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Intervening early in school helps prevent behavioral issues from developing into problems that lead to suspension, expulsion and dropping out. Enlisting parents and teachers can make these interventions more effective-and prevention approaches can be effective at various developmental stages, as indicated below.

Infancy and Early Childhood

The Incredible Years is a widely disseminated program engaging teachers, parents and children to reduce disruptive behavior disorders, violence and delinquency. It has been used with general populations and adapted for children with early onset conduct problems and other risk factors, including socioeconomic status and other mental health disorders. The program is designed to train parents and teachers to help children from birth through school age.

Studies show robust positive effects of the intervention for decreasing disruptive behavior and increasing prosocial behavior. A meta-analysis of research studies reported a 15.5% improvement across domains of behavior ³¹ for children whose families and school communities participated in the Incredible Years prevention program.

Teacher-Child Interaction Training (TCIT) is a classroom intervention for children aged 3-7, based on an individualized treatment for disruptive behavior and family conflict called Parent-Child Interaction Therapy (PCIT).

One study showed that after teacher training and coaching, positive teacher behavior improved more than 100%, from 9% of interactions to 20% of interactions. Focused positive encouragement - "labeled praise" - increased fivefold. ³²

Another study showed significant improvement in ratings of resilience and behavioral control. ³³

One assumption behind TCIT is that by improving the classroom environment, teachers will have more time and attention for teaching and encouraging each child, and young students will experience more of the benefits of focused early education and fewer of the distractions and ill effects of problematic behavior and disruption.

The Good Behavior Game (GBG) is a classroom-based behavioral management program shown to have long-lasting effects in preventing later poor outcomes. In a study, first and second graders in GBG classrooms were divided into teams that "compete" for rewards by adhering to teacher-defined rules for behavior. All teams can win by keeping the number of infractions down. The goal of the intervention is to encourage a positive learning environment and healthy social communication. ³⁴

GBG is effective in reducing problem behaviors in the classroom, and it also has significant effects many years later. A follow-up study of children in GBG classrooms when they reached the age of 19-21 found significantly lower rates of drug and alcohol use disorders, regular smoking, antisocial personality disorder, delinquency and incarceration for violent crimes and suicide thoughts.

Young adult outcomes for children in the GBG group showed a 50% reduction in risk of drug abuse or dependence; a 35% risk reduction for alcohol abuse or dependence; a 59% decreased risk for regular smoking; and a 32% reduction in risk of developing antisocial personality disorder. ³⁵

Middle Childhood and Early Adolescence

Daily Report Card (DRC) is another evidence-based behavior modification program developed for children with disruptive behavior disorders including ADHD. The DRC intervention works as a collaboration between school and home, and is constructed to address and reward progress related to problem behaviors identified in a child's individualized education plan (IEP). Each DRC intervention is unique to the child and to the relationship between child, teacher and parents.

One study showed that children aged 6-12 with ADHD participating in the DRC intervention were:

Twice as likely to be rated as unimpaired at the end of the study when compared to the control group.³⁶

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Prevention and Early Intervention | Child Mind Institute

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Intervening early in school helps prevent behavioral issues from developing into problems that lead to suspension, expulsion and dropping out. Enlisting parents and teachers can make these interventions more effective-and prevention approaches can be effective at various developmental stages, as indicated below. Infancy and Early Childhood The Incredible Years is a widely disseminated program engaging ...

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Starting from an early age, children should be taught in schools about mental health with access to mental health professionals. Children should also be taught with the needs of children with mental disorders in mind because the tactics used to teach these children would be beneficial to all.

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The Connecticut consultation program that Yale studied follows specific guidelines as laid out by the Center for Early Childhood Mental Health Consultation. However, experts agree that whenever educators collaborate with mental-health professionals to support students with social, emotional, and behavioral challenges, whether it's a consultation program or on-the-ground mental-health professionals, the outcome results in more well-adjusted students.

Michael Rosenblum, a fourth-grade teacher at the private McLean School in Potomac, Maryland, has seen the success of this approach in action. The school is in part targeted to students who have learning differences including ADHD, dyslexia, and anxiety, which can make just getting through the school day difficult. Although the school does not use the same mental-health consultation program that Connecticut has adopted, through working closely with on-site mental-health professionals, teachers are able to help their students reach their greatest potential.

