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Thursday / September 28.

Dr. Sharon Hoover on How Schools Are Stakeholders in Mental Health Crisis

Mental Health in Schools

Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at​

In May 2015, California students and teachers filed a landmark class-action lawsuit against the Compton Unified School District (CUSD). They argued that students have a basic right to school-based mental health support, and the district didn’t adequately train teachers to help children struggling with trauma. Trauma, said the plaintiffs, is a clear barrier to learning. Peter P., one of the plaintiffs, was a 17-year-old  who attended Dominguez High School in CUSD. He experienced repeated and sustained trauma, including physical and sexual abuse. In March 2015, he was homeless and began sleeping on the high school’s cafeteria roof. The administration’s response was to suspend Peter, telling him not to return or it would involve the police. Mark Rosenbaum, attorney for the plaintiffs and directing attorney at Public Counsel, said it’s akin to the district not providing ramps for children in wheelchairs. He told Susan Ferriss, a reporter for the Center for Public Integrity, “If we had children in wheelchairs, of course, we would say we have to build ramps. These kids need opportunity now. It’s an urgent matter. Trauma needs to be addressed, so these kids have a fighting chance.” He said that instead of asking, “What’s wrong with you?” teachers need to start asking kids, “What happened to you?” Just over four months after the initial filing, the students and teachers won the case, setting a critical precedent and alerting school districts across the nation that they were responsible for addressing their students’ trauma. 

Sharon A. Hoover, Ph.D., Co-Director, National Center for School Mental Health (NCSMH) at the University of Maryland School of Medicine, says the decision in Peter P. v. Compton Unified School District increased understanding in schools about trauma and its impact on learning, and why schools should be trauma-informed. That said, changes don’t happen overnight, and schools are still struggling not only to become trauma-informed but also obtaining sufficient support in implementation. 

Historically, says Dr. Hoover, local school districts have and still often do default to two unfortunate avenues when faced with a child in crisis: discipline or the emergency department. She says taking students out of school for three days and then allowing them to return does nothing to address the root of the crisis, and a trip to the emergency department often results in the child waiting 12 hours or longer to see a clinician, just to be sent home. “In my experience, at least half of the referrals coming into the emergency department are right out of the schools, which makes sense because kids spend at least half of their waking hours there, but emergency departments are not the best setting for positive outcomes.” She says zero-tolerance policies are ineffective and discriminatory, with children of color more likely to be disciplined, creating a school-to-prison pipeline. An incident that garnered intense scrutiny of the zero-tolerance approach was when a principal called the police on Alexa Gonzalez, a 12-year-old in Queens, New York. The offense: Gonzalez wrote on her desk with a green marker, “I love my friends, Abby and Faith. Lex was here. 2/1/10.” She then drew a smiley face. The officer handcuffed Gonzalez and walked her to the local police precinct for doodling. 

In 2008, the American Psychological Association did an evidentiary review of zero-tolerance policies and concluded that instead of reducing the likelihood of disruption, school suspensions do the opposite: predicting higher future rates of misbehavior and suspensions among suspended students. “Students may not be aware that their behavior is a manifestation of an emotional or behavioral issue or trauma history, so that’s not something they are likely to communicate to teachers or administrators.” Dr. Hoover says what perpetuates the cycle is that school administrators and teachers often feel helpless to manage mental health and behavioral health crises. She says discipline is often a measure administrators think they need to take to keep the school building secure but is not an effective way to manage kids’ mental health struggles. While the issue of safety is one often raised in the push and pull of what administrators should do when a child is in crisis, Dr. Hoover notes that getting upstream, before a crisis occurs, is what students and schools need, and states and school districts are catching on to this. Despite some discussion and concerns at the federal level about school-based restorative practices, there is significant momentum in states and school districts in most communities to implement trauma-informed approaches. “They understand that we can’t talk about kids in crisis without discussing schools as part of the equation because it’s where kids spend most of their time other than at home. Instead of turning to a discipline response, many school districts are responding to emotional and behavioral incidents with a restorative response, working to secure attachments, keep kids in schools, and put support around them. This practice not only helps in-the-moment scenarios but makes it much more likely that teachers will be able to identify a crisis in the future.” 

