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.