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• To improve your knowledge of the mental health issues that can affect schoolchildren
• To familiarise yourself with the extent of teachers’ knowledge of mental health issues in schoolchildren
• To understand how you can collaborate with teachers to support schoolchildren with mental health issues
Background Mental health disorders often begin in childhood and children spend a substantial amount of time in school. Adequately trained schoolteachers therefore have a role in the early identification of mental health issues in schoolchildren.
Aim To explore the experiences, knowledge and training needs of Irish primary school teachers in relation to mental health issues in their pupils.
Method This was a quantitative descriptive study with a cross-sectional design conducted in a convenience sample of primary school teachers in Ireland using an online survey sent to members of two teaching unions.
Results The mental health issues that respondents most often encountered in their pupils were anxiety, attention deficit hyperactivity disorder, autism and oppositional defiant disorder. Respondents had varying degrees of knowledge of symptoms of mental health issues and of mental healthcare for children. Most respondents had not received training in children’s mental health and were motivated to receive such training. Most respondents had positive attitudes towards supporting schoolchildren with mental health issues.
Conclusion There is an opportunity for mental health nurses to become involved in training and supporting primary school teachers to identify children’s mental health issues.
Mental Health Practice. doi: 10.7748/mhp.2021.e1538
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Nash M, Granada López JM (2021) Mental health issues in children: exploring primary school teachers’ experiences, knowledge and training needs. Mental Health Practice. doi: 10.7748/mhp.2021.e1538
Published online: 27 April 2021
Mental health and well-being are important public health concerns. Increasing mental health literacy across the population is an important policy goal in England (Public Health England 2019). Improving mental health is a priority in children, since research has shown that half of all lifetime mental health disorders have begun by the age of 14 years and that the median age of onset of anxiety and impulse control disorders is 11 years (Kessler et al 2005). Since children spend a substantial amount of time in school, schoolteachers can have a significant role in the early identification of mental health issues in schoolchildren. However, to undertake that role, they require adequate training.
This article discusses a study that explored the experiences, knowledge and training needs of Irish primary school teachers in relation to mental health issues among their pupils.
In an overview of child mental health policies and practices in 15 European countries or regions, Braddick et al (2009) reported that, on average, one in every five children and young people in the European Union experiences developmental, emotional or behavioural issues and that approximately one in eight has a clinically diagnosed mental health disorder. Cannon et al (2013) found that one in three young people in Ireland are likely to have experienced some type of mental health disorder by the age of 13 years, a figure that rose to more than one in two by the age of 24 years. There is also evidence that many children who do not meet the criteria or threshold for being diagnosed with a mental health issue are nonetheless at high risk of suboptimal mental health (Khan 2016).
Ogundele (2018) stated that mental health issues in childhood can impede learning and restrict access to normal activities and social contacts. Kutcher et al (2009) noted that early intervention and effective treatment of mental health issues in schoolchildren can improve social and behavioural adjustment, school performance and educational outcomes. According to Lesinskiene et al (2018), the early identification and treatment of mental health issues is in the best interest of children and young people, their families and society as a whole.
Public health approaches to mental health emphasise the importance of early identification and intervention. However, a qualified mental healthcare worker is unlikely to be the first point of contact when a child develops signs and symptoms of a mental health issue. Since children spend a substantial amount of time in school, primary school teachers may be first to notice something amiss, such as changes in mood and/or behaviour. This means that schoolteachers represent a strategic public health resource in the early identification of mental health issues in children, while schools represent an optimal environment for early mental health interventions (Graham et al 2011). However, while preventive screening programmes have been implemented for physical conditions, such as breast or bowel cancer in adults, no similar preventive screening exists for mental health issues in schoolchildren.
