Mental Health First Responders In schools, we often first see signs of mental health issues in our students. Here’s what to note behaviorally, socially and in speech-language patterns. Features
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Features  |   August 01, 2018
Mental Health First Responders
Author Notes
  • Sharon Baum, MA, CCC-SLP, provides services privately and in a middle-school ASD Nest Program in the New York City Public Schools. She is also a freelance writer. sbaum.k@gmail.com
    Sharon Baum, MA, CCC-SLP, provides services privately and in a middle-school ASD Nest Program in the New York City Public Schools. She is also a freelance writer. sbaum.k@gmail.com×
Article Information
School-Based Settings / Features
Features   |   August 01, 2018
Mental Health First Responders
The ASHA Leader, August 2018, Vol. 23, 54-60. doi:10.1044/leader.FTR2.23082018.54
The ASHA Leader, August 2018, Vol. 23, 54-60. doi:10.1044/leader.FTR2.23082018.54
I didn’t see the shock coming: “I was just in the hospital for trying to kill myself. I’m just back at school now,” Sarah,* a former student, told me when I ran into her while she walked home from her high school. Sarah’s worrisome words reminded me how challenging it is to help adolescents struggling with mental health problems.
Recently, concerns about mental illness, suicide and suicide contagion have only escalated in the wake of high-profile celebrity suicides, such as those of Anthony Bourdain and Kate Spade. When I worked with Sarah during her middle school years, I had been constantly concerned about her psychological state—and had tried to get her help by contacting the school counselor, her teachers and her parents. Now I thought about what could have been done differently. Our team had many conversations with Sarah’s parents about her mental health struggles and need for treatment, but I wondered if Sarah’s situation might have turned out differently if we had placed even more pressure on them.
As a middle school speech-language pathologist, I worked with Sarah on fluency. Sarah struggled with monitoring fluency when reading aloud and during conversation with peers, and needed help with adjusting vocal volume for clarity. These challenges may have exacerbated her struggles with mental health. Over time, I saw Sarah become increasingly withdrawn and less motivated. She began sharing struggles from her personal life—academic pressures and lack of emotional support from her parents—and admitted to being isolated from others during much of her time outside school. She acknowledged having few friends and having strained relationships with the few friends she did have.
Although Sarah had already started seeing a mental health counselor, her mother said she was most worried about Sarah’s slipping grades, which she attributed to laziness. Her teachers and I urged Sarah’s mother to focus more on Sarah’s mental health and work actively with the therapist on tracing the origins of her lack of motivation. Then Sarah graduated from middle school, making her mother’s concern about her failing out a non-issue. Unfortunately, Sarah’s mental health issues didn’t exit with graduation. They lingered and apparently escalated.
Mental health struggles are not isolated to adolescence—they affect all age groups—but adolescence is an especially at-risk time for our students, as they navigate puberty, growing achievement pressures, questions about their identity and sexuality, and pre-adulthood. In fact, 20 percent of youth ages 13 to 18 experience severe mental disorders in a given year, according to the Substance Abuse and Mental Health Services Administration. And in 2016, suicide was the second leading cause of death for people ages 10 to 34. Many adolescents don’t speak up about needing help. For example, in 2014, less than half of adolescents who experienced a major depressive episode in the past year received treatment for it.
As audiologists and SLPs working in the schools, we, along with teachers and other school personnel, can be “first responders” to signs of mental health problems in our students. To heighten my awareness of these signs, I recently attended “ThriveNYC Mental Health First Aid Training,” a day-long workshop for first responders initiated by Mayor Bill de Blasio. In addition to mental health warning signs and steps we can take, the workshop covered how we can adjust our approach to students so they can feel safe and comfortable disclosing their burdens. In the following paragraphs, I share highlights of what I learned, as well as subtle changes in students’ speech-language patterns that could possibly indicate inner turmoil.

