The Journal of School Nursing2023, Vol. 39(6) 524–535© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405221135186journals.sagepub.com/home/jsn
For many children of color, the cumulative impact of pre-existing stressors, disparities, and pandemic-related losses has contributed to a toxic level of stress. Toxic stress can disrupt healthy brain development making children vulnerable to physical and mental health problems. School nurses are the primary health professionals who interact with children daily during the academic year, which positions them to identify risk factors within the social determinants of health that contribute to the development of toxic stress. The Toxic Stress Schema (TSS) provides a framework for assessment and care planning related to social determinants of health and potential sources of stress and/or buffering support for the physical and mental well-being of children. A case study approach is used to demonstrate the application of the TSS to school nursing and provide the basis for conceptualizing a plan of care and identifying resources to support the child’s physical and mental health.
Keywordsbullying, covid-19, school nurses, toxic stress, screening/Risk identification, social determinants of health, mental health
The convergence of the COVID-19 pandemic, natural and man-made disasters, and a contentious political and social climate have created multiple significant stressors for children and adolescents (henceforth referred to as “childrenâ€) and their families. Children have been exposed to graphic media images of COVID-19 patients in hospitals, mass shootings, communities leveled by tornadoes or flooding, riots due to racial and political unrest, incivility among political leaders, and a war in Eastern Europe. Compounding the stress of witnessing, being subjected to and/or hearing about these events, children have experienced drastic changes in their daily routines as schools vacillated between in-person and remote learning, while interactions with peers were limited by mask mandates, illness, and social distancing (de Miranda et al., 2020).
Events such as these compounded by pre-existing stressors such as homework, pressure to make good grades, and family responsibilities, create a situation of chronic stress that results in “cumulative trauma.†Cumulative trauma (multiple traumatic events/situations occurring over time) can have a long-term impact on the mental health development of children. The COVID-19 pandemic has been associated with escalating numbers of children experiencing psychological stress and trauma-related physical, mental, and behavioral issues that result in poor school performance and compromise social and emotional development A systematic review of studies examining the effects of the pandemic on over 65,000 youth ages 4 to 19 identified high rates of anxiety (28%) and depression (23%) as well as loneliness (5%), stress (5%), fear (5%), and worry (3%) among other mental health concerns (Theberath et al., 2022). Calls to address the mental and behavioral health needs of children related to the COVID-19 pandemic have come from numerous researchers and organizations (American Academy of Pediatrics, 2021; de Miranda, et al., 2020, Jones et al., 2021, Meherali et al., 2021, UNICEF, 2021, Yard et al., 2021). The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Children’s Hospital Association (CHA), jointly declared a national emergency in children’s mental health (AAP, 2021) due to the extreme disruption of life, economic instability, loss or illness and disability of parents and caregivers. Because of disparities in access to COVID-19 testing, health care, personal protective equipment, and preexisting social and health inequities, COVID-19 associated deaths and long-term health impacts were disproportionately higher in communities of color, and children of color have been more adversely impacted (AAP, 2021; SAMHSA, n.d.). For this article, communities and children of color are defined as African American/Black, Latino, Indigenous, and Asian/Pacific Islander (Sanders-Phillips et al., 2009).
For many children of color, the cumulative impact of preexisting stressors and pandemic-related losses has contributed to a toxic level of stress. Toxic stress occurs when children experience repeated activation of the physiological stress response without adequate adult support to help buffer the detrimental impact (Harvard University Center on the Developing child, n.d.). Toxic stress can disrupt healthy brain development making children vulnerable to physical and mental health issues across the life span (Franke, 2014; National Scientific Council on the Developing Child, 2005/2014;). A range of factors can either be protective or can increase the risk of toxic stress. Social determinants of health are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks†(Healthy People 2030) (fig. 1). Within the social determinants of health are identifiable risk factors that contribute to the development of toxic stress in children and adolescents (Selvaraj et al., 2019). Without access to adequate resources and interventions, the risk factors and associated consequences will persist at various levels of intensity.
