Mental Health in Schools: New Roles for School Nurses, Exercises of Nursing

Download Mental Health in Schools: New Roles for School Nurses and more Exercises Nursing in PDF only on Docsity! Addressing Barriers to Student Learning Continuing Education Mental Health in Schools: New Roles for School Nurses Units I. Placing Mental Health into the Context of Schools and the 21st Century II. Mental Health Services and Instruction: What a School Nurse Can Do III. Working with Others to Enhance Programs and Resources Prepared by the School Mental Health Project/Center for Mental Health in Schools, Dept. of Psychology, UCLA, Los Angeles, CA 90095-1563 -- (310) 825-3634. Co-directors: Howard Adelman & Linda Taylor Mental Health in Schools: New Roles for School Nurses This set of three continuing education units is part of a series developed by the UCLA Center for Mental Health in Schools focused on addressing barriers to student learning. Each unit consists of several sections designed to stand alone. Thus, the total set can be used and taught in a straight forward sequence, or one or more units and sections can be combined into a personalized course. This design also allows learners to approach the material as they would use an internet website (i.e., exploring specific topics of immediate interest and then going over the rest in any order that feels comfortable). The units are packaged in a sequence that reflects the developers' preference for starting with a big picture framework for understanding the context and emerging directions for mental health in schools. Beginning each section are specific objectives and focusing questions to guide reading and review. Interspersed throughout each section are boxed material designed to help the learner think in greater depth about the material. Test questions are provided at the end of each section as an additional study aid. CONTENTS I. Placing Mental Health into the Context of Schools and the 21st Century A. Introductory Overview B. The Need to Enhance Healthy Development and Address Barriers to Learning C. Addressing the Need: Moving Toward a Comprehensive Approach Coda: A Wide Range of Responses for a Wide Range of Problems II. Mental Health Services & Instruction: What a School Nurse Can Do A. Screening and Assessment B. Problem Response and Prevention C. Consent, Due Process, and Confidentiality Coda: Networks of Care III. Working with Others to Enhance Programs and Resources A. Working Relationships B. Working to Enhance Existing Programs C. Building a Comprehensive, Integrated Approach at Your School Coda: Roles for the School Nurse: A Multifaceted Focus Introduction to a Continuing Education Module on Mental Health In Schools: New Roles for School Nurses Schools committed to the success of all children must have an array of activity designed to address barriers to learning. No one is certain of the exact number of students who require assistance in dealing with such barriers. There is consensus, however, that significant barriers are encountered by too many students. Among these barriers are a host of psychosocial and mental health concerns. Each day school nurses are confronted with many students who are doing poorly in school as a result of health and psychosocial problems. Increasingly, school nurses find it necessary to do something more than their original training prepared them to do. At the same time, education reform and restructuring are changing the whole fabric of schools and calling upon all pupil services personnel to expand their roles and functions. As a result, school nurses need to acquire new ways of thinking about how schools should address barriers to learning and they need additional skills to equip them for emerging new roles and functions. This continuing education module is designed to help meet these needs. This set of three units focuses on the school nurse's role in addressing psychosocial and mental health problems that interfere with students' learning and performance. Mental Health in Schools: New Roles for School Nurses Contents of All Three Units I. Placing Mental Health into the Context of Schools and the 21st Century A. Introductory Overview B. The Need to Enhance Healthy Development and Address Barriers to Learning C. Addressing the Need: Moving Toward a Comprehensive Approach Coda: A Wide Range of Responses for a Wide Range of Problems II. Mental Health Services & Instruction: What a School Nurse Can Do A. Screening and Assessment B. Problem Response and Prevention C. Consent, Due Process, and Confidentiality Coda: Networks of Care Follow-Up Reading C ABCs of Assessment C Managing and Preventing School Misbehavior and School Avoidance III. Working with Others to Enhance Programs and Resources A. Working Relationships B. Working to Enhance Existing Programs C. Building a Comprehensive, Integrated Approach at Your School Coda: Roles for the School Nurse: A Multifaceted Focus Mental Health in Schools: New Roles for School Nurses Unit I: Placing Mental Health into the Context of Schools and the 21st Century Sections A. Introductory Overview B. The Need to Enhance Healthy Development and Address Barriers to Learning C. Addressing the Need: Moving Toward a Comprehensive Approach Do not follow where the path may lead. Go, instead, where there is no path and leave a trail. Anonymous I-1 Unit I: Placing Mental Health into the Context of Schools and the 21st Century Section A: Introductory Overview Once upon a time, the animals decided that their lives and their society would be improved by establishing a school. The basics identified as necessary for survival in the animal world were swimming, running, climbing, jumping, and flying. Instructors were hired to teach these activities, and it was agreed that all the animals would take all the courses. this worked out well for the administrators, but it caused some problems for the students. The squirrel, for example, was an "A" student in running, jumping, and climbing but had trouble in the flying class -- not because of an inability to fly, for she could sail from the top of one tree to another with ease, but because the flying curriculum called for taking off from the ground. The squirrel was drilled in ground-to-air take-offs until she was exhausted and developed charley horses from overexertion. This caused her to perform poorly in her other classes, and her grades dropped to "D"s. The duck was outstanding in swimming classes -- even better than the teacher. But she did so poorly in running that she was transferred to a remedial class. There she practiced running until her webbed feet were so badly damaged that she was only an average swimmer. But since average was acceptable, nobody saw this as a problem, except the duck. In contrast, the rabbit was excellent in running but, being terrified of water, he was an extremely poor swimmer. Despite a lot of makeup work in swimming class, he never could stay afloat. He soon became frustrated and uncooperative and was eventually expelled because of behavior problems. The eagle naturally enough was a brilliant student in flying class and even did well in running and jumping. he had to be severely disciplined in climbing class, however, because he insisted that his way of getting to the top of the tree was faster and easier. It should be noted that the parents of the groundhog pulled him out of school because the administration would not add classes in digging and burrowing. The groundhogs, along with the gophers and badgers, got a prairie dog to start a private school. They all have become strong opponents of school taxes and proponents of voucher systems. By graduation time, the student with the best grades in the animal school was a compulsive ostrich who could run superbly and also could swim, fly, and climb a little. She, of course, was made class valedictorian and received scholarship offers from all the best universities. (George H. Reeves is credited with bringing this parable to America.) Contents: State of the Art Emerging Trends New Roles for School Nurses I-4 Objectives for Section A After completing this section of the unit, your should be able to: C identify a wide range of interveners who could play a role in counseling, psychological, and social service activity at a school C enumerate, with respect to the activities carried out by such interveners, two specific functions related to (a) providing direct services and instruction, (b) coordinating, developing, and providing leadership for programs, services, and systems, (c) enhancing connections with community resources C identify at least 2 major emerging trends related to health and psychosocial programs in schools C explain why school nurses should play a role in addressing mental health and psychosocial concerns in schools and specify three related examples of possible new roles A Few Focusing Questions C Who at a school might help students with psychosocial concerns? C What factors put students "at risk?" C How might a school nurse play a greater role in shaping a school's overall efforts to address barriers to learning and enhance healthy development? I-5 I-6 Types of interveners who might play primary or secondary roles in counseling, psychological, and social service activity Instructional professionals (e.g., regular classroom teachers, special education staff, health educators, classroom resource staff and consultants) Health office professionals (e.g., nurses, physicians, health educators, consultants) Counseling, psychological, and social work professionals (e.g., counselors, health educators, psychologists, psychiatrists, psychiatric nurses, social workers, consultants) Itinerant therapists (e.g., art, dance, music, occupational, physical, speech-language-hearing, and recreation therapists; psychodramatists) Personnel-in-training for the above roles Others • Aides • Classified staff (e.g., clerical and cafeteria staff, custodians, bus drivers) • Paraprofessionals • Peers (e.g., peer/cross-age counselors and tutors, mutual support and self-help groups) • Recreation personnel • Volunteers (professional/paraprofessional/ nonprofessional) It is widely recognized that social, emotional, and physical health deficits and other persistent barriers to learning must be addressed if students are to benefit appropriately from their schooling. Many professionals struggle to C ease problems C increase opportunities C enhance the well-being of students, families, and school staff. This box outlines an array of interveners involved in schools who are concerned with mental health and psychosocial matters. While all students can benefit from interventions to enhance social and emotional development, such activity is essential for those manifesting severe and pervasive problems. I-9 State of the Art Data on diagnosable mental disorders (based on