Mental Health and Academic Achievement: Role of School Nurses

Written By: Sam Savage

Published Date: October 14, 2007 Last Edited: October 14, 2007

By Puskar, Kathryn Rose Bernardo, Lisa Marie

PURPOSE. This article discusses how school nurses promote mental health and subsequent academic achievement by screening and referral for children demonstrating mental health problems. Nursing interventions are discussed at the individual, systems, and community levels. CONCLUSION. Mental health problems can affect school performance and academic achievement. When mental health problems are not recognized, students may be unable to reach their academic potential. School nurses are in a key position to provide interventions to address mental health and academic achievement.

PRACTICE IMPLICATIONS. The role of school nurses and examples of mental health collaborative activities are provided.

Search terms: Mental health care, mental health screening, school health nursing

First received October 17, 2006; Revision received December 18, 2006; Accepted for publication February 11, 2007.

During the 2004 State of the Union Address, President George W. Bush stated: “We expect third graders to read and do math at the third grade level-and that’s not asking too much” (2004). Is it too much to ask? The immediate answer that springs to mind is “no.” The more realistic answer may be “that depends.” It depends on the barriers students face to improve their academic achievement and the resources in place to assist students in overcoming those barriers.

Schools have more influence on the lives of young people than any other social institution except the family and provide a setting in which friendship networks develop, socialization occurs, and norms that govern behavior are developed and reinforced . . . Because healthy children learn better than children with health problems, schools also have an interest in addressing the health needs of students. Although schools alone cannot be expected to address the health and related social problems of youth, they can provide, through their climate and curriculum, a focal point for efforts to reduce health-risk behaviors and improve the health status of youth (U.S. Department of Health and Human Services [U.S. DHHS], Centers for Disease Control and Prevention and Health Resources and Services Administration, Issues and Trends, paragraph 7, 2000).

The Current Status of Mental Health in Schools: A Policy and Practice Analysis from the Center for Mental Health in Schools at UCLA (2006) contends that a school’s mission and mental health concerns usually overlap. To help a student that is not doing well, the factors interfering with the student’s progress must be addressed.

The literature has revealed that mental health certainly links with academic achievement (DeSocio & Hootman, 2004; Hootman, Houck, & King, 2002; Lamb, Puskar, Sereika, Patterson, & Kaufmann, 2003; Opie, & Slater, 1988; Puskar, Sereika, & Haller, 2003). Adelman and Taylor (2000) advocate for the use of school-based mental health programs to assist youth. In fact, several researchers have indicated in their studies that school nurses have the potential to provide mental health support in schools through a variety of prevention programs (DeSocio, Stember, & Schrinsky, 2006; Puskar, Lamb, & Norton, 1990; Puskar, Sereika, & Tusaie-Mumford, 2003). It is recommended that the missions of schools be broad to include screening, providing clinical services, and connecting community health providers to schools. Enhancing children’s mental health in schools is promising through partnerships among schools, the community, and the home (School Mental Health Project-UCLA, 2005).

Academic achievement can be improved through early detection of mental health problems, timely referral, and access to appropriate services (New Freedom Commission on Mental Health, 2003). School nurses, pediatric nurses, and education professionals are crucial in identifying students with mental health problems, collaborating to facilitate students’ enrollment in services, and evaluating the students’ health and academic outcomes. Thus, an interdisciplinary team of school and pediatric nurses, mental health professionals, administrators, teachers, counselors, and community health professionals can work together to promote mental health and subsequent academic achievement.

Purpose

The purpose of this article is to discuss how school nurses promote mental health and subsequent academic achievement by the screening and referral of children who demonstrate mental health problems. Nursing interventions are discussed at the individual, systems, and community levels.

Mental Health and Academic Achievement

Approximately one in five children and adolescents has a diagnosable mental health disorder in the course of a year. Five percent have impairment in functioning that is extreme (U.S. DHHS, Office of the Surgeon General, 1999). Therefore, 20% of students may have undiagnosed mental health problems that cause difficulty with academic work. Examples of such difficulties include the inability to concentrate in class, attend school on a regular basis, participate in group discussions and activities, or engage in cognitive, psychomotor, and affective learning tasks. Some signs of school behaviors related to poor academic achievement and possible mental health symptoms are poor grades and poor class participation, which are possibly due to low self-esteem, attention deficits, or depressed mood, just to name a few. Mental health symptoms assessed need referral to the student assistance program team for further evaluation.

