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Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

Chapter 34

ESTABLISHING AN INTEGRATED 

BEHAVIORAL HEALTH SYSTEM OF 

CARE AT SCHOFIELD BARRACKS

MICHAEL E. FARAN, MD, PhD*; ALBERT Y. SAITO, MD†; EILEEN U. GODINEZ, PhD‡; WENDI M. WAITS, 

MD§; VICTORIA W. OLSON, MBA¥; CHRISTINE M. PIPER, APRN, BC¶; MARGARET A. McNULTY, DrPH**; 

and CHRISTOPHER G. IVANY, MD††

INTRODUCTION

EARLY EFFORTS 

SOLDIER AND FAMILY ASSISTANCE CENTER

Concept Development, Structural Framework, and Financing 

Recruitment, Advertising, and Implementation

Outcomes and Current Activities

SCHOOL-BASED MENTAL HEALTHCARE

Early History

Program Evaluation and Student Demographics

Future Directions

BEHAVIORAL HEALTH LIAISON PROJECT

Army Community Service Support for 2004–2005 Deployments

Predeployment Support 

Deployment Sustainment 

Redeployment and Reintegration

Lessons Learned

SUMMARY

*Colonel, US Army (Retired); Director, Child, Adolescent, and Family Behavior Health Proponency, Madigan Army Medical Center, Madigan Annex 

Building 9913A, Ramp 2, McKinnley Road, Tacoma, Washington 98431; formerly, Director, School Based Mental Health, Child and Adolescent Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii

†

Clinical Director, Child and Adolescent Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, 

Hawaii 96859-5000; formerly, Staff Psychiatrist, Department of Child Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii 

‡

Inspector General Chief, Inspections and Outreach Branch, US European Command, CMR 480, Box 1865, APO AE 09128; formerly, Chief, Plans 

Analysis and Integration Office, US Army Garrison, Hawaii

§

Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient Psychiatry Service, Department of Psychiatry, 1 Jarrett White Road, Room 4B106, Tripler 

Army Medical Center, Hawaii 96859-5000; formerly, Child and Adolescent Psychiatry Fellow, Tripler Army Medical Center, Honolulu, Hawaii

¥

Executive Director, Hawai’i Army Museum Society, Post Office Box 8064, Honolulu, Hawaii 96830-0064

¶

Colonel, US Army (Retired); Coaching Trainer/Instructor, LivingWorks, Inc.; formerly, Chief, Soldier and Family Assistance Center, Schofield Barracks, Hawaii 

**Captain, US Navy (Retired); Assistant Professor, Department of Nursing, Kapiolani Community College, 4303 Diamond Head Road, Honolulu, 

Hawaii 96816

††Major, Medical Corps, US Army; Psychiatrist, Department of Behavioral Health, Evans Army Community Hospital, Building 7500, 1650 Cochrane 

Circle, Fort Carson, Colorado 80913; formerly, Division Psychiatrist, 4th Infantry Division, Fort Hood, Texas 
564

Combat and Operational Behavioral Health

INTRODUCTION

In 2003, members of four US combat infantry 

units (three Army units and one Marine Corps unit) 

participated in an anonymous mental health survey 

taken either before deployment or 3 to 4 months after 

their return.1 The percentage of soldiers and marines 

whose responses met the screening criteria for major 

depression, generalized anxiety, posttraumatic stress 

disorder (PTSD), or alcohol misuse was significantly 

higher after duty in Iraq (15.6%–17.1%) than after 

duty in Afghanistan (11.2%), particularly with regard to PTSD. The rates of PTSD are similar to those 

experienced in Vietnam, which led to large numbers 

of soldiers becoming disabled. Soldiers and marines 

whose responses were positive for a mental disorder 

were twice as likely to distrust mental health professionals, viewed seeing mental health practitioners 

as harmful to their career, and believed that mental 

healthcare does not work. The stigma of seeking help 

increased with the presence of mental disorders. Notwithstanding the reported stigma, veterans of Operation Iraqi Freedom (OIF) utilized mental healthcare at a 

higher rate during the first year postdeployment than 

veterans of Operation Enduring Freedom (OEF) in 

Afghanistan or those from other deployments. About 

one third of the OIF veterans sought mental healthcare 

during their first year as compared to 22% for OEF and 

24% for other regions.2

Recent ongoing studies suggest that deployment 

also significantly increases the risk of mental health 

problems in military children, family violence, and 

divorce. Anecdotal reports from the field suggest that 

soldiers who are worried about their families are not 

as able to focus on the mission. Family satisfaction and 

resilience are important factors contributing to soldier 

readiness and retention, and attrition of soldiers with 

mental health issues is particularly high. Hoge and colleagues2 found that attrition for any reason during the 

first year postdeployment from OIF was 17%, and those 

who reported a mental health concern were significantly 

more likely to leave the service. Other studies reported 

that 47% of all soldiers hospitalized for the first time 

for any mental disorder were separated from the Army 

within 6 months.3 Innovative mental health initiatives 

are required to meet these and other challenges facing 

the volunteer Army to conserve the fighting strength 

and meet the needs of soldiers and their families. 

The lineage of community mental healthcare in the 

military is rich, beginning in earnest during World 

War II, when clinicians and commanders alike recognized that psychiatric casualties decreased as morale 

increased.4

 Psychiatrists grasped the importance of 

treating soldiers within their social structures and 

strengthening their identification with their units, 

which led to cohesion with their peers and unit leadership. As clinicians came to recognize the soldier as 

a part of an interdependent network of social forces, 

they realized that much of their treatment amounted 

to intervention in some part of the social structure, 

and that the psychiatrist was often poorly equipped 

for these tasks.5

 Individuals in the community—social 

workers, chaplains, and spouses of active duty members in volunteer positions—encountered less stigma 

and had greater knowledge of individual units and 

access to a wider pool of community programs than 

did hospital-based psychiatrists. As psychiatrists 

embraced multidisciplinary approaches, treatment 

moved out of medical centers and became integrated 

into the military social network, shifting emphasis 

toward prevention and leading to the community 

mental healthcare system. 

