A formerly bright and promising student gradually loses interest in favorite activities, withdraws from friends and family, and becomes alternately irritable or sullen. Without help, the student's condition worsens and, in extreme instances, ends in tragedy. The National Institute of Mental Health reports that approximately 4 percent of adolescents get seriously depressed each year. Finding ways to help students deal with depression is a problem all too common at secondary schools nationwide.
Researchers who study depression know that it can affect anyone. "My daughter's descent happened very quickly," says Morton Sherman, the superintendent of Cherry Hill Public Schools in Cherry Hill, N.J. "It was over the course of her sophomore and junior year, probably only nine or 10 months. She went from being one person to [being] someone who would not return phone calls, could not stay awake, and who would get frightened walking down the hall." At one point, his daughter even tried unsuccessfully to take her own life. Her story is all the more compelling because she was already undergoing treatment for depression at the time of her suicide attempt. "She was already in therapy," Sherman adds. "We were warned that something like this might happen, and yet it happened anyway." Sherman's story is not unique. Suicide is the third leading cause of death among high school and college students, according to the American Federation for Suicide Prevention. For students between 10 and 14 years of age, the number of suicides increased 100 percent between 1980 and 1996. In some studies, 20 percent of adolescents have said they've thought about suicide at one time or another.
Many schools have adopted policies and initiatives aimed at intervening on behalf of depressed students and preventing teen suicide. Even so, educators are often confused about the roles schools should play when it comes to student mental health. Inadequate facilities and liability fears make addressing depression and mental health issues particularly challenging.
"It's pretty safe to assume that it's rare that a school has the mental health resources to deal with all the problems it faces," says Sharon Hoover Stephan, the director of research and analysis at the Center for School Mental Health Analysis and Action in Baltimore, Md. "What schools can do varies by their jurisdiction or program. Every district has different policies."
Renewed Importance
Highly publicized school shootings in the 1980s and 1990s led to significant changes in the ways schools address mental health issues, but many still find the subject difficult to address. "Schools are academic facilities, not mental health facilities," says Jennifer DiStefano, a student assistance coordinator with the Cherry Hill School District. "But schools also have an obligation to act in loco parentis to deal with the situations that arise, and that means having to do the best [you] can within the school when there are problems."
According to DiStefano and others, school counselors often learn about students who may be depressed from teachers, parents, or student peers. Sometimes depressed students themselves contact a counselor. "We follow the same process in each instance," DiStefano says. The counselor usually conducts a preliminary evaluation to determine the nature and scope of possible problems. The evaluation can include testing of the student, discussions with teachers, and observations in and out of the classroom.
Determining whether a student is depressed is extremely complicated. Drops in grades, for instance, are only one possible indication. "The things that you really want to be watching for are any changes in behavior," says Carl E. Paternite, professor of psychology at the Runs Center for School-based Mental Health Programs in Oxford, Ohio. Normally attentive and meticulous students, for instance, may begin turning in sloppy work and unfinished exams, or they may miss some assignments altogether. Frequent absences, tardiness, or inattention could be additional signs of problems, as could sudden outbursts from a normally well-behaved student or withdrawal by a formerly participative one. "These are the things you need to be watching for," Paternite adds. "You need to be looking for changes from the ordinary, but you also need to be alert to be looking for the changes. That's what's important."
As a rule, school officials notify parents once counselors begin an evaluation. Experts say that many parents initially resist school depression interventions. "From research, we know that labels do influence people in terms of what they expect from and how they treat children who are diagnosed as depressed," says Dawn Anderson-Butcher, associate professor of psychology at the Ohio State University. "Parents are very much afraid of having their child labeled because of the stigma that continues to surround mental illness."
It is important for school personnel to try to overcome that resistance, mental health authorities say, because parents play a critical role in helping their children deal with depression. "It is critical and essential to involve the family," Sherman says. "We don't do anything without involving the family at every step."
A Question of Responsibility
Given the high stakes, you would expect schools to readily embrace practices and policies aimed at addressing mental health issues, intervention, and prevention. The reality, however, is that the situation is so fraught with complexity that school officials sometimes hesitate to act—for many reasons.
"The people on the front line are the classroom teachers, and they're often not equipped or prepared to handle these kinds of issues," Paternite explains. "For most educators, [mental health issues] are as mysterious to them as they are to the general public." Further, he notes, step-by-step procedures for dealing with such situations can vary from school to school, resulting in inconsistent approaches even within states.
