Defining the problem.

Wassef, Adel ; Ingham, Denise ; Collins, Melissa Lassiter 等

Early recognition and management of emotional distress and behavioral problems in high school students present a great challenge. This section addresses the prevalence and seriousness of this issue as well as its relationship to dropping out of school. It also addresses how psychosocial stressors impact on students' well-being and ability to function.

To place the issue of emotional distress and behavioral problems in high schools into perspective and devise practical solutions, it is important to evaluate the magnitude of the problem. In a study of 497 adolescents from three high schools in a large metropolitan area in the Midwest, representing a broad socioeconomic spectrum, Offer et al. (1991) noted that 22% suffered from psychosocial distress. Frymier and Gansneder (1989) evaluated the records of 22,018 students and found that one fourth to one third were "At-Risk," meaning that they met six or more of 45 criteria previously identified as having a negative impact on student outcome. The social arrangement in which the students studied/lived was typical of, if not better than, that encountered in an average school. Several of the 45 criteria used can be linked or attributed to societal changes which increased psychosocial pressure on adolescents, e.g., higher divorce rate.

Despite the prevalence of the problems, there is a dearth of long-term studies examining the effect of psychosocial burdens on the future development of adolescents. However, comprehensive, prospective, longitudinal study of health, development, and social adjustment from the age of 4 to 18 years was carried out in Uppsala, Sweden to assess the effect of psychosocial burdens on 1,715 children born in 1965 (Mell-bin et al., 1992b). The analysis showed that 11.8% had a severe psychosocial burden which could hamper their future life as adults.

DuBois (1992), in a two-year longitudinal study, examined the relationship between stressful life events and social supports to psychological distress and school performance among 166 early adolescents (mean age = 13.5 years). Both stress and support variables made significant contributions to the prediction of subsequent psychological distress. Stress also made a significant contribution to the prediction of subsequent school performance. Evidence of reciprocal and interactive linkages also was found, including effects of psychological distress and school performance on subsequent stresses and supports, as well as greater adaptive impact of school-based supportive resources under conditions of heightened risk outside of school. Thus, stress can affect behavior and performance especially at times of increased vulnerability.

Since levels of stress increase as students enter high school, they are forced to cope with these as well as the many simultaneous biological and social definition changes which occur at this stage of their life (Simmons et al., 1987).

Several stressors contribute to one of the most serious behavioral problems - dropping out of school (Phi Delta Kappan, 1989). These include pressures from the family (e.g., family dissolution), peers (e.g., pressure to use drugs or to become sexually active which increases the risk of pregnancy), and culture (e.g., the role expectation of taking care of certain family needs rather than finish school). Also, identity conflict arises between "the adolescent-as-student" and "the adolescent-as-sexual-being" with the latter typically being dominant. The need for a source of income is also an important factor (Phi Delta Kappan, 1989) especially among Hispanics who accounted for over one third of the high school dropout rate in 1991 for those between the ages of 16 and 24. According to Celis (1992), the Hispanic students' dropout rate is four times that of Caucasians.

Each year 700,000 students drop out of school permanently, which has countless devastating effects; for instance, approximately half of the heads of welfare families, two thirds of the prisoners, and 80% of the unwed teenage mothers are school dropouts. In addition, dropouts compose a large portion of the untrained workers who cost U.S. companies $25 billion a year in remedial training and productivity losses (Cordtz, 1989).

Tidwell (1988) conducted interviews in the homes of 374 urban high school dropouts to determine their primary reason for leaving school. Respondents from both genders and five ethnic groups reported the following main reasons: poor grades (39.9%), family reasons (39.1%), being over 18 years of age (33.2%), work responsibilities (29.8%), and teacher problems (24.3%). For African-Americans, family reasons were more common than poor grades. Students who dropped out rated socialization, teachers, activities, counselors, and sports as "best" in high school while they rated boring and uncaring teachers, crowded classes, and gang violence as "worst." Virtually all of the dropouts (99.1%) agreed that learning is important. Thus, these and other relevant factors offer potential educational and psychosocial interventions which may reduce the incidence of serious behavioral problems among students.

