Feature                                                   Pages 24-30


The Schools' Role in Students'

Mental Health     

With needs apparent, an expert asks when educators will realize 'the head is not separate from the body?'


In every classroom in every school in every district in the country, at least one student is mentally ill. That’s reality.


The National Alliance on Mental Illness estimates 20 percent of American adolescents have a diagnosable mental disorder, from attention-deficit/hyperactivity disorder to autism to chronic behavioral issues. Perhaps 8 percent meet the criteria for major depression, according to NAMI.

“Until fairly recently, it was believed that young children could not experience depression,” says David Murphey, a senior research scientist at Child Trends, a nonprofit research center in Bethesda, Md. “Now we know differently.”

Each year, approximately 2 million teens attempt suicide; about 2,000 succeed. Suicide kills more American youth, ages 15 to 24, than any cause other than accidents (primarily auto-related) and homicides.

Morton Sherman, superintendent in Alexandria, Va., has been outspoken about the need for better attention to students' mental health.

Crying Needs
For years, a debate has raged about the capacity and responsibility of elementary and secondary schools and educators to effectively assess and address the mental health problems of their charges. Nowhere outside of the home do students spend more time. Teachers may see pupils more than parents. Schools would seem to be the first and natural place to seriously grapple with the factors that affect students’ mental well-being.

If so, it’s safe to say schools are doing a less-than-perfect job. In any given year, according to just one oft-cited statistic, only 20 percent of American children with mental disorders are identified and provided services. The rest, according to studies, are unlikely to receive any formal help.

And that leaves some people crying for help, among them Morton Sherman.

Sherman is superintendent of the 13,100-student Alexandria, Va., City Public Schools. An educator for 41 years, including four superintendencies, Sherman long has been a staunch and vocal proponent for improved mental health awareness and advocacy in schools, not least because he has personal experience with the subject. His own daughter was successfully treated for suicidal depression, a story he detailed in School Administrator magazine in February 2006. But Sherman is frustrated today.

“Even now, I am still struck by a comment made years ago by Ken Duckworth, the NAMI medical director, who said, ‘When are we going to wake up and realize that the head is not separate from the body?’”

Too many educators and policymakers, Sherman says, still haven’t made the connection.

“Caring for children means caring for all of them,” Sherman adds. “We routinely screen our kids for other problems. They get shots. They have their teeth checked. They have required physicals before they even begin school. Nobody questions any of that. We all want to make sure children are in good physical health, but we draw the line above the shoulders. I think it’s an issue of stigma and responsibility. If we screen, we might find something wrong.”

James Hodgkin, superintendent in Wales, Maine, addressed the 2013 AASA national conference on raising test scores by attending to students' health needs.
Reality Dissociation
Few educators, to be sure, are likely to argue students’ mental health isn’t inextricably linked to their personal well-being and academic achievement.

“The research on social-emotional learning and brain development is underscoring that students can’t perform to their potential on academic achievement without attention to their mental health needs. The most successful schools will be the ones that incorporate that knowledge,” says Brigitte Vaughn, a senior research analyst at Child Trends.

That perspective was shared with attendees at AASA’s 2013 national conference in Los Angeles by a member of AASA’s School Administrator Training Cadre for Coordinated Student Health, a five-year program funded in part by the Centers for Disease Control and Prevention.

James Hodgkin, a vocal advocate on the subject, says: “I think administrators understand that undiagnosed or unaddressed mental health issues not only get in the way of learning for affected students, they impact everyone else.” Hodgkin is the superintendent of Regional School Unit 4, a 1,500-student pre-K through grade 12 district in Wales, Maine.

But aside from talking about it, what are administrators like Sherman and Hodgkin to actually do?

“There’s plenty of research, but not a lot of practical advice for administrators like me,” Sherman says. “If I’m a principal and wake up one morning deciding to really implement a new mental health plan, where do I go? Beyond awareness, not a lot of attention has been paid to actual plans of action. Where’s the clearinghouse for student mental health information? I can find lots of material about what works in terms of effective reading or math, but I’d have a really hard time finding anybody who can tell me the five or 10 things I can do today to specifically improve student mental health.”

