Brief history of school-based mental health services in united states and some recomendations for Vietnam schools

HNUE JOURNAL OF SCIENCE DOI: 10.18173/2354-1067.2017-0045 Social Sci., 2017, Vol. 62, Iss. 5, pp. 139-145 This paper is available online at BRIEF HISTORY OF SCHOOL-BASED MENTAL HEALTH SERVICES IN UNITED STATES AND SOME RECOMENDATIONS FOR VIETNAM SCHOOLS Nguyen Thu Ha, Nguyen Thi Mai Huong and Nguyen Thi Anh Nguyet Faculty of Social Work, Hanoi National University of Education Abstract. Despite the accomplishments, the economic and social reform program of Vietnam has had negative effects, such as limited access to health care services for those disadvantaged in the new market economy. Among this group are persons with mental disorders. There are also a lot of children and adolescents have mental health problems. School-based mental health services are considered as a strategy to address these concerns. This paper aims to understand definition of school-based mental health, historical background of school-based mental health services in United States and give some recommendations to build school-based health services in Vietnam. Keywords: school-based mental health, mental disorders, school social work, history, mental health, schools, social workers, United States, Vietnam. 1. Introduction In United States, schools have a long history of providing mental health and support services to children. These are collection of models which emerge from diverse theories as well as varied intervention strategies. Implementation, however, has generally been piecemeal with only parts of the models being actualized in any one community. Beginning in 1986, Vietnam initiated an economic and social reform program called Doi Moi. Vietnam has made considerable progress in the economic and social well-being of population. Accessibility to health care services especially in schools is one of important targets in social security development strategy. The understanding and implement of school-based mental health services in Vietnam is still limited. Therefore, the purpose of this paper is to find out what is school-based mental health, history of these services in US, advantages in these services and some recommendations for Vietnam schools. It is hoped that policy- and decision-makers in both mental health and education will find the information presented helpful as they begin to build their school-based mental health services. Received date: 1/2/2017. Published date: 1/5/2017. Contact: Nguyen Thu Ha, e-mail: thuha.sw.hnue@gmail.com 139 Nguyen Thu Ha, Nguyen Thi Mai Huong and Nguyen Thi Anh Nguyet 2. Content 2.1. Brief history of school-based mental health services in United States 2.1.1. What is school-based mental health service? The term “school-based mental health” has generally been understood as any mental health service delivered in a school setting. School-based mental health services are evolving as a strategy to address mental health problems in schools. School-based mental health services offer the potential for prevention efforts as well as intervention strategies for mental health clients at schools. Schools are the primary providers of mental health services for many children. School-based mental health services range from minimal support services provided by a school counselor to a comprehensive, integrated program of prevention, identification, and treatment within a school. In some schools, comprehensive mental health services are provided [3;2]. School-based mental health services include a broad spectrum of assessment, prevention, intervention, postvention, counseling, consultation, and referral activities and services. These services are essential to a school’s ability to ensure a safe and healthy learning environment for all students, address classroom behavior and discipline, promote students’academic success, prevent and respond to crisis, support students’social-emotional needs, identify and respond to a serious mental health problem ,and support and partner withat-risk families. Ideally, school-based services dovetail with community-based services so that children and youth receive the support they need in a seamless,coordinated, and comprehensive system of care. 2.1.2. Brief history of school-based mental health services in United States Schools have a convoluted history of involvement in mental health since the late 1890s, when psychology clinics were placed in some schools in Philadelphia, Pennsylvania. At the end of the 1800s, in response to increasing numbers of children being placed in adult jails, the first child mental health services in US began by providing counseling to children with school problems. These services, along with juvenile court clinics that incorporated the first multi-disciplinary teams to work with children, gave rise to advocacy for building child guidance clinics throughout the country in 1922. The initial clinics were primarily staffed by social workers and later evolved to include multi-disciplinary teams that encouraged community-based, and non-hospital based, care for children, with many created to work specifically with school districts. These early clinics provided the foundation for currently operating community mental health centers throughout the country [5]. However, in the 1970s and 1980s there was a movement toward the medicalization of child mental health with child and adolescent psychiatric services directed toward a more hospital-based model of care, driven in part by financing policies. This led to a split between psychiatric hospital-based services and community-based mental health services. This split between the two treatment modalities allowed public mental health dollars to be absorbed by hospitals, leaving few resources for community-based care. Concomitantly, the first public law was passed addressing the education of students with disabilities, P.L. 94-142, the Education of All Handicapped Children Act, later reauthorized as the Individuals with Disabilities Education Act 140 Brief history of school-based mental health services in United States and some recomendations... (IDEA). P.L. 94-142 placed a larger responsibility on the education system to meet the mental health needs of students with emotional disturbances [5]. This legislation required that all support services needed to help educate students with disabilities must ultimately be supplied by the education system. Leaders in the mental health system viewed this new legislation as a mandate for schools to pay for mental health services—services that were under-funded within