School-Based Services and Adolescent Health:
Past, Present, and Future

Reprinted from:
ADOLESCENT MEDICINE: State of the Art Reviews
Vol. 7, No. 2, June 1996

Published by:
Hanley & Belfus, Inc. (copyrighted) 1996
210 S. l3th St., Philadelphia, PA 19107 (215) 546-7293

From The George Washington University
School of Business and Public Management

The views expressed in this article are those of the author; endorsement by The Robert Wood Johnson Foundation is not intended and should not be inferred.

THE HISTORY OF SCHOOL HEALTH

Beginning of Health Care Practice in Schools

The beginnings of school health in the United States have become a familiar story. Toward the end of the nineteenth century, as school attendance became mandatory and large numbers of poor, foreign-born children enrolled in elementary schools, public health and school officials initiated student screenings to exclude from the classroom those with contagious diseases. These screening efforts were succeeded by the establishment of nursing and home visiting services to help families take care of problems found during medical screenings.

As early as the 1870s, the newly formed New York Public Health Department was vaccinating children in the public schools. When epidemics occurred, the Health Department undertook special immunization efforts in the schools. In 1894, after several epidemics had swept through its schools, Boston employed 50 physicians to screen children for signs of infectious disease. Within a few years, New York, Chicago, and Philadelphia had followed suit. By 1910, the Russell Sage Foundation could report that 337 city school systems had instituted some form of medical screenings.^5,12,31

These initial school health services were patterned after European practice. First emphasizing school sanitation and then focusing on contagion and identification of students' medical problems, the cities of Western Europe pioneered the recruitment of physicians, dentists, and oculists for school-based services. In the 1 890s, the German city of Wiesbaden inaugurated a school health service that became a model for the United States. The Wiesbaden system called for regular examinations of students, on school entry and every 3 years thereafter, and established an extensive student health record-keeping system. Students found to have health problems were referred to community physicians for treatment. By 1908, in Germany alone, 1500 physicians were providing medical services in more than 400 cities.^10,31

In the United States, state governments began to adopt measures mandating action by schools to protect the health status of children. In 1899, Connecticut required teachers to test students' eyesight every 3 years. Five years later, Vermont mandated that each student have annual examinations of ears, eyes, nose, and throat. By the end of World War I, almost every state had enacted legislation related to school health.^10,12

The content of school health in those early decades was fluid. Many cities and towns had introduced physician screenings and nursing services. Nurses not only assisted families in obtaining help for children who had been excluded from school, but also they provided a continuous health care presence in the schools. Larger cities, especially those with substantial immigrant populations, made additional medical, dental, and social services available at the schools. These supportive programs had the twin goals of caring for poor, particularly foreign-born, children and their families and meeting society's need to incorporate these children into American culture and community. As described by Sedlak and Schlossman,²⁷ the objective was "to attract such children to school and hold them as long as possible." Vacation schools, school lunches, visiting teachers (in contemporary terms, school social workers), dental clinics, and expanded school nursing all became part of the mix of services that might be found in a school during the first two decades of the twentieth century.

Despite this array of possibilities, in the decades that followed, school-based health care came to be defined primarily as a nursing service. The greatest expansion in school health employment occurred in school nursing. By 1911, 102 cities employed 415 school nurses; by 1923, 84 of 86 cities surveyed by the American Child Health Association reported that they had school nursing services.¹²

Between 1920 and 1970, the components of school health care that might have remedied identified problems largely disappeared. What happened to the medical services? Why was the benefit of early intervention ignored? What was the impediment to continued home visiting, expanded dental services, and psychosocial support? There was an alternative route for school-based health care, but for the next five decades those in charge of school health chose a different course.