Children may lack the vocabulary to express their emotions (El-Radhi 2015), so mental health issues in children may become apparent through their behaviour. The challenge is to differentiate between ‘normal’ disruptive behaviour and behaviour indicative of a potential mental health issue. In attempting this differentiation, one question that can be considered is which types of behaviour are appropriate at what age. For example, Hong et al (2015) suggested that occasional low-intensity defiant and impulsive behaviour in schoolchildren may be regarded as ‘normal’, but that high-intensity argumentative and/or defiant behaviour, deceitfulness and/or stealing, destruction of property, and low- and high-intensity aggression towards people and/or animals were markers of preschool conduct disorder.
Rothì et al (2008) suggested that schoolteachers could use their experience of children’s behaviours, their intuition and/or their common sense, rather than clinical criteria, to identify children with potential mental health issues. The authors of this article believe that if primary school teachers are to play a public health role in detecting mental health issues in children, they need to be adequately trained, notably to avoid the risk of stigmatising individual children.
To explore the experiences, knowledge and training needs of primary school teachers in Ireland in relation to mental health issues in their pupils.
This was a quantitative descriptive study with a cross-sectional design. It was conducted in 2018 in a convenience sample of primary school teachers in Ireland using an online survey.
The survey was developed following a review of the literature on mental health issues in children and young people in general, and in schoolchildren specifically. That review enabled the authors to determine the types of mental health issues and areas of mental healthcare that the survey questions would be based on. A content validity exercise was conducted with five child and adolescent mental health nurses and then with six schoolteachers, all of whom provided feedback on the structure and content of the survey; there was an optimal level of agreement concerning the survey questions.
The final stage of survey development was a pilot exercise undertaken with four postgraduate student teachers; this did not identify any issues regarding the understanding or sequencing of survey questions.
The questions fell into four main categories:
• Types of mental health issues encountered by teachers.
• Teachers’ knowledge of symptoms of mental health issues and mental healthcare for schoolchildren.
• Teachers’ training needs.
• Teachers’ attitudes to role, knowledge and training.
The online survey was developed using online survey software.
A convenience sample of teachers working in primary schools in Ireland was used as well as snowball sampling. Permission was sought from two teachers’ unions to disseminate the link to the survey to their members via emails and newsletters.
Ethics approval was granted by the School of Nursing and Midwifery Research Ethics Committee at Trinity College Dublin. The survey was anonymous. Opening the link to the survey led potential respondents to an information leaflet explaining the study’s aim and method and making it clear that they could withdraw from it at any time up until the moment when they would submit their responses. If they decided to participate, the next step was for them to tick a consent box, following which they could start completing the survey.
Data were analysed using the reporting function of the online survey software, which was limited to providing descriptive statistics such as frequency. Some survey questions involved respondents using a five-point Likert scale to self-rate their degree of knowledge in an area or their level of agreement with a statement. For ease of analysis, responses to these questions were collapsed into two categories:
• ‘Agree’ (collapsing ‘strongly agree’ and ‘agree’ ratings) and ‘disagree’ (collapsing ‘disagree’ and ‘strongly disagree’ ratings); the fifth choice on the five-point Likert scale used to indicate a level of agreement was ‘does not know’.
• ‘Good knowledge’ (collapsing ‘excellent’, ‘very good’ and ‘good’ ratings) and ‘poor knowledge’ (collapsing ‘fair’ and ‘poor’ ratings).
The survey was accessed by 322 people, five of whom did not answer any of the survey questions, so the actual number of respondents was 317. Not all 317 respondents answered all survey questions. It is not possible to calculate a response rate, since a convenience sample was used and the total number of teachers who received the link to the survey is not known.
Table 1 shows respondents’ demographic and occupational characteristics.
