A School Mental Health Program: Development and Design William C. Adamson, M.D.
ABSTRACT:This paper describes the development of an educationalclinical mental health team model that has been effective on all levels of a medium-sized public school system, from the grass roots of classroom teacher to the administrative offices of principal, school superintendent, and school board members. Essentially the program served to reinforce the generic role of teachers in the classroom with a team-oriented opinion. While the team approach often served to reinforce what was already taking place in the classroom, it also helped to make such classroom experiences both more psychologically intelligible and more consistently constructive within an ego-building frame of reference. This decade of the z96o's has seen an increasing interest in the planning of community mental health and mental retardation programs to meet the social, emotional and educational needs of the individual learner in the classroom. Recent Congressional legislation to provide funds for community mental health facilities will continue to stimulate interest in this worthwhile effort on a national, state and local level. This paper highlights the experience of the school district of Cheltenham Township, Pennsylvania, in developing a mental health team-approach for its students. The role of a child psychiatrist as consultant in establishing such a program is also described. SOME BASIC PRINCIPLES In reviewing the program which was begun in z96o it was felt that several points served as guiding principles in setting up the program for a medium-sized public school system. These basic principles included the following: 5. Concept of support from the top administrative level. a. Building on existing clinical and guidance programs. Dr. Adamson is Director of Clinical Services of The Pathway School, leffersonville, Pennsylvania. This manuscript was prepared in collaboration with Dr. Ross M. Gill, recently retired Superintendent of Schools; M~ss Ruth Trevorrow, School Psychologist; Dr. Catherine Geary, Coordinator of Elementary Education; Mrs. Frances Link, Coordinator of Secondary Education; and Richard N. Smith, M.D., of the School District of CheItenham Township, Elkins Park, Pennsylvania. Community Mental Health Journal, Vol. 4 (6), 1968
454
William C. Adamson
455
3. Encouragement of mutual recognition and respect of multidisciplinary training and function. 4. Establishment of mutual responsibility within the mental health team.
This paper briefly describes these principles in action. It illustrates how these principles evolved through an administrative process: from notions to proposals, proposals to policies, policies to practices, and practices to total participation of all the schools and classrooms in the entire township public school system. SUPPORT FROM THE TOP Nine years ago the focus on preventive mental health as part of the educational process was initiated by the central administrative staff of the township school system. Monthly half-day meetings were planned with Dr. Meyer Sonis, now Director of the Pittsburgh Child Guidance Clinic, for discussion of relevant topics and case studies. In these administrative staff meetings, ways were explored to improve the understanding of emotional factors that interfere with the normal learning process. After a successful year of orientation, a part-time mental health consultant was appointed to assist in the development of an educational-clinical mental health team to augment the existing mental health services. The superintendent of schools and the township school board made a significant administrative decision at that time. They approved a plan for an administrative seminar for all of the key administrative staff of the Township schools. This monthly seminar induded the superintendent of schools, all the principals and guidance counselors in the Township. The agenda was planned by the coordinators of elementary and secondary education, the school clinical psychologist, and the newly appointed mental health consultant. This plan of action was a departure from the traditional role of the consultant child psychiatrist to a school system. Most often he is immediately deployed to "evaluate" scores of troubled children who are in emotional conflict with their puzzled teachers and/or parents. The foresight of the superintendent of schools and members of the school board in providing seminars during the school year in which to plan the long-range development of a mental health team-approach was somewhat unique at that time. It set the mental health program on a firm foundation. In these monthly discussions several important pillars of administrative support were defined, agreed upon by the total administrative staff, and became the foundation on which the long-range program was established. Thus, support from the top was evident at the outset of the program and has continued to be a guiding first principle. BUILDING ON EXISTING PROGRAMS In the administrative seminar a second basic principle was developed: to build on the existing educational, clinical and guidance
456
Community Mental Health Journal
