Clinical Psychology Review, Vol. 19, No. 2, pp. 137–163, 1999
Copyright © 1999 Elsevier Science Ltd
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MENTAL HEALTH IN SCHOOLS AND
SYSTEM RESTRUCTURING
Howard S. Adelman
University of California, Los Angeles
Linda Taylor
Los Angeles Unified School District
ABSTRACT. Because health is not the primary business of schools, a school’s response to mental health and psychosocial concerns usually is limited to targeted problems seen as direct barriers
to learning. And because resources are sparse, priority is given to problems defined in legislative
mandates. As a result, school-based mental health services are available only to a small proportion of the many students who require assistance, and interventions generally are narrowly focused and short-term. To better meet the needs of those served and to serve greater numbers, emerging trends are pushing for restructuring of school-owned services and greater linkage with
community resources to develop multifaceted, comprehensive, integrated approaches. This review
(a) provides an overview of what schools currently do related to mental health and psychosocial
concerns, (b) clarifies key emerging trends, and (c) explores implications for major systemic
changes. © 1999 Elsevier Science Ltd
WHILE PARTICIPATION OF clinical psychologists in schools is not extensive, the discipline of clinical psychology and the field of mental health have much to contribute
to the success of schools. In addition, schools provide invaluable access to students
and families in need of mental health services. Schools also offer unique opportunities for intensive, multifaceted approaches and are essential contexts for prevention
and research activity. Over the years, schools have benefitted greatly from the work of
exceptional leaders whose roots are in clinical psychology (e.g., Emory Cowen, Seymour Sarason, Ed Zigler). Renewed interest in school-based and school-linked mental
health and psychosocial programs is seen in early intervention, various forms of counseling, crisis intervention, problem prevention, and promotion of health and social
and emotional development (see Adelman & Taylor, 1993a; Comer, 1988; Day & RobCorrespondence should be addressed to Howard S. Adelman, Department of Psychology, University of California at Los Angeles, Box 951563, Los Angeles, CA 90095-1563.
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erts, 1991; Goodwin, Goodwin, & Cantrill, 1988; Henggeler, 1995; Knitzer, Steinberg,
& Fleisch, 1990; Sitwell, DeMers, & Niguette, 1985; Taylor & Adelman, 1996; Weist,
1997). Currently, most schools have at least a few programs and services that are
highly relevant to mental health research and practice.
Why do schools have any mental health-related programs? There are, of course, legal mandates requiring mental health services for some students diagnosed with special education needs (Duchnowski, 1994). In addition, school administrators, board
members, teachers, parents, and students have long recognized that social, emotional,
and physical health problems and other major barriers to learning must be addressed
so that schools function satisfactorily and students learn and perform effectively (see
Carlson, Paavola, & Talley, 1995; Dryfoos, 1994, 1998; Flaherty, Weist, & Warner,
1996; Tyack, 1992). This has led to a variety of student “support” services, including
some designed to reach out to underserved and hard-to-reach individuals.
Our purpose here is to (a) provide an overview of what schools currently do related
to mental health and psychosocial concerns, (b) clarify some emerging trends, and
(c) explore implications for major systemic changes—implied throughout are roles
for clinical psychology.
HOW DO SCHOOLS ADDRESS MENTAL HEALTH?
Everyday, teachers ask for help in dealing with problems; often they also would like
support to facilitate their student’s healthy social and emotional development. Yet, despite long-standing and widespread acknowledgement of need, such activities continue to be a supplementary item on a school’s agenda. This is not surprising; schools
are not in the mental health business. Their mandate is to educate. Thus, they tend to
see any activity not directly related to instruction as taking resources away from their
primary mission.
Table 1 highlights the types of problems, as well as areas related to healthy development, that arise in the context of schools. Efforts to deal with these concerns have led
to establishment of various school-owned services and programs and to initiatives for
school-community collaborations.
An extensive literature reports positive outcomes for psychological interventions
available to schools.1 However, enthusiasm about positive findings is tempered by the
reality of the restricted range of dependent variables (e.g., short-term improvement
on small, discrete tasks), limited generalization, and uncertain maintenance of outcomes. With respect to individual treatments, most positive evidence comes from work
done in tightly structured research situations; unfortunately, comparable results are
1Examples
of the literature reporting positive outcomes include: Adelman & Taylor, 1993b;
Albee & Gullotta, 1997; Anglin, Naylor, & Kaplan, 1996; Bond & Compas, 1989; Borders &
Drury, 1992; Carnegie Council on Adolescent Development, 1988; Christopher, Kurtz, & Howing, 1989; Dryfoos, 1990, 1994, 1998; Duchnowski, 1994; Durlak, 1995; Duttweiler, 1995; Goleman, 1995; Hickey, Lockwood, Payzant, & Wenrich, 1990; Holtzman, 1992; Kazdin, 1993; Kirby
et al., 1994; Knoff & Batsche, 1995; Larson, 1994; Mitchell, Seligson, & Marx, 1989; Price,
Cowen, Lorion, Ramos-McKay, & Hutchins, 1988; Schorr, 1988, 1997; Slavin, Karweit, & Madden, 1989; Slavin, Karweit, & Wasik, 1994; Thomas & Grimes, 1995; U.S. Department of Health
and Human Services, 1994; Weissberg, Caplan, & Harwood, 1991; Weissberg, Gullotta, Hamptom, Ryan, & Adams, 1997; Weisz & Weiss, 1993; Zigler, Kagan, & Hall, 1996.
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TABLE 1. Barriers to Learning and Areas for Enhancing Healthy Development
not found when prototype treatments are institutionalized in school and clinic settings (see Weisz, Donenberg, Han, & Kauneckis, 1995, and Weisz, Donenberg, Han, &
Weiss, 1995, for discussion of this matter specifically focused on psychotherapy; see
Gitlin, 1996, for a comparable discussion related to psychopharmacology.) Similarly,
most findings on classroom and small group programs reflect short-term experimental studies (usually without any follow-up phase). It remains an unanswered question
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as to whether the results of such projects will be sustained when prototypes are translated into widespread applications (see Adelman & Taylor, 1997a; Elias, 1997). And
the evidence clearly is insufficient to support any policy restricting schools to use of
empirically supported interventions. Still, there is a menu of promising practices, with
benefits not only for schools (e.g., better student functioning, increased attendance,
and less teacher frustration), but for society (e.g., reduced costs related to welfare, unemployment, and use of emergency and adult services). The state of the art is promising; the search for better practices remains a necessity.