The impetus for extending community mental 

healthcare to military family members, especially 

during deployments, rests on the emerging belief 

that strong social supports enhance the mental wellbeing of the parent remaining at home, which in turn 

prevents psychopathology in children. Research has 

shown that children’s behavioral problems increase 

(especially in young boys) when the nondeployed 

parent suffers from psychopathology.6 Practical 

remedies, such as strong spouse and family support 

groups; male companionship for young boys (eg, a 

big brother program or family members); education 

programs for spouses about separation and reunion; 

and regular communication with the deployed parent 

require community-level intervention.6 Rear detachment units, wives’ clubs, schools, childcare groups, 

and other community organizations can greatly 

contribute to building resilience in family members. 

Mental health providers have unique skills for identifying individual problem areas, but their interventions 

are most effective when integrated with the work of 

community groups that support families. Likewise, 

mental health providers working in interdisciplinary 

clinics located close to military housing areas are better 

able to implement treatment plans that involve these 

vital social support systems than those who work in 

hospital-based programs.

The responsibility for taking care of the physical 

and emotional needs of soldiers and their families is 

shared by numerous military, federal, and state agencies. These agencies each have specific portions of the 

overall caring “pie,” but historically have functioned 

independently. Often agencies staunchly protect their 

own areas of concern, which unfortunately may result 

in inefficient and costly duplication of services and 

staff. It is a significant challenge to integrate agencies 
565

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

in a common goal. Wenger and Synder7 describe the 

emerging concept of “communities of practice” and 

discuss how disparate groups with a shared agenda 

can come together, learn from each other, and develop 

strategies that work toward a common goal. Large 

numbers of corporations and governmental agencies 

are employing these principles with success; however, 

many organizations need leadership “buy-in” to facilitate cooperation and collaboration. 

The objective of this chapter is to describe the development of a multidisciplinary, integrated system of 

mental health support and care at Schofield Barracks 

in Oahu, Hawaii, during the deployment of the 25th 

Infantry Division Light (25th ID), aimed at promoting resilience and wellness in the Army community. 

Primary focus will be on the Soldier and Family Assistance Center (SAFAC), followed by a brief discussion 

of a school mental health initiative,8 mental health 

support to family readiness groups (FRGs [composed 

of Army spouses who support families]), and the Army 

Community Service (ACS). The discussion of the latter 

programs will focus on how these efforts came together 

to provide care for the soldiers and family members 

in the Schofield catchment area during OIF and OEF. 

(This chapter will not include detailed discussion of 

the Family Advocacy Program or the Army Substance 

Abuse Program [ASAP]. The Family Advocacy Program provides services when domestic violence is 

identified, and the ASAP delivers a wide range of 

prevention and treatment services for alcohol and 

drug abuse.) The overall development of the Schofield 

community behavioral health system is presented in 

chronological order to emphasize the importance of the 

process as it evolved within the entire community. 

EARLY EFFORTS

Schofield Barracks, including Wheeler Army Airfield, is located in central Oahu on 167,919 acres of 

land. It is home to the 25th ID and supports approximately 14,500 active duty soldiers. Additionally, about 

9,500 civilian employees and 3,000 contract employees 

work at Schofield. On post there are three elementary 

schools and an intermediate school that are part of the 

Hawaii Department of Education (DoE). Besides the 

usual stressors for military families, such as frequent 

moves and transitions, additional stressors of living in 

Hawaii are the high cost of living, parents’ concerns 

about their children’s education, and cultural differences. As with other overseas assignments, most families living in Hawaii are isolated from their extended 

families and visit their relatives on an infrequent basis 

because of travel costs. The Army community receives 

its primary healthcare at Schofield Barracks Health 

Clinic, except for specialty care, which occurs at Tripler 

Army Medical Center (TAMC), located 20 miles from 

Schofield and over an hour’s commute during rush 

hour. Before the establishment of the SAFAC, almost 

all child, adolescent, and adult mental health services 

(other than services for active duty personnel) were 

delivered at TAMC. 

In June 2003, the leadership of the 25th ID began 

preparation for deployment of a brigade combat team 

(BCT) to Afghanistan. By early fall of that year, the unit 

rotation schedule had expanded to include deployment of the entire 25th ID at Schofield. The 2nd BCT 

was slated for deployment to Iraq in January/February 2004, and the 3rd BCT and Division Headquarters 

were slated for Afghanistan between February and 

May. At the time, the 25th ID was the only division 

deploying to two separate theaters of combat operations. The division was also called upon to mobilize 

the US Army Reserves and Hawaii National Guard as 

part of the deployment. 

Through a combined effort of the 25th ID, Schofield 

Garrison Command, and TAMC, plans immediately 

began for soldier and family readiness and assistance 

during the deployment cycle, which presented significant challenges to these organizations. The 25th ID 

was deploying over 11,000 soldiers and leaving behind 

25,000 family members, including nearly 800 pregnant 

women. Because of the availability of medical care at 

TAMC, the division had a higher proportion of families than usual with “exceptional family members,” 

individuals with medical and mental health needs that 

require specialized care. During the first deployment, 

80% of the families of deployed soldiers elected to 

remain in Hawaii rather than return to their homes on 

the mainland during the deployment, which increased 

the need for mental healthcare. 

The predeployment preparation for soldiers and families began in earnest in November 2003 with coordination of services among the various on- and off-post agencies. Mental healthcare was already becoming integrated 

with the involvement of FRGs, schools, and the ACS; for 

example, since 2001, Child and Adolescent Psychiatry 

Service (CAPS) at TAMC had already been involved in 

a school mental health program at Schofield.

During the summer of 2004, it became clear that the 

OIF and OEF deployments were resulting in significant 

mental health casualties.1

 The FRGs, CAPS, and ACS 

began discussing ways to meet the projected increased 

need for support and mental health services for the 

entire community, and informed the commander of the 

25th ID, Major General Eric Olson, of their concerns. In 

December 2004, the 25th ID division surgeon returned 

from Afghanistan to meet with the commander of 
566

Combat and Operational Behavioral Health

Schofield Barracks Health Clinic and leaders in mental 

health at TAMC. This meeting resulted in a commitment to develop a mental health initiative, which later became the SAFAC. 

SOLDIER AND FAMILY ASSISTANCE CENTER

Concept Development, Structural Framework, and 

Financing 

The purpose of the SAFAC was to execute a plan 

that provides mental health support for returning soldiers and their families. Early in the process, six guiding principles for SAFAC’s development emerged: 

1. a variety of mental health resources would 

be developed and integrated under a single 

umbrella organization to facilitate coordination of services and increase capacity and 

flexibility in delivery of these services; 

2. a single point of entry would be established 

to make access to care easy and simple; 

3. the mental health resources of the 25th ID 

would be combined with those of the Schofield Barracks Community Mental Health 

Clinic; 

4. the funding of the SAFAC would be shared 

between Schofield Barracks Health Clinic and 

the 25th ID; 

5. leadership for the newly established clinics 

could come from either the 25th ID or from 

Schofield Barracks Health Clinic; and 

6. every effort would be made to decrease the 

stigma in seeking mental health assistance. 

