# Health & Wellness — Missouri K-12 Education Reference ```mermaid flowchart TD A[Student Health & Wellness] --> B[Mental Health] A --> C[Physical Health] A --> D[Prevention Programs] B --> E[Tier 1: SEL Curriculum & Climate] B --> F[Tier 2: Small-Group Counseling] B --> G[Tier 3: Individual Therapy & Crisis] D --> H[Suicide Prevention - RSMo 170.048] D --> I[Substance Abuse Prevention] H --> J[Warning Signs Recognition] J --> K[Risk Screening - C-SSRS] K --> L[Safety Plan & Referral] C --> M[School Nurse Services] C --> N[Chronic Conditions Management] C --> O[Immunizations - RSMo 167.181] A --> P[Staff Wellness & Secondary Trauma] ``` ## Table of Contents 1. Student Mental Health 2. Social-Emotional Learning (SEL) 3. Suicide Prevention 4. Substance Abuse Prevention 5. School-Based Health Services 6. Chronic Health Conditions 7. Immunizations 8. Crisis Response 9. Staff Wellness & Secondary Trauma 10. Health Education Curriculum 11. School Meal & Nutrition Programs 12. Physical Education Requirements --- ## 1. Student Mental Health ### Prevalence National data indicates approximately 1 in 5 children has a diagnosable mental health condition. Schools are increasingly the de facto point of access for mental health services, particularly for underserved populations. ### School-Based Mental Health Services | Service Level | Examples | |---------------|---------| | **Universal (Tier 1)** | SEL curriculum, positive school climate, mental health literacy education, anti-stigma campaigns | | **Targeted (Tier 2)** | Small-group counseling, check-in/check-out, social skills groups, grief groups, anxiety management | | **Intensive (Tier 3)** | Individual therapy, crisis intervention, psychiatric referral, wraparound services, day treatment | ### Providers in Schools - **School counselors:** academic, career, and social-emotional development (not long-term therapy) - **School psychologists:** assessment, consultation, crisis intervention, short-term counseling - **School social workers:** family engagement, community resources, attendance, behavioral support - **Licensed professional counselors (LPCs) / Licensed clinical social workers (LCSWs):** may provide therapy in schools through district employment or community partnerships - **Community mental health partnerships:** agencies providing therapists in school buildings (co-located services) ### Funding for School Mental Health - Title IV-A (Safe and Healthy Students pillar) - Title I (part of comprehensive support) - IDEA (related services for students with emotional/behavioral disabilities) - State mental health grants (when available) - Medicaid billing for eligible services to Medicaid-enrolled students - Project AWARE (federal SAMHSA/DOE grant, when awarded) - Community mental health partnerships (agency-funded staff placed in schools) --- ## 2. Social-Emotional Learning (SEL) ### CASEL Framework The Collaborative for Academic, Social, and Emotional Learning (CASEL) identifies five core competencies: 1. **Self-awareness** — recognizing emotions, strengths, limitations 2. **Self-management** — regulating emotions, setting goals, managing stress 3. **Social awareness** — empathy, perspective-taking, appreciating diversity 4. **Relationship skills** — communication, cooperation, conflict resolution 5. **Responsible decision-making** — ethical choices, evaluating consequences ### Evidence-Based SEL Programs Common in Missouri | Program | Grade Level | Focus | |---------|------------|-------| | Second Step | Pre-K–8 | Empathy, emotion management, problem-solving | | RULER | K–12 | Emotional intelligence, school climate | | Positive Action | K–12 | Self-concept, social-emotional, character | | MindUP | Pre-K–8 | Mindfulness, neuroscience-based SEL | | Responsive Classroom | K–8 | Teaching practices, morning meeting, classroom management | | Character Strong | 6–12 | Character development, social-emotional skills | | Botvin LifeSkills | K–12 | Substance abuse prevention, social-emotional skills | ### Missouri SEL Standards Missouri adopted Social-Emotional Learning Standards (DESE) providing a framework for integrating SEL across grades K-12. Standards are not assessed via state testing but guide curriculum and instruction. ### SEL and Equity - SEL programs must be culturally responsive (avoid imposing dominant-culture behavioral norms) - SEL should not be used as a behavior management tool to discipline students - Disaggregate SEL survey data by race, gender, disability, and income to identify disparities --- ## 3. Suicide Prevention ### Missouri Law (RSMo 170.048) - School employees must receive training in youth suicide awareness and prevention - Training must include: warning signs, risk factors, response procedures, referral processes - DESE provides guidance and resources ### Youth Suicide Risk Factors - Previous suicide attempt (strongest predictor) - Mental health conditions (depression, anxiety, PTSD, substance abuse, conduct disorder) - Family history of suicide - Exposure to peer suicide (contagion risk) - Bullying (victimization or perpetration) - LGBTQ+ identity (higher risk due to minority stress, rejection, discrimination — not identity itself) - Access to lethal means - Chronic pain or illness - Trauma history (ACEs) - Social isolation - Acute crises (breakup, discipline, humiliation, family conflict) ### Warning Signs - Talking about wanting to die or feeling hopeless - Giving away possessions - Withdrawal from friends and activities - Dramatic mood changes - Increased substance use - Searching online for methods - Writing or social media about death - Self-harm behaviors ### Response Protocol (Standard Framework) 1. **Take it seriously** — never