A program of comprehensive school-based mental health services in a large urban public school district: The Dallas model

Adolescent Psychiatry, 1999 by Pearson, Glen, Jennings, Jenni, Norcross, James

The long history of the relationship between adolescent psychiatry and public education is marked by a kind of reciprocal ambivalence, varying in intensity over time, from mutual neglect to territorial conflict. Over the past 30 years, educators and psychiatrists as professional groups have experienced many changes in the scientific, social, legal, economic, and political environments in which each must carry out its mission. Psychiatry has weathered the community mental health and patient advocacy movements, a nosological revolution, an explosion of knowledge in neuroscience and psychopharmacology, the rise and fall of proprietary psychiatric hospitals, deinstitutionalization of the seriously and persistently mentally ill, and, not least of all, the headlong implementation of managed care currently under way. Public education has borne the brunt of the burden of regressive social anomie in our inner cities-poverty, racial conflict, high crime rates, alcoholism, drug addiction, and family and youth violence-while enduring unendingly shifting pressures for change, including such trends as site-based school management, school improvement modeling, mental health and substance abuse curricula, community services programs, and federally mandated special education services to disabled or handicapped children. Although psychiatrists and educators have always been invested in producing healthy, well-educated, productive citizens, both have usually been too preoccupied with the vicissitudes of their own professional domains to see the larger picture of their shared common purpose, let alone come together and work synergistically in its service.

In 1993, in response to a request by two school principals, Dallas's public mental health agency helped the school staff to initiate a collaborative mental health clinic using existing resources and personnel along with a child and adolescent psychiatrist. In the 5 years that followed, this model matured, developed, and grew into a district-wide program of health, comprehensive mental health, and youth and family services in 10 sites serving all 160,000 students in more than 200 schools. In this chapter, we review the literature on school-based mental health services, trace the development of the Dallas service delivery model to its present configuration, and report the results of its program evaluation. We also discuss some of the advantages we have discovered, as well as the challenges that we have faced and those which still confront us.

Review of the Literature

Healthcare services have been provided in schools since the late 19th century, when doctors monitored outbreaks of infectious diseases such as tuberculosis and diphtheria. Even then, programs were plagued with funding problems, arguments over service responsibilities, and difficulty establishing and maintaining collaborative agreements (Dryfoos and Klerman, 1988). Although lacking in organization, services survived and even began to proliferate when the issue of teen pregnancy surfaced (Balassone, Bell, and Peterfreund, 1991). The social, psychological, and health problems of children necessitate a comprehensive approach (Halfon, Inkelas, and Wood, 1995). This has been especially true for teenagers, who have their own set of health issues due to risk-taking behaviors, difficulty accessing care, confidentiality, and the emotional upheaval that often characterizes adolescence (Brindis and Sanghvi, 1997). Schools have proved to be a vitally important site for the establishment of mental health services for children, as other existing community resources too often cannot meet this need (Flaherty, Weist, and Warner, 1996).

Historically, healthcare services and mental health services have been seen as separate and distinct-a dichotomy maintained over the years by such influences as the stigma associated with mental illness, the lack of hard medical evidence of the effectiveness of psychiatric treatment, the resistance of the profession to change, and financial barriers to accessing mental health services. Over the past 20 years, however, a revolution in neuroscience and the rapid development of effective biological therapies has helped reestablish the link between psychiatry and medicine. The partnering of health, mental health, and schools has brought about its own set of conflicts: turfism, funding issues, differences in eligibility for services, paperwork, accountability, and colocation issues (Hacker et al., 1994). Relationships between mental health providers and school personnel have often been awkward, even competitive, with differing ideologies regarding what is best for the child.

Successful integration of services requires interorganizational cooperation: interdependence, mutual benefit, common modes of communication, and complementary technologies (Goldman, 1982). Gottlieb and Kotch (1984) have suggested guidelines for developing school-based services: convening a network of partners, assessing healthcare needs and resources, deciding what services to offer, delineating gaps and duplications, choosing a site, and developing and monitoring implementation. A well-designed health services program, combined with comprehensive health education, can significantly advance the health of the nation's children. Once services are in place, students, parents, and school staff must know of their existence. Walter et al. (1995) found that referral sources in a large urban school clinic system consisted of clinic outreach (48%), self-referral (44%), and school staff referral (8%). Despite efforts to spread information, knowledge of available services is sometimes lacking. Reasons for nonuse by students include lack of parental permission, feelings that the clinic would not be able to help them, concerns about confidentiality, and no knowledge that the services existed (Balassone et al., 1991); others have reported not being able to leave class for appointments (Keyl et al., 1996); still others have complained of a lack of communication among school, parents, and health providers regarding needs and services available to meet them (Fox, Rankin, and Salmon, 1991).