Mary Kadera
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hope for mental health

4/28/2023

 
If you’ve read about teen (and child) mental health these days, I’m betting the headline contained the word “crisis” or the phrase “the kids are not all right” (Google it and see).

I once thought in these terms, until I stopped to consider what message it sends to the young people we’re concerned about.

When we say things like this, we’re branding a whole generation as broken. (This is my issue with the term “learning loss,” too).

By age 40, about 50% of us will have or have had a mental health issue. I’ve had them, and it never once helped me to feel like I was branded, broken, or exceptional. It helped me to know: Lots of other people feel this way sometime in their lives. You are still you, with all the qualities and talents that make you wonderful. This won’t last forever. There are ways to get help. Matthew Biel, Chief of Adolescent and Child Psychiatry at Georgetown Hospital, says, “Talk about it as part of the human condition, in every place humans spend time.”

It’s true that by many measures, there are more young people reporting mental health issues today than in years past. The pandemic undoubtedly took its toll on mental health, but there were signs of something going on even before 2020. There’s been a lot of research and discussion about the effects of social media; changes in diet, sleep and exercise; and the advent of new drugs that are more addictive than ever before.

While we untangle the answers to the “What’s going on?” question, in parallel we need to make good on the assurance “This won’t last forever. There are ways to get help.”

Part of the “crisis” is our ability to respond to those who need help. In Arlington, as in other communities, supply of treatment isn’t keeping up with demand. We don’t have enough clinicians who work with children and teens, and families are on waiting lists for public and private providers. There aren’t enough inpatient beds in public and private hospitals and treatment centers for young people who are truly in crisis.

It’s easy to feel paralyzed by problems that are hard to solve. As a nation (world?) we’ve never invested in mental health the way we should. I can’t wave a wand to conjure a new army of mental health providers. But there are smaller, more local steps we can take.

​I’ve been doing a lot of listening, reading and studying to understand what’s already in place in our community and what more might be possible. I compiled what I learned here, including twelve steps I think we could consider for Arlington. I’ll share a few of them below.
You Are Not Alone
In Arlington, 14% of students in grades 4-5 and 23% in grades 6-12 feel not at all connected or only slightly connected to other students at school. 1 in 3 of our students in grades 4-12 say they do not have a trusted adult outside of school they can talk to when they need help.

Some of the steps we could take to create more connection and belonging—an incredible protective factor for mental health—could include:

  • Creating smaller communities (school size, class size) and intentional relationship mapping: ensuring that every student has a trusted adult mentor within the school. Some schools will map peer relationships, too, and offer social skills groups or other ways to help students feel more included.
  • Community mentors: I love this article by teacher Renee Moore describing how mentoring worked at her school in Mississippi. And with a nod to Arlington Public Library’s Human Library Event tomorrow—what if we could create a human library of local citizens who are willing to share their talents and experiences with young people and their families?
  • Parent-to-parent mentors: In DC, the Early Childhood Intervention Network is training parents to become Family Leads and help other parents and caregivers with similar lived experiences. Family Leads go through a nine-month training and two-month apprenticeship. 100% of applicants have completed the training program, 100% are people of color, and Family Leads gain income and marketable skills by participating.
  • Teen Centers: Many communities are experimenting with models of care that combine recreational spaces where youth can spend time with peers in addition to attending appointments for mental health, tutoring, and college and career counseling. They’re located in storefronts, shopping centers and community centers, and accessible via public transportation including bus routes from schools. UpStreet in Pittsburgh is a great example. (Or, if you want to go abroad, check out Jigsaw at multiple locations throughout Ireland).
Easy Access on the School Campus
Many communities are making the decision to place critically needed services like medical, behavioral, dental, and vision care directly in schools so that all young people have easy access. Here’s what that looks like in communities close to ours:
  • At 31 schools in Montgomery County, the Department of Health and Human Services along with other local public and private nonprofit agencies offer counseling, psychiatric care, support groups and more. At 12 school-based health centers youth and families can get physicals, immunizations and prescriptions.
  • In DC Public Schools, the Department of Behavioral Services and community-based organizations offer family functional therapy, trauma-focused cognitive behavior therapy, parent-child interaction therapy, substance abuse services and more—even if students also have an outside provider.
  • At Alexandria’s two high school campuses, any resident aged 12-19 can visit the Teen Wellness Center tp receive free, confidential care including mental health and substance abuse counseling and reproductive health services. Non-confidential services include vaccines and treatment for minor illnesses.
One final point I’ll make: if we really want our young people to feel capable, resourceful and valuable, we have to treat them that way. And that means using a human-centered design approach that centers their ideas and involves them in creating any programs or solutions we develop for their benefit. We also know that having a sense of purpose protects our mental health—which means the young person who co-creates the solution may happily never need it.

