The range of psychological, educational, family and neighborhood problems affecting children, especially those with serious emotional disturbances or those in crisis, is extremely complex.

Developing services to address these problems requires a variety of resources that no agency alone could provide.  The needs are many —  finding adequate funding, initiating or strengthening relationships between mental health centers and communities, overcoming stigma, networking with other child service providers and adequately training mental health professionals — to name a few.

One way that the South Carolina Department of Mental Health (DMH) is meeting these needs is through its school based programs.

Under these programs, mental health professionals from community mental health centers set up their offices in schools in order to provide intensive, comprehensive services that are highly flexible, easily accessible and integrated into the everyday settings of children and their families.

Brenda Lipe and Brittany use puppets to communicate during a school-based counseling session.

School Based Mental Health Services Going Where the Children Are
By Susan F. Craft, AMHC

With funding from a four-year grant from the S. C. Department of Health and Human Services, they piloted school based programs in 20 sites 

Since that time, services have grown to encompass over 130 mental health professionals who work out of 232 schools across the state.

Setting up a school based program requires a great deal of local effort.

Funding has always been an issue.  DMH offers $10,000 annually to its community mental health centers to start up school based programs.  Centers must negotiate and partner with school districts, county government, law enforcement agencies and other sources to provide supplemental funds.

Mental health professionals from the centers meet with school superintendents and staff at district offices to determine a need for a school based program, to explain the services that could be provided and to determine school sites.  Usually, an innovative principal will request a program.

"We don't go anywhere we are not wanted," says Beth Freeman, MSW, LISW, DMH program director for coordination of school based services.  "We need support form the community and the school.  We'd be setting ourselves up for failure if we didn't have their acceptance and support."

In response, Mrs. Freeman says, "We often have to try to overcome preconceived ideas and misconceptions about mental health in general, as well as the stigma associated with seeking treatment.  I tell school officials that there are a lot of children, in middle schools especially, who may be perfectionists.  You don't know how severely they are hurting inside.  You don't know they have an eating disorder.   You don't know how depressed they are or that they want to hurt themselves or others, until it's too late.  Our school based 

"Because we are proactive, we can deter more serious problems.  Working together with a guidance counselor, principal, teacher and family, we often solve problems before they escalate, allowing a child who may have been expelled to stay in school."  Some school boards admit they have violence in their communities but feel it is domestic violence and want to know how those issues can be addressed without intruding into families' lives.

"To those people, I talk about how we work not only with the child, but with the entire family.  We address the problem once family at a time," says Mrs. Freeman.  "I stress the point that we never provide services to a child without parental permission.  Even when there is a crisis, we call the parents immediately and ask them to come to the school and work together with us.  We have not heard a single family say we were intrusive.  They were thankful we were there."
   

"For the most part, parents are also willing to work with me, because 

Jerome H. Hanley, Ph.D., director of DMH Services for Children, Adolescents and Their Families, shares his perspective of mental health services in schools this way:  "Children experience various types of emotional and behavioral problems and deal with difficulties associated with schooling in an array of ways and problems —  poor academic performance, anxiety from being at a new school, divorce, loss of a pet, death of a family member, physical or sexual abuse.

"Teachers represent the first line of mental health defense.  If a child is not feeling well, is frightened or suffering trauma, their teacher usually knows about it.  Depending upon the age of the age of the child, especially those in elementary or preschool, they will discuss problems with their teacher.

"The second line of defense is guidance counselors and social workers.  There are not nearly enough of them, and the ones who are out there are overwhelmed with scheduling courses, helping students prepare for college and helping the administrative and disciplinary activities.

School based counselors differ from guidance counselors in that they provide family therapy, whereas guidance counselors, in general do not.  As mental health center employees, they bill for their services, including a sliding fee scale.  They are also unique in that they offer a range of services for children with Attention Deficit Hyperactivity Disorder (ADHD), including a full assessment to rule out those who have true ADHD and those who do not.

School based counselors differ form traditional mental health center counselors in many ways other than where they are located.  They are often called upon to be facilitators, mediators and peacemakers.  They provide not only direct clinical services, but are also instrumental in setting up special school-specific programs.

For example, in one community, a school based counselor established a program to meet the emotional needs of youth and families of Hispanic migrant workers.  In another community, a counselor established a club for African-American youth.  In yet another, a counselor and several interns from Benedict College initiated a coat club that on one Saturday gave away over 500 coats that had been donated for students who needed them.  With assistance from volunteers from churches, sororities and fraternities and civic clubs, school based counselors also coordinate in-school and after-school mentoring and tutoring programs, after-school recreational activities and summer camps.  They also provide school-wide programs regarding anger management, conflict resolution, prevention of violence, study and organizational skills, self-esteem and choosing and maintaining friends.

The benefits of school based programs are phenomenal.

JoAnna Nichols, who recently attained her master of social work degree from USC  and who served as a school based intern at White Knoll Middle School, explains what the experience meant to her.  