department programs. The mental health consultant worked dosely with the full-time school psychologist who had been, and has continued to be, the mainspring of the program. School principals and guidance counselors worked dosely with the individual teachers in relationship to this program. (For example, all topics and cases for discussion in subsequent conferences came from the classroom teachers and principals.) The coordinators of elementary and secondary education served as regulators of the content and methods of presentation in the program. The child psychiatrist-mental health consultant's role was to bring greater understanding and clarity to the issues at hand. At times new ideas and new observations were made, but more often the consultant child psychiatrist identified the psychological variables and encouraged teachers to function in their generic role as classroom teacher. Throughout the nine years' experience the superintendent of schools remained the key administrator for the educational-clinical mental health services. MUTUAL RECOGNITION AND RESPECT The third guiding principle, that of mutual recognition of and respect for the generic functions of teacher, school psychologist, guidance counselor and mental health consultant, was also developed in the administrative seminar. There was general agreement among all participants in the program that the primary function of the school was education. In developing these services, no attempt was made to create a psychiatric treatment center. Nor were we attempting to make counselors, psychologists or psychiatrists out of our teachers. We wanted teachers to be teachers first. The primary goal was to provide a n educational-dinical team service that should make the teaching function both more enjoyable and more productive. The service, therefore, was primarily preventative rather than therapeutic in the limited sense of the word. In the broader sense, however, skillful involvement of principals and teachers served to encourage a positive learning climate in the dassroom and a healthy teacher-student relationship at all levels of student growth and development. The school nurse and other supportive staff, such as the remedial reading teacher, speech therapist and dental hygienist were also induded in our educational-clinical mental health team model. School principals were quick to see the importance of these professional people in the total effort, and they were included in the program in the second year. The role of the child psychiatrist-mental health consultant was defined in three areas: z. To aid in identifying learning problems as early as possible; and to participate as a member of the total team in helping students and teachers overcome these problems. a. To serve as a resource person in defining and describing the nature of emotional problems in students who came to the attention of this ser-
William C. Adamson
457
vice; and to determine the degree and the limits of the school's responsibility in helping these students (i.e., were we dealing with a schoolcentered or family-centered problem?). 3. To serve as liaison between the school, the interested parents, and the community resources, such as the heahh and welfare agencies, the physicians, clergymen, psychologists and psychiatrists. From this beginning, two cardinal rules became the watchword for all subsequent team action: first, respect for the confidentiality of information with which we were working, and secondly, parents were not to be blamed for the problems encountered. Rather, parents were to be viewed as the key to understanding and helping the troubled children with whom we worked. Mutual respect for one another and the job we were doing together also grew up between the staff. Such mutual respect was present at the outset, but it was encased in the traditional suspicious feelings about psychiatrists and the natural prestige-struggle that exists between professional disciplines. It was the early involvement of the superintendent of schools and the foresighted administrative seminar that offset this seed of doubt and nurtured the seed of mutual trust and respect. In our teacher conferences and larger workshops the initial emphasis was on recognizing the tools and insights of individual psychology with respect to (a) the teacher-student relationship in the classroom and (b) the emotional spill-over from known psychological forces and factors in the parentchild relationship at home. Consideration of the social and emotional growth of the individual student within the process of group dynamics and a classroom milieu grew out of this initial flame of reference. The growth of mutual respect for one another led to a wide variety of methods in working together. First, emphasis was on working with individual cases with small groups of teachers in an inservice program of mental health, the content of which was of case study type. Every school in the Township had two mental health conferences during that year, one at the beginning and one near the end of the year. The following year groups of teachers from the same grade participated in small study groups on similar or associated learning and behavior problems. In one junior high school the entire staff conducted a special study of the emotional and instructional needs of the slower-learning pupil. In the third year what later were referred to as mental health "warm-up sessions" were inaugurated. These consisted of group meetings before school classes began in the fall, with all teachers from kindergarten to second grade in one group, another group third through sixth grades, the junior high school group, and the senior high school group rounding out the picture. In these meetings the purpose of the educational-clinical mental health team was defined and specific material was presented by the mental health team to illustrate the nature of learning difficulties and some of the ways of dealing with them at all age levels in the child's school-life.