Variable | Respondents | ||
---|---|---|---|
n | % | ||
Gender | Male | 26 | 8 |
Age (years) | 21-30 | 37 | 12 |
Number of years since qualifying | 0-4 | 21 | 7 |
Work location | Private/independent primary school | 5 | 2 |
Geographical location | Within County Dublin | 111 | 35 |
Previous mental health training | Yes | 88 | 28 |
Female | 289 | 91 | |
Transgender | 2 | 1 | |
31-40 | 124 | 39 | |
41-50 | 71 | 22 | |
51-60 | 71 | 22 | |
≥61 | 14 | 4 | |
5-9 | 58 | 18 | |
10-14 | 75 | 24 | |
15-19 | 36 | 11 | |
≥20 | 127 | 40 | |
Public/state primary school | 307 | 97 | |
Public secondary school * | 5 | 2 | |
Outside County Dublin | 206 | 65 | |
No | 173 | 54 | |
Did not answer | 56 | 18 |
Respondents were asked to select, from a predetermined list, the types of mental health issues they had encountered in the children they work with; 261 respondents answered that question. The types of mental health issues encountered by the highest numbers of respondents were anxiety (98%, n=257), attention deficit hyperactivity disorder (ADHD) (95%, n=247), autism (94%, n=245), oppositional defiant disorder (ODD) (71%, n=186) and attachment disorders (59%, n=155). Bipolar disorder (10%, n=26), schizophrenia (5%, n=14) and alcohol or substance use (5%, n=12) were the least encountered types. Figure 1 shows the breakdown of responses to that question.
From a predetermined list of items, respondents were asked to rate their knowledge in two domains: symptoms of mental health issues and mental healthcare for schoolchildren.
Figure 2 shows the answers of the 261 respondents who replied to the question about their knowledge of symptoms of mental health issues. Respondents reported ‘good knowledge’ of the symptoms of autism (92%, n=241), ADHD (89%, n=231), anxiety (87%, n=226), depression (75%, n=197) and ODD (69%, n=180); they reported ‘poor knowledge’ of the symptoms of severe mental health issues such as bipolar disorder (75%, n=197), schizophrenia (88%, n=229) and personality disorder (81%, n=211); and they reported balanced levels of knowledge (halfway between ‘good’ and ‘poor’) of the symptoms of eating disorders, self-harm, attachment disorders and alcohol or substance use.
In relation to their knowledge of mental healthcare for schoolchildren, a majority of respondents self-rated their knowledge as ‘poor’ in the following areas:
From a predetermined list, respondents were asked to select the types of mental health issues for which they thought they needed training in the recognition of symptoms; 243 respondents answered that question and their responses are shown in Table 2.
To some degree, the training needs in symptom recognition shown in Table 2 mirror the types of mental health issues encountered by respondents (Figure 1). However, although respondents rated their knowledge of symptoms of anxiety, depression and ADHD as ‘good’ (Figure 2), 71% (n=173), 67% (n=164) and 55% (n=134) of them, respectively, still thought they needed training in the recognition of symptoms of these three conditions (Table 2).
Respondents were further asked to select, from a predetermined list, other areas relating to mental health issues in schoolchildren, beyond symptom recognition, in which they thought they needed training. The 243 respondents who answered that question identified training needs in mental health services for children and adolescents (79%, n=192); the types of professionals who work in these services (64%, n=155) and the type of work they do with children and adolescents (71%, n=173); how to communicate mental health concerns to parents and/or guardians (78%, n=190); how to write a school policy on mental health (72%, n=176); who to contact if a student may have a mental health issue (71%, n=173); and looking after one’s own mental health (53%, n=130).
Respondents were asked to indicate their level of agreement with statements about:
• Their role as primary school teachers in the mental health of children.
• Their knowledge of, and training in, mental health issues in children.
Those questions were answered by 243 respondents. Overall, respondents showed positive attitudes towards their perceived role in identifying and supporting children with mental health issues.
Training needs were noted by large proportions of respondents, with 222 (91%) disagreeing that they had received adequate training on mental health issues in children, 234 (96%) agreeing that they needed awareness training on mental health in children, and 236 (97%) potentially willing to attend training on mental health issues in schoolchildren. Table 3 shows respondents’ answers to the questions on their attitudes to role, knowledge and training.
Respondents to the survey encountered a range of mental health issue types and had varying levels of knowledge as well as a wide range of training needs.