community samples) suggest that from 12% to 22% of all children suffer from mental, emotional or behavioral disorders, and relatively few receive mental health services. The picture is even bleaker when expanded beyond the limited perspective of diagnosable mental disorders to include all young people experiencing psychosocial problems and who Joy Dryfoos defines as "at risk of not maturing into responsible adults." The number "at risk" in many schools serving low-income populations has climbed over the 50% mark. Harold Hodgkinson , director of the Center for Demographic Policy, estimates across the nation 40% of students are in "very bad educational shape" and "at risk of failing to fulfill their physical and mental promise." Because so many live in inner cities and impoverished rural areas and are recently arrived immigrants, he attributes their school problems mainly to conditions they bring with them when they enter kindergarten. These are conditions associated with poverty, difficult and extremely diverse family circumstance, lack of English language skills, violent neighborhoods, physical and emotional problems, and lack of health care. One impact is that at least 12% fail to complete high school, which leads to extensive consequences for them, their families, and society. An extensive literature reports positive outcomes for psychosocial interventions available to schools. While many of the reports are from narrowly focused brief demonstrations, the research is promising. A significant number of appropriately developed and implemented programs demonstrate benefits for schools (e.g., better student functioning and attendance, less teacher frustration) and for society (e.g., reduced costs for welfare, unemployment, and use of emergency and adult services). Thus, the literature is encouraging. It provides a menu of "best practices." And the search for better practices remains a high priority and must be pursued with full consideration of the diverse demographics and conditions that exist in our changing society. I-10 School nurses are engaged in an increasingly wide array of activity, including promotion of social and emotional development, direct services, outreach to families, and various forms of support for teachers and other school personnel. There is enhanced emphasis on coordination and collaboration within a school and with community agencies to provide the "network of care" necessary to deal with complex problems over time. Thus, services in schools are expanding and changing rapidly. Schools' efforts to address health and psychosocial problems encompass C prevention and prereferral interventions for mild problems C high visibility programs for high-frequency problems C strategies to address severe and pervasive problems. Emerging Trends Proliferation of health and psychosocial programs in schools tends to occur with little coordination of planning and implementation. As awareness of deficiencies has increased, major systemic changes have been proposed. Four emerging trends are C the move from narrowly focused to comprehensive approaches C the move from fragmentation to coordinated/integrated intervention C the move from problem specific and discipline-oriented services to less categorical, cross-disciplinary programs C the move from viewing health programs as "supplementary services" to policy changes that recognize physical and mental health services as an essential element in enabling learning. Each trend has implications for what goes on in schools. I-11 New Roles for School Nurses In addition to the key role they play in promoting health and helping specific students with physical health problems, school nurses have always been called upon to deal with psychosocial and mental health concerns. In recent years, these calls have increased. Moreover, emerging trends require that nurses and all pupil service personnel continue to expand their roles in advocating and facilitating systemic reforms so that they can be more effective in addressing barriers to student learning and promoting healthy development. Through an expanded set of roles and functions, such personnel can play a potent role in creating a comprehensive, integrated approach to meeting the needs of the young by helping to weave together what schools can do with what the community offers. The relatively small number of school nurses and other pupil service personnel available to schools can provide only a limited amount of direct services. Such personnel can have an impact on greater numbers of students if their expertise is used to a greater degree at the level of program organization, development, and maintenance than currently is the case. I-14 Test Questions -- Unit I: Section A (1) Which of the following were identified as potential interveners who could play a role could play a role in counseling, psychological, and social service activity at a school? ____(a) counselors ____(b) nurses ____(c) teachers ____(d) aides ____(e) students ____(f) a & b ____(g) a, b, & e ____(h) all the above (2) With respect to the activities carried out by such interveners, enumerate two specific functions related to (a) providing direct services and instruction ___________________________________________________ ___________________________________________________ (b) coordinating, developing, and providing leadership for programs, services, and systems ___________________________________________________ ___________________________________________________ (c) enhancing connections with community resources ___________________________________________________ ___________________________________________________ (3) Which of the following is not an emerging trend related to health and psychosocial programs in schools? ___(a) the move from narrowly focused to comprehensive approaches ___(b) the move from fragmentation to coordinated/integrated intervention ___(c) the move from problem specific and discipline-oriented services to less categorical, cross-disciplinary programs ___(d) the move from viewing health programs as "supplementary services" to policy changes that recognize physical and mental health services as an essential element in enabling learning ___(e) all are emerging trends (4) Enumerate three possible new roles that school nurses might play in addressing mental health and psychosocial concerns in schools. ___________________________________________________ ___________________________________________________ ___________________________________________________ Unit I: Placing Mental Health into the Context of Schools of the 21st Century Section B: The Need to Enhance Healthy Development and Address Barriers to Learning Range of Learners (categorized in terms of their response to academic instruction) I = Motivationally ready & able No Barriers Instructional Desired Component Outcome II = Not very motivated/ lacking prerequisite Barriers to knowledge & skills/ Learning different learning rates & styles/ minor vulnerabilities III = Avoidant/very deficient in current capabilities/ has a disability/ major health problems Contents: Promoting Healthy Development Personal and Systemic Barriers to Student Learning Family Needs for Social and Emotional Support Staff Needs for Social and Emotional Support I-15 Objectives for Section B After completing this section of the unit, your should be able to: C discuss why providing health and social services is an insufficient strategy for addressing barriers to student learning C identify at least five major areas of focus in enhancing healthy psychosocial development C differentiate between personal and systemic barriers to student learning and understand the bias toward personal rather than social causation C understand a range of family needs for social and emotional support and enumerate at least three characteristics of family-oriented interventions A Few Focusing Questions C What are the major barriers that interfere with students learning and performing effectively at school? C How can school staff build alliances with families? C How do persons and environments interact to cause problems I-16 I-19 Schools clearly are involved in dealing with barriers to learning. They hire pupil service professionals and institute services and programs aimed at such concerns as drug abuse, teen pregnancy, dropout prevention, and on and on. In addition, efforts increasingly are made to link with community health and social services. Unfortunately, the prevailing activity is not enough. Even though poor health and other barriers to student learning are seen as directly related to poor educational outcomes, programs to address barriers to learning are treated as "add-ons." That is, in terms of policy and practice, they are not assigned top priority and often are among the first cut when budgets are tight. As long as this is the case, many students will continue to encounter barriers that interfere with their benefiting from instructional reforms. And for schools serving large numbers of such students, this means continuation of the pattern of test score averages that do not rise substantially. This is a central paradox of school reform. That is: school restructuring clearly is intended to enhance student achievement. To this end, reform efforts predominantly focus on improving instruction and school management, with little attention paid to restructuring and enhancing resources that address barriers to learning. Consequentially, too many students are unable to take advantage of improved teaching. What is the solution to this paradox? Instruction ? Management I-20 One strategy is to help policy makers understand that current efforts to restructure schools are missing a major component. The missing component doesn't focus on health and social services per se, but it encompasses a strong emphasis on physical and mental health as one major facet of helping schools address barriers to student learning. Such a component is essential in any school committed to the success of all. By themselves, health and social services are an insufficient strategy for addressing the biggest problems confronting schools. They are not, for example, designed to address a full range of factors that cause poor academic performance, dropouts, gang violence, teenage pregnancy, substance abuse, racial conflict, and so forth. This is not a criticism of the services per se. The point is that such services are only one facet of a comprehensive approach. A broad perspective of what is needed emerges by conceiving the missing component for addressing barriers to learning as encompassing efforts to prevent and correct learning, behavior, emotional, and health problems. Such efforts include activity that fosters academic, social, emotional, and physical functioning. Instructional Component to Component Address Barriers