The Youth Risk Behavior Survey Data Summary & Trends Report: 2011–2021 provides the most recent surveillance data, as well as 10-year trends, on health behaviors and experiences among high school students in the United States (U.S.) related to adolescent health and well-being. These include sexual behaviors, substance use, suicidal thoughts and behaviors, experiences such as violence and poor mental health, social determinants of health such as unstable housing, and protective factors such as school connectedness and parental monitoring. We also highlight disparities in these important outcomes by sex, race and ethnicity, sexual identity, and sex of sexual contacts.

As we have seen in our previous reports, several areas of adolescent health and well-being are continuing to improve overall, including risky sexual behavior (i.e., ever and current sexual activity and having four or more lifetime sexual partners) and substance use (i.e., ever used select illicit drugs, ever misused prescription opioids, current alcohol use, and current marijuana use). We also saw a decrease in the proportion of youth who were bullied at school

Teen mental health already was deteriorating before the coronavirus pandemic. In the two years since, the isolation, grief and anxiety created by school closures, deaths and loss of family income have led to even steeper declines in children’s mental health, experts say.

Awash in federal pandemic relief money—roughly $190 billion in education and health grants over the next four years—states are responding.

Last year, 38 states enacted nearly 100 laws providing additional resources to support mental wellbeing in K-12 schools, according to the National Academy for State Health Policy, a Portland, Maine-based policy research group. Dozens of additional school mental health bills became law this year in at least 22 states, according to the group.

“That’s a huge increase in legislative activity over anything we’ve seen in recent years,” said Tramaine EL-Amin, client experience officer at the National Council for Mental Wellbeing, a nonprofit that represents mental health providers.

“The pandemic shined a spotlight on our children’s mental health,” she said. “There’s no question that it’s something we need to pay attention to and that we need to act pretty quickly so that things don’t get worse.”

Broadly, the new state laws aim to upgrade school mental health resources and create comprehensive plans to prevent teen suicides and promote child mental wellbeing.

A central theme in many of the pandemic-inspired new laws is mental health training.

At least 16 states, from Alaska to Massachusetts, plus the District of Columbia, now require K-12 teachers and other school staff to take training courses on how to recognize mental distress in students and what to do when they see it.

California, Connecticut, Illinois, Kentucky, Rhode Island, Utah and Washington enacted new laws recommending high school students take mental health training courses so they can help their friends, family and classmates.

“Teachers are critical to identifying students who need mental health supports,” said Nancy Lever, co-director of the National Center for School Mental Health at the University of Maryland School of Medicine.

“But we also need to make sure that parents and other school staff who interact with students are trained to recognize mental health crises and understand how trauma affects children’s mental health and learning,” she said.

In addition to laws aimed at training teachers, bus drivers, and security and lunchroom staff, states also are providing money to help schools meet recommended ratios of students to mental health professionals, including counselors, psychologists and social workers.

In some states, new laws provide money for mental health screening and data collection tools that schools can use to develop long-range mental health strategies and measure their progress. Other laws require school boards to develop evidence-based plans for protecting the mental health of K-12 students.

“This is not new territory,” Lever said, “but it’s important territory that schools need to plan for so they can promote the mental wellbeing of all students and staff, and at the same time, identify and care for those in crisis.”

A key to schools’ success will be building in sustainability so the programs can go on when the funding ends, she added.

Plummeting Mental Health

The COVID-19 pandemic exacerbated an already growing crisis in adolescent mental health. Last year, a group of pediatricians, child psychiatrists and children’s hospitals declared a state of emergency for children’s mental health.

In 2019, a national survey conducted by the federal Substance Abuse and Mental Health Services Administration showed that the percentage of young people ages 12 to 17 who reported experiencing a major depressive episode in the past year had nearly doubled over the past decade, increasing from 9% or 2.2 million children in 2004 to 16% or 3.8 million children in 2019.

By 2021, more than a quarter of U.S. parents reported their adolescent had seen a mental health specialist, with 59% doing so in the past year, according to a survey published last month by the C.S. Mott Children's Hospital at the University of Michigan.

Suicide is now the second leading cause of death among children 10 to 14, according to the federal Centers for Disease Control and Prevention.

In 2020, emergency room visits for suspected suicide attempts by girls 12 to 17 jumped 51% compared with 2019, according to CDC data.

