The U.S. Surgeon General’s Youth Mental Health Advisory: What Does it Mean for School Districts?

The pandemic era has been a significant challenge for all of us, but our young people have been uniquely affected. Therefore, it comes as no surprise that the last two years have taken a significant toll on the mental health of our nation’s children and adolescents.

Nevertheless, the public advisory issued by the U.S surgeon general, Dr. Vivek H. Murthy, on December 7 is sobering. Such advisories are rare, and the very fact that Dr. Murthy saw fit to issue this report sends a strong signal that the state of our young peoples’ mental health has reached crisis levels and demands our attention.

Titled “Protecting Youth Mental Health,” the 53-page report has received widespread coverage in the country’s major media. The advisory cites various causes of the current crisis, but it serves primarily as a call to action across all areas of society. As Dr. Murthy writes in the report, “Advisories are reserved for significant public health challenges that need the nation’s immediate awareness and action.”

The purpose of this Solution Brief is to help school districts focus on the key insights from the surgeon general’s report that are most relevant to them.

Key Insight #1: The Crisis Was Underway Before the Pandemic

The roots of the current crisis predate the pandemic. Educators and mental health professionals were sounding the alarm well before the pandemic arrived in early 2020. According to the surgeon general’s advisory, one in five children were already managing mental, emotional, developmental, or behavioral issues, and half of them failed to receive sufficient treatment.

The decade leading up to the pandemic saw a sharp rise of depressive symptoms and suicidal ideation among young people. “From 2009 to 2019, the proportion of high school students reporting persistent feelings of sadness or hopelessness increased by 40%; the share seriously considering attempting suicide increased by 36%; and the share creating a suicide plan increased by 44%. . . . Between 2007 and 2018, suicide rates among youth ages 10–24 in the US increased by 57%.”

No one, single cause accounts for these alarming trends. In the report, Dr. Murthy refers to a range of contributing factors: The gun violence that is rampant in our society, and the ongoing threat of school shootings. Climate change and the dire threat it poses to young people’s future. Racial injustice, which has only grown more evident in recent years. Income inequality and the opioid epidemic. And the pervasive impact of digital technology and social media. By now, it is indisputable that these technologies — while not harmful in themselves — can give rise to a host of negative consequences for everyone, and for young people in particular.

As Dr. Murthy notes, “The challenges today’s generation of young people face are unprecedented and uniquely hard to navigate. And the effect these challenges have had on their mental health is devastating.”

Key Insight #2: The Pandemic Added Fuel to the Fire

If a youth mental health crisis was already underway, the pandemic served to intensify it.

Since the start of the pandemic, rates of psychological distress among children and adolescents have increased. “Recent research covering 80,000 youth globally found that depressive and anxiety symptoms doubled during the pandemic, with 25% of youth experiencing depressive symptoms and 20% experiencing anxiety symptoms.”

The pandemic presented an unprecedented disruption for the entire global population, hitting young people especially hard. Children thrive on routine, but the lockdowns that characterized the early months of the pandemic turned stable routines on their head. Many kids experienced isolation. Masks and physical distancing altered how they learned and how they interacted with friends and loved ones. What’s more, the very nature of a global pandemic — with its continual threat of contracting the virus and becoming sick — is inherently stressful. While young people have mostly been spared severe illness, many have seen family members fall ill and in some cases die. In July of 2021 researchers reported that at least two million children around the world had lost a caregiving parent or grandparent during the pandemic. That number has continued to grow.

Add to this the pandemic’s economic fallout — job loss, food insecurity, homelessness — and it’s not hard to see how this crisis exacerbated the challenges many children and adolescents were already contending with.

The news, however, isn’t all dire. Many young people have come through the last two years relatively unscathed. And we know that kids are inherently resilient; many will bounce back from this period and go on to flourish. Yet the pandemic’s worst impacts have fallen on those who were vulnerable to begin with, including Black, Latino, and other students of color; immigrants; low-income youth; and those experiencing behavioral and emotional issues. We owe our most vulnerable kids, and all young people, a chance at the best future they can envision. That’s why acting on the surgeon general’s advisory is vital.

Key Insight #3: School Districts Must Play a Critical Role

The advisory addresses all elements of our society, from families and schools to governments and the media, and suggests they all have a role to play in helping vulnerable kids succeed. Schools, however, are uniquely positioned to have a positive and lasting impact and thus have a special role to play.

School is central to young people’s lives. It’s where they spend more hours of their day than any place other than home. Teachers and other members of the school staff often forge meaningful bonds with young people — and they can often identify mental health challenges more clearly than anyone else, even family and caregivers. At the same time, students’ mental health is inseparable from their growth academically and interpersonally. For all these reasons, school districts have an obligation to take an active role in addressing this crisis.

