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Gimba et al. BMC Public Health (2020) 20:1581
https://doi.org/10.1186/s12889-020-09713-2
R E S EAR CH A R TIC L E Open Access
The modules of mental health programs implemented in schools in low- and
middle-income countries: findings from a systematic literature review
Solomon Musa Gimba1,2* , Paul Harris1, Amornrat Saito3, Hyacinth Udah4, Averil Martin5 and Amanda J. Wheeler1,6
Abstract
Background: Secondary schools in low- and middle-income countries (LMICs) provide health promotion, preventive, and early intervention services. Nevertheless, literature indicates that the modules of these services are either adapted or modified from existing mental health programs in developed countries. The literature also highlights the provision of non-comprehensive services (mental health promotion, prevention, and early intervention), in LMICs. These findings inform the need for undertaking this systematic literature review. The aim of this review was thus to identify the modules of school-based mental health programs (SBMHP) that have been implemented in LMICs to guide the development of a culturally sensitive comprehensive mental health program for adolescents in a LMIC country.
Methods: The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was used to guide this review. The following databases were searched in September 2018, to identify the relevant literature: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and ERIC. The search was conducted by the first author and reviewed by the authors.
Results: Following the screening process, a total of 11 papers were identified and reviewed for quality. The systematic review highlighted that the mental health programs provided in schools included: an introduction module, a communication and relationship module, a psychoeducation module, a cognitive skills module, a behavioral skills module, establishing social networks for recovery and help seeking behavioral activities and a summary/conclusion module.
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* Correspondence: musasol19@gmail.com
1Menzies Health Institute Queensland, Griffith University, Brisbane,
Queensland, Australia
2Department of Nursing Science, University of Jos, Jos, Nigeria
Full list of author information is available at the end of the article
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Gimba et al. BMC Public Health (2020) 20:1581 Page 2 of 10
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Conclusion: This review sheds light on the characteristics of the programs in LMICs. Two programs were found to be universal in nature. Five programs were directed at key risk factors or at-risk groups, and four were early intervention programs. The review also revealed that only one program out of the 11 programs included modules for parents. The synthesis indicated that all the identified programs were adapted or modified from existing programs. The dearth of comprehensive programs in LMICs was also revealed. Lastly, the review revealed seven modules that can be useful for developing a SBMHP.
Keywords: Secondary school, Mental health programs, Adolescents, LMIC
Background
The provision of child and adolescent mental health (CAMH) interventions in schools has gradually taken centre stage in the global discourse [1–4]. Available lit erature highlights that schools play a major role in the provision of, and improving, access to mental health in terventions to children and adolescents [2, 5–13]. Evi dence from high-income countries (HICs) indicates that several programs have been developed and implemented to meet the mental health needs of children and adoles cents [14–20]. While this is the case in HICs, little is known about the development of these programs in low and middle-income countries (LMICs). The available lit erature in LMICs reveals that programs that have been implemented are either adapted and/or modified from HICs [21–29].
The potential benefits of mental health programs im plemented in schools have also been highlighted in LMICs. It is increasingly recognized that universal men tal health services provided in schools and other community settings, such as workplaces, are more ac ceptable than non-community settings because they limit stigmatization and discrimination [30, 31]. Other scholars [31, 32] have also demonstrated that commu nity mental health services are reducing stigmatization and discrimination through mental health promotion, prevention, and intervention in respect of mental health disorders. Indeed, the gap between the burden of mental illness and access to mental health services in LMICs can, in part, be addressed by investing in school-based mental health programs (SBMHP) and other community mental health services [33]. The research suggests that mental health services provided in the school settings have far-reaching benefits for students and for increasing access to services.
The economic benefits of providing mental health ser vices in schools have also been reported in the literature. The return on investment of early identification and intervention programs, such as SBMHP, has also been recognized [34, 35]. These include reducing crime, raising earnings, and promoting education [34, 35]. For instance, early mental health interventions, especially during adolescence, have been associated with
prevention of lifetime disability for most people with mental health disorders [35]. Prevention of diseases and health promotion was also identified by the authors as potential distal economic benefits of early life interven tions [34, 35]. It appears that, by investing in SBMHP, access to CAMH interventions can be improved in a way that is effective and valued by students in the short term, while realizing distal economic benefits.
Hence, experts are advocating for comprehensive men tal health services within school environments and other community settings, such as workplaces and homes [36, 37]. For instance, the mental health promotion interven tions continuum (MHPIC) is a group of primary and secondary prevention strategies used in a school com munity to provide a range of mental health services or interventions [1, 36, 37]. The three levels of the MHPIC are commonly referred to as universal, selective, and in dicated [36]. When these three levels are provided in a school or community setting, they are referred to as a comprehensive mental health program [38]. The univer sal approach focuses on providing interventions across the school population, i.e., all students [39]. The main aim of these programs is to make the school environ ment free of mental health stressors or predisposing fac tors by offering access to the programs to students, teachers, and the school community [29]. Reduction of stigmatization is one of the most important impacts of such a universal approach [36]. Selective approaches, in contrast, target groups of students and sometimes their family members who are susceptible to presenting with mental health problems [40]. These programs are mostly preventive [41] and are administered primarily to pre vent the development of mental health problems [36]. The main effects of these programs include reduction of disruptive behaviors, depressive symptoms, and the pro motion of feelings of togetherness. These programs further provide parents with mental health knowledge and skills that affect their responses to their children’s behavior [36]. The indicated approach focuses on indi vidual students and their family members who have manifested early signs and symptoms of mental health problems [37]. The goal of these interventions is thus the early identification and intervention of mental health
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problems to prevent or reduce the severity of these and the further development of symptoms. These programs furthermore help to reduce school disciplinary actions, depressive symptoms, and referrals to specialist mental health services [36]. The MHPIC approaches proffer dif ferent solutions to different populations within the school community. This indicates that implementing a comprehensive mental health program will allow for wider coverage and multiplier effects in terms of popula tion and solutions, respectively.
The available literature on the provision of culturally responsive comprehensive CAMH in LMICs is scarce. The available literature indicates that the majority of the ongoing child and adolescent research in LMICs has been aimed at identifying the burden of emotional, cog nitive, and behavioral problems; needs related to re sources; and the availability of resources for developing and implementing mental health programs in schools [6, 9, 42–45]. The scarcity of literature in this field supports the need for further studies that focus on developing culturally responsive mental health intervention pro grams. The only literature that describes a mental health program for adolescents suggests an existing indicated program in a HIC was adapted for an LMIC [46]. This clearly reveals that there is no existing LMIC literature that describes a culturally responsive comprehensive mental health program. Such a dearth of published stud ies on SBMHP underscores the need for further research about SBMHP in LMICs in general.
Thus, this systematic literature review sought to synthesize the literature regarding mental health pro grams in schools, with a view to identifying the modules of the SBMHP that have commonly been implemented in LMICs. The identified modules were used to guide the data collection process and the development of a culturally responsive comprehensive mental health pro gram for schools in a LMIC. The modules were also identified to promote the use of effective modules as baseline for the development of future programs. It is our belief that mental health programs implemented in schools in LMICs may be more beneficial than programs implemented in other community settings and mental health institutions.
Methods
The programs implemented in LMICs are either adapted from existing programs in HICs or focused on specific mental health problems [21–29, 46, 47]. The need to identify modules from the literature to guide the devel opment of a culturally sensitive program for LMIC was considered imperative. Thus, the current review looked at programs that had been developed and implemented in LMICs and identified modules of mental health pro grams based in schools.
Search strategy and eligibility criteria
The Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement [48] was used to select and refine all possible studies for inclusion in the study. Each step of the literature review was conducted according to the PRISMA statement (see Fig. 1). Articles were selected for inclusion based on the following selection criteria: the study must have been conducted in a school environment; it must have been undertaken with adolescents (12–18 years); and it must have described the modules of the mental health programs. This study focused specifically on adolescent populations of secondary schools; there fore, the exclusion criteria were studies conducted with a combination of children and adolescents, and studies undertaken in HICs.
The search was conducted in September 2018 by the first author. The following databases were searched: PubMed, Web of Science, Scopus, CINAHL, ERIC, and PschINFO. The reference list of full text articles, espe cially systematic literature reviews, was also searched for articles that met the inclusion criteria [49]. The limiters used were year of publication (2003–2018), peer review, English, human(s), and full text.
The search terms used were mental health, or psycho logical health, or psychological wellbeing, or life skills, or empowerment, or resilience, or social emotional, or mental health literacy, or mindfulness, AND secondary school, or high school, or junior high school, or middle school, or grades 7–12, AND programs*, or therapy, or intervention, or education, or training, or promotion, or prevention. A summary of the number of articles re trieved is presented in Table 1 (Figure Legends).
A total of 1872 articles were generated, and all were screened against pre-specified inclusion criteria. A total of 96 duplicates were excluded, resulting in 1776 unique articles for screening. The titles of the 1776 articles were read by three of the authors, and 1556 articles were identified as falling outside the scope of the review. The abstracts of the remaining 220 arti cles were all read by three of the authors, and there after a total of 203 were excluded for not meeting the inclusion criteria. The full texts of the remaining 17 articles were read, resulting in a further 11 articles being screened out, and six full-text articles were read again by the same authors. Of these six articles, three were single studies, while the other three were sys tematic reviews. The three authors then re-read the three systematic reviews, and eight articles mentioned in these three systematic reviews met the inclusion criteria. Therefore, the eight articles from the system atic reviews and the three single studies were in cluded in this review; giving a total number of 11 articles (see Fig. 1).
Gimba et al. BMC Public Health (2020) 20:1581 Page 4 of 10Fig. 1 PRISMA flow diagram (2003-2018)
Methodological quality assessment
The Grading of Recommendations Assessment, Devel opment and Evaluation (GRADE) system for rating the quality of evidence and strength of recommendations [50] was used to assess the quality of the 11 studies. The quality of evidence assessed the study design, the quality of the study and its consistency [51].
The GRADE system also highlighted the fact that studies are classified into observational and randomized trials [51]. In scoring a randomized control trial (RCT), high-quality evidence is awarded the maximum score (4
points), but factors such as study limitations, inconsist ency of results, indirectness of evidence, imprecision, and reporting bias can influence the confidence in the evidence, thereby reducing the score to moderate (3 points) or low (2 points) [45]. Conversely, the scoring of observational studies starts from low quality (2 points) and may be upgraded to moderate quality (3 points) if the magnitude of the intervention is large [50].
In addition, when further research is not likely to in fluence the confidence in the estimate of effect of an RCT, the evidence is said to be of high quality (4 points).
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Table 1 Summary of the Number of Articles Retrieved S/No Database Results (collected between 2003 and 2018) 1 ERICa 740
2 PubMeda 19
3 Web of Scienceb 455
4 CINAHLa 217
5 Scopusc 5
6 PsychINFOa 436
Total N = 1872
Key: aadvanced search, bbasic search & cdocument search
Evidence is said to be of moderate quality if further re search is likely to have an important impact on the con fidence in the estimate of effect, and it may change the estimate. Furthermore, evidence is considered low qual ity if further research is likely to change the findings, and very low quality when the results appear to be very uncertain [50, 51].
Results
Characteristics of the programs
As shown in Table S2, all the studies included were from middle-income countries (MICs); seven were from upper middle-income countries [21–27] and four were from lower middle income countries [28–30, 47], as indicated by the World Bank [52]. Three studies were conducted in South Africa [21, 22, 24], two in Bosnia and Herzegovina [26] and one study each was from India, Kosovo, Nigeria, Mauritius, Thailand, and Palestine [23, 27–30, 47]; Africa accounted for five studies (three from South Africa and one each from Nigeria and Mauritius).
A range of experimental designs was employed across the chosen studies, including quasi-experimental [21, 24, 27], Solomon four group design [22], experimental de sign (RCTs) [23, 26, 28, 30], mixed study design [24], intervention study [47] and a cross-sectional cohort study [29]. Sample sizes differed significantly: the smal lest sample was 12 [24], while the largest was 877 [29]. The quality of the studies also differed based on the GRADE system assessments: two studies were of high quality [23, 26], seven were moderate [21, 26–29, 47], and two were low quality [22, 24]. This suggests that most of the studies had adequate quality ratings.
Practical indices, such as the duration of the programs and who conducted the programs, were also evaluated. The duration of individual sessions of the programs ranged from 45 min to 12 h. The number of weekly ses sions per programs ranged from one to three sessions per week. The total duration for implementing the indi vidual programs ranged from 3 weeks to 1 year [21–30, 47]. The programs were implemented by a range of pro fessionals, including teachers [21, 23, 27, 30], school
counsellors [26, 29], researchers and research assistants [28], consultant psychiatrists, [47] and psychologists [22]. This highlights the culture of the multidisciplinary approach in the provision of mental health interventions in schools.
The involvement of stakeholders in the development of the programs was also highlighted. Out of the 11 programs, one program was developed through needs assessments conducted with multiple stakeholders, in cluding students, parents, non-governmental organiza tions (NGOs), and policy makers [27]. Others were developed by the researchers [28] or adapted from exist ing programs [47], while in some others, this was not in dicated [21–23, 26, 28–30].
The effectiveness of the 11 programs varied in relation to the individual outcomes of the programs. Five pro grams [23, 26, 29, 30, 47] were significantly effective across all measured outcomes, and were measured after a period that ranged from 3 months to 4 years. The ef fects of the five programs on adolescent mental health were maintained throughout the measured periods. One [23] of the programs, however, revealed different effects due to the maintenance dose. Improvements in self esteem and coping skills were maintained at 6 months’ follow-up, while improvements in depression symptoms and hopelessness were not maintained at 6 months’ follow-up [23]. Although three of the programs indicated improvements across all the outcomes [24, 26, 28], but they did not measure the effects after the implementation.
The remaining three programs [21, 22, 27] showed varying effects. One of the articles revealed that there was a significant improvement in interpersonal strength, emotional regulation, self-appraisal, and emotional reactivity, and these were also maintained at 3 months’ follow-up [22]. Also, no significant improvement was reported in family involvement, intrapersonal strength, school functioning, affective strength, sense of mastery, sense of relatedness, family appraisal, or general social support [22]. Another study [21] indicated significant increase in intrinsic motivation, decreased introjected motivation and amotivation in the intervention group. For the control group, there was a sharp increase in recent and heavy use of alcohol and cigarettes. The effects of the pro grams on alcohol and cigarette use were found to be greater for girls [21]. Significant improvement in self esteem, perceived self-efficacy, pro-social behavior, and perceived adequate coping was reported. Partici pants showed significantly better adjustment in respect of teachers, better adjustment in school, and improved classroom behavior. However, no change was observed in adjustment in respect of parents and peers [27].
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Description of the program modules
Modules of the universal programs
Universal programs were identified in two of the studies [26, 27]. The modules of these programs included psychoeducation, relationship and communication, cog nition, and coping skills modules. The psychoeducation module covered topics such as introduction of partici pants and areas to be covered in the programs, self introductions, and building rapport. The second module dealt with relationships and communication, and it covered self-awareness, empathy, learning how to be friendly, and learning how to communicate with friends. The cognition module, which was the third module, cov ered topics such as problem-solving skills and anger management, decision-making, and critical and creative thinking. The final module was related to coping skills; for example, how to manage emotion and stressful situa tions. Both programs targeted all the school students and/or parents, but not the teachers [26, 27].
Modules of the selective programs
A total of five programs were selective in nature [21–23, 26, 29]. The modules of the selective programs were de scribed based on the target population. The target popu lation categories included: 1) children predisposed to or experiencing mild cognitive, emotional, and behavioral problems; 2) children at risk for sexual behavior and substance abuse; 3) children who were victims of war; and 4) children living in conflict-prone areas.
Mild cognitive, emotional, and behavioral problems The modules of the program targeted children predis posed to or experiencing mild cognitive, emotional, and behavioral problems. The program included the introduc tion, relationship and communication, behavioral and cognitive modules for students and the behavioral module for teachers. The introduction module introduced partici pants to the areas to be covered in the programs [22]. The second module, viz., the relationship (intra- and interper sonal relationship) and communication skills, included developing a strong sense of identity, developing and maintaining realistic self-esteem, identification of emo tions, expression of emotions and basic communication skills. Cognition, the third module, covered topics like conflict management, assertiveness, and tolerance regard ing diversity [22]. Behavioral skill was included in the fourth module, and it dealt with teaching students suc cessful time management and adaptability [22].
Sexual behavior and substance abuse The program modules included drug-related psychoeducation and sexual relationship and cognition modules [22]. Drug related psychoeducation covered topics around the def inition of drugs, signs and symptoms. The relationship
module, the second module, covered topics such as self awareness and leisure activities. The third module was cognitive skills, which included problem-solving activities, decision-making activities, and coping skills activities [21].
Victims of war The programs targeting children who were victims of war included modules on relationship and communication, trauma related psychoeducation and training topics, cognitive, social support for recov ery, and behavior. The first module covered topics like self-awareness and self-esteem activities, building trust and sharing concerns [26, 29]. The second module was trauma-related psycho-education and training, which covered the following topics: learning about emotions, how to control emotions via bodily and verbal processes and regulating breathing, and somatic problems [26, 29]. The cognitive module was third and included problem identification and problem-solving skills. Examples of problem identification skills included writing about and drawing traumatic events (frightening, disturbing experi ences; dreams or memories). Problem-solving skills, such as talking about traumatic events to third parties, story telling, and exploration of emotions were also included. Other activities included coping skills, relaxation and breathing exercises, sleep, and role playing [27, 29]. The fourth and fifth modules covered topics such as help seeking behavior and recovery process activities [27, 29].
Conflict-prone areas The programs that targeted chil dren living in conflict-prone areas covered topics related to students and their parents. The modules for children included psycho-educational topics and relationship building activities, cognition, and social networks. The psycho-educational topics and relationship-building activities related to family harmony and avoiding the escalation of conflicts [23]. The third module covered cognition-related topics and problem-solving skills (stress inoculation techniques, trauma processing through narrative drawings, and reactions during and after times of danger) [23]. Establishing social networks was part of the fourth module [23].
This program also included activities for parents. Ses sion one involved identification of existing parental strengths and stressors, followed by management of stress to enhance calm and effective parenting; session two of fered information about normal adolescent development and strategies for promoting self-esteem and balancing in dependence and attachment issues; and session three pro vided strategies to promote family harmony and manage conflicts [23]. The modules covered by all five selective programs included introduction, psychoeducation, rela tionships and communication, cognition, behavior, and
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social support systems. These modules resembled those of the indicated programs (see below).
Modules of the indicated programs
Four programs [24, 28, 30, 47] were indicated, which tar geted adolescents with depression, learning disabilities, and negative thinking. The modules covered in these programs included an introduction, psychoeducation, intra-communication, and relationships, cognition, and a conclusion. The first module focused on introductory activities, such as exchanging pleasantries [28, 30, 47]; the second focused on psychoeducation, such as signs and symptoms of depression [47]; the third on intra communication and relationship activities, such as stabilization, self-actualization, and self-esteem-related activities [24, 28]. The fourth module covered cognitive activities, for example, identification and listing of daily pleasurable activities, identification of emotions, control ling emotions via coping skills, relaxation activities, and problem-solving activities such as boosting self-esteem, storytelling trauma narrative activities, and resilience ac tivities [24, 28, 47]. The conclusion, summary and revi sion made up the fifth module [24, 28, 47].
The systematic review highlighted that the mental health programs provided in schools were made up of the following modules: an introduction module, a com munication and relationship module, a psychoeducation module, a cognitive skills module, a behavioral skills module, establishing social networks for recovery and help seeking behavioral activities module and a sum mary/conclusion module.
Discussion
The current systematic review was undertaken to iden tify the modules of mental health programs imple mented in schools that could be used to develop a culturally responsive comprehensive mental health pro gram to be implemented in schools for adolescents (12– 18 years) in LMICs. To the best of our knowledge, this is the first systematic review to be conducted within the LMIC literature, primarily to identify possible effective modules of mental health programs that can be imple mented in schools for adolescents [52–59].
Our review, although it is the first to be undertaken in LMICs, is the second to be undertaken globally. A study conducted by Skeen et al. [60], is the first study that was aimed at identifying the modules of mental health pro grams implemented in schools. The findings of our re view and those of Skeen and co-authors [60] share some similarities and dissimilarities. The quality of the body of evidence of the studies included in our review was assessed using GRADE. The studies included in the first study [60] did not use GRADE or any assessment tool. According to Skeen et al. [60], the studies included in
their review were not assessed for quality. This could po tentially influence the bias in relation to the quality of the studies included in both reviews. There are also some similarities with both studies in terms of their limi tations. In this review, one of the studies did not indicate if there was allocation concealment or random sampling. In the first review [60], allocation concealment and ran dom sampling were also not done in some studies. In re lation to the research designs employed, the current review included studies that utilised both real life setting designs and research setting designs (i.e., RCTs and quasi-experimental designs). In the review undertaken by Skeen et al. [60], the studies reviewed utilised only experimental designs. The implication of this is that, while the findings of our review can be applied in both research settings and non-research settings, the findings from the first review undertaken [60], may only apply to research settings.
The review conducted in the current study confirmed the claim by [53] that there is a dearth of literature on SBMHP for adolescents in LMICs. This finding is in line with other reviews undertaken in LMICs, which has been attributed to a dearth of professionals, acceptability of interventions [60, 61], poor funding of mental health by LMICs and a shortage of open access publications [60, 62, 63]. The finding of this current study agrees with the finding of [52] which supports the need for develop ing culturally responsive and comprehensive mental health programs for schools in LMICs, advocating for more funding of mental health programs for adolescents by LMICs and undertaking more school-based mental health research by professionals. The fact that the num ber of SBMHPs was higher in Africa than in any other region [52] implies that African countries are increas ingly becoming responsive to the global discussion about mental health promotion and prevention in schools.
The current review indicated that the effectiveness of the 11 programs varied in relation to the individual out comes of the programs and the period of follow-up. This finding agrees with that of another study, which revealed that programs implemented by teachers were more effect ive than those implemented by other stakeholders, such as psychiatrists and researchers [64]. This implies that pro gram development should be outcome-dependent and that it should be followed up effectively and efficiently.
Regarding effectiveness, all the programs were effect ive. This finding is consistent with other existing litera ture. For instance, Lyn and co-authors [52] reports that SBMHP implemented in LMICs have significant positive effects on students’ emotional and behavioral wellbeing, including reduced depression and anxiety and improved coping skills.
Furthermore, one of the studies included in the review had modules for both parents and adolescents. Feedback
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from the parents recruited into the study revealed that the parent module allowed for improvement in the com pliance of the adolescents to the intervention regimen, which in turn, positively affected the outcomes. This supports the finding that programs that target multiple stakeholders may be more effective [2].
In our systematic review, five of the 11 programs were identified as selective and four as indicated, while two studies were universal. This highlighted that the univer sal programs were notably fewer. This is in contrast with the report of another study conducted in Australia (a HIC), which revealed that the universal program accounted for more than half of the programs included in the review [62].
Our systematic review indicated that seven modules were included in the 11 studies: an introduction, psy choeducation, relationship and communication, cogni tion, social support systems, behavioral and conclusion modules. These indicate the range of modules that have commonly been utilized in LMICs, and that hence can also be used to guide the development of future mental health programs to be implemented in schools in LMICs. Some of the modules identified in this review reflect those reported in the review by Skeen et al. con ducted in 2019 [60]. For instance, interpersonal relation ship and emotional stability were highlighted as modules in the 2019 study. These modules are similar to the communication and relationship module found in this review. Conversely, the other modules, which constitute most of the modules, differ in both studies. This could indicate that different settings in terms of geography may influence the applicability of a module or modules.
Study limitations
This systematic review has a few important limitations. The first is related to the scope of the systematic search. Due to the time scale and resources available, a system atic search for studies published in the grey literature (i.e., research and materials that are unpublished or that have been published by individuals and organizations outside the traditional commercial or academic environ ment) was not included. Furthermore, the search did not consider languages other than English and, therefore, studies in the other former colonial languages of French, Spanish, Portuguese, and Dutch were not included. The second set of limitations related to the selection criteria. The studies included were all peer reviewed, hence there is possibility that some programs were not identified. Another important limitation of the study is the fact that our search strategy missed eight relevant articles that were only found through other systematic reviews. This suggests that our search strategy/search terms were not comprehensive enough.
Conclusion
The systematic literature review indicated the unavail ability of universal and comprehensive programs in LMICs. It showed that two programs were universal programs, and that no comprehensive programs were available, thus highlighting the need to develop compre hensive SBMHP in LMIC settings. Furthermore, the sys tematic literature review revealed that one of the programs incorporated modules for parents [29]. This finding indicated the need to develop a culturally sensi tive, comprehensive SBMHP that incorporates modules for adolescents, their parents, and their teachers.
The literature review also revealed seven major pro gram modules, which include an introduction module, a communication and relationship module, a psychoedu cation module, a cognitive skills module, a behavioral skills module, a module on establishing social networks for recovery and help seeking behavioral activities, and a conclusion module. These options will form the basis for further research, consultations, and the development of a SBMHP in an LMIC.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10. 1186/s12889-020-09713-2.
Additional file 1: Table S2. Systematic Literature review of SBMHP for adolescents in LMIC.
Abbreviations
CAMH: Child and adolescent mental health; GRADE: Grading of Recommendations Assessment, Development and Evaluation; HICs: High Income Countries; LMICs: Low and middle-income countries; MHPIC: Mental health promotion interventions continuum; MICs: Middle-income countries; NGO: Non-governmental organization; RCT: Randomized controlled trial; SBMHPs: School based mental health programs
Acknowledgements
Not applicable.
Authors’ contributions
SMG designed the study and performed the data search; SMG reviewed the studies and carried out the quality assessment ratings; PH, AS, HU, and AW reviewed the search processes and results; all the authors contributed to the interpretation of the data and the drafting of the manuscript. AM contributed to the drafting of the manuscript and proofread and edited the manuscript. All authors read and approved the final manuscript.
Authors’ information
SMG is a PhD candidate at the School of Human Services and Social Work, Griffith University. He has a combined working experience of eight years as a clinical nurse in the Ministry of Health, Kaduna State, and is a clinical instructor and lecturer (Mental Health Nursing) at the University of Jos, Nigeria. He has embarked on several educational programs in secondary schools. His area of interest is CAMH.
AM has an MA Public Policy, and an MA Arts (Research). She is a Learning Adviser at Griffith University who works with research candidates to transition them into research culture. AM has 16 years of experience as an educator and professional adviser in tertiary institutions in Australia and New Zealand. Her current professional interests are the changing relationships between supervisors, research candidates and professional staff. AM’s personal research interests are thanatology, cultural research, and Māori death practices.
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PH has a PhD in Human Services and Social Work. He is currently Senior Lecturer (Disability Studies) with the School of Human Services and Social Work at Griffith University and the Editor of the Journal of Social Inclusion. AS is a nurse by background and is currently an academic with the School of Nursing and Midwifery, Griffith University, Australia. She has experience in mental health nursing practice, education and research in Australia and Thailand. Her research interests have included a focus on adolescent mental health issues and intimate partner violence.
HU is a Lecturer in Social Work and Human Services at the James Cook University. He holds Doctorate and master’s Degrees in Social Work from Griffith University, and the Australian Catholic University, respectively. He also has a First-Class Honors Degree in Theology and Philosophy. He is a leading scholar in the field of African immigrant settlement and wellbeing in Australia. His doctoral study explored the African immigrant experiences, and his recent research publications are extending his interests in immigrant and international student experiences, community and well-being promotion, decoloniality, race and mental health, critical race and social work education, research and practice. They seek to inform policy and improve practice. AW is Professor of Mental Health at Griffith University, Australia. She has extensive experience in pharmacy practice, health services, and person centered care research. Her research focuses on quality improvement, profes sional practice, workforce development, and capacity building, with the goal of improving outcomes for consumers and service providers.
Funding
This paper submitted for publication is part of the PhD program currently sponsored by Griffith University in South East Queensland, Australia.
Availability of data and materials
The data and materials used in this study can be access through the databases used. See supplementary table 2.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Yes.
Competing interests
The authors declare that they have no competing interests.
