Schools as Places for Health, Mental Health, and Social Services
by Joy G. Dryfoos - 1993
The article discusses the resurgence of school-based community health, mental health, and social services during a period of social upheaval, focusing on improving adolescent health through school-based initiatives. Three appendices describe school-based health service programs in New Jersey and Mississippi. (Source: ERIC)
The caring professions, community leaders, parents, and young people themselves are being overwhelmed by the threat of the “big four” adolescent problems: sex, drugs, violence, and depression.& every behavioral and attitudinal survey, these items are at the top of the list of what troubles teenagers and stands in the way of their achieving healthy and safe maturity. In the past, professional attention to these problems has been conducted within entirely separate domains, with categorical programs for prevention of substance abuse, teen pregnancy, and delinquency and promotion of mental health. Each domain has its own experts, interventions, and sources of funds. These programs are isolated from one other and, with few exceptions, are operated separately from the educational system. Only recently has there been an acknowledgement that behaviors such as abusing drugs or engaging in early sexual intercourse are interrelated with and influenced by educational outcomes such as grades, attendance, retention, and graduation. In a reciprocal mode, young people who do well in effective schools are less vulnerable to the “new morbidities” while young people who are protected from problem behaviors achieve academically.
Recognition of the linkages between adolescent health status and educational achievement is leading to the proliferation of new forms of institutional arrangements. Health, mental health, social services, recreation, and arts programs are being brought into schools to augment the services that school systems have put together to deal with the difficult problems arising in today’s social environment. The goal of these new efforts is to create “one-stop” service centers in a convenient place where young people can attend to their many needs. The place is the school. The theory is that school is where to find most adolescents, at least before they drop out, and if middle and junior high schools are included in these interventions, almost all young people could be reached through school-based facilities.
This is neither a new nor a radical idea. About a century ago, in response to the massive impact of immigration, urbanization, and industrialization, large numbers of doctors, dentists, and nurses were brought into overcrowded city schools to screen for communicable diseases, treat caries, get rid of pediculosis, and even perform minor surgery such as tonsillectomies and tooth extractions.  By the 1920s, the medical profession backed away from these interventions, fearing socialized medicine. Schools hired their own nurses to check for immunization and attendance status, relied on health-education curricula to influence youth to change health behaviors, and assumed that the private sector would take care of adolescent health needs. In the early 1970s, a new generation of pediatricians initiated demonstration projects in a few cities that brought medical and dental units back into schools, but these innovative programs lasted only as long as the grants. 
This article describes the resurgence of a school-based services movement, bringing an array of community-health, mental-health, and social services back into schools during another period of social upheaval. The description of these centers and programs is followed by an analysis of the advantages and the limitations of these developments. Finally, a discussion of the future for one-stop adolescent health centers is presented. The focus of this article is on improving the health status of adolescents through school-based initiatives. However, this subject comprehends only one side of an equation; the other side is the restructuring of schools to make them into places in which all young people have an equal opportunity to learn. Schools cannot assume the sole responsibility for producing competent adults if they are to fulfill their primary missionto educate. Other articles in this journal focus on that mission (see H. Craig Heller, Gordon M. Ambach, Deborah Meier, and James P. Comer, “At the Crossroads,” in this issue).
SUPPORT FOR THE CONCEPT OF SCHOOL-BASED PROGRAMS
Some twenty-five major reports were published between 1989 and 1991 that addressed the interconnectedness of young people’s health status and their educational experience, called for a more comprehensive approach to health, and supported the placement of health-promotion and health-service programs in schools. For example, two organizations representing disparate major interest groups, the American Medical Association and the National Association of State Boards of Education, issued Code Blue: Uniting for Healthier Youth. Code Blue is the parlance used in medicine to signify a life-threatening emergency, which is how the organizations’ joint commission characterized contemporary health problems of youth. Their recommendations stem from their agreement that education and health are inextricably intertwined, that efforts to improve school performance that ignore students’ health are ill-conceived, as are health-improvement efforts that ignore the role of education. Thus the commission strongly supported the establishment of health centers in schools, attention to the school climate and issues related to achievement, and the restructuring of public and private health insurance to ensure access to services: “Families, schools, neighborhoods, the health community, and the public and private sectors will need to forge new partnerships to address the interconnected health and education problems our young people are experiencing.” 
The Office of Technology Assessment (OTA), charged by Congress with reviewing the health status of American adolescents, recognized school-linked clinics as one of the most promising recent innovations to improve adolescent’s access to health services. The report proposed as its major strategy that “Congress could support the development of centers that provide comprehensive and accessible health and related services specifically for adolescents in schools and/or communities.” The OTA documented that many adolescents are not covered by private health insurance, and that many adolescents in low-income families are not enrolled in the Medicaid system. The report pointed out that all adolescents face age-related barriers to access to confidential medical care because of’ parental-consent requirements, lack of information about services, a scarcity of providers trained to deal with adolescent issues, and, in rural areas, long distances to travel and inadequate public transportation. The OTA recommended that the federal government provide "seed money" for the development of comprehensive health centers in or near schools and funding for continuation of established programs. They added a strong caveat, noting the limited systematic evidence that school centers improve adolescent health outcomes.
The movement toward creating service centers in schools is being driven by educators as well as health professionals. Studies of school-restructuring issues have highlighted the relationship of good health to educational achievement, and the importance of bringing health services into schools. Turning Points, the Carnegie Council on Adolescent Development’s challenge to middle-school reform, called for the placement of a health coordinator in every school to organize the necessary resources to ensure that young adolescents would be healthy in order to learn. The task force recognized, however, that the needs of some students might exceed the available resources, and therefore schools should consider options such as school-based and school-linked health centers. They envision a comprehensive services network with the school as the center, and community agencies acting as the lead coordinating organizations.
TRADITIONAL HEALTH AND SOCIAL SERVICES IN SCHOOLS
Every school system has its own board policies, and every state has different legislation covering school health. In general, our nation’s 83,000 public elementary and secondary schools rely heavily on school nurses and guidance counselors. School nurses typically provide vision and hearing screening, check for immunization compliance and head lice, arrange for emergency care, give students excuses to go home if they are ill or injured, and help with attendance records. Some schools still test for scoliosis (curvature of the spine), although this is no longer considered cost-effective because of low reliability of case finding and low incidence of serious problems. In most states, school nurses are not allowed to give students medication, even aspirin. Currently, there are about 45,000 school nurses, roughly one for every two schools. The ratio of school nurses to students is approximately one per 1,000, but the geographic distribution is uneven and some schools have no nurses (for example, in New York City) while others exceed the desirable ratio of 1:750. According to Philip Nader, a pioneer in school-based services:
Economic pressures on schools, a return to the basics and a lack of documentation of the value of school health services has resulted in a trend toward replacement of the professional school nurse by less qualified nurse aides or licensed practical nursing personnel, further diminishing the quality and quantity of school health services available to children.
There are about 70,000 guidance counselors in public schools, about 1 per 600 students. The high school guidance counselor’s primary role is to assist students in making decisions about curricular choices and applying to colleges. Because of the large number of students for whom they are responsible, they are not able to provide psychological counseling or deal with behavioral problems. The 1988 National Education Longitudinal Study of eighth-graders found that only 11 percent of students had talked to a school counselor or a teacher about personal problems within the previous year.  Some school systems employ social workers and psychologists who may work as part of the pupil personnel services team, specifically to attend to more complex problems of students and their families.
School administrators, particularly (but not only) in disadvantaged communities, are increasingly acknowledging that they cannot continue to be the “surrogate parents” for young people with overwhelming health, social, and psychological problems, needs that cannot be met by school personnel. In certain circumstances, parents are not available to help their children; they have too many problems of their own. Existing pupil personnel staff is being stretched to the limit. School systems are confronted with massive budget cuts in which school nurses and other support personnel are among the first to be eliminated. Faced with these daily crises, school administrators are much more open than in the past to allowing local health and social agencies to relocate their services in school building sites.