dismiss or promise secrecy 2. **Stay with the student** — do not leave them alone 3. **Notify** — administrator, school counselor, school psychologist (per building protocol) 4. **Assess** — trained professional conducts suicide risk screening (e.g., Columbia Suicide Severity Rating Scale — C-SSRS) 5. **Contact parent/guardian** — unless doing so would increase risk (rare; consult with crisis team) 6. **Safety plan** — develop immediate safety plan; may include removing access to means, supervision, follow-up appointments 7. **Referral** — connect to community mental health crisis services if indicated 8. **Document** — record actions taken; follow up 9. **Re-entry plan** — when student returns to school after an absence related to suicidality, develop a re-entry support plan with the family and treatment provider ### Resources - **988 Suicide & Crisis Lifeline:** call or text 988 (24/7, free, confidential) - **Crisis Text Line:** text HOME to 741741 - **Missouri Department of Mental Health crisis line:** varies by region - **Trevor Project (LGBTQ+ youth):** 1-866-488-7386 --- ## 4. Substance Abuse Prevention ### Common Substances of Concern in Missouri Schools - Alcohol, marijuana/THC (including vaping/edibles), nicotine/vaping (e-cigarettes), prescription drug misuse (opioids, stimulants, benzodiazepines), fentanyl, methamphetamine, inhalants ### Prevention Programs | Program | Approach | |---------|---------| | **Botvin LifeSkills Training** | Evidence-based universal prevention (Tier 1) — personal self-management, social skills, drug resistance | | **Too Good for Drugs** | Universal prevention K-12 | | **DARE (revised)** | School-based prevention with law enforcement partnership | | **Communities That Care** | Community-wide prevention framework | | **Screening, Brief Intervention, Referral (SBIRT)** | School-based screening and intervention model | ### Policy - District drug/alcohol policies (RSMo 160.261 requires reporting distribution of drugs on school property to law enforcement) - Drug testing: some districts implement random drug testing for students in extracurriculars (must comply with constitutional requirements per Board of Education v. Earls, 2002) - Naloxone/Narcan availability: increasingly available in Missouri schools; DESE and DHSS provide guidance on training and access ### Intervention & Referral - Student Assistance Programs (SAPs): school-based teams that identify at-risk students and connect them to services - Referral to community treatment providers - School-based support groups (after treatment/recovery) - Re-entry planning for students returning from treatment programs --- ## 5. School-Based Health Services ### School Nurse Services See `references/school-staff.md` for detailed school nurse requirements. Key health services: - Vision and hearing screening (mandated grades vary by state; typically K, 1, 3, 5, 7, 9) - Height/weight/BMI screening (CDC guidelines) - Scoliosis screening (typically grade 6-8) - Medication administration - Emergency care and first aid - Chronic disease management (diabetes, asthma, seizures, allergies) - Communicable disease surveillance and exclusion protocols ### School-Based Health Centers (SBHCs) Some Missouri schools partner with community health centers to operate SBHCs within school buildings: - Provide primary care, mental health services, dental care, and health education - Staffed by nurse practitioners, physicians, counselors, dental hygienists - Serve enrolled students (and sometimes families and staff) - Reduce barriers to health care access - Funded through Medicaid, CHIP, grants, and health center budgets ### Medicaid Billing in Schools Districts can bill Missouri Medicaid (MO HealthNet) for health-related services provided to Medicaid-enrolled students with IEPs: - Speech-language therapy, OT, PT, psychological services, nursing services, audiology, personal care - Requires proper documentation and qualified providers - Revenue generated offsets costs of related services - Medicaid Administrative Claiming (MAC): districts can also claim reimbursement for certain administrative activities related to connecting students to health services --- ## 6. Chronic Health Conditions ### Common Conditions Requiring School Management | Condition | School Considerations | |-----------|---------------------| | **Asthma** | Asthma Action Plan; self-carry inhaler (RSMo 167.627); nurse training; environmental triggers | | **Diabetes (Type 1)** | Diabetes Medical Management Plan; insulin administration; blood glucose monitoring; self-management (RSMo 167.621); staff training | | **Severe allergies/anaphylaxis** | Allergy Action Plan; EpiPen access (RSMo 167.627); staff training; food allergy management in cafeteria; 504 plan may be appropriate | | **Epilepsy/seizures** | Seizure Action Plan; staff training on seizure response; medication administration; activity modifications | | **ADHD** | Academic accommodations (504 or IEP); medication administration; behavioral supports | | **Sickle cell disease** | Pain crisis protocol; hydration; activity modifications; staff training | | **Mental health conditions** | Individualized support plan; medication; therapy access; crisis plan | ### Individualized Healthcare Plans (IHPs) - Developed by the school nurse in collaboration with the family and healthcare provider - Outline the student's condition, daily management needs, emergency protocols, and medication - Not a substitute for an IEP or 504 plan, but may be referenced in either - Should be accessible to all staff who work with the student (with FERPA considerations) --- ## 7. Immunizations ### Missouri Requirements (RSMo 167.181) Required