School Mental Health Services in the United States, 2002-2003 (U.S. DHHS, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2006) was the first national survey of mental health services of approximately 83,000 schools in the United States. Seventy-three percent of the schools reported social, interpersonal, and family problems as the most frequently reported mental health problems. Other findings included (a) one fifth of students, on average, received some type of school-supported mental health services; (b) school nurses spent approximately one third of their time providing mental health services; and (c) 49% of the school districts used contracts or formal agreements with communitybased individuals and organizations to provide mental health services to students. School nurses constituted 68% of those identified as providing mental health services in schools.

In the Current Status of Mental Health in Schools: A Policy and Practice Analysis (2006), the Center for Mental Health in Schools at UCLA states that children and adolescents with mental health and psychosocial problems needing assistance can be more than half of a school’s enrollment. School staff who address this need have been given various titles such as student support staff, pupil personnel professionals, and specialists. School staff may work in programs such as learning support or comprehensive student support systems.

Role of School Nurses

School nurses integrate mental health skills in their everyday interactions with students and refer to the student assistance team as needed. Through their academic preparation and experience, school nurses are sufficiently prepared to initiate and refer for mental health services. Their knowledge, skills, and abilities enable them to recognize mental health issues and recommend appropriate referral and follow-up. Such screening and referring to promote students’ mental health is within the scope of school nursing practice and follows the objectives set forth by Healthy People 2010 (U.S. DHHS, 2000).

When school nurses screen for mental health problems and make referrals to the student assistance team and other agencies, they maximize students’ academic achievement through individual-focused, systems-focused, and community-focused nursing practice. Creative use of time and resources will facilitate ways for school nurses to practice at these levels. A mental health and academic achievement focus can be the goal in professional development and continuing education at the systems- and community-focused nursing practice level to compensate for time constraints on the job.

Individual-Focused Nursing Practice

Individual-focused practice is changing the knowledge, attitudes, beliefs, practices, and behaviors of individuals (Minnesota Department of Health, Section of Public Health Nursing, 2001). For mental health and academic achievement, school nurses can become involved in screening, collaborating, consulting, casemanaging, referring, and conducting health programs. Resources are constrained in many school districts, making the nurse’s gatekeeping role critical in detecting student health problems on an individual level; however, the nurse’s time is precious and needs to be utilized efficiently to detect students’ mental health needs.

The individual-focused nursing practice is the primary level for the school nurse. School nurses are prepared to do thorough verbal assessments with a mental health focus, and consult and refer for further diagnosis and treatment by an advanced practice nurse or mental health specialist. School nurses are well prepared to provide health promotion interventions in a group or individual setting. It is beyond the scope of this paper and role to detail the diagnosis or treatment for students having mental health problems. School nurses are excellent advocates for early intervention for mental health problems in order to optimize academic success; and their recommendations are respected by the education team and families. Severity of symptoms can be screened verbally with assessment guidelines categorized under safety to self and others. School nurses should prioritize mental health problems; certainly suicide ideation is a priority and requires immediate intervention. The school nurse does not diagnose mental health problems; rather, the school nurse makes a nursing diagnosis related to mental health issues.

The ABC approach provides a general screening framework that can be used in every interaction (Fortinash & Holoday-Worret, 1991). A is the assessment of the student’s appearance. For example, are they neat and clean or dirty and disheveled? B is the assessment of their behavior. Are they calm or hyperactive? C is for conversation. Do they communicate with rapid or slow speech, rational or irrational comments? The outcome of the next part of the basic screening will depend on the trust the student has with the nurse’s role or the individual nurse.