A school-based health clinic (SBC) is a facility located in a school building or adjacent to a school building where an array of services is provided by medical and social service personnel. In general, the comprehensive package of services includes health screening, physical examinations, treatment of minor injuries and illnesses, and counseling and referral. Attention to reproductive health care and mental-health services varies according to the program. The Jackson-Hinds (Mississippi) Comprehensive Health Center’s School-Based Clinics program is typical of the earliest “models,” which focused more on reproductive health care than did later ones (see Appendix 1).
In 1984, only ten SBCs could be identified around the country. The first SBC at the high school level was organized in Dallas in 1970 by the Department of Pediatrics, University of Texas Health Science Center.  The program included family planning and a decline in the birth rate appeared during the early years of the project. The most publicized model, in St. Paul, Minnesota, was started in 1973 by the Maternity and Infant Care Program of the local medical center. When the program was first initiated in one high school clinic with a focus solely on family planning, it failed to enroll students. After the program was expanded to include comprehensive health services and placed in four sites, enrollment grew. In 1980, it was reported that birth rates had dropped significantly after the initiation of health services including family planning in four high school sites.  However, this research did not include a control group or account for abortions.
Between 1985 and 1991, SBCs were organized in high schools and middle schools in almost every state, primarily in urban areas. There is no exact count, but the most recent survey (1991) conducted by the Center for Population Options (CPO) started with a listing of 328 sites.  While a major goal of many of the earlier programs was prevention of pregnancy, more recent entries are focused on a wide range of goals, including dropout and substance-abuse prevention, mental health, and health promotion. Because of the early focus on pregnancy prevention, SBCs were the media and detractors, and until recently, this theme has dominated whatever attention school-based health service programs have received. Yet SBCs dubbed “sex clinics" by have not proven to be effective at pregnancy prevention, although they show enormous promise as centers for integrating services such as counseling and general health screening that may indirectly impact on sexual behaviors.
The growth of SBCs has resulted from a variety of forces: demand arising at the community level to help schools deal with the “new morbidities”; popularity of an innovative model for working with high-risk youth; responses to requests for proposals from foundations; and stimulation by state government initiatives. A number of the new program models have been designed by adolescent-medicine physicians and public-health practitioners who want to develop a delivery system of services for adolescents.
In 1986, the Robert Wood Johnson Foundation (RWJ) initiated a grants program to establish SBCs to make health care more accessible to poor children and reduce the rates of teen pregnancy. Some twenty-three health clinics were organized in schools by teaching and community hospitals, county health departments, not-for-profit agencies, and, in some cases, the school systems. However, school systems that received grants had to subcontract with community health providers rather than directly hiring health professionals. According to Lear et al.:
The primary reason for this approach was the belief that the way to strengthen health services provided in schools is to make those services an integral part of the community’s health care delivery system . . . [these] health care institutions are best able to arrange medical referrals, address infection control, arrange laboratory pick-ups, protect medical confidentiality, provide medical back-up when the health centers are closed and respond to the myriad of issues that arise in the daily management of a health center. 
Many states provide funds to stimulate the organization of SBCs at the local level, typically through competitive health department grants. Arkansas, California, Connecticut, Delaware, Florida, Georgia, Iowa, Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New York, and Oregon currently support some form of school-centered health and social services for children, youth, and families (see Appendix 2). The California State Education Department has been designated the lead agency for the new $20 million Healthy Start initiative for development of school-based health, mental health, and social and academic support services, and a consortium of foundations has set up a new nonprofit agency to provide monitoring, evaluation, and technical assistance to California communities and schools. Most state legislation has placed restrictions on the use of state funds for the distribution of contraceptives and referral for abortion on school premises.
No single SBC model has emerged during this developmental stage. A wide array of agencies administer SBCs. According to the Center for Population Options, in 1991 three-fourths of SBCs were sponsored by public-health departments, community-health clinics, and hospitals or medical schools; 6 percent by community-based organizations and private nonprofit agencies; and 7 percent by the school district itself.  Because of the great variety of models and sizes, annual costs range from about $50,000 to $300,000. Most of these funds come from state health departments, Medicaid, city governments, and foundations, not from school district budgets.
The average clinic enrollment is around 700 (with a wide range) and there are about 2,000 visits per year. In most schools, about 70 percent of the students register for the clinic. All schools require parental permission to enroll, with some exceptions covered by state and federal laws for emergency care, reproductive-health care, and drug and mental-health counseling.
SBCs are typically staffed by nurse practitioners, social workers, clinic aides, and other specialized personnel (nutritionists, health educators, psychologists). Physicians come in part-time for scheduled examinations and treatment, and are available on call for consultations and emergencies. The clinic coordinator is frequently the nurse practitioner. If the school still has a school nurse, her services are integrated with those of the clinic operations as much as possible. Most clinics provide general and sports physicals, diagnosis and treatment of minor injuries, pregnancy tests, immunizations, laboratory tests, chronic-illness management, health education, extensive counseling, and referral. Over 90 percent prescribe medications.
A 1990 CPO report reveals that 97 percent of high school and 73 percent of middle-school clinics provide counseling on birth-control methods.  About three-fourths of the high schools and half of the middle schools conduct gynecological examinations, follow up contraceptive users, and provide referrals to other agencies for methods and examinations. However, only half write prescriptions for contraceptives and-only 21 percent actually dispense them. Although the clinics say they are offering these “family-planning” services, only 10-20 percent of the students report using the clinics for family planning. Not surprisingly, the clinics that offer the most comprehensive family-planning services appear to be the most heavily utilized by the students for family planning. One study of six clinics found that at only two sites were more students using contraceptives than in comparison sites without clinics, but there were no differences in pregnancy or birth rates across sites. Kirby et al. concluded that the clinic could not have an effect on pill and condom use unless much higher priority were given to pregnancy or AIDS prevention throughout the program and the schoo1.  This implies much greater attention to follow-up of sexually active students to ensure compliance with contraceptive methods.
Program data show that clinic users are more likely to be female, African-American or Hispanic, and disadvantaged (eligible for free-lunch programs).  However, a large number of males douse the clinics, especially for physical examinations and treatment for accidents and injuries. Reports from clinic practitioners invariably mention personal counseling as the most sought after service, reflecting the stressful lives of contemporary adolescents. In some clinics, 30-40 percent of the primary diagnoses are mental-health related.  The presence of a non-threatening, confidential advisor apparently opens up communication about such issues as sexual abuse, parental drug use, and fears of violence.
In summary, a movement toward the development of school-based centers has emerged during the past decade reflecting a response to the overwhelming needs of today's students for health services. It is estimated that in aggregate some 400 school-based clinics may now be serving about 300,000 students per year, a minuscule proportion of the total number of enrollees in junior and senior high schools. Nevertheless, these “pioneer” programs prove that such efforts are both possible and feasible, and, in a sense, this cohort may be the “cutting edge” for the implementation of a wide range of service programs, each individualized to the particular needs of the students, the school, and the community.
MENTAL-HEALTH CENTERS IN SCHOOLS
A key finding in surveys of students is the high incidence of depression and suicidal ideation. The OTA estimated that one out of five adolescents age ten to eighteen suffers from a diagnosable mental disorder, including depression, and that one out of four adolescents reports symptoms of emotional distress. Yet few depressed students have access to mental-health care in the community, and the already overextended school psychologists and school social workers cannot possibly meet this critical need. As a result, there is a growing interest in bringing outside services into school sites.
