Gimba et al.

BMC Public Health (2020) 20:1581

https://doi.org/10.1186/s12889-020-09713-2

RESEARCH ARTICLE 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.
(Continued on next page)

* Correspondence: musasol19@gmail.com
1
Menzies Health Institute Queensland, Griffith University, Brisbane,
Queensland, Australia
2
Department 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

(Continued from previous page)

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 prevention of lifetime disability for most people with

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
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
Gimba et al. BMC Public Health (2020) 20:1581
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.
Page 3 of 10
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
Fig. 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
Page 4 of 10
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).
Gimba et al. BMC Public Health (2020) 20:1581
Table 1 Summary of the Number of Articles Retrieved
S/No Database Results (collected between 2003 and 2018)
1 ERICa 740
2 PubMeda 19
b in schools.
3 Web of Science 455
4 CINAHLa 217
c
5 Scopus 5 programs, one program was developed through needs
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
Page 5 of 10
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
The involvement of stakeholders in the development
of the programs was also highlighted. Out of the 11
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].
Gimba et al. BMC Public Health (2020) 20:1581
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
Page 6 of 10
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
Gimba et al. BMC Public Health (2020) 20:1581
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
Page 7 of 10
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
Gimba et al. BMC Public Health (2020) 20:1581
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.
Page 8 of 10
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.
Gimba et al. BMC Public Health (2020) 20:1581
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
1 psychology. J Sch Psychol. 2016;57:41–52.
Menzies 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 Staff

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 staff 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 staff 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 staff (n = 48) including classroom teachers, school counsellors, psychologists, administrators, and
various support staff members employed with two secondary schools in southern Alberta, Canada. A structured interview
guide was utilized to assess the roles, tasks, and processes school staff 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 staff 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

Gabrielle Wilcox and Paul D. Arnold are co-senior authors.
* Gina Dimitropoulos
gdimit@ucalgary.ca
1 Globally, one in five youth experiences symptoms of men-
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
Introduction
Adolescent Mental Health: Prevalence and the Role
of Schools
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
identification of adolescent mental health disorders.
In Canada, only 30% of youth have meaningful access
to necessary community and hospital-based mental health

13
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School Mental Health (2022) 14:402–415 403
services (Georgiades et al., 2019; Rowling et al., 2009).
Many youth first 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 identified 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 insufficient, and that this
is a significant concern for both school staff 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 influence 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 staff 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 staff regarding the
strategies they employ to create such an environment.
The Importance of Relationships in Supporting
Student Mental Health
Previous literature has identified that school staff 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 significant 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
influencing 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 influence
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
significant 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
influence of mental health stigma within schools from an
educator’s lens would assist in filling a gap in past research.
The Role of School Staff in Facilitating Access
to Right Level of Care
Multiple studies in different countries have demonstrated
that school staff (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 staff 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 affected how they sup-
ported the mental health of their students.
13

404
Lack of Training as a Barrier to Educators
Supporting Students with Mental Health Concerns
Previous qualitative studies have repeatedly identified lack
of confidence 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 identified, 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 staff 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 staff regarding their influence on stu-
dent mental health outcomes is needed, as current school
practices still lack a definite 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 reflect 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
13
School Mental Health (2022) 14:402–415
difficult to translate to other countries internationally, due to
the vast differences 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 staff want to
see future training implemented, as well as what specifically
they hope to gain from training.
Methods
This paper reports initial findings from a qualitative study
exploring how educators and school staff 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 final sample of 48 school personnel. Key staff 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 staff meeting. A purposive sampling process was
initially used (Etikan et al., 2015) to recruit members of the
school staff. Purposive sampling was deemed appropriate
in order to best allow the researchers to answer the spe-
cifically defined research question (Luborsky & Rubinstein,
1995) and to recruit individuals who offer experience and
first-hand knowledge of the topic being explored (Lubor-
sky & Rubinstein, 1995). In this study, purposive sampling
was initially used to recruit school staff 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 predefined 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 staff members at the two
secondary high schools who have contact with secondary
students. Snowball sampling was also utilized, as mem-
bers of the school staff shared information with their col-
leagues about the interview process and acted as methods
of referral (Luborsky & Rubinstein, 1995). Purposive and
School Mental Health (2022) 14:402–415 405
convenience sampling proved to be more successful modes
of recruiting interview participants, garnering 46 school
staff; only 2 school staff were recruited through snowball
sampling. Study inclusion criteria comprised: (a) school
staff 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
staff 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 staff 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 staff 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
staff 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 staff were asked
open-ended questions to facilitate participant descriptions
and perceptions of student mental health problems, defini-
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 staff; 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 difficulties?”; “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
identifies similarities and differences 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 five 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 first 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 staff of their roles vis-à-vis student
mental health, and identified 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 identified. The team further established a
code book with the meaning and definitions of the themes
identified. 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 specific headings and subheadings identified 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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406 School Mental Health (2022) 14:402–415

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 Characteristics No. of partici- Percentage
data to be organized under headings and subheading (codes pants (N = 48)
and sub-codes). Finally, the data were interpreted by the
Gender
research team (stage five; Srivastava & Thomson, 2009).
Female 32 66.7
At this stage, the team endeavoured to find patterns, com-
Male 15 31.3
monalities, and differences between information coded from
Age
the transcripts.
 > 30 10 20.8
To heighten trustworthiness, the team members took the
30–49 26 54.2
following steps: The research team independently coded
 < 50 11 22.9
all interviews, diligently kept notes of their reflections,
Roles in School
and also created memos of decision-making processes
Teacher 27 56.25
in the NVivo software. As described by Braun and Clark
Counselling and psychological staff 9 18.75
(2006), the determination of a theme should be guided by
Learning support staff 6 12.5
the researcher/team, and whether identified patterns reflect
School leadership 4 8.3
the overall research question and aims. For our manuscript,
Administrative support staff 2 4.2
our research team confirmed the strength of a theme when
Years in role
ideas, thoughts, and reflections were consistently identified
Up to 5 17 35.4
across the data (interviews conducted) rather than just within
6–10 12 27.1
a single or small number of interviews. Through the use of
11–20 10 20.8
reflexive dialogue and discussion, the research team also
 > 20 8 16.7
agree upon the strength of the pattern observed when the
Education
codes coherently/consistently fit together within a theme.
Post-secondary certificate 3 6.3
Further, the research team created a comprehensive code
Bachelor's 24 50
book and description of each code was reached through con-
Master's 20 41.7
sensus. The codebook contained detailed explanations on
Doctoral 1 2.1
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- classroom teachers (54%) and school counsellors, psychol-
ual coding process and to uncover any points of contention ogists, administrators, and various support staff members
and consulted with the leads of the project as needed. There (46%). Due to the wide range and multiple roles of those
were six researchers (from different disciplines including who took part in this study, all participants will be referred
education, social work, and psychology) who participated in to herein as school staff.
the coding process; this allowed for any disagreements to be Four interconnected themes were inductively identi-
solved through consensus. On the few occasions where there fied: (1) Relationships matter: Establishing and maintain-
was a disagreement, the researchers explained their coding ing strong relationships with students, their caregivers, and
decision and discussion was held until such a time that all other staff members are critical to supporting students with
analysers came to an agreement with one coding decision mental health concerns; (2) Empathetic and receptive com-
over the other. As a form of member checking (Birt et al., munication is an antidote to stigma: Various communication
2016), our team presented our findings to various stakehold- processes contribute to reducing stigma and thereby facili-
ers (educators, the leadership and administrative team of tate disclosures of mental health concerns and challenges;
the school board, and mental health providers) to verify the (3) Connecting and facilitating timely access to the right
accuracy of our analysis. person is key for students experiencing emotional crises;
and (4) Facilitators and barriers to address student mental
health concerns. Illustrative quotes from the anonymized,
Results transcribed interviews with school staff are provided below.
Quotes are identified using SS (school staff) followed by a
Demographic information (age, gender, type of profes- number, indicating the interview number.
sional role, level of education) on the sample of school Theme 1-Relationships matter: Establishing and
staff (n = 48) is summarized in Table 1. Most participants maintaining strong relationships with students, their
were women (67%), and nearly 90% of participants had a caregivers, and other staff members are critical to sup-
Bachelor or Master’s degree. Study participants included porting students with mental health concerns

13
School Mental Health (2022) 14:402–415 407
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 staff 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
staff member stated:
I think for staff the biggest thing is relationship and
connectedness. . . I think that’s probably the. . . biggest
value or, you know, the one that most staff 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
staff 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 staff 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 staff 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, staff 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 effectively to support students affected with
mental health issues:
Well, one of the first ways is through constant conver-
sation at every staff meeting. You know, at every staff
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 staff 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 staff 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 flags first (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 staff a wider circle through which they can
help their students access additional services as required.
School staff 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 staff can ensure
that students receive necessary supports specific to their
individual needs.
School staff 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 figure
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 staff have a
positive working relationship. School staff 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 staff and myself to talk about
mental health regularly (SS 36)”. These working relationships
help parents and school staff establish trust, collaboration, and
13

408
open lines of communication about student mental health,
with the overarching goal of improving support for students
affected 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 staff 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 staff towards parents/caregivers:
Parents are the expert on their child and I will always
say that, within my first 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 staff spoke to the positive effects 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-
fied as classroom teachers, argued against being responsible
for identifying and intervening to respond to mental health
problems in their students. Insufficient 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).
13
School Mental Health (2022) 14:402–415
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 staff 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 staff 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 staff discussed that through effec-
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 staff shared that they modelled healthy behaviours
to their students by appropriately and intentionally sharing
previous and/or current mental health challenges with them.
School Mental Health (2022) 14:402–415 409

Some participants shared that they would challenge stigma students to take the time needed to meet with guidance
associated with mental illness by disclosing their own lived counsellors and/or mental health providers:
experience: “…how powerful for the students to see you
We have a (specialized mental health room) so a lot
know teachers are not perfect—holy cow you can relate to
of teachers notice a kid is just having a crappy day
me (SS 33)”. School staff believed that sharing experiences
they might ask him if he wants to access the (special-
with youth had the potential to foster authentic connections
ized mental health room) they might come out for a
and to normalize mental health disorders: “I’ve shared [my
period of time and there’s caring adults in there as
experiences] with students and it’s… fine to know that I’m
well (SS 29).
like them; Not perfect (SS 10)”. School staff shared that
positive and strong relationships provided an opportunity Another participant stated: “I have directed them to the
for students to talk about their experiences and seek guid- guidance department… or taken to the guidance are[a]…
ance on those days when distressed or facing challenges that You know, walked with them to make sure that they got
seemed insurmountable. The processes of communication there safely and left them in the capable hands of our pro-
in the expression of empathy, understanding, and the dis- fessionals (SS 6)”. Other times educators reported locating
semination of educational information were all employed acute care specialized services for students in crisis. While
to challenge stigma, and diminish shame and apprehension most classroom teachers did not believe they should be
in talking about mental health concerns and seeking support actively involved in mental health interventions, many felt
when needed. 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
Theme 3: Connecting and facilitating timely to be connecting students to the proper resources: “I am
access to the right person is key for students also confident that I am aware where my knowledge and
experiencing emotional crises my competence ends... I would ensure that they get to the,
to the right places and where they need to be (SS 43)”. The
I think it’s important for the schools to be able,
counselling staff felt more comfortable in dealing directly
and teachers, to be able to say to students that
with students with mental health concerns, but they also
there are resources. And not even saying that those
noted that their role was an intermediary one, working
resources[exist] but showing them how to access them
closely with other colleagues and connecting students to
(SS 4).
appropriate services:
The participating school staff discussed how they would
I think we work pretty closely with student services
respond to a youth struggling with mental health issues
and the psychologist to develop pretty efficient sys-
and noted the specific steps they would undertake, includ-
tems to perhaps even triage and find kids where
ing sharing resources, directing students to needed mental
they’re at and how to align them with what feel are
health services, and assisting them to access services when
the appropriate services whether they are internal or
required:
external (SS 30).
I’ll usually chat with students myself first, and then I’ll
School staff acknowledged that a pivotal task in sup-
recommend. I’ll say, “Hey, are you okay? Do you need
porting their students was to encourage seeking support,
to chat with someone?” I’ll usually say, “I’m available
providing resources, and connecting and navigating stu-
to chat if you need to” and then I’ll present someone
dents to individuals or organizations that can provide
else because it feels to me very impersonal to meet
direct counselling for mental health issues and concerns.
with someone and say, “Hey, it looks like you’re strug-
When outside of their scope of practice, teachers noted
gling, you seem really down lately. Why don’t you go
that they worked with students to navigate the mental
chat with this other person that you don’t even know?”
health system to identify needed professional support for
I’ll offer myself first and then give their name (SS 13).
mental health disorders.
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
significant 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

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410
Theme 4: Facilitators and barriers
to addressing student mental health
concerns
School staff identified 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 different
facilitators and barriers that school staff 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 staff 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 findings, this study prioritized bolstering the current
understanding of the perception of school staff regarding
Table 2  Facilitators and barriers to addressing student mental health concerns
Facilitators
1. Administrative support is a significant enabler to school staff 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. Specific on campus resources help including multiple trained
psychological support staff on campus, as well as dedicated mental
health spaces for the students:
“we have psychologists on our staff so we do, so we can do some indi-
vidualized therapy…there’s a number of different 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)”.
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School Mental Health (2022) 14:402–415
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 staff. 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
staff suggest that they can curtail stigma and facilitate dis-
closures of mental health by establishing strong relationships
with students, other school staff, and those external to the
school (including parents/caregivers). Through intentional
and empathetic communication, school staff can facilitate
referrals to mental health programs and assist with connec-
tions to counsellors who can support students in a crisis.
The first 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 staff
noted that strong relationships with students help ensure that
students receive necessary supports specific to their indi-
vidual needs. Supportive relationships between students and
Barriers
1. Classroom teachers note a lack of training and knowledge in mental
health and the availability of resources to support students. Coun-
selling staff 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 stuff 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 confidence 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)”.
School Mental Health (2022) 14:402–415 411
staff 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 finding that is echoed
by a recent study by Wong et  al. (2021). In the current
study, the majority of school staff 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
staff 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 identified
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 findings in this study further
emphasize the ways that educators identify risk factors for
their students, with many school staff 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 staff in this study emphasized the importance of
working collaboratively with other disciplines and impor-
tantly emphasized open and effective communication
between teachers, and counselling staff can serve to facili-
tate timely help, including appropriate referrals for vulner-
able students. Mazzar and Rickwood (2015) reported that
involving other school staff 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, finding that close
collaborations across these two disciplines enhance access
to student mental health services for those in need. Such
collaboration could be particularly effective as there is evi-
dence that the type of information collected by teachers and
schools is valuable but different 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 specific symptoms (Green et al.,
2017). Our findings 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 staff 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 specific needs.
Our second theme captured the significance of commu-
nication and empathy of school staff 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 identified the impor-
tant role that school staff undertake facilitating, connecting,
and navigating students to mental health resources internal
and external to the educational system. School staff in this
study expressed confidence in identifying youth at risk and
with their ability to help connect these students to resources,
including other school staff 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,
13