“The needs keep coming"

3/12/2023

 
In July 2021, I found myself unexpectedly flying cross-country to my sister in San Francisco. Kathleen is an ICU nurse and COVID critical care had taken its toll: she was traumatized and had been approved for medical leave. My job was to bring her back east to be with the rest of our family while she waited for a spot to open up for her own treatment.

Kathleen’s breaking point underscored for me that no one is “too strong” or “too skilled” to be laid low by stress, trauma, and emotional exhaustion. She is an award-winning critical care nurse; she’s been published in peer-reviewed medical journals; she completed a Zen Buddhist chaplaincy program in order to minister to her colleagues at the hospital. A month prior, she’d been featured in The Atlantic’s coverage of COVID on the front lines.

Health care workers around the world, in my family and maybe in yours too have experienced not just trauma but moral injury. 

Moral injury was first described in the 1990s by Jonathan Shay, a psychiatrist who worked with Vietnam veterans. Since then, we’ve recognized moral injury in other settings, too, like health care. Moral injury arises when you take part in, witness, or fail to prevent an act that deeply violates your conscience or threatens your core values.

It can be individual in nature (e.g., I made an error in judgment; I did nothing as a bystander) or stem from systemic factors (e.g., I had to choose who to help because there weren’t enough supplies; I was told to adhere to policies that hurt someone).  In some cases, leadership piles on ever-increasing demands requiring workers to harm themselves (by pushing past their own human limits), their families (by being emotionally and physically unavailable), and those they serve (by turning away those in need of help). Outgrowths of moral injury can include depression, addiction, burnout and self-harm.
Picture
One moment among many for Kathleen was turning away a woman who was trying to visit her dying mother on Mother’s Day. She knew it was wrong, but it was what she was tasked with doing and she did it. Moral injury also comes about through being betrayed by those in positions of power - those in a position to do the right thing who choose otherwise. Kathleen talked about feeling “disposable” in those days before the vaccines. Nurses were at the bedsides doing the tasks of every other worker in order to minimize exposure to the virus. If something happened to her, she could be replaced. As an individual, she didn’t matter. 

Increasingly, I’m becoming concerned that there are a  significant number of educators in this country (and locally) who may be living with moral injury. 

Consider our school-based counselors, social workers and psychologists. The
CDC, the American Psychological Association, the American Academy of Pediatrics and other groups have recognized a significant increase in youth mental health issues and reported cases of trauma. Here’s how that looks through the eyes of a school psychologist—what she describes is above and beyond her regular duties and caseload.
[My calendar] does not reflect the 3 students who barreled into my office on Monday screaming and crying, the students who were waiting at my door when I was providing counseling to other students on Tuesday, the cursing student who came into my office as another student exited, the student who had a panic attack on Wednesday and needed to be seen again, the parent who showed up on Monday without an appointment who I have still not had time to call back, the parent who I had to call today because I’ve seen their teen 3 times this week, the student who I had to turn away because I had too many students in my office already, the teachers asking me to provide counseling, and the student who entered my office this afternoon just before the bell rang for dismissal and reported decades of trauma. The problem is this has become typical. 

I have parents calling because there are no appointments available [outside of school] and there are six-month waitlists for services at a minimum…. I have teachers crying and get calls to go to the classroom and meet with them. I write reports after school hours and on weekends. My counseling notes have not been updated in months.