Author details
1Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia. 2Department of Nursing Science, University of Jos, Jos, Nigeria. 3School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia. 4Social Work and Human Services, James Cook University, Townsville, Queensland, Australia. 5Academic Engagement Services, Griffith University, Brisbane, Queensland, Australia. 6Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
Received: 13 May 2020 Accepted: 15 October 2020
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School Mental Health (2022) 14:402–415
https://doi.org/10.1007/s12310-021-09475-1
ORIGINAL PAPER
“Teachers Often See the Red Flags First”: Perceptions of School Staf Regarding Their Roles in Supporting Students with Mental Health Concerns
Gina Dimitropoulos1,2 · Emma Cullen2 · Olivia Cullen1 · Chris Pawluk5 · Alan McLuckie1,2 · Scott Patten2,3 · Andrew Bulloch2,3 · Gabrielle Wilcox4 · Paul D. Arnold2,3
Accepted: 9 September 2021 / Published online: 23 September 2021
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Abstract
To date, minimal research has explored the perceptions of secondary school staf regarding their realized and potential contributions to the redress of mental health stigma and support of students with mental health concerns within school environments. The aim of this study was to identify and describe the practicable roles school staf perceive of themselves to hold with respect to promoting mental health, challenging stigma, and responding to student mental health problems. Using an interpretive qualitative approach, semi-structured interviews were conducted following purposive and conveni
ence sampling of school staf (n=48) including classroom teachers, school counsellors, psychologists, administrators, and various support staf members employed with two secondary schools in southern Alberta, Canada. A structured interview guide was utilized to assess the roles, tasks, and processes school staf undertake to assist students with their mental health concerns. Four main themes inductively emerged from the data: (1) Relationships matter: Establishing and maintaining strong relationships with students, their caregivers, and other staf members are critical to addressing student mental health issues; (2) Empathetic and receptive communication is an antidote to stigma: Various communication processes contribute to disclosures of mental health concerns and challenges; (3) Connecting and facilitating timely access to the right person is key for students experiencing emotional crises; and (4) Facilitators and barriers to addressing student mental health con
cerns. Clinical implications and policy recommendations are provided to inform directions for administrators, educators, and caregivers regarding student mental health supports.
Levels of Evidence: Qualitative study.
Keywords Educator roles · Qualitative research · Student mental health · Stigma
Introduction
Gabrielle Wilcox and Paul D. Arnold are co-senior authors.
🖂 Gina Dimitropoulos
gdimit@ucalgary.ca
1 Faculty of Social Work, University of Calgary, Professional Faculties, MLT 301, 2500 University Dr NW, Calgary, AB T2N 1N4, Canada
2 The Mathison Centre for Mental Health Research and Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
3 Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
4 Werklund School of Education, University of Calgary, Calgary, AB, Canada
5 Rocky View Schools, Rocky View, AB, Canada
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Vol:.(1234567890)
Adolescent Mental Health: Prevalence and the Role of Schools
Globally, one in fve youth experiences symptoms of men tal illness (Malla et al., 2018) with 18–22% of children and youth aged 4–17 years meeting criteria for at least one mental health diagnosis (Georgiades et al., 2019) and still more experiencing subclinical symptoms (Aldridge & McChesney, 2018). Half of all lifetime cases of mental ill ness start prior to the age of 14 years (Belfer, 2008; Kessler et al., 2005, 2007), suggesting the exigent need for early
identifcation of adolescent mental health disorders. In Canada, only 30% of youth have meaningful access to necessary community and hospital-based mental health
School Mental Health (2022) 14:402–415 403
services (Georgiades et al., 2019; Rowling et al., 2009). Many youth frst seek mental health support in schools (Georgiades et al., 2019; Rickwood et al., 2005; Rowling et al., 2009), thereby optimally positioning school person
nel for detection of early warning signs for mental health problems in this population (Atkins et al., 2010; Leggio & Terras, 2019; Mazzar & Rickwood, 2015; Mihalas et al., 2008; Rickwood et al., 2005). Teachers and other school personnel have identifed mental health needs as the greatest health care needs of their students (Mansour et al., 2002). However, previous research has shown that mental health support in the school system is insufcient, and that this is a signifcant concern for both school staf and students (Waddell et al., 2005; Georgiades et al., 2019). Most educa tors do not feel equipped to respond to the needs of their students who are presenting with mental health problems (Andrews et al., 2014; Froese-Germain & Riel, 2012; Moon et al., 2017; Reinke et al., 2011).
The Social Climate in Schools as a Protective Factor for Adolescent Mental Health:
There is emerging evidence that a supportive school envi ronment can positively impact the mental health of stu dents. Brière et al. (2013) conducted a longitudinal study (71 schools, 5262 students) to assess the infuence of the socio-educational environment on student depressive symp toms throughout their school experience. They reported that students who attend a school with better socio-educational environments (social climate, learning opportunities, rules, fairness, and safety) were at a reduced risk of developing depression (Brière et al., 2013). Kidger, Araya, Donovan and Gunnell’s (2012) systematic review on school envi ronment revealed enhanced mental health in students who perceived themselves as being supported by their educators (Kidger et al., 2012). School staf play a critically important function in fostering a safe environment for young people struggling with acute and chronic mental health concerns (Froese-Germain & Riel, 2012; Kutcher et al., 2010; Leg gio & Terras, 2019). Although there is growing evidence for the importance of a supportive school environment, little is known about the perspectives of school staf regarding the strategies they employ to create such an environment.
The Importance of Relationships in Supporting Student Mental Health
Previous literature has identifed that school staf play a piv otal role in creating trusting relationships and fostering safe and non-stigmatizing academic environments. A strong and supportive relationship between students and teachers has been shown to be a protective factor for positive socio-emo tional outcomes for youth (Wong et al., 2021). Halladay et al.
(2020) reported a signifcant association between students’ intentions to seek school-based support, the probability of actual service engagement, and how responsive students per ceive their teachers to be regarding their emotional needs. Educators who build healthy and supportive relationships with students encourage not only their academic success but also promote student social, emotional, and psychological well-being (Mihalas et al., 2008). Educators are prototypi cally amenable to supporting student well-being, including responding to mental health concerns in children and adoles cents despite this falling outside their usual scope and roles (Atkins et al., 2010; Franklin et al., 2012).
Addressing Stigma
Although stigma is well known to be an important factor infuencing the willingness of people of all ages to seek help for mental health disorders and is thought to be prevalent in school culture (Bowers et al., 2013; Froese-Germain & Riel, 2012), little is known about mental health stigma from the perspective of educators and how this might infuence their capacity to support students with mental health con
cerns. Bowers et al. (2013) surveyed and interviewed stu dents (n=49) and service providers (n=63) and found that both students and service providers stated stigma created a signifcant barrier to accessing supports in school regard less of whether they reported having mental health concerns (Bowers et al., 2013).Less is known about the perspectives of educators, and more qualitative studies to understand the infuence of mental health stigma within schools from an educator’s lens would assist in flling a gap in past research.
The Role of School Staf in Facilitating Access to Right Level of Care
Multiple studies in diferent countries have demonstrated that school staf (including teachers and counsellors) agree that their professional role includes addressing student men tal health (Beames et al., 2020; Phillippo & Kelly, 2014; Shelemy et al., 2019). However, there is a wide divergence of opinion among school staf as to what exactly this role entails. For example, in a recent study of 47 educators and school-based mental health providers, the majority of teach ers indicated their preference to refer students to in-school mental health supports rather than be directly involved, cit ing lack of skills in the area of mental health (Phillippo & Kelly, 2014). However, other teachers in the same study indi cated that with appropriate training they would be happy to play a more direct role in assisting students in their mental health struggles. Beames et al. (2020) similarly found dif fering views among teachers and counsellors in Australia regarding their roles, which greatly afected how they sup ported the mental health of their students.
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Lack of Training as a Barrier to Educators Supporting Students with Mental Health Concerns
Previous qualitative studies have repeatedly identifed lack of confdence and inadequate mental health knowledge and training as a perceived barrier to teachers supporting stu dents adequately (Kidger et al., 2010; Mazzar & Rickwood, 2015). A survey of 786 educators and 127 administrators across an American state explored perspectives of educators on mental health promotion and needs for further mental health training. The study indicated that there is a high level of concern among educators for student mental health needs and a desire for further training and capacity building as they did not feel their professional training had been adequate (Moon et al., 2017). A qualitative study of 49 secondary school teachers in the UK focusing on perceived needs for mental health training revealed that participants wanted training so they could provide support for students when they were initially identifed, without taking on the role of therapist (Shelemy et al., 2019). The perception by teach ers that they need more training in mental health has been reported in studies from North America, the UK, Australia, and Africa (Beames et al., 2020; Mbwayo et al., 2019; Moon et al., 2017; Shelemy et al., 2019). Similar to teachers, less than one third of students in a recent survey thought their teachers and school had adequate training and capacity to deal with mental illness in schools (Bowers et al., 2013).
Rationale for the Current Study
There are a number of gaps in our knowledge regarding the perspectives of school personnel on their roles and poten tial contributions in relation to mental health, and the chal lenges they face in the provision of support to their students. These gaps must be addressed to develop stronger mental health training for educators and better mental health sup port for students. The current study aims to understand the perceptions of school staf in relation to their practicable role, and that of the school environment, in the promotion of student mental health and wellness, detection of student mental health concerns, redress of mental health stigma, and intervention with students requiring psychosocial support and/or mental health services. An enhanced understanding of the perception of staf regarding their infuence on stu dent mental health outcomes is needed, as current school practices still lack a defnite course of action or indicator of change. This study further aims to explore perceptions of educators regarding what resources are critical to sup port their role in helping students. Such knowledge may contribute to the development of training and educational interventions that refect the needs of educators who work on the frontline with students. It has been noted by Beames et al. (2020) that the nature of research with schools makes it
difcult to translate to other countries internationally, due to the vast diferences in policies and mental health framework of each school; therefore, we also hoped our results would be of even greater relevance to educators and policy makers where little research has been conducted to date. This study will provide valuable insights on how school staf want to see future training implemented, as well as what specifcally they hope to gain from training.
Methods
This paper reports initial fndings from a qualitative study exploring how educators and school staf view their role in supporting student mental health and minimizing stigma. This paper follows the Consolidated Criteria for Report
ing Qualitative Studies (COREQ) guidelines for qualita tive research (Tong et al., 2007; see Appendix A) and was approved by the University of Calgary’s Conjoint Health Research Ethics Board (REB 16-1352) as well as the research committee of the partnering public school board.
Study Participants and Recruitment
Individuals were recruited from two participating schools that have a combined population of 1,683 students with a diverse student population. Approximately 100 staff employed by the schools were eligible to participate with a fnal sample of 48 school personnel. Key staf members, including school administrators and guidance counsellors, were contacted by the research team to introduce the study, with information subsequently presented to each school during a staf meeting. A purposive sampling process was initially used (Etikan et al., 2015) to recruit members of the school staf. Purposive sampling was deemed appropriate in order to best allow the researchers to answer the spe cifcally defned research question (Luborsky & Rubinstein, 1995) and to recruit individuals who ofer experience and frst-hand knowledge of the topic being explored (Lubor
sky & Rubinstein, 1995). In this study, purposive sampling was initially used to recruit school staf from diverse roles including teachers, school administrators, guidance counsel lors, and school-based mental health providers. Convenience sampling was further employed, having been deemed useful when doing research in a predefned population, as it allows anyone who meets the criteria to participate in an interview (Etikan et al., 2015; Luborsky & Rubinstein, 1995). For this study, enrolment was open to all staf members at the two secondary high schools who have contact with secondary students. Snowball sampling was also utilized, as mem
bers of the school staf shared information with their col leagues about the interview process and acted as methods of referral (Luborsky & Rubinstein, 1995). Purposive and
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convenience sampling proved to be more successful modes of recruiting interview participants, garnering 46 school staf; only 2 school staf were recruited through snowball sampling. Study inclusion criteria comprised: (a) school staf employed with either of two secondary schools in a large town in Southern Alberta (population~35,000) and (b) expressed interest in addressing school mental health issues. The only exclusion criterion for the present study was school staf who had no direct contact with students; however, all interested individuals were deemed eligible. Interviews were conducted the period of June 2017 to March 2018. Commen surate with school board procedures for research, to enable teachers to participate in the study, the researchers reim
bursed the schools who hired substitute teachers to provide release time and class coverage for all teaching staf wishing to participate in the study. The six research assistants who conducted the interviews with school personnel were trained by the primary author (GD), a qualitative research expert.
Data Collection
Semi-structured qualitative interviews were conducted with participating school personnel. After obtaining writ ten informed consent, school staf completed a demographic survey and participated in an individual interview, either face-to-face or by phone, scheduled at a convenient time and location for the participant. The duration of the interviews ranged from 45 to 60 min. Interviews were audio-recorded and transcribed verbatim, and all identifying information removed.
Individual interviews were used as they provided school staf with a forum to speak frankly about their perceptions and understanding of student mental health issues and stigma, potentially including their own experiences of men
tal health issues. The interview guide was created collabora tively with input from content experts in various disciplines including youth mental health, education curriculum devel opment, stigma, and school mental health. The interview guide was also piloted with a guidance counsellor and an educator who provided input on the length of the interview guide and the language employed. School staf were asked open-ended questions to facilitate participant descriptions and perceptions of student mental health problems, defni tions of stigma, school culture and school procedures, as well as their experiences discussing mental health with stu dents. The following is a sample of the questions used in interviews with school staf; prompts and follow-up ques tions were also asked to illicit additional information. Ques tions asked of interview participants included: “What do you think the role of the school and/or educators should be in working with student mental health difculties?”; “How prepared do you feel you are to work with issues of student mental health within your role at the school?”; “What do
you think the role of the school should be in supporting student mental health and/or stigma?”; “In what situations do teachers talk about student’s mental health?”; “In what situations do students talk about their mental health to teach
ers?”; “Have you ever talked to a student/students about their mental health?”.
Data Analysis Procedures
Qualitative analysis is successfully employed when explor ing a social issue and allows researchers to examine words and stories to help create a complete picture of a complex problem (Srivastava & Thomson, 2009). Thematic analy sis is a form of qualitative analysis that seeks to describe participants’ viewpoints (Smith & Firth, 2011). This type of analysis is especially helpful in qualitative research as it identifes similarities and diferences within data, and then focuses on relationships between the data, allowing research ers to sort information into themes (Gale et al., 2013). The framework method, a subset of thematic analysis, is a quali tative research method often used with multidisciplinary teams and when data analysis occurs across and between sets (i.e. participants), thereby ensuring that all participants’
responses are given equal weight (Gale et al., 2013). The framework method, which consists of fve distinct stages (Gale et al., 2013; Srivastava & Thomson, 2009), was employed to inductively analyse the data. The interviews were transcribed verbatim by a trained transcriptionist. Transcripts were checked for accuracy by a member of the researcher team against the recording, and all identifying information was removed. In the frst stage of analysis, the transcribed interviews were read in their entirety twice to increase familiarity with the data. The research team elected to focus on only 20 interviews in this primary familiarization stage. From these initial impressions, the team developed preliminary codes about the perceptions, understanding and descriptions by school staf of their roles vis-à-vis student mental health, and identifed exemplar quotes to establish the thematic framework, as well as the coding template and codebook (stage two) (Srivastava & Thomson, 2009). The research team met to create a coding template by collat ing the themes identifed. The team further established a code book with the meaning and defnitions of the themes identifed. Achieving consensus among the research team regarding the framework and the codebook marked the launch of stage three of the framework method in which three team members utilized the framework to continue analysing remaining interview transcripts. The fourth stage involved charting the data, organizing the coded information under specifc headings and subheadings identifed in the framework (Srivastava & Thomson, 2009). In both stages three and four, the team members worked independently to analyse and organize the data using. NVivo version 12,
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qualitative research software, allowed the team to easily
Table 1 Demographic information of interview participants
code data directly from the transcripts and allowed for the data to be organized under headings and subheading (codes and sub-codes). Finally, the data were interpreted by the
Characteristics No. of partici pants (N=48)
Gender
Percentage
research team (stage fve; Srivastava & Thomson, 2009). At this stage, the team endeavoured to fnd patterns, com monalities, and diferences between information coded from the transcripts.
To heighten trustworthiness, the team members took the following steps: The research team independently coded all interviews, diligently kept notes of their refections, and also created memos of decision-making processes in the NVivo software. As described by Braun and Clark (2006), the determination of a theme should be guided by the researcher/team, and whether identifed patterns refect the overall research question and aims. For our manuscript, our research team confrmed the strength of a theme when ideas, thoughts, and refections were consistently identifed across the data (interviews conducted) rather than just within a single or small number of interviews. Through the use of refexive dialogue and discussion, the research team also agree upon the strength of the pattern observed when the codes coherently/consistently ft together within a theme. Further, the research team created a comprehensive code book and description of each code was reached through con sensus. The codebook contained detailed explanations on all codes and included examples of when the code could be used. All team members analysing the data had the codebook and therefore the same understanding of the meaning of the codes. The researchers met weekly to discuss their individ ual coding process and to uncover any points of contention and consulted with the leads of the project as needed. There were six researchers (from diferent disciplines including education, social work, and psychology) who participated in the coding process; this allowed for any disagreements to be solved through consensus. On the few occasions where there was a disagreement, the researchers explained their coding decision and discussion was held until such a time that all analysers came to an agreement with one coding decision over the other. As a form of member checking (Birt et al., 2016), our team presented our fndings to various stakehold ers (educators, the leadership and administrative team of the school board, and mental health providers) to verify the accuracy of our analysis.
Results
Demographic information (age, gender, type of profes sional role, level of education) on the sample of school staf (n=48) is summarized in Table 1. Most participants were women (67%), and nearly 90% of participants had a Bachelor or Master’s degree. Study participants included
Female 32 66.7 Male 15 31.3 Age
>30 10 20.8 30–49 26 54.2 <50 11 22.9 Roles in School
Teacher 27 56.25 Counselling and psychological staf 9 18.75 Learning support staf 6 12.5 School leadership 4 8.3 Administrative support staf 2 4.2 Years in role
Up to 5 17 35.4 6–10 12 27.1 11–20 10 20.8 >20 8 16.7 Education
Post-secondary certifcate 3 6.3 Bachelor's 24 50 Master's 20 41.7 Doctoral 1 2.1
classroom teachers (54%) and school counsellors, psychol ogists, administrators, and various support staf members (46%). Due to the wide range and multiple roles of those who took part in this study, all participants will be referred to herein as school staf.
Four interconnected themes were inductively identi fed: (1) Relationships matter: Establishing and maintain ing strong relationships with students, their caregivers, and other staf members are critical to supporting students with mental health concerns; (2) Empathetic and receptive com munication is an antidote to stigma: Various communication processes contribute to reducing stigma and thereby facili tate disclosures of mental health concerns and challenges; (3) Connecting and facilitating timely access to the right person is key for students experiencing emotional crises; and (4) Facilitators and barriers to address student mental health concerns. Illustrative quotes from the anonymized, transcribed interviews with school staf are provided below. Quotes are identifed using SS (school staf) followed by a number, indicating the interview number.
Theme 1-Relationships matter: Establishing and maintaining strong relationships with students, their caregivers, and other staf members are critical to sup porting students with mental health concerns
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What we do is connect with kids and go from there because then there's a relationship if they're going to talk (SS 29).
School staf shared the importance of building strong rela tionships with students, parents/caregivers, other school staff, and community agencies/organizations that serve youth with mental health issues. The act of fostering and maintaining strong relationships with students was perceived as critical to promoting mental health wellness throughout the educational system. Participants further noted that they intentionally established meaningful connections with stu dents whom they perceived to be struggling with mental health problems. Strong ties with such students were per ceived as improving the chance that they would approach educators in the event of a mental health crisis. One school staf member stated:
I think for staf the biggest thing is relationship and connectedness. . . I think that’s probably the. . . biggest value or, you know, the one that most staf would say is the most important. Once you establish that trust
ing, authentic relationship, almost anything after that, kids will jump through hoops for you. So, I think that’s important (SS 41).
Participants further noted that when they had established a positive relationship with students, they were better able to observe changes and quickly and supportively respond in the event of a potential mental health crisis. One school staf member summed up this point by stating: “I believe [our] role really is about building relationships and they'll [students] usually buy into that you know, build relation
ship, notice when they're not at school, reach out, connect, know where to go when they tell you something scary (SS 40)”. School staf shared that positive and strong relation ships provided an opportunity for students to talk about their experiences and seek guidance when feeling distressed or
facing challenges that seemed insurmountable. In addition to building strong relationships with students, school staf indicated they worked diligently to maintain strong relationships with their colleagues including adminis trators and educators within the school and across the educa tion system. For instance, staf members reported frequently meeting with colleagues employed internally and externally to their school in order to formally and informally discuss concerns about students and strategize when and how to respond more efectively to support students afected with mental health issues:
Well, one of the frst ways is through constant conver sation at every staf meeting. You know, at every staf meeting guidance, guidance does, you know—says,
okay this is what we’re doing, these are some of the issues that we may be dealing with, etcetera (SS 42).
School staf noted that through relationships with other educators, they better understand what resources are avail able, what may be required when students are struggling.
Strong and close relationships between classroom teach ers and guidance staf were deemed critical, as this permits better coordination and expedited responses to students in crisis, as one guidance counsellor stated: “one of our focuses, is to kind of loop these teachers in… because the truth is that those teachers can often be the ones that see the red fags frst (SS 33)”. Many spoke to the importance of having linkages with organizations and agencies external to the traditional school system including social workers and family liaisons who work to bridge the gap between services in the school and connect students and families to exter
nal resources. Building these relationships is important as it gives school staf a wider circle through which they can help their students access additional services as required. School staf further stressed the importance of ensuring that culturally sensitive services were engaged. One participant provided the example of a relationship with family and Abo
riginal liaisons:
Basically, any students that we feel we cannot resolve as an admin, guidance, and teacher team, we also have our Aboriginal liaison and our family school liaison. She’s basically the social worker that goes back and forth and we also have our school psychologist and they basically provide another level of expertise and information for the students so we can come up with more planning for them on what might work (SS 29).
Through connections like this, school staf can ensure that students receive necessary supports specifc to their individual needs.
School staf also noted the importance of relationships with parents/caregivers of students struggling with mental health issues. In the words of one participant: “I think that parents and teachers actually need to try and get together and fgure out what is actually workable (SS 35);” in order to provide the best educational experience for youth, participants viewed it as essential that parents/caregivers and school staf have a positive working relationship. School staf described how par ents/caregivers and administrators worked to systematically and proactively identify how to address mental health issues and remove barriers to help-seeking behaviours in students, as shared by a participant: “(school) has partnered with me to do sessions at their parent council around mental health. So, in that situation, you have the parents working together with the Principals and school staf and myself to talk about mental health regularly (SS 36)”. These working relationships help parents and school staf establish trust, collaboration, and
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open lines of communication about student mental health, with the overarching goal of improving support for students afected by mental health concerns, as eloquently stated by one participant:
The parents need to feel that, that the school is there as a support and that the people in the building too; it’s about a relationship, they need to trust that the information that they share is going to help their child and that it is all going to work together and what is best for their students is going to happen (SS 43).
School staf strongly believed and argued that their role was not to prescribe how and when parents/caregivers intervene to support their child. One participant shared the general attitude of school staf towards parents/caregivers:
Parents are the expert on their child and I will always say that, within my frst three sentences to a parent I say “You are the expert on your child, and I will be the expert in the classroom, and then together we are going to create an awesome program!”, and that is my open
ing, it always has been my opening, and I think that once they get that I see them as the expert on their child then I feel like it kind of helps, it is not always perfect but it certainly helps (SS 45).
Overall, many school staf spoke to the positive efects they have on emotional well-being of their students by providing a positive presence and developing strong relationships. It is important to note that a small minority of participants, identi
fed as classroom teachers, argued against being responsible for identifying and intervening to respond to mental health problems in their students. Insufcient training and a lack of expertise contributed to the unwillingness of some classroom teachers to view themselves as a source of mental health sup
port to high school students. However, all of the participants posited that positive relationships with students promoted a safe, non-stigmatizing environment that simultaneously con tributed to academic success and optimal well-being:
We don’t just focus on education itself. We actually have to look at way more. We have to look at the holistic part of the student and we’re all looking at that. If they’re socially, emotionally not able to attain school and educa
tion, their frontal lobe obviously isn’t going to be open to retain any of the information. So, if their social, emo tional [wellbeing] isn’t looked after then we’re not doing our job in so many ways (SS 17).
Theme 2: Empathetic and receptive communication is an antidote to stigma
I think just the fact that the conversation is being started is really the biggest piece of it. Talking about it, letting people know that they’re not the only one, or this is what’s happening with individuals around them. I think that’s, that has the biggest impact (SS 36).
Participants described the communication processes used to foster a safe, supportive, non-stigmatizing school environ ment. School staf shared that they regularly inquire about their students’ lives, demonstrate kindness when students disclose personal challenges, and relay messages to students that taking care of their mental health should be a priority:
I’ll say, “I see you’re not doing good. What’s up?” And I’ll just put the school work to the side and go, “What’s going on?” Their mental health is more important, a lot of the time, than school work. When you get their mental health down and everything, their school work will just come back in (SS 17).
Another school staf member further illustrated these communication processes: “As teachers, we have to... model, I guess, empathy and understanding when people are strug gling and model some coping strategies where appropriate (SS 2)”. Participants further suggested they must be acutely aware of and attuned to their students because they may be struggling with a host of issues that might not be readily apparent:
. . .so it’s the understanding, like you don’t know what they come to school with that day and I’ve got to remind myself of that… so I guess it is just reading the kids every day and trying to be as supportive as possible (SS 32).
Importantly, school staf discussed that through efec tive communication with their students, they believe they can help to reduce stigma towards mental illnesses and help students recognize that mental health issues are common:
Remove the stigma—it’s the fact that everybody might go through some period of that in their life. It’s not unusual, and they shouldn’t feel awkward or, you know, they’re the only person who that applies to (SS 42).
School staff described how through regular commu nication, and their actions they challenge stigma that can interferes with student help-seeking behaviours: “role mod eling that it’s okay to ask for help when necessary (SS 24)”. School staf shared that they modelled healthy behaviours to their students by appropriately and intentionally sharing previous and/or current mental health challenges with them.
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Some participants shared that they would challenge stigma associated with mental illness by disclosing their own lived experience: “…how powerful for the students to see you know teachers are not perfect—holy cow you can relate to me (SS 33)”. School staf believed that sharing experiences with youth had the potential to foster authentic connections and to normalize mental health disorders: “I’ve shared [my experiences] with students and it’s… fne to know that I’m like them; Not perfect (SS 10)”. School staf shared that positive and strong relationships provided an opportunity for students to talk about their experiences and seek guid ance on those days when distressed or facing challenges that seemed insurmountable. The processes of communication in the expression of empathy, understanding, and the dis
semination of educational information were all employed to challenge stigma, and diminish shame and apprehension in talking about mental health concerns and seeking support when needed.
Theme 3: Connecting and facilitating timely access to the right person is key for students experiencing emotional crises
I think it’s important for the schools to be able, and teachers, to be able to say to students that there are resources. And not even saying that those resources[exist] but showing them how to access them (SS 4).
The participating school staf discussed how they would respond to a youth struggling with mental health issues and noted the specifc steps they would undertake, includ ing sharing resources, directing students to needed mental health services, and assisting them to access services when required:
I’ll usually chat with students myself frst, and then I’ll recommend. I’ll say, “Hey, are you okay? Do you need to chat with someone?” I’ll usually say, “I’m available to chat if you need to” and then I’ll present someone else because it feels to me very impersonal to meet with someone and say, “Hey, it looks like you’re strug
gling, you seem really down lately. Why don’t you go chat with this other person that you don’t even know?” I’ll ofer myself frst and then give their name (SS 13).
Classroom teachers acknowledged their lack of train ing in mental health and the provision of mental health services. They also revealed that counselling students with signifcant mental health problems was outside their scope of practice. However, classroom teachers stated they felt comfortable providing students an opportunity to connect with resources within the school and would encourage
students to take the time needed to meet with guidance counsellors and/or mental health providers:
We have a (specialized mental health room) so a lot of teachers notice a kid is just having a crappy day they might ask him if he wants to access the (special ized mental health room) they might come out for a period of time and there’s caring adults in there as well (SS 29).
Another participant stated: “I have directed them to the guidance department… or taken to the guidance are[a]… You know, walked with them to make sure that they got there safely and left them in the capable hands of our pro fessionals (SS 6)”. Other times educators reported locating acute care specialized services for students in crisis. While most classroom teachers did not believe they should be actively involved in mental health interventions, many felt it was their role to identify resources, support the referrals, and connect students to needed mental health services.
Classroom teachers described the limits to the support they can provide and perceived their most important task to be connecting students to the proper resources: “I am also confdent that I am aware where my knowledge and my competence ends... I would ensure that they get to the, to the right places and where they need to be (SS 43)”. The counselling staf felt more comfortable in dealing directly with students with mental health concerns, but they also noted that their role was an intermediary one, working closely with other colleagues and connecting students to appropriate services:
I think we work pretty closely with student services and the psychologist to develop pretty efcient sys tems to perhaps even triage and find kids where they’re at and how to align them with what feel are the appropriate services whether they are internal or external (SS 30).