School nurses are the primary health professionals who interact with children daily during the academic year. This work positions school nurses to be leaders in disease prevention and health promotion at the individual and community levels (Campbell & Anderko, 2020). The National Association of School Nurses’ Framework for twenty-first Century School Nursing Practice (2016) promotes school nurses as leaders in the development of programs, policies, and procedures to improve the physical and mental health of students (Kilfoy, 2020; NASN, 2016). The framework emphasizes the essential role of nurses in developing student-centered holistic care that considers the social and cultural context of the student’s family and community (National Association of School Nurses [NASN], 2016). An interdisciplinary approach is advocated by the National Association of School Psychologists, highlighting the importance of partnerships between school psychologists, counselors, social workers and school nurses in assessing and intervening in the mental and behavioral health of children within the school environment (National Association of School Psychologists, 2021).
The NASN position statement on “The Behavioral Health and Wellness of Students†underscores the prioritization of responding to and addressing behavioral health and wellness among students to promote student engagement and academic achievement in educational opportunities (NASN, 2021). School nurses have an exemplary history of assessing students through a broad bio-psycho-social lens. For children still dealing with the compounding stressors from the COVID-19 pandemic layered upon compromised protective factors, pre-existing stressors, and multiple coping challenges, a framework to address the complexity of their needs is warranted to assist school nurses with assessing the social determinants of health and identifying risk factors that impact children’s physical and mental wellbeing. The purpose of this paper is to illustrate how the Toxic Stress Schema (TSS) can guide the school nurse in assessing a child’s needs associated with cumulative trauma and possible cumulative toxic stress.
The Toxic Stress Schema (TSS) (Bowen et al., 2021) provides a framework for assessment and care planning related to social determinants of health and potential sources of stress and/or buffering support for the physical and mental well-being of children (Fig. 2) (Bowen et al., 2021). The TSS uses a social justice lens to examine the interpersonal relationships, organizations, and communities that children rely on to meet their psychosocial and physical needs. By using a social justice lens, the TSS focuses on advocacy and factors that impact educational equity, health equity, access to care and resources (British Columbia Teachers’ Federation, 2019). The TSS depicts perforated concentric circles of influence to show the fluidity of the interactions between the child and the multi-layered communities illustrating the exertion of surrounding influences on the child and family. The child’s system is covered by an arc that represents protective factors. Protective factors are attributes of the child’s family and social environment that reduce negative effects of stress (Substance Abuse and Mental Health Services Administration [SAMHSA], n.d). The solid arc represents intact protective factors, and the perforated arc represents a breakdown or vulnerability of the protective factors. Systemic and institutional racism, health disparities, and health inequalities, such as limited or no access to health care, contribute to diminished protective factors that can impact health outcomes at all levels depicted in the schema (Bowen et al., 2021).
The TSS aligns with the National Association of School Nurse’s Framework for the twenty-first Century School Nursing Practice ™ (NASN, 2016) in that the TSS focuses on the child within the context of family and community with the goal of supporting the overall well-being of the child. The TSS also aligns with policy recommendations of the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association by providing a framework for multi-level assessments and plans of care for children that contribute to effective school-based mental health models of care (AAP, 2021).
The exemplar presented in this paper is used to demonstrate the application of the TSS to school nursing and provide the basis for conceptualizing a plan of care and identifying tools and resources to support the child’s physical and mental health; however, presentation of an in-depth or detailed physical, nutritional, educational, and neighbor assessments are beyond the scope of this paper. The exemplar is based on pre-existing and COVID-19 pandemic related stressors experienced by the child within the context of the child’s family and community. The TSS begins with an assessment of the child as the center of a school nurse’s focus, then extends outward through concentric circles of influence surrounding the child, including the child’s interpersonal and family environment, the school and other local organizations, as well as the community. Factors from each circle of influence determine a child’s resources for coping and the family’s position and movement along a continuum of advantage and disadvantage.
Juan, a 12-year-old Latino male in the 7th grade, is seen by the school nurse for the fifth time this month for injuries sustained during fights with peers. Juan is a new student to the school, which recently returned to in-person classes after months of remote learning. Teachers’ concerns about Juan have also come to the school nurse’s attention, including his tardiness, inattention, sleepiness in class, and disruption of class due to aggressive behavior. Teachers describe Juan as “on edgeâ€, alert for any personal slight, and ready to defend himself. Using the TSS, the school nurse begins at the center with the child who presents in the health office for care.
