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Optimizing the Roles of School Mental Health Professionals.

The expanded school mental health services movement involves a shift of primary mental health care from community mental health centers and private offices to schools.[1] Working in schools, delivering an array of services, counselors, psychologists, social workers, nurses, and psychiatrists have a unique opportunity to address the mental health needs of youth. To establish a coordinated system of care, traditional roles must be redefined, and a new emphasis placed on collaboration. To deliver effective services, treatment modalities that have heretofore been used in clinics must be adapted for use and evaluated for effectiveness in school settings.

The first essential basis for effective collaboration is the mutual understanding of the core competencies of each of the school mental health disciplines. Accordingly, a brief overview of each discipline is provided, followed by a discussion of the issues involved in effective collaborative work.

SCHOOL MENTAL HEALTH DISCIPLINES

Counseling

School counselors hold a master's degree in school counseling or a related field and are employed by school systems. Fifteen states and the District of Columbia mandate the provision of school counseling services at all grade levels.[2] School counseling originated as part of the vocational guidance movement during the early 1900s. During this period, school counselors primarily performed vocational assessment and testing to help students understand their aptitudes, abilities, and interests and how these related to certain occupations. Subsequently, greater emphasis was placed on helping troubled students. More recently, the focus of the school counselor's work has shifted from a crisis-oriented, reactive service delivery model, to a more proactive, developmental approach emphasizing prevention.[3,4]

School counselors provide individual and group counseling to students using traditional theoretical paradigms and more newly developed short-term models of intervention. Areas of concern typically addressed in counseling include school attitudes and behavior, peer relationships, family transitions, test-taking and study skills, career and educational planning, decision making, and coping skills. School counselors provide crisis intervention services for individuals and also participate in school-based crisis teams to help students, faculty, and family members adjust to large-scale traumatic events.

School counselors consult with teachers and parents to effect change in student behavior. As consultants, school counselors may help teachers with general classroom management or design behavioral contract systems for teachers or parents to use with individual students. Counselors also help teachers and family members understand developmental issues and facilitate communication between a student and teacher, or a student and family members. They may offer parent education programs and provide inservice training to school staffs on a variety of topics related to student development and mental health.

Counselors participate on various school-based, multidisciplinary teams, such as the Admission-Review-Dismissal special education team or a more general educational management team. They are involved in program development including needs assessment, program design, and program evaluation. Identified student competencies and a planned curriculum that is an integral part of the larger educational program are essential components of a comprehensive developmental guidance program. School counselors coordinate referrals of students to varied school and community-based services to help ensure treatment compatibility and communication among service providers.

Education and Training. Most school counselors have a master's degree in school counseling or related field.[2] A common core area of training exists across all counselor preparation, with additional areas specified for school counseling. Accredited programs require a minimum of 48 semester hours or 72 quarter hours for all students at the graduate level.[5] Core areas include human growth and development, social and cultural foundations, helping relationships, group work, career and lifestyle development, appraisal, research and program evaluation, and professional orientation. Such requirements as teaching experience, courseware, practicum and internship, provisional employment, and written or oral exams vary from state to state? A national school counselor (NCSC) certification also exists.

Psychology

School Psychology. Since the 1975 passage of the Education for All Handicapped Children Act (PL 94-142), school psychologists have provided psychological assessment of children for special education services.[6] In recent years, the role of the school psychologist has undergone considerable expansion. It is expected to increase further under the 1997 Amendments to the Individuals with Disabilities Education Act (IDEA), which call for functional behavioral assessments and positive behavioral improvement plans.[7] The purview of the school psychologist is to identify and assess psychological functioning and needs of students to communicate psychological assessment results effectively to parents and educators to consult with parents, staff, and colleagues on instructional and behavioral problems of students and to provide individual and group counseling and psychotherapy for identified students.[8] Emerging roles for school psychologists include the provision of primary care for mental health disorders, psychological aspects of physical illness, and high risk behaviors, as well as prevention, health education, and health promotion activities.[6]

Education and Training. In addition to psychological assessment and treatment, the content of the school psychology graduate curriculum includes an emphasis on children's cognitive functioning and development, instructional design, and the organization and operation of schools, including special education schools.[9] This combined knowledge base enables school psychologists to determine and ameliorate the circumstances hindering optimal school performance, thereby effectively linking mental health status and educational attainment.[6]

There are multiple routes to the school psychologist credential. These include masters, specialist, and doctoral degree programs. The National Association of School Psychologists (NASP) has designated the specialist degree as entry level. Both the three-year specialist and four-year doctoral programs require practica and an internship. NASP requires that at least one-half of the one-year internship be completed in a school setting.