Several of these principles were unique to the Army 

experience, specifically principles 3, 4, and 5. Responsibility and leadership for the SAFAC would be shared 

so that the 25th ID had a vested interest in the direction 

and success of the initiative. A process action team, 

which was established and chaired by the rear division 

commander of the 25th ID, met monthly to evaluate 

progress and institute new initiatives or major changes 

in directions. A work group headed by the commander 

of Schofield Barracks Health Clinic met weekly to plan 

the next steps and evaluate progress.

The first task of the work group was to estimate the 

numbers of various specialty providers that would be 

required for the SAFAC to adequately meet the needs 

of the community. This process required estimates 

of baseline morbidity rates in soldiers and family 

members during peacetime, as well as rates resulting 

from deployment. Early estimates for the soldiers deployed to OIF and OEF were based on the research of 

Hoge et al,1

 and the work group assumed that not all 

soldiers with difficulties would seek help. Hoge et al1

reported that rates for PTSD were lower in OEF than 

OIF. Soldiers of the 25th ID deployed to either OIF or 

OEF. Rates of PTSD for soldiers were projected to be 

approximately 8% to 11%. Rates of other anxiety/depression were estimated at 5% to 7%, serious domestic 

violence at 8%, moderate domestic violence at 22%, 

divorce at 10%, and children with mental health issues 

at 25%. Projections of the rates of the mental health 

problems in the adult family members were based on 

the rates in soldiers. Because the SAFAC needed to care 

for not only the current active duty population but also 

the deployed reserve and National Guard soldiers and 

their family members, actual numbers for the entire 

population were not available. 

No algorithm was available to estimate the numbers 

of providers in each specialty needed to serve this 

population; the Army’s system of resource allocation 

is not based on empirical evidence. To develop an algorithm that later could be tested, several assumptions 

were necessary. These assumptions were (a) the average number of visits per year each individual would 

make, (b) the proportion of individuals who would 

require medications, (c) the numbers of patient visits 

each specialty provider could reasonably provide in 

a year, and (d) the ratio of patients who could be seen 

by a nurse practitioner versus a psychiatrist versus 

another provider. Based on these assumptions and 

those listed below, algorithms were developed and 

later refined. 

Exhibit 34-1 lists the assumed number of visits 

per year per specialty provider and the formula for 

its calculation. For example, it was assumed that 

an adult psychiatrist would be able to handle 3,290 

visits per year based on 7 hours of patient contact 

a day, two patients per hour, 5 days a week, for 47 

weeks each year; each patient visiting the three clinics 

would require an average of six visits a year; 0.8 of the 

adults being seen in the Soldier Assistance Center or 

the Adult Family Member Assistance Center would 

require medications; and approximately 50% of the 

patients under 18 years of age seen in the Child and 

Adolescent Assistance Center would require medications. There would be three psychiatrists to every one 

nurse practitioner for adults and one child psychiatrist 

to one nurse practitioner for children and adolescents. 

The ratio of social workers to psychologists would be 6 

to 1. Child psychiatrists, child nurse practitioners, and 

child psychologists would be in equal proportion. This 

algorithm could be further refined as actual data were 

collected, and it could be easily modified to adjust to 

differences in other clinics or at other installations. 
567

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

EXHIBIT 34-1

ALGORITHMS FOR CALCULATING PROVIDER NUMBERS

Visits per Practitioner per Year

	 •	 Psychiatrist: 3,290*

	 •	 Social worker: 1,645†

	 •	 Psychologist: 1,645†

	 •	 Nurse practitioner: 3,290*

	 •	 Child psychiatrist or child nurse practitioner: 2,467‡

	 •	 Psychologist: 1,645†

*7 h × 2/h × 5 days/wk × 47 wks = 3,290

†

7 h × 1/h × 5 days/wk × 47 wks = 1,645

‡

7 h × 1.5/h × 5 days/wk × 47 wks = 2,467

Formulas for Number of Practitioners Required

	 •	 Psychiatrists and nurse practitioners: population × 6 visits/patient/year × .8 needing medications ÷ 3,290

visits/psychiatrist/year

	 •	 Social workers and psychologists: population × 6 visits/patient ÷ 2,209 visits/provider/year

	 •	 Nurse practitioners: population × 6 visits/patient × .8 needing medications ÷ 3290 visits/year

	 •	 Child psychiatrists: population × 6 visits/patient × 0.5 needing medications ÷ 2,467 visits per year

	 •	 Child nurse practitioners: population × 6 visits/patient × 0.5 needing medications ÷ 1,645 visits/year

	 •	 Child psychologists: population × 6 visits/patient ÷ 1,645 visits/year

Proposed Ratios

	 •	 Adult psychiatrists to nurse practitioner = 3:1

	 •	 Adult social workers to psychologists = 6:1

	 •	 Child psychiatrists to child nurse practitioners = 1:1

By January 2005, five areas of care (Exhibit 34-2) 

were identified and a timeline for implementation of 

the clinics determined. Table 34-1 lists the projected 

deployed population and the estimated number of 

providers required in each of the five areas using the 

various algorithms. There would be a single point of 

entry into the mental health system (to be available 

24 hours a day), which became known as the Triage 

Assistance Center. Other areas of care were the establishment of three new clinics and augmentation of the 

Marriage and Family Assistance Center and the ASAP. 

The new clinics were called the Soldier Assistance Center (SAC), the Adult Family Member Assistance Center 

(AFMAC), and the Child and Adolescent Assistance 

Center (CAAC). The designation “assistance center” 

was utilized in an attempt to decrease the stigma surrounding mental healthcare. 