412
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 identified 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 findings are broadly consist-
ent with previous studies, which have found that the culture
of the school and attitudes of administrators can affect 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 findings are a
strong foundation for future recommendations of mandatory
administrative mental health training.
Many studies note that educators face significant 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 significant barriers classroom teachers face within
the school environment, which concurs with the responses
from school staff 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 fulfilling 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
staff 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 findings (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
13
School Mental Health (2022) 14:402–415
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 findings 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 staff 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 findings 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 findings would
be relevant to particular sub-populations which may have
specific 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 identified. 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 affected by
mental health disorders.
Implications for Practice, Professional Learning,
and Research
There are several implications for practice. First, school staff
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-Groff, 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
School Mental Health (2022) 14:402–415 413
outcomes, as highlighted by the school staff 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 staff 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
staff 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 staff
referred to their own mental health challenges in this study
highlighting the importance of also supporting the mental
health of school staff to in turn enable them to support stu-
dent mental health. The mental health of school staff, in
general, and teacher mental health specifically, contributes to
improved student outcomes (Briner & Dewberry, 2007). The
mental health of school staff is related to student–teacher
relationships, which was noted to be important in supporting
student mental health and help-seeking behaviours, while
poor school staff 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
staff 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://d​ oi.o​ rg/1​ 0.1​ 007/s​ 12310-0​ 21-0​ 9475-1.
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  Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology.
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

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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 KEYWORDS
The feasibility of addressing the mental health needs of young people at school is influenced by Secondary schools;
how staff perceive their role, and the role of schools, in mental health care. Using qualitative counselor; teacher; student
methodology, this study investigated the roles of Australian school teachers and counselors. The mental health; support
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.

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
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
3
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).
 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
Thematic analysis
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
5
appropriate because we wanted to represent manifest
(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 “Screening and assessing for mental health issues.”
mental health problems
“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 supports such as obtaining funding or special

This sub-theme refers to supporting student’s mental provisions.
health by advocating on their behalf. Counselors, but
not teachers, emphasized the importance of “being
Theme 2: being on the frontline
advocates” or “champions” for student mental health
within the school environment. In practical terms, This theme highlights that teachers and counselors feel
this meant increasing their opportunities to access they are on the frontline and are often the first point of
 INTERNATIONAL JOURNAL OF SCHOOL & EDUCATIONAL PSYCHOLOGY
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.
7
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
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
11
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
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
13
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
DOI: 10.1002/pits.22648
RESEARCH ARTICLE
Supporting primary school students' mental
health needs: Teachers' perceptions of roles,
barriers, and abilities
Louise Maclean | Jeremy M. Law
School of Interdisciplinary Studies, College of
Social Science, University of Glasgow,
Dumfries, UK
Correspondence
Jeremy M. Law, School of Interdisciplinary
Studies, College of Social Science, University
of Glasgow, Dumfries DG1, UK.
Email: Jeremy.Law@glasgow.ac.uk
This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2022 The Authors. Psychology in the Schools Published by Wiley Periodicals LLC
Psychology in the Schools. 2022;59:2359–2377.
15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| Accepted: 14 December 2021
Abstract
Mental health problems among children are on the rise
across the United Kingdom. Teachers are uniquely
placed to play a vital role in early identification and
intervention. This study aims to identify and discuss
potential barriers among Scottish teachers' concerning
their role in supporting children's mental health. One
hundred and seventy‐nine Scottish primary school
teaching staff from 30 different council areas completed
an online survey. The survey examined mental health
concerns observed in the classroom; barriers to support;
perceived personal knowledge; and training. Results
indicate that teachers believe they have a role in sup-
porting children's mental health. However, teachers
perceive themselves as having a lack of knowledge and
specific skills to promote positive mental health. A lack
of adequate training was identified as a primary barrier
to delivering adequate supports and identification.
Results demonstrate the need for a greater emphasis on
professional development and preservice training to
address this knowledge gap.
KEYWORDS
attitudes, barriers, knowledge, mental health, teacher perceptions,
teacher training
wileyonlinelibrary.com/journal/pits | 2359
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2360 | MACLEAN AND LAW

1 | INTRODUCTION

Mental health is defined by the World Health Organization (WHO) (2001) as:

A state of emotional and social wellbeing in which the individual realizes their abilities, can cope with
the normal stress of life, can work productively or fruitfully, and can contribute to his or her
community (as cited in Graham et al., 2011).

According to the NHS (National Health Service) Scotland, an estimate of one in four people are impacted, to
some degree, by mental health problems each year (NHS Research Scotland, 2019). Prevalence rates of mental
health problems among adolescents have been found to be the highest when compared to any other stage of life
(Gulliver et al., 2012), with the WHO (2012) reporting that up to 20% of adolescents are likely to experience some
form of mental health problems, with depression or anxiety being most common.
Mental health problems are one of the most significant contributors to disease and disability worldwide,
influencing an individual's quality of life and economic growth (Harnois & Gabriel, 2000; Reiss, 2013).
According to the Mental Health Foundation (2019), 50% of mental health problems observed in adulthood will
have already been present by the age of 14, with 10% of children having a clinically diagnosable mental health issue.
Mental health problems presented in childhood/adolescence have been linked with chronically poor adjustment;
reduced attendance at school and academic success; poorer vocational achievement and social interactions; higher
risk of alcohol and drug use, and reduced life expectancy (Audit Scotland, 2018; Gulliver et al., 2012; Kessler
et al., 1995; Tully et al., 2019).
Despite the life consequences, mental illness among adolescents in the United Kingdom continue to grow. For
instance, a recent survey of secondary school headteachers and the Royal College of Paediatrics and Child Health
have suggested an 87% increase in stress, anxiety, and panic attacks, an 80% increase in depression, and a 75%
increase in incidences of self‐harm between 2015 and 2017 (RCPCH, 2017; The Key, 2017). A 2018 audit report by
Child and Adolescent Mental Health Services noted a 20% increase in children being referred to treatment over
3 years in Scotland. At the same time, Brown et al. (2015) reported increased rates of self‐harm among Scottish
adolescents and young adults, especially among young women.
However, despite rising rates and known life consequences of mental health problems, help‐seeking behaviors
among young people remain low, with some estimates of help‐seeking rates being as low as 25% to 36% for mental
health disorders and 29% for suicidal thoughts and behaviors (Bruffaerts et al., 2019).
In response, the role and responsibilities of teachers and the school settings have had to expand beyond
teaching to address students' emerging mental health needs. Due to the extensive amount of time children spend in
schools, teachers are uniquely placed to observe variations in behavior and mood, making them a vital part of early
identification and intervention (Moor et al., 2007). As a result, greater levels of responsibilities have been placed on
teachers for the promotion of positive mental health, early identification of behavioral changes, and psychological
distress. For instance, within the Scottish context, the Curriculum for Excellence framework reflects the growing
responsibility of teachers as it places children's health and wellbeing at the center of learning, alongside, and equal
to, literacy and numeracy (Education Scotland, 2020).
However, a recent Mental Health Foundation (2019) review identified a failure in the provision of mental
health supports for children in the Scottish education system. The review noted that 70% of 5‐ to 16‐year‐olds who
have experienced a mental health problem had not been provided with an appropriate intervention during their
younger years. This is especially worrying as early identification and intervention are specifically important during
the current coronavirus disease 2019 (COVID‐19) pandemic, which led to nationwide school closure across the
United Kingdom. An expected by‐product of the prolonged closure is the psychological impact on children.
Stressors related to prolonged isolation, fears for personal and family safety, boredom, feelings of loneliness, lack of
personal space at home, and family financial loss can have significant and enduring effects on children and
 15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MACLEAN AND LAW | 2361

adolescents. A recent survey found that nearly one‐third of the children who experienced isolation or quarantine
during past pandemic disasters demonstrated symptoms that met the overall threshold for post‐traumatic stress
disorder (Sprang & Silman, 2013). However, for teachers to provide support for children at risk or identify those in
need of referrals to more specialist services, adequate training, skills, and knowledge among teachers is needed
(Atkins et al., 2017; Audit Scotland, 2018; Green et al., 2018; Young Minds, 2017).

2 | T E A C H E R S ' AT T I T U D E S A N D B E L I E F S

The beliefs and motivation of teachers are important factors to consider when discussing school‐based supports
and early identification of mental health problems. Negative attitudes and stigma regarding mental health problems
among teachers have been found to present barriers to successful and timely interventions. Jorm and Oh (2009)
found that in cases where teachers helped, negative attitudes concerning mental health access to appropriate
referrals and help‐seeking behavior were reduced.
However, past research has shown that teachers most often possess favorable attitudes about providing
mental health services in schools. For instance, Graham et al. (2011) reported that out of 2220 Australian primary
and high school teachers survived, 99% of teachers reported that promoting positive mental health among students
was extremely important. Similarly, an American survey of 292 teachers found that 89% of participating teachers
felt that schools should be involved in actions to address students' mental health problems (Reinke et al., 2011).
However, Reinke et al. (2011) noted that most teachers surveyed stated that screening, conducting assessments,
and teaching social–emotional lessons in the classroom should be the responsibility of school psychologists and not
teachers (Reinke et al., 2011). A contributing factor to this reluctance among teachers to provide these supports
may result from the lack of specific knowledge and training to address these problems. Studies have shown that
teachers often lack specific knowledge, confidence, and efficacy in recognizing mental health problems among their
students (Ohrt et al., 2020; Reinke et al., 2011; Walter et al., 2006). For instance, Reinke et al. (2011) noted that
only 34% of participating teachers reported feeling as if they had the skills and knowledge necessary to support the
mental health needs of students. In support, Moon et al. (2017) found that 93% of participating primary school
teachers from the United States had high levels of concern for student mental health needs, yet lacked confidence
in handling the mental health problems of their students. Moon and colleagues reported that 85% of respondents
indicated the need for further training. Similarly in Scotland, a recent survey of trainee teachers reported that 60%
of respondents lacked confidence when identifying mental health needs, while 73% felt there was a lack of mental
health training for teachers (Mental Health Foundation, 2018).
The lack of specific training concerning mental health has been shown to lead to dissemination of mis-
information about mental health, perpetuating stigmas and biases resulting in the creation of barriers to timely
interventions and appropriate referrals (Jorm & Oh, 2009; Martin et al., 2000). For instance, Loades and
Mastroyannopoulou (2010) found that teachers held a bias where externalized behavioral symptoms were inter-
preted as more serious than emotional disturbances, which led to neglecting the importance of internalization
problems. As a result, this lack of specific or accurate knowledge concerning the manifestation of mental health
problems could result in children who present repetitive externalizing behaviors being subjected to unnecessary
disciplinary actions resulting in no effect on the underlying causal mental health issue. While on the other hand,
internalizing problems may go entirely unidentified or ignored. As a result, unaddressed problems often lead to
academic underachievement, early school dropout, or, in some cases, self‐harm behaviors (Kessler et al., 1995).
With further teacher training, externalizing and internalizing problems could be prevented with early identification
and timely referrals.
An awareness of teachers' perceptions, knowledge gaps, and self‐identified training needs related to mental
health is crucial in developing future training targeting the recognition and identification of mental health problems
within a classroom setting. Reinke et al. (2011) noted that understanding teachers' perspectives concerning their
 15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2362 | MACLEAN AND LAW

role, abilities, and training could provide important information about the contextual influences that could help
develop new programmes to address the knowledge and practice gap in school‐based mental health supports.
Given the rising rates of mental health problems among young people across the United Kingdom, a
greater need for early screening and support is required. Due to the extensive amount of time children spend
in schools, teachers are uniquely placed to play a vital role in delivering these supports and providing
assistance in early identification and intervention delivery. However, lack of knowledge, training, and
unidentified barriers may pose potential hurdles in the adoption of these responsibilities by teachers. As a
result, this paper aims to identify Scottish teachers' perceptions of their roles and barriers in supporting
children's mental health. This paper's focus on a Scottish population is unique. It provides insights into the
views and knowledge of a UK‐based teacher population, which is currently absent from the literature. This
study will address the following questions through the use of an online questionnaire of teachers from
around Scotland, United Kingdom:

1. What, if any, mental health problems have teachers identified and witnessed within children in their school?
2. To what extent do teachers feel equipped with adequate knowledge, skills, and training to support children with
mental health problems?
3. What barriers do teachers identify when supporting children with mental health problems?

3 | M E TH O D

3.1 | Study design and sample

A total of 179 Scottish primary school teaching staff from 30 different council areas completed the survey, with
the majority being female (98.9%). The participants' years of teaching experience ranged from 1 year to
42 years with a mean of 13.3 years; teachers with less than 5 years' experience had the highest representation
overall (33.5%). All but four participants identified their teaching role, with 71.4% identifying as regular
classroom teachers; 9.1% as additional support needs teachers (special needs teacher); 4% as headteachers
(principal); 13.1% as probation teachers (a newly qualified teacher with less than 1 year experience); and 2.4%
as supply/occasional teachers. A total of 174 participants (97.2%) reported the council areas within Scotland
where they taught: Aberdeenshire (11.4%), Fife (8.6%), Glasgow City (7.4%), and South Lanarkshire (5.7%); the
remaining 28 council areas equated to less than 5% each with no participation from Orkney Island and West
Islands, both being remote Scottish islands.