Interveners and Their Functions
In schools, efforts to address barriers to learning and enhance healthy development
are not the sole province of professionals/specialists. Professionals trained to provide
mental health interventions play special roles with respect to preventing and correcting problems and enhancing the well-being of students, families, and school staff. But
family members, students, nonprofessional school staff, and many individuals and
groups in a community also can help address the concerns outlined in Table 1. Table
2 lists types of interveners and specific functions related to meeting psychosocial and
mental health needs found in schools.
Interveners. As noted in Table 2, the range of persons who may carry out functions related to mental health activity in schools encompasses all who are hired by a school, as
well as students, family members, community agency personnel, volunteers, and others. With respect to school specialists, there is no typical pattern of staffing. In most
states, elementary schools may only receive support 1 day a week from a couple of professionals, such as a school counselor, nurse, psychologist, or social worker. Middle
and high schools usually are assigned support for more days and from diverse practitioners. Schools with funding for compensatory interventions, special education, and
other categorical programs can afford more services. Additional resources also are
available at the small number of schools where health clinics, service centers, or
school-community collaborations have been established.
Taken as a whole, one finds in schools an extensive range of preventive and corrective activity oriented to student’s problems. Some programs are provided throughout
a school district, others are carried out at or linked to targeted schools. The interventions may be offered to all students in a school, to those in specified grades, or to
those identified as “at risk,” and may be designed for delivery to entire classes, small
groups, or individuals. Activities may be implemented in regular or special education
classrooms or as programs that pull students out of class for part of a period or day to
work on designated problems. With specific respect to mental health, the full range of
topics arise—including matters related to promoting mental health, minimizing the
impact of psychosocial problems, managing psychotropic medication, and participating in systems of care for seriously emotionally disturbed youngsters. It is common
knowledge, however, that few schools come close to having enough resources to deal
with a large number of students with mental health problems—nevermind mounting
a potent approach to address the wider range of psychosocial barriers interfering with
the learning and performance of so many. Various types of personnel and forms of intervention simply are not available to students. Most schools offer only bare essentials.
Too many schools cannot even meet basic needs. Primary prevention often is only a
dream.
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TABLE 2. Types of Interveners and Functions
Most school-owned and operated services are offered as part of what are called pupil personnel services. Federal and state mandates tend to determine how many pupil
services professionals are employed, and states regulate compliance with mandates.
Governance of daily practice usually is centralized at the school district level, often un-
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der a director or assistant superintendent. In large districts, counselors, psychologists,
social workers, and other specialists may be organized into separate units. Such units
straddle regular and special education. As school districts move to decentralize authority and empower all stakeholders at the school level, and as managed care takes
hold, a realignment is likely in how pupil service professionals are governed and how
they are involved in school governance and collective bargaining. Ultimately, this realignment and efforts to improve cost-effectiveness will play a major role in determining how many of such personnel there are at a school (Hill & Bonan, 1991; Streeter &
Franklin, 1993).
Currently, schools employ or contract with relatively few mental health practitioners. Based on a sample of 482 districts of varying sizes in 45 states, recent survey data
indicate that 55% report having counselors; 40.5% have psychologists; 21% have social workers; and 2.1% have psychiatrists (Davis, Fryer, White, & Igoe, 1995). Another
recent survey found that 84% of middle/junior high schools and 89% of high schools
report providing individual counseling, and 61% of middle/junior high schools and
59% of high schools report that they provide some type of group counseling (Small et
al., 1995). These figures are somewhat surprising in light of the estimated ratio of students to practitioners; for example, the ratio for school psychologists or school social
workers averages 1 to 2500 students; for school counselors, the ratio is about 1 to 1000
(Carlson et al., 1995). Given estimates that more than half the students in many
schools are encountering major barriers that interfere with their functioning, such ratios inevitably mean that more than narrow-band approaches must be used if the majority are to receive needed help (Knitzer et al., 1990).
Functions. Specialists oriented to mental health and psychosocial concerns tend to focus on students who are seen as problems or as having problems. Prevailing approaches identify the needs of targeted individuals and prescribe one or more interventions. Activity encompasses direct interventions, brief consultation, and gatekeeping
procedures (such as referral for assessment, corrective services, triage, and diagnosis).
In some situations, however, resources are so limited that specialists do little more
than offer brief consultations and make referrals to special education and/or community resources. Well-developed systems include mechanisms for case coordination, ongoing consultation, program development, advocacy, and quality assurance. There
also may be a focus on primary prevention and enhancement of healthy development
through use of health education, health services, guidance, and so forth; however, relatively few resources are allocated for such activity.
All the efforts are meant to contribute to a reduction in problem referrals for special assistance, an increase in the efficacy of mainstream and special education programs, and enhanced instruction and guidance that fosters healthy development. In
addition, it should be noted that personnel dealing with mental health and psychosocial concerns may also play a role in facilitating program development and system reform, as well as helping enhance school-community collaborations.
Professionals with psychological training bring to schools an understanding of psychosocial, developmental, and cultural factors that facilitate or interfere with positive
functioning. They also are expected to bring perspectives of intervention that emphasize attitude and motivation change, system strategies, use of “best fit” and “least intervention needed” approaches, and more (see Table 3). Such knowledge and related
skills are needed in assisting students with mild-to-moderate learning, behavior, and
emotional problems and in addressing targeted problems (e.g., school avoidance and
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TABLE 3. Some Key Intervention Considerations Related to Personnel
Working in Schools
dropout, substance abuse, gang activity, teen pregnancy, and depression). Such a
range of expertise also is essential in working with the diversity of backgrounds and
the wide range of individual and group differences found among students, their families, and school staff.
School-Community Collaborations
Concern about the fragmented way community health and human services are planned
and implemented has led to renewal of the 1960s human service integration move-
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TABLE 4. Key Dimensions Relevant to School-Community
Collaborative Arrangements
ment (see annotated bibliography by Walsh, Chastenay-Simpson, Craigie, & Holmes,
1997). The hope is to better meet the needs of those served and use existing resources
to serve greater numbers. To these ends, there is considerable interest in developing
strong relationships between school sites and public and private community agencies.