Funding was approved the same month. Preliminary estimate of the cost of the SAFAC for one year was 

$5.4 million. The 25th ID agreed to fund approximately 

20% of the total, including renovation of a floor in a 

EXHIBIT 34-2

SOLDIER AND FAMILY ASSISTANCE 

CENTER FIVE AREAS OF CARE

1. Triage Assistance Center telephone line (24 

hours a day/7 days a week) 

2. Soldier Assistance Center

3. Adult Family Member Assistance Center

4. Child and Adolescent Assistance Center

5. Marriage and Family Assistance Center

clinic to house the AFMAC, and hiring three providers to augment drug and alcohol treatment for family 

members and six social workers to bolster the AFMAC 

and the Marriage and Family Assistance Center. The 

remainder of funds came from TAMC. The 25th ID 

also assumed an active role in the SAFAC’s develop-
568

Combat and Operational Behavioral Health

ment, providing additional leadership and assistance 

to the assistant division surgeon and technical support 

through the loan of a division logistics officer. 

Recruitment, Advertising, and Implementation

The reorganization of the Community Mental 

Health Clinic and division mental health services into 

the SAC occurred immediately, and the SAC opened 

the second week in January 2005. Demand at the start 

far outweighed availability, and additional providers 

were immediately needed. In February, TAMC’s chief 

of psychiatry (Colonel CJ Diebold) and residency program director (Colonel David Orman) provided staff 

psychiatrists’ and residents’ time to the SAC as part 

of the graduate medical education program. This interim solution was essential to maintaining the SAC’s 

function while providers were recruited and hired. 

Specialty experts at Schofield Barracks Health Clinic or 

TAMC interviewed prospective candidates and made 

hiring recommendations. By April 2005, essentially all 

the positions had been filled. 

Although some family members were already being 

seen in limited numbers in the SAC, the AFMAC and 

Triage Assistance Center opened on March 15. In April, 

the division mental health staff returned from OEF and 

OIF, including the chief, Major Brian Bacon, who was 

appointed chief of the SAC, and division psychologist 

Captain Richard Schobitz, who became chief of the 

AFMAC and CAAC. The opening of the CAAC was 

delayed a month due to difficulty in recruiting child 

psychiatrists, but by May 2005 all clinics were operating at or above optimal staffing levels. 

Early in the program’s development organizers initiated an aggressive campaign to decrease the stigma 

associated with seeking mental health assistance at 

the SAFAC, and increase awareness among providers of war-related psychological trauma. Hoge and 

colleagues1

 found that the greater the likelihood of 

trauma, the greater the stigma in seeking help. The 

advertising campaign was initiated in February 2005, 

promoting the SAFAC and its available resources 

throughout the community. Ten thousand refrigerator 

magnets were produced that listed SAFAC’s mission 

and services, as well as the 24-hour triage telephone 

number. The television channel on post also promoted 

the new resources and encouraged people in need to 

seek help. Unit leaders were informed by their chains 

of command that any soldier having emotional difficulties should be identified and offered the opportunity to visit the SAFAC. Division leaders met regularly 

before and after redeployment to ensure that soldiers 

at risk were identified. 

The National Center for PTSD was invited to Schofield Barracks to instruct primary care providers in 

recognizing war-related mental health disorders and to 

teach behavioral health providers cognitive-behavioral 

therapy for PTSD. National Center for PTSD staff Matthew Friedman, MD, PhD (the center’s director); Frederick Gusman, MSW; Julia Whealin, PhD; and Gregory

Leskin, PhD, conducted 3 days of classes for the staff 

at Schofield Health Clinic and TAMC. Dr Whealin continued to come once a week to colead a soldier PTSD 

group at the SAC. Efforts by the center increased the 

knowledge of PTSD and depression among primary 

care providers and have been very beneficial to the 

entire Schofield Barracks community. The effectiveness 

of this campaign in decreasing stigma cannot be known; 

however, the demand for SAFAC services, particularly 

during the initial stages, has taxed its resources.

One of the SAFAC’s initial efforts was the Soldier 

Readiness Program (SRP), in which a mental health 

provider interviewed every soldier prior to and immediately upon redeployment, and those having serious 

concerns or requesting assistance were immediately 

referred to a doctoral-level provider. The psychology 

and psychiatry departments at TAMC supplied additional staff for the SRPs until the SAFAC was fully 

operational (currently the majority of the staffing of 

SRPs is done by the SAFAC).

TABLE 34-1

PROJECTED DEMAND OF PROVIDERS BASED ON POPULATION

Psychiatrists Psychologists Nurse Practitioners Social Workers

Soldier Assistance Center 4.10 1.95 1.37 11.72

Adult Family Member Assistance Center 2.41 1.15 0.80 6.88

Child and Adolescent Assistance Center 1.06 2.13 1.06 0

Marriage and Family Assistance Center 0 0 0 8.07
569

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

Outcomes and Current Activities

Key to success of the SAFAC team is flexibility. With 

regular moves of the active duty staff, contracts that 

require year-to-year negotiation, and deployments, 

staff flexibility to meet the demand of the current 

situation is critical. The clinics are organized under an 

“umbrella” of services, which allows for movement of 

staff between clinics to meet the changing needs of the 

population. For example, when some of the soldiers of 

the 25th ID deployed in summer 2006, staff were shifted from the SAC to the AFMAC, increasing services 

for family members while the soldiers were deployed. 

Additionally, two social workers transitioned from the 

AFMAC to the Marriage and Family Assistance Center 

in response to increased need. Recently the ASAP had 

a 2-month backload, which was relieved when the SAC 

developed a behavioral change group specifically for 

ASAP clients. In September 2005, the CAAC opened 

evening hours to see children, facilitating access for 

parents who work. A new position has been added 

to conduct outcome studies on the SAFAC’s efficacy. 

Despite minor fluctuations over time in each clinic’s 

staffing, the initial estimates for overall numbers of 

the various providers have proven to be fairly accurate. Figure 34-1 illustrates the number of client 

appointments at the three clinics from January 2005 

to November 2006.

Within the Schofield Barracks community, the 

SAFAC is involved in a variety of activities. Staff 

members teach classes and present seminars at ACS. 

A team composed of an AFMAC child psychologist 

and an ACS social worker present briefings at district 

schools on topics relevant to military children, such 

as “Effects of Deployment on Children,” “Children 

and Redeployment,” and “Building Resilience.” 

Every unit that returns from OIF or OEF receives a 

reintegration briefing from the SAFAC. In addition, 

a monthly caregiver team meeting is dedicated to 

improving community outreach, family support, and 

crisis intervention. 

Since the deployments of the Hawaii Army Reserve 

units and the National Guard, numerous requests have 

been made for outreach services on other islands in Hawaii, as well as in Alaska, Samoa, Guam, and Saipan. 

