By Christopher J. Leonard, MSW, LCSW, M.ED.
If you have not yet heard that there is a mental health crisis in America, you have not been paying attention. But because you have been paying attention, you know that this crisis is having a significant impact on school-aged children and adolescents.
Studies suggest that more than 1 in 5 adolescents between ages 13 and 18 will experience a severe mental health disorder at some point. Furthermore, between 13 and 20 percent of students nationwide will be affected to some degree. This means that it is highly likely that you have students in your school district who are in need of mental health intervention. The question is, how should schools respond?
Recognizing both the symptoms of common mental health issues and the subtle behavioral clues will empower you, your staff, and school counselors to take the most effective action.
What Are the Signs an Adolescent Needs Mental Health Intervention?
It’s not always easy to see the signs that indicate that a student needs mental health intervention. Many students struggling with an emerging mental health issue are either frightened by their developing symptoms, feeling ashamed, or both.
Frequently, the struggling student will not explicitly disclose their symptoms to anyone. It is certainly possible that a student will share their concerns with someone they trust. But the person with whom they share may not be a teacher, the school nurse, a school counselor, or another adult in a position to help. In fact, the student in crisis may confide in a peer, a custodian, a cafeteria worker, or another person they know and trust.
For this reason, it is helpful to ensure that your students, parents, and everyone in your school can recognize the signs of trouble. If you learn that a student has any of the following symptoms, it is important to seek the assistance of a trained mental health professional immediately. When I say immediately, I mean the same day.
- Feeling confused or disoriented
- Having bizarre or unusual thoughts
- Experiencing hallucinations
- Feeling significantly more restless, agitated, or lethargic than normal
- Having thoughts of suicide or self-harm
- Experiencing delusions (strongly believing something illogical or unreal to be true)
- Sudden mood swings without environmental causes
- Feeling anxious, depressed, or unable to function in school or social life
Behavioral Indicators That a Student Needs Mental Health Intervention
More frequently, the student struggling with a mental health issue will not actively seek help from anyone. Staff may notice more subtle signs of developing emotional issues which, taken together, may indicate the need for intervention.
I have listed the symptoms below in the left-hand column under What You See. Possible underlying issues are listed in the center column: What It Could Be. The Risk Level is indicated in the right column.
It is important to note that no individual symptom always points to the same single cause. It is also important to emphasize that accurate differential diagnosis requires evaluation by a trained professional. Following the table, I will discuss the best ways to respond at each level of risk.
How to Intervene Effectively
The appropriate intervention depends on the symptoms or observable behaviors. Taking appropriate action with evidence-based intervention strategies provides the best help for students who display these warning signs.
School-based counseling services are a best practice for providing these evidence-based interventions seamlessly and efficiently. The benefits of school-based counseling include:
- Strategic on-site individual counseling to work through issues, underlying symptoms, and behaviors
- On-site group counseling to build supportive peer relationships within the school
- Delivery of services by staff and clinicians who are trained in dealing with the emotional issues of adolescents
- Facilitation of collaboration between students, teachers, administration, counselors, and outside professionals
Here is a brief look at appropriate responses to the different levels of risk.
Mental health intervention for HIGH RISK LEVEL behaviors
IMPORTANT: High risk level behaviors and symptoms require intervention the same day they become apparent. A student exhibiting suicide risk must be screened immediately by a mental health professional trained in suicide assessment. It is not necessary, and usually not helpful, to send a student to the emergency room or to a psychiatrist.
Anyone trained in the Columbia-Suicide Severity Rating Scale (C-SSRS) can conduct the initial screening. This does not have to be a mental health professional. However, best practice entails having a readily available school-based counselor who can provide, or make a seamless referral to follow-up care.
For the remaining high risk behaviors and all behaviors marked (MEDICAL?) on the chart, it is important to have the student see a physician to rule out a possible undiagnosed medical issue.
Students under the influence in school are required by New Jersey law to have an immediate medical evaluation. Best practice calls for the medical evaluation to include a comprehensive screening for controlled substances and a follow-up evaluation by a treatment provider specializing in substance abuse treatment. If the provider recommends treatment, the school should require the student and family to follow through with the recommended treatment.
Once a medical issue has been ruled out, the student should be referred to a trained mental health professional who can diagnose and treat mental health disorders. Ideally, this professional works in the school (dedicated to mental health full-time) and can provide both scheduled counseling sessions and crisis intervention sessions during the school day.
Mental health intervention for MODERATE TO HIGH-RISK LEVEL behaviors
Behaviors and symptoms at the moderate to high risk level do not require same-day intervention but should be addressed within the first 7 to 10 days of appearing. As indicated in the chart, a single symptom may indicate one or more of a variety of mental health issues. This is why a core best practice for schools is to have at least one dedicated school-based counselor who is available full-time for assessment, intervention, and referral.
School refusal must be addressed early. Once the student becomes accustomed to staying home, it can be difficult to overcome the resistance to attending school. Best practice for school refusal is a team effort involving parents, educators, and mental health professionals. The goal is to understand the reasons behind school refusal, set limits and boundaries, provide point people at school who are available to the student, and to provide reasonable accommodations to enable the student to readjust to school.
Again, the presence of a dedicated school-based counselor is optimal. Students who frequently leave class to see the school nurse, and who do not have a diagnosable medical issue, are highly likely to be struggling with a mental health issue.
This is also the case for students who are frequent victims of HIB. Once in counseling, these students will frequently get in touch with underlying feelings of unexpressed anger of which they had no prior awareness. This thinly-masked anger can be irritating to peers, inducing aggression.
Other HIB victims lack assertiveness skills. Thus, effective HIB programs don’t merely punish aggressors but help victims become more self-aware and more effective in self-advocacy. Overall, assessment and intervention by a trained mental health practitioner can identify the underlying causes of the problematic symptoms and ensure the best possible response.
Mental health intervention for MODERATE RISK LEVEL behaviors
Behaviors and symptoms at a moderate risk level should be addressed within 30 days of appearing.
A drop in academic performance can have various causes, but teacher conferences with students and parents are a great way to start. Referral for evaluation by the special services team is, of course, the next step. By now, you should not be surprised by the idea that assessment and intervention by a trained mental health practitioner is your best approach to preserving and restoring mental wellness in your students.
Christopher J. Leonard, MSW, LCSW, M.ED.
Chris Leonard is Director of Operations for Sage Thrive and the Sage Day Schools. He is an experienced teacher, school administrator, social worker and psychotherapist with over 30 years of experience working with children, adolescents, and families. Mr. Leonard is married with two daughters and enjoys distance running, mountain and road biking, hiking, and the outdoors.