Mental health screening misses kids in need in South Dakota

The dark thoughts started at age 7.

Lacey Elznic, now 17, remembers laying in the bathtub and thinking about holding her head underwater.

She didn’t know what depression was, but she knew she wanted to be dead.

For six years, Elznic battled depression and suicidal thoughts in isolation.

No one ever asked her about her mental health at school because she seemed happy and got good grades. When doctors gave her routine depression screenings, she lied because she didn’t want anyone to see her as “weird.”

“I don’t think there were really any red flags,” said her mother, Carla Elznic.

Elznic learned of her daughter’s depression when, at 13, she came forward about her suicidal thoughts.

“Eventually, it was like, OK, I need to do something about this, or I don’t know if I’m going to be here for my next birthday,” Lacey Elznic said.

Carla Elznic took her daughter to Avera Behavioral Health, where she was immediately admitted to inpatient treatment.

But hospitalization shouldn’t be the first step into mental health treatment.

Part of an occasional series exploring adolescent mental health care in South Dakota.

More: S.D.'s regional mental health care centers not reaching most kids

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More: How to find mental health help in Sioux Falls

Ideally, kids and teens would enter the system of mental health providers before they’ve reached a crisis, said Phyllis Arends, executive director of the Sioux Falls branch of the National Alliance on Mental Illness.

Getting them into that system, though, can be a challenge, especially if no physical warning signs exist. But if kids and teens aren’t getting past the first step of screening for mental illness, they won’t receive treatment.

Schools and primary care doctors are the first line of defense in flagging kids and teens who need mental health counseling and connecting them with resources in the community, but despite a number of measures in place to provide safety nets for these adolescents, they aren’t catching everyone.

It's likely that thousands of South Dakota kids who need mental health treatment aren't getting it, based on the state's population and poverty rates. It’s not clear how much screening contributes to that gap.

“That is the million-dollar question,” said Hiedi Roberts, outpatient manager with Avera.

Schools a ‘major player’ in flagging kids who need help

In schools, the first step in identifying the need for mental health treatment could come from any teacher, staff member, administrator, school resource officer, counselor or classmate.

A student may be noticed as acting withdrawn, acting out or having some other type of behavior change, causing someone with the school (or a team of school officials) to refer them to a school counselor.

Though teachers can be the first to flag a child who needs help, the Sioux Falls School District is very clear that diagnosing or treating mental illness is not the role of teachers.

“While we want what is best for each child we serve, schools are not ‘identifying’ kids who need mental health treatment,” spokeswoman DeeAnn Konrad said.

Teachers are not required to have any mental health training, Konrad said, though a 2016 law does require at least one hour of suicide prevention training for teachers getting their initial certification or certification renewal as of last month.

Once a student is flagged, and provided they’re not going through a crisis requiring immediate hospitalization, they’ll typically meet with the school counselor.

“We do become a major player with mental health,” said Kurt Turbak, counselor at Hawthorne Elementary School.

Turbak is the only counselor in a building with between 300 and 400 kids (a ratio that's not uncommon), and for many of them, he’s the first trained mental health professional they see.

Students in Sioux Falls can meet with a school counselor up to six times before their care is considered “long-term,” and they’re referred to community services.

The district has a strong relationship with Southeastern Behavioral Health, a regional treatment facility. Neither Southeastern nor the district tracks the number of kids referred for mental health services, so there’s no way of knowing exactly how many treated at Southeastern originated from school referrals.

Before any referral is made, schools need to get in touch with parents.

If a parent consents (and signs the requisite papers) Southeastern counselors, or counselors with other community organizations like Lutheran Social Services, can set up an initial appointment for the student, where they’ll do an initial screening and work toward a diagnosis.

In some cases, schools reach out to parents and the parents are encouraged to take their child to a primary care doctor. Doctors at both Sanford and Avera give mental health screenings during regular checkups starting at age 11.

For adolescents, this is often a written questionnaire they fill out in private, away from their parents.

Depending on the outcome of that screening, the doctor may decide to recommend psychiatric care or, in cases with more immediate need, they’ll connect families with a triage therapist who can help make that first connection between kids and mental health professionals.

Holes in the safety net

Mental health screening is a relatively straightforward process in theory. Someone recognizes a child in need, gets parents involved in the conversation and helps connect the family to professional services in the community.

While that’s the best-case scenario, it’s rarely a straight-line trajectory from flagging the kid in need to that kid finding a diagnosis and treatment.

There’s no one place where kids fall through the cracks in mental health screening.

“You can lose them at any point,” said Zachary Seefeldt, assistant clinical director at Southeastern.

There are kids like Lacey Elznic, who hide their illness well, even when asked about their mental health.

A statewide task force in 2002 recommended integrating mental health screening into existing services like public health, schools and day cares. The group looked at the possibility of adding mental health as a part of kindergarten screenings, but 15 years later, schools have no systematic mental health screening in place.

Then, there are kids who don’t have the parental support they need to bridge the gap between a school counselor and long-term treatment.

Parents are a critical piece of mental health screening. Without parental buy-in, kids won’t move beyond those initial meetings with a school counselor or the primary care doctor’s appointment.

That’s especially difficult for families in poverty, families with two working parents, families with incarcerated parents or kids in foster care.

“If you’re a struggling family anyway, you’re not going to be able to handle very many hurdles to get what you need before you give up,” Turbak said.

All of these barriers don’t even touch on logistical challenges like transportation, cost of treatment, insurance coverage and wait times for specialists to do a screening and diagnosis.

And with each barrier, suffering for kids and teens is prolonged.

“The longer it takes to get help, unfortunately, the worse it’s going to get,” said Krysta Winter, a counselor for Lutheran Social Service’s PATH program, in which students can receive ongoing treatment through counseling sessions at their school.

One of the biggest barriers is the stigmatization of mental illness.

The fear of being seen as abnormal for her mental illness kept Elznic swallowing her sadness and anxiety for years.

She didn’t learn much about mental health at school, and when teachers told students to “tell somebody” if they were having suicidal thoughts or feeling depressed, Elznic never felt close enough to adults at school to come forward.

She also didn’t see mental illness as common and said if more people opened up about mental health, it’d be easier for kids in her situation to come forward and ask for help.

“With a broken arm, it’s right here,” Elznic said. “You can see it in an X-ray, and it’s common. You see people all the time with it, but I didn’t really know a lot of people who were going through the same thing as I was, so I thought it was different.”