This article is co-written by Henry Chung, MD.
One half of mental illnesses appear by the age of 14 and two thirds by the age of 24. These are the years when youth leave home for college or go on to university. In other words, mental illnesses, including alcohol and drug abuse, are the conditions that arise and may affect your child as he takes on the developmental steps of leaving home to go off to school. In fact, an important study of the mental health of college students by Dr. Carlos Blanco of Columbia University reported that almost 1in 2 college aged individuals had a mental disorder in the past year.
The most common conditions are alcohol and drug problems with 25 % of college youth (18-24) impacted. Remarkably, this is greater than the presence of a mood disorder (depressive or bipolar disorders) which was 11% and anxiety disorders (panic, social anxiety, phobic and generalized anxiety disorders) which were 12%. Importantly, less than 25% of those youth with a mental disorder sought treatment in the year prior to their identification in this survey; far more youth with mood and anxiety disorders in college sought treatment (34% and 16% respectively) than those with alcohol or drug disorders (only 5%).
As your child heads off to school there are a set of questions you may have and would like answered. These may be the questions that you have.
Q: What are the more common mental health conditions that strike when students go off to school? Why is that?
A: Mood and anxiety disorders are the most common. These conditions come on in adolescents and those in the college years. Social anxiety disorder is particularly prominent, and not a condition many think about.
Co-morbidity (the presence of more than one disorder at the same time) is highly prevalent - especially depression and anxiety. Some 60% of those youth with a social anxiety disorder will develop depression by the time they are in their 20s.
Depression is very common, and associated with suicidal thinking and behavior. Often youth come to college with a depressive condition that may or may not have been detected or treated. So, often they arrive at school already ill with this condition or develop a first depressive episode at the college.
Attention Deficit Hyperactivity Disorder (ADHD) is another common condition. This condition is often previously diagnosed and students (and their families) want assistance maintaining prescribed medications or receiving special accommodations for the condition.
Alcohol abuse and drug taking are unfortunately quite common challenges at colleges and universities. But many students do not see it as a problem, and don't seek help for these behaviors. There is a 1 item screening tool endorsed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA - http://www.niaaa.nih.gov/) that show how many times a student in the past year has had 5 or more drinks in one sitting, 4 or more drinks if a female. If the answer is yes a more extensive evaluation is in order.
Interestingly, when depression is identified in students they are generally relieved, even grateful, to have the problem detected and their troubles explained; but when schools identify alcohol or drug abuse in students the response is often "what's the big deal?" Clinicians may need to develop specific interviewing skills to help students overcome their dismissal of these problems - which are endangering their health and safety and compromising their school performance.
"Why now"? First, there is the biology of mental health disorders, which are common and emerge in this age group. A family history will often reveal which students are especially at risk for mental and substance use disorders. But there is something about going off to school that may be less about separation and more about a natural desire of youth to be independent. Those already with mental health problems, like depression or anxiety, often envision going to college as a "new phase of life". If they were on medications they often think "I can stop the meds, I can do it". Sometimes they tell their doctor at home and sometimes they don't. They have a good summer, go off to school, stop taking medications and by mid-semester they relapse. That's when they appear for help.
An underlying vulnerability combined with the stress of leaving home and facing the developmental challenges of living on one's own. These are heightened by the academic and social demands of school. Sexual exploration and the emotionally destabilizing effects of alcohol and drugs add to the risk for youth in college. In other words, quite a cauldron of ingredients for developing or worsening mental health problems.
Another problem, fortunately more talked about today than in the past, is the presence of sexual assault - in females principally but in males as well. This includes sexual abuse, rape and unwanted touching. Sexual assault in school also reawakens past traumas for some as their experience at school kindles an underlying history and vulnerability. The American College Health Association has a brochure entitled "Sexual Violence: What Everyone Should Know" - for a nominal price from their website http://www.acha.org. The psychological consequences of assault include anxiety (PTSD and other dissociative disorders) and depressive disorders as well as alcohol and drug problems.
Q: How can parents know a child is in trouble? What would they look for? How should they behave?