A Note on Terminology

Students exposed to psychosocial stressors which predispose them to emotional distress (e.g., physical abuse) and those whose behavior may place them at jeopardy (e.g., using drugs) are usually classified as "At-Risk." Frymier and Gansneder (1989) defined students as at-risk "if they were likely to fail either in school or in life." More specifically, "if a student fails a course in school, is retained a grade, or drops out of school, that student is at risk. Likewise, if a child uses drugs, has been physically or sexually abused, or has contemplated suicide, that child is at risk." According to the authors, at-riskness is a function of "what bad things happen to a child, how severe they are, how often they happen, and what happens in the child's immediate environment."

Although it is commonplace to use the term at risk in both the scientific and administrative arenas, there is no consensus on the exact definition. In most contexts, it is used to describe students who have a higher chance of negative outcome such as failing in school or life or dropping out of school, but emphasis on the emotional distress criterion, the behavioral manifestations, the adverse environment, and the guarded prognosis varies among different researchers and administrators. Also, there is no agreement on the number and severity of these criteria. Further, the factors which provide a protective effect are frequently ignored despite their importance. For example, a 17-year-old adolescent with an IQ of 130 who can discuss with her supportive affluent family her being pregnant may be less at risk when compared to a 14-year-old with an IQ of 85 who is impregnated by her sexually abusive stepfather and who cannot discuss the issue with her alcoholic nonsupportive mother.

There is a strong association between emotional distress, the factors which lead to such distress, and being characterized as at risk. For example, negative self-esteem, suicidal ideations, and physical and sexual abuse were common complaints (Frymier & Gansneder, 1989). Behavioral problems also prevail, e.g., suspension, drug and alcohol use, selling drugs, lack of participation in extracurricular activities, and pregnancy (Frymier & Gansneder, 1989). The prevalence of such problems noted in that study are believed to be conservative. At-risk students who actually dropped out also had five times as many serious discipline incidents as did students who did not drop out (DeRidder, 1991).

Other characteristics of at-risk students have been identified. Coon et al. (1992) noted the existence of a small group of boys who appeared to be significantly at risk for conduct disorder. This group was significantly associated with a difficult temperament in infancy, poor parental conduct when the parents were young, and with high achievement orientation in the home environment. DeRidder (1991) noted that a typical disruptive student who was likely to drop out or be suspended or expelled was a black male with a low sixth-grade achievement score, a low overall grade point average and verbal aptitude score, and who had not been referred for psychological services. Students who were held back a grade and those who were suspended were more likely to drop out. Students with learning disabilities were also noted to be at risk for dropping out (Phi Delta Kappan, 1989). Frymier and Gansneder (1989) pointed out that a significant number of the at-risk students were at least one year older than a typical student in that grade in school or to have been retained in grade or suspended from school at least once in the previous year. Also represented in the at-risk group were those who failed at least one course, missed 21 or more days of school in the previous year, attended three or more schools during the previous five years, lived in homes in which English was not the primary spoken language, or lived with family members who had used drugs the year before.

DeRidder (1991) used the term pushouts to describe a subgroup of the dropout population. He argued that many teachers hold disproportionately negative or low expectations of at-risk students. Those teachers sent signals indicating that the students were neither able nor worthy to continue through graduation and frequently encouraged them to leave. According to DeRidder, many pushouts share similar characteristics which may predispose them to the likelihood of failure, such as low reading and math achievement in the early grades, early academic retention, broken or unhappy homes, undereducated parents, low socioeconomic backgrounds, and minority or ethnic origin.

