Long gone are the days when school nurses were on hand to take a sick child's temperature, bandage a skinned knee or give students with chronic health conditions their medicine.
Also long gone is the time when each school, including elementary schools, had a counselor. As a result, schools and other agencies are scrambling to meet student mental-health needs that have grown more acute with the economic downturn.
The Tuolumne County Office of Education is attempting to secure a $1.2 million federal grant to provide both school counselors and nurses at some schools, while Calaveras County schools have taken a collaborative approach to addressing needs.
Mother Lode school administrators say they can't even recall a time when schools employed their own credentialed nurses working in school offices.
California has one school nurse for every 2,187 students, according to 2009 data from the National Association of School Nurses - a ratio that ranks California 45th in the nation for school nursing.
There are even fewer nurses in some regions. Not including nurses who work with special-education students, Calaveras Unified School District has one school nurse for its entire student body of about 3,300.
Calaveras Unified Superintendent Mark Campbell said the nurse-sharing arrangement between schools would work smoothly if the district could afford to hire a few more nurses.
"The person we have is phenomenal, but severely overworked," he said. "I would love to see additional staffing to support her."
Though the Tuolumne County Office of Education employs two nurses that perform periodic health screenings for students, the day-to-day duties of a school nurse have largely been taken up by school secretaries.
For example, a nurse's office at Sonora Elementary School has been turned into a health supply room where secretaries go to retrieve bandages and other basic items for students.
Sonora Elementary and other schools are able to give emergency medication, such as EpiPen injections, to students with chronic health conditions, according to Tuolumne County Deputy Superintendent of Schools Margie Bulkin.
"All schools have a designated person who's trained to provide that to a student (who) needs it," Bulkin said. "That's not the best scenario, but it's the only scenario we can provide at this time."
The employee tasked with giving emergency medication is often the student's teacher, according to Bulkin. But parents sometimes step up to take responsibility. When Bulkin was working as superintendent of Sonora Elementary, one student's father showed up every day at lunch to give a diabetic student her insulin injection.
Sonora High School is fortunate enough to employ an office assistant who also has a nursing degree, according to Principal Todd Dearden. Still, he is troubled by the lack of a full-time school nurse.
"It's making medical decisions for students when we don't have that kind of a degree," he said. "And so we end up calling parents and even 911 whenever there's a question of an emergency. We always err on the side of caution."
In extreme cases, the absence of school nurses has contributed to tragedy. A Washington student died in 2008 after suffering an asthma attack at an elementary school where no school nurse was available to execute a treatment plan on file. In the ensuing lawsuit, the jury found the school district was negligent but not responsible for her death.
The Tuolumne County Office of Education is seeking a federal grant, $400,000 a year for three years, that would put a full-time school nurse and a full-time counselor in each of three elementary schools. A total of six employees would be hired.
The schools included in the grant are Jamestown Elementary School, Curtis Creek Elementary School and Summerville Elementary School. The Tuolumne County Office of Education should find out this month whether its grant application was approved, Bulkin said.
The presence of both nurses and counselors would create what she calls a "health clinic approach on school sites." Counselors could help identify mental health issues and risky behavior in younger students so they can get further help, she said.
Additionally, they would be present on a daily basis for struggling students who aren't quite in need of need of professional help outside the school.
"We're far better off intervening at younger ages and remedying these emotional needs," Bulkin said.
The shortage of school counselors is almost as dramatic as the gap in nursing services. Just a few counselors in Calaveras and Tuolumne counties are responsible for helping hundreds of students.
Statewide, there is roughly one school counselor for every 945 students. The national average is 477 to one. According to the state Department of Education, this means California has the lowest number of school counselors in the country.
In Calaveras County, psychologists employed by the county Office of Education help fill the gap for districts that can't afford to hire counselors for each school.
But the situation is far from ideal, said Kathryn Eustis, director of Youth Development and Prevention Programs at the Calaveras County Office of Education.
With regional grant money that also applies to Tuolumne County, Eustis's office is helping schools create early intervention strategies for mental health issues.
Bulkin noted that it's especially rare for elementary schools to have counselors. She and several other administrators noted that mental health needs have grown even more acute with the economic downturn.
"When the economy's tough, it affects everyone," said Kerri McCluskey, Sonora Elementary's part-time counselor. "Even kids who don't have alcohol or drugs or violence going on at home, the parents are still stressed about money - and kids pick up on their stress."
McCluskey said she dealt with about eight cases of student self-injury last year, cases where children sought to dull their emotional pain with the physical variety.
A Sonora High School freshman committed suicide at the beginning of the summer, highlighting the need for counselors who can help spot students in trouble before it's too late.
"Sonora, as a community, is extremely high-risk for suicide," Dearden said. "If you look at it historically in our community, it's been a long-time problem. We've trained all our staff on suicide prevention strategies."
With funding from the California Mental Health Services Authority, schools in Calaveras and Tuolumne counties will soon be doing more staff training on the issue of student mental health.
The money will also allow the hiring of part-time counselors who'll work across multiple school districts and help identify troubled students.
"We're going to keep seeking grants to fill this deficiency," Bulkin said. "It's so needed."