School staf acknowledged that a pivotal task in sup porting their students was to encourage seeking support, providing resources, and connecting and navigating stu dents to individuals or organizations that can provide direct counselling for mental health issues and concerns. When outside of their scope of practice, teachers noted that they worked with students to navigate the mental health system to identify needed professional support for mental health disorders.
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Theme 4: Facilitators and barriers
to addressing student mental health concerns
School staf identifed a number of factors that contribute to their assistance of students dealing with mental health con cerns. Conversely, they also raised concerns about various considerations that negatively impact their ability to support students. In order to examine these elements, the two dis tinct aspects have been delineated in Table 2. Presenting the information in a table helps to better highlight the diferent facilitators and barriers that school staf face when attempt ing to support students.
Discussion
The purpose of this study was to explore the perspectives of school staff in supporting student mental health and addressing stigma. Using qualitative methods, we conducted semi-structured interviews to capture the perspectives of school staf at two secondary schools in a mid-sized city in southern Alberta, Canada regarding their roles in assisting students with their mental health concerns. Building upon past fndings, this study prioritized bolstering the current understanding of the perception of school staf regarding
their influence on student mental health outcomes and investigating the practical ways they carry out support. A strength of this study compared to most previous qualitative studies focused on the perspectives of school personnel is the large sample (n=48) and diversity of participants with regards to professional role, including school administra
tors, classroom teachers, psychologists and guidance coun sellors. Youth spend a large amount of time in school and by extension have regular contact with school staf. Eliciting the perspective of these individuals is therefore critical to better understand how youth can be supported with their mental well-being in a school environment. Overall, school staf suggest that they can curtail stigma and facilitate dis closures of mental health by establishing strong relationships with students, other school staf, and those external to the school (including parents/caregivers). Through intentional and empathetic communication, school staf can facilitate referrals to mental health programs and assist with connec
tions to counsellors who can support students in a crisis. The frst theme from our study was the importance of establishing and maintaining strong relationships. Support ive relationships with students were seen to decrease isola tion, which in turn facilitates safety in exploring and seeking mental health support and services. In this study, school staf noted that strong relationships with students help ensure that students receive necessary supports specifc to their indi vidual needs. Supportive relationships between students and
Table 2 Facilitators and barriers to addressing student mental health concerns Facilitators Barriers
1. Administrative support is a signifcant enabler to school staf build ing strong relationships with students and other key stakeholders: “The school administration plays a big role in, um, what sorts of supports are provided and then even, like, supported in the school culture (SS 5)
2. School culture is key to creating an anti-stigma environment 3. Specifc on campus resources help including multiple trained psychological support staf on campus, as well as dedicated mental health spaces for the students:
“we have psychologists on our staf so we do, so we can do some indi vidualized therapy…there’s a number of diferent services that we have been able to provide over the years for kids that are experienc ing some mental health can experience some support (SS 12)”.
1. Classroom teachers note a lack of training and knowledge in mental health and the availability of resources to support students. Coun selling staf acknowledge that teachers often feel ill prepared and overwhelmed when students face mental health concerns:
“it’s very frustrating when I don’t have the expertise or knowledge to respond appropriately and don’t know what to do or how to help (SS 14).”
“I would say you know, your regular classroom teachers probably feel, um, underprepared…it’s not an area where there’s a lot of focus in teacher training (SS 5)”.
2. Large class sizes “class sizes are a huge barrier for teachers being able to connect and understand kids’ mental health and it’s even a barrier to referring kids (SS 29)”.
3. Limited time to devote to helping students with mental health issues: “I really don’t think they see it because they’re so busy because they don’t have time so maybe …classroom is 35 to 40 students, I don’t know how they could... I’ve seen in a class a kid cutting in class and the teacher hasn’t seen it (SS 39)
Working outside of their scope of practice: “There are educators being required to do stuf that is not what they were trained to do (SS 8)”. 4. Classroom teachers have few professional development days in mental health:
“very rarely do they feel like they have enough confdence or that growth mindset of oh well I’m pretty solid in chemistry and science so I’m going to do a PD (Professional Development) on mental health, like that doesn’t happen, so it happens… piecemeal (SS 40)”.
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staf have been found to increase the likelihood that students will disclose mental health concerns (Breeman et al., 2015; Mihalas et al., 2008). Leggio and Terras (2019) note that teachers take time to establish trusting relationships with students and search for opportunities to converse daily in a non-threatening way to foster safety. Further, Kidger et al. (2012) noted that support from teachers has a correlation to positive student mental health, a fnding that is echoed by a recent study by Wong et al. (2021). In the current study, the majority of school staf agreed that cultivating and maintaining positive relationships with their students were critical in supporting students struggling with mental health concerns. Consistent with the perceptions of school staf in this study, research suggests that teacher receptive ness in listening to students expresses their mental health concerns, and their responsiveness to these concerns helps mitigate barriers to help seeking (Halladay et al., 2020). The importance of strong student–teacher relationships in creating a safe environment for students has been identifed in other studies including literature reviews, meta-analyses (Durlack et al., 2011; Kidger et al., 2012; Mihalas et al., 2008), and qualitative studies (Leggio & Terras, 2019; Maz zar & Rickwood, 2015). Furthermore, quantitative surveys (Halladay et al., 2020; LaRusso et al., 2008; Mariu et al., 2012) have shown that a positive, supportive relationship with teachers increases students’ help-seeking behaviours for mental health issues. The fndings in this study further emphasize the ways that educators identify risk factors for their students, with many school staf noting that because they had strong relationships with their students, they were able to more easily identify when students were exhibiting signs of mental health concerns. This study also provides insight on how the development of these relationships can be better supported through open and empathetic communica tion with students.
School staf in this study emphasized the importance of working collaboratively with other disciplines and impor tantly emphasized open and effective communication between teachers, and counselling staf can serve to facili tate timely help, including appropriate referrals for vulner able students. Mazzar and Rickwood (2015) reported that involving other school staf when a student is struggling leads to improved access to services. Berzin et al. (2011) specifically looked at the relationship between school social workers and classroom teachers, fnding that close collaborations across these two disciplines enhance access to student mental health services for those in need. Such collaboration could be particularly efective as there is evi dence that the type of information collected by teachers and schools is valuable but diferent from information contained in screening measures and assessments typically adminis tered by mental health professionals. For example, a recent qualitative study of 29 middle and high school teacher from
across the USA asked teachers to describe what they felt were important mental health indicators in their students and then compared the indicators that emerged with those that are typically measured by standardized screening scales. They found that teachers relied on academic indicators (e.g. grades), changes in behaviour over time, and “intuition” as opposed to standardized measures that tend to focus on the presence or absence of specifc symptoms (Green et al., 2017). Our fndings are also consistent with a recent qualita tive study of Australian teachers and counsellors in which one of the main themes to emerge was “Collaboration”. In this study, participants emphasized the importance of col
laboration between schools and a network including external mental health agencies, families, and the broader community (Beames et al., 2020).
In this study, school staf also emphasized the importance of collaborating with parents and caregivers when a young person is dealing with a mental health concern. Two recent studies (Beames et al., 2020; Mellin et al., 2017) similarly noted that one aspect of the teachers’ roles was to liaise with families to make them aware of emerging mental health problems in their children and the availability of needed resources, with open and honest communication being par ticularly important. However, more research is needed on the role of teacher–family relationships in supporting students with mental health concerns, reducing stigma (Atkins et al., 2015) and improving access to care. Exploring these rela
tionships in future research could lead to better coordination of support between school and home and better comprehen sive knowledge of a child or youth’s specifc needs.
Our second theme captured the signifcance of commu nication and empathy of school staf towards students, espe cially those concerned about stigma related to mental ill ness. Previous literature (Bowers et al., 2013) indicated that
stigma was recognized by students as the largest barrier for seeking mental health supports in school, which highlights the importance noted in our study of educators communicat ing empathetically with students to facilitate safety for them to disclose mental health concerns. This further aligns with other research demonstrating that teachers use empathetic communication to establish connections with students (Leg gio & Terras, 2019). Our third theme identifed the impor tant role that school staf undertake facilitating, connecting, and navigating students to mental health resources internal and external to the educational system. School staf in this study expressed confdence in identifying youth at risk and with their ability to help connect these students to resources, including other school staf better equipped to directly assist with student mental health issues. As noted in previous research, teachers are optimally positioned to facilitate stu dent referrals to necessary services in a timely manner (Maz zar & Rickwood, 2015; Phillippo & Kelly, 2014). Teach ers can also liaise with partners (internal school resources,
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families, or community associations) to promote youth mental health (Mellin et al., 2017). Mazzar and Rickwood (2015) found similar themes, especially the importance of educators connecting students to mental health resources when required. As noted above, educators often act as pri
mary role models for their students (Kidger et al., 2010) and hence are able to model behaviours (Mihalas et al., 2008) to the student body that promotes help seeking.
Finally, we identifed critical factors in the school envi ronment that help or hinder educators in supporting their students with their mental health. These factors included the school's social climate, knowledge of mental health, appropriate resources, and the capability of meeting the needs of large classes. These fndings are broadly consist ent with previous studies, which have found that the culture of the school and attitudes of administrators can afect the ability of educators to support students with mental health issues (Brière et al., 2013; Froese-Germain & Riel, 2012; Kidger et al., 2010; Mellin et al., 2017; Mihalas et al., 2008). Kidger et al. (2010) observed that a school’s culture to sup port, or not support, students dealing with mental health crises is established via the actions of school administrators. They noted that when a culture of support is established, this contributes to teachers feeling better prepared to deal with student crises. This research concurs with results from the current study showing that school culture and support ive school administrators were paramount in determining whether an individual educator would feel more comfortable in assisting students in distress. Both of these fndings are a strong foundation for future recommendations of mandatory administrative mental health training.
Many studies note that educators face signifcant chal lenges in their ability to support students. In previous studies (Mazzer & Rickwood, 2015; Mihalas et al., 2008; Moon et al., 2017; Reinke et al., 2011), educators note that lack of knowledge about mental health concerns is one of the most signifcant barriers classroom teachers face within the school environment, which concurs with the responses from school staf that we interviewed. Mazzer and Rickwood (2015) found that although educators hoped to support stu dents, there were extensive and often unrealistic expecta tions hindering educators from adequately fulflling this role. While educators expressed concern for their students’ men tal health (Reinke et al., 2011), educators felt unprepared and lacked comprehensive training to adequately respond (Reinke et al., 2011; Carr et al., 2017). Many of the school staf participating in our study were concerned with their lack of mental health knowledge and inadequate training of classroom teachers to address student distress, consistent with previous fndings (e.g. Kidger et al., 2010; Carr et al., 2017; Reinke et al., 2011). Further, a lack of resources and available time were important concerns for the classroom teachers we interviewed, who lamented struggling with
multiple competing priorities within the school. Many of the classroom teachers also indicated that large class sizes posed a formidable barrier to establishing meaningful relationships with students, identifying students at risk and intervening in a timely manner to support those struggling with mental health issues. These fndings identify clear structural barriers in the school system that limit educators in their role to sup
port students with mental health challenges. Future research that builds upon these structural limitations and investigates how systematic changes may be implemented could make a long-term impact on these concerns.
Limitations
Our study had a number of limitations. First, participants self-selected; therefore, the school staf who chose to par ticipate in the study may have been more likely to be aware of and willing to speak about student mental health issues compared to those who did not participate. Second, the par ticipants were only recruited from two high schools from a mid-sized city in Alberta and the fndings may not be gen eralizable to other contexts (e.g. rural areas and large urban cities). The two participating schools serve a diverse popula tion, including a large Indigenous population and newcom ers to Canada; however, given the small sample size, we cannot determine the degree to which our fndings would be relevant to particular sub-populations which may have specifc mental health needs. Third, although we took exten sive precautions to protect their identity, participants may nonetheless have been reluctant to express a range of con cerns about their schools for fear of being identifed. Future research is needed to identify how students perceive the role of important adults including teachers, guidance counsel lors, and principals in promoting mental health, combating stigma, and facilitating help seeking in those afected by mental health disorders.
Implications for Practice, Professional Learning, and Research
There are several implications for practice. First, school staf need professional development related to mental health in schools. There are several relevant areas for professional development, such as supporting positive mental health, identifying potential signs of mental health disorders, strat
egies for referring students for more intensive supports, and identifying ancillary pathways to support rapid access to services. For example, academic success is related to better mental health (Clark & Teravainen-Grof, 2018; Goldston et al., 2007), suggesting a bidirectional relationship in which improved mental health leads to academic success, and academic success also enhances mental health. Posi
tive school climate is a facilitator for positive mental health
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outcomes, as highlighted by the school staf in this study. A positive school climate facilitates mental health through promoting open discussions and reducing stigma (Townsend et al., 2017). Additionally, students reported feeling safer at school when they felt school staf cared about them and were invested in creating positive teacher–student relation
ships (Manvell, 2012). Academic engagement is related to student mental health, especially when teachers support stu dents to engage behaviourally, emotionally, and intellectu ally (Klem & Connell, 2004; Reschly & Christenson, 2012). Consequently, professional development providing school staf with training and supports in developing programming to improve their mental health literacy, support academic success, positive school climate, and academic engagement
will support student mental health (Whitley et al., 2012). Second, while not a main theme, several school staf referred to their own mental health challenges in this study highlighting the importance of also supporting the mental health of school staf to in turn enable them to support stu dent mental health. The mental health of school staf, in general, and teacher mental health specifcally, contributes to improved student outcomes (Briner & Dewberry, 2007). The mental health of school staf is related to student–teacher relationships, which was noted to be important in supporting student mental health and help-seeking behaviours, while poor school staf mental health is related to burn out, leav ing the profession, and poor teaching practices (Bowles & Arnup, 2016). As a result, investing in teacher mental health is an important component of supporting student mental health.
Finally, it is imperative that there are adequate mental health resources in schools. As noted, only 30% of youth in need access appropriate mental health services (Mariu et al., 2012; Rickwood et al., 2005; US Public Health Service, 2000) and 70–80% of those in receipt of mental health ser
vices access them via their school environments (Rones & Hoagwood, 2000). Consequently, it is imperative that school staf are equipped and supported to provide or facilitate timely access to appropriate supports to students in need, as well as to promote mental wellness to the student body.
Supplementary Information The online version contains supplemen tary material available at https://doi.org/10.1007/s12310-021-09475-1.
Funding This study is funded by Brain and Mental Health Strategic Research Fund, University of Calgary, and the Alberta Innovates Trans lational Health Chair in Child and Youth Mental Health.
Declarations
Conflict of interest The authors declare that they have no competing interests.
Availability of data and material Data are available from the corre sponding author on reasonable request.
Ethics approval Approval for this study was obtained from the Uni versity of Calgary’s Conjoint Health Research Ethics Board (REB 16-1352).
Consent to participate Written informed consent was obtained from all participants prior to participation.
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International Journal of School & Educational Psychology
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/usep20
Addressing the mental health of school students: Perspectives of secondary school teachers and counselors
Joanne R. Beames , Lara Johnston , Bridianne O’Dea , Michelle Torok , Katherine Boydell , Helen Christensen & Aliza Werner-Seidler
To cite this article: Joanne R. Beames , Lara Johnston , Bridianne O’Dea , Michelle Torok , Katherine Boydell , Helen Christensen & Aliza Werner-Seidler (2020): Addressing the mental health of school students: Perspectives of secondary school teachers and counselors, International Journal of School & Educational Psychology, DOI: 10.1080/21683603.2020.1838367
To link to this article: https://doi.org/10.1080/21683603.2020.1838367
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INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
https://doi.org/10.1080/21683603.2020.1838367
Addressing the mental health of school students: Perspectives of secondary school teachers and counselors
Joanne R. Beames , Lara Johnston, Bridianne O’Dea , Michelle Torok, Katherine Boydell, Helen Christensen, and Aliza Werner-Seidler
Black Dog Institute, University of New South Wales, Sydney, Australia
ABSTRACT
The feasibility of addressing the mental health needs of young people at school is influenced by how staff perceive their role, and the role of schools, in mental health care. Using qualitative methodology, this study investigated the roles of Australian school teachers and counselors. The aims were two-fold: (i) to explore how teachers and counselors perceive the role of the school in student mental health; and (ii) to explore their views about what is being practically done in schools to provide this support. Ninety-one secondary school teachers and 83 counselors (Mage = 39.45) across New South Wales responded to open-ended questions between November 2017 and July 2018. Key themes included support, being on the frontline, collaboration, and education, although there were some discrepancies between staff. Further, counselors endorsed evidence based programs in schools that directly targeted student mental health. Results indicated that clear professional roles and a coordinated effort are needed to appropriately address student mental health.
KEYWORDS
Secondary schools;
counselor; teacher; student mental health; support
Mental health services are under-utilized by young people. Approximately 20% of young people experience mental disorders each year, but fewer than half receive professional treatment (Belfer, 2008; Waddell et al., 2002). Barriers to help-seeking include stigma, mental health literacy, con
cerns about privacy, geographical location, financial costs, and time (Gulliver et al., 2010; Salaheddin & Mason, 2016). Youth mental health services are overburdened and frag mented, further limiting access for young people seeking treatment (McGorry et al., 2013). Improving young peo ples’ access to care is important in prevention and early intervention efforts and will help to minimize mental health burden throughout the lifespan.
Student mental health in secondary schools
One way to overcome barriers to help-seeking and treat ment access is to provide mental healthcare in secondary schools. Secondary schools are those responsible for stu dents in grades 7–12 (typically ages 12–17 years), incor porating the terms middle school (grades 7–9) and senior or high school (grades 9–12). Secondary schools provide ready access to large numbers of youth, at the develop ment phase when mental illness first emerges (i.e., 14 years of age; Kessler et al., 2007; Masia-Warner et al., 2006). Australian schools, for example, have relatively
high attendance rates; 84.5% of young people who start Year 7 (11–12 years-of age) go on to complete their final year of school (Year 12; 17–18 years-of-age; Australian Bureau of Statistics [ABS], 2019). One factor contributing to this retention rate is that it is compulsory to attend school in Australia until at least 16 years-of-age.
Given the impact of mental illness on learning and behavior, schools are playing an increasing role in provid ing care for students’ social and emotional development (Farrington et al., 2012; Weare, 2015). The traditional role of classroom teachers has expanded to include augment ing mental health care from prevention to intervention (Weston et al., 2008). Teachers are required to teach young people about mental health, identify emerging psychological difficulties, and communicate these difficul ties to parents (Fazel et al., 2014). Education departments now employ trained mental health professionals including school counselors and psychologists to support student mental health. In Australia, psychologists who work in schools can have different titles, including educational psychologists, school psychologists, guidance officers or school counselors. The role of counselors and psycholo gists (hereafter referred to as counselors) in Australian schools are often equivalent and involve similar training. National surveys in Australia have shown that young people commonly receive help from mental health
CONTACT Joanne R. Beames j.beames@blackdog.org.au Black Dog Institute, University of New South Wales, Sydney, NSW, Australia This article has been republished with minor changes. These changes do not impact the academic content of the article. © 2020 International School Psychology Association
2 J. R. BEAMES ET AL.
professionals, including counselors, through their school (Hall et al., 2019; Lawrence et al., 2015). Mental health education can also be integrated into schools directly via the curriculum, thereby reducing barriers to access (Farrington et al., 2012; Weare, 2015). The suitability of secondary schools to educate and detect psychological changes in students, together with the availability of trained mental health professionals, means that they are ideally placed to support student mental health.
Large-scale universal prevention efforts are one way that schools can support the mental health of young people. Prevention of mental disorders has been recognized inter nationally as a public health priority (World Health Organization [WHO], 2004). Prevention science is also consistent with multi-tiered service delivery models (e.g., Weist et al., 2014) and whole-school approaches to mental health, such as Expanded School Mental Health Programs (ESMHP; Tashman et al., 2000). These approaches empha
size the importance of providing care across the continuum of mental health, as well as across child development more broadly. Economic cost analyses indicate that preventative efforts can reduce the direct (e.g., health care) and indirect (e.g., unemployment) costs associated with mental health problems (Arango et al., 2018). While the benefits are clear, school context factors (e.g., culture and leadership), staff support, and how staff see their own role can affect capacity for delivering preventive strategies. School counselors in secondary education often find themselves providing reac tive mental healthcare, with limited time for individualized therapies, ongoing treatments, or preventative actions (Australian Psychological Society [APS], 2013; O’Dea et al., 2017). Limited resources within schools and varied responsibilities (e.g., teaching and administration) can further hamper school counselors’ efforts to implement proactive and preventive initiatives (O’Dea et al., 2017; Thielking & Jimerson, 2012). Indeed, a recent report released by Mission Australia documented that few sec ondary schools have capacity to adopt a universal and preventative framework (Carlisle et al., 2018). Understanding how different staff members perceive the role of schools in student mental health, as well as their own role, will clarify how the school context can be capi talized upon to improve students’ mental health.
Perspectives about the roles of secondary schools (and staff) in student mental health
Roles of teachers and counselors
Across the United States, United Kingdom, Europe, and Australia, teachers and counselors generally agree that preserving student mental health is part of their profes sional role (e.g., Ekornes, 2017; Graham et al., 2011; Mazzer & Rickwood, 2015; Reinke et al., 2011; Shelemy
et al., 2019). In qualitative studies, for example, Australian and Norwegian secondary teachers report that it is their responsibility to identify students’ mental health concerns, provide an inclusive school context, and educate students about mental health (Ekornes, 2017; Mazzer & Rickwood, 2015). At the same time, teachers generally believe that counselors have a greater role in screening for mental health problems, conducting assessments, teaching social emotional les sons, delivering psychological treatment, and referring to other services (Mazzer & Rickwood, 2015; Reinke et al., 2011; Shelemy et al., 2019). Although these per
spectives map onto the multi-specialist roles that coun selors in Australia report performing (O’Dea et al., 2017; Thielking & Jimerson, 2012), they do not necessarily reflect counselor roles internationally. Counselors in the United States typically spend most of their time helping students with academic administration, despite wanting to focus on counseling, consultation, and curri culum activities (Mau et al., 2016; Scarborough & Culbreth, 2008). Different school policies and mental health frameworks likely drive how counselors spend their time in schools. Student care may differ across schools (and countries) depending on the priorities and remit of the counselor.
Despite acknowledging their role in student mental health, teachers raise concerns about caring for students’ mental health. Teachers have reported feeling afraid of exacerbating students’ mental health problems (Ekornes, 2017). A common finding is that teachers want more mental health training to increase their own literacy and competence (Frauenholtz et al., 2017; Koller et al., 2004; Mazzer & Rickwood, 2015; Reinke et al., 2011; Shelemy et al., 2019; Willis et al., 2019). There are many teacher training programs that focus on student mental health (e.g., Franklin et al., 2017); however, few studies have evaluated teacher outcomes such as mental health literacy (for a related review, see Anderson et al., 2019). Teachers also view consultation between teachers and counselors as important to facilitate appropriate referrals (Cholewa et al., 2018; Thielking & Jimerson, 2012). An implication is that counselors have the responsibility of identifying when an issue is beyond the teachers’ level of expertise. Having a clear under standing of their respective roles helps teachers and counselors respond to the needs of students effectively, with communication being critical to minimize the risk that students are overlooked.
Role ambiguity and conflict
Role ambiguity and role conflict affect how teachers and counselors provide mental health support to students.
INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY 3
Role ambiguity occurs when not enough information is provided about the expectations of a job (Kahn et al., 1964). Role conflict occurs when two or more job demands arise simultaneously and complying with one makes it difficult to comply with the other (Kahn et al., 1964). School counselors often face role ambiguity about what they should be doing for students, which can reduce job satisfaction and increase role conflict (Cervoni & DeLucia-Waack, 2011). Being a multi specialist can create uncertainty about what services to provide or how to provide enough services with limited resources (Cervoni & DeLucia-Waack, 2011; Havlik et al., 2018).
Another source of role ambiguity comes from the increasing responsibilities of teachers in student mental health. There is some overlap where school-based men tal health professionals, such as counselors, and teachers’ work can intersect. Uncertainty about respective roles and best practices can result, impacting the ability of schools to implement a comprehensive support system for students (Ball et al., 2010). Phillippo and Kelly described the confusion among teachers about where their responsibilities began and ended as a “fault line” (Phillippo & Kelly, 2014, p. 185). Overlapping responsi
bilities are acknowledged within the ESMH model, which highlights the importance of a shared agenda and collaboration between different stakeholders in stu dent development (Weist & Murray, 2008). Although models such as ESMH guide how different professionals within and outside of education can support student mental health, the extent to which this is seamlessly integrated into practice is limited.
Summary
The available research has predominantly examined tea chers’ perspectives about their own role, or the role of counselors, in student mental health. Few studies have directly examined how counselors perceive their role, tending to focus on what they actually do in schools (e.g., O’Dea et al., 2017). Further, little differentiation has been made between the perceived or ideal roles of teachers and counselors and what they practically do to support student mental health. Finally, most research has examined perspectives of teachers or counselors across different education levels (i.e., primary and sec
ondary schools). Examining perspectives exclusively from secondary school staff is important because per ceptions and job activities vary by education level (e.g., Dahir et al., 2010). In sum, additional research is neces sary to distinguish what secondary staff think schools should be doing to support student mental health and compare this with current efforts. This would highlight
where the discrepancies are and provide the foundations for improvements in how secondary schools manage the mental health of their students.
The current study
We use a qualitative approach to understand the role of Australian secondary schools in student mental health from the perspectives of both teachers and school coun selors. A qualitative approach allows richly textured descriptions and in-depth understandings of individual roles within the school context. The aim of this study is twofold: (i) to explore differences and similarities in how secondary school teachers and counselors perceive the role of the school in student mental health (i.e., per
ceived roles); and (ii) to investigate differences and similarities in teachers and counselors views about what schools are practically doing to support student mental health (i.e., actual delivery of mental health stra
tegies). We specifically asked about digital mental health options here, given their capacity to minimize burden on school staff (standardized delivery), capacity to reach more students at one time, and effectiveness for range of mild-to-moderate problems (prevention). The latter aim will help to identify the types of strategies that different staff members implement or are aware of in the school context (i.e., expertise) and allow comment on the appropriateness of those strategies.
Based on previous research, we broadly hypothesized that both teachers and counselors will support the role of schools in student mental health (e.g., Graham et al., 2011; Thielking & Jimerson, 2012; Willis et al., 2019). Given that the direct delivery of metal health programs, preventative or interventive, is largely the remit of school counselors, we anticipate that they will demon strate expertise regarding specific evidence-based pro
grams that are indicated for young people. Results from this study will identify specific role based needs that are not currently being addressed within schools. These needs could, in turn, guide tai lored professional development and training opportu nities for different staff members, as well as shift how schools are responding to student mental health more broadly. Our focus on the Australian context offers an opportunity for developing a nuanced understanding about the roles of teachers and counselors in student mental health. Very little research about school staff perspectives has been conducted within Australian schools compared to other countries such as the United States, United Kingdom, and Canada. Although there are similarities across these countries in terms of staff experiences (e.g., high workload, burnout, role ambiguity) and student mental health (e.g., high
4 J. R. BEAMES ET AL.
prevalence of mental health disorders), there are some structural differences that warrant special attention. For example, there are differences in wellbeing roles and capabilities, the transition periods between school years, and academic testing systems. Exploring Australian perspectives will replicate and extend existing knowledge in this area, providing valuable insights about school-based approaches to student mental health that are relevant in an international landscape.
Method
Design, participants, and recruitment
This qualitative study involved online surveys of Australian secondary school staff from New South Wales including teachers and school counselors. School principals’ were also included in recruitment and data collection, however, their responses are not included in this analysis because of their limited rele
vance to the research questions and aims. Relevant data will be reported elsewhere. Ethical approval was received from the University of New South Wales Human Research Ethics Committee (HC17468) and the State Education Research Applications Process (SERAP2017339). Convenience and snowball sampling methods were used for recruitment, which involved flyers and e-mails to the research team’s network of individuals and associations working with or in schools throughout New South Wales. Flyers were also posted on the Black Dog Institute’s online channels (e.g., Twitter, Facebook, and website). Eligible participants were encouraged to share the study within their net works. Eligible participants were employed in an Australian secondary school as a teacher (including gen eral classroom teachers and Year Advisors) or a school counselor or school psychologist. Surveys were com
pleted between November 2017 and July 2018, with recruitment e-mails and online promotion of the study taking place at key times (e.g., beginning of school terms) within this period. Participants were able to pro
vide an e-mail address if they wished to be reimbursed with a $20AUD electronic giftcard.