A: First, be attentive but don't be hovering.
What a parent should do starts before the child goes off to school. This is a conversation, that doesn't happen nearly often enough, where a parent finds the moment to talk about both the academic and health aspects of going to school. A parent needs to say "I care about your health, not only your grades." The conversation ought to cover the main health areas of significant concern for students, which are sexually transmitted diseases (STDs), alcohol and drugs, and depression. You child may say or think "...mom/dad, you'll never understand" (or look at you like you are suddenly speaking Latin - but don't be put off. A parent can say "...I have read that 55-60% of students report stress, and that it affects their lives and their grades." And add "...Going to school can be wonderful but I know things happen to lots of kids, so I want you to know not only that I know these are common problems but that I am here for you if they occur."
The three things that tell you your child is having trouble are: academic difficulties, her reporting she is "not fitting in", and any call or contact from the school.
Once a child is off to school the first signs of trouble are typically academic performance. Yet many students minimize the problem and a parent is not apt to get a report from their child about grades. There are school agreements a student can sign that allow parents access to their transcript and grades - but these can be revoked by a student at any time, as can permission to know anything about medical problems or treatments. In fact, even when these agreements exist many schools first check with the student even when the agreement is in place saying "we have it but do you want us to use it?" So, open communication with your child is always the best route to follow.
Most students are on their family's medical plan, even though schools also offer insurance plans. Parents can discover that their child has used medical benefits from the EOB (explanation of benefits), the insurance form we all receive in the mail after using medical services, which are sometimes identified in language we can understand. Medications may also be covered by the family medical plan and on the EOB.
Some youth bring up the stress of school by saying something along the lines of "I'm just not fitting in. A parent can say that indeed she heard that at orientation (or somewhere) that stress is one of the most common experiences new students have. A parent can ask "how do you think you can connect? Are there things on the school website or around the campus that offer opportunities, since you are likely among many feeling the same thing?" This may help make their distress feel not so strange and at the same time encourages autonomy to act. Some youth may welcome contact with a counselor. For them, you can suggest turning to the health center or an academic adviser. But always say, "Call me - there are some things I know you will want to keep private. I am always here for you."
The third sign is any contact from the school. Any. This is a warning sign a parent should not blow off. It may be the school calling to report dormitory or other conduct violations. There may be episodes of drinking that exceed the school's rules. Whatever it is - take it as a sign that there is trouble because schools are very reluctant to call. A threshold has been reached and the school is telling you something is the matter.
Finally, and this is not really a sign, but something parents need to know: you as a parent can call if you have reason to be concerned. Families may see or hear something that the school may not. A parent can call the Dean of the School or the Counseling Center. They might want to call a faculty advisor. A parent has a right to be heard. If the person on the line is not listening and taking your call seriously then go up the ladder. Call the President of the school if that is needed to get someone to listen. Your perspective as a parent is but one perspective but it needs to be considered. [More about this below when we talk about being alarmed by what you see.]
Q: What about when a child returns home on school break? What should a parent know or look for?
A: These are unique moments where a child may let down his defenses. In an unguarded moment, feeling the need to communicate, a child may turn to a parent and cue that they are having trouble. Alternately, if your child is especially withdrawn or reclusive, different from how she was, that is important to recognize. If your child goes from being a talker to someone who doesn't hardly say a word that is also something to note.
Significant weight loss can also suggest a mood or eating disorder. In other words, any significant change in your child may be a signal that you need to find out more, and perhaps do something about.
Q: What else can parents do besides ask their child?
A: A parent can make contact with the student's 'collaterals'. By this we mean others who may know their child. These can be parents of the youth's friends, even friends themselves. But be careful since you can really put off your child, as well as other parents or friends of your son or daughter. To do this tactfully, ask questions like "How is your child doing in school? Our children were such good friends before they left for college. Are they spending time together?" Calling friends is even more delicate: is you do, ask about them, as one would about a neighbor or a caretaking person would ask about someone they knew well before school began. The conversation aims to open an opportunity for that youth to say something about their friend if they are concerned. But reserve any call like this one for when you really need to use it.