As a result, a variety of forms of school-community collaborations are being tested, including statewide initiatives in California, Florida, Kentucky, Missouri, New Jersey,
and Oregon (First, Curcio, & Young, 1994; Palaich, Whitney, & Paolino, 1991). Table
4 outlines key dimensions relevant to such collaborative arrangements.
School-linked services. Initiatives to restructure community health and human services
have fostered the concept of school-linked services and contributed to the burgeoning of
school-based and linked health clinics (U.S. Department of Education, 1995). It
should be noted that the terms school-linked and school-based encompass two separate
dimensions: (1) where programs/services are located and (b) who owns them. Literally,
school-based indicates activity carried out on a campus, and school-linked refers to
off-campus activity with formal connections to a school site. In either case, services
may be owned by a specific school, the school district at large, or a community-based
organization or in some cases are co-owned. (It also should be noted, however, that
the term school-linked is commonly used to denote only community owned on- and offcampus services and is strongly associated with the notion of coordinated services.)
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As discussed later, other related concepts that are widely used include wrap-around
services, one-stop shopping, full service schools, and community schools. Also related is the notion of systems of care, but this concept usually is reserved for the set of services provided to individual’s who have been designated as emotionally disturbed (Bickman,
1997; Day & Roberts, 1991; Duchnowski & Friedman, 1990; Hoagwood, 1997). Adoption of these concepts reflects the desire to develop a sufficient range of accessible interventions to meet the needs of those served. Many projects illustrating such concepts offer an array of medical, mental health, and social services housed in a Family
Service or Resource Center established at or near a school (see Dryfoos, 1994, 1995).
As the concept of school-linked services spreads, the terms services and programs are
often used interchangeably. This leads to confusion, especially since addressing a full
range of barriers to learning requires going beyond a focus on services. The term services tends to denote special assistance provided to specific clients individually or in
small groups (e.g., clinical interventions) or to the public at large (e.g., ad hoc public
service announcements related to mental health). And given this range, such activity
should be differentiated at least to distinguish between narrow-band, personal/clinical services and broad-band, public health and social services (Adelman, 1995). However, even this distinction is not sufficient. It is important to recognize that, although
services often are provided as part of a program, not all are. For example, counseling
to ameliorate mental health problems can be offered on an ad hoc basis or may be offered as one element of a multifaceted program. Programs characteristically involve a
range of activity that are part of a systemic approach and are programmatically designed to meet the broad aims of an organization or society. Pervasive and severe psychosocial problems, such as substance abuse, teen pregnancy, physical and sexual
abuse, gang violence, and delinquency, require multifaceted, programmatic interventions. Beside providing services to correct existing problems of individuals, such interventions encompass primary prevention activity (e.g., public health policies and practices that target groups seen as “at risk”) and a broad range of open enrollment
didactic, enrichment, and recreational activities. Differentiating services and programs helps mediate against tendencies to limit the range of interventions for addressing barriers to learning. The distinction also underscores the breadth of activity
that requires coordination and integration.
In analyzing school-linked service initiatives, Franklin and Streeter (1995) categorize five approaches—informal, coordinated, partnerships, collaborations, and integrated services. These are seen as differing in terms of the degree of system change required. As would be anticipated, most initial efforts focus on developing informal
relationships and beginning to coordinate services.
As Knapp’s (1995) review notes, the contemporary literature on school-linked services is heavy on advocacy and prescription and light on data. Each day brings more
reports from projects such as New Jersey’s School-Based Youth Services Program, the
Healthy Start Initiative in California, the Beacons Schools in New York, Communitiesin-Schools, and the New Futures Initiative. Not surprisingly, the reports primarily indicate how hard it is to establish collaborations. Still, a reasonable inference from available data is that school-community collaborations can be successful and cost effective
over the long-run. By placing staff at schools, community agencies make access easier
for students and families—especially those who usually are underserved and hard to
reach. Such efforts not only provide services, they seem to encourage schools to open
their doors in ways that enhance family involvement. Analyses suggest better outcomes are associated with empowering children and families, as well as the capability
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to address diverse constituencies and contexts. Families using school-based centers
are described as becoming interested in contributing to school and community by
providing social support networks for new students and families, teaching each other
coping skills, participating in school governance, and helping create a psychological
sense of community (White & Wehlage, 1995).
Systems of care. Properly developed, a system of care is a special form of school-community collaboration designed to provide comprehensive services for youth with serious emotional problems. The concept also is becoming a popular way to talk about
any effort to provide cohesive assistance to clients. Thus, recent research on systems of
care is likely to find its way into discussions of the value of collaborative efforts among
services. Based on their evaluation of a major system of care demonstration project in
Fort Bragg, Salzer and Bickman (1997) conclude that while systems of care produce
important system-level changes, early results suggest these system changes do not enhance clinical outcomes. They argue that the primary direction to improving children’s mental health services should be through effectiveness research, in contrast to
continued large-scale investments in system research and development. In response,
others have interpreted the findings from the Fort Bragg study as supportive of the
concept of systems of care, because participants in both the elaborate system of care
model and the more simplified continuum of services comparison model showed improvements (Hoagwood, 1997). For example, Hoagwood’s interpretation is that the
more elaborate model did not improve upon the already adequate interventions provided in the comparison sites.
Some concerns. Research issues aside, initiatives for school–community collaborations
raise various concerns (see Adelman, 1996b; Lawson & Briar-Lawson, 1997; Smrekar,
1994). They may enhance access to services, reduce redundancy, improve case management, coordinate resources, and increase efficacy—all of which clearly are desirable goals. In pursuing these ends, however, the tendency is to think mainly in terms
of coordinating community services and putting some on school sites. This has produced tension between school district service personnel and their counterparts in
community-based organizations. When “outside” professionals are brought into a
school, school specialists often view it as discounting their skills and threatening their
jobs. Moreover, the emphasis on school-linked services downplays the need for restructuring the various education support programs and services schools own and operate. Initiatives for school-linked services also lead some policy makers to the mistaken impression that such an approach can effectively meet the needs of schools in
addressing barriers to learning. In turn, this leads some legislators to view schoollinked services as a replacement for school-owned services. The reality is that even
when one combines community and school assets, the total set of services in economically impoverished locales is woefully inadequate (Koyanagi & Gaines, 1993).