Participant demographics
A total of 97 teachers (75.3% female) and 93 counselors (89.2% female) responded to the open-ended questions. Teachers were on average 38.3 years old and had been in their role for 9.8 years. School counselors had a mean age of 39.45 years, with 6.9 years’ experience in their role. Most teachers (88.5%) taught in government schools, with 68.1% of counselors also in government
schools. Teachers and counselors were more likely to be employed in coeducational schools (94.8% and 82.4%, respectively), and more counselors than teachers were employed in schools located in a capital city (61.5% and 24.0%, respectively). Of these respondents, 91 teachers and 83 counselors provided data relevant to this study.
Measures and procedure
Surveys included demographic details, current and pre vious employment information, and current school pro file using both quantitative and qualitative questions. Quantitative outcomes are peripheral to the aims of the study described in this paper. We report the data elsewhere. Qualitative outcomes primary to the aims of the study were prompted using specific, open-ended questions, including: (i) What do you think is the role of the school in protecting the mental health of students? (teachers only); (ii) What do you think is the role of school counselors and or school psychologists in pro tecting the mental health of students? (counselors only); (iii) What programs or strategies does your school cur rently have to manage the mental health of students? (both); and (iv) Have you ever used or recommended online programs to your students? Which ones? (coun selors only). Questions (i) and (ii) assessed perceived roles of schools and staff in general. Questions (iii) and (iv) assessed the prevalence of mental health strategies in the context of respondents’ own schools. Participants were asked to type their response to the questions pre sented to them in as much detail as they desired, and as honestly as possible.
The surveys were administered via an online survey platform (Qualtrics, 2017). Interested participants clicked the online link to the survey that matched their role and provided informed consent. All questions required a response in order to progress to the next page. Surveys took approximately 30–45 minutes to complete.
Analysis
Research rigor
Rigor in thematic and content analysis was addressed by being attentive to research practices through reflection and embedding the data and interpretation within the school context (Given, 2008). Procedural rigor was addressed by corroborating findings through team dis
cussions, using multiple coders, an audit trail of codes and decision making, and ongoing engagement with the text data (Given, 2008).
Thematic analysis
INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY 5appropriate because we wanted to represent manifest
Qualitative data were primarily analyzed using Clarke and Braun (2013) six-stage seminal thematic analysis guidelines. Data from questions (i) and (ii) were ana lyzed using this approach. Thematic analysis allows for the identification, interpretation, and reporting of repeated patterns of meaning within data (Tuckett, 2005). This method is appropriate for the current data due to its flexibility (Aronson, 1995), rigor (Fereday & Muir-Cochrane, 2006), and capacity to incorporate the reflexive role of the researcher in interpretation (Mays & Pope, 2000). Given our research aims and the novelty of using qualitative analysis to compare teacher and coun
selor perspectives on the mental health programs and strategies used in schools, we used an inductive approach to developing a coding framework (Bengtsson, 2016; Erlingsson & Brysiewicz, 2017).
Analysis involved an iterative process of reading and coding responses to extract overarching themes and interpretations. Coding was conducted by two primary coders (JRB and AWS) using Excel. The coders inde
pendently reviewed and coded a subset of responses to generate a preliminary coding framework. Discrepant codes were resolved via discussion. Both coders then independently reapplied the revised framework to the initial responses and coded the remaining responses. Codes were compared again, and discrepancies were resolved to create code descriptions that could be applied consistency to the text. Final inter-coder relia bility between coders was high (Cohen’s Kappa = 1). We also calculated percent agreement to account for missing data within the codes. Percent agreement was 97% for codes and 86.2% for sub-codes. Another round of comparison between the coders was used to further refine the codes and generate higher-order explanatory themes. A senior qualitative analyst then reviewed the thematic groupings (KB). Themes and sub-themes were refined through discussion during the iterative coding process until they were internally coherent, consistent, and distinctive. The consolidated criteria for reporting qualitative research checklist was used to guide study design and reporting (see Appendix 1; Tong et al., 2007).
Content analysis
Conventional qualitative content analysis was used to analyze a smaller subset of the data (Hsieh & Shannon, 2005; Neuendorf, 2016), questions (iii) and (iv). This approach enables categories to be derived systematically and directly from text data without interpretation (Hsieh & Shannon, 2005). A content approach was
(or literal) content recorded by respondents numeri cally. Our approach to the analysis followed established coding techniques: (1) data immersion, (2) data reduc tion (i.e., systematic coding and generation of codes, categories, and themes), and (3) data interpretation (Bengtsson, 2016; Erlingsson & Brysiewicz, 2017). Two coders (JRB and AWS) read and re-read responses and independently generated first-stage codes and categories detected in the text. Coding was compared for conver gence and discrepancies were resolved through discus sion. The codes and categories were then applied to the remaining responses in an iterative fashion, which formed the basis of the quantitative analysis (i.e., fre quency of counts or proportions). Percent agreement following discussion was 100%.
Thematic analysis results
The thematic analysis generated four distinct themes regarding teachers’ and counselors’ perceived role of the school in student mental health. The themes included: (1) Support; (2) Being on the frontline; (3) Collaboration; and (4) Education. Themes were further categorized into sub-themes. All themes are listed in Table 1, with sub
themes and illustrative quotes listed for each.
Theme 1: support
This theme refers to the different ways that schools can provide support to protect and improve the mental health of their students. Three sub-themes were identified:
Providing a holistic model of care
This sub-theme refers to prioritizing both the academic and emotional needs of students. Eight teachers and one counselor reported that the role of the school was to support emotional and academic outcomes. One teacher raised the possibility of integrating mental health content into the school curriculum, noting that it should be “part of students education just like reading or writing”.
Providing safety and protection
This sub-theme highlights the prioritization of safe guarding the welfare and wellbeing of young people in the school environment. Teachers reported that the role of the school was to protect students, support high-risk students with more severe mental health problems and who need immediate attention (e.g., suicidality), mini mize danger and distraction to others, and provide a safe environment for all students.
6 J. R. BEAMES ET AL.
Table 1. Sub-themes, and illustrative quotes for each theme that was identified in the thematic analysis. Theme Sub-Theme Examples
Support
Holistic model of care “I believe we play a role in maintaining a calm and mindful environment . . . ” “To ensure that they can be comfortable in themselves enabling them to perform to their best . . . ”
“We need to support students in all aspects of health and wellbeing.”
Safety and protection “Provide support networks and a safe environment for all students.”
“I think it is the role of the school to protect the mental health of students.”
Student advocacy “Being their champion.”
“Advocate for students and their wellbeing in the school.”
“Being advocates for students and increasing their opportunities to
access support at school and in the community.”
Being on the frontline
Identification and assessment of mental health problems
“Screening and assessing for mental health issues.”
“Identifying sub-clinical and clinical disorders that have not been addressed by family or in the community.” “We work at the coalface, seeing the students daily . . . teachers can identify changes in behavior in their students early on and have a responsibility to deal with such matters if they arise.”
Prevention of mental health problems “I think it’s important for schools to have a prevention model of mental health promotion. Preventing issues from occurring is just as important as supporting students who are experiencing mental health.”
“Promotion of proactive strategies to decrease risk of mental health.”
“The school counselor role is mostly reactive. As much as I would love to facilitate something preventative
I would not have enough time in any of the schools I work in to do that and effectively address the
students with current mental health issues. I think that preventative programs for mental health are
a brilliant idea but I don’t think school counselors in schools would have the time available to be the
facilitators.”
Delivery of interventions “Delivering preventative and early intervention programmes such as YMHFA [Youth Mental Health First Aid], Friends, SKIPS [Supporting Kids in Primary Schools], Mind UP with staff support and input.”
“We use appropriate evidenced based interventions to improve wellbeing and address their mental health.”
“ . . . early intervention/Prevention Model around mental health risk factors . . . counseling and therapy of
students”
Referral “I would compare school counselors to the [National Roads and Maritime Assistance] breakdown service – we intervene and assist students to get ‘back on the road’ but when [mental health] problems are chronic
we need to refer students to external supports. The sheer volume of referrals made to the school
counselor on a daily basis does not allow us to intensively support individual students.”
“ . . . a clear referral path to external clinicians. In school, providing low level psychological support and
liaising with external clinicians when there are more complex presentations to support the students
when they are at school.”
“We are often the entry point into other services.”
“There are restraints to the role, however. For example, calling students out of class can be problematic.
There can be difficulties between what the counselor would like the school to do for a student, compared
to what a teacher might want, due to a difference in focus. Not being available over school holidays can
be concerning.”
“ . . . more serious issues are the domain of the professional counselors/social workers, not the educators.”
Collaboration
“Having a close collaboration with parents and speaking honestly to them about if there are any issues that
may be informing the students’ presentation at school is also very important.”
“Facilitator – often families don’t know where to go, how to start, what to do. Sometimes parents need help
to recognize the heath of their child.”
“Contacting parents to inform them how to access external psychological support.”
“ . . . increasing [students’] opportunities to access support at school and in the community.”
Education
Mental health literacy “Providing psychoeducation to students, parents and staff to support mental health issues at school.” “Educating students about how to care for their own mental heath [sic] and how to support (rather than
undermine) the mental health of their peers and families.”
“Students need to feel safe at school and to understand that mental health issues are as common as having
a cold and that it is okay to have a mental health issue – it shouldn’t be stigmatized.”
Help-seeking “Knowing where to get help.”
“ . . . it is imperative that students are aware of the support in the community.”
Supporting students through advocacy
This sub-theme refers to supporting student’s mental health by advocating on their behalf. Counselors, but not teachers, emphasized the importance of “being advocates” or “champions” for student mental health within the school environment. In practical terms, this meant increasing their opportunities to access
supports such as obtaining funding or special provisions.
Theme 2: being on the frontline
This theme highlights that teachers and counselors feel they are on the frontline and are often the first point of
INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY 7
contact and entry point into mental health services for students. Four sub-themes were identified:
Identification and assessment of mental health problems
This refers to the initial assessment and identification of mental health problems in students. A recurring theme throughout all responses was the capacity of teachers and counselors to identify even small changes in student behavior early. Counselors provided additional informa
tion about the identification of mental health problems relative to teachers, indicating that their role included assessments and screening (e.g., risk of harm to self and suicidality).
Prevention of mental health problems
There was a consensus among staff that prevention was just as important as treatment and that schools needed to incorporate preventative approaches. Despite the per ceived importance, practical constraints reduced the feasibility of implementing preventative mental health strategies. Many counselors explicitly described their role as primarily reactive rather than proactive, with a focus on responding to the needs of high-risk students as they occurred.
Delivery of interventions
Delivery refers to the interventions or programs that schools provide directly to students, which are focused on developing skills and strategies to manage mental health problems. Both teachers and counselors empha
sized that schools were responsible for “equipping”, “giving strategies”, and “showing students ways” to manage anxiety, depression, and anger. Counselors also referred to working one-on-one with students to provide “individual counseling/support”.
Referral
Referral to appropriate mental health professionals, pro grams, and services was a major sub-theme that was evident from being on the frontline. Two clear referral pathways were identified: (i) the first being communica tion between teachers and counselors, leading to referral from the classroom to the counselor, and (ii) the second being a triage system whereby counselors refer to exter nal mental health professionals and services within the community. Teachers and counselors endorsed both referral pathways, and school counselors emphasized that external referrals were an important and necessary part of their role. Both teachers and counselors empha sized the importance of external referrals because schools had limited capacity to be the sole support or provider of mental health assistance for students.
Limited resources, such as time and availability, were identified as inhibiting teachers and counselors from providing an appropriate level of care to students. Counselors also emphasized the duration of care pro
vided, noting that schools were typically equipped to provide only short-term support (although the length of this short-term support was not specified).
Theme 3: collaboration
Teachers and counselors emphasized that schools were part of a larger network that involved collaborating with various groups to support the mental health of students. Examples included external mental health organizations and services, families, and the broader community. Key ideas for improving collaboration included increased communication about the mental health of the young person, services and programs being utilized by the young person, and additional supports available to help the young person. Teachers and counselors empha sized the importance of being able to speak openly and honestly with parents about their child’s mental health, particularly in the context of emerging problems. Only one counselor commented on the role of community, suggesting that relationships with local mental health professionals or services was important to increase access to services.
Theme 4: education
Education was a major theme, which includes providing psychoeducation to students to increase their knowledge about mental health problems and available treatments and resources. Two sub-themes were identified:
Mental health literacy
Both teachers and counselors emphasized the importance of increasing student knowledge of the “signs and symp toms” of mental illness, factors that “contribute to or exacerbate mental ill health”, and ways to “care for their own [mental health], as well as others”. Counselors further noted the importance of educating other staff, family members, and students themselves. One teacher and one counselor also referred to providing education that nor
malizes mental health problems and targets stigma.
Help-seeking
Teachers and counselors consistently identified that it was the role of the school to educate students about “how to access help” and to provide information about the types of help available. Counselors also indicated the importance of empowering students to seek help and educating other staff about appropriate referral
8 J. R. BEAMES ET AL.
decisions and pathways both within and external to the school (e.g., when to refer a student to the counselor).
Content analysis results
Delivery of mental health strategies in schools
Questions pertaining to the approaches that teachers and school counselors used to address the mental health of students were categorized into three main groups: (1) Programs; (2) Services; and (3) School Initiatives. Programs were defined as standalone interventions that school staff could choose to implement on an indi
vidual or school-wide level. Programs included mental health programs (e.g., myCompass), non-mental health programs (e.g., Love Bites), government health promo tion initiatives or programs (e.g., MindMatters), apps (e.g., Smiling Mind), and nonspecific programs (e.g., anxiety or resilience programs). Services were defined as platforms, groups, or individuals that provided inte grated care or access to a range of support options. Services included mental health services (e.g., eHeadspace, Kids Helpline), non-mental health services (e.g., generalist community groups that might indirectly influence youth mental health), and medical profes sionals (e.g., GPs). School initiatives were defined as any strategy designed by staff for specific use within their school environment. School initiatives included tailored strategies or clubs (e.g., peer support, fitness clubs), adjusting the school environment (e.g., creating safe spaces), employing well-being staff with specialized roles (e.g., counselors, chaplains), and providing educa tion about mental health (e.g., curriculum requirements such as Personal Development, Health and Physical Education lessons). Responses had to refer to an approach at least once to be classified into one of the four main codes.
The proportion of responses identifying that schools used Programs to address and protect student mental health was greater for counselors than teachers (see Figure 1). A similar pattern of results was also found for Services, but the overall proportion for both groups was relatively low. The proportion of responses identify
ing School Initiatives was greater for teachers than counselors.
The most frequently reported Programs used in schools were mental health programs, although this was greater for counselors than teachers (see Figure 2). The frequency of counts was low for all other Programs.
Counselors more frequently reported referring out to mental health services, and less frequently reported School Initiatives, relative to teachers (see Figures 3 and 4, respectively).
We further sub-divided the mental health program code to identify specific programs that school counselors named (including apps). We only report school counse lor results given their area of expertise and knowledge about what mental health programs are used within their schools. The top three programs named by coun selors included the online BRAVE program, Smiling Mind app, and Moodgym (see Figure 5). These pro grams represented 60% of the data.
Discussion
This study examined how secondary school teachers and counselors in Australia perceived the role of schools in student mental health. To the best of our knowledge, no previous research has examined how Australian second
ary teachers and counselors view their own role, and the role of schools more generally, in caring for students’ mental health using qualitative methods. Understanding the perspectives of teachers and counselors in this way is important given they are typically responsible for the delivery and implementation of school-based mental health education and programs. Our thematic analysis revealed four broad themes, which convey that teachers and counselors perceive the role of schools in student mental health as multi-faceted, complex, and part of a larger system. These themes also suggest that schools often take a reactive rather than proactive and systema tic approach to mental health, with different approaches being adopted to suit immediate student needs and contextual limitations. Our results provide insight into what teachers and counselors think they should be doing to support student mental health, as well as how they should be supported by other key stakeholders.
Our results echo prior research indicating that school staff perceive that schools are responsible, at least in part, for student mental health (e.g., Ekornes, 2017; O’Reilly et al., 2018; Willis et al., 2019). This responsibility is captured within role theory of schools and adolescent health (Bonell et al., 2019), which proposes that schools innately shape the mental and physical development of young people (Bonell et al., 2019). Schools were perceived by both teachers and counselors as being responsible for providing support, identifying emerging problems, providing mental health interventions (i.e., treatment and prevention), conducting referrals, collaborating with other profes sionals and services about student mental health, and providing education. The extent to which teachers and counselors perceived these responsibilities as being specific to their individual roles differed in some respects, however. For example, in line with prior research findings, teachers emphasized that supporting
INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY 9
Figure 1. Proportion of approaches used within schools. Note. Bar graph depicting the proportion of approaches used within schools to protect the mental health of students as reported by teachers and counselors.
Figure 2. Specific type of programs used by schools to protect student mental health. Note. Bar graph depicting specific types of Programs used by schools to protect the mental health of students as reported by teachers and counselors (counts).
Figure 3. Specific types of services used by schools to protect student mental health. Note. Bar graph depicting specific types of Services used by schools to protect the mental health of students as reported by teachers and counselors (counts).
10 J. R. BEAMES ET AL.
Figure 4. Specific types of school initiatives used to protect student mental health. Note. Bar graph depicting specific types of School Initiatives used by schools to protect the mental health of students as reported by teachers and counselors (counts).
Figure 5. Top three mental health programs used in schools reported by counselors. Note. Bar graph depicting the top three mental health programs used in schools (counts) as reported by counselors.
students involved providing a holistic model of care (Willis et al., 2019) and ensuring safety and protection (Mazzer & Rickwood, 2015). Counselors, but not tea chers, emphasized that supporting students involved advocating for their mental health needs within the school. Teachers and counselors in our study sup ported student mental health in many different, yet complementary, ways. A practical implication is that support from teachers and counselors is necessary in ongoing efforts to use the school environment as a platform for addressing student mental health.
Key insights
In this next section, we identify points of tension within the responses provided by teachers and counselors.
Viewed through the lens of the themes and sub themes, we interpret these points as reflecting discre pancies between what teachers and counselors think they should be doing, and what they actually do in their school.
Role ambiguity
Role ambiguity is the extent to which expectations asso ciated with a role are clearly defined and understood (Kahn et al., 1964). In our sample, role ambiguity in relation to student mental health was evident through responses about referral and communication channels between different members of staff. Consistent with prior literature, knowing who, and when, to refer stu dents to counselors was a key area of uncertainty for teachers (Rothì et al., 2008; Shelemy et al., 2019). One
INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY 11
counselor reported that referring students to counseling services when it was not needed risked pathologizing behavior that was typical of adolescent development. The results from our study indicate that clear guidelines documenting what, when, and how teachers and coun
selors should respond to student’s mental health needs are necessary to provide appropriate duty of care.
Reactive versus proactive model of care
A key theme identified in responses was that both tea chers and counselors perceived schools as an ideal con text to provide proactive and preventative mental health initiatives for young people. Similar to prior findings, in our study, some counselors noted that although a school-wide focus on prevention was ideal, it was not often feasible given their other responsibilities (e.g., Thielking & Jimerson, 2012). One counselor described his or her role as providing individual level support only, while others specified the delivery of short-term reactive care that was supplemented by external referrals. Referrals were described as necessary to provide high risk or vulnerable students with appropriate mental health care. This was particularly evident with complex mental health presentations that required longer-term, more intensive treatment plans. Importantly, both tea chers and counselors reported that schools were not solely responsible for youth mental health (e.g., also see Danby & Hamilton, 2016). Reactive approaches and emphasis on external referrals reflect practical con straints within schools including limited time and com peting demands. These constraints likely stem from inadequate integration of mental health prevention pro grams into the standard school curriculum and lack of
a “whole-of-school” approach to mental health. Our results suggest that school counselors identify as mental health experts responsible for delivering inter ventions to students, including prevention and early intervention. Collaboration and referral are necessary for counselors to perform these roles. Teachers mainly referred to providing general support, identifying pro blems, and referring on individual students. This finding fits with prior accounts that teachers see themselves as educators, rather than experts and purveyors of treat ment and prevention strategies (Mazzer & Rickwood, 2015; Willis et al., 2019). Despite this, teachers still need to have mental health literacy around their students’ needs to provide the type of support that they perceive as within their remit. Whereas counselors are typically trained and employed to provide mental health inter ventions in schools, this is not necessarily the case for teachers. Teachers want to increase their own literacy and competence (e.g., Frauenholtz et al., 2017), and
counselors in our study stated that some teachers might benefit from mental health literacy training. Additional mental health literacy training programs that build teachers’ capacity to understand, identify and appropriately respond to their students’ needs are therefore needed. Few studies have evaluated mental health literacy training programs for teachers, although one meta-analysis provides support for their efficacy (Anderson et al., 2019). An implication of our findings is that counselors should be supported within schools to become a critical component of preventative, or proac tive, action (Goodsell et al., 2017). Further, teachers are likely to need additional training to provide this support, particularly in building basic skills and knowledge about young people’s mental health.
The tension between reactive and proactive health care within schools has been documented in prior research and incorporated into models of care (e.g., Forness, 2003; Hoagwood & Johnson, 2003). These models of care are typically based on the public health model of delivery, which involves universal, selective, and indicated supports for the delivery of evidence based interventions (Merrell & Buchanan, 2006). Multi
tiered systems of support (MTSS) offer a population based approach to prevention (Weist et al., 2014) that involves the delivery of evidence-based services along a continuum (Jimerson et al., 2015). Different levels of care are provided depended upon individual need for more or less supports, which are identified through the structured assessment of risks and early warning signs. This model has previously been shown to be effective in supporting a school-wide model of behavior supports (see Sugai & Horner, 2002; Sugai & Horner, 2009) and academic interventions (Fletcher & Vaughn, 2009). The County Schools Mental Health Coalition in the United States has developed a more recent example for identify
ing, intervening, and referring students who are at risk for, or are exhibiting, mental health problems. Application of these frameworks into school contexts is practically challenging, however, due factors such as resource constraints and unclear service delivery roles (Albers et al., 2007).
Delivery of mental health programs
Counselors endorsed the use of mental health programs and services to a greater extent than other, non-mental health specific options. Relatedly, counselors, but not teachers, endorsed evidence-based programs designed to prevent and treat youth mental illness. The most frequently reported programs were the BRAVE program (http://www.brave-online.com/), Smiling Mind (https:// www.smilingmind.com.au/smiling-mind-app/), and Moodgym (https://www.moodgym.com.au/). BRAVE
12 J. R. BEAMES ET AL.
and Moodgym are internet-based programs based on cognitive-behavioral therapy. Several randomized con trol trials have supported the efficacy of these programs in preventing and decreasing symptoms of depression and anxiety in young people (for a review, see Calear & Christensen, 2010). Smiling Mind is a smartphone appli cation that teaches meditation and mindfulness practice. Despite the wealth of research supporting the efficacy of mindfulness as a psychological tool, the Smiling Mind app has not yet been evaluated as a standalone program with secondary school students. Overall, the types of programs that counselors endorse to support student mental health are promising. Our results demonstrate the expertise of many counselors in selecting appropri ate mental health programs for young people that are supported by research. To maximize the effectiveness of mental health care provided in schools, the selection and implementation of mental health programs should be guided by counselors.
Recommendations: future steps for school-based mental health
In this next section, we outline key implications and recommendations for Education practice and policy (see Table 2). As part of broader organizational changes, results from this study indicate that Education policy makers should clearly define the roles of school staff involved with the delivery of mental health promotion, prevention, and intervention. Reducing role ambiguity will increase accountability and knowledge about who has the expertise to provide different kinds of support and services, thereby reducing the number of young people being missed. Developing clear guidelines about who is responsible for what, and when that responsibility should be enacted, will streamline student mental health care in schools, as well as foster effective ways of collaborating.
Consistent with the MTSS framework, another way to streamline student mental health is to inte grate screening, prevention, treatment, and referral
Table 2. Key issues and recommendations for secondary educa tion practice and policy.
1. Develop guidelines that define the roles and scope of activity undertaken by secondary school staff involved in the mental health of students, including identification of role overlap (e.g., general support, observation, and early identification) and differentiation (e.g., counselors primarily responsible for the selection and delivery of universal prevention programs).
2. Integrate mental health prevention programs into the standard school curriculum, enabling a “whole-of-school” approach.
3. Establish clear referral pathways between staff members within secondary schools (e.g., outline when teachers refer individual students to counselors).
4. Integrate screening, treatment, and referral pathways within secondary schools.
pathways within schools (e.g., Arora et al., 2019). Digital approaches in mental health care are well suited for integration into a broader MTSS. For example, Smooth Sailing is an online universal screening service developed specifically for students and uses a stepped-care model that matches stu
dents to an appropriate level of care based on their symptom severity. An initial pilot in Australia found that Smooth Sailing is an effective mental health screening tool, identifying vulnerable students who may not have otherwise accessed care or reached out for help (O’Dea et al., 2019). Providing an online service as part of a sustained, regular assessment would enable schools to identify those in need early, and provide support either themselves or through referral, which ultimately may reduce the burden placed on teachers to identify those in need. This would also streamline how treatments could be delivered. For example, personalized online pro grams could be offered to those with mild-to
moderate symptoms, freeing up counselors to deal with the more severe cases. If the overall burden on counselors was reduced, this would provide addi tional time to incorporate preventive approaches as well.
For any mental health approach to integrate effectively into the existing work flow of schools, teachers and coun selors need to have the appropriate skills and capacity to provide support. The input of school principals is essen tial for this integration. School principals could play an active role in investing in mental health literacy training for teachers, providing resources and the impetus that enable them to attend (e.g., on-site delivery, time out of standard teaching schedule). Principals could also consult with teachers and counselors before deciding to adopt mental health programs or services for students, ensuring that those who will be responsible for providing day-to day support are willing and able to do so. Involving teachers and counselors in the decision to adopt is impor tant to identify whether implementation is feasible, who is best suited to provide support (and in what way), as well as increase ownership of that support.
Limitations and future research
The current study is limited in some respects. Participants were recruited via an online survey using convenience and snowball sampling methodology. An implication of approaching schools and staff with an established connection to the Black Dog Institute, or who had prior knowledge of the Institute, is that indivi
dual responses might be influenced by positive self presentation (although the survey was anonymous)
INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY 13
and selection biases. Further, those who responded were likely to already be engaged or interested in the mental health of students. It is also unclear whether we would generate similar findings using other data collection methods, such as focus groups or interviews, although it is notable that our findings align with the broader literature on the topic.
Given the role overlap between school counselors and psychologists in Australian schools, we grouped these professionals together. This approach may have obscured important differences between their activities and perspectives, limiting generalizability to other con
texts, such as the United States, where counselors and psychologists have a more differentiated role. Further, our approach did not account for other school staff (e.g., Year Advisors, chaplains, pastoral care staff) that pro
vide mental health support within Australian schools. Our rationale was that these workforces do not typically have the training and skills to effectively address student mental health in comparison to counselors and psychol
ogists. Further, the characteristics of schools (e.g., socio economic status, district, and location) included in our study might not be representative of the broader schools in Australia.
These limitations notwithstanding, our study contri butes to the broader literature on school-based mental health by identifying and comparing perspectives of staff members who are “on-the-ground”. The themes that we identified provide an important starting point to guide future studies and develop evidence-based practical recommendations for education policy.
Conclusion
Student mental health is high on the educational agenda for many countries, including Australia. Supporting the mental health of secondary school students requires cooperation between school personnel, families, and young people. Teachers and counselors are a core part of this system and, in this study, self-identified as impor
tant contributors to youth mental health. While some of the roles of secondary school teachers and counselors were generic, others were specific to the areas of exper tise and training of their profession. Clear understand ings about responsibilities within schools is imperative for teachers and counselors to be part of an effective support system for young people when their mental health deteriorates. Guided by our themes and the cur rent secondary schooling system in Australia, we have made several recommendations to inform decision making by policy makers and school administrators. Incorporating our recommendations into policy will
increase student access to appropriate, evidence-based services.
Author contributions
Aliza Werner-Seidler conceived of the study and secured fund ing. All authors contributed to the methodology, including the development of the survey measures. Lara Johnston collected the data, Joanne Beames conducted the data analysis and wrote the manuscript, with assistance from Aliza Werner-Seidler. All authors read, reviewed, refined, and approved the final manuscript.
Consent for publication
Not applicable.
Disclosure statement
The authors declare that they have no competing interests.
