- Email: [email protected]
The role of schools
them. But the most effective change agent is going to be joining with girls, asking girls what issues are on their minds, and helping them become critical analysts of how the system has not served them," Ms. Wahl said.
Suggested Reading Past the pink and blue predicament: freeing the next generation from sex stereotypes. New York: Girls Incorporated, 1992. Truth, trust and technology: new research on preventing adolescent pregnancy. New York: Girls Incorporated, 1992.
THE ROLE OF SCHOOLS Candace Sullivan is Director of the Center on Coordinated Services for Children at the National Association of State Boards of Education, where she has concentrated on developing collaborative school and community programs supporting the healthy growth and development of children and families. She has 25 years' experience working at the federal, state, and local level on policies and programs addressing elementary and secondary education, early childhood and youth development, and housing and community development. Why is it that some girls succeed, even in the face of adversity, and some don't? Researchers have identified a number of protective factors which seemingly contribute to what they call "resiliency" in youth---that is, their ability to overcome problems and barriers and have healthy growth and development. Resilient youth, as Ms. Sullivan describes them, are "basically socially competent. They're responsive, they care about others, they often have a sense of humor in other words, they're nice to be around." In addition to that, "they have problem-solving skills, they can think, they're reflective, they have a sense of who they are, some control over their lives, and a sense of purpose and future, both in terms of their future education, job, and family aspirations." These kids are "persistent and hopeful, and far more likely to avoid health-risking behaviors than peers without these kinds of characteristics," she concluded. The rest of her presentation focused on the ways in which schools can foster resiliency. Actually it is the family, the school, and the community, all working in tandem, that help young women to succeed, she said. All three institutions tend to "reinforce and support each other, and in many instances one can fill in where the other may be a bit weaker for some period in time," Ms. Sullivan said. Because the family is usually regarded as the youngster's primary underpinning, Ms. Sullivan began by describing the kinds of things that a girl derives from her family members, beginning with caring and support, and close bonds with individuals who can provide sustained care and caring attention over time. "They think she's terrific. They hang in if she's in trouble. They have expectations of her and expect her to work hard and stay in school," Ms. Sullivan said. "And they help her out. They make sure she gets to doctors' appointments, does her homework, pursues after-school interests, and develops socially." Last, but not least, "they let her participate in a meaningful way in the life of the family--not just by having her do chores, but by respecting her opinions and suggestions."
80
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WH1 Vol. 4, No. 2 Summer 199,
All these things "are not a good deal different from what a good school can provide a girl," Ms. Sullivan asserted. The most critical variable is "a positive school climate, where there is quality of relationships among and between students and teachers and other staff and families." To achieve this, she said, schools have to become far more personal institutions and create environments that better support students' physical, emotional, and social needs. "What makes a school personal? It's small. People know each other by name. They notice when things are going well or not well," Ms. Sullivan described. Even in heavily populated school systems, this change can be achieved by breaking down large structures into "schools within schools." The other qualities of a good school, she said, are that it holds high expectations for all students, academically and personally, and conveys these to students; it watches for students who are having difficulties, either academicaUy or personally, and makes sure that someone responds; it tries to assure that all students, not just outstanding athletes or scholars, experience some success at school and are publically recognized for special talents and accomplishments; it reaches out more directly to families, especially when kids are experiencing difficulties; it seeks help from other professionals and providers in the community when it lacks expertise to deal with problems; and, finally, its faculty and staff reflect the ethnic and cultural mix of society and provide appropriate role models. Students in an environment like this are far more likely to fulfill their educational and human potential. Ms. Sullivan said. An increasing amount of research shows that middle and high school environments can have a significant effect on academic achievement, on drop-out rates, on pregnancy and antisocial activities, and on crime, and that "particularly the academically and economically marginal kids are most strongly affected by the quality of the school environment." With regard to health curricula, students need "honest and relevant information" about their