A SAFAC team was appointed to provide services at 

these geographically remote areas through ongoing 

visits to each of these locations. 

SCHOOL-based MENTAL HEALTHcare

SAC CAAC

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

3,000

2,600

2,200

1,800

1,400

1,000

600

200

1,745

1,858

2,160

1,745 1,759

1,749

1,490

1,732

1,938

2,499

2,163

AFMAC TOTAL

Figure 34-1. Monthly patient or client visits in the three 

Soldier and Family Assistance Center clinics, January 2005 

to November 2006.

AFMAC: Adult Family Member Assistance Center

CAAC: Child and Adolescent Assistance Center

SAC: Soldier Assistance Center

In partnership with Solomon Elementary School 

in Schofield Barracks, CAPS developed a model for 

school mental health preventive care, early intervention, evaluation, and treatment of military children. 

Dr Mark Weist, director of the Center of School Mental 

Health at the University of Maryland, was consulted 

during the establishment of the Solomon Wellness Educational Program (SWEP), which began in 2001 with 

the goal of facilitating easy access to mental healthcare 

for students.8

 The project initially expanded to four 

schools. The following discussion only pertains to 

Solomon Elementary School, because it has the longest 

history and has received the most evaluation. Although 

not discussed here, programs at the three other schools 

are ongoing and highly valued by each school. 

Solomon Elementary is a public school administered 

and funded by the Hawaii DoE. Administrators, teachers, counselors, and support staff are state employees. 

The school currently has an enrollment of about 830 

students, 99% of whom are military dependents. The 

students come mainly from families of junior enlisted 

active duty soldiers who are usually assigned to a 

3-year tour in Hawaii. Of the students, at least one 

third transition (move from the area) each year. A large 

proportion of these families have young children, as 

reflected by the school’s eight kindergarten classes, 

eight first-grade classes, six second-grade classes, five 

third-grade classes, four fourth-grade classes, and four 

fifth-grade classes. Of the children at Solomon, 49% 

qualify for a reduced-price or free lunch. In addition, 

seven self-contained special education preschool classes serve 51 young children with severe communication 

disorders, autistic disorder, global developmental delays, or severe behavioral disorders. An additional 69 
570

Combat and Operational Behavioral Health

special education students are in kindergarten through 

fifth grade. Three self-contained classrooms are for 

children with severe behavioral disorders, serving 12 

children from 5 years to 11 years of age. 

Early History

A formal agreement has existed between Solomon 

Elementary and the Child Psychiatry Service at TAMC 

since 1985. Second-year child psychiatry fellows spent 

one half day per week for 6 months providing consultation services at the school for children referred 

by school counselors. Fellows mainly provided triage 

after observing the children and discussing the counselors’ concerns. Children in need of services were 

referred to TAMC or to a civilian provider through 

TRICARE—the military’s health insurance program. 

In 2000, CAPS decided to offer more services by sending the child psychiatry fellow into the school for a full 

day each week for the entire school year. The referral 

process remained the same, but full evaluations were 

now conducted at the school. These early experiences 

helped form the vision and goals of a comprehensive, 

integrated, school mental health program: 

Vision: Develop and implement a comprehensive 

array of school programs and services to support students, family, and community.

Goals: 

	 •	 Provide a full continuum of mental health

promotion and intervention programs and 

services, including early identification and 

intervention, prevention, evaluation, and 

treatment.

	 •	 Remove barriers to learning and improve the

academic success of students. 

	 •	 Enhance strengths andprotective factors in students, families, and the school community.

	 •	 Promote quality oflife and wellness in military

families. 

	 •	 Provide training, staff development, and

research opportunities to improve children’s 

mental health and education.8

Several tenets were developed concurrently to 

guide program decisions. The first tenet stated that 

SWEP is a collaborative program responsive to the 

needs of its stakeholders. An advisory board composed 

of various stakeholders in the school and community 

meets on a monthly basis. The board’s responsibility 

is to attend to the mental health of the students, teachers, parents, and the community. For example, to deal 

with the increased interpersonal difficulties between 

students at recess, the board developed a program 

of structured games and contests that resulted in declining referrals to the office during recess. Another 

example was the regular publication of a newsletter 

for teachers on mental health topics. During the first 

OIF deployment of the 25th ID, the advisory board 

held parent support meetings at the school to help the 

nondeployed parent and children successfully cope 

with the situation. The board also established a crisis 

plan to ensure a coordinated, empathic response to 

the children and families of soldier parents who were 

killed or severely injured. The plan called for verification of all information before intervention, followed by 

a clearly defined, graded approach to meeting families’ 

needs with sensitivity. 

The second tenet required that all programs and 

services for children and families be coordinated. DoE 

and TAMC policies needed to be integrated, followed 

by frequent and clear communication. This led to 

weekly triage meetings following an algorithm for how 

a child is referred for evaluation and provided care, attended by the treating physicians, counselors, a school 

behavioral specialist, a student services coordinator, 

the school principal, and the medical director. After 

appropriate parental consents are given, information 

about the child and family is shared, and a coordinated, 

multidisciplinary treatment plan is devised. 

Program Evaluation and Student Demographics 

SWEP incorporates ongoing performance improvement to ensure timeliness and quality of services, including a recent review of 133 closed charts of students 

evaluated from August 2001 to February 2007. Of the 

133 children referred to SWEP, nine failed to appear 

for their initial appointments, for a noncompliance rate 

of 7%, and 113 of the 124 evaluated were seen within 4 

weeks of the date of referral, including over one third of 

the children who were seen within 10 days of referral. 

Although 11 children were seen after 4 weeks, three 

were delayed due to cancellations by the parents and 

four because of school vacations, particularly during 

the winter holiday vacation when school was closed 

for 2 weeks. The majority of the children evaluated 

were 7 years of age and under (Figure 34-2). 

The majority of children had externalizing disorders, with a boy-to-girl ratio of about 4 to 1. Modalities 

of treatment at the school included individual and 

group therapy, family therapy, parent guidance, and 

pharmacotherapy. Of the children treated, only four 

required a higher level of behavioral intervention, including special education certification. Three of these 

children were diagnosed with bipolar disorder and the 

other child (whose parents were both deployed) was 
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Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

diagnosed with severe attention deficit hyperactivity 

disorder and oppositional defiant disorder.