Thus, emotional distress and behavioral problems are prevalent in high schools, but it is hard to determine the exact relationship between emotional distress, behavioral problems, dropping out of school and being classified as at risk in the absence of a consensus on definitions and severity criteria of the term. Until a clear definition and operational criteria emerge, it may be preferable not to use it altogether in outcome studies. The authors prefer instead to use reports of emotional distress expressed or manifested by the student or noted by others, e.g., frequent crying and behavioral problems reported by self or others, as inclusion criteria when studying efficacy of interventions. This approach parallels that taken by the Research Diagnostic Criteria and the DSM-III to increase interrater reliability rather than continuing to use the vaguely defined, though sometimes more etiologically linked, syndromes described in DSM-II. Using this approach would allow for a better definition of the populations studied and, as a result, a more effective evaluation of the impact of different psychosocial factors on students' emotional and educational outcome.

It is clear that certain undesirable behaviors, cognitive patterns, interpersonal events, and feelings are associated with each other, with psychosocial stressors, and with a higher risk for serious behavioral manifestations including dropping out of school. These usually have serious educational, financial, and social implications for the student.

Difficulties in Managing Emotional Distress and Behavioral Problems

Success in current management of emotional distress and behavioral problems in high schools has been hampered in three major ways: (1) factors which exacerbate the situation; (2) overemphasis on behavior modification in the school management system; and (3) a tendency of the mental health system to focus on treating a limited number of persons with serious problems rather than a large number of students with psychopathology at its earlier stages.

Factors which exacerbate emotional distress and behavioral problems. Irwin and Vaughan (1988) predicted that an increasing proportion of adolescents in the 1990s would be raised in impoverished and disrupted family environments and that more individuals would enter adolescence with an alienated view of the world which, in turn, might place them at greater risk for disengagement from family and other adults. The growing divorce rate and number of single parents, and families with two working parents and teenage mothers, have increased the number of adolescents under psychosocial pressure. These same factors have resulted in abdication of the family from its role in managing the consequent emotional distress and behavioral problems and turning it over to the schools without increasing that system's resources. This trend has been associated with a gradual shift of societal focus from conformity to individualism, which has restricted the schools' ability to enforce rules. Also, increasing emphasis on competitiveness rather than group harmony and cohesiveness has created greater pressure on students to achieve what they perceive to be success. Success in some other cultures is measured mainly by the ability of the individual to participate in activities which contribute to the well-being of the entire group, e.g., many Japanese students are involved in cleaning the school at the end of the day. Success in our schools, on the other hand, is mainly measured by the individual's ability to achieve personal goals even within team-based activities such as group sports. Thus, having more money from selling drugs, for example, could provide some adolescents with a sense of success. The emphasis on individual achievement, at times, comes at the cost of group belonging and loyalty to the family or society. For example, frequent moves to further parents' career goals may affect the children's sense of security and their perception of how important their needs are in the family unit. It also may endanger their sense of belonging to the family. As a result, membership in a gang may then provide some adolescents with a sense of belonging and caring which may not be achievable otherwise due to actual or perceived parental desertion.

The widening of the gap between rich and poor within the same school has increased tension and encouraged socially undesirable behavior as a reaction to the perceived inequities. In addition, increased violence in society, gang-related activities in schools, and racial and social tension frequently create an intimidating environment for both students and teachers who may find it safer to look the other way rather than confront certain behaviors. Drug and alcohol abuse by parents (as well as by the students) and its consequences also complicate the picture.

Some educators claim that the tendency to accommodate students with learning difficulties within regular classrooms results in a "watering down" of the curriculum for all students, decreasing students' engagement in school work; this accommodation has made school boring for many students and reduced their motivation to excel. It reduces teachers' morale. Accommodation also occurred at the institutional level through the bending of school rules. As a result, students frequently believe that some kind of "arrangement" can always be worked out and that they are not required to be even moderately engaged with their school work (Phi Delta Kappan, 1989).

