). Because the mission of SBHCs was to provide comprehensive health programs (Baltimore City Health Department, 1995; Juszczak, Fisher, Lear, & Friedman, 1995), they constituted a legitimate framework within which to set up mental health services. Additionally, SBHCs provided convenient access points for youth in schools to utilize these services. Indeed, it is within the context of SBHCs that the need for mental health services in schools has gained increasing recognition (Weist, 1997). Essentially, as SBHCs have expanded to more than 1,200 nationwide (Lear & Schlitt, 1998; National Assembly on School-Based Health Care, 1998), they have spurred the development of ESMH programs by underscoring tremendous mental health needs in youth. Over time, ESMH programs have gained sufficient recognition and legitimacy of their own to expand in school systems independent of the SBHCs.

Despite the national growth of these ESMH programs, little is known about the activities that facilitated their establishment, operation, and legitimization. A review of the literature showed minimal published information on how ESMH programs have developed (Flaherty et al., 1996). Because Baltimore has been recognized regionally and nationally as a leading city in the development of these programs, other cities may benefit from knowledge of the Baltimore experience. In this chapter, we provide relevant background to the development of ESMH programs nationally, and provide an historical account of the Baltimore programs from their inception to the current program operation.

THE NEED FOR EXPANDED SCHOOL MENTAL HEALTH PROGRAMS

The problems of children and their families, particularly those living in urban areas, have been well documented (e.g., Feigelman, Stanton, & Ricardo, 1993; Lear, Gleicher, St. Germaine, & Porter, 1991; Warner & Weist, 1996). These include poverty, exposure to crime and violence, frequent abuse and neglect, substance abuse, drug trafficking, family breakdown, illegitimacy, teen pregnancy, truancy, runaways, and juvenile delinquency (Baltimore City Children and Youth Task Force [Task Force], 1987). In 1991, the Congressional Office of Technology Assessment reported that up to 20 percent of youth under the age of twenty exhibit psychosocial problems severe enough to warrant intervention, but less than one-third of these youth actually receive mental health services.

Youth from inner cities such as Baltimore are particularly at risk for experiencing significant levels of life stressors. These include increased levels of crime and violence, poverty, substance abuse, and a greater occurrence of neglect and physical and sexual abuse. A 1986 estimate indicated that 15 percent (32,000) of the children and adolescents in Baltimore were in need of mental health treatment (Task Force, 1987).

Although these problems had existed for some time, the Task Force (1987) cited several factors that led bureaucratic agencies at the national, state, and local levels to address them. The first impetus came from the publication of research during the early- to mid-1980s documenting the scope and prevalence of emotional and behavioral problems among youth. Particularly influential in setting the policy direction regarding systems of care for children and adolescents was Jane Knitzer’s Unclaimed Children (1982). The culmination of policy-related analyses during the next three years led to another influential work entitled A System of Care for Severely Emotionally Disturbed Children and Youth (Stroul & Friedman, 1986). Stroul and Friedman’s goal was to outline a comprehensive interagency model of service for severely disturbed youth based on inputs from local community agencies. Given that their research was within a federal policy framework, this book became a primer in providing a detailed report on one of the biggest federal mental health programs for youth, the Child and Adolescent Service System Program (CASSP). The CASSP, a tertiary intervention model of systems of care, became so successful that this federal program had a significant impact on how the states organized their service delivery system.

Second, advocacy groups (e.g., Children’s Defense Fund; Mental Health Association; Baltimore Mayor’s Office for Children and Youth) placed the issue of children’s mental health at the top of their agenda, and succeeded in making a profound impact on the general public and on state legislatures. In fact, these advocacy groups were seen by the Task Force as critical players in mobilizing community resources and promoting alternative services, including ESMH programs, for children and youth.

Third, a number of newspaper articles published in the Baltimore Sun (October 24,1986; November 24, 1986; January 15, 1987) and the New York Times (September 6, 1987) increased awareness during 1986–87 of the mental health problems experienced by children and adolescents. Such coverage not only heightened public awareness but also underscored the deficiencies of governmental agencies in addressing these problems.

Fourth, in spite of budget cuts in social programs, in 1986 the federal government provided funds to twenty-six states to strengthen and widen the mental health services to children and youth offered by its CASSP. Tom Merrick of the Maryland State Department of Health and Mental Hygiene (DHMH) considered the CASSP to be a watershed federal program with a mission to move a significant proportion of mental health services from CMHCs to the school setting. That is, as states began to endorse this successful CASSP model for their most severely disturbed youth, greater recognition was given to the need for intervention as well as prevention. Thus mental health services would be available to all youth in need, not just those with severe emotional disturbance.

