Vivek H. Murthy

U.S. Surgeon General Vivek H. Murthy tours King/Drew Magnet High School of Medicine and Science in Los Angeles, California on Dec. 6, 2021, before talking to a panel of students about mental health issues. (Carolyn Cole/Los Angeles Times/TNS)

LOS ANGELES -- When U.S. Surgeon General Vivek H. Murthy issued a public health advisory this month on protecting youth mental health, he brought attention to the widespread challenges facing today's young people. But he also emphasized that these challenges are surmountable — and often preventable.

One of his recommendations, as part of what he calls a "whole-of-society" effort to mitigate the pandemic's corrosive effects on mental health, is to support students' mental health in schools.

What kind of support systems do students have there? What can parents rely on school counselors to handle, and when does an issue become something that requires extra assistance? Debra Duardo, the superintendent of schools for Los Angeles County; Loretta Whitson, executive director of the California Assn. of School Counselors; and staff from the Santa Ana Unified School District explain.

How does it all work?

Schools have a combination of counselors, social workers, psychologists and nurses who work together as a mental health team on campus, Duardo said.

The team's No. 1 priority is making sure students can learn. This includes identifying and removing (or at least reducing) any barriers that are preventing a child from receiving or absorbing instruction.

But it's important to understand that all school employees are trained in how to identify distress in children, Duardo said.

"Because sometimes children won't go to a counselor," she said. "Maybe the first person they're going to talk to is their teacher or custodian, someone else that they connect with."

If a parent is concerned, Duardo recommends talking to the teacher first. "They spend so much time with the children in their classroom that they can see when something is off and a child is behaving differently than they typically do."

The teacher will know what resources are available at the school and be able to refer parents to the appropriate person.

Here are the main roles on campus

Duties may vary — and blur together — depending on the school and district. Middle and high schools tend to have more support than elementary schools, but that gap is narrowing.

School counselors 

There are many different types of school counselors.

Some are academic or college counselors who help students set up classes and plan for the future. There are also attendance counselors, who try to figure out why some kids aren't showing up in school. And there are counselors who are more clinically oriented. They may work in campus wellness centers and give short-term care to students struggling with depression, anxiety or other mental health challenges.

Counselors can also provide support for parents and caretakers. Sometimes a parent needs advice on how to deal with a kid who refuses to attend school. Sometimes students need help communicating something that they're scared to tell their parents — for example, if a student is pregnant or HIV-positive.

"You can't help a child without addressing the parent," Duardo  said.

School psychologists 

Though one might assume psychologists are the ones providing therapy at schools — and they can be — school psychologists are usually the ones working with students with special needs. They help special education teachers develop individualized education plans and monitor progress.

School social workers 

The role of school social workers can vary as well. They are trained in counseling and crisis intervention. They could also be working to help with a child's living situation, assisting kids with disabilities or developing trauma-informed programs.

School nurses 

Though nurses deal with physical ailments, these symptoms can often be tied to mental health. If children are getting sick because they aren't sleeping enough or eating enough, this could be a sign of a mental health issue.

The goal is for all these providers to collaborate and understand the fuller picture of what a child's struggles are. Then they can pass the baton — what schools call "warm handoffs" — to the appropriate person at each stage of a student's need.

According to Sonia Llamas, assistant superintendent  at Santa Ana Unified School District, that process starts with the early identification of the problem and continues to intervention and coordination of care and services. And if a student requires hospitalization, the school needs to provide support to help the child's transition back to campus.

What are the limitations of school-based mental health systems? 

School counselors have extremely high caseloads. Though the American School Counselor Assn. recommends a ratio of 250 students per counselor, the national average for the 2019-20 school year was 424 students per counselor. California had a ratio of 601 to 1.

When school counselors have such a high caseload, they're forced to try to identify students' issues very quickly so they can figure which cases they need to prioritize, Duardo said.

Many schools use a framework called Multi-Tiered System of Supports. There are three tiers that correspond to different levels of student need. The majority of kids are in Tier 1, which focuses on prevention. Tier 2 is for kids who require early intervention, which can come in the form of group sessions. And Tier 3 is for kids who need individualized care.

For the most part, schools provide short-term counseling, and if students need extra support, schools refer them to an agency or work with the parents to see what kind of therapy or other assistance is covered by their insurance. Care Solace, for example, works with 300 school districts to help connect families with mental health providers.

What are some of the goals moving forward? 

Schools have been working over the years to offer more assistance to students and caregivers who reach out for help. But they're also trying to do more to head off problems by integrating social and emotional learning lessons into the classroom. This includes teaching kids such fundamental skills as how to make friends, encouraging them to talk about their feelings and showing them the importance of being resilient.

Referring to the pandemic's numerous disruptions, Whitson said: "Kids have been thrown a real hard curve here. What we're working on is trying to help them understand that this is not permanent. And help them cope with it."

One reason schools are advocating for more counselors is because it makes it easier to be proactive in tackling the youth mental health crisis.

Just this year, the Santa And Unified School District successfully met the nationally recommended ratio of 250 students per counselor. This has made a world of difference in counselors being able to build trust with students, said Rebecca Pianta, the district's coordinator of college and career readiness.

There is more time for one-on-one connection, and counselors can build relationships with students — with fun activities in the quad or surveys to learn what topics they are curious about — before they need assistance.

This is especially important in communities where there is stigma associated with asking for help, said Káty Castellanos, the district's director of college and career readiness. Their district serves a majority Latino population.

"Because the mentality is that if you have a problem at home, you don't talk about it, you don't discuss it with anybody," she said. "And if you go to a school counselor and social worker, you're 'crazy.' So we're trying to demystify that."

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