ERIC Identifier: ED390019
Publication Date: 1995-00-00
Author: Paavola, James C. - And Others
Source: ERIC Clearinghouse on Counseling and Student Services Greensboro NC., American Psychological Association Washington DC.
Health Services in the Schools: Building Interdisciplinary Partnerships. ERIC Digest.
There are two essential social systems with which virtually all children and families have routine, significant contact: school and health care settings. The school is an environment wherein children not only engage in academic learning and growth, but where they also experience social and emotional interactions with adults and peers so as to build self-esteem and social competence. These essential experiences can serve to increase later prospects for success in relationships, the work place, and personal pursuits. It is vital that schools support the broad developmental needs of children and families.
Schools are being asked to address the needs of children and youth at a time when fundamental transformations of schooling structures and outcome expectations are also being demanded (Children's Defense Fund, 1992). Restructured schools alone cannot satisfactorily address the multidimensional needs of children and youth. Schools and other child- and family-service organizations must collaborate to enhance the likelihood of educational and personal success for all children. Recent legislative and policy initiatives, such as Healthy People 2000 (1990), a blueprint for disease prevention and health promotion, highlight the important role that schools must play in assuring the well-being of our nation's children and youth.
In order to address the developmental needs of children and families in a comprehensive and preventive manner, schools and communities must coordinate services. Therefore, a service integration perspective that recognizes the central role that schools play in the lives of children should guide efforts to establish an empowering, healthy climate for them and their families within the community at large (Institute for Educational Leadership, 1992; Oomes & Herendeen, 1989). Such a view acknowledges the complex, reciprocal interaction among social systems, including families, when problems are conceptualized and service systems are designed. It assumes that children and families are most likely to benefit from collaborative, focused efforts among the various systems responsible for addressing their needs, both formal and informal.
INTERDISCIPLINARY PARTNERSHIPS IN HEALTH CARE
There is an emerging consensus among professionals and consumers that the current health care service delivery system is not meeting the needs of children and families (Knitzer, 1982; National Commission on Child Welfare and Family Preservation, 1990). Solutions must move beyond adding resources (e.g., more funding, more programs) and toward fundamental changes in how the system operates. Social and political institutions have not considered the needs of children and families as funding priorities (Melaville & Blank, 1991, 1993). Individual service delivery systems for children (e.g., health care, education, social service, mental health) are funded and designed to address isolated and crisis-oriented needs, rather than to promote healthy development for all children and families in a comprehensive fashion. In addition, some parents either have no knowledge of how to access available services, or they may not value them. Thus, services provided to children and families frequently are not comprehensive, responsive, or integrated.
Key sources of difficulty in the current service delivery system are the lack of clarity, coordination, and comprehensiveness, resulting in inflexible patterns of funding, training, and service provision. Since the cognitive, social, emotional, educational, and physical needs of children are complex, an integrated services model provides for a more coherent, needs-based response to these complex problems (Chaudry, Maurer, Oshinsky & Mackie, 1993; Dunst, Trivette, Gordon, & Pletcher, 1989).
HEALTH CARE IN SCHOOLS THROUGH SERVICE INTEGRATION
The efficacy of services to children and families can be viewed from the perspective of the families themselves. When examined in this manner, emphasis is placed upon the nature of service delivery events or episodes that occur, and the impact these events have on children and families. Within a well-integrated program, typically:
1. services are available in close proximity and are accessible without reference to physical, psychological, social, linguistic, sexual orientation, or other barriers;
2. services are comprehensive and appropriate, in that they possess features that address priority needs the family has identified, at a level of service sufficient to their need;
3. services are formulated and delivered at a high level of quality such that the family perceives them as an organized whole and can participate in a consistent and effective manner;
4. services promote psychological competence and self sufficiency rather than focusing exclusively on dysfunction and pathology;
5. services are oriented toward full participation, partnership, and empowerment of family members;
6. services are sensitive to cultural, gender, racial, linguistic, class, disability, and sexual orientation issues; and,
7. interventions are driven by concern for the needs and desires of the consumers (i.e., children and families) and emphasize explicit outcomes stated in a positive manner. (Paavola et al., 1995, p. 22).
FEATURES OF AN INTEGRATED SERVICE SYSTEM
Relative to the definition offered previously, there is a continuum of integrated services that varies as a function of need, service availability, problem severity, and related dimensions. From the perspective of children and families, many opportunities and services can best be accessed through a single provider and implemented in an integrative manner. An integrated services model also assumes that the greater the number of providers involved (e.g., psychologists, nurses, teachers, social workers, physicians, day care workers), the greater the need for effective collaboration. Timely and responsive interventions on behalf of children and families therefore rely on effective communication, coordination, and collaboration among service providers, agencies and organizations, and the consumers of services (children and families).
