The crisis of student mental health is much vaster than we realize

Photo for Washington Post by Caitlin O’Hara
Organizers with Arizona Students for Mental Health sign a pledge poster to do their part to prevent teen suicide.

The change was gradual. At first, Riana Alexander was always tired. Then she began missing classes. She had been an honors student at her Arizona high school, just outside Phoenix. But last winter, after the isolation of remote learning, then the overload of a full-on return to school, her grades were slipping. She wasn’t eating a lot. She avoided friends.

Her worried mother searched for mental health treatment. Finally, in the spring, a three-day-a-week intensive program for depression helped the teenager steady herself and “want to get better,” Alexander said. Then, as she was finding her way, a girl at her school took her own life. Then a teen elsewhere in the district did the same. Then another.

“It just broke my heart that there were three different people who were going through what I was, and they never got the chance to heal,” said Alexander, 17, now a high school senior.

After that devastating stretch in May, families and classmates in the Chandler Unified School District mourned the three 15-year-olds. They would enjoy no more summer vacations, no birthdays or graduations. The losses ignited a debate about what schools should be doing to support students in despair.

Nationally, adolescent depression and anxiety – already at crisis levels before the pandemic – have surged amid the isolation, disruption and hardship of covid-19. Even as federal coronavirus relief money has helped schools step up their efforts to aid students, they also have come up short. It’s unclear how much money is going to mental health, how long efforts will last or if they truly reach those who struggle most.

“The need is real, the need is dire,” said Alberto Carvalho, superintendent of the Los Angeles Unified School District, who recalled hearing just that day from the district’s mental health partners that calls about suicidal thoughts had quadrupled. “We’re living through historically unprecedented times,” he said.

More than 75 percent of schools surveyed in spring said their teachers and staff have voiced concerns about student depression, anxiety and trauma, according to federal data. Nearly as many schools cited a jump in the number of students seeking mental health services.

But mental health is not the only pandemic priority. Schools are spending vast sums of their coronavirus relief money on ventilation upgrades, expanded summer learning, after-school programs, tutors and academic specialists.

The federal spending plans of 5,000 school districts nationally show that more than one-third intend to bring new mental health professionals into schools, and around 30 percent plan to fund social-emotional learning efforts, according to an analysis by FutureEd, a think tank at Georgetown University’s McCourt School of Public Policy.

“This is an incredible increase in the amount of money being spent and the number of districts pursuing it,” Phyllis Jordan, associate director of FutureEd. But it is still, advocates say, not nearly enough.

In many areas, even when money is in hand, hiring is not easy. As this school year opened, nearly 20 percent of schools reported vacancies in mental health positions, according to federal data. Schools often said they employed too few staff to manage the caseload but also complained about difficulties finding licensed providers, the data showed.

“We simply don’t have enough people in our profession to meet the need,” said Kelsey Theis, president of the Texas Association of School Psychologists. When families seek private therapists, “sometimes there’s a wait list of months and months before they get help,” she said.

In Maine, waiting lists grew so long last year that school counselor Tara Kierstead began looking out of state for therapists who had openings – a solution that was not practical for many families.

“It was the hardest I’ve ever had to work to get resources to people,” Kierstead said. “I know some kids who were never seen.”

Surgeon General Vivek H. Murthy called out the “devastating” effects of the pandemic on youth mental health in a public advisory last December. Earlier that year, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association together declared “a national state of emergency” in children’s mental health. They pointed out that young people of color were especially affected and linked the struggle for racial justice to the worsening crisis.

A year later, this October, they sounded the alarm again. Things are not getting better.

A deepening crisis

Not long after the pandemic started, researchers began to document declines in child and adolescent mental health. The numbers are stark.

Hospital emergency room visits spiked for suspected suicide attempts among girls ages 12 to 17, according to the Centers for Disease Control and Prevention. From February to March 2021, the number jumped by 51 percent compared to the same period during 2019. For boys, the increase was 4 percent. Early research from MIT suggested the suicide rate for people aged 10 to 19 increased in 2020, compared to before the pandemic. More recently, CDC provisional data for 2021 showed an increase in the national rate from 2020 to 2021, especially for people ages 15 to 24.

