School Based Health Centers - Head to Toe · School Based Health Centers ... Children from families...

School Based Health Centers

“Lets toot our horns for a bit”

School Based Health Centers are poised to assist with the development of positive health behaviors by providing wholistic services (Shuler, 2000).

Kerns et al (2011) found that there are maleable health risk factors associated with academic achievement that can be addressed within a SBHC:

Unmanaged chronic health conditions

Substance abuse

Attention problems

Risky sexual behaviors

Adjustment problems

School Based Health Centers “Lets toot our horns for a bit”

SBHC’s serve as an important health care safety net for

disadvantaged and medically underserved youth

(McNall et al, 2010).

SBHC’s users reported significant improvement in

student reported quality of life over 3 years when

compared with students in non- SBHC schools

(McNall et al, 2010)

Systems/Policies/Barriers

Social Problems often associated with indigent youth

create a need for special programs, and schools

represent an ideal institution for delivery of public

services to youth (Rienzo et al, 2000).

Public policy reforms often are resisted in the name of

moral tradition or, more recently, “family values”.

Such “communal protest” appears to generate intense

opposition to SBHC’s (Rienzo et al, 2000).

Systems/Policies/Barriers

SBHC’s, by their sheer convenience and location, are designed to overcome many health care access barriers (Guo et al, 2010).

SBHC’s have the potential to implement health care models for children and adolescents that fully integrate prevention-primary, secondary, and tertiary- into clinical care and that address biological, social and economic determinants of health (Clayton et al, 2010).

School Based Health Center

Populations

In many SBHC’s, the majority of the enrolled are

uninsured, or low income 50-90% (Guo et al, 2010).

Children from low income families have a higher

prevalence of mental health problems than other

children (Guo et al, 2008).

Children from families on welfare were almost 2x as

likely to manifest impaired health and behavior ratings

(Guo et al, 2008).

School Based Health Center

Populations

Socioeconomically disadvantaged children were often inadequately covered for health services including mental health, substance abuse treatment, and preventive health visits (Guo et al, 2008).

Children from families with very low incomes and/or receiving welfare were significantly more likely to have at least 1 of 4 disorders: hyperactivity, conduct disorder, emotional disorder, and somatization (Guo et al, 2008).

Incidence and Prevalence Data

Percent of persons 12 years of age and over with any illicit drug use in the past month: 8.7% (CDC factstats,2009).

Percent of persons 12 years of age and over with marijuana use in the past month: 6.6% (CDC factstats,2009).

Percent of persons 12 years of age and over with any nonmedical use of a psychotherapeutic drug in the past month: 2.8% (CDC faststats, 2009)


The 2011 CDC National Youth Risk Behavior Survey (YRBS): 15,425 usable surveys, 158 schools, 43 states, 81% school response, 87% student responsiveness.

Ever used cocaine one or more times in life: 6.8%

Ever used inhalants one or more times in life: 11.4%

Ever used heroin one or more times in life: 2.9%


Ever used methamphetamine 1 or more times in life:

3.8%

Ever used steroids 1 or more times in life: 3.6%

Ever injected drugs with a needle 1 or more times in

life: 2.3%

Ever been offered, sold or given drugs on campus

within year of survey: 25.6%


Prevalence of add/adhd in school age children: 3-6% (Guo

et al, 2010).

Lifetime prevalence rates of alcohol use/month for 8th, 10th,

12th graders: 41%, 62%, 73% (Griffin et al, 2010).

Lifetime prevalence rates of marijuana for same grades are:

16%, 32%, 42%.

Over 40% of adults who reported early aclohol use (before

age 14) met criteria for dependence vs. 10% for persons who

waited till after age 20 (Winters et al, 2007).

Intervention Themes/Concepts

Disengagement from school and poor student-teacher relations were associated with higher drug use (Fletcher et al, 2008).

Truancy, suspension from school, frequent changes in school, were associated with higher drug use (Fletcher et al, 2008).

Preventative interventions show consistent evidence of positive effects on substance abuse in school settings (Brown et al, 2007).

Intervention Themes/Concepts

Skills-focused programs appear to have a positive effect

on drug knowledge, decision making, self esteem, and

& peer pressure with a 20% reduction in marijuana and

55% “hard drug” use reduction (Brown et al, 2007).