3.2 | Procedure

In February and March 2020 (a month before the nationwide school closure due to the COVID‐19 pandemic), a link
to the online survey was posted with permissions on a Facebook page titled Scottish Primary Teachers with some
25,000 members. The online format allowed participants to engage with the survey in their own time. Participation
was voluntary and anonymous. Participants were informed of the purpose of the study before completion through
the provided Plain Language Statement displayed at the start of the survey. Participant consent was obtained by
checking the compulsorily “agree” field following the question: "After reading the Plain Language Statement, do you
give consent for the information provided to be used within this research?". Each participant received a randomly
generated alpha‐numeric ID identity at the point of registration. The average completion rate of the entire survey
was 10 min.
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MACLEAN AND LAW | 2363

3.3 | Measures

To assess teachers' perceptions concerning student mental health needs, their role in supporting students, and
barriers to the provision of support, this study adapted the original survey reported in Reinke et al. (2011). Evidence
of validity for the original content included in Reinke and colleagues' survey was established through a stakeholder
review from four experts in the field of mental health practices in schools and relevant stakeholders, including
teachers, school counselors, school psychologists, and special education teachers. Stakeholder feedback was sought
concerning the coverage and relevance of survey domains, suggested responses, and any missing aspects of the
survey that could better inform our understanding. Based on the feedback, some terminology was adapted to suit
better the UK context (i.e., council areas were used instead of the term district area).
Three of the four subscales of teachers' perceptions reported by Reinke and colleagues were used for the
purposes of this study: Roles of the teacher; Barriers; and Cracks. Reinke and colleagues used confirmatory factor
analysis to demonstrate the distinctiveness of these subscales. Reinke reported that all items were found to have
acceptable loadings on their respective subscales (0.30 or higher), with the majority of loadings exceeding 0.60.
Description and reported internal consistency of each subscale are reported below.
An online platform was used to administer the survey. Survey questions were scored in the form of a 5‐point
Likert scale, offering the respondents a greater range in choice compared to a simple yes/no structure, allowing
consideration of how strongly they feel while allowing for a neutral response (Mcleod, 2012). After a set of
demographic‐based questions (gender, age, years in the profession, council area, and job role), a total of 43
questions were organized in specific subsection categories following the structure of Reinke et al. (2011), resulting
in the following categories: participant consent, participant demographics, Mental Health Concerns; Roles of the
teacher, Knowledge, Skills, and Training; Barriers and Cracks. See Appendix A for the complete list of survey
questions.

3.3.1 | Mental health concerns

From a list of 13 presented options, the participants were asked to identify mental health concerns they had noticed
among their students within the past year. Potential options included disruptive behavior/acting out, problems with
inattention, defiant behavior, family stress, peer problems, aggressive behavior, anxiety problems, bullying, victims
of bullying, immigration and cultural adjustment issues, and school phobia. The 13 presented options were based on
Reinke et al. (2011). They were validated through feedback from stakeholders, including scholars, teachers, school
counselors, school psychologists, special education teachers, and school administrators who reviewed the items.

3.3.2 | Knowledge, skills, and training

Teachers' perception of their knowledge and training related to mental health was assessed through a series of
questions regarding their beliefs in possessing adequate knowledge, skills, and cultural knowledge required to
support, identify, and direct students to seek help. Based on Wei et al. (2015), all terms were defined with examples
to ensure participants knew what was being asked while supporting consistency in responses. Definitions were
reviewed and agreed on by the stakeholder committee described above.
Participants were asked to indicate the type and duration of training they had been provided concerning mental
health. Types of training options included workshops, independent study, undergraduate course work, post-
graduate course work, and not applicable. Further elaboration of the training relevance was measured through
questions assessing how often they used behavioral interventions to promote positive mental health. Responses
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2364 | MACLEAN AND LAW

were collected using a 5‐point Likert scale and provided with the options: substantial (1), moderate (2), minimum (3),
none (4), and the final option, unsure (5).

3.3.3 | Roles of the teacher

To understand how teachers perceived their role in supporting mental health in the classroom, the teachers were
directed to respond to questions including “what role teachers” felt the school played when identifying and im-
proving mental health concerns', and “the role of the teacher in screening, the delivery of social‐emotional lessons,
behavioral interventions and assessments.” Participants responded using a 5‐point Likert scale ranging from strongly
agree (1) to strongly disagree (5) about their perceived roles as teachers. Reinke et al. (2011) reported that the scale
had high internal consistency, as indicated by Cronbach's α of .78.

3.3.4 | Barriers and reasons children fall through cracks

Twelve items from Reinke et al. (2011), including lack of training and lack of funding for school‐based mental health
services, were used to measure teachers' perception of barriers in providing mental health services in schools (see
Appendix A for complete list). Using a 5‐point Likert scale, participants rated their agreement with each statement
ranging from strongly disagree to strongly agree. The internal consistency of the scale was adequate (Cronbach's
α = .80). Furthermore, teachers were asked to rate their perceptions of why the mental health needs of children are
often not attended to. A total of 10 items included lack of parenting programs, lack of prevention programs, and
lack of administrator support, were rated on a 5‐point Likert scale, ranging from strongly disagree to strongly agree.
The internal consistency of the scale was adequate (Cronbach's α = .86).

3.3.5 | Missing data

The survey was attempted by 232 people resulting in 179 being completed, representing a 77.2% completion rate.
According to Kowalska (2019), the average completion rate for surveys with 15 or more questions is 41.94%,
demonstrating a high completion rate of the current survey. However, not all questions were mandatory for
completion, resulting in some missing data; questions such as demographic and questions appearing towards the
end of the survey were the most missed, potentially being related to "Participant fatigue" (Reinke et al., 2011). χ2
tests revealed no significant differences between individuals who completed all items versus those who did not,
concerning their role (teacher vs. headteacher) or being from a particular local education authority (ps > .05).

3.4 | Statistical analysis

Statistical analyses were performed with SPSS 20.0 software (IBM Corp., released 2011). All variables were found
to be normally distributed as checked within each group by the Shapiro–Wilk's test for normality (p > .05). Fre-
quency and percentages of group representation (i.e., gender, teaching role) and specific responses to question
options (i.e., barrier questions) were calculated. Group comparisons were investigated based on an analysis of
variance (ANOVA). A p value of .05 was used to identify the threshold of achieved significance. Effect sizes were
calculated using Cohen's d value. Determination of the scale of the effect was based on a scale where d = 0.2 is to
be considered a “small” effect size, 0.5 is a “medium" effect size, and 0.8 is a "large" effect size (Mcleod, 2020).
Correction for multiple testing was applied across all group comparisons to avoid the likelihood of false‐positive
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MACLEAN AND LAW | 2365

conclusions by applying the false discovery rate (FDR) procedure. This simple sequential Bonferroni‐type procedure
has been proven to control the FDR for independent test statistics (Benjamini & Hochberg, 1995).

4 | RESULTS

4.1 | Types of mental health problems identified by teachers

Participants were asked to indicate which of the 13 listed mental health problems they felt they had witnessed in a
child within the past year (see Table 1). The top five acknowledged were: (1) disruptive behaviors/acting out (90.4%
reported), (2) anxiety problems (88.2% reported), (3) problems with inattention (84.8% reported), (4) family stressors
(83.1% reported), and (5) defiant behavior (79.8% reported). In comparison, the least reported mental health issue
was immigration and cultural adjustment issues was only 13.5% of teachers identified this within the past year.

4.2 | Teacher knowledge, skills, and training in supporting mental health

When asked: “Do you feel that you have enough knowledge required to meet the mental health needs of the
children in your school?” (e.g., knowing how to seek help, being aware of the stigma and how to reduce it, etc.), 10%
strongly agreed, 34.7% agreed, 50.6% were neutral, with the remaining 4.7% indicating strongly disagreed. When
asked: “Do you feel you have the skills (ability to make use of your knowledge) required to meet the mental health
needs of children within the school?”, 7.1% strongly agreed, 27.1% agreed, 17.6% were neutral, 45.9% disagreed,
and 2.4% strongly disagreed.
A total of 171 participants responded to questions related to the form/type of training experienced: workshops
and in‐service days (74.1%), independent study (63.2%), graduate course work (7%), undergraduate study (6.4%),

TABLE 1 Teacher reported mental health issues in children from past year (n = 176)

Issues % of teachers

Disruptive behaviors/acting out 90.4

Anxiety problems 88.2

Problems with inattention 84.8

Family stressors (e.g., parent death, divorce) 83.1

Defiant behavior 79.8

Peer problems 74.2

Hyperactivity 70.8

Aggressive behavior 69.7

Bullying 49.4

Victims of bullying 47.2

Depression 31.5

School phobia 30.9

Immigration and cultural adjustment issues 13.5

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2366 | MACLEAN AND LAW

and no training (11.6%). Concerning training on mental health‐related behavioral interventions, the most common
response was minimum (49.1%), followed by: moderate (26%), none (16.6%), and substantial (8.3%).
A one‐way repeated‐measures ANOVA was conducted to determine whether there was a statistically sig-
nificant difference in perceived knowledge and skills between self‐determined levels of received training. There
were no outliers, and the data were normally distributed at each time point, as assessed by boxplot and
Shapiro–Wilk test (p > .05). The assumption of sphericity was met. Statistically significant differences in perceived
knowledge across training duration groups (substantial, moderate, minimum, and none) was found, F(3,
168) = 15.404, p < .000, partial ω2 = 0.02, with knowledge significantly increasing with each level of training
duration experienced. Similarly, a statistically significant difference in perceived skills across training level groups
was found, F(3, 168) = 17.211, p < .000, partial ω2 = 0.02, with skill significantly increasing from low levels of training
to substantial.

4.3 | Perception of teachers' roles in supporting children with mental health needs

When responding to the question: “Do you feel that schools should be involved in identifying and improving mental
health problems in pupils?”, more than 92% agreed or strongly agreed, while less than 3% disagreed (0.6% strongly
disagreed).
When asked about their perceived roles in carrying out specific tasks related to mental health support and
monitoring, over 90% of respondents felt that it was the teacher's role to implement classroom behavioral inter-
ventions, teach social–emotional lessons, and monitor student progress. While, on the other hand, the survey
results revealed a divide among participants concerning the role of teachers in aspects of mental health screening
and referrals (see Table 2 for a full breakdown)
To understand if self‐determined levels of received training was a factor in how teachers perceived their role in
supporting children's mental health needs in the classroom, a series of one‐way repeated‐measures ANOVAs were
conducted. This analysis included seven roles, as reported in Table 2, as dependent variables and perceived training
as the independent variable. No outliers were found, and the data were normally distributed at each time point, as
assessed by boxplot and Shapiro–Wilk test (ps > .05). The assumption of sphericity was met in all cases. Statistically
significant differences in teachers' views on their role in implementing classroom behavioral interventions differed
across training duration groups (substantial, moderate, minimum, and none), F(3, 168) = 3.567, p < .015, partial
ω2 = 0.061, with a stronger agreement to the question significantly increasing with each higher level of training
duration experienced. Similarly, a statistically significant difference in perceived role of the teacher in, conducting
behavioral assessments, F(3, 168) = 3.057, p = .047, partial ω2 = 0.047, referring children and families to

TABLE 2 Teachers perceptions of their role in supporting children's mental health

Role A/SA N D/SD

Screening for mental health 30.9% 26.3% 42.9%

Implementing classroom behavioral interventions 91.4% 8.0% 0.6%

Teaching social–emotional lessons 92.6% 6.3% 1.1%

NOT conducting behavioral assessments 45.4% 26.4% 28.2%

Monitoring student progress 98.8% 0.6% 0.6%

Referring children and families to school‐based services 53.4% 15.5% 31.0%

NOT referring children and families to community‐based services 46.3% 22.9% 30.8%

Abbreviations: A/SA, agree or strongly agree; D/SD, disagree or strongly disagree; N, neutral.
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MACLEAN AND LAW | 2367

school‐based services, F(3, 168) = 3.409, p = .019, partial ω2 = 0.059, and community‐based services, F(3,
168) = 3.409, p = .019, partial ω2 = 0.059, was found across training level groups, with those receiving no training
most statistically (ps > .05) likely to disagree with these being the role of the teacher. While no statistical differences
were found across training groups and all other perceived roles, as indicated in Table 2.

4.4 | Barriers and reasons children fall through cracks

Table 3 reports the results of participant responses when asked how much they believe a given issue is a reason for
children with mental health needs going unrecognized or “falling through the cracks.” The top five reasons, all with
more than 80% of resonance support, include the lack of: (1) prevention programs for students with internalized
behavior; (2) adequate parent support programs; (3) early screening and prereferral programs; (4) prevention
programs for students with externalized behavior; and (5) staff training and coaching.
When asked to report barriers for supporting children with mental health needs (see Table 4), the top five
barriers teachers indicated were: (1) insufficient number of school mental health professionals, (2) lack of funding
for school‐based mental health services, (3) lack of adequate training for dealing with children's mental health
needs, (4) lack of coordinated services between schools and community, and (5) lack of referral options in the
community. In contrast, only 4% of the teachers agreed/strongly agreed with the statement “mental health
problems do not exist and are just an excuse.”

5 | DISC US SION

This study has investigated the perceptions of 179 Scottish primary teachers concerning their roles, abilities and the
barriers faced when supporting children's mental health. The present study set to answer the following questions:
(1) What mental health concerns have teachers identified in children? (2) Do teachers feel equipped with adequate
knowledge, skills and training to support children with mental health problems? (3) What barriers do teachers
identify when supporting children with mental health problems?

