This paper describes the mental health services provided at a high school based health center that integrates mental health and medical services. Five years after the inception of the center in 1988, mental health visits had quadrupled. In 1992 alone, students made 1,002 mental health visits. Strikingly, one-third of these students reported problematic substance use among other family members. Other leading reasons for utilizing mental health services included pregnancy (19%), past or present suicidal ideation (14%), obesity (8.7%), ongoing depression (8%), and issues related to sexuality (7.5%).
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 psychosoc ial 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.
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.
At the time of data collection, the center was staffed by (1) a social worker; (2) a doctoral student in clinical psychology, who worked two days a week and was supervised by an off-site licensed psychologist; (3) two pediatric nurse practitioners, one of whom served as the center's director; (4) attending physicans and fellows from North Shore University Hospital, who rotated to cover the center 3-5 hours three times a week; and (5) two health aides provided by the school, who were responsible for record keeping, emergency services for both enrolled and nonenrolled students, reception, triage, and basic, on-site screening tests.
Since the inception of the program, the goal has been to integrate mental health and medical services, which has been accomplished on two levels. First, clinic staff interact on an ongoing basis and discuss both policy issues and individual cases. Second, the initial evaluation communicates to each student that staff are interested in both medical and psychosocial issues, and provides for a screening of every registered student in these areas. The center has been successful in treating a large number of students for a wide range of medical and psychosocial problems. The services provided by the center are listed in Table 1.
Students are seen in the center either for scheduled appointments or as walk-ins. Each new student receives a comprehensive health evaluation, which includes a patient and family medical history; a psychosocial history; a complete physical examination, including a gynecologic examination for sexually active females or those with gynecologic complaints; and laboratory screening tests.
Information obtained from all health evaluations is maintained in patient charts and compiled on a regular basis. Additional information is gathered for each visit (including reason for visit, services provided, diagnosis, referrals, and length of contact), and these data are also compiled regularly.
During the initial evaluation, students who respond affirmatively to questions relating to depression, past or present suicidal ideation, moderate or severe family or interpersonal problems, or any farm of self-destructive behavior are referred to the center's mental health providers for a more in-depth interview. Students are also referred if they request "to talk with somebody" or if during the medical examination it appears that mental health services are warranted--such as in the case of physical findings that indicate child abuse.
For the purpose of this study, the charts of all students who used the mental health between January and December 1992 were reviewed for a primary diagnosis. Because the clinic serves adolescents from multiproblem families, only the most urgent treatment issue was recorded. Treatment issues were therefore ranked in order of salience. In cases where crisis intervention was needed, only the reason for the intervention was recorded regardless of whether that student had been using the mental health services for other reasons.
In nearly all of the cases, the primary diagnosis was easily ascertained. As no chart contained more than one type of crisis (e.g., suicidal ideation, psychosis, rape, abuse), each crisis could be recorded as the reason for treatment. Substance abuse and pregnancy (no student had been seen for both) were ranked immediately after crises. Where several psychosocial problems were equally weighted and no crisis had occurred, a primary diagnosis of multiple psychosocial stressors was recorded. Multiple psychosocial stressors included such combinations of ongoing difficulties as general familial discord, nonviolent peer conflict, occasional truancy, and general academic difficulties.
Based on the findings of this study, a group for children of substance abusers was formed. Identified students were invited to participate in weekly meetings lasting the length of one class period (40 minutes). Teacher cooperation was enlisted through the use of student contracts guaranteeing that course work would be completed on time. The contract protected confidentiality by divulging only that students would be participating in a group conducted by clinic staff. Data from these students are presented as an example of use of the group process in mental health treatment provided at a school-based health enter.
Student Visits to the School-Based Health Center
Students have increasingly sought mental health services (see Table 2). Five years after the inception of the center, the number of mental health visits had quadrupled, while the percentage of visits for mental health services had nearly doubled. Between January and December 1992, there were a total of 4,852 visits to the center, 1,002 of which were for mental health services.
Mental health issues represent 17% of all clinic diagnoses generated during 1992 (see Table 3). Of the 265 students who sought mental health services during that year, 253 were referred by the center's medical staff, while 12 came on their own or were referred by school personnel. These students used the mental health services an average of four times during the year. The majority of visits were from females (79%). The ethnic background of students using the mental health services (72% African American, 21% Hispanic, 7% other) was generally representative of the center and school as a whole. Most of the visits were made by 16-year-olds (29%), followed by 17-year-olds (19%) and 18-year-olds (17%).