Whose Duty?
The challenge begins with deciding who is primarily responsible for students’ mental health. By default, teachers often find themselves in the category of first responders, but almost no one believes they should shoulder the role of therapist.

“They’re not trained for that job,” says Mark D. Weist, founder and director of the Center for School Mental Health, a think tank, and a professor in the Department of Psychology at the University of South Carolina. “Most teachers want help. When they don’t get it, they feel isolated and at a loss about what to do. That’s when many decide to leave the profession.”

A more obvious choice would be the school psychologist.

“We are trained in school law, school systems functioning, how to assess and provide interventions for a variety of learning, mental health and behavioral needs, and how to provide quality consultation to teachers,” says Melissa Reeves, a consulting school psychologist and lecturer at Winthrop University in South Carolina who has testified to Congress on these subjects.

“No other professional has this unique training that allows students to be served during the school day when they need immediate help,” she adds. “School psychologists ensure that mental health services are infused into learning and instruction, benefiting the child socially and academically.”

Reeves blames deficiencies in school mental health services, at least in part, on constraints imposed by superintendents and administrators who don’t fully understand or value school psychologists’ work. School psychologists too often are limited to assessing students for special education eligibility or assigned to so many schools that their services are overstretched and marginalized.

With appropriate support and resources, Reeves contends, school psychologists can provide counseling services; help select and implement schoolwide prevention programs; provide consultation to teachers to help them meet the academic, behavioral and mental health needs of their students; conduct threat and suicide assessments; help with collection of data to make informed programming decisions; collaborate with community service providers; provide leadership regarding crisis prevention and intervention; and work with families.

“If a district could afford to place a minimum of one full-time psychologist per school, we could make such a positive impact and also help teachers who are overwhelmed trying to meet needs of students for which they have had no training,” says Reeves.

Melissa Reeves (right), a consulting school psychologist in Rock Hill, S.C., spends lunchtime with students.
Unwieldy Ratios
There are roughly 37,000 full- and part-time school psychologists in the United States, according to the National Association of School Psychologists. The U.S. Bureau of Labor Statistics projects average job growth (about 11 percent) in the field over the next decade.

In hard budgetary times, however, school psychologists often are regarded as something of an educational luxury, a comparatively pricey staff position. The national association recommends one psychologist per 500 to 700 students, though actual ratios are closer to one per 2,000 or more students nationwide.

What about relying on the school counselor? The American School Counselor Association recommends a ratio of 250 students per counselor, but the average ratio is 457:1, based on 2008-09 data, the latest available. Only five states were operating at or above that recommended level: Louisiana (238:1), Mississippi (234:1), New Hampshire (233:1), Vermont (207:1) and Wyoming (197:1). California topped the list at 814 students per counselor.

Even then, many experts argue school counselors are not really the complete answer. Their primary job is to ensure every student has the tools — psychological and otherwise — to be successful in school and in life. They may be ideally situated to act as sentinels for students’ mental health. “They know teachers and kids better than anybody,” says Peggy Hines, director of the National Center for Transforming School Counseling. But they may lack the time, training and resources to delve deeply into each and every student’s problems.

“Twenty percent of students take up 80 percent of a school counselor’s time,” Hines says. “For a kid with mental health issues, a school counselor might have just a few sessions, each just a few minutes long, to try to work things out.” 

Clinics on Campus
A more promising answer is a coordinated, collaborative series of steps leading, ultimately, to professional psychological services outside of the educational system. It’s a middle path that can work with broad support and on-going effort, says William Dikel, a Minneapolis, Minn.-based psychiatrist and 25-year consultant to school districts and policymakers on mental health issues. He’s seen both ends of the spectrum, from full-service districts to no-service districts.