Watch for life circumstances that could trigger a mental health crisis, including social media bullying, financial troubles at home, and family instabilities.

Speech-language tip-offs
Mental illness in adolescence is “anything that impacts a student’s ability to live, love, laugh and learn,” according to the workshop curriculum. Mental health challenges are typically differentiated from an officially diagnosed mental illness, but both affect the way a person feels, thinks and relates to their surroundings. As communication sciences and disorders professionals, our intuition and close rapport with our students can attune us to warning signs that may be overlooked in the large classroom setting. We are skilled at picking up subtle changes in how students communicate.
Based on my experience working with adolescents, I’ve compiled a list of speech and language/overall emotional changes that could warrant concern and/or further investigation into a student’s mental health. Watch for:
Shifts in a student’s typical social role.
For example, I have students who are naturally outgoing. They like to delegate tasks to their peers, lead the conversation and initiate social activities. Other students are generally more shy and withdrawn. When these roles start changing with regularity—for example, the student who likes to take charge is increasingly withdrawn—we need to stop and assess the situation.
New or adjusted medications.
Be aware of your students’ medications. Note any changes in mood and behavior that could indicate a medication initiation, change or termination. If a student suddenly seems more withdrawn or overly excited, inform the parents and confirm any medication changes or initiations.
Alterations in a child’s expressive language.
A significant change in sentence structure during conversation or written narratives could indicate a change in mental health. The student who otherwise formulates complete ideas may now provide simplistic responses to questions. They may seem uncharacteristically unmotivated and “coast” through sessions.
Differences in pragmatic language and the degree students interact with peers.
The student may show social-skill regression or reluctance to work with other students. I had a student who had previously been eager to interact with peers and then started refusing to work with others. Instead he only wanted to work alone. His mother informed me during a check-in conversation that he had been refusing to take his medications, despite continued prompting. The social worker and I met with her to brainstorm possible solutions to motivate him to take the medication. She made a follow-up appointment with the psychiatrist, who helped resolve the situation.
Delays in processing or ability to break down information.
A student who once answered questions quickly now takes a long time to answer. This could be the byproduct of a medication change or emotional shift. Long stares from students as they prepare a response can also be cause for concern if this behavior is atypical.
Cognitive changes.
Watch out if a student shows a quick decline in ability to generate inferences and predict outcomes in situations and text. They may fail to use prior knowledge to figure out how to navigate new situations.

When a student is in distress, it is better not to offer a potentially false promise that “tomorrow will be OK.”

First line: Talk to students
Keep in mind that students don’t need to show obvious changes to be at risk. Some may arrive with characteristics that warrant our attention: They may have frequent crying spells, seem to always be the brunt of jokes, consistently take the blame and be lethargic. Also watch for life circumstances that could trigger a mental health crisis, including social media bullying, financial troubles at home and family instabilities.
Simply talking to our students can help draw them out on problems causing them mental health anguish. Taking the perspective of our students can help us determine the best way to communicate with them, we learned while role-playing with each other in our mental health first-aid training. Sometimes statements meant to comfort and support the student actually close the open line of communication that we are trying to foster. For example, when a student is in distress, it is better not to offer a potentially false promise that “tomorrow will be OK.” Even though we want to provide immediate relief for our students, we can only empathize.
We also need to be culturally sensitive, and aware of communication styles unique to particular cultures and racial groups. For example, in some cultures, emotions are typically described using physical characteristics (“my stomach hurts”) rather than labeling anxiety or depression with feelings. I have had students who use physical characteristics to express their emotions, and I learned over time that I had mistakenly not picked up on the connection to anxiety and/or sadness. This cultural awareness and sensitivity can also help you communicate with parents about choosing support services. For example, some families prefer using family and community supports to help their struggling children. They may use mental health services only as a last resort.
Examples of statements/questions that validate the student’s feelings and your readiness to help include:
  • “Are you OK?”

  • “I am concerned about you.”