Several different approaches are being used to bring mental-health services into schools: on-site counseling and treatment for mental-health problems by mental-health professionals; building mental-health teams to work with school personnel to develop more effective responses to high-risk children; and development and implementation of competency-building curricula in classrooms. These three kinds of interventions have in common that they are designed, implemented, and funded by community agencies, outside of the school system, and brought into schools in the same way as SBCs, primarily through foundation grants and/or statewide funding.
While all of these models are interesting and important, I will concentrate here primarily on the emergence of centers within schools that provide actual screening, diagnosis, and treatment for psychosocial disorders. These direct-service programs are similar in organization to school-based health clinics but they start out with the specific goal of remediation of psychosocial problems. The School-Based Youth Services Program in New Brunswick (N.J.) is an example of a mental health program operated in a school by a local community mental health center (see Appendix 3).
The work of carving out this subset of activities is being refined by the School Mental Health Project at the University of California-Los Angeles, a national clearinghouse that offers training, research, and technical assistance.  This project works in conjunction with the Los Angeles Unified Schools District’s School Mental Health Center based on that experience is in the process of developing a guidebook for practitioners who want to follow a mental-health model. Howard Adelman and Linda Taylor, who direct the project, believe that the major challenge for school-based mental health centers is to identify and collaborate with what is already going on in the school district. Many schools have programs focused on substance abuse and teen pregnancy prevention, crisis intervention (suicide), violence reduction, and “self-esteem” enhancement, and other kinds of support groups. However, these efforts lack cohesiveness in theory and implementation, often stigmatize students by targeting them, and suffer from the common bureaucratic problem of poor coordination between programs. One of the most demanding roles for the mental-health center is to establish working relationships with key school staff members.
In response to the often overwhelming demand for services, mental-health practitioners (primarily social workers or clinical psychologists) have initiated a number of innovative group-counseling approaches. For example, staff at the San Fernando Heights School (Los Angeles) school-based center developed "Bi-culturation Groups" for helping students from other countries make the transition into a new school and community.  Three kinds of problems are dealt with: acculturating to a new environment; coping with common problems of adolescence; and dealing with pre-immigration problems such as war-related trauma or family separation.
A school-based clinic program in four junior high schools in the Washington Heights area of New York City operated by the Columbia University School of Public Health has added mental-health components to the original health model in response to the serious psychosocial problems of the students. Social workers provide individual and group counseling, offer group intervention, and maintain contact with parents, teachers, and other school personnel as needed to meet the needs of the students. The social workers do comprehensive psychosocial assessments on children identified by surveys, medical staff, and school personnel for given problems and follow up with group, individual, or family counseling; home visiting; mentoring; parent workshops; or school consultation with guidance counselors or teachers. As this program has evolved, the social work staff (rather than the nurse practitioners) have assumed most of the responsibility for dealing with sexuality issues. They run groups focusing on decision-making skills, reproductive knowledge, and refusal skills. As part of this activity, they escort sexually active students to the family-planning clinics at the back-up hospital. They are also responsible for following up contraceptive patients to ensure their compliance. Direct and immediate social work intervention is required in all cases of reported or suspected child abuse and psychiatric emergencies. In addition to the development of direct mental-health services in schools, other initiatives have received considerable attention, particularly the “Comer Process.” Developed in 1968 by James Comer at Yale University and currently being widely replicated, this program attempts to transfer mental-health skills to schools, where “change agents” must be created by strengthening and redefining the relationships between principals, teachers, parents, and students. An essential element is the creation of a mental-health team including the school psychologist and other support personnel, who provide direct services to children and advise school staff and parents. A member of the mental-health team plays an active role on the management-oriented School Improvement Team, along with representatives of teachers, teacher aides, and parent groups.
In summary, a variety of mental-health programs are being offered in schools by community mental-health centers, university psychology and social work departments, and mental-health practitioners. A few might be classified as school-based mental health centers but most of the efforts to cope with the rising number of psychosocial problems appear to be attached to existing health clinics or other approaches. It is not possible to enumerate the number and location of schools with discrete mental-health programs (as distinguished from school psychologists and social workers who may counsel students as part of school function).
COMPREHENSIVE MULTIFACETED PROGRAMS
School-based health centers increasingly use the language of “comprehensiveness.” As centers open in schools, the demand for many different services arises. As we have seen, programs that started out as pregnancy-prevention rapidly shifted to general health services, and those that provided general health services had to incorporate psychosocial counseling. As the demand for personal counseling grew, the clinics began to assume more of the aura of mental-health services.
Yet when these centers are opened in school sites, they often meet a bewildering array of categorical prevention and treatment programs. One principal of an inner-city junior high school in New York displayed a list of 200 different programs coming into his school from outside community agencies. He stated that he had no idea what they did, and would be happy to replace them with one central facility that coordinated and monitored services provided to his students.
The call for coordinated services is being heard across the land, not only in relationship to adolescent health issues, but in regard to maternal and child health, early childhood services, welfare reform, and practically every other social endeavor. Most of the new plans call for the development of one-stop centers and typically these centers are in or near schools. “Teen Moms” is an example of a comprehensive model that has been in existence for some time. Those interested in alleviating the many problems connected with early teenage parenthood have long been packaging services for teenage parents that include on-site infant care along with educational remediation, parenting skills, health services, and personal counseling.  More recent models embrace the concepts of case management with the use of “community women” who are supposed to act as mentors and advocates. A few of these teen-parent programs are located within schools (as in Jackson, Mississippi) but most are operated by school systems as alternative schools.
New York State supports fourteen community schools charged with developing school/community collaborations that use the schools as sites for access to social, cultural, health, recreation, and other services for children, their families, and other community adults.  In Rochester, New York, the Chester Dewey School uses a full-time coordinator to-encourage community agencies to bring in after-school care and mentoring, and evening programs and activities for adults. The Community School Project has worked with the Department of Social Services to address the serious housing needs of the parents through workshops on tenants’ rights, assisting parents to find better housing and to reduce evictions.
The national Cities in Schools (CIS) initiative has promoted the collaborative model, bringing social services into schools by placing social workers from community agencies as case managers on school sites.  Each participating community works out its own version of this approach and there are a number of “spin-offs” that were started by the CIS process but later became independent. One large-scale undertaking in Pinal County, Arizona, the Prevention Partnership, places site directors in twelve schools along with VISTA volunteers who act as service brokers to 120 service providers in the county. This program employs a school-based management system, and referrals are made for counseling, mentoring, parenting skills, employment and welfare assistance, prenatal and preventive health services, and emergency services. The four New Futures experiments being conducted by the Annie Casey Foundation in Pittsburgh, Savannah, Dayton, and Little Rock are attempting to build “oversight collaboratives” that will bring together community leaders, schools, and community agencies to create new institutional arrangements that will alter the way services (including education) are delivered to children. Preliminary reports suggest that these New Future initiatives are “slow going,” with little effect on restructuring schools or changing the ways that agencies conduct their business. However, researchers found enhanced dialogue between leaders in schools and community agencies with the potential for improvement in the future. Aside mented supplemental new initiatives such as case management and schoolbased clinics.
SINGLE-PURPOSE SCHOOL-BASED PROGRAMS
Perceptions about what can be brought into schools by outside community agencies are becoming more and more inclusive. As has been pointed out, many task forces and commissions have recommended comprehensive collaborative community-wide programs. Yet some of these large-scale comprehensive programs are proving difficult to implement (e.g., New Futures) and slow to evaluate (e.g., Cities in Schools). In fact, most of the documented successful prevention programs are categorical and are operated by individuals and/or teams from single community agencies that come into schools and provide specialized counseling, treatment, and referral to outside agencies.