This month, the federal health agency reported that in the first half of 2021, more than 4 in 10 high school students surveyed said they had “persistent feelings of sadness or hopelessness” in the prior year, which was one of isolation and school closures for most teens.

“These data echo a cry for help,” CDC acting Principal Deputy Director Dr. Debra Houry said in a news release. “The COVID-19 pandemic has created traumatic stressors that have the potential to further erode students’ mental wellbeing. Our research shows that surrounding youth with the proper support can reverse these trends and help our youth now and in the future.”

But mental health experts say schools, which are often the only place troubled youth can look to for help, are not prepared to address the growing adolescent mental health crisis.

Historically, most states have failed to meet national minimum standards for the number of students served by mental health professionals, including school psychologists, counselors and social workers.

Only Idaho and the District of Columbia meet the recommended ratio of one school psychologist for every 500 students. At the bottom of the list, Georgia schools employ only one psychologist for every 6,390 students, according to America’s School Mental Health Report Card, published in February by a coalition of mental health organizations.

No state meets the nationally recommended ratio of one social worker for every 250 students. Farthest behind, West Virginia employs one social worker for 15,433 students. And only New Hampshire and Vermont meet the standard of one counselor for every 250 students.

Mental Health First Aid

The number of K-12 schools signing up for one of the most commonly used mental health training programs, called Mental Health First Aid, jumped 17.5% since the end of last year, according to the National Council for Mental Wellbeing, which administers the course.

“Every state in this country has adopted youth mental health first aid in some schools in some way,” the council’s EL-Amin said. “This year’s surge in legislative activity is helping get the word out.”

Developed and tested in Australia, the roughly 32-hour training program was adopted in the U.S. in 2008 by the council in collaboration with the Maryland Department of Health and Mental Hygiene and the Missouri Department of Mental Health.

With 25,000 instructors, the evidence-based curriculum has been used to train 2.7 million Americans in a variety of professions. Offered online and in person, the course teaches people to recognize the signs of a mental health or substance use problem, respond to someone in crisis rather than turn away and urge the person to talk to a mental health professional.

In the U.S., about 1 million people have completed a specialized version of the course designed for teachers, parents and others who interact with adolescents. More than half work in K-12 schools.

The course also has been adapted so teens can help each other, and more than 125,000 students in 700 schools and youth groups have completed it since 2020.

Graduates of the course say they’re able to use what they learned to help someone within an average of three months, EL-Amin said.

Emma Bap, who took the first aid course last year at Bellows Free Academy High School in St. Albans, Vermont, told the council that the program gave her “more confidence to reach out to someone who seems to be struggling—and quite possibly save a life.”

Mental health training courses typically offer scripts for what to say and what not to say to teens who may be thinking about ending their life. The training also emphasizes that teens should report to a teacher or another adult any potential suicide concerns they may have about a friend or classmate.

Separate training programs for adults and youths spell out ways to intervene in a potential suicide, underscoring that suicide is preventable.

But training alone is not enough to prevent suicides and ensure that kids experiencing mental illness get the care they need, said Julie Goldstein Grumet, an expert in suicide prevention.

“Schools need to create a safe and open culture where kids know it’s OK to talk about suicide and mental illness,” said Grumet, vice president of the Boston-based Education Development Center, a policy research group.

They also need to develop and sustain strong mental health community partners they can rely on to help their at-risk students, she added.

“Training is great and important, but it has to be embedded in a comprehensive approach where it’s not ‘one and done,’” Grumet said. “Schools shouldn’t be saying ‘we did the training,’ but rather ‘we transformed the entire culture around suicide prevention and mental health.’”

Record-high numbers of U.S. high schoolers struggle with depression, anxiety, and suicide. Here’s how schools can help.

Xavier is cutting himself with a knife on his arms and wrist.

The 16-year-old student lives with five family members in a one-room apartment. His mom is a house cleaner and dishwasher and speaks only Spanish. Xavier is the “parentified” family leader because his dad isn’t present. In response to his stress, Xavier has depression and anxiety and began cutting himself a few years ago.

“It’s a common form of self-harm, a maladaptive coping mechanism,” says his therapist, Joseph Gutierez, a former public school counselor in private practice in San Mateo County, CA, who assists clients referred by overloaded schools.