"I learned so much.  It was a hands-on experience where I was 

Suzanne Ash follows up on students with intern JoAnna Nichols.

"For instance, I worked with a child who has severe diabetes.  She refused to take her blood sugar levels and was depressed about having the illness and embarrassed about being different from the other children.  I involved her family and the school nurse, and now she is more comfortable about taking insulin and getting regular blood checks.  I even referred her to a summer camp for diabetics."

Institute for Families in Society surveys of teachers revealed that they view school based services as supportive of their mission to educate youth and that they are taking advantage of the availability of both therapeutic and preventive services for their students.

Surveys of families who received both school based services and center based services consistently reported greater satisfaction with school based services.  Families reported that the services were easily accessible, were provided in a non-stigmatizing environment and help build academic and behavioral competencies for their children.  In the more rural areas of the state, families who have difficulties with transportation or with work schedules deeply appreciate the convenience of accessing the services at schools.

"It's an excellent program," she says. "Without it I don't know what I would have done.  It's so much easier for Brittany to be able to come to someone at school rather than wait for an appointment at the mental health center.  Plus, if she goes to the center, they only see her for an hour once a month. Brenda [the school based counselor] can check on her in the classroom and see how she's doing in the lunchroom, in the library or on the playground.  If Brittany ever feels like she needs to talk to someone right away, she can go see Brenda.  She gets individual attention, and the teachers are aware of what she's going through.  It's a great program."

Most importantly, children are learning to communicate

According to Dr. Hanley, "We are a leader in the nation in the provision of school based services.  Other states see us as a model and have requested our help in training their staff.  We are one of only a very few states in which school based services are Medicaid reimbursable.  We were one of only five states to receive a four-year grant from the federal Maternal, Infant and Child Health Bureau (Adolescent Branch), which DMH is using to create through Benedict College and South Carolina State University field placements for bachelors level workers to augment school based services.

Despite funding issues (DMH received no new dollars in its budget this year to expand school based programs), the future of the initiatives is bright.

Through close partnerships with schools and communities, Dr. Hanley plans to increase the number of school based workers by 5 to 10 percent.

Dr. Hanley's vision for the program is to develop a child-centered, family-focused, community-based, culturally competent system of care and to infuse child mental health services into all existing formal and informal systems that serve children.

Dr. Hanley's goals may be lofty, but, according to current attitudes in South Carolina, they are attainable.  These attitudes came to the fore during the Department of Mental Health's efforts to create a strategic plan.  In January and February of 1998, DMH brought together 300 professionals, parents, advocacy representatives, consumers, DMH staff and concerned citizens from across the state, who met in four regional groups to discuss mental health services in the state, how they see DMH's role, what services the agency should provide and what its priorities should be.  

While all four groups voiced strong support for current school-based programs, three of the four groups listed them as a top priority and emphasized the critical need to expand them throughout the state.

• crisis episodes, such as suicide, which would be referred to mental health, are easily handled on site by a mental health counselor
     
• counselor is able to work with "problem students" daily if needed
    
• consultation services provided by counselor are viewed as beneficial and important to providing services to at-risk students
    
• counselors are able to share some information to school staff toward understanding the child's problems better, thus helping the school staff work better with child toward educational needs
    
• counselors are able to work with a student and family more often
    
• counselors are able to provide information within human service systems, which the schools were unable to access prior to school based services
    
• students and/or parents who were once viewed as a problem by the school staff are viewed as approachable and reachable, thus providing school staff with an avenue to meet the students' needs
    
• counselors provide information related to emotional and mental health issues more clearly to school staff
    
• counselors are viewed as additional staff in the school environment
    
• counselors help schools meet requirements of the state plan and IDEA Act

Families Like Mental Health Services in Schools Because . . .

• easy access to mental health clinical services
    
• frequent visits for child at school with counselor 
    
• transportation problems eliminated
    
• crisis episodes are easily handled at school
    
• family involvement more frequent by phone or in person at school
    
• length of time for services are decreased
    
• counselor intervenes in order to solve problems more effectively for child and family at school with teachers, administrators, etc.
    
• counselor is able to attend Student Assistant Team Meetings and Individual Educational Plan Meetings with parent at school
   
• counselor understands child's problems at school and has firsthand knowledge, allowing the counselor to help the parent and child with the problem more effectively
    
• counselor is able to work more effectively with school administrator when child is in "trouble"
    
• counselor is able to visit child and family in home as needed
    
• counselor is able to relay up to date clinical and medical information to the doctor as needed

Students Like Mental Health Services in Schools Because . . .

• stigma of going to see a counselor at a clinic is eliminated
    
• students enjoy talking with a counselor when the problem exists and obtaining problem solving interventions immediately
    
• students with school phobia, depression, delusions and paranoia find easy access to the counselor beneficial to normalize their school experience 
    
• students like attending groups sessions at school with their peers
    
• students feel safe attending rehabilitate psychological therapy activities with other students in their school