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DOI: https://doi.org/10.34069/AI/2022.59.11.12
How to Cite:
Bozhkova, E.D., Konovalov, A.A., & Katunova, V.V. (2022). International experience in mental health provision in secondary
schools. Amazonia Investiga, 11(59), 130-140. https://doi.org/10.34069/AI/2022.59.11.12
International experience in mental health provision in secondary
schools
Международный опыт обеспечения психического здоровья в общеобразовательных
школах
Received: November 22, 2022 Accepted: December 15, 2022
Written by:
Bozhkova E.D.37
SPIN code: 2887-9548
https://orcid.org/0000-0003-0105-0360
Konovalov A.A.38
SPIN code: 1957-7849
https://orcid.org/0000-0001-5251-778X
Katunova V.V.39
SPIN code: 8908-8480
https://orcid.org/0000-0002-7775-1545
Abstract
The protection of children's mental health is an
important task, since missed opportunities for
psychiatric care during this period are very
difficult to make up for in the future. On the basis
of research by domestic and foreign authors in
recent years, we analyzed the foreign experience
that has developed to date in providing
psychological and psychiatric care to children in
school settings from the position of their
applicability in domestic practice. The current
state of knowledge on models of mental health
care for children in the school setting is reviewed,
and possibilities for their use in mental health
promotion are identified. Mental health services
embedded in the educational system, both abroad
and in Russia, synergistically promote mental
health and education. The school as an organized
collective provides a broad organizational
opportunity to provide diagnostic and treatment
interventions, as well as to equalize the
availability of mental health care. However, it is
currently recognized that the educational system
and the mental health care delivery system are
structurally, administratively and legislatively
disconnected.
37
Privolzhsky Research Medical University, Nizhny Novgorod, Russian.
38
Privolzhsky Research Medical University, Nizhny Novgorod, Russian.
39
Privolzhsky Research Medical University, Nizhny Novgorod, Russian.
Bozhkova, E.D., Konovalov, A.A., Katunova, V.V. / Volume 11 - Issue 59: 130-140 / November, 2022
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Keywords: child psychiatry; mental health
service at school; psychiatric support of
education; foreign experience in psychological
and psychiatric care; preventive medicine.
Introduction
In modern society, the tasks of mental health care
are relevant at all stages of human life, but
especially for the child population, as missed
opportunities for psychiatric care in this period
are very difficult to make up for in the future. In
most countries of the world, children spend a
significant portion of their time in school. The
protection of children's mental health during the
school period is all the more relevant because it
provides a synergistic effect: on the one hand, in
providing medical care and improving personal
mental health, on the other hand, in improving
the quality of the emotional and communicative
environment in the children's community and, as
a result, in improving academic performance and
the quality of the educational process. In the
absence of proper attention to the mental health
of schoolchildren, all of these aspects suffer
equally. In addition to the indisputable factor of
the necessity of mental health care at school age,
it is necessary to consider the broad
organizational possibilities of diagnostic and
therapeutic measures in the school setting, as
well as the equalization of the availability of
mental health care. The combination of these
advantages along with the constant complication
of the structure of medical care and the
strengthening of pathogenetic factors which
provoke mental disorders suggests a high
potential effect of psychological and psychiatric
care in school settings. The conducted researches
direct on further studying of possibilities on
cooperation of efforts of psychiatric service and
educational system, including taking into
account foreign positive experience (Fazel, Patel
Thomas & Tol, 2014). In the present review the
modern foreign experience on mental health
protection in school conditions is studied, models
of actions on mental health protection which
differ by structure of involved experts, principles
of target groups choice, methods of treatment and
an estimation of its results are allocated and
described.
Theoretical Framework
ANALYSIS OF INTERNATIONAL
EXPERIENCE WITH MENTAL HEALTH
CARE IN SCHOOL SETTINGS
4P-medicine (predictive, preventive,
personalized and participatory) is a new
paradigm of medical care, represented by
preventive and predictive medicine (care-
medicine), where the main object becomes the
healthy person and prenosological approach
(Flores, Glusman, Brogaard, Price & Hood,
2013). This is a fundamentally new concept, the
social and economic potential of which,
according to foreign scientists, will dramatically
increase in the XXI century. (Gefenas,
Cekanauskaite, Tuzaite, Dranseika &
Characiejus, 2011). An important principle of
this concept is participativeness, i.e., the
involvement of the maximum number of
interested parties - patients, their relatives, school
employees, social institutions, etc. - in health
care, including mental health care.
