The School Health Service

Symposium on Ambulatory Pediatrics

The School Health Service Making Primary Care Effective

Philip R. Nader, M.D.*

In our time the role of the school physician will perforce be closely linked to the era of human renewal, anti-poverty, and concern for the individual as an integral and indispensable part of our society .... There will be more concentration on understanding the environmental and social factors which influence children, and more emphasis on techniques of coping with them. MILTON

J. E. SENN

1965

If the preceding prediction is every realized, then school health will have come a long way since the early 1900's when physicians were brought into schools in the interest of controlling outbreaks of infectious disease. A similar prediction of a broader focus for primary health care is also heard today: Primary health care will "promote health" as well as control and treat disease. However, most people still think of going to the doctor or to a clinic only when they are sick. The problem for the primary health care team comes, then, in deciding how to provide illness care, and still have a commitment to trying to keep people well. How much effort for prevention? When? In what way? School health could play an important role in the future delivery of preventive primary health care services. Barriers exist, however, which work against both school health and primary health care in fully achieving these new goals of health promotion. These barriers are deeply rooted in the institutions of education and medicine, but they are not insurmountable. They are: unwillingness to change traditional ways, territoriality, protective professionalism among child development personnel, lack of trust and communication between "school people" and "health people," fragmentation of services, and bureaucracy. '''Associate Professor of Pediatrics and Psychiatry, and Director, School Health Programs, University of Texas Medical Branch, Galveston, Texas Supported in part by grants from The Commonwealth Fund, The Children's Bureau, and The Office of Economic Opportunity.

Pediatric Clinics of North America- Vol. 21, No. 1, February 1974

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SCHOOL HEALTH AND PRIMARY CARE IN THE FUTURE: A MARRIAGE? Senn28 has written elegantly and extensively on the role, prerequisites, and training of the school physician. He maintains that the physician should become part of the school institution itself, in order to exert optimal influence. A closer relationship is indeed required. However, once he becomes part of the school system he is then isolated from his medical professional colleagues. If he were to some degree independent, he would be able to operate more effectively. A useful relationship would be a marriage of the resources of school health and health care in a joint effort to accomplish their mutual goals-the health and education of children. This paper proposes just such a marriage between school health and primary care. Courtship through the years has helped achieve certain goals common to both: physical health screening including vision and hearing, immunization surveillance, sanitation, school lunches, and some aspects of physical education. A closer bond is required, since neither educational nor health professionals alone can tackle the larger tasks they have now posed for themselves. The arguments for a union between school health and primary care will take the following route: (1) rationale and need for a redefinition of school health; (2) a conceptual model for school health-primary health care; (3) geographic considerations in developing school health-primary health care services; (4) training for school health; (5) a "dramatis personae" for school health; and (6) implementation.

RATIONALE AND NEED FOR A REDEFINITION OF SCHOOL HEALTH There are at least three reasons for approaching school health jointly with primary care: The past record of school health, the current unmet health needs of children, and the opportunity to affect the future health of generations of children and 'adults. The past record of school health is not particularly distinguished. Routine examinations are not useful for detection of defects. 31 Problems, once identified, are difficult to remedy because often there is no link to the provider of primary health care. 5 • 17 Research in school health is sparse but has consistently pointed up some of its deficiencies. The American Child Health Association in 1925 did a survey of School Health Services which stressed the need for "better cooperation between schools and parents, between school physicians and private physicians." The survey was also unable to detect a "rational basis for many of the city to city variations in child health services." Wagner's study of school physicians30 indicated that they felt unprepared and were not meeting children's needs. Paradoxically, they were happy with their roles in the school health service. The current epidemic of dental, emotional, and learning problems constitutes the major unmet school health needs of today's children. 1

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Surveys in St. Louis 10 and Buffalo 14 document a 15 to 30 per cent incidence. Parents of school children were queried in a 1 per cent survey in Monroe County (Metropolitan Rochester, New York) in 1967 and 197J.19 School functioning of their children was measured by questions such as: "Has "Has "Has

ever had trouble with school? What was the trouble?" ever been held back a grade? Why was that?" ever been asked to leave school?"

The percentage of children 5 to 17 years of age reported by their parents to have any of these three problems was 27 per cent in 1967, and 29 per cent in 1971. "Trouble with school" was about 23 per cent in both years; "Ever held back" was 16 per cent in 1967 and 14 per cent in 1971. The proportion of children "ever asked to leave" increased slightly from 2 to 3 per cent in 1967 to 5 per cent in 1971. Parents gave various reasons for school problems which were finally condensed into three major categories: academic and reading problems, behavioral problems, and a third group composed of a mixture of discipline, absenteeism, mobility, teacher-pupil interaction, physical handicaps and language problems. Overall, "trouble with school" was attributed mainly to behavioral and academic causes; being "held back" for academic and reading reasons; and "being asked to leave" chiefly for disciplinary reasons. In addition to this tremendous psychological and emotional morbidity, children's future health is also important. The leading causes of mortality in the U. S. today can be viewed primarily as educational problems: heart disease, motor vehicle accidents, suicide, cirrhosis of the liver, stroke, and lung cancer. These health problems, obviously of concern to primary health care deliverers, in large part stem from lifestyle, decisionmaking processes, and values. The school is an ideal setting for observing children's personality and peer-group interaction and for structuring activities which will tap those issues which are important in maintaining personal and community health. It also is a logical place to involve parents and other family members in therapeutic strategies aimed at prevention of these lifestyle diseases.

