Frontline Report

For adolescents who weather a mental health emergency or psychiatric hospitalization, the transition back to school and community can be an overwhelming challenge. Often discharged from brief hospital stays before symptoms have remitted, teens return to the community at high risk of relapse. Lack of intensive aftercare resources and a fragmented service system compound the difficulty of resuming academic work and reintegrating into the social milieu.

In Brookline, Massachusetts, an urban community with great economic and cultural diversity, school staff, a local community mental health center, and family members worked together to develop a novel approach for students reentering school. They believed that a timely intervention after psychiatric hospitalization, substance abuse treatment, a serious medical event, or incarceration might improve reintegration and prevent relapse, academic failure, and derailment of socioemotional development. About 120 (6 percent) of the school's 1,900 students were thought to be in need of such services.

The program provides intensive school-based support and care coordination during the first six to ten weeks after discharge. Staff consists of two master's-level social workers—called clinician coordinators—and a classroom aide. The program is located in a dedicated classroom, the "home base." Each clinician coordinator focuses on six to eight students at any given time and has the flexibility to provide the time-consuming set of services needed by students and their families. Services can include assessment, counseling, family support, case management, care coordination, and educational planning. Students are referred to the program by school guidance counselors or other staff; involvement is entirely voluntary.

Before reentry, the clinical coordinator meets with students and their families at school, their home, the hospital, or another community setting. Working with students, parents, mental health providers, teachers, and administrators, the coordinator helps parties reach consensus on short-term goals and plans, which can include schedule changes, referral to mental health or medical services, educational assessment, and tutoring.

Once the student has returned to the classroom, the clinical coordinator provides ongoing assessment and emotional support for students and families while facilitating communication between school personnel, mental health and substance abuse treatment providers, pediatricians, court personnel, and staff from other agencies. The full-time classroom aide helps students organize and complete assignments and keeps teachers informed about students' current status and capabilities. The home-base classroom offers a safe and manageable respite between classes and a quiet work environment and often serves as a first step toward reintegration. In addition to working with families individually, the program sponsors a parent support and psychoeducation group.

From the inception of the program in October 2003 through November 2005, a total of 99 adolescents were served. Most students had multiple diagnoses; the most frequent were mood disorders and substance abuse. Twenty-one students had special-education status. Length of involvement ranged from two to 20 weeks (median of eight weeks), during which, on average, students required 21 hours of care coordination and seven hours of family support.

Three months after joining the program, 88 students had remained successfully in the community for the entire period; 11 required rehospitalization. Follow-up information on educational status at three months was available for 67 of the students, all of whom had resumed studies. Of these, 59 students (88 percent) were attending school regularly and eight (12 percent) were receiving home tutoring. Students' functioning status improved significantly during their tenure in the program, as measured by the total score on the Child and Adolescent Functional Assessment Scale (CAFAS). The total CAFAS score decreased from a mean of 89 at admission to 64 at three-month follow-up (t=6.00, df=44, p<.01; range of possible total CAFAS scores: 0 to 240). Parents reported that having a single, reliable, and accountable point of contact, consistent communication, and assistance in negotiating complex systems of care resulted in substantial lessening of stress and improved their relationships with the school and the agencies involved. Direct program costs are estimated to be $1,400 per student, a modest amount compared with the expense of hospital care or out-of-school special education placements.

This innovative and replicable school-based program lies in the continuum of care between hospital and outpatient services. It is an effective mechanism to prevent relapse and hasten reintegration of students into their community and resumption of academic work. Because the program is fully integrated into the school environment, access is easy, acceptance of services by students and families is enhanced, and staff members are available immediately to respond to crises and emergencies. Individualized, flexible plans emphasize coordination and collaborative use of resources.

Our documented success in helping a population of students with great ethnic and clinical diversity suggests that this program design may be applicable to a broad range of schools and communities that are faced with the daunting task of reintegrating and caring for youths with very serious emotional disorders.

Dr. White is program director of the Brookline High Risk Youth Taskforce (BHRYT) and clinical director of the Brookline Community Mental Health Center, 43 Garrison Road, Brookline, MA 02445 (e-mail: [email protected]). Ms. Langman, who is the BHRYT evaluation consultant, is chief executive officer of the Lee Mental Health Center, Fort Myers, Florida. Ms. Henderson is BHRYT program coordinator.