The Road Not Taken

No sooner had the medical screening programs come into wide acceptance than they acquired their critics. Writing in 1913, Rapeer,²¹ who had carried out a study of school health programs in 25 American cities, noted:

Hoag and Terman,¹⁰ among the earliest and most noted authors on school health, argued that for school health to reach its full potential, the schools would have to take control of school health from local boards of health, expand school nursing, and establish medical clinics in schools. The boards of health, they believed, were preoccupied with the issue of contagion and insufficiently attentive to broader child health concerns. Nursing services would ensure home visiting and the education of parents on the proper care of their children. Medical clinics would provide treatment of problems revealed by routine inspections and offer preventive care as well. Hoag and Terman urged the inclusion of dental services, eye care, and psychological services. The benefits of a comprehensive service were obvious to Hoag and Terman: "By the old way (of organizing school health), everything had to be done with a maximum of inconvenience, resistance and leakage. The chief obstacle always was human inertia, the most characteristic trait of mankind. . . . The old system tried to persuade the parents to do something; the school clinic only asks their assent."¹⁰

To suggest that medical care be routinely provided to children through the schools was a giant leap, even with the diverse school health services that were developing in various U.S. cities. Hoag and Terman were particularly influenced by events in England. Although not early proponents of health care in schools, the English had been spurred to action by the national dismay occasioned by the rejection of half the con scripts for the Boer War on grounds of physical unfitness. That fact generated wide-spread support for the establishment of school health services and physical education programs. Parliament enacted the Education Act of 1907, which mandated medical inspections in all public elementary schools. This legislation, according to Hoag and Terman,¹⁰ became the foundation for a nationwide effort to establish school-based medical clinics.

The idea of free medical care in schools aroused some opposition in England but generated stronger, more effective hostility in the United States. Hoag and Terman¹⁰ noted that this opposition came from two sources: (1) those who argued that health supervision in schools infringes on the rights of home and family and (2) those who argued that school health was an unnecessary intrusion into the domain of private practice. Although it did not appear to be a significant barrier to the expansion of medical services, the parental rights issue did reflect the suspicions of immigrant families that Protestant-controlled schools intended to interfere with the parental rights of foreign-born, non-Protestant families. It was the latter argument, however, backed by the political power of the American Medical Association, that ultimately determined the future of school health services.

The Containment of School Health

The struggle to control medical practice in the United States dominated health care in the early decades of the twentieth century. Increasingly, private physicians successfully restricted the medical services that could be provided by public health agencies. School health was identified as a component of public health (although commonly administered by the boards of education), and public health was fighting a losing battle to engage in medical treatment. Medical sociologist Paul Starr noted that when the New York City Health Department hired a chief medical inspector and 150 part-time inspectors to make daily examinations of children suspected of being sick, the Health Department pledged that the inspectors would provide no medical service but would refer to family physicians, hospitals, or dispensaries. Reflecting the deeply felt opposition to medical services delivered by health departments, the Public Health Committee of the New York Academy of Medicine wrote to congratulate the Health Department's Bureau of Child Hygiene when it closed five special nose and throat clinics for school-children in 1915. "The functions of the Department of Health," the Committee declared, "should be restricted to the prevention of disease and no therapeutic activities should be undertaken."^6,12,29

By the 1920s, the separation of medical treatment from preventive health services was complete: Public health except in the most narrow circumstances would not provide medical care. Nationwide there was a general retreat from the reform agenda that had dominated the first two decades of the century. Health departments no longer led the fight to improve housing, sanitation, and nutrition for the poor as part of their mission to improve the public's health. According to the disappointed Progressives, public health had become politically cautious, limiting its agenda to health education, personal hygiene, and environmental health. School health followed suit.

Despite the remaining vestiges of medical treatment being swept from the schools, restorative dental work continued to be offered in school dental clinics. Dental services had been introduced in the schools almost simultaneously with school nursing. Officials in Reading, Pennsylvania, hired a dentist to examine schoolchildren's teeth in 1903. Within 10 years, Cleveland, Cincinnati, New York, and Philadelphia had launched dental programs, and in 1914, Bridgeport, Connecticut, had hired 10 dental hygienists to clean teeth.

