Mental health care in a high school based health service

Adolescence, Spring, 1998 by Lisa Jepson, Linda Juszczak, Martin Fisher

Since the early 1970s, over 600 health centers have been established in American schools in order to assist with the management of medical and psychosocial problems of high-risk youth (Schlitt, Rickett, Montgomery, & Lear, 1994; Hauser-McKinney & Peak, 1994). Because of the particularly complex biopsychosocial problems faced by urban youth, the majority of these centers are located in poor, inner-city neighborhoods (Hauser-McKinney & Peak, 1994). Accessibility and the comprehensive services offered by a multidisciplinary team of professionals make school-based health centers uniquely suited for reaching large numbers of young people who otherwise might not receive medical or psychosocial services (Hauser-McKinney & Peak, 1994; Fisher, Juszczak, Friedman, Schneider, & Chapar, 1992; Lear, Gleicher, St. Germaine, & Porter, 1991; Siegel & Krieble, 1987; Allensworth & Kolbe, 1987).

Although school-based health centers have primarily been located in urban senior high schools, they are increasingly serving middle and elementary school populations as well as suburban and rural regions (Hauser-McKinney & Peak, 1994). Moreover, although these centers were initially established to meet the needs of pregnant and parenting adolescents in low-income areas, data have shown that reproductive health constitutes only a third of all services provided in some clinics and significantly less in many others (Harold & Harold, 1993; Fisher et al., 1992; Kirby, Waszak, & Ziegler, 1989; Siegel & Krieble, 1987). Other medical problems typically seen at these health centers include accidents and injuries, acute and chronic illness, nutrition and dermatologic concerns, and health screenings and immunizations (Fisher et al., 1992; Lear et al., 1991; Kirby et al., 1989; Siegel & Krieble, 1987). In addition to providing these medical services, school-based health centers identify and treat emotional and psychosocial problems, make referrals to specialists, and educate students on a variety of health-related issues.

Because risk-taking behaviors are now a leading cause of mortality and morbidity among Americans in general and youth in particular, it has become imperative that mental health services be fully integrated with the medical services provided in school-based health centers (Huizinga, Loeber, & Thornberry, 1993; White & DeBlassie, 1992; Lavin, Shapiro, & Weill, 1992; Orr, Beiter, & Ingersoll, 1991; Kirby, 1990). Mental health services represent a large part of those school-based health centers that include psychosocial services (Klein, Starnes, Kotelcheck, Earp, DeFriese, & Loda, 1990). Data from surveys of school-based health centers indicate that 79% offer mental health and psychosocial counseling, 76% offer family counseling, and 58% offer support groups (Waszak & Neidell, 1991). Results of a 1990 survey of 194 school-based health centers showed that 69% provide social work and 73% provide mental health counseling (Klein et al., 1990). Baseline surveys at schools that have centers have shown that substantial numbers of teenagers report such problems as drug use, anxiety, and depression (Balassone, Bell, & Peterfreund, 1991). As noted by Adelman (1993), research conducted as part of specific demonstration projects has produced evidence supporting the usefulness of a range of school-based mental health interventions. When appropriately implemented, these programs are generally seen as benefiting not only the school, but also society at large (Adelman, 1993; Adelman & Taylor, 1993; Fisher et al., 1992).

Despite the fact that mental health services have been an integral part of the school-based health concept from the beginning, and that national health statistics link psychosocial risk factors with adolescent mortality and morbidity, the contributions of mental health providers in school-based clinics have not been extensively studied (Harold & Harold, 1993). Only recently have school-based mental health services begun to receive some attention (Hoberman, 1992; Balassone et al., 1991). In order to more fully integrate mental health and medical services in school-based health centers, it is necessary to broaden our knowledge base by examining the nature of the mental health problems experienced by students using these services. This paper examines the mental health services and psychosocial problems seen in one health center based in an inner-city high school, and presents recommendations for integrating these services into the overall clinic program.

METHOD

Facility

Since February 1988, the Division of Adolescent Medicine of North Shore University Hospital has been operating a high school based health center in an isolated but urban section of Queens, New York, serving approximately 2,000 students. The center is open from 8 A.M. to 4 P.M., five days a week, including summers. The center is divided into offices, examining rooms, laboratory space, an emergency area, and a waiting room.

Each student using the center must receive the consent of a parent or legal guardian, who is allowed to choose specific services that can or cannot be provided. Students who have a primary care provider may use the center, as well as students who do not have a regular health provider. Students are not charged out-of-pocket fees, but insurance information is sought so that third-party reimbursement can be obtained when appropriate. Clinic charts are maintained separately from school health records; health service personnel have access to both sets of records, while school personnel have access only to the latter.