An example in the substance-abuse prevention and treatment field is called Student Assistance. In this effort, social workers from an outside agency are assigned to schools, where they work with the principal, teachers, and other support personnel to identify high-risk students, provide individual and group counseling, facilitate referrals and follow-up, and help create a healthy and safe school climate. 
A similar model has proven successful in the teen-pregnancy prevention field. Counselors, usually social workers, from outside agencies are placed in schools, where they conduct individual and group counseling and referral for family planning. Each counselor has a private office in the school and confidentiality is carefully safeguarded. Another school-based pregnancy prevention program, Team Outreach, incorporates a life-planning curriculum, mentoring, and counseling along with volunteer job placements in the community. 
The successful categorical programs feature a number of common components such as early intervention, intensive one-on-one individual attention, training in social skills and competency building, exposure to the world of work, and involvement of peers and parents. Many programs that work to prevent social-behavioral problems focus on the acquisition of basic academic skills and schools are essential partners in much of the prevention activity. However, no one component is believed to work miracles. The comprehensive efforts that are currently emerging typically package most of these elements into an integrated intervention.
ADVANTAGES OF PLACING SERVICES IN SCHOOLS
Schools are rapidly becoming the locus of a wide range of collaborative efforts related to health, mental health, and social services. Although these programs are diverse in size, function, organization, and outcome, there are important common features of school-based programs for adolescents. Placing services in schools gives certain students access to care they would not otherwise be able to obtain. Most of the clinic sites are in low-income communities that do not have a large supply of private physicians, and many of the families have no medical insurance. While some qualify for Medicaid, the children in the family may not have confidential access to the Medicaid card. Almost all school-based services are free. A few charge a token fee but collections are minimal.
Adolescent-medicine physicians and public-health practitioners support the concept of school-based services because such services give them access to high-risk populations that do not ordinarily use private-sector medicine or even community-based clinics. Some SBC advocates believe that by utilizing these clinics, adolescents gain a “medical home” while in high school and learn communication skills that will help them access the medical care system in the future. It is probable that the utilization of school clinics lowers the demand on emergency rooms, where adolescents frequently go for crisis care and even general health services. Preliminary data suggest that school-based clinics may be more cost-effective than purchasing comparable care from private physicians (assuming that physicians were available). 
Almost all of these programs have been implemented with funds from state, foundation, local, or private sources. Very few school systems are able to finance these kinds of programs, estimated to cost about $100,000$200,000 per year. However, school systems have contributed matching funds by making space available and providing maintenance and security. In some systems, school personnel such as school nurses and psychologists become integrated with the staff of the clinic or center.
Almost all of the programs are organized and managed-by outside agencies that bring in their own funds and protocols. Experience has shown that planning a school-based clinic or center takes at least a year. The selection of the service mix results from planning by a representative committee including school staff, community agencies, parents, and students. In the most effective efforts, one staff member is designated coordinator to give full attention to developing the program, supervising staff, and negotiating between the school and provider agencies.
Evaluation of the effectiveness of school-based centers is still at an early stage. An excellent management-information system, designed by David Kaplan for the Denver school-based clinic program, is now being utilized by more than 100 programs around the country.  A number of unpublished papers have been presented at professional meetings, and it should be expected that these findings will soon appear in journals. While the earlier study results were quite optimistic about school-based clinic programs’ potential for preventing pregnancy, they were also crude. More recent work has failed to find a consistent effect on pregnancy rates, although it seems clear that in those schools where clinics make contraception available, contraceptive use is higher. As part of their study of SBCs, Kirby and Wascek compiled data on a high school in Jackson, Mississippi (see Appendix l). Students were asked to check off school-clinic services ever used: About one-third had used the clinic for sports and health examinations, 26 percent for counseling in general, 28 percent for contraceptive counseling, 22 percent for contraceptive supplies, and 15 percent for immunizations. The researchers found few significant differences in pregnancy-prevention practices between clinic users and nonusers; however, they did find that 77 percent of the students who had ever used the school clinic to obtain contraceptives had used an effective method at last intercourse, compared with 48 percent of the students who had not used the clinic for this purpose. Between 1979 and 1990, more than 7,200 adolescents were served by the Jackson school-based program. Among the 180 student mothers followed up, only 10 experienced a repeat pregnancy and the pregnancy-related dropout rate decreased from about 50 percent to zero.
Scattered results from preliminary studies around the country show small positive impacts. One question that is often raised is whether the mere presence of a clinic in a school influences the sexual activity rate. Research on the effect of clinics on the incidence of sexual activity among the students has yielded no evidence that the rates increase after the clinic opens. A two-year follow-up survey in Kansas City revealed almost no change in reported sexual behavior.  Following a three-year school-clinic demonstration project in Baltimore, Zabin et al. found a postponement of first intercourse that averaged seven months among program participants.
A survey conducted by the Houston school-based clinic program showed that clinic users were more than twice as likely to use contraception every time they had sex as those who had not been to the clinic and they were less than half as likely never to use contraception.  Among students who were already sexually active, clinic patients in Kansas City showed higher rates of contraceptive use than non-patients, and a striking increase in use of condoms among males. In Baltimore, younger female students and males in the experimental schools were much more likely to use birth control than those in the control schools, and in St. Paul, female contraceptive users had an extremely high rate of continuation: 91 percent were still using the method (mostly the pill) after a year and 78 percent after two years of use.  (Freestanding family planning clinics report a twelve-month program dropout rate of close to 50 percent.)
The Kansas City program reported a substantial drop in substance use during a two-year period.  This program places high priority on teaching healthy life-styles and reducing risk-taking behaviors through group and individual counseling. The Kansas City SBC also reported changes in mental-health outcomes: reductions in hopelessness, suicidal ideation, and low self-esteem. The Pinelands, New Jersey, program reported reductions in suspensions, dropouts, and births among students two years after the program started and the Hackensack, New Jersey, program showed a reduction in fights, which they attributed to conflict-resolution interventions. Almost three-fourths of New York City students who used SBCs thought that the clinic had improved their health and more than a third stated that the clinic had improved their school attendance. Most (91 percent) stated that the clinic had improved their ability to get health care when they needed it and 88 percent stated that the clinic had improved their knowledge of and ability to take care of their bodies.
At this point in time, the primary evidence that school-based programs are having an impact lies in utilization figures, with large proportions of student bodies enrolled and using services. One study found that the highest risk students (with multiple problem behaviors) were the heaviest users of the clinic. Screening and assessments have resulted in extensive case findings- particularly heart murmurs, asthma and other respiratory diseases, need for immunization, sexual abuse, parasites, sexually transmitted diseases, and other problems that beset disadvantaged-youth.
The school-based mental-health programs can document extensive hours of counseling and treatment. In New Brunswick, more than one-fourth of the student body has received intensive psychological care. These same students and their families did not use the local community mental health center for services because of costs and perceived inaccessibility. A-clinic in Quincy, Florida, reported that about one student a week comes in saying that he or she is either contemplating or has attempted suicide. Most of the cases found in school clinics require counseling and crisis intervention for depression, stress, and severe family problems, rather than long-term treatment for psychoses and conduct disorders.
No data are available about the outcomes of the provision of direct mental-health services to adolescents in schools, nor have new research findings been reported from current replications of the Comer process. We would expect that achievement and attendance rates would improve in communities that recognize the importance of mental-health interventions. Categorical programs have been identified that can document improvement in categorical outcomes such as pregnancy prevention and lower substance use. Comprehensive programs targeted to a specific population can produce some successes, such as teen parents-programs that reduce repeat pregnancies and improve school completion.