Primary Diagnoses of Mental Health Service Users
Table 4 shows the primary diagnosis for each of the 265 students who visited the clinic between January and December 1992. Table 5 presents three principal clusters into which many of the primary diagnoses may be divided: pregnancy and sexuality, dysphoria and depression, and conflict and violence. Together, these three diagnostic clusters represent 65.4% of all mental health visits.
Issues related to pregnancy were the leading reason for seeking mental health services. This category refers to actual pregnancies only and therefore does not include preventive services, parent training, or issues related to sexuality and intimacy. Pregnancy-related services include options counseling, family intervention, referrals for prenatal care or termination of pregnancy, and grief counseling for miscarriages or terminated pregnancies.
Cumulatively, suicidal ideation (past or present) and ongoing depression represent 22% of all mental health visits. This does not include those students reporting crises or treatment issues involving underlying depression. Because issues related to grief and mourning (2.3%) and homesickness (.7%) were circumscribed and unrelated to acute crises, they were classified separately. Grief and mourning refers primarily to the loss of friends or family members through death, relocation, parental separation, or the dissolution of relationships, and does not include pregnancy-related losses.
Nonviolent parent-child conflict represents a minimum of 5% of all mental health visits. This category includes familial discord around developmental issues (e.g., autonomy), cultural conflict (e.g., conflict between teenagers who are attempting to acclimate to American culture while their parents identify with the culture and values of their country of origin), and role reversals (e.g., conflict arising when children are supporting their parents financially, or when children are more fluent in English than their parents, who may depend on them for assistance outside of the household), and excludes any conflict warranting intervention from the police or child protective services. Because many issues in the multiple psychosocial stressors classification include nonviolent conflict both between parents and children and between peers, conflict may represent from 5% to 15% of all mental health visits. Mental health visits related to violence include physical fights (3.4%), physical abuse (1.5%), sexual abuse (1. 5%), and rape (.7%). Cumulatively, conflict and violence represent between 12.1% and 22.1% (with psychosocial stressors included) of mental health visits.
Although substance abuse represents only 3.4% of mental health visits (1.9% for substance use in the family, 1.5% for student use), analysis of initial evaluations and notes from subsequent visits indicates that 34% of the students seeking mental health services at the center between January and December 1992 reported problematic substance use in members of their families, regardless of whether they were using the center for reasons related to substance abuse (this percentage includes those students using the mental health services specifically for problems associated with substance abuse among family members). Six percent of the students reported some concern over their own use of drugs or alcohol.
Group for Children of Substance Abusers
Because 34% of the students using the mental health services reported problematic substance use among family members, a group for children of substance abusers was developed for the following academic year. Due to limited space, the group was restricted to nine participants (all female, between ages 14 and 19). Three were African American and six were Hispanic. Of the nine members, four reported personal use of alcohol or marijuana in addition to that of family members. Although this group focused on issues related to substance abuse, this problem represents only one of the many complex psychosocial issues confronting these youth (see Table 6). The multiple psychosocial stressors shown in Table 6 are not only typical of those situations encountered in inner-city school-based health centers, but clearly indicate that high-risk youth are using clinic services.
The data indicate that adolescents need and use a broad range of psychosocial services available to them in a school-based health center. Over a five-year period, the number of mental health visits quadrupled, while the percentage of visits devoted to mental health issues nearly doubled. As school-based health centers become established, the experience has been that increasing numbers of students present with mental health needs and that an increasing amount of staff time must be devoted to these issues.
There are distinct advantages to providing a broad range of mental health services in school-based health centers. The integration of mental health and medical services reduces the need to make referrals to outside facilities, which, in our experience, increases the likelihood that students will receive needed care. Our experience is consistent with that of Harold and Harold (1993), who argue that adolescents are less likely to seek services in unfamiliar settings, and with that of Hoberman (1992), who argues that adolescents require convenient, comprehensive services that do not involve complex or extensive planning for access. That nearly 95% of children and youth are in elementary and secondary schools underscores the convenience and accessibility of school-based health centers (Iverson & Kolbe, 1983). With high-quality care freely available in schools, parents are neither obligated to take time off from work to accompany their children on health care visits nor confronted with having to choose between th eir children's health and economic hardship. These issues become most crucial where professional care must be provided on a regular basis, which is generally the case with mental health services. The regular attendance at group meetings by the children of substance abusers supports our belief that school-based health centers represent an optimal solution to the multiple barriers involved in providing health care to adolescents.