Brief interventions have the highest effect sizes among

all treatments for alcohol and drug use/dependence

(Winters et al, 2007).

Culture/Socialization of

Substance Abuse

Adolescents tend to select peers that share their own substance use/abuse habits (Kuntsche et al, 2006).

Adolescents initiate or increase use when associating with substance abusing peers (Kuntsche et al, 2006).

Ease of use and availability has been shown to increase consumption of substances (Kuntsche et al, 2006).

Environments where substances are readily available and provide opportunity for use, creates a social atmosphere in which substance is normalized (Kuntsche et al, 2006).

Culture/Socialization of

Substance Abuse

Messages of abstinence, harsh penalties, or harm-minimization messages all demonstrated lower levels of self reporting of substance abuse, which implies that schools that implement clear policy messages can be effective in lowering levels of use in a school (Evans-Whipp et al, 2007).

Conversely, heavy substance abuse monitoring programs may increase perceptions of students that they live in a rich drug culture environment, and is associated with higher levels of 1st time “initiation” users (Evans-Whipp et al, 2007).

Drug Schedules

Schedule I Controlled Substances-Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.

Schedule II Controlled Substances-Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.

Schedule III Controlled Substances-Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.

Schedule IV Controlled Substances-Substances in this schedule have a low potential for abuse relative to substances in Schedule III.

Schedule V Controlled Substances-Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.

Common Drugs of Abuse

http://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs/commonly-abused-drugs-chart

Tobacco

Nicotine Found in cigarettes, cigars, bidis, and smokeless tobacco (snuff, spit tobacco, chew).

Not scheduled

Smoked, snorted, chewed

Acute Effects - Increased blood pressure and heart rate

Health Risks - Chronic lung disease; cardiovascular disease; stroke; cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and acute myeloid leukemia; adverse pregnancy outcomes; addiction.



Alcohol (ethyl alcohol) Found in liquor, beer, and wine.

Not scheduled

Swallowed +

Acute Effects - In low doses, euphoria, mild stimulation, relaxation, lowered inhibitions; in higher doses, drowsiness, slurred speech, nausea, emotional volatility, loss of coordination, visual distortions, impaired memory, sexual dysfunction, loss of consciousness

Health Risks - Increased risk of injuries, violence, fetal damage (in pregnant women); depression; neurologic deficits; hypertension; liver and heart disease; addiction; fatal overdose.



Cannabinoids

Marijuana-Tetrahydrocannabinol (THC) Blunt, dope, ganja, grass, herb, joint, bud, Mary Jane, pot, reefer, green, trees, smoke, sinsemilla, skunk, weed.

Schedule I -Smoked, swallowed

Hashish- Boom, gangster, hash, hash oil, hemp

Schedule I -Smoked, swallowed

Acute Effects - Euphoria; relaxation; slowed reaction time; distorted sensory perception; impaired balance and coordination; increased heart rate and appetite; impaired learning, memory; anxiety; panic attacks; psychosis.

Health Risks - Cough, frequent respiratory infections; possible mental health decline; addiction.



Opioids

Heroin- Diacetylmorphine: smack, horse, brown sugar, dope, H, junk, skag, skunk, white horse, China white; cheese (with OTC cold medicine and antihistamine).

Schedule I- Injected, smoked, snorted

Opium- Laudanum, paregoric: big O, black stuff, block, gum, hop

Schedule II, III, V -Swallowed, smoked

Acute Effects - Euphoria; drowsiness; impaired coordination; dizziness; confusion; nausea; sedation; feeling of heaviness in the body; slowed or arrested breathing.

Health Risks - Constipation; endocarditis; hepatitis; HIV; addiction; fatal overdose.



Stimulants

Cocaine- Cocaine hydrochloride: blow, bump, C, candy, Charlie, coke, crack,

flake, rock, snow, toot.

Schedule II- snorted, smoked, injected

Amphetamine- Biphetamine, Dexedrine: bennies, black beauties, crosses,

hearts, LA turnaround, speed, truck drivers, uppers.

Schedule II- swallowed, snorted, smoked, injected

Also, for cocaine – Nasal damage from snorting.



Stimulants

Methamphetamine- Desoxyn: meth, ice, crank, chalk, crystal, fire, glass, go fast, speed.