"We've had students that come to McLean in third, fourth, fifth grade that basically have been told by educators that they will not be able to graduate from high school and that they are not capable of going to a college," said Frankie Engelking, McLean's director of student and community wellness. "Those exact students come to us, are very successful academically, grow emotionally, build confidence, graduate from McLean, go on to four-year programs, and have very meaningful lives and careers."

It's through McLean's comprehensive approach to mental health, which gives children coping strategies rather than punishing them for poor behavior, that allows children to succeed. Teachers are encouraged to give equal importance to teaching skills like kindness, communication, and building strong relationships as teaching subjects like math and science. Using approaches and curricula such as Responsive Classroom and Second Step, educators are able to weave activities that promote mental wellness into daily classroom activity.

"From a teacher's point of view, being in a type of environment where administration, from Frankie and from others-just having the support to make issues of mental health, and stress, and anxiety a priority-is really important," Rosenblum said. "We're really empowered to try these different strategies, and it works wonders with these kids."

While McLean's students don't take any standardized tests, making it difficult to empirically assess the impact of the school's mental-health focus on their achievement, Rosenblum sees the McLean School's success in his students' increased confidence and excitement to participate in class. As students progress through McLean, Rosenblum said, many begin to advocate for themselves more often and learn to cope with anxieties and stressors that were once debilitating to their learning experience. And most students make progress on reading as evaluated at the beginning and end of the school year-a sign that the school's model is effective considering many students enroll at below grade level.

McLean School's approach, however, is not something that all children and their parents can afford to experience. The school does offer financial aid, but without assistance the price tag for kindergarten enrollment is upwards of $30,000 - and tuition only increases as students get older. This reinforces the need for programs like Connecticut's statewide model that provide mental-health resources for all children, not just those with the means to afford it.

This story is part of our Next America: Early Childhood project, which is supported by grants from the Annie E. Casey Foundation and the Heising-Simons Foundation.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

Emily Goldberg is a former editorial fellow at The Atlantic.

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Mental Health Is Not Just an Adult Problem

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The Connecticut consultation program that Yale studied follows specific guidelines as laid out by the Center for Early Childhood Mental Health Consultation. However, experts agree that whenever educators collaborate with mental-health professionals to support students with social, emotional, and behavioral challenges, whether it's a consultation program or on-the-ground mental-health professionals, the outcome results in more well-adjusted students.

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NPR's Ailsa Chang talks to Sen. Creigh Deeds (D- Va.), one of the sponsors of the new state law requiring mental health education in schools.

AILSA CHANG, HOST:

This week, New York and Virginia become the first two states to require mental health education in public schools. This comes as the Centers for Disease Control and Prevention report a 30 percent rise in suicide rates in the U.S. in the past two decades.

Virginia state Senator Creigh Deeds knows the reality behind these statistics all too well. In 2013, his son repeatedly stabbed him and then killed himself. He was 24 years old. Senator Deeds was one of the sponsors of the new Virginia law, and he joins us now to talk about it. Senator Deeds, thank you very much for speaking with us.

CREIGH DEEDS: Thanks for having me.

CHANG: I read that this decision to sponsor this law came after you listened to a presentation from high schoolers in your district.

DEEDS: Yes. And I was really blown away by their thoughtfulness, by their passion. These young people had seen bullying in school. They'd seen their peers under pressure who had either died by suicide or come close to dying by suicide. And specifically, they had really pretty well thought out about why it was important to target ninth- and 10th-graders and why health class was the place to talk about mental health.

CHANG: And what do you think ninth- and 10th-graders need to know about mental health?

DEEDS: OK, they need to know the basics about how mental illness affects a person. They need to know what the warning signs are, what to look for in their peers and in themselves. You know, 70 percent of those people who struggle with mental illness first experience an episode sometime between 14 and 24. So that's - in 10th grade is exactly the right time when people ought to be given the tools they need to be able to understand these illnesses.

CHANG: It sounds like there was no controversy as to how important this was. But who ultimately would come up with the details of the curriculum?

DEEDS: The board of education. The parameters around this were drawn by this legislation, and they're pretty broad parameters. But the details have to be worked out by the board of education and to have be built into the curriculum for ninth- and 10th-graders. And I'm hopeful that some work will be done this summer so we can begin the program in the fall.

CHANG: And will teachers get additional training to develop more of an expertise in mental health issues?

DEEDS: I think they will have to. I'm very hopeful that some of our institutions of higher learning when they're training health teachers can do a better job of incorporating some awareness of mental illnesses in their curriculum.