As shown in Table 4, high-risk behaviors, particularly those related to sexuality, are among the leading reasons adolescents seek mental health services in school-based health centers. Taken together, 26.5% of the students using the mental health services were seeking assistance with issues related to either sexuality or pregnancy. Although 19% of this total represents pregnant teens, the other 7.5% represents students seeking information that may be used to postpone sexual activity, to engage in safe sexual activities, or to prevent unwanted pregnancies. It should be noted, however, that at the time of data collection, the social worker was responsible for follow-up visits with pregnant teens, a responsibility that has since been delegated to the nurse practitioner. At present, therefore, the number of visits related to pregnancy would be significantly smaller than that found in this study. Given the shifts in clinic priorities and staff interests, data are likely to vary both among practices and staff memb ers.
Because youth suicide is now recognized as a national mental health problem (Alcohol, Drug Abuse, and Mental Health Administration, 1989), all students who screen positively for a history of suicidal ideation are referred for a more in-depth interview with one of the clinic's mental health providers. It has been our experience that large numbers of teens at risk for suicide seek clinic services. In the group for children of substance abusers alone, four of the nine members admitted past suicidal ideation, with one having made a suicidal gesture. Although some of the reports of previous suicidal ideation represent issues that have already been resolved by the student, our screening and referral practice has nonetheless been invaluable. In addition to identifying students experiencing active suicidal ideation, this process immediately establishes the potential for a caring relationship upon which each student at risk for suicide can rely throughout the remainder of his or her high school experience. Speaking w ith a mental health professional can reassure adolescents that the developmental changes they are experiencing can be contextualized and understood. This can be particularly helpful for youth who, in addition to experiencing the challenge of adolescence, are confronted with parent conflict or acculturation issues, because each of these factors may have an impact on their senses of identity, agency, and security.
An interesting finding was the high percentage (34%) of teens reporting problematic substance use among family members. During the first years of clinic operation, staff were surprised by the low incidence of substance abuse among students. When the problem was redefined to include family members, striking results began to emerge, suggesting a possible link between high-risk behaviors among both youth and family members. The psychosocial stressors among members of the group for children of substance abusers provide some indication of the plausibility of such a link. One of the group members reported that her pregnancy represented an attempt to gain the unconditional love she never felt she received from either of her substance-dependent parents. She worried, however, that becoming pregnant at 16 reenacted what her mother had done at the same age, which made her question her ability to care for her unborn child.
Other links between family substance abuse and high-risk behaviors among youth emerged from group discussions about conflict management and coping skills. When confronted with conflict, violence, or sexually inappropriate behavior on the part of substance-dependent caretakers, many group members reported engaging in physical violence, running away, or making plans to live with others. Given their sense of insecurity, desperation, and low self-esteem, it is not surprising that many of the alternatives these young women sought ultimately perpetuated their experiences of self-defeat. Due perhaps to underlying identification with substance-dependent parents, or to an intense longing for relationships with emotionally unavailable parents, several group members admitted their own increasing use of alcohol and marijuana. For those youth, who often feel responsible for family troubles, the developmental task of emotional separation and differentiation from family members and caretakers is particularly difficult. It is not unusual, for example, for students who have had enormous social and academic success to suddenly begin having difficulties during their senior year while applying to college or making plans to move away from a chaotic home environment.
Some of the challenges of providing school-based health care also warrant examination. Although it is important that all health center staff develop positive relations with school personnel, this may be most important for mental health providers, whose work may require weekly sessions with students. Effective care within secondary schools must meet the unique needs of students without detracting from their education. One relatively successful solution to this dilemma has been the formation of student groups from targeted classes. This method facilitates teacher cooperation while increasing the number of students who can receive regular assistance.
School-based health centers represent an effective means of providing health care services to young people. For high-risk youth in particular, the convenience and accessibility of these centers can mean the difference between obtaining timely medical and mental health assistance and going without care altogether. School-based health centers are, moreover, ideally situated for identifying and responding to the needs of specific subpopulations.
The availability of quality health care in schools can increase the likelihood that students will become future consumers of medical and mental health services, while the exposure to such care can decrease existing stigmas attached to utilizing these services. In addition, the goals of school-based health centers can be achieved without restricting the contributions of other school personnel who are also committed to promoting the well-being of students. Finally, although the findings presented here describe the health services at one inner-city high school, we believe these data provide a relevant depiction of student needs and an optimal approach to meeting those needs.
The authors thank Glenda Combs, C.S.W., for her assistance with data collection, and the Robert Wood Johnson Foundation for its support.
Linda Juszczak, R.N., P.N.P., Project Director, North Shore University Hospital School Health Centers.