Other services provided by SWEP included quarterly teachers’ workshops and parent workshops on 

behavioral interventions, as well as a recently initiated bullying awareness and prevention program. 

For the past 3 years, SWEP physicians have provided 

weekly consultations to the Primary School Adjustment Program, which screens all younger children 

and identifies those having trouble adjusting to the 

school environment. Two paraprofessionals then offer 

individual and small group services to these children. 

The child psychiatry fellows have given guidance and 

instruction on topics such as child development, as 

well as offering workshops to the parents. Addition120

100

80

60

40

20

0

Age 9 3 4 5 8 6 7 10 11 Total

# Male # Female

Figure 34-2. Ages and gender of children evaluated at Solomon Elementary School in the Solomon Wellness Educational 

Program, from August 2001 to February 2007 (total: 133).

ally, support groups for children whose parents are 

separating and divorcing have been initiated.

Along with training opportunities for TAMC child 

psychiatry fellows, SWEP has expanded to include 

training of social work students from the University 

of Hawaii. A formal memorandum of agreement was 

established whereby master’s-level students obtained 

practicum experience at SWEP under the supervision 

of the medical director, child fellows, and a DoE school 

social worker. Practicum students performed intakes 

and offered individual and family therapy, parent 

guidance, and group therapy. A similar collaborative agreement was established with the university’s 

Counseling Education Department, whose practicum 

student performed intakes, provided therapy, and 

received training in psychological testing.

Future Directions 

Efforts are underway to use measurements before 

and after program participation to document student 

progress. The Strengths and Difficulties Questionnaire9

 has been administered to teachers and parents 

before and at selected intervals after to determine the 

treatment’s effect. In addition, patterns of behavioral 

referrals to counselors or the vice principal are being 

analyzed before and after treatment to determine if 

treatment has an impact on disciplinary referrals. Further efforts are planned to identify deployment-related 

stresses on parents and children, including effects of 

reunions and postdeployment family readjustment. 

BEHAVIORAL HEALTH LIAISON PROJECT

In February 2004, the TAMC psychiatry residency 

program launched a behavioral health liaison (BHL) 

project, modeled on a similar program conducted at 

Letterman Army Medical Center in San Francisco, California (1988–1989), aimed at familiarizing psychiatry 

residents with operational Army units.10 Unbeknownst 

to organizers, it also resembled a program being 

piloted simultaneously by ACS in the 1st Armored 

Division using social workers as consultants, which 

later gained widespread acceptance as the Soldier 

and Family Life Consultants (or Military Family Life 

Consultants) program.

The BHL program was different, however, in that 

residents supported the rear elements of a deployed 

military force. It included both service and training 

missions, providing preventive and consultative mental healthcare to rear-detachment units and FRGs, as 

well as familiarizing residents with these units and 

their day-to-day activities. The BHL team consisted 

of 17 TAMC psychiatry residents at various levels of 

training, along with a supervising attending psychiatrist. Each resident was assigned a 25th ID unit to support; junior residents were given battalions and senior 

residents were given brigades. Over the course of a 

12-month deployment cycle, BHLs provided education 

on relevant psychosocial issues to rear-detachment 

commanders and FRG leaders, and facilitated access 

to mental health resources for soldiers and their family members.

Initial challenges included generating interest 

among residents while minimizing additional demands on their already burdensome academic schedules. At a minimum, residents were required to contact 

their assigned unit’s FRG leader and offer the group 

an initial educational briefing. Beyond that, they were 

encouraged, but not required, to attend their unit’s 

monthly FRG meetings and provide additional education and consultation as requested.

Outcome data later revealed that almost exactly one 

third of the residents perceived their welcome by the 
572

Combat and Operational Behavioral Health

unit as “easy/welcoming,” one third perceived their 

welcome as “average,” and one third perceived their 

welcome as “difficult/unwelcoming” (Figure 34-3). 

Although these relationships were not objectively 

measured, a direct correlation was perceived between 

the openness with which units welcomed their BHL 

and the amount of contact the BHLs subsequently had 

with their assigned units; disinterested units did not 

receive as many visits or educational briefings as units 

that proactively reached out for assistance. 

Every interested unit received an initial briefing 

from their BHL on the emotional cycle of deployment, a concept originally described by Pincus and 

colleagues.11 Topics covered in subsequent briefings 

are listed in Exhibit 34-3. Beyond the initial contact, 

residents had a substantial amount of flexibility in 

choosing how to work with their FRGs and remained 

involved with the groups on a variable basis. Some 

attended FRG meetings every month, kept in close 

contact with FRG leaders, and attended various unit 

functions. Others took a more passive role, remaining 

available to field questions from FRG leaders only 

when issues arose.

When the program ended, feelings about the proEXHIBIT 34-3

FAMILY READINESS GROUP BRIEFING 

TOPICS 

	 •	 Behavioral health liaison introduction

	 •	 Emotional cycle of deployment

	 •	 Common mental illnesses

	 •	 Combat stress/posttraumatic stress disorder

	 •	 Children and deployment

	 •	 Midtour rest and recuperation

	 •	 Loss and grieving

	 •	 Reunion and reintegration

Easy/Welcoming Average Welcome Difficult/Unwelcoming

6

4

2

0

Number of Respondents

Figure 34-3. Quality of welcome by unit in the behavioral 

health liaison project.

gram were overwhelmingly positive among FRG leaders, who unanimously felt that the program should be 

continued following redeployment. The psychiatry 

residents, however, had a mixed response. Ultimately, 

the program was discontinued and replaced with a 

mandatory 2-month senior resident rotation through 

the SAC, with supervision by either the 25th ID 

division psychiatrist or an active duty community 

psychiatrist. 

Army Community Service Support for 2004–2005 

Deployments

The deployment of the 2nd BCT to Iraq in January 

2004, followed by the deployment of the 3rd BCT to 

Afghanistan in March 2004, prompted further community efforts to prepare and support soldiers and 

families of the 25th ID. ACS took a leadership role 

in ensuring that 25th ID soldiers and families were 

trained and ready to handle what became a long and 

challenging 18 months. ACS concentrated on preparing the families of the 2nd BCT first, followed by the 

3rd BCT, and then launched an aggressive sustainment program of continued support to families during the deployment. Finally, ACS developed a robust 

redeployment program that strategically addressed 

reintegration issues. 

