Today, it’s more difficult than ever for students to deal with the pressures they face in secondary schools, and there’s no single blueprint defining the role of the principal on this extremely important issue. To get a better perspective on dealing with student mental health issues, we convened a roundtable that included Christopher Berry, principal of James Hubert Blake High School in Montgomery County, MD; Brett Blanchard, principal of Fair Haven Union High School in Fair Haven, VT; and Darcy Gruttadaro, director of advocacy at the National Alliance on Mental Illness (NAMI). Principal Leadership Senior Editor Michael Levin-Epstein moderated the discussion. 

Levin-Epstein: What’s the role of the secondary school principal in dealing with mental health issues?

Blanchard: The most immediate thing I deal with happens to be working directly with students. I added a new position last year—a second full-time, school-based clinician. I try to connect regularly with my assistant principal and our clinicians just to keep updated and see where things are.

Berry: As context, Blake is a school of 1,650 students, and we’re part of a large suburban school system of roughly 150,000 students, so we have a large central office to support us. My role really is to work with my counseling department on mental health issues, ensuring they have a handle on our students and are in tune with what students are experiencing. Specifically, it’s about providing opportunities for personal education, resources that are external to the school that we can connect them with, as well as providing group-processing situations for them. We do not have a clinician on hand; unfortunately, I can’t provide that service to my students.

Gruttadaro: These are great examples of ways in which principals can play a leadership role in supporting students who may have mental health conditions. Twenty percent of youths between the ages of 13 and 18 live with a mental health condition. Half of all lifetime [mental health] cases start by age 14. So, these are conditions that impact high school students. Obviously, school leaders, principals, and secondary school principals have a key role to play because students spend six-plus hours a day at school. School is an important place to identify students who may be struggling with mental health conditions, because we don’t identify the majority of young people who experience a mental health condition. We have large lag times between when a condition begins and when a student is connected with care. 

It’s important that teachers and school staff know the early warning signs of mental health conditions and how to talk with families about mental health concerns. For many, mental health remains a taboo topic. So, it’s important that school staff becomes more comfortable talking with students and families about mental health issues. That comes with educating school staff and the whole school community about mental health conditions. 

We agree with Brett about the importance of adding a school mental health professional to the school staff. We lose about 4,400 young people every year to suicide, and suicide is now at a 20-year high. Losing about 4,400 young people every year to youth suicide is the equivalent of the lives lost in the 9/11 tragedy. Knowing the early warning signs, how to start conversations, and how to connect students and families with care in the community is extremely important. We need to build bridges between the school and the community mental health system so that students and families can access needed care.

Levin-Epstein: What are some of the early warning signs, especially of serious issues?

Gruttadaro: NAMI has a number of resources on our website about the early warning signs of mental health conditions. These include suddenly acting differently, feeling sad or withdrawn for an extended period of time, changes in behavior (like serious risk-taking behaviors), also severe mood swings that interfere with getting along with peers and academic performance. 

[Other symptoms include] extreme difficulty concentrating, intense worries or fears that get in the way of daily activity, and signs of eating disorders (which can be hidden, so recognizing significant and unexplained changes in weight). Look out for signs of cutting/self-harm and related signs of extreme distress on the part of students. 

Knowing the early warning signs and what to do if you see them is important. Teachers, school resource officers, coaches, counselors, and staff in the cafeteria all play a role in identifying students who may be experiencing early warnings signs of a mental health condition. Take action to talk with the student and to connect them with services and supports.

Berry: I would also add-what Darcy said is spot on-it takes a great number of people to keep an eye on kids. There are a lot of different warning signs and different personnel see different things. Just because we’re seeing something on the school end does not mean the parents are seeing that as well, and vice versa. It is building that bridge to the parents, and giving them a perspective of what’s happening at school versus what might be happening at home. Sometimes those two are diametrically opposed to one another.

Levin-Epstein: As principals, how do you make the decision about when to involve parents?

Blanchard: My assistant principal does a great job trying to get parents involved with most any serious concern. We created an alternative school with flexible time and inquiry-driven, project-​based learning as the foundation called the Annex. Our Annex instructors try to keep parents apprised regularly of what’s going on. We’ve also added a mental health component as part of it. But it’s a tough call.