School psychologists are typically certified through a state department of education. However, doctoral-level school psychologists can be licensed by a state board of psychology and practice independently outside of school settings. Depending on state regulations, psychologists with degrees in clinical and counseling psychology may qualify for school psychologist positions With additional graduate coursework in such areas as developmental and educational psychology and special education. School psychologists may also obtain additional certification by passing an examination, the National School Psychology Examination, thereby becoming a Nationally Certified School Psychologist (NCSP).

Although the training of school psychologists extends beyond psychometric assessment,[9] their role has been limited to this function in many school systems owing to caseload volume and categorical restrictions under the former IDEA. Recommendations for enhancing school psychology have included increased graduate-level training in consultation and more flexibility in funding for psychological services.[10]

Clinical and Counseling Psychology. Related to growing recognition of the limitations of office-based practice and the potential for providing a full range of mental health services to youth in schools, increasing numbers of clinical and counseling psychologists are also working in schools.[1] Usually, these professionals hold doctoral degrees in psychology, undergoing on average four or five years of academic training, one year of a predoctoral internship, and one or two years of practice at the postdoctoral level prior to obtaining licensure. Academic training covers a range of topics including biological, cognitive and affective bases of behavior; growth and lifespan development; ethical, legal, and professional issues; social and multicultural influences on behavior; clinical assessment and diagnoses; and treatment and intervention at individual, family, and community levels.[11,12]

Importantly, as the movement toward comprehensive mental health care for youth in schools accelerates,[1] there will likely be a corresponding increase in multiple disciplines (eg, school, clinical, counseling, and pediatric) within the field of psychology working in schools. This will only serve to increase pressures for these disciplines to understand, and work collaboratively with one another.[13] In this developing collaborative effort, school psychologists should assume positions of leadership, given their training and experience in working in schools.[26]

Social Work

Within the school setting, social workers may be employed by the educational system, a school-based health center, or an outside mental health or family service agency. They provide services to promote students' social, emotional, and academic adjustment to school and society. School social workers provide the link between the home, school, and community in providing direct as well as indirect services to students, families, and school personnel.

School social workers are highly skilled in mobilizing the resources of the local educational agency and the community to meet the needs of children and their families. Typically, they provide social-developmental assessments and case management services. They are also able to render individual and group counseling, support groups for students and parents, crisis prevention and intervention, and home visits. They may offer parent education and support and advocate for students, parents, and the school system to ensure that educational, family, and community needs are met. School social workers often help coordinate programs for youth including those that involve early academic enrichment, mentoring, peer counseling, and vocational training. Because of their skills in linking with other disciplines and professionals, they are well-suited for participating on interdisciplinary school teams.[14]

Education and Training. A school social worker typically holds a master's degree in social work (MSW) from a university accredited by the Council of Social Work Education. A specialist credential in School Social Work may be obtained by successfully completing at least two years of postmaster's supervised school social work experience and a written examination. Continuing education must be documented to maintain this credential. The National Association of Social Workers' Standards for School Social Work Services identify requirements for professional competence and practice, professional preparation and development, and administrative structure and support.[14]

Nursing

Nursing encompasses a broad field with a tradition of school-based health care. Psychiatric- mental health nursing is an advanced practice specialty in nursing, with a subspecialty of child and adolescent psychiatric-mental health nursing. Nurses with all levels of education work in schools, and most mental health nursing care in schools is provided by nurses who are not advanced practice psychiatric nurses (APPNs). However, there is a trend for more APPNs to provide services in the school setting as school nurses are increasingly called upon to address psychosocial and mental health problems.[15] These nurses are able to practice autonomously and are often in charge of school-based health centers (SBHCs). The APPN may assume the role of the generalist nurse, in addition to mental health specialist roles.