In other research, the CDC found nearly 45 percent of high school students were so persistently sad or hopeless in 2021 they were unable to engage in regular activities. Almost 1 in 5 seriously considered suicide, and 9 percent of the teenagers surveyed by the CDC tried to take their lives during the previous 12 months. A substantially larger percentage of gay, lesbian, bisexual, other and questioning students reported a suicide attempt

Family upheaval, meanwhile, was widespread, particularly in the early pandemic: Nearly 30 percent of students said an adult in their home had lost a job, and 24 percent said they went hungry for a lack of food.

There are no directly comparable pre-pandemic studies, but Kathleen Ethier, the CDC’s director of the division of adolescent and school health, said student well-being is significantly better for teens who report feeling connected to their schools – a problem for a population that, nationwide, was kept out of them for so long.

“There is 20 years of research showing that it not only has an impact on how young people do while they’re adolescents, but it has 20-year impacts on all kinds of measures of health,” including emotional well-being, suicidality and substance use, she said.

It also left many children grieving. More than 230,000 U.S. students under 18 are believed to be mourning the ultimate loss: the death of a parent or primary caregiver in a pandemic-related loss, according to research by the CDC, Imperial College London, Harvard University, Oxford University and the University of Cape Town. In the United States, children of color were hit the hardest, another study found. It estimated that the loss for Black and Hispanic children was nearly twice the rate of White children.

Too much need, too little help

In Maryland, Julia Horton, 16, recalls that, as her struggles worsened last year, she fell asleep in class a lot and did not turn in work; her grades dropped. Looking back, she said, “it is very obvious it was a cry for help.” Some teachers were compassionate, but others less so. “A lot of teachers talk about understanding mental illness, but they don’t act upon it,” she said.

Her school in suburban Montgomery County had two mental health professionals within its wellness center, county officials said, but Horton – like many students – had no idea. She talked to a counselor she liked about getting more time for assignments but it did not help. Her mother ultimately found her an excellent therapist to help Horton with her depression and anxiety, but she wonders about other teens who may not be as fortunate.

Montgomery County school officials said they inform students about mental health services through community messages, their website, student forums and advisory period lessons – though School Board Member Lynne Harris said messaging should be more robust and focused on platforms students use most.

In Philadelphia, Mikayla Jones, then 15, took care of her father in spring 2020 when he caught covid-19 and she had little contact with teachers and friends during remote learning. She wanted to talk to a therapist, but her mother couldn’t find one with an opening and she’d never heard of any mental health specialist at school. “I feel like this should not be something that’s possible,” she said. Now a 17-year-old senior, Jones is starting a club to advocate for mental health support across Philadelphia’s schools. “All youth deserve someone to be there for them.”

Philadelphia officials said counselors were meeting with students virtually or in person during the pandemic to assess their needs and help decide next steps. Still, the high school senior never found a therapist. The first meeting of her mental health support club is later this month.

Told about the school system’s comment, the teenager said: “If the school does not communicate the availability of counselors, and their role as counselor has been repeatedly labeled as ‘college counselor,’ then how will we know that they are there as a mental health resource?”

Shortages of mental health professionals have been the norm in schools. Professional organizations recommend one school psychologist per 500 students, but the national average is one per 1,160 students, with some states approaching one per 5,000. Similarly, the recommended ratio of one school counselor per 250 students is not widespread. The national average: one per 415 students.

National research from 2019 showed that students of color have not received equal access to school counselors. At that time, 38 states were shortchanging students of color, students from low-income families or both, according to the study done by the Education Trust.

As the pandemic has persisted, students have spoken out – in Nebraska, Arizona, Connecticut, Washington.

