Podcast: Promoting Positive Mental Health in K-12 Students

Jeff talks to Dr. Mills Smith-Millman about proven strategies for supporting the mental well-being of students in kindergarten through high school. They discuss mental health training options for school professionals, and Mills answers audience questions about common mental illnesses impacting children and adolescents.

Mills Smith-Millman, PhD, is a staff psychologist with the McLean School Consultation Service, which trains educators and school mental health staff around Massachusetts in the use of scientifically proven mental health interventions. Dr. Smith-Millman specializes in improving the delivery of mental health services to students in K-12 schools.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there and welcome. My name is Jeff Bell. And on behalf of McLean Hospital, I’d like to thank you for your interest in our educational webinar series. Our topic today, Promoting Positive Mental Health in K-12 students.

And over the next hour, we’re going to explore strategies for supporting the mental well-being of students in kindergarten through high school, while also looking at common mental illnesses that can impact children and adolescents. In addition, we’ll share some mental health training options for school professionals.

For all of this and much more, we have lined up an expert in this field. Dr. Mills Smith-Millman is a Staff Psychologist with the McLean School Consultation Service, which trains educators and school mental health staff around Massachusetts in the use of scientifically proven mental health interventions. Mills, thanks so much for making some time for us today.

Mills: Yes. Thank you so much for having me.

Jeff: Well, I’ve really been looking forward to this conversation because it’s such an important one. And I want to start by asking you to help us understand the opportunity that K-12 teachers and other faculty members have to support and promote their students’ mental well-being.

Mills: What a great question, Jeff. And I think that it’s an answer that contains multitudes because I think that this is one of those things where K to 12 educators and staff members, whether they’re administrators, mental health providers, school resource officers, the whole gambit.

They all have an exceptionally large opportunity to have a positive impact on students’ mental health. And not in by being, becoming therapists or anything like that, but rather the weight of having one important person in school is incalculable.

And I think, if everybody on this call today takes one moment to think about an educator or somebody in school setting, whether it was a coach after school or somebody within the school building who impacted their education, you probably can think of at least one person or I hope that you can, right.

And I think for educators striving to be that person for one or more students can go really a long way. And so again, it really is about being able to connect with students, be interested in what’s going on with them, be interested in their interests, can have an enormous effect on a student’s mental health and just feeling of belongingness and school connectedness.

Jeff: We’re obviously talking about teachers today, but who are some of the other key players on campus that can make a difference on this front?

Mills: Truly, I think it’s any educator or educational staff member who’s working with students. And so, I think you certainly see this with education supports, specialists, and professionals, administrators, school resource officers, obviously, also school mental health staff, school psychologists, social workers, adjustment counselors, counselors.

There are many different words that we use to describe student mental health staff. And some schools use sort of different terms for the same thing. It’s kind of different over the course of it. But really anybody who’s directly working with students in a school setting, can I think have a pretty profound impact on the life of a child.

Jeff: Can you give us an example or two just to kind of set the stage for what these interventions, these support projects might look like?

Mills: Sure. And I think it depends based on the school professional working with the student. So, on the teacher level or educator level, like the non-mental health person, right. We’re not asking anybody to do therapy by any means. It’s really about, I think being a validating presence in a student’s life, right.

And so, when I talk about validation, that really is all about this idea of really trying to connect with a student and connect in a way that says, hey, your experience, whether or not I agree with what your behavior is, but your experience of emotion makes sense.

So, you could have a student who, for example, a student in your class who’s having a really difficult time and maybe having some disruptive behaviors. You may not agree with the behavior, like I don’t think it’s great for a kid to walk out of class or be disruptive or what have you.

But you can say to that kid, I understand that you’re angry right now or that you’re feeling really revved up and there’s a lot going on in your body. And that simple sort of instance of validation is an exceptionally potent intervention at the teacher level.

Just being able to really level with someone and say they understand where they’re coming from, can have a very profound impact. And then when we speak, more to like the school mental health professionals, those interventions I think, are many and varied.

And that can look like providing individual counseling to a student to talk about things that are impacting their ability to access the curriculum effectively. Whether that’s behavior or mental health difficulties like depression or anxiety. The interventions would change sort of based on what the behavior is, or the symptom.

Jeff: So, before we drill down too far, I want to ask for some historical perspective here. I know this is your expertise, your field. What does the trend line look like over the years? Are we talking more about these issues today than we were 10, 15, 20 years ago?

Mills: Yes. Overall, I think definitely, yes. I think we’re talking a lot more about it and part of the reason we’re talking more about it, is because mental health in kids and I think adults as well, has worsened over the past 10 or 20 years.

I was just recently reviewing the Youth Behavioral Risk Surveillance Survey data, which is national data, typically collected of high school students across the country. And we are seeing some fairly alarming trends over particularly the past 10 years.

And so, this is a survey that’s done every two years. The most recent data hot off the press is from 2021. And what we’re seeing are some pretty disturbing trends in terms of mood and suicidal thoughts and behavior.

We’re seeing a trending in the wrong direction indicating that kids are report or high school aged students, are reporting more depression, more suicidal thinking, and more suicide attempts over time.

And so, by virtue of the worsening mental health of youth, we are certainly talking a lot more about how are we servicing kids more effectively in the place they spend most of their time, which is the school building.

Jeff: It’s not easy to be a kid today or a teenager or a young adult. Let’s talk about some of the pressures that K-12 students face in their day-to-day lives.

Mills: Yeah. And I think that looks very different depending on the school level, right. I think, certainly at the secondary level, you get into the college pressure, is I think a beast of its complete own, that could be its own webinar, but the pressure of grades and getting into highly competitive schools can be enormous.

And that’s really for kids who are on track for college education. Also, just the pressure of graduating from high school and figuring out your post-secondary plans, whether that’s college or vocational training or getting a job right away, et cetera. I think that that pressure can be very high.