Current Policy Status
With respect to policy, national and state legislation and statements by education
agencies, school administrators’ associations (e.g., Council of Chief State School Officers), and school boards clearly acknowledge that services are needed to enable students to benefit from instruction. At the same time, despite the existence of a variety
of counseling, psychological, and social interventions in schools, it is evident that pu-
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pil services and school health programs do not have high status in the educational hierarchy and in current health and education policy initiatives (Allensworth, Wyche,
Lawson, & Nicholson, 1997; Dryfoos, 1998; Zigler, Kagan, & Hall, 1996). The continuing trend is for schools and districts to treat such activity, in policy and practice, as desirable, but not essential. The efforts are frequently referred to as “auxiliary” or “support” services. Because of this devalued status, there is no cohesive policy vision for
addressing barriers to learning and enhancing healthy development. Relatedly, pupil
services personnel too often are among those deemed dispensable as budgets tighten.
For example, although some groups have increased their numbers (e.g., school social
workers), overall staffing of pupil services in most districts has been significantly cut
back in recent years (Gibelman, 1993). All this results in disjointed advocacy and planning and inevitable fragmentation in providing services and programs (Adelman,
1995, 1996a, 1996b; Adelman & Taylor, 1993b, 1997b; Adler & Gardner, 1994; Carnegie Council on Adolescent Development, 1988; Dryfoos, 1993, 1994, 1995; Hickey,
Lockwood, Payzant, & Wenrich, 1990; Hodgkinson, 1989; Lawson & Briar-Lawson,
1997; Melaville, Blank, & Asayesh, 1993; White & Wehlage, 1995).
Funding policies also contribute to intervention fragmentation. Funds are often
earmarked for use only in treating narrowly defined problems, and budget cuts tend
to increase competition for resources and work against collaboration. And the expanding managed-care environment and changes in the welfare system are exacerbating the situation (Brellochs, Zimmerman, Zink, & English, 1996; DeGraw, Park, &
Hudman, 1995; DeMers & Bricklin, 1995; Lourie, Howe, & Roebuck, 1996; Rand Corporation, 1996; Twentieth Century Fund, 1995a, 1995b). It should be noted also that
the emphasis on entrepreneurship in public education has resulted in schools seeking
more and more specially funded projects. Obviously, schools need more resources.
However, such projects—including those connected with university faculty research—
tend to shift time and energy away from other programs and from efforts to build infrastructure for comprehensive, integrated approaches to address barriers to learning
and enhance healthy development. The trend is for special projects to operate as ad
hoc programs, and they almost always disappear once the funding period ends. The
phenomenon is so prevalent that the term projectitis has been coined to raise consciousness about the dangers inherent in pursuing grants that distract and fragment
staff and create programs that cannot be sustained after the grant ends.
Given the policy context, it is not surprising that so little is done at any administrative level to create the necessary leadership and organizational structure for establishing a potent approach to address barriers to learning and enhance student’s healthy
development. Mental health and other specialist personnel are almost never a prominent part of a school’s organizational structure. As schools move toward school-based
management and shared decision-making, such personnel are rarely included in new
shared governance and planning bodies. One result is that the planning of programs,
services, and delivery systems often is done on an ad hoc basis. Service personnel tend
to operate in relative isolation of each other and other stakeholders, with a great deal
of the work oriented to discrete problems and with an overreliance on specialized services for individuals and small groups.
With respect to the organization of services and programs offered at schools, the
trend toward fragmentation is compounded by most school-linked services initiatives.
This happens because such initiatives focus primarily on coordinating community services and linking them to schools, rather than integrating such services with the ongoing efforts of school staff. Fragmentation also reflects the failure of educational re-
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form to restructure the work of school professionals who carry out psychosocial and
health programs, as well as the dearth of policy establishing effective mechanisms for
coordination and integration. In some schools, the deficiencies of current policies
give rise to such aberrant practices as the involvement of a student identified as at risk
for dropout, suicide, and substance abuse in three counseling programs operating independently of each other.
With respect to on-the-job education, policy makers allocate few resources to considerations related to addressing barriers to learning and enhancing healthy development. Almost none of a teacher’s inservice training focuses on improving classroom
approaches for dealing effectively with mild-to-moderate behavior, learning, and emotional problems. Paraprofessionals, aides, and volunteers working in classrooms and
in the area of pupil services still receive little or no formal training/supervision before
or after they are assigned duties. And little or no attention is paid to cross-disciplinary
training.
EMERGING TRENDS
Efforts underway to refine existing reforms and fill major policy gaps are expected to
produce fundamental shifts in thinking about mental health in schools and about the
personnel who provide such services. Two emerging trends are discussed here: (a) the
move from fragmentation to cohesive intervention and (b) the move from narrowly focused, problem specific, and specialist-oriented services to comprehensive general
programmatic approaches.
Toward Cohesiveness
As already noted, most school health and human service programs (as well as compensatory and special education programs) are developed and function in relative isolation of each other. Available evidence suggests that this produces fragmentation
which, in turn, results in waste and limited efficacy. National, state, and local initiatives to increase coordination and integration of community services are just beginning to direct school policy makers to a closer look at school-owned services (Adler &
Gardner, 1994; Kahn & Kamerman, 1992; Los Angeles Unified School District, 1995;
U.S. General Accounting Office, 1993). This is leading to new strategies for coordinating, integrating, and redeploying resources (Tharinger, 1995). Of particular relevance are (a) processes for mapping and matching resources and needs and (b)
mechanisms for resource coordination and enhancement.
Mapping and matching resources and needs. The literature on resource coordination
makes it clear that a first step in countering fragmentation involves “mapping” resources (e.g., clarifying existing programs and services that support students, families,
and staff; delineating referral and case management procedures). A comprehensive
form of need and asset assessment is generated when resource mapping is paired with
surveys of unmet needs and existing strengths of students, their families, and school
staff. Analyses of these data allow for systematic formulation of strategies for resource
enhancement, including (a) outreach to link with additional resources at other
schools, district sites, and in the community and (b) establishing better ways to use existing resources.
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For both the school and community agencies, mapping and analyzing resources
provides a basis for redeploying and improving cost-effectiveness. In some schools,
about 40% of the resources are assigned to functions other than regular instruction
(Tyack, 1992), but, as yet, little attention has been paid to analyzing and restructuring
such resources. Among community agencies, there is acknowledged redundancy
stemming from ill-conceived policies and lack of coordination (Hodgkinson, 1989).