Juan is small in stature and below weight for height. His school-record includes the name of a pediatric healthcare provider and up-to-date immunizations, but no health history. Juan appears to be Tanner stage 2 with early signs of puberty and is on-track with developmental milestones for an early adolescent. His clothes are clean but outdated with signs of repeated mending. He speaks English fluently but converts to Spanish when excited. The school nurse’s assessment yields three health-related concerns.
Injuries Related to Aggressive Behavior. There were five health visits in four weeks for physical injuries from fights with peers that in some instances resulted in minor physical injuries (e.g., a bloody nose, scrapes to hand). Juan’s aggressive behavior and injuries were a priority health concern. Teachers describe aggressive encounters between Juan and his peers, but there are no reports of aggression toward teachers and Juan has been respectful in interactions with the nurse. Pursuing further details from Juan’s teachers, the nurse learns that Juan is defensive and reacts aggressively, but he is not the initiator of these conflicts. The instigation is from peers who tease him for speaking Spanish, for his outdated and mended clothing, and his small stature. Older boys have been seen pushing Juan in the hallways and taunting him with racial slurs. This resonates with Juan’s report: When asked why he gets into fights with peers, Juan replies, “They disrespect me and call me names.â€
Weight Below Expected for Health. Juan’s weight is below the curve for his height, gender, and age, calling for evaluation of his nutritional health and raising questions of neglect, which the nurse considers unlikely given Juan’s good hygiene and clean, mended clothing. Juan’s nutritional health also raises questions about food insecurity and whether Juan’s community is in a food desert. The school nurse learns that Juan eats breakfast at home and brings his lunch to school. In addition to planning a nutritional assessment, the school nurse makes note of evaluating Juan for the school’s free lunch program.
Daytime Sleepiness. Juan’s daytime sleepiness is reported by his teachers and interferes with his learning and may be a source of his inattention. The school nurse examines Juan’s constellation of health concerns and recalls that aggression, problems with sleep, and changes in appetite can be signs of depression, anxiety, and trauma in children (CDC, 2021). Information from Juan’s parents is needed to fully evaluate the health concerns found by the school nurse and Juan’s teachers. The school nurse proceeds to the TSS interpersonal assessment.
Efforts to contact Juan’s parents are unsuccessful – the phone listed in his school-record does not accept messages and there has been no response to notes sent home with Juan. After numerous parental contacts are attempted, social services is alerted and a home visit is made, revealing the following information from Juan’s mother.
Juan’s parents fled to the U.S. from Mexico, fearing for their lives after Juan witnessed his 14-year-old brother’s murder by a gang, and they are currently working to obtain asylum. Juan, his mother, and three younger siblings ages 11, 9, and 7 years are living with a maternal aunt while his father, a farmworker, is away for seasonal employment. Their apartment has two medium-sized bedrooms and one bathroom. Juan’s mother established healthcare at a Community Health Center to acquire the necessary school immunizations but, lacking health insurance, they have not sought further routine care. Juan’s mother speaks little English and relies on her sister, who speaks English fluently, to communicate with the school and health provider. Juan’s mother cleans offices in commercial buildings overnight and Juan is responsible for watching his siblings. He feeds them, walks them to and from school, and helps them with their homework before beginning his own assignments, which keeps him up late into the night. Juan did not participate in the months of remote education provided by the school because the family does not have a computer or internet access, and being new to the school district, the family was not on the outreach list for technology support.
During the early months of the pandemic, Juan’s maternal aunt was laid off from her position as a food preparation assistant at a local restaurant and has been taking hourly domestic work wherever she can find it. The family does not own a car and relies on public transportation or walking to get to work, appointments, and the grocery store. They are living below the poverty level for a family of seven and family members are not eligible for federal or state aid.
Juan and his family identify as Latino and speak primarily Spanish at home. In Mexico, Juan lived in a multigenerational household and was cared for by his grandparents who remained in Mexico. Last summer Juan’s family learned of the deaths of his grandparents due to COVID-19, which deeply affected the entire family and they sought supportive connections through a local church that offers services in Spanish.
During the home visit, the maternal aunt explained to the social worker that Juan’s family follows the traditional ways of Mexican families with fathers and eldest sons holding positions of authority within the family. With the death of his grandfather in Mexico and his father away from home, responsibility has fallen on Juan’s shoulders to help his mother out at home and take care of his younger siblings. Based on the additional information provided by the social worker, the school nurse expands Juan’s assessment, incorporating interpersonal trauma and loss, which creates a clearer picture of his health needs.
