Rather than responding in crisis, expanded mental health supports guide and nurture students and staff to process trauma, restore their equilibrium within the school community, and participate fully in teaching and learning.
It has been said time and again that the students who re-enter our schools in September 2021 are very different from those who left in March 2020. The same is true for teachers, staff, and families.
As schools move to fully reopen, our first inclination may be to focus on the learning gaps that students have developed during the pandemic. But the psychological and emotional well being of all members of a school community must also remain in the foreground. Establishing school as a space that is both physically and emotionally safe is essential (see the Safe and Supportive Climate section for more). All students and teachers have experienced unprecedented disruption to normal patterns of interaction, and many have had to cope with uncertainty or substantial hardship. They will need support as they transition back into a full-time academic environment. In addition, many students will be managing grief, anxiety, or other emotional responses to recent events that will require long-term monitoring and an ongoing response.
Amid the instability of the 2020–21 school year, school leaders identified students’ mental health as one of their top concerns. A recent survey of more than 32,000 caregivers found widespread growth in child mental-health concerns. However, most educators do not feel confident in their ability to identify students who might require additional mental health supports. Furthermore, many schools lack a clear, coherent system for addressing students’ mental health needs. Roughly 40 percent reported that they currently address concerns on a “case by case basis.”
This is not a new challenge. According to the U.S. Department of Health and Human Services, one in five children and adolescents experience a mental health problem during their school years. While some schools have found ways to add the required resources through complicated funding and staffing pictures, others have struggled to get even one mental health professional on campus. With the sudden influx of federal COVID-19 relief funds, the financial barriers to providing these services in schools are disappearing, at least temporarily.
The time for ad hoc responses is over. Having a distinct plan in place as students and educators reacclimate to the classroom environment will be an integral component in ensuring the well being of students.
Our recommendations fall into five major types of action:
School mental health is its own subset of mental health, and not all licensed practitioners are prepared for what it means to be in a school setting. Schools should be clear about the expectations for student services and any limitations they would put in place, such as that students not be pulled from core classes. Possible provider types include licensed psychologists, licensed clinical social workers (LCSW), licensed master social workers (LMSW) and licensed professional counselors (LPC).
Adding headcount can be a tricky proposition for school districts using federal stimulus funds to make new hires. It raises the obvious question: what happens when that temporary support runs out? This is an area where using approved contractors, who can offer specialized supports across multiple schools, may be wise.
In addition, recent changes to federal Medicaid guidelines have opened up a potential pathway for long-term funding of these services. In 2014, Medicaid released updated guidelines known as the Free Care Reversal Policy that clarified that states can allow schools to bill Medicaid for mental health services for all students—not just those with IEPs, which is how Medicaid had previously functioned. This pathway has the potential to provide long-term sustainable funding for schools to provide these mental health services. However, each state must go through a process to authorize this change, and to date, only 13 have.
As with anything else in a school, in order to know what a student needs, their current ability must be assessed. This is no different in mental health. All schools should have a universal screening tool in place to be completed for all students before or immediately after the beginning of the year.
Keep in mind, however, that these screening tools can do more harm than good if schools do not follow up with services. If educators ask a student what they need and the screening tool shows they need support for depression or anxiety but the school does not then provide that service, the student learns that being vulnerable and asking for mental health support does not mean that that support will come.
We know that students have experienced the pandemic in different ways. While some may not have weathered significant anxiety or personal hardship, others have experienced traumatic personal events. This is most common among low-income students and students from racial and ethnic minorities, whose families are far more likely to have suffered economic hardship, illness, and death.
Students who have been physically separated from their school or community may feel isolated or neglected, including those who are vulnerable in their homes as a result of the volatility or abusive behavior of a family member. Many students, and particularly Black students, may also be contending with anxiety, fear, or confusion in a climate of anti-Black racism and police violence.
Knowing the state of any one student’s emotional well-being is difficult, unless they voluntarily disclose that information or, perhaps more likely, exhibit stress-induced behaviors like misbehaving (externalizing) or shutting down (internalizing). And educators must be ready to support all students, without treating them all the same. Mary Walsh, a professor of counseling and developmental psychology at Boston College, has estimated that even among students who have experienced trauma during the period of the closure, only about one-third are likely to develop serious issues, such as PTSD. Monitoring students for behavior changes will be important, but Walsh cautions against pathologizing students, suggesting that “If we put the right protective factors in place, kids have enormous resilience.”