But overall, I think what we’re seeing for students is really a lot of impact of various, sort of like mental health pressures. There’s a lot of peer pressure of figuring out, like with social media, et cetera, how to be cool and how to really navigate the world socially.

And that’s something that was certainly affected also by the pandemic and kids really missing out kind of blipping out on some major years and important critical years in terms of social development. We’re certainly seeing a major spike in anxiety and worry and fear across, I think from K to 12.

And I think that when our kids, and I can certainly speak as a parent, when our kids are anxious and worried, we as parents get very anxious and worried. We as educators get very anxious and worried, which could make it, kind of a snowballing issue.

And we’re also seeing some increases, certainly in depression, et cetera as well. So, there’s a lot of different pressures I think, on kids these days.

Jeff: In terms of how all this manifests itself in kids for mental health challenges, walk us through some of the more common mental illnesses impacting K-12 students.

Mills: Yeah. And so, if you look to the data, depending again on age, some of the major ones are like ADHD and behavioral difficulties. Now you’ll notice, behavioral difficulties is not actually a diagnosis. It’s just something a lot of people talk about because it’s most obvious, especially to educators, right.

So, if a student is experiencing behavioral difficulties in your classroom, it’s pretty clear because it’s usually somewhat disruptive at the very least that student’s learning and most of the time of other folks’ learning.

And so, we see a lot of, and ADHD falls under the sort of umbrella of neurodevelopmental disorders where there’s some biological components that make it hard for a kid to be able to focus, like maintain attention and sometimes like sort of self-regulate their need to move around and more of via hyperactivity piece.

But we’re also seeing very high rates of depression and anxiety. I think anxiety is still eking out depression to some degree. But that said, they’re pretty closely linked. So many people who experience anxiety and, or depression, we don’t always know which one comes first, experience the other one as well.

And so, because you can imagine if you’re very scared a lot of the time and very anxious, that could make you fairly sad, right. You miss out on a lot of things. The action urge with anxiety inherently is a voice. When I’m anxious about something, I don’t want to do it, so I want to leave, I want to go away and isolate.

When we isolate more, we feel more sad, which can easily sort of lead to depression. So, I would say those are sort of the big ones these days.

Jeff: Let me run a couple more by you too, just for around this out here, eating disorders. Are we seeing challenges around that for K-12 students?

Mills: Most certainly, I think you mostly see eating disorders more at the middle and high school level, but they certainly can persist because one of the pieces with eating disorders is it isn’t always about weight and shape.

There are some other eating-based disorders, folks don’t know as much about like restrictive feeding and eat intake disorder, which isn’t about weight or shape, but it’s more about like a sensitivity to like certain food textures and kids may have a very, very confined diet.

It’s very common for folks on the autism spectrum. And so, we certainly are seeing difficulties across anorexia, bulimia, binge eating disorder, and ARFID, and other disorders. I don’t think it’s spiking as much.

Jeff: What about substance misuse? I’m sorry.

Mills: That’s a great question. That’s okay. It’s a great question. Substance misuse is also a big one. In some of the schools I work in, I’ve certainly seen a major problem with vaping currently. Some schools are trying to get fancy within sort of get with the times and install vaping, smoking detectors in their bathrooms.

So even though they’re smokeless that it can be detected because it is vaping. But we’re definitely seeing a high use of vaping both with tobacco products and marijuana at the secondary level.

Jeff: I want to talk a little bit about some of the impacts of mental health challenges on campus. What happens when these issues go untreated?

Mills: It’s a great question. And so, what happens when they go untreated is obviously quite idiosyncratic. It depends on the student, right. For some kids they could struggle tremendously with their mental health and still show up every day and do all their work, and get straight A’s, and suffer internally.

For other kids, it extremely impacts their ability to access the curriculum and to do schoolwork for some kids with anxiety and if they fall behind in class, you can see things really snowball and its most extreme, sort of end up in chronic absenteeism or school refusal. So, kids who won’t leave the house in the morning to go to school.

And as it turns out, it’s exceptionally hard to educate a student if they’re not there, right. Some of the other impacts though, or just like peer impacts, feeling isolated from peers and not feeling like connected to others, is a big one, and that can worsen depression.

You definitely can see some like substance abuse or substance misuse within the school setting at times, like kids vaping, et cetera in the bathroom, whether that’s marijuana or tobacco and other substances as well at school, which is difficult. But the impacts are quite multifaceted, right.

And I think that we know, we have a major paucity of treatment options right now and the need far outstrips the capacity for many mental health providers, which is another difficulty.

So, we know a lot of these things are going untreated and yet whether treated or not, kids usually are still going to school. And so, schools are sort of in this interesting position to really be trying to help students who may or may not be getting help outside of school.

Jeff: And before I forget to circle back to this, Mills, we often hear that these years, the K-12 years are really critical in the development of emotional and social well-being. Why is that the case? I mean, is that physiologically the case?

Mills: Yeah, I mean I think when you look at like neurodevelopment, et cetera, where as children, our brains are developing, we know our brains are generally speaking under construction at least until the age of 25, right.

Earlier on, well, very early on, we’re learning how to interact meaningfully with our world, with our peers, with adults, with teachers, et cetera. Adults and teachers, same thing, but with our family members, with teachers, et cetera.

And so, it is exceptionally critical, it’s an exceptionally critical time period because our brains are developing and the more we’re sort of practicing the patterns we’re in, the more of patterns they will become and habitual they will become over time.

So, if I have a lot of difficulties interacting with my peers when I’m eight and that goes untreated, and I continue to have a lot of negative interactions at school or negative interactions with my peers for the rest of my time in school until I’m 18, so that’s like 10 years of negative interactions.

Then my brain is really very much going to learn like you know what, people don’t like me very much. It’s hard to be in the world. There’s something wrong with me perhaps.

Like there’s all sorts of core beliefs you can form over time with these difficulties as they go untreated. And so, we know that children’s brains are more malleable than those of adults. And these have major impacts on us for sure.