to Learning Management Component I-21 Promoting Healthy Development Areas of Focus in Enhancing Healthy Psychosocial Development Responsibility and integrity (e.g., understanding and valuing of societal expectations and moral courses of action) Self-esteem (e.g., feelings of competence, self- determination, and being connected to others) Social and working relationships (e.g., social awareness, empathy, respect, communication, interpersonal cooperation and problem solving, critical thinking, judgement, and decision making) Self-evaluation/self-direction/self- regulation (e.g., understanding of self and impact on others, development of personal goals, initiative, and functional autonomy) Temperament (e.g., emotional stability and responsiveness) Personal safety and safe behavior (e.g., understanding and valuing of ways to maintain safety, avoid violence, resist drug abuse, and prevent sexual abuse) Health maintenance (e.g., understanding and valuing of ways to maintain physical and mental health) Effective physical functioning (e.g., understanding and valuing of how to develop and maintain physical fitness) Careers and life roles (e.g., awareness of vocational options, changing nature of sex roles, stress management) Creativity (e.g., breaking set) Promoting healthy development is one of the keys to preventing mental health and psychosocial problems. For schools, the need is to maintain and enhance health and safety and hopefully do more. This requires programs that inoculate through providing positive and negative information, skill instruction, and fostering attitudes (e.g., using facets of health education -- physical and mental -- to build resistance and resilience). Examples of problems addressed with a preventive focus are substance abuse, violence, pregnancy, school dropout, physical and sexual abuse, suicide directly facilitate development in all areas (physical, social, emotional) and in ways that account for differences in levels of development and current developmental demands. Examples of arenas for activity are parent education and support, day care, preschool, early education, elementary classrooms, recreation and enrichment programs identify, correct, or at least minimize physical and mental health and psychosocial problems as early after onset as is feasible I-24 It is not surprising that debates about labeling young people are so heated. Differential diagnosis is difficult and fraught with complex issues. The thinking of those who study behavioral, emotional, and learning problems is dominated by models stressing person pathology. Because of this, diagnostic systems do not adequately account for psychosocial problems. This is well-illustrated by the widely-used Diagnostic and Statistical Manual of Mental Disorders -- DSM V (American Psychiatric Association). As a result, formal systems for classifying problems in human functioning convey the impression that all behavioral, emotional, or learning problems are due to internal pathology. Thus, most differential diagnoses of children's problems are made by focusing on identifying one or more disorders (e.g., oppositional defiant disorder, attention-deficit/hyperactivity disorder, or adjustment disorders), rather than first asking: Is there a disorder? I-25 Bias toward labeling problems in terms of personal rather than social causation is bolstered by factors such as (a) attributional bias --a tendency for observers to perceive others' problems as rooted in stable personal dispositions (b) economic and political influences -- whereby society's current priorities and other extrinsic forces shape professional practice There is a substantial community-serving component in policies and procedures for classifying and labeling exceptional children and in the various kinds of institutional arrangements made to take care of them. "To take care of them" can and should be read with two meanings: to give children help and to exclude them from the community. Nicholas Hobbs Overemphasis on pathology skews theory, research, practice, and public policy away from environmentally caused problems and psychosocial problems. There is considerable irony in all this because practitioners understand that most problems in human functioning result from the interplay of person and environment. That is, it is not nature versus nurture, but nature transacting with nurture that determines human behavior. I-26 Stop, Think, discuss To illustrate, let's look at something every school nurse encounters everyday -- students who clearly have learning problems and whose misbehavior and various physical complaints seem very much connected to their negative experiences related to academic learning difficulties. Of the many students who come to the see you with some problem, how many are doing poorly with their classwork? Do you think some of their physical complaints are relate to their learning problems? As you know, not all learning problems stem from the same causes. How do you understand the range of factors that cause such problems? In the classroom, it is evident that some students learn easily, and some do not; some misbehave, some do not. Even a good student may appear distracted on a given day. Everyone who wants to help students who manifest problems needs some basic understanding of Why the differences? A common sense answer suggests that each student brings something different to the situation and therefore experiences it differently. And that's a pretty good answer -- as far as it goes. What gets lost in this simple explanation is the reciprocal impact student and situation have on each other -- resulting in continuous change in both. I-29 Parents and other caretakers find it difficult to attend to the needs of their children when their own pressing needs are not attended to. This may help account for why parents who are most receptive to efforts to involve them in schools and schooling are a relatively small group. Parents and others in the home need to feel welcomed and appreciated by the school. Parents and others in the home often need to have an opportunity to share concerns. Parents and others in the home need good information when there are problems -- information about the problem and presentation of such information in a context that also recognizes assets. Parents and others in the home need information and ready access to resources. In situations where there are large numbers of students who are having problems, the need is for healthy families, healthy schools, and healthy communities. It seems likely that efforts to involve increasing numbers of parents in improving the well-being of their children must include a focus on improving the well-being of the many parents who are struggling to meet their own basic personal and interpersonal needs. Thus, schools must be prepared to add programs and services that address such basic needs and staff must reach out to parents with interventions that are welcoming and encourage use of such programs. At the same time, schools must resist the temptation to scold such parents. I-30 Prevailing agendas for parent involvement emphasize meeting societal and school needs. It is not surprising, therefore, that little attention is paid to schools helping parents and caretakers meet their own needs. Schools do offer some activities, such as parent support groups and classes to teach them English as a second language, that may help parents and contribute to their well-being (e.g., by improving parenting or literacy skills). However, the rationale for expending resources on these activities usually is that they enhance parents' ability to play a greater role in improving schooling. Another reason for involving parents is to support their efforts to improve the quality of their lives. This includes the notion of the school providing a social setting for parents and, in the process, fostering a psychological sense of community. If a school wants home involvement, it must create a setting where parents, others in the home, school staff, and students want to and are able to interact with each other in mutually beneficial ways that lead to a special feeling of connection. This encompasses finding ways to account for and celebrate cultural and individual diversity in the school community. To these ends, ways must be found to minimize transactions that make parents feel incompetent, blamed, or coerced. At the same time, procedures and settings must be designed to foster informal encounters, provide information and learning opportunities, enable social interactions, facilitate access to sources of social support (including linkage to local social services), encourage participation in decision making, and so forth. Remember: the primary intent is to improve the quality of life for the participants. Although any impact on schooling is a secondary gain, it is encouraging to note that fostering such a climate is consistent with the school reform literature's focus on the importance of a school's climate/ethos/culture. I-31 Barriers to Involving Parents/Home in Schools and Schooling FORMS OF BARRIERS Lack of Negative Mechanisms/ Practical Attitudes Skills Deterrents e.g., school e.g., insufficient staff e.g., low priority given Institutional administration is hostile toward assigned to planning and implementing to home involvement in allocating resources T increasing home ways to enhance such as space, time, Y involvement home involvement; and money P no more than a token E effort to accommodate S different languages --------------------------------------------------------------------------------------------------- O e.g., home e.g., rapid influx of e.g., school lacks F involvement immigrant families resources; majority Impersonal suffers from overwhelms school's in home have B benign neglect ability to communicate problems related to A and provide relevant work schedules, R home involvement childcare, R activities transportation I --------------------------------------------------------------------------------------------------- E e.g., specific e.g., specific teachers e.g., specific teachers R teachers and and parents lack and parents are S Personal parents feel home relevant language and too busy or lack involvement is not interpersonal skills resources worth the effort or feel threatened by such involvement I-34 The case of Jose and his family raises many issues. For example, involvement of the home in cases such as Jose's usually is justified by the school as "in the best interests of the student and the others in the class." However, clearly there are different ways to understand the causes of and appropriate responses to Jose's misbehavior. By way of contrast, another analysis might suggest the problem lies in ill-conceived instructional practices and, therefore, might prescribe changing instruction