Limitations of the schools' management system. Students who perceive themselves to be distressed may elect to see a school counselor. However, counselors usually focus on such matters as providing advice on study habits, career choices, and course selection. Some schools with greater means employ psychologists or counselors who offer supportive therapy for a limited number of students. But considering the magnitude of the problem, their role is usually limited to identifying psycho-pathology and referring the student to an outside mental health agency, or offering brief in-school counseling, typically limited to one visit per month. Although teachers are permitted to refer students with serious problems, most schools do not have a screening process to identify students who need help. Thus, because in-school diagnosis and treatment not related to education are minimal, these are generally performed outside the school system.

With regard to the management of students with behavioral problems, the school system has traditionally relied mainly on behavior modification, particularly positive and negative reinforcement, regardless of the etiology of the problem. For example, a student who behaves well may receive better grades or be complimented for the good behavior, while a student who commits an infraction of the rules is reprimanded, punished or pushed out of the school system as discussed earlier (DeRidder, 1991).

The increase in behavioral problems indicates that the current behavior modification system has had limited success. In addition, some behavioral problems cannot be handled under the current system, e.g., achievement below expectations based on the student's Intelligence Quotient cannot entail consequences other than lower grades unless the student actually fails. Crying in the classroom, perfectionism, and repeated attempts to please others at one's own expense are examples of behavioral problems which may not always be possible to classify as "wrong and punishable."

Obstacles to using the current mental health system to address the problem. The mental health system has frequently been proposed to address emotional distress and behavioral problems in the school system. However, high prevalence of problems and the limited resources available have limited use of the mental health system to students with financial resources and those with serious problems, e.g., when the potential for suicide and violence is present. Several additional obstacles stand in the way of using the mental health system in schools. These include:

1. The stigma of mental illness: "Normal" adolescents in distress typically prefer help from non-mental health professionals, e.g., parents, peers, favorite teachers, school counselors or trusted adults (Offer et al., 1991). A referral outside the school system may be perceived as rejection, especially when behavioral problems are involved. Additionally, parents and students often have justified concerns about the stigma attached to the receipt of a psychiatric diagnosis which is a prerequisite for receiving services and for third-party reimbursement in the mental health system. Some parents and school administrators do not encourage diagnosis and treatment of mental disorders in the school setting due to concerns about the effect of labeling and loss of confidentiality. Additionally, parents frequently do not want their children associating with "problem children" in the mental health system. Mental health services may not always coincide with the perceived needs of the parents. For example, service providers and families of youths released from a state psychiatric facility consistently agreed on three service areas of high need: psychotherapy for the child, family therapy, and parenting skills training; but families perceived a need for a number of other services that are not traditionally provided by the mental health system, such as after-school recreation activities and self-help and support groups for the child (Solomon & Evans, 1992).

2. The cost of providing traditional mental health services once a diagnosis is made is beyond the budgets of most schools and many families. This may limit recognition and management to the more seriously distressed and disruptive students.

3. Although there is an emerging consensus that the treatment of some severe psychopathology should be handled with the help of mental health professionals, "territorial disputes" often arise between mental health professionals and educators as to who is best qualified to handle the milder (e.g., adjustment disorders) and subsyndromal states, as well as "normal" adjustment difficulties (e.g., inability to communicate effectively with the opposite sex or dealing with a school "bully").

4. It is frequently difficult to differentiate between the normal emotional instability and maturational and physiologic changes and the milder (subsyndromal) forms of mental illness in adolescents (Offer et al., 1990). This may lead to delayed recognition of psychiatric problems and referral of the student for help.