In Seattle, students who formed the Seattle Student Union to promote racial justice decided this year to push for mental health supports in schools. Chetan Soni, a 17-year-old who co-founded the union, said there are too few mental health professionals to meet rising student needs. The district told him it doesn’t have the money, he said.

Seattle teachers who went on strike in September included a call for more mental health supports for students as one of their bargaining points. The strike settlement included part-time social workers at most schools – a sign of progress, Soni said, but not enough to help all. “Students are suffering from the pandemic and so many other things too,” he said.

His school, Lincoln High, is fortunate in having a school-based health clinic, run by Neighborcare Health. But just one therapist works there, said Rachel Gordon, the company’s school-based mental health clinical manager. Nearly all therapists based at Seattle’s schools have full caseloads and wait lists, Gordon said. Many run group therapy sessions as a way to serve more students. “We’ve seen increases in anxiety, disordered eating, suicidal ideation, OCD and many other mental health challenges,” she said.

In rural Montana, the squeeze was different: Altacare, a for-profit provider, decided to halt services in the state this year amid recruitment difficulties and funding issues. Districts scrambled to cover for the loss, but many could not, and state officials were limited in what they could do. “Unfortunately they were serving a lot of the very small rural schools that were already struggling,” said Mary Windecker, executive director of the nonprofit Behavioral Health Alliance of Montana.

The shortages meant that Montana kids who needed residential care, for the most serious mental illnesses, were mostly being sent to other states, she said: “Not because we don’t have beds for those children but because we don’t have people to staff those kids,” she said. “Imagine a six-year-old with a serious emotional disturbance being sent as far away as Georgia. That’s happening.”

One result of all these deficiencies: More students are acting out. Last school year, nearly 40 percent of schools nationally reported increases in physical attacks or fights, and roughly 60 percent reported more disruptions in class because of student misconduct, according to federal data. Las Vegas officials reported several alarming attacks on teachers. In Louisiana, dads at a Shreveport school showed up to help keep the peace after a particularly heated week of student fighting.

National test scores also plummeted to levels not seen since 1999, according to recent data – setting off a wave of alarm among educators, many of whom consider the mental health crisis a contributing factor.

Photo for The Washington Post by Caitlin O’Hara
Organizers, including 13-year-old Elle Mramor, center, talk before a vigil.

Scrambling for solutions

School administrators across the country are clear-eyed about students’ worsening mental health, many of them strategizing about school initiatives that may help.

“We know that when kids are mentally well, they’re much more likely to attend school and do well in school,” said Sharon Hoover, co-director of the National Center for School Mental Health.

In Maryland’s Montgomery County, the state’s largest school system has expanded school-based wellness centers that provide mental health services: Five are open, a sixth debuts in January and 19 others are being phased in.

In Georgia, Hawaii and a host of other states, schools rely on telehealth services to help meet the gap. They often involve contractors – such as Hazel Health – that respond to referrals from teachers, school counselors or parents; services are often covered through government funding or payer reimbursements.

Some school systems have adopted student mental health “check-ins” to get a quick read on student well-being. Others created calming rooms for students or found ways to build mindfulness, yoga or meditation into student life.

A growing number of schools now offer therapy. Many have forged partnerships with community providers who treat students in person on campus. Health or wellness centers that are located inside of schools numbered roughly 3,000 before the pandemic.

“School-based health centers fill a void, particularly in low-income communities,” said Robert Boyd, chief executive at the nonprofit School-Based Health Alliance. “In rural communities, sometimes it’s the only provider around.”

More broadly, school systems are expanding social-emotional learning intended to help students understand and regulate their emotions, develop positive relationships and face challenges. These lessons may be embedded in classes (say, a discussion of empathy related to characters in a novel) or they may come directly through an activity about, for instance, decision-making. In some parts of the country, social-emotional teachings are tangled up in the culture wars, particularly when material deals with gender and racial equity.