rather than strategies focused on the misbehavior per se. Even given an evident need for home involvement, the way the mother was directed to parent training raises concerns about whether the processes were coercive. Questions also arise about social class and race. For example, if the family had come from a middle or higher income background, would the same procedures have been used in discussing the problem, exploring alternative ways to solve it, and involving the mother in parent training? And, there is concern that overemphasis in parent workshops on strategies for controlling children's behavior leads participants such as Jose's mother to pursue practices that often do not address children's needs and may seriously exacerbate problems. All this reflects the fact that schools have different agendas related to parent involvement, and the different agendas determine the ways they interact with the home. I-35 Agendas for Involving Homes • socialization • economics • politics • helping Major Intervention Tasks ______________________________________________________________________ Institutional Facilitating organization Inviting early Maintaining for involvement involvement involvement involvement ______________________________________________________________________ ____________________________________________________Continuum of Types of Home Involvement ________________________________________________________________________________________________ Meeting basic Communicating Supporting Problem solving Working Working obligations & making student's & providing for for toward student/ decisions basic support at home school's improvement meeting own regarding learning & & school for improvement of all basic needs student development student's schools at home special needs Improve Improve individual<-------------------------------------------------------------------------------------------------------------->system functioning functioning I-36 Staff Needs for Social and Emotional Support No one needs to tell a school nurse how stressful it is to come to work each day. Stress is the name of the game for all who work in school settings and, unfortunately, some working conditions are terribly stressful. Some of the stress comes from working with troubled and troubling youngsters. Some is the result of the frustration that arises when everyone works so hard and the results are not good enough. Over time, such stressors can lead to demoralization, exhaustion, and burnout. The cost of ignoring staff stress is that the programs and services they offer suffer because of less than optimal performance by staff who stay and frequent personnel turnover. As with family members, school staff find it difficult to attend to thee needs of students when their own needs are going unattended. From this perspective, any discussion of mental health in schools should address ways to help the staff at a school reduce the sources of stress and establish essential social and emotional supports. Such supports are essential to fostering awareness and validation, improving working conditions, developing effective attitudes and skills for coping, and maintaining balance, perspective, and hope. Mother to son: Time to get up and go to school. Son: I don't want to go. It's too hard and the kids don't like me. Mother: But you have to go -- you're the principal. Objectives for Section C After completing this section of the unit, you should be able to: C state several implications of understanding students' problems in terms of a causal continuum that ranges from internal to external causes C identify two major reasons why school-based health centers have come to find it necessary to address mental health and psychosocial concerns C understand the difference between a comprehensive school health program and a comprehensive approach for addressing barriers to learning A Few Focusing Questions C How do environments cause individuals to have problems? C Why is it necessary to go beyond clinical interventions? C What should a continuum of services and programs consist of in order to adequately address barriers to learning and promote healthy development? I-39 I-40 Meeting Mandates: Necessary . . . but Insufficient and Often Unsatisfying The following are some of the typical tasks assigned school nurses: C health appraisal of new enrollees C assessment and follow-up of state mandated immunization and Mantoux requirements C vision screening as mandated (e.g., upon entry and every three years) C physical health screening (including assessment of students referred for special education placement) C screening and reporting for suspected child abuse C screening and reporting for suspected substance abuse C assessment and follow-up to control communicable (including sexually transmitted) diseases C health education to prevent communicable (including sexually transmitted) diseases C health appraisals related to activities such as interscholastic athletics and driver training C dental health screening and consultation C emergency care for major illness and injury C participation in emergency and crisis planning (e.g., planning for how the school should respond to fires, floods, earthquakes, acts of violence and their aftermath) And of course the ever present "Other tasks as assigned." These tasks require use of assessment, counseling, referral, consultation, monitoring, follow-up, information dissemination, and clerical skills related to remedial and preventive health concerns. They involve interactions with students, families, school staff, and professionals in the community. I-41 Anyone seeing school nurses in action as they pursue their many tasks knows they are more than busy. Anyone who talks with enough school nurses also knows that they are inundated with referrals for students whose problems stem from more than physical health concerns. Many school nurses want to redesign their roles so that much of the clerical and simple screening activity related to "mandates" can be streamlined. This would allow them to perform an array of other functions that their training and licenses indicate they are capable of doing. It would allow them to work more intensively with others at a school site to maximize the impact schools have on addressing the most profound barriers causing students to fall by the wayside. And all this has the potential not only to enhance the success of a great many more students, but also should prove more satisfying to nurses and their colleagues. How can this be done? "Not by working harder, but by working smarter." One essential element in working smarter is to have an enhanced conceptual base that can increase effectiveness. And one of the essential elements of such a conceptual base is accounting for full range of factors that cause students to have problems. I-44 To highlight a few points about the illustration: C Problems caused by the environment are placed at one end of the continuum and referred to as Type I problems. C At the other end are problems caused primarily by pathology within the person; these are designated as Type III problems. C In the middle are problems stemming from a relatively equal contribution of environmental and person sources, labelled Type II problems. Also note that in this scheme, diagnostic labels denoting extremely dysfunctional problems caused by pathological conditions within a person are reserved for individuals who fit the Type III category. Obviously, some problems caused by pathological conditions within a person are not manifested in severe, pervasive ways, and there are persons without such pathology whose problems do become severe and pervasive. The intent is not to ignore these individuals. As a first categorization step, however, it is essential they not be confused with those seen as having Type III problems. At the other end of the continuum are individuals with problems arising from factors outside the person (i.e., Type I problems). Many people grow up in impoverished and hostile environmental circumstances. Such conditions should be considered first in hypothesizing what initially caused the individual's behavioral, emotional, and learning problems. (After environmental causes are ruled out, hypotheses about internal pathology become more viable.) To provide a reference point in the middle of the continuum, a Type II category is used. This group consists of persons who do not function well in situations where their individual differences and minor vulnerabilities are poorly accommodated or are responded to hostilely. The problems of an individual in this group are a relatively equal product of person characteristics and failure of the environment to accommodate that individual. There are, of course, variations along the continuum that do not precisely fit a category. That is, at each point between the extreme ends, environment-person transactions are the cause, but the degree to which each contributes to the problem varies. Toward the environment end of the continuum, environmental factors play a bigger role (represented as E<--->p). Toward the other end, person variables account for more of the problem (thus e<--->P). I-45 Clearly, a simple continuum cannot do justice to the complexities associated with labeling and differentiating psychopathology and psychosocial problems. Furthermore, some problems are not easily assessed or do not fall readily into a group due to a lack of information and comorbidity. Starting with a broad model of cause, however, helps practitioners counter tendencies to prematurely conclude that a problem is caused by pathology within the individual and thus helps avoid blaming the victim (Ryan, 1971). It also helps highlight the notion that improving the way the environment accommodates individual differences may be a sufficient intervention strategy. Stop, Think, Discuss Think about the last time you had a significant problem related to doing your work. What caused it? Was it because of something wrong with you? the environment? the interaction between the two? Outlined on the next page is an aid for thinking about the many causes of learning, behavior, and emotional problems. I-46 Factors Instigating Emotional, Behavioral, and Learning Problems Environment (E) Person (P) Interactions and Between E and P (Type I problem) (Type III problems) (Type II problems) 1. Insufficient stimuli 1. Physiological insult 1. Severe to moderate personal (e.g.,prolonged periods in (e.g., cerebral trauma, such as vulnerabilities and impoverished environments; accident or stroke, endocrine environmental defects and deprivation of learning dysfunctions and chemical differences opportunities at home or imbalances; illness affecting (e.g., person with extremely school such as lack of play brain or sensory functioning) slow development