458
Community Mental Health Journal
Far from being on the sidelines, parents gave early impetus to the program by their continued expression of interest and inquiry. The concept and nature of the educational-clinical mental health team service was presented to PTA groups throughout the township school district. ESTABLISHMENT OF MUTUAL RESPONSIBILITY Our final principle, the establishment of mutual responsibility, was the ferment that kept the program vital and effective. In the Cheltenham program, responsibility continues to rise from the grass roots level, from teacher interest and concern. There has been no formula imposed from above. All topics for discussion have come from teachers and princcipals. The topic headings have been both extensive and intensive (see Table I). It has been through the establishment of such mutual responsibility that a significant depth and scope of effectiveness has been achieved.
TABLE x
Topics Suggested for Mental Health Sessions, School District of Cheltenham Township, ~963-x 964 Overall Expectancies for Children with Delayed Development Programming to influence their development by a. partial departmentalizafion b. small group learning c. homogeneous grouping on basis of performance (allowing for variations in abilities and personality, and with an effort to create positive community reaction to such grouping) Anxiety Symptoms as a Behavior Pattern in Coping with Learning and Other School Expectancies Mental Health Implications in Heterogeneous, Homogeneous and Academically Advanced Groupings Effect of Adoption on Developmental Growth and Learning Process Cultural Differences in Student Population and Expectancies Special Study of ~9 Homogeneously Grouped Children of Moderate to Severe Delayed Readiness for Instruction in First Grade Investigation of Factors Common to Prolonged Learning Difficulties from Kindergarten to Third Grade Personal and Social Adjustment Problems of Eighth Grade Girls (Normal Expectancie s, both Personal and Social) Understanding and Improving School Attitude of Ninth Grade Students Severe School Adjustment Problems in Seventh and Eighth Grade Students (Studied in group sessions with teachers) Poor Performance in Bright Adolescent Boys (Became an ongoing research project at secondary school level)
William C. Adamson
459
SCOPE AND EFFECTIVENESS Some of the statistics that serve to define the scope of this program (Table 2) were impressive. Such extensive coverage and follow-up were made possible by the extensive effort of the school psychologist in organizing the topics, case folders, case discussions, and follow-up data from all the team members.
TABLE 2 Scope of Educational-Clinical Team Services, School District of CheItenham Township, I963-I964 Actual Contacts
Teachers in conferences Teachers in workshops Kindergarten through 4th grade Junior-Senior High Schools
xx2 79 xxa
Total Teacher Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Students--individual case study in detail Special project study Total Student Involvement . . . . . . . . . . . . . . . . .
303
x34 38 ...........
x7z
Parents
7
Follow-Up, Definitive Action
Students--Individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
Estimated Time in Program for Mental Health Consultant
Total psychiatrist's time in one school year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9~ hours
In general it appears that 5 ~ percent of our total school population are never "seen" or discussed by this team service. Of the remaining 5o percent who may come to the team's attention during their growing years in the school system, the breakdown might be as follows: one-third viewed as transitional or situational problems; one-third behavioral or reaction problems largely in the area of discipline and classroom management (primarily male population); and one-third neurotic adjustment problems. In this last group, at least 5o percent (or roughly 8 to zo percent of the total school population) have long-standing internalized emotional problems, which cannot be modified by our school educational-clinic team approach. These family-centered problems require referral to professional persons and mental health centers in the community. Skillful and responsible referral processes from the school program to these community resources are constantly being developed.
460
Community Mental Health Journal
Speaking on this point of responsible referral to community resources, the Superintendent of Schools made this observation: The specific help which the Mental Health Consultant was able to bring to the teachers by having particular students referred to the proper agency or private psychiatrist was a very important part of this program. Over and over again I heard teachers say, in effect, that once the Mental Health Consultant got in on a case something would happen. I think much too often educators tend to taIk about problems but don't really bring relief to the classroom teacher who is dealing daily with a difficult child. When the Consultant was able to point out to parents, doctors and other professional resources in the community that a certain area was not for school concern, we knew the Consultant was right in offering insulation and protection. On the other hand, when the Consultant in a conference would say, "I will call Doctor so and so to enlist his support," we knew the Consultant was mobilizing action which classroom teachers were not in a position to accomplish . . . . . Of course not all students improved as we would have wished, but the fact that teachers were being supported and helped in dealing with students who needed such help causes everyone to continue to support our Mental Health Program.
