The School Nurse’s Role in Behavioral Health of Students
It is the position of the National Association of School Nurses (NASN) that registered, professional school nurses (hereinafter referred to as school nurses) serve a vital role in promoting positive behavioral health outcomes in students through evidence-based programs and curricula in schools and communities. Behavioral health is as critical to academic success as physical well-being. As members of interdisciplinary teams, school nurses collaborate with school personnel, community healthcare professionals, students, and families in the assessment, identification, intervention, referral, and follow‐up of children in need of behavioral health services. School nurses, because of their regular access to students, are uniquely qualified to identify students with potential behavioral health concerns. School nurses can serve as advocates, facilitators, and counselors of behavioral health services within the school environment and in the community.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines behavioral health as “mental/emotional well-being and/or actions that affect wellness” (SAMHSA, 2017a). SAMHSA also states that behavioral health includes the “service systems that encompass prevention and promotion of emotional health; prevention of mental and substance use disorders, substance use, and related problems; treatments and services for mental and substance use disorders; and recovery support” (SAMHSA, 2017a). Behavioral health and wellness occur across a continuum. Schools and school nurses have an essential role in addressing behavioral health disorders, promoting mental wellness and social-emotional competencies, enhancing protective factors, and referring to and collaborating with behavioral health support networks when appropriate.
Behavioral health disorders that school-age children commonly experience include, but are not limited to, attention deficit hyperactivity disorders, mood disorders, depression, bipolar disorders, conduct disorders, anxiety disorders, panic disorders, eating disorders, psychotic disorders, and substance use disorders. Behavioral health disorders affect a significant number of America’s school-age children. According to the Centers for Disease Control and Prevention (CDC), 13% to 20% of children living in the United States experience a mental disorder in a given year, and surveillance from 1994 to 2011 indicated increasing prevalence over time (CDC, 2013). In 2014, approximately 5% of adolescents ages 12-17 in the U.S. had a substance use disorder (SAMHSA, 2017b).
The (CDC) 2015 Youth Risk Behavior Survey found that 17.7% of high-school students had seriously considered attempting suicide in the past twelve months; 14.6% had made plans to do so; and 8.6% had made one or more attempts to do so (Kahn et al., 2016). Suicide is the second leading cause of death in adolescents (Banspach et al., 2016). Data from the Youth Risk Behavior Survey also indicates that 21.7% of students were offered, sold, or given an illegal drug on school property in the past year; and 17.7% of students consumed five or more servings of alcohol in a row in the past 30 days (CDC, 2015). In addition, adverse childhood experiences (ACEs), including physical, emotional and sexual abuse and other potentially traumatic experiences, are common among youth and are related to increased risk for lasting negative effects on physical and mental health (CDC, 2015). The CDC Behavioral Risk Factor Surveillance System Survey ACE Data, 2009-2014, indicates that approximately 66% of adults surveyed report experiencing at least one ACE; and more than 20% reported experiencing three or more ACEs. An increased risk for long term health and mental health problems was noted as the total number of ACEs experienced increased (CDC, 2015).
Behavioral health disorders result in significant psychosocial and economic costs not only for the young people who experience them but also for their families, schools, and communities (Mental Health America, 2016). Childhood mental health and substance use disorders not only result in poorer school outcomes but also often persist into adulthood. These disorders are associated with multiple risk factors throughout one’s lifespan such as reduced employment opportunities, adverse health conditions, earlier mortality, and financial burden (Bitsko et al., 2016).
The American Academy of Pediatrics estimates that only 10% to 40% of students needing behavioral health services receive them (AAP, 2016; SAMHSA, 2012). Barriers to treatment include the stigma associated with mental illness, families not recognizing the signs of mental illness, and families not knowing where to go to seek help (Bowers, Manion, Papadopoulos, & Gauvreau, 2012). Additional barriers include inadequate funding at the state and federal level, lack of insurance or limited coverage for behavioral healthcare services, and a shortage of child behavioral health providers, which lead to long wait times for treatment and/or families having to travel long distances for care (AAP, 2017).
The AAP Council on School Health (2013) recommends screening for mental health disorders and early intervention of at‐risk students and families. The AAP (2013) noted that meeting the child’s needs for mental health services and nurturing positive coping strategies early are critical for normal development and can significantly influence the child’s ability to become socially adept and academically successful.