Ethics approval and consent to participate
This study has ethics approval from the University of New South Wales Human Research Ethics Committee (HC17468) and the State Education Research Applications Process (SERAP2017339). All participants provided active consent to participate.
Funding
The project was funded by an New South Wales Health Early Mid Career Fellowship awarded to Aliza Werner-Seidler. The funding body had no role in any aspect of the study design or this manuscript.
Notes on contributors
Joanne R. Beames is a Postdoctoral Fellow at the Black Dog Institute, with expertise in youth, prevention, and implemen tation research.
Lara Johnston is a Research Assistant at the Black Dog Institute, with expertise in youth, e-health, and schools research.
Bridianne O’Dea has expertise in online interventions for depression and anxiety, adolescent mental health and well being, and social networking.
Michelle Torok is a Senior Research Fellow at the Institute, with expertise in suicide prevention, e-health and translational science.
Katherine Boydell is a Professor of Mental Health and Medicine, with expertise in knowledge translation and quali tative research.
14 J. R. BEAMES ET AL.
Helen Christensen is Director and Chief Scientist at the Black Dog Institute and Professor of Mental Health at UNSW.
Aliza Werner-Seidler is an Early-Mid Fellow and Clinical Psychologist. She has expertise in youth, prevention, e-health, and schools research.
ORCID
Joanne R. Beames http://orcid.org/0000-0003-3630-0980 Bridianne O’Dea http://orcid.org/0000-0003-1731-210X
Availability of data and materials
Not available.
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Received: 7 July 2021 | Revised: 6 December 2021 | Accepted: 14 December 2021
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Mental health problems among children are on the rise
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across the United Kingdom. Teachers are uniquely
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intervention. This study aims to identify and discuss
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This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use,
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1 | INTRODUCTION
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some degree, by mental health problems each year (NHS Research Scotland, 2019). Prevalence rates of mental
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.
2
2
health problems among adolescents have been found to be the highest when compared to any other stage of life
6
4
8
b
y
(Gulliver et al., 2012), with the WHO (2012) reporting that up to 20% of adolescents are likely to experience some
U
n
i
v
e
form of mental health problems, with depression or anxiety being most common.
r
s
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t
y
O
Mental health problems are one of the most significant contributors to disease and disability worldwide,
f
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a
s
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influencing an individual's quality of life and economic growth (Harnois & Gabriel, 2000; Reiss, 2013).
o
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According to the Mental Health Foundation (2019), 50% of mental health problems observed in adulthood will
i
l
e
y
O
n
have already been present by the age of 14, with 10% of children having a clinically diagnosable mental health issue.
l
i
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e
L
i
b
Mental health problems presented in childhood/adolescence have been linked with chronically poor adjustment;
r
a
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y
o
reduced attendance at school and academic success; poorer vocational achievement and social interactions; higher
n
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risk of alcohol and drug use, and reduced life expectancy (Audit Scotland, 2018; Gulliver et al., 2012; Kessler
1
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2
0
2
2
et al., 1995; Tully et al., 2019).
]
.
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e
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Despite the life consequences, mental illness among adolescents in the United Kingdom continue to grow. For
h
e
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e
r
m
instance, a recent survey of secondary school headteachers and the Royal College of Paediatrics and Child Health
s
a
n
d
have suggested an 87% increase in stress, anxiety, and panic attacks, an 80% increase in depression, and a 75%
C
o
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d
i
t
increase in incidences of self‐harm between 2015 and 2017 (RCPCH, 2017; The Key, 2017). A 2018 audit report by
i
o
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s
(
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Child and Adolescent Mental Health Services noted a 20% increase in children being referred to treatment over
t
p
s
:
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o
n
3 years in Scotland. At the same time, Brown et al. (2015) reported increased rates of self‐harm among Scottish
l
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adolescents and young adults, especially among young women.
r
a
r
y
.
w
i
However, despite rising rates and known life consequences of mental health problems, help‐seeking behaviors
l
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y
.
c
o
m
among young people remain low, with some estimates of help‐seeking rates being as low as 25% to 36% for mental
/
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r
m
s
health disorders and 29% for suicidal thoughts and behaviors (Bruffaerts et al., 2019).
-
a
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d
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c
In response, the role and responsibilities of teachers and the school settings have had to expand beyond
o
n
d
i
t
i
o
teaching to address students' emerging mental health needs. Due to the extensive amount of time children spend in
n
s
)
o
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schools, teachers are uniquely placed to observe variations in behavior and mood, making them a vital part of early
i
l
e
y
O
identification and intervention (Moor et al., 2007). As a result, greater levels of responsibilities have been placed on
n
l
i
n
e
L
teachers for the promotion of positive mental health, early identification of behavioral changes, and psychological
i
b
r
a
r
y
distress. For instance, within the Scottish context, the Curriculum for Excellence framework reflects the growing
f
o
r
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u
l
responsibility of teachers as it places children's health and wellbeing at the center of learning, alongside, and equal
e
s
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u
s
to, literacy and numeracy (Education Scotland, 2020).
e
;
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A
However, a recent Mental Health Foundation (2019) review identified a failure in the provision of mental
a
r
t
i
c
l
e
s
health supports for children in the Scottish education system. The review noted that 70% of 5‐ to 16‐year‐olds who
a
r
e
g
o
have experienced a mental health problem had not been provided with an appropriate intervention during their
v
e
r
n
e
d
younger years. This is especially worrying as early identification and intervention are specifically important during
b
y
t
h
e
the current coronavirus disease 2019 (COVID‐19) pandemic, which led to nationwide school closure across the
a
p
p
l
i
c
a
United Kingdom. An expected by‐product of the prolonged closure is the psychological impact on children.
b
l
e
C
r
Stressors related to prolonged isolation, fears for personal and family safety, boredom, feelings of loneliness, lack of
e
a
t
i
v
e
C
personal space at home, and family financial loss can have significant and enduring effects on children and
o
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s
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adolescents. A recent survey found that nearly one‐third of the children who experienced isolation or quarantine
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during past pandemic disasters demonstrated symptoms that met the overall threshold for post‐traumatic stress
l
o
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e
d
disorder (Sprang & Silman, 2013). However, for teachers to provide support for children at risk or identify those in
f
r
o
m
h
need of referrals to more specialist services, adequate training, skills, and knowledge among teachers is needed
t
t
p
s
:
/
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o
(Atkins et al., 2017; Audit Scotland, 2018; Green et al., 2018; Young Minds, 2017).
n
l
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e
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i
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r
a
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y
.
w
i
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y
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c
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2 | TEACHERS' ATTITUDES AND BELIEFS
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The beliefs and motivation of teachers are important factors to consider when discussing school‐based supports
/
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s
.
2
2
and early identification of mental health problems. Negative attitudes and stigma regarding mental health problems
6
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b
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among teachers have been found to present barriers to successful and timely interventions. Jorm and Oh (2009)
U
n
i
v
e
found that in cases where teachers helped, negative attitudes concerning mental health access to appropriate
r
s
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referrals and help‐seeking behavior were reduced.
f
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a
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However, past research has shown that teachers most often possess favorable attitudes about providing
o
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mental health services in schools. For instance, Graham et al. (2011) reported that out of 2220 Australian primary
i
l
e
y
O
n
and high school teachers survived, 99% of teachers reported that promoting positive mental health among students
l
i
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i
b
was extremely important. Similarly, an American survey of 292 teachers found that 89% of participating teachers
r
a
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y
o
felt that schools should be involved in actions to address students' mental health problems (Reinke et al., 2011).
n
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However, Reinke et al. (2011) noted that most teachers surveyed stated that screening, conducting assessments,
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0
2
2
and teaching social–emotional lessons in the classroom should be the responsibility of school psychologists and not
]
.
S
e
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t
teachers (Reinke et al., 2011). A contributing factor to this reluctance among teachers to provide these supports
h
e
T
e
r
m
may result from the lack of specific knowledge and training to address these problems. Studies have shown that
s
a
n
d
teachers often lack specific knowledge, confidence, and efficacy in recognizing mental health problems among their
C
o
n
d
i
t
students (Ohrt et al., 2020; Reinke et al., 2011; Walter et al., 2006). For instance, Reinke et al. (2011) noted that
i
o
n
s
(
h
t
only 34% of participating teachers reported feeling as if they had the skills and knowledge necessary to support the
t
p
s
:
/
/
o
n
mental health needs of students. In support, Moon et al. (2017) found that 93% of participating primary school
l
i
n
e
l
i
b
teachers from the United States had high levels of concern for student mental health needs, yet lacked confidence
r
a
r
y
.
w
i
in handling the mental health problems of their students. Moon and colleagues reported that 85% of respondents
l
e
y
.
c
o
m
indicated the need for further training. Similarly in Scotland, a recent survey of trainee teachers reported that 60%
/
t
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r
m
s
of respondents lacked confidence when identifying mental health needs, while 73% felt there was a lack of mental
-
a
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d
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c
health training for teachers (Mental Health Foundation, 2018).
o
n
d
i
t
i
o
The lack of specific training concerning mental health has been shown to lead to dissemination of mis
n
s
)
o
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W
information about mental health, perpetuating stigmas and biases resulting in the creation of barriers to timely
i
l
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y
O
interventions and appropriate referrals (Jorm & Oh, 2009; Martin et al., 2000). For instance, Loades and
n
l
i
n
e
L
Mastroyannopoulou (2010) found that teachers held a bias where externalized behavioral symptoms were inter
i
b
r
a
r
y
preted as more serious than emotional disturbances, which led to neglecting the importance of internalization
f
o
r
r
u
l
problems. As a result, this lack of specific or accurate knowledge concerning the manifestation of mental health
e
s
o
f
u
s
problems could result in children who present repetitive externalizing behaviors being subjected to unnecessary
e
;
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A
disciplinary actions resulting in no effect on the underlying causal mental health issue. While on the other hand,
a
r
t
i
c
l
e
s
internalizing problems may go entirely unidentified or ignored. As a result, unaddressed problems often lead to
a
r
e
g
o
academic underachievement, early school dropout, or, in some cases, self‐harm behaviors (Kessler et al., 1995).
v
e
r
n
e
d
With further teacher training, externalizing and internalizing problems could be prevented with early identification
b
y
t
h
e
and timely referrals.
a
p
p
l
i
c
a
An awareness of teachers' perceptions, knowledge gaps, and self‐identified training needs related to mental
b
l
e
C
r
health is crucial in developing future training targeting the recognition and identification of mental health problems
e
a
t
i
v
e
C
within a classroom setting. Reinke et al. (2011) noted that understanding teachers' perspectives concerning their
o
m
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o
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s
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,
role, abilities, and training could provide important information about the contextual influences that could help
D
o
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n
develop new programmes to address the knowledge and practice gap in school‐based mental health supports.
l
o
a
d
e
d
Given the rising rates of mental health problems among young people across the United Kingdom, a
f
r
o
m
h
greater need for early screening and support is required. Due to the extensive amount of time children spend
t
t
p
s
:
/
/
o
in schools, teachers are uniquely placed to play a vital role in delivering these supports and providing
n
l
i
n
e
l
i
b
assistance in early identification and intervention delivery. However, lack of knowledge, training, and
r
a
r
y
.
w
unidentified barriers may pose potential hurdles in the adoption of these responsibilities by teachers. As a
i
l
e
y
.
c
o
m
result, this paper aims to identify Scottish teachers' perceptions of their roles and barriers in supporting
/
d
o
i
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1
children's mental health. This paper's focus on a Scottish population is unique. It provides insights into the
0
.
1
0
0
2
views and knowledge of a UK‐based teacher population, which is currently absent from the literature. This
/
p
i
t
s
.
2
2
study will address the following questions through the use of an online questionnaire of teachers from
6
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b
y
around Scotland, United Kingdom:
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i
v
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s
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O
1. What, if any, mental health problems have teachers identified and witnessed within children in their school?
f
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2. To what extent do teachers feel equipped with adequate knowledge, skills, and training to support children with
o
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mental health problems?
i
l
e
y
O
n
3. What barriers do teachers identify when supporting children with mental health problems?
l
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e
L
i
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r
a
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y
o
n
[
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3 | METHOD
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]
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3.1 | Study design and sample
t
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s
a
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d
A total of 179 Scottish primary school teaching staff from 30 different council areas completed the survey, with
C
o
n
d
i
t
the majority being female (98.9%). The participants' years of teaching experience ranged from 1 year to
i
o
n
s
(
h
t
42 years with a mean of 13.3 years; teachers with less than 5 years' experience had the highest representation
t
p
s
:
/
/
o
n
overall (33.5%). All but four participants identified their teaching role, with 71.4% identifying as regular
l
i
n
e
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i
b
classroom teachers; 9.1% as additional support needs teachers (special needs teacher); 4% as headteachers
r
a
r
y
.
w
i
(principal); 13.1% as probation teachers (a newly qualified teacher with less than 1 year experience); and 2.4%
l
e
y
.
c
o
m
as supply/occasional teachers. A total of 174 participants (97.2%) reported the council areas within Scotland
/
t
e
r
m
s
where they taught: Aberdeenshire (11.4%), Fife (8.6%), Glasgow City (7.4%), and South Lanarkshire (5.7%); the
-
a
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d
-
c
remaining 28 council areas equated to less than 5% each with no participation from Orkney Island and West
o
n
d
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t
i
o
Islands, both being remote Scottish islands.
n
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)
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i
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3.2 | Procedure
L
i
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r
a
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y
f
o
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In February and March 2020 (a month before the nationwide school closure due to the COVID‐19 pandemic), a link
e
s
o
f
u
s
to the online survey was posted with permissions on a Facebook page titled Scottish Primary Teachers with some
e
;
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A
25,000 members. The online format allowed participants to engage with the survey in their own time. Participation
a
r
t
i
c
l
e
s
was voluntary and anonymous. Participants were informed of the purpose of the study before completion through
a
r
e
g
o
the provided Plain Language Statement displayed at the start of the survey. Participant consent was obtained by
v
e
r
n
e
d
checking the compulsorily “agree” field following the question: "After reading the Plain Language Statement, do you
b
y
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h
e
give consent for the information provided to be used within this research?". Each participant received a randomly
a
p
p
l
i
c
a
generated alpha‐numeric ID identity at the point of registration. The average completion rate of the entire survey
b
l
e
C
r
was 10 min.
e
a
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s
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s
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1
3.3 | Measures
,
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o
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d
To assess teachers' perceptions concerning student mental health needs, their role in supporting students, and
f
r
o
m
h
barriers to the provision of support, this study adapted the original survey reported in Reinke et al. (2011). Evidence
t
t
p
s
:
/
/
o
of validity for the original content included in Reinke and colleagues' survey was established through a stakeholder
n
l
i
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e
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i
b
review from four experts in the field of mental health practices in schools and relevant stakeholders, including
r
a
r
y
.
w
teachers, school counselors, school psychologists, and special education teachers. Stakeholder feedback was sought
i
l
e
y
.
c
o
m
concerning the coverage and relevance of survey domains, suggested responses, and any missing aspects of the
/
d
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/
1
survey that could better inform our understanding. Based on the feedback, some terminology was adapted to suit
0
.
1
0
0
2
better the UK context (i.e., council areas were used instead of the term district area).
/
p
i
t
s
.
2
2
Three of the four subscales of teachers' perceptions reported by Reinke and colleagues were used for the
6
4
8
b
y
purposes of this study: Roles of the teacher; Barriers; and Cracks. Reinke and colleagues used confirmatory factor
U
n
i
v
e
analysis to demonstrate the distinctiveness of these subscales. Reinke reported that all items were found to have
r
s
i
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y
O
acceptable loadings on their respective subscales (0.30 or higher), with the majority of loadings exceeding 0.60.
f
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l
a
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Description and reported internal consistency of each subscale are reported below.
o
w
,
W
An online platform was used to administer the survey. Survey questions were scored in the form of a 5‐point
i
l
e
y
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n
Likert scale, offering the respondents a greater range in choice compared to a simple yes/no structure, allowing
l
i
n
e
L
i
b
consideration of how strongly they feel while allowing for a neutral response (Mcleod, 2012). After a set of
r
a
r
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o
demographic‐based questions (gender, age, years in the profession, council area, and job role), a total of 43
n
[
0
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/
1
questions were organized in specific subsection categories following the structure of Reinke et al. (2011), resulting
1
/
2
0
2
2
in the following categories: participant consent, participant demographics, Mental Health Concerns; Roles of the
]
.
S
e
e
t
teacher, Knowledge, Skills, and Training; Barriers and Cracks. See Appendix A for the complete list of survey
h
e
T
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r
m
questions.
s
a
n
d
C
o
n
d
i
t
i
o
n
s
(
3.3.1 | Mental health concerns
h
t
t
p
s
:
/
/
o
n
l
i
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e
l
i
b
From a list of 13 presented options, the participants were asked to identify mental health concerns they had noticed
r
a
r
y
.
w
i
among their students within the past year. Potential options included disruptive behavior/acting out, problems with
l
e
y
.
c
o
m
inattention, defiant behavior, family stress, peer problems, aggressive behavior, anxiety problems, bullying, victims
/
t
e
r
m
s
of bullying, immigration and cultural adjustment issues, and school phobia. The 13 presented options were based on
-
a
n
d
-
c
Reinke et al. (2011). They were validated through feedback from stakeholders, including scholars, teachers, school
o
n
d
i
t
i
o
counselors, school psychologists, special education teachers, and school administrators who reviewed the items.
n
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)
o
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i
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n
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e
3.3.2 | Knowledge, skills, and training
L
i
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r
a
r
y
f
o
r
r
u
l
Teachers' perception of their knowledge and training related to mental health was assessed through a series of
e
s
o
f
u
s
questions regarding their beliefs in possessing adequate knowledge, skills, and cultural knowledge required to
e
;
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A
support, identify, and direct students to seek help. Based on Wei et al. (2015), all terms were defined with examples
a
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t
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c
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e
s
to ensure participants knew what was being asked while supporting consistency in responses. Definitions were
a
r
e
g
o
reviewed and agreed on by the stakeholder committee described above.
v
e
r
n
e
d
Participants were asked to indicate the type and duration of training they had been provided concerning mental
b
y
t
h
e
health. Types of training options included workshops, independent study, undergraduate course work, post
a
p
p
l
i
c
a
graduate course work, and not applicable. Further elaboration of the training relevance was measured through
b
l
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C
r
questions assessing how often they used behavioral interventions to promote positive mental health. Responses
e
a
t
i
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e
C
o
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o
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were collected using a 5‐point Likert scale and provided with the options: substantial (1), moderate (2), minimum (3),
D
o
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none (4), and the final option, unsure (5).
l
o
a
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e
d
f
r
o
m
h
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s
:
/
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3.3.3 | Roles of the teacher
o
n
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e
l
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r
a
r
y
.
w
To understand how teachers perceived their role in supporting mental health in the classroom, the teachers were
i
l
e
y
.
c
o
m
directed to respond to questions including “what role teachers” felt the school played when identifying and im
/
d
o
i
/
1
proving mental health concerns', and “the role of the teacher in screening, the delivery of social‐emotional lessons,
0
.
1
0
0
2
behavioral interventions and assessments.” Participants responded using a 5‐point Likert scale ranging from strongly
/
p
i
t
s
.
2
2
agree (1) to strongly disagree (5) about their perceived roles as teachers. Reinke et al. (2011) reported that the scale
6
4
8
b
y
had high internal consistency, as indicated by Cronbach's α of .78.
U
n
i
v
e
r
s
i
t
y
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f
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l
a
s
3.3.4 | Barriers and reasons children fall through cracks
g
o
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,
W
i
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e
y
O
n
Twelve items from Reinke et al. (2011), including lack of training and lack of funding for school‐based mental health
l
i
n
e
L
i
b
services, were used to measure teachers' perception of barriers in providing mental health services in schools (see
r
a
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y
o
Appendix A for complete list). Using a 5‐point Likert scale, participants rated their agreement with each statement
n
[
0
9
/
1
ranging from strongly disagree to strongly agree. The internal consistency of the scale was adequate (Cronbach's
1
/
2
0
2
2
α = .80). Furthermore, teachers were asked to rate their perceptions of why the mental health needs of children are
]
.
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e
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t
often not attended to. A total of 10 items included lack of parenting programs, lack of prevention programs, and
h
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e
r
m
lack of administrator support, were rated on a 5‐point Likert scale, ranging from strongly disagree to strongly agree.
s
a
n
d
The internal consistency of the scale was adequate (Cronbach's α = .86).
C
o
n
d
i
t
i
o
n
s
(
h
t
t
p
s
:
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o
3.3.5 | Missing data
n
l
i
n
e
l
i
b
r
a
r
y
.
w
i
The survey was attempted by 232 people resulting in 179 being completed, representing a 77.2% completion rate.
l
e
y
.
c
o
m
According to Kowalska (2019), the average completion rate for surveys with 15 or more questions is 41.94%,
/
t
e
r
m
s
demonstrating a high completion rate of the current survey. However, not all questions were mandatory for
-
a
n
d
-
c
completion, resulting in some missing data; questions such as demographic and questions appearing towards the
o
n
d
i
t
i
o
end of the survey were the most missed, potentially being related to "Participant fatigue" (Reinke et al., 2011). χ2
n
s
)
o
n
W
tests revealed no significant differences between individuals who completed all items versus those who did not,
i
l
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y
O
concerning their role (teacher vs. headteacher) or being from a particular local education authority (ps > .05).
n
l
i
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e
L
i
b
r
a
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o
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3.4 | Statistical analysis
l
e
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;
O
A
Statistical analyses were performed with SPSS 20.0 software (IBM Corp., released 2011). All variables were found
a
r
t
i
c
l
e
s
to be normally distributed as checked within each group by the Shapiro–Wilk's test for normality (p > .05). Fre
a
r
e
g
o
quency and percentages of group representation (i.e., gender, teaching role) and specific responses to question
v
e
r
n
e
d
options (i.e., barrier questions) were calculated. Group comparisons were investigated based on an analysis of
b
y
t
h
e
variance (ANOVA). A p value of .05 was used to identify the threshold of achieved significance. Effect sizes were
a
p
p
l
i
c
a
calculated using Cohen's d value. Determination of the scale of the effect was based on a scale where d = 0.2 is to
b
l
e
C
r
be considered a “small” effect size, 0.5 is a “medium" effect size, and 0.8 is a "large" effect size (Mcleod, 2020).
e
a
t
i
v
e
C
Correction for multiple testing was applied across all group comparisons to avoid the likelihood of false‐positive
o
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,
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,
conclusions by applying the false discovery rate (FDR) procedure. This simple sequential Bonferroni‐type procedure
D
o
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has been proven to control the FDR for independent test statistics (Benjamini & Hochberg, 1995).
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4 | RESULTS
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4.1 | Types of mental health problems identified by teachers
i
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y
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c
o
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1
Participants were asked to indicate which of the 13 listed mental health problems they felt they had witnessed in a
0
.
1
0
0
2
child within the past year (see Table 1). The top five acknowledged were: (1) disruptive behaviors/acting out (90.4%
/
p
i
t
s
.
2
2
reported), (2) anxiety problems (88.2% reported), (3) problems with inattention (84.8% reported), (4) family stressors
6
4
8
b
y
(83.1% reported), and (5) defiant behavior (79.8% reported). In comparison, the least reported mental health issue
U
n
i
v
e
was immigration and cultural adjustment issues was only 13.5% of teachers identified this within the past year.
r
s
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y
O
f
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W
4.2 | Teacher knowledge, skills, and training in supporting mental health
i
l
e
y
O
n
l
i
n
e
L
i
b
When asked: “Do you feel that you have enough knowledge required to meet the mental health needs of the
r
a
r
y
o
children in your school?” (e.g., knowing how to seek help, being aware of the stigma and how to reduce it, etc.), 10%
n
[
0
9
/
1
strongly agreed, 34.7% agreed, 50.6% were neutral, with the remaining 4.7% indicating strongly disagreed. When
1
/
2
0
2
2
asked: “Do you feel you have the skills (ability to make use of your knowledge) required to meet the mental health
]
.
S
e
e
t
needs of children within the school?”, 7.1% strongly agreed, 27.1% agreed, 17.6% were neutral, 45.9% disagreed,
h
e
T
e
r
m
and 2.4% strongly disagreed.
s
a
n
d
A total of 171 participants responded to questions related to the form/type of training experienced: workshops
C
o
n
d
i
t
and in‐service days (74.1%), independent study (63.2%), graduate course work (7%), undergraduate study (6.4%),
i
o
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s
(
h
t
t
p
s
:
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o
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i
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TABLE 1 Teacher reported mental health issues in children from past year (n = 176)
r
a
r
y
.
w
i
l
e
Issues % of teachers
y
.
c
o
m
/
t
e
r
Disruptive behaviors/acting out 90.4
m
s
-
a
n
d
-
Anxiety problems 88.2
c
o
n
d
i
t
i
o
n
Problems with inattention 84.8
s
)
o
n
W
i
Family stressors (e.g., parent death, divorce) 83.1
l
e
y
O
n
l
i
n
Defiant behavior 79.8
e
L
i
b
r
a
r
Peer problems 74.2
y
f
o
r
r
u
l
e
Hyperactivity 70.8
s
o
f
u
s
e
;
Aggressive behavior 69.7
O
A
a
r
t
i
c
Bullying 49.4
l
e
s
a
r
e
g
Victims of bullying 47.2
o
v
e
r
n
e
d
b
Depression 31.5
y
t
h
e
a
p
School phobia 30.9
p
l
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c
a
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l
e
C
Immigration and cultural adjustment issues 13.5
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e
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,
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,
and no training (11.6%). Concerning training on mental health‐related behavioral interventions, the most common
D
o
w
n
response was minimum (49.1%), followed by: moderate (26%), none (16.6%), and substantial (8.3%).
l
o
a
d
e
d
A one‐way repeated‐measures ANOVA was conducted to determine whether there was a statistically sig
f
r
o
m
h
nificant difference in perceived knowledge and skills between self‐determined levels of received training. There
t
t
p
s
:
/
/
o
were no outliers, and the data were normally distributed at each time point, as assessed by boxplot and
n
l
i
n
e
l
i
b
Shapiro–Wilk test (p > .05). The assumption of sphericity was met. Statistically significant differences in perceived
r
a
r
y
.
w
knowledge across training duration groups (substantial, moderate, minimum, and none) was found, F(3,
i
l
e
y
.
c
o
168) = 15.404, p < .000, partial ω2 = 0.02, with knowledge significantly increasing with each level of training
m
/
d
o
i
/
1
duration experienced. Similarly, a statistically significant difference in perceived skills across training level groups
0
.
1
0
0
2
was found, F(3, 168) = 17.211, p < .000, partial ω2 = 0.02, with skill significantly increasing from low levels of training
/
p
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t
s
.
2
2
to substantial.
6
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O
4.3 | Perception of teachers' roles in supporting children with mental health needs
f
G
l
a
s
g
o
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,
W
When responding to the question: “Do you feel that schools should be involved in identifying and improving mental
i
l
e
y
O
n
health problems in pupils?”, more than 92% agreed or strongly agreed, while less than 3% disagreed (0.6% strongly
l
i
n
e
L
i
b
disagreed).
r
a
r
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o
When asked about their perceived roles in carrying out specific tasks related to mental health support and
n
[
0
9
/
1
monitoring, over 90% of respondents felt that it was the teacher's role to implement classroom behavioral inter
1
/
2
0
2
2
ventions, teach social–emotional lessons, and monitor student progress. While, on the other hand, the survey
]
.