ABSTRACT:This paper describes the development of an educationalclinical mental health team model that has been effective on all levels of a medium-sized public school system, from the grass roots of classroom teacher to the administrative offices of principal, school superintendent, and school board members. Essentially the program served to reinforce the generic role of teachers in the classroom with a team-oriented opinion. While the team approach often served to reinforce what was already taking place in the classroom, it also helped to make such classroom experiences both more psychologically intelligible and more consistently constructive within an ego-building frame of reference. This decade of the z96o's has seen an increasing interest in the planning of community mental health and mental retardation programs to meet the social, emotional and educational needs of the individual learner in the classroom. Recent Congressional legislation to provide funds for community mental health facilities will continue to stimulate interest in this worthwhile effort on a national, state and local level. This paper highlights the experience of the school district of Cheltenham Township, Pennsylvania, in developing a mental health team-approach for its students. The role of a child psychiatrist as consultant in establishing such a program is also described. SOME BASIC PRINCIPLES In reviewing the program which was begun in z96o it was felt that several points served as guiding principles in setting up the program for a medium-sized public school system. These basic principles included the following: 5. Concept of support from the top administrative level. a. Building on existing clinical and guidance programs. Dr. Adamson is Director of Clinical Services of The Pathway School, leffersonville, Pennsylvania. This manuscript was prepared in collaboration with Dr. Ross M. Gill, recently retired Superintendent of Schools; M~ss Ruth Trevorrow, School Psychologist; Dr. Catherine Geary, Coordinator of Elementary Education; Mrs. Frances Link, Coordinator of Secondary Education; and Richard N. Smith, M.D., of the School District of CheItenham Township, Elkins Park, Pennsylvania. Community Mental Health Journal, Vol. 4 (6), 1968
454
William C. Adamson
455
3. Encouragement of mutual recognition and respect of multidisciplinary training and function. 4. Establishment of mutual responsibility within the mental health team.
This paper briefly describes these principles in action. It illustrates how these principles evolved through an administrative process: from notions to proposals, proposals to policies, policies to practices, and practices to total participation of all the schools and classrooms in the entire township public school system. SUPPORT FROM THE TOP Nine years ago the focus on preventive mental health as part of the educational process was initiated by the central administrative staff of the township school system. Monthly half-day meetings were planned with Dr. Meyer Sonis, now Director of the Pittsburgh Child Guidance Clinic, for discussion of relevant topics and case studies. In these administrative staff meetings, ways were explored to improve the understanding of emotional factors that interfere with the normal learning process. After a successful year of orientation, a part-time mental health consultant was appointed to assist in the development of an educational-clinical mental health team to augment the existing mental health services. The superintendent of schools and the township school board made a significant administrative decision at that time. They approved a plan for an administrative seminar for all of the key administrative staff of the Township schools. This monthly seminar induded the superintendent of schools, all the principals and guidance counselors in the Township. The agenda was planned by the coordinators of elementary and secondary education, the school clinical psychologist, and the newly appointed mental health consultant. This plan of action was a departure from the traditional role of the consultant child psychiatrist to a school system. Most often he is immediately deployed to "evaluate" scores of troubled children who are in emotional conflict with their puzzled teachers and/or parents. The foresight of the superintendent of schools and members of the school board in providing seminars during the school year in which to plan the long-range development of a mental health team-approach was somewhat unique at that time. It set the mental health program on a firm foundation. In these monthly discussions several important pillars of administrative support were defined, agreed upon by the total administrative staff, and became the foundation on which the long-range program was established. Thus, support from the top was evident at the outset of the program and has continued to be a guiding first principle. BUILDING ON EXISTING PROGRAMS In the administrative seminar a second basic principle was developed: to build on the existing educational, clinical and guidance
456
Community Mental Health Journal