Q: What about when a parent is alarmed by what she is seeing or hearing?
A: Alarm should mean alarm. Like when a child has been missing for a day or two. Or efforts to reach your child have been unsuccessful for a day or more. Or another student has contacted you and wonders where your son/daughter is.
These are the moments to contact the school. Call the dean of students (general dean or a dean specific to your child's course of study) or a residence hall director (if your child is living in a school residence). You want to speak with someone with responsibility at the school. They should listen, or if they do not then keep going until you find someone who will. You need to provide information, like "My son has been missing since...," and if you know more, like "The last time I spoke with him he said 'life is not worth living'" or "His roommates are very worried since he had been so discouraged after an exam...and now they don't know where he is." And you want to ask: "Can someone look into what is happening and get back to me?"
Responsible schools will take your call, gather what information they can, and look into your concern. They are apt to contact your child, if your child is to be found, and say why they are calling, as they should since after all they have to be responsible to their student as well as to you. A school can meet that responsibility by being transparent about what they are doing. Trust is maintained, even if privacy is intruded upon.
Q: What do parents need to know about the privacy rules that colleges and universities live under?
A: There are two types of privacy rules: one applies to academics, called FERPA -- the Federal Rights and Privacy Act, and the other applies to health services (this includes mental health and counseling), called HIPAA - the Health Insurance Portability and Accountability Act. Schools typically do not prominently display these rules. Sometimes the school's policies will be on its website.
The US Department of Education has a good primer on FERPA (available at
http://www.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/index.html -- click on For Parents: Parents' Guide to the Family Educational Rights and Privacy Act: Rights Regarding Children's Education Records). Parents have a right to review their child's academic record until that child is 18 or goes away to school, so that means for colleges and universities the information belongs to the student, not you. Schools can, however, disclose educational information in the event of a health or safety emergency (but see how this is curtailed by HIPAA - below). Schools also can inform parents of youth under 21 if there has been a violation of a law or policy related to alcohol or drugs. Finally, and this is notable, a school official can share information based on their personal observations or knowledge about a student.
HIPAA (The Health Insurance Portability and Accountability Act) is a Federal law enacted in 1996 to protect the health information of individuals. While it has various components it is the privacy part that is generally best known, and governs the actions of health care organizations, which include student health services (and hospitals). HIPAA makes it clear that your child, as an adult, has full privacy protection from anyone trying to find out health care information - and this includes parents.
Q: Doesn't the school have to contact a parent in an emergency?
A: This is a very good question to ask when you go to orientation or at parents' weekend (preferably in the sessions for parents, not the sessions with parents and their children). In general, the answer will be yes, but the way a school defines an emergency is all over the map. And parents can themselves have quite different ways of seeing something as an emergency.
In the end, a good student health service will make the decision to contact a family on the basis of clinical judgment: namely, when they decide that contact is in the best interests of the student. There is no legal requirement to notify a parent of anyone over 18, especially if that student says no. A school is obligated in an emergency to do all that is necessary to respond to that emergency. This may or may not include contacting the family which is a clinical judgment and depends on what has happened.
Some schools with tend to err on the side of contacting the family. But doing that can create a "chill" among the student body since word gets out and students become wary of the school and its services. As both doctors and psychiatrists we would rather violate privacy than create conditions, including limiting contact with family, that could worsen a student's state of mind and keep them from needed support and help.
Q: How can students seek help?
A: Help comes in many ways. Students, we hope, are already seeking support and help from family and friends. But when more is needed, more is usually available.
One place a student can start is with the resident hall advisor (RAs). These are their peers, often senior students who are well informed and well trained about how to respond to another student's distress. RAs can be very helpful to your child, and sometimes to you, in putting some things in perspective since your child is not the first one to have the problem she has.
Students can also turn to a faculty member, or a faculty advisor. Whom they turn to is often, not unexpectedly, someone that student sees as more approachable or responsive. As a rule, every student has an assigned faculty advisor. While the ratios of advisor to students vary considerably, and with that the time available, there is someone who has been designated for your child to turn to.
