Mental Health Services

Mental health problems in children are a major deterrent to learning. Yet the President’s New Freedom Commission on Mental Health in 2002 pointed out that mental health services for children are so fragmented as to be ineffective in major ways. The commission’s report emphasizes the importance of using the school system as the means of delivering such services. The school-based approach to mental health helps accomplish several goals: • Minimizing barriers to learning • Overcoming stigma and inadequate access to care • Providing comprehensive on-site counseling services • Creating a school climate that promotes students’ social and emotional functioning • Promoting healthy psychological and social development This chapter will describe the mental health services at the Children’s Aid Society (CAS) community schools, focusing on staffing, structure, and strategies and describing the clinic at one school in greater detail. Questions of space, accountability, and funding will be explored, and some conclusions based on our work will be discussed. CAS’s school-based clinics, located in elementary and middle schools, provide individual and family counseling, group therapy, in-depth assessments and referrals, and crisis intervention for students and their family members. Referrals to the clinic are made by students, teachers, and parents. Assessment and intervention plans include the active participation of the child, his or her family, school staff, and anyone else who can help in understanding the child’s needs. Based on the assessment, the child and/or family are engaged in shortor long-term individual, group, or family counseling aimed at ameliorating the problems that precipitated the referral. An in-depth psychosocial assessment is the first step in developing a comprehensive treatment plan that includes short- and long-term goals. Psychological and psychiatric evaluations are scheduled as appropriate. Clinicians (social workers with M.S.W. or C.S.W. degrees) generally have caseloads of 18–22 students, with enough room in their schedules to see walk-ins and emergencies. Problems that have been successfully treated include suicide ideation, physical and sexual abuse, drug and alcohol use, disruptive school behaviors, academic delays, hyperactivity, family and peer conflicts, and depression.

Early Childhood Programs

The Children’s Aid Society (CAS) early childhood initiative is located in two of our New York City community schools, Primary School (PS) 5 and PS 8, in the Washington Heights section of northern Manhattan. This initiative was conceived as a partnership between the New York City Board of Education and CAS. The collaboration brought newborns and their families into the schools in which the children would complete fifth grade. The initiative began in 1994 and has been in full operation since 1996. Since then, the need for such a project has been confirmed and experience has provided insights into how a program for pregnant women and children through age five (often called a Zero to Five Program) can be effectively implemented within a public school. The CAS Zero to Five model connects two federally funded programs—Early Head Start (birth to age three) and Head Start (ages three to five)—to provide comprehensive educational and social services to low-income families and their children. The population attending the Zero to Five Program confronts the obstacles facing all new immigrant families living in poverty in an urban setting. In both schools more than 75% of the families are from the Dominican Republic; another 20% come from other Central and South American countries. The parents’ language is Spanish, and language barriers and acculturation issues result in social isolation. In addition, because many residents lack legal documentation, they are reluctant to access health and social services. The few early childhood programs in the neighborhood all have long waiting lists. A majority of the families share overcrowded apartments with other families or extended family; whole families often live in one bedroom where books and age-appropriate toys are scarce and there may be little child-centered language interaction. However, in spite of the difficulties, these parents have a drive to succeed and they understand the importance of education. By combining and linking Early Head Start and Head Start programs and integrating them into a community school, the CAS Zero to Five Program provides children and families with quality educational, health, and social services, after which the children transition into public school classes within the same building.