“There are districts that hire social workers, do psychological assessments and treatment plans, even bill Medicaid,” he says. “And there are districts that don’t want to hear ‘mental health’ and ‘school’ in the same sentence, who think the former is really somebody else’s job.”

Both approaches are problematic, according to Dikel. In a recent policy paper for the National School Boards Association’s Council of School Attorneys, Dikel said school staffs that provide diagnostic and treatment services must recognize “that their records containing sensitive student and family information become part of the educational record. Schools cannot get malpractice coverage, and their existing coverage may not be sufficient to protect them from liability.”

Conversely, schools that completely avoid addressing mental health issues still deal with the indirect costs, which he defines as “time-consuming visits to the principal’s office, educational failure and one-to-one aides and other educational interventions that would have been more successful had the student been receiving effective mental health services.”

Dikel adds: “Every school classroom has at least one kid with a mental health disorder. Many of these children end up in special education. They may be emotionally disturbed. They are typically undertreated, inappropriately treated or not treated at all. The result is generally incredibly poor outcomes — high dropout rates, high arrest rates, poor educations and job histories.”

The optimal course falls in between. “The best approach is for schools to stay out of the mental health business of diagnosing and treating but play a crucial role in the continuum of collaborative services that includes parents, medical and mental health providers, community agencies and county services,” he says.

Specifically, Dikel recommends schools adopt mental health procedures and guidelines that help build connections to community mental health services for students, but protect schools and personnel from liability risks. These include defined roles for school staff and an effective system of collaboration with external mental health service providers.

As an example, Dikel cites a consultation request from the special education director of a 5,000-student school district. The director had noticed a disproportionately high number of students were being referred to restrictive Setting 4 placements in which they receive services at a separate facility. A file review revealed that 85 percent of the students had received psychiatric diagnoses in the past, but only 5 percent were receiving any mental health treatment.

“The director set up space in several schools for a colocated community mental health clinic to provide services. Many students received treatment for the mental health disorders that were causing their severe emotional and behavioral problems and, as a result, they were able to return to less restrictive programming, which resulted in a savings of more than $800,000 per year for the district.”

Short of treating students with psychological problems, teachers can contribute in other ways.

“They can talk to parents. They can collect information and observations that can be helpful to clinicians. They can accommodate and modify classrooms to be more environmentally friendly for kids with issues. Depending on the problem, they can alter the way teaching is done to be more helpful.”


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Space and Access
Administrators and school boards can play equally supportive roles.

“Most children with mental health problems are in general education. School leaders should know this and advocate for policies and systems that provide schools, teachers and students with necessary skills and resources,” says Dikel, who is completing a book tentatively titled Student Mental Health: A Practical Guide for Teachers. “Plus, a school district isn’t going to get the outside help it needs unless it reaches out and invites it in.”

Dikel recounts the example of a school district that collaborated with the county health department’s crisis unit to provide psychological interventions for students showing evidence of potential danger to themselves or others. With parental permission, school social workers gave background information to county social workers, which enabled the latter to more accurately assess students’ risks and take appropriate action, including hospitalization if necessary.

There are, of course, the real limitations of the real world. Sherman, the veteran superintendent in Alexandria, Va., notes that many schools struggle just to stay on top of core functions. “Nobody really has the time, resources or training to provide services like therapy,” he says.

Nonetheless, Sherman advocates for strong, collaborative relationships between schools and community mental health providers. Of course, much depends upon whether these services are available and sufficient in the community. Schools can help, he says, perhaps by providing necessary space and access on campus for mental health professionals.

“A lot of schools already do this with other health services. They have clinics on campus with separate entrances. Some deal with controversial issues, such as teen pregnancy. I don’t see why mental health can’t also be addressed this way. It might provoke a lively conversation in a community, but it’s one that should happen.”

Scott LaFee is a health sciences writer at the University of California, San Diego. E-mail: scott.lafee@gmail.com


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