immunizations for school entry (schedule updated periodically by DHSS): - DTaP (Diphtheria, Tetanus, Pertussis) - IPV (Polio) - MMR (Measles, Mumps, Rubella) - Hepatitis B - Varicella (Chickenpox) - Tdap booster (for 8th grade entry or age-appropriate) ### Exemptions | Type | Requirements | |------|-------------| | **Medical** | Written statement from licensed physician documenting medical contraindication | | **Religious** | Written statement from parent/guardian that immunization conflicts with religious beliefs | **Note:** Missouri does not have a personal/philosophical exemption — only medical and religious exemptions are recognized. ### Enforcement - Students without documented immunizations or valid exemptions must be excluded from attendance - Schools must maintain immunization records and report compliance data - Schools must notify parents of exclusion and provide timeline for compliance --- ## 8. Crisis Response ### Crisis Response Team Every school should have a crisis response team (often called a Building Crisis Team): - Membership: principal, counselor, psychologist, social worker, nurse, security/SRO, teacher representative - Roles defined in advance: team leader, communications, student support, staff support, liaison with emergency services, parent contact ### Types of Crises | Type | Response Framework | |------|-------------------| | **Student death (any cause)** | Notification plan, counseling support, memorial guidelines, media response | | **Suicide or attempt** | Postvention protocol (AAS guidelines), contagion prevention, counseling, parent communication | | **Active threat** | Lockdown/Run-Hide-Fight, law enforcement response, reunification, after-action review | | **Natural disaster** | Evacuation or shelter-in-place, student accountability, family reunification, facility assessment | | **Community violence** | Student support, processing activities, referrals, community coordination | | **Pandemic/outbreak** | DHSS coordination, exclusion policies, communication, continuity of learning | ### Postvention (After a Suicide) - Follow the American Foundation for Suicide Prevention (AFSP) and American Association of Suicidology (AAS) postvention guidelines - Identify and support students at higher risk (close friends, students with known mental health conditions) - Provide factual, age-appropriate information (avoid details of method) - Make counseling available but not mandatory - Monitor social media for contagion indicators - Memorial guidelines: avoid permanent memorials or activities that could glamorize suicide - Long-term follow-up: anniversary dates, check-ins with affected students --- ## 9. Staff Wellness & Secondary Trauma ### Educator Burnout and Stress Teaching ranks among the highest-stress professions. Contributing factors: workload, student behavior challenges, lack of resources, accountability pressures, secondary trauma exposure, low compensation. ### Secondary Traumatic Stress (STS) Staff who work closely with traumatized students may experience secondary traumatic stress: - Symptoms mirror PTSD: intrusive thoughts, hypervigilance, emotional exhaustion, avoidance, irritability - Highest risk: counselors, social workers, special education teachers, nurses, administrators handling crisis ### Prevention and Support Strategies - Proactive training on secondary trauma awareness - Peer support programs - Employee Assistance Programs (EAP) - Administrative practices that protect staff time and boundaries - Reasonable caseloads and workload distribution - Wellness initiatives (mindfulness, physical activity, social connection) - Substitute coverage for mental health days - Supervision and consultation for counseling staff --- ## 10. Health Education Curriculum ### Missouri Requirements - Health education is part of the Missouri Learning Standards (Health & Physical Education) - RSMo 170.015 requires districts offering sex education to provide abstinence-focused instruction; parents may opt their child out in writing - Topics covered: nutrition, substance abuse prevention, disease prevention, mental health, personal safety, first aid, human growth and development ### Controversial Topics - Sex education opt-out: parents have the right to opt their child out of sex education and human sexuality instruction (RSMo 170.015) - Instruction on sexual orientation/gender identity: no statewide mandate or prohibition (district policy governs) - Districts should follow board-adopted curriculum and communicate transparently with families --- ## 11. School Meal & Nutrition Programs See `references/funding-programs.md` for detailed NSLP/SBP/CEP information. ### Key Points - USDA meal patterns must be followed - Free/reduced eligibility based on income (or CEP for high-poverty schools) - Students must not be publicly identified by meal status (avoid stigma) - Meal debt policies should avoid punitive measures that embarrass students (many Missouri districts have adopted "no lunch shaming" policies) - Food allergy accommodations required with physician documentation - Farm-to-school programs encouraged (connecting local agriculture to school meals) --- ## 12. Physical Education Requirements ### Missouri Standards - Physical education is a graduation requirement (1.0 credit minimum) - Missouri Learning Standards for Health and Physical Education guide instruction - PE should include: fitness education, motor skills, team and individual activities, lifetime physical activity - Adapted PE must be provided for students with disabilities (per IEP) - PE waivers/substitutions: some districts allow substitution of PE credit for JROTC, marching band, or varsity athletics (board policy)