Although not a universal practice, providing dental services to low-income school children was not uncommon. The Denver Public Schools ran a dental clinic for poor children from 1925 through 1971. Cleveland and New York offered dental care in schools through most of the twentieth century. Other school systems in New Mexico, Rhode Island, Michigan, Tennessee, Georgia, and Kentucky, at various points in time, offered comprehensive dental services, typically organized and staffed by local public health departments.^10,12,31

School Health Between 1920 and 1970

During this period of consolidation in the school health field, the content of school health was defined by three firmly held beliefs:

From 1920 to 1970, school health services, in addition to meeting state mandates concerning immunization documentation and other obligatory practices, focused on improving child health through case finding and referral to community physicians. The utility of this approach has been debated since the beginning of school health. As early as 1909, a medical officer for the London County Council commented:

One of the most severe critics of the link and refer approach was Lynch.¹⁵ Her often quoted remark that "There is no health in school health" reflected the view that school health had failed to keep up with changing needs of the school population. The decreased threat from contagious disease and the failure of traditional school health programs to secure treatment for children led her to conclude that too many school health programs were allocating their resources to the least productive activities. Although part of this discontent reflected the decades-old debate about the adequacy of medical follow-up to problems found during health screenings, the criticism was given new energy by increasing discussion concerning the wisdom of pediatricians spending the majority of their time conducting well-child examinations.³³

CHANGING ENVIRONMENT FOR SCHOOL HEALTH SERVICES

Although the evidence concerning the effectiveness of case finding and referral was in many cases contradictory, pressures to change school health programs began to mount in the 1960s and 1 970s. Increased documentation of the unmet health care needs of poor children, new legislation and court orders requiring schools to incorporate disabled children into the educational mainstream, and the beginning of a new wave of immigrant children increasingly brought demands for new additions to the menu of school health services.

The War on Poverty revived awareness of the needs of poor children. The demand for better schools and school reform brought new dollars to support health and social services for low-income children. Medicaid, which in 1966 provided health insurance coverage for many poor children, specified that insured services should include Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. This benefit created an opportunity, further down the road, to fund additional school health services. Most powerful of all, in 1975, the Education for the Handicapped Act created a legal requirement that schools provide health-related services to disabled students to reduce barriers to learning.

Social changes during this period were more sweeping but less beneficial. As documented in a seminal article by Fuchs and Reklis,⁸ cultural changes begun during the 1960s combined with deteriorating economic conditions for poor children in the 1980s to produce a decline in mental, physical, and emotional well-being. Rising divorce rates, increased unwed motherhood, reduced income available for children, and reduced time investments in children by adults conspired to place some children at particular risk for poor outcomes.

Although social circumstances created greater risks to the well-being of many children, within health care itself, new possibilities for improved children's services emerged. In the mid-1960s, training programs for nurse practitioners began. Launched at the University of Colorado, these programs offered registered nurses an additional year of training in physical examination, diagnosis, treatment, and patient management. By the 1990s, most nurse practitioner training programs were master's degree tracks that required a 4-year college degree as a prerequisite. Nurse practitioner training coupled with its recognition in the state nurse practice acts made possible the expansion of primary care services in schools. Services could be brought into the schools without incurring the higher costs associated with pediatricians or family physicians.

Innovative models for reorganized health services in schools began to appear. In Cambridge, Massachusetts, toward the end of the 1960s, Philip Porter, head of the Pediatrics Department at Cambridge Hospital and director of the Maternal and Child Health office at the city health department, combined his community-based and school-based child health services and opened a primary care medical clinic in Harrington Elementary School. The clinic was staffed by nurse practitioners. Four more clinics opened in Cambridge during the years that followed.²³ In Galveston, Texas, Mildred Williamson, coordinator of health services for the public schools, teamed up with pediatrician Philip Nader at the University of Texas Medical Branch to strengthen the quality of Galveston school health services. In 1976, many of those involved in rethinking the structure of school health services came together in Galveston for a National School Health Conference supported by The Robert Wood Johnson Foundation.⁴

With support from foundations as well as federal agencies, a number of new school health service models blossomed. Shortly after the Cambridge clinic opened, the Dallas Children and Youth Project, based at Parkland Memorial Hospital and funded by the federal Maternal and Child Health Bureau (MCHB), opened a comprehensive health center at Pinkston High School. A year later, the St. Paul, Minneapolis Maternal-Infant Care Program, also funded by MCHB, opened its first school-based health center at Mechanic Arts High School. Both clinics were staffed by nurse practitioners, physicians, and mental health professionals. A slightly different model using school-based nurse practitioners linked to community-based primary care physicians was replicated in four states with support from The Robert Wood Johnson Foundation.²² Family re source centers, programs for pregnant and parenting teens, and school-based mental health centers became new types of services provided through the schools.⁵