Baltimore’s response to the increase in published studies, reports, and recommendations was to establish a Task Force on Mental Health Services for Children and Youth. The Task Force, created in April 1986 under the auspices of its local health department, adopted the CASSP and Caplan prevention (1964) models as their guiding principles. As in the CASSP model, the Task Force called into action a system of care that was “to be child-centered and community-based … non-residential” (Task Force, 1987, p. 27). Drawing from the Caplan model, the Task Force fostered the integration of programs offered by various agencies so as to achieve a comprehensive system of care that included: (1) primary prevention that would also reduce the likelihood of problems to occur; (2) secondary treatment that would address problems in the incipient stage; and (3) tertiary treatment to respond to problems that were already well established. With these principles as guideposts, the Task Force established a network of linkages among several lead agencies. It is from the collaborative work of these public and private organizations, such as the Baltimore City Health Department (BCHD), the Baltimore City Public Schools (BCPS), the State of Maryland DHMH, Johns Hopkins University (JHU), the University of Maryland, Baltimore (UMB), the Department of Social Services (DSS), the Juvenile Services Administration (JSA), and the Mayor’s Office for Children and Youth, that the ESMH programs have been crystallized from an idea on the drawing board into a national presence.

AN HISTORICAL PERSPECTIVE

The emergence of more comprehensive mental health services in schools was part of a broader movement to establish a package of social services, including mental and physical health, social welfare, and vocational preparation programs, in elementary and secondary schools (Sedlak, 1997). The early history of this movement was associated with the changing role of formal education in America, especially at the secondary level.

During the late nineteenth and early twentieth centuries, secondary schools transformed their mission from teaching disciplinary knowledge to privileged students to preparing the majority of children for life by enhancing their vocational skills, improving the efficiency of their occupational choices, preventing social maladjustment, and ensuring adequate levels of personal hygiene and public health. Accordingly, schools were obligated to offer more than traditional classes in history, science, mathematics, and languages (Dryfoos, 1994; Levine & Levine, 1992).

While school administrators and teachers welcomed the movement, the catalyst for establishing and maintaining most initiatives came from outside the schools. Private-sector groups and public service organizations launched efforts to organize mental health and social services for schoolchildren.

Among the earliest, but also among the smallest, were programs designed to investigate and attempt to treat emotional and mental problems among schoolchildren, especially those from immigrant families. More prevalent were programs that provided direct relief from poverty and unemployment so that children would be able to attend school. In addition, specialists in guidance and counseling joined school faculties at the intermediate and secondary levels in an effort to help adolescents connect with higher education or the labor market.

Capitalizing on efforts to engage schools in the medical care of children, psychologists in the United States determined that the captive audience provided by compulsory attendance policies provided a ripe opportunity to apply their science to understanding and treating “special” children. During the late 1890s, in Philadelphia and a small number of other urban centers, psychological clinics were established by universities and medical institutions in partnership with public schools. The initial purpose of these clinics was to help schools manage “blind, deaf, feebleminded and delinquent children” (Levine & Levine, 1992, p. 28), many of whom were suffering from “mental and moral retardation” (p. 32), and who were emerging in greater numbers in regular classrooms (Levine & Levine, 1992).

After 1906, at approximately the same time that the psychological clinics were becoming reinvigorated, private organizations and public schools in several large cities began to perform well-defined social welfare functions such as addressing truancy and delinquency, rehabilitating poor and disorganized families, and encouraging the “Americanization” of the immigrant population. The focus early on was to intervene on the behalf of students whose attendance and behavior problems stemmed from poverty, unemployment, sickness, or the inability to negotiate urban bureaucracies. Individuals who worked most directly in this area called themselves “visiting teachers.” Visiting teachers saw an opportunity to gain access to the families of schoolchildren and to work on strengthening their values and habits.

Guidance and counseling professionals similarly worked in partnership with private-sector organizations, primarily to help adolescents and their families understand and participate in their local economies. Early activists, such as Frank Spaulding, claimed the right to exercise considerable control over students (Sedlak, 1997). Accordingly, guidance counselors soon established themselves as a group with responsibility for minimizing or preventing many of the social maladies they attributed to the improper alignment of youth and occupations. Targeting the processes through which children and youth selected and prepared for their careers, guidance counselors assisted young people in making course selections appropriate to certain occupations.