A CONCEPTUAL MODEL A major drawback for school health services besides lack of a link to primary care is the difficulty in organizing a "preventive" school health program. Caplan4 suggests a model for preventive mental health services which can easily be applied to the delivery of school health services. Underlying this conceptual framework outlined below is the important link to the provider of first-line health care. This will insure the basics of physical health screening (vision, hearing, immunizations), care for sporadic mild illnesses, and coordination of care for chronic illness.

Primary Preventive Care · Primary preventive care attempts to improve the milieu or supporting school environment of all children, or in some situations identifies

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groups of children at high risk (such as those experiencing parental illness, death, or separation, disorganized family life, or academic or social failure). A service for primary prevention develops programs which aid in adjustment and coping with these stresses. One example of primary preventive care would be a special medical and educational program for adolescent pregnant girls. Another would be teacher workshops in various areas of child development and behavior. This would improve the school milieu by helping teachers increase their understanding of children. Attention to the physical plant of a school is also a primary preventive activity. If pupils who are physically handicapped or confined to a wheelchair are to use the school, are doorways, ramps and other access routes available? If the newer open21 concepts of school construction and instruction are being developed, is provision being made for students who may need a quiet, isolated setting for concentrated study? Pleasant surroundings also have a marked effect on children and staff. The emotional climate set by the school staff must be noted and dealt with by the school health service. Biber studied the effect of school environment on children's "positive mental health." She found that children in a "modem" school environment, geared to meeting individual learning needs, reflected more positive "mental health" attitudes than children who were similar in all respects but attended more "traditional" and "regimented" schools. The educational philosophy in the "modern" school was defined as student-directed learning activities. The "traditional" school philosophy described children as "empty vessels which had to be kept in order with lids open so that knowledge could be poured in.'' Flanders7 investigated verbal classroom interaction and has developed a widely applied scheme for recording it. This procedure yields patterns of teacher-pupil interactions. He showed that teachers who lecture less and allow more student talk and participation, who reinforce and praise rather than criticize, have students who academically achieve more. Educational approaches dealing with mental health24 concepts are also legitimate preventive health activities. Humanistic education15 and value clarification 22 are just two recent developments from the field of education dealing with the affective domain. 13 Most of these approaches, either directly or indirectly, attempt to improve children's self-concept. A positive self-concept is probably essential for academic achievement. It also may be key in developing appropriate decisions and values about maintaining good. personal health. Some approaches also sharpen children's skills in getting in touch with their own feelings and the feelings of others. To give the reader an idea of this kind of activity a contribution of Gerald Weinstein is taken from Lyon's book,t 5 which is a good overview of the field: Gerald Weinstein will enter, for example, a sixth grade inner city classroom with a box full of old dimestore glasses. In one classroom he explained to the children that he had very special "one way feeling glasses." "When you put these on, you see things suspiciously." He asked for a volunteer to try on the glasses. A small boy in the front of the classroom came up and put them on. He looked around

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and smiled. When asked what he saw through the suspicious glasses, he replied, "I wonder why you're here today, and the teacher is out loafing and goofing off?" Gerald Weinstein told him, "That's exactly the way suspicious glasses work!" The boy looked around the room, and said, "I wonder if those two boys in the back of the room are talking about me?" Several other children used the suspicious glasses with equal success. Gerald Weinstein then pulled another pair of glasses out of the box and said, "These are 'I know they really care about me no matter what they say or do glasses.'" Several children tried them on with revealing results. One of the pairs of glasses, the "self righteous glasses," provided some interesting results. When asked who might wear "self righteous glasses," one child replied, "Batman." Another said the counselor. When asked more about this, he replied that whenever you go in to see the counselor, he asks, "What trouble have you been in again?" Another said, "the principal." When asked what the opposite of "self righteous glasses" might be one student replied, "People are not too different from me glasses." When the students in the class all put on "strong point glasses," and looked around at their fellow students, the classroom became alive with feeling as students began honestly telling their associates, in most cases for the first time, about their strengths. A warm pleasant feeling seemed to spread among these ghetto hardened children as they heard reinforcing feedback about their strong points from others in the class. When asked what kind of glasses "a new kid" coming into the class ought to have, the students replied "power glasses" to make it through the struggle. A new student in the class emphatically agreed, and this touched off a discussion on how he had been accepted by the others. This ended with the conclusion that he was .now definitely a member of the group. The author has used the "strong point glasses" technique with graduate students with amazing results. After having each student, in turn, put on "strong point glasses" and give each of the others' strong points, th~ author passed around a hand mirror and asked each student to tell what he saw in the mirror, still wearing his "strong point glasses." This gave students the rare opportunity of openly and honestly stating what they felt their strong points to be. It was a most intimate, warm, and satisfying experience for the entire group of 15 students. This technique of one way feeling glasses has infinite variation and application limited only by the teacher's imagination and self enlightenment.

