These are tough times for kids. Homicide, suicide, child abuse, street violence, obesity, substance abuse, too-early childbearing and unprotected sex are some of the “new morbidities” that threaten young Americans today.
In Sex, Kids, and Politics: Health Services in Schools (1997), Catherine Emihovich and Carolyn D. Herrington write “…There is a steadily growing conviction that a generation of children are growing up in environments lacking the essential material, social and spiritual resources that nourish bright, happy and productive young people.
Without question, the quality of life of children today has declined and the structures that sustain the qualify of life have been weakened.” But where can kids get the support they need? And how can support systems-social services, medical and mental health care-reach “at risk” kids?
In the early 1990s, Matthew Mock, PhD, director of Family, Youth and Children’s Services in Berkeley, California, noticed that despite all the high risk issues in the adolescent community, most kids weren’t coming into the city’s outpatient clinics. Mock and his colleagues decided to “bring the services to the students.” So in 1991 the Berkeley High School Health Center was founded.
The Health Center is a collaborative project between the City of Berkeley and the Berkeley Unified School District. What started in a 10′ by 10′ room now occupies an entire wing of the high school.
The Center offers a broad array of comprehensive services to approximately 3,000 students from diverse backgrounds: emergency medical care; primary care and health maintenance; health education; peer education; psychological counseling; suicide prevention; case management of “at risk” youth; student support groups; Pregnancy/STD prevention and treatment; violence prevention; youth advocacy; and HIV counseling, testing and outreach.
The Berkeley High School (BHS) Health Center is part of a recent trend to expand the role of school health programs to encompass a more activist and preventive approach. A school-based health center isn’t just a place where students go to get a bandaid. It’s a full-fledged health center.
Today, health centers operate in approximately 900 of the 80,000 U.S. public schools. 41 percent of the centers are housed in high schools, like Berkeley High.
Mental Health Care
“A lot of kids feel there’s a stigma attached to mental health and counseling. So we made it a component under an entire health ‘hat’,” says Mock. “It’s a component of the health center but not the only one.” In the 1996-97 academic year, the BHS Health Center served over 1500 students. The mental health services are the most used, at 36 percent, and HIV/pregnancy prevention at 34 percent and primary care at 30 percent. “It’s good to have all the services combined…there’s a more holistic approach.
It’s a place where adolescents can get one stop shopping,” says Mock. And why fragment the services? For instance, Mock notes, in cases of eating disorders, without having a health component to deal with diet, etc., “it’s only dealing with one part.”
Students who come to the BHS Health Center seeking counseling or those who have been referred may see one of several mental health providers. There’s an interdisciplinary staff, with several master’s or doctoral level interns, including marriage and family therapy students. And the Center makes use of providers from the community.
Some local therapists volunteer to lead support groups or teach psychoeducational seminars, for example. “We had some providers who came and co-led a group on teens who have parents with substance abuse problems,” notes Mock.
A Day in the Life…
For the mental health staff, a typical day will never include a dull moment, Mock says. There are ongoing appointments, possible crisis interventions, support groups to be led, and consultation with a lot of different providers. And mental health providers at the center do a lot of psychoeducation.
“We might have several teachers say ‘Gosh, I don’t know what ADHD means, or ‘Can someone come talk about depression?'” he says. Providers must also respond to crisis situations. After one of the football players was killed in an accident the staff went to the locker room and talked with the players about loss and grief, for example.
Sometimes students just come to talk. In an article about the BHS Health Center, mental health intern Leigh Lightfoot told The Monthly (January 1998), a Berkeley community newspaper, “They have huge questions during this phase. …Everything is open for change, reevaluation and experimentation.”
In addition to many health, mental health and peer education services that might fall under the realm of prevention services, the center staff pays close attention to at risk students. They watch for red flag behaviors like high sexual activity, a history of violence or abuse, possession of a weapon, experimentation with drugs, or less than average academic performance.
“We look at each kid and determine the cornucopia of services they need,” Mock says. Some students may not be seen in counseling or family therapy.
Some might get an array of domestic violence services. Others might go to conflict resolution or a support group.
There are case coordinators who continue to stay involved with the student. The Center works on a case management model where several providers may see one student through several different points of entry, but the providers meet and talk about what needs to be done.
“This can be tricky because there are lots of issues around territory or different understandings of what’s helpful for the student that vary along different disciplines or perspectives,” Mock says. Systems training is helpful in this respect. “Having a systems orientation helps tremendously,” he notes. Providers may have to work with several significant individuals and larger systems in a student’s life.
What about Family Therapy?
Counseling can, at times of identified risk, be mandatory. Mock says he wishes it could be mandatory for parents at times too. “The students are right there. But with parents, they are one removed and it can be harder to get them to understand that they have a role.” The parents have to give permission for their child to obtain services at the Health Center.
Each year, a consent form is sent home with each student along with an information package on the Center’s services. “Every year we try to get a buy-in from the parents.” “There’s nothing that prohibits us from doing family therapy on campus.
However, because of ownership issues or maybe peer acceptance issues, a lot of times teens balk at having their parents involved,” Mock says. But he does note that there have been a significant number of situations where parents have come in after school or individual work with the student on campus has been coupled with family work at a city outpatient clinic.
Some kids just don’t have a lot of parental support. In The Monthly article, a physician assistant working at the BHS Health Center said “A lot of young people are fending for themselves nowadays. And what’s really shocking is that some kids are on their own.
The Monthly told of one student who was living in her car after her mother kicked her out of the house. Another student went to the health center complaining of headaches. As it turned out, he was walking the streets until 3:00 a.m. because his parents drank and fought every night.
Comprehensive school health centers can provide necessary medical care and “someone to talk with regularly, who will take a direct interest in their welfare and perspective, and who will speak honestly to them about their present and future life circumstances,” Mock says.
School-based health centers attempt to take care of the whole child. And in order to do so, providers must “understand and communicate with the system-from referral sources to academic counselors to administrators.
This is key to integrated, not fragmented, services,” says Mock. Linking with the community is also an important part of the success of a school health program. The BHS Health Center has a strong Community Advisory Board composed of parents, community advocates, students, practitioners and decision-makers.
Mock likens a school to a small town, explaining that each has its own existing values, perspectives, and ways of operating. For mental health providers working in schools, it is important to understand the stresses and strains of the citizens of this small town-the students, teachers, families and administrators.
It seems that marriage and family therapists (MFTs) might be well-equipped to work in such a comprehensive care setting. “…An understanding of systems and how to work with them has been critical and highly beneficial,” he says.
With comprehensive school-based health centers continuing to crop up around the country, it seems that the trend toward this kind of care for children and adolescents will only keep growing.
Many states have begun to subsidize school-based health care, reported the June 1997 APA Monitor. “In 1996, 34 states funded school-based clinics and 21 states offered communities technical assistance to start the clinics.” And also in 1996, two technical assistance centers were established with partial support from the U.S. Department of Health and Human Services and other federal agencies.
One center is located at the University of California, Los Angeles-the Center for Mental Health in Schools-and the other is located at the University of Maryland, Baltimore-the Center for School Mental Health Assistance.
“There’s no turning back. We’re here to stay. We’ve had great acceptance and the students will speak for themselves,” says Mock with pride.