Mental Health Action Signs & School Avoidance

School Nurse’s Mental Health Toolkit

Despite well-documented levels of emotional and behavioral problems in the nation’s youth, studies have repeatedly shown that 75% of youth with these problems are not identified and do not receive needed care. School nurses, as part of the mental health team, are key partners in identifying and supporting students experiencing a mental health crisis. The REACH Institute offers the “Actions Signs” Project to help caregivers, educators, and healthcare professionals identify children at behavioral and emotional risk. Know your school’s crisis protocols and participate in mental health crisis training with other school mental health team members. If you think that one of your students may have any of the following signs, take immediate action, collaborate with your school’s mental health team, and follow your school’s protocol to help your student feel better.

  • Feeling very sad or acting withdrawn for more than two weeks.
  • Seriously trying to harm or kill themselves, or making plans to do so.
  • Sudden overwhelming fear for no reason, sometimes with a racing heart or fast breathing.
  • Involved in many fights, using a weapon, or wanting to badly hurt others.
  • Severe out-of-control behavior that can hurt them or others.
  • Not eating, throwing up, or using laxatives to make themselves lose weight.
  • Intense worries or fears that get in the way of their daily activities
  • Extreme difficulty in concentrating or sitting still that puts them in physical danger or causes school failure.
  • Repeated use of drugs or alcohol.
  • Severe mood swings that cause problems in relationships.
  • Drastic changes in behavior or personality.

Download the “Action Signs” Project

For more information about youth mental health support, resources, and tools, visit here.

See the resource section in this toolkit for connections that can help adults in need, such as Bridge2ResourcesVA.org

The parent/guardian/caregiver is the most important member of the team of support for the student

Sometimes, the parent may seem unwilling or unable to help. In this case, approach with curiosity, not judgment. Does the parent have unmet needs, mental health conditions, or other stressors? Providing support for the parent supports the student.

School Avoidance

School avoidance is the regular refusal to attend school or maintain consistent attendance.

This can lead to chronic absenteeism, missing 18 days or more of school within an academic year. The sooner school avoidance is recognized, the better: not attending school is an emergency. Multiple factors contribute to school avoidance.

External Factors

  • Bullying from a student or adult in the building.
  • Family violence, trauma/disruption.
  • Family illness leading to separation anxiety.
  • Poverty, lack of access to resources, need to work to support the family.
  • Racism or LGBTQ+ discrimination.
  • Natural disasters, violence in the community.

Student Factors

  • Mental health conditions (depression, anxiety).
  • Personal medical challenges (e.g., constipation causing student to avoid using the bathroom at school).
  • Chronic or acute medical illness (e.g., diabetes, concussion).

What others might see

  • Refusal to participate in class activities (recess, PE, etc).
  • Temper tantrums or outbursts, crying, especially upon arrival to school.
  • Improvement on weekends or breaks.
  • Chronic tardiness or early departures.
  • Missing class, presentations, or tests
  • Frequent clinic visits.

Strategies

Unmet needs contribute to school avoidance.

Develop a communication process and team within the school so nurses are made aware of students who are missing school but may not be coming to clinic. Check in with the student:

Ask open ended questions, starting with easy ones.

  • Be curious and supportive – “You have been missed lately! How are you?”
  • Have you been sick? How have you been feeling?
  • What do you like (or dislike) about school these days?
  • Can you tell me about your friends? Are you being bullied by anyone?
  • Has anything scary happened at school
  • How is everything going at home? What kind of changes are happening?
  • Is there anything specific (classes or stressful situations) that keeps you from school?
  • If chronically tardy, say: “I see you are often late in the morning. What do your mornings look like? How is everything at home? How can I help?”

Provide personalized early outreach to families. The longer a child misses school, the harder it is to return. Connect with an open mind:

  • “I am calling to see how we can support you and [student] in order for [him/her] to be in school regularly. Are there any specific reasons that your child has been absent?”
  • If chronically tardy, ask: “Are there ways we can help your child arrive on time?”
  • Recognize that stepwise approaches can be helpful. Consider a 504 plan for gradual re-entry to school.
  • Connect families to local resources.
  • Encourage a visit to their medical provider.

Encourage intra-school connectedness. A counselor, trusted teacher or coach, extra curricular activities, and clubs help students’ motivation to attend. Who can be on the support “team” for the student?

Recognize when students need a 504 plan or IEP for unmet medical or educational needs.