in a highly and practice situations and demanding environment, all poor instruction; inadequate 2. Genetic anomaly of which simultaneously and diet) (e.g., genes which limit, slow equally instigate the problem) 2. Excessive stimuli development) 2. Minor personal vulnerabilities (e.g., overly demanding not accommodated by the home, school, or work 3. Cognitive activity and affective situation experiences, such as states experienced by self as (e.g., person with minimal overwhelming pressure to deviant CNS disorders resulting in achieve and contradictory (e.g., lack of knowledge or auditory perceptual disability expectations; overcrowding) skills such as basic cognitive trying to do auditory-loaded 3. Intrusive and hostile stimuli cope effectively with emotions, forced into situations at home, (e.g., medical practices, such as low self-esteem) school, or work that do not especially at birth, leading to tolerate this level of activity) physiological impairment; 4. Physical characteristics contaminated environments; shaping contact with 3. Minor environmental defects conflict in home, school, environment and/or and differences not workplace; faulty child- experienced by self as deviant accommodated by the rearing practices, such as (e.g., visual, auditory, or individual long-standing abuse and motoric deficits; excessive or (e.g., person is in the minority rejection; dysfunctional reduced sensitivity to stimuli; racially or culturally and is family; migratory family; easily fatigued; factors such as not participating in many language used is a second race, sex, age, or unusual social activities because he or language; social prejudices appearance that produce she thinks others may be related to race, sex, age, stereotypical responses) unreceptive) physical characteristics and behavior) 5. Deviant actions of the down, or lead to any atypical strategies; lack of ability to tasks; very active person individual (e.g., performance problems, such as excessive errors in performing; high or low levels of activity) Transactions * May involve only one (P) and one (E) variable or may involve multiple combinations.* I-49 The school-based clinic movement was created in response to concerns about teen pregnancy and a desire to enhance access to physical health care for underserved youth. Soon after opening, most clinics find it essential also to address mental health and psychosocial concerns. The need to do so reflects two basic realities. One, some students' physical complaints are psychogenic, and thus, treatment of various medical problems is aided by psychological intervention. Two, in a large number of cases, students come to clinics primarily for help with no medical problems, such as personal adjustment and peer and family relationship problems, emotional distress, problems related to physical and sexual abuse, and concerns stemming from use of alcohol and other drugs. Indeed, up to 50% of clinic visits are for nonmedical concerns. Thus, as these clinics evolve, so does the provision of counseling, psychological, and social services in the schools. At the same time, given the limited number of staff at such clinics, it is not surprising that the demand for psychosocial interventions quickly outstrips the resources available. Without a massive infusion of money, school-based and linked health clinics can provide only a restricted range of interventions to a limited number of students. Thus, the desire of such clinics to be comprehensive centers in the full sense of the term remains thwarted. School-Based Health Centers I-50 Family Service Centers and Full Service Schools Joy Dryfoos described the trend to develop school-based primary health clinics, youth service programs, community schools, and other similar activity under the rubric of full service schools. (She credited the term to Florida's comprehensive school-based legislation.) As she noted 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 one stop, 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. Full service schools reflect the desire for comprehensiveness; the reality remains much less than the vision. As long as such efforts are shaped primarily by a school-linked services model (i.e., initiatives to restructure to community health and human services), resources will remain too limited to allow for a comprehensive continuum of programs. And in their struggle to find ways to finance programs for troubled and troubling youth, community agencies and schools are forced to tap into resources that require assigning youngsters labels that convey severe pathology. Reimbursement for mental health and special education interventions is tied to such diagnoses. This fact dramatically illustrates how social policy shapes decisions about who receives assistance and the ways in which problems are addressed. It also represents a major ethical dilemma for practitioners. That dilemma is not whether to use labels, but rather how to resist the pressure to inappropriately use those labels that yield reimbursement from third party payers. I-51 Programmatic Approaches: Going Beyond Clinical Interventions to Address the Full Range of Problems A large number of young people are unhappy and emotionally upset; only a small percent are clinically depressed. A large number of youngsters behave in ways that distress others; only a small percent have ADHD or a conduct disorder. In some schools, the majority of students have garden variety learning problems; only a few have learning disabilities. Thankfully, those suffering from true internal pathology (those referred to here as Type III problems) represent a relatively small segment of the population. Society must never stop providing the best services it can for such individuals and doing so means taking great care not to misdiagnose others whose "symptoms" may be similar but are caused to a significant degree by factors other than internal pathology (those referred to above as Type I and II problems). Such misdiagnoses lead to policies and practices that exhaust available resources in serving a relatively small percent of those in need. That is a major reason why there are so few resources to address the barriers interfering with the education and healthy development of so many youngsters who are seen as troubled and troubling. Because behavior, emotional, and learning problems usually are labelled in ways that overemphasize internal pathology, it is not surprising that helping strategies take the form of clinical/remedial intervention. And for the most part, such interventions are developed and function in relative isolation of each other. Thus, they represent another instance of using piecemeal and fragmented strategies to address complex problems. One result is that an individual identified as having several problems may be involved in programs with several professionals working independently of each other. Similarly, a youngster identified and treated in special infant and pre-school programs who still requires special support may cease to receive appropriate help upon entering school. And so forth. I-54 Needed: A Full Continuum of Programs and Services School health programs always have been concerned with more than offering clinical services. And over the last decade, leaders in the field have advocated for an eight component model to ensure schools have a comprehensive focus on health. The components are (1) health education, (2) health services, (3) biophysical and psychosocial environments, (4) counseling, psychological, and social services, (5) integrated efforts of schools and communities to improve health, (6) food service, (7) physical education and physical activity, and (8) health programs for faculty and staff. The focus on comprehensive school health is admirable. It is not, of course, a comprehensive approach for addressing a full range of barriers to learning -- nor does it profess to be. Moreover, its restricted emphasis on health tends to engender resistance from school policy makers who do not think they can afford a comprehensive focus on health and still accomplish their primary mission to educate students. Reform-minded policy makers may be more open to proposals encompassing a broad range of programs to enhance healthy development if such programs are part of a comprehensive approach for addressing barriers to learning. Some are suggesting that the school-linked services movement, especially in the form of full service schools is the answer. And each day brings additional 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, Cities-in- Schools, and the New Futures Initiative. A review by Michael Knapp underscores the fact that the literature on school-linked services is heavy on advocacy and prescription and light on findings. Not surprisingly, findings primarily reflect how hard it is to institutionalize such approaches. I-55 Keeping the difficulties in mind, a reasonable inference from available data is that school-community collaborations can be successful and cost effective over the long-run. Outstationing community agency staff at schools allows easier access for students and families -- especially in areas with underserved and hard to reach populations. 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 and having the capability 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. At the same time, it is clear that initiatives for school-linked services produce tension between school district pupil services personnel and their counterparts in community-based organizations. When "outside" professionals are brought in, school specialist staff often view the move as discounting their skills and threatening their jobs. These concerns are aggravated whenever policy makers appear to overestimate the promise of school-linked services with regard to addressing the full range of barriers to learning. And, ironically, by downplaying school-owned resources, the school- linked services movement has allowed educators to ignore the need for restructuring the various education support programs and services that schools own and operate. I-56 With respect to addressing barriers to learning, comprehensiveness requires more than C a focus on health and social services C outreach to link with community resources C coordination of school-owned services C coordination of school and community services. Moving toward comprehensiveness in addressing barriers to learning encompasses restructuring, transforming, and enhancing C all relevant school-owned programs and services C community resources and C weaving these school and community resources together. Test Questions -- Unit I: Section C (1) Which of the following are implications of understanding a student's problems in terms of a causal continuum that ranges from internal to external causes? ___(a) some problems primarily