Schedule II- swallowed, snorted, smoked, injected

Acute Effects - Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration, increased energy, mental alertness; tremors; reduced appetite; irritability; anxiety; panic; paranoia; violent behavior; psychosis.

Health Risks - Weight loss, insomnia; cardiac or cardiovascular complications; stroke; seizures; addiction.

Also, for methamphetamine – Severe dental problems



Club Drugs

MDMA (methylene- dioxy-methamphetamine)- Ecstasy, Adam, clarity, Eve, lover's speed, peace, upper.

Schedule I- swallowed, snorted, injected

Flunitrazepam ** Rohypnol: -forget-me pill, Mexican Valium, R2, roach, Roche, roofies, roofinol, rope, rophies.

Schedule IV- swallowed, snorted

Acute Effects, for MDMA - Mild hallucinogenic effects; increased tactile sensitivity; empathic feelings; lowered inhibition; anxiety; chills; sweating; teeth clenching; muscle cramping.

Health Risks, for MDMA - Sleep disturbances; depression; impaired memory; hyperthermia; addiction.

Also, for Flunitrazepam - Sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination- May have addiction potential.



Club Drugs

GHB ** Gamma-hydroxybutyrate:- G, Georgia home boy, grievous bodily

harm, liquid ecstasy, soap, scoop, goop, liquid X.

Schedule I- swallowed

Also, for GHB - Drowsiness; nausea; headache; disorientation; loss of

coordination; memory loss.



Dissociative Drugs

Ketamine Ketalar SV- cat Valium, K, Special K, vitamin K.

Schedule III- injected, snorted, smoked

PCP and analogs Phencyclidine-: angel dust, boat, hog, love boat, peace pill.

Schedule I, II- swallowed, smoked, injected

Acute Effects - Feelings of being separate from one’s body and environment; impaired motor function .

Also, for ketamine - Analgesia; impaired memory; delirium; respiratory depression and arrest; death.

Also, for PCP and analogs - Analgesia; psychosis; aggression; violence; slurred speech; loss of coordination; Hallucinations.

Health Risks - Anxiety; tremors; numbness; memory loss; nausea.



Dissociative Drugs

Salvia divinorum- Salvia, Shepherdess's Herb, Maria Pastora, magic mint, Sally-D.

Not Scheduled- chewed, swallowed, smoked

Dextromethrphan (DXM)- Found in some cough and cold medications: Robotripping, Robo, Triple C.

Not Scheduled -swallowed

Acute Effects - Feelings of being separate from one’s body and environment; impaired motor function.

Also, for DXM - Euphoria; slurred speech; confusion; dizziness; distorted visual perceptions.

Health Risks - Anxiety; tremors; numbness; memory loss; nausea.



Hallucinogens

LSD- Lysergic acid diethylamide: acid, blotter, cubes, microdot yellow sunshine, blue heaven.

Schedule I- swallowed, absorbed through mouth tissues

Mescaline- Buttons, cactus, mesc, peyote.

Schedule I- swallowed, smoked

Acute Effects - Altered states of perception and feeling; hallucinations; nausea.

Also, for LSD - Increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness, dizziness, weakness, tremors; impulsive behavior; rapid shifts in emotion -Health Risks, for LSD - Flashbacks, Hallucinogen Persisting Perception Disorder.

Also, for Mescaline - Increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness, dizziness, weakness, tremors; impulsive behavior; rapid shifts in emotion.



Hallucinogens

Psilocybin- Magic mushrooms, purple passion, shrooms, little smoke.

Schedule -I swallowed

Acute Effects - Altered states of perception and feeling; hallucinations; nausea.

Also, for Psilocybin - Nervousness; paranoia; panic.



Other compounds

Anabolic steroids Anadrol, Oxandrin, Durabolin, Depo-Testosterone, Equipoise- roids, juice, gym candy, pumpers.

Schedule III- Injected, swallowed, applied to skin

Acute Effects, for Anabolic steroids - No intoxication effects

Health Risks, for Anabolic steroids - Hypertension; blood clotting and cholesterol changes; liver cysts; hostility and aggression; acne; in adolescents—premature stoppage of growth; in males—prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females—menstrual irregularities, development of beard and other masculine characteristics.



