Mental Health Goes to School Mental Health Goes To School

Note: This episode discusses mental health crises and mentions suicide. If you or a loved one are experiencing thoughts of suicide, know that you are not alone and help is available. You can call or text “988” - the National Crisis/Suicide Hotline. They are available 24 hours a day, 7 days a week.

Dr. Shivana Naidoo is a child and adolescent psychiatrist with a broad range of experience working in various settings including inpatient, outpatient, emergency, partial treatment, and private practice both virtually and in person. She joins Jo-Ann and Candida to discuss communication when a child or teen (or anyone) is in a difficult mental health situation or crisis in a school or healthcare setting.

Dr. Naidoo emphasized that parents and teens are empowered in most situations to ask questions, to get more information from other sources, and to not agree to anything that doesn’t seem right. She acknowledges that the available care options vary depending on where you live - state by state, county by county as well as the type of place you live in such as rural, suburban, or urban settings. However, in general, there are protocols for schools and hospitals to follow when a student of any age presents behavior or symptoms that indicate the need for further evaluation. If there is a situation at home in which parents/caregivers may question whether to inform the school, the risks of survival and health of the child should be considered.

Unless it is a medical or psychiatric emergency, avoiding the emergency room is best, if at all possible. Most hospital emergency rooms are not well suited to dealing with mental health situations or crises, especially for children and teens. If that is the best or only option at the time, and if you can choose which hospital to go to, an academic medical center or larger hospital will often provide the most resources. If a school has reached out to you about your child needing to go to the emergency room, Dr. Naidoo explains that, when possible, the parent/guardian should first make phone calls to the child’s pediatrician and mental health providers to get more information and consider if there are options besides emergency rooms, such as Mobile Crisis Teams.

Dr. Naidoo advises that once the child is being evaluated in an emergency room or other acute care setting, the caregivers ask questions and write down the names and responses. This ensures that the information will not be lost and often encourages hospital personnel to be more attuned to the patient and parent/caregiver. If there is a decision being made between hospital admission or discharge to home a parent/caregiver can take several steps to ensure that, if the child is discharged, they will have appointments as soon as possible with the appropriate providers (therapist, psychiatrist, pediatrician). If the parent/caregiver can assure the hospital staff that the home setting is safe, that information will be included in the decision making about whether a child goes home or is admitted.

 In terms of home safety planning Dr. Naidoo recommends using the GOSECURE acronym to remove or secure hazards in the home and make a safety plan:

Guns
Overdose options
Sharps
Electric cords
Car keys
Underage drinking
Reattempt [likely to be the same method]
Exits/Entrance [elopement]

The best decisions about how to help a child experiencing a mental health crisis will grow out of honest conversations with everyone on the team - the child, parent/caregivers, outpatient treatment providers, and hospital staff. School personnel are also often involved, especially if the crisis occurred at school. Communication between all of these parties is essential for successfully navigating these difficult situations. 

Resources

Do Better MD - Dr. Naidoo’s website

Bradley REACH - virtual partial hospital program

Orchid Exchange - online therapy and support groups

American Academy of Child and Adolescent Psychiatry

Youth Risk Be

E12: Lori Krinsky: NAMI - You Are Not Alone

Lori Krinksy joins Candida and Jo-Ann to discuss her involvement with NAMI (National Alliance on Mental Illness). Lori is her local chapter's president (volunteer) and walks us through NAMI’s national, state, and local programs and resources. NAMI is volunteer-driven, with some paid staff at the national and state levels. The 600 local chapters, while connected to the national organization, are run by volunteers and thus vary in program offerings and availability of resources. 

Lori tells us how NAMI was founded in the 1970s by a group of parents of young adults with mental illness who connected in a waiting room and realized that accessing mental health care was too complicated and often overwhelming. They wanted to help others avoid some of the frustrations and pitfalls and to help others know they were not alone. Unfortunately the mental health system is still extremely difficult to navigate, as Lori learned when she helped a family member with mental health challenges. Lori determined when she could see the light at the end of the tunnel she would work to help others on this journey.

The three main prongs of NAMI’s work are support, education, and advocacy. Support includes connections to peers for individuals living with mental illness, peer connections for family members, and basics for caregivers of minors. There is a helpline (not a crisis line) to help connect to local resources and providers. Education includes sharing accurate information about mental illness across many settings, educating about mental health care systems and how to navigate them, training first responders, and working with schools to eliminate stigma around mental illness. NAMI is also active in advocacy at all levels, including working to get the 988 suicide and crisis hotline up and running, supporting reimbursement of telehealth appointments, and promoting structural supports in schools, among others. This list is incomplete. Refer to the list below for links to NAMI resources.  