Schools as Centers of Community: Planning and Design

As we stand at the beginning of the twenty-first century, we face a national challenge in planning and designing learning environments that meet the needs of all learners. Throughout the country, elementary and high school districts are spending unprecedented amounts of money to renovate existing school facilities or build new ones. In 2001 alone roughly $27 billion worth of kindergarten through grade 12 construction projects were approved and funded, a trend that is likely to continue for several years. In 2000 public and private kindergarten through grade 12 school enrollment reached a record 53 million students. The Department of Education projects that 55 million children will enroll in 2020 and 60 million in 2030. By 2100 the pattern of steady growth is expected to result in a total of 94 million school-age children, an increase of 41 million students over the century. It is also projected that diversity will increase, with most of the growth among Hispanic children. They represented about 15% of the public school population in 2000; that proportion is expected to grow to 24% by 2020. This steady increase in the number and diversity of school children, all of whom need and deserve a quality education, suggests that the design of new school facilities and the modernization of old ones will be an ongoing process in communities across the United States. One important component of this challenge is the need to rethink how we plan learning environments to coincide with some new ways of thinking about education. It seems as if such a short time has passed since Howard Gardner introduced the theory of multiple intelligences at a time when other educational strategies, including project-based learning, cooperative learning, primary source learning, real world experiential learning, and their many variations, were enjoying a renaissance or were in the developmental stages. Many of these teaching and learning strategies have found their way into the mainstream as powerful tools that help to create more meaning-centered and personalized learning for students and educators alike. This new group of educational strategies is more diverse, more integrated, and, perhaps, more compelling than their more predictable predecessors.

National and International Adaptations of the Children’s Aid Society Model

When the CAS community schools first opened in New York City in 1992, they attracted many visitors interested in learning about and adapting our model. In response CAS created its National Technical Assistance Center for Community Schools (NTACCS) in 1994 to handle the increasing number of requests for information, coordinate the large number of visitors to the schools, and provide technical assistance in the process and operations involved in creating a community school. People who wish to adapt our model can now tour the various components of our program and meet with our staff to ask questions and learn about the implementation of our program. This chapter will explore the core components of the CAS model and how adaptation sites in the United States and other countries have been able to incorporate elements that represent their signature style and reflect the needs of their individual communities. An immediate dilemma occurs when program planners seek to learn from the experience of others—should they try to replicate the model precisely or should they try to adapt it to their own local circumstances? Replicators often speak of the importance of “program fidelity,” while adaptors talk about differing needs among various communities and populations. The National Institute of Mental Health (NIMH) astutely assesses the dilemma: “While individual tailoring may account for success at a given location, there is pressing need for theoretically grounded interventions that will be effective in a wide range of communities. Therein lies a challenge. On the one hand, ‘replication’ implies fidelity to the original while, on the other hand, ‘community-based and culturally sensitive’ implies expectation of variation and sensitivity to that variation. The need to vary interventions is widely accepted, but systematically developed and articulated only occasionally.” The NIMH study found two key components that improved the effectiveness of HIV prevention programs as they were implemented in multiple sites around the country. One component was that they were “community-based,” designed with the input and skills of the particular communities in which they were implemented. The second was that the programs were “culturally sensitive”—that is, they reflected the needs and cultures of the individuals expected to participate in the intervention and used media and messages relevant to those individuals and their lives.

Introduction

In addition to providing services, community schools need to be governed. In this part you will learn how one principal views the overall partnership and his role in a community school, Intermediate School 218. You will also learn more about other Children’s Aid Society (CAS) schools and how they came into being. The all-pervasive subject of financing is treated by my coeditor, who believes that it is possible to sustain these efforts, but not without constant attention to seeking new funds. Finally, we learn about various attempts to evaluate the CAS schools. As would be expected, the principal is in charge. A full-service community school cannot exist unless the principal is willing to facilitate the arrangement. At the same time, this model cannot be implemented without the presence of a full-time community school director or coordinator (see Negrón, ch. 3 in this volume). The principal works closely with the community school director to integrate new services with what is already there. In one such community school, the principal shares her office with the coordinator, ensuring regular communication. The role of the lead agency, in this case CAS, is extremely important. Just as the principal and the school staff have to support the community school concepts, so do the lead agency and its personnel. CAS is a long-established social service agency that also operates homemaker services, adoption and foster care programs, medical and mental health services, and other similar services. When such an infrastructure is already in place to support community schools, the whole enterprise is enriched, and the transformation of the traditional school into a community school is expedited by back-up from the lead agency’s “home office.” Such matters as payroll, benefits, public relations, and, most important, resource development can be addressed by existing staff members. The expansion of CAS’s community schools initiative—from one community school to ten in a single decade—made it clearer than ever that one size does not fit all. Adapting the model to various populations and conditions and to a wide range of partners requires sensitivity and flexibility on everyone’s part.