These facts do not translate into evidence that there are pools of unneeded personnel; they simply suggest there are resources that can be used in different ways to address unmet needs. Given that additional funding for reform is hard to obtain, such
redeployment of resources is the primary answer to the ubiquitous question: Where will
we find the funds?
Mechanisms for resource coordination and enhancement. An example of a mechanism designed to reduce fragmentation and enhance resource availability and use (with a view
to enhancing cost-effectiveness) is seen in the concept of a Resource Coordinating Team
(Adelman, 1993; Rosenblum, DiCecco, Taylor, & Adelman, 1995). Such a mechanism
is used to weave together existing school and community resources and encourage cohesive functioning of services and programs.
A resource-oriented team differs from teams created to review individual students
(such as a student study or a teacher assistance team). That is, its focus is not on specific cases, but on clarifying resources and their best use. In doing so, it provides what
is often a missing mechanism for managing and enhancing systems to coordinate, integrate, and strengthen interventions. Such a team is assigned responsibility for (a)
mapping and analyzing activity and resources with a view to improving coordination,
(b) ensuring that there are effective systems for referral, case management, and quality assurance, (c) guaranteeing that there are sound procedures for management of
programs and information and for communication among school staff and with the
home, and (d) exploring ways to redeploy and enhance resources—such as clarifying
which activities are nonproductive and suggesting better uses for the resources, as well
as reaching out to connect with additional resources in the school district and community.
Although a resource-oriented team might be created solely around mental health
and psychosocial programs, such a mechanism is meant to bring together representatives of all major programs and services supporting a school’s instructional component (e.g., guidance counselors, school psychologists, nurses, social workers, attendance and dropout counselors, health educators, special education staff, bilingual
program coordinators, and representatives of any community agency that is significantly involved at the school). The intent also is to include the energies and expertise
of one of the site’s administrators, one or more regular classroom teachers, noncertificated staff, parents, and older students. Where creation of “another team” is seen as a
burden, existing teams, such as student study teams, teacher assistance teams, and
school crisis teams, have demonstrated the ability to extend their focus to resource coordination.
Properly constituted, trained, and supported, a resource team complements the
work of the site’s governance body providing overview, leadership, and advocacy for
all activity aimed at addressing barriers to learning and enhancing healthy development. Having at least one representative from the resource team on the school’s governing and planning bodies ensures essential programs and services are maintained,
improved, and increasingly integrated with classroom instruction.
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To facilitate resource coordination and enhancement among a complex of schools
(e.g., a high school and its feeder schools), the mechanism of a Resource Coordinating Council brings together representatives of each school’s resource team. Schools in a
given locale usually try to link with the same set of community resources, and a resource council can help ensure cohesive and equitable deployment of available resources. A complex of schools working together also can achieve economies of scale.
Moreover, since many families have children at different levels of schooling, a high
school and its feeder schools often are dealing with the same family and can both enhance consistency of effort and reduce redundancy through coordination and integration of effort.
Toward Comprehensiveness
Most schools still limit many mental health interventions to individuals who create significant disruptions or experience serious personal problems and disabilities. In responding to the troubling and the troubled, the tendency is to rely on narrowly focused, short-term, cost intensive interventions. Given that resources are sparse, this
means serving a small proportion of the many students who require assistance and doing so in a noncomprehensive way. The deficiencies of such an approach have led to
calls for increased comprehensiveness—both to better address the needs of those
served and to serve greater numbers. To enhance accessibility, the call has been to establish schools as a context for providing a significant segment of the basic interventions that constitute a comprehensive approach for meeting such needs. One response to all this is the growing movement to create comprehensive school-based
centers. Another response is seen in efforts to balance generalist and specialist approaches. Ultimately, the need is for a full continuum of prevention and corrective
programs that are integrated with each other and with instruction.
Schools as service centers. Over the last decade, many of the now over 1000 schoolbased or linked health clinics have been described as comprehensive centers (Advocates for Youth, 1994; Dryfoos, 1994; Robert Wood Johnson Foundation, 1993). Initially, school-based clinics were created in response to concerns about teen pregnancy
and a desire to enhance access to physical health care for underserved youth. Soon after opening, such clinics found it essential also to address mental health and psychosocial concerns. The need to do so reflects two basic realities: (a) the physical complaints of some students are psychogenic, and thus, treatment of various medical
problems may be aided by psychological intervention, and (b) in a large number of
cases, students come to clinics primarily for help with nonmedical problems related to
peer and family relationships, emotional distress, physical and sexual abuse, and
abuse of alcohol and other drugs. Indeed, up to 50% of visits may be for nonmedical
concerns (Adelman, Barker, & Nelson, 1993; Anglin, Naylor, & Kaplan, 1996; Center
for Reproductive Health Policy Research, 1989; Robert Wood Johnson Foundation,
1989). Thus, as clinics evolve, so does provision of psychological and social services in
the schools. At the same time, given the limited number of staff at such clinics and in
the schools, it is not surprising that the demand for psychosocial interventions quickly
outstrips available resources, and the problem is compounded if the staff overrelies on
a clinical model (Adelman, 1996b).
Relatedly, as noted above, policy initiatives in an increasing number of states encourage linkages between schools and community agencies to enhance comprehen-
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siveness, integration, accessibility, and use of services by students and their families.
The focus on serving families is seen as ensuring benefits to all youngsters in a community. Pioneering demonstrations of school-based Family Service Centers show the
promise and problems related to developing relationships between schools and such
community agencies as county public health, mental health, and child and family services. Dryfoos (1994, 1995) encompasses the trends to develop family service centers,
school-based primary health clinics, youth service programs, community schools, and
other similar activity under the rubric of full service schools. (She credits the term to
Florida’s comprehensive school-based legislation.) As she notes in her review:
Much of the rhetoric in support of the full service schools concept has been presented in
the language of systems change, calling for radical reform of the way educational, health,
and welfare agencies provide services. Consensus has formed around the goals of onestop, seamless service provision, whether in a school- or community-based agency, along
with empowerment of the target population . . . most of the programs have moved services from one place to another; for example, a medical unit from a hospital or health department relocates into a school through a contractual agreement, or staff of a community mental health center is reassigned to a school, or a grant to a school creates a
coordinator in a center. As the program expands, the center staff work with the school to
draw in additional services, fostering more contracts between the schools and community
agencies. But few of the school systems or the agencies have changed their governance.