bodies, sex education, family life, and interpersonal relationships, Ms. Sullivan said. They also need a chance to engage in roleplaying, discussion, and other open-ended activities as part of learning to make wise decisions, developing positive values, dealing with group pressure, working cooperatively, and avoiding fights. Such nontraditional learning activities "can be a little threatening to schools, because they're noisy," she said, but they are "much more likely to influence attitudes and behaviors down the line. These things cannot be taught very effectively by lectures and text." But even the best of curricula cannot solve the problems of poor health and nutrition. Some 70% of all teachers see these as very serious problems for their students, and "it's pretty clear to everybody that unhealthy kids don't learn real well," Ms. Sullivan said. Therefore, as a necessary corollary to reforms in curriculum and instruction, schools are also being encouraged to look at the needs of the whole child, not just the very narrow cognitive needs, which is what they tend to do now. One tactic is to model healthy behaviors by providing appropriate nutrition in school cafeterias and engaging youth in physical activities that can be life-long. Beyond that, Ms. Sullivan there is a growing consensus that schools should take some responsibility for ensuring that students get needed health services. She called school-based and school-linked health centers "extremely promising" approaches because of their convenience, ease in providing follow-up, and the positive contributions that school-based health professionals can make to curricula and learning opportunities. Whether schools can or even should provide direct services, they would still have a role in identifying and referring individuals who need health or
WHI Vol. 4, No. 2 Summer 1994
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psychosocial interventions. Few do this well now, but more and more appear willing to collaborate in some fashion in the future, Ms. Sullivan said. Congress appears interested in this topic and may be willing to fund some demonstration projects. Momentum may build if the topic is given more recognition nationally. "You don't see health education in the national education goals for the year 2000," Ms. Sullivan observed.
Suggested Reading Bernard B. Fostering resiliency in kids: protective factors in the family, school, and community. Prevention Forum 1992;12. Center for the Future of Children, David and Lucile Packard Foundation. School hnked services. Future of Children 1992;2. Fine M. Middle and secondary school structures as they affect adolescent health outcomes. Office of Technology Assessment, U.S. Congress 1990. National Commission of the Role of the School and Community in Improving Adolescent Health. Code blue: uniting for healthier youth. Washington, DC: National Association of State Boards of Education and the American Medical Association, 1993. Sullivan C, Bogden J. Today's education policy environment. J Sch Health 1993;63. Task Force on Education of Young Adolescents, Carnegie Council on Adolescent Development. Turning points: preparing American youth for the 21st century. New York: Carnegie Corporation, 1989.
Open Discussion April Rubin (to Dr. Wahl): Pregnant girls in school get attention. How can we give attention to those who choose not to get pregnant, or to not even have intercourse?
Dr. Wahl: The bulk of money from the Office of Adolescent Pregnancy has gone to programs for pregnant and parenting teens, not to prevention. That speaks to the ambivalence about sexuality and teen sexuality in this country. The minute that a girl becomes a potential mother, it legitimizes the sexual process. I think all of those things are playing into the cockeyed messages that girls are getting.
Susan Newcomer: Human beings have a right to seek pleasure in their sexual interactions. To deny the positive value of sexuality, even outside of marriage, contributes to the ambivalences, which then contribute to the lack of planning for contraception, which then contributes to the unwanted, unintended pregnancy. We've got to talk about sex in a more positive fashion all along. Laurie S. Zabin: To what extent do we put down boys in an attempt to raise up girls? Isn't it a problem in our society that we're putting people down rather than putting women down alone? Sandra Kaplan: Health education at all ages should include something about gender value and human development. I don't think we should wait until people have children. It should really be part of all health education in American schools. Ms. Wahl: You have to weigh the resource question. When you put resources into boys and men, you're putting less into girls and women. And that's always a struggle for us, because, on one hand, you do have to change the larger society if you're going to make a difference for girls.
Jacqueline Darroch Forrest: We talk about wanting women to have health screening and reproductive health care, yet we don't trigger that until nine months to a year after they become sexually active. Is there a way we could 82
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WHI Vol. 4, No. 2 S u m m e r 1994
trigger that in the early stages of puberty or at menarche? That also may be a time when it's easier to get the parents involved in talking to their kids.