The mental health issues most encountered by participants – anxiety, ADHD, autism and ODD – reflected the general trends in the literature (Honeyman 2007, Reinke et al 2011). The mental health issues most encountered by participants also corresponded with respondents’ levels of knowledge of symptoms: these were higher for anxiety, ADHD, autism and ODD than for conditions such as schizophrenia, bipolar disorder and personality disorder, which were encountered by fewer respondents.
Anxiety was the mental health issue encountered by the highest number of respondents. This is in keeping with the results of a study by Sadler et al (2018), which found that one in 12 children and young people aged 5-19 years in the UK had an emotional disorder, anxiety disorders being the most common type. Autism came third in the list of mental health issue types encountered by respondents, yet Sadler et al (2018) identified a low prevalence of autism spectrum disorders (1.2%) among those aged 5-19 years in the UK. It may be that survey respondents incorrectly interpreted certain behaviours as indicative of autism when these may have been, for example, behavioural changes following an individual or family trauma.
Severe mental health issues such as schizophrenia and bipolar disorder were encountered by fewer respondents. This could be because these are controversial diagnoses in children (Parens and Johnston 2010). Duffy et al (2020) suggested that psychiatric disorders evolve over childhood and adolescence and that their symptoms are often non-specific. This means that there is a risk of misdiagnosis; for example, symptoms of what may be bipolar disorder could be misinterpreted as pertaining to ADHD (Singh 2008).
Half of the respondents in the present study reported not having sufficient knowledge to identify a pupil who may have a mental health issue. Similar results have been found in other studies. Reinke et al (2011) found that teachers did not have the levels of knowledge required to meet the mental health needs of the children they taught. According to O’Reilly et al (2018), the primary role of a teacher is education, not the identification of mental health issues. However, because they spend a lot of time with children, teachers represent a strategic resource in the early identification of mental health issues (Graham et al 2011). For example, a teacher may notice a child becoming gradually more distracted or disorganised and this may trigger a conversation with parents and lead to a more structured, formal and/or specialist assessment of, and response to, the child’s potential mental health support needs. However, if teachers are to have a role in the early identification of mental health issues in children, they need a basic knowledge of these issues. Whitley et al (2013) expressed the view that teachers – and other school staff – can play an important role in prevention, identification and intervention for mental health issues in children, but only if they have sufficient mental health literacy.
It has been suggested that, in the school environment, there is often a lack of knowledge about mental health, which can impair the ability of teachers to identify children with mental health issues (Walter et al 2006, Pereira et al 2015). However, research has also suggested that some schoolteachers regard the use of psychiatric language as potentially harmful, since it may lead, for example, to children being ostracised by peers and stigmatised (Rothì et al 2008).
Involving local mental health services in the development of school mental health policies may contribute to improve teachers’ and schools’ response to mental health issues in children. According to Fazel et al (2014), involving mental health services in schools can develop a continuum of care that improves children’s mental health and educational attainment.
Sadler et al (2018) found that one in four children aged 11-16 years in the UK had self-harmed or attempted suicide. In the present study, 122 (47%) and 91 (35%) respondents out of 261 reported encountering self-harm and suicidal ideas (Figure 1) and 162 (67%) and 156 (64%) respondents out of 243 (Table 2) expressed a need for training in the recognition of symptoms of self-harm and suicidal ideas, respectively.
According to Simm et al (2010), self-harm and suicidal ideas are complex mental health issues that primary school teachers feel unprepared to manage. These are high-risk areas of mental healthcare that require specialist intervention, and it may be beyond the ability of primary school teachers to support children who experience such issues. The authors of this article suggest that supporting schoolchildren who self-harm or have suicidal ideas requires specialist input, provided for example by mental health nurses. However, teachers can assist by reducing factors that may contribute to self-harm and suicidal ideas, notably by educating children in techniques to counter bullying. Whitley et al (2013) suggested that reducing bullying and peer victimisation is an area that teachers can focus on as a means of promoting mental well-being.
