State of emergency: How youth mental health became its own epidemic

Earlier this year, the Children’s Hospital of Colorado declared a state of emergency for youth mental health after reporting that doctors are seeing more children for mental health than they are for any type of physical trauma of illness.

This state of emergency “is something we’ve also experienced in Eagle County,” said Hannah Ross, a school-based clinician and lead clinical supervisor for the Hope Center. “We have worked with a number of students reporting suicidal ideation and suicide attempts, which was happening in years’ past, but has been occurring at high rates over the past year.”

During the 2020-2021 school year, Hope Center’s school-based clinicians supported 500 unique students through 8,775 interactions to prevent them from progressing into crisis, with 228 unique students participating in group sessions. Through these interactions, these school-based clinicians intervened with over 100 students experiencing active suicidal thoughts.

Carrie Benway, executive director of the Hope Center, said that going into this current academic year there’s an expectation that the numbers will only increase as students return to in-person learning five days a week.

Melisa Rewold-Thuon, assistant superintendent of support services for Eagle County Schools, said that last year, the district was concerned because suicide risk assessments decreased as did referrals to Health and Human Services and Child Protective Service.

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“We think it’s because we didn’t have eyes on the kids,” she said. “Even within the first three weeks of school, it’s ramping back up pretty quickly with our students now that they’re back.”

Being an adolescent is hard and, in many ways, it always has been, even in the best of times.

“Now that we’re past our teens, it’s hard to remember how tumultuous of a time it is, how much is going on in their bodies and their brains in terms of development,” said Megan Vogt, a licensed professional counselor and owner of Megan Vogt Counseling in Eagle County.

During this tumultuous time, kids (especially teenagers) are grappling with questions of identity on top of dealing with social, academic and family pressures.

“They want to fit in. They want to figure out who they are and they want to be liked by their peers,” said Michelle Stetcher, the executive director of Mountain Youth.

Ross said that while it depends on the day and the student, the most common concerns she hears from students surround “their overall stress levels, anxieties, worries for friends, difficulties in communicating with important people in their lives (parents, friends, teachers), and frequently thoughts about suicide.”

And for students, the way these concerns manifest also varies.

“Some students internalize these difficulties, and you may not know by looking at them that they are having these struggles. These students may engage in self-harm, report intrusive thoughts about their difficulties, or a lot of negative self-talk,” Ross said. “Other students externalize their behaviors, and may present with behavioral challenges at the school or in the community (breaking rules), and are sometimes the students who are easier to tell that something is happening with.”

Candace Eves, a prevention coordinator with Eagle County Schools, said that according to the district’s prevention coordinator referral data, youth are facing “a plethora of behavioral health challenges.”

This includes anxiety, depression, impulsivity, being withdrawn, trauma, grief and loss, substance use and abuse, suicide ideation, conflict with peers and family members, abuse and neglect, underdeveloped social skills due to technology, and gender identity issues and a need for acceptance.

Pressures of a pandemic

COVID was a pervasive part of all of our lives this past year, but for students, the pandemic heightened a number of existing problems.

Children are “not immune to the unrest of the entire world,” said Dr. Teresa Haynes, clinical supervisor at the Hope Center.

The pandemic increased isolation, forcing many to lose vital social interactions like sports, prom and graduation. It increased dependence on social media and virtual connection, and in some cases on substances. It intensified a lot of family problems. All of this was compounded with an uncertainty about how long the pandemic would last, what else would be taken from students and what it’s lasting impacts would be.

“Youth mental health has been increasing in intensity over the past year,” Ross said. “I think that a lot of these symptoms are similar to pre-pandemic, but I would also say that the pandemic stress has heightened a lot of these symptoms for our students.”

“The ambiguity brought on by this pandemic has created a layer of anxiety and confusion for many, including our students,” Eves said. “Childhood development is heavily influenced by social interactions, which have been vastly impacted due the pandemic and the consequences of not being able to gather.”

As the world shifted into a new virtual reality, “there were a lot less opportunities to have that real, genuine, human connection,” Stecher said. This isolation and lack of connection, she added, is a “big indicator to depression, which is then a big indicator for suicide ideation.”

The added pressures of social media — and this virtual communication — have concerned many mental health professionals far before the pandemic.

“Thinking back to a generation ago, students were able to disconnect from their peers when they got home from school or through the weekend. Now, their phones keep their peers in their pocket 24/7. That can be really hard for students, and parents,” Ross said. “I think the stay-at-home orders and school closures in 2020 enhanced the unhealthy relationship that a lot of our students experience with social media.”