With major changes affecting the school and health care environment and creative ideas being tested in the provision of care to school-age children, the 1980s became a period of extraordinary ferment. School health became a concept in transition. New providers joined the school health team. Old issues such as funding, turf, and politics took on greater importance. Determining what should be done in schools, who should do it, and who would control it became pressing questions once more.

SCHOOL HEALTH APPROACHES THE END OF THE TWENTIETH CENTURY

As has been the case for the past hundred years, school health remains primarily a locally crafted, locally funded phenomenon. The federal and state government roles, however, have not been insignificant. Federal agencies have provided service standards for children with disabilities, helped pay for school health services to Medicaid-enrolled special education students, funded alcohol and drug abuse prevention education and services, and promoted a broader understanding of school health programs. Some federal grants have strengthened the capacity of traditional school health services through training and technical support; other initiatives have funded new models of services such as school-based health centers. State governments have established standards for school health services and provided funding to local school districts. A few states offer technical assistance and support to the development of local programs.

Federal Role

Until fairly recently, federal government involvement in school health focused on child feeding and health education programs. Although the feeding programs have been described as a component of school health programming, subsidized or free school lunches were mostly a response to child hunger rather than an effort to increase children's nutritional knowledge or encourage healthy eating habits. Many communities began to feed poor children at school shortly after the turn of the century. The federal government became involved with passage of the National School Lunch Program in 1946. The School Breakfast Program was added 30 years later. Shortly thereafter, federal school meal programs expanded to provide nutrition training for teachers and students. The 1994 School Health Policies and Programs survey supported by the Centers for Disease Control and Prevention (CDC) found that although slightly less than half the states require that school meals be offered during the day, nearly 90% of school districts participate in the National School Lunch Program and 57% participate in the School Breakfast Program.²⁰ The finding documents not only the widespread support for child feeding programs at the community level, but also the imperfect linkage between state mandates and local activities.

In the 1980s and 1990s, the threats of drugs, violence, and human immunodeficiency virus (HIV) infection inspired additional school-based service programs. In 1986, the Drug Free Schools and Community Act began federal support for drug education and treatment efforts in the schools. The 1994 reauthorization of Drug Free Schools expanded the scope of funded activities to include violence prevention measures. During the same period, the Division of Adolescent and School Health within the CDC (DASH-CDC) initiated a series of grant programs to assist state education agencies to strengthen health education programs to reduce tobacco use, increase physical activity, and reduce the spread of HIV and other sexually transmitted diseases among students.¹¹ The DASH-CDC initiatives that have supported both categorical and comprehensive school health education programs have been funded annually with nearly $50 million from the agency budget.

General school health services have received substantially fewer federal dollars. This reflects both the controversy concerning the proper scope of school health services and the disagreement over which federal office should have primary responsibility in school health. With no consensus on the definition of school health services and no lead agency, only a few small-scale service initiatives have taken place. The MCHB within the Department of Health and Human Services has supported the development of school nurse consultants at the state level and created a special grant program to train school-based health professionals in multi-disciplinary teaming. Additionally, the MCHB has encouraged state Maternal and Child Health offices to use their MCHB block grant funds to support school-based health centers. A 1994 national survey found that 25 states had allocated $12 million in MCHB block grant funds to the school-based centers during the 1994 fiscal year.²⁵ The Bureau of Primary Health Care, through its Healthy Schools/Healthy Communities initiative, has funded 28 school-based health centers to serve homeless children and children at risk of homelessness. Funding for this effort is approximately $5 million.

Through the federal-state partnership to fund Medicaid, the federal government has paid for the provision of certain health services to Medicaid beneficiaries by school-based health programs. As described subsequently, the federal government assists states in funding special education services. Some, but not all, state Medicaid pro grams reimburse school nurses and other school-based professionals for EPSDT services provided to Medicaid beneficiaries. All school districts must pay for health-related services for special education students, and to varying degrees states provide education funds to school districts that may be used for health-related services. A number of Medicaid programs also reimburse for some of these services.

