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December 1, 2009

Partners in Health

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By linking families to local providers and launching a health awareness campaign, a community-school partnership improves students' health—and their sleep habits.
The teacher's phone calls to Kai's mother about her son's habit of falling asleep in class were strained. Kai's mother said that although she wanted her son to get more sleep, she couldn't get him to stop watching television in the evening. A working, single mother of several children, Kai's mother viewed her children's sleep habits as a private matter. She also believed that their bedtime routines were too ingrained to change.
After Kai's school hosted an evening "sleep awareness" event, however, Kai's mother remarked that she had enjoyed the night of camaraderie with other families and had gained learned tips about how to ensure that her children got enough sleep. She removed the television from the children's bedroom.
Addressing sleep problems as a schoolwide issue proved to be a more effective way to engage Kai's family than treating his daytime fatigue as an individual problem. As clinicians with Children's Hospital Neighborhood Partnerships, which offers preventive school-based health services to children in schools, we have found that taking a more universal approach is a powerful way to encourage healthier conditions for children.
Kai's story highlights the important link between students' wellness and their readiness to learn. Healthier students tend to attend school more regularly and perform better academically (Chan, 2002; Hair, Halle, Terry-Humen, Lavelle, & Calkins, 2006). This places students from socio-economically disadvantaged families at even greater risk: They often have difficulty gaining access to mental and physical health services and show higher rates of health problems (Brown, Grubb, Wicker, & O'Tuell, 1985; Chan, 2002; Frame, Tait, & Doll, 1998; Hair et al., 2006).

School-Family Partnerships Build Capacity

Researchers and practitioners have recommended that schools collaborate with families and community agencies around mental and physical health care to promote students' well-being (Chan, 2002; Council of Chief State School Officers, 2004).
Involving families and fostering community partnerships are two strategies Children's Hospital Neighborhood Partnerships (CHNP) relies on. CHNP is a community mental health outreach program of the Department of Psychiatry at Children's Hospital Boston. The following are some of the strategies that psychologist Jacqueline Zeller and social worker Suzanne Costello have used in elementary schools, particularly schools at which the majority of students qualify for free or reduced-price lunch, to connect students' families to resources and encourage healthful practices.

Reaching Out to Families

We believe that providing prevention services in schools is an effective way of reaching a large number of students and families. Prevention work is more cost-effective than waiting until health problems become more serious and expensive. Through offering families services in familiar environments, we build their capacity to seek resources on their own and reduce the stigma sometimes associated with seeking help.
We consider "the family" to be all people who are responsible for caring for a student or who play a meaningful role in that student's life. Inviting grandparents, aunts, uncles, older siblings, neighbors, or clergy who play important caregiving roles to family events makes it more likely that students will receive essential help.
Acknowledging families' strengths and allowing families to identify areas of health to which they want to devote energy is a key part of the collaborative process. We conduct needs assessments at partner schools through whole-school questionnaires and focus groups with families so we can tailor workshops to them. For instance, in response to an assessment of a school community's needs, we have led workshops in behavior management techniques, fashioned extracurricular programs, and helped create morning learning routines. Focus groups and questionnaires also help families understand the role mental health practitioners play in the school and alert them to the array of preventive health services available in their area.
Often we facilitate workshops for families in partnership with other health professionals. Nutritionists, pediatricians, psychiatrists, and other specialized health-care providers have come to speak at our schools. Through a partnership with a local hospital, a pediatrician regularly attends one school's family drop-in meetings to answer questions. These opportunities enable parents to meet local health care providers and learn how to access services outside the school. It's important to plan carefully with other community professionals when cofacilitating family workshops to ensure that resources are relevant to the particular school's families—for example, presenting affordable community options or translating materials into Spanish.
Once trust develops, CHNP clinicians often learn about more pressing familial issues. Caregivers commonly stay after meetings to discuss personal concerns. Parents have approached us to discuss school services, family members experiencing domestic violence, or their own struggles with untreated mental health disorders. These discussions enable school-based clinicians to work with families to access much-needed resources. For example, after a workshop we hosted on anxiety and depression, several families requested referrals for treatment for themselves and their children. Several families later reported to us that conflicts with their children had diminished as a result of receiving treatment.