In the psychiatric aspect, the priority goals are
broad health monitoring, identification of
borderline psychopathology and risk factors, as
well as the development of a set of preventive
measures.
Prevalence of mental disorders in school-age
children
Results of multicenter field studies in the United
States indicate that the incidence of mental
disorders in school-age children is 8-18%, with a
significant prevalence of premorbid distress that
impairs academic performance and quality of life
acknowledged (Costello, Egger & Angold, 2005).
Children with mental health problems are not
segregated in school, so corrective interventions
for them are beneficial for the whole community
(Goodman & Goodman, 2011).
The prevalence of mental disorders varies among
school children of different ages (Costello et al.,
2005). The most frequent difficulties in school-
age children are disruptive behavior and anxiety
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disorders. Attention deficit hyperactivity
disorder (ADHD) and autism spectrum disorders
also pose particular difficulties for school
children. Separation anxiety and oppositional-
defiant disorder are seen mostly in elementary
school-aged children (ages 6-10), while
generalized anxiety, conduct disorder, and
depressive disorders are more common in middle
school students (ages 11-18). The frequency of
eating disorders and psychoses begins to increase
rapidly in adolescence.
Childhood mental disorders often persist and
evolve into older adulthood (Patton et al., 2014).
In the UK Combined Child and Adolescent
Mental Health Surveys, half of children with
established psychiatric disorders persisted into
adolescence after therapy. In the Great Smoky
Mountains Multidisciplinary Study (Copeland,
Angold, Shanahan & Costello, 2014), 36.7% of
children had at least one disorder, including a
mental health disorder, diagnosed by age 16.
Children with psychiatric disorders, however,
were three times more likely to be diagnosed in
follow-up studies, including in adulthood, than
patients with general medical conditions
(Pawliczuk, Kaźmierczak-Mytkowska,
Srebnicki & Wolańczyk, 2018).
Some factors in the development of
psychopathology are directly specific to the
school setting. A British survey showed that 46%
of school-age children had been bullied (HM
Government, 2015) resulting in more than double
the risk of experiencing suicidal thoughts and
suicide attempts (Van Geel, Vedder & Tanilon,
2014). Peer pressure later translates into an
increased prevalence of anxiety, depression, and
self-harm in adulthood (Meltzer, Vostanis, Ford,
Bebbington & Dennis, 2011). Dissonant
relationships between teachers and students are
also an established predictor of mental disorders
in children and poor academic performance
(Lang, Marlow, Goodman, Meltzer & Ford,
2013).
Screening and intervention needs assessment
systems
Many professionals who work with children
advocate for the use of a multiscreening system
to determine mental health needs in schools. This
screening involves three stages:
Stage 1 - assignment of testing to a specified
group;
Stage 2 - processing and interpretation of the data
by mental health professionals to determine
which students require assistance;
Stage 3 - interviewing students who need help
and organizing this help (Walker, Small,
Severson, Seeley & Feil, 2013).
Assessment can include components that
correspond to different types of interventions.
For example, staff may complete a school
climate scale (measures students' or teachers'
perceptions of how the environment in different
classrooms and schools affects education) to
conduct school-wide interventions, or use a
screening of children at risk for suicide
(Labouliere, Kleinman & Gould, 2015).
Schools use a variety of methods to identify
students who need interventions: for example,
functional behavioral assessments, teacher or
student ratings, and systematic screening.
It has been noted that screening creates risks of
both overidentifying children (false positives)
and false negatives (Borg, Salmelin, Kaukonen,
Joukamaa & Tamminen, 2014; Laido et al.,
2017). However, understanding these risks by
well-trained staff and using standardized
methods with the informed consent of children
and caregivers, and in the context of available
service options for those who screen positive, can
provide a useful mechanism for schools to
identify and support students with psychological
disorders (Burns & Rapee, 2016).