Federal as well as state support for health care in schools increased dramatically through support for health-related services to students under the Education for the Handicapped Act and its successor legislation. Beginning with the Education for the Handicapped Act of 1975 and continuing with the Individuals with Disabilities Education Act of 1991, federal funding to states was authorized to ensure that children with certain specified disabilities receive free, appropriate education. Under the law, school districts must prepare an Individualized Education Program for each eligible child specifying all special education and related services needed. The school districts are obligated by federal statute and court rulings to provide these services. In addition to federal grant support for special education, Medicaid programs may pay for those related services that are specified in the federal Medicaid statute and determined to be medically necessary by the state Medicaid agency. Related services most commonly include speech therapy, physical and occupational therapy, and child counseling. The most costly related service is transportation.²⁴ Health services that must be available include speech pathology, audiology, psychological services, physical and occupational therapy, early identification and assessment of disabilities, counseling services, school health services, social work services in schools, and medical services for evaluation and diagnostic purposes.¹³

State Government Role

State efforts to support school health programs have focused on standard setting and funding. School health standards cover a range of issues, including environmental concerns, such as asbestos removal, fire safety, accessibility to the handicapped, food service conditions, and sanitary inspections; and health education programs, including requirements for classes, teacher credentials, and texts. State standards or mandates for health services typically address topics including staffing credentials, immunizations, health screenings, health records, HIV infection, and medication administration. As reflected in the School Health Policies and Programs Survey (Table 1), state requirements for screening services are anything but uniform. The most commonly required screen is for hearing problems; not quite two thirds of the states require hearing screenings. Nearly all districts require hearing and vision screening.

Although the administrative burden on school health professionals because of record-keeping requirements has been a concern, Table 2 suggests great variability among the states and the districts. Three fourths of all districts require records in only three areas: immunizations, medical emergency forms, and medical information forms. The contrast between state and district requirements underscores the preeminent role of local government in determining the content of school health.

State funding to support school health programs at the community level varies as widely as the mandates. Although most states support state-level personnel to provide a contact point for various aspects of school health, not all states assist localities in paying for school health activities. For example, in the field of health education, the American School Health Association reported in 1989 that 17 states helped fund health education at the local level, but the level of support ranged from $500 to $2 million. Eleven states provided funds for health services; the dollar amounts ranged from $3000 to $18 million.¹⁴ Additional funds for school health services are made available through state funding for special education through the state education dollars provided to local communities. As noted previously, the state Medicaid program may also reimburse providers for school-based services to its beneficiaries.

Local Government Role

School health services, indeed the entire school health program, are mostly deter mined by decisions at the district level. As a result, with no single state or federal authority responsible for financing or data collection, assembling a meaningful picture of what is happening locally in school health is difficult. Information on staffing, funding, and program priorities must be drawn from various overlapping sources. The resulting picture is at best impressionist, not photographic.

Although policy makers at the state and federal level continue to define school health services as school nurse services, substance abuse initiatives, services for special education students, and new efforts to provide primary care and mental health services in schools have transformed the content of school health care. Data from New York City suggest the dramatic changes. In Fiscal Year 1992, the New York City Department of Health, the official provider of school health services, budgeted $8.8 million for school health services. In the same year, the city Department of Mental Health, Mental Retardation and Alcoholism Services spent $5.6 million on school-based mental health services. Two years earlier (the most recent data available at the time), the New York City Public Schools spent $41.7 million on health education and related services and $65.9 million for therapeutic services for special education students.¹⁶ In terms of re source utilization, the health-related services provided to special education students represent the lion's share of health care in schools.