A Schoolwide Push for Sleep

CHNP's initiative to promote better sleep habits at Kai's school illustrates how our approach connects school and family to spread awareness of health-related problems—and solutions. Many students were having trouble engaging in the classroom and were often agitated and tired. A CHNP clinician collected data from family members about their children's sleep patterns. The results confirmed that some students were sleeping two to three hours less than the recommended guidelines for that age group of 10 to 11 hours each night. Like Kai, many watched television late into the night and fell asleep with their TVs on. Many families had relatives living with them, which sometimes created crowded and noisy sleep environments. Follow-up interviews indicated that some parents were too overwhelmed to establish bedtime routines.
Realizing that students' engagement in school, academic achievement, and good sleep patterns were common goals of both school staff and families, the clinician developed a schoolwide sleep awareness campaign that aimed to increase knowledge about sleep deprivation and to promote better sleep habits.
The campaign offered families strategies to encourage better sleep habits, including practicing relaxation techniques, reducing barriers to good sleep, and developing sleep routines. Throughout the school, the clinician led classroom discussions and activities about the importance of sleep and shared tips for getting a good night's sleep. The school community got out the message through posters, flyers, and newsletters, largely developed from materials available through the National Sleep Foundation (www.sleepfoundation.org).
We adapted materials to be relevant to the school's families and students. For example, flyers for parents acknowledged nonjudgmentally the many stressors families face and the societal problem of overusing televisions, video games, and computers. The materials encouraged families to set up more healthful habits.
The bedtime routines of school staff members, including the principal, were featured on large posters throughout the school. One poster read, "How does the principal get her Zs?" and showed the principal and her young daughter in their pajamas reading a book. Encouraging reading as a bedtime routine supported the school's emphasis on reading at home and reinforced caregivers' pride in their children's reading skills.
The campaign emphasized connections between sleep, mood, and readiness to learn. Students learned that "sleep stealers"—such as televisions and other electronic media—were everywhere. We encouraged children to talk to family members about how to combat sleep stealers. The school hosted a schoolwide pajama day and a sleep slogan contest.
About 250 family members attended the evening sleep awareness event. A pediatrician presented information about sleep in a nonthreatening manner that enabled family members to ask questions and share sleep tips with one another. Through donations from community partners, participants received prizes and gift bags containing a clock, nightlight, and earplugs, and the school also raffled off a bed. Students tracked their sleep and evening activities for a week for a "Big Snoozer" contest; all students who had tracked their sleep habits and got the recommended amount of sleep for one week were recognized.

Encouraging Results

Six weeks after CHNP launched the sleep awareness campaign, we surveyed all the school's teachers and students to evaluate the program's effectiveness. The majority of family members, teachers, and students surveyed reported that they were more aware of the importance of sleep and the impact of sleep barriers.
Students got the message about adequate sleep being central to health and attention. Of the 130 students we surveyed, the majority commented that they learned how lack of sleep can affect learning and mood. Students described possible outcomes from lack of sleep: "being too tired to focus in class" and "falling asleep when the teacher is talking." Even more impressive, students' behavior changed; 66 percent said they had removed sleep stealers from their environment, mostly by removing electronic media from bedrooms.
  • 77 percent stated that the event helped them better understand how sleep barriers hinder sleep.
  • More than 70 percent said they were talking with their children more about sleep; all said their children were more aware of the importance of sleep.
  • More than 90 percent reported learning new strategies for helping their children sleep, including bedtime routines.
  • The majority enjoyed hearing other parents' ideas and concerns regarding sleep. One parent expressed a common sentiment: "It feels like we're in this together."
We are encouraged by the success of this sleep initiative, and we hope it will inspire other professionals and community partners. By using a preventive, whole-school approach to a health problem that was thwarting students' learning, students, families, and school staff were motivated to change behaviors. If we want students to fully benefit from academic instruction, schools, families, and community partners must collaborate to encourage healthier lives.
References

Brown, J. L., Grubb, S.B., Wicker, T. E., & O'Tuel, F. S. (1985). Health variables and school achievement.Journal of School Health, 55(1), 21–23.

Chan, W. (2002). Report of the Select Committee on California's Children's School Readiness and Health: Preparing our children to learn. Sacramento, California: California State Legislature. (ERIC Document Reproduction Service No. ED463837)

The Council of Chief State School Officers. (2004). Policy statement on school health. Washington, DC: Author. Available:www.ccsso.org/content/pdfs/SchoolHealthPolicyStatement.pdf

Frame, M. W., Tait, C. T., & Doll, B. (1998). Comprehensive school mental health specialists: An answer to urban students' mental health needs. Urban Education, 33(4), 492–515.

Hair, E., Halle, T., Terry-Humen, E., Lavelle, B., & Calkins, J. (2006). Children's school readiness in the ECLS-K: Predictions to academic, health, and social outcomes in first grade. Early Childhood Research Quarterly, 21, 431–454.

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