Jeff: When it comes to seeking help for mental health challenges impacting K-12 students, what does that look like? I mean, who is typically stepping forward?

Is it the parents, is it the teachers or their faculty members, the students themselves, a combination of all the above? Talk a little bit about that please.

Mills: Yeah. It’s most definitely the sort of like option D, all of the above here. It very much depends on the school structure, the resources, how informed folks are. A lot of times when students or kids show up to my office, like their parents are making the referral for outpatient therapy or counseling.

That said, sometimes kids certainly self-refer themself. It’s usually more at the middle and high school level is the self-awareness sort of increases and students may feel like they have more to talk about or really want to be able to talk about that with somebody else.

Definitely teachers can refer in many schools. There are processes, there’s often what’s called a student support team or an SST in many school levels where teachers, administrators, school counselors, and mental health professionals all come together on sort of a regular basis to discuss students who are struggling.

And so, it could be students struggling academically with reading, math, et cetera, and, or students who are also having mental health difficulties. And during those meetings, a lot of times students could be identified for in-school counseling or for somebody to help connect the family to outside resources.

Jeff: How critical is it for the various players in this mix to be working together in helping the student?

Mills: Very much so. I think collaboration is always key across most difficulties in life. And so, the more fluid communication that can be had via home and school. And within the school, I think the better a student will be supported.

Jeff: So, you’ve talked about a number of resources that are available for teachers and other educators and parents, and so forth. What are the barriers that stand in the way of actually getting those resources? Let me start with stigma for example, does that factor into all this?

Mills: Of course. And I think that stigma can be a huge difficulty right now. And I think that as our population particularly, in Massachusetts continues to diversify, there’s also some different cultural beliefs about mental health disorders and mental health difficulties that need to be really carefully addressed, right.

Where we may think of it as stigma, but it may just be a different cultural belief or orientation to what it means to have mental health difficulty or what it means to be struggling with a particular difficulty or problem.

And I think that it takes a lot of nuance and a lot of community-based conversations and coming together and listening to all voices at the table to sort of figure that one out over time. And then I think you have the other issue of, sort of your garden variety stigma that just exists.

So though mental health may not exist or perhaps some of the stigma ties in comments, I hear more often is like they’re just trying to get attention. Like, so the student’s just trying to get attention, they’re just doing it just to do it, whatever the it is, if it’s like a behavioral difficulty or some type of mental health difficulty, it can be pretty hard to smooth out and work against.

And yet, if we can try to move to a more curious stance with students and try to have a better understanding of the root causes of their behavior, I think they would be better or better able to help and assist in getting them treatment.

Jeff: We ask a lot of our teachers, I mean of course, they’re shaping young minds, they’re helping educate kids and getting them ready for their lives ahead.

We also want them to be able to recognize mental health challenges. How do we go about doing that as a society and what is being done at this point?

Mills: So, there are many different trainings that are out there that schools can avail themselves of. So, one of the most popular ones is called, Youth Mental Health First Aid. And this is one that many schools, and it is not just for educators, this can be for parents, for community organizations like the Boys and Girls Club of America, the YMCA, et cetera.

Lots of youth serving organizations, the Adventure Scouts, et cetera. And this is a training that does directly help increase awareness of mental health difficulties among non-mental health professionals, among lay folks that can be super helpful.

And really it is about being able to recognize some of the signs and symptoms. What’s difficult again about mental health difficulties is not all of them are super apparent.

So, you can have a kid who’s horrifically depressed or extremely anxious, and you might not actually know because they show up to school, they do their work and they get it done, but there’s like a lot of internal turmoil. And there’s no way to say that we could always identify a kid either.

But a lot of this is trying to increase the awareness of the nuance where we see oftentimes, kids with more externalizing difficulties or difficulties that are more clear because they’re disruptive in some way or more outward, are more easily identifiable than the kids who are more internalized and dealing with things internally.

Jeff: You work with a lot of teachers and school staff in terms of helping support them and educate them. Do you find that there are some common misconceptions in terms of their students’ mental health?

Mills: That’s a great question. And I think to harken back to one point, I think a lot of times, there can be a bit of a misconception of sort of the culpability or the amount of control someone has over their behavior, or oftentimes what gets in the way, and I would be a hundred percent lying, if I said I didn’t do this myself too.

I think we all as human beings do this, is judgments. And becoming judgmental of a student’s behavior or the manifestations of what they’re managing and judgments are a very normal part of human life.

If we didn’t make judgments, we wouldn’t have survived as a species, because we wouldn’t have been able to discriminate between safe and unsafe things or things we like and things we don’t like, et cetera.

And so, judgments are important, but what we see when judgments become problematic is when it becomes like sort of judging a student’s behavior or a manifestation of what they’re managing in this moment. So, a lot of times you may hear like, well, this kid’s being manipulative or things like that, right?

And they may or may not be, but ultimately, that judgment can actually impede our ability to really help that kid move forward, right. Because it then becomes this kind of adversarial conversation of, or you’re just trying to get what you want or whatever.

But really in life, we’re all just trying to get what we want in the end. And so, a big piece is really trying to sort of come together and take more of a kind of collaborative problem-solving approach or an approach to really meet kids where they’re at and increase that validation to try to come together to figure out solutions. So, it’s certainly one thing I see.

Jeff: We’re going to work in some audience questions here pretty quickly, but I want to ask you a little bit more for some specific examples of what we’re talking about here and let’s start with the challenge of diagnosing, not even so much diagnosing but recognizing mental health challenges in a student.

Can you give us an example of why it might be difficult for a teacher to recognize OCD or ADHD or something similar?

Mills: Sure. So, ADHD is actually a pretty good example, because a lot of times people would think, well, they’re hyperactive, of course, we’d know. And yet, ADHD does not have to necessarily include hyperactivity.

So, there are folks who have ADHD hyperactive, predominantly hyperactive type. There are folks who have combined hyperactive and inattentive type, but then there’s this whole other section of folks who have ADHD inattentive type.