5. Many teachers have limited knowledge about psychotherapy and psychotropic medications which may be used by mental health professionals. School personnel rely heavily on behavioral descriptors and concepts, while mental health professionals tend to group behaviors and feelings under diagnostic categories. This increases the communication difficulty between them. In addition, the relationship among emotional distress, behavioral problems, and standard psychiatric nomenclature is very complex. Some behavioral problems can be more clearly linked to specific psychiatric diagnoses, e.g., a long-standing inability to sit still is commonly present in Attention Deficit Hyperactivity Disorder. Frequent crying in the classroom and poor academic performance, on the other hand, can result from different diagnostic categories, e.g., Major Depression, Adjustment Disorders, or can represent a nonpathological response to losing a boyfriend or girlfriend. Symptoms of psychiatric illnesses and certain mood states frequently lead to behavioral manifestations, adding to the complexity of making a diagnosis, e.g., the irritability associated with depression frequently results in fighting which may then be identified as the primary rather than secondary problem. Other behavioral manifestations may not reflect pathology in the student, but rather in the student's environment, e.g., parental discord and physical and sexual abuse frequently are manifested as behavioral problems in adolescents. In some cases, the student may qualify for an Axis I diagnosis, e.g., Adjustment Disorder with Depressed Mood, receive a V code diagnosis, present at a subsyndromal level, or even qualify for no psychiatric diagnosis at all (e.g., fears due to having to face an abusive parent). At times, behavioral problems can ensue when an adolescent attempts to assert individuality or reflect a normal maturation process in an environment which resists such natural processes (e.g., desire to date at an age which some parents may consider premature though society considers it acceptable). Other manifestations can result from attempts by the adolescent to adjust to perceived adversities in the environment (e.g., an adolescent who joins a gang to achieve a sense of belonging).

In essence, although some behavioral manifestations may be easier to understand and treat when linked to specific psychiatric diagnoses, others (especially the milder ones) may not. Emotional distress, whether linked to a specific psychiatric diagnosis or not, may manifest as behavioral problems, especially when the distress is ignored. Relying on expressed or observed emotional distress and early behavioral problems rather than waiting until the student meets the full syndromal level of the diagnostic criteria ensures early intervention. In this regard, current mental health services have not been completely successful in the school setting. This makes it necessary to look for alternative ways to detect and manage emotional distress and milder behavioral problems before they precipitate the kind of serious behavioral problems which qualify the student to receive traditional mental health services.

Could school-based peer support groups be effective for early intervention? Awareness of the enormity of the problems that face adolescents in accessing health care and support led the Office of Technology Assessment (OTA), an analytical arm of the U.S. Congress, to recommend school- or community-based comprehensive health services for adolescents (Dougherty et al., 1992). The prevalence of the problem strongly argues for a low-cost gate-keeping mechanism which would avoid exhausting the already limited mental health services available to adolescents.

A prolonged supportive environment with graded steps toward autonomy was recommended by a study group led by Irwin and Vaughan (1988) to promote healthy adolescent development. The group argued that (a) early separation and emotional emancipation from family or significant adults could have a negative effect on adolescents; (b) this negative effect can increase the risk of alienation or susceptibility to negative peer influences and participation in "unhealthy" behaviors; and (c) factors associated with early separation included large and impersonal school environments, immersion in a negative peer culture, and tolerance of social deviance. The study group concluded that a prolonged supportive environment with guiding adults is beneficial. The interdependence promotes positive social behaviors and skills and offsets the negative impact associated with "transitional behaviors" such as smoking and drinking.

Recent studies linking social support/social resources and health outcomes showed that people are better off in supportive social environments. Social support was noted to have a positive association with adaptation and mental health. Longitudinal studies demonstrated the predictive power of social support on future depression and personal control (reviewed by Eggert et al., 1990). Since intervention acceptance is crucial to the success of a program, patterns of seeking help by adolescents may provide evidence that high school students would attend and benefit from peer support groups. The following points need to be considered:

In a study of 497 adolescents from three high schools in a large metropolitan area in the Midwest representing a broad socioeconomic spectrum, Offer et al. (1991) noted that the characteristics of the persons offering help (rather than the level of emotional disturbance) predicts adolescents' response. "Normal" adolescents were not likely to ask for help from traditional mental health resources. They prefer parents and friends (contrary to disturbed adolescents who utilize mental health professionals as well as parents and friends). In fact, adolescents very rarely seek help from mental health professionals, and most of the 20% who suffered from emotional disturbance did not receive any help. Some adolescents had no one with whom to discuss personal problems, and the majority of disturbed adolescents had not come into contact with a mental health professional (except adolescents with eating disorders). Adolescents were also unaware of the majority of professional help agencies available in the community. In the third part of this series we will present our own data which confirm Offer's assertions that students prefer in-school support groups to out-of-school groups (or have access only to the former).