result from biological or psychological factors ___(b) some problems primarily result from environmental causes ___(c) some problems are caused by the environment not accommodating individual differences and vulnerabilities ___(d) a and b ___(e) all of the above ___(f) none of the above (2) Improving the way the environment accommodates individual differences may be a sufficient intervention strategy. _____True _____False (3) School-Based Health Centers have come to find it necessary to address mental health and psychosocial concerns because ___(a) mental health is more important than physical health ___(b) many students physical complaints are psychogenic ___(c) mental health services are less costly ___(d) many students come to the centers for help with psychosocial problems ___(e) a and b ___(f) a and c ___(g) b and d ___(h) all of the above (4) With respect to addressing barriers to learning, a comprehensive approach requires more than a focus on health and social services. _____True _____False (5) A comprehensive approach to addressing barriers to learning is achieved by outreaching to link with community resources. _____True _____False (6) With respect to addressing barriers to learning, a comprehensive approach requires more than coordination of school and community services. _____True _____False (7) Moving toward comprehensiveness in addressing barriers to learning encompasses restructuring, transforming, and enhancing (a) relevant school-owned programs and services, (b) community resources, and (c) weaving these school and community resources together. _____True _____False I-59 Coda: A Wide Range of Responses for a Wide Range of Problems Most schools and many community services use weak models in addressing barriers to learning. The primary emphasis in too many instances is to refer individuals to specific professionals, and this usually results in narrow and piecemeal approaches to complex problems, many of which find their roots in a student's environment. Overreliance on referrals to professionals also inevitably overwhelms limited, public-funded resources. More ideal models emphasize the need for a comprehensive continuum of community and school interventions to ameliorate complex problems. Such a continuum ranges from programs for primary prevention and early-age intervention -- through those to treat problems soon after onset -- to treatments for severe and chronic problems. Thus, they emphasize that promoting healthy development and positive functioning are one of the best ways to prevent many problems, and they also address specific problems experienced by youth and their families. To be most effective, such interventions are developmentally-oriented (i.e., beginning before birth and progressing through each level of schooling and beyond) and offer a range of activity -- some focused on individuals and some on environmental systems. Included are programs designed to promote and maintain safety at home and at school, programs to promote and maintain physical/mental health, preschool and early school adjustment programs, programs to improve and augment social and academic supports, programs to intervene prior to referral for intensive treatments, and intensive treatment programs. It should be evident that such a continuum requires meshing together school and community resources and, given the scope of activity, effectiveness and efficiency require formal and long-lasting interprogram collaboration. One implication of all this is formulated as the proposition that a comprehensive, integrated component to address barriers to learning and enhance healthy development is essential in helping the many who are not benefitting satisfactorily from formal education. Schools and communities are beginning to sense the need to adopt such a perspective. As they do, we will become more effective in our efforts to enable schools to teach, students to learn, families to function constructively, and communities to serve and protect. Such efforts will no longer be treated as supplementary ("add-ons") that are carried out as fragmented and categorical services; indeed, they will be seen as a primary, essential, and integrated component of school reform and restructuring. I-60 Mental Health in Schools: New roles for school nurses Unit II: Mental Health Services & Instruction: What a School Nurse Can Do Sections A. Screening and Assessment B. Problem Response and Prevention C. Consent, Due Process, and Confidentiality Deciding what is best for a child often poses a question no less ultimate than the purposes and values of life itself. Robert Mnookin II-1 initial problem identification screening/ assessment identifying and processing students client consultation & referral triage initial case monitoring crisis intervention Direct Services mental health & education Instruction primary prevention & treatment psychosocial (inc. support for transitions) guidance & support (classroom/ individual) psychosocial counseling ongoing case monitoring Unit II: Mental Health Services & Instruction: What a School Nurse Can Do Section A: Screening and Assessment Contents: Initial Problem Identification Connecting a Student with the Right Help Screening to Clarify Need Client Consultation and Referral Triage Initial Case Monitoring II-4 Objectives for Section A After completing this section of Unit II, you should be able to: C explain what is involved in the process of identifying and processing students in need of assistance for mental health and psychosocial problems and identify five specific facets of the process C know of and be able to use at least two instruments for screening psychosocial and mental health problems A Few Focusing Questions C What is the school nurse's role in the initial identification of students who may have psychosocial and mental health problems? C Once a student is identified as having problems, what screening activity can a school nurse do to help clarify the nature and severity of the problems? C What are the purposes and processes of client consultation, referral, triage, and initial case monitoring? II-5 II-6 Initial Problem Identification Nurses identify many mental health problems when students come to their office or in the process of screening for other health problems. Such problems also come to the nurses' attention during attendance and discipline reviews, assessments for special education placement, and related to crisis interventions, or as a result of others (staff, parents, students) raising concerns about a given youngster. In this last respect, part of a nurse's job may be to educate teachers, peers, parents, and others about appropriately identifying and referring students. And, of course, some students come seeking help for themselves. How should you handle all this? If there are accessible referral resources at the school (e.g., a school psychologist, a counselor, a social worker, a school-based health center with a mental health professional) or in the community, the answer may be to help a student connect with such an individual -- assuming it is not something you can handle without making a referral. Of course, when other professionals are not available or when a student will not follow-through, your only choice is to decide whether to do something more yourself. If you decide to proceed, you will want to assess the problem for purposes of triage and consulting with the student and concerned others. II-9 Screening: A Note of Caution Formal screening to identify students who have problems or who are "at risk" is accomplished through individual or group procedures. Most such procedures are first-level screens and are expected to over identify problems. That is, they identify many students who do not really have significant problems (false positive errors). This certainly is the case for screens used with infants and primary grade children, but false positives are not uncommon when adolescents are screened. Errors are supposed to be detected by follow-up assessments. Because of the frequency of false positive errors, serious concerns arise when screening data are used to diagnose students and prescribe remediation and special treatment. Screening data primarily are meant to sensitize responsible professionals. No one wants to ignore indicators of significant problems. At the same time, there is a need to guard against tendencies to see normal variations in student's development and behavior as problems. Screens do not allow for definitive statements about a student's problems and need. At best, most screening procedures provide a preliminary indication that something may be wrong. In considering formal diagnosis and prescriptions for how to correct the problem, one needs data from assessment procedures that have greater validity. It is essential to remember that many factors that are symptoms of problems also are common characteristics of young people, especially in adolescence. Cultural differences also can be misinterpreted as symptoms. To avoid misidentification that can inappropriately stigmatize a youngster, all screeners must take care not to overestimate the significance of a few indicators and must be sensitive to developmental, cultural, and other common individual differences. II-10 A Few Comments on Screening/Assessment and Diagnosis C When someone raises concerns about a student with you, one of the best tools you can have is a structured referral form for them to fill out. This encourages the referrer to provide you with some detailed information about the nature and scope of the problem. An example of such a form is provided at the end of this section. C To expand your analysis of the problem, you will want to gather other available information. It is good practice to gather information from several sources -- including the student. Useful sources are teachers, administrators, parents, sometimes peers, etc. If feasible and appropriate, a classroom observation and a home visit also may be of use. You will find some helpful tools in the accompanying materials. C And you can do a screening interview. The nature of this interview will vary depending on the age of the student and whether concerns raised are general ones about misbehavior and poor school performance or specific concerns about lack of attention, overactivity, major learning problems, significant emotional problems such as appearing depressed and possibly suicidal, or about physical, sexual, or substance abuse. To balance the picture, it is important to look for assets as well as weaknesses. (In this regard, because some students are reluctant to talk about their problems, it is useful to think about the matter of talking with and listening to students -- more on this in Section II-B.) C In doing all this, you will want to try to clarify the role of environmental