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SUMMARY OF THE POSITION:
It is the position of the National Association of School Nurses (NASN) that mental health is as critical to academic success as physical well-being. School nurses play a vital role in the school community by promoting positive mental health development in students through school/community-based programs and curricula. As members of interdisciplinary teams, school nurses play a vital role in supporting early assessment, planning, intervention, and follow-up of children in need of mental health services. In addition, school nurses serve as advocates, facilitators and counselors of mental health services both within the school environment and in the community.
HISTORY:
Mental health is determined by the inter-relationship of physical, environmental, social and psychological factors and is an integral part of every child’s healthy development. An imbalance between one or more of these factors can lead to a child who experiences mental health issues that interfere with the child’s ability to successfully complete his/her development into a healthy productive adult. Issues that children encounter that can create an imbalance include peer bullying, victimization, youth violence, homicide, suicide, child abuse including sexual abuse and/or neglect, substance abuse, family violence, mental illness, and barriers to mental health care.
DESCRIPTION OF ISSUE:
Mental health issues refer to a myriad of health problems that interfere with student success. Good health and a good education are closely linked, and education is one of the strongest predictors of health (Freudenberg & Ruglis, 2007). Untreated mental health disorders in youth lead to increased rates of juvenile incarcerations, school drop out, and substance abuse (American Academy of Pediatrics [AAP], 2004). According to the American Academy of Pediatrics more than 14 million children and adolescents in the United States have a diagnosable mental health disorder that causes impairment in functioning. Mental health disorders that students experience include autism spectrum disorders, anxiety disorders, conduct disorders, depression, bipolar disorder, disordered eating, attention deficit hyperactive disorders, and substance abuse. It is estimated that only one-third of adolescents with a mental health disorder receives needed services (Patton, Hettrick, & McGorry, 2007).
Homicide and suicide are the fourth and fifth leading causes of death among children aged 5-14 and the second and third leading causes of death among people aged 15-24 years (Centers for Disease Control and Prevention [CDC], 2007). Ninety percent of suicides have a diagnosable mental illness at the time of the suicide, with depression being the most common.
Depression affects 8.5% of teens and 2.5% of children (Davis, 2005). As with many mental health diagnoses, co-morbidity is a significant factor in depression affecting approximately two-thirds of children and adolescents (Barcalow, 2006; Davis, 2005; DeSocio & Hootman, 2004; Woodard, 2006).
Substance abuse and/or peer or Internet bullying have been implicated in both school homicides and suicides. Children in grades 6 through 10 indicate that approximately 29.9% of them are bullied moderately or frequently (Raskauskas & Stoltz, 2004). Bullying has been identified as an issue for students with chronic health issues including obesity, disordered eating, learning disabilities, autism, and attention deficit hyperactive disorder (Hendershot, Dake, Price, & Lartey, 2006; Meyer & Gast, 2008; Robinson, 2006). In addition, 33% to 49% of students whose sexual orientation is lesbian, gay, bisexual, transgender, or questioning report being victimized at school (Selekman, 2007). Chronic bullying can lead to depression, academic failure, and absenteeism (Raskauskas & Stoltz, 2004).
Domestic violence affects every member of the household. It is estimated that between 3 and 10 million children are exposed to some form of violence in their homes each year. This exposure puts the students at risk for developing a variety of problems including depression, anger, aggression, or anxiety (Kolar & Davey, 2007). Domestic violence also puts the child at an increased risk for sexual and physical abuse, post-traumatic stress disorder, and becoming an abuser as an adult (Homor, 2005). The number of homeless youth is estimated to be 1.3 to 2 million, of which approximately 1 million are runaways. Physical or sexual abuse is a common reason for adolescents running away from home. However, their homelessness places them at a much higher risk for physical and sexual abuse (Taylor-Seehafer, 2004).
