'We need a million more': Access to mental health care in NC schools is growing

As the need for mental health services has risen, schools in North Carolina are increasingly a place to find them.

Schools are adding or expanding in-house mental health services contracts with community providers.

Triangle Family Services, with the help of a fundraiser and a grant from insurer Aetna, last year started providing a mostly free, full-time therapist who rotates among four schools within the Johnston County Public Schools system. The therapist counsels 22 students once per week, billing insurance if it’s available or providing services for free if it’s not.

Lisa Lowe-Hall, chief executive of Triangle Family Services, said the service was spurred by worsening suicide rates in the Triangle area and beyond.

“[We] continue to see those numbers rise at alarming rates,” Lowe-Hall said. “And so we couldn't just sit here with them in our backyard. And so we really started talking about, ‘What can we do? How can we join this fight of suicide prevention?’ ”

Triangle Family Services is planning another partnership with North Carolina State University, too.

In Wake County, the state’s biggest school system has revived its school-based mental health services in dozens of higher-needs schools, where counselors were inundated with students asking for help but who didn’t feel qualified to help them.

“We’ll have a kid that maybe has mental health concerns, maybe they’ve self-harmed before or had suicidal thoughts or something's going on and they need mental health services, but there’s a lot of barriers that families face outside of school to get their kid into therapy,” said Ashlyn Smith, social worker at West Lake Middle School in Apex. “Like parents that are working crazy hours, they don't have transportation, there's a wait list for programs everywhere. So the school-based therapists are able to see our kids in the school building during the day.”

Before school-based mental health services, many students’ needs were not being met because of the logistical challenges to getting treatment. That’s a problem when providers and schools want to stay ahead of a crisis.

“If we didn't have somebody at school, they would just be going untreated, because there's not the option, for Mom or Dad or [a] single mom to come and pick that kid up during the day and get them to the resources that they need,” Lowe-Hall said.

The rise in school-based mental health is part of a larger focus for many school leaders on providing more health care services to children where they spend large amounts of their time, helping ensure they get the heath care their parents want for them. And many counties are also focusing on using schools as resources for the larger community, to host clinics for parents, food pantries and other services.

Medicaid spent $189.9 million in North Carolina schools during the 2022 federal fiscal year, the latest year for which data is available. That’s up from $15 million in 2007. It’s unclear how much has been spent in private insurance, out-of-pocket expenses or provided pro bono. Many services are offered for free if insurance can’t be billed.

School-based health is designed to keep children from having to leave school — and parents from having to leave work — and make it easier for children to more consistently receive care.

It works like this: School systems form partnerships with mental health care providers who assign staff members to handle referrals from schools. When school officials suspect a child may need help, or a parent suspects a child may need help, the family is referred to the provider. The family must consent to the referral and the services, and the services can’t be forced on them. The child is then pulled out of class — typically, an elective class — for services at an agreed-upon frequency.

The results in many schools so far are anecdotal in some cases and are backed up by data and research in others.

Schools have pointed to higher attendance among students who use school-based health and improvements in children’s moods.

“Teachers are seeing positive outcomes when a student is connected [to] mental health support,” said Amanda Allen, executive director of student services at Johnston County Public Schools, which partners with Triangle Family Services and four other agencies. “They’re seeing improvements in their classrooms and in the demeanor of the students that they're working with.”

Schools that have the services don’t want to see them leave, Allen said.

Lisa Williams, seventh-grade counselor and lead counselor at West Lake Middle School in Apex, said she saw a lot of growth in some of her students who received therapy on campus last year. That includes one who “was really withdrawn” at the beginning of the school year.

“In the beginning of year, she did not smile. She was very dark,” Williams said. Now, “she seems happier and more outgoing.”

West Lake Middle has therapists from two different agencies available two days per week, one of a few dozen schools with an agreement with an outside provider in the Wake County school system.

Therapy doesn’t necessarily change a life overnight, but she’s seen students feel relieved to have a professional they can regularly talk to and dig deep with.

‘We need a million more’

Mental health struggles have been worsening for young people in North Carolina and beyond for years.

The North Carolina Child Fatality Task Force has found a slight uptick in suicides among children over the past decade. The Youth Risk Behavior Survey, administered every other year, has shown steep increases in sadness and loneliness among middle and high school students.

Young people have been dealing with a lot, even before a global pandemic shut them off from in-person interactions with their peers in 2020.

Counselors and social workers point to smartphones as doing more harm than good.