This is often diagnosed in folks that were assigned female at birth. There are many assigned male at birth folks who also have inattentive type ADHD, but we see assigned male at birth folks overrepresented in hyperactive type ADHD. Whereas, we know that ADHD inattentive type is often diagnosed in students who are assigned female at birth.

And what we see there, is that there’s all this like inattention that happens that may not be immediately evident. A teacher or staff member may think that somebody’s just spacing out or not realize that it’s hard for that student to sustain their attention in the moment and that’s leading to poor grades and things like that.

So, it can be really difficult or you may not notice that their backpack is really disorganized if they hide it, or there are things that you may not be as cued into. And that’s one that often will go underdiagnosed. Because ADHD is something that is often diagnosed much earlier on in life around between the ages of like seven and 12.

But for many, and I’ve had several clients in my own practice who have been diagnosed, who are assigned female at birth and diagnosed later in life due to some of the that piece. OCD is another good example where that’s really an anxiety-based disorder.

Then there’s a lot of internal things. So, you may notice if somebody is having compulsions that are very obvious, like checking something or not being able to leave a room until something is just right and it’s time to transition, like the bell has rung and it’s time for them to leave. That might be more obvious.

But there’s a lot of obsessions or compulsions that happen completely inside of one’s head and you might be totally unaware of that, right. Because they’re just sitting in class and they’re thinking, oh, I’ve got to count in this particular way or whatever it is, right. Or having an intrusive thought about something. But there’s no way for a teacher to necessarily know that.

Jeff: I suspect we have a number of parents in our audience today as well, Mills. And I want to ask you to speak to them a little bit about recognizing challenges in their kids, equally difficult for them to recognize some of the signs as it is for the teachers.

Mills: Yeah. And so, there’s a few good guidelines I think to sort of follow when thinking about identifying that a kid or your kid or a student you’re working with, may need some mental health support. So one is that, have there been any major changes in their behavior recently?

So oftentimes, when a student starts to struggle with mental health or perhaps when the struggle sort of tips into an unmanageable sort of part, we see some changes in behavior. So, have they stopped doing anything they used to enjoy doing? That’s usually a pretty big sign.

So, did they quit the baseball team? Did they stop going to clubs or something like that? Are there any differences in how they’re taking care of themselves and their hygiene? Are they showering less?

Are they putting less effort into their appearance if that’s something they used to do? So, if there’s a kid who wears a lot of makeup and then suddenly just stops altogether with no particular rhyme or reason, isn’t voicing, I just want it to change something, et cetera.

So major changes in behavior can certainly be one. Another one is certainly big reactions just to non-large stimuli. So, if there’s something that seems like, oh, usually that would just kind of irritate my child, but suddenly they’re having a really major reaction to it.

So, in school perhaps, they got a lower grade than anticipated and usually they would be like, oh, like that’s kind of hard but they’re having an extremely big reaction, crying a lot or something like that, could be a good indicator and if that goes on.

So, it’s not like a one-time thing. But if that’s like, oh, I’m noticing that my child seems more irritable or just having major much bigger reactions than is typical for my child or my student, that can be another big indicator as well.

And so, I think major changes in behaviors, sort of like big reactions to non-big stimuli or stimuli that usually don’t cause big reactions. And then of course, subjective distress. If they’re reporting being a lot of distress, that’s always a clear sign.

But there’s also this piece where some kids, particularly with anxiety and sometimes depression and across cultures, this also presents differently where for in some cultures, distress is felt more somatically in the body.

So, if you’re noticing that there’s nothing, you’ve taken your child to the doctor, there’s no medical cause for something, but they’re having a lot of belly aches or headaches or feeling really fatigued for no medical reason, et cetera.

And there are a lot of somatic complaints that can also be the sign of a mental health difficulty, particularly when paired with these other things we’re talking about here today. But that’s one that often goes underdiagnosed, because folks are like, oh, there’s something medically going on. But if there really isn’t a medical cause, it could be anxiety or depression, et cetera.

Jeff: We often hear about the importance of dialogue between parents and their kids when it comes to mental health. Do you suggest that parents proactively bring up the topic even if they’re not noticing challenges with their children?

Mills: Definitely. I think it’s a good thing to have on docket of just something that we talk about. I think that mental health, I think one thing to think about is that we can think about mental health in a positive way. Having mental health is good, right. We want to be mentally healthy.

A lot of times, we kind of pivot to talking about mental wellness, right. And so, we can model to our kids if they’re not having any difficulty of like, well, how do we remain mentally well or how do we boost our mental wellness, boost our mental health? What are things I do as a parent or as a person, rather, to boost my mental health.

Like I like to wake up earlier than my kids, which is sometimes really hard, and work out in the morning, because I know that really helps stabilize my life, right. And that’s something we can model to our kids and talk about, and we can ask them, right. What are things you do to boost it, right? Sort of proactively.

And then you can also talk about like, hey, how would you know that things aren’t going so well or that you’re not feeling great or might need some extra help? What are signs for you?

So, for me, I might notice that I feel a little more disconnected at work or disconnected when I’m trying to engage with my friends or I might find that I’m avoiding some things that I don’t usually avoid. Like those are kind of signs for me. What might it feel like for you?

And those are conversations of course, a little more skewed towards your middle/high school aged kids. Whereas I think, talking about, but talking about and modeling mental wellness can be done across the age range, right?

I also think another big part of this is, is talking openly about emotions, because emotions are not inherently bad. In fact, emotions are quite important. If we didn’t need them, we would’ve evolved out of having them.

And yet, biologically and from the sort of an evolution psychology perspective, our emotions are actually critically important, right? If we don’t feel fear, we don’t run away, we all would’ve been eaten by mammoths or what have you.