department programs. The mental health consultant worked dosely with the full-time school psychologist who had been, and has continued to be, the mainspring of the program. School principals and guidance counselors worked dosely with the individual teachers in relationship to this program. (For example, all topics and cases for discussion in subsequent conferences came from the classroom teachers and principals.) The coordinators of elementary and secondary education served as regulators of the content and methods of presentation in the program. The child psychiatrist-mental health consultant's role was to bring greater understanding and clarity to the issues at hand. At times new ideas and new observations were made, but more often the consultant child psychiatrist identified the psychological variables and encouraged teachers to function in their generic role as classroom teacher. Throughout the nine years' experience the superintendent of schools remained the key administrator for the educational-clinical mental health services. MUTUAL RECOGNITION AND RESPECT The third guiding principle, that of mutual recognition of and respect for the generic functions of teacher, school psychologist, guidance counselor and mental health consultant, was also developed in the administrative seminar. There was general agreement among all participants in the program that the primary function of the school was education. In developing these services, no attempt was made to create a psychiatric treatment center. Nor were we attempting to make counselors, psychologists or psychiatrists out of our teachers. We wanted teachers to be teachers first. The primary goal was to provide a n educational-dinical team service that should make the teaching function both more enjoyable and more productive. The service, therefore, was primarily preventative rather than therapeutic in the limited sense of the word. In the broader sense, however, skillful involvement of principals and teachers served to encourage a positive learning climate in the dassroom and a healthy teacher-student relationship at all levels of student growth and development. The school nurse and other supportive staff, such as the remedial reading teacher, speech therapist and dental hygienist were also induded in our educational-clinical mental health team model. School principals were quick to see the importance of these professional people in the total effort, and they were included in the program in the second year. The role of the child psychiatrist-mental health consultant was defined in three areas: z. To aid in identifying learning problems as early as possible; and to participate as a member of the total team in helping students and teachers overcome these problems. a. To serve as a resource person in defining and describing the nature of emotional problems in students who came to the attention of this ser-
William C. Adamson
457
vice; and to determine the degree and the limits of the school's responsibility in helping these students (i.e., were we dealing with a schoolcentered or family-centered problem?). 3. To serve as liaison between the school, the interested parents, and the community resources, such as the heahh and welfare agencies, the physicians, clergymen, psychologists and psychiatrists. From this beginning, two cardinal rules became the watchword for all subsequent team action: first, respect for the confidentiality of information with which we were working, and secondly, parents were not to be blamed for the problems encountered. Rather, parents were to be viewed as the key to understanding and helping the troubled children with whom we worked. Mutual respect for one another and the job we were doing together also grew up between the staff. Such mutual respect was present at the outset, but it was encased in the traditional suspicious feelings about psychiatrists and the natural prestige-struggle that exists between professional disciplines. It was the early involvement of the superintendent of schools and the foresighted administrative seminar that offset this seed of doubt and nurtured the seed of mutual trust and respect. In our teacher conferences and larger workshops the initial emphasis was on recognizing the tools and insights of individual psychology with respect to (a) the teacher-student relationship in the classroom and (b) the emotional spill-over from known psychological forces and factors in the parentchild relationship at home. Consideration of the social and emotional growth of the individual student within the process of group dynamics and a classroom milieu grew out of this initial flame of reference. The growth of mutual respect for one another led to a wide variety of methods in working together. First, emphasis was on working with individual cases with small groups of teachers in an inservice program of mental health, the content of which was of case study type. Every school in the Township had two mental health conferences during that year, one at the beginning and one near the end of the year. The following year groups of teachers from the same grade participated in small study groups on similar or associated learning and behavior problems. In one junior high school the entire staff conducted a special study of the emotional and instructional needs of the slower-learning pupil. In the third year what later were referred to as mental health "warm-up sessions" were inaugurated. These consisted of group meetings before school classes began in the fall, with all teachers from kindergarten to second grade in one group, another group third through sixth grades, the junior high school group, and the senior high school group rounding out the picture. In these meetings the purpose of the educational-clinical mental health team was defined and specific material was presented by the mental health team to illustrate the nature of learning difficulties and some of the ways of dealing with them at all age levels in the child's school-life.