The degree to which adolescents rely on others for help has changed somewhat over the past three decades. Identical questionnaires administered to samples of high school students (N = 570) in 1963 and 1976 showed no monolithic orientation. Teenagers showed lowest peer orientation in 1963, highest in 1976, and intermediate in 1982. While many adolescents would seek help when they needed it, the nature of the issue seemed to determine who would be contacted. Educational, career, and financial concerns were more parent oriented, but almost all social activities were peer oriented (Sebald, 1989).

In addition to family and peers, Offer et al. (1991) indicated that adolescents in a low-income southern rural area most frequently chose guidance counselors as helping agents for problems related to family and getting along with others. Family and friends were followed by school personnel, physicians, and ministers as the most frequently sought in response to the open-ended question "If you had a problem with your health or your emotions, you would want to talk with what adults?" Regarding ratings of helpfulness, approximately 90% indicated that friends and family were helpful "somewhat" or "a great deal." These were followed by doctors (75%), nurses and other health professionals (69%), teachers (63%), guidance counselors (59%), clergy (58%), and principals (40%).

A school-based suicide prevention program reported by Vieland et al. (1991) also showed the importance of friends as support network. In answer to questions related to helping friends who felt depressed or who were thinking about suicide, the students indicated that they would do so by themselves or together with other friends rather than call on adults to help. The majority said that they themselves would talk to the depressed (85%) or suicidal (56.1%) friends. The majority (72.3%) also said that if they had bad emotional or personal problems they would talk to a friend. A smaller percentage said that they would talk to a parent (40%), siblings (24.6%), school counselor (16.9%), or other family members (13.8%).

Taken together, these studies emphasize the role of friends (in addition to family) in providing support, and indicate adolescents' willingness to provide and receive support from friends. Fortunately, intimacy of friendship becomes increasingly important during early adolescence allowing them an additional source of help (Buhrmester, 1990) for neutralizing the added stress experienced as they enter high school. Adolescents seem to favor utilizing friends and trusted adults (especially school personnel) to using mental health professionals. Thus, if adolescents are capable of sufficient self-disclosure with these individuals and an acceptable format is devised, then an avenue for verbalizing distress and receiving support will have been found.

Papini et al. (1990) discussed self-disclosure in adolescents noting that: (1) self-disclosure is shaped in the family, extends to other relationships, and increases with the perception of parents as warm and nurturing, and (2) disclosure to friends increases with age and is associated with the adolescent's self-esteem in the peer context and identity development. The role of confidentiality was emphasized by Offer et al. (1991) who noted that the majority of adolescents experiencing emotional distress would go to the school-based clinic for help with their problems and concerns, but only if confidentiality was guaranteed.

Characteristics of an Ideal In-School Early Intervention Program for Adolescents

Since adolescents are already affiliated with the school system and are willing to receive services there if confidentiality is guaranteed, it is logical that prevention and early intervention programs be school-based. Students do not become affiliated with other systems, e.g., the welfare or justice systems until their problems are more pronounced, and these systems are not primarily geared to address the underlying psychosocial problems which contribute to the behavioral problems. The prerequisites for success are that the programs:

1. Should use available resources, such as the school student assistance program, since external agents are frequently viewed with suspicion. Community-based leadership and "ownership" of interventions enhances the sustainability of effective approaches and the commitment needed for success of such programs (Levine et al., 1992).

2. Can be sustained within the limited school budget, e.g., using volunteers and teachers to facilitate support groups (rather than highly trained mental health professionals conducting individual counseling).