the community mental health centers. Leaders in the education system viewed this as an unfunded mandate and had to engineer ways to piece together meager resources across a multitude of students with physical and emotional disabilities with hopes that the mental health system would supply necessary resources for children with emotional disturbances. IDEA legislation has played a key role in blurring the lines of who is responsible for providing mental health services to children and adolescents. This confusion in roles and responsibility between education and mental health persists to this day in many communities and the renewed interest in school-based mental health services has, for some, triggered renewed conflict between the two systems. It is clear that both the education and mental health systems have a long history of providing mental health services to students. Sometimes these services are delivered collaboratively between the two systems, but more often, the services work in parallel fashion with each other or do not operate effectively at all in either system. Efforts to conceptualize school-based mental health services will be advanced by including a clear delineation of the role of each system. 2.2. Components and advantages of school mental health propram There are a 3-tiered model of services and needs of a school mental health program: The first tier is an array of preventive mental health programs and services. Activities in this tier need to be ubiquitous so that they target all children in all school settings. Preventive programs are those that focus on decreasing risk factors and building resilience, including providing a positive, friendly, and open social environment at school and ensuring that each student has access to community and family supports that are associated with healthy emotional development. A sense of student “connectedness” to schools has been found to have positive effects on academic achievement and to decrease risky behaviors [6]. For example, schools should provide students with multiple and varied curricular and extracurricular activities, thereby increasing the chances that each student will feel successful in some aspect of school life. Schools also should provide numerous opportunities for positive individual interactions with adults at school so that each student has positive adult role models and opportunities to develop a healthy adult relationship outside his or her family. Schools can provide families with support services and should implement “prevention” curricula (eg, curricula that decrease risk-taking behaviors). Behavioral expectations, rules, and discipline plans should be well publicized and enforced school-wide. A recent review of effective programs is available for schools and those who advise schools on development of their preventive programs [6]; The second tier consists of targeted mental health services that are designed to assist students who have 1 or more identified mental health needs but who function well enough to engage successfully in many social, academic, and other daily activities. Services in this tier would include the provision of group or individual therapy to students. For students in special education for learning problems who also have behavioral problems, this tier 141 Nguyen Thu Ha, Nguyen Thi Mai Huong and Nguyen Thi Anh Nguyet also may consist of the behavioral components of these students’ individualized education programs (IEPs) or individual health service plans that address these students’ behavioral issues; The third tier of health services targets the smallest population of students and addresses needs of children with severe mental health diagnoses and symptoms. These students require the services of a multidisciplinary team of professionals, usually including special education services, individual and family therapy, pharmacotherapy, and school and social agency coordination[6]. One advantage of the familiar setting of school for provision of mental health services is that students and families avoid the stigma and intimidation they may feel when they go to an unfamiliar and perhaps less culturally compatible mental health settings. Of course, receiving services at school may put students at risk of another form of stigmatization, that is, stigmatization by their peers. This issue must be addressed on both a programmatic level (eg, discretion, strategic scheduling of appointments, private waiting areas) and individually with each student receiving services. Providing school-based mental health services eliminates the need for transportation of students to and from off-site appointments and facilitates parent participation in mental health appointments, because many parents live within walking distance of neighborhood schools. These advantages may encourage more parents to seek mental health care for their children and more students to self-refer for treatment. In addition to eliminating barriers to access to care, school-based mental health services offer the potential to improve accuracy of diagnosis as well as assessment of progress. One of the major challenges to providing mental health services to students is gaining access to information concerning the functionality of the student in various environments. Schools have a wealth of opportunities to acquire information on how children deal with physical and social stresses and challenges and on how they perform in the academic setting, on community-related roles in which children engage (eg, in sports, with younger children as a mentor, etc), and on the nature and extent of many sorts of interpersonal relationships (eg, adults, peers). 2.3. Some recomendations for Vietnam schools Like many developing countries, Vietnam began the transition of developing from a primarily rural, agricultural economy to a more modern, mixed industrial economy. The rapid economic growth has placed increased pressure on families and children threatening families’ traditional ability to socialize their children into healthy, adaptively functioning adults. In response to increased economic opportunity as well as increased economic pressure, for instance, parents often work two jobs or long hours, with many young children left alone at home for extended periods without adult supervision. Overall, these social changes have increased Vietnamese children’s risk for development of mental health problems. There have been several studies assessing the mental health of Vietnamese children. The combined results of these studies indicate that children in Vietnam face substantial mental health challenges. In a study in Ho Chi Minh City in southern Vietnam, Anh, Minh and Phuong (2007) assessed the mental health functioning of high school students, and found that 16% were above the threshold for experiencing significant affective problems, 19% were above the threshold for social relationship problems, and 142 Brief history of school-based mental health services in United States and some recomendations... 