Thus, "coordinated and collaborative services" should be the essential standard by which effective services are delivered. The service system must respond to the multiplicity of needs exhibited by children and families through carefully orchestrated teamwork. At a minimum, this collaboration takes the form of different providers (from independent agencies) communicating regularly by phone regarding a child or family. Or, it may involve regular face-to-face meetings and case conferences among providers. Ideally, providers and family members would work as an integrated team to provide needed services. The net result of the integrated team concept could be service delivery models such as "one-stop shopping" or more staff sharing and program development activity.
The service delivery system should also allow for both "ease of entry and flexibility of movement." For example, if the point of initial contact in a community is a school setting, there should be a clear connection between the school and the array of community services that the family needs, regardless of categorical restrictions. This requires that individual providers and agencies see themselves as part of a much larger ecology that is community-wide and geared to aiding the overall climate within which children grow and develop. The point of initial entry into such a system should be less critical than the fact that child and family needs are considered paramount in responding to the concerns presented. The flexibility of movement concept allows for a child or family to enter such a system at any point and move flexibly between services as their needs dictate without having to confront barriers.
The service delivery system must be organized for both "maximum development of the child and for accountability," first to the family, and also to the community within which the child lives. This means that providers need to be re-trained within a consumer-oriented model, with children and families seen as customers with whom one must collaborate, rather than as patients or adversaries. Community accountability refers to concern for improving the quality of life in communities through community resource development, advocacy, and related activities.
"Funding for coordinated and collaborative service needs to be both flexible and shared" (where possible) among agencies, such that different agencies can be encouraged to develop together programs that serve children and families holistically. Funding and program decisions need to be made from the "bottom up" and those providers who have on-going contact and communication with the family should be the major decision makers about how pooled and/or flexible funds can be utilized most effectively, with direct input from the consumers of services.
"Interdisciplinary interaction and training" for providers needs to be a top priority in an integrated service model. It will be necessary for providers from different disciplines to know what other disciplines can contribute to solutions for issues confronting families. Collaborative effort outside of traditional disciplinary lines creates opportunities for true communication and integration among providers.
RELEVANCE TO PSYCHOLOGY
"Role of Psychologists"
Psychologists develop systems that ensure the healthy development of children and the strengthening and empowerment of families. In both primary health care and school settings, psychology can play an integral role in "prevention, assessment, treatment, consultation, and advocacy" for children and families. Psychologists employed in other social service, mental health, and related organizational settings can also have considerable impact on the welfare of children and families through early intervention and treatment activities. In all settings, psychological services must be integrated with other necessary services and then provided in a manner that does not artificially separate the physical, emotional, and social needs of children and families.
There are a number of integrated service efforts underway, many of which involve or are led by psychologists. For example, the School of the Future project (Holtzman, 1992) in Austin, Dallas, Houston, and San Antonio, Texas (partially funded by the Hogg Foundation) focuses on the coordination and delivery of an extensive array of health and human services through neighborhood schools. In the Memphis City Schools, educational, mental health, and social services have been integrated within a "one-stop shopping" paradigm (Paavola, Hannah, & Nichol, 1989). The National Institute of Mental Health promotes the Child and Adolescent Service System Program (CASSP) initiative, designed to improve mental health services for children with severe emotional disabilities by encouraging states to provide more comprehensive and coordinated services through interagency collaboration and service coordination (Day & Roberts, 1991).
The Robert Wood Johnson Foundation is extensively involved in health promotion and in improving systems of care for children with emotional and behavioral problems. Other prominent foundations sponsor large-scale family support and integrated services demonstration projects in a number of states (e.g., Annie B. Casey Foundation, Pew Charitable Trust). Scattered across the country are numerous other projects and activities in this same vein (e.g., within Head Start and related early education programs). Emerging from these projects is evidence that integrated services can be effective, responsive, and cost-efficient (Illback, 1992, 1993). Furthermore, there is a recognition of the need to extend these findings to the health-service system as a whole.
IMPLICATIONS FOR SCHOOL HEALTH PSYCHOLOGY
The concept of service integration has several implications for psychology as a profession and psychologists as health-service providers in schools. Implications for psychological training, practice, research, and leadership, are discussed below.
TRAINING. Service integration has major implications for both graduate and in-service training of psychologists since this integration will require greater breadth and flexibility among practitioners. A school health psychologist with expertise in behavioral health who serves an elementary school, for example, will need to be competent in a broad number of skills and approaches, ranging from typical developmental concerns and issues, to guidelines for monitoring commonly used child psychotropic medications, family interventions, and community consultation. Professionals who are "generalists" in human services will have greater possibilities for employment in an integrated service system than those whose background is limited specifically to traditional psychological practice specialties. There will, of course, always be some need for specialization, particularly with respect to low-incidence or highly technical problems. Psychologists will need more systematic training in collaborative and consultation-based approaches to practice.
PRACTICE. Psychological services within an integrated services framework will look and feel substantially different. Practitioners will be able to exercise greater flexibility in the range of activities in which they engage, and will not be as constrained in regard to funding source and eligibility considerations. They will spend more time working as part of a team, in concert with a variety of providers, caregivers, and community members. In addition to the school-based services they provide, school-health psychologists are likely to spend more time in homes and other community settings. These psychologists will routinely work across interdisciplinary boundaries among various social systems that impinge on children and families to coordinate activities, manage conflict, and insure focus and quality of services.
