Bridges and Firewalls: Contractual Relationships for Mental Health Services Provided in School Settings
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When boundaries of clinical, educational, legal and financial responsibility are clearly outlined in contractual agreements between school districts and mental health treatment providers, students can benefit from the “bridge” to mental health services, while the district maintains sturdy firewalls that limit its financial and legal liability. The provision of services under this model benefits students, their families, the mental health provider and the school district, resulting in cost savings and improved educational outcomes.
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The provision of mental health diagnostic and treatment services on-site within school settings is a rapidly growing phenomenon across the United States. Although there are significant advantages to this model of service delivery, there are also numerous pitfalls that must be avoided in order to limit school districts’ financial and legal liabilities.
Mental Health Disorders and the Classroom
Students who have mental health disorders often have academic, emotional and/or behavioral problems in educational settings. This has a significant impact on school districts, as demographic research indicates that approximately 20% of students have emotional disorders (e.g., anxiety disorders, mood disorders, autistic spectrum disorders, Attention Deficit Hyperactivity Disorder, etc.), and approximately 5% have severe emotional disorders with extreme impairment (1).
Only one in five children or adolescents who have psychiatric disorders receive treatment, and the majority of those who do receive treatment receive it from primary care physicians who often have limited expertise in the diagnosis and treatment of these disorders.
Since the Severe Emotional Disturbance category of special education generally makes up less than 2% of a school district’s population, the vast majority of emotionally disturbed students and the majority of students with severe disturbances are taught in general education settings. Most of the children in special education and regular education who have psychiatric disorders receive no treatment.
Students served in the SED special education category frequently have mental health disorders, and the core symptoms of these disorders contribute to acting out behaviors and difficulties within the academic environment. This group is notable for its poor outcome despite its high costs. They have poor graduation rates, high arrest rates, high percentages of out of wedlock pregnancies, and poor vocational outcomes. Research indicates that the major contributor to the poor outcome is that the “E” in SED (the student’s emotional disorder) is rarely treated [2].
Many students in the mainstream setting who are referred for special education assessments have undiagnosed and untreated mental health disorders. If these disorders were effectively identified and treated, many of these students would no longer require referrals for special education services [3].
It is the responsibility of schools to teach, and the responsibility of parents, health care professionals, insurance companies, counties and public health systems to assure that mental health treatment is provided to at-risk children and adolescents. Unfortunately, as most of these children do not receive treatment, the educational system is thus faced with the responsibility of educating numerous students who would have significantly improved educational outcomes at a much lower cost, were they to be treated for their disorders.
School-Based Mental Health Services
The President’s Freedom Commission for Mental Health recommended that schools play a larger role in mental health care for children, and should improve and expand school mental health programs. These programs have been shown to improve educational outcomes by decreasing absences, decreasing discipline referrals and improving test scores [4].
Schools employ professionals who address some student’s emotional problems. School counselors, social workers and school psychologists may provide counselling services to assist students concerning their educational needs. For example, they may assist in developing positive behavioral intervention strategies, provide group counselling to assist students who have difficulty with social skills, help students resolve disputes with teachers or other students, and assist school teams in providing appropriate accommodations and modifications for students with emotional disorders. However, these activities are not the same as the provision of mental health diagnostic and clinical treatment services.
Access to treatment is a major problem. Many parents simply cannot afford to leave their jobs on a weekly basis to pick up their child from school and bring him or her to a mental health professional for treatment. Clinics may have limited availability of outpatient appointments, and child psychiatry services are difficult to access nationwide.
The provision of on-site, co-located mental health diagnostic and treatment services within a school building during the school day has the potential to effectively solve problems of access to treatment. These services provide a “bridge” between educational and mental health services for students in need. This concept is gaining significant momentum across the U.S.- for example, South Carolina has on-site mental health clinicians in 40% of its public schools.
However, if clear boundaries are not established, school districts become significantly vulnerable for legal and financial liability. Thus, firewalls need to be established to protect school districts.
Unfortunately, many well-meaning school districts, in an attempt to provide needy students with on-site mental health services, enter into contractual relationships with mental health professionals who become paid employees of the district.