The outside agency is not involved in school restructuring or school policy, nor is the
school system involved in the governance of the provider agency. The result is not yet a
new organizational entity, but the school is an improved institution and on the path to becoming a different kind of institution that is significantly responsive to the needs of the
community. (p. 169)
Balancing specialist and generalist perspectives. Another response to the call for comprehensiveness is a quest to balance problem-specific and specialist-oriented services with
a generalist perspective, including less categorical, cross disciplinary programs (e.g.,
Henggeler, Schoenwald, Pickrel, & Rowland, 1994). Specialized approaches currently
dominating psychosocial interventions in schools are shaped primarily by two factors.
One is funding agency regulations and guidelines, for example, those related to legislatively mandated compensatory and special education programs and to categorical
programs for addressing social problems, such as substance abuse, gang and on-campus violence, and teen pregnancy. The other shaping force is the prevailing intervention models taught by various fields of professional specialization, such as school
counseling, school and clinical psychology and social work, and other specialty areas
of therapeutic intervention.
To counter what some describe as “hardening of the categories,” the trends are toward granting (a) flexible use of categorical funds and (b) temporary waivers from
regulatory restrictions. There is also renewed interest in cross-disciplinary training—
with several universities already testing interprofessional collaboration programs.
These trends are intended to increase the use of generalist strategies in addressing the
common factors underlying many student problems. The aim also is to encourage less
emphasis on who owns the program and more attention to accomplishing desired
outcomes (see Adelman, 1996a, 1996b; Adelman & Taylor, 1994, 1997b; Dryfoos,
1998; Lawson & Briar-Lawson, 1997; Lawson & Hooper-Briar, 1994; Lipsky & Gartner,
1996; Meyers, 1995; Young, Gardner, Coley, Schorr, & Bruner, 1994).
With respect to designing a comprehensive, integrated approach, the intent is to
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develop and evolve a continuum of programs and services encompassing instruction
and guidance, primary prevention, early-age and early-after-onset interventions, and
treatments for severe problems. To this end, the most radical proponents of a generalist orientation argue for a completely noncategorical approach. In doing so, they
point to data suggesting limited efficacy of categorical programs (e.g., Jenkins, Pious, &
Peterson, 1988; Kahn & Kamerman, 1992; Slavin et al., 1991). Their advocacy lends
support for policy shifts toward block grants in distributing federal welfare, health,
and education dollars to states. More moderate proponents of a generalist perspective
argue for a softening of the categories and use of waivers to encourage exploration of
the value of blended funding. Debates over balancing generalist and specialist roles
have given renewed life to discussions of differentiated staffing and specific roles and
functions for generalists, specialists, and properly trained paraprofessionals and nonprofessionals.
Examples of a nonradical (moderate) generalist approach are seen in two extensive
demonstrations, one of which is designed to restructure health and human services
throughout a large urban school district (Los Angeles Unified School District, 1995).
The other is part of one of the nine “break the mold” models funded by the New
American Schools Development Corporation (Learning Center Model, 1995). Both
drew on analyses that suggest that existing student support services and programs cluster rather naturally into six general programmatic areas. These six interrelated areas
encompass interventions to (a) enhance classroom-based efforts to enable learning,
(b) provide prescribed student and family assistance, (c) respond to and prevent crises, (d) support transitions, (e) increase home involvement in schooling, and (f) outreach to develop greater community involvement and support—including recruitment of volunteers (Adelman, 1996a; Adelman & Taylor, 1994). At schools where
existing interventions were mapped and analyzed with reference to the six areas, the
process quickly identified redundant and nonproductive programs. It also helped
clarify the strengths and weaknesses in each area, including a variety of coordination
and resource needs. The mapping and analyses then became the bases for making priority decisions regarding redesigning interventions and enhancing outcome efficacy.
In sum, current reforms highlight (a) the undesirable redundancy stemming from
addressing overlapping problems through categorical funding and (b) the value of a
generalist approach that is balanced with specialist assistance for those who need it.
More specifically, the work underscores that enhancing programs in each of the six
basic areas designated above often requires turning specialist knowledge and skills
into generalist programs that are carried out collaboratively by a variety of stakeholders at a school. And the demonstrations validate that some students (albeit considerably less than current reports suggest) continue to require assistance of a specialist nature, and thus, specialist personnel must still devote a portion of their time to meeting
these needs.
A full continuum of integrated interventions. Ultimately, addressing barriers to learning
and enhancing healthy student development must be viewed from a societal perspective.
From this viewpoint, the aim becomes that of developing a comprehensive, integrated
continuum of community and school programs for local catchment areas. The framework
for such a continuum emerges from analyses of social, economic, political, and cultural
factors associated with the problems of youth and from reviews of promising practices.
Figure 1 illustrates such a continuum. The outlined examples highlight that a comprehensive approach is built with a holistic and developmental emphasis. Such an ap-
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FIGURE 1. From Primary Prevention to Treatment of Serious Problems: A Continuum of
Community-School Programs to Address Barriers to Learning and Enhance Healthy
Development, by H. S. Adelman and L. Taylor, 1993a, Forest Grove, CA: Brooks/Cole.
Copyright 1993 by Brooks/Cole. Adapted with permission.
proach requires a significant range of programs focused on individuals, families, and
environments and encompasses peer and self-help strategies. Implied is the importance of using the least restrictive and nonintrusive forms of intervention required to
address problems and accommodate diversity. With respect to concerns about integrating activity, the continuum of community and school interventions underscores
that interprogram connections are essential on a daily basis and over time.