Such activities will become more frequent in our schools. The opportunity for interaction with and observation of these classroom activities by health professionals will enhance their effectiveness. It will be helpful to school personnel to have health personnel to rely on for interpretation of behavior and for support in dealing with any difficult situations should they arise. The activities will also provide important information useful to the health professional in dealing with specific children or families. Close involvement with and understanding by parents is also important in reaching the optimal impact of these activities. Participation and endorsement by the health professional will legitimize them as well as ensure quality control with regard to teacher preparation and back-up. These primary preventive mental health activities, if creatively and carefully applied, could be extremely useful in the health education efforts of a school or community. Similar techniques should begin to get at those processes which are basic to the important health and mental health decisions being made by growing individuals.

Secondary Preventive Care Secondary preventive care is the notion that early identification of learning and/or emotional difficulty will lead to easier and earlier resolu-

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tion of such problems. Cowen6 has done the longest and most rigorous evaluation of effectiveness in this area. In his studies with some of the schools in the Rochester, New York area over the past 10 years, he has demonstrated that (a) consistently 30 per cent of children can be identified at first grade as having existing or potential adjustment or behavioral problems; (b) the difficulties persist at least into the junior high school years; (c) and women who have successfully raised children and who have the on-going back-up of school mental health staff, can provide emotional support for identified children. These identified children, who had such support over a 3 year period in the early prevention project, were compared to peers from demographically similar, geographically contiguous control schools with traditional school mental health services. Children who had the paraprofessional aides exceeded their peers on seven measures, including fewer nurse referrals, higher grades and achievement test scores, superior achievement relative to aptitude, lower self-rated anxiety, and teacher behavior ratings indicating superior adjustment. With the onslaught of increasing numbers of children being "identified" and "diagnosed" as suffering from leaming disabilities, minimal cerebral dysfunction, and the like, there is a parallel push to "diagnose" and "identify" them at the earliest possible encounter with the formal educational system. Much of this well-intentioned effort originates in the frustrations of parents who see their child caught in a "developmental mismatch" between the school's (or parents) expectations and the child's current abilities. 8 Such parents join organizations whose main function is to pressure the schools to "do something" about the large numbers of children not academically thriving. As a result, an intensive drive is now underway in many places in the country for "prescreening" of kindergarten children to "detect" learning disabilities. Parents are mailed or given self-administered forms to "test" their child's visual-motor skills, ability to repeat digits (auditory rote memory), and other tasks. A suggested cut-off point score may be indicated, and concerned parents are requested to contact school officials before entering the child in school. Even if such action results in a more definitive evaluation, or, in a suggestion that the child remain home another year, a serious "labeling" problem may have been created. Though data are negligible, one speculates that an effective "early screening" or "detection" program of the future should have the following features. Ideally, it will be closely tied to previous developmental evaluations and a comprehensive health care system which already has known the child during the critical infancy and early preschool years, probably the most key years in this regard. 3· 26 It will be developmentally based 25 recognizing that there is wide variability among "normals." Thus, its aim will not be necessarily to pick out "brain-damaged," "learningdisabled," or "emotionally disturbed" youngsters, but will attempt instead to clearly define children's physical, cognitive, and social development.31t will be an integral part of an educational system which will have the sophistication and resources required to implement educational programs which will meet the developmental needs of children. This latter

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point cannot be overemphasized. Educational technology and pedagogy is just beginning to be able to match instructional methodologies to individual children's cognitive or learning styles. Careful joint planning of all such programs will concentrate as much on this remediation portion of the program as on the sophisticated diagnostic tools available. Parental involvement is mandatory to effectively remediate some of the deviations detected in social or emotional development. The link with the health care provider will enhance this involvement and should facilitate the remediation efforts. Tertiary Preventive Services Attempting to return a child to as "normal" a functional state as possible after "diagnosis" and "treatment" are completed is the business of tertiary preventive services. Examples frequently encountered today include children with juvenile rheumatoid arthritis, chronic asthma, diabetes, allergies, seizure disorders, obesity, and children with a serious or potentially fatal illness. School learning problems and school phobia also fall frequently into this category, requiring on-going medication or educational and psychological follow-up in their management. The team model of casework is one which seems to facilitate the potential of all team members: physician, nurse, principal, teacher of child in question, school mental health personnel (psychologist, social worker, guidance counselor) and, as needed-or available-reading teachers, speech/language specialists, etc. Here, the teacher presents his or her concerns about a pupil, the team pools immediate suggestions, and decisions are made as to how to proceed-have parents and child seen by pediatrician and/or psychologist, etc. Then, after data has been collected, the team meets again, plans are made and a date for follow-up is set. The teacher in this model is able to observe and participate in the on-going evaluation of the given child and therefore is better able to understand and use the results. A brief case example will illustrate how pediatrician, school mental health staff, teachers, and parents communicated in order to care for a boy with a specific learning disability: D. R., a 12 year old suburban fifth grader, was referred to the team by the reading consultant because he became so "keyed up" in a reading group (second grade level at best) he virtually would become paralyzed. He had repeated first grade and was referred in second grade for psychological testing because of "little progress in word recognition and retention of material taught." A Weschler Intelligence Scale for Children revealed a verbal IQ of 94 and a performance IQ of 127, full scale of 110. A Bender-Visual Motor Gestalt test revealed rotations and it was noted he was still reversing letters at age 9 years. He reported to the school nurse frequently with complaints of stomachaches, and parents frequently had to force him to go to school when he was younger. Both his current teacher and school nurse felt he lacked confidence and had a poor image, though he seemed to be well liked by his peers. Parental interview revealed a normal developmental history with the exception that parents noted he was always more irritable and less coordinated than their other son, who was 14 and excelled in everything- sports and acadeinics. Fatherwas somewhat critical of D. (if he wasn't so "lazy" he could get the work done) and though both enjoyed skiing, neither would go with the other. Mother's sister's son had had "dsylexia" diagnosed.

