Increased mental health needs and new roles in school communities

Hootman, Janis

TOPIC. Mental health issues and partnership roles in school communities.

PURPOSE. To heighten the awareness of healthcare providers about the multiple mental health conditions students bring into school communities and the impact of these conditions on students’ ability to learn; to encourage partnering between healthcare providers and educators to support students in achieving academic and developmental success.

SOURCES. Literature review and authors’ experiences with assessment of and intervention with school-age children presenting with impaired mental health.

CONCLUSIONS. Health and education systems must increase their partnerships on behalf of children for a healthy future.

Search terms: School health, mental health, professional partnerships

Fifty-three million of America’s children spend more than one third of their day at school (U.S. Department of Health and Human Services [USDHHS], 2003). The school setting is thereby a central context in which children are not only educated but also grow and develop in community with other children. Thus, school personnel are potentially key agents in the socialization of children. Although initially designed to provide education, academic institutions are increasingly required to meet a range of needs and demands. In addition to special education, these include providing early intervention with younger children, support for chronically ill students, and attention to children with emotional problems and mental illness. This article describes the nature of these demands and explores strategies for addressing them.

Mental Health Issues for Today’s School Communities

Special education services. Currently, the public school system has responsibility for the education of children from birth through 21 years of age. Initially, in 1973, the Individuals With Disabilities Education Act (IDEA, originally Public Law 94-142) extended accountability (to schools receiving federal support) beyond the regular education of school-age children. Specifically, school systems were directed to provide special education services in the least restricted environment for eligible students as young as 3 through 21 years of age. The target population for special education services was expected to include emotionally disturbed children. Subsequently, in 1986, an amendment provided for early intervention to children from birth through 2 years of age who have a condition that entitles them to receive special education services.

The IDEA and its 1986 amendment dramatically shifted the expectations for schools to educate students in two ways: across a broader age range-from infancy through preschool, middle childhood, and adolescence-and across a diverse set of special needs. This latter point was emphasized by Section 504 of the Rehabilitation Act, which prohibits discrimination against people (students) with any handicapping condition, including mental impairment, and mandates accommodations. This means school systems must be able to accommodate those handicapping conditions that affect the student’s ability to learn as well as conditions that do not impede learning.

Children with special health needs. Currently, 11% of the nation’s students are estimated to have disabilities (U.S. Department of Education Office for Civil Rights, 2000). The number of students who are chronically ill and technology dependent has been steadily increasing in schools for several decades. Beyond the numbers, however, is a growing understanding of the complexity of care required for this student population. For example, children may be ventilator reliant, require gastrostomy feeding, or use mechanical pumps for medication infusion. In addition, chronic health conditions are typically associated with emotional challenges. According to Healthy People 2010 (UDSHHS, 2000b), 31% of children and adolescents with disabilities were reported to be sad, unhappy, or depressed. Further, chronic health conditions may adversely affect learning through accompanying memory difficulty, impaired attention, confusion, slower response time, impaired information processing, school phobia, and/or other neuropsychiatric deficits (Thies, 1999).

Emotional disorders. The numbers of school children diagnosed with or at high risk for mental and emotional disorders are increasing as well. Almost 21% of children ages 9 to 17 years suffer from a diagnosable mental or addictive disorder, with an additional 6 million to 9 million youngsters thought to have serious emotional disturbances without receiving the help they need (Shalala, 1999). These mental health problems seriously impede students’ ability to acquire academic skills and social competence, thereby impairing their functional development.

Social risks. In addition to dealing with chronic illness, handicapping conditions, and mental and emotional disorders, school systems also must educate children experiencing a variety of social risks. Consider that children living in stressful family environments have been found to be nearly twice as likely to exhibit low levels of school engagement and four times as likely to have high levels of behavioral and emotional problems (Vandivere, Moore, & Zaslow, 2000). The sheer numbers of children experiencing stressful family environments-and, therefore, who are at risk for negative socioemotional outcomes-is alarming:

* In 1999, 28% of children under age 18 lived with a single parent. Single parents were more likely to report aggravation-frequently feeling frustrated and stressed by the experience of caring for their child-and symptoms of poor mental health (Vandivere et al., 2000).

