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. Registered professional school nurses (hereinafter referred to as school nurses) serve a vital role in the school community by promoting positive mental health outcomes in students through school/community evidence-based programs and curricula. As members of interdisciplinary teams, school nurses collaborate with school personnel, community health care professionals, students and families, in the assessment, identification, intervention, referral, and follow-up of children in need of mental health services. School nurses are uniquely qualified to identify students with potential mental health problems. In addition, school nurses serve as advocates, facilitators, and counselors of mental health services both within the school environment and in the community.
Mental health is “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community” (World Health Organization, 2010, 3rd para.). Mental health encompasses behavioral, emotional, neuro-developmental, psychiatric, psychological and substance abuse issues, as well as family and community issues that can contribute to this condition and the somatic manifestations of mental health issues (American Academy of Pediatrics [AAP], 2009). An imbalance between one or more of these factors can interfere with the child’s ability to successfully develop into a healthy, productive adult.
Mental health disorders that students experience include, but are not limited to, attention deficit hyperactive disorders, autism spectrum disorders, anxiety disorders, conduct disorders, depression, bipolar disorder, disordered eating, and substance abuse. Approximately one in five children has a mental health problem, and one half of all lifetime cases of mental health disorders begin by the age of 14 ( Stagman & Cooper, 2010). According to the Substance Abuse and Mental Health Administration (SAMSHA) (2012), 5 to 9% of children aged 9 to 17 experience a serious emotional disturbance in any given year that affects their ability to function at home, in school or in the community.
Stress and psychological trauma encountered by children can increase the probability of developing mental health disorders (SAMHSA, 2012). These may include victimization, grief and loss, divorce or separation, violence, child abuse or neglect, substance abuse, natural disasters, school crises, military deployments, familial mental illness and poverty (AAP, 2009; National Association of Chronic Disease Directors [NACDD], n.d.; SAMHSA, 2012). Chronic health conditions in youth continue to rise, with increasing numbers of students with diabetes, 10 % diagnosed with asthma and 30% with obesity; many of these students have increased risk for mental health disorders and risk-taking behaviors (NACDD, n.d.). According to the NACDD (n.d.), the 1998 Adverse Childhood Experiences (ACE) study by Felitti and Anda identified the relationship between adverse childhood experiences and the development of emotional and physical illness in adults with increased mortality rates. The ACE study highlights the need to manage disease with a holistic approach that includes physical and behavioral health strategies (NACDD, n.d.).
The use of psychotropic drugs has increased sharply in children, with two-thirds of the prescriptions written for stimulants and antidepressants (Center for Health and Health Care in Schools, 2012). SAMHSA (2012) indicates that 40% of children receive treatment for their mental health issues, and of those that received help, nearly two-thirds received treatment only at school (National Association of School Psychologists, n.d.). Children with mental health problems have lower educational achievement, greater involvement with the criminal justice system, and fewer stable and long-term placements in the child welfare system than their peers (Stagman & Cooper, 2010).
Suicide is the third leading cause of death for 10-24 year olds (Cooper, Clements & Holt, 2012). The Center for Disease Control (CDC) Youth Risk Behavior Surveillance Service (YRBSS) (2011) reported that 15.8% of respondents contemplated suicide, and 7.8% attempted suicide in the previous 12 months. Bossarte, Swahn and Breiding (2009) reported that interpersonal violence and suicide were significant public health problems among adolescents and that exposure to violence has been associated with a broad range of negative physical and mental health outcomes.
CDC’s YRBSS (2011) states 20.1% of children reported being bullied on school property and 16.2% reported being victims of cyber-bullying, through email, chat rooms, instant messaging, web sites, or texting. Cooper et al., (2012) identified a strong correlation in the literature between bullying and suicidal behavior and noted that according to the CDC, bullying is associated with substance abuse, mental health and behavior problems, and psychosomatic complaints. Both cross-sectional and longitudinal studies appear to suggest females are at greater risk for suicidal behavior than males resulting from bullying, even with less exposure (Kim, Leventhal, Koh, & Boyce, 2009; Klomek et al., 2009).
According to the 2011 National School Climate Survey, 81.9% of lesbian, gay, bisexual, transgender (LGBT) students reported being verbally harassed, while 38.3% were physically harassed, and 18.3% were assaulted in school. Another 31.8% of the respondents missed at least one day of school in the past month because of safety concerns (Gay, Lesbian and Straight Education Network [GLSEN], 2012). GLSEN (2012) links school victimization with compromised academic outcomes, attendance problems, and poorer psychological well-being. GLSEN also notes that middle school students reported higher levels of victimization on sexual orientation than high school students.