Finally, a student can always contact the health services. Any contact with the health services is by nature confidential. Some health services will have the professional staff to respond directly, some will refer your child to professionals that the school knows. Your child needs to understand that the health service is an important part of their lives as independent adults who, like everyone, may need services for an illness, trauma, or mental health or substance use problem.
Q: What are mental health services like at colleges and universities?
A: They too are all over the map. Most schools have counseling services -- but they are staffed very differently. Some have staff, few have a lot of staff, and some are organized to assess and refer.
You want to consider your child's needs beforehand. Some parents and students will decide to arrange for private mental health services in advance of starting school for students with identified problems who were engaged and responding to treatment at home. When visiting schools with their child during the selection process a parent should find out about their health and mental health services; for some families this will be a factor in considering what school to choose. Alternately, orientation or parents' weekend are times to understand the capacities of the mental health service (though as I mentioned earlier, this is always best done in the context of overall health).
Q; Are counseling services available 24/7?
A: Their availability varies. It is pretty uncommon for a school to be able to operate a counseling service with this kind of coverage. After hours, counseling services generally refer to local emergency rooms.
Q: Will using counseling services threaten my child's academic career?
A: We won't say that a depressed, traumatized or dead child won't get very good grades.
All students, and their families, should know that mental health treatment is fully protected from the academic activities of the school. The records are not shared between a school and its health center - unless a student's behavior is a danger to self or others.
Most good schools recognize that mental disorders are common and treatable. Generally, good schools understand that mental health and substance abuse treatment actually improve a child's functioning, including academic performance. So, they are supportive of these types of treatments - and appreciate that a student can and should continue with treatment. Stigma, although still a barrier, is not what it was, especially with conditions like depression and with the use of antidepressants.
Q: Are there return to school policies for students who go on leave for a mental health condition?
A: Every school is required to post its policy, so ask for it or go to the school website to find it. If you cannot find it, check with the Dean's office.
The decision itself, however, is one that should balance the importance of school in a young person's life with their readiness to return. This decision can be nuanced and requires very good judgment, so having the student, parents, school administrators, and expert clinicians involved will help in coming to a decision that best fits your child.
Q: What are the challenges that student mental health services face?
First, the economic recession. Cuts in budgets are everywhere, and can erode mental health services at a school. Enhancing services, which often do not meet needs, is becoming more elusive that ever.
Second, we are seeing more students begin school taking medications for psychiatric condition prior to enrollment in colleges. Access to professionals who can prescribe psychiatric medication is challenging in an urban area such as NYC or Boston or SF; it is far more challenging for schools in rural areas. Students may have to turn to primary care physicians and nurses with prescribing privileges. Thus, it is important to plan how medications will be monitored (before school starts) if your child is taking a medication that is helping. Sometimes the prescribing can be done by a clinician in your home area who knows your child; if not, develop a plan for what can be done before your child leaves for school and avoid that moment, away from home, when they discover they are out of medication.
Third, we need to do more and do better regarding suicide prevention in colleges and universities. There needs to be less stigma, more information and more accessible paths for students to follow when they are having difficulties or see their lives as not worth living. In a sad way the Virginia Tech tragedy has underlined the need for student mental health services and many colleges and universities are doing a better job. Tragedy sometimes produces responses and resources we would otherwise not see.
Colleges and universities are where the future leaders of our society are. Student mental health services provide direct benefits to youth in need that enable them to better succeed in school and in their careers, as well as to remain safe. There is also the important -- if indirect -- effect where every student who has a positive experience with mental health will feel less stigma about themselves and others - for a lifetime.
College and university mental health services pay exceptional dividends. Mental health conditions are highly prevalent and remarkably effective. Use them if you or your child needs them and support them for they are surely worth their price.
Lloyd I Sederer, MD, is Medical Director, New York State Office of Mental Health and Adjunct Professor, Columbia University School of Public Health. Henry Chung, MD is Executive Director, New York University Student Health Center and Clinical Associate Professor of Psychiatry, New York University School of Medicine.
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