‘I just started flowing. It was the only thing that helped’

When he was 16, DeMarrco Nicholson came home to find his mother unresponsive in the bathroom of their Washington, D.C., apartment, dead from sudden heart failure. In a matter of weeks, he was separated from his siblings, thrown into foster care and bounced from group home to group home in Anacostia, one of the poorest, high-crime neighborhoods in the nation’s capital.

After struggling for a year, Nicholson’s self-control cracked, and he violently lashed out, kicking and punching lockers, and threatening other students. It was the kind of episode that commonly ends in suspension or even arrest and puts teenagers — especially in neighborhoods like Nicholson’s — into what’s known as the “school-to-prison pipeline.” Forced out of school for bad behavior, unsupervised kids can get into even more trouble, wind up in the juvenile justice system and enter a spiral that becomes difficult to escape.

His school took a different tack. Instead of being disciplined for his outburst, Nicholson was greeted by a school-based therapist, who spent the rest of the day talking to him and learning about the traumatic experiences that brought him to that breaking point.

He was assigned a social worker and a therapist he could conveniently visit between classes. They formed a relationship and learned about his passion for rap music. He was encouraged to write rap lyrics to express his emotions instead of acting out. His therapist even set up a makeshift recording studio in his office.

Today, Nicholson credits those sessions – the therapy and the rapping — with helping him cope with the trauma of his mother’s death. “I started writing in my notebook. I’d tell him, I think I’m ready to record,” Nicholson, now 19, said in an interview. “He’d set a time. I’d come in and I just started flowing. It was only thing that helped.”

A growing number of school districts, like the District of Columbia school system, are beginning to provide comprehensive mental health services on campus, seeing it as not just a service to students, but a key way to keep lives on track, keep kids out of the justice system, and to treat problems before they get out of hand.

Nicholson gradually worked through the pain that he couldn’t deal with alone. He graduated from Anacostia High School this year and is preparing to enroll at the University of the District of Columbia this fall. He wants to study music business. “I would be lost without it,” he says of the therapy he received at school.

THE RELATIONSHIP BETWEEN mental health and bigger societal costs is becoming more important the more we learn about it – and one of the key links is between mental health and the justice system. Kids with unstable family lives or other traumas are often the ones who act up in school. By suspending them for bad behavior, schools make their problems even worse, by taking them out of a place with stable adults and other supports and leaving them out on the streets, unsupervised, where it’s all too easy to get into more trouble – and all too hard to get out of it.

Health experts say for a large proportion of students who act out, the bad behavior is rooted in untreated mental health problems, conditions like depression or anxiety or more serious illnesses like bipolar disorder that often show their first symptoms in adolescence. Often, the illnesses are triggered by the kind of traumatic experiences that Nicholson went through. According to the National Center for Mental Health and Juvenile Justice, roughly 70 percent of students in the juvenile justice system have a mental health issue and most haven’t had proper treatment. A severe shortage of child psychiatrists and psychologists, coupled with the difficulties of finding insurance coverage for mental health, are some of the largest barriers to treatment.

“Parents have limited abilities to deal with behavioral issues and so kids with these issues, some of whom are more prone to acts of aggression, end up being pushed over to the juvenile justice system,” said Wayne Bear, executive director of the Pennsylvania-based Juvenile Detention Centers’ Association.

And that’s one of the worst places for kids experiencing a mental crisis, said Darcy Gruttadaro, director of advocacy at the National Alliance for Mental Illness. “It’s loud and scary and there are a lot of structure and rules to follow, which is a major challenge for a person with a mental illness. Conditions often worsen and they’re more likely to keep getting into trouble, lengthening their stay.”

“And do they get effective interventions and evidenced-based treatment while they’re in a juvenile treatment facility? ‘’ she added. “The answer is probably no.”

That’s where schools come in. School-based mental health services are viewed by experts as the best place for early intervention and detection programs because, as Olga Price, who founded D.C.’s school mental health program nearly two decades ago puts it: “It’s where all of the kids are.”

After trying out the idea for a few years in a handful of schools, the city went all in after a shooting in Anacostia in 2010 left three students dead and galvanized support for measures designed to reduce truancy and increase behavioral health services for youth. Children in D.C. public schools now have access to mental health care regardless of their family’s income, or whether or not they have health insurance or have dependable transportation to get to a clinic. All kids have to do is get to school and the treatment they need is there.

“The goal is to bring mental health services to children in the setting where they spend the most time,” said Tanya A. Royster, director of the D.C. Department of Behavioral Health. “You have access to parents, you have access to teachers, you also have a location it makes the services easier to access.”