Predeployment Support 

ACS developed a four-pronged approach to predeployment support including (1) dissemination of 

information, (2) training and education, (3) community outreach, and (4) mental health integration. The 

extensive community outreach element included three 

deployment information fairs with more than 20 community service organizations participating, such as 

finance, legal, and housing assistance organizations; 

TRICARE; child development centers; and SAFAC. 

Military and civilian organizations were available to 

answer questions and provide information about making personal deployment decisions for soldiers and 

families. The fairs were open to the entire community; 

local sponsors provided door prizes and refreshments. 

More than 2,500 soldiers, families, and community 

members attended the three fairs.

A separate job fair was conducted with the community employment assistance program to educate 

spouses about employment opportunities. Many 

spouses were undecided about whether to remain in 

Hawaii or move back to the mainland during deployment. Because employment factored into this decision, 

ACS partnered with over 30 local businesses and organizations to extend employment opportunities to 
573

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

spouses. More than 250 spouses attended the fair. 

Community town hall meetings, beginning several 

months before deployment, offered the latest information from the division commander about deployment 

status and myriad community service providers. The 

division commander and his staff were on hand to 

answer questions and quell any rumors or misinformation. The town hall meetings continued on a monthly 

basis throughout the duration of both deployments. 

Free childcare during the meetings ensured high 

attendance. Additionally, over 30 school briefings 

were presented to teachers, school administrators, 

counselors, and parents, in partnership with CAPS, on 

deployment-related topics affecting children.

ACS training and education opportunities included: 

	 •	 preparation and guidance for FRG leaders,

either as individuals or in classes, on how to 

best support families and themselves during 

deployment;

	 •	 education of rear-division commanders

(nondeployed) in collaboration with division 

training resources;

	 •	 financial readiness classes for soldiers and

families to prepare them for the financial issues of deployment; and 

	 •	 family wellness classes teamed with various

TAMC child and adolescent psychiatrists, 

SAFAC staff, and chaplains. 

The ACS provided over 58 sessions of financial 

readiness training. Numerous other classes for families covered such topics as “Impact of Deployment on 

Children,” “Helping Children Cope With Stress,” and 

“Dealing With Rumors.” Several classes addressed 

relationship issues for parents and the importance 

of meaningful communication during separation 

between spouses. ACS contracted Drs John and Jane 

Covey to train 27 ACS employees and chaplains for 

certification in “Seven Habits of Highly Effective 

Families”; the trainees in turn conducted almost two 

dozen 1-day sessions for Army couples. 

ACS joined with the SRP to offer soldiers a plethora 

of information, as well as collecting data on soldiers 

and their families. ACS designed a predeployment 

information sheet, distributed to all soldiers, asking 

for information on the soldiers and their families, their 

needs, potential concerns, and requested assistance. 

Data were collected for ACS to determine where 

spouses would be residing during the deployment 

and any special needs they may have. Single soldiers 

were asked to provide an address of a parent or friend 

they wanted to be kept informed during their time 

deployed. Upon completion of the forms, over 8,500 

records were collected and input into a database. 

Demographics such as spouse or parent addresses, 

pregnancies, family members with special needs, non–

English-speaking spouses, and planned relocations 

were used to develop specific deployment programs 

for target audiences. Approximately 22% of spouses 

moved to the mainland, 9% of married women were 

pregnant, 13% of spouses did not speak English as their 

first language, 15% had a special-needs family member, 56% of soldiers were married, and 69% of those 

married had children. A deployment newsletter was 

published bimonthly and mailed to over 8,000 spouses, 

parents, and friends of soldiers, containing information 

on Army community services available to families and 

important resource telephone numbers. 

Deployment Sustainment 

To ensure that quality services were available for 

spouses, ACS extended its operations to 7 days a 

week. Classes and training for FRG leaders and family 

members continued, with frequent seminars on such 

topics as “Coping With Deployment,” “Care for the 

Care-Giver,” and “Taking Care of Me.” ACS offered a 

weekly “spouses night out” every Thursday with pizza 

and other refreshments provided by sponsors, fun activities, and free childcare (also available for the FRG 

Wednesday meetings). Guest speakers, craft nights, 

game nights, support groups, and more were offered 

during the 52 weekly sessions. In addition, ACS made 

20 hours a month of free childcare easily accessible to 

spouses to provide child-free opportunities for errands 

or respites. However, 88% of childcare employees 

were spouses of deployed soldiers, and burnout and 

stress were common among staff. In hindsight, the 

free childcare was excessive and created challenges for 

subsequent deployments when expectations could not 

be sustained because of decreased funding.

ACS worked directly with the 125th Signal Battalion to connect soldiers and families via video 

teleconference (VTC) equipment available 7 days a 

week. Spouses found seeing their deployed spouses 

and speaking to them face to face to be comforting, but 

children had mixed experiences with the VTC sessions. 

Younger children sometimes became visibly upset by 

seeing mom or dad on the screen, while others used 

the opportunity to update their parents on school and 

home activities. In general, the VTC sessions proved 

to be very valuable to families.

Redeployment and Reintegration

In December 2004, ACS developed a workshop to 
574

Combat and Operational Behavioral Health

prepare spouses and families for reunion after deployment. ACS again invited Drs John and Jane Covey 

to participate. The workshop included a list of local 

professionals who offered such classes as “Effects of 

Combat Stress on Families,” “Helping Children Prepare for Reunion,” and “Putting the Welcome in Welcome Home.” The workshop was in a “round-robin” 

format, affording spouses the opportunity to attend 

three of the five sessions provided. Over 150 spouses 

attended. The workshop was followed by a series of 

programs with guest speakers offered every 2 weeks in 

the evenings. Mental healthcare providers, chaplains, 

and social workers were brought in to present topics 

on reunion and reintegration. 

ACS developed a “Ready 4 Reunion” DVD with 

three segments that addressed reunion and reintegration, one of which focused on children and deployment and was produced by ACS with the help 

of local volunteers and a TAMC child psychiatrist. 

The other two segments were taken from “Operation 

Ready” material (www.mwrarmyhawaii.com/acs/

managing_deployment.asp). Mailed to over 6,000 

family members, the DVD had a 3-fold purpose: (1) 

to reach as many spouses as possible, both those who 

remained in Hawaii and those who had moved back 

to the mainland; (2) to provide spouses with reunion 

information in their own homes; and (3) to generate 

awareness of the postdeployment reintegration process and encourage spouses to take advantage of the 

training and services available to them. The DVD was 

successful in generating interest in reunion training 

and was later made accessible on the ACS Web site 

(http://www.mwrarmyhawaii.com/). 

