Schools and adolescent health: strengthening services and improving outcomes

School-based health services have made limited contributions to the well-being of school-age children. However, they have the potential for promoting health and improving service delivery for 50 million children and adolescents enrolled in the nation's schools. Recent changes in health care, particularly the spread of managed care and development of integrated health service networks, have reawakened mainstream interest in school health and created the possibility for strengthening its efficiency and effectiveness. Two promising strategies for enabling school health programs to fulfill their potential are being implemented by the Massachusetts state government and by an Austin, Texas, hospital system. These strategies suggest measures to create either closely linked school and community health systems or fully integrated school/community child health systems that may have widespread benefit for children and their families. Barriers to fully implementing these strategies and replicating them in other communities will include the challenge of securing adequate funding, disagreements regarding the appropriate content of a school health program, and opposition to new staffing and employment arrangements from professional and union organizations. Whether this moment of opportunity yields gains for child health and school health will, for the most part, depend on forces outside school health. Success will be particularly dependent on the degree to which the managed care plans or large health care organizations see value in building more comprehensive child health systems or identify financial benefits from linking more closely with school-based services.