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Medical evaluation done by the pediatrician with the teacher observing revealed some fine motor incoordination and possible auditory memory difficulties. Repeat psychometric evaluation (also with teacher watching) documented arithmetic achievement at 5.9 grade level, but reading at 2.6 level. The tests also showed severe auditory and visual memory difficulties. Educational evaluation revealed a good phonetic approach, but little sight vocabulary. VAKT (visual, auditory, kinesthetic, tactile) materials were developed for him. Teaching approaches were developed which allowed him to use material already presented, and to give oral reports rather than produce written work. A family conference held by pediatrician and the teacher with father, mother and child, clarified D's difficulties as well as strengths. One-year follow-up indicated less frequent nurse visits, more academic success, and D's appearing less "keyed-up." In addition, he and his father went on a camping trip together.

A conceptual framework has been laid for the definition and development of a coordinated school health service. Aspects requiring discussion include geographic considerations, training for school health, and implementation of this coordinated approach.

GEOGRAPHIC CONSIDERATIONS Urban School Health Services It is a great challenge to deliver useful health and educational services to a population beset with social and economic handicaps of the magnitude usually found in·today's urban centers. In 1969 one metropolitan county-wide random sample survey of parents of school-age children in two ghetto wards of Rochester, New York,t 9 about one-third of children were reported as being "held back" in school. These figures were significantly higher than those reported by parents residing in nonghetto parts of the city (18 per cent) and the suburbs (13 per cent). Similar differences persisted in 1971 when the survey was repeated, with inner-city wards' rates of 22 per cent and 28 per cent compared to 19 per cent for the rest of the city and only 10 per cent for the suburban areas of the county. The collaboration of a neighborhood health center and the surrounding schools makes sense if only the needs of the students are considered. The only problems are those of communication, records, perceived duplication of services, and lack of familiarity with each institution's goals and methods of providing services. One modeF 7 of collaboration in the delivery of school health services utilizes an allied health professional, the health office assistant. She is a high-school graduate, resident of the geographic area, was employed initially in the health center first as a family health assistant, and then as a pediatric clinic aide, was given a Red Cross First Aid course, and then was placed in the local school full-time in the school nurse's office. The school physician input comes via a health center pediatrician who works in team fashion with other school and center staff. Tables 1 and 2list the types of problems referred, and the rate of completed referrals, in such a project. Compared to a similar inner-city school with a traditional School Health Service which had no formal ties to a health center, fewer "medi-

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Table 1.

Reasons for Referrals for Children Served by School Health Programs 11 TRADITIONAL

(School #3)

Number Per Cent Dental Behavioral-learning Speech-hearing Medical (trauma, fever, impetigo, hernia) Vision Social, other Total

DEMONSTRATION

(School #6)

Rate/100 Rate/100 Students Number Per Cent Students

27 4 9

20.9 3.1 7.0

8.2 1.2 2.7

20 34 12

12.0 20.5 7.2

2.7 4.7 1.7

55 30 4 129

42.6 23.3 3.1 100.0

16.8 9.1 1.2

34 58 8 166

20.5 34.9 4.8 100.0

4.7 8.1 1.1

Raw chi square = 36.28. df= 5 p= <0.01.

cal" problems required outside referral, more behavioral-learning problems were referred, and more referrals reached a source of care. While the percentage of children reaching care compares favorably to other 'studies in this type population, the figure is still only slightly better than half of those referred. Communication of outcome of such referrals still needs attention. One follow-up study of school health referrals showed that only 17 of a possible 64 teachers were informed of the results of evaluations for school problems by either parents, school health or mental health personneJ.23 The following example of the difficulty of delivering service to urban children and families is from the same follow-up study. 23

J. R. 's medical chart at the health center showed that many health care facilities had at one time or another dealt with the boy: Head Start, a general hospital pediatric OPD, the health center, a mental health center, a community chest speech Table 2. Percentage of Completed Referrals from School Health Programs Compared to Family's Usual Source ofCare 11 NO REGULAR CARE

Referral completed Not completed Total

HOSPITAL/CLINIC

Numher

Per Cent

Numher

2 10 12

16.7 83.3 100.0

41 68 109

*Rochester Neighborhood Health Center. Chi square = 9.38. df=3 p= <.05.