When engaging a student in conversation, the school nurse can specifically ask about his or her (a) eating, (b) sleeping, and (c) outlook, but the responses will vary based on the student’s ability to trust. Use simple direct questions such as, “What did you eat for breakfast, lunch, and dinner yesterday?”, “How is your appetite?”, and “How are you sleeping?”. The outlook question is more complex; broad, open-ended questions are the best. Asking “How do you think school is going for you?” allows the student to guide the assessment process. If the student replies “OK,” the school nurse can then ask about his or her grades and attendance. The responses reflect the student’s outlook, which may include family, social, or academic problems. Asking the student, with a depressive affect, specific questions like “Do you ever feel sad, how sad do you get?” and “Do you ever feel like hurting yourself or others?” encourages deeper responses.

Poor nutrition, insomnia, hopelessness, and suicidal or homicidal ideation are examples of need for immediate referral, based on severity and safety. In general, as a triage screening function, the nurse consults and refers immediately and then follows in a case manager capacity. In less severe cases, the school nurse will use clinical judgment on how many times to provide therapeutic listening before consulting, calling parents, and referring the student to mental health specialists. A conservative rule of thumb could be three visits of minor severity and then refer to specialists for an evaluation. Due to the complexity of ways to conceptualize mental health problems, it is best to prioritize using the student’s expressed thoughts and behaviors that affect safety, family, social, or academic functioning. Diagnoses are made by the specialists and are used for understanding the use of medications and different treatment modalities. The school nurse can support the use of medication by administering and evaluating the effectiveness of the medications along with reporting observed side effects.

Risks and benefits of school nurses intervening in regard to mental health are far reaching. The benefits are obvious if nurses can prevent students from inflicting violence to themselves or to others. Improvement in the student’s ability to achieve academic success by improving mental health is the goal. Other less obvious benefits include the student’s perception of the nurse’s help. The student may feel safe and valued by the nurse’s care and emulate this in identification by becoming a healthcare professional. One risk is when the nurse does not refer early enough and a student hurts him- or herself or another person. On the other hand, if the nurse refers too soon, he or she may lose the trust of the student.

School nurses conduct state-mandated health screenings, such as height and weight. Vision, hearing, and scoliosis are also screened to document individual and school trends in these parameters. During these screenings, school nurses identify students with physical risks or problems. Upon further investigation, the nurse may learn that these students have poor academic achievement related to their health condition. Mandated screenings provide an opportunity to be alert to mental health needs and maximize time. For example, if students cannot see the blackboard or hear the teacher, their learning may be impaired. In contrast, students may have normal hearing and vision but due to anxiety or attention deficit do not stay on task.

Through early assessment, school nurses are attuned to students’ needs. They are then able to provide early intervention to help students, parents, and teachers address mental health issues to promote academic success. For example, students with weight problems, such as very low or very high body mass index, may have low self-esteem, which may prevent them from participating in physical education. They may be embarrassed to change clothes in front of other students or unable to perform assigned exercises and physical activities. These students may be receiving failing grades due to their lack of participation or absences. Similarly, these students may present weekly to the school nurse with vague complaints before or during physical education classes.

On any given day, school nurses assess, treat, and refer a proportion of the school population. According to Schneider, Friedman, and Fisher (1995), approximately 25% of students present to the school nurse’s office for headache, 17% for infection (generally a sore throat or “cold”), 12% for dizziness or tiredness, 12% for stomachache, and 30% for other medical complaints. Students indicated that “not sleeping well” and “stress,” which are psychosocial symptoms, were the two most common factors that played a role in visits to the school health office. Other common factors included “poor eating,” depression, school problems, and problems with a boyfriend or girlfriend, all of which have mental health implications.

Visits to the school health office for somatic complaints, such as headache, dizziness, tiredness, or stomachache, may be motivated by psychological problems or may be markers for underlying psychosocial stressors. Furthermore, these symptoms may occur prior to a class that the student does not want to attend. This reluctance to attend class may be due to a variety of reasons. For example, a student who does not perform well in a mathematics class may have a stomachache or headache prior to an examination to be given in this class.

School nurses care for students with ongoing health needs, including chronic illnesses such as cancer, diabetes mellitus, and asthma. All of these chronic diseases may have a mental health component that can help or hinder adaptation. For example, a diabetic child may deny the need to control his or her diet and to take insulin. In this population, school nurses must be particularly adept at assessing physical health from mental health needs during health office visits and when reviewing their academic achievements.