factors in contributing to the student's problems. Remember: < Students often somaticize stress; and, of course, some behavioral and emotional symptoms stem from physical problems. < Just because the student is having problems doesn't mean that the student has a pathological disorder. II-11 < The student may just be a bit immature or exhibiting behavior that is fairly common at a particular development stage. Moreover, age, severity, pervasiveness, and chronicity are important considerations in diagnosis of mental health and psychosocial problems. The following are a few examples to underscore these points. Common Low Frequency Age Transient Problem Serious Disorder 0-3 Concern about monsters under the bed Sleep Behavior Disorder 3-5 Anxious about separating from parent Separation Anxiety Disorder (crying & clinging) 5-8 Shy and anxious with peers Reactive Attachment Disorder (sometimes with somatic complaints) Disobedient, temper outbursts Conduct Disorder Oppositional Defiant Disorder Very active and doesn't follow directions Attention Deficit- Hyperactivity Disorder Has trouble learning at school Learning Disabilities 8-12 Low self-esteem Depression 12-15 Defiant/reactive Oppositional Defiant Disorder Worries a lot Depression 15-18 Experimental substance use Substance Abuse < The source of the problem may be stressors in the classroom, home, and/or neighborhood. (Has the student's environment been seriously looked at as the possible culprit?) < At this stage, assessment is really a screening process such as you do when you use an eye chart to screen for potential vision problems. If the screening suggests the need, the next step is referral to someone who can do indepth assessment to determine whether the problem is diagnosable for special education and perhaps as a mental disorder. To be of value, such an assessment should lead to some form of prescribed treatment, either at the school or in the community. In many cases, ongoing support will be indicated, and hopefully the school can play a meaningful role in this regard. II-14 A Few Comments on Client Consultation and Referral Referrals are relatively easy to make; appropriate referrals are harder; and ensuring follow-through is the most difficult thing of all. Appropriate referrals are made through a consultation process that is consumer oriented and user friendly. They also are designed as a transition-type intervention; that is, recognizing that many students/families are reluctant to follow-through on a referral, they include procedures that support follow-through. A consumer oriented system is designed with full appreciation of the nature and scope of student problems as perceived by students, their families, and their teachers. Such problems range from minor ones that can be dealt with by providing direct information, perhaps accompanied by some instruction to severe/pervasive/chronic conditions that require intensive intervention. The process must not ignore the social bases of a student's problems. This means attending to environmental concerns such as basic housing and daily survival needs, family and peer relations, and school experiences. A student's needs may range from accessing adequate clothes to acquiring protection from the harassment of gang members. In many instances, the need is not for a referral but for mobilizing the school staff to address how they might improve its programs to expand students' opportunities in ways that increase expectations about a positive future and thereby counter prevailing student frustration, unhappiness, apathy, and hopelessness. A consumer oriented system should minimally C provide readily accessible basic information about relevant resources C help students/families appreciate the need for and value of a potential resource C account for problems of access (e.g., cost, location, language and cultural sensitivity) C aid students/families in reviewing their options and making decisions in their own best interests C provide sufficient support and guidance to enable students/families to connect with a referral resource C follow-up with students/families (and referrers) to determine whether referral decisions were appropriate. II-15 Thinking in terms of intervention steps, a good consultation and referral process helps you do the following: (1) Provide ways for students/families and school personnel to learn about existing resources This entails widespread circulation of general information about on- and off-campus programs and services and ways to readily access such resources. (2) Establish whether a referral is necessary This requires an analysis of whether current resources can be modified to address the need. (3) Identify potential referral options with the student/family Review with the student/family how referral options can assist. A resource file and handouts can be developed to aid in identifying and providing information about appropriate services and programs -- on and off-campus -- for specific types of concerns (e.g., individual/group/family/professional or peer counseling for psychological, drug and alcohol problems, hospitalization for suicide prevention). Remember that many students benefit from group counseling. And, if a student's problems are based mainly in the home, one or both parents may need counseling -- with or without the student's involvement as appropriate. Of course, if the parents won't pursue counseling for themselves, the student may need help to cope with and minimize the impact of the negative home situation. Examples of materials that can provide students, families, and staff with ready references to key resources are provided in the accompanying Resource Aid Packet on Client Consultation and Referral: a Transition Intervention. (4) Analyze options with student/family and help with decision-making as to which are the most appropriate resources This involves evaluating the pros and cons of potential options (including location, fees, least restrictive and intrusive intervention needed) and, if more than one option emerges as promising, rank ordering them. For example, because students often are reluctant to follow-through with off-campus referrals, first consideration may be given to those on-campus, then to off-campus district programs, and finally to those offered by community agencies. Off-campus referrals are made with due recognition of school district policies. II-16 (5) Identify and explore with the student/family all factors that might be potential barriers to pursuing the most appropriate option Is there a financial problem? a transportation problem? a problem about parental consent? too much anxiety/fear/apathy? At this point, it is wise to be certain that the student (and where appropriate the family) truly feels an intervention will be a good way to meet her or his needs. (6) Work on strategies for dealing with barriers to follow-through This often overlooked step is essential to follow-through. It entails taking the time to clarify specific ways to deal with apparent barriers. (7) Send the student/family off with a written summary of what was decided including follow-through strategies A referral decision form can summarize (a) specific directions about enrolling in the first choice resource, (b) how to deal with problems that might interfere with successful enrollment, and (c) what to do if the first choice doesn't work out. A copy of such a form can be kept on file for purposes of case monitoring. (8) Also send them off with a follow-through status report form Such a form is intended to let the school know whether the referral worked out, and if not, whether additional help is called for in connecting the student/family to needed resources. Also, remember that teachers and other school staff who asked you to see a student will want to know that something was done. Without violating any confidentiality considerations, you can and should send them a quick response reassuring them that the process is proceeding. (9) Follow-through with student/family and other concerned parties to determine current status of needs and whether previous decision were appropriate This requires establishing a reminder (tickler) system so that a follow- up is made after an appropriate period of time. Obviously, the above steps may require more than one session with a student/family and may have to be repeated if there is a problem with follow- through. In many cases, one must take specific steps to help with follow through, such as making direct connections (e.g., by phone) to the intake coordinator for a program. Extreme cases may require extreme measures such as arranging for transportation or for someone to actually go along to facilitate enrollment. II-19 (4) Initial Case Monitoring It is wise to do an immediate check on follow-through (e.g., within 1-2 weeks) to see if the student did connect with the referral. Besides checking with the student/family, it is also a good idea to get a report on follow-through from those to whom referrals are made. If there has been no follow-through, the contact can be used to clarify next steps. If there has been follow-through, the contact can be used to evaluate whether the resource is meeting the need. The opportunity also can be used to determine if there is a need for communication and coordination with others who are involved with the student's welfare. This is the essence of case management which encompasses a constant focus to evaluate the appropriateness and effectiveness of the interventions. Follow-up checks are indicated periodically. If the findings indicate the student did not successfully enroll or stay in a program or is not doing well, another consultation session can be scheduled to determine next steps. Remember that from the time a student is first identified as having a problem, there is a need for someone to monitor/manage the case. Monitoring continues until the student's service needs are addressed. Monitoring takes the form of case management to ensure coordination with the efforts of others who are involved (e.g., other services and programs including the efforts of the classroom teacher and those at home). The process encompasses a constant focus to evaluate the appropriateness and effectiveness of the various efforts. Stop, Think, Discuss Gathering Some Assessment Data Joan asked Mrs. Johnson to have the doctor send her a medical report. Although she was already convinced that Matt's problems were not physical, she wanted some validation. To get a sense of his past experiences at school, she went to Matt's school records. It was clear from his grades and achievement test scores that the problems at school had not appeared until he entered 4th grade. She talked with his teacher, Mr. Briggs. He didn't much like Matt but said the boy was smart and that his basic skills were pretty