But also, if we don’t feel fear, we may not avoid like an actual unsafe like “now” situation or we might not avoid like a socially unsafe situation. If I feel a little worried about going to a party as a high school student where I know there aren’t going to be parents home and it might be really raucous, I might go to that party and the police might come, right?

It’s good to feel fear, right. Just like it’s good to feel sadness and anger, et cetera. All of our emotions are giving us very important information.

And one of the most important things we can do is any adult who works with kids, whether that’s in a school setting or as a parent, is I think really modeling your experience of emotions of like, well, I feel sad or I feel X and this is how I know I feel it because I feel a pit in my stomach or I feel heaviness in my chest.

Like these are the ways I know it and then this is what I do with it, right. That I know it won’t last forever. Because a lot of times, I think we can have a pervasive avoidance of feeling any negative emotion.

But it wouldn’t be a life if we only ever felt happy, because we wouldn’t really know what happiness was because we wouldn’t know the other side. And so, I think it’s a major part too of proactively having discussions.

Jeff: Definitely want to talk more about mental wellness and some strategies for promoting that on campuses. But we are getting a lot of questions coming in. So let me tap into our question file here for you. And I’m just going to go ahead and read a couple of these here.

Let’s start with this. Who can kids approach if they are part of the LGBTQ+ community, but their immediate family does not support them? Are you seeing more mental health issues in this community, especially pertaining to schools?

Mills: Excellent question and very pertinent, and topical at this time. Yes. We’re a hundred percent seeing significantly worse mental health in the LGBTQIA community, particularly in the trans community, given the political climate and thankfully not in Massachusetts.

And yet, we know that there’s a major political backlash against the trans community at this time. We are seeing and the data shows, if you look at go to thetrevorproject.com, they have some recent data about mental health of LGBTQIA+ kids, both cisgender and transgender and non-binary folks that shows that our community is really struggling right now.

We really are with mental health and the rates of depression, suicidality, anxiety, sort of, you name it, are far higher in the LGBTQIA+ community than in the cisgender heterosexual one. And so, who can kids go to? I think that part of that is, identifying somebody safe at school. They certainly can go to school staff.

There has been some backlash and there was recently a lawsuit I think in the last couple of years in Massachusetts. About a school knowing a student was transgender and not telling the family. I believe the suit was thrown out, but there’s a lot of pieces here.

But in my experience working with schools, there’s many school staff members that will very much welcome a kid coming out to them. Whether they’re sexuality-wise diverse or gender-wise diverse, and have that conversation without sharing it. And I think it can be an incredible resource.

Jeff: Is there a typical age at which identity challenges begin surfacing, begin to surface more than other times in life?

Mills: That’s a great question. So, there’s some real misconceptions out there. I think particularly with gender identity. There’s this sort of conception that somebody can’t really come out or know who they are until they’re a teenager.

I have seen children as young as three or four years old, very confidently and clearly identify as transgender and never change.

And so, gender identity really, sort of starts coming into the picture around three or four years old where kids realize that they have gender and if your gender doesn’t match your sex assigned at birth, it can be very obvious as young as three or four years old of like, oh, no, I’m not, this isn’t lining up.

And kids may not have the words to say that all the time, although some do and they say, oh, mommy, I’m a girl, or oh, mommy, I’m a boy. Or I don’t feel like either.

But we can see that actually quite early on and we’re certainly seeing it as we have a more diverse view and understanding of gender and sexuality now than we ever have before. We are seeing a lot of kids question these things more earlier on and more often.

Jeff: Another question, given the prevalence of stigma in self-reporting mental health issues, do you have any tips for making students more comfortable disclosing their struggles to parents and, or teachers?

Mills: What another really great question here. And so, I think that the best thing you can do is improve the school climate, right. And that’s a big task. I say that as if it’s like, oh, yes, just improve your climate.

I know obviously, it’s an exceptionally difficult thing to do, but I think the more welcoming the school environment can be to struggles and the more validating the staff can be and the more welcoming the school as a whole can be about this, students are going to feel more supported and more safe, and better able to disclose these things.

And so, what does that look like? I think that looks like talking about mental health and mental wellness. It looks like really having clear discussions about this and making it clear how students in need can get help.

And obviously that’s often done in schools at the beginning of the year with like introductions to school counselors, et cetera. But continuing that on throughout the year and making it clear who students can go to.

Jeff: A very specific question, what advice do you have when there is an instance of a student, a minor under the age of 18 who is seeking mental health support but their parent refuses to provide parental consent, especially if a student needs more information individualized intensive therapy than a school counselor is able to provide.

Mills: Another good one. And so, this is a difficulty that comes up in every school that I work and consult with, where there can be mismatches between family beliefs about counseling or access to and many other cases and a student’s need for it, and self-professed need or desire.

You’d have to look back at the laws in Massachusetts. There are some laws in some states that allow a student to access mental health care starting at age 16. I’m not a hundred percent sure of the laws in Massachusetts. So that could be something to look into in terms of a student seeking out services themselves.

I think this is one where as schools, it’s a little bit of really supporting the student to the best of your ability and within your scope of competence. So not saying like you need to become this intensive therapist that does all of these things that are beyond your capacity as a school-based provider.

But doing as much as you can to support the student to that magic 18 mark when they can legally get services on their own. And of course, you can continue to work with the parent or caregiver to try to work to increase their willingness to seek out those services as well. And these are very difficult conversations.

Jeff: We typically have a number of providers in our audiences for these webinars as well. And I wanted you to speak to them a little bit in terms of how they can best work with K-12 educators and parents for school-based issues around mental health.

Mills: Another great one. So, I think that one of the biggest things I can suggest is really increasing that collaboration as much as possible. And so oftentimes, what I hear when I’m consulting with schools is, well, the student has like this outside provider but the provider’s not seeing any of the things we’re seeing in school, which makes sense, right?

If you’re doing outpatient therapy, it’s you and a kid. You oftentimes have a pretty good rapport, right? There aren’t a lot of pressures, I’m not asking kids to do mathematics. There’s a lot of pieces that that aren’t there. And so, the more you can collaborate and get those releases, and I know everybody is short on time, right?