The problem with social media, Ross said is that it’s difficult to remove it fully. Students do use it to connect with their friends and peers; however, social pressures often intensify on the platforms. “It can be a lot easier to say something cruel or unkind behind a phone or computer screen than in person,” she said.

The other problem, Eves said is that “social media leads with the idea of perfectionism and instant gratification, which impacts how youth see themselves and others around them, often painting a very unrealistic reality. This experience can perpetuate negative feelings and thoughts, oftentimes leading to further isolation and lack of meaningful connection to others.”

COVID-19 also added a layer of challenges for many students within their home lives. According to Eves, the last year brought an increase in crisis calls due to family distress in the challenges in the homes.

This included, “challenges with meeting basic needs for some families and students as seen by the increase in food security concerns, the housing crisis leaving many families feeling transient and living in hotels and motels until housing can be found,” she said.

These factors, especially in light of COVID-19, have created “a real level of family stress that trickles down to kids,” Haynes said.

Students often internalize their family’s concerns around employment, finances and home life, said Casey Wolfington, a licensed psychologist and the senior director of community behavioral health at Eagle Valley Behavioral Health.

“I really feel like our youth have the same stress that their parents are experiencing, but they just also have the added stresses of everyday aspects of school,” Wolfington said.

If there is one bright spot, however, Wolfington says, it’s that, regardless of the crisis we find ourselves in, the pandemic has helped destigmatize behavioral health. The “shared trauma of COVID,” she said, while it has cause damage, it has also opened conversations and has “done a tremendous amount to normalize anxiety, depression and concerns.”

Getting to where we are today

16 years ago, when Agnes Harakal’s son John had his first psychotic break, he was 16. Since then, John has been diagnosed as bipolar. But at the time of his first episode, he needed in-patient services and he was taken to Grand Junction, in shackles in an ambulance, to get the help he need.

“It was heartbreaking,” Harakal said.

This wouldn’t be John’s, or the Harakal’s last trip to Grand Junction. While the family worked to find the right balance of treatment for John, they made this trek often (although Harakal drove her son after the first time). But the fourth trip, where Harakal sat with her son for 30 hours with a police officer, “was the thing that broke the camel’s, or mother’s back,” Harakal said.

At that time, Harakal set out to start a conversation and change the stigmas around mental health. The family’s work started with a parade in 2016 under the banner of “Changing Minds.” And since then, Harakal has worked tirelessly — alongside many other community organizations and in her role on the county’s mental health advisory committee — to change the conversations.

Overall, she thinks the community has done “a hell of a job,” with the big difference being “we’re talking about it as a community, and people care.”

“I think the change here has been amazing. I think the openness of our community to embrace people with mental health, whatever it may be, is amazing,” Harakal said.

This change has, over the years, made its way to the youth population in Eagle County through a variety of avenues, including community organizations, and within the school district.

A lot of the changes for the school district came around 2017 and 2018, Rewold-Thuon said. According to her, the district began to put more emphasis on resources and services in schools as it saw their student suicide risk assessment numbers increase, and with the tragic suicide of 13-year old Olivia Ortega in 2018. Ortega wasn’t a student with the district when it occurred, but had been a previous student.

“We didn’t seem to have adequate resources to help a student that is struggling,” Rewold-Thuon.

In fall of 2017, the district was awarded a school-based health professional grant from the Colorado Department of Education. This grant was awarded to increase its capacity around social and emotional learning; professional development opportunities for staff to learn about youth mental health, trauma, substance abuse and resiliency; increase the schools’ abilities to address and help navigate high need areas for students and families; and to create teams between middle schools and high schools to identify student behavioral health trends. As part of this, the district paid for the prevention specialists and the scope of their work

When the grant expired in 2020, Eagle Valley Behavioral Health extended the grant for a year and in 2021, this funding was extended by the Eagle County government through tobacco tax revenue. And, it updates the roles of the prevention specialists, adding more days and more organization of services.

Around this same time the initial grant was awarded, the district in collaboration with the county government put out a request for a proposal to bring dedicated clinicians to the schools. The result was that the Hope Center brought school-based programming to the Eagle River Valley in October 2018. Benway said this school-based program receives funds from the marijuana tax money, which was passed in 2018.

“In October of 2018, we had 24/7 crisis response and two Hope Center clinicians in two middle schools,” Benway said. “Three years later, in September 2021, we have 13 clinicians in 14 schools.” And it still offers 24/7 crisis support.

Ross was the first school-based clinician hired.

“We have been able to provide thousands of hours of needed behavioral health support to students in Eagle County,” Ross said. “We are right there at the school, so if a crisis arises, we can provide immediate support and connect with students that same day, instead of days or weeks later.”