Organization of mental health care in the
school setting
There are significant differences between the
principles of medical and educational services.
These differences relate not only to the
composition of specialists, but also to funding
mechanisms, criteria for the availability of
quality and effectiveness of these services.
The need for mental health care may be
underestimated: for example, a child with
depression will be perceived by peers and
teachers as underachieving, as having cognitive
deficits, poor motivation, and/or low self-esteem.
Responsibility for children's mental health in
schools is shared between educators and
clinicians, but varies from country to country.
This is influenced by socio-cultural differences
and different configurations of health and
education. Nevertheless, even with the positive
effects of "school-based" interventions (remedial
educators (Franklin, Kim, Ryan, Kelly &
Montgomery, 2012) and school counselors
(Pearce, Sewell, Cooper, Osman, Fugard & Pybis,
2017), many schools rely heavily on mental
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health professionals who are administratively
and geographically distant from them (Perou et
al., 2013).
Mental health services in schools are both staffed
and outsourced. School staff members tend to
have workloads that limit their ability to
approach students individually. For example,
school psychologists in the United States often
spend most of their time performing routine
psychological testing and assessment of students
without applying their broad counseling and
intervention skills. In many countries, staff work
primarily with students with educational
difficulties that are caused by emotional and
behavioral problems and are not qualified to
work with psychiatric disabilities. Mental health
professionals involved in schools have a variety
of specialties: social workers, occupational
therapists, psychologists, and psychiatrists
(Allen-Meares, Montgomery & Kim, 2013).
Three typical models of integration are common:
Outside professionals contract to work in the
school;
The school collaborates with a psychiatric clinic;
the school has its own medical center that
provides psychiatric care.
The use of telemedicine is recognized as
successful due to the widespread shortage of
child psychiatrists (Grady, Lever, Cunningham
& Stephan, 2011), and there is an increasing
emphasis on cost-effective options, such as
additional training for teachers and school nurses
(Kaess et al., 2014).
Although teacher-led mental health promotion
and prevention activities have a significant
impact on students' psychosocialization and
academic performance, they are recognized as
less effective than psychiatric care (Kellam,
Mackenzie & Brown, 2011). Models that
integrate mental health promotion into the
natural context of learning and include coaching
to increase teacher confidence in their own
abilities require further development and
evaluation.
The U.S. uses an empirically developed
multilevel approach (National Research Council
(US) and Institute of Medicine (US) Committee,
2009; Patel, Chisholm & Dua, 2016) that
includes universal interventions for all students
(universal approach), selective interventions for
selected students who face special risks
(selective approach), and treatment interventions
for children with the greatest needs (indicative
approach).
Methodology
The main methods used in this review include a
theoretical analysis of data representing the
current state of mental health provision in
secondary school systems. The use of a
comparative research method allowed us to
compare models and approaches from different
geographic, socio-economic contexts, in order to
highlight the main strategies, directions and
difficulties associated with early diagnosis and
prevention of mental health disorders, as well as
active work in the provision of psychiatric and
psychological care in secondary schools.
Results and Discussion
The provision of mental health services in
schools includes mental health promotion,
prevention, and treatment. The ultimate goal is to
promote the well-being of students, prevent the
development or exacerbation of mental health
problems, and improve the effectiveness of
education - in the system (Lean & Colucci, 2013).
Prevention of psychological problems in
students
The universal promotion of mental health
programs often focuses on aspects such as social
and emotional skills, positive behavior, social
integration, effective problem solving, and
positive interaction with the community (Sklad,
Diekstra, Ritter, Ben & Gravesteijn, 2012). A
comparative meta-analysis confirmed the
benefits of mental health promotion: in schools
with social emotional learning programs, there
was an average 11-17% increase in academic
achievement on standardized tests (Payton et al.,
2008).
In whole-school and classroom activities,
universal mental health support programs are
often implemented by educators (Kaess et al.,
2014), particularly in elementary and middle
schools (Cheyne, Schlosser, Nash & Glover,
2014). An example is the Mind Matters program,
conducted in the late 1990s in schools in
Australia with significant state investment in
educator training (Rowling, 2007; Langford et al.,
2014). It included social and emotional learning
programs, developing students' self-awareness
and emotion management skills, effective
communication, and stress management.
