Prioritizing Mental Health and Trauma Supports in Schools

One public school teacher talks with a BMC psychiatrist on how to support kids struggling with chronic absenteeism and mental health issues.
A young black girl is looking at and speaking to a school guidance counselor.
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As a veteran teacher in the Boston Public Schools, I have learned to prioritize listening to students as a way of building trusting relationships. Since the pandemic, the middle schoolers I serve have increasingly shared their worries about violence, both at school and in the streets, as well as their pervasive feelings of worry and sorrow about everything from their assignments to their friendship and crushes to their separation from family members (often due to immigration and, at times, incarceration) to inexplicable yet consuming sensations of discomfort and stress. Some students have stopped coming to school on most days all together, popping up perhaps once or twice a week or arriving two or more hours into the school day.

Statistics about Boston Public Schools (BPS) indicate that middle and high school students’  feelings of sadness and hopelessness increased by 9% between 2019 and 2021, compared to 5% nationally. Middle schoolers have climbing rates of suicidality, with more than a quarter reporting that they have seriously considered suicide. Additionally, incidents of youth violence and high rates of chronic absenteeism present significant challenges to educational achievement in BPS.

Nationally, the COVID-19 pandemic has caused tremendous drops in academic achievement in K-12 schools and has had troubling effects on the mental wellness of students. Youth face accelerating rates of anxiety, depression, and loneliness, and homicide rates among children and teenagers soared during the first year of the pandemic.

While sifting through data about student mental health certainly validates my serious concerns from my students’ well-being, it provides neither an understanding of the particular causes of these struggles nor a way to support students in feeling more comfortable and secure. In order to better understand these issues, I interviewed Christine Crawford, MD, MPH, an adult, child, and adolescent psychiatrist at Boston Medical Center (BMC) who has been actively involved in community outreach through organizations including the National Association for the Advancement of Colored People (NAACP) and the National Alliance for Mental Illness (NAMI).

Jennifer Dines: Why are children struggling so much in school?

Christine Crawford, MD, MPH: Kids aren't doing well in school academically because they're distracted by what may be happening at home, what's happening in their communities, and what's happening in the world.

They're also distracted by the school environment itself; seeing other kids who are experiencing distress, seeing the adults in the school who are stressed to the max and don't have adequate tools or strategies for how to cope in the classroom.

We need supports in place to ensure that kids have the tools and strategies that they need to cope, such that when there is an acute stressor [such as a violent incident] that does happen, it will be devastating, but not to the point where it's impossible for kids to be resilient and able to move forward.

JD: More specifically, can we talk about middle schoolers? Why are middle schoolers in particular showing such alarming rates of suicidality, even compared to high schoolers?

CC:  When we see middle school kids who are experiencing really intense emotions, they're experiencing a lot of social and academic pressures really for the first time ever. So, they don't have that experience of going through it, surviving it, and seeing that, "Oh, stress is something terrible, but then I can get through it." High school students actually have a little bit of that under their belt.

But with middle school, when you're experiencing all of these hormones, intense emotions, pressures and stressors for the first time, and you don't have the tools and skills and strategies to cope, it's not a good situation.

JD: BPS reported chronic absenteeism at 42% in 2022, compared to 25% in 2019. It’s very challenging for students to access curriculum when they miss so many days, not to mention just getting them back into the rules and routines of school when they return. Why are so many students now missing so much school?

CC: For kids who experience a significant anxiety, they're preoccupied by worries about what could potentially happen. There’s so much uncertainty in the world we're living in that they'll wake up in the morning and say, "I have a stomachache. I have a headache. Can I stay home from school? I don't feel well." The parents are often left trying to figure out what to do. As a parent, you want to take care of your kid and you don't want your kid to suffer.

Then it starts to snowball. There's this slippery slope effect where the kid now has identified [staying home] as a strategy that's effective for them: avoiding the thing that's causing a lot of stress. Once your kid is really relying heavily on engaging in this avoidant behavior, it puts parents in a difficult position —they could be trying their best and their kid still isn't going in. School avoidance, secondary to anxiety, is one of the most challenging things that comes up as a child psychiatrist.

With have kids experiencing significant depression or ongoing anxiety, this may be also secondary to learning-related issues. That’s another thing that can contribute to missed days in school. Kids experience low self-esteem because they're not academically where they should be or not performing at the same level as their peers. They want to be like everyone else. They don't want to be behind. They don't want to be in an environment in which they don't feel good. They think: "I can't do this stuff."

JD: Chronic absenteeism has such devastating impact on academic achievement, literacy, and graduation. How can schools most effectively address this issue?

CC:  We need to think about what self-care looks like and how to make it accessible for all. To teach teachers, to teach our parents, to teach our kids: What is it that you need to do to take care of yourself? How is it that you can listen to your body and thoughts and allow them to be a signal to indicate you need to engage in some of these measures?

We also need to reframe the way in which we think about self-care, so that it isn't associated with these negative connotations, but it's more like, "Good for you. You're able to be so attuned to yourself that now is the time to pause." Or, "You're so in touch with yourself and your feelings. Wow. Kudos to you. Amazing. Strong work."

People get really caught up on the outcomes. Like, "Oh, they're not going to do well on their MCAS." "Oh, they're not going to graduate in on time." But we're not caught up in what the kids' experience really is. If we're so focused on thinking about outcomes and stats and data, we're not meeting the kids where they're at. If they don't even want to wake up the next day, if they don't even want to be alive, it really doesn't matter whether they graduate. If they feel so overwhelmed and preoccupied by all these anxious thoughts, it really doesn't matter about having a conversation with them about how they're not going to graduate and get a good job.