But particularly when a student is really struggling in school and a lot of the things you’re working with outside of school have to do with school, trying to increase that communication and create plans together, and really work as much as you can to try to figure out what would be most helpful and what will help with skills generalization over time.

Because I think a lot of times, you see a kid who’s practicing some type of mental health skill or coping skill, but it’s just not generalizing, it’s not going out to these other areas of their life.

Jeff: Circle back to the topic of proactively promoting mental well-being for K-12 students. What can schools and school districts do on that front? Are there campaigns, assemblies, projects? I mean where do you normally start that conversation off with the school district?

Mills: So, there’s a lot of things that schools can do and many schools are very familiar with the multi-tiered systems of support or MTSS model, which sort of is the public health model with this idea that at tier one, is this like universal prevention tier. And so, there’s a million, so many things schools do already to address that certainly, academically.

And there’s many things schools are doing to address that for mental health and that’s where social emotional learning or SEL really comes in, which is a big buzzword. Many of you on the call are likely familiar with, where there are many different curricula out there to support SEL at the younger grades.

There’s a lot of like classroom push-in levels, certainly in elementary school and sometimes into middle school, and really finding ways to promote sort of like positive behavior and some of these core SEL competencies like self-management and regulation, et cetera.

And so, there’s different campaigns, there’s lots of assemblies I think the most effective that I often see of these programs are ones that aren’t one and done. So, it’s not just one assembly and then we leave it forever, but that are sort of ongoing and infused throughout the school year.

Another major part of this is engaging in universal screening for social emotional health. So, identifying kids earlier on who may be having social emotional difficulties and getting them care earlier on, so that they can sort of prevent needing sort of like tier three or IEP level or other type services later on.

So, the sort of the more we know about a kid earlier on, the better we can help them.

Jeff: What are some strategies for schools looking to better involve parents in this conversation as well?

Mills: Another good question. And so, I think the more open communication between schools and their communities and caregiver communities, the better, right? And so, this can be like having increasing the amount of parent events or there a lot of schools will do like parent coffees or about certain topics.

So, in one school district I’m working in, they just had an ice cream social and you know we’re talking with middle school and elementary school aged parents, student aged parents about attendance and other important pieces that affect their student community.

And so, I think opening up those lines of communication, welcoming that feedback, you can’t address everything obviously. And the more sort of two-way communication that can be had, I think the better.

Jeff: An audience member wants to ask you this, how can parents best advocate to their schools or school districts to adopt what you’re saying, improve their services, and change the school’s mindset about all of this? That’s a great question.

Mills: That’s another great question. That’s a big one, right.

Jeff: That’s a big one.

Mills: And I think that some school districts are very predisposed to have these conversations and very much have these mindsets. And I would argue that a lot of school districts, certainly the ones I’ve worked with, really are committed to this and it’s hard to implement because change is hard and there’s so many academic demands.

And sort of where we’re at, in terms of MCAS testing, et cetera, make it difficult to incorporate other curricula or other initiatives. That said, I think the more parental advocacy you can do, the better.

So sometimes tapping into the parent, the PTAs, so Parent Teacher Associations or CPACs, which are like a sort of a, I’m not going to explain this well and I’m sure somebody who’s in a CPAC will be like, oh, no, that’s not exactly what it’s. But it’s a group of parents who have students on IEPs or who are receiving special education services.

Tapping into those sort of communities that are already like linked to the school can be really helpful. And so, it’s another way of sort of amping it up and increasing that conversation around this.

Jeff: Where are we in 2023 with accommodations in schools for kids who are dealing with various mental health challenges? And what are your thoughts on those interventions?

Mills: Now that is a big question because I have many thoughts on it. And I think that there are many ways to accommodate students in school with different mental health challenges.

Now, the effectiveness of accommodations is going to change based on the difficulty or symptoms that a student is experiencing and sort of the ways in which their academics are affected. And so, there are times where kids are very appropriately accommodated and they’re getting exactly what they need.

There are times where kids are under-accommodated and they don’t get the accommodations they need. There are also times when kids are over-accommodated and they’re getting more than they really need and then they learn to be reliant on those accommodations.

I think accommodations, particularly for anxiety for example of where we can sort of misstep a bit, is if we give the student the impression that like, you know what, everything is really too hard for you to do.

We can end up unintentionally over-fragilizing a student where we take away too much of the demand and we’re not pushing a kid to try to do the things they really, really can do and can try, and we’re unintentionally reinforcing the avoidance.

And so, there are many, many, many different accommodations and it can be hard to figure out the exact right mixture for the kid in front of you. But I think it does take a lot of nuanced discussion of figuring out what exactly are the accommodations we need to do and how are we measuring this and how are we making sure it’s working over time.

Jeff: Equity question that’s come in.

Mills: Yeah.

Jeff: What are some issues that you have noticed and some solutions that you have for kids with socioeconomic barriers in accessing support?

Mills: Another great question and this is one of the big ones. So, we know that most kids with mental health difficulties do not get outside support or really any support, whether it’s in school or out of school, of the kids who do get support for mental health care, over 75% of kids that get actually get treatment, get it in schools.

And so, in terms of socioeconomic diversity and other aspects where there are many barriers, transportation, money, insurance, time, parental, and caregiver jobs, et cetera, in the way of them getting health care and mental health care as well. Getting them care in school can be a really good way to do that.

In some under-resourced financially districts, there are, like, agencies that will come in and provide the services in schools and usually they take MassHealth, which is very helpful.

And so, there’s different agencies like The Home for Little Wanderers and others that will come push into the school day to see a kid and give them those mental health like individual counseling and therapy, which I think could be a great way of increasing access to care.

In some school districts and under-resourced communities, communities that are under-resourced financially, we’ll see like school-based health centers. In the research, they’re very effective, because it sounds great, right? I have a whole health center in the school building, so kids can get medical care, health care, mental health care, et cetera.