The advisory lays out the following eight recommendations for schools and districts.

1. Create positive, safe, and affirming school environments.

Our schools should be places of safety and inclusion, where all young people can learn, grow, and thrive. Efforts to create and maintain this environment must be foundational for all schools and districts.

2. Expand social and emotional learning programs and other evidence-based approaches that promote healthy development.

As schools broaden their vision of education, they can promote not only academic success but also behavioral and social-emotional development — so that all aspects of students can flourish.

3. Learn how to recognize signs of changes in mental and physical health among students, including trauma and behavior changes. Take appropriate action when needed.

Teachers and other school staff are often in the best position to identify students who are struggling and help them get adequate care, support, and helpful interventions.

4. Provide a continuum of supports to meet student mental health needs, including evidence-based prevention practices and trauma-informed mental health care.

Not all young people have the same needs, and students’ needs change over time. Providing different levels of support allows schools to support students who need differing levels of care.

5. Expand the school-based mental health workforce.

As mental health needs increase, many schools will be unable to provide the spectrum of services that students need. Increased staff is a first step toward bridging this gap.

6. Support the mental health of all school personnel.

Now and into the future, the demands on school staff will be greater than ever before. Taking steps to safeguard educators’ wellbeing and mental health — along with that of students — is crucial to ensuring a healthy learning environment for everyone.

7. Promote enrolling and retaining eligible children in Medicaid, CHIP, or a Marketplace plan, so that children have health coverage that includes behavioral health services.

8. Protect and prioritize students with higher needs and those at higher risk of mental health challenges, such as students with disabilities, personal or family mental health challenges, or other risk factors (e.g., adverse childhood experiences, trauma, poverty).

Providing services and strategies to support our most challenged students is essential.

Implementing the Recommendations: Finding New Solutions

As school districts seek to respond effectively to the mental health crisis and implement the surgeon general’s recommendations, many will find they need additional support. In recent years, districts across the country have had success partnering with outside expert providers to offer a Multi-Tiered System of Support (MTSS) that offers comprehensive clinical mental health programs.

In general, school districts will implement MTSS through a combination of internal capabilities and external partners, particularly for key areas that require specialized or supplemental expertise.

Effective School Solutions (ESS) is one such provider. ESS provides a continuum of care through MTSS programs, tailored to meet the needs of individual districts and to complement the great work being done by a district’s internal staff. Many of the services ESS provides are aligned with the surgeon general’s recommendations.

ESS’s MTSS includes three distinct tiers. Tier 1 is the largest and most comprehensive, offering mental health wellness and prevention services — not only for students but for caregivers and school staff.

ESS’s Tier 1 activities and practices include the following:

• Universal Mental Health Screening. This screening takes place at the beginning of each school year to identify students who may need additional support that goes beyond Tier 1 instruction and activities. (Recommendations 1, 2, 4)
• Whole-school professional learning for teachers and parents. Workshops educate teachers and parents on the warning signs of mental health challenges and equip teachers to manage challenging behaviors, emphasizing social-emotional learning. (Recommendations 3, 4)
• A Trauma-Attuned Model®. This approach integrates a set of tools to help educators recognize and manage the effects of trauma and the challenging behaviors that often occur as a result. (Recommendations 2, 4)
• A welcoming and supportive classroom culture. Trauma-informed practices form the basis of classroom-based wellness activities, such as social-emotional learning and mindfulness instruction to enhance self-awareness and self-care. (Recommendations 1,2, 4)
• A modified disciplinary system that includes a schoolwide early warning system to identify students who are disconnected, disengaged, and/or are exhibiting risky or disruptive behaviors. (Recommendations 3, 4)
• Activities that foster relationships with parents/caregivers, support staff, mentors, and community agencies. (Recommendation 6)

At the next level, Tier 2 services are designed to meet the needs of students with mild to moderate mental health symptoms and those who may be experiencing an isolated mental health crisis. These services include referrals for additional mental health support, coordination with case management, and other supports. (Recommendations 1, 2, 4, 8)

Tier 3 services are the most intensive and are reserved for students with severe mental health challenges. ESS provides embedded, state-of-the-art clinical care within the four walls of the school building. The programs include a variety of components to preserve student safety, address trauma, and build self-regulation and other skills to manage the symptoms of serious mental health disorders. (Recommendations 1, 2, 4, 8)

This continuum of care enables schools to respond appropriately to all students, from the most resilient to the most challenged, so that every young person has the best chance to thrive.

The surgeon general’s advisory suggests that the difficulties of the current era may also provide an opportunity to reimagine many of our institutions in ways that promote greater mental health for all our young people.