Imagine you are 15 years old, struggling with changes in your body and new and complicated feelings—not to mention peer pressure to do things that might not be good for you. You don't feel like talking to mom and dad about everything right now, so where do you go?

Frequently, kids are pulled out of schools to attend counseling and receive mental health services at community institutions—a practice that doesn't help to reduce the stigma already attached to mental health problems. But now that experts have come to view mental health not as an individual issue but as an important part of children's overall health, some schools are beginning to see mental health services as a core part of everyday education.

In 1992, the Children's Aid Society formed a unique partnership with the New York City Board of Education to establish a new model of public school—community schools that provide families with medical and dental clinics, after-school, evening and weekend programming, adult education and mental health services. Together with the New York City Board of Education, the Children's Aid Society has created eight community schools concentrated in the Washington Heights area of Manhattan.

The premise is that education does not take place in isolation and that the most effective school reforms will combine educational excellence with needed human services, delivered through school, family and community partnerships. Says Ellen Lubell of the Children's Aid Society, "School based mental health programs can help identify and treat children that show signs of mental illness and may not have caught the attention of teachers and administrators."

Suffering Silently
The National Alliance for the Mentally Ill reports that of the 65 million young people in American under the age of 18, approximately 7.5 million have diagnosable mental disorders, though only one in five of those youths is receiving treatment. In addition, the Children's Aid Society reports that American schools have only one guidance counselor for every 1,000 children and one social worker or school psychologist for every 2,500 in the U.S.—an indication that kids may be suffering in silence.

A recent study by the National Assembly of School Based Health Centers (NASBHC) reports that risky behaviors like substance abuse, unprotected sex and violence are the leading threat to the health of adolescents and are increasingly responsible for the majority of deaths to adults under age 50. Adolescents (ages 10-19) have the lowest utilization of health care services of any age group and are the least likely to seek care at a provider's office. The school based services respond to this need to help kids whose problems may otherwise go unnoticed.

The NASBH study also reports that traditional providers may have limited impact on behavior-related problems because they are less likely to have frequent contact with their patients. They are also less likely to practice alongside professionals trained to focus on mental health and health education issues. During puberty in particular, when physical and mental health issues are intertwined, students may feel most comfortable revealing problems in familiar settings.

David Rosenthal, the director of school-based mental health services for the Children's Aid Society, believes that providing mental health programs in schools is critical because the majority of children who are referred to outside mental health services don't ever access them. Families face many barriers, including language and transportation, that keep them from using services outside the school . "When children are referred within the school," Rosenthal says, "almost all of them attend."

Benefits of School Based Health Care
Assistance in school based health centers doesn't end with mental health. The Children's Aid Society community schools offer after-school and early childhood programs for working families who may not have access to these services elsewhere. "When we find out families need medical or dental care," Rosenthal says, "we have that in our building, too."

Dr. Steve Adelsheim, child psychologist and director of the New Mexico School Mental Health Initiative, believes that the school based health services help kids transcend social, emotional and environmental problems, like poverty and abuse. "In order for kids to be successful in school," Adelsheim says, "they have to overcome barriers to successful learning."

Adelsheim points to the fact that many learning issues kids have are tied to mental health, and many kids dropping out or getting expelled have mental health problems. A survey by the Centers for Disease Control showed that 7 percent of high school students have tried to kill themselves, and 20 percent have considered it. The ups and downs of adolescence, when taken to extremes, Adelsheim says, can interfere with learning: "It's hard to focus on the job of childhood, which is to go to school and be successful."

Dr. Linda Freeman directs the Depression Screening and Treatment Project at the Children's Aid Society's Community School IS 218. Freeman and her colleagues conducted psychiatric assessments on every youngster attending the school and provided necessary treatment on site. Says Freeman, "We address all kinds of mental health needs, not just those that might interfere with the school's academic achievement."

According to Freeman, many schools still operate under a traditional structure where the goal is to have just enough professionals in-house to refer kids to professionals in the community. "Most schools have a social worker, a guidance counselor, a district commissioner for special education that helps them evaluate kids who are not making it with the goal of finding out whether they need smaller classroom settings or more restrictive environment." Children with mental health problems can become referred to special education classes where mental health issues are not dealt with specifically.

But learning issues and mental health issues are often tied together. The community school format allows professionals to observe students in their learning settings, and within their families. "We'll see a whole family," Freeman says. "We'll see parents and students, whether or not they attend the school."

Challenges for School Based Health Care
Statistics show that school based health centers are becoming more commonplace. According to NASBHC, school-based health centers have grown rapidly during the 1990s, increasing from about 200 in 1990 to 1,157 in 1998. Thirty-three percent of school based health centers are in elementary schools, 16 percent in middle schools, and 38 percent in high schools. In a survey of 26 school-based health centers, mental health was reported as the leading service provided.

So what is holding us back from creating more of these multi-service centers? "People think it's financially prohibitive, but it's not," Freeman says.

Financial support is, however, a continual challenge for these centers. A report from the Urban Institute Report concludes that although school based health centers might be one of the best hopes for reaching the increasing number of children in need, these centers will require the continuing financial support from outside sources, such as state health agencies and private foundations. In addition, school based health centers will likely need technical support and expert consultation on a variety of issues.

At present, state governments continue to provide substantial funding for school-based health centers through state general funds and through the targeting of Maternal and Child Health block grant moneys. According to the NASBHC, the level of state contributions to school-based health centers varies greatly. Four states account for nearly three-fourths of state-directed Maternal and Child Health dollars for school-based health centers: Illinois, Minnesota, New York and Texas. In addition, five states account for nearly sixty percent of state general revenues flowing to school-based health centers: Arizona, Connecticut, Delaware, Michigan and New York.

Since 1996, state Maternal and Child Health dollars have decreased, while Medicaid reimbursements appear to have increased. Contributions from private enterprises will become continually important to keep these centers thriving.

Another challenge to the school based health center movement is acceptance. Says Freeman, "Many are worried that things will not be confidential and therefore the things they consider private between doctor and patient will be revealed to bureaucracies like school systems."

Rosenthal agrees that schools and boards of education may not necessarily welcome outside programs coming in or value the role of counseling within an educational setting. "Usually we think of once-a-week session in the privacy of an office as the ideal way for counseling to take place," Rosenthal says. But there is a great need for adolescents to have additional support at this time. "Even the most well-adjusted youngsters are struggling at this time of transition and would benefit from having an interested grown-up to listen and help," Rosenthal says.

The key is involving all stakeholders in the process. Says Freeman, "You can't walk into a school and say, 'I've got mental health services for you.' You have to make sure you have a solid relationship with the community. Parents have to be willing, the school has to be ready, and you have to include the family as participants."