TABLE 3 Reasons students with mental health needs fall through the cracks (n = 159)

Because of a lack of: A/SA N D/SD

Prevention programs for students with internalized behavior 88.0% 9.4% 2.5%

Adequate parent support programs 86.8% 7.5% 5.6%

Early screening and prereferral programs 86.8% 11.3% 1.9%

Prevention programs for students with externalized behavior 86.2% 11.9% 1.9%

Staff training and coaching 83.1% 8.2% 8.8%

Early intervention programs 81.8% 11.3% 6.9%

Adequate crisis planning and support 78.6% 15.7% 5.6%

Ongoing monitoring for students with mental health needs 78.6% 11.3% 10.0%

Implementation of existing programs as intended 69.1% 20.8% 10.1%

Administrative support 60.4% 23.9% 15.7%

Bullying programs 42.7% 25.8% 31.4%

Abbreviations: A/SA, agree or strongly agree; D/SD, disagree or strongly disagree; N, neutral.
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TABLE 4 Teacher reported barriers for supporting mental health needs (n = 152)

Barrier A/SA N D/SD

Insufficient number of school mental health professionals 95.4% 3.9% 0.7%

Lack of funding for school‐based mental health services 94.7% 4.6% 0.7%

Lack of adequate training for dealing with children's mental health needs 88.8% 9.2% 2.0%

Lack of coordinated services between schools and community 85.5% 10.5% 3.9%

Lack of referral options in the community 82.3% 12.5% 5.3%

Competing priorities taking precedence over mental health 80.3% 8.6% 11.2%

Difficulty identifying children with mental health needs 53.3% 19.1% 27.7%

Stigma associated with receiving mental health services 50.6% 20.4% 29.0%

Language and cultural barriers with culturally diverse students 26.5% 46.4% 27.1%

Mental health issues are not considered a role of the school 25.7% 22.4% 51.9%

Mental health problems do not exist and are just an excuse 4.0% 3.3% 92.8%

Abbreviations: A/SA, agree or strongly agree; D/SD, disagree or strongly disagree; N, neutral.

5.1 | What mental health concerns have teachers identified in children?

The examination of areas of concern expressed by teachers can aid in the development of content for mental health
training programs for teachers. Results of the present study identified disruptive behavior/acting out as the most
common area of concern, with 90.4% of teachers identifying it as a mental health concern they have witnessed
within the past year. This result mirrored the findings of the past work of Moon et al. (2017) and Reinke et al.
(2011), who both reported that the top areas of concern that teachers identified for training needs included
managing externalizing behaviors, classroom management, and behavioral interventions. The similarities across
studies demonstrate the continuity of teachers' reported concerns across regions (Scotland vs. the USA) and over
time (2011–2020).
These results are surprising given the volume of published literature in the past decade concerning effective
classroom management practices and best practices in the management of externalizing behavior problems. Our
findings, as well as in others (i.e., Graham et al., 2011; Moon et al., 2017; Reinke et al., 2011), suggest a potential
disconnect between research and practice resulting in the failure of initial teacher education programmes and
career‐long professional learning to equip teachers with effective classroom management and behavior support
planning skills.
The second most identified area of concern was anxiety problems, which 88.2% of teachers identified.
According to the Child Mind Institute (2020), anxiety problems among youth often are expressed as disruptive
behavior, explaining the high co‐occurrence of these concerns. An interesting finding of the survey is the potential
underreporting of concern for depression among students. According to the Mental Health Foundation (2020),
anxiety and depression are reported as Britain's most common mental health problems. Although results of this
study reported a high concern for anxiety problems among students, only 31.5% of teachers identified depression
as a mental health concern, placing it 11th out of a possible 13 options. Depression in childhood is often observed
as persistent unhappiness, loss of interest, change in eating and sleeping habits, and constant fighting (Lima
et al., 2013; Workman & Prior, 1997). Childhood depression can have various impacts on the child, varying between
mild and severe. If left untreated, it could result in later relationship problems, recurring depression, reckless
behavior, substance abuse, and suicidal thoughts and/or behaviors (DiMaria, 2020). However, early signs of
childhood depression often vary slightly from what would be expected within adults leading to depression among
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MACLEAN AND LAW | 2369

youths being mistaken for other concerns such as disruptive behavior or inattentiveness/disinterest. This confusion
of early symptoms may explain why primary school teachers may not express specific concerns related to
depression.

5.2 | Do teachers feel equipped with adequate knowledge, skills, and training to
support children with mental health problems?

Results of this study support past international research (e.g., Froese‐Germain & Riel, 2012; Moon et al., 2017;
Reinke et al., 2011; Walter et al., 2006) evaluating teachers' perceptions of their role in supporting and promoting
positive mental health among students with 92.7% of teachers agreeing that schools should play a part in identi-
fying and improving mental health problems. Similar to Graham et al. (2011), the results of this study demonstrated
that teachers recognized mental health problems within the context of their daily practice of teaching, yet felt that
some aspects of support remain the responsibility of other support professionals.
A dominant view appeared to be that teachers view themselves as best placed to support mental health‐related
issues for students through the monitoring and implementation of classroom behavioral interventions and lessons.
This result is encouraging as monitoring student progress can help teachers prioritize, plan, and improve on sup-
porting the child and their family and improving the interaction between school staff and the child (Mentally
Healthy Schools, 2020). Mentally Healthy Schools (2020) have also highlighted that monitoring a child's progress
helps identify how effective different approaches and strategies are, ensuring that they are not wasting effort,
making no difference, or, in some cases, possibly making the situation worse.
Although teachers are well placed to observe and recognize any change in behavior or personality expressed by
a student, participating teachers were divided on their role in the assessment/identification and provision of
referrals to specialists of students exhibiting mental health distress for additional supports. Two potential
explanations could be offered to explain this result. First, these results could suggest that teachers may not
understand the critical role they could play in identifying children who may be in need. Second, the lack of
knowledge and training related to identifying mental health problems has resulted in a lack of confidence in taking
up these roles among teachers. This study showed that teachers who had not received training were statically less
likely to see tasks related to screening and referrals as a teacher's responsibility, thus indicating the need for greater
professional development targeting these roles as well as mentorship provided by educational psychologists could
act to support the teachers.
Echoing past research, the results from this survey demonstrated that over half of the participating teachers
(65.7%) had received a minimum or no training (Moon et al., 2017; Reinke et al., 2011; Rothì et al., 2008;
SAMH, 2017). While those who reported receiving mental health training indicated feeling inadequately prepared
to recognize and support the mental health needs of their students. These results support the 2017 report by the
SAMH, which found that 66% of teachers did not feel they had received sufficient training in mental health to allow
them to carry out their role properly (SAMH, 2017). This study found statistically significant growth in knowledge
and skill with a greater duration of training experienced by participating teachers, thus demonstrating the need for
mental health‐focused professional development programs and their inclusion in initial teacher training
programmes.
Our results demonstrate an apparent willingness of Scottish teachers to help support the promotion of mental
health; nevertheless, teachers lack adequate knowledge or skills to do so. Therefore, providing effective practice in
schools will require effective training and ongoing consultation or coaching for teachers. Results indicate a will-
ingness of teachers to engage in such professional development opportunities as the majority of responding
teachers have attempted to address their knowledge/skill gap through in‐service professional development
workshops or independent study. However, a recent review of mental health teacher training programmes in-
dicated that outcomes of in‐service or self‐directed study programmes varied across content areas, training
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2370 | MACLEAN AND LAW

modality, and training facilitation (Ohrt et al., 2020). For instance, many training programmes focused on a specific
diagnosis or mental illness such as attention‐deficit/hyperactivity disorder, depression, anxiety, or behavioral dis-
orders, thus not fully addressing the needs of the participating teachers. Ohrt et al. (2020) noted that programmes
that aimed to improve teachers' knowledge of mental health, in general, demonstrated significant increases in
knowledge, attitudes, mental health literacy, and a decrease in stigma (Baum et al., 2009; Eustache et al., 2017;
Hussein & Vostanis, 2013; Jorm et al., 2010; Kutcher et al., 2016; Powers et al., 2014).
In the absence of effective, evidence‐based mental health training programs, Reinke et al. (2011) suggested
that school psychologists working within school authorities could serve as consultants or coaches supporting
teacher‐implemented programs and practices.
Since 2012, the General Teaching Council for Scotland's Professional Standards for Registration stated that
qualified teachers must know how to promote and support the cognitive, emotional, social, and physical wellbeing
of all learners (General Teaching Council for Scotland, 2012). Therefore, we were surprised that only 13.4% of
teachers reported receiving training related to mental health from formal education pathways, such as during
undergraduate initial teacher training (6.4%) or graduate course work (7%). The Scottish Government has recently
moved to help bridge this training gap as action points were set out by the Scottish Government's Mental Health
Strategy 2017–2027: to roll out improved mental health training for those who support young people in educa-
tional settings.

5.3 | What barriers do teachers identify when supporting children with mental health
problems?

The study posed two questions to identify specific barriers facing the implementation and success of mental health
supports in schools. The first attempted to ascertain why students with mental health needs went without support.
While the second sought to understand the specific barriers teachers faced when supporting mental health needs.
Results concerning barriers related to students missing out on support found that teachers believe this resulted
from a lack of support and prevention programs for students with internalized and externalized behavior, in-
adequate parent support programs, and insufficient early screening and prereferral programs. The perception that
there is a lack of support programs and referral options is understandable when considering the waiting times and
rejection rate of referrals within Scotland; as only 69.7% of children referred to CAHMS (Child and Adolescents
Mental Health Services) are seen within the 18‐week target time frame set by CAHMS (Information Services
Division, 2019). Furthermore, in Scotland, nearly one in five children and young people's referrals are rejected based
on quick decisions with a lack of face‐to‐face assessment (Scottish Government, 2018).
Reflecting concerns discussed earlier when considering the reason students with mental health needs fall
through the cracks, 83.1% of teachers agreed that lack of training was a contributing factor, and 88.8% of teachers
agreed that a lack of adequate training for dealing with children's mental health needs is a barrier for supporting the
said child. The lack of training could be linked to the limited amount of time teachers have to dedicate to training
and the reflecting and planning of implementation of it into the classroom. Results of this study found that 80.3% of
teachers reported that competing priorities took precedence over mental health needs, supporting the work of
Rothì et al. (2008), who highlighted that teachers were aware that there are other areas they need further training
on which mental health support competes with (Rothì et al., 2008).
Lastly, 94.7% of teachers noted that a lack of funding for school‐based mental health services was a barrier to
supporting children's needs. This is something that has been identified in previous literature as an issue, including
the 2014 Audit Scotland report and 2016 Care Quality Commission report, which suggests that there has been a
lack of progress made around funding concerning the mental health of children services (Audit Scotland, 2014;
Rosa, 2018). According to the Scottish Association of Mental Health, the costs of training all Scottish school staff in
mental health support would require an initial investment of £4.4 m (SAMH, 2018).
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MACLEAN AND LAW | 2371

6 | C ONC LUS I ON A N D I M PL I CAT IO NS

It is evident from past research that teachers play a crucial role in identifying and addressing students' mental health
concerns. The majority of participating teachers in this study were committed to the school's role in delivering
mental health education and demonstrated a belief that they have a role in supporting children. However, results
show that teachers perceive themselves as having a lack of knowledge and specific skills to promote positive mental
health. A lack of adequate training was identified as a primary barrier to delivering adequate supports and iden-
tification. It was suggested that the lack of training among Scottish teachers might be linked to inadequate funding
and/or limited available time due to competing priorities.
Results indicated that teachers in Scotland had received little in their preservice (or subsequent) teacher
education to adequately prepare them for the complexity of mental health problems faced in the classroom. This
highlights that the resourcing of initial teacher training in mental health must become more of a priority for the
Scottish Government and the providers of initial teacher training programmes. A review of initial teacher training
programmes should be undertaken to identify if teachers' relevant and appropriate knowledge, understandings, and
skills are being taught.
Supporting the conclusions of Graham et al. (2011), these findings suggest that mental health promotion should
be strengthened to ensure there remains an emphasis on advocacy for children, improved funding, increased
capacity and knowledge of teachers, and better use of the existing evidence base programmes. There has been no
time more critical for this to occur as Scotland and the rest of the world emerge from the COVID‐19 pandemic and
the associated nationwide school closures seen across the globe. As noted earlier, an expected by‐product of the
prolonged closure of schools and lockdown is the psychological impact on children (Sprang & Silman, 2013). If left
unrecognized and unsupported early on, these mental health problems will only further exacerbate the strain
already placed on mental health services across Scotland and elsewhere (Atkins et al., 2017). Teachers have an
essential role in addressing these issues by identifying, supporting early signs of mental health distress, and facil-
itating referrals to appropriate resources (Green et al., 2018), justifying the need for the provision of greater training
and funding to address the knowledge gap reported in this study.
Furthermore, to ensure interventions are adequately tailored for the individuals whose lives they seek to
improve, a priority should be given to further research that seeks the views and perspectives of children in relation
to mental health education and the role of teachers and schools in supporting their needs.

7 | L IM I TAT I ONS

This study employed an online survey as the primary method of data collection. However, this method comes with
several advantages; several limitations should be noted, such as the potential of a participant misinterpreting the
question or participants being unable to explain further the reason for their answer due to the closed‐ended format
of the questions. Although the Likert‐scale approach helped gather an overall idea about how participants feel, it
could have been helpful to allow a section for participants to add their comments. An option to allow participants to
respond freely could have provided further insight concerning the rationale of teachers' responses. Another po-
tential limitation of this study result from the lack of male primary teacher participation in the survey, as 98.9% of
respondents identified as female. Although the representation of female teachers is high, it somewhat reflects the
gender imbalance among primary school teachers across Scotland, which is reported to be 90% female (Scottish
Government, 2019). Finally, it is important to acknowledge that the results were based on teachers' perceptions
and, therefore, do not necessarily provide an accurate picture of children's mental health in schools.

CO NFL I CT OF INTERES T S
The authors declare that there are no conflict of interests.
 15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2372 | MACLEAN AND LAW

ETHICS STATEME NT
The research reported in this article meets ethical guidelines, including adherence to the legal requirements of the
study country. Ethical approval was obtained from the University of Glasgow's ethics committee.

D A TA A V A I L A B I L I T Y S T A T E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable
request.