The biggest benefit to having Hope Center Clinicians in the schools, Wolfington said, is that it removes so many barriers to access.

“When we think about rural health, often times we’re facing transportation barriers, financial barriers, the ability to balance competing needs,” Wolfington said. “And the Hope Center school-based clinicians erase all those barriers because they’re in school. A student can walk down the hall and access services that are completely free of charge.”

These school-based clinicians also work in conjunction with teachers and school counselors to provide a more comprehensive approach to student mental health.

And at many of the schools, depending on the need and the counselor’s capacity, counselors provide small group counseling services for a variety of students’ needs. This could include groups for students of divorce, students struggling with social interactions or grief and loss.

The success of these Hope Center clinicians was demonstrated immediately, Wolfington said.

“There were so many students that were in need of behavioral health support that those clinicians, their caseload filled almost instantaneously and it becomes this piece of how do we then add additional clinicians to support that need?” she said. “Our school-based programs demonstrated success so incredibly quickly.”

The school district didn’t stop there, however, and continued to partner with community agencies to fill the gaps needed to support students. According to Eves, this includes adding social and emotional learning to the curriculum as well as engaging in partnerships with the Behavioral Education coalition. This coalition includes Mountain Youth, Red Ribbon Project, SpeakUp ReachOut and Bright Future Foundation.

“We work with these other organizations to do some very targeted prevention work with students and then some intervention work,” Rewold-Thuon said.

Amy Lewis, currently the grant administrator for the Education Foundation of Eagle County, has been involved with this coalition since its second year and has helped secure sustainable funding for these organizations to increase their operational capacity within the public schools.

To date, Lewis said that EFEC has been able to raise $568,920 to facilitate programming that supports the schools counseling and social-emotional efforts. This funding has come from two consecutive grants from the Colorado Health Foundation, the second of which was awarded earlier this month.

“The Colorado Health Foundation, they have said over and over that we’re the only coalition throughout the state that’s doing something like this and that’s why they want to continue funding us,” she said. “They see this community coming together to support our youth and it fits all of their priorities.”

And for the public school district, the coalition compliments its work and bolsters itspriorities.

“The overall wellness of our students is our top priority and we want students and families to know that they can reach out to us at any time and we can help them connect with resources or provide resources,” Rewold-Thuon said. “And that this community is very, very rich in resources right now.”

The growth of these resources has had a big community impact.

Vogt’s first year in private practice — she had previously served as a school-based mental health clinician, working in local schools — was right after Ortega died by suicide.

“There was a lot of fear from parents, and a lot of angst within just the kiddos that I saw coming through my door,” Vogt said. “Since then it really has evolved. It’s been kind of a big three years in this town, with COVID and the schools shutting down and a lot more awareness about LGBTQ issues.”

With the introduction of more clinicians and counselors in the schools, more resources, including Olivia’s Fund, “it makes kids feel so much less alone,” she said.

“Just the knowledge that help is out there and these things are being talked about and all of that is just comforting for anybody to know, because I think that so much anxiety happens when you are struggling, but you don’t know where to go or if there’s anything available for you,” Vogt said.

“It’s a really small community and there’s been a lot of tragedy and a lot of hardship and I think that generally we really care about our kids and it’s pretty cool to see that,” Vogt said. “None of us can do this alone. So I’m just really grateful for the teachers and the counselors and the parents and everyone involved because it takes everybody.”

And this sense of community has only gotten stronger through the pandemic, Wolfington said.

“Every community organization has a stronger connection than we’ve ever had,” she said. “Going through a pandemic together, we were having some really big behavioral health conversations on an almost daily basis for the past two years. And so I think that we are probably closer aligned than we’ve ever been and really know the needs.”

A foundation of mental health education

Through the implementation of these partnerships and the influx of resources, kids today are getting a much more robust education when it comes to mental health.

“Creating a solid foundation for mental health matters to our students and our community,” said Robin Roche, a licensed school counselor at Gypsum Creek Middle School. “This is my third year at Gypsum Creek and during this time, I believe that our social emotional learning team has integrated well-being and mental health into the forefront of so many of our conversations about students. These conversations ripple out and have a positive impact on our whole school community.”

Social-emotional learning has been a big push from the district in recent years. According to Rewold-Thuon, this helps get students ready for all the academic aspects of learning.

“If students aren’t in a place where they’re able to learn, it’s not going to help to give them more content and information,” she said. “The social-emotional aspect is how the student is dealing with themself, with others, their ability to handle stress, their ability to be resilient, their ability to get through their day and their relationships.”