Interpersonal Trauma, Loss, and Grief. Juan’s constellation of health concerns can be viewed as responses to trauma, loss, and grief, as well as his current difficulties in establishing supportive peer relationships within the school. His emotional functioning was initially highly impacted by witnessing his brother’s murder, which according to Clements & Burgess (2002) would increase his chances of developing PTSD (Post Traumatic Stress Disorder), depression, distress, aggressive behavior, as well as other externalizing negative behaviors. In addition to experiencing the trauma of his brother’s violent death, Juan and his family were subjected to threats from the people who murdered his brother, which led to the family’s precipitous move from Mexico. Juan’s emotional functioning is also likely affected by the cumulative strain on his parents related to the traumatic event of losing a child, acculturation stress, and economic pressures they faced (Lorenzo-Blanco et al., 2016; McCord et al., 2019).
Juan’s emotional functioning is further impacted by the separation from his grandparents, who cared for him as a child, which became a permanent loss following their deaths from COVID-19. Juan is also experiencing separation from his father who is working away from home, giving Juan greater responsibilities for his siblings while his mother works to support the family. Consequently, Juan’s aggression might be viewed as his effort to cope with disparate identities, shifting from his adult-like role and responsibilities at home, to a marginalized identity among peers at school where he is taunted and teased.
Pandemic Hardships. The COVID-19 pandemic has had a greater morbidity and mortality impact on families of color compared to White families. Latinos were more likely to become infected during the first wave of the pandemic, and if infected, they were 4 times more likely to be hospitalized and 2.8 times more likely to die (Zamarripa & Roque, 2021) than their non-Hispanic White counterparts. Adults like Juan’s mother and aunt, who work in the service industry and rely on public transportation, experienced greater risks of exposure to the virus. If a family member became infected, then their close living arrangements made social distancing at home unrealistic, contributing to fears that they were at risk for infections spreading through the family. The economic impact of the pandemic also has been disproportionately experienced by Latina women. In December 2020, Latina women accounted for a disproportionate 45% of job losses among women (Zamarripa & Roque, 2021). Juan and his siblings also experienced a greater educational impact because of the pandemic, due to their lack of computer and internet access needed for remote learning.
Strengths and Protective Factors. Juan’s interpersonal context also highlights family and individual strengths and protective factors. Juan’s parents care about him and his siblings and underwent major life changes including the loss of a child because of a violent act. It was difficult following this trauma to assure their children’s safety and promote their welfare; thus, they took the courageous step of leaving their country and support community and seeking a safer living situation for their family in the U.S. Juan’s family has a strong family identity, with a supportive extended family network that includes an aunt who opened her home to Juan’s family. His parents and aunt have a strong work ethic, providing food and shelter for Juan and his siblings through hard work. They are members of a local church that connects them with other Latino families. His parents and aunt-initiated contact with the healthcare system, via a free clinic, assuring Juan and his siblings had the immunizations they needed for school.
Juan’s commitment to his family is an asset. He helps his parents and takes on responsibilities beyond his years. He cares about his siblings and looks after their needs. Juan also maintains his sense of personal integrity, asserting his need to be treated with respect. He has learned to speak English thus navigating a cross-cultural language barrier.
Juan’s health assessment is becoming more complete. Yet another level of organizational and community assessment is needed to determine what resources are available to the school nurse in formulating a plan of care for Juan.
The middle school Juan attends serves a student population that identifies as 40% White, 25% Hispanic or Latino, 15% African American, 10% Asian, and 10% two or more races. Approximately 40% of students receive free lunch and breakfast at school, which is a proxy for poverty. A certified school nurse staffs the health office two days a week and is invited to participate in meetings called by the principal to review students of concern. The school has two on-site counselors, one of whom is bilingual and speaks Spanish. A school bullying policy is in place and is congruent with recommendations of the CDC (David-Ferdon et al., 2016), but not all teachers, administrators, and staff are fully trained or agree with the policy, so its enforcement is irregular.
The economy of the urban community where Juan lives suffered during the COVID-19 pandemic. Several local businesses closed during the pandemic and have not reopened, while other businesses reduced staffing or decreased worker hours resulting in an unemployment rate of 4.3% and poverty rate of 16.3%. A growing population of immigrant families contributes positively to the rich ethnic diversity of the community but is perceived by some longstanding residents as competing for jobs and resources and altering their culture.