ORCID
Jeremy M. Law http://orcid.org/0000-0001-6075-2384

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How to cite this article: Maclean, L., & Law, J. M. (2022). Supporting primary school students' mental health
needs: Teachers' perceptions of roles, barriers, and abilities. Psychology in the Schools, 59, 2359–2377.
https://doi.org/10.1002/pits.22648

A P P E N D IX A : S U RV E Y Q U E S T I O N S

1. After reading the Plain Language Statement do you give consent for the information provided to be used
within this research?
○ Yes
○ No
 15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MACLEAN AND LAW | 2375

2. Do you give consent for the information provided to be used within this research?
o Yes
o No
3. What gender do you identify as?
4. What age are you?
5. How many years have you been in the teaching profession?
6. Which council area do you work in?
7. Job title
8. In the past year which of the following mental health concerns have you noticed in the children within the
school? Please tick all you have seen with in past year
○ Disruptive behaviours/acting out
○ Problems with inattention
○ Hyperactivity
○ Defiant behaviour
○ Family stress (parent death, divorce etc)
○ Peer problems
○ Aggressive behaviour
○ Anxiety problems
○ Bullying
○ Victims of bullying
○ Depression
○ Immigration and cultural adjustment issues
○ School phobia
9. Do you feel that schools should be involved in identifying and improving the mental health issues in pupils?

A B C D E

STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE

For the following page (question 10 ‐ 19) please indicate how much you agree with the given statement;

A B C D E

STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE

10. “It is the role of the teacher to screen mental health problems”
11. “Teachers should be conducting social‐emotional lessons”
12. “Teachers should be implementing classroom behavioural interventions”
13. “Teachers should NOT be conducting behavioural assessments”
14. “Teachers should be monitoring student progress”
15. “It is the role of the teacher to refer children and families to school‐based services”
16. “It is NOT the role of the teacher to refer children and families to community‐based”
17. Do you feel that you have enough knowledge required to meet the mental health needs of the children in your
school? e.g, knowing how to seek help, being aware of the stigma and how to reduce it etc
 15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2376 | MACLEAN AND LAW

18. Do you feel you have the skills (ability to make use of your knowledge) required to meet the mental health
needs of children within the school
19. Do you feel you have adequate cultural knowledge and communication/interpersonal skills to meet the needs
of culturally diverse children in the school
20. Where do you learn about behavioural interventions that aim to promote positive mental health schoolwide?
Please select all that apply
o Workshops and in‐service days
o Independent study
o Undergraduate course work
o Graduate course work
o Not Applicable ‐ I have had no training
21. How much training have you had on, mental health related, behavioural interventions
o Substantial
o Moderate
o Minimum
o None
o Unsure
22. How often do you use behavioural interventions to promote positive mental health?
o Substantial
o Moderate
o Minimum
o None
o Unsure
For the following page (question 23‐33) please indicate to what extent you believe the given issue is a
reason students with mental health needs fall through the cracks;

A B C D E

STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE

23. Lack of adequate parent support programs

24. Lack of prevention programs for students with externalized behaviour
25. Lack of prevention programs for students with internalized behaviour
26. Lack of staff training or coaching
27. Lack of early screening and prereferral programs
28. Lack of ongoing monitoring for students with mental health needs
29. Lack of early intervention programs
30. Lack of implementation of existing programs as intended
31. Lack of adequate crisis planning and support
32. Lack of bullying programs
33. Lack of administrative support
For the following page (question 34‐43) please indicate to what extent you feel the issue is an identifiable
barrier for supporting mental health;
 15206807, 2022, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22648 by University Of Glasgow, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MACLEAN AND LAW | 2377

A B C D E

STRONGLY AGREE AGREE NEUTRAL DISAGREE STRONGLY DISAGREE

34. Insufficient number of school mental health professionals

35. Lack of adequate training for dealing with children's mental health needs
36. Mental health issues are not considered a role of the school
37. Lack of funding for school‐based mental health services
38. Stigma associated with receiving mental health services
39. Competing priorities taking precedence over mental health
40. Difficulty identifying children with mental health needs
41. Lack of coordinated services between schools and community
42. Lack of referral options in the community
43. Language and cultural barriers with culturally diverse student
 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
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

practice gap in school-based mental health practices. The purpose of this study was to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

examine teachers’ perceptions of current mental health needs in their schools; their
knowledge, skills, training experiences and training needs; their roles for supporting
children’s mental health; and barriers to supporting mental health needs in their school
settings. Participants included 292 teachers from 5 school districts. Teachers reported
viewing school psychologists as having a primary role in most aspects of mental health
service delivery in the school including conducting screening and behavioral assess-
ments, monitoring student progress, and referring children to school-based or commu-
nity services. Teachers perceived themselves as having primary responsibility for
implementing classroom-based behavioral interventions but believed school psychol-
ogists had a greater role in teaching social emotional lessons. Teachers also reported a
global lack of experience and training for supporting children’s mental health needs.
Implications of the findings are discussed.

Keywords: school-based intervention, evidence-based, mental health, children

School-based prevention and intervention
practices have become essential for reducing the
incidence of mental health problems that inter-
fere with learning and social development
(Dwyer, 2004). The vast majority of individuals
who receive any mental health services receive
them in school (Rones & Hoagwood, 2000;
U.S. Department of Health & Human Services,
1999). The need for providing these services is
clear. Prevalence estimates indicate that 20% of
children younger than 18 years of age have
mental health concerns and the percentage in-
creases to 25% for children in adverse environ-
ments (World Health Organization, 2004). Of
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
(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-
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chologists advocating for increased implemen-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
tation of evidence-based interventions in school
settings. Therefore, this study evaluated teach-
ers’ attitudes and perceptions of mental health
needs in their schools including most common
concerns, barriers for addressing mental health
needs, and issues related to their experience,
knowledge, training, and adoption of interven-
tions. Further, teacher perceptions of their roles
in comparison to school psychologists’ roles for
specific activities (e.g., delivering social emo-
tional curriculum) were explored to determine if
teachers feel they play a role in some aspects,
but not others of school-based mental health.
The individual and system level factors that
influence whether evidence-based practices are
utilized in school have been the topics of recent
research. For instance, researchers have recently
evaluated teacher perceptions (individual level
factors) of classroom interventions for children
with ADHD toward gaining important insights
into strategies for effective consultation (Curtis,
Pisecco, Hamilton, & Moore, 2006). If teachers
are reluctant to implement recommended
school-based programs and practices (e.g., Gra-
cyzk et al., 2005) efforts to understand the atti-
tudes and perceptions causing the reluctance
will be important, especially for school psychol-
ogists consulting with teachers. Other research
has focused on system level mechanisms for
promoting the use of evidence-based practices
in schools, including expert and peer social in-
fluences on implementation (Atkins et al.,
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
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
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role and feel they are adequately trained to be
This document is copyrighted by the American Psychological Association or one of its allied publishers.
successful. Therefore, understanding the
teacher perspective can provide important infor-
mation about contextual influences that can be
leveraged to bridge the research to practice gap
in school-based mental health practices.
Thus, in order to build capacity and inform
system level needs it is important to know the
educational and training requirements of teach-
ers regarding implementation of effective men-
tal health practices in schools and/or if schools
need to focus their efforts on overcoming spe-
cific barriers for providing services. However,
few studies have assessed teachers’ perceptions
of mental health needs in schools or their pre-
paredness and roles for supporting children with
mental health needs. At the most fundamental
level, it is important to determine if teachers see
the relevance of supporting children with men-
tal health needs (Ringeisen et al., 2003;
Schaughency & Ervin, 2006). More specifi-
cally, do teachers believe it is a role of schools
and teachers to support mental health needs in
children, and, if they do, do they feel they have
the knowledge and skills to be successful? Also,
what specific roles for supporting children’s
mental health do teachers affirm and how do
these compare to their perceptions of roles for
school psychologists? School psychologists are
often viewed as mental health professionals in
the school and may be seen as more responsible
for supporting the mental health of children in
schools.
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
3
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
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-
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based practices in schools. Terms were defined
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for participants throughout the survey to ensure
understanding of the questions. Mental health
issues/needs was defined as “any psychological,
social, emotional, or behavioral problem that
interferes with the students’ ability to function.”
Mental health intervention/practice was defined
as “any type of support or service provided to
students who are at risk for or have been iden-
tified as having psychological, social, emo-
tional, and/or behavior problems, or to prevent
these problems.” In the case of the term evi-
dence-based, an initial question in the survey
asked if respondents had heard of the term. The
next section asking about their use of evidence-
based interventions, including the following
definition: “treatment approaches, interventions
and services, which have been systematically
researched and shown to make a positive dif-
ference in children” (Association for Children’s
Mental Health, p. 4).
The survey items were based on an extensive
review of related surveys and literature (Aarons,
2004; Chorpita, Becker, & Daleiden, 2007; Ell-
iot & Van Brock, 1991; National Center for
Education Evaluation & Regional Assistance,
2003; White & Kratochwill, 2005). The final
items were developed based on an iterative re-
view process that included feedback from a
range of constituent groups with expertise on
the topic. Content validity was established in
the first draft of the survey; this draft was re-
viewed and revised based on input solicited
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
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
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needs “fall between the cracks.” A total of 10
This document is copyrighted by the American Psychological Association or one of its allied publishers.
items were rated on a 5-point Likert scale, rang-
ing from strongly disagree to strongly agree.
Items included lack of parenting programs, lack
of prevention programs, and lack of administra-
tor support. The internal consistency of the
scale was adequate (Cronbach’s alpha ⫽ .86).
Roles of school personnel. Teachers were
also asked using a 5-point Likert scale rang-
ing from strongly disagrees to strongly agree
if they felt supporting the mental health needs
of children was a role of the school. Addi-
tionally, teachers were asked to rate the extent
to which they felt teachers and school psy-
chologists should be involved in addressing
mental health needs of students across eight
domains, including screening, referring to
community-based providers, implementing
classroom interventions, and conducting as-
sessments. Answers were provided using a
5-point Likert scale, ranging from strongly
disagree to strongly agree. Both scales had
high internal consistency as indicated by
Cronbach’s alpha of 0.78 for the teacher scale
and 0.86 for questions pertaining to the role
of the school psychologist.
To provide further evidence of the distinc-
tiveness of these latter four subscales, we sub-
mitted all 44 items from the Barriers, Cracks,
Teacher Roles, and School Psychology Roles
subscales to a confirmatory factor analysis using
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.
5
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
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
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them. Then, the data were systematically eval-
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uated and coded. Over the course of the coding
process, when the coders noticed new responses
in large numbers that did not fit with the original
themes, additional codes and categories were
added to the original list. A consensus was
required between both the coders for a response
to be assigned a certain code. A third coder
reviewed the broad codes developed and en-
tered the codes into SPSS accordingly.
Missing Data
Results were reported using listwise deletion
for missing data on all variables. Missing re-
sponses were more likely for questions that
occurred later into the survey, most likely due to
participant fatigue. However, over 91% of re-
spondents completed all items.
Chi-square tests revealed no significant dif-
ferences between individuals who completed all
items versus those who did not with regard to
their role (special education vs. general educa-
tion) or being from a particular school or school
district ( ps ⬎.05).
Results
Types of Mental Health Issues
Teachers indicated whether they had taught
or worked with a student in the past year with
specific mental health and behavioral concerns
(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-
Table 1
Teacher Reported Mental Health Concerns in
Children From Past Year (n ⫽ 292)
% of
Concern teachers
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 p d
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
⫺10.96
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Referring children and families to school-based services 3.92 (.89) 4.59 (.70) .000 .84
⫺17.87
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Referring children and families to community-based services 3.46 (1.0) 4.63 (.63) .000 1.41
Note. Likert scale for mean ratings: 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), 5 (strongly agree).

calculated to determine the magnitude of effect
(Cohen, 1988). Cohen’s (1988) guidelines for
interpreting scores include: small effects range
from 0.20 to 0.49, medium from 0.50 to 0.79,
and large above 0.80.
Teacher Knowledge, Training, and
Experience in Supporting Mental Health
Teachers were asked whether they had heard
of the term “evidence-based practices,” 55.5%
of teachers indicated they had, while 44.5%
indicated they had not or were unsure. More
specific questions were included on involve-
ment, knowledge, and skills in relation to sup-
porting children’s mental health needs in
schools. In response to the question “I feel that
I have the level of knowledge required to meet
the mental health needs of the children with
whom I work,” 4% of teachers indicated that
they strongly agreed, 24% indicated they
agreed, 31% were neutral, 36% disagreed, and
5% strongly disagreed.
Teachers also responded to the question “I
feel that I have the skills required to meet the
mental health needs of the children with whom
I work,” and 4% of teachers indicated that they
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

Barriers to Services ogists’ roles in supporting the mental health

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
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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

programs, and (4) staff training and coaching. In referring students with mental health issues over
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addition, teachers provided their opinions re-
garding whether certain factors were barriers to
supporting children with mental health needs in
schools (see Table 4). The top three barriers
were insufficient number of school mental
health professionals, lack of training for dealing
with children’s mental health needs, and lack of
funding for school-based mental health.
Discussion
School professionals are under increased
pressure to be accountable for the practices they
implement with current legislation directing
teachers to use evidence-based practices (Yell
& Drasgow, 2003). Factors that influence adop-
tion of evidence-based practices are the focus of
extensive research as researchers try to bridge
the research to practice gap by understanding
more about what makes an intervention trans-
portable (Walker, 2004). To add to the literature
in this area, the purpose of this study was to
determine teachers’ perceptions of current men-
tal health needs and issues in their schools and
their perceived role as well as school psychol-
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

Table 3
Reasons Students With Mental Health Needs Fall Through the Cracks (n ⫽ 276)
Because of a lack of: A/SA N D/SD
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
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%
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Lack of referral options in the community 37% 40% 23%

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Language and cultural barriers with culturally diverse students 29% 32% 39%
Mental health issues are not considered a role of the school 27% 35% 38%
Mental health problems do not exist and are just an excuse 19% 26% 55%
Note. A/SA ⫽ 4 (agree) or 5 (strongly agree); N ⫽ 3 (neutral); D/SD ⫽ 2 (disagree) or 1 (strongly disagree).