Other Compounds

Inhalants Solvents (paint thinners, gasoline, glues); gases (butane, propane, aerosol propellants, nitrous oxide); nitrites (isoamyl, isobutyl, cyclohexyl):- laughing gas, poppers, snappers, whippets.

Not scheduled- Inhaled through nose or mouth

Also, for Inhalants - Cramps; muscle weakness; depression; memory impairment; damage to cardiovascular and nervous systems; unconsciousness; sudden death.

Also, for Inhalants (varies by chemical) - Stimulation; loss of inhibition; headache; nausea or vomiting; slurred speech; loss of motor coordination; wheezing.

Managing the Impaired Student

Primary drug(s) of addiction, and specific event that lead to visit:

Age of Onset of drug use:

Any Periods of sobriety:

Average daily use:

Last use:

Drug Use History:

Etoh, Pot, Meth, Coc/Crack, Opiates/Opioids, Benzodiazepines, Spice, Hallucinogens, X.

Tobacco use history: ppd/yrs.

Consequences of drug use (legal, social, psychological, medical)

Complications of Detox (seizures, hospitalization for withdrawal, symptoms)


Current or Past Medical problems and History:

Past Surgical History:

Current Primary Care Provider/Recent Medical Care/other prescribers:

Medications:

Allergies (reaction type):

GYN History: LMP: G:P:AB:Last WH exam: CBE: Mammo: Abnormals/tx:

Social History (living situation, partner, children, employment, finances, educational level, learning problems, social support, disability):


Sexual History (currently active; # of current partners; sex with men, women, or both; history of STI; sexual dysfunction):

Family History (addiction, psych, and medical):

Mom:Dad:Siblings:

Insurance- (remember confidential services for children)

Psychiatric History: Psychiatric Diagnoses (when, made by whom, what symptoms/history support diagnosis; ask about depression, anxiety, mania, symptoms of PTSD, psychosis, gambling):

BH Hospitalizations/ Suicide Attempts

History of Abuse: Sexual: Physical: Emotional: And perpetrated by who:

Current psych. provider:


Complete Review of systems: Head to Toe with a focus on neuro, cardiac, pulmonary, psych.

Complete set of vital signs: HR, T, RR, BP, Sao2

Diagnostics: urine tox, breathalyzer- can help with disclosure.

Complete physical exam: Head to Toe with a focus on neuro, cardiac, pulmonary, psych.


Queensland Mental Health; (MIND Essentials, 2010) recommends:

Ensure intoxication is the accurate diagnosis for the person’s condition establishing the type and quantity of the substance(s) consumed and when they last consumed these substances.

Assess for potential withdrawal symptoms and manage these withdrawal symptoms (if applicable).

Develop a relationship with the person based on empathy and trust.

Provide a safe environment for the person and ensure they remain free from injury.

Ensure the safety of one’s self, other staff and other people.


Once the person is no longer intoxicated, promote healthy lifestyle behaviors and establish interest in addressing any issues, thoughts or situations that may cause drug and/or alcohol use.

Ensure the goals for addressing substance use are included on care plans and other relevant service providers are involved.

Promote the person’s engagement with their social and support network.

Ensure effective collaboration with other relevant service providers, through development of effective working relationships and communication.

Support and promote access to relevant information, support and self-care activities for families and carers of the person who is intoxicated.


The following considerations are also relevant to responding to someone who presents with intoxication:

Any person presenting as incoherent, disoriented or drowsy should be treated as if suffering from a head injury until diagnosed otherwise.

Ensure that an accurate medical history and substance use history are taken. All other causes for the person’s condition must be considered. (ie, a misdiagnosis of intoxication instead of ketoacidosis can be fatal.)

Ensure collateral information regarding substance use is obtained from caretakers/family/significant others and laboratory tests.

Look for risk factors for withdrawal. These include frequent and regular use, duration of use and time and date of last dose. (CIWA, COWS)

Manage withdrawal symptoms by monitoring vital signs, ensuring adequate fluids, monitoring signs of withdrawal.

Provide a low stimulus environment away from bright light and noise where possible.


Treat intoxicated people with respect. Speak slowly and simply and give information clearly.

Move them to a quiet place if possible.

Observe for suicidal behavior both while the person is intoxicated and if withdrawing.