458
Community Mental Health Journal
Far from being on the sidelines, parents gave early impetus to the program by their continued expression of interest and inquiry. The concept and nature of the educational-clinical mental health team service was presented to PTA groups throughout the township school district. ESTABLISHMENT OF MUTUAL RESPONSIBILITY Our final principle, the establishment of mutual responsibility, was the ferment that kept the program vital and effective. In the Cheltenham program, responsibility continues to rise from the grass roots level, from teacher interest and concern. There has been no formula imposed from above. All topics for discussion have come from teachers and princcipals. The topic headings have been both extensive and intensive (see Table I). It has been through the establishment of such mutual responsibility that a significant depth and scope of effectiveness has been achieved.
TABLE x
Topics Suggested for Mental Health Sessions, School District of Cheltenham Township, ~963-x 964 Overall Expectancies for Children with Delayed Development Programming to influence their development by a. partial departmentalizafion b. small group learning c. homogeneous grouping on basis of performance (allowing for variations in abilities and personality, and with an effort to create positive community reaction to such grouping) Anxiety Symptoms as a Behavior Pattern in Coping with Learning and Other School Expectancies Mental Health Implications in Heterogeneous, Homogeneous and Academically Advanced Groupings Effect of Adoption on Developmental Growth and Learning Process Cultural Differences in Student Population and Expectancies Special Study of ~9 Homogeneously Grouped Children of Moderate to Severe Delayed Readiness for Instruction in First Grade Investigation of Factors Common to Prolonged Learning Difficulties from Kindergarten to Third Grade Personal and Social Adjustment Problems of Eighth Grade Girls (Normal Expectancie s, both Personal and Social) Understanding and Improving School Attitude of Ninth Grade Students Severe School Adjustment Problems in Seventh and Eighth Grade Students (Studied in group sessions with teachers) Poor Performance in Bright Adolescent Boys (Became an ongoing research project at secondary school level)
William C. Adamson
459
SCOPE AND EFFECTIVENESS Some of the statistics that serve to define the scope of this program (Table 2) were impressive. Such extensive coverage and follow-up were made possible by the extensive effort of the school psychologist in organizing the topics, case folders, case discussions, and follow-up data from all the team members.
TABLE 2 Scope of Educational-Clinical Team Services, School District of CheItenham Township, I963-I964 Actual Contacts
Teachers in conferences Teachers in workshops Kindergarten through 4th grade Junior-Senior High Schools
xx2 79 xxa
Total Teacher Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Students--individual case study in detail Special project study Total Student Involvement . . . . . . . . . . . . . . . . .
303
x34 38 ...........
x7z
Parents
7
Follow-Up, Definitive Action
Students--Individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
Estimated Time in Program for Mental Health Consultant
Total psychiatrist's time in one school year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9~ hours
In general it appears that 5 ~ percent of our total school population are never "seen" or discussed by this team service. Of the remaining 5o percent who may come to the team's attention during their growing years in the school system, the breakdown might be as follows: one-third viewed as transitional or situational problems; one-third behavioral or reaction problems largely in the area of discipline and classroom management (primarily male population); and one-third neurotic adjustment problems. In this last group, at least 5o percent (or roughly 8 to zo percent of the total school population) have long-standing internalized emotional problems, which cannot be modified by our school educational-clinic team approach. These family-centered problems require referral to professional persons and mental health centers in the community. Skillful and responsible referral processes from the school program to these community resources are constantly being developed.
460
Community Mental Health Journal
Speaking on this point of responsible referral to community resources, the Superintendent of Schools made this observation: The specific help which the Mental Health Consultant was able to bring to the teachers by having particular students referred to the proper agency or private psychiatrist was a very important part of this program. Over and over again I heard teachers say, in effect, that once the Mental Health Consultant got in on a case something would happen. I think much too often educators tend to taIk about problems but don't really bring relief to the classroom teacher who is dealing daily with a difficult child. When the Consultant was able to point out to parents, doctors and other professional resources in the community that a certain area was not for school concern, we knew the Consultant was right in offering insulation and protection. On the other hand, when the Consultant in a conference would say, "I will call Doctor so and so to enlist his support," we knew the Consultant was mobilizing action which classroom teachers were not in a position to accomplish . . . . . Of course not all students improved as we would have wished, but the fact that teachers were being supported and helped in dealing with students who needed such help causes everyone to continue to support our Mental Health Program.