good. He also stressed that, because of the way Matt acted, none of the other students liked him. As far as the teacher was concerned, Matt just needed parents who could control him. When she told Matt she wanted to talk with him, he wanted to know why. She explained her concerned that things weren't going well for him and that she thought he might have some ideas about how the school could help him make things better. She let him know that he didn't have to talk about anything he didn't want to discuss. She also said they could meet at a time that was good for him. Matt was skeptical, but he agreed to talk with her during math time. When he appeared at her office, Joan put a "Conference in Progress" sign on the door and proceeded to engage Matt in a dialogue designed to find out what was wrong and what might be done to help him. What types of things should a school nurse explore in interviewing a student about psychosocial and mental health concerns? What is likely to facilitate and what can inhibit student talk during an interview? II-20 Request for Assistance in Addressing Concerns about a Student/Family Extensive assessment is not necessary in initially identifying a student about whom you are concerned. Use this form if a student is having a significant learning problem, a major behavior problem, or seems extremely disturbed or disabled. Student's Name _______________________________________ Date:_______ To: ___________________________________ Title: ___________________ From: ___________________________________ Title: ___________________ Apparent problem (check all that apply): ___ physical health problem (specify) _______________________________ ___ difficulty in making a transition ( ) newcomer having trouble with school adjustment ( ) trouble adjusting to new program ___ social problems ( ) aggressive ( ) shy ( ) overactive ( ) other __________________ ___achievement problems ( ) poor grades ( ) poor skills ( ) low motivation ( ) other _____________________ ___ major psychosocial or mental health concern ( ) drug/alcoh. abuse ( ) pregnancy prevention/support ( ) self esteem ( ) depression/suicide ( ) eating problems (anorexia, bulim.) ( ) relationship problems ( ) grief ( ) physical/sexual abuse ( ) anxiety/phobia ( ) dropout prevention ( ) neglect ( ) disabilities ( ) gang involvement ( ) reactions to chronic illness Other specific concerns Current school functioning and desire for assistance Overall academic performance ( ) above grade level ( ) at grade level ( ) slightly below grade level ( ) well below grade level Absent from school ( ) less than once/month ( ) once/month ( ) 2-3 times/ month ( ) 4 or more times/month Has the student/family asked for: information about service Y N an appointment to initiate help Y N someone to contact them to offer help Y N If you have information about the cause of a problem or other important factors related to the situation, briefly note the specifics here (use the back of the sheet if necessary). II-21 Test Questions -- Unit II: Section A (1) Which of the following were discussed as major facets of identifying and processing students in need of assistance for mental health and psychosocial problems? ___(a) initial problem identification ___(b) screening/assessment ___(c) client consultation and referral ___(d) triage ___(e) initial case monitoring ___(f) a, b, d ___(g) a, b, e ___(h) all the above (2) It is especially hard to know the underlying cause of a problem when a student is not very motivated to learn and perform at school . ___True ___False (3) Screening can be used to help clarify the nature, extent, and severity of a problem? ___True ___False (4) The instrument for screening suicidal risk doesn't ask about ___(a) past attempts, current plans, and view of death ___(b) reactions to precipitating events ___(c) available psychosocial support ___(d) attitudes toward school ___(e) history of risk-taking behavior (5) Which of the following are a focus of the initial interview/questionnaire instruments ___(a) the student's perception of the problem ___(b) what has been tried previously to deal with the problem ___(c) motivation to do something about the problem ___(d) a, b ___(e) all the above II-24 Unit II: Mental Health Services & Instruction: What a School Nurse Can Do Section B: Problem Response and Prevention The many pieces of the helping puzzle. How do we put them together? Initial Problem Identification Screening/Assessment Triage Client Consultation and Referral Guidance and Support Direct Instruction Counseling Open-Enrollment Programs Highly Specialized Interventions Contents: Psychological First Aid: Responding to a Student in Crisis Primary Prevention and Treatment Mental Health Education Psychosocial Guidance and Support Psychosocial Counseling Ongoing Case Monitoring To Review II-25 Objectives for Section B After completing this section of Unit II, you should be able to: C explain the immediate objective of psychological first aid. C identify three phases of crisis intervention C identify seven activities related to providing psychosocial guidance and support C identify at least 5 specific things that can be done to facilitate student communication in a psychosocial counseling situation A Few Focusing Questions C Besides providing immediate psychological first aid, what other concerns arise during crisis intervention? C What is the potential scope of mental health education in schools? C What can a school nurse do to provide additional guidance and support related to psychosocial concerns? C How does one develop a psychosocial counseling relationship with a student? C What is involved in providing ongoing case monitoring? C What does the term informed consent really mean? C What due process rights do parents have? C When are the major exceptions to ensuring a student that what is said in counseling will be kept confidential? II-26 II-29 A Few General Principles Related to Responding to Crises Immediate Response -- Focused on Restoring Equilibrium In responding: C Be calm, direct, informative, authoritative, nurturing, and problem- solving oriented. C Counter denial, by encouraging students to deal with facts of the event; give accurate information and explanations of what happened and what to expect -- never give unrealistic or false assurances. C Talk with students about their emotional reactions and encourage them to deal with such reactions as another facet of countering denial and other defenses that interfere with restoring equilibrium. C Convey a sense hope and positive expectation -- that while crises change things, there are ways to deal with the impact. Move the Student from Victim to Actor C Plan with the student promising, realistic, and appropriate actions they will pursue when they leave you. C Build on coping strategies the student has displayed. C If feasible, involve the student in assisting with efforts to restore equilibrium. Connect the Student with Immediate Social Support C Peer buddies, other staff, family -- to provide immediate support, guidance, and other forms of immediate assistance. Take Care of the Caretakers C Be certain that support systems are in place for staff in general C Be certain that support (debriefing) systems are in place for all crisis response personnel. Provide for Aftermath Interventions C Be certain that individuals needing follow-up assistance receive it. II-30 Primary Prevention and Treatment As already noted, many school nurses can and want to be more involved in programs to prevent and correct mental health and psychosocial problems. Among the functions some already are carrying out are (1) mental health education (2) psychosocial guidance and support (3) psychosocial counseling (1) Mental Health Education Educative functions range from disseminating mental health information to actual course instruction related to positive social and emotional development and wellness. Every school needs to disseminate information that helps protect, promote, and maintain the well-being of students with respect to both physical but mental health. School nurses already play a major role in disseminating health related information. It does not take much imagination to see how important it is that such activity encompass mental health. This includes providing highly visible information related to prevention and correction: C positive opportunities for recreation and enrichment C opportunities to earn money C how to stay healthy -- physically and mentally (this includes instruction using curricula on special topics such as social skills and interpersonal relationships, substance abuse, violence prevention, physical and sexual abuse prevention, sex education, and so forth) C early identification of problems C what a student/parents should do when problems arise C warm lines and hotlines C services on- and off-campus. II-31 During the instructional day, the curricula in many classes touches upon matters related to positive social and emotional development and wellness. In addition, some schools actually have incorporated mental health as a major facet of health education. And school staff are involved each day in dealing with matters related to mental health and psychosocial concerns. Related to these matters, efforts should be made to capitalize on the school nurse's strengths by facilitating ways for her or him to play a direct role with students as part of a school's efforts to provide comprehensive health education and an indirect role by participating in developing the capacity of other staff to address these matters. In addition, nurses can play a role in a variety of open-enrollment programs designed to foster positive mental health and socio-emotional functioning. They can also help establish strategies to change the school environment in ways that make it more inviting and accommodating to students. This involves participation in staff development, but even more, it requires working with school staff to restructure the school so that it effectively promotes a sense of community. Examples include establishing welcoming programs for new students and families and strategies to support other transitions, developing families of students and teachers to create schools within schools, and teaching peers and volunteer adults to provide support and mentoring. Intervening at this environmental level also encompasses working with community agencies and businesses to enhance the range of opportunities students have with respect to recreation, work, and community service. Effective open-enrollment and prereferral intervention programs and environment change strategies can minimize the number of mild to moderate problems that develop into severe ones. This reduces the number in need of specialized interventions and helps reserve such help for those who inevitably require them.