I mean, I think that would be the gold standard and that takes a lot of money, funding, time, effort, et cetera to set up. But I do think in terms of equity, trying to increase sort of, the amount of partnerships between schools and outside providers, the better off we’ll be.

Jeff: We touched on this briefly, the pandemic and its impact, but we’d be remiss not to circle back and talk a little bit more about that. And I want to ask you how that impacted those out of classroom years, how they impacted the kids at the time, and then also perhaps how they’re impacting kids today.

Mills: Excellent question. And I think, the further out we get from the pandemic, the better the mental health seems to be and the better prepared students seem to be back in the classroom. I think at the time, what we saw was an incredible amount of school disengagement where many students K to 12 were just not signing on to their virtual days.

And so, early days of the pandemic, nobody really knew what was going on, and so– and a lot of kids weren’t being educated, because they weren’t signing on to be for many different reasons. They may not have had access to Internet, they may not have had a private space. There are so many different reasons.

As we get further out from the pandemic though, I think we’re seeing again, these like lagging skills for a lot of kids, particularly kids that were at like a really critical age.

So, I think that sort of like late elementary school, those kids that then just like started middle school, missed a lot of very important social development by not being in school full-time and you’re seeing some lags and a lot of immaturity.

A lot of schools talked a lot, particularly in 21 and 22 as kids were really returning to the classroom more full-time about like this maturity gap in kids. And I think the further we get out from it, the better it will be. And it was really hard.

And I think at the older kid level, teenagers were not built to be isolated by definition. And so, we saw a lot more depression and anxiety, and I think for some, when the pandemic restrictions lifted, so did the depression and anxiety and for some it did not.

The mental health stuff really continues, because it kind of activated something that was hard to put– It was a little bit like Pandora’s box. It was hard to put it away once activated.

Jeff: When you look at the pandemic’s impact through your lens of working with schools on mental health well-being, what are some of the lessons that you have learned that you’d like to see implemented moving forward?

Mills: That’s a great question. And so, I think the most we can do in terms of the– I mean hopefully, we won’t have quite another global event like that. But I think the more we can engage students, the better we’ll be, right?

And so, I think that obviously, the pandemic was this great fertile ground for school disengagement because it was really difficult to engage, I think for teachers and school staff as well. And so, I think the one of the lessons I think I’ve taken from it in mental health is, increasing that school belongingness, connectedness, and engagement is really key.

Because the more engaged and plugged in, and connected kids are, the happier they are, and the more able they are to access their curriculum. And there’s like really great positive sequelae from that.

Jeff: I want to ask you about the special challenges that athletes might feel, student athletes. And I imagine that this is more of an issue for high school students than it is for younger kids, but there are pressures by the time you hit high school.

If you’re going after your scholarship collegiately for example. What should we know about those particular mental health challenges?

Mills: That’s a great question. And so, I think, a lot of this comes down to performance pressure, and I actually see this in as young as middle school. So, kids who may do like a very competitive sport outside like swimming or ice skating, and things like that, that are– gymnastics, that are highly competitive where you really can see this like real increase in anxiety and perfectionism.

And this isn’t true of every student athlete, but I think those are like some of the things to be aware of, is like high anxiety, high perfectionism. And feeling like, if I don’t get this exactly right, the world will, you know, something bad is going to happen, or I will have failed as a person, if I don’t succeed in this thing I’m doing.

And really helping kids differentiate their full-on identity from a thing they do. And so obviously, an athlete is an athlete, right? We even use a word, we’re not talking about them as a student, we’re talking about them as an athlete, right?

And yet, I think there can be this sort of, like, over-fusion between sense of self and one’s performance, which can be helpful in some ways, but really hurtful in others.

And so, really being aware of the sort of perfectionist tendencies and helping kids see the value and wonderful things they bring to the world, whether or not they win the game or hit a PR in the race, et cetera.

Jeff: Here’s an important question that came in. What suicide prevention training would you recommend for school counselors? The reality is, that they sometimes are the only mental health support for students.

Mills: Another really great one. And so, there’s a lot to be said about suicide prevention and training. I think that the most important training for anybody like kind of on the front line of identifying and assessing a student for suicide risk, is really risk assessment training and trying to get a better sense of what is your protocol for identifying a student at risk for suicide?

How are you determining whether they need a higher level of care? And then sort of what’s the protocol for referring them out to that or does your school have crisis? Like do you call in crisis? Can you send a kid out the ambulance? What is your sort of protocol for contacting the family, et cetera?

So, I think risk assessment training is really critical. That said, there are also some great tier one or there’s one particular great tier one program for suicidality and addressing that called SOS, Signs of Suicide. And I’ve seen many schools use it. One of the more difficult parts of using it, is that it does include a universal screener about suicidality.

Meaning you’re asking every student receiving the curriculum about whether they’re having symptoms of depression or thoughts of suicide, which many schools can shy away from for obvious reasons.

Like, that that could be a lot of students you’ve identified that need to be checked in with by end of school day. And so, I think it’s a great program and it’s only one you can really implement if you have the staff capacity to manage that.

Jeff: What about resources for teachers? Somebody who is listening to what you have to say today and wants to better train themselves to be prepared to identify and work with students who might be struggling on the mental health front?

Don’t really know where to start, where would you point them?

Mills: Yeah. So again, the Mental Health First Aid training can be very helpful. Another thing, another great resource online is the Child Mind Institute. They have a lot of information on there for both parents, caregivers, and school staff about basically any diagnosis that can be diagnosed.

And so, there’s things as niche as like selective mutism, which would be referring to a person who doesn’t speak in certain settings. This is certainly one I see at school. Often, you see this a little more in the younger years, elementary school, but sometimes who’ll get a middle or high schooler with selective mutism.