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SYSTEM RESTRUCTURING
The prevailing state of affairs and emerging trends just described suggest the need for
fundamental systemic reform. Central to such reform are policies and strategies that
can counter fragmentation by integrating the efforts of school, home, and community. On a hopeful note, there is some evidence of favorable policy movement at national, state, and local levels. An example is the mental health in schools initiative begun in 1995 by the U.S. Department of Health and Human Service’s Maternal and
Child Health Bureau (Office of Adolescent Health). As a first step, five statewide, multiyear projects and two national training and technical assistance centers were established and already are pursuing a wide range of activity designed to improve how
schools address barriers to learning and enhance healthy development. Another example is seen in support by the Centers for Disease Control and Prevention (CDC) of
counseling, psychological, and social services as one of eight components of a school
health program (e.g., Kolbe, 1986; see also the 1997 Institute of Medicine report edited by Allensworth et al. [1997]). To advance this model of school health programs,
CDC has funded a large-scale, multiyear project (Marx & Wooley with Northrop,
1998). Relatedly, several years ago, CDC began supporting an administrative arrangement to enhance interagency collaboration between state health and education agencies to build each state’s capacity to improve school health programs (Kolbe, 1993).
The U.S. Department of Education (DOE) is also concerned about countering service fragmentation. In 1995, DOE initiated a working group to address the lack of integrated effort across various federal agencies concerned with health and social services. DOE is also using the Improving America’s Schools Act to encourage schools to
develop schoolwide approaches (e.g., pulling together compensatory education, bilingual education, and safe and drug-free school programs) rather than continuing to
pursue categorically oriented activities. Title XI of this act allows school districts to divert a portion of their federal funding to organize service coordination.
Many states, counties, and philanthropic foundations also have initiatives aimed at
stimulating system reform and restructuring by enhancing school–community collaborations and service integration. Other forms of support for system change emanate
from the many policy and research centers and the various associations that represent
professionals and youngsters and their families (e.g., guilds and advocacy groups).
Although such efforts indicate recognition of the need for systemic change, the initiatives themselves are fragmented and marginal. And, there are a variety of other federal programs finding their way into schools that usually result in further fragmentation of intervention efforts (e.g., juvenile justice and delinquency prevention programs,
abstinence education, and family preservation and support programs). It is ironic that
some federal initiatives have been introduced to counter the extensive fragmentation
that categorically funded programs have produced, and at the same time, new categorical programs are being propagated.
Policy Considerations
In our work, we suggest a basic policy shift that elevates efforts to address barriers to
learning, including social, emotional, and physical health problems, to the level of
one of three fundamental and essential facets of education reform and school and
community agency restructuring (see Figure 2). That is, to enable teachers to teach effectively, we suggest that there must not only be effective instruction and well-man-
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FIGURE 2. Placing School Mental Health Interventions Within a Three-Component
Model for School/Community Reform.
aged schools, but that barriers to learning must be handled in a comprehensive way
(Adelman, 1996a, 1996b; Adelman & Taylor, 1994, 1997b). The current situation is one
where, despite awareness of the many barriers to learning, school reformers continue
to concentrate mainly on improving instruction and school management. In effect, they
pursue school reform using a two- rather than a three-component model. As a result,
the need to restructure education support programs and services remains unmet, and
this works against meshing school resources with initiatives to integrate community
services and link them to schools. Comprehensive approaches to addressing barriers
to learning and enhancing healthy development require weaving together programs
to address mental health and psychosocial concerns and much more. In the process,
there must be mechanisms to coordinate and eventually integrate (a) school-owned
activity for addressing barriers to learning, (b) school- and community-owned resources, and (c) the enabling, instructional, and management components.
Although most educators are aware of the value of health (mental and physical)
and psychosocial interventions in enabling students to become full participants in
their own academic achievement and healthy development, efforts to create a comprehensive approach are not assigned a high priority. One way to understand this is to
recognize that the primary and essential nature of relevant programs and services has
not been thrust before policy makers and education reformers in an effective manner.
Current demonstrations of “comprehensive” approaches are attracting some attention. However, they are not viewed as evidence that interventions addressing barriers
to teaching and learning are essential to the success of school reform. The next step in
moving toward a comprehensive approach is to bring the following message to policy
makers at all levels. For school reform to produce desired student outcomes, school and commu-
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nity reformers must expand their vision beyond restructuring instructional and management
functions and recognize that there is a third primary and essential set of functions involved in enabling teaching and learning.
As illustrated in Figure 2, this third facet of school and community restructuring has
been dubbed the Enabling Component. In a policy context, the concept of an enabling component is meant to provide a focal point around which policy for addressing barriers to development, learning, and teaching can be unified. By emphasizing
the essential nature of this third facet of school and community reforms, the intent is
to help elevate policy priorities related to addressing such barriers. For daily practice,
the concept has been operationalized into the six general, interrelated, programmatic
areas outlined in a preceding section of this review. (For a detailed discussion of the
Enabling Component in terms of policy and practice, see Adelman, 1996a; Adelman
& Taylor, 1997b; Center for Mental Health in Schools, 1997; Learning Center Model,
1995.)
By calling for reforms that enhance the focus on a wide range of psychosocial factors interfering with school learning and performance, the concept of an Enabling
Component encompasses the type of models described as full-service schools—and
goes beyond them (Adelman, 1996b). The concept calls on reformers to expand the
current emphasis on improving instruction and management to include a comprehensive component for addressing barriers to learning. All three components are
seen as essential, complementary, and overlapping. Emergence of a cohesive enabling
component requires policy reform that facilitates weaving together what is available at
a school, expanding this through integrating school, community, and home resources, and enhancing access to community programs and services by linking as
many as feasible to programs at the school. This involves extensive restructuring of
school-owned enabling activity, such as pupil services and special and compensatory
education programs. By offering a delimited set of program areas for restructuring
school-owned enabling activity and blending school and community resources, the
concept provides a much-needed intervention focus around which to formulate new
policy.
Adoption of an inclusive unifying concept is pivotal in convincing policy-makers to
move to a position that recognizes the essential nature of activity to enable learning.
Evidence of the value of rallying around a broad unifying concept is seen in the fact
that in 1995 the state legislature in California considered the type of policy shift outlined here as part of a major urban education bill (AB 784). And in 1997, California’s
Department of Education included a version of such a concept (called Learning Supports) in their school program quality review guidelines.
Developing a Comprehensive Integrated Approach
After policy-makers adopt a component for addressing barriers to learning as essential, it should be easier to blend all enabling activity together (including special and
compensatory education) and elevate the status of programs to enhance healthy development. It also should be easier to gain acceptance of fundamental policy shifts to
reshape pre- and in-service professional education.