Xavier is among the 41 percent of U.S. students growing up in a low-income household. This group — often dealing with unstable housing, food insecurity, and violent neighborhoods — is associated with certain adverse mental health outcomes, such as a high rate of Posttraumatic Stress Disorder (PTSD). Middle- and upper-class students suffer equally, or even more, from mental distress, research from Columbia University suggests.

“In higher economic households, the absence of parents, plus no supervision, rules, or boundaries, but high expectations and academic pressure, creates mental instability,” Gutierez says. “Eating disorders, suicide ideation, and suicide attempts are prominent in this group.”

The mental health of high schoolers — from families that are wealthy, poor, and from every ethnic group — has plummeted since the 1970s, and continues to decline every year. Consider these woeful statistics:

• 13 percent of teens ages 13 to 17 experience at least one major depressive episode annually. This figure rose 59 percent between 2008 and 2017.
• 18.8 percent of high school students reported seriously considering suicide; 8.9 percent reported having attempted suicide. Suicide is the second leading cause of death among teens ages 14 to 18 after unintentional injuries.
• Nearly one in three adolescents (31.9 percent of U.S. adolescents) have a diagnosable anxiety disorder.
• 14 to 18 percent of high school students engaged in cutting and other forms of self-injury.

Why are today’s teenagers experiencing so many mental issues? A survey by the Harris Poll revealed the top reasons to be school work, thinking about their future, pressure from their family, and social isolation.

Although one in four teenagers have mental health issues, 80 percent never receive help in high school because there’s an insufficient number of counselors. (In U.S. high schools, the average counselor-to-student ratio is 441 to 1.)

“A full-time counselor can see five students a day, at most,” explains Gutierez. “That’s 25 students a week. They need to see these students every week, but the counselor-student ratio isn’t 25 to 1 in California.” Instead, California has the worst ratio in the nation at 951 to 1.

Peg Johnson, a recently retired counselor from Chico High School in Chico, CA, said, “The ratio [of students to counselors] was 400 to 1. That would work if we were only working with academic guidance issues. But most of our days were filled with social/emotional issues, especially in the last eight years, when the level of anxiety was on the increase.”

7 ways understaffed high schools can help with the escalating mental health crises among teens

1. Mental health education for everyone

   Three Virginia students from Monticello High, Western Albemarle High, and Albemarle High designed and helped pass a bill to provide mental health education in the state’s K-12 public schools in 2018. The reform was sponsored by state senator Creigh Deeds, who was stabbed multiple times in 2013 by his mentally ill son, who ended up killing himself. The instruction goals are to teach students how to maintain mental health, identify symptoms, seek help, and reduce the stigma.

   Texas law HB 18 requires all teacher certification programs to teach strategies to help students with mental health conditions. Certification curriculum in California also includes mental health. Damian Martin, a counselor at Woodland Senior High, notes, “Teachers are asking more questions now because they’ve been trained better to look for self-harm, abuse, and depression.”

2. Counselors who care

   When student Sol Garcia had a panic attack at Jimmy Carter Early College High School in La Joya, TX, she said that “the counselor immediately went up to me. She helped me a lot.” Garcia praises her high school staff, describing them as “very caring. Their priority was, ‘Are you mentally healthy? What can we do to get you to feel better?’ That really helped me.”

   To provide students support at this useful, empathetic level, counselors need to be committed and informed. “The best technique I could offer is listening and encouragement through attentiveness,” says former counselor Peg Johnson. “I basically operated on motherly instinct and [with] a heart of compassion. I always tried to encourage the students to speak with their parents and to create a team of support.”

3. Relax the teen mind

   Research indicates meditation helps adolescents reduce “self-harm thoughts, disruptive behavior, stress, anxiety, impulsivity, and psychological distress.”

   Paul Covey, principal of Valle Verde Early College High School in El Paso, TX, observed students’ “stressful anxiety and panic attacks.” To counteract this, his school started doing a schoolwide “Mindful Minute” of silent meditation or listening to nature sounds or soothing music each day to help the students clear their minds and relax. They also started a student club for yoga and meditation. “Some teachers like [the “Mindful Minute”] so much, they do it to start off every class,” Covey says.

   At Woodland Senior High, counselor Damian Martin helps anxious students by “talking them into listening to music conducive to relaxation, as a coping mechanism. I recommend slower-paced music. I encourage them to find their own songs that put them in a positive mood.”

