Salli-Ann Holloway could not breathe. Sitting in her Advanced Placement English class, she could not stop shaking. Her neck twitched relentlessly. She gasped for air. Her body went numb.

Holloway, 17, rushed to the school nurse’s office as she had many times before. Panic attacks had become commonplace for her as the stress of junior year took hold. The nurse soothed her as they waited for her mother to arrive. This would not be the last time Holloway’s illness interrupted her life.

Holloway is not alone. About 8 percent of today’s U.S. teens suffer from some type of diagnosed anxiety disorder, according to the National Institute of Mental Health. And anxiety has been on the rise among children and young adults since at least the 1950s. School counselors and nurses alike have cited increased amounts of stress, pressure, social media, and divorce as causes for this surge in anxiety that has not only affected the teens who suffer but school administrators trying to help their students.

“Things have changed dramatically with my students over the past couple of decades,” said Dr. Sharon Sevier, chair of the board of The American School Counselor Association and counselor at Lafayette High School in St. Louis. “Early in my career, I saw very few mental-health issues, and the home and family issues were more rare.”

Sevier said she now encounters students with anxiety on a “daily basis.” Thirty years ago, Sevier said she dealt with more “normal” teenage issues, such as conflicts with parents, friends, and significant others. Now, Sevier said she sees more severe cases of anxiety.

Jason Bradley, counselor at Roseville High School in Northern California, attributes a lot of the anxiety to the growing presence of technology in students’ lives.

“With the rise in the digital world, kids very often feel rushed and pressured,” Bradley said. “There’s a lot of info, a lot to learn, a lot to know.”

More than information overload, Amber Lutz, counselor at Kirkwood High School in St. Louis, said “high performance expectations” surrounding school and sports often result in stress and, in turn, anxiety. As top-tier universities increase in both price and selectivity each year, students tell Lutz they feel more pressure to perform. Sevier attributed colleges’ rising selectivity as a cause of teens’ anxiety today as well.

“The competition and pressure on kids have really increased,” Sevier said. “There seems to be a belief that there are certain courses that are the ‘right’ ones to take. Getting the ‘right’ grade in those classes leads to the potential of getting into the ‘right’ college or university. Many of those ‘right’ schools have stiff admission requirements. Students are challenged to take a demanding course of study, to get a high GPA and gain admission into those schools. So many times, if they are denied, students take it as a personal failure. School is more challenging, the stakes seem to be higher, and pressure is alive and well.”

Sevier said that the increased amount of testing teenagers face today, including the SAT, SAT Subject tests, PSAT, ACT, IB, and AP exams, additionally contribute to stress and anxiety. And over-commitment, between school, sports, a social life, and family obligations, becomes a balancing act that students can have trouble dealing with, Sevier said.     

For Angelica Marinelli, a senior at Hackensack High School in New Jersey, the stress of school, specifically her AP classes, resulted in a mix of migraines and panic attacks that led to a diagnosis of general anxiety in January.

“I didn’t want to put myself under that stress, but I had to,” Marinelli, 17, said. “It’s like this battle. There was a lot of pressure to succeed and do the best that I could.”    

Holloway said that her anxiety also developed as the strain of AP and honors courses, coupled with fear for the future, became overwhelming.

“A lot of people always say junior year is the hardest,” Holloway said. “With people telling me that, it got me in that mindset, and I was taking challenging classes. It was definitely a year when everybody did a lot of growing up and so a lot of things changed with your friendships, the classes and thinking about the future more than we’ve ever had to. That all just contributed and made it worse.”

As the number of students like Holloway and Marinelli grow, school nurses and counselors across the country have seen more cases of panic attacks, headaches, and stomachaches come through their offices each year. And when school is part of what’s driving students’ anxiety, a school counselor or nurse may be the first person to learn something is wrong.

Cindy Zellefrow, a nurse at South-Western City Schools in Grove City, Ohio, has not only seen the number of these cases multiply, but said their severity has increased as well. While Zellefrow said she usually sees three to five suicidal kids each year, during the 2013-2014 school year she said she treated 12 students whose anxiety was causing suicidal thoughts.  

“Some of these kids see things, go through things, experience things, and are surrounded by things it feels like no kids should ever have to be exposed to,” Zellefrow said. “It breaks my heart to see a kid who feels like at this age whatever it is has gotten so big that the only solution is to end their life.”