* In 1998, the poverty rate for children was 18%. Poverty typically characterizes disorganized communities. It is not surprising, then, that children living in poverty tend to have difficulty in school (Federal Interagency Forum, 2000), experience maltreatment (USDHHS, 2000a), and live in single-parent families with the attendant difficulties (Vandivere et al., 2000).

* The 1998 rate of child maltreatment was 12.9 per 1,000 children (USDHHS, 2000b). The cognitive, social, and emotional sequelae of maltreatment are well documented (American Academy of Child and Adolescent Psychiatry, 1998; Mazza, 2000).

* Six percent of children under 18 years of age are being raised in grandparent-headed households. Most of these grandparents are now single and parenting their grandchildren and, therefore, are more likely to live in poverty (AARP, 2001). Further, these grandparents are typically responding to problems in the parent generation-death, illness, divorce, immaturity, incarceration, substance abuse, child abuse, or neglect (AARP). Such experiences are also known to have mental health implications for children.

Given these growing populations of children with handicapping conditions, chronic illness, mental and emotional disorders, and social risk, it is not surprising that one child in four is considered at risk for school failure because of social, emotional, or health problems (Dryfoos, 1998). Although there are large populations of healthy schoolchildren, even they reflect unsettled social conditions. Stress creates issues for otherwise healthy students whose needs are often overlooked. For example, students who are intensely competitive in academics and/or sports often experience duress and suffer negative health sequelae. This strain to “always be best” in athletics and/or academics is clinically evident in students’ health room complaints of various somatic symptoms, anxiety, and exhaustion. Wrestlers, gymnasts, dancers, cheerleaders, and runners whose intense eating and exercise regimens are designed to attain certain weights are among those whose health risk tends to be ignored (Zalaquett, 2001). Increasing local and national demands on school systems for improved academic performance are creating more stressful school environments for students as well. Clearly the pressure cannot only be self-imposed by students but also externally imposed by school staff displacing their own tension surrounding enhanced achievement expectation.

Alienation. An underlying concern for all the student groups discussed thus far is alienation from the student community. Alienation can result from an insecure attachment formation; children from dysfunctional families with unavailable or uninterested parents are going to have difficulty building relationships at school. The preceding risk factors-handicapping conditions, chronic illnesses, mental and emotional disorders, and social risk conditions-also enhance children’s vulnerability with respect to social isolation and consequent alienation. Similar concerns exist for students who are homeless and those who move frequently. Although accurate incidence of homeless students is hard to quantify, some schools estimate a yearly mobility rate of 30% and higher. Concerns about social isolation and alienation are also extended to children who speak a language other than English; in 1998, 5% of all U.S. school-age children spoke a language other than English at home and had difficulty speaking English at school (Federal Interagency Forum, 2000).

Taken together, a substantial portion of the student population in our nation’s schools are groups characterized by factors that serve to socially isolate and potentially alienate them from the school community. The school system is presented with a range of psychosocial demands across a considerable age range. Existing traditional resources have not been able to readily meet these demands.

Existing Mental Health Resources in School Systems

Typically, individualized programs or plans are developed for children requiring special education or health management at school. Two important activities in this regard include the Individualized Education Programs (IEPs), developed for children receiving special education services, and Individualized Health Management Plans (IHPs), which are prepared for students with special healthcare needs. Whereas these plans are quite effective in the academic or physiological domains, they fail to address the associated social and emotional issues (e.g., mood, self-esteem, peer relations).

Mental health resources are otherwise rather limited in the context of the many student needs. Although federal legislation has specified that schools hold responsibility for providing support services to students, no national regulation directs who performs the services (Rapport & Lasseter, 1998). Most schools have educational psychologists and counselors and even social workers who reside in their facilities. However, these professionals tend to be more focused on testing activities to determine eligibility for special education services, diagnoses of learning disabilities and ascertaining accommodations, and eligibility for other academic programs. That is, these professionals are focused more on meeting the educational needs of students than the mental health needs that may exist.