The neighborhood includes a grocery store that specializes in Latino food products, Mexican restaurants, and a church that holds religious services in Spanish. The Community Health Center provides culturally sensitive healthcare to the Latino population and offers a wide range of health services including primary care, dental, mental health, a pharmacy, and community health education programs that have been provided virtually during the pandemic. The health center is staffed predominantly with bilingual providers including a full-time Latina social worker and a part-time (biweekly) psychiatric mental health nurse practitioner. The health center has a grant-funded program that provides health services to those who are uninsured and unable to pay. The school nurse knows providers at the community health center and has referred students there on many occasions.
Many Latino families attend a neighborhood church that provides religious services in Spanish and hosts a food pantry for needy parishioners. The school, community health center, and the church will be important organizations for connecting Juan and his family with social and health services.
The concentric circles of influence of the TSS provide a framework for conceptualizing a plan of care for Juan. The NASN and Framework for twenty-first Century School Nursing Practice describe the care of school nurses as student-centered and holistic, taking into consideration the child’s family and community as contexts that influence a child’s health and capacity to learn (Kilfoy, 2020, NASN, 2016). While school nurses predominantly focus on the health and needs of individual children within the school environment, they utilize interprofessional networking and advocacy to affect multiple circles of influence, as represented by the TSS, to promote optimal environments for child health and wellbeing.
Interventions to address Juan’s identified health concerns involve engagement by the school nurse at multiple levels; individual, interpersonal, organizational and community. The meetings called by the principal to discuss “students of concern†offer an avenue for the school nurse to engage with school administration and Juan’s teachers in developing a plan tailored to Juan’s needs. The nurse can advocate for an Individual Intervention Plan for Juan that includes additional services such as appointments with the counselor to discuss his aggressive behaviors, and time set aside during the school day for completing homework to alleviate the need for latenight studying after putting his siblings to bed. Ascertaining if Juan qualifies for the school’s free breakfast and lunch program will help address Juan’s nutritional needs. Learning is severely compromised without the needed technology, so advocating for his family to be placed on the school’s technology outreach list will give Juan and his siblings important resources for learning.
The principal understands that children learn best when they are in a safe and supportive environment. Bullying is a form of violence and an adverse childhood experience (ACE) that negatively impacts a child’s ability to learn and achieve their potential. The principal can review evidencebased implementation plans established by the Center for Disease Control and Prevention (David-Ferdon et al., 2016) and direct faculty to implement the school’s bullying policy fairly and consistently. The principal can also provide opportunities for faculty to attend training sessions on managing and addressing issues of bullying in the classroom.
Based on the assessments of the school nurse, a referral to the psychiatric mental health nurse practitioner at the Community Health Center is warranted. The established relationship between the school nurse and health center providers helps with the referral process. The bilingual providers and Latina social worker will make it possible for Juan and his family to receive culturally sensitive care at the Community Health Center, interpreting Juan’s experiences and those of his parents through the language and meanings of their culture (Kimmell et al., 2020). The community health center’s grant funded program to serve uninsured families without resources will provide a source of funding for services for which Juan and his family qualify. This would include an overall health assessment of Juan’s mental, physical, and nutritional health.
The school nurse can play a significant role in outreach to Juan’s family. Since the mother speaks little English and the aunt is fluent in English, it is important to engage Juan’s mother and aunt in the process of developing Juan’s IEP so that the family’s strengths are leveraged to support Juan’s health and education. Through relationship with the mother and aunt, the school nurse can assess the family’s health literacy related to mental, physical, and nutritional health; and consider how family beliefs may influence their readiness to seek and utilize health services for Juan offered through the community health center (Tambling et al., 2021).
Even prior to the pandemic, wait lists for children to see mental health providers were long. If a mental health counselor is not available in the school, the school nurse considers interventions that can be initiated within the school to support Juan while waiting for a mental health appointment. During the pandemic, the Community Health Center offered a virtual training program in Youth Mental Health First Aid. This program teaches basic mental health skills to adults who encounter children in crises (National Council for Mental Wellbeing, 2022). The program emphasizes that every encounter with an adult is a potentially therapeutic encounter for a child and empowers adults to recognize and reach out to children in crisis. The school nurse could advocate for staff and teacher to complete the Youth Mental Health First Aid training program, which builds the capacity for health promoting encounters for all children in the school community.
