Addressing the Mental Health Crisis in Children

When Millis Public Schools in Boston reopened its doors for the 2021-22 school year, teachers and staff were excited to see students back in real classrooms. Within weeks, that excitement quickly shifted to concern as students presented with noticeable and troubling signs of mental and emotional stress.¹ “From the beginning, we’ve seen elevated levels of stress, anxiety and different behavioral issues in students,” said Bob Mullaney, the superintendent of the suburban Boston school district. Of course, Mullaney’s district is far from alone when it comes to dealing with unprecedented mental health challenges in student populations. According to staff, pediatricians and mental healthcare workers, K-12 schools across the country have been overwhelmed by students struggling with a range of mental health symptoms. Not only has this surge made the return to classrooms more challenging for educators, it’s also taxing an already strained healthcare system in the United States.

A Pre-Pandemic Concern Escalates to a National Emergency

The rise in children’s mental health symptoms didn’t start in 2020: It’s a problem years in the making. Studies indicate that the pandemic exacerbated an already growing crisis in youth mental health. The Centers for Disease Control and Prevention (CDC) states that one in five teenagers in the United States has experienced an episode of major depression at some point, according to data collected between 2013 and 2019. The findings were pulled from nine federal surveillance systems of children’s mental health, including the National Health and Nutrition Examination Survey, the National Survey on Drug Use and Health and the Youth Risk Behavior Survey. “The fact that this report precedes the pandemic is stunning,” said Richard Besser, MD, pediatrician and the president of the Robert Wood Johnson Foundation. “What it says to me is that this is a dramatic underestimation in terms of how significant this crisis truly is.”²

CDC data also show that the proportion of mental health emergency visits for kids began going up very early in the pandemic, and by the fall of 2020, the American Academy of Pediatrics (AAP), the Children’s Hospital Association (CHA) and the American Academy of Child and Adolescent Psychiatry (AACAP) declared an emergency in child and adolescent mental health.³ The incidents have continued to escalate. According to CHA, there were more than 47,000 mental health visits to emergency departments at 38 children’s hospitals around the country in the first three quarters of 2021 — nearly 40 percent higher than the same period in 2020.⁴

Increased Violence and Self-Harm

In the Millis school district, Mullaney notes that fights among students have risen at an alarming rate, while there have also been reports of violence against those in authority. A school principal in Massachusetts, for example, was assaulted by a student, and other schools in his district have had staff members assaulted by students.¹

Sadly, many students are also resorting to hurting themselves. Based on data from nearly 40 children’s hospitals around the country, there were 14,630 emergency room visits for children aged 5 years to 18 years between January and September of 2021. “Unfortunately, younger children are experiencing higher rates of this than they have in the past,” said Amy Knight, president of CHA, who moderated a congressional briefing on the youth mental health crisis.⁵

Again, while the pandemic certainly put a magnifying glass on childhood mental health crises, it’s a concern that has been simmering for over a decade. Alexandre T. Rotta, MD, division chief of pediatric critical care medicine at University Hospitals Rainbow Babies and Children’s Hospital and senior author of a recent study, analyzed data from the Nationwide Emergency Department Sample database for years 2008 through 2013. Dr. Rotta and his team hoped to characterize the magnitude of the problem and spot any trends in the number of children and adolescents being treated for deliberate self-harm. “We found a slight decrease in the number of emergency department visits in the usual self-harm group — the 16- to 19-year-old age group over the six-year study period,” Dr. Rotta says. “But the 13- to 15-year-old group had a 45 percent increase in visits for self-harm. For children 11 to 12 years old, the increase was 94 percent.”⁶

The Journal of Clinical Pediatrics adds, “Historically, it was thought that children in this age group could not develop the concept of the finality of death. It was believed that due to their concrete operational thinking patterns, this age group could not estimate the lethality or outcomes of their self-destructive acts. With more research focus and attention being paid to the pediatric population as a whole with regard to suicide and self-harm, it has been suggested that even children this young can exhibit suicidal behavior and thinking.”⁶

The Cry for a National Agenda

Stakeholders at all levels of public health are recognizing the need for a national agenda to address mental health issues in children and adolescents. In his March 2022 State of the Union address, President Joe Biden laid out a national strategy to tackle our nation’s mental health crisis. As the administration implements a whole-of-government strategy to transform mental health services for all Americans, one of the key goals is to ensure all children and families have easy, affordable and equitable access to the care, support and services they need, including $35 million in funding opportunities to strengthen and expand community mental health services and suicide prevention programs for America’s children and young adults.⁷ “As the President made clear in the State of the Union, children’s mental health needs are a national priority,” said Health Resources and Services Administration (HRSA) Administrator Carole Johnson. “At [HRSA], we are answering [President Biden’s] call by focusing on expanding pediatric mental health services, training more mental healthcare providers and making mental health a key part of primary care to ensure that children get the quality care they need and deserve.”

There are also some notable ways psychologists are working to address students’ mental health challenges. By bringing mental health into the classroom, the American Rescue Plan Act, passed in March 2021, included $170 billion for school funding, and many schools used the funding to hire mental health workers, including psychologists.⁸

Other federal and state funding is being allocated toward training more psychologists. For example, Nevada State College received funding to create a new program to train school mental health clinicians, including psychologists.