24% were above the threshold for behavior problems. In northern Vietnam, Hoang-Minh and Tu (2009) found that about 25% of adolescents in their sample were at or above the clinical cutoff on at least one Child Behavior Checklist scale [7]. School social workers provide mental health services in schools and have specialized training to meet students’ social-emotional needs. School social workers serve as the primary mental health providers for students and school mental health settings usually include services in three broad levels of health care application: prevention, treatment and rehabilitation. There are some recommendations for schools and school social workers in Vietnam following: 2.3.1. Recommendations for schools The mental health program (preventive strategies and mental health services) should be coordinated with educational programs and other school-based health services. School social workers, guidance counselors, school psychologists, school nurses, and all mental health therapists should plan preventive and intervention strategies together with school administrators and teachers as well as with families and community members; Preventive mental health programs should be developed that include a healthy social environment, clear rules, and expectations that are well publicized. Staff members should be trained to recognize stresses that may lead to mental health problems as well as early signs of mental illness and refer these students to trained professionals within the school setting; Mental health referrals (within the school system as well as to community-based professionals and agencies) should be coordinated by using written protocols, should be monitored for adherence, and should be evaluated for effectiveness; School-based specific diagnostic screenings, such as for depression, should be implemented at school only if they have been supported by peer-reviewed evidence of their effectiveness in that setting; Roles of all the various mental health professionals who work on campus with students should be defined so that they are understood by students, families, all school staff members, and the mental health professionals themselves; Group, individual, and family therapies should be included as schools arrange for direct services to be provided at school sites. Alternatively, referral systems should be available for each of these modes of therapy so that students and families receive the mode of therapy most appropriate to their needs; It should be documented that mental health professionals providing services on site in school (whether hired, contracted, or invited to school sites to provide services) have training specifically in child and adolescent mental health (appropriate for students’ ages) and are competent to provide mental health services in the school setting; Private, confidential, and comfortable physical space should be provided at the school site. Often, this is not difficult for schools if mental health services are provided after school hours. Having school-based services should not preclude the opportunity for mental health services to be provided at nonschool sites for situations in which therapy at school for a student may be ill advised (eg, a student who feels uncomfortable discussing a history of sexual abuse at the school setting). During extended school breaks, schools must provide continued access to mental health services; Staff members should be provided with opportunities to consult with a child psychiatrist or clinical psychologist (on or off the school site) so that they may explore specific difficult situations or student behaviors and review school policies, programs, and protocols related to mental health; Quality-assurance strategies 143 Nguyen Thu Ha, Nguyen Thi Mai Huong and Nguyen Thi Anh Nguyet should be developed for mental health services provided at school, and all aspects of the school health program should be evaluated, including satisfaction of the parent, student, third-party payers, and mental health professionals. 2.3.2. Recommendations for school social workers - School social workers should advocate for schools to develop comprehensive mental health programs with a strong preventive component that focuses on building strengths and resilience, not just on problems, and that involves students’ families. - School social workers should develop a relationship with local schools, serve on school health advisory councils, and promote school-based mental health services. - School social worker at prevention tier should build a program that provides students with classroom social skills training, and teachers with in-classroom consultation on program implementation and classroom-wide behavior management. Mental health functioning (emotional and behavioral mental health problems) was the ultimate outcome target, with social skills intermediate outcomes targeted to improve mental health functioning. Significant treatment effects were found on both social skills and mental health functioning. - Management of one’s own client cases with mental health problems should be coordinated with school-based mental health professionals. - School social workers should advocate for financial and institutional changes that are likely to provide medical homes and families with the option of access to mental health services through school settings, such as coverage of school-based mental health services by health insurers and school billing of Medicaid for school-based mental health services payable under this program. - School social workers should work with schools to help identify strategies and community resources that will augment school-based mental health programs. - School social workers through enhanced collaboration and communication with school mental health service professionals, can strengthen the medical-home model and improve the mental health of their patients. 3. Conclusion Mental health is directly related to children’s learning and development. It encompasses or intersects with interpersonal relationships,social-emotional skills,behavior, learning,academic motivation,certain disabilities,mental illness (e.g.,depressi