Kaci Rodriguez knew her son was struggling mentally. His behavior was increasingly impulsive. He was becoming more easily distracted. And he was having more trouble with academic work and behavior issues at his elementary school. When she brought her concerns to his teachers, they often replied, “Oh, he’s just being a boy,” or, “Give him time.” But Rodriguez could tell something more profound was going on.

“I felt I had lost my child,” she said. “I had nowhere to turn.”

Her growing anxiety eventually prompted Rodriguez to seek help from mental health services. But getting her son evaluated took time. “The lack of access to mental health services is a huge problem where we live,” she said. Where she lives—Roswell, New Mexico—is a town of nearly 48,000 people located in the high desert plains in the southeast corner of the state.

Eight months passed before Rodriguez could get her son an evaluation. He was diagnosed with ADHD and placed in the moderate to severe range of the condition. And it was recommended he be placed on medication.

Getting a prescription was also a challenge. Pediatricians are few and far between in Roswell, according to Rodriguez, and wait times to get an appointment are lengthy.

But once the meds kicked in, “the difference was like night and day,” Rodriguez said. “I felt like I had my boy back.”

The difference was also reflected in her son’s schoolwork, as his grades rose from failing to C’s and B’s.

The whole experience left Rodriguez with the lasting impression that finding mental health access for children shouldn’t be so difficult. “Parents in this situation don’t know what to do,” she said. “Teachers don’t know what to do either. They haven’t been trained for this.”

Her experience motivated her to go back to school to get certified as a special education teacher. She completed her certification and now serves as a resource teacher at Del Norte Elementary School in Roswell.

It also persuaded Rodriguez that when her son transitioned from elementary to middle school, they should find a school that offered an educational approach, commonly called community schools, where the school acts as a hub for accessing a wide range of student and family services, including mental health services.

“We specifically selected Sierra Middle School because of its community schools program,” she said.

Rodriguez is not alone in linking her child’s mental health struggles, and the lack of access to treatments, to the need for more schools to adopt the community schools approach.

In the aftermath of the tragic school shootings in Uvalde, Texas, in 2022, U.S. Secretary of Education Miguel Cardona testified at a congressional hearing in May 2022 that his department’s 2023 budget would prioritize mental health supports for K-12 school children, and he linked that effort to expanding the number of community schools nationwide, according to K-12 Dive.

But Rodriguez’s success in placing her son in a community school that provides ready access to mental health services hit a snag this summer when she learned that Sierra Middle School would reopen for fall classes without continuing its association with the nonprofit that operated the school-based health center.

Although the school will continue to adhere to the community schools approach, it will need to pursue new partnerships in order to provide mental health support for students and their families.

The school district’s partnership with a local nonprofit La Casa Family Health Center, which operated the school-based health centers, ended abruptly in June, and it’s not clear what alternatives are being put into place instead. (Repeated inquiries by Our Schools to La Casa and the Roswell Independent School District (RISD) went unanswered.)

The only explanation for the school-based health centers’ apparent demise is that “the funding ran out,” according to sources Our Schools spoke with, which is a way of saying that the philanthropic community and governments failed to sustain a program that was providing an important service to the community and was necessary to ensure the welfare of the students.

“Not having [a school-based health center] is a huge disservice to staff and students,” Rodriguez said. “It’s a travesty. Really horrible.”

The despair Rodriguez expressed might as well be a rallying cry for families everywhere as evidence mounts of a mental health crisis among children and teens nationwide.

Yet policymakers and politicians send mixed messages about the importance of increasing mental health support for children and teens.

Prior to Cardona’s defense of his budget proposal before Congress in 2023, Virginia Foxx, the Republican chair of the Congress’ Committee on Education and the Workforce, stated, “We must be thoughtful about how we discuss and handle school safety and mental health issues.”

Before taking leadership of that committee, Foxx stated, in a September 2022 hearing that “[S]chools should have a role in addressing student mental health struggles,” according to K-12 Dive.

Yet she also seemed to hedge on what that role for schools should be when she added, “At the same time, I know parents are concerned schools are becoming so focused on the students’ mental health and social-emotional learning, the schools are losing sight of their core mission.”

Also, in an October 2022 vote, Foxx opposed a bill passed in the House that would provide federal funding for states to recruit and retain mental health providers at public schools, preferring instead to blame rising evidence on “pandemic-related school shutdowns.”

But as this story out of Roswell shows, many families, especially those who live in rural communities, are being left on their own to sort out very complicated problems. And, meanwhile, educators, who know all too well their students’ struggles with mental health issues are calling for ideas like the community schools approach that seem to offer promising remedies.

‘Schools Play a Critical Role’

Even before the pandemic hit in 2020, the percentage of children aged four to 17 years diagnosed with ADHD had increased from around 6 percent in 1997-1998 to approximately 10 percent in 2015-2016, according to a 2018 research study by the National Health Interview Survey.

The overall mental health of children and adolescents was also trending negatively. According to an analysis by the Centers for Disease Control and Prevention (CDC) between 2007 and 2018, the suicide rate among Americans 10 to 24 years old jumped by nearly 60 percent.