S
e
e
t
results revealed a divide among participants concerning the role of teachers in aspects of mental health screening
h
e
T
e
r
m
and referrals (see Table 2 for a full breakdown)
s
a
n
d
To understand if self‐determined levels of received training was a factor in how teachers perceived their role in
C
o
n
d
i
t
supporting children's mental health needs in the classroom, a series of one‐way repeated‐measures ANOVAs were
i
o
n
s
(
h
t
conducted. This analysis included seven roles, as reported in Table 2, as dependent variables and perceived training
t
p
s
:
/
/
o
n
as the independent variable. No outliers were found, and the data were normally distributed at each time point, as
l
i
n
e
l
i
b
assessed by boxplot and Shapiro–Wilk test (ps > .05). The assumption of sphericity was met in all cases. Statistically
r
a
r
y
.
w
i
significant differences in teachers' views on their role in implementing classroom behavioral interventions differed
l
e
y
.
c
o
m
across training duration groups (substantial, moderate, minimum, and none), F(3, 168) = 3.567, p < .015, partial
/
t
e
r
m
ω2 = 0.061, with a stronger agreement to the question significantly increasing with each higher level of training
s
-
a
n
d
-
c
duration experienced. Similarly, a statistically significant difference in perceived role of the teacher in, conducting
o
n
d
i
t
i
o
behavioral assessments, F(3, 168) = 3.057, p = .047, partial ω2 = 0.047, referring children and families to
n
s
)
o
n
W
i
l
e
y
O
n
l
i
n
TABLE 2 Teachers perceptions of their role in supporting children's mental health
e
L
i
b
r
a
r
y
Role A/SA N D/SD
f
o
r
r
u
l
e
Screening for mental health 30.9% 26.3% 42.9%
s
o
f
u
s
e
;
Implementing classroom behavioral interventions 91.4% 8.0% 0.6%
O
A
a
r
t
i
c
l
Teaching social–emotional lessons 92.6% 6.3% 1.1%
e
s
a
r
e
g
o
NOT conducting behavioral assessments 45.4% 26.4% 28.2%
v
e
r
n
e
d
b
Monitoring student progress 98.8% 0.6% 0.6%
y
t
h
e
a
p
p
Referring children and families to school‐based services 53.4% 15.5% 31.0%
l
i
c
a
b
l
e
C
NOT referring children and families to community‐based services 46.3% 22.9% 30.8%
r
e
a
t
i
v
e
C
Abbreviations: A/SA, agree or strongly agree; D/SD, disagree or strongly disagree; N, neutral.
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,
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,
1
1
school‐based services, F(3, 168) = 3.409, p = .019, partial ω2 = 0.059, and community‐based services, F(3,
,
D
o
w
n
168) = 3.409, p = .019, partial ω2 = 0.059, was found across training level groups, with those receiving no training
l
o
a
d
e
d
most statistically (ps > .05) likely to disagree with these being the role of the teacher. While no statistical differences
f
r
o
m
h
were found across training groups and all other perceived roles, as indicated in Table 2.
t
t
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s
:
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4.4 | Barriers and reasons children fall through cracks
i
l
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y
.
c
o
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/
d
o
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1
Table 3 reports the results of participant responses when asked how much they believe a given issue is a reason for
0
.
1
0
0
2
children with mental health needs going unrecognized or “falling through the cracks.” The top five reasons, all with
/
p
i
t
s
.
2
2
more than 80% of resonance support, include the lack of: (1) prevention programs for students with internalized
6
4
8
b
y
behavior; (2) adequate parent support programs; (3) early screening and prereferral programs; (4) prevention
U
n
i
v
e
programs for students with externalized behavior; and (5) staff training and coaching.
r
s
i
t
y
O
When asked to report barriers for supporting children with mental health needs (see Table 4), the top five
f
G
l
a
s
g
barriers teachers indicated were: (1) insufficient number of school mental health professionals, (2) lack of funding
o
w
,
W
for school‐based mental health services, (3) lack of adequate training for dealing with children's mental health
i
l
e
y
O
n
needs, (4) lack of coordinated services between schools and community, and (5) lack of referral options in the
l
i
n
e
L
i
b
community. In contrast, only 4% of the teachers agreed/strongly agreed with the statement “mental health
r
a
r
y
o
problems do not exist and are just an excuse.”
n
[
0
9
/
1
1
/
2
0
2
2
]
.
S
e
e
5 | DISCUSSION
t
h
e
T
e
r
m
s
a
n
d
This study has investigated the perceptions of 179 Scottish primary teachers concerning their roles, abilities and the
C
o
n
d
i
t
barriers faced when supporting children's mental health. The present study set to answer the following questions:
i
o
n
s
(
h
t
(1) What mental health concerns have teachers identified in children? (2) Do teachers feel equipped with adequate
t
p
s
:
/
/
o
n
knowledge, skills and training to support children with mental health problems? (3) What barriers do teachers
l
i
n
e
l
i
b
identify when supporting children with mental health problems?
r
a
r
y
.
w
i
l
e
y
.
c
o
m
/
t
e
r
TABLE 3 Reasons students with mental health needs fall through the cracks (n = 159)
m
s
-
a
n
d
-
c
Because of a lack of: A/SA N D/SD
o
n
d
i
t
i
o
n
Prevention programs for students with internalized behavior 88.0% 9.4% 2.5%
s
)
o
n
W
i
l
Adequate parent support programs 86.8% 7.5% 5.6%
e
y
O
n
l
i
n
Early screening and prereferral programs 86.8% 11.3% 1.9%
e
L
i
b
r
a
r
y
Prevention programs for students with externalized behavior 86.2% 11.9% 1.9%
f
o
r
r
u
l
e
Staff training and coaching 83.1% 8.2% 8.8%
s
o
f
u
s
e
;
Early intervention programs 81.8% 11.3% 6.9%
O
A
a
r
t
i
c
l
Adequate crisis planning and support 78.6% 15.7% 5.6%
e
s
a
r
e
g
o
Ongoing monitoring for students with mental health needs 78.6% 11.3% 10.0%
v
e
r
n
e
d
b
Implementation of existing programs as intended 69.1% 20.8% 10.1%
y
t
h
e
a
p
p
Administrative support 60.4% 23.9% 15.7%
l
i
c
a
b
l
e
C
Bullying programs 42.7% 25.8% 31.4%
r
e
a
t
i
v
e
C
Abbreviations: A/SA, agree or strongly agree; D/SD, disagree or strongly disagree; N, neutral.
o
m
m
o
n
s
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s
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,
TABLE 4 Teacher reported barriers for supporting mental health needs (n = 152)
D
o
w
n
l
o
Barrier A/SA N D/SD
a
d
e
d
f
r
o
m
Insufficient number of school mental health professionals 95.4% 3.9% 0.7%
h
t
t
p
s
:
/
/
o
Lack of funding for school‐based mental health services 94.7% 4.6% 0.7%
n
l
i
n
e
l
i
b
r
Lack of adequate training for dealing with children's mental health needs 88.8% 9.2% 2.0%
a
r
y
.
w
i
l
e
Lack of coordinated services between schools and community 85.5% 10.5% 3.9%
y
.
c
o
m
/
d
o
Lack of referral options in the community 82.3% 12.5% 5.3%
i
/
1
0
.
1
0
0
Competing priorities taking precedence over mental health 80.3% 8.6% 11.2%
2
/
p
i
t
s
.
2
2
6
Difficulty identifying children with mental health needs 53.3% 19.1% 27.7%
4
8
b
y
U
Stigma associated with receiving mental health services 50.6% 20.4% 29.0%
n
i
v
e
r
s
i
t
y
Language and cultural barriers with culturally diverse students 26.5% 46.4% 27.1%
O
f
G
l
a
s
g
Mental health issues are not considered a role of the school 25.7% 22.4% 51.9%
o
w
,
W
i
l
Mental health problems do not exist and are just an excuse 4.0% 3.3% 92.8%
e
y
O
n
l
i
n
e
Abbreviations: A/SA, agree or strongly agree; D/SD, disagree or strongly disagree; N, neutral.
L
i
b
r
a
r
y
o
n
[
0
9
/
5.1 | What mental health concerns have teachers identified in children?
1
1
/
2
0
2
2
]
.
S
e
e
t
The examination of areas of concern expressed by teachers can aid in the development of content for mental health
h
e
T
e
r
m
training programs for teachers. Results of the present study identified disruptive behavior/acting out as the most
s
a
n
d
common area of concern, with 90.4% of teachers identifying it as a mental health concern they have witnessed
C
o
n
d
i
t
within the past year. This result mirrored the findings of the past work of Moon et al. (2017) and Reinke et al.
i
o
n
s
(
h
t
(2011), who both reported that the top areas of concern that teachers identified for training needs included
t
p
s
:
/
/
o
n
managing externalizing behaviors, classroom management, and behavioral interventions. The similarities across
l
i
n
e
l
i
b
studies demonstrate the continuity of teachers' reported concerns across regions (Scotland vs. the USA) and over
r
a
r
y
.
w
i
time (2011–2020).
l
e
y
.
c
o
m
These results are surprising given the volume of published literature in the past decade concerning effective
/
t
e
r
m
s
classroom management practices and best practices in the management of externalizing behavior problems. Our
-
a
n
d
-
c
findings, as well as in others (i.e., Graham et al., 2011; Moon et al., 2017; Reinke et al., 2011), suggest a potential
o
n
d
i
t
i
o
disconnect between research and practice resulting in the failure of initial teacher education programmes and
n
s
)
o
n
W
career‐long professional learning to equip teachers with effective classroom management and behavior support
i
l
e
y
O
planning skills.
n
l
i
n
e
L
The second most identified area of concern was anxiety problems, which 88.2% of teachers identified.
i
b
r
a
r
y
According to the Child Mind Institute (2020), anxiety problems among youth often are expressed as disruptive
f
o
r
r
u
l
behavior, explaining the high co‐occurrence of these concerns. An interesting finding of the survey is the potential
e
s
o
f
u
s
underreporting of concern for depression among students. According to the Mental Health Foundation (2020),
e
;
O
A
anxiety and depression are reported as Britain's most common mental health problems. Although results of this
a
r
t
i
c
l
e
s
study reported a high concern for anxiety problems among students, only 31.5% of teachers identified depression
a
r
e
g
o
as a mental health concern, placing it 11th out of a possible 13 options. Depression in childhood is often observed
v
e
r
n
e
d
as persistent unhappiness, loss of interest, change in eating and sleeping habits, and constant fighting (Lima
b
y
t
h
e
et al., 2013; Workman & Prior, 1997). Childhood depression can have various impacts on the child, varying between
a
p
p
l
i
c
a
mild and severe. If left untreated, it could result in later relationship problems, recurring depression, reckless
b
l
e
C
r
behavior, substance abuse, and suicidal thoughts and/or behaviors (DiMaria, 2020). However, early signs of
e
a
t
i
v
e
C
childhood depression often vary slightly from what would be expected within adults leading to depression among
o
m
m
o
n
s
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e
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0
6
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,
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2
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,
1
1
,
youths being mistaken for other concerns such as disruptive behavior or inattentiveness/disinterest. This confusion
D
o
w
n
of early symptoms may explain why primary school teachers may not express specific concerns related to
l
o
a
d
e
d
depression.
f
r
o
m
h
t
t
p
s
:
/
/
o
n
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i
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e
l
5.2 | Do teachers feel equipped with adequate knowledge, skills, and training to
i
b
r
a
r
y
.
w
support children with mental health problems?
i
l
e
y
.
c
o
m
/
d
o
i
/
1
Results of this study support past international research (e.g., Froese‐Germain & Riel, 2012; Moon et al., 2017;
0
.
1
0
0
2
Reinke et al., 2011; Walter et al., 2006) evaluating teachers' perceptions of their role in supporting and promoting
/
p
i
t
s
.
2
2
positive mental health among students with 92.7% of teachers agreeing that schools should play a part in identi
6
4
8
b
y
fying and improving mental health problems. Similar to Graham et al. (2011), the results of this study demonstrated
U
n
i
v
e
that teachers recognized mental health problems within the context of their daily practice of teaching, yet felt that
r
s
i
t
y
O
some aspects of support remain the responsibility of other support professionals.
f
G
l
a
s
g
A dominant view appeared to be that teachers view themselves as best placed to support mental health‐related
o
w
,
W
issues for students through the monitoring and implementation of classroom behavioral interventions and lessons.
i
l
e
y
O
n
This result is encouraging as monitoring student progress can help teachers prioritize, plan, and improve on sup
l
i
n
e
L
i
b
porting the child and their family and improving the interaction between school staff and the child (Mentally
r
a
r
y
o
Healthy Schools, 2020). Mentally Healthy Schools (2020) have also highlighted that monitoring a child's progress
n
[
0
9
/
1
helps identify how effective different approaches and strategies are, ensuring that they are not wasting effort,
1
/
2
0
2
2
making no difference, or, in some cases, possibly making the situation worse.
]
.
S
e
e
t
Although teachers are well placed to observe and recognize any change in behavior or personality expressed by
h
e
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a student, participating teachers were divided on their role in the assessment/identification and provision of
s
a
n
d
referrals to specialists of students exhibiting mental health distress for additional supports. Two potential
C
o
n
d
i
t
explanations could be offered to explain this result. First, these results could suggest that teachers may not
i
o
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s
(
h
t
understand the critical role they could play in identifying children who may be in need. Second, the lack of
t
p
s
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o
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knowledge and training related to identifying mental health problems has resulted in a lack of confidence in taking
l
i
n
e
l
i
b
up these roles among teachers. This study showed that teachers who had not received training were statically less
r
a
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y
.
w
i
likely to see tasks related to screening and referrals as a teacher's responsibility, thus indicating the need for greater
l
e
y
.
c
o
m
professional development targeting these roles as well as mentorship provided by educational psychologists could
/
t
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m
s
act to support the teachers.
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d
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Echoing past research, the results from this survey demonstrated that over half of the participating teachers
o
n
d
i
t
i
o
(65.7%) had received a minimum or no training (Moon et al., 2017; Reinke et al., 2011; Rothì et al., 2008;
n
s
)
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SAMH, 2017). While those who reported receiving mental health training indicated feeling inadequately prepared
i
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y
O
to recognize and support the mental health needs of their students. These results support the 2017 report by the
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SAMH, which found that 66% of teachers did not feel they had received sufficient training in mental health to allow
i
b
r
a
r
y
them to carry out their role properly (SAMH, 2017). This study found statistically significant growth in knowledge
f
o
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l
and skill with a greater duration of training experienced by participating teachers, thus demonstrating the need for
e
s
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mental health‐focused professional development programs and their inclusion in initial teacher training
e
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A
programmes.
a
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t
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e
s
Our results demonstrate an apparent willingness of Scottish teachers to help support the promotion of mental
a
r
e
g
o
health; nevertheless, teachers lack adequate knowledge or skills to do so. Therefore, providing effective practice in
v
e
r
n
e
d
schools will require effective training and ongoing consultation or coaching for teachers. Results indicate a will
b
y
t
h
e
ingness of teachers to engage in such professional development opportunities as the majority of responding
a
p
p
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i
c
a
teachers have attempted to address their knowledge/skill gap through in‐service professional development
b
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e
C
r
workshops or independent study. However, a recent review of mental health teacher training programmes in
e
a
t
i
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e
C
dicated that outcomes of in‐service or self‐directed study programmes varied across content areas, training
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modality, and training facilitation (Ohrt et al., 2020). For instance, many training programmes focused on a specific
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diagnosis or mental illness such as attention‐deficit/hyperactivity disorder, depression, anxiety, or behavioral dis
l
o
a
d
e
d
orders, thus not fully addressing the needs of the participating teachers. Ohrt et al. (2020) noted that programmes
f
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h
that aimed to improve teachers' knowledge of mental health, in general, demonstrated significant increases in
t
t
p
s
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knowledge, attitudes, mental health literacy, and a decrease in stigma (Baum et al., 2009; Eustache et al., 2017;
n
l
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i
b
Hussein & Vostanis, 2013; Jorm et al., 2010; Kutcher et al., 2016; Powers et al., 2014).
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a
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y
.
w
In the absence of effective, evidence‐based mental health training programs, Reinke et al. (2011) suggested
i
l
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y
.
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o
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that school psychologists working within school authorities could serve as consultants or coaches supporting
/
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teacher‐implemented programs and practices.
0
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Since 2012, the General Teaching Council for Scotland's Professional Standards for Registration stated that
/
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s
.
2
2
qualified teachers must know how to promote and support the cognitive, emotional, social, and physical wellbeing
6
4
8
b
y
of all learners (General Teaching Council for Scotland, 2012). Therefore, we were surprised that only 13.4% of
U
n
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e
teachers reported receiving training related to mental health from formal education pathways, such as during
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s
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undergraduate initial teacher training (6.4%) or graduate course work (7%). The Scottish Government has recently
f
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moved to help bridge this training gap as action points were set out by the Scottish Government's Mental Health
o
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Strategy 2017–2027: to roll out improved mental health training for those who support young people in educa
i
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tional settings.
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5.3 | What barriers do teachers identify when supporting children with mental health
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problems?
]
.
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T
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The study posed two questions to identify specific barriers facing the implementation and success of mental health
s
a
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d
supports in schools. The first attempted to ascertain why students with mental health needs went without support.
C
o
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d
i
t
While the second sought to understand the specific barriers teachers faced when supporting mental health needs.
i
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s
(
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Results concerning barriers related to students missing out on support found that teachers believe this resulted
t
p
s
:
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n
from a lack of support and prevention programs for students with internalized and externalized behavior, in
l
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adequate parent support programs, and insufficient early screening and prereferral programs. The perception that
r
a
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y
.
w
i
there is a lack of support programs and referral options is understandable when considering the waiting times and
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y
.
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m
rejection rate of referrals within Scotland; as only 69.7% of children referred to CAHMS (Child and Adolescents
/
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m
s
Mental Health Services) are seen within the 18‐week target time frame set by CAHMS (Information Services
-
a
n
d
-
c
Division, 2019). Furthermore, in Scotland, nearly one in five children and young people's referrals are rejected based
o
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t
i
o
on quick decisions with a lack of face‐to‐face assessment (Scottish Government, 2018).
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s
)
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Reflecting concerns discussed earlier when considering the reason students with mental health needs fall
i
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through the cracks, 83.1% of teachers agreed that lack of training was a contributing factor, and 88.8% of teachers
n
l
i
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e
L
agreed that a lack of adequate training for dealing with children's mental health needs is a barrier for supporting the
i
b
r
a
r
y
said child. The lack of training could be linked to the limited amount of time teachers have to dedicate to training
f
o
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r
u
l
and the reflecting and planning of implementation of it into the classroom. Results of this study found that 80.3% of
e
s
o
f
u
s
teachers reported that competing priorities took precedence over mental health needs, supporting the work of
e
;
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A
Rothì et al. (2008), who highlighted that teachers were aware that there are other areas they need further training
a
r
t
i
c
l
e
s
on which mental health support competes with (Rothì et al., 2008).
a
r
e
g
o
Lastly, 94.7% of teachers noted that a lack of funding for school‐based mental health services was a barrier to
v
e
r
n
e
d
supporting children's needs. This is something that has been identified in previous literature as an issue, including
b
y
t
h
e
the 2014 Audit Scotland report and 2016 Care Quality Commission report, which suggests that there has been a
a
p
p
l
i
c
a
lack of progress made around funding concerning the mental health of children services (Audit Scotland, 2014;
b
l
e
C
r
Rosa, 2018). According to the Scottish Association of Mental Health, the costs of training all Scottish school staff in
e
a
t
i
v
e
C
mental health support would require an initial investment of £4.4 m (SAMH, 2018).
o
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6 | CONCLUSION AND IMPLICATIONS
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o
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It is evident from past research that teachers play a crucial role in identifying and addressing students' mental health
f
r
o
m
h
concerns. The majority of participating teachers in this study were committed to the school's role in delivering
t
t
p
s
:
/
/
o
mental health education and demonstrated a belief that they have a role in supporting children. However, results
n
l
i
n
e
l
i
b
show that teachers perceive themselves as having a lack of knowledge and specific skills to promote positive mental
r
a
r
y
.
w
health. A lack of adequate training was identified as a primary barrier to delivering adequate supports and iden
i
l
e
y
.
c
o
m
tification. It was suggested that the lack of training among Scottish teachers might be linked to inadequate funding
/
d
o
i
/
1
and/or limited available time due to competing priorities.
0
.
1
0
0
2
Results indicated that teachers in Scotland had received little in their preservice (or subsequent) teacher
/
p
i
t
s
.
2
2
education to adequately prepare them for the complexity of mental health problems faced in the classroom. This
6
4
8
b
y
highlights that the resourcing of initial teacher training in mental health must become more of a priority for the
U
n
i
v
e
Scottish Government and the providers of initial teacher training programmes. A review of initial teacher training
r
s
i
t
y
O
programmes should be undertaken to identify if teachers' relevant and appropriate knowledge, understandings, and
f
G
l
a
s
g
skills are being taught.
o
w
,
W
Supporting the conclusions of Graham et al. (2011), these findings suggest that mental health promotion should
i
l
e
y
O
n
be strengthened to ensure there remains an emphasis on advocacy for children, improved funding, increased
l
i
n
e
L
i
b
capacity and knowledge of teachers, and better use of the existing evidence base programmes. There has been no
r
a
r
y
o
time more critical for this to occur as Scotland and the rest of the world emerge from the COVID‐19 pandemic and
n
[
0
9
/
1
the associated nationwide school closures seen across the globe. As noted earlier, an expected by‐product of the
1
/
2
0
2
2
prolonged closure of schools and lockdown is the psychological impact on children (Sprang & Silman, 2013). If left
]
.
S
e
e
t
unrecognized and unsupported early on, these mental health problems will only further exacerbate the strain
h
e
T
e
r
m
already placed on mental health services across Scotland and elsewhere (Atkins et al., 2017). Teachers have an
s
a
n
d
essential role in addressing these issues by identifying, supporting early signs of mental health distress, and facil
C
o
n
d
i
t
itating referrals to appropriate resources (Green et al., 2018), justifying the need for the provision of greater training
i
o
n
s
(
h
t
and funding to address the knowledge gap reported in this study.
t
p
s
:
/
/
o
n
Furthermore, to ensure interventions are adequately tailored for the individuals whose lives they seek to
l
i
n
e
l
i
b
improve, a priority should be given to further research that seeks the views and perspectives of children in relation
r
a
r
y
.
w
i
to mental health education and the role of teachers and schools in supporting their needs.
l
e
y
.
c
o
m
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t
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s
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a
n
d
-
7 | LIMITATIONS
c
o
n
d
i
t
i
o
n
s
)
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W
This study employed an online survey as the primary method of data collection. However, this method comes with
i
l
e
y
O
several advantages; several limitations should be noted, such as the potential of a participant misinterpreting the
n
l
i
n
e
L
question or participants being unable to explain further the reason for their answer due to the closed‐ended format
i
b
r
a
r
y
of the questions. Although the Likert‐scale approach helped gather an overall idea about how participants feel, it
f
o
r
r
u
l
could have been helpful to allow a section for participants to add their comments. An option to allow participants to
e
s
o
f
u
s
respond freely could have provided further insight concerning the rationale of teachers' responses. Another po
e
;
O
A
tential limitation of this study result from the lack of male primary teacher participation in the survey, as 98.9% of
a
r
t
i
c
l
e
s
respondents identified as female. Although the representation of female teachers is high, it somewhat reflects the
a
r
e
g
o
gender imbalance among primary school teachers across Scotland, which is reported to be 90% female (Scottish
v
e
r
n
e
d
Government, 2019). Finally, it is important to acknowledge that the results were based on teachers' perceptions
b
y
t
h
e
and, therefore, do not necessarily provide an accurate picture of children's mental health in schools.
a
p
p
l
i
c
a
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CONFLICT OF INTERESTS
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The authors declare that there are no conflict of interests.
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ETHICS STATEMENT
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The research reported in this article meets ethical guidelines, including adherence to the legal requirements of the
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study country. Ethical approval was obtained from the University of Glasgow's ethics committee.
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DATA AVAILABILITY STATEMENT
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The data that support the findings of this study are available from the corresponding author upon reasonable
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request.
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ORCID
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Jeremy M. Law http://orcid.org/0000-0001-6075-2384
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Lima, N. N. R., Do Nascimento, V. B., De Carvalho, S. M. F., De Abreu, L. C., Neto, M. L. R., Brasil, A. Q., Junior, F. T. C.,
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De Oliveira, G. F., & Reis, A. O. A. (2013). Childhood depression: A systematic review. Neuropsychiatric Disease and
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Treatment, 9, 1417–1425. https://doi.org/10.2147/NDT.S42402
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Loades, M. E., & Mastroyannopoulou, K. (2010). Teachers' recognition of children's mental health problems. Child and
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Adolescent Mental Health, 15(3), 150–156. https://doi.org/10.1111/j.1475-3588.2009.00551.x
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Martin, J. K., Pescosolido, B. A., & Tuch, S. A. (2000). Of fear and loathing: The role of 'disturbing behavior,'labels, and causal
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Mcleod, S. (2012). What's the difference between qualitative and quantitative research?. https://www.simplypsychology.org/
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simplypsychology.org-QualitativevsQuantitative.pdf
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Mcleod, S. (2020, May 24). Likert scale. https://www.simplypsychology.org/likert-scale.html
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Mental Health Foundation. (2018). Make it count: Let's put health and well‐being at the heart of Scotland's schools. https://
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www.mentalhealth.org.uk/sites/default/files/make-it-count-policy-briefing-scotland.pdf
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Mental Health Foundation. (2019, December 19). Mental health statistics: Children and young people. https://www.
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mentalhealth.org.uk/statistics/mental-health-statistics-children-and-young-people
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Mental Health Foundation. (2020, May 4). Mental health statistics: The most common mental health problems. https://www.
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Mentally Healthy Schools. (2020). Needs and progress. https://www.mentallyhealthyschools.org.uk/whole-school
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approach/school-and-local-commissioning/needs-and-progress/
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Moon, J., Williford, A., & Mendenhall, A. (2017). Educators' perceptions of youth mental health: Implications for training and
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the promotion of mental health services in schools. Children and Youth Services Review, 73(1), 384–391. https://doi.
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r
org/10.1016/j.childyouth.2017.01.006
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Moor, S., Ann, M., Hester, M., Elisabeth, W. J., Robert, E., Robert, W., & Caroline, B. (2007). Improving the recognition of
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depression in adolescence: Can we teach the teachers? Journal of Adolescence, 30(1), 81–95. https://doi.org/10.1016/
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NHS Research Scotland. (2019, December 19). Mental health. http://www.nhsresearchscotland.org.uk/research-areas/
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mental-health
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Ohrt, J. H., Deaton, J. D., Linich, K., Guest, J. D., Wymer, B., & Sandonato, B. (2020). Teacher training in K–12 student
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mental health: A systematic review. Psychology in the Schools, 57(5), 833–846. https://doi.org/10.1002/pits.22356
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Powers, J. D., Wegmann, K., Blackman, K., & Swick, D. C. (2014). Increasing awareness of child mental health issues among
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elementary school staff. Families in Society: The Journal of Contemporary Social Services, 95(1), 43–50. https://doi.org/
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RCPCH. (2017). State of child health report 2017. https://www.rcpch.ac.uk/sites/default/files/2018-05/state_of_child_
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health_2017report_updated_29.05.18.pdf
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2374 | MACLEAN AND LAW
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,
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Reinke, W. M., Stormont, M., Herman, K. C., Puri, R., & Goel, N. (2011). Supporting children's mental health in schools:
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Teacher perceptions of needs, roles, and barriers. School Psychology Quarterly, 26(1), 1–12. https://doi.org/10.1037/
n
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Reiss, F. (2013). Socioeconomic inequalities and mental health problems in children and adolescents: A systematic review.
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Social Science & Medicine, 90(1), 24–31. https://doi.org/10.1016/j.socscimed.2013.04.026
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Rosa, G. (2018). Using children's rights in mental health policy and practice. http://www.crae.org.uk/media/125976/
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Rothì, D. M., Leavey, G., & Best, R. (2008). On the front‐line: Teachers as active observers of pupils' mental health. Teaching
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SAMH. (2017). Going To Be…Well‐Trained: SAMH survey on school staff training in mental health. https://www.samh.org.uk/
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1
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documents/welltrained.pdf
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1
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SAMH. (2018). Draft budget 2017–18. https://www.parliament.scot/S5_HealthandSportCommittee/Inquiries/DRB030_
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Scottish_Association_for_Mental_Health_(SAMH).pdf
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Scottish Government. (2018). Rejected referrals Child and Adolescent Mental Health Services (CAMHS). https://www.gov.
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scot/binaries/content/documents/govscot/publications/research-and-analysis/2018/06/rejected-referrals-child
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adolescent-mental-health-services-camhs-qualitative-quantitative/documents/00537523-pdf/00537523-pdf/
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govscot%3Adocument/00537523.pdf
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Scottish Government. (2019). Summary statistics for schools in Scotland No. 9. https://www.gov.scot/binaries/content/
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documents/govscot/publications/statistics/2018/12/summary-statistics-schools-scotland-9-2018/documents/
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Sprang, G., & Silman, M. (2013). Post‐traumatic stress disorder in parents and youth after health‐related disasters. Disaster
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Medicine and Public Health Preparedness, 7(1), 105–110. https://doi.org/10.1017/dmp.2013.22
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The Key. (2017). State of Education Survey Report 2017. Rising to the challenge: Examining the pressures of schools and how
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they are responding. https://view.joomag.com/state-of-education-report-2017/0676372001494577623.
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Tully, L. A., Hawes, D. J., Doyle, F. L., Sawyer, M. G., & Dadds, M. R. (2019). A national child mental health literacy initiative
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is needed to reduce childhood mental health disorders. Australian & New Zealand Journal of Psychiatry, 53(4), 286–290.