I am exhausted. We are all exhausted… The needs keep coming. And we’re not able to meet them. We are drowning as we try to save the world."

​Here’s what a social worker had to say:
This year has been even harder than last year. I’m spending more time in classrooms, intervening with students, providing counseling support to students (and really their parents too), trying to problem solve, being a listening ear for teachers, and sitting in on more Special Education meetings than I ever have.  This is on top of all of the new initiatives and programming that are getting added to our work loads, including a more active role in threat assessments and prevention.

I want my students to feel like I did everything I could so that they feel supported in their educational journey. That their school is a safe place. I love my job and I love the kids that I get to work with. These students have never once made me question if working in schools was the profession for me. But I am tired.”

And from a school counselor: ​
We desperately need intervention teachers to support kids. I’ve watched teachers in tears this week asking for support to meet students’ learning/behavioral needs. Teachers don’t need coaches or specialists to tell them what to do, they need people in the building to help them do it.” ​
And finally, from a teacher: ​
Today was another difficult day… we received an email [from central administration]. More training. My English team teacher read the email, closed her Macbook, and wept. She said she cannot do one more thing. Her family life is falling apart because of the constant demands [at work].

At our staff meeting, I sat next to one of the most amazing teachers I have ever met. Her eyes were red and welled with tears… She said she has seven and a half years left; she doesn’t know how she is going to make it. We are trying to prop each other up."
Like my sister, these are veteran professionals with advanced degrees and certifications. As with my sister, their work is a calling. 

​
What they are describing is not “too busy” or “too stressed” or “going through a rough patch”—it feels to me like moral injury. Education shares with nursing an ethics of care and a history of innovation. Let’s be bold in seeking to build a public education system in which all can flourish.

Repairing  what was broken

5/23/2022

 
Since I joined the School Board in January, there hasn’t been a week that’s gone by when I haven’t been part of a conversation about mental health and school safety.

Locally and nationally, we have data confirming that many of our young people are struggling, socially and mentally. And that struggle manifests in many ways: anxiety, depression, self-harm, truancy, substance abuse, withdrawal, bullying, fighting and more.(1)

“We’re seeing a lot of juvenile behavior this year,” Martin Urbach, a teacher at Harvest Collegiate High School in New York City, told me during a Zoom conversation a few weeks ago. “Misbehavior in class, throwing things, horsing around. Also more interpersonal issues—many students have lost the ability to socialize.” He’s also concerned about behaviors stemming from deep trauma that many students have experienced. “Life is not OK.”

I reached out to Martin because I had visited his school in 2018 and 2019. At the time, I was struck by the strong culture they’d created in a public high school serving predominantly students of color and students from lower-income families. I was curious how the school was faring since the onset of COVID.

Martin, who now works full-time as the school’s restorative justice coordinator, told me that it has been “exhausting.” The 31 students trained in peer mediation at Harvest have run more than 200 restorative justice circles this year—a significant increase over prior years.

In response to what they’re seeing, Martin and his students (at Harvest they’re called “Circle Keepers”) have added a mentorship component to their restorative justice work.  Every 10th grade Circle Keeper is mentoring a 9th grader who’s been involved in a circle due to concerning behavior. Amber, one of the 10th grade mentors, told me, “I want them to think of me friend-wise, and just to be there to help them whenever they need.”

Martin, Amber, and the other students involved in Harvest’s restorative justice work are part of a larger movement to infuse restorative practices at schools across the country. Restorative justice is an approach that emphasizes mediation, helping students understand the causes and consequences of their behavior, and making amends for harm that was done in order to repair and restore relationships.

"We have to change the paradigm of how we look at ‘infractions,’” Martin told me when we talked earlier this month. “We reframe it from ‘rules are broken’ to ‘people are harmed.’”

Across the country at Balboa High School in San Francisco, principal Kevin Kerr has pinned to his bulletin board a list of five “restorative questions” to ask students in trouble. Among them is the one he considers most important: “What do you think needs to be done to make things as right as possible?”