The COVID-19 pandemic revealed the importance of school-based services for children and the toll on their health and well-being when access to school services is disrupted (Donnelly & Patrinos, 2021). Events of the past few years have added a level of trauma and stress into the daily lives of all children and necessitate an increased focus on their mental health and its profound impact on their wellbeing and school performance. For racial and ethnic children of color, events of the past few years have added more stress and trauma to their prior experiences of trauma and stress. School nurses have been recognized as key to mitigating stresses associated with adverse academic outcomes thus contributing to the health, safety, and well-being of students, their parents, and the communities in which they live, work, worship, and play (Center for the Child & Community Children’s Hospital & Medical Center, 2021).
The case study illustrates how the school nurse can use the TSS as a guide for assessing the social determinants of health that impact the physical and mental health of children. It also illustrates the importance of the multilevel approach of the TSS for identifying the stressors and potential risk factors at the individual, interpersonal, organizational, and community levels as well as protective factors and strengths within each area of influence. This approach allows for understanding of the importance and impact of culture, family structure, and community in shaping the context of a child’s life, thus influencing the child’s overall physical and mental wellbeing. The TSS depicts the necessity of assessing for deficits but also incorporating a strengths-based approach to understand the situations in which children and their families are functioning and to develop effective working relationships with families to develop plans of care that meet the needs of the children and their families (Gottlieb & Gottlieb, 2017; Rashid & Ostermann, 2009).
The case study exemplifies the vital role of the school nurse in identifying underlying factors beyond the school setting that impact the physical and mental health of children in their schools. School nurses are in a unique position of being able to interact with children in their schools daily for most of the calendar year, whereas children’s interactions with other healthcare providers in the community are far more limited (Rattermann et al., 2021). The case study also highlights the school nurse’s role as student advocate. As a student advocate, the school nurse collaborates with other health professionals to gain more information about the social determinants of health that are likely impacting a child’s behavior. The school nurse is also well-positioned to use information about the child to coordinate efforts to create comprehensive, culturally competent, family guided strategies that support optimum physical and mental for the child and their family (Schroeder et al., 2018).
An important aspect of student advocacy is the ability to build trusting relationships and effective communication with the child’s family. Because school nurses interact with children daily for most of the year, they tend to establish long-standing relationships with children and their families (Schroeder et al., 2018). These relationships are key for developing a collaborative relationship between the school nurse and the child’s family. Albeit at times challenging, partnering with family members is key to helping mitigate the trauma and stressors children experience in society and schools. The case study illustrates the vital role family members play as “protective†and buffering agents. Effective family-centered services and partnerships can lead to a reduction in missed school days, higher academic achievement, and improved literacy performance (Concepcion et al., 2007).
The case study presented in this article demonstrates how interactions among children, their families, and people within their communities can contribute to children’s overall physical and mental health. It also illustrates some of the impact of poverty on child coping and school performance. Housing issues and neighborhood safety are concerns of many children living in low-income situations. Incorporating social and economic factors as part of a comprehensive assessment gives the school nurse more knowledge to effectively work with families
Although this case study focused on a child of color from one ethnic group, similar challenges exist among children of other racial and ethnic groups as well as other vulnerable populations such as students with disabilities, lesbian, gay, bisexual and transgender (LGBT) students. Children from these groups also may experience cumulative toxic stress and the TSS can be applied to their situations for the purpose of developing comprehensive, evidence-based plans of care.
School nurses are an essential part of school-based health services and have long been recognized as vitally important in implementing and modeling effective partnerships with families and communities. School nurses engage in children and family advocacy at multiple levels, including school meetings with professional staff, health planning meetings, individual education plan meetings, student study team meetings, school events and activities, and communications with community agencies and organizations. They also take primary roles in advocating for needed mental health services in schools and in establishing referral networks that can be more easily accessed by families and school personnel.
Schroeder et al. (2018) emphasized the need for school nurses to consider the social determinants of health when providing care and developing plans of care for children. The TSS provides a multilevel approach for assessing social determinants of health as well as identifying deficits and strengths. The application of the TSS to this case study demonstrates the necessity of having access to resources to develop a comprehensive plan of care. Resources ranging from tools for screening for social determinants of health (see Table 1) to resources about trauma-informed approaches and psychological first aid (see Table 2) are publicly available on the internet. Ensuring that school nurses are aware of these resources and have easy access to those resources is imperative in their role as expert clinician, student advocate, and coordinator of care and resources.