Finally, parents, students, teachers, school administrators, and program staffs have extremely positive attitudes toward the concept of’ one-stop services located in schools. A Harris poll found that 80 percent of parents and 81 percent of teachers believe that developing school programs-to provide counseling and support services to children with emotional, mental, social, or family problems would “help a lot” to improve educational outcomes.  The public does not fear that attention to reproductive-health issues will increase the level of sexual activity among students. In fact, a survey of public attitudes toward provision of birth control information and contraceptives in schools showed an approval rating of 73 percent. Approval was highest among African-American respondents (88 percent) and unmarried people (86 percent). Fully 80 percent approved of school clinic referrals to family-planning clinics.
The AIDS scare has begun to have an impact on policies regarding the distribution of condoms in schools. In recent months, New York City, Philadelphia, Los Angeles, San Francisco, and Baltimore authorities have revised policies to make condoms available to students. In New York City condoms are being distributed by teachers and other staff who volunteer to be trained for this mission. In Baltimore, the nine school-based clinics initiated a policy to distribute contraceptives after a parent survey showed wide approval. In summary, school-based programs are developing at a rapid rate because they are providing services to a very needy population, junior and senior high school students who have little access to other sources of care. They bring into disadvantaged school systems committed and caring staff workers who can give all of their attention to the physical and psychosocial needs of the students. The development of these diverse programs is taking place all around the country despite trying conditions that include competition for scarce resources, acute shortages of nurse-practitioners, and a constant struggle to maintain services.
LIMITATIONS OF SCHOOL-BASED PROGRAMS
Two issues frequently arise in discussions about the merits of placing services in schools: the problem of negotiating governance between school systems and community agencies, and the lack of long-term funding.
Given the complex processes involved when one or more community agencies moves into a school system, it is surprising that these models are being replicated as rapidly as they are. Each party has its own board of directors, policies, funding, accounting procedures, personnel practices, and insurance. There are different union contracts and salary structures in schools and outside health and social service agencies. Working out the details for collaboration requires endless planning and negotiation.
From the point of view of the community agencies, school boards are often inflexible. Many initiatives have been delayed because of difficult policy decisions, for example, the use of school facilities, reproductive-health care, and personnel practices. Often, the host school is already overcrowded and finding adequate space for a clinic requires extensive remodeling. Clinic hours differ from those of the school, necessitating arrangements with the custodial staff. The school nurse may feel threatened by the new facility and raise objections to procedures that conflict with her turf.
One might think that policies regarding birth control create the most conflict. This has not generally been the case. Only one or two clinics have failed to open because of community dissension. So much has been made of this issue that it is typically dealt with early in the planning process. Few school systems allow distribution of contraceptives on site and almost all programs allow for parental consent. These policies have assuaged critics but they have also limited the effectiveness of school-based clinics in their work with sexually active teenagers in regard to compliance with contraceptive methods. As pointed out above, these policies are currently under review in light of the AIDS epidemic.
Operating a school-based clinic requires constant nurturing of the relationship between the clinic program and the school. The key player in these ongoing negotiations is the school principal. As the primary gatekeeper, the principal facilitates access to students, promotes good working relationships between the school staff and the program staff, and makes sure the building is safe and clean. If the principal does not cooperate, the program will not work.
School clinics open the door to many turf issues. One question that frequently arises when a program is placed in a school with existing support personnel such as a psychologist, a social worker, or even a guidance counselor, is who is in charge of mental health “cases.” This becomes particularly sensitive in dealing with special education students. Ensuring confidentiality can be very difficult in situations in which school and clinic staff are both involved. Similar questions have been raised about the “ownership” of health-promotion curricula. If the school-based clinic is providing extensive individual and group counseling, is it necessary to use school time for health-promotion curricula? If clinic personnel are willing to go into classrooms and take on the responsibility for sex-education, substance-abuse and suicide-prevention, and violence workshops, what is the role of school health educator? If the clinic assumes the health-promotion role, is it necessary to train teachers to do sex education and substance-abuse prevention?
Teachers in schools with clinics are sometimes reluctant to allow students to leave classes to make clinic visits. They may also be threatened by the confidential relationship between clinic counselors and students. In some cases, stress-related behavior derives from negative school experiences, and specific teachers have been implicated in lowering student’s expectations and accused of failing to teach. Clinic practitioners may have negative views of school discipline policies that rely heavily on suspension and expulsion and practices such as tracking and grade retention that have been shown to undermine achievement.
Many school systems are driven by the desire to raise test scores and lower dropout rates. Teachers are frustrated because they believe that the students’ behavioral problems and the social environments of the communities in which the schools are located stand in the way of achievement. School-restructuring efforts try to create a learning community equalizing outcomes for all students. In some instances, the school-based clinic programs have become involved with school restructuring because they see that they cannot successfully treat the students’ psychosocial problems without massive changes in the way the students are treated in school.
School-based health and social service programs derive funds from diverse sources. More than half of the funding derives from Maternal and Child Health and other state health department grants. Few programs are adequately funded and almost all of them rely on a mix of resources that require complicated and time-consuming accounting procedures. Each source of funds has its own regulations and eligibility. Foundation support is time-limited. The twenty-three Robert Wood Johnson grants have now reached their limit and those programs have to find other sources of funding, what the foundation calls “institutionalization.”
One approach to long-term funding being appraised by RWJ-supported researchers and others is to increase the use of Medicaid funds for eligible students, particularly in light of new provisions to stimulate the use of Early Periodic Screening Treatment and Diagnosis programs. It has been estimated that about one-third of the students served in school-based clinics are eligible for Medicaid but only about 3 percent of the services are financed by such reimbursements. A recent survey found that the major barriers to the use of Medicaid or private insurance by school-based clinics were (1) students did not know whether their families were Medicaid or private insurance recipients; (2) time and costs of paperwork involved in billing were prohibitive; (3) state Medicaid or private insurance companies refused to pay for services; (4) Medicaid did not recognize schools as qualified medical providers; and (5) confidentiality issues.  Clinics administered by private community health agencies and hospitals or medical schools were the most likely to be using Medicaid. The tighter the link to a medical base, the more likely a program is to have access to third-party funds. Increasingly, clinics are placing Medicaid eligibility workers on school sites to help students with eligibility determinations. In some communities and states, the concept of declaring an entire school Medicaid-eligible is being explored. This would cut down on the bureaucratic hassle and ensure continuity of funding and confidentiality.
Another important source of support of school-based centers is a line item in the state budget, as in the New Jersey Department of Human Resources and the Kentucky Department of Education. The limitations of this approach are that only enough money may be included for demonstration projects, as in New Jersey, or that the grants may be very small, as in Kentucky. At one point, the state of Michigan developed a plan to fund 100 school-based clinics, but the appropriation so far covers only 20 such programs. The continuity of state funds depends on continuing legislative approval, not easily guaranteed during this period of fiscal constraints, and a change of governor can bring changes in priorities (although the school-based program has weathered changes in administration in most states). A further limitation is that state funds usually have restrictions, particularly prohibiting distribution of contraception and/or counseling regarding abortion.
In summary, many issues remain to be resolved in regard to the creation of one-stop centers in schools, issues that are similar despite the significant differences in the health, mental-health, and social services models. All programs suffer from shortages of funding and most operate in a crisis mode. The demand for services in schools is often overwhelming. Although most of the current school-based programs follow a medical model, starting with assessments, screening, and physical examinations, the most frequently cited unmet need is for mental-health counseling. The acute shortage of emergency psychiatric and day-treatment facilities for adolescents and the shortage of bilingual mental-health clinicians are widespread. As new staff and services are brought into centers, the utilization rates increase.