The American School Counselors Association and the National Association of School Psychologists recommend collecting data to inform a psychological “triage” approach, to allow schools and districts to identify students who need mental-health supports most. That includes students who have lost someone close to them, whose families have experienced financial distress or dislocation, who have previous mental-health concerns, and who have a history of trauma, including membership in a community with previous history of educational disruption (such as natural disasters or mass casualties).
The next step is to connect students to appropriate services. Selecting those services should not be done on a case-by-case basis. Rather, staff need to have a clear understanding of what is available to best respond to student needs well in advance of any incident. A clear process for referrals can make this step more efficient and maximize the impact of this response.
Project Aware Ohio has detailed a comprehensive referral protocol to help schools and districts identify gaps in current procedures:
Trauma is a psychological or emotional response to “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening,” according to the federal Substance Abuse and Mental Health Services Administration. Many students and families have personally experienced trauma related to health and economic consequences of the pandemic. And the period of disruption itself may have been traumatic for some. Viewing these events as presenting multiple potential traumas can help guide school policies, practices, and interactions among staff and students.
The adoption of trauma-informed practices in schools has steadily gained steam over the past several years. Dr. Howard Bath, a clinical psychologist and expert in developmental trauma, has identified three key pillars of trauma-informed care: safety, connection, and managing emotional impulses
Ensuring students feel safe is essential. Even in the absence of a distinct threat, the brains of traumatized children tend to remain in a state of alarm, with energy focused on ensuring safety rather than engaging in growth-promoting activities. Creating consistent, reliable, and predictable environments in which students feel they have a degree of power and choice can help establish school as a safe place where they can relax their guard and trust the adults that they interact with regularly.
Trust and the perception of safety cannot occur without the second pillar, connection. Positive relationships with caring adults have great therapeutic value and may help to counteract negative associations from past experiences. Educators can foster such relationships by attending to, validating, and creating space for the strengths that students bring to the classroom. This also supports students’ seeing themselves as competent, worthwhile individuals.
Maintaining compassionate connections is complicated, however, by the difficulty traumatized individuals often have in self-regulation and managing emotional impulses. Responses to trauma are frequently observed as behavioral responses. In a school environment, where establishing strong routines and behavioral norms is a necessary part of creating a physically and emotionally safe space, trauma may prevent students from complying with all expectations for behavior right away. Students will need time to adjust, and disobedience may simply be a function of students’ challenges to regulate themselves.
Educators need to keep this in mind, rather than categorizing behavior as willful disobedience. Rather than assuming negative classroom behaviors (such as outbursts, defiance, or shutting down) are intentional and responding in a punitive fashion, trauma-sensitive educators help students “co-regulate” by modeling and explicitly teaching students how to manage their emotional impulses. Connectedness with peers is also an important protective factor, both for students dealing with trauma and those with other mental health conditions. Explicit social and emotional learning instruction can help facilitate these relationships.
While the field of trauma therapy in schools is still developing, EMDR (Eye Movement Desensitization and Reprocessing) therapy is well-researched and highly effective at alleviating stress from traumatic memories. Licensed mental health practitioners can be trained in EMDR in a relatively short amount of time. Schools with student populations who have experienced significant levels of trauma should consider using some of the federal COVID-19 relief funds to pay for their mental health practitioners to be trained in EMDR. This is a one-time expense that can have a long-term positive effect for individual schools.
A strong mental health program should offer a diverse array of services and be tied into every aspect of the school day. Though adopting trauma-informed practices as generalized supports is beneficial, for some students, that won’t be sufficient support. A subset of students will have had direct traumatic experiences or be suffering from mental health conditions. They will need intensive interventions above and beyond generalized trauma-informed care in order to be ready to learn.
School leaders cannot assume these students will receive appropriate treatment outside of school, since approximately one-third of all adolescents who receive mental health care are served only in the setting of their school. This is particularly true for students who identify as members of a racial or ethnic minority or who come from a low-income household. Responding appropriately to these students’ needs will take the involvement of all staff members with mental-health training, including school counselors, psychologists, social workers, and nurses.
Tools for Coping: Some students have not been in a regular classroom for more than a year, and returning to that environment will be an over-stimulating environment for many. In addition to mental-health staff, schools should have tangible tools to help them cope on campus, such as headphones, music options, and quiet rooms that give students a break from excessively stimulating environments. Students who display more severe symptoms of overstimulation should receive individual plans to help them ease back into the school environment. They can use federal COVID funds for plans prepared by a qualified mental health professional.
Group Therapy: Well-done groups are one of the most effective therapeutic techniques for schools. They not only help students address common mental health concerns but also facilitate interpersonal social-emotional growth. From an organizational perspective, groups allow one mental health professional to serve multiple students in a shorter amount of time. Schools can explore adding a group session before, after, or during regular school day to meet student need for families who opt in.