Behavior management interventions through
school-wide or classroom-based interventions
are increasingly supported. In the United States,
programs such as I Can Problem Solve (Shure,
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2001) and the Good Behavior Game are reported
to have long-term success. (McIntosh, Mercer,
Nese & Ghemraoui, 2016).
PREVENTING MENTAL HEALTH
PROBLEMS IN STUDENTS: A THREE-
TIERED APPROACH
Schools are the optimal environment for
organizing prevention interventions among
children, so the three-tiered approach mentioned
earlier has become the accepted model for
interventions aimed at preventing students from
developing psychiatric problems. The three
components are represented by different types of
interventions: universal interventions target the
whole school or class; selective interventions
target subgroups whose risk of developing a
mental disorder is significantly higher than
average; therapeutic (individual) interventions
target young people already exhibiting clinical
symptoms (Costello et al., 2005). Research
suggests that treatment in school settings,
including the use of group models, is optimal
(McMillan & Jarvis, 2013).
Universal interventions
These approaches have several advantages: they
are the least intrusive, low-cost, and have the
greatest chance of acceptance in a school setting
(Kidger et al., 2016). In addition, these
interventions are easier to implement and provide
potential benefits to all students rather than an
isolated group (Manassis, 2014).
Universal approaches have been developed and
evaluated for a wide range of problems,
including deviant behavior as well as anxiety and
depressive disorders (Johnson et al., 2014).
However, randomized controlled trials (Clarke,
Hill & Charman, 2017) found that universal
interventions were less effective than selective
and individual programs. One of the largest
studies of universal interventions for depression
prevention Beyondblue (Zetterström, Landstedt,
Almqvist & Gillander, 2017) found that a course
of 30 teacher-led sessions did not reduce
depression in adolescents.
Some evidence suggests that children at low risk
for mental health problems may benefit more
from universal interventions than children at
higher risk (Stallard et al., 2014; Merry, Hetrick,
Cox, Brudevold-Iversen, Bir & McDowell,
2012). For example, the Resourceful Adolescent
Program is another universal intervention that
focuses on adolescents' self-esteem, conflict
resolution, and stress management skills and has
been shown to be effective for adolescent
depression (Stallard & Buck, 2013).
Selective approaches
Interventions to address specific risk factors have
proven successful in schools. Such interventions
raise awareness among school staff about
behavioral patterns of children and adolescents
that are indicative of substance use or risk of
developing dependence.
Prevention programs are often conducted in
classrooms or in small groups of students at high
risk for aggressive behavior, substance abuse and
delinquency (e.g., the Coping Power Program)
(Zetterström, Landstedt, & Gillander, 2015).
Data are also emerging on the positive effects of
working with specific populations (e.g., youth
from low-income neighborhoods and refugees)
(Farahmand, Grant, Polo & Duffy, 2011; Tyrer
& Fazel, 2014).
Evidence from selective school-based prevention
and early intervention programs suggests that
they are reliably effective on specific behavioral
difficulties for students with stressors as a risk
factor (e.g., parental divorce) and for students
with anxiety or depressive disorders (Cairns, Yap,
Pilkington & Jorm, 2014).
Therapeutic (individualized) interventions
Many studies have positively evaluated school-
based treatment programs for anxiety or
depression, intentional self-harm, and post-
traumatic stress disorder (De Silva, Parker,
Purcell, Callahan, Liu & Hetrick, 2013). These
programs typically show better outcomes and
more pronounced reductions in depression
symptoms than universal or selective programs.
There have been several evidence-based studies
on suicide prevention (Martin & Oliver, 2018).