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Walter, H. J., Gouze, K., & Lim, K. G. (2006). Teachers' beliefs about mental health needs in inner‐city elementary schools.
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Journal of the American Academy of Child & Adolescent Psychiatry, 45(1), 61–68. https://doi.org/10.1097/01.chi.
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0000187243.17824.6c
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Wei, Y., McGrath, P. J., Hayden, J., & Kutcher, S. (2015). Mental health literacy measures evaluating knowledge, attitudes
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and help‐seeking: A scoping review. BMC Psychiatry, 15(1), 2. https://doi.org/10.1186/s12888-015-0681-9
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WHO: Adolescence Mental Health. (2012). Mapping actions of nongovernmental associations and other international
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development organisations. World Health Organisation. http://apps.who.int/iris/bitstream/handle/10665/44875/
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9789241503648_eng.pdf;jsessionid=B09D1D46A7AA36AA5757E9E191B3F023?sequence=1
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Workman, C. G., & Prior, M. (1997). Depression and suicide in young children. Issues in Comprehensive Pediatric Nursing,
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20(2), 125–132. https://doi.org/10.3109/01460869709026883
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d
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Young Minds. (2017). Wise up to wellbeing in schools. https://youngminds.org.uk/media/1428/wise-up-prioritising
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wellbeing-in-schools.pdf
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APPENDIX A: SURVEY QUESTIONS
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1. After reading the Plain Language Statement do you give consent for the information provided to be used
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within this research?
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○ Yes
b
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○ No
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MACLEAN AND LAW | 2375
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2. Do you give consent for the information provided to be used within this research?
D
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o Yes
l
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e
d
o No
f
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3. What gender do you identify as?
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4. What age are you?
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5. How many years have you been in the teaching profession?
r
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6. Which council area do you work in?
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7. Job title
/
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8. In the past year which of the following mental health concerns have you noticed in the children within the
0
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1
0
0
2
school? Please tick all you have seen with in past year
/
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.
2
2
○ Disruptive behaviours/acting out
6
4
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○ Problems with inattention
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○ Hyperactivity
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○ Defiant behaviour
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○ Family stress (parent death, divorce etc)
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○ Peer problems
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○ Aggressive behaviour
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○ Anxiety problems
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○ Bullying
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[
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9
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○ Victims of bullying
1
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0
2
2
○ Depression
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○ Immigration and cultural adjustment issues
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○ School phobia
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9. Do you feel that schools should be involved in identifying and improving the mental health issues in pupils?
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A BC D E
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STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE
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For the following page (question 10 ‐ 19) please indicate how much you agree with the given statement;
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A BC D E
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STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE
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10. “It is the role of the teacher to screen mental health problems”
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11. “Teachers should be conducting social‐emotional lessons”
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12. “Teachers should be implementing classroom behavioural interventions”
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13. “Teachers should NOT be conducting behavioural assessments”
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14. “Teachers should be monitoring student progress”
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15. “It is the role of the teacher to refer children and families to school‐based services”
a
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16. “It is NOT the role of the teacher to refer children and families to community‐based”
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17. Do you feel that you have enough knowledge required to meet the mental health needs of the children in your
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school? e.g, knowing how to seek help, being aware of the stigma and how to reduce it etc
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18. Do you feel you have the skills (ability to make use of your knowledge) required to meet the mental health
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needs of children within the school
l
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a
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d
19. Do you feel you have adequate cultural knowledge and communication/interpersonal skills to meet the needs
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of culturally diverse children in the school
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/
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20. Where do you learn about behavioural interventions that aim to promote positive mental health schoolwide?
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Please select all that apply
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y
.
w
o Workshops and in‐service days
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.
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o Independent study
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o Undergraduate course work
0
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1
0
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2
o Graduate course work
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2
o Not Applicable ‐ I have had no training
6
4
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21. How much training have you had on, mental health related, behavioural interventions
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o Substantial
r
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O
o Moderate
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o Minimum
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o None
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22. How often do you use behavioural interventions to promote positive mental health?
r
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o
o Substantial
n
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o Moderate
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o Minimum
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o None
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o Unsure
s
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For the following page (question 23‐33) please indicate to what extent you believe the given issue is a
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d
i
t
reason students with mental health needs fall through the cracks;
i
o
n
s
(
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A BC D E
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STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE
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23. Lack of adequate parent support programs
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24. Lack of prevention programs for students with externalized behaviour
n
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)
o
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W
25. Lack of prevention programs for students with internalized behaviour
i
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y
O
26. Lack of staff training or coaching
n
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27. Lack of early screening and prereferral programs
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28. Lack of ongoing monitoring for students with mental health needs
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29. Lack of early intervention programs
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30. Lack of implementation of existing programs as intended
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31. Lack of adequate crisis planning and support
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32. Lack of bullying programs
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33. Lack of administrative support
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For the following page (question 34‐43) please indicate to what extent you feel the issue is an identifiable
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barrier for supporting mental health;
a
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a
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STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE
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34. Insufficient number of school mental health professionals
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35. Lack of adequate training for dealing with children's mental health needs
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.
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36. Mental health issues are not considered a role of the school
/
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/
1
37. Lack of funding for school‐based mental health services
0
.
1
0
0
2
38. Stigma associated with receiving mental health services
/
p
i
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s
.
2
2
39. Competing priorities taking precedence over mental health
6
4
8
b
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40. Difficulty identifying children with mental health needs
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41. Lack of coordinated services between schools and community
r
s
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42. Lack of referral options in the community
f
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43. Language and cultural barriers with culturally diverse student
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School Psychology Quarterly © 2011 American Psychological Association 2011, Vol. 26, No. 1, 1–13 1045-3830/11/$12.00 DOI: 10.1037/a0022714
Supporting Children’s Mental Health in Schools:
Teacher Perceptions of Needs, Roles, and Barriers
Wendy M. Reinke, Melissa Stormont, Keith C. Herman, Rohini Puri, and Nidhi Goel University of Missouri
There is a significant research to practice gap in the area of mental health practices and
interventions in schools. Understanding the teacher perspective can provide important
information about contextual influences that can be used to bridge the research to
.
practice gap in school-based mental health practices. The purpose of this study was to
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l
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examine teachers’ perceptions of current mental health needs in their schools; their
a
o
r
knowledge, skills, training experiences and training needs; their roles for supporting
b
d
children’s mental health; and barriers to supporting mental health needs in their school
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settings. Participants included 292 teachers from 5 school districts. Teachers reported
n
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m
viewing school psychologists as having a primary role in most aspects of mental health
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s
s
service delivery in the school including conducting screening and behavioral assess
i
d
ments, monitoring student progress, and referring children to school-based or commu
e
b
nity services. Teachers perceived themselves as having primary responsibility for
o
t
t
implementing classroom-based behavioral interventions but believed school psychol
o
n
ogists had a greater role in teaching social emotional lessons. Teachers also reported a
s
i
d
global lack of experience and training for supporting children’s mental health needs.
n
a
Implications of the findings are discussed.
r
e
s
u
l
a
Keywords: school-based intervention, evidence-based, mental health, children
u
d
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v
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n
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c
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P
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a
c
ir
e
m
A
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gi
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s
ih
T
School-based prevention and intervention
h
t
f
practices have become essential for reducing the
o
e
incidence of mental health problems that inter
s
u
l
fere with learning and social development
a
n
o
(Dwyer, 2004). The vast majority of individuals
s
r
e
who receive any mental health services receive
p
e
h
them in school (Rones & Hoagwood, 2000;
t
r
o
U.S. Department of Health & Human Services,
f
y
l
1999). The need for providing these services is
e
l
o
clear. Prevalence estimates indicate that 20% of
s
d
e
children younger than 18 years of age have
d
n
mental health concerns and the percentage in
e
t
n
i
creases to 25% for children in adverse environ
s
i
e
ments (World Health Organization, 2004). Of
l
c
i
t
r
a
s
i
h
T
Wendy M. Reinke, Keith C. Herman, Rohini Puri, and Nidhi Goel, Department of Educational, School, and Counseling Psychology, University of Missouri; Melissa Stormont, Department of Special Education, University of Missouri.
This research was supported by a grant from the Missouri Partnership for Educational Renewal at the University of Missouri.
Correspondence concerning this article should be ad dressed to Wendy M. Reinke, Ph.D., Department of Edu cational, School, and Counseling Psychology, University of Missouri, 16 Hill Hall, Columbia, MO 65211. E-mail: reinkewmissouri.edu
1
the 5% to 9% of children and youth who meet the criteria for severe emotional disorder, only a small percentage are served (Kauffman, 2005; Walker, 2004).
In response to the need for expanded mental health services for children, research on the use of universal (i.e., targeting all students) and selective (i.e., targeting students at risk) school based interventions for mental, emotional, and behavior problems has grown considerably over the past decade (Hoagwood et al., 2007; Stor mont, Reinke, & Herman, 2010; Weissberg, Kumpfer, & Seligman, 2003). Schools provide excellent settings for targeting children’s men tal health, their academic performance, and the important connection between them (Green wood, Kratochwill, & Clements, 2008). Despite the increased availability of evidence-based in terventions and the importance of targeting the school setting, the widespread adoption and im plementation of evidence-based practices and interventions to both promote children’s mental health and intervene with children with specific issues has not occurred (DuPaul, 2003; Kratochwill, 2007; Schaughency & Ervin, 2006). This research to practice gap appears to be very pronounced in the mental health field
2 REINKE, STORMONT, HERMAN, PURI, AND GOEL
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b
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l
a
s
t
i
f
o
e
n
o
r
o
n
o
i
t
a
i
c
o
s
s
A
l
a
c
i
g
o
l
o
h
c
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s
P
n
a
c
i
r
e
m
A
e
h
t
y
b
d
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t
h
g
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r
y
p
o
c
s
i
t
n
e
m
u
c
o
d
s
i
h
T
(Walker, 2004). One group of school personnel in particular, classroom teachers, play a key role in understanding this gap regarding school based mental health. For instance, teachers are often the individuals in the school asked to implement school-based universal interven tions, as well as to refer students in need of additional supports.
Understanding the perspective of teachers can be useful for researchers and school psy chologists advocating for increased implemen
.
y
l
tation of evidence-based interventions in school
d
a
o
settings. Therefore, this study evaluated teach
r
b
d
ers’ attitudes and perceptions of mental health
e
t
a
needs in their schools including most common
n
i
m
concerns, barriers for addressing mental health
e
s
s
needs, and issues related to their experience,
i
d
e
knowledge, training, and adoption of interven
b
o
t
tions. Further, teacher perceptions of their roles
t
o
in comparison to school psychologists’ roles for
n
s
i
specific activities (e.g., delivering social emo
d
n
a
tional curriculum) were explored to determine if
r
e
teachers feel they play a role in some aspects,
s
u
l
but not others of school-based mental health.
a
u
d
The individual and system level factors that
i
v
i
d
influence whether evidence-based practices are
n
i
utilized in school have been the topics of recent
e
h
t
research. For instance, researchers have recently
f
o
e
evaluated teacher perceptions (individual level
s
u
l
factors) of classroom interventions for children
a
n
o
with ADHD toward gaining important insights
s
r
e
into strategies for effective consultation (Curtis,
p
e
Pisecco, Hamilton, & Moore, 2006). If teachers
h
t
r
are reluctant to implement recommended
o
f
y
school-based programs and practices (e.g., Gra
l
e
l
o
cyzk et al., 2005) efforts to understand the atti
s
d
tudes and perceptions causing the reluctance
e
d
n
will be important, especially for school psychol
e
t
n
i
ogists consulting with teachers. Other research
s
i
has focused on system level mechanisms for
e
l
c
i
t
promoting the use of evidence-based practices
r
a
in schools, including expert and peer social in
s
i
h
fluences on implementation (Atkins et al., T
2008), collaboration between research and pol icy or practice communities (Frazier, Formoso, Birman, & Atkins, 2008), and the interactions between individual characteristics, the interven tion, and systems (Graczyk, Domitrovich, Small, & Zins, 2006). Ringeisen and colleagues (2003) argued that effective school-based men tal health services will result from the marriage of systems reform efforts, capacity building, and the delivery of evidence-based intervention
strategies. School psychologists operate at the individual level, consulting with teachers and providing student services, and at the system level by advocating for the adoption and use of evidence-based interventions and practices for supporting student mental health in schools. Therefore, insights into the attitudes and per ceptions of teachers can help school psycholo gists address important issues for reform and capacity building.
There are a number of challenges in success fully implementing and maintaining mental health practices in schools. For instance, while educators and policymakers recognize that good mental health is essential to achieving success in life, schools are not primarily organized to facilitate the provision of mental health services (Cunningham & Cunningham, 2001; Adelman & Taylor, 1998). Furthermore, teachers, the professionals who are most likely to be able to impact behavior and mental health needs in children on a daily basis, may neither have the resources nor knowledge to do so (Kratochwill, & Shernoff, 2004). A critical factor affecting how individuals within the school successfully use a new program is the type of professional training and support that is available (Ringeisen et al., 2003). Understanding the needs for train ing and current knowledge of teachers regarding school-based mental health will provide in sights into how we train and support current and future teachers.
The need for more attention to the disconnect between efficacious practices (practices that have been determined to be effective in research trials), and effective practices (practices that are adopted and used in the desired contexts), is evident (Schaughency & Ervin, 2006; Walker, 2004). School personnel operate within a system of mul tiple, and sometimes competing, demands. In or der to build capacity for utilizing evidence-based practices within school contexts, the exchange of information about dissemination needs to be bidi rectional (Schaughency & Ervin, 2006). Re searchers need to explore the use of practices within context in order to determine factors that can support the actual implementation of evi dence-based practices within school settings. As such both implementer/provider level and orga nization level factors need attention. Within the schools, teachers are natural implementers who can significantly influence mental health out comes in children through the use of evidence
MENTAL HEALTH IN SCHOOLS 3
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n
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o
n
o
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a
i
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o
s
s
A
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a
c
i
g
o
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o
h
c
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P
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m
A
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b
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s
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s
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T
based practices. Many of the evidence-based universal interventions for school-based mental health require teacher implementation and se lective or indicated interventions often involve teacher referral (see Greenberg et al., 1999). However, teachers may perceive some of these practices as falling within the expertise of an other professional, such as a school psycholo gist. If universal interventions are to be effec tive in the classroom, teachers must accept this role and feel they are adequately trained to be
.
y
l
successful. Therefore, understanding the
d
a
o
teacher perspective can provide important infor
r
b
d
mation about contextual influences that can be
e
t
a
leveraged to bridge the research to practice gap
n
i
m
in school-based mental health practices.
e
s
s
Thus, in order to build capacity and inform
i
d
e
system level needs it is important to know the
b
o
t
educational and training requirements of teach
t
o
ers regarding implementation of effective men
n
s
i
tal health practices in schools and/or if schools
d
n
a
need to focus their efforts on overcoming spe
r
e
cific barriers for providing services. However,
s
u
l
few studies have assessed teachers’ perceptions
a
u
d
of mental health needs in schools or their pre
i
v
i
d
paredness and roles for supporting children with
n
i
mental health needs. At the most fundamental
e
h
t
level, it is important to determine if teachers see
f
o
e
the relevance of supporting children with men
s
u
l
tal health needs (Ringeisen et al., 2003;
a
n
o
Schaughency & Ervin, 2006). More specifi
s
r
e
cally, do teachers believe it is a role of schools
p
e
and teachers to support mental health needs in
h
t
r
children, and, if they do, do they feel they have
o
f
y
the knowledge and skills to be successful? Also,
l
e
l
o
what specific roles for supporting children’s
s
d
mental health do teachers affirm and how do
e
d
n
these compare to their perceptions of roles for
e
t
n
i
school psychologists? School psychologists are
s
i
often viewed as mental health professionals in
e
l
c
i
t
the school and may be seen as more responsible
r
a
for supporting the mental health of children in
s
i
h
schools.
T
Accordingly, the purposes of this study were twofold. First, we examined teacher perceptions of mental health concerns for children in their school, barriers to providing services, and per ceived gaps in services and training. Second, we examined teacher perceptions of their role in supporting children’s mental health in compar ison to school psychologists. Given the large research to practice gap noted above, we ex pected teachers to indicate lack of knowledge in
selecting and implementing evidence-based in tervention, as well as a need for more training. We also expected that teachers would identify a lack of resources and training to be key barriers to supporting children’s mental health. Further, we hypothesized that teachers would rate the school psychologist as having primary responsibility for most of the roles in supporting children’s mental health, particu larly with regard to conducting assessments, screening, implementing interventions, and monitoring outcomes.
Method
Participants
A total of 292 early childhood and elemen tary school teachers from five schools districts (rural, suburban, and urban) completed the sur vey online. The majority of participants were European American (97.3%) and female (97%). A small percentage of participants were African American (1.5%), multiracial (.8%), or Asian American (.4%). The participants’ years of ex perience ranged from 1 year to 37 years with an overall mean average of 13 years. While the mean average of years of experience reported by teachers was representative of the state over all, two of the school districts had a slightly higher mean compared to the years experience represented by teachers in their specific district (15 years vs. 9 years for both). However, teach ers with 5 or fewer years of experience were represented in the overall sample (26%) and across districts (range 17–33%). The sample included classroom teachers (91.1%) and spe cial education teachers (8.9%). Paraprofes sional and other nonclassroom-based teachers were excluded from the sample. Forty percent of respondents were from rural school dis tricts, 31.8% were from urban school dis tricts, and 27.7% were from suburban school districts. Of the five school districts only one district, a large urban district, had schools, and therefore teachers, who did not partici pate in the survey. The demographics of stu dents attending schools that did not partici pated in the survey were twice as likely to be predominantly African American with high rates of free and reduced lunch.
4 REINKE, STORMONT, HERMAN, PURI, AND GOEL
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o
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o
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o
s
s
A
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o
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P
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m
A
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T
Measures
Mental health needs and practices in schools survey. The survey included items across three main categories: (1) demographic information related to the participants and their schools; (2) participants’ perceptions and atti tudes toward the role of schools in children’s mental health; and (3) participants’ perceptions, knowledge, and attitudes toward evidence based practices in schools. Terms were defined
.
y
l
for participants throughout the survey to ensure
d
a
o
understanding of the questions. Mental health
r
b
issues/needs was defined as “any psychological,
d
e
t
a
social, emotional, or behavioral problem that
n
i
interferes with the students’ ability to function.”
m
e
s
s
Mental health intervention/practice was defined
i
d
e
as “any type of support or service provided to
b
o
students who are at risk for or have been iden
t
t
o
tified as having psychological, social, emo
n
s
i
tional, and/or behavior problems, or to prevent
d
n
these problems.” In the case of the term evi
a
r
e
dence-based, an initial question in the survey
s
u
l
asked if respondents had heard of the term. The
a
u
d
next section asking about their use of evidence
i
v
i
based interventions, including the following
d
n
i
definition: “treatment approaches, interventions
e
h
t
and services, which have been systematically
f
o
e
researched and shown to make a positive dif
s
u
l
ference in children” (Association for Children’s
a
n
Mental Health, p. 4).
o
s
r
e
The survey items were based on an extensive
p
e
review of related surveys and literature (Aarons,
h
t
r
2004; Chorpita, Becker, & Daleiden, 2007; Ell
o
f
y
iot & Van Brock, 1991; National Center for
l
e
l
o
Education Evaluation & Regional Assistance,
s
d
2003; White & Kratochwill, 2005). The final
e
d
n
items were developed based on an iterative re
e
t
n
i
view process that included feedback from a
s
i
range of constituent groups with expertise on
e
l
c
i
the topic. Content validity was established in
t
r
a
the first draft of the survey; this draft was re
s
i
h
viewed and revised based on input solicited T
from five expert scholars in the field of mental health practices in schools. Experts provided feedback about all aspects of the survey. In particular, we requested their feedback about the coverage of survey domains, relevance of each domain, and any missing aspects of the survey that could inform understanding of school professionals’ roles and attitudes toward mental health practices in schools. In addition to expert scholars, the survey was administered to
a group of 10 teachers, school counselors, school psychologists, special education teach ers, and school administrators. These practitio ners were asked to complete the survey and provide feedback about the questions, language, and content of the survey. The authors dis cussed the feedback from this group and edited the survey accordingly.
The revised survey was converted to an elec tronic version on Survey Monkey. The online version of the survey was then piloted among members of the research team (n 25). The members include faculty and graduate students with experience in school-based mental health. Their feedback was incorporated into the survey before dissemination to schools. The focus of this study was on items pertaining to teacher reported mental health concerns in their schools, report of knowledge, skills, and train ing, barriers and gaps in services, and perceived roles of teachers and school psychologists.
Mental health concerns. Teacher reported on whether they had taught a student in the past year with a mental health concern across 14 domains such as having aggressive behavior, depression, peer problems, and inattention. In addition, teachers provided in open format the top five mental health concerns they encounter in schools.
Knowledge, skills, and training. Teach ers were asked a series of questions to deter mine their current knowledge, skills, and train ing in school-based mental health practices. First, they were asked to rate the amount of training and experience they had in using be havioral interventions by indicating none, min imal, moderate, or substantial amounts of train ing or experience. Additionally, they were asked to report what type of training, if any, they had received in behavioral interventions. Teachers were also asked if they felt they had the knowledge or skills required to meet the mental health needs of the children with whom they work on a 5-point Likert-type scale ranging from strongly disagree to strongly agree. Teachers were also asked to answer a yes or no question about if they had heard the term evidence-based. Lastly, teachers provided open answers to areas they would like addi tional training.
Barriers. Teachers were asked to rate their perception of barriers to providing men tal health services in schools on a 5-point
MENTAL HEALTH IN SCHOOLS 5
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o
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o
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a
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o
s
s
A
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c
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g
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o
h
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P
n
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m
A
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s
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T
Likert-type scale, ranging from strongly dis agree to strongly agree for 12 items, including lack of training, lack of funding for school based mental health services, and the belief that mental health problems do not exist. The inter nal consistency of the scale was adequate (Cronbach’s alpha .82).
Reasons children fall through cracks. Teachers were asked to rate their perception of the reasons that children with mental health .
needs “fall between the cracks.” A total of 10
y
l
d
a
items were rated on a 5-point Likert scale, rang
o
r
b
ing from strongly disagree to strongly agree.
d
e
t
Items included lack of parenting programs, lack
a
n
i
of prevention programs, and lack of administra
m
e
s
tor support. The internal consistency of the
s
i
d
scale was adequate (Cronbach’s alpha .86).
e
b
Roles of school personnel. Teachers were
o
t
t
also asked using a 5-point Likert scale rang
o
n
s
i
ing from strongly disagrees to strongly agree
d
n
if they felt supporting the mental health needs
a
r
e
of children was a role of the school. Addi
s
u
l
tionally, teachers were asked to rate the extent
a
u
d
to which they felt teachers and school psy
i
v
i
d
chologists should be involved in addressing
n
i
mental health needs of students across eight
e
h
t
f
domains, including screening, referring to
o
e
community-based providers, implementing
s
u
l
classroom interventions, and conducting as
a
n
o
sessments. Answers were provided using a
s
r
e
p
5-point Likert scale, ranging from strongly
e
h
t
disagree to strongly agree. Both scales had
r
o
f
high internal consistency as indicated by
y
l
Cronbach’s alpha of 0.78 for the teacher scale
e
l
o
s
and 0.86 for questions pertaining to the role
d
e
of the school psychologist.
d
n
e
t
To provide further evidence of the distinc
n
i
s
tiveness of these latter four subscales, we sub
i
e
l
mitted all 44 items from the Barriers, Cracks,
c
i
t
r
a
Teacher Roles, and School Psychology Roles
s
i
h
subscales to a confirmatory factor analysis using T
MPlus 6.0. The model fit for the four factor solution was in the acceptable range by conven tional standards: the Root Mean Square Error of Approximation (RMSEA) value was 0.08 (90% confidence interval .078-.085) and the Stan dardized Root Mean Square Residual (SRMSR) was 0.06 (Browne & Cudeck, 1993). All items had acceptable loadings on their respective scales (.30 or higher) with the vast majority of loadings exceeding .60.
Procedures
Two of the authors attended a meeting with a large group of superintendents from the state of Missouri and invited school districts to take part in the study. Superintendents were told that the purpose of the study was to survey staff from early childhood programs and elementary schools on their perceptions of mental health needs and practices in schools. Eleven superin tendents indicated they were interested in the study and gave permission for a follow up con tact. Of these 11 districts, 5 agreed to participate by soliciting the survey to their primary and elementary education personnel (45% response rate). School districts who decided not to par ticipate indicated that other priorities took pre cedence at that time.
Interested district superintendents were con tacted over the phone or through email, depend ing on their communication preferences, to con firm participation. The district-level officials were then asked to provide contact information for the elementary and primary schools in the district and encouraged to inform the school administrators in their district about the research project. School administrators were contacted by telephone or electronic correspondence, and 21 schools from the five districts agreed to participate and provided information on their staff for recruitment purposes. A total of 590 teachers were solicited to participate in the sur vey for a response rate of 50%. Recent research documented that a response rate of 40% or more in survey research was acceptable for accurate reliable data (Kramer, Schmalenberg, Brewer, Verran, & Keller-Unger, 2009). In other re search on online survey response rates, the av erage rate across 63 studies was 40% (Cook, Heath, & Thompson, 2000). Thus, our response rate is acceptable and even above average for online surveys. The survey took, on average, 15 to 20 minutes to complete. Responses were col lected during a 1-month window from mid March to mid-April in 2008.
As an incentive for participating, administra tors and teachers were told their school would be entered into a lottery for a chance to win $500 for their school if 85% of staff completed the survey. Those schools that qualified (n 8) were entered into a lottery with one school winning. Also, individual participants who
6 REINKE, STORMONT, HERMAN, PURI, AND GOEL
completed the survey were entered into a lottery for a chance to win a $25 gift card.
Coding of Open-Ended Items
Table 1
Teacher Reported Mental Health Concerns in Children From Past Year (n 292)
% of
Concern
teachers
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o
n
o
i
t
a
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o
s
s
A
l
a
c
i
g
o
l
o
h
c
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P
n
a
c
i
r
e
m
A
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y
b
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g
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y
p
o
c
s
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n
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m
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o
d
s
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T
Two open-ended items were coded using the following process. Two coders worked together to code the open-ended questions of the survey. During the first review of the data, broad themes were identified and codes were assigned to them. Then, the data were systematically eval
.
y
l
uated and coded. Over the course of the coding
d
a
o
r
process, when the coders noticed new responses
b
d
in large numbers that did not fit with the original
e
t
a
themes, additional codes and categories were
n
i
m
added to the original list. A consensus was
e
s
s
i
required between both the coders for a response
d
e
to be assigned a certain code. A third coder
b
o
t
reviewed the broad codes developed and en
t
o
tered the codes into SPSS accordingly.
n
s
i
d
n
a
Missing Data
r
e
s
u
l
a
Results were reported using listwise deletion
u
d
i
for missing data on all variables. Missing re
v
i
d
sponses were more likely for questions that
n
i
e
occurred later into the survey, most likely due to
h
t
f
participant fatigue. However, over 91% of re
o
e
spondents completed all items.
s
u
l
Chi-square tests revealed no significant dif
a
n
o
ferences between individuals who completed all
s
r
e
items versus those who did not with regard to
p
e
h
their role (special education vs. general educa
t
r
o
tion) or being from a particular school or school
f
y
l
district ( ps .05).
e
l
o
s
d
e
Results
d
n
e
t
n
i
Types of Mental Health Issues
s
i
e
l
c
i
t
Teachers indicated whether they had taught
r
a
or worked with a student in the past year with
s
i
h
specific mental health and behavioral concerns T
(listed in Table 1). Additionally, using an open response format, teachers were also asked to indicate what they felt to be the most concern ing mental health issues in their schools. The top five student mental health concerns were as follows in order from most concerning: (1) Be havior problems, including disruptive, defiant, aggressive, and conduct problems, (2) Hyperac tivity and inattention problems, (3) Students with significant family stressors, (e.g., di
Disruptive behaviors/acting out 97% Problems with inattention 96% Hyperactivity 96% Defiant behavior 91% Family stressors (e.g., parent death, divorce) 91% Peer problems 87% Aggressive behavior 78% Anxiety problems 76% Bullying 75% Victims of bullying 69% Depression 54% Immigration and cultural adjustment issues 29% School phobia 18%
vorced parents, parents in prison, parents with mental health concerns), (4) Social skills def icits, and (5) Depression. A large number of teachers also reported peer-related problems such as bullying and student victims of bul lying as major concerns.