For example, one school nurse told us that a student presented to her for urinary incontinence. The student was also found to have emotional issues related to her history of cancer and treatment. The school nurse referred this student to the student assistance program team. The student was later placed in an alternative school as a way of meeting her physical, emotional, and academic needs.

The school nurse uses empathetic listening skills to uncover the student’s feelings related to the symptoms. In another example, a female student was sent to the school nurse with a complaint of dizziness. The student reported that she was being harassed by another female peer and wanted to avoid her in the next class, which she confessed was her reason to visit the nurse. The school nurse provided the student time and support to explore problem-solving options. The student declined the nurse’s offer to meet with her and the peer to attempt conflict resolution with the nurse’s support. After talking with the school nurse, the student demonstrated a renewed strength to return to class. She chose to ignore the female peer, with the knowledge she could later request a meeting with this girl and the nurse if things did not improve.

School nurses are familiar with students’ patterns of health office visits. They know which teachers are administering examinations and when students should be excused from a class. The school nurse differentiates between physiological illnesses and mental health problems, both of which contribute to academic barriers. Based on the assessment, the nurse intervenes by (a) treating the physical symptoms, (b) exploring with the student his or her life situation, and (c) collaborating with the school team targeted for providing academic and mental health support. The outcome may be offering the student a referral for physical and mental health care, along with academic counseling, as needed.

In another example, one student met with the school nurse and expressed stress over her parents’ divorce and her mother’s increased need to work. The guidance counselor was consulted. She was aware of the situation, and she was appreciative of being informed of the child’s current thoughts and feelings. The mother was called by the guidance counselor and was surprised about her child’s concerns. The mother was grateful for the information. This student was already in an educational support network. Collaboration was done with the support teacher to further enhance educational planning around this current situation.

School nurses synthesize their education and experience to differentiate between physical and mental health needs in their students. An example of a behavioral intervention for physical illnesses is the one developed by Grey (2004) to teach youth to cope with diabetes. Nurses are well aware of the relationship between physical health, mental health, and learning. Equipped with this knowledge, school nurses collaborate with teachers and counselors to refer students to the appropriate resources to promote mental health and academic achievement. Knowing that the school nurse is available to assess students, intervene, and follow up in a timely manner is crucial for the ongoing health of any given school. The school nurse contacts students’ families, as needed, and serves as a liaison between the student, family, school, and community. Health and learning are interrelated, and school nurses know that students learn best when they have optimal health. When school nurses conduct screenings and provide episodic care, they are constantly alert to changes in students’ health that may impact their learning. Other examples of individual-focused practice are school-based programs conducted by nurses to improve coping skills called Teaching Kids to Cope (TKCe) (Puskar, 2000) and Teaching Kids to Cope with Anger (TKC- A) (Puskar et al., 2006) which are school-based behavioral interventions that offer health promotion to youth through education about coping methods. Outcomes were measured by changes in the scores on the Reynolds Adolescent Depression Scale (Reynolds, 1987) and the Coping Response Inventory (Moos, 1993) administered preintervention, postintervention, at 6 months, and at 12 months. Puskar, Sereika, and Tusaie-Mumford (2003), in a randomized controlled trial, found that the TKC intervention lowered depressive symptomatology and increased coping strategies in adolescents.

Screening interviews were performed by nurses to identify the need for referral of any student having high depressive symptoms. Results showed improvement in depressive symptomatology and coping skills. Students in the intervention group reported a higher use of cognitive problem-solving coping skills (Puskar, Sereika, & Tusaie- Mumford, 2003). Other schools have requested that the TKC or TKC-A program be implemented at their location.

Systems-Focused Nursing Practice

Systems-focused practice includes changing organizations, policies, laws, and power structures (Minnesota Department of Health, Section of Public Health Nursing, 2001). For mental health and academic achievement promotion, school nurses have the potential to become involved in policy development and policy enforcement. One example is the participation of school nurses in school-based mental health services (SBMHS). SBMHS increase the accessibility of mental health care for both healthy and impaired students. Students are more likely to utilize SBMHS than clinicbased mental health services (Adelman & Taylor, 1999). The need for school-based mental health programs is increasingly acknowledged across different sectors for what these programs can do for school-age students and adolescents in terms of cost effectiveness and mental health care accessibility. SBMHS include surveillance, screening, case management, health teaching, counseling, consultation, and collaboration.