LEADERSHIP. Psychologists should be trained and encouraged to assume leadership roles within integrated service programs. In addition to the more traditional aspects of program administration and supervision, leadership activities should focus on establishing an integrative strategic vision for child-serving organizations, building collaborative teams, and facilitating planned organizational change in the direction of more integrated services.
RESEARCH. Psychological research on the efficacy of integrated service delivery approaches for children and families represents a unique contribution for psychology. Such research is distinct from traditional controlled experimentation, in that the array of target problems is vast, treatment programs are diverse and multifaceted, and outcome measurements complicated. Practicing psychologists need to become proficient in a broader range of methods and procedures (e.g., quasi-experimental design, multivariate analysis, program evaluation techniques, qualitative research) in order to conduct such social policy and program-related investigations. Psychologists would also be in a unique position to help service systems develop and validate information systems to allow for on-going program monitoring and management.
These changes would result in considerably greater effectiveness in the use of psychology to advance the delivery of health-care services in schools. There are at present large numbers of children and families whose needs in the areas of health, behavioral health, mental health, education, and social welfare are not being met. In addition to the personal cost to these individuals, the prosperity of the country suffers from their resultant inability to contribute fully as citizens. Psychology, in collaboration with other concerned persons and professions, has an opportunity to exercise the leadership necessary to secure for these children and families effective, responsive, and comprehensive health services in schools and other settings.
Chaudry, A., Maurer, K. E., Oshinsky, C., & Mackie, J. (1993). Service integration: An annotated bibliography. New York: National Center for Service Integration, Columbia University.
Children's Defense Fund. (1992). The state of America's children: 1992. Washington, DC: Children's Defense Fund.
Day, C., & Roberts, M. C. (1991). Activities of the child and adolescent service system program for improving mental health services for children and families. Journal of Clinical Child Psychology, 20, 340-350.
Dunst, C. J., Trivette, C. M., Gordon, N. J., & Pletcher, L. L. (1989). Building and mobilizing informal support networks. In G. H. Singer & L. K. Irvin (Eds.), Support for caregiving families: Enabling positive adaptation to disability. Baltimore: Brookes.
Healthy People 2000: National health promotion and disease prevention objectives. (1990). (DHHS Publication No. (PHS) 91-50212). Washington, DC: U.S. Government Printing Office.
Holtzman, W. H. (Ed.). (1992). School of the future. Washington, DC: American Psychological Association and Hogg Foundation for Mental Health.
Illback, R. J. (1992). Plan for evaluating the Family Resource and Youth Service Centers. Frankfort, KY: Kentucky Cabinet for Human Resources.
Illback, R. J. (1993). Formative evaluation of the Kentucky Family Resource and Youth Service Centers. Frankfort, KY: Cabinet for Human Resources.
Institute for Educational Leadership. (1992). Developing collaborative leaders: A selected bibliography of resources. Washington, DC: Institute for Educational Leadership.
Knitzer, J. (1982). Unclaimed children: The failure of public responsibility to children and adolescents in need of mental health services. Washington, DC: Children's Defense Fund.
Melaville, A. I., & Blank, M. J. (1991). What it takes: Structuring interagency partnerships to connect children and families with comprehensive services. Washington, DC: Institute for Educational Leadership.
Melaville, A. I., & Blank, M. J. (1993). Together we can: A guide for crafting a profamily system of education and human services. U.S. Office of Education (Office of Educational Research and Improvement) and US Department of Health and Human Services (Office of Assistant Secretary for Planning and Evaluation). Washington, DC: U.S. Government Printing Office.
National Commission on Child Welfare and Family Preservation. (1990). A commitment to change. Washington, DC: American Public Welfare Association.
Oomes, T., & Herendeen, L. (1989). Integrated approaches to youths' health problems: Federal, state, and community roles. Washington, DC: American Association for Marriage and Family Therapy.
Paavola, J. C., Cobb, C., Illback, R. J., Joseph, Jr., H. M., Torruella, A., & Talley, R. C. (1995). Comprehensive and coordinated psychological services for children: A call for service integration. Washington, DC: American Psychological Association.
Paavola, J. C., Hannah, F. P., & Nichol, G. T. (1989). The Memphis City
Schools Mental Health Center: A program description. Professional School
Psychology, 4, 61-74.
Library Reference Search
Please note that this site is privately owned and is in no way related to any Federal agency or ERIC unit. Further, this site is using a privately owned and located server. This is NOT a government sponsored or government sanctioned site. ERIC is a Service Mark of the U.S. Government. This site exists to provide the text of the public domain ERIC Documents previously produced by ERIC. No new content will ever appear here that would in any way challenge the ERIC Service Mark of the U.S. Government.