Another picture of school health services emerges from the CDC School Health Policies and Programs Survey of physical health services provided in middle/junior high and senior high schools.²⁸ According to a representative sample of secondary schools, although 86% of middle/junior and senior high schools reported offering some type of health services such as first aid or medication administration, only 66% reported having a health service facility. Among those schools with health service facilities, 92% have a health room, 8% have a school-based health center, 6% have a school wellness center, and 2% have a school-linked clinic. About half of the schools with health facilities have a registered nurse on staff. Nearly 80% of all middle/junior high and senior high schools identify having other health professionals on staff. Fifty-six percent of the schools report the presence of hearing technicians; 39% report vision technicians; 35% report occupational therapists, and 31% report physicians. Mental health professionals were not included in the survey.²⁸

Tables 3 and 4 document the variety of health-related and social services provided at the middle/junior high and senior high schools. Nearly 90 percent of schools offer individual counseling, 60 percent offer group counseling, and 46% offer pregnancy management as well as family counseling. Social support services are less common but still impressive in their variety and numbers.

A review of available data on school-based health professionals underscores the diversity of the school health services team.

SCHOOL NURSES

According to best estimates, approximately 40,000 registered nurses are working in the 82,000 public schools in the United States with credentials ranging from licensed practical nursing to master's-prepared nurse specialists.¹⁸ Depending on the state and school district, school nurse responsibilities include documenting immunization status; conducting screening programs; administering medications; providing first aid and emergency care; and participating in the care of disabled students, particularly those requiring complex nursing care.

SCHOOL PSYCHOLOGISTS

School psychologists are reported to number between 20,000 and 22,000. According to a 1984 survey, 17% of these have masters degrees, 67% have a master's degree plus additional training, and 16% have a doctorate in psychology.⁷ The training of the school psychologists varies widely, ranging from educational testing and assessment to extensive hours in supervised clinical evaluation and treatment of children. Demand for school psychologists exploded with the expansion of special education programs. By the 1993-1994 school year, more than 4.8 million children ages 6 and older were enrolled in special education, and each of them required individual assessments.²⁶ Slightly more than half the time of school psychologists is spent in psychoeducational assessment. Consultation, primarily with education staff, occupies about 20% of the time, and a little more than 20% of the time is spent in counseling and remedial interventions.⁷

GUIDANCE COUNSELORS

Guidance counselors, reported to number 81,000 in 1990, provide educational and vocational assistance to students but increasingly provide psychological counseling as well.¹⁹ No firm estimates are available to distinguish between the amount of time devoted to counseling and to educational guidance. Nonetheless, a conservative estimate of 25% of time dedicated to psychosocial support of students constitutes a full-time equivalent of more than 20,000 counselors. Guidance counselors are primarily master's prepared. Forty-two states require a master's degree for certification as a guidance counselor. Three states require a bachelor's degree plus a minimum of 24 graduate hours, and five states require only a bachelor's degree. Thirty-six states re quire both a supervised internship and teacher certification to qualify as a counselor.¹⁴ According to the American School Counselor Association, elementary school counselors consult with teachers and parents to help them design interventions that support the personal development of students, work with students with handicaps and develop mental delays, and provide educational and career counseling to students in the upper grades. Middle or junior high school counselors as well as senior high school counselors assist students with the transition to adolescence and continue to work with those who experience developmental difficulties and school adjustment problems. These counselors generally provide more vocational and educational guidance than developmental support.

SOCIAL WORKERS

In 1993, data from the National Association of Social Work and the state associations of social workers indicated that there might be as many as 12,000 school social workers.¹ A 1976 survey identified 4,500 school social workers, most of whose time was spent in providing direct services to individual students and their families.² Although individual case work remains a major component of school social workers' responsibilities, group work, consultation with teachers, and other professional tasks involve increasing amounts of time.

Three Perspectives on School Health at the End of the Twentieth Century

Societal concerns for more effective schools, family-centered programs, and strengthened health services for adolescents have stirred rethinking about health and social services in the schools. Rooted in the experiences of the twentieth century, three distinct visions of school-based services have emerged as strategies to secure children's well-being. These strategies can be termed the services integration approach, the comprehensive school health program approach, and the school-based health center approach. As indicated by Figure 1, these visions are championed by different disciplines and government agencies, have identified different issues as central problems to be ad dressed, and draw on different aspects of the school health tradition.