4. Supportive social groups

   Woodland Senior High provides “personal power groups specifically for students with mental health struggles,” counselor Damian Martin says. “We offer the group ‘My Strength’ to boys and ‘Be Strong’ for girls,”
   Martin says. “They help self-conscious teenagers open up and talk about their issues.”

   Atherton High School in Louisville, KY, provides social clubs to enhance student mental health. “We have internal groups that allow African-American students to have a sense of community,” explains Principal Thomas Alberli. Studies indicate gay-straight alliances can have mental health benefits for students participants and racial anxiety can be alleviated when cross-group meetings seek friendship between kids of different ethnicities. A study in California high schools found that student-initiated clubs reduce stigma around mental health issues and that homerooms can provide stability to anxious teens if they can depend on the teacher for counseling and advice.

5. Time off and text therapy

   Hailey Hardcastle had a panic attack in her classroom at Sherwood High School in Sherwood, OR during her junior year. The experience motivated her to work with three fellow students and two pro bono lobbyists to draft House Bill 2191, which was signed into law in 2019. The reform allows students to take mental health days off from school, similar to sick days. Utah offered the same benefit a year earlier when it included mental illness in its re-definition of excused absences.

   Desert Hills High in Saint George, UT pioneered “text counseling” four years ago when it adopted SchoolPulse, a platform offering simple, fast, comfortable communication with students. The technology’s goals are to promote mental wellness, improve suicide prevention, and empower students to speak up about their feelings.

6. Extra help on- and off-campus

   Crockett High School in Austin, TX, was the location of the first Vida Clinic, launched in 2012 as an on-campus mental health center. Its goal was to prove “accessible, trauma-informed mental health care can significantly aid students struggling with depression, anxiety and a host of trauma-induced conditions.” In only a few months, student clients improved “in their grades, behavior, and overall happiness.” Vida Clinic’s next goal is to be embedded in all of Austin’s 130 public schools.

   Many states like Arizona and Tennessee allocate funds for high schools to hire extra counselors and social workers, and referrals to outside counselors are the norm. Joseph Gutierez helps both adolescents and their parents, noting, “most of these clients have MediCal to pay for their services, but undocumented individuals aren’t able to get MediCal. For them I offer a sliding scale, starting as low as $5 an hour.”

7. Extra care and connection

   Teen mental health is enhanced by social-emotional support from caring adults. The resulting self-esteem helps prevent depression. The American School Counselors Association (ASCA) suggests counselors build positive relations with students by attending their extracurricular events, like sports and performing arts, and offering them regular encouragement, even something as simple as letting them know, “You did a great job!”

   Students living with poverty might also be hungry. ASCA’s advice is to help them with weekend food bags, as well as connecting them to community services and fee waivers for SAT, ACT, and college applications. Students from low-income families also transfer schools frequently as their parents seek employment. These “new kids in school” endure loneliness and stress that can be alleviated if counselors help them integrate into campus life via introductions to classmates with similar interests, or campus clubs they might enjoy.

Tips to promote mental health support for high schoolers

For parents

• Sign your child up for classes in mindfulness, yoga, guided imagery, and tai chi to learn de-stressing techniques that will help now and in the future.
• Use technology. There are apps to help kids decrease stress, elevate mood, and help with multiple mental health challenges.
• Movies are increasingly focused on mental health themes. Encourage viewing to help everyone recognize and destigmatize mental illness.
• Connect your teen’s school to local nonprofit organizations like the Youth Mental Health Project that assist adolescents with mental health struggles. Many provide parent support groups.
• Ask outside agencies, like county health services, to establish a wellness center on the high school campus. Ask state representatives to provide mental health days as an option for students.

For educators and administrators

• Provide support groups for students with mental health struggles by working with agencies such as NAMI (National Alliance of Mental Illness) .
• Teens who are physically and verbally harassed and subjected to cruelty by fellow students suffer long-term mental health challenges. Educators and administrators can increase empathy on campus by working with anti-bullying nonprofits.
• Help teachers recognize students’ emotional struggles by providing them with training courses like Mental Health First Aid.
• Offer student classes in mindfulness and other relaxation techniques, like yoga, guided imagery, and tai chi. Here’s eight tips from an experienced instructor.
• Use technology. Apps are available to decrease stress, elevate mood, and help with multiple mental health challenges. Circulate this list to students.