Per Cent 37.6 62.4 100.0

PRIVATE

Numher 11 12 23

Per Cent 47.7 52.3 100.0

RNHC* Numher

Per Cent

41 33 74

55.4 44.6 100.0

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and hearing center, a medical school neurology clinic, and a psychodiagnostic center. Mrs. R. had great difficulty speaking English during the parent interview. Two of her school-age children, who were home from school to do some cleaning and babysitting, interpreted for her. Mrs. R's surface hostility toward the interviewer was mixed with a sort of grief reaction about her son, whom she saw as having "trouble in the head." Despite all the resources mentioned in the boy's chart, Mrs. R. felt that she and her son were obtaining little help for his problems. The medication prescribed at the health center was not very effective and the school could not handle ]. "The teacher puts him in a closet when he's bad and I don't like that. Now they're going to have him go to school for only half the day and he's in a bilingual class. The Spanish speaking teacher slaps him in the face and twists his ear and he shouldn't even be there. We speak Spanish at home. Let him learn English in school." She comments later: "It's bad to be like him .... I feel so sad for him." J's current teacher reported him to be a child with many problems who was not getting along well. She had no knowledge of any referral.

In some urban areas where medical consultation services are limited to the sites of delivery of health and illness care, school nurse practitioner/trained public health nurses are being used in the schools for outreach work and for delivering first-line illness care. They are still based in health departments, health centers, or clinics, thus providing a link to attempt some coordination of services. Liaison can be built up between all providers of health and mental health services and the school without formal projects and alliances- but it seems that such demonstration programs are required to initiate such cooperative activities.

Suburban School Health Services Primary health care is usually in reasonably ample supply for suburban residents. However, there are probably also more inappropriate and underutilized resources in the suburban setting. Allowing a highly trained and paid school nurse teacher to do minor first aid, take attendance, and answer the principal's phone when his secretary is at lunch, is a shameful waste of taxpayers' dollars. Psychological and social services for learning and behavioral disturbance for various reasons may still be out of reach for many suburban residents. The primary role for school health services of the future in this segment of society may be (1) to avoid duplication of services, (2) to ease communication with the access to specialized services, (3) to provide certain parent-support and group counseling services in the school where they are otherwise not available or are underutilized. For the primary care practitioner, the school is a natural setting for keeping in touch with the young family after the child passes his fourth birthday. An arrangement between a school district and the primary care practitioners of an area, could add benefits to both school and doctors. A school nurse practitioner hired by the school but released for a half to one day per week to see patients and team with the physician(s) delivering primary care, would enable her to follow-up with the physician's supervision on illnesses for which she had initiated diagnosis and treatment, provide a new dimension of services for children and families who attend that group or physician, and allow the physician to per-

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form consultative and teaming services in the school as opposed to routine cursory physical examinations.

Rural School Health Services The "last frontier" of developing health delivery systems is for rural America. The school is a logical place in which to base comprehensive primary care health services to a dispersed population. The utilization of paraprofessionals in a site where all the children of even a. widely dispersed population congregate 5 days a week, 10 months a year holds appeal. In theory, transportation links to each family (and therefore preschoolers as well as parents and seniors) also exist. Rural schools usually have fewer resources for helping children with special needs. The collaboration of health and education in this setting may be economically advantageous in providing for some of these special needs. "Newtown" Concepts The Peckham Experiment20 attempted long ago to meld health and educational, recreational, and social services to a limited neighborhood population in England. While successful, its continuation was a victim of the war and "other health priorities." The developers of some of the .~'newtowns" around the United States are keen on building and designing space considering human needs and activities, rather than along programmed institutional needs. One such neighborhood center, currently in the planning stages,9 will provide elementary education, adult education, community theater, indoor and outdoor recreation, day-care facilities, meeting rooms, and health services for preschool and school-age children. The physical layout will enhance communication and cooperation among the home, community, and school.