Timely Notice
NAMI Central Middlesex MA “College and Your Mental Health” webinar
3/18/24, 7:00 pm ET, will not be recorded
Learn more and register: namicentralmiddlesex.org/newsletter/february-2024/college-and-your-mental-health

NAMI National
nami.org
800-950-NAMI (6264)


NAMI Help Line and Teen & Young Adult Help Line
Call 1-800-950-NAMI (6264), Text 62640, Chat nami.org/help, M-F 10:00-10:00 ET

NAMI Teen & Young Adult Resource Directory
nami.org/NAMI/media/NAMI-Media/Images/FactSheets/NAMI-Teen-and-Young-Adult-HelpLine-Resource-Directory.pdf

NAMI Mental Health College Guide
Collegeguide.nami.org

NAMI Family to Family
https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Family-to-Family

NAMI Peer-to-Peer
https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Peer-to-Peer

NAMI Basics
https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Basics

NAMI In Our Own Voice
https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-In-Our-Own-Voice

NAMI Walks
https://www.namiwalks.org

988 Suicide & Crisis Lifeline
https://988lifeline.org

NAMI Ending the Silence
https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Ending-the-Silence

Local Programs
To find programs in your area search for your NAMI state organization which may connect you to a local NAMI affiliate. Programs for parents/guardians include: Family Support Groups, Family to Family Classes, Basics Class. For classrooms: Ending the Silence.

NAMI Central Middlesex MA “College and Your Mental Health” webinar
3/18/24, 7:00 pm ET, will not be recorded
Learn more and register: namicentralmiddlesex.org/newsletter/february-2024/college-and-your-mental-health


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In Part 2 of the conversation with Dr. Jacqui Springer, Assistant Dean for Student Support and Advocacy Services at the University of Rhode Island, we focus on the transition to college and learning what supports are available and what students and families should consider when applying to college.

The most important thing is for students to have honest conversations with providers, teachers, and caregivers. The biggest error is wishful, magical thinking that it will all work out, without considering what supports students are currently using and are key to their success in high school. 

Questions to ask and concerns to think about before applying to colleges include:
Which aspects of student support have been the most valuable to the student in high school? The most common accommodation from high school Individual Education Plans (IEPs ) is 50% extended time for exams and some assignments. These accommodations don’t transfer automatically from high school- the student must re-apply at the college level. 
College accommodations may look much different than those in high school. Many students are shocked to learn that flexibility around deadlines and due dates for assignments is not as commonly available at the college level.
What are residence requirements? Are there opportunities for first-year students to have single rooms in dormitories or will the student be required to have a roommate unless medical documentation says they need a single? What challenges will the student face in living with a roommate?
What support may be needed outside the classroom? Can the student independently function in non-academic ways - including taking care of their health and well-being?
What documentation is needed that the student does not currently have? Some schools require recent psychological or neuropsychological testing before they will provide accommodations.
What is offered through campus health services such as psychiatry and therapy? What model of counseling is used?
Find the disability and access services: locate the office and learn how accommodations are provided.
A question that is not asked as much as it used to be is what does it mean to be “otherwise qualified”? In addition to academic skills, students need adequate mental stamina, persistence, and self-regulation to manage demands at the college level. 
What impact will the student have on the campus community?

The cost of college education is high and in addition to the standard tuition, room & board, and other fees, students and families should consider other possible costs such as:
Tutoring
More time to complete a degree by taking a manageable class load may end up costing more
Recognizing trouble early because refunds may not be available after a cutoff date
Implications of dropping or withdrawing from courses may include limits on the availability of future financial aid or even having federal aid taken back from the student.
Federal aid information is often buried in the financial aid section of the school’s website

Other factors that should be considered

Type of school: urban, rural, suburban; small, medium, large; typical class sizes; residence requirements; private or state; the range of majors available in the student’s areas of interest
Location: near home or far away; city or self-contained campus; near activities that students can participate in
Readiness to live independently


REFERENCES


University of Rhode Island
https://www.uri.edu/

FAFSA
https://studentaid.gov/h/apply-for-aid/fafsa

Pell Grants
https://studentaid.gov/understand-aid/types/grants/pell



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Candida and Jo-Ann talk with Dr. Jacqui Springer, Assistant Dean for Student Support and Advocacy Services at the University of Rhode Island. Our discussion focuses on the transition back to school from hospitalization or partial hospitalization for mental health treatment.

In most cases, the need for a higher level of care for a student does not come as a surprise - there is usually some sort of buildup. There may or may not be a precipitating event, but educators and school staff observe that the student is struggling more than usual.

Dr. Springer reviews some considerations that can help the school and caregivers prepare even before hospitalization is needed. One key question to ask is ” What would it look like to have a higher level of care? What would it mean for school”? Other information to have would be who is the person or office within the school or district that is holding the information to help make a plan moving forward. Who can help the caregivers and navigate the systems to allow communication between the school and the hospital?