CHANG: But has the state Legislature provided extra funds to provide that training?

DEEDS: We haven't done it yet. I mean, at some point - this year we invested more money in mental illness and behavioral health issues than we ever have before - $192 million over the biennium. So we've taken a major step this year. The last few years, we've done some pretty important things in terms of recognizing what we need to do to provide more services to those people and families that struggle. But we're not where we should be, and very few states are.

CHANG: As we mentioned, this is obviously an issue that resonates quite deeply and quite personally with you. You said after your son died that the state had failed your son, that he was turned away from an institution before he took his own life. What are some things you feel people still do not understand about mental illness?

DEEDS: Well, at the end of the day, sometimes they don't know how to react to someone who is struggling. And sometimes just our language - there was recently a headline in a local newspaper about a loony bin. Sometimes we just insult those people who struggle. Mental health issues need to be given the same dignity as physical health issues.

CHANG: Senator Creigh Deeds, thank you very much for joining us.

DEEDS: Thank you, ma'am.

Copyright © 2018 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR's programming is the audio record.

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New Virginia Law Mandates Mental Health Education In Public Schools

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NPR's Ailsa Chang talks to Sen. Creigh Deeds (D- Va.), one of the sponsors of the new state law requiring mental health education in schools. AILSA CHANG, HOST: This week, New York and Virginia become the first two states to require mental health education in public schools.

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SPARTANBURG, S.C. - On a hot summer day last month, Sydney, 15, and Laney, 8, were enjoying their last two weeks of freedom before school started. The sisters tried to do flips over a high bar at a local playground.

"You've got to pull your hips into the bar, like you've got to kick up like that," explained their mother, Selena.

"I tried to kick! I did this - you told me not to stick out," said Laney indignantly.

Both girls have been diagnosed with mental illnesses - Sydney with bipolar disorder and Laney with a similar illness called disruptive mood dysregulation disorder. The family asked that their last name not be used to protect the girls' privacy.

School has been a real challenge for them. That's not unusual for the 1 in 5 children with a mental illness. They often suffer anxiety, difficulty focusing and social challenges. Half of them drop out of high school, in part because many schools don't manage to meet their needs.

Selena has spent the past eight years trying to get the girls the resources to help them succeed. Like a lot of parents of kids with mental health issues, she's had to be her children's biggest advocate.

"It's definitely a journey. It wasn't easy," she said, even though she's a school guidance counselor herself.

"I used to cry the night before, because I didn't want to go to school."

Sydney describes class as "boring, distracting. It's hard to pay attention. It's overwhelming." She struggles to focus or process information, which makes her so anxious and depressed that she often has to leave school in the middle of the day.

She wants to be a rock star like Courtney Love. Every so often she pretends to take drag from a bubble gum cigarette. But she's an extremely sensitive kid, and school has been a painful experience.

"I used to cry the night before, because I didn't want to go to school," she said.

Laney on the other hand is a ball of chaotic energy. At school, she often gets frustrated and acts out. Sometimes, she is sent home.

Schools do not all screen students for mental health issues, and the practice varies widely across states. Even if students are successfully identified, many areas lack the community-based mental health treatment options that would be needed to help them. Just 38 percent of youth with a mood disorder such as depression or bipolar disorder receive treatment services. In 2014, the federal government announced $48 million in new grants to support teachers, schools and communities in recognizing and responding to mental health issues. Still, many students' mental health problems continue to go unidentified and untreated.

When Selena first noticed the girls were having problems, she took them to the doctor. Sydney started taking medication at the age of 7 and Laney at just 4, but it wasn't a quick fix.

"The brain is complex," said Selena. "It's not like you just take a medicine and it fixes it." It took years to get the girls' diagnoses and prescriptions right.

Selena said she needed to educate teachers about her daughters' illnesses. "I really tried to do my homework. I did a lot of research. Obviously I talked to parents online in a support group," she said.

Schools are starting to better recognize that mental health is key to academic and social success, said Darcy Gruttadaro, director of advocacy at the National Alliance on Mental Illness, a grassroots organization headquartered outside Washington, D.C.

"Kids spend six hours a day in school, and mental health is essential to learning.

"Kids spend six hours a day in school, and mental health is essential to learning. So schools that are very data-driven understand that in order for some kids to succeed, their mental health needs must be met," she said.