This situation is highly problematic, as school districts are not likely to be able to obtain malpractice insurance, and their general liability and errors and omissions insurance is unlikely to protect them in situations such as a student’s suicide, where the clinician is sued for providing inadequate care and the district is sued for providing inadequate clinical supervision. Insurers write policies for school districts based on their understanding of the risks associated with providing traditional programs of education. They do not contemplate a risk based on the negligent provision of mental health treatment services.
Records of treatment provided by a school employee do not have the degree of confidentiality as those of mental health professionals in the community; in fact, these treatment records become part of the student’s educational record.
Additionally, if a clinician providing mental health services is a school district employee, the district could be found to be responsible for providing evening, weekend and vacation coverage, psychiatric backup services, crisis intervention services and billing mechanisms.
These issues provide a compelling argument against school social workers, school counselors and school psychologists providing diagnostic and treatment services in the school setting, even if those professionals have the licensure that would allow them to do so in a private practice in the community.
The ideal method of providing on-site mental health services in a school setting resolves the “bridges and firewalls” issue by having the district lease space to a community mental health clinic, with the clinic being the employer of the clinicians, and the clinic being responsible for malpractice insurance, backup crisis coverage, record-keeping, billing, etc. This keeps the school district “out of the mental health business” of diagnosis and treatment.
The ideal clinic would be one that is overseen by a county or non-profit agency, that has a multidisciplinary team of psychologists, social workers and psychiatrists, and that can provide services to students and their families during non-school hours when appropriate (e.g., evening appointments for family therapy, summer follow-up appointments for students on vacation, etc.).
Even this arrangement creates potential liability for the district, but if contractual relationships are crafted correctly, the benefits of providing these services within schools far outweigh the risks.
These are the essential components of a contract between school districts and providers of mental health services:
Defining a Joint Powers Agreement
The purpose of the agreement should be clearly defined from the District’s perspective. It:
-Clarifies the financial responsibility of the participating parties in advance
-Establishes accounting and payment procedures and standards
-Designates a fiscal agent, and defines its duties
-Provides a location in a school building convenient to school students (a “co-location” agreement) where the services can be provided. This agreement is, essentially, a lease of space.
When the relationship is with a county that has the responsibility to assure accessible mental health services, the agreement should also:
-Obtain a guarantee of access to county funded mental health treatment facilities for IDEA students who require such treatment as a related service, and provide for convenient, and perhaps guaranteed access to day treatment services for IDEA students who are determined by the county to be eligible to receive them but who do not require them as a related service.
-Provide for convenient access for non-IDEA students determined by the county to be eligible to receive such services.
Defining the Role and Responsibility of the Respective Parties Under the Agreement in a Manner Consistent with its Stated Purpose
The contractual agreement:
-Specifies which party will have responsibility for actually providing mental health therapy or treatment, and distinguish mental health therapy and treatment from school counselling, social work services or psychological services.
-Specifies which party will provide required supervision for therapy or treatment services
-Specifies what power, if any, each party will have to direct the activities of employees of the other party(ies).
-Specifies that participation in the interagency agreement will not in any manner or to any degree result in the delegation of the powers or responsibilities of any party to another party
Unless it is the school board’s clear intent to do so, the district should not agree to share responsibilities that are not statutorily imposed upon it, and should not share responsibilities imposed on the district (e.g., determination of eligibility to receive services under IDEA, determination of whether mental health treatment services will be provided as related services, etc.).
Licensure Issues
The contractual agreement:
-Requires that all participants, including private service providers under contract with the county or other agency that is providing mental health services, demonstrate that all staff working with students have appropriate licensure.
-Requires notification by any participant or provider contracting with a participant if the license of any person or volunteer providing services to a district student is suspended, revoked or lapses, or if discipline is imposed by a licensing agency.
Criminal Background Checks
-Criminal background checks should be required for all staff, including volunteers, for all participating entities and providers of contracted services.
-The contract should require notification by any participating entity and provider of contracted services if any of its employees or volunteers has been convicted of a “child abuse crime”, and reserves the power to deny access by that employee or volunteer to district students.
Administrative Control
The contract should clearly outline:
-Security and access issues
-The power to direct staff
Data Privacy Concerns
The mere fact that a county or clinic, or their contracted providers, provide services under an interagency agreement to a student who is receiving educational services from a school district does not, in and of itself, authorize the participating entities to exchange private data, including educational data, regarding the student or his/her family.