While the field of psychology recognizes a shortage of mental health services for kids, addressing those needs may not be a realistic solution until the workforce grows. “Relying on temporary funding to hire permanent staff isn’t financially sustainable for lower-income districts,” said Kenneth Polishchuk, senior director for congressional and federal relations at the American Psychological Association (APA). As a result, Polishchuk said, many schools are hiring mental health providers on a short-term basis, as well as taking a preventive approach that trains teachers in psychology principles.⁸

“Psychologists in some districts are training teachers in basic social and emotional skills to help students cope with stress and anxiety in real time,” said Kathryn H. Howell, PhD, associate professor of child and family psychology at the University of Memphis and chair-elect of APA’s Committee on Children, Youth and Families. Dr. Howell said equipping kids with coping skills in the classroom can prevent strain on school psychologists while also improving students’ ability to learn. “As psychologists, we don’t just want to bring in interventions that only we as experts can deliver,” Dr. Howell said. “We need to make it sustainable by teaching those on the frontlines how to equip kids with the skills they need to thrive.”⁸

Trauma Training in the Classroom Setting

To address mental health symptoms in the student populations, some teachers are incorporating formal mental health lessons into their curriculum with help from psychologists. New York state requires basic mental health education in health classes, and Peter Faustino, PsyD, a school psychologist in Scarsdale, N.Y., said he’s been receiving requests from teachers for help incorporating pandemic-relevant topics like anxiety, trauma and warning signs of suicide into their classes. Other schools, he said, are investing in social and emotional health training programs for staff such as Yale University’s Ruler Program, which teaches school leaders and teachers how to equip students with emotional intelligence skills.⁹

Along with more minor mental and behavioral health concerns, teachers are also facing an unprecedented number of students with trauma, said Laurie McGarry Klose, PhD, president of the National Association of School Psychologists and director of the School Psychology Program at Trinity University in San Antonio, Texas. Studies show that roughly half of American school children have experienced at least some form of trauma, from neglect to abuse and violence. In response, educators often find themselves having to take on the role of counselors, supporting the emotional healing of their students, not just their academic growth.¹⁰

It’s not surprising that many teachers don’t feel equipped to handle their students’ struggles. A 2020 survey by the New York Life Foundation and American Federation of Teachers found that only 15 percent of educators said they felt comfortable addressing grief or trauma tied to the pandemic.¹¹

As a result, psychologists are finding new ways to share their expertise with school personnel. For example, Samuel Song, PhD, a professor of school psychology at the University of Nevada, Las Vegas, is working on a grant with colleagues to deliver a four-part web-based curriculum on trauma-informed practices. Programs like this can help teachers identify signs of trauma in students and also cope with their own trauma, which Dr. Klose says are equally important. Teachers are more likely to dismiss trauma-driven behaviors as belligerence when they’re under strain, so with proper resources and training, they can better identify kids who are struggling and route them to appropriate support services within the school system.¹⁰

Another resource titled Mental Health Primers was developed by the Coalition for Psychology in Schools and Education. This topical-based resource identifies mental health symptoms in children based on specific scenarios and potential triggers. It also provides information for teachers to identify behaviors in the classroom that are symptomatic of mental health and other psychological issues, with the goal of directing teachers to access appropriate resources for their students.¹²

A Multipronged Approach for Lasting Change

Whether kids are facing trauma because of child abuse, loss of a family member or everyday anxiety about the pandemic, they need even more support now — all amid a significant shortage of children’s mental health resources.
AAP, AACAP and CHA universally acknowledge that the challenges facing children and adolescents are so widespread that policymakers at all levels of government and advocates for children and adolescents are tasked with working together to create sustainable support systems and lasting change.³ Proposals for change include:

• Increasing federal funding dedicated to ensuring all families and children, from infancy through adolescence, can access evidence-based mental health screening, diagnosis and treatment, with particular emphasis on under-resourced populations.
• Addressing regulatory challenges and improving access to technology to assure continued availability of telemedicine mental health services to all populations.
• Increasing sustainable funding for and implementation of effective models of school-based mental healthcare, including clinical strategies and models for payment.
• Accelerating adoption of effective and financially sustainable models of integrated mental healthcare in primary care pediatrics.
• Strengthening efforts to reduce the risk of suicide in children and adolescents through prevention programs in schools, primary care and community settings.
• Fully funding comprehensive, community-based systems of care that connect families in need of behavioral health services and supports for their child with evidence-based interventions.
• Advancing policies that ensure compliance with and enforcement of mental health parity laws.
  “We know one-on-one therapy won’t be possible for every kid who’s struggling, so we need a multipronged approach to help build the capacity of teachers and staff to support kids in the classroom setting,” said Melissa Pearrow, PhD, a professor of counseling and school psychology at the University of Massachusetts, Boston.⁸

At a national level, awareness of the issues has been acknowledged, and as new laws continue to go into effect, stakeholders at all levels are committed to finding new ways to address children’s mental health, not only for their own well-being but for the future success of society as a whole. “It’s not only the right thing to do to make sure people can have as full a life as they possibly can,” said Alan Leshner, PhD, the former director of the National Institute on Drug Abuse and former deputy and acting director of the National Institute of Mental Health. “Young people are critical to the future of society, so it’s in society’s interest to make sure we don’t lose the talent youth could contribute to a set of problems that can be alleviated.”⁸