TRAINING FOR SCHOOL HEALTH The development of school health and primary health care services-be they urban, suburban, or rural-should match the needs of the specific population. This matching will require working closely with other disciplines. Therefore, it is important to provide for joint training of individuals likely to be involved in delivering school health services in the future. People from different disciplines trained together are more likely to appreciate the contributions of each, and perhaps are more likely to work better together during their professional lives. The list of such students would be quite lengthy, and therefore very difficult to meld into a viable training model. It might include: education (reading, special-education and learning disabilities); health education ("humanistic education," "mental health education"); family medicine; adolescent medicine; pediatric primary care; psychiatry (consultative care); social work; nursing (school nurse practitioner); psychology (school, consultative); guidance (elementary, secondary, vocational

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counseling); and allied health professionals (mental health aides, school health office assistants, and psychometricians). Such training programs should include adequate and stimulating multiprofessional faculty and exposure to advances in knowledge in the areas of child development, guidance, education, psychology and psychiatry. They should be based in a university center with its attendant resources, but also have a demonstrable community orientation, with onsite training in schools. This will aid the student in realizing the practical aspects of case management in the setting where the patient must continue to live-his school and his home. Thus, in one training program,t 8 residents and fellows in pediatrics, along with graduate students in education, combine their leaming in child development with one half day per week spent in a public school. There the medical trainee, with pediatric practitioner faculty supervision, participates in team evaluations of children identified as experiencing leaming or emotional problems. One major objective is to accomplish as much of the evaluation as possible within the school setting where follow-up and re-evaluation can be more conveniently accomplished. In another program12 pediatric intems spend a 1 month rotation in the public schools with on-site training accomplished by guidance counselors previously trained by a mental health project. The intern also meets regularly with child psychiatry staff during this experience. The curriculum for training in school health is very broad and includes growth and development, interviewing skills, family therapy and dynamics, group process, and child advocacy. One program27 has outlined the following content areas (by no means exclusive) for medical trainees in School Health: I. The Learning Process and its Disorders A. Clinical examination skills and the diagnostic process of learning disorders. B. Direct observation in school and clinic settings. C. Analysis of learning process. D. Remediation skills. E. Communication of outcome with child, parents, and school personnel. Parent counseling. F. Developmental screening and "prevention" of learning problems. II. Health Education A. A model of growth and development during this period. B. The role of the physician and medical personnel. C. Group process techniques. III. Emotional Milieu of School A. Educational techniques and methods. B. Innovative approaches. C. Research findings. D. Medical impact and the role of the consultant. IV. Delivery of School Health Services A. Role of various health professionals and paraprofessionals. B. Innovative methods of delivery. C. Evaluation of School Health Services.

Some providers of primary care are currently working as consultants in schools in the same geographic area as their practice. This connection is a third necessary ingredient in providing good training for the future

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deliverers of school health services. These physicians often have special interest in behavior, child development, and/or adolescent medicine which led them to glean what they could from residency programs, to take special electives or postgraduate courses, or (for a very few) to take a fellowship. Even those without such "formal training" but whose "attitude, personality, and community orientation"28 make them likely candidates for school physician jobs, can gain valuable training by merely committing themselves to the general principles and learning from those individuals already in the school. Continuing experience with a school (like that with a patient) is required to fully appreciate the strengths and weaknesses, and the multiple sources for helping a specific child. Group interaction, either with other physicians as in the workshop model,29 or with a multidisciplinary group, will also be helpful. This group of individuals can meet to discuss the clinical and cognitive issues involved in analyzing behavioral and learning disorders, as well as implementing the health education curriculum and program. Group members will profit from a discussion of the feelings of the individuals and the small group dynamics involved in working in such collaborative programs. This learning process of "school acculturation" for the resident, fellow and practitioner alike, requires some struggling, some floundering with new roles, expectations and experiences. However, once experienced, the new breadth and depth of understanding of children and human interaction which develops is gratifying and useful in clinical problem solving. A "DRAMATIS PERSONAE" FOR SCHOOL HEALTH No attempt can be adequate to fully describe the numerous pupil personnel who are in today's schools in supporting positions for teachers, parents, and students. Some attempt should be made, however, for the primary-care giver who, although interested, has not been in a school since attending one as a child. Many such school professionals overlap in skills and responsibilities. This condition is only a natural outcome of the separation and compartmentalization of existing educational and medical institutions. Some schools may have none or only one of these individuals, while others may have all plus additional personnel. Roles for Health Professionals in School Health Services HEALTH OFFICE AssisTANT. An allied health professional, usually with high school education or equivalency, possibly from the community in which the school is located. She would be familiar with (? even briefly trained by) the providers of illness and health care in a community. She is responsible for first aid, health room management, triage, and screening activities. PHYSICIAN (SCHOOL CONSULTANT). He helps establish health service/health education priorities; interprets and helps school board and ad-

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ministrators establish health policies. Other activities could include "teaming" with other professionals/paraprofessionals in solving pupil problems on referral from parents, teachers, or school staff; becoming involved with inservice training for school personnel, and in health education consultation. These activities can be done if the given physician possesses such interests; skills, and knowledge, or is willing to develop them. The School Nurse Practitioner role will include the ability to do a thorough developmental, historical, and physical evaluation on a child. The full range of the potential of this role is still being developed.

