About one in five children in the United States shows signs of a mental health disorder — anything from ADHD to eating disorders to suicide.
And yet, as we've been reporting this month, many schools aren't prepared to work with these students. Often, there's been too little training in recognizing the problems, the staff who are trained are overworked, and there just isn't enough money.
When there are enough people to handle the job, how should all the different roles fit together?
Many experts point to one model. It's got a bureaucratic name — the "multi-tiered system of supports" — but when you picture it, just imagine an upside-down pyramid, or maybe a funnel. It starts with support for everyone and moves on to more and more specialized help.
Here, everyone in the school has a part to play. The collective mission is broad: Create a school environment of general well-being, and a climate where mental health isn't stigmatized.
It takes a lot of planning — with big decisions often coming from the top. Just ask Amanda Aiken.
She is now the Senior Director of Schools at New Orleans College Prep, a charter school network. But before that she was a principal at one of their schools, Lawrence D. Crocker College Prep.
In that role, she made a point to stand outside her New Orleans school every morning. When the buses drove in, she was at each door. Other staff were stationed at the front and back entrances.
Every student, from preschool to eighth grade, shook at least two hands before they even get inside the building.
Every student, every day?
Sometimes, Aiken conceded, it was a hug rather than a handshake.
"They hear a lot of good-mornings and a lot of how-are-you-doings," says Aiken. "I require that human touch."
Now her successor carries on that tradition.
But Aiken wasn't just being nice. It was strategic.
Many students at Crocker, part of a charter school network, have a higher risk for mental health problems. Most students receive free or reduced-price lunches, and Aiken estimates as many as 70 percent have experienced some form of trauma in the last two years: violence in their neighborhoods, family troubles, the daily stress of living in poverty.
"We need to make sure what we're doing is not retraumatizing," she says. "I see the principal as the leader in setting the tone and the culture of how school will support students and families."
That starts in the morning, but extends far beyond. Crocker is a "trauma-informed" school, which means all staff are trained on how to work with, and identify, students who have gone through trauma.
It also means they have a focus on structure, so students know what to expect. They also have a social-emotional curriculum, yoga after school and a focus on keeping suspension rates low through restorative justice.
"They aren't going to be prepared for college if they're suffering," Aiken says.
As principal, she tried to prevent crises, rather than addressing them as they come up.
"If you have everyone trained and take an 'it takes a village' approach, you can do a lot of preventative measures to reduce the risk significantly," says Aiken.
But, she adds, a healthy school environment isn't enough.
"Teachers are trained to teach. We have all taken a child psychology class, but we're not trained to work with kids with mental health needs," she says.
That's where other professionals come in.
The First Responders
When a student does show signs of trouble, one of the first steps is to talk with them. That conversation will dictate what happens next, but getting students to open up? It's easier said than done.
School social worker Ana Bonilla-Galdamez is a pro at that. Her office at Charles Barrett Elementary School in Alexandria, Va., is a testament to the different strategies she uses to unleash the gift of gab in even the most guarded of students.
There's a lot going on in there. First, there's her bookshelf, with titles like: Growing Good Kids, The Special Education Treatment Planner, Small Group Counseling.
And then there's everything else. She has a lot of board games: Candyland, Operation and her favorite, Uno. She also has art supplies, balls, a dollhouse and a sand box. A Superman doll sits in her chair, because even Superman has a weakness.
These are her tools. They help students open up, and they also help build the skills those kids will need throughout life, like managing emotions.
Although now at an elementary school, Bonilla-Galdamez spent most of her 20-year career at the high school level, working largely in what she describes as "crisis mode."
"We would think, 'Man, if we just had met this kid before,' " she says. A few years ago, a job opened up in the elementary school and she decided to apply.
"I thought, this is my chance to see where this starts," she says.
Early intervention for the child — and education for the parent — is key, she says. That's where the games in her office and the phone calls home come in.
"My job is to dig," she says, "For me to do that, I need to build the trust of the parent and the child."
She tells the story of the time a young mom came in, worried about her kindergarten son. He had been telling her he wanted to die. In her office, Bonilla-Galdamez let the boy choose whatever game he wanted. As he grew comfortable, she asked him about life at home.
"He had witnessed people being killed," she says. "He had witnessed a lot of violence."
What to do next all depends on what that child needs. That kindergartner might have ended up in a small group, working on coping skills or managing his emotions. But, in this case that wasn't the answer: She had also learned that the young boy had run out into traffic when he was upset.
"The threat was imminent, so I referred him to emergency services," says Bonilla-Galdamez. "Our environment isn't suited to clinical interventions."
At that point, Bonilla-Galdamez continued working with the family, but she also helped them connect to more specialized help, and the kindergartner moved on to the third level for more support.
At this level, a doctor or therapist may get involved for the first time. Often, school plays a vital role in connecting the student to a clinic.
Vital, but not necessarily easy. When school psychologists Monique Leopold and Danielle Palmer refer students to a mental health clinic, they know that a lot of the time, the appointment never happens.
The two women have a handful of high-quality programs that they rely on for referrals near their schools — a network of public charter schools in the nation's capital called DC Prep. Sometimes though, families can't get an appointment for months. And when they do, with so many living in poverty, getting there is one more complication in already chaotic lives.
"It's not that [those families] don't love their kids, it's that they don't have the capacity," says Palmer.
And even when the students do get professional treatment or medication, sometimes prescriptions lapse before the child could be seen again.
"Triggers are brought from the community into school," says Leopold, "They go to school without what they need."
To try and meet those needs, DC Prep started a partnership with Children's National Health System. Now, a psychiatrist visits the schools once or twice each month.
"I told a family this morning, 'Listen, we have a doctor here,' " Leopold says, "and the mom's eyes lit up."
Lisa Cullins, one of those psychiatrists who visits, says school is a logical place for students to get clinical mental health care.
"At school, they're going to be there anyway. It's something they do everyday," she says. The partnership isn't just easy on families. It's also easier on her.
"To know our patients, we have to know their school setting," she says. "When I walk in, I have a comprehensive packet of information on how the child has been doing since the beginning of the year." Copyright 2019 NPR. To see more, visit https://www.npr.org.