ERIC Identifier: ED390019
Publication Date: 1995-00-00
Author: Paavola, James C. - And Others
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,
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
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
services are available in close proximity and are accessible without reference
to physical, psychological, social, linguistic, sexual orientation, or other
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;
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;
services promote psychological competence and self sufficiency rather than
focusing exclusively on dysfunction and pathology;
services are oriented toward full participation, partnership, and empowerment of
services are sensitive to cultural, gender, racial, linguistic, class,
disability, and sexual orientation issues; and,
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
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,
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.
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