The contractual agreement should:
-Establish “firewalls” between data maintained by each party where no release of information has been obtained from a student’s parent.
Funding and Fiscal Considerations
In rare circumstances, mental health treatment services are required to be “related services” on students’ IEPs. The IEP team should use a “but for” test in order to determine whether a student requires mental health therapy or treatment as a related service. Mental health services must be made a part of a student’s program of special education only if the failure to provide the service would prevent the student from receiving educational benefit from the IEP and would thereby deny the student a Free Appropriate Public Education (FAPE). In these situations, the district isn’t required to have school employees provide these services, but it is required to pay for the services. In case law, schools have been obligated to provide mental health services to students when the students’ educational needs are determined to be “inextricably intertwined” with their educational needs. Unfortunately, case law is often contradictory, with vaguely defined terminology, resulting in significant confusion about this issue.
The expenses for mental health services cannot be subject to reimbursement by the State Educational Agency unless the student is receiving those services as a related service on the IEP. Special education funds cannot be used to pay for mental health services provided to general education students or special education services for whom the need for related services is not supported by the IEP.
Funding models employed in contracts for day treatment and other contracted services and student placements are subject to examination by the State Education Agency for compliance through the fiscal monitoring process.
In most circumstances, a district does not have a fiscal responsibility to cover the costs for mental health treatment for a student in regular or special education.
If the contract is with the local county to provide mental health services within the school, and if the county in your jurisdiction is ultimately responsible for the availability of mental health services, then contractual language should commit the county to meet its statutory obligation for funding children’s mental health services.
Insurance Considerations
Hold harmless and indemnification agreements:
-Contractually assuming liability may violate the terms of a school district’s insurance policies and void its coverage.
-If the stakes are large, a hold harmless and indemnification agreement increases the risks of litigation to determine its implications.
-Particularly where mental health treatment or therapy is being provided through a private contractor, a hold harmless and indemnification agreement may be of no value. What assets does the contractor have to indemnify or to hold harmless your school district?
The District should examine the policies of the other participants to make sure that their coverage is adequate and complies with statutory requirements. The following questions need to be addressed:
-Does the coverage match or exceed the statutory limits?
-Is the coverage stated on an aggregate basis, as opposed to a claims made basis?
-Do the parties providing or supervising treatment services carry malpractice insurance?
It would be useful to consider inserting a provision requiring each party to name the school district as an additional named insured in its applicable policies.
Implementing the Interagency Agreement
The District needs to:
-Guard against the blurring of lines of authority and division of responsibilities by staff implementing programs at the site.
-Assure that IEP teams understand the terms of the Interagency Agreement.
-Make sure that IEP’s do not ignore the division of authority established in the Interagency Agreement.
-Provide badges or similar identification consistent with the division of responsibilities established in the Interagency Agreement.
-Advise parents and students as to the separate and distinct roles of district staff as well as the staff of other entities.
Miscellaneous Issues
The contract should specifically state which policies of each party will apply regarding:
-Smoking, alcohol and tobacco policies
-Sexual, gender and racial harassment policies
-Specific policies of the State Education Agency and those of other state agencies.
-Policies regarding responses to violent or threatening behaviors
Issues of the consequences of students’ dangerous behavior can become problematic if they are not clearly outlined in contractual agreements. For example, an on-site day treatment program may prefer to have a different threshold for disciplinary responses to aggressive behaviors than does the school. If the day treatment services were provided off the school grounds in a private facility, this threshold could be determined by the day treatment provider. However, if the service is provided on school grounds, the school district needs to be the party who defines this threshold.
Summary
When boundaries of clinical, educational, legal and financial responsibility are clearly outlined in contractual agreements between school districts and mental health treatment providers, students can benefit from the “bridge” to mental health services, while the district maintains sturdy firewalls that limit its financial and legal liability. The provision of services under this model benefits students, their families, the mental health provider and the school district, resulting in cost savings and improved educational outcomes.
Mental Health Disorders and the Classroom
Students who have mental health disorders often have academic, emotional and/or behavioral problems in educational settings. This has a significant impact on school districts, as demographic research indicates that approximately 20% of students have emotional disorders (e.g., anxiety disorders, mood disorders, autistic spectrum disorders, Attention Deficit Hyperactivity Disorder, etc.), and approximately 5% have severe emotional disorders with extreme impairment (1).