An observation of one inner-city project showed that
as soon as the doors of a new clinic site open, mobs of students pour in seeking minor items like band-aids, ice packs and sanitary napkins, producing a steady stream of work for the staff. At the same time, a small number of students are identified who have been battered, are severely depressed, have burdensome family problems, are taking drugs or require a complex mix of many different kinds of services. The new clinics are overwhelmed by the two extreme ends of the spectrum of needs and find little time to reach the vast majority of students in between. Reorganization of the work load, targeting high risk individuals and the development of specialized protocols have alleviated this problem somewhat, but the clinic staff perceive it as one-which school based clinics can never overcome. As they say, “it goes with the territory.” 
The absence of evaluation and the minimal published literature on the subject produce an impression of haphazard diffusion of an idea, implemented at widely disparate levels of effectiveness. With the exception of some of the state-supported programs, each program is packaged in a different way and there is no central system for monitoring quality. A common problem is the complexity of governance in a model that brings the services, staff, and funding from an outside community agency into a school.
OUTLOOK FOR ONE-STOP CENTERS IN SCHOOLS
In disadvantaged communities, schools cannot address the challenge of raising the quality of education and at the same time attend to the problems of young people and their families without a substantial mobilization of health and social services resources. Poverty rates among youth are growing, housing is deteriorating, and violence threatens everyone. These worsening conditions are accelerating the drive among concerned people to find new solutions that incorporate the linkage between educational achievement and adolescent health. While school-based services will not solve the underlying problems of poverty and discrimination, they are perceived by both health and educational practitioners as one potentially cost-effective approach to alleviating the symptoms. Young people can receive support to stay in school, manage their psychosocial problems, prepare for the work force, and experience positive relationships with caring adults. Thus, the idea of packaging services together and putting them in a central place like a school is very attractive.
Thus far, the school-based clinic model has been conceived as an intervention for “high-risk” communities. Many but not all of the clinics are located in metropolitan areas with the highest incidence of the “new morbidities” teen pregnancy, sexually transmitted diseases, AIDS, drug abuse, violence, and depression-and the highest school failure and dropout rates. Although advocates of this model acknowledge that there are high-risk adolescents in affluent communities as well, there is no consensus on whether every school should have such a center or only those schools that serve disadvantaged populations. Suburban youth, who make up the majority of high school students, increasingly lack parental support and also need the attention of caring adults to help them get through their teen years. They also must learn to deal with a fragmented health, mental-health, and social service system. Suburban schools, because they have larger budgets than city schools, are more likely to employ support personnel including psychologists, speech therapists, school nurses, and guidance counselors. In order to ensure that all adolescents have access to the full range of services they need, suburban schools might take an intermediate step by assigning a staff member in every school to foster coordination with community agencies (as recommended in Turning Points). This would entail school-wide planning for individual counseling, crisis intervention, family involvement, and systematic referrals for services along with follow-up.
My own vision of the ideal community school is a center in a school that brings together those services most needed in that community. At the high school level, these might include health, mental-health, and career-training and job-placement services; after-school recreation and cultural events; parent education; and public-assistance and community police force programs. Most importantly, the center would facilitate arrangements for individual and family counseling. The employment of youth advocates who assist students with family and school problems would ensure that those most in need receive the services they require as soon as possible. Health-promotion activities such as pregnancy and substance-use prevention would become the responsibility of the center staff. The schoolhouse doors would be open most of the time, including evenings, weekends, and summers.
Community schools set up to serve elementary school populations would include preschool and after-school care, parent training, home visiting, educational programs for parents, and other health and social services. Experience to date suggests that once a school community enters the process of thinking about centralizing services in schools, almost any public or private community agency can be transported from its community base into the school facility. Edward Zigler of Yale University has long articulated the need for “Schools of the 21st Century” incorporating these services. His model is being replicated in more than 200 schools throughout the nation (particularly in Kentucky and Connecticut).
The bottom line here, of course, is how to make this vision a reality. If the current crop of school-based clinics are having a hard time maintaining their bases of support, how can community schools be institutionalized on a large enough scale to have any impact? Schools, community agencies, foundations, states, and the federal government have various roles in meeting this challenge. The primary role for school systems is to encourage the development of these collaborative relationships, to make it known that they are willing to use their facilities to host an array of services. The role of the community agencies is to gear up to provide then services in new locations, much as hospitals and health departments organize satellite clinics. Community agencies have to be prepared to deal with the ambiguities and frustrations that arise in negotiations with school systems. Schools and community agencies together have to hammer out the governance arrangements that will assure efficient functioning of the center.
Articulate grass-roots support is an essential component in gaining the ear and pocketbook of both the citizenry and the decision-makers. Parents, students, and community leaders can make their voices heard at budget hearings and planning sessions.
Foundations have already played an important role in funding demonstration projects, but they must be prepared to do more. It is unlikely that evaluation will be conducted on a large enough scale without extensive foundation support. One of the advantages of foundations is that they can assist grantees to monitor programs and document processes.
Many states are already heavily involved in the extension of the school-based clinic model. These state programs, usually placed in state health or human resources departments, need to develop collaborative relationships with state education agencies. In some states, collaboration is legislatively mandated, while in others governors have created childand youth-services “mini-cabinets” to foster integration of services. Together, state agencies need to be able to provide technical assistance to communities, monitor the quantity and quality of the services, and organize training and conferences. States can promote the development of school-based centers not only through funding, but also by waiving various regulations in regard to Medicaid and other state-controlled resources.
The federal government has played virtually no role in the advancement of these new kinds of service models. Yet the potential for moving from demonstration programs to institutionalization lies within the power of Congress, which in 1990 passed but did not fund the Young Americans Act. This legislation would create a central commission and council for generating a coordinated federal response to the multiple needs of children. Funds would be provided to states for planning and coordination. Congress could also create a new cabinet-level agency and integrate the hundreds of categorical youth-serving programs into a more rational delivery system.
The federal government could be instrumental in changing policies now to allow categorical funds to be used to design and implement community-school collaboratives. Possible sources of funds in addition to Medicaid include Drug Free Schools, Office of Substance Abuse Prevention, Juvenile Justice, Division of Adolescent and School Health of the Centers for Disease Control, and other AIDS prevention monies. It is possible that the mission of Chapter 1 to aid economically disadvantaged children could be expanded to encompass their health and psychosocial needs as well as educational remediation. There are definitely signs in Washington that integration of youth and family services is the direction of the future, but almost all of the proposed school-based efforts are directed toward preschool or elementary school children, prior to the age of puberty.
All health and social indicators confirm that our society will have to move rapidly to enable disadvantaged adolescents to mature into responsible, literate, productive adults. The combined forces of the educational, health, and welfare systems working together are necessary to counteract the effects of the decaying social environment on this generation of youth. The traditional approaches to health and psychosocial problems are not working. New school-based centers of health and mental-health care are emerging but they will remain in the demonstration phase or disappear completely without significant support and attention.
APPENDIX 1 JACKSON-HINDS COMPREHENSIVE HEALTH CENTER'S SCHOOL-BASED CLINICS
The federally funded Comprehensive Health Center in Jackson, Mississippi, currently operates school-based health services in four high schools, three middle schools, and one elementary school. In 1979, when the program was first initiated at Lanier High School, the staff found many conditions that demonstrated the extensive unmet needs of the students, includingurinary tract infections, anemia, heart murmurs, and psychosocial problems. In a student body of 960, they found more than 90 girls who were either pregnant or already had a child. Some 25 percent of the pregnancies had occurred while the youngsters were in junior high, leading the program to extend resources to an inner-city junior high school and a second high school the following year. The other clinics were added in the late 1980s.
Clinics are located in whatever rooms schools can make available. At Lanier High School, two small rooms near the principal’s office are equipped as clinics. Group counseling and health-education classes are provided in a large classroom with private offices for individual counseling. The infantcare center is located in a mobile unit attached to the school. The staff at Lanier includes a physician, a nurse practitioner, a licensed practical nurse, two nurse assistants, and an educator/counselor, part-time workers.