Certainly, some schools may have mental health specialists who provide direct service to students who come to their attention. However, the students’ needs for treatment exceed the availability of mental health specialists to provide it. Another effective strategy for addressing mental health needs has been for school districts to employ psychiatrists as consultants to faculty and mental health specialists. Unfortunately, they rarely provide direct intervention, to students. Mental health resources, more often than not, have been available in the school setting through crisis team responses, usually after a death or natural disaster. Health education, mental health promotion, and the prevention of mental health problems generally receive fewer hours out of the school year in the face of intense pressure for heightened academic achievement and limited financial resources.

Role of School Nurses

School nurses are the largest providers of health services in schools, with an estimated 58,000 school nurses in 89,000 schools (Igoe, 1999). Students often turn to school nurses, who become the primary contact for their entry into the healthcare system. In part, this phenomenon arises from a lack of health insurance and/or lack of access to a medical home. Even with the State Children’s Health Insurance Plan (SCHIP), a significant number of children remain medically indigent. More than 11 million American children remain uninsured (Edmunds & Coye, 2000). Further, parents and students too often report to school staff their negative experiences with healthcare systems (e.g., difficult access to a provider, inflexible hours, high costs, long waits). Consequently, parents frequently choose to access the school nurse for their care, even with urgent health conditions, and may delay timely intervention. With respect to mental health care, these circumstances are compounded by such dynamics as shame, stigma, and/or limited problem-solving capacity. Thus, many more families do not seek mental health care.

Mental health demands on school nurses. Many school nurses report more than 100 student encounters a day (Hootman, King, & Houck, 2000). School nurses and school-based clinics identify many children with diagnoses that reflect visits for nonmedical or psychosocial reasons (e.g., abuse, family relationship challenges, drug and alcohol issues). For example, the presenting conditions to a high school nurse for one randomly selected morning included physical abuse, life-threatening physiological status from disordered eating, suicide attempt, stomach pain related to distress about parent’s arraignment for murdering the spouse, stab wounds from a physical altercation, and poor school attendance secondary to overhearing faculty and students’ derogatory comments on obesity. Students’ stories may vary, but we are convinced that similar mental health issues exist across grade levels and socioeconomic strata.

We are also convinced that the school nurse’s role is evolving into one that centers largely on student mental health. Findings from a survey of 477 school nurses by the National Association of School Nurses (NASN, 1998) revealed that the previously described school nurse’s morning was not an isolated one; 67% of the nurses surveyed had identified and/or counseled a depressed or suicidal student. Further, 82% of those surveyed had assessed and identified an abused child, always a complex and sensitive process. Finally, more than half (51%) of the surveyed school nurses had identified and/or counseled a student who abused substances. The image of the school nurse belies the required sophistication of assessment, the essential sensitivity and creativity for reporting and referral processes, and the necessary complex of intervention skills with children and adolescents.

The role of the school nurse has necessarily become multidimensional-direct care provider, case manager, consultant. For the school nurse, direct service in mental health issues emerges rather indirectly through student relationships. The school nurse holds an especially advantaged position for relationship building with students. Whereas children and adolescents typically do not identify themselves as having social or emotional problems-let alone present for treatment-they do see the school nurse for any number of somatic complaints. In this way, school nurses have opportunities to develop relationships with students over time. In the context of a relationship, then, school nurses are able to carry out assessments, monitor health status, coach the development of personal health management, and facilitate referral and access to health services. When assessment and intervention are required in sensitive social, health, and mental health issues, a relational foundation is in place.

Unfortunately, in most school systems there are insufficient ratios of school nurses to students. For years NASN has recommended a ratio of 1 nurse to every 750 regular education students, and lower ratios for severely compromised and complex students (NASN, 1995). Fortunately, the 2010 Health Objectives has taken up the call for more appropriate ratios of school nurses to students, and reaffirmed the NASN goal of a school nurse-to-student ratio of no more than 1:750 in our nation’s schools (USDHHS, 2000b).