Berry: It is. I would say, in my instance, I will oftentimes err on the side of communicating on the front end of things, because I believe it’s important to raise awareness among parents-provide them with as much objective data about their child and what our concern is. It’s about educating them, because sometimes not only are they not as aware of their own children as perhaps they need to be, but they don’t know what the resources are. 

And sometimes the situation is just the opposite: The parents have a very strong understanding of where their children are and what issues they’re facing. I would rather have early communication with parents to just let them know what we’re observing versus allowing it to linger for a period of time waiting for additional or stronger signs.

Blanchard: I agree.

Gruttadaro: Yes, it is true that behaviors can look quite different at home and at school, which is why schools play such an important role in connecting students with services and supports. The fear of being stigmatized remains a barrier to many seeking mental health care. For families to hear that their child may be experiencing a mental health condition is difficult. So, it is important for school staff to be sensitive and handle it delicately. 

NAMI has 900 state and affiliate organizations around the country, and we stand ready to work with schools on ways to effectively talk with families about mental health concerns. We strongly urge schools, if they haven’t already done so, to connect with NAMI in the community. NAMI has programs that are delivered in schools. This includes NAMI Parents & Teachers as Allies, a free in-service program that informs school staff about early warning signs, how to talk with families, and other important information. We recognize that schools have a tremendous amount on their plates and are often underresourced, with many experiencing deep budget cuts. NAMI is in the community to support and work with schools and with families around mental health issues. Secondary school principals are strongly encouraged to reach out to NAMI in their community.

Levin-Epstein: Are there stressors today on students that might not have existed 10 years ago?

Berry: I would say yes to that. Being an adolescent today is more difficult than it was even five to 10 and definitely 15 years ago. It isn’t that students’ ability to cope or navigate is any less, but what they’re exposed to at a younger age is different than it was, say, 15 years ago. The game-changer has been the internet and social media. The 24/7 nature of information being in their face and in their minds is much more than it was 15 years ago. An adolescent’s ability to cope or problem solve is more challenging. I’m seeing more cases of depression. That being said, I think our recognition of these things, our desire to recognize and work with students as parents, as a school, and as a society has increased as well. I do agree with Darcy that I think there is still a strong stigma around mental health issues, but I think we are making progress in that area. It’s probably a good thing because of these greater challenges.

Blanchard: In five years the world has changed pretty dramatically for us with mental health needs. A piece of that is what Chris said. There’s also a real, true, deep sense of immediacy, unlike any other time, I think ever. They [students] get information immediately, they expect immediate results, and it just complicates their world so quickly. There’s not even a lot of time to try to process. So, a lot of this really slow, painful process to improve mental health is becoming more difficult because of this rapidly paced world that they live in. There’s nothing comparable that I can come up with over the last 10 years. It’s just this rapid, rapid world of exchange and socialization and all the angst that comes with that.

Berry: That’s a very good point, Brett. I agree with that. I am not a brain expert by any stretch of the imagination, but the adolescent brain is still developing, and their ability to problem solve is challenged when they are constantly barraged with both information and the rapidity of that information. The idea of “thinking through” something and the intentionality that goes with good problem solving too frequently goes out the window.

Gruttadaro: Interestingly, the cover story of the [early November] issue of TIME magazine is “Anxiety, Depression and the Modern Adolescent: Why the Kids Are Not Alright.” I agree with Chris that we are making progress on stigma, and there is hope that we will continue to see stigma eradicated. We are seeing mental health more in the media, talked about by political leaders and more in public conversations. That is promising. NAMI also has a program called Ending the Silence, a classroom program delivered to students. When NAMI delivers this program to high school students, kids seem much more willing to come forward and talk about mental health, including their own experiences. We want to see mental health information in all of our high school health curriculum.

Berry: It actually is included in our health curriculum. There’s a unit devoted to “red flags,” which is very helpful. I believe that today’s young people are more open to the idea of reflecting on their own well-being than some adult parents are. A helpful analogy that I use to frame the issue with adults is this: If you go to the doctor and he/she says that you have high blood pressure, most people have no qualms about taking medication that might help you treat that. Why is it, then, when a doctor or a trusted adult says to you, “You may have mental health issues, and you may wish to take such-and-such course” that people question that and say, “Well, is that really true?” or “Why is that?” or there’s just a feeling of not a complete trust in working at being mentally healthy?