Martin Fisher, M.D., Chief, Division of Adolescent Medicine, North Shore University Hospital, and Medical Director, North Shore University Hospital School Health Centers.
Reprint requests to Lisa Jepson, M.A., Psychology Extern, Far Rockaway High School Health Center, North Shore University Hospital, 300 Community Drive, Manhasset, New York 11030.
Adelman, H. (1993). School-linked mental health interventions: Toward mechanisms for service coordination and integration. Journal of Community Psychology, 21, 309-319.
Adelman, H., & Taylor, L. (1993). School-based mental health: Toward a comprehensive approach. Journal of Mental Health Administration, 20(1), 32-45.
Alcohol, Drug Abuse, and Mental Health Administration. (1989). Report of the Secretary's Task Force on Youth Suicide (DHHS Publication No. ADM 89-1621). Washington, DC: U.S. Government Printing Office.
Allensworth, D., & Kolbe, L. (1987). The comprehensive school health program: Exploring an expanded concept. Journal of School Health, 57(10), 409-412.
Balassone, M., Bell, M., & Peterfreund, N. (1991). A comparison of users and nonusers of a school-based health and mental health clinic. Journal of Adolescent Health, 12, 240-246.
Fisher, M., Juszczak, L., Friedman, S., Schneider, M., & Chapar, G. (1992). School-based adolescent health care: Review of a clinical service. American Journal of Diseases in Children, 146, 615-621.
Harold, R., & Harold, N. (1993). School based clinics: A response to the physical and mental health needs of adolescents. Health and Social Work, 18(1), 65-75.
Hauser-McKinney, D., & Peak, G. (1994). School-based and school-linked health centers. Washington, DC: The Center for Population Options.
Hoberman, H. (1992). Ethnic minority status and adolescent mental health services utilization. Journal of Mental Health Administration, 19(3), 246-267.
Huizinga, D., Loeber, R., & Thornberry, T. (1993). Longitudinal study of delinquency, drug use, sexual activity, and pregnancy among children and youth in three cities. Public Health Reports, 108(1), 90-96.
Iverson, D., & Kolbe, L. (1983). Evaluation of the national disease prevention and health promotion strategy: Establishing a role for the schools. Journal of School Health, 53(5), 294-302.
Kirby, D. (1990). Comprehensive school health and the larger community. Journal of School Health, 60(4), 170-177.
Kirby, D., Waszak, C., & Ziegler, J. (1989). Six school based clinics: Their reproductive health services and impact on sexual behavior. Family Planning Perspectives, 23(1), 6-16.
Klein, J., Starnes, S., Kotelcheck, M., Earp, J., DeFriese, G., & Loda, F. (1990). Comprehensive adolescent health services in the United States. Chapel Hill, NC: The Cecil G. Sheps Center for Health Service Research, the Center for Early Adolescence, and the Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill.
Lavin, A., Shapiro, G., & Weill, K. (1992). Journal of School Health, 62(6), 212-228.
Lear, J., Gleicher, H., St. Germaine, A., & Porter, P. (1991). Reorganizing health care for adolescents: The experience of the school-based adolescent health care program. Journal of Adolescent Health, 12, 450-458.
Orr, D., Beiter, M., & Ingersoll, G. (1991). Premature sexual activity as an indicator of psychosocial risk. Pediatrics, 87(2), 141-147.
Schlitt, J., Rickett, K, Montgomery, L., & Lear, J. (1994). State initiatives to support school-based health centers. Washington, DC: Making the Grade Report.
Siegel, L., & Krieble, T. (1987). Evaluation of school-based, high school health services. Journal of School Health, 57(8), 323-325.
Waszak, C., & Neidell, S. (1991). School-based and school-linked clinics update 1991. Washington, DC: The Center for Population Options.
White, S., & DeBlassie, R. (1992). Adolescent sexual behavior. Adolescence, 27(105), 183-191.
Services Provided at the School-Based Health Center
I. Dental Services
On-Site Dental Services (6 Months Each Year)
II. Health Education
Classroom Health Education Group and Individual Patient Education
III. Medical Services
Comprehensive Medical and Psychosocial History (Intake)
Diagnosis and Treatment of Acute and Minor Medical Problems
Dispensing of Selected Medications
Management of Chronic Medical Problems
Referrals to Specialty Services
Well Child Care for Students Children
IV. Mental Health Services
Comprehensive Developmental, Medical, and Psychosocial History
Crisis Intervention and Follow-Up
Individual Mental Health Assessment and Treatment
Mental Health Referrals