One of the difficulties with the hospital-to-school transition is that at the time of hospital discharge, while the patient/student may no longer meet medical criteria for hospitalization, they may not be ready to return to school, at least full time and/or full demand One way schools can help with the gray area is to have a multi-disciplinary team that focuses on student transition back to school. Most schools will have some students who are hospitalized or transitioning back to school at any given time. While it may not be easy to keep such a team due to the many demands on educators’ and administrators’ time and energy, a planful approach to this situation could help students, caregivers, and school staff in the long run.

Dr. Springer pointed us to the BIRCh (Behavioral Health Integrated Services for Children) Project, based at UMass- Boston, UMass - Amherst, and Boston Children’s Hospital. The project is evidence-based and offers graduate-level training opportunities as well as training for educators.

The BIRCh Project
https://www.umb.edu/birch/about/

University of Rhode Island
https://www.uri.edu/

American Academy of Child and Adolescent Psychiatry
https://www.aacap.org/

UMass Boston
https://www.umb.edu/

Boston Children's Hospital
https://www.childrenshospital.org/

UMass Amherst
https://www.umass.edu/

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In this episode Jo-Ann and Candida spin off from our last interview about school avoidance, digging a little deeper into the high rates of chronic absenteeism being seen across the country since COVID-19. Public discussions have tended to focus on this problem as one of kids and families falling into bad habits since the pandemic. In our experience and reading we have found that there are numerous reasons for students to be chronically absent and that solving this problem will need a broader perspective and a focus on understanding unmet needs.

Jo-Ann and Candida spend some time discussing the need for schools to respond to extended absences with curiosity and increased communication, rather than an impersonal, punitive letter or demands from the school or district. Offering a non-judgmental space in which families feel comfortable talking about what’s going on is a big first step. Of course, families need to stay in touch with the school, and encouraging that is part of a more welcoming approach by the school.

The discussion covers a range of mental and physical health needs that might lead a student to be out of school for a long time including anxiety, ADHD, and depression. Social challenges, including bullying, are frequent reasons that students don’t want to go to school. Physical illnesses, including things such as gastrointestinal distress, are commonly seen in children and teens and can be embarrassing for them. Understanding students’ needs and providing accommodations and modifications are essential in these situations.

Academic struggles and teacher/student communication challenges can be central reasons children avoid school. Trying to catch up after being out sick is a common jumping-off point for school avoidance. Modifying or off-loading missed work is a common modification that can make a world of difference in getting students back - along with welcoming them, without calling them out for their absence.

The discussion recalls prior interviews - including those in which we talked about how hungry, tired, scared, angry, or hurting children can’t learn. Ensuring these needs are met is essential to helping students get back to school regularly. The discussions in several episodes focused on helping children, teens, and adults increase their emotional literacy and skills for regulation to improve feelings of safety and emotional well-being at school. 

Other critical barriers to school attendance can include a parent’s illness or other struggles, challenges in financial and/or housing resources, absent or inconsistent school transportation, lack of access to laundry facilities, and many other social determinants of health significantly increase the risks of chronic school absenteeism. While districts all over the country are trying to create ways to help children address some of these needs, many of these problems can’t be solved at school. However, a curious approach to children and families struggling with attendance can help uncover unmet needs and can change the whole approach from punishment to support.

School Avoidance Alliance

Lauri DeSautelis Revelations in Education

Washington Post - Students who miss school get help, not punishment 

Providing laundry machines at school to combat absenteeism


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School refusal or avoidance is a real problem that is not the same as not liking school. Some students miss school for weeks, months, or even entire academic years. The reasons students avoid or refuse to attend school are rooted in anxiety and are not just a desire to do something else. It’s not playing hooky.

Jayne Demsky started her journey with school refusal when it became a problem for her son. As she learned and traveled this path, she was determined that other parents and students shouldn’t have to feel alone or that they were bad people. The resources and connections that she has developed over the past decade are now available on her website School Avoidance Alliance. 

One of the difficulties in addressing school refusal is that the anxiety signals leading up to a crisis typically happen at home and frequently aren’t recognized by caregivers or educators. Communication between the home and school is crucial to preventing an avoidance pattern from becoming a crisis. 

Our conversation briefly touches on the challenges of chronic absenteeism, which has increased since the pandemic. We reference an article that describes ongoing research into defining and solving the problem of chronic absenteeism. Their data, which is still evolving, suggests that family engagement with schools correlates with improved attendance, and this overlaps with the need for school and family engagement in addressing school avoidance.

While acknowledging the severity of staffing shortages, Jayne reviews some key ways that schools can help caregivers connect with appropriate staff and resources. She also advocates for mental health education from the earliest grades so that students can better understand how their mental health is connected to their overall health and how they can use skills to help self-regulate and to know when they should seek help.


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