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.
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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
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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
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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
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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
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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
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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