Restorative practices are gaining traction as many school districts move away from the “zero-tolerance” exclusionary discipline popularized in previous decades. “In the ‘90s and 2000s, schools started cracking down on minor misbehavior,” said Aaron Kupchik, a professor of sociology and criminal justice at the University of Delaware. “These behaviors posed no threat to student safety—talking back, cursing, dress code violations. Suspension became the normal reaction.”

In contrast, restorative justice aims to keep students integrated into the school community whenever possible. “We want to be sure they don’t think they’re throwaways,” Martin told me. Students can be suspended at Harvest, or even expelled, if restorative practices haven’t worked or if the school is legally required to suspend in response to certain behaviors (e.g., bringing a knife to school). But it’s widely understood to be the option of last resort, and the school follows specific restorative protocols when it’s time for the student to rejoin the school community.

I wasn’t sure if the uptick in concerning behaviors at Harvest this year (as in many other schools across the country) would have compelled school leaders to adopt more traditional discipline. I get it: school staff members are under tremendous pressure this year. Parents are worried. Police have been called to both of my own kids’ schools in the past few months in response to threats. Why, especially now, would anyone take on the extra work that real restorative justice requires?


The trouble with suspensions and the benefits of belonging

When a student is a danger to themselves or others, it’s absolutely appropriate to remove them to a setting where danger is minimized and they can get help. In theory, this is what suspension is supposed to accomplish.

​In many US schools, however, it’s overused, and that has negative consequences for the whole school community.(2) Suspended students are less likely to graduate from high school and more likely to be incarcerated. Students with disabilities and Black students are suspended at disproportionately high rates, and research has confirmed that this overrepresentation is because they are punished more harshly for similar offenses.

Are suspensions an effective deterrent to future misbehavior? No—in fact, they increase its likelihood. What does deter fighting, bullying, and other troubling behaviors are restorative practices.  Recent, rigorous evaluations in Minnesota and California confirm that restorative approaches also improve academic performance.

This makes sense to me, because I believe that behavior is a form of communication, and “misbehavior” is a student trying to communicate that something is very wrong. Often it’s difficult (even for adults!) to articulate exactly what’s bothering us and what we need. It can take real time and effort to get to root causes and solutions, and sometimes that’s not our go-to response.

“Our instinct is to hate the other person,” says Tamar Shoshan, a junior at Manhattan Hunter Science High School in New York City. “Cancel culture plays a large part in that. We’re taught that if a person does one thing wrong, we label them as a bad person. [We have to] acknowledge that people are complex, and they have reasons for acting out.” We have to call them in—not call them out.

Seeing others this way requires curiosity, generosity and empathy—but without stinting on accountability. “Nobody is letting anybody off the hook,” said Balboa HS principal Kevin Kerr. “Whenever we have one of these restorative justice sessions, the perpetrator inevitably walks out of the room crying. That’s not our goal, but it’s just natural. We’re human beings, we’re going to have a sense of compassion for this person that we harmed, once we have a chance to see how our actions made them feel.”

What does it take to do it right?

Restorative justice is most effective when it’s part of a larger fabric of restorative practices in schools. “Restorative justice” is commonly understood to be a method for intervening in response to specific conflicts or misdeeds—it’s often reactive. “Restorative practices” encompass a larger set of tactics that schools can use to proactively build strong communities.

Schools that have a holistic approach to restorative practices often have a tiered system that looks something like this:
  • Tier One: Community-building activities like morning meetings, small-group advisories, and teachers and students working collaboratively to create classroom rules and jobs. These activities involve all staff and students at the school, and often families. For example, last year at Harvest Collegiate while instruction was virtual, the school coordinated weekly mental health circles co-led by students and staff members.
  • Tier Two: Smaller groups convene in response to a specific problem or conflict. The group includes the harmed student, the person causing the harm, and a group of their peers and/or adults. They’ll talk about what happened and what can be done to repair the harm. The student who was harmed must feel no pressure to participate, but often elects to do so.
  • Tier Three: Practices aimed at reintegrating students who’ve been out of school due to suspension, expulsion, incarceration or truancy.