In California’s Natomas School District, Superintendent Chris Evans brought in an administrator with mental health expertise seven years before the pandemic. Each school already had a psychologist. But as the pandemic began, social workers were hired for each school, too – a decision that no one regretted. “About one in every two of our students,” Evans said, “accessed some form of mental health resource.” Suicide assessments more than doubled last year, to 191, compared to 71 before the pandemic.

A big worry in many areas is what happens when federal aid runs out. The school board in Natomas voted this spring to retain the new hires even after the money is gone, Evans said.

Other efforts flowed from legislation. At least 12 states have adopted some form of “mental health days,” which excuse student absences for mental health purposes. In Illinois, students are now allowed five days per year under a new measure approved by the legislature.

Critics see the excused days off as counterproductive for students who have already missed too much school, but supporters say the laws recognize the stressful reality of many students’ lives and elevate the stature of mental health so that it is comparable to physical health.

Twenty states also require mental health education in schools – which Barb Solish, director of youth and young adult initiatives with the National Alliance on Mental Illness, said will reduce stigma and increase literacy so students recognize symptoms and learn how to get help for themselves or their friends.

Mental health in schools is expected to get a big boost, too, Solish said, from the passage of the Bipartisan Safer Communities Act, which allots more than $1 billion over five years to support school-based mental health services. More than $500 million is slated for a grant program to hire and retain providers in schools, and another $500 million is for building a pipeline of future professionals.

A call to do more

Photo for The Washington Post by Caitlin O’Hara
Riana Alexander, a 17-year-old organizer with Arizona Students for Mental Health, was struggling with her mental health last winter.

Riana Alexander and other students in Chandler, Ariz., showed up at school board meetings for several months, distressed about the string of suicides that left three 15-year-olds dead. At a meeting in June, many of them acknowledged their own mental health difficulties as they pressed the school district to do more.

The father of a teen who took his life joined them, his voice breaking in grief. “I don’t have the answers,” he said. He vowed to work with the students as they seek change and called them brave.

Then his voice stiffened.

“It’s a shame they have to come in here and ask for this,” he said.

Two months later, another teenager took her life. She was 16. School had been open less than three weeks.

“This is a crisis,” Sofia Borczon, a 10th-grader, told the board at another meeting. She’d had mental health struggles for four years, she said, and never felt there were necessary resources. “Kids are dying – and they have been for years.”

She and others – part of Arizona Students for Mental Health, which was founded by Alexander – asked for mental health “first-aid training,” so that everyone would know more about how to help kids in need, and for “student action boards” to elevate mental health concerns at schools. They wanted to lead a town hall meeting, so their peers could be heard too.

Chandler officials told The Washington Post the requests either take time to implement or might conflict with best practices. Eventually, Chandler’s prevention coordinator started to meet with the students, and the school system held a mental health event in October, with speakers and resource information.

Chandler schools spokeswoman Stephanie Ingersoll said the district has suicide prevention training for all teachers and staff, going beyond what is required by the state. At a meeting in August, the school system outlined a list of other initiatives. The district plans to begin teen mental health first aid training, but only for students 15 and older who have parent consent, Ingersoll said, and offers mental health first aid for staff within its training department. “We hope there is an understanding that implementing anything new takes time,” she said in an email.

Alexander said the school system’s recent efforts are a step forward, but lack urgency and are not enough. She and others testified before a state committee on teen mental health.

In September, the students gathered with classmates for a Saturday evening vigil to remember students who died recently by suicide and those who preceded them. It was World Suicide Prevention Day – a month after the most recent Chandler student took her life.

“Mental health is hard,” Alexander told those gathered. “It’s hard to talk about it, it’s hard to struggle with it, it’s hard to open up about it. But struggling in silence isn’t the way and it’s not the answer. There are people out there who have gone through or are currently going through exactly what you are. There are people out there who love you and there are people out there who care about you.”

Photo for The Washington Post by Caitlin O’Hara
Riana Alexander, right, speaks next to Elle Mramor. “Mental health is hard,” Alexander said told those gathered. “It’s hard to talk about it, it’s hard to struggle with it, it’s hard to open up about it.”