Confidentiality is another issue. "Within the mental health area, you're talking about something that's linked to the medical field, and there are very strict guidelines regarding the disclosure of information," Paternite says. "Within the educational field, you still have confidentiality, but the standards are different." For example, officials might normally exchange e-mails to coordinate meetings regarding students' progress. "In the mental health environment, those kinds of conversations wouldn't happen that way because there are very strict guidelines regarding whom you can or can't communicate with," says Paternite.
On top of these concerns, many school officials worry that becoming too involved with students' mental health puts the school and its officials in a double-bind: They can be damned for what they do and equally damned if they do not do enough.
"There is a lot of concern about identifying students as having a mental illness," says Stephan. "It sometimes becomes a question of over-identification versus under-identification." If a school fails to identify students experiencing mental health problems, for example, the results could be disastrous. "If a school identifies a kid as being suicidal but doesn't have the resources to deal with the issue or is unable to handle the situation promptly enough and something happens, some people might try to argue that the school should be considered responsible," Stephan says. That fear, however, could lead some school officials to over-identify students in a well-intentioned effort to err on the side of caution. "When that happens, you can have kids who aren't depressed getting labeled as being depressed," Stephan adds. The school then faces the wrath of parents concerned about the effect such a designation will have on their child's future, leaving school officials in what is essentially a no-win situation.
A New Emphasis
Recent federal legislation designed to improve learning has actually renewed the focus on mental health in school systems. The results, according to sources, have been both positive and negative.
"One result of efforts to implement NCLB and the recently reauthorized Individuals with Disabilities Education and Intervention Act . . . has been a focus on addressing conditions that promote academic achievement," Paternite points out. "In this regard, it is well-documented that mental health issues are often the biggest barriers to student achievement."
Others, however, point out that recent legislation has not been without some negative effects as well. "No Child Left Behind has had some unfortunate consequences," says Robert Burke, assistant professor of education at Miami University in Oxford, Ohio. "Many feel that so much attention is now being paid to test scores that matters related to social-emotional development have largely been marginalized to the point where they are not even being discussed."
This crowding-out effect, Burke and others feel, makes it all the more difficult for schools to deal with setting up programs designed to address mental health issues because so little time is left for anything unrelated to test preparation and adequate yearly progress showings. "We're having a lot of difficulty getting into the schools now because too much time is being devoted to raising test scores," says Karen Weston, assistant director at the Center for the Advancement of Mental Health Practices in Schools at the University of Missouri-Columbia in Columbia, Mo. "Inservices are now focusing purely on the academic—reading, writing, and mathematics."
The irony is that available evidence strongly suggests positive mental health leads to higher academic achievement. "Increasingly, schools are recognizing that mental health supports are on an equal footing—or should be—with the supports we give schools for other reasons and needs," says Ted Feinberg, assistant executive director for the National Association of School Psychologists in Bethesda, Md. "Mental health is linked with general health and success in the classroom, and the more we can keep kids healthy, the more productive they will be," he adds.
To address this, some school systems have organized mental health task forces to deal with students' problems and to help improve the climate in their schools. "We've put together a number of programs in our system," says Sherman, the Cherry Hill superintendent. "We've instituted policies dealing with suicide issues and ideation [the discussion or expression of suicidal thoughts or intentions], and at each of our high schools we've also created Yellow Ribbon Clubs." The clubs, organized nationwide, help students focus on the needs of peers and classmates and encourage students to report warning signs. Other programs, such as Teen Screen, help educators analyze students' answers on two specialized set of questions to determine whether cause for concern exists. Other school systems have also begun incorporating mental health into their schools' health curricula to raise awareness among both teachers and students of the importance of mental health issues.
The results have been dramatic. "We've had a couple of hundred parents indicate that they were concerned about their children after some of these steps [were taken]," says Sherman. "They indicated that some of these kids did need support or referral for professional care, and they got it."
A New Outlook
Despite the addition of new programs and policies, however, many sources say that progress in dealing with mental health will continue to be limited until people learn to let go of the stigma that still surrounds the issue. "I really don't think things will change that much until there's a societal and cultural recognition of this problem," says Burke. "Too often, mental health remains an issue that is to be avoided, ignored, or swept under the rug. That has to change."
Sherman and others agree. "My daughter is now 22," he says. "She has to live with her depression; it's an illness that can be treated. She goes out and talks to high school groups regularly. Her message is really quite simple: No matter who you are or where you are, you're not alone. Help is out there."
