Promoting Mental Health in Schools

The declining mental health of children and adolescents is a tremendous concern. In the United States, almost 20% of those age 3 to 17 have a mental, emotional, developmental, or behavioral disorder, and suicidal behaviors among high school students increased by more than 40% from 2009 to 2019.¹ Many children are subjected to one or more traumatic experiences that can have long-term adverse effects on their physical and mental health.^2,3 

School can have a major impact on children and adolescents’ mental health. School-based mental health promotion programs aim to support students’ mental health by creating a safe and open environment, focusing on the emotional and social aspects of school, and fostering inclusivity.⁴ These programs can cater to a specific student or to an entire school, working to reduce barriers that might prevent students from accessing mental health resources.⁴ They often focus on building resilience or addressing trauma. This article describes the effects of trauma in children and adolescents, and how mental health promotion programs in a school setting can optimize students’ well-being.

Understanding Trauma in Children and Adolescents

Adverse childhood experiences are stressful or traumatic events that one experiences before age 18 years that affect long-term health.^2,3 These experiences can be categorized into 3 groups^5,6:

• Abuse (psychological, physical, and/or sexual);
• Neglect (emotional and/or physical); and 
• Household dysfunction (divorce/separation, substance abuse, mental illness, criminal behavior, parental absence, or domestic violence). 

Other stressful experiences in adolescence that have long-term health effects include home, community, and school problems such as discrimination, bullying, violence, homelessness, parental stress, and poverty or economic hardship.^5,6 Some of these experiences are common — an estimated 37% of adolescents experience bullying or cyberbullying.⁷ 

School shootings and gun violence are also a source of childhood trauma. Since 1999, approximately 150 students and educators have been killed and 300 injured by a shooting at school, and more than 236,000 students have been exposed to gun violence at their school.⁸ While the main concern is for the victims, students who witness these events are at increased risk for mental disorders, including posttraumatic stress disorder, depression, anxiety, acute stress disorder, substance abuse, and panic disorder.⁸ After a school shooting, students make lose their sense of security and safety at school, which deters learning and can lead to mental health disorders.⁸

Adverse childhood experiences can have negative consequences on a student’s emotional, behavioral, psychological, social, and cognitive abilities, all of which influence their social and academic development and engagement.^6,9 Globally, the World Health Organization estimated that in 2019, 58 million children and adolescents were living with an anxiety disorder, 23 million were living with depression, and 3 million were experiencing eating disorders.¹⁰ When mental health conditions are not appropriately treated, children and adolescents struggle academically and are at a higher risk of substance use, suicide, incarceration, and dropping out of school.¹¹ Exposure to trauma during childhood can increase the risk of negative outcomes, including poor physical and mental health, in adulthood.⁹

Mental Health Care in Schools

While mental health symptoms and disorders are common among children and adolescents, many of those affected do not seek or receive treatment.¹¹ Because children and adolescents spend much of their time at school, schools are a logical place to supplement traditional mental health care.¹¹ 

School-based psychosocial interventions have been used to improve mental health services for children and adolescents.¹¹ These interventions can be used to target both internalizing disorders (those with prominent anxiety, depressive, and somatic symptoms) or externalizing disorders (those with prominent impulsive, disruptive conduct, and substance abuse symptoms).¹¹ More than one-half of school-based psychosocial interventions are offered in schools in low-income communities, and many are administered by teachers who do not have traditional mental health care training.¹¹

School-based mental health services often focus on building resilience, which is important for preventing and reducing the severity of mental health symptoms and disorders.¹² Although such programs often are designed to target a specific mental health concern in a specific demographic, others take a universal approach, in which the interventions are delivered to all students within a class, grade, or school.¹² Resilience-building programs typically include lectures, demonstrations, role-playing, educational resources, clinical tools, and more.¹²

One systematic review found that the most effective school-based resiliency programs were interactive and used a variety of these methods in a supportive environment.¹² They emphasized tools that teach coping, mindfulness, relationship-building techniques, self-efficacy, and emotional regulation.¹² 

Another approach to promoting mental health in schools is trauma-informed care. Instead of using a clinical approach to target specific symptoms, trauma-informed care entails developing a holistic understanding of how adverse childhood experiences affect an individual’s health and how to respond and provide care without re-traumatizing.^{3, 9} The 4 Rs of trauma-informed care are as follows⁹:

• Realize (understanding the widespread impact of trauma);
• Recognize (identifying the signs and symptoms of trauma in patients and families);
• Respond (coordinating health care, community, and educational resources to best support the child and family); and 
• Resist (rethinking the clinical approach to patient care, including support for those who provide the care). 

 The aim of trauma-informed care is to promote resilience in children and adolescents who have been exposed to trauma, and to increase parent/caregiver’s knowledge, awareness, and acceptance of childhood trauma.⁶

Who Provides Mental Health Programs in Schools?

As the mental health needs of children and adolescents have grown, teachers have become more involved in mental health care, usually by delivering school-based psychosocial interventions.^1,11 Teachers typically deliver these interventions in the classroom, providing social skills training consisting of activities, strategies, and techniques to improve students’ mental health, functional impairment, and well-being.¹¹ Evidence suggests involving teachers in mental health promotion programs at school can provide benefits in academic achievement, social and emotional skills, behavior, and anxiety and depression.^11,12

School nurses also can provide school-based mental health services.¹³ Students often visit the school nurse for physical symptoms, such as a headache or abdominal pain, that might be related to a mental health disorder, such as anxiety, depression, or an eating disorder. School nurses’ familiarity with students and their families can make them vital in identifying underlying stressors and mental health concerns.¹³

In a review of 14 studies, Kaskoun et al found that school nurses emphasized the need for appropriate training so they could communicate effectively and feel confident in handling their students’ mental health.¹³ Specifically, the nurses cited training in motivational interviewing, depression interventions, and identifying bullying and cyberbullying as being necessary to improve their ability and confidence in providing school-based mental health services. In this review, school nurses also reported that earning students’ trust, particularly in regards to confidentiality, is a key to helping those with mental health disorders.¹³ Many students might not be aware of confidentiality when receiving care from a school nurse and therefore do not seek out treatment; a better understanding of confidentiality by could increase the school nurse’s ability to help them.¹³ 

Collaboration and support among teachers, administrative staff, and school nurses is vital to facilitate school-based mental health programs.¹³ To effectively promote students’ mental health, teachers and nurses need support and appropriate training in understanding how adverse childhood experiences affect students’ behavior.⁶ Interventions that focus on strengthening the teacher-student relationship can improve student behavioral issues and contribute to students’ long-term resilience.⁶ 

Avoiding Burnout

Any approach to promoting students’ mental health also has to take into account the mental health of those who provide the interventions. Burnout is a long-term stress reaction characterized by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.¹⁴ A review of 18 articles found that school counselors’ risk of burnout was correlated with having non-counselor duties such as clerical tasks, being assigned large caseloads, experiencing a lack of supervision, providing fewer direct student services, and having greater perceived stress.¹⁵ 

There are no easy solutions for preventing or addressing burnout in those who provide mental health care to children and adolescents. Commonly suggested strategies include identifying symptoms of burnout, focusing on self-care (for example, by exercising, eating a healthy diet, and getting adequate sleep), prioritizing a work/life balance, and advocating for change at an organizational level.¹⁶