Dr. Zabin: We ought to be encouraging clinicians to start establishing private and one-on-one relationships with kids from very early ages, so that they begin to recognize their doctors as people they can talk to. This could be done not only in the private setting, but in the clLnic setting. The important thing is that the young person believes that the pediatrician, the physician, the clinician, the nurse practitioner, is their person to talk to right from the early ages. Kate Kalb: An issue for people who have been working with adolescents for a long time is that now we're seeing kids at younger and younger ages, and we don't know how to counsel them. It's almost more confusing to children to be approached in an adult way, and yet it's the way we've been trained. Renee Jenkins: Some of the more recent AAP [American Academy of Pediatrics] guidelines suggest that these issues be introduced much earlier and in an ageappropriate way. They have reference materials for practitioners, and even reading materials for preschoolers on sexuality. Parents, also, have no role model for initiating this kind of communication. Whatever help practitioners can give them at a time when it's not a conflictual, crisis situation, is probably going to have a lasting benefit and be a more effective intervention. Anne C. Petersen: Another effort like this is the American Medical Association's Guidelines for Adolescent Preventive Services. When finished, it will be helpful for private offices and clinics. Elaine Locke: In the past, when we've seen a girl developing early, there was a tendency to think, "If I cross my fingers, maybe I can hold this thing off." Do we need a more active approach to looking for those early developing adolescents, who need interventions now? I really think that's the message we need to give to parents and health professionals and educators. Jan Chapin: I was struck by Laurie's talk this morning about the need for an investment. We've talked about that in various ways all afternoon. The investment in youth-serving organizations. The investment in education. Unfortunately, one of the things that we don't do very well is quantify things. It's important to make manageable, to keep it from seeming like it's going to break the budget, or it won't happen. Ms. Sullivan: As budgets currently exist, just a school nurse for, say, every three elementary schools would break the budget. Unfortunately, we're at a time when federal dollars are capped domestically, and if we take funds from maternal and child health and give it to education, or vice versa, we're creating some serious problems. We're going to have to think of some very different and creative solutions. Dedicated taxes in some instances seem to work. The resource issue is a very serious one. I would say for us to accomplish a lot would take considerably more investment in children and families. But equally important is a kind of attitude. To be a more caring institution is not a resource issue and yet that, too, is something we need to work on. Dr. Petersen: This relates to the whole issue of valuing children and families and women. If you look at other things that have gotten money, we shouldn't be timid. We should be bold, and make clear what the costs are of not doing something. If we don't do it because we're worried that there's not enough money, or people aren't going to back it, we'll never get it on the table at all. Dr. Zabin: We have to think through what things are cost-effective and what are not before we make demands, however. The most expensive single thing we could be doing is to put a whole clinic in every single school. In our most inner cities, 40% to 50% of the kids are not even in school. What should we
WHI Vol. 4, No. 2 S u m m e r 1994
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83
do in the school? Identity high-risk kids, counsel them, and establish linkages. We need to beef up community health resources, because that's where 40% to 50% of the adolescents are. I. Ronald Shenker: We run a school-based health program in an extremely large
high school, 4,500 kids. We have one clinical nurse practitioner and about a three-quarters' time pediatrician. We take care of about 1,500 students in the school, and the funding agencies want to know w h y we don't see more patients. But if you want to see patients in an effective manner, you need time. You can't do comprehensive physicals, which they demand, on 1,500 kids, and also take care of the emergencies. It is difficult to get community support for these programs. To go into this inner-city high school, which is the largest in Queens, we had to promise the community that we would not deliver contraceptive services. The irony is, we're sitting in a city that is mandating condom distribution in high school, yet in our high school, if you want to get a condom, you can't come to our clinic. You have to go someplace else in the school, because we promised the community we wouldn't give them out. You have to start building self esteem in kindergarten or even before. We surveyed several middle class school districts and found that the girls have extremely negative views about their bodies, about puberty, about menstrua t i o n . . , they don't want to know. H o w do you get them interested in what's going to happen to them before it happens? To prepare for the changes that are going to occur?
84
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Suggested Reading Past the pink and blue predicament: freeing the next generation from sex stereotypes. New York: Girls Incorporated, 1992. Truth, trust and technology: new research on preventing adolescent pregnancy. New York: Girls Incorporated, 1992.