Only one in five children or adolescents who have psychiatric disorders receive treatment, and the majority of those who do receive treatment receive it from primary care physicians who often have limited expertise in the diagnosis and treatment of these disorders.
Since the Severe Emotional Disturbance category of special education generally makes up less than 2% of a school district’s population, the vast majority of emotionally disturbed students and the majority of students with severe disturbances are taught in general education settings. Most of the children in special education and regular education who have psychiatric disorders receive no treatment.
Students served in the SED special education category frequently have mental health disorders, and the core symptoms of these disorders contribute to acting out behaviors and difficulties within the academic environment. This group is notable for its poor outcome despite its high costs. They have poor graduation rates, high arrest rates, high percentages of out of wedlock pregnancies, and poor vocational outcomes. Research indicates that the major contributor to the poor outcome is that the “E” in SED (the student’s emotional disorder) is rarely treated [2].
Many students in the mainstream setting who are referred for special education assessments have undiagnosed and untreated mental health disorders. If these disorders were effectively identified and treated, many of these students would no longer require referrals for special education services [3].
It is the responsibility of schools to teach, and the responsibility of parents, health care professionals, insurance companies, counties and public health systems to assure that mental health treatment is provided to at-risk children and adolescents. Unfortunately, as most of these children do not receive treatment, the educational system is thus faced with the responsibility of educating numerous students who would have significantly improved educational outcomes at a much lower cost, were they to be treated for their disorders.
School-Based Mental Health Services
The President’s Freedom Commission for Mental Health recommended that schools play a larger role in mental health care for children, and should improve and expand school mental health programs. These programs have been shown to improve educational outcomes by decreasing absences, decreasing discipline referrals and improving test scores [4].
Schools employ professionals who address some student’s emotional problems. School counselors, social workers and school psychologists may provide counselling services to assist students concerning their educational needs. For example, they may assist in developing positive behavioral intervention strategies, provide group counselling to assist students who have difficulty with social skills, help students resolve disputes with teachers or other students, and assist school teams in providing appropriate accommodations and modifications for students with emotional disorders. However, these activities are not the same as the provision of mental health diagnostic and clinical treatment services.
Access to treatment is a major problem. Many parents simply cannot afford to leave their jobs on a weekly basis to pick up their child from school and bring him or her to a mental health professional for treatment. Clinics may have limited availability of outpatient appointments, and child psychiatry services are difficult to access nationwide.
The provision of on-site, co-located mental health diagnostic and treatment services within a school building during the school day has the potential to effectively solve problems of access to treatment. These services provide a “bridge” between educational and mental health services for students in need. This concept is gaining significant momentum across the U.S.- for example, South Carolina has on-site mental health clinicians in 40% of its public schools.
However, if clear boundaries are not established, school districts become significantly vulnerable for legal and financial liability. Thus, firewalls need to be established to protect school districts.
Unfortunately, many well-meaning school districts, in an attempt to provide needy students with on-site mental health services, enter into contractual relationships with mental health professionals who become paid employees of the district.
This situation is highly problematic, as school districts are not likely to be able to obtain malpractice insurance, and their general liability and errors and omissions insurance is unlikely to protect them in situations such as a student’s suicide, where the clinician is sued for providing inadequate care and the district is sued for providing inadequate clinical supervision. Insurers write policies for school districts based on their understanding of the risks associated with providing traditional programs of education. They do not contemplate a risk based on the negligent provision of mental health treatment services.
Records of treatment provided by a school employee do not have the degree of confidentiality as those of mental health professionals in the community; in fact, these treatment records become part of the student’s educational record.
Additionally, if a clinician providing mental health services is a school district employee, the district could be found to be responsible for providing evening, weekend and vacation coverage, psychiatric backup services, crisis intervention services and billing mechanisms.
These issues provide a compelling argument against school social workers, school counselors and school psychologists providing diagnostic and treatment services in the school setting, even if those professionals have the licensure that would allow them to do so in a private practice in the community.
The ideal method of providing on-site mental health services in a school setting resolves the “bridges and firewalls” issue by having the district lease space to a community mental health clinic, with the clinic being the employer of the clinicians, and the clinic being responsible for malpractice insurance, backup crisis coverage, record-keeping, billing, etc. This keeps the school district “out of the mental health business” of diagnosis and treatment.