The work of the APPN involves mental health promotion, psychobiologic interventions, and psychotherapy. APPNs in schools play a special role in integrating health and mental health care. They can treat the psychosocial correlates of physical illnesses such as cancer, AIDS, asthma, headaches, diabetes, obesity, and acute and chronic pain. Interventions in school settings, in addition to the usual psychotherapeutic modalities, include diet/nutrition regulation, relaxation techniques, and ordering of appropriate diagnostic and laboratory tests.[16] APPNs can prescribe pharmacological agents in most states.

Case management, home visits, crisis intervention, and consultation are also roles of the APPN in the school setting.[17] The APPN conducts community and school mental health needs assessments, and plans, implements, and evaluates mental health primary prevention and education programs.[18] Inservice training for school staff and faculty and workshops to create parental and public awareness of mental health issues may also be provided.

Education and Training. The nursing profession recognizes the baccalaureate degree in nursing as the basic education required for beginning general practice in psychiatric nursing.[19] APPNs are required to complete at least a master's degree in psychiatric nursing, with most programs being two years in length. Criteria for national certification as a specialist in psychiatric mental health nursing requires graduate education in psychiatric mental health nursing and clinical practice with expert supervision for a required number of hours post degree, as well as successful completion of a written examination. Recertification requires continuing education, practice, and supervision.[20]

Psychiatry

Psychiatrists are physicians who have completed at least four years of specialty training beyond medical school. Child and adolescent psychiatry is a subspecialty of medical practice within psychiatry and requires an additional two years of residency. Unlike the other disciplines noted, child and adolescent psychiatry does not offer specialization within school mental health. In some ways it is a very general specialty, encompassing areas of pediatrics, psychology, and social work. Thus, child and adolescent psychiatrists may be uniquely skilled in integrating data from psychological, social, and biological domains, particularly in complex situations.

The origins of child and adolescent psychiatry stem from the interdisciplinary and community-based child guidance movement, which began in the early part of the 20th century. Although this discipline evolved toward a predominantly office-based, private practice model, most child and adolescent psychiatrists also work part-time as consultants to schools and other child-serving agencies. Typically their role in school settings is to consult with other mental health professionals and school staff, participate in diagnostic evaluations, and make treatment recommendations.[21] Because they are relatively few in number compared to the other mental health professionals, the role of consultant allows for maximal use of their expertise.[22]

In keeping with their general training emphasis on the more severe psychiatric disorders, child and adolescent psychiatrists tend to be more involved with special education facilities and with special education populations within public school systems. They are trained to evaluate the effects of metabolic and brain abnormalities on functioning and to prescribe and monitor psychiatric medications. While their training also prepares them to deliver a range of psychotherapeutic modalities, they are generally not employed to do so in school settings.

Education and Training. Training for child and adolescent psychiatrists involves successful completion of five years of residency beyond medical school. The residency experience is a combination of supervised patient care in a variety of settings and didactic lectures and conferences or seminars. The residency training includes a first postgraduate year experience in primary care, followed by at least two years each of residency training in general psychiatry and child and adolescent psychiatry. Accreditation requirements specify that school consultation experience is required during the latter two years.[23]

Subspecialty certification in child and adolescent psychiatry is available for psychiatrists who are already certified in general psychiatry by the American Board of Psychiatry and Neurology (ABPN) and who meet training requirements and pass an oral and written examination given by the ABPN. A separate group, the American Board of Adolescent Psychiatry, offers certification in adolescent psychiatry via a written examination to ABPN board-certified general psychiatrists who wish to demonstrate competency in adolescent psychiatry.

IMPORTANCE OF INTERDISCIPLINARY COLLABORATION

There is growing recognition that a collaborative effort on the part of school health, mental health, and education professionals is needed to reach out effectively to all students.[24-26] The goals of comprehensive school health services are to improve school attendance and achievement, and to optimize health, mental health, and overall quality of life for all students, including those in regular and special education. These ambitious goals can never be met by any one discipline working in isolation. Without collaboration among school professionals, "piecemeal interventions rather than development of an integrated programmatic approach" will be the result.[27]