THE ROLE OF SCHOOLS Candace Sullivan is Director of the Center on Coordinated Services for Children at the National Association of State Boards of Education, where she has concentrated on developing collaborative school and community programs supporting the healthy growth and development of children and families. She has 25 years' experience working at the federal, state, and local level on policies and programs addressing elementary and secondary education, early childhood and youth development, and housing and community development. Why is it that some girls succeed, even in the face of adversity, and some don't? Researchers have identified a number of protective factors which seemingly contribute to what they call "resiliency" in youth---that is, their ability to overcome problems and barriers and have healthy growth and development. Resilient youth, as Ms. Sullivan describes them, are "basically socially competent. They're responsive, they care about others, they often have a sense of humor in other words, they're nice to be around." In addition to that, "they have problem-solving skills, they can think, they're reflective, they have a sense of who they are, some control over their lives, and a sense of purpose and future, both in terms of their future education, job, and family aspirations." These kids are "persistent and hopeful, and far more likely to avoid health-risking behaviors than peers without these kinds of characteristics," she concluded. The rest of her presentation focused on the ways in which schools can foster resiliency. Actually it is the family, the school, and the community, all working in tandem, that help young women to succeed, she said. All three institutions tend to "reinforce and support each other, and in many instances one can fill in where the other may be a bit weaker for some period in time," Ms. Sullivan said. Because the family is usually regarded as the youngster's primary underpinning, Ms. Sullivan began by describing the kinds of things that a girl derives from her family members, beginning with caring and support, and close bonds with individuals who can provide sustained care and caring attention over time. "They think she's terrific. They hang in if she's in trouble. They have expectations of her and expect her to work hard and stay in school," Ms. Sullivan said. "And they help her out. They make sure she gets to doctors' appointments, does her homework, pursues after-school interests, and develops socially." Last, but not least, "they let her participate in a meaningful way in the life of the family--not just by having her do chores, but by respecting her opinions and suggestions."
80
ROLE OF SCHOOLS AND COMMUNITY ORGANIZATIONS
WH1 Vol. 4, No. 2 Summer 199,
All these things "are not a good deal different from what a good school can provide a girl," Ms. Sullivan asserted. The most critical variable is "a positive school climate, where there is quality of relationships among and between students and teachers and other staff and families." To achieve this, she said, schools have to become far more personal institutions and create environments that better support students' physical, emotional, and social needs. "What makes a school personal? It's small. People know each other by name. They notice when things are going well or not well," Ms. Sullivan described. Even in heavily populated school systems, this change can be achieved by breaking down large structures into "schools within schools." The other qualities of a good school, she said, are that it holds high expectations for all students, academically and personally, and conveys these to students; it watches for students who are having difficulties, either academicaUy or personally, and makes sure that someone responds; it tries to assure that all students, not just outstanding athletes or scholars, experience some success at school and are publically recognized for special talents and accomplishments; it reaches out more directly to families, especially when kids are experiencing difficulties; it seeks help from other professionals and providers in the community when it lacks expertise to deal with problems; and, finally, its faculty and staff reflect the ethnic and cultural mix of society and provide appropriate role models. Students in an environment like this are far more likely to fulfill their educational and human potential. Ms. Sullivan said. An increasing amount of research shows that middle and high school environments can have a significant effect on academic achievement, on drop-out rates, on pregnancy and antisocial activities, and on crime, and that "particularly the academically and economically marginal kids are most strongly affected by the quality of the school environment." With regard to health curricula, students need "honest and relevant information" about their bodies, sex education, family life, and interpersonal relationships, Ms. Sullivan said. They also need a chance to engage in roleplaying, discussion, and other open-ended activities as part of learning to make wise decisions, developing positive values, dealing with group pressure, working