Regarding the more general evolution of the helping professions, the school-based social and mental health service initiatives became increasingly professionalized following World War I. The release in 1918 of the National Education Association’s Cardinal Principles of Secondary Education provided an influential, systematic, and coherent justification for school-based social services. Originating in environmental and social reform, the mental health movement turned rapidly toward individual case management and away from attempting to remedy broader social and economic conditions. As such, the mental health professionals focused more on problems grounded in family dynamics or internal psychological conflict and less on those rooted in social and economic deprivation. Scientific principles and diagnosis penetrated the field of psychology, and school-based clinics began to utilize contemporary measurement and evaluation procedures.

With the professionalization of perspective and technique came two major shifts in the domain of the mental health field. First, psychiatric or psychoanalytic casework began to focus more narrowly on the “inner psychological problems of individuals” (Levine & Levine, 1992, p. 89). Second, practitioners moved away from working only with immigrant, working-class, and disadvantaged children to working with clients from the middle and upper classes.

One of the most enterprising youth-oriented initiatives of the 1920s demonstrated these changes. The Commonwealth Fund of New York City launched juvenile delinquency intervention programs in thirty urban, smalltown, and rural communities in 1921. The Commonwealth Fund’s professional approach to the prevention of juvenile delinquency drew upon the insights provided by the mental hygiene movement. Essentially, the mental hygiene movement reflected the efforts of social service workers to move away from working exclusively with the most intractable, disruptive, and delinquent children to engaging all children, especially middle-class adolescents with emotional and adjustment problems.

Economic difficulties present in the 1930s halted most school-based social services. It was not until after World War II in the mid-1940s that counselors and social workers were able to offer their services to middle-class children and adolescents in some schools.

Several national policy studies that examined the status of children and youth and the potential for school-based social services to counteract growth in delinquency among middle-class adolescents contributed to the rebuilding during the late 1930s and the 1940s. The reports called for schools to accept responsibility for providing physical and mental health programs and a full complement of guidance, counseling, and occupational-adjustment services for all children. Professional social work and mental health practitioners abandoned traditional social reform activities and refocused their efforts toward providing therapeutic, clinical, and personality adjustment services on an individual, case-by-case basis. Social and mental health professionals became committed to strengthening interpersonal relationships between children and their peers, their parents, and their teachers.

Social service staff were joined by professionals affiliated with state departments of education to lobby legislators to encourage investment in social and psychological services in schools. State officials began to provide special funding to school districts to identify and treat emotionally disturbed children.

By the late 1950s, mental health services had expanded notably. This trend was accelerated by professional aspirations to serve a broader clientele than the urban poor, state mandates to serve emotionally disturbed and delinquent youths, and increasing federal funds for counseling, guidance, special education, and social welfare services. From the Smith-Hughes Act passed during World War I to the National Defense Education Act of the Cold War, the federal government became continually more immersed in shaping and financing school-based guidance and counseling programs in districts serving families of all income levels.

The professionalization of mental health and social welfare services and the infusion of federal and state funds shaped the provision of services for the next several decades. Unlike efforts in the 1950s to “universalize” services by expanding markets to include middle- and upper-class students, many practitioners in the 1960s concentrated on disadvantaged populations. While school systems willingly received programs that were accompanied by state and federal reimbursement funds during the 1960s and 1970s, administrators and school board members found that the levels of external support were not sufficient to cover the costs of delivering the services. This resulted in the resistance and defection of many educational administrators.

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Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• Acknowledgments
• Introduction Principles Behind the Proactive Delivery of Mental Health Services to Youth Where They Are
• Part 1: School-Based Approaches
• Chapter 1 School-Based Mental Health in the United States An Historical Perspective and Baltimore's Experience
• Chapter 2 An Elementary School Mental Health Program Serving Immigrant and Minority Children
• Chapter 3 Establishing Successful School Mental Health Programs Guidelines and Recommendations
• Chapter 4 Practical Issues in School Mental Health Referral Procedures, Negotiating Special Education, and Confidentiality
• Chapter 5 Evaluation and Quality Improvement in School Mental Health
• Part 2: Home- and Community-Based Approaches
• Chapter 6 Home- and Community-Based Services Historical Overview, Concepts, and Models
• Chapter 7 Development and Implementation of Mobile Crisis Services for Emotionally Disturbed Youth
• Chapter 8 Home- and Community-Based Treatment Programs for Severely Emotionally Disturbed Treatment-Resistant Youth and Their Families The Child Mobile Team
• Chapter 9 Family-Driven Treatment Families as Full Partners in the Care of Children with Psychiatric Illness
• Chapter 10 Institutional Treatment Transferred Narrative Family Therapy Approach to Acute Services
• Part 3: Special Issues
• Chapter 11 Children's Mental Health Partnering with the Faith Community
• Chapter 12 Children Are Newsworthy Working Effectively with the Media to Improve Systems of Child and Adolescent Mental Health
• Contributors
• Index