It takes real time, effort and intention to do this with fidelity. School staff members need a strong, shared definition of restorative practices: what they are, why they’re important, and how to implement them. Often, one or more staff members are designated as restorative justice coordinators and receive special training for that role; all staff members need time, training and support to implement “Tier One” practices like those described above.

Derek Hinckley, a eighth-grade teacher in Chicago, taught for ten years but still didn’t feel like he had a good working knowledge of restorative practices, despite working in a school that espoused the approach.

“I never received any formal training on what restorative practices look like and how to do them well,” Hinckley said. “I have my understanding of how to use restorative practices in my classroom, but that’s not necessarily what everybody else means.”

Shifting a school to a restorative model is hard work for leaders, too. Dr. Ben Williams, the founding principal of Ron Brown Collegiate Preparatory High School in Washington, DC, talked to me in 2018 about the difficulty of launching the District’s first all-male public high school with a restorative justice culture. “There’s nobody out there trying to do what I’m doing,” he told me. “It’s lonely work.” Even though Williams recruited staff with the understanding that they’d need to buy into the school’s restorative approach, and even though parents actively opted in to send their sons to the new school, he noted that many families and staff members still expected, and even pushed for, exclusionary discipline measures.

Allan Benton, a school principal in California, has been using restorative practices for nearly a decade. He cautions that it’s all too tempting for school and district administrators to distort restorative justice as a “quick fix”solution to unfavorable rates of suspension and expulsion.

“We saw schools quickly turn [toward restorative justice],” Benton said. “Suspensions went to zero, but you had a horrible school climate, and kids were afraid because [their peers] were doing really bad things that weren’t being properly dealt with. Just getting suspensions to disappear isn’t helping, nor is it actually restorative justice.”

With time and effort, however, restorative practices yield good dividends. At Harvest, 98% of students report that their teachers treat them with respect. 97% say they feel safe in the hallways, bathrooms, locker rooms, and cafeteria. And 93% of families say that school staff work hard to build trusting relationships with families like them.

Perfect? No—but I like those odds. I’m curious to learn more and do more in this area, and I hope you are, too.


(1) See for example the CDC Adolescent Behaviors and Experiences Survey; the AACAP’s Declaration of a National Emergency in Children’s Mental Health; and this recent RAND survey of California principals.
(2) For an excellent roundup of relevant research, please see the Learning Policy Institute’s October 2021 brief “Building a Positive School Climate Through Restorative Practices.”





How trauma shows up at school

3/18/2022

 
If you tuned in to this week’s School Board budget work session, you may have heard me asking about funding for trauma-informed work in our schools next year.

“Trauma-informed” is a term that’s we’re hearing more and more connected to students, schools and teaching. This is because we’re understanding more and more about how childhood trauma affects students’ ability to learn and thrive, and because childhood trauma has escalated during the pandemic.

Trauma matters first and foremost because of our human compassion for those who have experienced it. It also matters because it can significantly disrupt a student’s learning and a school’s ability to operate.


In Virginia, 6 out of 10 students have experienced some form of childhood trauma. 3 in 10 have endured multiple traumatic events. And that was before the pandemic.*

What is “childhood trauma,” anyway?

Researchers in the 1990s originally identified ten types of childhood trauma, or what they termed “adverse childhood experiences” (ACEs). Five are personal: physical abuse, verbal abuse, sexual abuse, physical neglect and emotional neglect. The remaining five are related to other family members: a parent who has a substance abuse problem, a parent who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and experiencing divorce of parents.  Based on how many types of trauma a child has experienced, they might have an ACE score anywhere from zero (has experienced none of these things) up to ten.

In the 2000s, the definition of childhood trauma was expanded to include other experiences like homelessness, involvement with foster care, involvement with the juvenile justice system, chronic poverty, recovering from a severe accident, bullying, racism and more.