3. Should conform to the prevailing values of the community to ensure support by the teachers and school board.

4. Fit within the guidelines of the school board and the state board of education and be compatible with the prevailing behavioral approach in the school system. (Making a diagnosis and providing psychotherapy in the school is more difficult to implement in some districts, while making behavioral observations, such as noting withdrawal and lack of participation in activities, and making support groups available may meet less resistance.)

5. Fit into the school curriculum, e.g., formulated on a semester basis rather than on a fixed number of sessions; frequent and long meetings should be avoided. Daily sessions may be viewed by some as interfering with the educational role of the school, and are less likely to be supported by teachers and school administrators.

6. Demonstrate academic value (e.g., improve grades) and make schools safer and more harmonious for both students and teachers (e.g., decrease the need for disciplinary action) while improving attendance and reducing dropout rates.

7. Protect the confidentiality of the students.

8. Be simple enough to replicate without much training or application of sophisticated techniques.

9. Be promoted as a way to provide support for students who are in distress rather than for controlling "problem students" or those with "mental problems" in order to increase acceptability and reduce stigmatization.

10. Have an early screening process which identifies students who require professional mental health services, and a mechanism for alerting the school counselor if a student deteriorates.

11. Should not be restricted to students previously identified as at risk since, as Mellbin et al. (1992ab) noted, school records of preadolescents did not contain adequate information for determining who was at risk.

CONCLUSIONS

1. A significant proportion of students suffer from emotional distress and behavioral problems which can lead to more serious behaviors, e.g., dropping out of school. Since there is a lack of consensus on the definition of terms, it is important to use the subjective complaints and behavioral descriptors until greater agreement is reached as to who is at risk.

2. Considering the magnitude of the problem, budgetary limitations, and the patterns of seeking help by adolescents, traditional mental health services are not likely to succeed in providing prevention or early intervention. Currently, traditional mental health services appear to be reserved for those with financial means or those with severe problems. Thus, the limited resources hinder recognition of emotional problems in adolescents.

3. Students are inclined to approach family, friends, and school personnel for assistance. Also, they are not adverse to receiving help in the school setting if confidentiality is assured.

4. The current behavior modification system in the schools appears to fall short of its goal of controlling behavioral problems in the school setting. It is also not suited for dealing with emotional and nondisruptive problems. In order to deal with the new responsibilities acquired by/imposed on the schools, a new system needs to be developed to address emotional distress and behavioral problems.

5. Considering that the normal maturational process in adolescents leads to greater intimacy in relationships with peers, and the fact that adolescents frequently reach out to peers for help, more consideration should be given to assessing the use of peer support groups in high schools. If proven effective, they can serve as a more economical approach to reaching the majority of the students in distress before more serious problems arise. The proposed programs should not be considered replacements for traditional mental health services but to complement them by dealing with the milder cases and identifying those that are potentially problematic for appropriate referral to more intensive levels of care.

Since no recent literature review is available on the program aimed at remedying emotional distress and behavioral problems, including dropping out and at riskness, this will be the topic of the second article of this series. This will be followed by the authors' own preliminary results of a three-year, school-based volunteer-facilitated peer support program.

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This work was supported, in part, by the Dickinson Independent School District. The authors thank all of the volunteers who donated their time as peer support group facilitators, the Dickinson High School Board, the District Superintendent Bill Borgers, Ph.D., the School Principal Ron Ahlhorn, M.S., Louise Bell, Ed.D., and Jon VanHaalen, M.S. for their effort and support.

Melissa Lassiter Collins, B.A., University of Texas Medical Branch, Galveston, Texas.

Denise Ingham, M.D., Harris County Mental Health Mental Retardation Authority, Houston, Texas.

Gayle Mason, B.A., Dickinson High School, Dickinson, Texas.

Reprint requests to Adel Wassef, M.D., Department of Psychiatry and Behavioral Sciences, University of Texas, Houston, Psychiatry Dept., P.O. Box 20708, Houston, Texas 77225.