Other School Health Related Roles The school social worker may be the best professional to act as a coordinator of services. Skills possessed by social workers often include interviewing, data gathering, interpretation of family and group dynamics, and psychotherapy-individual and group. Guidance counselors often do many of the same activities, but their training has often focused on so-called "normal" child growth and development. Some schools are considering "differentiated staffing" (of all personnel). The application here would be to have "schedulers-registrar" type guidance counselors, "educational-job preparation" guidance counselors, and guidance counselors whose main job is to be of emotional support to needy students. The school psychologist role is difficult because he is torn between demands for individual testing and evaluation and a broader role of working with teachers, parents, and other school personnel. One possible solution is to utilize an allied professional, the psychometrician who can perform the testing functions, with the supervision and interpretation of the psychologist. An educational therapist (be he "speech," "reading," etc.) needs to know the various educational programs available, what their usefulness is, given children with specific learning disabilities, for example. This role is the most difficult to fully develop in today's system. In some cases it may be an innovative and experienced teacher who can creatively concoct an interesting and useful program for a child who has some deviant learning profile which doesn't allow him to progress "on his own." Speech therapists are also utilized in some schools both for speech and language evaluations, as well as remedial work. A health educator, specifically trained, is almost always needed for leadership and vitality in bringing coordination, parent involvement and teacher training into the health education program. IMPLEMENTATION Some beginning guidelines are required for implementation of the concepts and ideas proposed in this article for the future development of school health services.

Approaching the School Most schools have some conception of health services. They may range from virtually non-existent to merely meeting legal requirements

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for periodic physical examinations, sports, and bus driver certification. Some districts request a more consultative role of the physician, coordinating with other pupil service personnel. Ascertaining this concept will reveal how much fnput will be necessary in order to promote a school health service which is' more intimately related to other health services in the community. In initial work with schools, several key features are important: 1. Involvement, collaboration, and support of administrative staff. Without'support from the district superintendent through the principal, implementation of a joint program is next to impossible. Should this factor not be present, then it may be necessary to generate interest from neighborhood or community groups, school board members, or Parent-Teacher Association. 2. Time is needed for mutual trust and respect to be generated. The physician is, by nature and training, in a hurry, and impatient with perceived inefficient use of time. Experience has shown, however, that successful collaboration will require on the average of no less than half a day per week- even over several years time. 3. Communication. It is extremely important to be aware of verbal and nonverbal messages to the physician (and from him) in the school setting. A physician's inquiry: "How do we know the child is bright?" maybe interpreted by a school staff member as challenging their competency rather than an honest request for data. 4. Flexibility and willingness to participate as a team member is important (even if the team is solely the teacher and the physician). Physicians, often as a result of their training, may expect to possess "the answer" or "the solution" which will "cure or resolve" whatever complex problem is presented to them. It is wise to avoid this "savior fallacy" pitfall. Such attitudes only reinforce the oft present unrealistic expectations of the magical powersof the physician.

Funding of School Health Those who fund comprehensive health services are usually wary of supporting school health and health education programs as they currently exist. Rising educational costs and school taxes make it unlikely that school health or pupil service budgets will increase significantly. However, some cost benefits to the community might accrue if closer ties existed between the providers of these services. One small study of the impact of School Nurse Practitioners 11 indicated they sent home only half as many students because of illness as compared to the regular school nurse. This increased the revenue to the school district from the State based on attendance. Careful analysis cif cost productiveness of services should be obtained and scrutinized, but difficulties will present themselves. What is the cost benefit of half a day per week of the primary care giver's involvement in a school? Is it to be measured in his increased knowledge of aspects of his patients' lives he otherwise would not know? Is it to be measured in the influence on a large number of adults who deal with an even larger number of children for long periods of time (much greater than the number of children seen in a health facility)? Is it to be measured in terms of the satisfaction of an exciting, stimulating change

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of pace to intersperse the duties of more acute illness care? Is it to be measured in the numbers of elementary and high school students oriented to health careers because of the exposures and models they otherwise might not have had? National programs of funding for medical care may be a dominant factor in the future practice of medicine. The impact of such programs on comprehensive School Health Services, will have to be awaited.

CONCLUSION Schools and institutions of health care are changing. How they will interact in the future is yet to be determined. Outlined here has been a statement of the need for closer interaction than currently exists. This is mandatory if the goals of either are to be fully realized. A conceptual framework is suggested, and some considerations for training and implementation put forth. One conclusion seems warranted. Health and learning must be defined by more than the current performance of the institutions which claim to serve these ends. How primary care deliverers interact with others will determine the outcome of new attempts at defining the future of school health. ACKNOWLEDGMENT

The author would like to gratefully acknowledge the ideas, collaboration, and consultation of the following individuals: Robert]. Haggerty, M.D., Evan Charney, M.D., Greg Wright, M.Ed., Ray Coleman, M.S.W., Stan Friedman, M.D., W. C. Stebbens, M.Ed., K. Burnham, M.P.H., and Ruth Rockowitz, M.S.W.