Potential COVID-related group topics include: grief, for students who have lost family and friends to the pandemic; germaphobia or compulsive tendencies, for students who have internalized hand washing and mask wearing to the extreme; and sensory issues, for students who are struggling to return to large and busy buildings after spending months in the relative quiet of their homes.
Schools with enough specialized staff can offer individual and group-based interventions such as Cognitive Behavior Intervention for Trauma in Schools (CBITS). Multiple studies have demonstrated that students who participate in a CBITS program experience significant improvement in self-reported symptoms of post-traumatic stress compared to a control group.
Suicide Prevention: In order to correctly identify students who are at-risk for suicide, schools must do comprehensive training for all staff members (not just teachers) on how to look for risk signs and what to do if they find them. This training should take place during summer professional development, but it should also be an ongoing topic throughout the year. Schools should have a set process to evaluate student risk and a clear plan of what to do if the student is an immediate risk to themself or others (going to the hospital immediately) or is not a current active risk but may be at some point (create a safety plan). A good safety plan should help students and the people around them identify potential triggers for self-harming behavior and have places to go, people to speak to and emergency numbers to call if a student feels unsafe.
Regardless of the intervention approach, it is important to ensure that administration and instructional staff all have a shared understanding regarding the importance of these interventions. And it is critical to remember that there will always be some students whose needs are too urgent or intensive to be served within the school setting. Intensive interventions should be handled in collaboration with external partners.
No mental healthcare plan would be complete without considering the needs of the adults in the building, especially those in student-facing roles. The past year—full of sleepless nights, radical changes to instruction, long hours, unexpected childcare duties, and worries about safety for their students and themselves—has taken a toll on educators. A Louisiana study found that the prevalence of clinically significant symptoms of depression had almost doubled among early childhood educators. And in another study, approximately 85 percent of teachers reported that their mental health had declined compared to the previous year.
The recovery period already threatens to be a pressure-cooker for teachers. They are burdened with the expectation to make up for months of lost learning while also accommodating students’ heightened social and emotional needs. Proactive planning can help educators feel supported in their work and decrease instances of burnout that may lead ineffective instructional environments or turnover. When referring to “burnout,” we adopt the definition used by The World Health Organization: the feelings of exhaustion, negativity, or cynicism, and the reduced professional efficacy that may result from insufficiently managed and/or chronic workplace stress.
Developing an organizational culture in which frank and open conversations can occur about staff emotions and mental health takes time, but schools and districts can nonetheless teach strategies and create structures that lay the groundwork for a healthy and open workplace.
First and foremost, schools should ensure that staff members have appropriate access to mental health care, such as counselors or therapists. Adequate coverage must be available so that staff have the ability to take the time they need to address their healthcare and personal needs. These basic supports can be bolstered by building in intentional opportunities for staff to connect with each other, whether by having periodic “check-ins,” developing mentorship relationships, or creating opportunities to socialize or decompress with other adults in the school community. To ensure educators take advantage of these supports, it can be productive for leaders to model emotional vulnerability and help-seeking behaviors. That helps staff to view these practices as indicators of strength rather than weakness.
It is also important to encourage stress-management strategies, such as healthy eating, exercise, adequate sleep, and relaxation techniques, including by weaving them into school culture. In particular, mindfulness practices have been shown to be effective in helping teachers manage occupational stress. There are a variety of models and resources that organizations can adopt depending on their unique circumstances. The Cultivating Awareness and Resilience in Education (CARE) professional-development program, which teaches mindfulness techniques, has been shown to improve teacher well being, efficacy, burnout, and stress. Freely available resources such as Diana Tikasz’s excellent Pause-Reset-Nourish framework can also be helpful.
Above and beyond these practices, leadership should pay particular attention to staff members who seem to have difficulty coping with the challenges of their role and offer support as needed. Educators working in areas of high poverty or high trauma may be at risk of developing secondary traumatic stress (STS), in which they experience trauma due to hearing about the traumatic experiences of their students. While similar to burnout in terms of its external expression, STS is often not alleviated by a change in occupational environment. Particular educators may be more susceptible, including those who have experienced trauma themselves, are highly empathetic or inexperienced, or who work in communities that have experienced elevated levels of poverty, crime, or tragic events. The organization Support for Teachers Affected by Trauma offers a free training program to help educators recognize symptoms and engage in protective strategies.
As the adage goes, you need to put on your own oxygen mask first before helping others. Once we’ve done that, we’re better equipped to get through this turbulence together.
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