Kids no longer get a break from bullying or drama at school; it follows them online into the nights and weekends. They don’t spend as much time outside playing anymore. At West Lake Middle School, anonymous accounts are dedicated to “West Lake drama” or post rumors that stir up trouble at school. Kids have access to all kinds of information online, including information on self-harm or other sensitive topics.

“When I grew up in the 80s and 90s, you could make a mistake, and a week later, somebody else was going to make a mistake, so all the talk was going to be about them,” Lowe-Hall said. “That's not the case these days, because things are on social media. You can't make a mistake and forget about it. It's always there for everybody to see, and that has really impacted our young people.”

That stress — even if it originates outside of school — becomes the school’s problem.

“We deal a lot with, again, the aftermath of when somebody talks about you on the phone,” said Mina Bozman, the eighth-grade counselor at West Lake. “So we have a lot of situations that come from the drama or the bullying, really. I mean, sometimes it's bullying, which the bullying leads into the stress and anxiety causes suicidal thoughts and could be cutting some injury.”

Many kids aren’t talking with their parents about what they’re seeing online, said Abby Bishop, the sixth-grade counselor at West Lake Middle.

But what’s online is more visible and consequential now, Smith said. Kids used to say things to each other in-person, but now they do so on social media, causing relationship issues.

“There are positives — you can keep in touch with your friends and family and things like that,” Smith said. But vulnerable teenagers also don’t know how to use social media responsibly, she said.

“And they're not being monitored, that's the biggest issue,” Bishop said.

That’s why it’s so important that parents monitor and limit their children’s internet use, as well as talk with their kids about what they’re seeing on the internet or about sensitive topics they might expect their children to run across, the West Lake counselors said.

Counselors spend a lot of their days putting out fires, they said. Having a therapist with more training in mental health services able to serve kids makes a big difference. Many children are referred to services after they have frequent or severe issues that prompt them to go to the counselors, signaling they need more help than what the counselors can provide.

Without the therapists coming to school, officials are certain many students currently receiving therapy wouldn’t be getting it all.

“A lot of these families with really high needs, they can't get their kids to consistent therapy appointments outside of school,” Smith said. “Parents don't have transportation that's reliable. Every week they're working super long hours after school hours, so they can't take kids anywhere.”

Having a therapist also frees up counselors to spend more time focusing on more students.

“We need a million more,” Smith said. “... We only have therapists on site twice a week right now, and I wish we had one every day, just because then we could easily fill out their caseload with with kids that need it.”

Expanding help across NC

The North Carolina Department of Health and Human Services plans to invest $7 million toward clinical services for students with behavioral health needs, said Hanaleah Levy Hoberman, director of child and family strategy. DHHS has also expanded training for mental health first aid to educators and students.

The Wake County Public School System has restarted several school-based mental health programs and expanded a pilot program for higher-needs schools. Chatham County Schools started a telehealth program for students seeking therapy, on top of the school-based mental health services it had already offered. Guilford County Schools also recently expanded telehealth services.

All school systems must now have a mental health plan for their schools and submit an annual report on that plan to the General Assembly.

A handful of school systems are conducting screening and comprehensive support under the state’s pilot program called Project Advancing Wellness and Resiliency in Education.

“One of the most powerful things that they've seen is a reduction in suspensions so students are able to stay in school,” Levy Hoberman said. “And those students who otherwise might miss out academically are now thriving.

Johnston County Schools has been expanding its school-based mental health services, which now span five partners reaching all but a few schools. They served almost 400 students last year, though more were referred for the services.

Andi Harrington, chief development officer at Triangle Family Services, sees expanded mental health services in the community as a way to provide both crisis intervention but also a longer-lasting solution. When the community is more aware and engaged in the crisis, the community can build a better understanding of what’s happening and how to prevent crises.

Therapy itself is about skill-building for the person who goes to it.

“If I have a physical ailment that I need help with, I may go to physical therapy,” Allen said. “I’m going to work through the primary issue that's coming up, but I'm also going to have sustainable strategies that I know to do on my own when I'm not in physical therapy. Counseling is the same exact thing for your mental health.”

Parental involvement is critical for the services at school, Levy Hoberman said.

“That's an essential part of any clinical service, right?” Levy Hoberman said. “[It’s] not just the front end, getting permission, but also engaging the family. That's a big part of what schools can offer, is engaging the whole family so that the young person has the support they need in school and out of school.”