SERVICES INTEGRATION

Services integration is not a concept unique to school health. For at least 25 years, human services organizations and those that fund them have struggled to pull together the separate organizations that serve the poor. During the 1980s, a growing body of opinion, lodged particularly in the education and social services sectors, called for greater use of schools in poor communities to serve as linking points that would "integrate" the variety of social services needed and used by low-income families.¹⁷ Drawing on the Progressive vision that sought to integrate schooling, social services, and health care, services integration initiatives are targeted to low-income children and their families and reflect a desire both to create more effective schooling in poor neighborhoods and to weave a stronger social safety net for at-risk children.

Operationally, services integration programs reflect a belief that poor children, who experience more school failure and less academic achievement than their richer peers, would benefit from easier access to the helping services designed to reduce the consequences of poverty. The goal of one-stop shopping for family support services is common to services integration projects. Generally, health services have not been a major component of this strategy. Health care, especially that which is corrective, is se cured primarily by referral from the school nurse. As described by the American Academy of Pediatrics guide, School Health: Policy and Practice,³ "the reason that many school health programs have not been able to help each child overcome any health factors that might impede their success in school has been the lack of linkages between the school and a regular source of health care for the child." For the most part, the services integration approach seeks to strengthen the link and refer model by em bedding the health component in a larger social service-linked strategy. Note, however, that the Beacon Schools or Full-Service Schools described by Dryfoos⁵ represent a services integration strategy that has been linked with a school-based health center. In these instances, the services integration efforts bring comprehensive physical and mental health services into the schools.

Two of the most frequently cited services integration or community collaborative initiatives are the Walbridge Caring Communities in St. Louis and New Beginnings in San Diego. In both instances, the initiatives are based in an elementary school and rooted in the notion that "children live in families; families live in communities; there fore, to help children, one must help families and communities."¹⁷

The goal of the Walbridge program included keeping children in school, increasing their academic success, and reducing both foster home placements and children's contacts with juvenile justice. The resultant program included a range of before and after school programs, a youth center for Friday evening, intensive services for troubled families, case management, substance abuse counseling for families, day treatment for emotionally disturbed children, and health services ranging from "first aid to transportation to treatment facilities."¹⁷

New Beginnings, a collaborative effort based at Hamilton Elementary School in San Diego, brought together the San Diego City Schools, the San Diego Community College District, the city of San Diego, the county of San Diego, the San Diego School of Medicine, San Diego's Children's Hospital and Health Center, and the IBM Corporation. Some partners put in money; some put in services. The result is a multiservice center based in several portable classrooms on the Hamilton campus that houses staff to provide direct services such as immunizations and counseling as well as to provide linkages to other human services. Although health screenings take place in the campus-based facility, primary care is provided off-site.

COMPREHENSIVE SCHOOL HEALTH PROGRAMS

Over the past decade, the DASH-CDC has elaborated on the three basic components of school health (health education, healthful environment, and health services) to focus on ways the traditional health program can strengthen its health-promoting effectiveness. Similar to the early school health programs, the comprehensive school health approach is mostly based in education and seeks to preserve and protect the health pro motion and education linkages that have been developed through decades of school health program development. The comprehensive school health model and its eight components (health education, health services, social and physical environment, physical education, guidance and support services, food service, school and worksite health promotion, and integrated school and community health promotion) are described at length by Vernon and Wooley elsewhere in this issue.

In contrast to the services integration strategies, which focus on low-income communities, the target for comprehensive school health programs is all school-age children. The goal of comprehensive school health programs is to promote student health through implementation of a K-12 health education curriculum, enhanced collaboration between health and education systems, and strengthened school nursing with better referral systems for medical and mental health problems. Health services to be provided in the schools are generally described as including emergency care and first aid, health appraisal through periodic examinations, immunizations, screening and communicable disease procedures, medication administration, oral examinations, nutritional assessments, counseling, health-related services for special education students, and substance abuse programs.

Grants made by DASH to local health departments, national health and education organizations, state and local education agencies, individual researchers, and universities support the development of school health education programs, strengthen education and health agency involvement in school health programs, and raise the saliency of school health.

