School-Based Mental Health Services in Urban Communities

The large gap between efficacy and effectiveness research has resulted in a new consensus regarding the need for research that will inform practice (National Institute of Mental Health, 1999; Weisz, 2000). Epidemiological studies indicate that fewer than 20% of children who need mental health care actually receive any services (Goodman et al., 1997). Earlier studies indicated that of those children who did receive services, fewer than 50% received the appropriate service relative to their need (Kazdin, 1996). These realities have led to two important movements in child mental health services: efforts to increase the effectiveness of services prin cipally by advocating evidence-based treatments (Hibbs & Jensen, 1997; Weisz_s 2000) and calls for alternative models for mental health services (Burns, 1999; National Institute of Mental Health, 1999)

Nowhere are these efforts more needed than in urban, low-income communities where the unprecedented rise in community violence, poverty, and substance abuse places children at high risk of becoming perpetrators and/or victims of aggressive conduct (Attar, Guerra, & Tolan, 1995; Hess & Atkins, 1999). In fact, children in low-income, urban settings are exposed to violent crime rates that exceed the national average by 4 to 10 times (Gorman-Smith, Tolan, & Henry, 1999). For example, a recent survey in Baltimore indicated that 90% of students knew at least one victim of violence, 77% witnessed violence, and 47% reported victimization by violence (Weist, Acosta, & Youngstrom, 2001). The effects of increasing community violence, gang activity, drug use, and poverty place urban, minority children at substantial risk for mental health difficulties (Gorman-Smith et al., 1999)

The effects of community violence on parents may also mediate the impact of community violence on children. Violence and poverty affect parents' ability to monitor and discipline their children consistently and to provide needed support and nurturance (Gorman-Smith et al., 2000). Inner-City children's exposure to violence predicted increases in aggression and depression at a 1-year follow-up, even after controlling for prior levels of these problems (Gorman-Smith & Tolan, 1998). However, family support moderated the effect of community violence, such that in families with high levels of parent-child conflict, high-witnessed violence had no additional influence on antisocial outcome (Miller et al., 1999)

With the advent of welfare reform, urban families have been facing these extraordinary pressures with the added strain of diminishing mental health services and community-based resources (Knitzer et al., 2001). A decade ago, a nationwide survey of parents found that those living in urban, low-income communities reported less than half the access to after-school programs as compared either to parents (either poor or nonpoor) living in nonurban communities or to nonpoor families living in urban communities (National Commission on Children, 1991). More recently, Halpern (1999) surveyed after-school programs in low-income communities and found that there were only enough programs to provide for fewer than one-third of families in need of services. The lack of community resources exacerbates the already pernicious effect of poverty by increasing parental burdens to provide for their children's safety (Jarrett, 1995). Not surprisingly, prevalence rates for children's disruptive behavior in low-income communities are almost three times the national estimates (Tolan et al., 1997), placing it among the most significant mental health problems in these communities (Bell, 1997)

The urgent and unique needs of low-income, urban families demand a response from the mental health community in the form of accessible, effective, culturally sensitive, and ecologically meaningful services. In this chapter we will present the case for how school-based services can overcome obstacles to services for urban communities and the rationale for a school-based services model focused on keeping children, parents, teachers, and community members invested in services that promote healthy outcomes. As we will describe, given the enormous mental health needs of children and families living In these communities, It Is important that school-based services are integrated with more traditional social and clinical services to form a coordinated mental health services system