Nonetheless, schools vary greatly in the degree to which they are willing and able to accommodate mental health issues. "Some are doing a lot and training teachers on how to recognize warning signs and talk to families. And others are doing very little to understand the needs of students and how to work with families," said Gruttadaro.

Sydney's and Laney's public schools were willing to make accommodations - but the girls' struggles continued. So, Selena transferred both to a smaller charter school called High Point Academy.

Principal John Hurley said he's seen a growing number of students coming in with mental health diagnoses. The school wants to help - but teachers are not well prepared to handle these issues.

"My training in mental health was one chapter in a book that we covered in one day," recalled Hurley. Many teachers have experience with attention deficit hyperactivity disorder, he said, but they don't have the tools to draw on when dealing with mood disorders.

"Because we're left in the dark, we have to fumble around to figure out what works best."

"Because we're left in the dark, we have to fumble around to figure out what works best," explained Hurley. "Sometimes you can be wildly successful, and sometimes you can fail miserably and you could have done the exact same thing for two different students."

That's a pretty good description of what happened with Laney and Sydney.

Laney started High Point in the second grade and, by October, had already begun acting out.

"A lot of the times she didn't like to write, so ... she'd get frustrated and she might tear up her paper just depending on how she was feeling," said her second grade teacher, Erica Smith. Occasionally, Laney would also tear up other students' assignments.

Selena was thrilled when Smith reached out and asked for advice. They started communicating almost daily, sharing tips about how best to reach Laney. They developed an individualized education plan, and Smith had a "safe spot" in the classroom where Laney could go to cool down until she could rejoin the class.

At the same time, Laney's doctor adjusted her medications to help balance her mood. The solutions worked - pretty soon Laney was thriving. But Selena knew from experience that what works with one kid doesn't always work with the other.

Selena helped get Sydney an individualized education plan that gave her extra time on tests, fewer assignments and two periods a day with special education teacher Pam Smith, who has a background in mental health.

"I really feel we had everything we could have had that was available to us to meet her needs," said Pam Smith. "I really feel that we went over and above sometimes."

"I started realizing it just wasn't working. I can't send my child somewhere every day and ignore the fact that it's having a negative impact on her mental health."

But nothing seemed to work. Sydney had trouble making friends and often shut down in class. She kept falling further behind.

"I started realizing it just wasn't working. I can't send my child somewhere every day and ignore the fact that it's having a negative impact on her mental health," said Selena.

So in March, she pulled Sydney out of High Point and home-schooled her for the rest of the year.

She looked for a therapeutic school for Sydney to attend this year, but she couldn't find one in her area. So this year, Sydney is attending an online school from home, while Selena works and Laney goes to the third grade at High Point. It's not an ideal solution. Selena wanted Sydney to be in a brick and mortar school with other kids, but she said she's had to learn to be flexible.

"You think as a parent you're supposed to just say, 'Get up and go back to school' the next day. And so you really have to sometimes stop and take stock of what's going on and maybe change the path," she said.

As for Sydney, she said she was looking forward to studying from home. For the first time in years, she said she hadn't been crying ahead of the first day of school.

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One out of five children have mental illness, and schools often don't help

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School has been a real challenge for them. That's not unusual for the 1 in 5 children with a mental illness. They often suffer anxiety, difficulty focusing and social challenges.

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February 15
Grief counselors are always made available to help students when there is a traumatic event at a school, such as this week, when a gunman entered a Florida high school and fired a military-style assault weapon, killing 17 people. While health experts say counseling after a tragedy is vital, too many schools don't have anywhere near enough health professionals to help students before the catastrophes.

Consider:

In U.S. public schools today, it's estimated there is one school psychologist for every 1,381 students. The National Association of School Psychologists recommends one psychologist for every 500 to 700 students (which itself makes very busy work days for psychologists).

Let's turn to school counselors.

According to the latest available information from the American School Counselor Association, there was one counselor for every 482 students in 2014-2015. It's nearly twice what the association recommends: one counselor for every 250 students (which makes for very busy days for school counselors.)

And then there are school-based nurses. The National Association of School Nurses and the National Association of State School Nurse Consultants recommend that every student have direct access to a school nurse, though some states have recommended there be one school nurse for every 750 students in the healthy student population (which makes for a busy day for school nurses).