are doing a disservice to the field. The profes-
sion of teaching is an incredibly important and
challenging career. The results of this survey
indicate the need for training, strategies, and
attention toward supporting teachers faced with
students displaying significant behavioral, so-
cial, and emotional difficulties.
Second, teachers reported that they felt it is
the schools’ responsibility to support children’s
mental health needs and that teachers should
play a specific role in doing so. In particular,
89% of teachers agreed that schools should be
involved in addressing the mental health needs
of children. However, only 34% of teacher re-
ported that they felt they had the skills neces-
sary to support these needs in children. This is
important information in regard to the research
to practice gap. If teachers believe they should
play a role in addressing the mental health needs
of children, but lack adequate knowledge or
skills to do so, transporting effective practice to
schools will require intervention developers to
include effective training and ongoing consul-
tation/coaching as part of dissemination prac-
tices. Further, school psychologists working
within school districts wanting to utilize evi-
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
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
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
literature over the past decade. For instance,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
when conducting a search in PsycInfo of man-
uscripts using the term “evidence-based” in the
title for the year 1999, only 49 articles are
identified, but for the year 2009, a total of 245
articles are identified. Further, many organiza-
tions have attempted to systematically identify
and document programs that are considered
“evidence-based” (e.g., Blueprints for Violence
Prevention, Office of Juvenile Justice and De-
linquency Prevention, What Works Clearing-
house). The data from this survey clearly point
to the lack of dissemination of this information
to teachers. If we hope to close the research to
practice gap, we as researchers will need to
become better at communicating the common
language that is developing around these prac-
tices. An important first step toward increased
dissemination is making teachers aware of evi-
dence-based practices. Further, teachers as nat-
ural implementers of evidence-based programs
and practices will need access to information
about correctly identifying these programs and
practices. School psychologists, who often re-
ceive more specialized training in the area of
student mental health, evidence-based practice,
and research, can be a resource to their school
districts and teachers in understanding and iden-
tifying effective practice. Additionally, school
psychologists can provide inservice trainings
on what it means to be evidence-based, where
to locate information about these practices
and programs, and how to implement them
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
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
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
evidence-based practices within school settings.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Further, school psychologists can interface be-
tween teachers and research in a way that sup-
ports use of effective practices in local contexts.
In efforts to bridge the gap between what
researchers have shown to be effective in reduc-
ing mental health issues in children and what
practitioners select to implement, it is important
to understand issues related to this gap. The
survey pinpoints a clear need for connecting
teacher training to the specific areas of chal-
lenges that they encounter in working with stu-
dents. In this case, the major concerns con-
nected to training were externalizing problems,
engaging families, supporting social develop-
ment, and children showing signs of depression.
Additionally, providing training to preservice
and inservice teachers that promotes the use of
evidence-based practice and programs is
needed. Teachers understand that they can play
a role in supporting students with behavioral,
emotional, and social difficulties, but need the
training and support to implement effective
practices. School psychologists can work to-
ward filling some of these gaps by acting as
resources to teachers in identifying evidence-
based programs and practices, training and pro-
viding ongoing consultation in these practices,
and supporting the ongoing evaluation of these
practices within the real world. Next, effective
dissemination will require researchers to de-
velop systematic plans for training, consultation
and coaching, and supervision to ensure that
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
11
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
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-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
out the key players at the table, including those
This document is copyrighted by the American Psychological Association or one of its allied publishers.
who would be implementing evidence-based in-
terventions (i.e., teachers), the research to prac-
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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Reading’s research outputs online
 Journal of Mental Health Training, Education and Practice
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Journal: Journal of Mental Health Training, Education and Practice

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Manuscript Type: Research Paper

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Teachers, Qualitative, School, Interpretative phenomenological analysis,

Keywords:
Adolescence, Mental Health
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Page 1 of 25 Journal of Mental Health Training, Education and Practice
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5 1 Secondary school teachers’ experiences of supporting mental health
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10 3 Purpose: Teachers are often the first contact for students with mental health difficulties. They
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12 4 are in an ideal position to identify students who are struggling and frequently support them
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tal
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5 using different approaches and techniques. This qualitative study aims to investigate secondary
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17 6 school teachers’ experiences of supporting the mental health of their students.
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19 7 Methodology: 7 secondary school teachers from state-funded schools in the UK participated in
ea

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8 face-to-face semi structured interviews. Interpretative phenomenological analysis was used to
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24 9 understand and structure the data into themes.

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26 10 Findings: Five superordinate themes emerged from the data analysis: Perceived role of teacher,
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28 11 nature of relationship, barriers to helping the child, amount of training and resource, and
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31 12 helplessness and satisfaction. Participants described the lack of training, resource and clarity
ini

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33 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
,E

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40 16 generalised to the wider population due to the nature of qualitative interviews.
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42 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
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47 19 directly meets their needs and abilities.
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49 20 Originality/value: This paper finds value in recognising the lived experience and
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51 21 difficulties faced by teachers supporting students’ mental health problems. A theoretical
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54 22 model novel model is presented based on this analysis that can help inform best practice
55
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56 23 for schools.
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58 24
59 25 Keywords: “teachers” “qualitative” “school” “interpretative” “adolescence” “mental health”
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 Journal of Mental Health Training, Education and Practice Page 2 of 25
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3 26 The amount of time teachers spend in contact with students makes them well placed to notice
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6 27 symptoms and behaviours associated with internalizing and externalising disorders difficulties
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8 28 such as irritability, social withdrawal and changes in concentration (Ginsburg and Drake, 2002;
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10 29 Chatterji et al., 2004). Teachers working in secondary schools are faced with a high prevalence
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30 of mental health problems in their students. In the UK, two-thirds of children and adolescents
tal
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15 31 with diagnosable mental health disorders have spoken to a teacher about their mental health
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17 32 (Newlove-Delgado et al., 2015). Teachers are in an ideal position to refer and signpost students
H

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33 to mental health care services (Fazel et al., 2014). They are often the first point of contact for
ea

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22 34 parents who are worried about their child’s emotional wellbeing (Sax and Kautz, 2003; Ford
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24 35 et al., 2008).
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26 36 Many teachers acknowledge their ability to identify students who are in difficulty and
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29 37 manage mental health problems in the classroom (Rothì, Leavey and Best, 2008; Andrews,
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31 38 McCabe and Wideman-Johnston, 2014) and the link between academic and emotional health
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33 39 outcomes (Kidger et al., 2009). However without training, teachers have low confidence in
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40 their knowledge and ability to recognise mental health problems, as well as providing support
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38 41 within school (Roeser and Midgley, 1997; Walter, Gouze and Lim, 2006; Moor et al., 2007;
,E

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40 42 Andrews, McCabe and Wideman-Johnston, 2014). Previous studies have found teachers often
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43 feel uneasy when discussing mental health with students and are unsure how to manage
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45 44 emotional difficulties in the classroom (Roeser and Midgley, 1997; Walter, Gouze and Lim,
ca

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47 45 2006; Cohall et al., 2007; Moor et al., 2007).
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49 46 There is a demand from governmental bodies in response to public campaigns

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47 for secondary school teachers in the UK to have increased mental health knowledge and
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54 48 training (Department of Health, 2015; Department of Health and Department of Education,
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56 49 2018). It is important to understand the context and experiences faced by teachers in secondary
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50 schools in order to develop appropriate resources and interventions. There are many
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3 51 programmes that train school staff around mental health (Anderson et al., 2018). However tTo
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6 52 date, few studies have explored teachers’ beliefs about specific aspects relating to students’
fM
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8 53 mental health, and their role in supporting students. A holistic understanding of teachers’ lived
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10 54 experience of students’ mental health problems is needed to facilitate the design of resources
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55 and training that may best support teachers (Kirkpatrick, 2008). By learning about the
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15 56 experiences teachers have had regarding mental health in schools, intervention developers can
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17 57 optimally design interventions and resources that may best help teachers in the future.
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58 The present study
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22 59 The aim of the current study is to explore teachers' perspectives of supporting students' mental
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24 60 health, focusing on their emotional and cognitive processing of these experiences. The
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26 61 rigorous, detailed and phenomenological exploration of the experiences of teachers will help
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29 62 to better understand the impact of supporting students on participants’ own beliefs and
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31 63 emotions. The study uses the methodological framework of Interpretative Phenomenological
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33 64 Analysis (IPA) to generate a rigorous, detailed and in-depth exploration of the ‘lived
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65 experience’ of individuals, thus enabling a rich understanding of participants’ stories and
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38 66 perspectives (Smith, 2004). In the last decade IPA has been increasingly used in qualitative
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40 67 health research, particularly when the topic is under-studied and participants’ experiences have
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68 yet to be systematically explored (e.g. Fox and Diab, 2015; Smith and Rhodes, 2015).
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45
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46 69 The present study aims to explore the experiences teachers have had regarding the
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48 70 mental health of their students in schools. A better understanding of teachers’ experiences,
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50 71 needs and opinions can improve the development of future mental health interventions targeted
51
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53 72 at teachers (Han and Weiss, 2005; Neil and Christensen, 2009).
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55 73
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57 74 Method
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3 75 The study uses the methodological framework of Interpretative Phenomenological Analysis
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6 76 (IPA) to generate a rigorous, detailed and in-depth exploration of the ‘lived experience’ of
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8 77 individuals, thus enabling a rich understanding of participants’ stories and perspectives (Smith,
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10 78 2004). In the last decade IPA has been increasingly used in qualitative health research,
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79 particularly when the topic is under-studied and participants’ experiences have yet to be
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15 80 systematically explored (e.g. Fox and Diab, 2015; Smith and Rhodes, 2015). IPA employs a
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17 81 systematic approach to analysis, which recognizes the role of the researcher as an interpreter
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82 of the insights from the participant. IPA uses idiographic inquiry in which each participant’s
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22 83 story is analysed in detail and considered as an individual, separate narrative prior to exploring
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24 84 commonalities across participant accounts (Smith, Harr and Van Langenhove, 1995; Smith,
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26 85 2004).
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29 86 Ethical approval for the study was granted by the University of Reading Research
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31 87 Ethics Committee (reference number 2016-037-PW). The study used IPA and was conducted
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33 88 following established criteria for rigour in qualitative research (Denzin and Lincoln, 1994),
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89 using the COREQ checklist for reporting (Tong, Sainsbury and Craig, 2007) (Appendix A).
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38 90 SamplingParticipants
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40 91 Participants were eligible for inclusion if they were a) secondary school teachers who
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92 b) had experience of a conversation with at least one student about their mental health. We also
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45 93 only recruited participants in the South East of England due to travel limitations of the research
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47 94 team. The study was advertised via word of mouth and online social media (Twitter, Facebook)
48
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49 95 snowballing distribution of information. Advertisements were shared from the personal and
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96 university social media accounts, and subsequently ‘re-shared’ by members of the public.
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54 97 Eligible participants contacted the lead researcher and were contacted with further information
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56 98 about the study. Nineteen people expressed interest in the study. From this pool of potential
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99 participants, seven individuals met the inclusion criteria (reasons for exclusion: 5 people taught
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3 100 in primary schools, 7 people did not respond past initial contact). The number of participants
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6 101 in the study was determined by the recommendation from Smith, Flowers and Larkin (2009)
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8 102 that the number of interviews for an in-depth IPA analysis should be between four and ten.
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10 103 Participants were seven teachers working in different secondary state schools in the South East
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104 and London regions of the UK. There were five female and two male teachers and their ages
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15 105 ranged from 24 to 53 years. Five participants were White British, one was Asian British and
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17 106 for the remaining participant, ethnicity was not provided. Years of experience working as a
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107 teacher ranged from 2 to 26 years.
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22 108 Procedure
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24 109 One-to-one interviews were conducted by the male lead author, a PhD student trained
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26 110 in qualitative research methods at the University of Reading. The interviewer had no prior
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29 111 relationship with the participants before the study. Interviews took place in a private room in
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31 112 the teacher’s school or the University of Reading. Participants gave their informed written
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33 113 consent for their data to be included in the research. The interviews lasted between 38 to 84
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114 minutes. Participants were reimbursed £15 for their time. Interviews were audio-recorded and
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38 115 transcribed verbatim by the lead author. Detailed field notes were written by the lead researcher
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40 116 following interviews and were used as an aid during analysis.
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117 At the start of the interview participants were asked to think about a specific time that
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45 118 they had supported a student who was struggling with mental health difficulties. Interviews
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47 119 followed a semi-structured topic guide written by the authors and piloted with a secondary
48
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49 120 school teacher by the lead author (Appendix B). The topic guide was used flexibly to explore
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121 in depth the emotions, cognitions and beliefs felt by the participants when recalling their single
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54 122 experience interacting with a student with a mental health problem.
55
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56 123 Data Analysis

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3 124 The data analysis was completed in several stages following the IPA framework (Smith et al.,
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6 125 2009). This methodology ensured an in-depth and idiographic analysis by focusing initially on
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8 126 individual interviews and eventually working towards an overall categorisation of themes.
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10 127 Firstly, the lead researcher (LS) read and re-read each transcript to ensure a high level of
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128 familiarisation with the data. In the second stage, transcripts were independently coded into
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15 129 nodes with interpretative annotations added that focused on the cognitive and emotional
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17 130 experiences of the participant. The computer software package NVivo (QSR, 2014) was used
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131 to facilitate coding of the transcribed data. After this idiographic approach, nodes from the
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22 132 different interview transcripts were compared and linked. The following stage involved
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24 133 grouping and organizing nodes into themes. Themes were discussed and questioned with two
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26 134 further researchers (KH, an experienced qualitative researcher & PW, an experienced
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29 135 researcher into young people’s mental health and a clinician) acting as independent auditors
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31 136 (Smith, Flowers and Larkin, 2009). Superordinate themes were derived from the data following
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33 137 an iterative processing and rearrangement of the themes until the authors felt that the data was
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138 well represented.
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38 139
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40 140
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141 Results
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45 142 The interpretative analysis of the interviews resulted in five superordinate themes that are
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47 143 shown presented in Table 1 and are explored further below. A map of the superordinate themes
48
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49 144 and their relation to each other is presented in Table 2.