To facilitate reintegration, the 25th ID planned to 

provide comprehensive training to redeploying soldiers and families beginning 90 days before homecoming and ending 30 days after redeployment. The resulting Tropic Lighting University, based on Iron Horse 

University at Fort Hood, Texas, was a three-phase 

reunion program designed specifically for intensive 

reunion training to soldiers and their spouses. 

Phase I included intensive reunion training to 

spouses beginning 90 days prior to homecoming. 

Phase II, the 3-day deployment cycle support program 

mandated by the Army, included a series of briefings, mental health screenings, and medical checks. 

Spouses were invited to attend the briefing portion of 

this phase. Phase III occurred immediately following 

the soldier’s 30-day leave period and consisted of a 

series of classes over 2.5 days. Four target audiences 

were identified for training: (1) single soldiers, (2) 

single soldiers with children, (3) married soldiers, and 

(4) married soldiers with children. Unit integrity was 

maintained throughout the program. Tropic Lighting 

University trained over 10,000 soldiers. The curriculum 

included 

	 •	 stress management (2 hours) for all soldiers,

	 •	 anger management (1 hour) for all soldiers,

	 •	 money management (1.5 hours) for all soldiers, 

	 •	 single parent workshop (1.5 hours),

	 •	 single soldier workshop (1.5 hours),

	 •	 marriage workshop (3 hours),

	 •	 communication with children (1 hour), and

	 •	 divorce recovery (2 hours) for soldiers going

through a divorce.

Lessons Learned

	 • 	 Partnership with the mental health community was invaluable and should be mirrored 

on all Army installations. 

	 • 	 Global war on terror funds provided ACS

with the needed financial resources to provide 

extensive deployment services.

	 • 	 Twenty hours a month of free childcare was

excessive and created an unsustainable expectation.

	 • 	 ACS and childcare staff experienced burnout.

Extended hours and additional childcare 

requirements put a great deal of stress on 

the staff, many of whom were spouses of 

deployed soldiers. 

	 • 	 Keeping the community informed and building relationships with schools helped identify 

potential family issues and at-risk families, 

and connected families with available resources before issues became elevated. The 

community served as ACS’s eyes and ears. 

The responsibility for taking care of the physical 

and emotional needs of soldiers and their families is 

shared by numerous military, federal, and state agencies. These agencies each have specific portions of 

the overall caring “pie,” but historically have largely 

functioned independently. Often agencies staunchly 

protect their own areas of concern (“defend their 

turf”), which unfortunately may result in duplication 

of services and staff, and that is not only inefficient 

and costly, but also results in barriers to care due to 

lack of coordination of services and multiple portals 

of access. It is a significant challenge to integrate 

agencies in a common goal. Wegner and Synder10

describe the concept of “Communities of Practice” as 

being the “organizational frontier” and define how 

disparate groups that have a “shared agenda” may 

come together, learn from each other, and develop 
575

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

strategies that work toward a common goal. Large 

numbers of corporations and governmental agencies 

are employing the principals embodied in the concept 

of a “community of practice” with success. However, 

within many organizations there needs to be a “buy 

in” from the leadership. 

SUMMARY

The rapid development and success of SAFAC is 

attributable to strong leadership in the 25th ID and 

TAMC. Likewise, strong leadership from the Schofield 

Barracks Garrison Command, the National Center for 

PTSD, and the Hawaii DoE district superintendent 

facilitated the coming together of the various agencies, schools, and the SAFAC in maximizing resource 

utilization and cooperation. For example, the SAC, 

composed of the combined mental health resources of 

the 25th ID and the Community Mental Health Clinic, 

greatly increased capacity and access to care for soldiers returning from OIF and OEF. Such collaboration 

greatly expands the Army’s ability to provide mental 

healthcare for soldiers. Taking mental healthcare to 

the community is another important principle. School 

mental healthcare brings services to youth where they 

spend a large portion of their day. It is often more 

convenient for parents and has less stigma for children and parents alike than going to a mental health 

clinic. Outreach in collaboration with ACS educates the 

community and further decreases stigma. Embedding 

mental health resources within the FRGs provides 

direct support to spouses during deployments and 

makes seeking help easily accessible. 

Occasional conflict in Schofield’s program had a 

negative impact on services. Areas that presented difficulties were the direction and control of social work 

resources and, to a lesser extent, integration of substance abuse resources, particularly for family members. These problems were never fully overcome.

Based on the experience with integrating mental 

health resources in an Army community like Schofield 

Barracks, the following is recommended:

	 •	 Command and control of mental health resources must be established and made clear 

under a single umbrella organization. The 

combination of all mental health resources 

under a single organization greatly facilitates 

integration and coordination of services. 

Failure to integrate such services generates 

numerous and costly problems even in a 

peacetime environment. If psychology, psychiatry, and social work need to respond to a 

crisis as a team, then these agencies should be 

organized as a team with a leader.

	 •	 The current system of accounting for providers’ clinical time must be changed to reflect the 

value of prevention and early identification 

programs. Under the present accounting system, programs that emphasize prevention and 

early identification are not counted as patient 

care and actually count against “productive 

work.” Similarly, community outreach is not 

quantified as productive workload. 

	 •	 Army combat units such as the 25th ID should

play an integral role in any mental healthcare 

initiative. Shared responsibility between 

mental health components and combat units 

greatly enhances the care of soldiers and their 

families.

Another important concern is allocation of mental 

health resources within the Army system. Traditionally, Army staffing guidelines have called for approximately one adult psychiatrist for every 7,000 adults and 

one child psychiatrist for every 18,000 youths under 

age 18. The experiences described in this chapter, as 

well as empirical evidence, suggest that one medication-prescribing practitioner is needed for every 3,000 

adults, and one child medication provider for every 

3,300 children. This is a greater than 2-fold increase in 

adult providers and almost a 5-fold increase in child 

providers. Even so, this staffing level does not take into 

account the numbers of youth seen in schools or those 

treated at TAMC. Additionally, these data represent a 

system that permits ready access to care. Within the 

SAFAC, nurse practitioners were used as much as possible for prescribing medication in both the adult and 

child clinics to reduce expenses. The assumptions in 

the algorithms described in this chapter need further 

testing; however, the estimated numbers of providers 

the equations predicted appear to be fairly accurate, 

and in general do not overestimate the need. 

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