Adverse childhood events defined as abuse, neglect, or household dysfunction lead to childhood and adolescent risky behavior, including pregnancies, suicide attempts, smoking, sexual activity, and drug use (Middlebrooks & Audage, 2008). In addition, research is now showing that the number and types of adverse events experienced as a child is linked to health and behavioral problems as adults, including alcoholism, depression, illicit drug use, multiple sexual partners, sexually transmitted diseases, and suicide attempts (Middlebrooks & Audage, 2008).
Barriers to mental health care include inadequate funding at the state and federal level, uninsured and insufficient or no coverage for mental health, managed care barriers, lack of transportation, financial constraints, shortage of trained child mental health professionals, and the social stigma related to mental health issues. In addition, physicians in primary care practices and the emergency room setting are not sufficiently prepared in their training to recognize and address mental health problems (AAP, 2004; AAP, 2006). These barriers may explain why many people attend only one or two sessions of therapy and approximately 40% to 60% of families who access mental health services end therapy prematurely (AAP, 2004).
Prevention, early identification, and intervention will ensure more successful outcomes for students. School nurses are often the health care professionals who first identify the subtle signs that have been associated with emotional or behavior issues in children. These signs can include frequent somatic complaints and unexplained physical symptoms with no medical reason (DeSocio & Hootman, 2004). Behavior problems in school, absenteeism, and academic problems can also be signals of underlying mental health issues. (DeSocio & Hootman, 2004; Goldenring & Rosen, 2004). Children with emotional, behavioral, and developmental problems on average miss at least 11 school days or more (CDC, 2005). Absenteeism rates for inner city teens can range from 15% to 20% (Goldenring & Rosen, 2004). Furthermore, the more lost school time the student has, the more likely the student is to experience academic difficulties.
RATIONALE:
School nurses promote student success and nurture positive youth development by using a systematic approach to healthy social and emotional development that strengthens students, families, schools and communities. School nurses enhance a positive school climate by becoming part of their school district’s interdisciplinary team whose responsibility it is to create safe school environments. This interdisciplinary team promotes school-based curricula and initiatives that teach and role-model to children and adolescents positive self-esteem, tolerance, cultural diversity, resiliency behaviors and protective buffers, help-seeking behaviors, anti-bullying programs, anti-violence programs, and suicide prevention programs. Through early identification and treatment of problems, school nurses help students to manage chronic health conditions, thereby improving their attendance and enhancing their ability to achieve academic success. Using their advocacy skills, school nurses promote family-centered care and link parents and children with school and community resources for mental health services and monitor continued treatment and follow-up. For students with a mental health diagnosis, school nurses are able to promote their success through developing and implementing 504 plans, the health portion of the Special Education Individual Education Plan (IEP), and the Individualized Healthcare Plan (IHP). Using these same tools, the school nurse can assist in the re-entry of students into the school environment following homebound instruction or hospitalization and serve as a liaison between community mental health providers, the family, and school personnel.
Using a holistic approach, school nurses provide ongoing assessment, intervention, and follow-up of the mental and physical health of the school community. School nurses also provide education for the school staff to enable staff to recognize signs and symptoms of potential mental health issues and help build the capacity of the staff to address barriers to learning. In addition, School Nurses educate staff about the negative effects that bullying and victimization have on students and their ability to learn. They strategize with the staff about how to prevent opportunities for bullying in the school environment thereby promoting a safe learning environment for the student body.
School nurses recognize that positive mental health is essential for academic success and that services providing prevention, early identification, intervention, and treatment of mental illness are necessary to support student achievement. Services that are easy to access and provide comprehensive coordinated programs are needed to reduce the impact of mental health problems on the learning process. The stigma of a mental health diagnosis, fragmentation of care, and barriers to mental health services need to be eliminated. By joining forces with other health professionals in the school setting and the community, school nurses can act as strong advocates for child mental health programs in the political and public arena.
