Charles Ungerleider, Professor Emeritus, The University of British Columbia
[permission to reproduce granted if authorship is acknowledged]
Society is paying more attention to mental health issues among children and adolescents, making it hard to know whether there is an actual increase in the prevalence of mental health challenges or mainly increased attentiveness. It is probably both.
There has been a significant increase in awareness and understanding of mental health issues in children and adolescents over the last ten years. Society is more open to talking about mental health and it is less stigmatized than in the past. This has likely led to higher rates of diagnosis and greater willingness to disclose adverse mental health conditions.
Some of the increase in mental health challenges faced by children and youth are likely the consequence of changes in family structures, community relationships, and even the nature of childhood itself. Greater academic pressures on children and adolescents, bullying and cyberbullying, increased use of technology, and the impact of social media also play a part.
Increased screen time and exposure to social media can lead to feelings of inadequacy, anxiety, and depression. Cyberbullying is a major problem. Sleep deprivation due to excessive screen plays a part for some.
The pandemic has had a significant impact. Factors such as fear of the virus, disruptions to education, isolation from peers due to social distancing and school closures, and witnessing parental stress or other household difficulties no doubt had a negative impact on mental health.
The increased prevalence of mental health issues in children and adolescents is in part due to better recognition and diagnosis, but it is also clear that sociocultural, technological, environmental factors have contributed to its increase.
Mental health issues among children and adolescents vary widely, but certain conditions are more prevalent. Anxiety disorders are among the most common mental health issues affecting children and adolescents. The estimate is that generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias account for about a quarter of the challenges faced by school-age children and youth.
Depressive disorders account for another estimated 10-15%, although this figure may underrepresent the true proportion because diagnosing depression in young people is hard. Inattention, hyperactivity, or impulsivity are referred to attention-deficit/hyperactivity disorder (ADHD). ADHD affects slightly less than 10% of children aged 2-17 in the United States. Conduct disorder and oppositional defiant disorder account for another 3-5%. Eating disorders affect about 2-3% of adolescents, mostly adolescent women. Autism Spectrum Disorder (ASD) accounts for 1-2% with the prevalence appearing to increase in recent years due to improved recognition and changing diagnostic criteria. Substance use disorders account for an estimated 15-20% typically among secondary school students.
These are broad estimates largely based on US data and many children and adolescents who are diagnosed with one disorder might also be diagnosed with another.
Schools have come to play a role in recognizing and addressing mental health issues given the significant amount of time children and adolescents spend there. However, the capacity of schools to effectively address these issues varies widely depending on resources, training, and policies.
Schools can play a crucial role in early identification and intervention with students who manifest anxiety and depressive disorders. Counselors and psychologists in schools can provide initial assessment and intervention and can refer students to external services when necessary and available. Some provinces have implemented mental health education in their curriculum to promote awareness and provide coping strategies. But the reality is that not all schools have the resources to adequately provide these services, a situation that is made more difficult because there is often a shortage of trained school-based mental health professionals.
Schools are often involved in the identification and management of ADHD through individualized education plans, which provide accommodations to help students succeed. However, teacher and staff training in recognizing and managing ADHD can vary widely.
Schools are usually the first to notice behavioral disorders given their disruptive nature. However, managing these disorders can be challenging and may require a combination of special education services, behavioral intervention plans, and collaboration with external mental health professionals.
Eating disorders might be less visible within a school setting unless they are severe. But schools can play a role in promoting healthy body image and eating habits, and school nurses – where they still exist - or health programs can help with early identification.
Schools provide special education services for students with Autism to help meet their unique needs. These might include speech-language therapy, social skills training, and other interventions. However, the quality and availability of these services vary widely.
Schools can offer support for students dealing with trauma through counseling and other mental health services. Some schools have started to implement trauma-informed care approaches that recognize and respond to the signs of trauma. However, these services and approaches are not universally available or implemented.
Schools can help prevent substance abuse through education. Some schools have established policies and resources to support students struggling with substance use, but students who abuse often require specialized treatment beyond what schools can provide.
A key challenge is the gap between the number of students who need mental health services and the availability of resources. This includes the lack of sufficient trained staff, funding, and comprehensive school-based mental health programs. Stigma about mental illness can prevent students from seeking help, and privacy concerns can make the communication among schools, families, and external mental health providers complicated.
It is important to recognize that schools are primarily educational institutions and not a substitute for professional mental health services. While they can provide support for the mental health of students, collaboration with families and community mental health services is necessary to provide comprehensive care.
There is a considerable amount of evidence supporting the value of providing mental health services in schools. Many students who might not otherwise receive mental health services can access them in the school setting. Early identification and intervention can help prevent the escalation of mental health problems.
Based on the accumulated evidence and expert consensus, the best practices for providing mental health services in schools include a multitiered system of supports. This includes universal prevention programs for all students, focused interventions for those at risk, and intensive services for students with significant mental health challenges. School Mental Health Ontario is leading such an approach.
Schools should employ professionals with special preparation for providing mental health services such as school nurses, school psychologists, social workers, and counselors. Such personnel are qualified to provide individual and group counseling, crisis intervention, mental health assessments, and referrals to community mental health services when needed.
Schools can partner with community mental health providers to deliver more intensive services in the school setting, helping to overcome barriers to access like transportation or stigma. But, if we expect schools to provide mental health services, staff need training in recognizing the signs of mental health issues, strategies for managing them in the classroom, and have an established process for referring students for mental health services.
Incorporating mental health education into the curriculum can improve awareness, reduce stigma, and give students strategies for managing their own mental health. Increasingly schools are providing instruction in emotional regulation, stress management, and forming and maintaining healthy relationships.
Families play an important role in supporting students' mental health. Schools should involve families in planning and delivering mental health services and should also provide resources to help families support their children's mental health. But they will need preparation and resources for doing so. If schools provide mental health services, the services provided should be sensitive to the cultural and linguistic needs of students and families.
Instead of an exclusive emphasis on addressing mental health issues when they arise, schools should focus on promoting overall well-being and resilience. This should include fostering a positive school climate, promoting social-emotional learning, and providing opportunities for physical activity and creative expression. In an earlier blog I lamented the loss of school-based nurses. Were they reinstated, nurses could be very helpful in early identification of the broad ranges of mental health issues.
School mental
health is a rapidly evolving field. Best practices continue to be refined based
on research and experience. The challenge remains in ensuring these best
practices are widely adopted and adequately resourced, and that there is policy
support, professional development, and funding to ensure all students get the
mental health services they need.