Increased impulsivity, the physical symptoms of withdrawal and the dis-inhibition produced by intoxication can heighten the risk of self-harm.

The person may have clinical symptoms of overdose, intoxication or withdrawal and may be responding to hallucinations or delusions that place the person and the providers at risk of injury. The person may also be experiencing delirium.

Regardless, the person requires close observation, appropriate care and reduced stimulation.

Dual Diagnosis

Substance Abuse/Mental Illness (National Alliance of Mental Illness, 2013)

Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions.

Mental health services are often not well prepared to deal with patients having both afflictions.

Often only one of the two problems is identified.

If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them.

Dual Diagnosis


It is now generally agreed that as much as 50 percent of the mentally ill population also has a substance abuse problem.

The drug most commonly used is alcohol, followed by marijuana and cocaine.

Prescription drugs such as tranquilizers and sleeping medicines may also be abused.

The incidence of abuse is greater among males and those aged 18 to 44.

People with mental illnesses may abuse drugs covertly without their families knowing it.

It is now reported that both families of mentally ill relatives and mental health professionals underestimate the amount of drug dependency among people in their care.

Dual Diagnosis


Substance abuse complicates almost every aspect of care for the person with mental illness.

First, these individuals are very difficult to engage in treatment.

Diagnosis is difficult because it takes time to unravel the interacting effects of substance abuse and the mental illness.

Violence is more prevalent among the dually diagnosed population.

Both domestic violence and suicide attempts are more common, and of the mentally ill who wind up in jails and prisons, there is a high percentage of drug abusers.

Dual Diagnosis


Some of them may begin to use drugs or alcohol for

recreational use, the same as many other people do.

Various factors may account for their continued use.

Probably many people continue their use as a misguided

attempt to treat symptoms of the illness or the side effects of

their medications.

By "self-medicating," they find that they can reduce the level

of anxiety or depression- at least for the short term.

Dual Diagnosis


People with mental illnesses suffer from what has been

called "downward drift." This means that as a consequence

of their illness they may find themselves living in marginal

neighborhoods where drug use prevails.

Having great difficulty developing social relationships,

some people find themselves more easily accepted by groups

whose social activity is based on drug use.

Some may believe that an identity based on drug addiction

is more acceptable than one based on mental illness.

Example Policy

Background and significance

ACE Leadership Charter High School is dedicated to serving students with limited means and resources to pursue successful and meaningful careers in the construction industry. This population has significant risk, exposure, and prevalence of substance use and abuse. A quality model to address incidence in the population is necessary to help ensure success and gains among its student population.

Example Policy

A literature review of CINAHL- free text utilizing

Boolean terms of: “impaired student”, “intoxicated

student”, “acutely intoxicated student”, “intoxicated

high school student” demonstrated poor results that

were directed mostly at college- level students and their

substance abuse and dependence. No information was

gleaned regarding the acutely intoxicated student or

impaired school age student who presents to school

staff or a school-based health center.

Example Policy

A review of the New Mexico Department of Health, Office of School and Adolescent Health (OSAH), School-Based Health Center Manual at www.nmschoolhealthmanual.org offered algorithms based upon clinics staffed solely by Registered Nurses- not advanced practice providers. The most specific algorithm addressed the issue under “Emergency Services/First Aid- Poisoning/Overdose”. The crux of this algorithm suggests calling poison control and activating EMS via 911 if directed to do so by Poison Control. Unfortunately, this is only helpful if the exposure is known, it is an acute intoxication, and if an advanced practice provider is not available in house.

Not all substances ingested by the student population are life threatening and need Emergency Medical Services and transport, the student does not always disclose the substance ingested, the student may be hemo-dynamically stable, not a risk to self or others, and have a guardian who can monitor and keep the client safe at home during the intoxication phase.

Example Policy

The following document is an attempt at providing a

systematic process for managing the acutely

intoxicated or impaired student and or the substance

abusing or dependent student. The process will outline

engagement possibilities through intervention, referral

and in rare exceptions- expulsion from the academic

environment.

Example Policy

Referral Process

Students can be introduced to services through five primary methods/routes:

-possession of a controlled substance

-failed random drug testing already a part of school policy

-personal disclosure of substance use/abuse

-peer disclosure of substance use/abuse

-staff discovery or suspicion of substance use/abuse-acute intoxication or impairment

Example Policy

Example Policy

Exceptions:

If it is determined that the student is selling substances to peers or within the community or has the intent to distribute, there may be immediate expulsion and cessation of academic services.

