The Certified School Nurse: Untapped Resource Dr. Barbara Zimmerman, RN Associate Professor in Nursing Coordinator School Nurse Certification Program Millersville University

Untapped Resource Recognizes subtle changes of youth Knowledge, skills and expertise to assess for and refer Return to school plan Follow-up Advocate The certified school nurse (CSN) is an untapped resource for mental health providers. The CSN has the knowledge, skills and expertise to assess for, refer and provide mental health interventions to school age youth. In addition, the CSN is a connection from the student to the family and mental health providers to promote continuity with interventions. Often the CSN is the first to recognize the red flags, many times very subtle, for mental health problems. The CSN can play a key role in the return-to-school plan, with follow-up and support in that difficult time for the student and family. Frequently, the CSN is also involved in prevention and health promotion activities related to mental health. These types of activities provide a proactive approach to mental health problems that enable the CSN to partner with mental health providers for education and support group assistance. School nurses serve a multitude of student health needs in addition to promoting primary health prevention activities for student/faculty well-being. Although the number of school age youth with chronic illnesses has sharply increased, as a result of asthma, allergies and diabetes, the school nurse provides care for just as many or more students with mental health problems. If it hasn’t already, the United States will reach a point where mental health/psychosocial problems and risk-taking behaviors result in a greater morbidity and mortality for school age youth than physical illnesses (Melnyk, Brown, Jones, Kreipe & Novak, 2003). Given the barriers to mental health care, fragmentation of care for school age youth is most prevalent. How can these children stop “slipping through the cracks,” obtain follow-up care or be screened for problems before they reach a crisis A key person who could link the mental health provider, parent and student is the certified school nurse (CSN). How can we best use the CSN to help students in school and how can the CSN support the student returning to the school setting from mental health treatment? How can a partnership between CSNs and the mental health system develop to help decrease the effect of fragmented care?

Overview History SN Educational criteria for SN Certification Roles of School Nurses

History School Nursing 1902 NYC to reduce absenteeism Communicable disease Chronic disease Physical Mental “Specialized practice of professional nursing that advances the well being, academic success and life-long achievement of school age youth” NASN School health is delivered in three ways across the nation. The first way is by a school nurse employed by the Department of Education and hired by the local School Board of Directors. This primarily occurs in the New England, Mid-Atlantic States to Illinois and some western states. The southeast (beginning with Maryland) and midwest tier of states provide school health services through public health nurses who are employed by the Department of Health. The third means of providing health services is for the local school board to contract care out to public health departments. Very few states (6-7) serve their students in this manner. The first two methods for providing school health are about evenly split (~22-21 states).

School Nurses Facilitate positive student responses to normal development Promote health and safety Intervene with actual/potential problems Provide case management services Collaborate with others to build student and family capacity for adaptation, self management, self advocacy and learning Mental health morbidities extend into the school and require the school nurse to be knowledgeable of these problems and trajectories, primarily as they affect learning. Often, difficulties in academic performance or social relationships and absenteeism precede a mental health diagnosis. Many of the mental health disorders that emerge in childhood are likely to persist through adult life. With this in mind, many have concluded that the incidence of students with difficulties in school must be viewed as an educational and health crisis (DeSocio & Hootman, 2002). School absences or frequent visits to the health office for vague, nonspecific physical health problems are often related to an underlying mental health problem (Campo, Jansen-McWilliams, Comer & Kelleher, 1999). Students frequent the health office with aches, pains, stomachaches and other unexplained physical symptoms. Somatic complaints often are seen in the school-age child with depression but adolescents can present that way as well (Lyon & Morgan-Judge, 2000). The CSN can often identify mental health problems, such as depression, drug involvement and suicidal behavior (Eggert, Thompson, Randell & Pike, 2002). The disruptive behaviors that come with Attention Deficit Disorder and Oppositional Defiant Disorder often appear during preschool and early school age, making school transitions and social functioning difficult as well as academic success. Even though children and adolescents with depression attract less attention, their academic functioning still suffers. Being compromised by symptoms of poor concentration, distractibility, insomnia and day time sleepiness, students do not succeed academically. Anxiety disorders and Post Traumatic Stress Disorder (PTSD) are often co-morbid with depression and also contribute to school avoidance or lack of achievement. Tiet et al. (2001) notes that events like changing schools are associated with an increase in anxiety disorder and depression. Other adverse events (abuse, violence, divorce, homelessness) in these students’ lives also put them at risk for mental health problems. These students, depressed or anxious, are often frequent health room visitors. Studies (e.g., Insel, 2003) indicate that behaviors as a result of mental health disorders affect school performance causing academic impairment. The CSN recognizes these markers of psychosocial distress and compromised school functioning and is able to achieve prompt mental health promotion and prevention activities or referral for diagnosis and treatment.

PA School Nurses BSN plus additional educational content school law with special needs- IEP and 504 educational psychology counseling techniques practicum in school health Specialist I and II School Nurse 24 graduate credits and 3 years practice Ratio: 1: 1500 Act 48

Roles of School Nurses Assessment Coordination Education Advocacy Collaboration The CSN recognizes these markers of psychosocial distress and compromised school functioning and is able to achieve prompt mental health promotion and prevention activities or referral for diagnosis and treatment. The CSN is often the individual who has the total picture of the student and can initiate referral for diagnosis and care. The CSN role in identifying a student with a mental health disorder is crucial for prompt referral and diagnosis. Since the CSN is also a member of the Student Assistance Team (SAP), this makes his or her role even more advantageous to facilitating ongoing collaboration with mental health providers

Assessment Role Holistic view aware of subtle changes Physical and Mental Screening TeenScreen – Columbia University SAP team assessment Individualized Educational Program Assessment and objectives

Coordination SAP Team member Connect students with mental health providers Support groups Monitor health status Give information Problem solve Emotional support

Education Students Faculty Parents Health promotion and prevention Stress reduction Symptoms of depression or anxiety Chronic illness management Adherence Crisis prevention, recognizing triggers Faculty Parents

Advocacy Absenteeism Support groups Youth Parent

Collaboration School community Mental Health Community SAP Transition of students back into school Consultants Co-facilitators Educators

Partnership for Success Coordination of services within school Connection to mental health providers Collaboration Seamless transition Support groups Updates of student progress-problems Screening Advocacy