The school-based clinic protocol includes a medical history and routine lab tests of hematocrit, hemoglobin, and urinalysis. Each enrolled student completes a psychosocial assessment that reveals risk levels for substance abuse, violence, suicide, pregnancy, sexually transmitted diseases (STDs), accidents, and family conflict. Depending on indications from the health history and assessment tool, the student is scheduled for a visit with the physician and/or counselor. However, the clinic is always open, from 8:00 A.M. to 5:00 P.M., for walk-in visits for emergency care and crisis intervention.
Clinic staff conduct individual and group counseling sessions. If sexually active, students are given birth-control methods including condoms and followed up bi-monthly, Staff also dispense formal health instruction about specific issues such as compliance with medication protocols or treatment of acne, and informal "rap sessions" on parenting, the reproductive health system, birth-control methods, sexual values, STDs, and substance abuse. The counseling and clinic services are closely coordinated. Enrollees in the school clinic are referred to the primary community health center for routine dental screening, cleaning, and fluoride application. This facility is always open to students after school hours and on weekends and holidays.
Arrangements for early prenatal care are made through the obstetrical department of the health center. Teen mothers are carefully monitored throughout their pregnancies with special attention paid to keeping the young women in school as long as possible and getting them back within a month after delivery. Day care is provided at the school. Young mothers are counseled and instructed about child development and parenting skills. The Day Care Center is also used for teaching child psychology to high school students.*
* This description is based on “A Community Based Education and Intervention System,” Jackson-Hinds SchoolBased Adolescent Health Program (undated); and Douglas Kirby and Cynthia Waszak, An Assessment of Six School-Based Clinics: Services, Impact and Potential (Washington, D.C.: Center for Population Clinics, 1989). Additional information was provided by Dr. Aaron Shirley, director of the Jackson-Hinds Community Health Center on the occasion of a visit to Lanier High School and thereafter.
APPENDIX 2 NEW JERSEY SCHOOL-BASED YOUTH SERVICES PROGRAM
The School-Based Youth Services Program (SBYSP) has served as a model for other states. Following a competitive process, grants were made by the New Jersey Department of Human Services in 1987 to 29 communities for collaborative projects to be operated jointly by the school system and one or more local nonprofit or public health, mental health, or youth-serving agencies and to be located in or near the school. Based on the theme of “one-stop services,” each project had to provide core services including mental health and family counseling, drug and alcohol counseling, educational remediation, recreation, and employment services at one site. Health services had to be available on site or by referral. In addition, child care, teen parenting, family planning examinations and referral for contraception, transportation, and hotlines could be provided with the grant (but not contraceptives or referral for abortion services). All centers had to be open after school, weekends, and during vacations.*
*Janet Levy and William Shepardson, “A Look at Current School-linked Service Efforts,” in The Future of Children: School-Linked Services (Los Altos, Calif.: Center for the Future of Children, David and Lucile Packard Foundation, 1992), pp. 141-42.
APPENDIX 3 SCHOOL-BASED YOUTH SERVICES PROGRAM, NEW BRUNSWICK (N.J.) PUBLIC SCHOOLS
This mental health program was initiated in New Brunswick High School in 1988, funded by the New Jersey School Based Centers program. It is operated by the Community Mental Health Center, which is part of the University of Medicine and Dentistry of New Jersey. The program was stimulated by New Brunswick Tomorrow, a local business-sponsored effort that is trying to revitalize New Brunswick. In 1991, New Brunswick School-Based Youth Services Program (SBYSP) was awarded new state funds to expand services into five local elementary schools.
The SBYSP is a centralized service delivery system that integrates existing school programs, creates new services within schools, and links a network of youth-service providers. Although its primary thrust is mental-health promotion and treatment, it “looks like” a comprehensive youth center in a school setting. Currently, the program has ten full-time core staff members, including eight clinicians (psychologists and social workers), one of whom serves as the director. The staff conduct individual, group, and family therapy and serve as consultants to school personnel and other agencies involved with adolescents. An activities/outreach worker plans and supervises recreational activities and outreach contacts at the high school. Specialized part-time staff include a pregnancy/parenting counselor, a substance abuse counselor, and consultants in suicide prevention, “social problems,” and medical care. A number of student interns from Rutgers University Graduate Schools have field placements in this program and there are also some volunteers.
The facility at New Brunswick High School is located in the old band room, fixed up very attractively to resemble a game room in a settlement house, with television, pingpong, and other active games, comfortable furniture, and books and tapes for the students to borrow. Private offices where students can go for individual psychological counseling ring the main room. The center offers tutoring, mentoring, group activities, recreational outings, and educational trips. A number of “therapeutic” groups have been organized: social problem solving, substance abuse, Children of Alcoholics, and coping skills for gifted and talented. Students are referred to the local neighborhood health center for health services and treatment. Children of teen parents are offered transportation to child-care centers.
Of the 650 students in the New Brunswick High School, 91 percent are enrolled in the program and have parental consent statements on file. During the past two years, one in four of the enrolled students has been involved in active mental-health counseling with one of the clinicians. Many of the students, especially the girls, appear to be clinically depressed. According to Gail Reynolds, the director, the demand for services is overwhelming. Many of the problems require immediate and time-consuming interventions with the family, school, and social agencies. After a student has made three visits, parents must come in for counseling sessions. Staff make home visits in order to involve parents.
In the process of setting up the program within the school, the superintendent was a key player and supportive from the start. The first summer was spent overcoming the resistance of the people in the school, preparing the school staff, and working out referral procedures with the school’s four guidance counselors and the teachers. Reynolds meets with the counselors once a month and with the principal and vice-principal weekly. Relationships with school staff are complex and vitally important to the functioning of the center. One problem that had to be overcome was convincing the maintenance staff to allow the premises to stay open after 3:00 P.M. The center is open all day and into the evening, and all summer.*
* Based on “School Based Youth Services Program,” New Brunswick Public Schools (undated); and visits to program and discussions with Gail Reynolds, director.
 Joy G. Dryfoos, Adolescents-at-Risk: Prevalence and Prevention (New York: Oxford University Press, 1990).
 David Tyack, “Health and Social Services in Public Schools: Historical Perspectives,” in The Future of Children: School Linked Services (Los Altos, Calif. Center for the Future of Children, David and Lucile Packard Foundation, 1992), vol. 2, pp. 19-31.
 Godfrey Cronin and William Young, 400 Navels: The Future of School Health in America (Bloomington, Ill: Phi Delta Kappa, 1979).
 See Alison T. Lavin, Gail R. Shapiro, and Kenneth S. Weill, Creating an Agenda for School-Based Health Promotion: A Review of Selected Reports (Cambridge: Harvard School of Public Health, 1992).
 The National Commission on the Role of the School and the Community in Improving Adolescent Health, Code Blue: Uniting for Healthier Youth (Washington, D.C.: American Medical Association and National Association of State Boards of Education, 1990).
 Ibid., p. 41.
 U.S. Congress, Office of Technology Assessment, Adolescent Health-Volume I: Summary and Policy Options, OTA-H-468 (Washington, D.C.: Government Printing Office, April 1991).
 Task Force on Education of Young Adolescents, Turning Points: Preparing American Youth for the 21st Century (Washington, D.C.: Carnegie Council on Adolescent Development, 1989).
 This discussion focuses on actual health services. However, schools are involved in other health-related activities such as providing health education, paying attention to nutrition, and maintaining a healthy and safe school environment. An unknown number of school systems employ health educators, school psychologists, and other special-education experts.