CURRENT ISSUES IN IMPLEMENTING
MENTAL HEALTH PROGRAMS IN
SCHOOLS
Research on school-based interventions has
limitations, including small sample sizes, wide
variation in the findings, and difficulty in
generalizing due to factors unique to specific
school settings. In addition, it has been pointed
out that the validity of these treatments is
insufficient (Schoenwald & Garland, 2013),
interventions need to be tested in real-world
settings with intermediate controls. Another
shortcoming is recognized as a lack of research
on the cost-effectiveness of various interventions
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(Bywater & Sharples, 2012). Interaction between
parents, children, and teachers regarding the
mental health and well-being of children and
adolescents is rated as low in systematic studies
(Collishaw, Goodman, Ford, Rabe-Hesketh &
Pickles, 2009). In addition, not all school-based
interventions have yielded positive results, so the
potential for adverse effects of psycho-
psychiatric interventions must be recognized and
monitored (Stallard, Sayal & Phillips, 2012).
A common barrier to implementing evidence-
based interventions in schools is the poor
involvement of all levels of school personnel-
teachers, counselors, and support staff (Manassis,
2014; Catalano, Fagan & Gavin, 2012). There are
additional barriers for individuals (stigma,
mental health status), communities (geographic
and social location), and systems (funding, wait
times, availability of trained staff) (Schwean &
Rodger, 2013).
Individual work with children in schools can be
hampered by complex ethical considerations
regarding informed consent (O’Connor, Dyson,
Cowdell & Watson, 2018), especially when a
child may see a school nurse or counselor
without parental knowledge or consent.
It is important to develop a scientific approach to
mental health promotion in schools (Blase &
Fixsen, 2013) to avoid low sustainability of
results due to lack of specificity and incomplete
coverage of the target population (Wiltsey,
Kimberly, Cook, Calloway, Castro & Charns,
2012).
Ongoing research increasingly focuses on
universal or selective strategies (e.g., promoting
alternative thinking strategies (Bermejo-Martins,
López-Dicastillo & Mujika, 2018) and self-
monitoring (Mooney, Ryan, Uhing, Reid &
Epstein, 2005)) and shows that successful
interventions allow teachers to establish positive
behavioral norms, which in turn enhances
teacher-student interaction (Allen, Pianta,
Gregory, Mikami & Lun, 2011).
An important challenge for research is to find
activities that are easy to organize and integrate
into the regular school schedule, especially when
implemented with school resources (Atkins et al.,
2011; Becker, Bradshaw, Domitrovich & Ialongo,
2013).
Improving the quality of specialized care in
schools is a promising factor in mental health
care. For example, E. Nadeem et al., (2013)
identified 14 factors for improving the quality of
such care, including face-to-face sessions,
telephone counseling, and improving the quality
of staff training.
Interdepartmental cooperation, the use of social
networks (Nembhard, 2012) and meta-analysis
of data from similar studies (Eisenberg, Hunt,
Speer & Zivin, 2011) appear to be extremely
important. It has been argued that to achieve a
positive impact on children's mental health, a
system of evaluations built into interventions
must be developed to monitor selected programs
(Schwean & Rodger, 2013).
Conclusions
Mental health services embedded in the
educational system both abroad and in Russia
synergistically promote mental health and
education. However, it is currently recognized
that the educational system and the mental health
care delivery system are structurally,
administratively, and legislatively disconnected
(Resch, 2017). Lack of resources does not allow
schools and educational authorities to carry out
full-fledged activities to ensure the mental health
of children and adolescents. The issue of "shared
responsibility" for schoolchildren's mental health
is a topic of discussion all over the world
(Hawkins, Oesterle, Brown, Abbott & Catalano,
2014).
It is also clear that there is a lack of knowledge
both among teachers about mental health and
among psychologists and psychotherapists about
school-specific issues (Mian, Milavić &
Skokauskas, 2015). Practical guidelines for the
development of peer counseling skills are being
developed (Müller-Luzi & Schmid, 2017;
Network Solutions, 2010). At the same time,
training teachers in mental health promotion
skills can not only help to identify and correct
children who need it, but also reduce their own
stress levels (National Research Council (US)
and Institute of Medicine (US) Committee, 2009;
Schwean & Rodger, 2013). Given the ever-
increasing costs of psychiatric consultation for
school-age children, relocating mental health
interventions can have an economic impact
(Snell, Knapp & Healey, 2013; Gray, 2013).
Future research should focus on the
implementation and maintenance of integrated
interventions involving interdisciplinary teams
of professionals both at the classroom or school
level and at the individual level.
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