And that can be extremely jarring to school professionals, especially if the kid’s not talking and you can’t really get a sense of what’s going on for them or where their learning is. Great resources on Child Mind Institute for that in addition to really any other diagnosis. And so, I really encourage you to check out that resource.

Jeff: Question about peer-to-peer programs and their effectiveness, I assume that we’re talking about, well, I guess, we could be talking about teacher to teacher or student to student.

Mills: Usually, those are student to student programs. And so, I think it depends. I don’t know that I could speak to that universally. I think it depends on the program.

I think it’s peer mentoring can be exceptionally helpful when you have an older student really trying to help out a younger student, particularly for like chronic absenteeism and other difficulties like dropout prevention. A lot of peer mentoring programs have been used.

I think it just depends on the application, right? I’ve had some schools where students are advocating to have like a mental health group, but one where it’s like group therapy, but there isn’t a therapist. It’s just the kids, which I don’t think is particularly helpful.

And I would definitely shy away from that, because that could go in a lot of different difficult directions versus something that’s more structured where peers are helping each other in a very clear way, I think can be really helpful.

Jeff: So, this whole discussion is obviously a very complex matrix. I want to break it down by age for a moment or two here. Let’s start with the youngest kids. When do we start seeing the manifestations of some mental health challenges? How young can these kids be?

Mills: There really isn’t an age limit on these things, unfortunately, right. So, it isn’t like, oh, on your fifth birthday then the thing emerges. You can see mental health challenges in very young children starting, most commonly with like separation anxiety.

You can see in preschool-aged kids who have a really hard time being away from their caregiver over and above and beyond that of other students in their class or around them. So, I think as parents, many of us have left our kids in tears that drop off, but then they’re okay once they get in the school building.

There are some kids that will sort of persist and be very upset, and continue to cry, and continue to have a very difficult time. And so, you can see that quite young. Neurodevelopmental disorders, autism, ADHD, et cetera, you see very young, those can be signs as young as a year for autism spectrum disorder can be very, very young.

ADHD typically is identified somewhere in the school aged realm, can be as young as kindergarten, and anxiety certainly can persist. I mean, so especially separation anxiety is one example, but other types of anxiety can certainly proliferate in kids quite young as well.

Jeff: Particular challenges that stand out in terms of say pre-teen, the middle school years.

Mills: Ah, the middle school years. Yeah. I think that a lot of times in the middle school years, you see some increasing in depression. Sometimes in some like self-harm behaviors, et cetera, which also can be, so in the adolescent, full adolescents in high school.

But depression and anxiety are some of the biggest ones. Also, for the high school level as well where you can see a lot of that.

Jeff: And then at the high school level, I assume that we start getting into a lot of perfectionism as you’ve already referenced issues, and also anxiety around what comes next, whether that’s college or careers.

Mills: Yes.

Jeff: What guidance do you have for parents and teachers specifically for, say, high school juniors and seniors who are facing that critical juncture?

Mills: Such a great question and I think one of the biggest things you can do is really try to listen. It is very tempting, and I say this as someone who often gives advice without being solicited, to give unsolicited advice in these moments, right? And to say what you think a kid should do or where you think they should go or what path you think they should be on.

And a big part of being an adolescent is figuring out your own way. And so, not without guideposts, not to say like, oh yeah, I want to like, go travel around the country in a van and only follow my favorite band and make no money, and you’ll bankroll me, mom, dad, et cetera, not like that.

But really, really do some in-depth listening to where your child, student, et cetera wants to go. And then figuring out how to help them connect to that. Another important way to have this conversation is really connecting your student or child to their value system.

So, identifying, what are your values? What do you want, right? Like what are you trying to go towards? What are your goals? And like kind of advance that. And then you can really link their behavior to, like, okay, well, is like, not studying for your math test going to help you get into Harvard or no? Or whatever the example is, right.

But I think the more we can step back and let our own anxiety go a little bit to be able to really engage with kids to figure out how they want to play it and where they want to go, and then be instrumental in helping them get there, the better off we’ll be.

Jeff: As we’re watching the clock wind down here for our time, I do want to ask you to kind of project forward and talk about the frontier here.

What do you see missing? What would you like to see more of in the mix in terms of policy around this, in terms of funding, in terms of innovative programs? Where would you like to see this conversation go?

Mills: Well, I think, we absolutely need more funding for mental health in schools and mental health more generally. I think the more clinicians, the more highly trained, culturally competent clinicians, we can get out there, the better.

Increasing access to care is an enormous one. And so, making sure the folks who are in the most dire need of treatment get it, right. So, breaking down barriers such as transportation, money, insurance, et cetera, time, all of these things is really helpful from a policy perspective.

So, where I want to see things go is increasing funding, both at the school level and for outpatient care, increasing the sort of availability and resources connecting those two things. So increasing schools’ ability to refer out more effectively to outside providers and just increasing care in schools.

I think if the idea of school-based health centers could really get legs and we could see those in many more schools throughout the country, I think we’d be much better for it.

Jeff: Let’s wrap things up with a word of encouragement for teachers and other faculty members out there who are really wanting to do more with this. What do you say to them? What is your message for those educators and the role that they can play?

Mills: My message is, to start with, is you’re doing a great job already. Every one of you that’s on this call, I am positive, has had a major impact in the life of a child and probably way more than one already. And so, keep up the good work. You’re doing a wonderful job of connecting with kids and making the effort. And so, keep going, is really the big piece of it.

Advocate for more mental health care and policy, and more interventions where you can at the school level and continue those great relationships you have with those individual kids and really strive to be that person they think about in 20 years when they think back to their schooling of like, oh yeah, that person was really instrumental to me and really helpful.

Jeff: What a great place to leave things. Mills, I want to thank you again for loaning us your time and your expertise today.

Mills: Of course.

Jeff: We very much appreciate both.

Mills: Yeah, thank you for having me.

Jeff: And finally, to those of you who joined us today, thank you for your interest in our educational webinar series. We hope you’ll come back for our future sessions and we wish you a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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