The Behavioral Health and Wellness of Students
It is the position of the National Association of School Nurses (NASN) that student behavioral health and wellness must be prioritized for students to successfully access and engage in educational opportunities. It is imperative that school systems respond to, and address, student behavioral health and wellness to ameliorate disparities related to the social determinants of health (Combe, 2019). School nurses are often the initial access point to identify concerns, determine interventions, and link families to school and/or community resources.
BACKGROUND AND RATIONALE
Behavioral health is defined by the promotion of mental health, resilience and wellbeing; treatment of disorders; and support of individuals and families who experience these disorders. Families and community partners are crucial in the effort to address these unmet needs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019).
COVID-19 has highlighted the need for enhanced monitoring of children’s mental health during public health crises (Leeb et al., 2020). The length of loneliness and social isolation imposed by disease mitigation measures can predict later mental health problems for up to nine years post-event (Loades et al., 2020). A population health perspective examines multiple determinants of health outcomes such as access to healthcare, public health interventions, social and physical environment, genetics, and individual behavior (Kindig & Stoddart, 2003). Applying a population health perspective will be critical to determine the actual effects of the pandemic in the absence or presence of other known risk factors that impact mental health (Boden et al., 2021).
A myriad of family, community, and environmental factors that often begin in childhood affect mental health, wellness, and access to care (Kaushik et al., 2016). Age, poverty, living in a rural area, a shortage of providers, an increased distance to services, and lack of transportation are frequently identified as causes of inadequate treatment for behavioral health concerns including anxiety, depression, and behavior problems (Ghandour et al., 2019). These problems are prevalent among US children with significant disparities in treatment. In the US, 13% to 20% of children, especially ages 12-17, have a mental, emotional, or behavioral disorder. Behavioral/conduct problems affect more than twice the number of boys as girls ages 6 – 11. Overall, children who are in poor health have a higher prevalence of each of these disorders (Ghandour et al., 2019). The school nurse is in a unique position to identify and assist students in obtaining appropriate referral and access to community resources.
Adverse Childhood Experiences (ACES) include physical, emotional, and sexual abuse as well as other childhood traumatic experiences. ACES are known to have negative and prolonged effects on children’s mental health (Larson et al., 2017). Multiple studies show a risk of mental health disorders and academic failure when children are exposed to trauma. Students at poverty level and from minority racial/ ethnic groups have amplified exposure to trauma, yet these same students have reduced access to mental health services (Larson et al., 2017). Twenty-two percent of children living below the federal poverty level have a mental, behavioral, and/or developmental disorder (CDC, 2020a).
According to the CDC, “mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day” (2020a). The percentage of children diagnosed with mental health disorders has increased, with 49.5% of adolescents having some form of mental health disorder and 22% experiencing severe impairment (National Institute of Mental Health [NIMH], 2020). The CDC reports that ADHD, behavior problems, anxiety, and depression are the most commonly diagnosed childhood disorders.
- 9.4% of children aged 2-17 years have received an ADHD diagnosis.
- 7.4% of children aged 3-17 years have a diagnosed behavior problem.
- 7.1% of children aged 3-17 years have diagnosed anxiety.
- 3.2% of children aged 3-17 years have diagnosed depression (CDC, 2020a).
Suicide is the second leading cause of death in youth age 10-24 (Curtain & Heron, 2019). Data obtained from United States students in grades 9-12 from the CDC 2019 Youth Risk Behavior Surveillance Survey (YRBS) reveals:
- 37% of adolescents persistently felt sad or hopeless to a point where they did not engage in normal activities,
- 18.8% of students reported having seriously considered suicide, and
- 8.9% reported having attempted suicide (CDC, 2020b).
School nurses are frequently the first to identify and address behavioral health concerns and connect students and families with systems of support. The National Academies (2019) determined programs that include children, families and the community have a greater influence on positive health outcomes, especially when dealing with those from lower socioeconomic status. Positive child experiences (PCE) can offset the effects of ACES (Bethel et al., 2019). School nurse referral options to support student needs include comprehensive school mental health systems as well as primary care providers, mental health specialists, telemedicine, and school-based health centers (National Center for School Mental Health, 2019; CDC, 2018).
The Framework for 21st Century School Nursing Practice™(NASN, 2016) is aligned with the Whole School, Whole Community, Whole Child model (CDC, 2014). School nurses apply these practice components to address social, mental, and physical health concerns at the individual student and population level. Given the early onset of emotional, mental health and substance use disorders and their subsequent costs, investments in prevention and early intervention programs are necessary (Starkey, 2019). Proactive school nursing practice encompasses the principles of community and public health nursing. School nurse services address access to care, cultural competency, health education, health equity, outreach, risk reduction, social determinants of health, and surveillance (NASN, 2020).
Student behavioral and mental wellness is essential for students to be healthy, safe, and ready to learn. The incidence of behavioral health concerns is on the rise and negatively impacts educational achievement (Rosvall, 2020). The school nurse is the bridge between health and education in the school setting, promoting positive behavioral health and using assessment skills to identify children at risk for behavioral health needs. School nurses, in collaboration with the interdisciplinary education team, provide critical links to prevention, early identification, intervention, and referral for behavioral/mental health concerns (Ramirez, 2018).
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Rosvall, Per-Åke (2020). Perspectives of students with mental health problems on improving the school environment and practice. Education Inquiry, 11(3), 159-174. https://doi.org/10.1080/20004508.2019.1687394
Starkey, S. (2019). Legislation would improve mental health services in schools. The Capitol Connector. https://www.thenationalcouncil.org/capitol-connector/2019/04/legislation-would-improve-mental-health-services-in-schools/
Substance Abuse and Mental Health Services Administration (SAMHSA). (2019, May 1). Behavioral health integration https://www.samhsa.gov/sites/default/files/samhsa-behavioral-health-integration.pdf
Andrea Ferguson, RN, CSN
Cindy Begley, BSN, RN, NCSN
Kimberly Bartholomew, BSN, RN, BA, CSN
MaryAnn Strawhacker, MPH, BSN, RN, SEN
Julie Hudson, MSN, RN, NCSN
Adopted: June 2017, Revised August 2018
Revised: June 2021
Suggested citation: National Association of School Nurses. (2021). The Behavioral Health and Wellness of Students [Position Statement]. Silver Spring, MD: Author.
“To optimize student health, safety and learning, it is the position of the National Association of School Nurses that a professional registered school nurse is present in every school all day, every day.”
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.