Supporting School Communities

Not only are schools presently under duress to increase their academic outcomes and be safe, but they also are expected to manage-if not fix-students’ social and emotional problems. School nurses and educators work as partners to identify problems and explore their solutions in order to enhance the educational, health, and mental health outcomes for children and families. However, these efforts would benefit from much-needed support provided by mental health nurses, clinical specialists, and nurse practitioners.

Whatever their internal mental health resources, school systems can benefit from the following support in helping children and families:

* Increased availability and accessibility of mental health services. More mental health resources for children and adolescents must be developed. Innumerable hours are spent by school nurses and other personnel in efforts to locate clinical assessment and treatment resources for children beyond what schools can offer. Students in acute emotional distress may be embedded in dysfunctional families, with parents or other caretakers who may have precarious parenting and/or problem-solving skills. Such students must depend on the advocacy of school staff to seek and secure mental health services. Health insurance may constrain the reimbursement for mental health services so that students and families in crisis do not attain prompt access to a provider when they most need support. Mental health services also must be available at times that are compatible for students and working parents. Many parents have vulnerable employment conditions and are unable to get releases from work to accompany or transport their children to healthcare providers. Consequently, these parents become unavailable even in emergent circumstances, and school personnel are left to manage critical situations.

* Training and consultation. School nurses should not be the primary therapists for students needing psychotherapy, yet their role in providing mental health assessment and intervention requires recognition. Schools are a central setting in which children’s and adolescents’ social and emotional difficulties readily manifest in academic declines, behavioral problems, and peer relationship difficulties. Thus, schools can and should serve as a primary site for the early identification of unhealthy behavioral indicators. To do so effectively, however, school nurses and educators will benefit from in-service training from mental health specialists. It is essential to remain current with the changing clinical knowledge regarding assessment, intervention, and prevention. School nurses and other personnel will be more effective if they have access to advanced practice nurses in mental health nursing to provide interpretation and guidance regarding unusual student behavior or events affecting the school community. Schools will gain from expert coaching about mental health prevention and support services that could be offered within the school community.

* Advocacy. Advocacy for the health and mental health needs of children and adolescents can be best provided by an alliance between educators and pediatric healthcare providers. A partnership between school nursing and mental health nursing can be an additional powerful alliance on behalf of children and adolescents. Together, perhaps, the values for prevention and health-promotion activities can become integrated into our school communities and applied to optimize the mental health and social outcomes for children and their families.

* Dialogue. Despite the well-recognized importance of school information in the evaluation and diagnostic process for attention deficit hyperactivity disorder, contact with the school was not made in almost half the cases in Carey’s (1999) study. As stated earlier, schools are a central setting in which children’s and adolescents’ difficulties readily manifest in academic declines, behavioral problems, and peer relationship difficulties. School personnel are able to share observations and data potentially crucial to the diagnosis of learning and mental health disorders. Conversely, too often neither parent nor healthcare provider make contact with the school when there is a mental health condition or a new mental health diagnosis. Schools can be much more effective in their support to students and families when included in care planning.

Building a Health Village for Children

The 2010 Health Objectives include enhanced mental health as a priority for our nation’s youth (USDHHS, 2000b). This objective exists in the face of the World Health Organization’s projection that depression will be the second leading cause of “lost healthy years” by 2020 (Kennedy 2000). It is time to develop strategies for meeting this objective; otherwise, crisis management will prevail and our children will continue to suffer, which does not bode well for the future. Schools can be used for prevention activities and the early identification and management of mental health conditions. The provision of support services to schools (e.g., quality health instruction, a school nurse, a mental health counselor on staff) has been found to relate to a reduction in the number of students using illicit drugs, becoming pregnant, leaving school, and avoiding school due to fear of violence (U.S. Public Health Service, 1999). A project in Portland, OR, reaffirmed that mental health intervention by school nurses can be significantly helpful to children (Hootman, Houck, & King, 2002). This is not new information, but rather confirms study findings from the 1960s that illustrated the effectiveness of such early intervention (Cowen, Gesten, & Wilson, 1979). Schools require designated resources and effective community partnerships, however, to assume such roles in addition to their primary responsibility for educating children. Several models to initiate local discussion and design follow.