School-Based Health Services

In order to be successful in school, children must be able to see and hear and must be free of troubling health problems. Our experience with community schools confirms the idea that locating health services within a school provides easy access for students who are not receiving health care elsewhere. However, many problems, such as working with children who lack health insurance and typically end up in the emergency room for episodic care, have to be overcome. More and more of these children and their parents in our schools are recent undocumented immigrants who fear dealing with the health care system. An even larger number of children are simply from “working poor” families in which parents work off the books or for employers that do not or cannot provide health insurance. For those families who are enrolled in public health insurance plans (most typically Medicaid), having that insurance card in hand does not necessarily provide access to care if the family does not know how to negotiate the health care system. Adolescents raise another issue altogether. It has been well documented that adolescents are the largest group of uninsured children. They generally want help with issues they do not want anyone to know about, such as birth control, sexually transmitted diseases, and depression and suicidal thoughts. However, they can, and do, access school-based health centers (SBHCs) for these health needs. The goal of SBHCs is to improve the overall physical and emotional health of children and adolescents. They do this in two important ways—by providing prevention services and by providing direct health care. The majority of school-based clinics are started by a health care provider who has approached a particular school and formed a relationship with the school’s administrators. Such SBHCs are organizationally external to the school system, administered by local health care facilities such as hospitals and community health centers. Once the clinic is in the school, constant outreach to administrators, teachers, and parents must be maintained to remind them that the health center is on-site. The biggest challenge such providers face is the integration of the health services with the activities of the school.

Introduction

All of the contributors to this book are clearly in favor of community schools. We would like to see this movement grow rapidly or, as we often say, “go to scale.” This would mean that communities with high needs and low performance would be assisted in transforming their schools. The Children’s Aid Society (CAS) work is one of the streams that have come together to create a new field of full-service community schools. The CAS model has been strengthened by many adaptations throughout the country and overseas. A National Technical Assistance Center for Community Schools has been set up at Intermediate School (IS) 218 with facilities for orientation and training. More than 6,000 policy makers and practitioners from all over the world have taken the tour and observed the rich climate at this pilot school. The concepts of community schools do not necessarily sink in at first encounter; it sometimes takes a while for people to “get it.” The question often arises: Do you really expect the schools to do all of that? It is not well understood that the idea behind the community school movement is for schools to do less, not more! Partners such as CAS come into the building and take responsibility for health, social services, extended hours, and parent and community involvement. However, some school superintendents do get it; Thomas Payzant is a good example (see ch. 15 in this volume). Arne Duncan, head of the Chicago Public Schools, is another strong advocate: “We started with 20 community [school] centers this year [and] we want to add 20 each of the next five years so we will get up to 100 over five years. . . . [T]he Chicago School System cannot do this alone. . . . We have universities, local Boys & Girls Clubs, the YMCA’s, Jane Addams’ Hull House . . . helping to run our program with us.” The quest for appropriate space within schools for the core components is being addressed in large new school building initiatives around the country.