Conclusion:

This policy and process is designed to ensure quality and consistent care and processes for substance abuse/dependence, pursue behavior change, ensure best possible outcomes, and reduce risk for the student, school, and clinician.

Struggles

Buy-in by staff, administration, board for policy

Consistency by staff referring students

Consistency of self implementing policy

Referral options in community: NM Solutions, Rio

Grande, Hogares, Sage Neurosciences, etc.

Inpatient services: UNM Children’s Psych, Kaseman

Presbyterian, Mesilla Valley Hospital, soon Turquoise

Lodge Adolescent unit.

Questions/Comments?

References Brown, C., Guo, J., Singer, L., Downes, K., & Brinales, J. (2007). Examining the effects of school-based drug

prevention programs on drug use in rural settings. Journal of Rural Health, 23, 29-36.

Centers for Disease Control and Prevention. (2011). Fast stats- illegal drug use. Retrieved from http://www.cdc.gov/ nchs/fastats/druguse.htm

Centers for Disease Control and Prevention. (2012) MMWR-youth risk behavior surveillance. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf

Clayton, S., Chin, T., Blackburn, S., & Echeverria, C. (2010). Different setting, different care: integrating prevention and clinical care in school-based health centers. American Journal of Public Health, 100(9),1592-1596.

National Institute on Drug Abuse. (2011). Commonly abused drug chart. Retrieved from http:// www.drugabuse.gov/drugs-abuse/commonly-abused-drugs/commonly-abused-drugs-chart

Evans-Whipp, T., Bond, L., Toumbourou, J., & Catalano, R. (2007). School, parent, and student perspectives of school drug policies. Journal of School Health, 77(3), 138-146.

Fletcher, A., Bonell, C., & Hargreaves, J. (2008). School effects on young people’s drug use: a systematic review of intervention and observational studies. Journal of Adolescent Health, 42, 209-220.

Griffin, K., Bang, H., & Botvin, G. (2010). Age of alcohol and marijuana use onset predicts weekly substance ause and related psychosocial problems during young adulthood. Journal of Substance Abuse.15(3), 174-183.

Guo, J., Wade, T., & Keller, K. (2008). Impact of school-based health centers on students with mental health problems. Public Health Rep, 120, 768-780.

Guo, J., Wade, T., Pan, W., & Keller, K. (2010). School-based health centers: cost-benefit analysis and impact on health care disparities. American Journal of Public Health, 100(9), 1617-1623.

References

Kerns, S., Pullman, M., Walker, S., Lyon, A., Cosgrove, T., & Bruns, E. (2011). Adolescent use of school-based health centers and high school dropout. Archives of Pediatric Adolescent Medicine, 165(7), 617-623.

Kuntsche, E., & Jordan, M. (2006). Adolescent alcohol and cannabis use in relation to peer and school factors results of multilevel analyses. Drug & Alcohol Dependence, 84, 167-174.

McNall, M., Lichty, L, & Mavis, B. (2010). The impact of school-based health centers on the health outcomes of middle school and high school students. American Journal of Public Health, 100(9), 1604-1610.

National Alliance on Mental Illness. (2013). Dual diagnosis: substance abuse and mental illness. Retrieved from http:// www.nami.org/Content/ContentGroups/Helpline1/Dual_Diagnosis_- _Substance_Abuse_and_Mental_Illness.htm

Rienzo, B., Button, J., & Wald, K. (2000). Politics and the success of school-based health centers. Journal of School Health, 70(8), 331-337.

Queensland Health. (2010). Queensland MIND essentials. Retrieved from http://www.health.qld.gov.au/ mentalhealth/mindessentialsfinal.pdf

Shuler, P. (2000). Evaluating student services provided by school-based health centers: applying the shuler nurse practitioner model. Journal of School Health, 70(8), 348-352.

Winters, K., Leitten, W., Wagner, E., & Tevyaw, T. (2007). Use of brief interventions for drug abusing teenagers within a middle and high school setting. Journal of School Health, 77(4), 196-206.

http://www.health.qld.gov.au/

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