Interdisciplinary collaboration involves sharing information from varied perspectives to develop a complete picture of the child and a comprehensive treatment plan. Tasks are assigned to service providers appropriate to their level of expertise, ensuring they will be implemented in a more effective fashion. The likelihood of duplicating costly and scarce services is thereby reduced, a benefit to the stakeholders in the health and educational systems who fund programs. Children and families who need specialized mental health services receive better quality care arising from the application of broader expertise to the development of a more effective treatment plan. Benefits to providers include shared decision-making and responsibility, peer supervision and a support network, enhancement of communication and negotiation skills, increased sensitivity to other providers, and broader awareness of clinical and ethical issues.[28]

Barriers to Collaboration

Despite the fact there is virtually no argument to be made against interdisciplinary collaboration in school services, the coordination of school support services has been described as "one of the most challenging tasks in a school"[8] and as the largest hurdle to developing school-linked and school-based health services.[29] As Rosenblum et al explained: "Given the difficulty of collaborating effectively, it is not surprising that many school support services, programs, and projects are developed in isolation of each other and with no formal linkages to off-site resources. The problem is further exacerbated by the long-standing history of school personnel working alone -- teachers in their respective classrooms, support service workers in different sites on different days."[27]

Other significant barriers to interdisciplinary collaboration include logistics, organizational structure, and group dynamics.[27,30] Finding time when the school mental health professionals (who may work part-time) are available to meet and deem that they can afford the time to do so is difficult. In more service-intensive schools, this challenge is compounded by the sheer number and different types of professionals. Further, the very factors that make collaboration appealing have the potential to cause internal strife among team members. Professional disciplines have different backgrounds, perspectives, priorities, norms, and expectations. They may also employ different terminology and treatment approaches. While this diversity can lead to creative and informed decision-making, these elements also have the potential to restrict communication and limit the sharing of ideas, unless the professionals develop a good working relationship.[26,27]

Questions of status, division of labor, and systems of evaluation and authority, which are common to all organizations, also may pose significant obstacles to interdisciplinary collaboration. Initially, there is likely to be mistrust among the various professional groups, along with competition for rank, status, and limited resources.[27] Some professionals may fear that a change in their role definition will ultimately lead to their displacement and job loss. These factors have the unfortunate potential to lead to "turf battles" among the various professionals, undermining the broader, integrated scope of services that might be available in a more collaborative atmosphere.[8]

Overcoming Barriers to Collaboration

Various strategies implemented at the outset can help to forge collaborative working relationships across mental health disciplines. These include developing job descriptions that underscore the collaborative nature of the position, clearly define the professionals' roles, and reflect complementary rather than competing goals.[24] The school system should provide strong administrative support for interdisciplinary collaboration by allocating sufficient time and resources. The school principal should provide assistance in resolving logistical conflicts and should provide opportunities for the team to educate the school faculty about the collaborative process.[31]

Training in the collaborative process, both within and across disciplines, should be provided for school mental health professionals in graduate school, continuing education, and inservice programs. Interdisciplinary training enables mental health professionals to become aware of and appreciate their shared competencies, as well as their unique skills and knowledge bases. Thus, they begin to develop a common language and ways to enhance their work through a broader perspective.[26]

Interdisciplinary Team

The most frequent mechanism for collaboration is the interdisciplinary team. Most teams operate within the special education sector, where mental health professionals have traditionally worked with teachers, school administrators, and parents to develop and implement an individualized education plan (IEP) for children with special education and related service needs. More recently, interdisciplinary teams have assumed a broader role of reaching out to nonspecial education students, and various models have been described.[1,27,31] Adelman and Taylor developed a model that involves restructuring of school-owned services and the forging of closer ties with community resources to create a more integrated, comprehensive service delivery system.[24,32] For interdisciplinary teams to work well a group leader must be designated and a process determined for allocating resources and selecting outcome measures.