In its Youth Risk Behavior Survey covering the years from 2011 to 2021, the CDC found that “[I]n the 10 years prior to the COVID-19 pandemic, mental health among students overall continues to worsen, with more than 40 percent of high school students feeling so sad or hopeless that they could not engage in their regular activities for at least two weeks during the previous year—a possible indication of the experience of depressive symptoms.”

But the waning pandemic has brought on a widespread realization that mental health issues of all kinds among school-aged children are a growing problem in the United States.

“Mental illness and the demand for psychological services are at all-time highs—especially among children,” according to a 2022 report by the American Psychological Association.

The crisis is at its worst in predominantly rural states like New Mexico.

Prior to the pandemic, according to the CDC, New Mexico was fifth—at 19.6 percent—among the five worst states for suicide rates for persons aged 10 to 24 from 2016 to 2018. All five of those states are predominantly rural.

Rural states, including New Mexico, also tend to provide much less access to mental health services. According to Mental Health America, “65 percent of rural counties do not have a psychiatrist [and] 81 percent do not have a psychiatric nurse practitioner.”

A 2022 report by Initium Health, a public benefit corporation, found, “Due to… [a] very limited number of beds to serve 357,583 children and adolescents in… [New Mexico], it is even more difficult to find inpatient care for pediatric patients. This leaves families in a lurch, where they are facing long distances for care and the potential of being separated from their child during a psychiatric inpatient stay, which is not optimal for the child or the family.”

An analysis by the American Academy of Child and Adolescent Psychiatry that found an acute shortage of child and adolescent psychiatrists nationwide also found that there was not a single practicing child and adolescent pediatrician in the entire southeastern corner of New Mexico, where Roswell is located. “There are approximately 8,300 practicing child and adolescent psychiatrists in the U.S. and [more than] 15 million children and adolescents in need of the special expertise of a child and adolescent psychiatrist,” the report found.

Children, in fact, often wait 8 to 10 years between the first symptoms of a mental health problem and an intervention. These are “critical developmental years in the life of a child,” according to the report.

There’s widespread agreement that schools can play a role in addressing mental health.

Schools are where children’s mental health problems often first show up. According to 2022 data from the federal government, “More than two-thirds of public schools reported an increase in the percentage of students seeking mental health services from school since the start of the pandemic.”

“As the number of young people experiencing depression and anxiety continues to grow,” U.S. News and World Report stated in 2022, “schools play a critical role as providers of mental health services.” Yet, the article cites the many obstacles schools often face in providing students access to mental health supports, including the inadequate numbers of counselors and school psychologists.

‘Nearly Impossible to Get an Appointment’

In Roswell, “it can be nearly impossible to get an appointment with a pediatrician that isn’t weeks or even months away,” according to Kristen Salyards the community school coordinator at Sierra Middle School and the district’s lead coordinator for community schools programs at three other schools in the Roswell Independent School District.

“Even getting a prescription from a pediatrician’s office for something like an ear infection or the flu can take days. For an X-ray, students need to go to the hospital,” Salyards said.

Regarding mental health services, there could be a four- to six-month waiting list for local in-person mental health services, said Salyards. And the school counselor is usually overwhelmed.

Consequently, according to Salyards, students are often left with no other choice but to search online for answers or talk to their friends about mental health issues.

Lack of access to care is an especially difficult problem for students dealing with an acute crisis, according to Salyards, which often requires them to go to the local hospital’s emergency room.

If the crisis is serious enough to warrant lockdown, the child would need to be taken to a hospital that is three hours away in Albuquerque, she said. Further, students returning to school after a crisis would need to undergo a mental health assessment to reenter classrooms, which could also take days.

‘Every Kid Is Struggling’

In Roswell, the link between mental health and the community schools approach is direct. Sierra Middle School was the first school in the district to adopt the community schools approach in 2019. Since then, three other schools have adopted the approach: El Capitan Elementary School, Mesa Middle School, and University High School.

All three schools had access to school-based mental health services operated by La Casa Health Center. La Casa operated its school-based health services at three RISD campuses—Mesa Middle School and Goddard and Roswell high schools—which were accessible to all RISD students and their families.

But schools that have community schools programs have a special advantage in their relationship with the health care center. This approach uniformly provides a coordinator, such as Salyards, and these schools have a staff member who has the sole responsibility of taking on the work of providing a contact point and advocate between teachers, health practitioners, and families.

When Salyards first took on that role in 2019, she sensed that establishing a school health center should be a priority for families. The process of implementing the community schools approach convinced her of that need.

One of the first requirements of adopting the community schools approach is for the school to conduct an extensive needs assessment of the assets that exist in the community and the needs of students, families, school staff, and the surrounding community.

As Salyards conducted her initial assessments, she found widespread signs of trauma, grief, and other mental health issues among the students and their families. She also learned how much gun violence in the community had, in her words, “gotten out of control.”

What was also particularly shocking to her was the number of students who reported having lost a family member within the past six months. One of her emails to students asking about whether they had experienced a family-related fatality within the last six months drew 30 positive replies.

The aftereffects of the pandemic have further elevated the need for mental health services, according to Salyards. Because schools across New Mexico were closed for in-person learning for more than a year, students missed learning and practicing socialization skills. Middle schools and high schools were especially impacted, according to Salyards.