Then came the pandemic. Dr. Shannon Thyne, director of pediatrics at the Los Angeles County Department of Health Services, says “I think of the pandemic as an ‘ACE’ for every kid in America.” Dr. Thyne’s colleagues in the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association echoed this when they jointly declared a national emergency in children’s mental health last October.


Trauma shows up at school in many ways—but often it’s what looks like “bad behavior.”
​

We know that trauma causes actual biological changes in our brains and bodies. It disrupts the normal processes that help us with emotional self-regulation, organization, memory, focusing our attention, calming our bodies and more.
Children who have experienced trauma are often triggered by a perceived loss of control, anxiety around changes in routine, fear of disappointing or upsetting others, and unexpected events, sounds, sights and activities.

But sometimes the triggers are less obvious. Jamie Howard, a child psychologist in New York, remembers working with a student who refused to go to the front of the classroom to write on the whiteboard. “He seemed defiant, but actually it was scary to him to have his back exposed to the whole room,” she says, because of things he’d experienced at home.

Because many children are not routinely screened for trauma--including at their pediatric check-ups—it’s often difficult for school staff to know what’s going on for some of their students. However, Matthew Portell, principal at Fall-Hamilton Elementary School in Nashville, argues that we shouldn’t wait to have all the details; he writes, “It is not imperative to know a child’s ACE score or specific traumatic experience to provide effective interventions. Being trauma-informed is a mindset with which educators approach all children.”


There are things schools can do—for students and their teachers.

Fall-Hamilton Elementary is an internationally recognized trauma-informed school. The staff at FHES employ numerous practices to address and heal trauma at school and have even created a “Trauma-Informed Practitioner” position to provide extra support to staff and students. After implementing trauma-informed approaches, behavior referrals at the school decreased by 76%, English/Language Arts test scores improved, and 98% of students reported that there was an adult at school who cared about them. To see what this looks like in action at FHES, I encourage you to watch these brief videos and read this interview with the school’s principal.

In the interview Portell cautions, “Trauma-informed, this whole mindset, is truly a movement, and we have to be cautious in trying to find the answer because there’s a lot of people trying to build processes and protocols that are the answer, and ultimately, we are the answer. We have to be able to empower ourselves. There is no magical program that’s going to fix kids because we’re not fixing kids. We’re supporting kids in being successful.”

Providing that support can sometimes feel overwhelming to school staff members. Dr. Art McCoy, a school superintendent in Missouri, shares: “It was incumbent upon me as a leader to authorize the hiring of two therapists specifically for our staff only that were separate from human resources and separate from any type of health care plan. They’re solely dedicated to walking through the schools and being on call 24 hours a day for any staff member who is suffering from secondary trauma [incurred by working with traumatized youth] or trauma in their personal life, while trying to sustain a successful professional life.”

Educators in our own system are feeling the strain as well. One of our APS school social workers emailed this week: “I am tired… My students are struggling. Right now, so much of my time is spent working with students with significant mental health or behavioral needs who aren’t able to access outside support. DHS is working on restricted protocols, private providers have waiting lists miles long or don’t accept insurance, and out-of-pocket sessions are not something many families can afford.”

When students and families are struggling in this way, academics often drop to a lower spot on the priority list. When I asked a parent who’s a leader in the disability community about learning loss, she wrote: “It's not that it's not an issue, but so many students with disabilities are struggling with more fundamental concerns right now such as behavior, mental health/anxiety, health/COVID safety, bullying, and school refusal. These need to be addressed before students can be in a position to learn.”


The (admittedly longwinded :) point I am making here is that I don’t think of the time, energy and resources required to address childhood trauma and students’ mental health as somehow “taking away” from academic success in school, even though at points during my time in education I’ve heard them pitted against each other. Instead, I hope as a country we’ll acknowledge that it’s a scientifically sound, fundamentally necessary and compassionate investment.


*Source: Fairfax County Government, 2020

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    Mary Kadera is a school board member in Arlington, VA. Opinions expressed here are entirely her own and do not represent the position of any other individual or organization.

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