Interdisciplinary teams have the potential for inducing systemic change within the school, via developing and implementing schoolwide programs to educate children and school personnel about mental health issues.[1] Increasing the amount of information available in the school about such concerns as depression, suicide, substance abuse, child abuse, and school violence may lead to earlier identification and treatment of children in need of services. Other services that interdisciplinary teams can provide include classroom management techniques; instructional-learning strategies; teacher and family support and consultation; individual, group, and family therapies; crisis management; curriculum development for impulse control and healthy choices; and health education.[33]

CONCLUSION

The recent rapid expansion of school mental health services offers opportunities for more effective interventions for children and adolescents. Each of the mental health disciplines has core competencies that are valuable for working in school settings. While there is considerable overlap of knowledge and skills among these disciplines, each offers unique perspectives and enhancements to school-based programs. Mental health services can be delivered most effectively through collaborative efforts among the various professionals working within schools. Effective interdisciplinary collaboration, although eminently desirable, has been difficult to achieve.[26,34] Through understanding what each discipline can offer, recognition of the elements that may create barriers to collaboration, thoughtful definition of roles, and careful efforts at working together, this goal can be achieved. The task of developing trust and mutual respect takes time and the experience of working together. The results can be far-reaching and benefit children, schools, families, and communities.

References

[1.] Weist MD. Expanded school mental health services: A national movement in progress. In Ollendick TH, Prinz RJ, eds. Advances in Clinical Child Psychology, Vol. 19. New York, NY: Plenum Press; 1997;319-352.

[2.] Farrell P. A Guide to State Laws and Regulations on Professional School Counseling. Alexandria, Va: Office of Public Policy and Information, American Counseling Association; 1997.

[3.] Paisley P, Borders LD. School counseling: an evolving specialty. J Counsel Dev. 1995;74:150-153.

[4.] Wittmer J. Managing Your School Counseling Program: K-12 Developmental Strategies. Minneapolis, Minn: Educational Media Corp; 1993.

[5.] CACREP Accreditation Standards and Procedures Manual. Alexandria, Va: Council for Accreditation of Counseling and Related Educational Programs; 1994.

[6.] American Psychological Association Task Force on Psychology in the Schools. Guide for the School Psychologist: A System for the Promotion of Diversified Psychological Services in Schools. Washington, DC: American Psychological Association; 1995.

[7.] Douglas LS. The New IDEA and Opportunities for School Mental Health. Baltimore, Md: Center for School Mental Health Assistance; 1997.

[8.] Flook W. The Role of Coordinated Pupil Services in School Mental Health. Baltimore, Md: Maryland State Dept. of Education; 1996.

[9.] Standards for Training and Field Placement Programs in School Psychology. Washington, DC: National Association of School Psychologists; 1994.

[10.] Johnston NS. School consultation: the training needs of teachers and school psychologists. Psychol Sch. 1990;27:51-56.

[11.] Phillips S, Clawson L, Osinski A. Pediatricians' pet peeves about mental health referrals. Adolesc Med. 1998;9:243-258.

[12.] Information for Candidates: Examination for Professional Practice in Psychology. Montgomery, Ala: Association of State and Provincial Psychology Boards; 1997.

[13.] Brems C, Johnson ME. Comparison of recent graduates of clinical versus counseling psychology programs. J Psychol. 1997;13:91-99.

[14.] NASW Standards for School Social Work Services. Washington, DC: National Association of Social Workers; 1992.

[15.] Uris P. Excellence in school-based nursing. Presented at meeting of the Association of Child and Adolescent Psychiatric Nurses; September 1998; Atlanta, Ga.

[16.] Survey of Certified Nurse Practitioners and Clinical Nurse Specialists. December 1992, final report. Rockville, Md: Division of Nursing, Health Resources and Services Administration, DHHS (Report prepared by Washington Consulting Group); 1994.

[17.] Opie N, Slater P. Mental health needs of children in school: Role of the child psychiatric mental health nurse. J Child Adolesc Psychiatr Mental Health Nurs. 1988;1:31-35.

[18.] Puskar K, Lamb J, Martsolf D. The role of the psychiatric/mental health nurse clinical specialist in an adolescent coping skills group. J Child Adolesc Psychiatr Mental Health Nurs. 1990;3:47-51.

[19.] US Dept. of Health and Human Services. Mental Health, United States, 1996. Rockville, Md: Center for Mental Health Services; 1996.

[20.] American Nurses Association. A Statement on Psychiatric-Mental Health Clinical Nursing Practice and Standards of Psychiatric-Mental Health Clinical Practice. Washington DC: American Nurses Publishing; 1994.