cooperatively, and avoiding fights. Such nontraditional learning activities "can be a little threatening to schools, because they're noisy," she said, but they are "much more likely to influence attitudes and behaviors down the line. These things cannot be taught very effectively by lectures and text." But even the best of curricula cannot solve the problems of poor health and nutrition. Some 70% of all teachers see these as very serious problems for their students, and "it's pretty clear to everybody that unhealthy kids don't learn real well," Ms. Sullivan said. Therefore, as a necessary corollary to reforms in curriculum and instruction, schools are also being encouraged to look at the needs of the whole child, not just the very narrow cognitive needs, which is what they tend to do now. One tactic is to model healthy behaviors by providing appropriate nutrition in school cafeterias and engaging youth in physical activities that can be life-long. Beyond that, Ms. Sullivan there is a growing consensus that schools should take some responsibility for ensuring that students get needed health services. She called school-based and school-linked health centers "extremely promising" approaches because of their convenience, ease in providing follow-up, and the positive contributions that school-based health professionals can make to curricula and learning opportunities. Whether schools can or even should provide direct services, they would still have a role in identifying and referring individuals who need health or
WHI Vol. 4, No. 2 Summer 1994
ROLE OF SCHOOLS AND COMMUNITY ORGANIZATIONS
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psychosocial interventions. Few do this well now, but more and more appear willing to collaborate in some fashion in the future, Ms. Sullivan said. Congress appears interested in this topic and may be willing to fund some demonstration projects. Momentum may build if the topic is given more recognition nationally. "You don't see health education in the national education goals for the year 2000," Ms. Sullivan observed.
Suggested Reading Bernard B. Fostering resiliency in kids: protective factors in the family, school, and community. Prevention Forum 1992;12. Center for the Future of Children, David and Lucile Packard Foundation. School hnked services. Future of Children 1992;2. Fine M. Middle and secondary school structures as they affect adolescent health outcomes. Office of Technology Assessment, U.S. Congress 1990. National Commission of the Role of the School and Community in Improving Adolescent Health. Code blue: uniting for healthier youth. Washington, DC: National Association of State Boards of Education and the American Medical Association, 1993. Sullivan C, Bogden J. Today's education policy environment. J Sch Health 1993;63. Task Force on Education of Young Adolescents, Carnegie Council on Adolescent Development. Turning points: preparing American youth for the 21st century. New York: Carnegie Corporation, 1989.
Open Discussion April Rubin (to Dr. Wahl): Pregnant girls in school get attention. How can we give attention to those who choose not to get pregnant, or to not even have intercourse?
Dr. Wahl: The bulk of money from the Office of Adolescent Pregnancy has gone to programs for pregnant and parenting teens, not to prevention. That speaks to the ambivalence about sexuality and teen sexuality in this country. The minute that a girl becomes a potential mother, it legitimizes the sexual process. I think all of those things are playing into the cockeyed messages that girls are getting.
Susan Newcomer: Human beings have a right to seek pleasure in their sexual interactions. To deny the positive value of sexuality, even outside of marriage, contributes to the ambivalences, which then contribute to the lack of planning for contraception, which then contributes to the unwanted, unintended pregnancy. We've got to talk about sex in a more positive fashion all along. Laurie S. Zabin: To what extent do we put down boys in an attempt to raise up girls? Isn't it a problem in our society that we're putting people down rather than putting women down alone? Sandra Kaplan: Health education at all ages should include something about gender value and human development. I don't think we should wait until people have children. It should really be part of all health education in American schools. Ms. Wahl: You have to weigh the resource question. When you put resources into boys and men, you're putting less into girls and women. And that's always a struggle for us, because, on one hand, you do have to change the larger society if you're going to make a difference for girls.
Jacqueline Darroch Forrest: We talk about wanting women to have health screening and reproductive health care, yet we don't trigger that until nine months to a year after they become sexually active. Is there a way we could 82
ROLE OF S C H O O L S A N D COMMUNITY ORGANIZATIONS
WHI Vol. 4, No. 2 S u m m e r 1994
trigger that in the early stages of puberty or at menarche? That also may be a time when it's easier to get the parents involved in talking to their kids.