Community-Focused Nursing Practice

Community-focused practice includes changing community norms, attitudes, practices, and behaviors (Minnesota Department of Health, Section of Public Health Nursing, 2001). The community may be at an international, national, or local level. School nurses can become involved in developing community education programs on obesity, drug use, or depression to promote mental health and increase academic achievement. School nurses also can work with the parent-teacher organization to assess needs and goals.

At the national/international level, the International Alliance for Child and Adolescent Mental Health and Schools (INTERCAMHS) validates the belief that mental health and schools are important (School Mental Health Project-UCLA, 2003). This international network of agencies and individuals (including educationalists, mental health, and other professionals) has more than 200 members representing 22 countries. Their mission is to promote the international exchange of ideas and experiences related to student health. INTERCAMHS believes that addressing mental health issues in schools is important to ensure the continued well-being of school communities. School nurses can use the programs in INTERCAMHS as well as be a member.

Another example of community-focused practice is the Keep Your Children Safe and Secure (KySS) program (Melnyk et al., 2001; Melnyk, Brown, Jones, Kreipe, & Novak, 2003). KySS was started in 2001 by the National Association of Pediatric Nurse Practitioners (National Association of Pediatric Nurse Practitioners, 2007). KySS began its campaign with a national survey of children, teens, parents, and practitioners to assess the needs and knowledge deficits related to preventing and reducing mental health and psychosocial comorbidities in children and teens. KySS aims to decrease stigma and raise public awareness of the increase in mental health problems. Armed with the knowledge obtained from these surveys, KySS will advocate for continuing education, health promotion, development of interventions, and increasing public awareness. School nurses are encouraged to become involved in KySS and its activities for professional development and improving public awareness about mental health for children and teens (Melnyk et al., 2001, 2003; National Association of Pediatric Nurse Practitioners, 2007).

Conclusion

To succeed in improving academic achievement, schools are recommended to have efforts focused on not only improving learning but also the psychosocial issues that impact upon learning. School nurses promote mental health and academic achievement through teaching, screening, and collaborating with pediatric and psychiatric specialist nurses, teachers, counselors, and families at the individual, systems, and community levels. School nurses can advocate on behalf of students to support mental health to facilitate academic success. Students demonstrating mental health problems and academic problems need to be referred to individualized services. The school nurse’s role supports early detection and treatment of mental health problems with the goal of strengthening children’s abilities to achieve future success as productive, healthy adults.

How Do I Apply This Information to Nursing Practice?

School nurses make a difference in a variety of ways to promote mental health and academic achievement in their school districts. These nurses can work through three levels of health practice: individual, systems, and community. Nurses meet students on an individual basis to screen, teach, and conduct groups to help children and adolescents cope with problems. At the systems level, they can join organizations and lobbv for SBMHS. At the community level, nurses can become involved in developing community education programs, such as drug and alcohol prevention, healthy lifestyle choices, and mental health support. Collaboration, consultation, and case management are interventions used to promote mental health and academic achievement. By addressing the mental health needs of the student, the school and pediatric nurse can assist the student to focus on learning and maximize academic potential.

Acknowledgments. This research was supported by funding from the National Institute of Mental Health (NIH), National Institute of Nursing Research (NINR), ROl NR008440-01. The authors would like to thank Beth Grabiak, MSN, CRNP, and Kirsti M. H. Stark, MSN, APRN- BC, for editorial assistance in manuscript preparation.

. . . 20% of students may have undiagnosed mental health problems that cause difficulty with academic work.

Poor nutrition, insomnia, hopelessness, and suicidal or homicidal ideation are examples of need for immediate referral, based on severity and safety.

School nurses can become involved in developing community education programs on obesity, drug use, or depression to promote mental health and increase academic achievement.

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Kathryn Rose Puskar, DrPH, RN, FAAN, is Professor and Director, Psychiatric CNS Program; and Lisa Marie Bernardo, PhD, MPH, RN, HFI, is Associate Professor, Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA.

Author contact: [email protected], with a copy to the Editor: [email protected]

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