[21.] American Psychiatric Association. Psychiatric Consultation in Schools, A Report of the American Psychiatric Association. Washington DC: American Psychiatric Press; 1993.

[22.] Jellinek MS. School consultation: evolving issues. J Am Acad Child Adolesc Psychiatr. 1990;29:311-314.

[23.] American Medical Association. Program requirements for residency education in child and adolescent psychiatry. In: Accreditation Council for Graduate Medical Education, Essentials and Information Items. Chicago, Ill: American Medical Association; 1996:230.

[24.] Adelman HS, Taylor L. School-based mental health: toward a comprehensive approach. J Mental Health Admin. 1993;20:32-45.

[25.] Dryfoos JG. Full-Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families. San Francisco, Calif: Jossey-Bass; 1994.

[26.] Waxman RP, Weist MD, Benson D. Toward collaboration in the growing education - mental health interface. Clin Psychol Rev. in press.

[27.] Rosenblum L, DiCecco MB, Taylor L, Adelman HS. Upgrading school support programs through collaboration: resource coordinating teams. Social Work Educ. 1995;17:117-124.

[28.] Kubiszyn T. Disciplines working together in school mental health: focus on psychology. Presented at 2nd National Conference on Advancing School-Based Mental Health Services; 1997; New Orleans, La..

[29.] Shaw SR, Kelly DP, Joost JC, Parker-Fisher S.J. School-linked and school-based health services: a renewed call for collaboration between school psychologists and medical professionals. Psychol in Sch. 1995;32:190-201.

[30.] Koeske GF, Koeske RD, Mallinger J. Perceptions of professional competence: cross-disciplinary ratings of psychologists, social workers, and psychiatrists. Am J Orthopsychiatry. 1993;63:45-54.

[31.] Comer JP, Haynes NM, Joyner EP, Ben-Avie M, eds. Rallying the Whole Village: The Comer Process for Reforming Education. New York, NY: Teachers College Press; 1996.

[32.] Adelman HS, Taylor L. Mental health in schools and system restructuring. Clin Psychol Rev. in press.

[33.] Marx E, Wooley SF, Northrop D, eds. Health is Academic: A Guide to Coordinated School Health Programs. New York, NY: Teachers College Press; 1998.

[34.] Gibelman M. School social workers, counselors, and psychologists in collaboration: a shared agenda. Social Work Educ. 1993;15:45-53.

Lois T. Flaherty, MD, Clinical Associate Professor, University of Pennsylvania School of Medicine, and Adjunct Associate Professor, University of Maryland School of Medicine, Dept. of Psychiatry, 770 Lantern Lane, Blue Bell, PA 19422; Ellen G. Garrison, PhD, Clinical Assistant Professor and Consultant, Center for School Mental Health Assistance, University of Maryland School of Medicine, Dept. of Psychiatry, 5604 Harwick Road, Bethesda, MD 21202; Robyn Waxman, PhD, Consulting Psychologist, Center for School Mental Health Assistance, University of Maryland School of Medicine, Dept. of Psychiatry, 307 Woodlawn Road, Baltimore, MD 21210; Patricia F. Uris, RN, PhD, Assistant Professor and Project Director, CE for Excellence in Mental Health Nursing in the School Setting, School of Nursing, University of Colorado Health Sciences Center, 4200 East Ninth Ave., Denver, CO 80262; Susan G. Keys, PhD, Assistant Professor, Dept. of Counseling and Human Services, Johns Hopkins University Montgomery County Center, 9601 Medical Center Drive, Rockville, MD 20850; Marcia Glass- Siegel, LCSW-C, Coordinator, School-Based Services, Baltimore Mental Health Systems, Inc., 201 East Baltimore St., Suite 1340, Baltimore, MD 21202; and Mark D. Weist, PhD, Associate Professor and Director, Center for School Mental Health Assistance, University of Maryland School of Medicine, Dept. of Psychiatry, 680 West Lexington St., 10th floor, Baltimore, MD 21201-1570.
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Author:Flaherty, Lois T.; Garrison, Ellen G.; Waxman, Robyn; Uris, Patricia F.; Keys, Susan G.; Glass-Siege
Publication:Journal of School Health
Geographic Code:1USA
Date:Dec 1, 1998
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