Currently, the district is working with Eagle Valley Behavioral Health to bring in social-emotional curriculum into all schools and grade levels. Currently, the middle schools have a program that they are using and there are two elementary schools piloting a program for the elementary level.

A big part of adopting this mentality goes back to training staff as well.

“School staff have increasingly become advocates for reducing stigma with mental health, normalizing mental health as just as important as physical health and the link between academic success being dependent on wellness,” Eves said.

The district also relies on its community partners to fill in any gaps for students.

SpeakUp ReachOut provides signs of suicide education to students starting in fifth grade and going through 12th grade. Starting these conversations young and progressing the conversation, said Carol Johnson, director of programs and events with Speak Up Reach Out, not only breaks down stigmas, but can help prevent unwanted behaviors later on.

“The more we can talk about things, the more stigmas will break and the healthier we’ll be,” she said.

In fifth grade, the students receive two classes from SpeakUp ReachOut. The first of which delves into feelings and emotions and how to control and understand them. The second talks about mental illness, its prominence as well as forming definitions around anxiety and depression.

From there, each grade level progresses forward, getting more in depth each year. Discussions include the difference between sadness and depression, how to positively access social media, finding trusted adults as well as developing positive coping skills and avoiding negative ones. Students also learn ACT — acknowledge, care, tell — as a method for talking to friends about mental health and helping refer them to further help.

As a part of these sessions, students are able to request mental health support and also refer friends who may be struggling for support as well.

It is SpeakUp ReachOut’s goal to do these trainings in every Eagle County classroom. This year, it already has 95 classrooms on the schedule.

In collecting information about students’ mentalities and tracking behaviors like drinking, smoking, vaping, and exercise, it partners with Mountain Youth on the Healthy Kids Colorado survey. The organization also provides programming in the schools “focused at helping young people navigate adolescence better,” Stecher said. This includes topics like goal setting, communication, boundaries and resilience.

The district also relies on the Red Ribbon Project for sexual health and maturity education and on Bright Future Foundation for learning about health and abusive relationships.

Students are also educated on where they can go to get help. In addition to the Hope Center’s crisis line, students are told about the Colorado Crisis Center, Safe2Tell and how to find or access a therapist, if needed.

Many of these resources become vital out of school as well, particularly over weekends or during winter, summer or holiday breaks. Having these resources can provide students support when they don’t have access to in-school support.

“We have more resources to identify possible concerns and then provide supports for young people than we ever have, and a benefit of that is it normalizes help,” Stecher said. “I still think there are stigmas, especially with some sub-populations, but I think we’ve come a long way in helping to reduce those stigmas as a community.”

Existing barriers

Gerry Lopez was a junior in high school in 2016 when he began struggling with suicidal thoughts and loneliness. Ultimately, rather than end his life, he reached out for help.

“Through opening up and therapy, I’ve been able to become more open to behavioral health and less afraid to ask for help,” Lopez said.

In high school, therapy led Lopez to discover his strengths, starting with joining the cross-country and track team. And since graduating, he has dedicated himself to sharing his story, becoming involved with his community and helping others become more open about mental health.

Today, Lopez is the mentoring and project manager at My Future Pathways and acts as a liaison for Eagle Valley Behavioral Health and Latino youth efforts. He hopes to help students understand that they are not alone.

“A lot of kids suffer in silence and I wish that those kids knew that they are not alone and that help is available for them,” Lopez said.

Since graduation, Lopez does see that some strides have been made — having the Hope Center clinicians in schools and having more openness around the topic — but still feels that there is a lot more to accomplish.

For starters, there is a lack of Spanish-speaking and bilingual clinicians available. Vogt said this was one of the “biggest gaps” in local services right now.

Not only is there a lack of bilingual clinicians, but there is still a need for more clinicians and counselors with expertise in working with children. While the demand and need for pediatric psychiatric care has been established, the needed services aren’t always available.

“We recognize that there are certain situations where some students would benefit from outside of school therapy services,” Ross said. “Our community providers are being utilized to full capacity, which sometimes creates a barrier for accessing therapy services in the community.”

Wolfington said this is something Eagle Valley Behavioral Health is seeking to address through adding more pediatric providers and tiered levels of care.

“We don’t have enough services, we don’t have enough specialty providers, we don’t have enough tiered levels of care, which really means that if somebody needs to be seen more than once a week or more than every other week, there’s really not a lot of options here,” Wolfington said.

The labor shortage is exacerbating this challenge as well. Rewold-Thuon said that the district, through COVID-19 relief funds, now has the capacity to hire additional counselors and social workers at the high schools. However, officials haven’t been able to fill these vacancies. This includes two open counseling positions at the middle school and high school level. And for school psychologists, it has the capacity to have six, but only has three.