We want to extend our gratitude to Tammie Childs, RN, Nurse Supervisor, Greenville County Schools, Greenville, SC, for sharing her expertise and insightful comments during the development of the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article
Gwendolyn D. Childs https://orcid.org/0000-0002-1328-4239
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Gwendolyn D. Childs, PhD, RN, FAAN, is an associate professor and associate dean for Undergraduate and Prelicensure Education at the University of Alabama at Birmingham School of Nursing. Her area of research is adolescent decision making focusing on sexual risk-taking behaviors and HIV and STD prevention.
Janiece DeSocio, PhD, RN, PMHNP-BC, FAAN, is a professor at Seattle University College of Nursing. Her area of research focuses on child adolescent behavioral health and epigenetics and the neuroscience of toxic stress.
Elizabeth Sloand, PhD, CPNP-PC, FAANP, CNE, FAAN, is a professor at Johns Hopkins University School of Nursing. Her area of research focuses on child health, primary care, underserved populations, and global health.
Faye Gary, EdD, MS, RN, FAAN, is the Medical Mutual of Ohio Kent W. Clapp Chair and professor of Nursing at Case Western Reserve University Frances Payne Bolton School of Nursing. Her area of research focuses on prevention of mental health problems, child/adolescent mental health, and attention deficit and hyperactivity in children.
Pamela J. Burke, PhD, RN, CPNP-PC, FSAHM, FAAN, is the Co-Director for Nurse Training, Leadership Education in Adolescent Health (LEAH) at Boston Children’s Hospital Division of Adolescent & Young Adult Medicine. Her area of research is child/adolescent mental health and substance abuse.
Freida H. Outlaw, PhD, RN, APRN, FAAN, is the Executive Academic Consultant for the Substance Abuse and Mental Health Services Administration Minority Fellowship Program American Nurses Association. Her area of research is child/adolescent mental health and substance abuse.
Julie A. Snethen, PhD, RN, FAAN, is a Professor and PhD Program Director at the University of Wisconsin-Milwaukee College of Nursing. Her area of research is child/adolescent obesity and chronic illness in children.
Linda A. Lewandowski, PhD, RN, FAAN, is dean and professor at the University of Toledo, College of Nursing. She is also the Vice-Provost for Health Affairs for Interprofessional and Community Partnerships and Executive Director for University Campus Health Services-Rocket Health. Her area of research is cumulative trauma in children/adolescents, toxic stress, and child/adolescent mental health.
Felesia R. Bowen, PhD, DNP, APRN, FAAN, is a professor and associate dean for Diversity, Equity, and Inclusion at the University of Alabama at Birmingham, School of Nursing. Her area of research is pediatric asthma focusing on health equity and health disparities of childhood asthma, and toxic stress and trauma among children living in urban communities.
1 Associate Professor and Associate Dean for Undergraduate and Prelicensure Education, University of Alabama at Birmingham, School of Nursing, Birmingham, AL, USA
2 Professor of Nursing, Seattle University College of Nursing, Seattle, WA, USA
3 Johns Hopkins University School of Nursing, Baltimore, MD, USA
4 Medical Mutual of Ohio & Kent W. Clapp Chair and Professor of Nursing, Cleveland, OH, USA
5 LEAH Program Faculty/Senior Advisor for Nursing, Division of Adolescent & Young Adult Medicine, Boston Children’s Hospital, Boston, MA, USA
6 Executive Academic Consultant, Substance Abuse and Mental Health Services Administration, Minority Fellowship Program, American Nurses Association, Silver Spring, MD, USA
7 Professor and PhD Program Director, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
8 Dean, College of Nursing, and Vice-Provost for Health Affairs, University of Toledo College of Nursing, Toledo, OH, USA
9 Professor and Associate Dean for Diversity, Equity, and Inclusion, The University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA
Corresponding Author:Gwendolyn D. Childs, PhD, RN, FAAN, Associate Professor and Associate Dean for Undergraduate and Prelicensure Education, University of Alabama at Birmingham, School of Nursing, Birmingham, AL, USA.Email: gchilds@uab.edu