Dr. Zabin: We ought to be encouraging clinicians to start establishing private and one-on-one relationships with kids from very early ages, so that they begin to recognize their doctors as people they can talk to. This could be done not only in the private setting, but in the clLnic setting. The important thing is that the young person believes that the pediatrician, the physician, the clinician, the nurse practitioner, is their person to talk to right from the early ages. Kate Kalb: An issue for people who have been working with adolescents for a long time is that now we're seeing kids at younger and younger ages, and we don't know how to counsel them. It's almost more confusing to children to be approached in an adult way, and yet it's the way we've been trained. Renee Jenkins: Some of the more recent AAP [American Academy of Pediatrics] guidelines suggest that these issues be introduced much earlier and in an ageappropriate way. They have reference materials for practitioners, and even reading materials for preschoolers on sexuality. Parents, also, have no role model for initiating this kind of communication. Whatever help practitioners can give them at a time when it's not a conflictual, crisis situation, is probably going to have a lasting benefit and be a more effective intervention. Anne C. Petersen: Another effort like this is the American Medical Association's Guidelines for Adolescent Preventive Services. When finished, it will be helpful for private offices and clinics. Elaine Locke: In the past, when we've seen a girl developing early, there was a tendency to think, "If I cross my fingers, maybe I can hold this thing off." Do we need a more active approach to looking for those early developing adolescents, who need interventions now? I really think that's the message we need to give to parents and health professionals and educators. Jan Chapin: I was struck by Laurie's talk this morning about the need for an investment. We've talked about that in various ways all afternoon. The investment in youth-serving organizations. The investment in education. Unfortunately, one of the things that we don't do very well is quantify things. It's important to make manageable, to keep it from seeming like it's going to break the budget, or it won't happen. Ms. Sullivan: As budgets currently exist, just a school nurse for, say, every three elementary schools would break the budget. Unfortunately, we're at a time when federal dollars are capped domestically, and if we take funds from maternal and child health and give it to education, or vice versa, we're creating some serious problems. We're going to have to think of some very different and creative solutions. Dedicated taxes in some instances seem to work. The resource issue is a very serious one. I would say for us to accomplish a lot would take considerably more investment in children and families. But equally important is a kind of attitude. To be a more caring institution is not a resource issue and yet that, too, is something we need to work on. Dr. Petersen: This relates to the whole issue of valuing children and families and women. If you look at other things that have gotten money, we shouldn't be timid. We should be bold, and make clear what the costs are of not doing something. If we don't do it because we're worried that there's not enough money, or people aren't going to back it, we'll never get it on the table at all. Dr. Zabin: We have to think through what things are cost-effective and what are not before we make demands, however. The most expensive single thing we could be doing is to put a whole clinic in every single school. In our most inner cities, 40% to 50% of the kids are not even in school. What should we
WHI Vol. 4, No. 2 S u m m e r 1994
ROLE OF S C H O O L S AND COMMUNITY ORGANIZATIONS
83
do in the school? Identity high-risk kids, counsel them, and establish linkages. We need to beef up community health resources, because that's where 40% to 50% of the adolescents are. I. Ronald Shenker: We run a school-based health program in an extremely large
high school, 4,500 kids. We have one clinical nurse practitioner and about a three-quarters' time pediatrician. We take care of about 1,500 students in the school, and the funding agencies want to know w h y we don't see more patients. But if you want to see patients in an effective manner, you need time. You can't do comprehensive physicals, which they demand, on 1,500 kids, and also take care of the emergencies. It is difficult to get community support for these programs. To go into this inner-city high school, which is the largest in Queens, we had to promise the community that we would not deliver contraceptive services. The irony is, we're sitting in a city that is mandating condom distribution in high school, yet in our high school, if you want to get a condom, you can't come to our clinic. You have to go someplace else in the school, because we promised the community we wouldn't give them out. You have to start building self esteem in kindergarten or even before. We surveyed several middle class school districts and found that the girls have extremely negative views about their bodies, about puberty, about menstrua t i o n . . , they don't want to know. H o w do you get them interested in what's going to happen to them before it happens? To prepare for the changes that are going to occur?
84
ROLE OF SCHOOLS AND COMMUNITY ORGANIZATIONS
WHI Vol. 4, No. 2 Summer 199~