References/Resources:
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians and Pediatric Emergency Medicine Committee (2006). Policy Statement: Pediatric mental health emergencies in emergency medical services system [Electronic Version]. Pediatrics, 118(4), 1764-1767.
American Academy of Pediatrics, Committee on School Health (2004). Policy Statement: School-based mental health services [Electronic Version]. Pediatrics, 113(6), 1839-1845.
Barcalow, K. (2006). Oppositional defiant disorder: Information for school nurses. Journal of School Nursing, 22(1), 9-16.
Bartlett, R., Holditch-Davis, D., & Belyea, M. (2007). Problem behaviors in adolescents. Pediatric Nursing, 33(1), 13-18.
Centers for Disease Control and Prevention, (2005). Mental health in the United States: Health care and well being of children with emotional, behavioral or developmental problems, United States, 2001. Morbidity and Mortality Weekly Report, 57(02), 33-36.
Centers for Disease Control and Prevention. (2008). School-associated student homicides, United States, 1992-2006. Morbidity and Mortality Weekly Report, 57(02), 33-36.
Centers for Disease Control and Prevention. (2007). The effectiveness of universal school-based programs for the prevention of violent and aggressive behavior. Morbidity and Mortality Weekly Report. Recommendations and Reports, 56 (RR07), 1-12.
Davis, N. (2005). Depression in children and adolescents. Journal of School Nursing. 21(6), 311-317.
DeSocio, J., & Hootman, J. (2004). Children’s mental health and school success. Journal of School Nursing. 20(4), 189-196.
Freudenberg, N., & Ruglis, J., (2007). Reframing school dropout as a public health issue. Preventing Chronic Disease Public Health Research, Practice, and Policy. 4(4), 1-11.
Galinat, K., Barcalow, K., & Krivda, B. (2005). Caring for children with autism in the school setting. Journal of School Nursing, 21(4), 208-217.
Goldenring, J., & Rosen, D., (2004). Getting into adolescent heads: An essential update. Contemporary Pediatrics, 21(1), 64-90.
Hendershot, C., Dake, J.A., Price, J. H., & Lartey, G. K. (2006). Elementary school nurses’ perceptions of student bullying. Journal of School Nursing, 22(4), 229-236.
Homor, G. (2005). Domestic violence and children [Electronic Version]. Journal of Pediatric Health Care, 19(4), 206-212.
Kolar, K., & Davey, D. (2007). Silent victims: Children exposed to family violence. Journal of School Nursing, 23(2), 86-91.
Meyer, T., & Gast, J. (2008). The effects of peer influence on disordered eating behavior. Journal of School Nursing, 24(1), 36-42.
Middlebrooks, J. S., & Audage, N. C. (2008). The effects of childhood stress on health across the lifespan. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Available at: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf
Patton, G. C., Hetrick, S. E., & McGorry, P. (2007). Service responses for youth onset mental disorders [Electronic Version]. Current Opinion Psychiatry, 20(4), 319-324.
Raskauskas, J.U. & Stoltz, A. D. (2004). Identifying and intervening in relational aggression. Journal of School Nursing, 20(4), 209-215.
Robinson, S. (2006). Victimization of obese adolescents. Journal of School Nursing, 22(4), 201-206.
Samargia, L. A. Saewyc, E. M., & Elliott, B. A. (2006). Foregone mental health care and self-reported barriers among adolescents. Journal of School Nursing, 22(1), 17-24.
Selekman, J.U. (2007). Homosexuality in children and/or their parents. Pediatric Nursing, 33(5), 453-457.
Taylor-Seehafer, M. A. (2004). Positive youth development reducing the health risks of homeless youth. American Journal of Maternal/Child Nursing, 29(1), 36-40.
Woodard, R. (2006). The diagnosis and medical treatment of ADHD in children and adolescents in primary care: A practical guide. Pediatric Nursing, 32(4), 363-370.
Adopted: 1972
Revised: June 1982; June 1996; June 2000; June 2005; June 2008
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