“We know that kids could use more counseling, working with school psychologists,” Rewold-Thuon. “Without the number we should have, it cuts in half the amount of services that we can provide.”

Ross said that the community pressures felt around housing and child care are felt by clinicians as well.

“It feels difficult to plant roots fully, which could wind up becoming a barrier to services for youth if we cannot retain these behavioral health professionals,” she said.

From the district’s perspective, while it has come a long way, there is still an immense need for “additional financial resources for mental health and substance abuse intervention and prevention,” Eves said.

On the financial side, the Education Foundation of Eagle County has been dedicated to finding sustainable and local funding around youth mental health since 2018, because the state doesn’t prioritize social-emotional learning like it does academic learning, according to Lewis.

“Unfortunately, in the state of Colorado, schools are not held accountable for social-emotional learning the way they are held accountable for academics,” Lewis said. “Academics will always take a seat in front of social-emotional learning.”

Even though, she said, they are inextricably linked.

“We’re fighting for social-emotional learning to be as important as academic learning and we’re fighting to keep those counselors in the schools, because we saw what happened when we got rid of them at this really crucial time in society,” Lewis said.

With substance abuse, Wolfington said that, similar to the county’s adult population, there is a “high number of youth that are turning to substances and substance use and abuse to manage their emotions.”

This community problem is one where services fail to meet the need for intervention and prevention around substance abuse.

“Living in a resort community, we still struggle with an environment where alcohol is everywhere,” Stecher said. For its part, Mountain Youth hosts many alcohol-free family events.

Hope ahead

The benefit of much of this work is that kids are starting to have more open and honest conversation around emotions, feelings and mental health. This means that even with existing gaps in services and resources, the community is ready to fill those gaps.

For some schools, this includes bringing the kids themselves to the forefront of the conversation.

“I think if we want to make a difference in this community for youth, then we need youth at the table helping to make those decisions and lead those efforts,” Stecher said.

Last year, both Homestake Peak (now, for students grades four through eight) and Gypsum Creek Middle School welcomed a peer-to-peer suicide prevention program. Called Hope Squad, the program is part of a national organization and is designed to destigmatize mental health and suicide so students are encouraged to talk about their struggles and seek help.

Students nominate peers that they see as leaders, good listeners and trustworthy to the Hope Squad. The students then receive education around Question, Persuade, Refer — something SpeakUp ReachOut also teaches. This method is “designed to increase the chance of survival in the event of a crisis by providing a set of skills that may help prevent suicide,” said the Homestake Peak middle school counselors.

With QPR, the students are training to report concerns to a trusted adult or counselor which Homestake’s counselors called “monumental,” as students often reach out to peers.

“Hope Squad helps create visibility for mental health and well-being amongst the students. The student leaders have the opportunity to feel like they are the experts on their own lives and that they know how to help support their peers when they are going through challenging times,” Roche said. “Having a Hope Squad helps create a visual reminder for students that they can reach out to each other when they need help.”

This visual reminder is just one of many ways that the schools and other organizations are building hope for a brighter future for youth mental health.

For its part, the school district has plans to continue identifying students who need help through a universal social-emotional screening tool, as well as adding tiered-levels of support so all students receive the support that they need.

“I think that we do a better job of identifying the students that are not the outspoken students,” Rewold-Thuon said. “We hope that this social emotional screening will help us identify is the students that are hurting inside but may not be very vocal about it.”

Plus, Eves said that this program will ensure that the district is providing the correct resources to students as well as learn about the state of students’ wel-being.

As part of its collaborative approach to student well-being, the district also hopes to further train its staff on suicide assessment and “youth mental health first aid,” Rewold-Thuon said. “So helping get teachers the tools to recognize when students have trauma or when students are at risk in their classrooms and how to engage with the students in a way that is safe and helpful for the students.”

For a while now, the school district has been working on a wellness plan that encompasses all of these future goals around mental health, and then some.

“All of the district wellness team efforts, while some of the work not specific to mental well-being, funnels to support the whole child who has the knowledge, skills, ability and support to achieve their goals,” said Dana Whelan, the district’s wellness coordinator. “Primary support for mental well-being is learning self care and creating healthy habits for all students’ ability to have the best starting point to cope with the challenges of being a young person during a pandemic.”

While the community has come along way, the work is just getting started. There are still barriers, there are still challenges, but these organizations are just getting started.

“I do think that we have a lot of amazing providers in our community and they’re very busy. So it always feels like we could continue to use more,” Haynes said. “There’s always room for improvement and touching on those other things as well to increase and just support the mental health of students.”