The ideal clinic would be one that is overseen by a county or non-profit agency, that has a multidisciplinary team of psychologists, social workers and psychiatrists, and that can provide services to students and their families during non-school hours when appropriate (e.g., evening appointments for family therapy, summer follow-up appointments for students on vacation, etc.).
Even this arrangement creates potential liability for the district, but if contractual relationships are crafted correctly, the benefits of providing these services within schools far outweigh the risks.
These are the essential components of a contract between school districts and providers of mental health services:
Defining a Joint Powers Agreement
The purpose of the agreement should be clearly defined from the District’s perspective. It:
-Clarifies the financial responsibility of the participating parties in advance
-Establishes accounting and payment procedures and standards
-Designates a fiscal agent, and defines its duties
-Provides a location in a school building convenient to school students (a “co-location” agreement) where the services can be provided. This agreement is, essentially, a lease of space.
When the relationship is with a county that has the responsibility to assure accessible mental health services, the agreement should also:
-Obtain a guarantee of access to county funded mental health treatment facilities for IDEA students who require such treatment as a related service, and provide for convenient, and perhaps guaranteed access to day treatment services for IDEA students who are determined by the county to be eligible to receive them but who do not require them as a related service.
-Provide for convenient access for non-IDEA students determined by the county to be eligible to receive such services.
Defining the Role and Responsibility of the Respective Parties Under the Agreement in a Manner Consistent with its Stated Purpose
The contractual agreement:
-Specifies which party will have responsibility for actually providing mental health therapy or treatment, and distinguish mental health therapy and treatment from school counselling, social work services or psychological services.
-Specifies which party will provide required supervision for therapy or treatment services
-Specifies what power, if any, each party will have to direct the activities of employees of the other party(ies).
-Specifies that participation in the interagency agreement will not in any manner or to any degree result in the delegation of the powers or responsibilities of any party to another party
Unless it is the school board’s clear intent to do so, the district should not agree to share responsibilities that are not statutorily imposed upon it, and should not share responsibilities imposed on the district (e.g., determination of eligibility to receive services under IDEA, determination of whether mental health treatment services will be provided as related services, etc.).
Licensure Issues
The contractual agreement:
-Requires that all participants, including private service providers under contract with the county or other agency that is providing mental health services, demonstrate that all staff working with students have appropriate licensure.
-Requires notification by any participant or provider contracting with a participant if the license of any person or volunteer providing services to a district student is suspended, revoked or lapses, or if discipline is imposed by a licensing agency.
Criminal Background Checks
-Criminal background checks should be required for all staff, including volunteers, for all participating entities and providers of contracted services.
-The contract should require notification by any participating entity and provider of contracted services if any of its employees or volunteers has been convicted of a “child abuse crime”, and reserves the power to deny access by that employee or volunteer to district students.
Administrative Control
The contract should clearly outline:
-Security and access issues
-The power to direct staff
Data Privacy Concerns
The mere fact that a county or clinic, or their contracted providers, provide services under an interagency agreement to a student who is receiving educational services from a school district does not, in and of itself, authorize the participating entities to exchange private data, including educational data, regarding the student or his/her family.
The contractual agreement should:
-Establish “firewalls” between data maintained by each party where no release of information has been obtained from a student’s parent.
Funding and Fiscal Considerations
In rare circumstances, mental health treatment services are required to be “related services” on students’ IEPs. The IEP team should use a “but for” test in order to determine whether a student requires mental health therapy or treatment as a related service. Mental health services must be made a part of a student’s program of special education only if the failure to provide the service would prevent the student from receiving educational benefit from the IEP and would thereby deny the student a Free Appropriate Public Education (FAPE). In these situations, the district isn’t required to have school employees provide these services, but it is required to pay for the services. In case law, schools have been obligated to provide mental health services to students when the students’ educational needs are determined to be “inextricably intertwined” with their educational needs. Unfortunately, case law is often contradictory, with vaguely defined terminology, resulting in significant confusion about this issue.
The expenses for mental health services cannot be subject to reimbursement by the State Educational Agency unless the student is receiving those services as a related service on the IEP. Special education funds cannot be used to pay for mental health services provided to general education students or special education services for whom the need for related services is not supported by the IEP.
Funding models employed in contracts for day treatment and other contracted services and student placements are subject to examination by the State Education Agency for compliance through the fiscal monitoring process.