Blanchard: That’s part of the health curriculum that we’re trying to work on-healthy choice-making, positive peer relationships, all of that. There is a component with counseling being seen as negative, but that’s a real societal, American type of issue. It’s getting better, by the way. It’s certainly much better here that the so-called stigma, whatever you want to call it, has greatly lessened for me in this building in the last five years.

Gruttadaro: The National Collegiate Athletic Association (NCAA) medical director informed us that when he went around the country and talked with coaches and athletes about their major health concerns, he expected to hear most about concern with concussions and related issues from college athletes and coaches. Instead, he shared that the No. 1 concern that came up was mental health. It is extremely helpful that the NCAA has been active in addressing mental health and stigma. This represents an important change on these issues. We want all young people who need help to come forward so they can keep their lives on track and get the care and support they need.

Levin-Epstein: Can you describe a situation involving a student who had a mental health issue that sticks in your mind for a particular reason?

Berry: The most obvious situation for me as principal at Blake is that we have had two student suicides in the last 45 days. Each was different in its own way. The first student was seemingly happy-go-lucky, positive, no signs of crisis or mental health to the average person. He took his own life, and among the impressions left was that too often we don’t know a teenager’s full story. It is possible for a student to arrive at the point where they want to take their own life and there not be many, if any, overt symptoms of that. 

Our student community has reacted in a number of ways, some of which have to do with the young men themselves, some of which have to do with their own issues that they are coping with. Some have not reacted at all because they did not know these young men, and it really didn’t impact their lives other than a general sense that it’s a tragic thing to have happened. 

What has been one of the underlying learning experiences for me as a principal is that when you are leading a community through the grief process and dealing with issues that have an underlying mental health component, there are many different permutations of how people grieve, how they process information, how they integrate this with circumstances in their own lives. It is a real challenge to work with students and the overall community to come to grips with this. And that’s where outside sources such as NAMI are really crucial to helping the community as a whole.

Blanchard: We had a student whom we had to process for a drug issue but also knew that recently the student had tried to commit suicide. So, we were in a very difficult place of holding the person accountable, processing with the parent-who rightfully is then thinking how’s this going to impact their child-then, when we did have to suspend [the student], she did attempt suicide over that weekend. The good news from that kind of grim scenario-and when I hear Chris, it does shake me to the core-is that in this case we were able to work with the facility where she was placed, and when she came in, it was a positive structured environment that so far-it’s been a couple of weeks-she’s been more outgoing. It points to how you are always on that edge of which, God forbid, it does kick it to the other side.

Berry: I think Brett raises a good point, that one of the changes we’ve seen with drugs and alcohol-which is really a symptom, not a root cause-is our working to treat it less as a discipline issue unless that is called for, and more as an issue of a person’s health-trying to get them help and identify programs and assistance for them, and making that the first priority.

Gruttadaro: Youth suicide shakes a community to its core-the school community, families, youth … everyone. We’ve seen clusters of youth suicide in multiple communities around the country. We must continue to address stigma, continue to let students know, “If you know someone who’s struggling, who may be suggesting they are considering suicide, speak up, involve a trusted adult.” As Chris and Brett suggested, the more we look at mental health and substance use as health issues that require connection to effective services and support, the more we will continue to see positive outcomes. We can tackle teen suicide in this country, but we need to tackle stigma, raise broader awareness about mental health conditions, and keep encouraging students to come forward when they need help. Students also need to know how to help a friend if someone else is struggling.

Berry: We’ve gotten a lot of information and advice over the last 45 days, but one of the ideas that has resonated the deepest with me and others is this: “The best way to prevent suicide is to talk about suicide.” That fits with what Darcy has said in terms of the communication process, the destigmatization of those sorts of issues. On the positive side of this horrible tragedy for Blake, there has been a significant identification of students in need, a good deal of parents coming forward seeking attention and assistance. In many cases we’ve done good work in the wake of some horrible things.

Gruttadaro: There’s a myth that talking about suicide will plant the seed in a person’s mind. In fact, research shows that if you are worried about a person who may be suicidal, it is helpful to ask the person if they are suicidal and to help them connect with help. You stand a much better chance of preventing suicide by talking about it with a person who is struggling.