A cursory review of undergraduate teacher training programmes would probably reveal little by way of mental health training, which means newly qualified teachers may start working in schools without adequate mental health knowledge and skills. In the present study, training needs were emphasised by large proportions of respondents; for example, 222 out of 243 respondents (91%) reported not having received adequate training on mental health issues in children. This is a common finding in the literature. Koller and Bertel (2006) found that teachers reported inadequate undergraduate training in mental health, which left them underprepared to take on a role in this area.
A survey by the Mental Health Foundation (2018) found that 71% of teachers in Scotland lacked training to address mental health issues in schools, with only 13% having received mental health first-aid training. A UK-wide survey of 300 newly qualified teachers (Leeds Beckett University 2018) found that 60% were not confident about identifying mental health needs in students and that 73% felt mental health was given insufficient priority in teacher training. In the present study, 236 out of 243 respondents (97%), including some who would have already received some mental health training, were willing to attend training on mental health issues in children, which demonstrates a high level of motivation.
Developing a standard procedure for how to manage children with mental health issues appeared to be an organisational requirement, since only 51 out of 243 respondents (21%) said their school had such a procedure in place. To develop and implement such procedures, schools could learn from each other through networking and peer learning, and local mental health services could be involved in this process.
Communicating concerns about mental health to parents and/or guardians was recognised as a training need by 190 of 243 respondents (78%). In a survey of teachers’ perspectives on student mental health conducted by the Canadian Teachers’ Federation (Froese-Germain and Riel 2012), 62% of respondents agreed that a lack of coordination between schools and parents was a potential barrier to providing mental healthcare. When developing mental health initiatives in schools, parents and/or guardians should be included.
There is little published research on collaboration between mental health nurses and schoolteachers, but that does not mean such collaboration does not occur in practice. There could be an opportunity for mental health nurses to extend their practice, for example by providing training to primary school teachers and school nurses or by undertaking in-reach public health work in schools in their catchment area. Gulliver et al (2010) found that stigma and embarrassment prevented young people with mental health issues from seeking support. Mental health nurses working with teachers in schools could contribute to the normalisation of mental health issues, thereby encouraging students to seek support and promoting early detection and intervention.
School nurses are an important resource and some authors have suggested that they have an important role in mental healthcare because of their expertise in public health and education (Pryjmachuk et al 2012, Smith and Bevan 2020). Yet Membride et al (2015) found that school nurses thought that they lacked the skills and training required to confidently address mental health issues in children. A potential solution would be for mental health nurses to use their reflective practice and clinical supervision skills to support school nurses to address mental health issues in children confidently and efficiently.
The use of a convenience sample limits the generalisability of results to a wider population of primary school teachers. There was a risk of social desirability bias: respondents may have held contrary views to those they expressed in the survey, but this could not be verified because their practice was not observed. The number of non-respondents to certain questions should also be considered when interpreting the results.
In this study of the experiences, knowledge and training needs of primary school teachers in Ireland in relation to children’s mental health issues, most respondents recognised that they had training needs, displayed positive attitudes towards their role in identifying and supporting children with mental health issues, and were highly motivated to receive training in this area. While primary school teachers cannot be expected to fulfil the role of mental health professionals, if equipped with sufficient mental health literacy they can contribute to the early identification of mental health issues in schoolchildren.
Mental health nurses have a long history of working effectively across boundaries with a range of professionals and there is an opportunity for them to become involved in training and supporting primary school teachers to identify children’s mental health issues.
• Primary school teachers and school nurses could benefit from training and supervision by mental health nurses in relation to schoolchildren’s mental health
• Schools could benefit from the involvement of local mental health services to support them to develop mental health policies
• Mental health nursing academics could liaise with university schools to promote the inclusion of mental health in teacher training programmes
• Shared learning for mental health nursing students and student teachers could increase their knowledge of each other’s roles and enhance future collaboration to promote better mental health in schoolchildren
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