  • “It’s hard for me to understand exactly what you are going through, but I can see that it’s distressing for you.”

  • “Something seems to be bothering you. Do you want to talk about it?”

Examples of statements that may discourage the student from asking for help include:
  • “I understand exactly what you are going through, that happened to me two years ago.”

  • “You’ll get over it. You’ve just got to ignore it and get on with your life.”

  • “You’ve just got to face up to reality. Life is not a bed of roses.”

  • “You’ll feel differently tomorrow.”

In some cultures, emotions are typically described using physical characteristics (“my stomach hurts”) rather than labeling anxiety or depression with feelings.

Quick-response protocol
When talking to a student indicates a potential mental health issue, a quick-reference framework shared at the workshop can guide you on next steps. As first responders, we can make a quick assessment and figure out who to consult next. The simple protocol (that doesn’t need to be followed in a fixed order) is:
  • Action A: Assess for risk of suicide or harm.

  • Action L: Listen nonjudgmentally.

  • Action G: Give reassurance and information.

  • Action E: Encourage appropriate professional help.

  • Action F: Foster self-help and other support strategies.

Action A is particularly important: Immediately consider whether the student seems likely to harm themselves based on their verbal statements and/or having close access to a weapon that can harm them, in which case you should seek emergency help. In this situation, it is important to immediately contact the guidance counselor, who can collaborate with the principal and call 911.
Some warning signs of a student contemplating suicide may include: threatening to kill or hurt themselves, increased alcohol or drug use, feeling trapped, having excessive rage or anger, giving away prized possessions, sleeping all of the time or being unable to sleep, expressing hopelessness or no reason/purpose for living, talking or writing about death and suicide (can be expressed in journal or through artwork and other outlets), and having a dramatic shift in mood with no observable cause. While mental illness alone does not indicate that someone is suicidal, it elevates the risk.

If we use our professional skills to inform mental health, we can more quickly identify students who are struggling and help them access appropriate help.

Our colleagues are key
When we see signs of mental health issues in our students, our go-to people should, of course, be school psychologists and counselors. They can help us understand the nuances of our students’ struggles, and often act as direct liaisons to parents for serious conversations and concerns. They can also suggest or—in more extreme cases—mandate outside services and supports when the services in school cannot adequately address a student’s needs.
A school counselor I work with urges us to report red flags immediately, so we don’t lose time in helping our students. After learning of the red flags, she typically meets with the SLP, who sometimes has developed the closest rapport with the student. Next, she talks with the student to determine their state of mind. After collaborating with the student, teachers and providers, she determines how to approach the situation with the parent. Sometimes, a brief conversation with the parent with recommendations suffices. In more serious situations, a parent may be called in immediately and mandated to take the child to the emergency room.

When we see signs of mental health issues in our students, our go-to people should, of course, be school psychologists and counselors.

If we use our professional skills to inform mental health, we can more quickly identify students who are struggling and help them access appropriate help. But it takes all of us to get them the help they need. Sarah was just one student who was red-flagged for serious struggles with mental health. We worked together to come up with a game plan to make sure her parents would be better informed.
I learned how important it is to not only include parents in the collaboration process, but also to use all the strength we can muster as a team to ensure parents fully comprehend the severity of their child’s situation. We benefit our students most when we collaborate with counselors, school psychologists, occupational therapists, social workers, teachers and parents, just to name a few.
We also shouldn’t hesitate to keep pressuring parents to access the help their children need, and make sure that they are not just paying us lip service by stating that they understand. Follow-up calls with parents and outside support services can help determine if there’s a genuine plan of action in place. This can prevent an escalation of symptoms before a crisis occurs.
We are not only SLPs, but first responders as well. It is our job to provide a supportive environment for our students that not only targets speech and language goals, but helps us identify mental health challenges. That way, we can quickly intervene and pave the way for our students to achieve their goals.
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August 2018
Volume 23, Issue 8