Changes in policy are necessary but insufficient. For significant systemic change to occur,
new policies must be translated into appropriate daily practices. This is accomplished
through organizational reform and/or restructuring—including allocation/redeploy-
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ment of resources (e.g., finances, personnel, time, space, and equipment) and modification of existing organizational mechanisms. With respect to mechanism redesign,
the focus is on at least five fundamental organizational concerns: (a) governance, (b)
planning and implementation related to specific organizational and program objectives, (c) coordination and integration to ensure cohesive functioning, (d) daily leadership, and (e) communication and information management. Well-designed mechanisms must ensure local ownership, a critical mass of committed stakeholders,
processes that can overcome barriers to stakeholders working together effectively, and
strategies that can mobilize and maintain proactive effort so changes are properly implemented and systems are renewed over time. In terms of specific task focus, mechanisms must attend to (a) integrating resources related to the enabling, instructional,
and management facets of school and community, (b) reframing inservice programs—including an emphasis on cross-training, and (c) establishing suitable forms
of quality improvement, accountability, and ongoing systemic evolution and renewal.
In reforming mechanisms, new collaborative arrangements must be established,
and authority (power) must be redistributed—all of which is easy to say and extremely
hard to accomplish. Reform obviously requires providing adequate resource support—not just initially but over time—to those who operate critical mechanisms. And,
there must be appropriate incentives and protections for risk-taking for those undertaking the tasks. Perhaps a bit less evident is the need to staff mechanisms with persons who already are highly motivated and competent to enter into collaborative
working relationships.
Clearly, all this requires greater involvement of pupil service professionals in every
facet and especially in the governance structure at the district level and at their
schools. For this to happen, however, there must be a shift in roles as well as in priorities with respect to daily functions. Theirs must be a multifaceted role—providing services and much more. Jobs must be recast so that such personnel are not completely
consumed by their caseloads and can focus more on functions related to coordination, development, and leadership and evolving long-lasting collaborations with community resources. And there must be guaranteed time and opportunity for representatives of enabling activity to serve on school and district governance, planning, and
evaluation bodies.
Changing systems. The type of institutional changes involved in moving toward a comprehensive, integrated approach cannot be achieved without a sophisticated and appropriately financed process for getting from here to there. Restructuring on a large
scale involves substantive organizational and programmatic transformation at multiple jurisdictional levels. Although this seems self-evident, its profound implications
are often ignored (e.g., see Adelman, 1993; Adelman & Taylor, 1997a; Argyris, 1993;
Barth, 1990; Connor & Lake, 1988; Elias, 1997; Fullan & Stiegelbauer, 1991; Knoff,
1995; Replication and Program Services, Inc., 1993; Sarason, 1996).
At any site, key stakeholders and their leadership must understand and commit to
restructuring existing activity. Commitment must be reflected in policy statements
and an organizational structure that ensures effective leadership and resources. The
process begins with activity designed to create readiness for the necessary changes by
enhancing a climate/culture for change. Steps include creating readiness for systemic
change by (a) building interest and consensus for developing a comprehensive approach to addressing barriers to learning and enhancing healthy development, (b) introducing basic concepts, especially basic program elements, to relevant groups of
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stakeholders, (c) establishing a policy framework that recognizes the approach is a
primary and essential facet of the school’s activity, and (d) appointment of a site
leader (of equivalent status to the leaders for the instructional and management facets) who can ensure implementation of policy commitments.
Creating the necessary readiness for systemic change overlaps development of a
start-up and phase-in structure for implementing organizational change. Such a structure involves (a) establishing mechanisms and procedures, such as a steering group
and leadership training, to guide development of reforms, (b) formulating specific
start-up and phase-in plans, (c) establishing and training a resource coordinating
team, (d) phasing-in reorganization of all activity for addressing barriers and enhancing healthy development, (e) forging linkages with other schools and with district and
community resources, and (f) establishing systems to ensure quality improvement,
momentum for reforms, and ongoing systemic renewal.
Use of pupil services personnel to facilitate systemic change has long been advocated. Recent work demonstrates the value of redeploying and training a cadre of
such professionals as change agents in moving schools toward a comprehensive approach for addressing barriers to learning (Early Assistance for Students and Families
Project, 1995). Designated as organization facilitators, such personnel start from a relevant base of knowledge and skills. In addition, because they are seen as internal agents
for change, many of the negative reactions their colleagues direct at outside reformers
are minimized. Specialized training gives them an understanding of specific activities
and mechanisms for establishing and maintaining a comprehensive, integrated approach and increases their capacity for dealing with the processes and problems of organizational change.
CONCLUDING COMMENTS
As many public schools struggle to deal with poor achievement and escalating psychosocial problems, concerns about addressing barriers to learning and enhancing
healthy development warrant greater attention. Clearly, all this encompasses a variety
of mental health considerations.
An extensive array of school-based and school-linked preventive and corrective activity already exists—some of which the data suggest should be part of any effort to establish comprehensive, integrated approaches to improve school effectiveness. There
are, however, fundamental concerns that must be dealt with regarding how problems
are understood and classified, what approaches are appropriate for different groups
and individuals, how to plan and implement intervention so that it is most cost effective, and how to improve interventions and evaluate cost effectiveness. Clearly, these
are areas to which clinical psychologists (and the mental health field as a whole) have
contributed already and can continue to do so.
Although schools are not in the health business, it is clear that schools must address
mental health and psychosocial concerns. As indicated by the Carnegie Council Task
Force on Education of Young Adolescents (1989): “School systems are not responsible
for meeting every need of their students. But when the need directly affects learning,
the school must meet the challenge” (p. 61). To meet this challenge, the search for
better practices must be a high priority. The search must not be limited, however, to
clinically oriented interventions. Those concerned with mental health in schools must
pursue a full continuum of multifaceted programs and services. This requires weaving
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together school and community resources to address barriers to learning and integrating these efforts with those designed to promote development and learning.
The need is evident; so are the opportunities for research, development, and practice. Clinical psychology has much to contribute to meeting the needs of schools and
communities and much to gain in the process.
Acknowledgment—This article was prepared in conjunction with work done by the Center for Mental Health in Schools at UCLA, which is partially supported by funds from
the U.S. Department of Health and Human Services, Public Health Services, Health
Resources and Services Administration, Bureau of Maternal and Child Health, Office
of Adolescent Health.
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