SCHOOL-BASED HEALTH CENTERS

School-based health centers, although not equivalent to a school health program, have become a rallying point for those who have been dissatisfied with the practice limitations of traditional school health services. Supporters of this vision are primarily health care providers, including school nurses and other health professionals, who worry about the inadequacy of community-based health services for adolescents in particular and for poor schoolchildren of all ages.

The school health centers blend medical care with preventive and psychosocial services as well as organize broader school-based and community-based health promotion efforts. Recognizing that the centers vary from school to school and community to community, the organization of school-based health centers is typified by the health center at Blackham Elementary and Middle School in Bridgeport, Connecticut. That health center serves an ethnically diverse mix of the very poor, poor, and the simply poorly insured. The health team includes a full-time nurse practitioner, clinical social worker, health aide, and outreach worker. In addition, the health team is joined by a dentist. The volume of dental work in the city's four school-based dental suites is such that a full-time dentist stays busy spending a day a week at each school health center and allocates the fifth day to the school with the longest waiting list.

When asked to compare her elementary school and high school health centers, the clinic director notes that for about 75% of the care, the content--acute care, care for chronic conditions, and mental health--is relatively similar. The elementary school program, however, is distinguished by an outreach worker who has been hired to make home visits and to assist families secure social services. The vision of Hoag and Terman at the beginning of the twentieth century has been reborn in the efforts of school-based health centers at the end of the century.

RETHINKING SCHOOL HEALTH

One of the striking aspects of all three approaches to rethinking school health is that none of them takes into account the changes that have occurred in individual schools over the last 20 years. There is vast ignorance about the health services currently provided in the schools. As previously noted, no single agency pays for or tracks what is happening. School health services are funded by public health departments, Medicaid, local school systems, state agencies, federal grants, private grants, and combinations of the aforementioned. Some school health providers may be members of the school faculty (school nurse teachers); others are public health employees who may be responsible for several schools and may rarely have time to attend faculty meetings or meet with individual faculty. Special education staff, even if they are health professionals, may report to an entirely different school division than other health-related staff. Nurse practitioners, physicians, physician assistants, and substance abuse staff may work for the school system, the public health department, or any one of a number of community-based health care organizations. Mental health professionals, working as part of a comprehensive school-based health center staff, may be employed by still other community-based organizations.

Intensifying the consequences of these Balkanized arrangements is the absence of a collaborative tradition in school health. The traditional school emphasis on professionals working independently within their own classrooms accentuates the difficulty.

Three developments in the mid-1990s have created an opportunity for not only exploring the expansion of school-based services, but also fostering coordination and integration of already established services. These developments include the emergence of managed care as a way of organizing and paying for health services, the movement of Medicaid beneficiaries into managed care plans, and proposed government health care reforms.

With the growing importance of Medicaid in helping to subsidize school nursing services and health-related services to special education students, health care financing reform has become critically important to some school health programs. The survival of many community programs depends on the ability of those communities to link their services with managed care plans. Others see not the dissolution of their school health programs, but the opportunity in the new environment to relate what is being done in the school to what is occurring in community-based health care. They also see the opportunity to link all the pieces of what is being done within the school, attempting to create for the first time a truly integrated school health program.

In June 1994, a group of experts in school health, health care financing, public health, and primary care was brought together by the Departments of Education and Health and Human Services to consider the implications of health care reform for school-based health services. The resulting report by the School Health Services Analytic Project Panel reviewed health service delivery in schools and suggested possible impacts of the proposed Clinton reforms on these services as well as some consequences of managed care. For reasons unknown, the report was not publicly distributed. It deserves widespread dissemination and discussion. Its primary recommendation provides a clear statement on a desirable first step in rethinking school health services. The report notes the great diversity of professionals, purposes, and funding involved in school-based health care. The report argues that representatives of all these health services, from primary care to specialized services for children with disabilities, must come together and form a single cohesive strategy. School health services must respond to the identified needs of children in the community, and they must do so in an organized approach that builds on carefully developed ties to community-based services as well as fully integrated partnerships among those who provide care within the school setting. Only in that way can school-based health services play an effective role in the future child health care in the United States.

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