Dr. Hoover says Peter P. v. Compton Unified School District highlighted that school districts need to better support students who have a trauma history, but that training alone isn’t sufficient and, without adequate support, can make teachers feel helpless. “The train on trauma-informed approaches left the station quickly without enough support for implementation. Now many teachers can identify trauma but don’t know what to do with that information.” She says this is where Comprehensive School Mental Health Programs come in, building on critical partnerships between schools and the community, such as mental health centers, hospitals, and universities, and offering students a full continuum of mental health support in schools. Dr. Hoover says that while schools are a vital part of the equation, mental health is a shared responsibility between schools and the mental health sector. In a comprehensive system, the in-school support typically includes the school psychologist, social worker, and counselor. This can vary by the school as some have more counselors or social workers. “Ideally, the school’s efforts are augmented by community mental health partners who are based in the schools.” 

Since 1989, in Baltimore, as a part of the Expanded School Mental Health (ESMH) Network, clinicians from the community have been housed in school buildings and offer a continuum of support during the school day. This is critical, says Dr. Hoover, because kids don’t access care in the traditional community mental health setting. The literature shows that, on average, children will attend roughly three to four sessions, if they go at all. She says this is particularly true in more stressed communities, but even in less stressed communities, kids attend only a small number of sessions. No matter the setting, children across the board aren’t consistently making into community care. By eliminating barriers and bringing treatment to students, children are getting the help they need. “In contrast to community care, mental health professionals in schools are constantly seeing students because, well, they are in the same place as the kids who need them. It also helps to bypass stigma, which often results in families waiting until the child is in crisis by the time they take him or her to community mental health. The benefit of working with children in schools is it helps with early identification and intervention.”

Additionally, while teachers should not be expected to be mental health experts, they are essential first responders to crisis because children are with them for a vast portion of the day. Dr. Hoover says that they can’t just be taught about trauma conceptually but also need to be equipped with tools to help them identify trauma, develop crisis management skills, and ensure that they know how to do a warm handoff to a mental health professional. De-escalation tools in the classroom have started to lean toward collaborative problem-solving (Ross Greene has renamed his model Collaborative and Proactive Solutions (CPS)), allowing teachers to help students before or during a crisis when they have “gone amygdalar,” a term Dr. Hoover uses to describe when children aren’t able to engage their frontal lobe. She says the technique is a way to attend to the crisis while giving a young person choice. “Instead of confronting the child with responses that will ultimately lead to defensiveness and feeling cornered psychologically, it’s a way of taking the situation down a few notches and allowing them to feel more in control. For kids who have a trauma history, it can be incredibly useful.” Dr. Hoover says it’s a mix of distraction and choice, helping kids reconnect to their prefrontal cortex and, by offering options, allow them some autonomy in deciding what to do next. 

Industry disruptors are beginning to take note that school mental health is an untapped space for technology. Simulation platforms like Kognito allow teachers to engage with virtual students experiencing psychological distress. “It’s almost like a choose your own adventure, prompting teachers to respond, and if the teacher doesn’t select the best option, the virtual coach pops up and says, “You might want to try something different because that wouldn’t be the best thing to say to someone who might be in crisis. The teachers really like it.” The problem is that many of these programs are cost-prohibitive. Fortunately, the Substance Abuse and Mental Health Services Administration (SAMHSA) is funding mental health technologies, including developing a training curriculum, that will be in the public domain so that any teacher can access these tools. The National Center for School Mental Health (NCSMH), the Mental Health Technology Transfer Center (MHTTC) Network Coordinating Office at Stanford, and regional center leads are designing the program and plan to launch it in the spring. “It’s an exciting development to see federal funders take such an interest because very often, mental health is siloed out from schools into the community, bifurcating child mental health. To say that they have to wait until 4 pm to have their crisis and mental health distress attended to is absurd.” 

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