 Julia Lear et al., “Reorganizing Health Care for Adolescents: The Experience of the School-Based Adolescent Health Care Program,” Journal of Adolescent Health 12 (1991): 450580.
 Philip Nader, “School Health Services,” in Maternal and Child Health Practices; Third Edition, ed. Helen Wallace, George Ryan, and Allan Oglesby (Oakland, Calif.: Third Party Publishing, 1988), p. 464. Schools and Social Services 565.
 National Center for Education Statistics. National Education Longitudinal Study of 1988: User's Manual, NCES-464 (Washington, D.C.: U.S. Department of Education, 1990).
 An earlier school-based clinic started in 1965 provided comprehensive health services primarily to young children in Cambridge, Massachusetts. See Philip Porter, “School Health is a Place, not a Discipline,“Journal of School Health 57 (1987): 417-18.
 L. Edwards et al., “Adolescent Pregnancy Prevention Services in High School Clinics,” Family Planning Perspectives 12 (1980): 6-14.
 The Center for Population Options organized the Support Center for School Based Clinics in 1984, and has surveyed the field annually. Only preliminary data are available from the 1991 survey. See the Factsheet “School-Based and School-Linked Clinics (Washington, D.C.: Center for Population Options, 1991).
 Joy G. Dryfoos, “School and Community-Based Prevention Programs,” in Adolescent Sexuality: Preventing Unhealthy Consequences, ed. Susan Coupey and Lorraine Klerman (Philadelphia: Hanley and Belfus, 1991).
 The Robert Wood Johnson Foundation, Making Connections (A Summary of The Robert Wood Johnson Foundation programs, Princeton, New Jersey, n.d.)
 Lear et al., “Reorganizing Health Care for Adolescents,” p, 450.
 Center for Population Options, "Factsheet," p. 2.
 Cynthia Waszak and Shara Neidell, School-Based and School-Linked Clinics: Update 1991 (Washington, D.C.: Center for Population Options, 1992).
 Center for Population Options, School-Based Clinics Update 1990 (Washington, D.C.: Center for Population Options, 199.1).
 Douglas Kirby, Cynthia Waszak, and Julie Ziegler, An Assessment of Six-School-Based Clinics: Services, Impact, and Potential (Washington, D.C.: Center for Population Options, 1989).
 Claire Brindis et al., “Utilization Patterns among California’s School Based Health Centers: A Comparison of the School Year 1989-90 with the Baseline Year of 1988-1989” (Unpublished paper from Center for Reproductive Health Policy Research, University of California, San Francisco, February 1991).
 For example, see San Jose School Health Centers1990-91 Annual Report (San Jose, Calif.: San Jose Medical Center, 1991).
 Office of Technology Assessment, Adolescent Health, p. 97.
 Howard Adelman and Linda Taylor, “Mental Health Facets of the School-Based Center Movement: Need and Opportunity for Research and Development,” Journal of Mental Health Administration (in press). See also Mental Health Network News, published by the School Mental Health Project of the Department of Psychology, University of California, Los Angeles.
 Adelman and Taylor, “Mental Health Facts.”
 Described in Mental Health Network News 2 (1991): l-2.
 Joy G. Dryfoos, “Bringing Health and Social Services into Inner City Junior High Schools” (Report to Center for Population and Family Health, Columbia University School of Public Health, 1991):
 James P. Comer, “Improving American Educational Roles for Parents,” Hearing before the Select Committee on Children, Youth and Families,June 7, 1984(Washington, D.C.: Government Printing Office, n.d.), pp. 55-60.
 See Lavin et al., Creating an Agenda; Atelia Melavill and Martin Blank, What It Takes: Structuring Interagency Partnerships to Connect Children and Families with Comprehensive Services (Washington, D.C.: Education and Human Services Consortium, 1991); and Heather Weiss, Family Support and Education, Programs and the Public Schools (Cambridge: Harvard Family Research Project, 1988).
 P. Nickel and H. Delany, Working with Teen Parents: A Survey of Promising Approaches (Chicago: Family Resource Coalition, 1985).
 Melaville and Blank, What It Takes, p. 42.
 Dryfoos, Adolescents-at-Risk, pp. 214-15.
 Center for the Study of Social Policy, New Futures in Pittsburgh: A Mid-PointAssessment(Washington, D.C.: Center for the Study of Social Policy, February 1991).
 Gary Wehlage, Gregory Smith, and Pauline Lipman, “Restructuring Urban Schools: The New Futures Experience,” American Educational Research Journal 29 (1992): 51-93.
 Dryfoos, Adolescents-at-Risk.
 National Institute of Alcohol Abuse and Alcoholism, Prevention Plus: Involving Schools, Parents and the Community in Alcohol and Drug Education (Washington, D.C.: Department ofHealth and Human Services, 1984), pp. 194-99.
 Inwood House, “Community Outreach Program: Teen Choice. A Model Program Addressing the Problem of Teenage Pregnancy” (Summary Report, 1987).
 Joseph Allen et al., “School-Based Prevention of Teenage Pregnancy and School Dropout: Process Evaluation of the National Replication of the Teen Outreach Program,” American Journal of Community Psychology 18 (1990): 505-24.
 Dryfoos, Adolescents-at-Risk.
 Lucy Siegel and T. Kriebel, “Evaluation of School-Based High School Health Services,” Journal of School Health 57 (1987): 323-27.
 David Kaplan, “School Health Care-Online!!!, School-based Clinic Management Information System” (Denver: The Children’s Hospital, 1992).
 Kirby et al., An Assessment of Six School-Based Clinics.
 Ibid., pp. 9-10.
 Gerald Kitzi, Presentation at Third Annual Conference of the SupportCenterfor School-Based Clinics, Denver, 1986.
 Laurie Zabin et al., “Evaluation of a Pregnancy Prevention Program for Urban Teenagers,” Family Planning Perspectives 18 (May/June 1986): 123.
 Christine Galavotti and Sharon Lovick, “The Effect of School-Based Clinic Use on Adolescent Contraceptive Effectiveness” (Paper presented at National Conference on School-Based Clinics, Kansas City, MO., November 1987).
 Linda Edwards and Kathleen Arnold-Sheeran, Unpublished data from St. Paul presented at American Public Health Association meeting, November 1985.
 James Shea, Roberta Herceg-Baron, and Frank Furstenberg, “Clinic Continuation Rates according to Age, Method of Contraception and Agency” (Paper presented at the annual meeting of the National Family Planning and Reproductive Health Association, March 1982).
 Kitzi, Presentation.
 Thomas Kean, Speech, Carnegie Council on Adolescent Development (Washington, D.C., April 14, 1992).
 Welfare Research Inc., Health Services for High School Students, Short-term Assessment of New York City High School-based Clinics (Report to New York City Board of Education, June 3, 1987).
 James Stout, “School-Based Health Clinics: Are They Addressing the Needs of the Students” (Master’s thesis, University of Washington, 1991), p. 22.
 Clinic News (Center for Population Options) 2 (April 1986): 3.
 Dryfoos, Adolescents-at-Risk.
 Metropolitan Life, Louis Harris and Associates, Inc., The American Teacher, 1988 (New York: Metropolitan Life, 1989).
 Planned Parenthood Federation of America, Inc., and Louis Harris and Associates, Public Attitudes toward Teenage Pregnancy, Sex Education and Birth Control (New York: Planned Parenthood Federation of America, 1988).
 Center for Population Options, Factsheet, p. 2.
 Sarah Palfrey et al., “Financing Health Services in School-Based Clinics,” Journal of Adolescent Health Care 3 (1991): 233-39.
 Dryfoos, “Bringing Health and Social Services,” p. 33.
 Task Force on Education of Young Adolescents, Turning Points.
 Information supplied by Yale Bush Center in Child Development and Social Policy, 1992.