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145
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54 146 [Table 1 near here]
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56 147
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148 Perceived Role of Teacher
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3 149 Participants presented their role of a teacher as a ‘balancing act’ between adequately providing
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6 150 support and facing the consequences of being too close to a student. All participants
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8 151 acknowledged how they did not want to become a ‘therapist’, and yet still expressed difficulty
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10 152 in knowing how close they should be to students.
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153 Going beyond the role of an educator.
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15 154 All participants viewed their primary role as educators, with a focus on the academic
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17 155 achievement of their students. It became clear that participants worried that they would be
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156 giving incorrect advice if they were to advise students.
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22 157 I’m so much more confident to listen and no I’m not there to fix
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24 158 it for them but … I can have a discussion with him and then
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26 159 slowly they will start talking more and more and then hopefully
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29 160 calm - Participant 2 (P2); female
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31 161 Some participants were unsure whether to support students suggesting a lack of clarity over
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33 162 their role as caregivers.
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163 I’m there to be a caregiver but like to a certain degree. I don’t know
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38 164 what the degree is yet – P5; female
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40 165 Consequences from being too close to students.
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166 Many of the participants worried around boundaries and the consequences of being too close
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45 167 with students when discussing their mental health. Participants described felt that they had
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47 168 difficulty maintaining a disciplinary role with a student whilst supporting them.
48
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49 169 Things can go wrong very easily and very quickly and then as I
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170 found before … my relationship with this child as a teacher was
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54 171 compromised because of the relationship that I had with the child
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56 172 as somebody who cared about her and that was not my role so I
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173 think I learnt a valuable lesson – P7; female
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3 174 Role of teacher to refer and signpost.
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6 175 Some participants described how it is not their responsibility to support students directly but
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8 176 that they felt they should be referring students to other appropriately trained professionals.
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10 177 Several participants spoke about the mental health of their students in a medicalised way,
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178 perceiving their problems as something that ‘required fixing’ by a health professional rather
tal
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15 179 than more holistically by the people around the young person.
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17 180 It's not our responsibility. I think we're not trained to be counsellors
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181 we should ... send them off, refer them to someone else cause we
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22 182 can't take responsibility. That's what I feel - P5; female
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24 183 In contrast, other participants argued that in fact teachers can work collaboratively to support
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26 184 a student.
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29 185 It doesn't always have to become someone else's problem … this is
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31 186 everybody’s responsibility, we're all in this together absolutely and
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33 187 you … just have to be given the right language and some structures
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188 on what advice to offer - P2; female
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38 189 Nature of relationship
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40 190 Participants invested in the mental health of their students exhibited a parental-like caring and
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191 sympathy. These participants described a more trusting relationship and found that this made
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45 192 it easier for the young person to be open.
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47 193 Conversations depend on good relationships.
48
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49 194 Participants clearly emphasised that they felt trust was important in building a good relationship
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195 with the young person.
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54 196 I felt like obviously this person trusted me because people don’t
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56 197 obviously share random horrible stories about themselves to

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3 198 random members of the public. They find safe confiding people
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6 199 that they trust, so I did feel like this person trusts me – P5; female
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8 200 Showing care and positive regard for the student.
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10 201 Many of the participants spoke of how much they cared about the wellbeing of their students.
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202 These participants tended to be those who considered student wellbeing as part of their role.
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15 203 You know this person's come to you in trust and you want to you
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17 204 want to be there to help them because you know what it's taken for
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205 them to do that - P2; female
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22 206 Several participants were protective over the young person, such as defending the student in
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24 207 front of their parents.

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26 208 I had a parents’ evening with her mum ... and I remember getting
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29 209 really annoyed at her mum for not quite realising how talented she
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31 210 is or how unique and special she is” - P1; female
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33 211 Ability to provide stable environment.
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212 The participants believed that mMany of the students supported by participants experienced
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38 213 transitory and unstable lives at home and with their friendship groups. It was clear that
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40 214 participants saw the school setting as one that can be consistent and secure for their students.
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215 The participants spoke about their responsibility to provide this stable care as if they are ‘in
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45 216 loco parentis/in place of parents’ whilst the student is in school.
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47 217 We are a stable environment for her. We're somewhere where she
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49 218 can come and get the support and have the family relationship that
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219 she needs – P3; male
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54 220 Barriers to helping the young person
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56 221 All of the participants described various barriers to obtaining appropriate help for their
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222 students.
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3 223 Amount of time or space.
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6 224 All participants described how the pressures of time and space when working in a school were
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8 225 barriers for them adequately supporting their students. When a student with a mental health
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10 226 problem approached them, participants found that their academic commitments got in the way
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227 of them feeling confident in providing good support being able to provide good support to the
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15 228 student.
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17 229 I felt frustrated as well because if I couldn't fix this in five to ten
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230 minutes then well then I couldn't fix it because I had to be
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22 231 somewhere else because the school timetable is so rigorous – P2;
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24 232 female
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26 233 Working with other teams and services.
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29 234 Participants described overburdened external services as a clear barrier for getting the young
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31 235 person appropriate help. The NHS Child and Adolescent Mental Health Services’ (CAMHS)
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33 236 long waiting times and low referral rates was viewed by many participants as a problem that
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237 often contributed to mental health decline in students.
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38 238 I want action immediately. I understand that CAMHS and other
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40 239 professional agencies have longer waiting lists. I understand the
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240 cuts that they’ve gone through and I understand the frustrations
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45 241 they have but it doesn't stop still when you've got a young person
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47 242 in front of you crying out for help that you want to help them and I
48
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49 243 think you then pick up those frustrations – P6; male

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244 Involvement of parents.
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54 245 Parents were occasionally seen as a source of difficulty and a contributing factor to the
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56 246 student’s poor mental health. Some participants described how parents’ own beliefs and
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247 cultural views about mental health stopped students from accessing appropriate help. This
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3 248 made it very difficult for participants to talk to the family about their child and try to
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6 249 recommend services and strategies.
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8 250 I think also we're not only having to deal with the mental health of the
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10 251 young people but also their parents ... don't acknowledge it themselves
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252 – P6; male
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15 253
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17 254 Amount of training and resource
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255 Many of the participants spoke about the training and resources necessary to adequately support
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22 256 their students. Often participants reported a lack of understanding and knowledge about how
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24 257 best to help. In various examples participants resorted to using ‘common sense’ and their
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26 258 teaching skills to independently provide solutions.
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29 259 Previous understanding about mental health.
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31 260 Unanimously participants mentioned a lack of training and preparation to help students with
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33 261 mental health problems. Participants subsequently felt ill-prepared and unable to competently
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262 support students.
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38 263 It was a case of trying to make a square fit a circle so with the
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40 264 training we had and with the resources we had trying to support
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265 them, it just felt very inadequate, it felt superficial the support we
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45 266 were giving and it didn't feel like we were actually supporting them
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47 267 in any real way - P7; female
48
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49 268 Having to independently come up with ideas.

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269 Frequently participants described having to support students doing what they instinctively
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54 270 thought was the right thing to do.
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56 271 I just had to sort of rely on my natural teaching skills which is just
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272 to listen to her and to say to her is it's probably not as bad as you're
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3 273 making it out, it's all in your head, it's all in your mind, but a lot of
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6 274 the time what I was saying was probably not the right thing and she
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8 275 was getting more and more anxious - P2; female
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10 276 Helplessness and Satisfaction
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277 The emotions described by many participants were those of helplessness and feeling as though
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15 278 they had let down their students. On the other hand, there were participants who felt that they
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17 279 positively impacted their student’s mental health and were glad to help.
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280 Sadness and Helplessness.
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22 281 At times during the interview many participants became upset and emotional. When they
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24 282 perceived that theirir student was not showing signs of improvement or receiving appropriate
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26 283 support, some participants felt devastated. This was especially the case for those that had a
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29 284 strong empathetic investment in their student.
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31 285 How do we feel? You do feel helpless ... you feel that you're losing
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33 286 a child - P3; male
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287 The perceived lack of options for support or treatment for the young person led participants to
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38 288 feel that there was nothing else that they could do to improve the mental health of their student.
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40 289 Initially there was nothing there was nothing I could do, there was
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290 nowhere I could send her, there was no referral, there was nothing
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45 291 - P2; female
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47 292 The culmination of not being able to adequately support a student together with other services’
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49 293 limited availability meant some participants felt as though they had failed in their role as a
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294 teacher.
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54 295 I came into teaching to help young people to be more successful to
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56 296 change their lives for the positive and generally I've been
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297 successful in doing that but when you can't and when ... that
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3 298 support is either not there or they can't do it, that that's a horrible
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6 299 feeling - P4; female
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8 300 Frustration.
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10 301 The barriers to getting the student appropriate help combined with the participants’ own lack
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302 of knowledge and capability often contributed to feelings of anger and frustration. Participants
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15 303 described aggravation at not being able to have resources within the school to support a high-
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17 304 risk student.
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305 There was nowhere I could put her, there was nowhere private I
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22 306 could take her ... so it was just very frustrating the kind of mental
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24 307 health support we were offering - P2; female

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26 308 Satisfaction and hope from helping.
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29 309 In the cases where participants felt that they had helped their students, they expressed a great
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31 310 deal of relief and satisfaction. Many participants were hopeful that their support would make a
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33 311 positive change to the young person’s life.
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312 I just felt so pleased that I did it [helped]. I said to my daughter in
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38 313 the car on the way home it was the right thing to do ... I just felt
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40 314 elated that he was coming out the other end – P4; female
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315 Some participants described their desperate hope that the mental health of their students would
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45 316 improve. The quote below highlights the resilience and perseverance of the participant to help
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47 317 his student and keep him safe in the face of various barriers and setbacks.
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49 318 You just keep going and keep trying to help them so you hope that
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319 they're going to be in school on a Monday after a weekend and you
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54 320 hope that you get another chance of keeping them safe for another
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56 321 week and hoping that something is going to change that's gonna
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3 322 give them a better opportunity, give them better support. You just
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6 323 keep going - P3; male
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8 324
9
10 325 Discussion
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326 Semi-structured interviews were conducted with seven secondary school teachers in the UK.
tal
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15 327 The interviews explored participants’ experiences of conversations with students concerning
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17 328 their mental health. Five superordinate themes were generated exploring the different factors
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329 of participants’ experiences.
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22 330 Based on the findings from this study, we propose an interpretative and theoretical
23
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24 331 model to represent of the experiences and perceptions of the participants (shown in Figure 1).
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26 332 The emotional response from participants depended on their observed changes in the students’
27
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29 333 mental health and the extent of their own investment in the emotional health of the student.
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31 334 The changes in the mental health of the student relied on two factors: a) the barriers to getting
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33 335 the child appropriate help, and b) the internal knowledge and expertise of the teacher to help
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336 the student. The participant’s interest in the mental health of their students was determined by
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38 337 how they themselves view the role of the teacher their closeness to students. These two streams:
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40 338 a) the ability for the child to get appropriate help from the school, external services or the
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339 teacher themselves and b) the teacher’s own investment in the student’s mental wellbeing
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45 340 combine and impact on the emotional reaction of each participant.
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47 341
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49 342 [Figure 1 near here]

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343
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54 344 Many of the participants felt unable to successfully help their students and spoke as if
55
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56 345 they had failed them. The helplessness described by participants included feelings of failure,
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346 isolation and negative predictions for the student’s future. This helplessness has previously
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3 347 been linked to the perceived ‘ambiguity of the teacher’s role’ as highlighted in our own analysis
4
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6 348 (Travers and Cooper, 1993). This helplessness is likely to impact on teachers’ own wellbeing
fM
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8 349 and ability to work effectively as well as them feeling emotionally drained (Kidger et al., 2010).
9
10 350 A common generated theme was the lack of knowledge from participants about what
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351 to do and the right way to respond to students with mental health difficulties. Several
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15 352 participants viewed their student’s mental health as a medical problem to be fixed. This has
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17 353 potential to limit the perception of their own capacity to support them. This theme is held
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354 consistently across similar studies, in which school teachers describe their lack of training or
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22 355 knowledge to adequately support the mental health of their students (e.g. Walter, Gouze and
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24 356 Lim, 2006; Kidger et al., 2009; Knightsmith, Treasure and Schmidt, 2013; Andrews, McCabe
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26 357 and Wideman-Johnston, 2014). Many researchers and teachers themselves have emphasized
27
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29 358 the importance of school staff receiving adequate training, information, and resources to
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31 359 distribute to students with mental health problems (Roeser and Midgley, 1997; Reinke et al.,
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33 360 2011).
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361 Participants’ experience of helplessness was often attributed to poor communication
37
38 362 and input from external services, notably CAMHS. Similar UK studies have highlighted the
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40 363 negative experience that teachers have had with external support services, such as the lack of
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364 communication from CAMHS and external services’ long waiting times (Ford and Nikapota,
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45 365 2000; Rothi and Leavey, 2006). The time restrictions from the teaching profession on the
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47 366 ability to support emotional issues in students has been repeatedly been reported by teachers in
48
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49 367 previous research (Walter, Gouze and Lim, 2006; Williams et al., 2007). School-based
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368 interventions may help staff feel able to not rely as heavily on external services and avoid the
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54 369 identified barriers to providing support.
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56 370
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3 371 Similarly, parents of students were often viewed as a barrier to helping the young
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6 372 person. Other studies have identified that teachers find working with parents a frustrating
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8 373 process in which parents are often perceived to be “uncooperative, disengaged, and unwilling
9
10 374 to take responsibility for their children’s actions” (Williams et al., 2007; Knightsmith, Treasure
en
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375 and Schmidt, 2013). In one questionnaire, teachers endorsed lack of parental involvement as a
tal
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15 376 barrier to getting help for their students (Walter, Gouze and Lim, 2006). Teachers have rated
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17 377 problematic relationships with parents as the most common barrier to supporting students with
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378 behavioural health difficulties (Ford and Nikapota, 2000).
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22 379 Strengths and limitations
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24 380 The qualitative method of this study enables a valid exploration of the issues that
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26 381 concern teachers when discussing mental health in schools. The study met all of the
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29 382 requirements of the COREQ guidelines for rigorous qualitative research (Appendix A). All of
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31 383 the participants were practicing teachers with first-hand experience of mental health difficulties
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33 384 in students and therefore in a position to contribute to the research question. Whilst
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385 participants’ specific experiences with students differed extensively, the themes that have been
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38 386 generated were consistent across all those interviewed.
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40 387 It is important to acknowledge the limitations encountered when conducting qualitative
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388 research. Participants were teachers who expressed an interest in discussing their experiences
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45 389 and were willing to give up their time to participate in the research. It would be useful to
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47 390 investigate the experiences of teachers who have not had supportive interactions with their
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49 391 students and are not interested in their mental health. The participants were all teachers within
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392 schools with a ‘Good’ or ‘Outstanding’ Ofsted rating, meaning that their schools are deemed
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54 393 above average in academic, social and behavioural ability. It would be of interest to future
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56 394 research to learn more about teachers’ experiences in lower-ability or lower-Ofsted rating
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395 schools. Characteristically these schools are less financially flexible and so may present
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3 396 different experiences and problems for teachers. Likewise, the participants were all based in
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6 397 schools in the South East of England. The demographic uniqueness of the sample has potential
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8 398 to shape the data and their experiences. Going forward, further research should be conducted
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10 399 with samples that differ in their geographic and demographic characteristics. This is important
en
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400 to understand to what extent the interpretational model may be generalised to other school staff.
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15 401 The opinions, beliefs and own school experiences of the authors themselves have
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17 402 potential to shape the data and analysis. The lead author has an interest in the role of mental
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403 health in school and is passionate about there being provision of mental health support for
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22 404 students. Similarly, the lead author’s research is funded by a charity focused on young people’s
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24 405 mental health. One of the authors is a clinical psychologist with a strong interest in mental
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26 406 health in young people.
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29 407 Whilst we intend that the current study has ‘theoretical generalisability’, in that the
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31 408 knowledge and understanding from these unique accounts may extend and be relevant to the
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33 409 wider experiences of others, these results are not intended to be generalizable to the wider
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410 population. It would be interesting to explore whether participants’ experiences are shared by
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38 411 other teachers, other support staff within the school, as well as the students themselves.
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40 412 Conclusion
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413 This paper aims to use an idiographic and experiential-driven qualitative analysis to
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45 414 better understand the experiences of secondary school teachers in supporting the mental health
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47 415 of their students. Participants from this study expressed a great deal of caring for their students,
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49 416 but also a range of negative cognitions due to lack of training, resources and adequate
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417 guidelines. These findings suggest that the emotional reaction of participants to these
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54 418 experiences is determined by a) how they view their own role in relation to supporting their
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56 419 students, and b) whether their student is receiving effective and informed help from the school,
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3 420 external services or from the teacher. This interpretation is presented as a model that can help
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6 421 inform the design of future teacher-targeted mental health interventions.
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8 422
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10 423 Acknowledgments
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424 We would like to thank the teachers who took part in this research for their help. The research
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15 425 materials can be accessed by contacting the corresponding author.
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17 426
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427 References
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19 student
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21 ● Ability to provide stable environment
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23 3. Barriers to helping the young person ● Amount of time or space
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24 ● Working with other teams or services