D.C.’s program, which now serves 60 of the city’s 200 public and charter schools, includes at least one full-time therapist stationed at every school, who takes walk-in appointments, but also runs group therapy and class and schoolwide prevention programs. Students who need more intensive care are referred to a specialist in the community. The services are far more comprehensive than traditional school counselors, who often don’t have the training or the bandwidth to handle serious behavioral health problems. The city plans to expand the program to every school in the district in the coming years.

The program is financed in part by federal and state grants and local city funding. Many of its services are reimbursed by Medicaid or private insurance. Other community mental health centers provide services in a handful of schools to supplement the program’s costs. Still, funding remains a challenge and the city is struggling to find the funds for expansion.

As a result, Price said the program prioritizes schools with higher needs; officials look at attendance information, high-risk neighborhoods, the prevalence of students in need of special education. Anacostia High School, for example, is located in one of the poorest neighborhoods in D.C., with the highest rates of violence. The graduation rate in 2016 was just 42 percent.

D.C.’s PROGRAM IS part of a national trend toward approaching children’s behavioral issues from a clinical standpoint as opposed to a disciplinary approach. Treating kids who act out in school, whether it’s frequent outbursts or one act of aggression or violent behavior, as symptoms of underlying behavioral health conditions is seen as a more long-term solution that can help facilitate a more productive life down the road.

The growing consensus is that if children with mental health issues are spotted early and get support and treatment they need, they are more likely to finish school, attend college and hold a steady job. More traditional forms of discipline, particularly suspension, increase the likelihood of getting into more trouble, and potentially getting entangled in the juvenile justice system.

“There is a lot of blurring of the lines, especially for children, in terms of what is a behavioral health issue, what is a manifestation of experience in trauma and what is a disability. It’s complicated,” said Sharra Greer, policy director for the Children’s Law Center that advocates for school-based mental health programs. “You have a child who is in school, who is throwing chairs in the classroom — it’s important to focus on why is that happening, as opposed to this kid should be punished. It’s important to get people to look at it from that lens.”

Keeping troublesome kids in schools also keeps them closer to services that can help.

“They tend to want to come to school because they know that someone will want to come and talk to them,” said Marisa Parrella, the manager of Mary’s Center’s School-Based Mental Health, one of the community providers that supplements D.C.’s school program.

According to an evaluation report of D.C.’s program, the top reasons children were referred to the school mental health provider were anger and aggression, disruptive behavior, family problems, grief and loss, and poor relations with other students.

D.C. health officials say the program has already helped reduce the number of behavioral problems at schools. The number of suspensions reported throughout D.C.’s schools has fallen by nearly 40 percent in the past couple of years from 11,078 in the 2013-14 school year to 6,695 in the 2015-16 school year, according to city figures. Though the mental health program isn’t exclusively responsible for the decline, city officials say it has played a role.

New York City has also been building a school mental-health program. In New York, the program is administered by the Montefiore Medical Center, which operates in 80 public schools in the Bronx, making it the largest school-based health program in the country.

“Schools tend to bring us the children who get into fights or have some behavioral issues,” said Gail Shafran, a nurse practitioner who works in one of the Montefiore school clinics. “We often get to know the kids really well, we know a lot of their social and medical history and whether they’ve experienced trauma. We’re able to detect the high-risk kids.” That close relationship with students and providers at school makes it easier to get kids help early.

But for school districts that don’t have a major medical center willing to integrate their services into the schools, like Montefiore, or an existing federal or city funding stream like D.C., it can be difficult to replicate such a robust system.

Recent federal legislation, the Every Student Succeeds Act, provided new grants for states and districts across the country to develop more comprehensive mental health programs, including screening and early intervention. But challenges remain.

“We haven’t seen enough communities with schools that take it to the next level,” said NAMI’s Gruttadaro. “Schools are recognizing they need to do more but it really depends on the school budget and the funding they have available.”

Allen said another hurdle is finding school mental health providers. According to the Bureau of Labor Statistics, there are about 39,000 school social workers and 44,000 school psychologists in public schools across the country, but about 51 million public school students. Because there aren’t enough providers to go around, some schools try to train teachers and other staff how to recognize and respond to mental health issues.

But experts say that’s not enough, and are pushing for more comprehensive school-based services to avoid more kids with mental health issues from being sucked into the school-to-prison pipeline.

“You can ask any kindergarten teacher to pick out which one of their kids are most likely to get into trouble down the road, and they’re almost always right,” the Juvenile Detention Center’s Bear said. “So we need to get better at identifying kids earlier so you can intervene before it gets to be a diagnosable problem.”

Brianna Ehley is a health care reporter for POLITICO Pro.

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