In the face of the student population’s changing problems, both nurses and counselors have had to adapt the way they practice to continue meeting kids’ needs. Lutz, a counselor of 12 years, said that with the rising prevalence of anxiety, she has had to become more knowledgeable about the illness and more connected to resources that can aid students and families. Sevier agreed that constant education is key.

“Professional development is huge for a school counselor,” Sevier said. “We have to be in a continual state of learning in order to stay current and abreast of what's happening in the field. I want to bring as much knowledge and expertise to my students and their families as I can.”

To stay familiar, Sevier looks to school counselor conferences, webinars, and seminars discussing mental illness, so she can better cater to her students’ needs. Bradley similarly attends various workshops and conventions to combat changes.

Devin Dinkel, meeting planner for the National Association of School Nurses (NASN), organizes an annual nationwide conference to keep school nurses, like Zellefrow, continually educated on rising health issues. After arranging the conference for four years, Dinkel said she has started hosting more talks on mental illness, and has noticed more requests from attendees to address the topic.

“That has been one thing that’s always in our evaluation,” Dinkel said. “Every year we try to add more sessions, because we know there has been an increase in mental illness.”

Through these conferences, conventions, and workshops, Zellefrow said she learned how to help students calm their bodies when feeing anxious and how to teach students to recognize their symptoms so they can soothe themselves before having a full-on panic attack. She said these resources also helped her create a safe atmosphere for students to get help. Finally, they taught her the importance of distinguishing the physical symptoms of anxiety—such as chest pain, quickened heartbeat, and difficulty breathing—from more serious heart conditions, so as not to overlook dangerous medical issues.

All three counselors, Sevier, Bradley and Lutz, emphasized that the prevalence of anxiety among students has grown gradually, so they’ve had time to make the necessary adaptations.

“As school counselors, we still work with challenges and ways to solve problems,” Sevier said. “It's just that the problems today are different from when I first started my career. School counselors stay in a constant state of learning, so you take the changes in stride.”

Bradley added that his job has not become necessarily harder, just that he has to manage his time better today than he has in the past. Bradley said he must now balance the prevalence of mental illness with his ordinary counseling tasks, like students’ academic needs.

“When you focus on one thing, you’re obviously going to have less time to spend in other areas,” Bradley said. “It comes with practice and efficiency and delegating responsibilities to yourself. You have to prioritize.”

School nurses have similar struggles—and similar solutions—to counselors. Zellefrow said that although she has always had to be aware of the resources available to her, in recent years those resources have grown. Zellefrow now has support brought directly to her school through specialized mental health counseling services for students, as well as expert-led staff training about mental health.

If the nurses I spoke with emphasized one thing, it was the growing importance of communication for school nurses—communicating with fellow staff members, a patient’s parents, and professional therapists and counselors.

“You have to work as a team because you don’t treat the child in isolation,” said Beth Mattey, a Delaware school nurse elected as the next president of NASN. “It takes talking to the student and finding out what’s going on, what kind of feelings they're having and sometimes talking to the teachers. We’re all working in the best interest of the child.”

Marinelli found her school nurses integral in not only helping her cope with migraines and panic attacks at school, but in improving her overall mental health. In addition to being patient and caring, Marinelli said the nurses helped her seek outside assistance by giving her a list of therapists to contact and talking with her parents.

“They definitely made it a priority to make me feel comfortable and get me to calm down and give me the assistance they thought I needed,” Marinelli said. “They [affected] the way my parents thought about my situation and the way I thought about my situation.”

At a different school, Holloway’s mother, Jennifer, was also pleased with the treatment her daughter received.

“The school nurse helped Salli-Ann breathe through every panic attack, which was very helping and comforting,” Jennifer said. “The last panic attack the nurse told Salli-Ann that she was not sick, so she needed to stay at school and breathe through her anxiety. I appreciated that so much. I could not be more grateful for the nurse and her help.”

As for the future of anxiety diagnoses, school counselors and nurses hope to continue helping their students through education and continued reassurance of support, although it is unlikely the issue will go away. Bradley said it’s hard to take preventive action against anxiety, since most people don’t worry about the illness until they have it, but he will continue reaching out to ensure his students are healthy. Seemingly recognizing the important role school nurses have the potential to play, Institute of Education Sciences earlier this year awarded a grant of more than $1 million to Johns Hopkins University to study ways school nurses can reduce anxiety.

“What I would hope that students know is that there is support available for them,” Sevier said. “When students are feeling anxious, I would hope that they would come to their school counselor and know that this one person can be their advocate for all the entities that impact their lives.”