* In El Paso, Texas, a district uses Title 1 funds to support a psychiatric nurse practitioner. She takes referrals only from school nurses and forms support groups that she subsequently turns over to the campus nurse. The practitioner is able to support school nurses in their role as the primary contact person for school personnel by helping with the time-intensive activities of writing IEPs, providing inservice education, and participating on district crisis and student support teams.

* In Los Angeles, there is a child-psychiatric clinic operated by the school system and funded equally by the county and Medicaid reimbursements. Subsequently, the district has realized a nearly 50% decrease in the incidence of suicide among its students (Portner, 2000).

* The Portland, OR, project completed by the Multnomah Education Service District enhanced the assessment and intervention skills of the school nurses (Hootman et al., 2002). This project was funded by a 2-year grant from the Northwest Health Foundation, a local philanthropic institution supporting efforts to provide innovative, quality health services within Oregon’s communities. The project’s foci included (a) prevention through early identification (e.g., with indicators of students’ risk for alienation, depression, and/or poor self-esteem through signs such as somatic complaints, absenteeism, and disruptive behavior) and (b) facilitating enhanced relationships with at-risk students. Student outcomes included increased bonding and social interaction with peers, decreased somatic complaints, improved problem-solving skill, and greater confidence with consequent improvement in academic performance. School nurses have earned respect from students and faculty for their enhanced mental health skills in schools and stress management/coping skill development.

This completed project has been the foundation for a sequel project in progress by the Multnomah Education Department of School Health Services. A psychiatric nurse practitioner has been added to the staff to consult with and support school nurses and districts in managing complex mental health conditions and to build the capacity for early school nurse-initiated intervention in mental and emotional health problems.

The service models and funding streams are uniquely different in the preceding examples. Although the needs of students are evident, entitlement is not the venue for student access to health services. Consequently, outcome evaluation is an essential component for service programs. We must consider linking with program evaluation specialists to help with this work. When sharing data with people outside traditional health care, the awareness of children’s mental health issues is broadened and advocacy for children to have appropriate community resources is encouraged.

Some schools may already be approaching community healthcare providers for a helping hand. In other communities, private providers may need to initiate communication with the school districts and express concern for and interest in supporting students’ mental health. Generally, health and social service providers are welcome guests in the hosts’ educational environment. “Visitors” intentions may be suspect and their worth diminished if the visitor is aggressive or the host’s role is redefined in a less favored way. Professional boundaries must be respected, especially in terms of the supervisory person to whom one is ultimately accountable. Further, the notion of multiple “bosses” in the partnership must be recognized. Thus, interagency partnerships require meticulous communication skills. As Cavanaugh (2000) advised, community partners must observe, listen, learn the rules and language, go slowly, be flexible, follow through, and find a buddy. A sense of trust must develop before one can expect information sharing and a request for help. Ultimately, by speaking to the mutuality of vision statements and program objectives, partners will maintain the common focus for their work.


For pediatric Healthcare providers and educators, the mutual connection is about children’s health, normal growth and development, and successful learning. School is a usual place for children to be. It has not been a usual place for mental health services. Today, schools are providing medical and mental health services, and both deserve equal opportunity. It is time for a new design and new partnerships, for mental health must be the work of villages rather than individuals.

Acknowledgment. Special acknowledgment to Catherine Kittams, BSN, RN, for her critical review and recommendations.


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Janis Hootman, PhD, RN, Gail M. Houck, PhD, RN, and Mary Catherine King, PsyD, RN

Janis Hootman, PhD, RN, is Supervisor, Department of School Health Services, Multnomah Education Service District; Gail M. Houck, PhD, RN, is Professor, Oregon Health Sciences University, School of Nursing; and Mary Catherine King, PsyD, RN, is Clinical and Curriculum Consultant, Portland, OR.

Author contact:, with a copy to the Editor:

Copyright Nursecom, Inc. Jul-Sep 2003

Provided by ProQuest Information and Learning Company. All rights Reserved

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