Teachers’ and School Psychologists’ Roles in Supporting Children With Mental Health Needs
In response to the question “I feel that schools should be involved in addressing the mental health issues of students,” an over whelming majority agreed that schools should be involved (38% of teachers indicated that they strongly agreed, 51% indicated they agreed) with only 6% of teacher disagreeing with this statement (1% disagreed and 5% strongly disagreed).
Paired t tests were conducted for seven roles for supporting children’s mental health in schools; paired tests included teachers’ agree ment with performing different roles for sup porting children’s mental health paired with their perceptions of school psychologists’ roles for the same items (see Table 2). To control for Type I error given the number of tests run, Bonferroni correction was used (.05/7 tests run), which resulted in an adjusted alpha of .007 required for results to be considered significant (Myers & Well, 1995). Six of the 7 t tests yielded significant results and effect sizes were
MENTAL HEALTH IN SCHOOLS 7
Table 2
Results of T-Tests and Means (SD) For Teachers’ Perceptions of Their Roles and School Psychologists’ Roles for Supporting Children’s Mental Health Needs (n 280)
School
Role Teacher
psychologist T pd
.
s
r
e
h
s
i
l
b
u
p
d
e
i
l
l
Screening for mental health problems 3.07 (1.1) 4.63 (.62) 21.00 .000 1.77 Implementing classroom behavioral interventions 4.50 (.64) 3.98 (.94) 7.32 .000 .66 Teaching social-emotional lessons 3.87 (.97) 4.09 (.92) 2.91 .000 .23 Conducting behavioral assessments 3.47 (.99) 4.53 (.65) 15.77 .000 1.29 Monitoring student progress 4.23 (.75) 4.36 (.72) 2.25 .025 .18 Referring children and families to school-based services 3.92 (.89) 4.59 (.70) 10.96 .000 .84 .
y
Referring children and families to community-based services 3.46 (1.0) 4.63 (.63) 17.87 .000 1.41
l
d
a
o
Note. Likert scale for mean ratings: 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), 5 (strongly agree).
r
b
d
e
t
a
n
i
m
e
s
a
s
t
i
f
o
e
n
o
r
o
n
o
it
a
ic
o
s
s
A
la
c
ig
o
lo
hc
y
s
P
n
a
c
ir
e
m
A
e
h
t
y
b
d
e
t
h
gi
r
y
p
o
c
s
i
t
n
e
m
u
c
o
d
s
ih
T
calculated to determine the magnitude of effect
s
i
d
(Cohen, 1988). Cohen’s (1988) guidelines for
e
b
interpreting scores include: small effects range
o
t
t
from 0.20 to 0.49, medium from 0.50 to 0.79,
o
n
s
and large above 0.80.
i
d
n
a
r
e
s
Teacher Knowledge, Training, and
u
l
a
Experience in Supporting Mental Health
u
d
i
v
i
d
Teachers were asked whether they had heard
n
i
of the term “evidence-based practices,” 55.5%
e
h
t
of teachers indicated they had, while 44.5%
f
o
e
indicated they had not or were unsure. More
s
u
l
specific questions were included on involve
a
n
o
ment, knowledge, and skills in relation to sup
s
r
e
porting children’s mental health needs in
p
e
schools. In response to the question “I feel that
h
t
r
I have the level of knowledge required to meet
o
f
y
the mental health needs of the children with
l
e
l
o
whom I work,” 4% of teachers indicated that
s
d
they strongly agreed, 24% indicated they
e
d
n
agreed, 31% were neutral, 36% disagreed, and
e
t
n
i
5% strongly disagreed.
s
i
Teachers also responded to the question “I
e
l
c
i
t
feel that I have the skills required to meet the
r
a
mental health needs of the children with whom
s
i
h
I work,” and 4% of teachers indicated that they T
strongly agreed, 30% indicated they agreed, 29% were neutral, 32% disagreed, and 4% strongly disagreed. Teachers were also asked to respond to a question on their cultural knowl edge and skills. In response to the question “I feel that I have adequate cultural knowledge and communication/interpersonal skills to meet the mental health needs of the culturally diverse children with whom I work,” 6% of teachers indicated that they strongly agreed, 35% indi
cated they agreed, 37% were neutral, 20% dis agreed, and 2% strongly disagreed.
Teachers’ perceptions of experience, level and type of training related to behavioral inter ventions were also solicited. Teachers indicated their most common experiences learning about behavioral interventions occurred through workshops and inservices (68%), staff develop ment (53%), independent study (36%), under graduate course work (33%), and graduate course work (29%). Some teachers reported having no training experience in behavioral in terventions (9%). Teachers also rated their over all education or training on behavioral interven tions with 21% rating their education or training as none or minimal, 62% reported moderate, and 17% reported substantial education or train ing. In terms of experience using behavioral interventions, 20% rated their experience as none or minimal, 48% reported moderate, and 32% reported having substantial experience.
Teachers were asked to provide the top three areas in which they felt they needed additional knowledge or skills training. This was asked in an open format with responses coded utilizing the same procedures as described previously. From these data the top three areas identified for additional training were as follows: (1) Strategies for working with children with ex ternalizing behavior problems, (2) recogniz ing and understanding mental health issues in children, and (3) training in classroom man agement and behavioral interventions. A large number of teachers also reported the need for training in engaging and working effectively with families.
8 REINKE, STORMONT, HERMAN, PURI, AND GOEL
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Barriers to Services
Teachers’ also reported on the reasons they felt children needing mental health support fall through the cracks (see Table 3). The top four reasons, which were supported by more than half of teachers, included the lack of: (1) ade quate parent support programs, (2) prevention programs for students with externalizing behav ior, (3) prevention programs for internalizing programs, and (4) staff training and coaching. In
.
y
l
addition, teachers provided their opinions re
d
a
o
garding whether certain factors were barriers to
r
b
supporting children with mental health needs in
d
e
t
a
schools (see Table 4). The top three barriers
n
i
were insufficient number of school mental
m
e
s
s
health professionals, lack of training for dealing
i
d
with children’s mental health needs, and lack of
e
b
o
funding for school-based mental health.
t
t
o
n
s
i
Discussion
d
n
a
r
e
School professionals are under increased
s
u
l
pressure to be accountable for the practices they
a
u
d
implement with current legislation directing
i
v
i
teachers to use evidence-based practices (Yell
d
n
i
& Drasgow, 2003). Factors that influence adop
e
h
t
tion of evidence-based practices are the focus of
f
o
extensive research as researchers try to bridge
e
s
u
the research to practice gap by understanding
l
a
n
more about what makes an intervention trans
o
s
r
e
portable (Walker, 2004). To add to the literature
p
e
in this area, the purpose of this study was to
h
t
r
determine teachers’ perceptions of current men
o
f
y
tal health needs and issues in their schools and
l
e
l
their perceived role as well as school psychol
o
s
d
e
d
n
e
t
n
i
s
Table 3
i
e
l
ogists’ roles in supporting the mental health needs of children. Our hypotheses related to teachers’ knowledge of evidence-based prac tices, need for additional training, and barriers for supporting mental health were validated in our descriptive analyses, which will be dis cussed first.
Several findings emerged from the descrip tive analyses. First, 75% of all of the participat ing teachers reported either working with or referring students with mental health issues over the past year. A large percentage of teachers reported working with children with disruptive and acting out behavior, children with attention problems and children with hyperactivity. Fur ther, results indicated that nine out of 10 teach ers reported working with children with defiant behavior and children who were experiencing family stressors. This coincides with the reports of teachers feeling they need additional training in the areas of working with children exhibiting externalizing problems, effective classroom management and behavioral interventions, and engaging and effectively working with families. These findings provide us with important infor mation about the types of issues faces by teach ers on a regular basis as well as a guide on how to effectively train both inservice and preservice teachers. Given the robust literature about ef fective classroom management practices, it is disconcerting that so many teachers feel unpre pared to manage challenging student behaviors. Teacher education programs that fail to equip future educators with effective classroom man agement and behavior support planning skills
d
s
ih
T
Reasons Students With Mental Health Needs Fall Through the Cracks (n 276)
c
i
t
r
a
Because of a lack of: A/SA N D/SD
s
i
h
T
Adequate parent support programs 67% 23% 10% Prevention programs for students with externalizing behavior 62% 20% 18% Prevention programs for students with internalizing behavior 61% 23% 16% Staff training and coaching 51% 25% 23% Early screening and prereferral programs 46% 26% 28% Ongoing monitoring for students with mental health needs 45% 30% 25% Early intervention programs 44% 27% 29% Implementation of existing programs as intended 44% 32% 24% Adequate crisis planning and support 41% 38% 21% Bullying programs 34% 26% 40% Administrative support 34% 24% 42%
Note. A/SA 4 (agree) or 5 (strongly agree); N 3 (neutral); D/SD 2 (disagree) or 1 (strongly disagree).
MENTAL HEALTH IN SCHOOLS 9
Table 4
.
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s
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b
u
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i
l
l
a
s
t
i
Teacher Reported Barriers for Supporting Mental Health Needs (n 266)
Barrier A/SA N D/SD
Insufficient number of school mental health professionals 82% 12% 6% Lack of adequate training for dealing with children’s mental health needs 78% 16% 6% Lack of funding for school-based mental health services 66% 27% 7% Stigma associated with receiving mental health services 63% 27% 10% Competing priorities taking precedence over mental health 59% 30% 11% Difficulty identifying children with mental health needs 51% 18% 31% Lack of coordinated services between schools and community 41% 39% 20% Lack of referral options in the community 37% 40% 23% .
y
Language and cultural barriers with culturally diverse students 29% 32% 39%
l
d
a
Mental health issues are not considered a role of the school 27% 35% 38%
o
r
Mental health problems do not exist and are just an excuse 19% 26% 55%
b
d
e
t
Note. A/SA 4 (agree) or 5 (strongly agree); N 3 (neutral); D/SD 2 (disagree) or 1 (strongly disagree).
a
n
i
m
e
s
s
i
d
e
f
o
e
n
o
r
o
n
o
it
a
ic
o
s
s
A
la
c
ig
o
lo
hc
y
s
P
n
a
c
ir
e
m
A
e
h
t
y
b
d
e
t
h
gi
r
y
p
o
c
s
i
t
n
e
m
u
c
o
d
s
ih
T
are doing a disservice to the field. The profes
b
o
t
sion of teaching is an incredibly important and
t
o
challenging career. The results of this survey
n
s
i
indicate the need for training, strategies, and
d
n
a
attention toward supporting teachers faced with
r
e
students displaying significant behavioral, so
s
u
l
cial, and emotional difficulties.
a
u
d
Second, teachers reported that they felt it is
i
v
i
d
the schools’ responsibility to support children’s
n
i
mental health needs and that teachers should
e
h
t
play a specific role in doing so. In particular,
f
o
e
89% of teachers agreed that schools should be
s
u
l
involved in addressing the mental health needs
a
n
o
of children. However, only 34% of teacher re
s
r
e
ported that they felt they had the skills neces
p
e
sary to support these needs in children. This is
h
t
r
important information in regard to the research
o
f
y
to practice gap. If teachers believe they should
l
e
l
o
play a role in addressing the mental health needs
s
d
of children, but lack adequate knowledge or
e
d
n
skills to do so, transporting effective practice to
e
t
n
i
schools will require intervention developers to
s
i
include effective training and ongoing consul
e
l
c
i
t
tation/coaching as part of dissemination prac
r
a
tices. Further, school psychologists working
s
i
h
within school districts wanting to utilize evi T
dence-based practices could serve as consul tants or coaches supporting teacher-imple mented programs and practices.
We also hypothesized that teachers would rate school psychologists as having primary re sponsibility for most of the roles in supporting children’s mental health; we found that teachers regarded the role of school psychologist to be more expansive than their role in supporting mental health services. For instance, teachers
felt that school psychologists should play a greater role in screening, conducting assess ments, and teaching social emotional lessons in the classroom. However, teachers indicated that the role of implementing behavioral interven tions in the classroom was a teacher role. This is promising in that it indicates openness for teachers to implement behavioral interventions in their classroom. Thus, school psychologists can play a more supportive role through consul tation with teachers to develop and implement these interventions. However, it is interesting that teachers indicated the role of teaching so cial emotional lessons as being more appropri ate for school psychologists. Teachers clearly distinguish between teaching academics and teaching social competence. This is an area that researchers and school psychologists may target by making the important connection between academics and mental health evident. Children who struggle socially or emotionally are less likely to benefit from academic instruction (McClelland, Morrison, & Holmes, 2000). Sup porting teachers to integrate evidence-based so cial emotional curriculum into their classroom could produce positive outcomes for children while bridging the gap between research and practice. Furthermore, making the connection between the primary purpose of our schools, improving academic performance, with the mental health of children may help to bridge the communication gap between the educational and mental health systems, and increase the likelihood that activities are integrated into the existing school organization and structure (see Capella, Frazier, Atkins, Schoenwalk, &
10 REINKE, STORMONT, HERMAN, PURI, AND GOEL
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T
Glisson, 2008). It is important to also stress that if school psychologists take on this sup portive role, they need to have time and train ing in order for efforts to be successful.
Another interesting finding was the lack of knowledge regarding what is considered evi dence-based practice. Nearly half of teachers indicated that they had never even heard the term “evidence-based.” This seems surprising given the expansion of the term in research literature over the past decade. For instance,
.
y
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when conducting a search in PsycInfo of man
d
a
o
uscripts using the term “evidence-based” in the
r
b
d
title for the year 1999, only 49 articles are
e
t
a
identified, but for the year 2009, a total of 245
n
i
m
articles are identified. Further, many organiza
e
s
s
tions have attempted to systematically identify
i
d
e
and document programs that are considered
b
o
t
“evidence-based” (e.g., Blueprints for Violence
t
o
Prevention, Office of Juvenile Justice and De
n
s
i
linquency Prevention, What Works Clearing
d
n
a
house). The data from this survey clearly point
r
e
to the lack of dissemination of this information
s
u
l
to teachers. If we hope to close the research to
a
u
d
practice gap, we as researchers will need to
i
v
i
d
become better at communicating the common
n
i
language that is developing around these prac
e
h
t
tices. An important first step toward increased
f
o
e
dissemination is making teachers aware of evi
s
u
l
dence-based practices. Further, teachers as nat
a
n
o
ural implementers of evidence-based programs
s
r
e
and practices will need access to information
p
e
about correctly identifying these programs and
h
t
r
practices. School psychologists, who often re
o
f
y
ceive more specialized training in the area of
l
e
l
o
student mental health, evidence-based practice,
s
d
and research, can be a resource to their school
e
d
n
districts and teachers in understanding and iden
e
t
n
i
tifying effective practice. Additionally, school
s
i
psychologists can provide inservice trainings
e
l
c
i
t
on what it means to be evidence-based, where
r
a
to locate information about these practices
s
i
h
and programs, and how to implement them T
effectively.
Limitations
While the findings from this survey are infor mative to the field, it is important to note that the sample is limited to teachers from within one state. Many of the teachers were most likely trained by teacher education programs within this state. Therefore, their training and per
ceived needs may not be representative of teachers from other regions of the country. Ad ditionally, while the response rate was fairly high for survey research, only 50% of teachers solicited actually responded to the survey. It is possible that teachers who did not respond may have views that were not adequately repre sented. For instance, you might expect that in dividuals who chose not to take the survey on school-based mental health practices may not feel that this issue is a priority for them or they may have less positive views about the involve ment of schools in student mental health. Addi tionally, teachers working with students from diverse low-come backgrounds may not have been adequately represented in the current sam ple. Therefore, these findings may not general ize to teachers working in schools with high numbers of diverse students from low-income backgrounds. Further, survey data only pro vides a glimpse into the perspective of respon dents. The use of focus groups or individual interviews would potentially add richer infor mation on the topic. We also did not ask teach ers about their willingness to participate in trainings to improve their practices. Lastly, the survey was only conducted with teachers from preschool and elementary classrooms. There fore, the results are not representative of teach ers of students from higher grade levels. Middle school and high school teachers may express different mental health concerns, barriers, and training needs.
Implications
The process for selecting and implementing school-based mental health practices by school personnel does not typically occur in a sys tematic manner, nor are the training needs, resources needed to implement, fidelity of im plementation, and evaluation of outcomes asso ciated with daily practice routinely assessed (Ringeisen, Henderson, & Hoagwood, 2003; Walker, 2004). The findings of this study indi cate the complex nature of the research to prac tice gap. For instance, although teachers per ceive the need to promote the mental health of students many feel inadequately prepared to identify or implement practices to do so. Mod els for granting access to information, skills, and resources will be required to increase the use of evidence-based practice. Nutley, Walter,
MENTAL HEALTH IN SCHOOLS 11
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and Davies (2009) outline several helpful mech anisms for supporting this notion, stating that interactive approaches, such as partnerships that encourage communication and links between researchers, policymakers, and practitioners can promote adoption of evidence-based practices. This model fits nicely with several findings in that improving communication and links be tween researchers and practitioners could sup port teachers in being able to identify and apply evidence-based practices within school settings.
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Further, school psychologists can interface be
d
a
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tween teachers and research in a way that sup
r
b
d
ports use of effective practices in local contexts.
e
t
a
In efforts to bridge the gap between what
n
i
m
researchers have shown to be effective in reduc
e
s
s
ing mental health issues in children and what
i
d
e
practitioners select to implement, it is important
b
o
t
to understand issues related to this gap. The
t
o
survey pinpoints a clear need for connecting
n
s
i
teacher training to the specific areas of chal
d
n
a
lenges that they encounter in working with stu
r
e
dents. In this case, the major concerns con
s
u
l
nected to training were externalizing problems,
a
u
d
engaging families, supporting social develop
i
v
i
d
ment, and children showing signs of depression.
n
i
Additionally, providing training to preservice
e
h
t
and inservice teachers that promotes the use of
f
o
e
evidence-based practice and programs is
s
u
l
needed. Teachers understand that they can play
a
n
o
a role in supporting students with behavioral,
s
r
e
emotional, and social difficulties, but need the
p
e
training and support to implement effective
h
t
r
practices. School psychologists can work to
o
f
y
ward filling some of these gaps by acting as
l
e
l
o
resources to teachers in identifying evidence
s
d
based programs and practices, training and pro
e
d
n
viding ongoing consultation in these practices,
e
t
n
i
and supporting the ongoing evaluation of these
s
i
practices within the real world. Next, effective
e
l
c
i
t
dissemination will require researchers to de
r
a
velop systematic plans for training, consultation
s
i
h
and coaching, and supervision to ensure that T
evidence-based programs and practices can be transported to real world practice. While teach ers are natural implementers of many universal prevention and intervention programs, school psychologists may serve as natural dissemina tors and consultants, providing the supports necessary for teachers to implement these pro grams and practices with high fidelity.
Lastly, barriers to provision of mental health services included training, but also, the lack of
funding and presence of mental health person nel in schools. School psychologists need to advocate their role in supporting the implemen tation of evidence-based practices in school based mental health. While school psycholo gists can provide training and ongoing support for implementation of universal strategies by teachers, they can also provide the much needed evidence-based selective and indicative pro grams and practices. School psychologists need to inform school district administrators and pol icy leaders of the need for promoting and im plementing school-based mental health prac tices, pushing for expansion of funding and practitioners to meet the need for these prac tices. Further, teachers can play important roles in screening, monitoring progress, and teaching social emotional lessons in their classroom. Helping teachers identify these components to supporting mental health in children as roles they can integrate into practice may begin to remove barriers to services.
Future research should explore connections between teacher characteristics (e.g., training) and their perceptions of school mental health. Past research has documented that position (teacher vs. aid) and educational level (graduate vs. undergraduate) are associated with teachers’ ratings of importance of behavioral supports for preschoolers with behavior problems (Stormont & Stebbins, 2005). Further research on this topic can help inform specific training needs for subgroups of teachers. Additionally, prepost as sessments of implementation and maintenance of skills, as well as acceptability of the training and program or practice, following trainings for teachers focused on school-based mental health would provide information on whether teachers find the information useful and if they transfer it to practice. Furthermore, collecting data on po tential mediators of teacher implementation, in cluding teacher self-efficacy, burnout, and school organizational health following trainings could provide important information about fac tors that can impede or promote evidence-based practices in schools.
Overall, our findings suggest that despite the growing popularity of the concept of evidence based practices many teachers have never heard the term. Further, most teachers did not feel they had the knowledge, skills, or resources to make sound decisions about selecting and im plementing appropriate mental health supports
12 REINKE, STORMONT, HERMAN, PURI, AND GOEL
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for children. On a positive note, most teachers believe schools and educators should play a role in supporting the mental health among students in their schools. Although researchers have not regularly invited educators to be part of the dissemination conversation, it is clear from this survey that teachers would make great partners in the process, particularly if the goal is to transport evidence-based practices and inter ventions into real world school settings. With .
out the key players at the table, including those
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who would be implementing evidence-based in
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terventions (i.e., teachers), the research to prac
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tice gap is likely to remain.
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Secondary school teachers' experiences of supporting mental health
Article
Accepted Version
Shelemy, L., Harvey, K. and Waite, P. (2019) Secondary school teachers' experiences of supporting mental health. Journal of Mental Health Training, Education and Practice, 14 (5). pp. 372-383. ISSN 1755-6228 doi:
https://doi.org/10.1108/JMHTEP-10-2018-0056 Available at https://centaur.reading.ac.uk/84491/
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Journal of Mental Health Training, Education and Practice
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Secondary school teachers' experiences of supporting
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1 Secondary school teachers’ experiences of supporting mental health
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ental Health Training, Education and Pra2
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3 Purpose: Teachers are often the first contact for students with mental health difficulties. They
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4 are in an ideal position to identify students who are struggling and frequently support them 13
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5 using different approaches and techniques. This qualitative study aims to investigate secondary 15
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6 school teachers’ experiences of supporting the mental health of their students.
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7 Methodology: 7 secondary school teachers from state-funded schools in the UK participated in
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8 face-to-face semi structured interviews. Interpretative phenomenological analysis was used to 22
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9 understand and structure the data into themes.
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10 Findings: Five superordinate themes emerged from the data analysis: Perceived role of teacher,
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11 nature of relationship, barriers to helping the child, amount of training and resource, and 29
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12 helplessness and satisfaction. Participants described the lack of training, resource and clarity
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13 about their role to be causes of frustration. Internal and environmental factors often influenced
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14 participants’ feelings of helplessness.
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15 Research limitations/implications: The findings from this study cannot be readily 38
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16 generalised to the wider population due to the nature of qualitative interviews.
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17 Practical implications: This study has led to a greater understanding of the experiences of
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18 teachers within a school setting. It is crucial that mental health training for teachers 45
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19 directly meets their needs and abilities.
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20 Originality/value: This paper finds value in recognising the lived experience and
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21 difficulties faced by teachers supporting students’ mental health problems. A theoretical 52
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22 model novel model is presented based on this analysis that can help inform best practice
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23 for schools.
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25 Keywords: “teachers” “qualitative” “school” “interpretative” “adolescence” “mental health” 60
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26 The amount of time teachers spend in contact with students makes them well placed to notice 4
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27 symptoms and behaviours associated with internalizing and externalising disorders difficulties
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28 such as irritability, social withdrawal and changes in concentration (Ginsburg and Drake, 2002; 8
ental Health Training, Education and Pra
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29 Chatterji et al., 2004). Teachers working in secondary schools are faced with a high prevalence 11
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30 of mental health problems in their students. In the UK, two-thirds of children and adolescents 13
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31 with diagnosable mental health disorders have spoken to a teacher about their mental health
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32 (Newlove-Delgado et al., 2015). Teachers are in an ideal position to refer and signpost students 18
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33 to mental health care services (Fazel et al., 2014). They are often the first point of contact for 20
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34 parents who are worried about their child’s emotional wellbeing (Sax and Kautz, 2003; Ford
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35 et al., 2008).
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36 Many teachers acknowledge their ability to identify students who are in difficulty and 27
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37 manage mental health problems in the classroom (Rothì, Leavey and Best, 2008; Andrews,
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38 McCabe and Wideman-Johnston, 2014) and the link between academic and emotional health
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39 outcomes (Kidger et al., 2009). However without training, teachers have low confidence in 34
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40 their knowledge and ability to recognise mental health problems, as well as providing support 36
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41 within school (Roeser and Midgley, 1997; Walter, Gouze and Lim, 2006; Moor et al., 2007;
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42 Andrews, McCabe and Wideman-Johnston, 2014). Previous studies have found teachers often 41
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43 feel uneasy when discussing mental health with students and are unsure how to manage 43
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44 emotional difficulties in the classroom (Roeser and Midgley, 1997; Walter, Gouze and Lim,
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45 2006; Cohall et al., 2007; Moor et al., 2007).
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46 There is a demand from governmental bodies in response to public campaigns 50
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47 for secondary school teachers in the UK to have increased mental health knowledge and
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48 training (Department of Health, 2015; Department of Health and Department of Education,
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49 2018). It is important to understand the context and experiences faced by teachers in secondary 57
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51 programmes that train school staff around mental health (Anderson et al., 2018). However tTo 4
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52 date, few studies have explored teachers’ beliefs about specific aspects relating to students’
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53 mental health, and their role in supporting students. A holistic understanding of teachers’ lived 8
ental Health Training, Education and Pra
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54 experience of students’ mental health problems is needed to facilitate the design of resources 11
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55 and training that may best support teachers (Kirkpatrick, 2008). By learning about the 13
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56 experiences teachers have had regarding mental health in schools, intervention developers can
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57 optimally design interventions and resources that may best help teachers in the future. 18
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58 The present study
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59 The aim of the current study is to explore teachers' perspectives of supporting students' mental
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60 health, focusing on their emotional and cognitive processing of these experiences. The
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61 rigorous, detailed and phenomenological exploration of the experiences of teachers will help 27
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62 to better understand the impact of supporting students on participants’ own beliefs and
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63 emotions. The study uses the methodological framework of Interpretative Phenomenological
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64 Analysis (IPA) to generate a rigorous, detailed and in-depth exploration of the ‘lived 34
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65 experience’ of individuals, thus enabling a rich understanding of participants’ stories and 36
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66 perspectives (Smith, 2004). In the last decade IPA has been increasingly used in qualitative
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67 health research, particularly when the topic is under-studied and participants’ experiences have 41
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68 yet to be systematically explored (e.g. Fox and Diab, 2015; Smith and Rhodes, 2015). 43
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69 The present study aims to explore the experiences teachers have had regarding the
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70 mental health of their students in schools. A better understanding of teachers’ experiences,
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71 needs and opinions can improve the development of future mental health interventions targeted 51
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72 at teachers (Han and Weiss, 2005; Neil and Christensen, 2009).
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74 Method
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75 The study uses the methodological framework of Interpretative Phenomenological Analysis 4
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76 (IPA) to generate a rigorous, detailed and in-depth exploration of the ‘lived experience’ of
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77 individuals, thus enabling a rich understanding of participants’ stories and perspectives (Smith, 8
ental Health Training, Education and Pra
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78 2004). In the last decade IPA has been increasingly used in qualitative health research, 11
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79 particularly when the topic is under-studied and participants’ experiences have yet to be 13
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80 systematically explored (e.g. Fox and Diab, 2015; Smith and Rhodes, 2015). IPA employs a
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81 systematic approach to analysis, which recognizes the role of the researcher as an interpreter 18
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82 of the insights from the participant. IPA uses idiographic inquiry in which each participant’s 20
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83 story is analysed in detail and considered as an individual, separate narrative prior to exploring
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84 commonalities across participant accounts (Smith, Harr and Van Langenhove, 1995; Smith,
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85 2004).
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86 Ethical approval for the study was granted by the University of Reading Research
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87 Ethics Committee (reference number 2016-037-PW). The study used IPA and was conducted
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88 following established criteria for rigour in qualitative research (Denzin and Lincoln, 1994), 34
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89 using the COREQ checklist for reporting (Tong, Sainsbury and Craig, 2007) (Appendix A). 36
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91 Participants were eligible for inclusion if they were a) secondary school teachers who 41
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92 b) had experience of a conversation with at least one student about their mental health. We also 43
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93 only recruited participants in the South East of England due to travel limitations of the research
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94 team. The study was advertised via word of mouth and online social media (Twitter, Facebook)
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95 snowballing distribution of information. Advertisements were shared from the personal and 50
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96 university social media accounts, and subsequently ‘re-shared’ by members of the public.
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97 Eligible participants contacted the lead researcher and were contacted with further information
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98 about the study. Nineteen people expressed interest in the study. From this pool of potential 57
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99 participants, seven individuals met the inclusion criteria (reasons for exclusion: 5 people taught 59
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