The AAP Council on School Health (2013) recommends screening and early intervention of at-risk students and families. The AAP (2013) noted that meeting the child’s need for care and nurturing early is critical for normal development and can significantly influence the child’s ability to become socially adept and academically successful. According to Stagman and Cooper (2010, p.4) ”preschool children face expulsion rates three times higher than children in kindergarten through grade12 due in part to lack of attention to social-emotional needs”, and children with mental health disorders may miss 18-22 days of school per year. School absences are associated with increased dropout rates that lead to economic and social repercussions for individuals, families and communities (NASN, 2012).
Barriers to mental health care include inadequate funding at the state and federal level, uninsured or limited coverage for mental health care services, health insurance 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, 2011). Many clinics have lost their funding, and schools function as a mental health system for 70 to 80% of children with mental health needs (AAP, 2011). Although the legislative reauthorization of the 2009 Children’s Health Insurance Program requires that mental health and substance abuse treatment be included with other medical benefits, and the Affordable Care Act of 2010 improves access to health insurance, there remains a lack of pediatric providers and programs providing services to children (Stagman & Cooper, 2010).
NASN (2012) notes in The Case for School Nursing that the top five health conditions of children in the United States are mental health problems and that school nurses spend 32% of their time providing mental health services. School nurses work on the front lines and are familiar with the prevalence of depression, self-harm, and suicidality among children and youth (Zupp, 2013). School nurses are often the health care professionals who first assess and identify the subtle signs exhibited as externalizing behaviors such as fighting, verbal aggressiveness, substance abuse, abuse, and risky sexual behaviors or internalizing behaviors, which include self-harm, withdrawal, somatic complaints, suicidal ideation and school behaviors associated with achievement, attendance and tardiness (NASN Editorial, 2011).
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 participating in their school district’s interdisciplinary team whose responsibility it is to create safe school environments. This team promotes school-based curricula and initiatives that teach and role model to children and adolescents positive self-esteem, tolerance, diversity, resiliency behaviors and protective buffers, help-seeking behaviors, anti-bullying programs, antiviolence programs, and suicide prevention programs.
Early identification and treatment of problems place school nurses on the forefront of identifying students struggling with mental, psychosocial or emotional issues, which, when not recognized, may affect educational achievement and development of full academic potential (Stevenson, 2010). 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.
Advocacy skills help school nurses promote family-centered care by connecting parents and children with school and community resources for mental health services and monitoring continued treatment and follow-up. By joining forces with other health professionals in the school and the community, school nurses can act as strong advocates for child mental health programs in the political and public arena.
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 staff to enable them to recognize signs and symptoms of potential mental health issues and help build their capacity to address barriers to learning. They educate staff about the negative effects of bullying and victimization on students. School nurses also offer themselves as a resource to learn and strategize with the staff to prevent bullying and promote a safe learning environment for the student body.
School nurses recognize that positive mental health is essential for academic success, and services providing prevention, assessment, early identification, intervention/treatment of mental illness, support student achievement and improve outcomes. These services must be easy to access and be designed as comprehensive coordinated programs to reduce the impact of mental health problems on the learning process. Increasing health literacy will help to eliminate or reduce the stigma of a mental health diagnosis, fragmentation of care, and barriers to mental health services.
School nurses are uniquely positioned between policymakers and the student body as caregiver, advocate, and expert (Cooper et al., 2012). This vantage point affords the school nurse the ability to identify and intervene with at risk adolescents as well as lead in developing prevention policy (Cooper et al., 2012).
Non-compliance with treatment is a major challenge for managing behavioral health issues in children and adolescents (Davis, Banks, Fisher, Gershenson, & Grudzinskas, 2007). 40 to 60% of families that access mental health services end therapy prematurely (AAP, 2004). Treatment and services for children and adolescents drop off rapidly after three months. School nurses provide critical case management of students to ensure that compliance with treatment continues as long as necessary (Davis et al., 2007).
Emotional and psychiatric health is necessary for optimal academic success (Stevenson, 2010). Mental health is a key component in childrens healthy development; children need to be healthy in order to learn, grow, and lead productive lives. When appropriately treated, children and youth with mental health problems fare better at home, in schools, and in their communities (Stagman & Cooper, 2010). Understanding the relationship between frequent health office visits or somatic complaints as a sign of underlying problems, which may be organic or psycho emotional in origin, requires the unique skill set of the school nurse.
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Zupp, A. (2013, January). School nurses as gatekeepers to plan, prepare, and prevent child and youth suicide. NASN School Nurse 28(1), 24-26. doi: 10.1177/1942602X12468331
Acknowledgement of Authors:
Mary Blackborow, MSN, RN
Christine Tuck, MS, BSN, RN, NCSN
Patrice Lambert, MSN, RN, SNC
Jody Disney, PhD, RN
Jessica Porter, BSN, RN, NCSN
Alicia Jordan, BSN, RN, NCSN
Revised: June 1982; June 1996; June 2000; June 2005; June 2008; June 2013