Yet a 2017 survey by the National Association of School Nurses found that only 39 percent of private and public schools in the United States have full-time nurses. In North Carolina, for example, a new legislative study found that the state would need to spend up to $79 million a year in additional money to meet the 1 to 750 nurse-student ratio in public schools.

School-based psychologists, counselors and nurses do related but different things for students, but they are all professionals who are supposed to be part of the human scaffolding constructed around students to help them do their best in school.

According to the Association for Children's Mental Health, addressing mental health needs in schools is vital because "1 in 5 children and youth have a diagnosable emotional, behavioral or mental health disorder, and 1 in 10 young people have a mental health challenge that is severe enough to impair how they function at home, school or in the community." And it says that many estimates show that among kids aged 6 to 17, "at least one-half and many estimate as many as 80 percent" don't receive the mental health care they require.

"It's a huge issue," said Amanda Nickerson, director of the Alberti Center for Bullying Abuse Prevention at the University at Buffalo Graduate School of Education, who is attending the annual convention in Chicago of the National Association of School Psychologists. "We do not have enough mental health professionals to meet the increasingly complex needs of the students that are walking through the door."

Nickerson said the inevitable calls for immediate action after a shooting often miss the point.

"We are getting better providing, unfortunately in some ways, the crisis intervention, but that's after something terrible happens," she said. "As we look toward solutions after something like this happens, people automatically go to highly expensive hardware sorts of solutions. Why don't we have metal detectors? Where are the cameras? Where are the guards?

"I'm not saying those things aren't important," she said. "But to create a safe and secure environment, we have to address psychological safety and connectedness and how we are resolving conflicts that doesn't involve more conflict. That is critically important, and our school-based mental health experts are trained to do that. But there aren't enough people and not enough hours in the day currently with the way our staffing is."

Though research and common sense say that schools should be properly staffed with health professionals, that has not been the focus of modern school reformers, who have focused not on the health of students but on testing metrics.

That was true in Democratic and Republican presidential administrations, including the current one. President Trump's statement about the shooting in South Florida, which left 17 people dead, said in part:

Our administration is working closely with local authorities to investigate the shooting and learn everything we can. We are committed to working with state and local leaders to help secure our schools, and tackle the difficult issue of mental health.

Yet on Monday, his administration released a 2019 budget proposal that mental health professionals said does not show a commitment to tackling the many issues affecting mental health.

The National Association of School Psychologists, for example, expressed "deep concern" with specific proposed items, including gutting significant programs in the federal K-12 law. The American Psychological Association said while the budget includes additional resources to address the nation's opioid epidemic, improve veterans' health care and fund scientific research, it "would decimate critical education, justice and behavioral health workforce programs if enacted."

There is something else missing in the United States that affects the mental health of students, as explained in this Washington Post story about mass shootings at U.S. schools compared with other countries:

There's also another crucial difference with the United States: extensive, mandatory health insurance, which allows schools to have direct and immediate access to psychologists and intervention teams.

[Europeans had school shootings, too. Then they did something about it.]
If schools are calling in grief counselors, it's already too late to avoid disaster. And if Americans really cared about having the personnel in schools to address mental health needs, then schools would be adequately staffed with the professionals who students need to be healthy and do their best.

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Analysis | If Americans really cared about students' mental health, these school ratios would be very different

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February 15 Grief counselors are always made available to help students when there is a traumatic event at a school, such as this week, when a gunman entered a Florida high school and fired a military-style assault weapon, killing 17 people.

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Part One in an NPR Ed series on mental health in schools.
You might call it a silent epidemic.

Up to one in five kids living in the U.S. shows signs or symptoms of a mental health disorder in a given year.

So in a school classroom of 25 students, five of them may be struggling with the same issues many adults deal with: depression, anxiety, substance abuse.

And yet most children - nearly 80 percent - who need mental health services won't get them.

Whether treated or not, the children do go to school. And the problems they face can tie into major problems found in schools: chronic absence, low achievement, disruptive behavior and dropping out.

Experts say schools could play a role in identifying students with problems and helping them succeed. Yet it's a role many schools are not prepared for.

Educators face the simple fact that, often because of a lack of resources, there just aren't enough people to tackle the job. And the ones who are working on it are often drowning in huge caseloads. Kids in need can fall through the cracks.
"No one ever asked me"
Katie is one of those kids.

She's 18 now. Back when she was 8, she had to transfer to a different school in Prince George's County, Md., in the middle of the year.