Sustaining Community Schools: Learning from Children’s Aid Society’s Experience

Before The Children’s Aid Society (CAS) opened its first two community schools in Washington Heights (1992–1993), our staff and board had already begun to address the issue of sustainability—that is, how to plan for the long-term development, implementation, assessment, and institutionalization of this new line of work. Internal strategic planning led to decisions by CAS board and staff leadership to realign existing resources in support of this new work, while external planning resulted in explicit partnership agreements, forged in 1990, with the New York City Board of Education and Community School District 6 (see appendix to Coltoff, ch. 1 in this volume) that also set the stage for long-term sustainability. As CAS’s assistant executive director for community schools, my responsibilities include planning and overseeing our sustainability efforts. This chapter describes CAS’s experience in raising funds for its community schools and offers suggestions for how other practitioners might proceed. CAS views sustainability as involving not only aggressive fundraising but also public relations, constituency building, and advocacy, using a conceptual framework developed by the Finance Project, a national research and policy organization. These four components are interrelated; work in one area supports and complements efforts in the other three. For fiscal year 2003–2004, the operating budget for CAS’s 10 community schools totaled almost $13 million, which included approximately $8.6 million for the extended-day, summer camp, teen, parent, and adult education components and $2.8 million for health services (medical, dental, and mental health). In addition, two sites have Early Head Start and Head Start programs operated by CAS; the costs for these programs are covered entirely by federal grants totaling approximately $1.4 million. Because the programs differ, each school has a different budget, but the estimated additional cost per student per year of a fully developed community school is $1,000. CAS generates support for its community schools from a wide variety of sources. During the initial years, core support came primarily from private sources, including foundations, corporations, and individuals; the exception was the health and mental health services, which were financed partially by Medicaid and Child Health Plus (federally supported children’s health insurance), as well as by other public and private sources.

History of the Children’s Aid Society Model

The Children’s Aid Society’s concept of community schools came to life in February 1992 with the opening of the Salomé Ureña de Henriquez Middle Academies (Intermediate School [IS] 218) and the opening in March 1993 of the Ellen Lurie School (Primary School [PS] 5). These were the first community schools operated by The Children’s Aid Society (CAS) in partnership with New York City’s Board of Education. PS 5 is an elementary school whose students advance to middle school at IS 218. The model has evolved into a well-integrated, multidimensional community school involving CAS, the Board (now Department) of Education, and the parents and many other partners from the broader community. Before the two schools opened, several years were spent in preparation and planning. Initially, CAS surveyed New York City communities to identify those that would benefit most from CAS’s services. This was part of an ongoing effort on CAS’s part to examine its current programs in order to modify them to meet current social and familial needs. The survey led to the selection of the Washington Heights community, which was characterized by a large influx of recent immigrants, substantial poverty, large families, and a dearth of services. A more intensive study conducted by CAS in 1987 had documented the dramatic needs of families in this community and the shortage of services available to them. The school system ranked 32nd of 32 districts in nearly every category. The type of poverty that characterizes new immigrants was endemic: very low-wage jobs, two and three families sharing one apartment, and a reluctance to accept outside help. Washington Heights was the substance- abuse and drug-trafficking hub for the tri-state area and had the city’s highest homicide rate. Teenage pregnancy rates were also among the city’s highest. This community is not unlike those that CAS has traditionally served throughout its 150-year history. What was to be strikingly different was how CAS would address these problems. In setting out to plan a service model, CAS drew on its long and rich history of operating community centers in low-income neighborhoods.

Looking to the Future

It may seem strange in a chaotic political period to say that the community school movement is alive, well, and growing. Yet such chaos can give rise to collaborative concepts. Out of adversity comes action, and that action is directed toward helping children succeed in an increasingly difficult environment of higher poverty levels, less health insurance, failing schools, more mental health problems, and a widening gap between social classes and races. It is not a pretty picture, but it is a challenging one. The Children’s Aid Society (CAS) is moving forward with its commitment to community schools. Although we thought we would stop at 10 school sites in New York City, during the 2003–2004 academic year we initiated three more—two in the Bronx and one on Staten Island. Our Technical Assistance Center is in great demand, hosting more than 600 visits in 2003 and responding to more than 500 requests for technical assistance. Also in 2003 we convened representatives from more than 60 of the national and international adaptation sites for a three-day practicum—a training and networking session at which we heard testimonials to success and stories about challenges. Many of the original adaptation sites have moved from one dynamic community school to a cluster of schools within their neighborhoods or districts. And some of these original adaptation sites have matured to the point of providing guidance to other schools that want to emulate their success. There are now more than 200 adaptation sites—community schools based on the CAS model—in the United States and other countries. We are often asked, “Just how many community schools are there in this country?” We have a reasonable census of CAS sites (13) and adaptations (215), but that is only the beginning of a count. The question is difficult to answer because there are so many versions of other models and so many schools without any of these components that nevertheless call themselves “community schools.” We have tried to construct a continuum along which schools can measure themselves.