“Every kid is struggling,” she said.

According to Salyards, “The school-based health center proved to be an effective way to ensure students and families got quick and timely physical treatments, medications, and mental health care that would otherwise not be obtainable in Roswell.”

After opening the school-based health center, students who couldn’t get an appointment with the counselor could go to the clinic. Students experiencing a crisis could be seen by a trained mental health professional and could quickly get the assessments allowing them to reenter classes.

There were even bigger benefits that went beyond mental health. Students could get flu tests, routine vaccinations, and annual physicals to play sports. Kids who needed eye and dental check-ups could get it at the school.

“All of this was free and accessible,” Salyards said.

The Wrong Alternative for Families

As families lose access to the school-based health centers and schools scramble to find new partners for mental health services, one fear is that the only alternative for families is the open market, which in New Mexico is dominated by for-profit providers, including those backed by private equity investors that have poor track records for serving children and adolescents.

In its 2022 report on the impact of private equity-backed youth behavioral services, the Private Equity Stakeholder Project (PESP) found, “increasingly for-profit companies, including companies owned by private equity firms, make up a significant share of providers.”

In several of the largest for-profit service providers that operate residential facilities, PESP found evidence of widespread neglect and abuse of youth under their care, including “[i]nadequate counseling or education services; [p]hysical, sexual, and emotional abuse; [f]orced isolation; [u]se of physical and chemical restraints; [and] [s]qualid living conditions.”

PESP’s report concluded that the growing presence of the private equity business model in this sector would likely worsen these problems because of the business model’s demands for “outsized return expectations over relatively short time horizons [that] can lead to cost-cutting that hurts care. In addition, use of high levels of debt can divert cash from operations to interest payments and dividends paid out to private equity owners.”

Regarding autism, “private equity firms have become dominant players in the market for autism services,” according to a 2023 report by the Center for Economic And Policy and Research. “They have bought out many provider organizations across the country and created massive national chains with the primary purpose of extracting high returns in a short period of time.

The involvement of private equity investors in the treatment of autism “can cause therapists to see double or triple the recommended number of children, and it can lead to overloaded supervisors, undertrained support staff, and cookie-cutter learning plans,” wrote Vincent Strully Jr., founder of the New England Center for Children, in an opinion piece for Spectrum. “[Private equity]-based centers also tend to over-bill hours, shirking accountability and decreasing transparency. In general, quality care is sacrificed to boost the bottom line.”

Hospitals are the other option as providers of mental health services for children and adolescents that are also increasingly dominated by private equity operators, especially in rural states like New Mexico. According to a tracker on the PESP website, New Mexico “has the highest proportion of private equity-backed hospitals compared to all private non-government hospitals at 43 percent.”

In Roswell, Lovelace Regional Hospital is owned by Ardent Health Services, whose primary investor is Equity Group Investments (EGI), a private equity firm based in Chicago, Illinois, according to PESP and the Ardent Health website.

Another Roswell-area hospital, Eastern New Mexico Medical Center, also has its business practices rooted in the tactics of for-profit operations backed by private equity.

The hospital is operated by Community Health Systems, Inc. (CHS), according to the CHS website, a Franklin, Tennessee-based company that, through its subsidiaries, owns, leases, or operates 76 hospitals in 15 states.

According to a 2019 article in the American Prospect, CHS was acquired in 1996 by private equity firm Forstmann Little and Co. And although Forstmann has since returned CHS to the public domain and sold its shares, CHS has “continued to operate using the private equity business model, including the use of leveraged buyouts to add on smaller health care companies and loading CHS with dangerous amounts of debt.”

‘Providing These Kinds of Services Ensures Kids Can Learn’

It is unlikely that these are the kinds of partners Salyards and other RISD community schools are interested in forming new relationships with. But despite losing the school-based health centers, she remains convinced that the community schools approach is still the way to address the needs of her students and families.

“I fully embrace the idea of the community schools approach and believe in its ability to address systemic change as well as address the needs of families,” she said. “I can see the difference the community schools approach has made already and know the promise it holds as we expand the model.”

As evidence of that progress, she noted that in her most recent annual survey asking students if they have at least one adult in their lives who will stick up for them, the number of positive replies has gone from 4 percent three years ago to 31 percent in her most recent survey, an indicator that students are forging new positive adult relationships they can rely on for support.

In the year ahead, she is focusing on getting a federal grant to form new partnerships with other nonprofits and increasing the sustainability of the community schools program throughout the district.

“My idea is to provide students with more social-emotional instruction with a focus on preventing problems that can come from experiencing grief and trauma, including anger management, depression, and substance abuse,” she said.

And Rodriguez is still relieved to have her son in a school that uses the community schools approach, despite not having access to the school-based health center.

“School is so much more than academics,” she said. “You can’t educate a kid who is hungry or scared—who doesn’t know how they’re getting home from school or are afraid of what’s going on at home. Providing these kinds of services ensures kids can learn.”

(Photo by Allison Shelley for American Education: Images of Teachers and Students in Action, CC BY-NC 4.0).