School nurses are in a unique position to play an active role in mental wellness promotion, mental health screening, and early intervention programs and to assist in managing the ongoing treatment of mental health and substance use disorders in the school setting. The CDC notes that schools are one of the most efficient systems for reaching children and youth to provide health services and programs, as approximately 95% of U.S. children and youth attend school (CDC, 2014). School nurses are educated to identify somatic complaints and co-occurring behavioral health concerns (Shannon, Bergren & Matthews, 2010). Thus, school nurses are often a student's first point of entry into behavioral health services. School nurses are also part of the normal school experience and are easily accessible to students seeking assistance with behavioral health issues. Visiting the school nurse may be viewed as less stigmatizing for students than seeking a school behavioral health provider (Pryjmachuk, Graham, Haddad, & Tyler, 2011). It has been reported that school nurses spend approximately one third of their time providing mental health services (Bobo & Shubert, 2013).
As integral members of school behavioral health service teams, school nurses:
- Work on the front lines and are familiar with and educated to recognize warning signs such as changes in school performance, mood changes, complaints of illness before or during the school day, problems at home, self‐harm, and suicidality (Zupp, 2013; American School Counselor Association [ASCA], 2015).
- Adhere to appropriate guidelines regarding confidentiality (ASCA, 2015).
- Promote student success by developing and implementing Section 504 plans, the health portion of the Special Education Individual Education Program (IEP), and the Individualized Healthcare Plan (IHP). Using these 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 care coordinator among community behavioral health and primary care providers, the family, and school personnel.
- Provide behavioral health screening and basic behavioral health skills that include education about mental health and substance use disorders, psychotropic medication information, and cognitive behavioral skills.
- Recognize care coordination as a critical component of comprehensive behavioral health services, and regularly make referrals and connect parents and children with school and community behavioral health resources (NASN, 2015). School nurses’ regular contact with students allows them to provide ongoing assessment, monitor treatment compliance, and provide timely feedback to families, physicians and mental health professionals regarding a student’s response to treatment, thus allowing for better medical management of behavioral health conditions and health outcomes (AAP, 2016; Bobo & Shubert, 2013).
- Regularly provide educational programming to teachers, administrators, parents and guardians, and students about behavioral health concerns, and assist with crisis intervention planning.
School nurses recognize that positive behavioral health is essential for academic success. School nurses are critical to the school mental health team in that they can help address and reduce the stigma of a behavioral health diagnosis, decrease fragmentation of care, and remove barriers to behavioral health services. School nurses, because of their regular access to students and their experience with care coordination, are also uniquely equipped to assist school and community-based behavioral health professionals in providing services including prevention, assessment, early identification/intervention, and treatment of mental illness and substance use disorders.
American Academy of Pediatrics. (2017). Promoting children’s mental health. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/pages/mentalhealth.aspx
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American School Counselor Association. (2015). The school counselor and student mental health. Retrieved from https://www.schoolcounselor.org
Banspach, S., Zaza, S., Dittus, P., Michael, S., Brindis, C.D., & Thorpe, P. (2016). CDC grand rounds: Adolescence--preparing for lifelong health and wellness. Morbidity and Mortality Weekly Report (MMWR), 65(30), 759-762. doi: http://dx.doi.org/10.15585/mmwr.mm6530a2
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Pryjmachuk, S., Graham, T., Haddad, M., & Tyler, A. (2011) School nurses’ perspectives on managing mental health problems in children and young people. Journal of Clinical Nursing, 21, 850-859. doi: 10.1111/j.1365-2702.2011.03838.x
Shannon, R., Bergren, M., & Matthews, A. (2010). Frequent visitors: Somatization in school-age children and implications for school nurses. The Journal of School Nursing, 26, 169–182.
Substance Abuse and Mental Health Services Administration. (2012). Identifying mental health and substance abuse problems of children and adolescents: A guide for child‐serving organizations. Retrieved from http://store.samhsa.gov/product/Identifying‐Mental‐Health‐and‐Substance‐Use‐Problems‐of‐Children-and‐Adolescents‐A‐Guide‐for‐Child‐Serving‐Organizations/SMA12‐4700
Substance Abuse and Mental Health Services Administration. (2017a). National Behavioral Health Quality Framework. Retrieved from https://www.samhsa.gov/data/national-behavioral-health-quality-framework
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Zupp, A. (2013). 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:
Elizabeth McDermott, BA, BSN, RN, NCSN
Jill Haak Bohnenkamp, PhD
Mary Freedland, BA, RN
Dian Baker, PhD, RN
Karla Palmer, MSN, RN, NCSN
Date adopted: June 2017
This position statement replaces the position statement titled Mental Health of Students.
Suggested citation: National Association of School Nurses. (2017). Behavioral health of students (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.