In most circumstances, a district does not have a fiscal responsibility to cover the costs for mental health treatment for a student in regular or special education.
If the contract is with the local county to provide mental health services within the school, and if the county in your jurisdiction is ultimately responsible for the availability of mental health services, then contractual language should commit the county to meet its statutory obligation for funding children’s mental health services.
Insurance Considerations
Hold harmless and indemnification agreements:
-Contractually assuming liability may violate the terms of a school district’s insurance policies and void its coverage.
-If the stakes are large, a hold harmless and indemnification agreement increases the risks of litigation to determine its implications.
-Particularly where mental health treatment or therapy is being provided through a private contractor, a hold harmless and indemnification agreement may be of no value. What assets does the contractor have to indemnify or to hold harmless your school district?
The District should examine the policies of the other participants to make sure that their coverage is adequate and complies with statutory requirements. The following questions need to be addressed:
-Does the coverage match or exceed the statutory limits?
-Is the coverage stated on an aggregate basis, as opposed to a claims made basis?
-Do the parties providing or supervising treatment services carry malpractice insurance?
It would be useful to consider inserting a provision requiring each party to name the school district as an additional named insured in its applicable policies.
Implementing the Interagency Agreement
The District needs to:
-Guard against the blurring of lines of authority and division of responsibilities by staff implementing programs at the site.
-Assure that IEP teams understand the terms of the Interagency Agreement.
-Make sure that IEP’s do not ignore the division of authority established in the Interagency Agreement.
-Provide badges or similar identification consistent with the division of responsibilities established in the Interagency Agreement.
-Advise parents and students as to the separate and distinct roles of district staff as well as the staff of other entities.
Miscellaneous Issues
The contract should specifically state which policies of each party will apply regarding:
-Smoking, alcohol and tobacco policies
-Sexual, gender and racial harassment policies
-Specific policies of the State Education Agency and those of other state agencies.
-Policies regarding responses to violent or threatening behaviors
Issues of the consequences of students’ dangerous behavior can become problematic if they are not clearly outlined in contractual agreements. For example, an on-site day treatment program may prefer to have a different threshold for disciplinary responses to aggressive behaviors than does the school. If the day treatment services were provided off the school grounds in a private facility, this threshold could be determined by the day treatment provider. However, if the service is provided on school grounds, the school district needs to be the party who defines this threshold.
Summary
When boundaries of clinical, educational, legal and financial responsibility are clearly outlined in contractual agreements between school districts and mental health treatment providers, students can benefit from the “bridge” to mental health services, while the district maintains sturdy firewalls that limit its financial and legal liability. The provision of services under this model benefits students, their families, the mental health provider and the school district, resulting in cost savings and improved educational outcomes.
About author Paul Ratwik, J.D.
Paul Ratwik, J.D. ([email protected]) is an attorney specializing in Education Law, particularly in the areas of special education law, construction law, the Government Data Practices Act, the Open Meeting Law, and the discipline and discharge of employees. In addition to frequent appearances at hearings, trials, and state and federal appellate arguments, he specializes in working with clients before crises develop to implement strategies to resolve disputes before they become contested cases.
Paul Ratwik, J.D. ([email protected]) is an attorney specializing in Education Law, particularly in the areas of special education law, construction law, the Government Data Practices Act, the Open Meeting Law, and the discipline and discharge of employees. In addition to frequent appearances at hearings, trials, and state and federal appellate arguments, he specializes in working with clients before crises develop to implement strategies to resolve disputes before they become contested cases.
References
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[1] Mental Health: A Report of the Surgeon General- Chapter 3: Children and Mental Health http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c3.pdf
[2] Wagner, Mary. Outcomes for Youths with Serious Emotional Disturbance in Secondary Schools and Early Adulthood. The Future of Children, Critical Issues for Children and Youths, Volume 5, No. 2- Summer/Fall, 1995. [3] Dikel, W.: "Mental Health and the Schools: What Educators Need to Know" Minnesota Department of Children, Families and Learning, 1999http://www.nasponline.org/advocacy/MentalHealth.PDF [4] Jennings, J., Pearson, G., & Harris, M. (2000). Implementing and maintaining school-based mental health services in a large, urban school district. Journal of School Health, 70, 201-205. |