"At recess, I didn't have friends to play with," she recalls. "I would make an excuse to stay inside with the teachers and finish extra work or do extra credit."

We're not using Katie's last name to protect her privacy. She's been diagnosed with bulimia and depression.

She says that in the span of a few months, she went from honor roll to failing. She put on weight; other kids called her "fat." She began cutting herself with a razor every day. And she missed a ton of school.

"I felt like every single day was a bad day," she says. "I felt like nobody wanted to help me."

Katie says teachers acted like she didn't care about her schoolwork. "I was so invisible to them."

Every year of high school, she says, was "horrible." She told her therapist she wanted to die and was admitted into the hospital.

During all this time, she says, not a single principal or teacher or counselor ever asked her one simple question: "What's wrong?"

If someone had asked, she says, she would have told them.
Who should have asked?
We talked to educators, advocates, teachers and parents across the country. Here's what they say a comprehensive approach to mental health and education would look like.
The family
The role: The first place to spot trouble is in the home, whether that trouble is substance abuse, slipping grades or a child who sleeps too much. Adults at home - parents, siblings, other relatives - are often the first to notice something going on.

The reality: Many families do not know what to look for. Sometimes a serious problem can be overlooked as "just a phase." But it's those sudden changes - angry outbursts, declining grades, changes in sleeping or eating - that can signal problems. When something unusual crops up, families can keep in close touch with the school.
The teacher
The role: During the week, many students see their teachers even more than their own families. Teachers are in a prime spot to notice changes in behavior. They read essays, see how students relate with other kids and notice when they aren't paying attention.

The reality: Teachers already have a ton on their plates. They're pressured to get test scores up, on top of preparing lessons and grading assignments. Plus, many teachers receive minimal training in mental health issues. But when they do see something concerning, they can raise a flag.
The social worker
The role: Social workers act like a bridge. If teachers come to them with a concern - maybe a child is acting withdrawn - one of the first things they'll do is call home. They see each child through the lens of their family, school and community. They might learn that a family is going through a divorce or homelessness.

The reality: There aren't enough of them. According to one model, every school should have one social worker for every 250 students. The reality is that in some schools, social workers are responsible for many more.
The counselor
The role: In some schools, counselors focus solely on academics: helping students pick classes and apply to college. But in others, they also act a lot like social workers, serving as a link to families and working with students who need support.

The reality: Like school social workers, there just aren't enough counselors. On average nationwide, each counselor is responsible for nearly 500 students. The American School Counselor Association recommends a caseload nearly half that size.
The special education teacher
The Role: Special education teachers may start working with students when a mental health problem affects the ability to do school work. They are primarily responsible for working on academic skills.

The reality: Again, there aren't enough of them. Nearly every state has reported a shortage of special education teachers. Half of all school districts say they have trouble recruiting highly qualified candidates.
The school psychologist
The Role: Here's one job that, on paper, is truly dedicated to student mental health. School psychologists are key players when it comes to crisis intervention and can refer students to outside help, such as a psychiatrist.

The reality: If you sense a pattern here, you're right. In the U.S., there is just one school psychologist for every 1,400 students, according to the most recent data available from the National Association of School Psychologists.
The school nurse
The role: Most any school nurse will tell you, physical and mental health are tough to separate. That puts nurses in a prime spot to catch problems early. For example: A kid who comes into the nurse's office a lot, complaining of headaches or stomach problems? That could be a sign of anxiety, a strategy to avoid a bully, or a sign of troubles at home.

The reality: The U.S. Department of Health and Human Services recommends at least one nurse for every 750 students, but the actual ratio across the country can be much higher.
The principal
The role: As the top dogs in schools, principals make the big decisions about priorities. They can bring in social-emotional, anti-bullying and suicide-prevention programs.

The reality: Principals also have a lot on their plates: the day-to-day management of student behavior, school culture and teacher support.
Getting help, and "excited for life"
Katie says things started to turn around for her when she met a nurse at the Children's National Health System in Washington, D.C., who finally showed interest in what was wrong.

Now, she's begun college and wants to be a pediatric nurse.

"I'm doing a lot better now" she says. " Obviously, I mean, I'm a lot happier. I'm excited for school. I'm excited to graduate. I'm excited for life."

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Mental Health In Schools: A Hidden Crisis Affecting Millions Of Students

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An estimated 20 percent of children show signs or symptoms of a mental health problem. It's a destructive force in schools, but most educators don't have the training or resources to help.