REFERENCES 1. American Academy of Pediatrics Committee on School Health: School Health; a guide for physicians. Evanston, Illinois, 1972. 2. Biber, B.: Schooling as an influence in developing healthy personality. In Kotinsky, R., and Witmer, H. L., eds.: Community Programs for Mental Health. Cambridge, Massachusetts, Harvard University Press, 1955, p. 158. 3. Bloom, B.S.: Stability and Change in Human Characteristics. New York, John Wiley and Sons, 1964. 4. Caplan, G.: Principles of Preventive Psychiatry. New York, Basic Books, 1964. 5. Caufman, J. G., Warburton, E. A., and Shultz, C. S.: Health care of school children. Effective referral patterns. Amer. J. Publ. Health, 59:86, 1969. 6. Cowen, E.: Emergent directions in school mental health. American Scientist, 59:723, 1971. 7. Flanders, N. A.: Teacher influence, pupil attitudes and achievement, U.S. Department of Education Cooperative Research Monograph No. 12, Washington, D.C., 1965. 8. Frostig, M., and Maslow, P.: Reading developmental abilities and the problem of the match. J. Learning Dis., 2:571, 1969. 9. Gananda, N.Y.: New Wayne Communities, S. Fitzhugh St., Rochester, New York, 14605. Nader, P., and Chamberlin, R., Consultants, 1972. 10. Glidewell, J. C., Domke, H. R., and Kantor, M. B.: Screening in schools for behavior disorders; Use of mother's reports of symptoms. J. Educ. Res., 56:508, 1963. 11. Hilmar, N., and McAtee, P.: The school nurse practitioner and her practice: A study of the traditional and expanded health care responsibilities for nurses in elementary schools. Presented at American School Health Association. October 1972.

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12. Katz, S.: School health training at Duke University. Speech given at the Massachusetts Chapter of the American Academy of Pediatrics, May, 1973. 13. Krathwohl, D., Bloom, B., and Masea, B.: Taxonomy of Educational Objectives, The Classification of Educational Goals. Handbook II. Affective Domain. New York, David McKay Company, 1964. 14. Lapouse, R., and Monk, M.: An epidemiologic study of behavior characteristics in children. Amer. J. Pub. Health, 48:1134, 1958. 15. Lyon, H. C., Jr.: Learning to Feel-Feeling to Learn. Studies of the Person. Edited by Carl R. Rogers and William R. Coulson, Columbus, Ohio, Charles Merrill Publishing Company, 1971. 16. Mitchell, H. H.: School medical services in perspective. Pediatrics, 35:1011, 1965. 17. Nader, P.R., Emmel, A., and Charney, E.: The school health service: A new model. Pediatrics, 49:6, 805, 1972. 18. Nader, P.R., and Friedman, S. B.: Community schools and pediatrics, Philosophy of a collaborative approach to school health. Clin. Pediat., 10:2, 90, 1971. 19. Nader, P.R., Umansky, R., and Roghmann, K.: Frequency and nature of school problems in a metropolitan community. In Child Health and the Community; Results from the Rochester Child Health Studies. 1966-1971, Haggerty, Roghmann, Pless (ed.): Springfield, Charles C Thomas, awaiting publication, 1973. 20. Pearse, I., and Crocker, L.: The Peckham Experiment: A Study in the Living Structure of Society. London, George Allen and Unwin, Ltd., 1943. 21. Rathbone, Charles H., ed.: Open Education: The Informal Classroom. Citation Press, New York, 1971. 22. Raths, L., Harmin, M., and Simon, S.: Values and Teaching. New York, Charles Merrill, 1966. 23. Rockowitz, R., and Nader, P. R.: Some Considerations in Providing Health and Educational Services to an Urban Population. Unpublished manuscript, School Health Programs, University of Rochester, 1971. 24. Roen, S. R.: Primary prevention in the classroom through a teaching program in the behavioral sciences. In Cowen, E., Gardner, E., and Zax, M., eds.: Emergent Approaches to Mental Health Problems. Century Psychology Series, Appleton-Century-Crofts, 1967, p. 252. 25. Rutter, M., Tizzard, J., and Whitmore, K.: Education, health and behavior; Psychological and medical study of childhood development, London, Wiley, 1970. 26. Schaefer, E.: Parents as educators: Evidence from cross-sectional longitudinal and intervention research. Young Children, 27:227, 1972. 27. School Health Programs, Department of Pediatrics, University of Rochester School of Medicine; (elective description for residents); 1545 Mt. Hope Avenue, Rochester, New York 14620, 1971. 28. Senn, M. J.: The role, prerequisites, and training of the school physician. PEDIAT. CLIN. N. AMER., 12:4, 1039, 1965. 29. Sumpter, E., and Friedman, S. B.: Workshop dealing with emotional problems: one method of preventing the "dissatisfied pediatrician syndrome." Clin. Pediat., 7:149, 1968. 30. Wagner, M.G., Levin, L. S., and Heller, M. H.: The school physician: a study of satisfaction with his role. Pediatrics, 40:1009, 1967. 31. Yankauer, A., and Lawrence, R.: A study of periodic school medical examinations (series). Amer. J. Pub. Health, 45:71, 1955; 46:1554, 1956; 47:1421, 1957.

Department of Pediatrics University of Texas Medical Branch 1202 Market Street Galveston, Texas 77550