25 ● Involvement of parents
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4. Amount of training and resource ● Previous understanding about mental
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30 ● Having to independently generate ideas
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● Frustration
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35 ● Satisfaction and hope from helping
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38 Table 1: The superordinate and subordinate themes generated from analysis
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and common sense
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24 Investment in child
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Emotional reaction (e.g.
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38 Figure 1. A theoretical model based of teacher’s experience when supporting a student with a
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Supporting students’ mental health in
schools: what do teachers want and
need?
Article

Accepted Version

Shelemy, L., Harvey, K. and Waite, P. (2019) Supporting

students’ mental health in schools: what do teachers want and
need? Emotional and Behavioural Difficulties, 24 (1). pp. 100-
116. ISSN 1363-2752 doi:
https://doi.org/10.1080/13632752.2019.1582742 Available at
https://centaur.reading.ac.uk/82380/

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 Supporting students’ mental health in schools: what do teachers want and need?

Lucas Shelemya*, Kate Harveya and Polly Waitea

a
School of Psychology and Clinical Language Sciences, University of Reading, United
Kingdom

*Corresponding author: l.shelemy@pgr.reading.ac.uk; +44 (0)118 378 8523; ORCID Lucas

Shelemy: 0000-0002-2831-3434
 2

Supporting students’ mental health in schools: what do teachers want and need?

There is a growing expectation in the UK for teachers to have an understanding of common

mental health problems in young people. This study aims to identify the training needs of
secondary school teachers to enable them to adequately support and educate their students
around mental health. Nine focus groups, each with between four to eight participants, were
conducted with secondary school teachers in the UK. Discussions were centred on the needs
and wants of teachers in terms of mental health training, provision and advice. Participants
were also shown three online resources as an example of existing training. Thematic analysis
was used to structure the data. Participants wanted training on how to identify and provide early
support for students who are struggling, without taking on the perceived role of a therapist.
Participants also emphasised the strong need for practical, interactive and expert-led training
that provides resources that can be adapted to individual settings. Implications and
recommendations are discussed.

Keywords: teachers, school, training, focus groups

Word count (inclusive of references, tables and captions): 7903

 3

Despite the high prevalence of mental health disorders in young people, relatively few
of those in need access timely, evidence-based treatment within specialist child and adolescent
services (Frith 2017; Essau 2005). Increasingly, it is recognized that support for young people’s
mental health must be broader than specialist mental health services, encompassing schools
alongside other services (Frith 2017; Department of Health 2015). There has been a recent
increase in the number of secondary school exclusions in the UK, suggesting that schools are
not able to appropriately address challenging behaviour in a classroom setting (Department of
Education 2018). Over the last 20 years school-based mental health prevention programmes
and interventions have become increasingly prevalent (Weissberg, Kumpfer, and Seligman
2003), with many young people receiving help for their social, emotional and behavioural
needs within school settings (Hoagwood et al. 2007; Stormont, Reinke, and Herman 2009).
There is an increased expectation within the UK for teachers in schools to have
responsibility for identifying young people with mental health difficulties and referring them
forward to appropriate services (Department of Health and Department of Education 2017).
The amount of time teachers spend in contact with students makes them well placed to notice
symptoms and behaviours associated with anxiety, depression and other common mental health
problems, such as irritability, social withdrawal and changes in concentration (Puura et al.
1998; Chatterji et al. 2004; Ginsburg and Drake 2002). Teachers are in an ideal position to refer
and signpost students to mental health care services (Fazel et al. 2014; Schwean and Rodger
2013) as they are often the first point of contact for young people and parents who are worried
about their child’s emotional wellbeing (Ford et al. 2008; Sax and Kautz 2003). Previous
studies have shown that increased emotional support to students by teachers is associated with
reductions in students’ behaviour problems and depressive symptom scores (Way, Reddy, and
Rhodes 2007; Undheim and Sund 2005; Joyce and Early 2014).
As well as signposting, identifying and supporting young people, teachers may also
deliver universal mental health interventions within the school setting. Many mental health
educational prevention programmes in school are teacher-led, with 40.8% of interventions
including teacher involvement, and 18.4% of interventions having teachers as the sole deliverer
of content (Franklin et al. 2012).
Despite these responsibilities, teachers are not required to learn about and understand
mental health disorders as part of their initial training (Shepherd et al. 2013) and many have a
limited understanding of the link between school exclusion and mental health difficulties
(Nash, Schlösser, and Scarr 2016). Teachers typically have limited access to support and
supervision from professionals with expertise around mental health (Sharpe et al. 2016).
In a survey of teachers, 99% considered acknowledging and managing their students’
mental health needs to be part of their role (Roeser and Midgley 1997). In many studies,
teachers have described mental health education (Graham et al. 2011) or the management of
mental health problems in the classroom as being very important (Walter, Gouze, and Lim
2006). Many teachers acknowledge their ability to identify mental health problems in the
classroom (Rothì, Leavey, and Best 2008) and the link between academic and emotional health
outcomes (Kidger et al. 2009). Similarly, the majority of teachers believe that schools should
be a place where mental health issues are addressed (Reinke et al. 2011).
Previous qualitative and quantitative studies with teachers have highlighted the call
from school staff for in-depth specialised mental health training (Graham et al. 2011; Moon,
Williford, and Mendenhall 2017; Rothì, Leavey, and Best 2008; Walter, Gouze, and Lim 2006).
Without training, teachers have low confidence in their knowledge and ability to recognise
mental health problems, or to provide support and manage emotional difficulties in the
classroom (Moor et al. 2007; Roeser and Midgley 1997; Cohall et al. 2007). Teachers have
expressed helplessness resulting from the perceived inability to help their students (Kidger et
al., 2009; Shelemy, Harvey, and Waite, under review).
 4

In one qualitative study in the UK, school teachers expressed concern about the realistic
implementation of mental health training, such as finding an appropriate time in a busy school
schedule and transferring what is learnt into a classroom setting (Rothì, Leavey, and Best 2008).
Similarly, teachers have reported that previous teacher-led interventions fail to account for their
time, pressure and ability to flexibly and continuously commit to the manualised program
(Taylor et al. 2014). Poor sustainability of teacher-led interventions may be due to low levels
of acceptability for teachers (Han and Weiss 2005).
Existing mental health training programmes need to evaluate their acceptability to
teachers and focus their materials on teachers’ needs. In several teacher-led mental health
interventions, adherence to programme manuals is low. For example in one study, only 47% of
the core items of the intervention were delivered satisfactorily by the teacher facilitators
(Gillham et al. 2007). In the BeyondBlue teacher-led program, 70-74% of the 16 planned
lessons were delivered fully by secondary school teachers (Sawyer et al. 2010). One possible
explanation for this may be that the training and resources provided for teachers failed to be
adaptable and account for teachers’ own needs and time restrictions. Research should be done
to learn more about the causes behind poor adherence to identify ways that teacher training can
be more engaging and better utilised in the classroom.
Collaboration and consultation with teachers is necessary to properly develop school-
based mental health services, programs and whole-school changes (Lynn, McKay, and Atkins
2003; Rothì, Leavey, and Best 2008). It is crucial that training programs are developed with a
clear understanding of the attitudes and requirements of those delivering them in order for them
to be successfully implemented (Graczyk et al. 2006; Han and Weiss 2005), as teachers are
experts in understanding their classroom, school structure and students’ difficulties (Dupaul,
Weyandt and Grace, and Janusis 2011; Rothì, Leavey, and Best 2008). Similarly, effective,
engaging and evidence-based training for teachers must be designed with a thorough
knowledge of what school staff need and would like (Reinke et al. 2011).
Previous studies have demonstrated the value of consultation with teachers to
successfully develop school-based interventions. In one study, academic and motivation
outcomes for young people with ADHD were improved following a collaborative consultation
between researchers, school psychologists and teachers (DuPaul et al. 2006). The identification
of what teachers judged feasible and effective via a ‘problem identification interview’ was a
critical aspect of intervention design (DuPaul et al. 2006). This study aims to mirror this
approach by consulting teachers about what they need from training to be able to successfully
support students with mental health difficulties.
There is not yet an in-depth analysis of what practical ideas and tools teachers actually
need and want regarding mental health support and training. Focus groups are an effective
qualitative approach that can generate a wide range of views on an issue (Underhill and Olmsted
2003). In comparison to one-to-one interviews, focus groups harness the group dynamic
enabling ideas to be explored and developed. This qualitative study uses focus groups and
thematic analysis to better understand teachers’ wants, needs and opinions around the mental
health needs in schools, and the resources and training that would be necessary.
The research aims of this study are to (i) better understand what teachers would like
from mental health resources and training, (ii) explore their opinions of different modes of
delivery (by allowing them to sample various resources), (iii) identify factors that teachers feel
help and obstruct the provision of good support to students.

Method

The present study was conducted following established criteria for rigour in qualitative
research (Denzin and Lincoln 1994), and used the COREQ checklist for reporting (Tong,
 5

Sainsbury, and Craig 2007) (Appendix A). Ethical approval for the study was obtained from
the University of Reading Research Ethics Committee.

Participants

Participants were eligible for inclusion if they were currently practicing secondary
school teachers in the UK. There were no exclusion criteria. Nine focus groups with the
recommended four to eight participants (Howitt 2016) were conducted in nine schools across
the UK between October 2016 and January 2017. Forty-nine teachers took part in the study. 33
(67%) of participants had never received mental health training before, while 10 (20%) had
taken part in a certified course (including Mindfulness, Attachment Training, Mental Health
First Aid, Art Psychotherapy and Support Work training). The remaining 6 (12%) participants
reported that they had received a single session of mental health training previously. The
sample characteristics are presented in more detail in Table 1.

[Table 1 here]

Sampling

Advertisements about the study were shared and distributed via online social media
(Twitter, Facebook) from the university and authors’ accounts. Social media users shared the
advertisements to reach a wide audience. Pastoral leads (e.g. Special Educational Needs Co-
Ordinators, Assistant Headteachers) of schools who saw the advertisement online contacted
the lead researcher to register their interest in participating the study. Of the eighteen pastoral
leads that got in contact, five were excluded from the study as they were based in primary
schools, and nine were purposively sampled to reflect different location of schools (urban vs
rural), socio-economic areas, type of institution (state-funded vs private) and sex of students
(single-sex or co-educational) using a multiple category design (Howitt 2016). The selected
schools were located in five different counties (Wiltshire, Berkshire, Greater London,
Hertfordshire, Flintshire) across three regions of the UK (South East England, South West
England, North Wales). The pastoral lead helped organise and recruit teachers within their
school to attend the focus group. Participants were selected by the pastoral leads within each
school based on availability and interest in contributing to the focus group. Focus groups were
conducted until response saturation was judged by the lead author to have been reached (Braun
and Clarke, 2013), as data analysis and collection were completed concurrently.

Procedure

Focus groups were moderated by the male lead author, a PhD student trained in
qualitative research methods at the University of Reading. The interviewer had no prior
relationship with the participants before the study. An undergraduate placement student took
notes during each session with the aims of ensuring all participants had an opportunity to
contribute to the discussion and recording field notes about any non-verbal behaviour by
members of the group. This information was given to the focus group moderator during the
focus group break.
Interviews took place in a private room in each school after the school day had finished
to ensure convenience for the participants and a quiet environment. Participants were told the
research aims of the study and that all data would be anonymised. Informed written consent
was obtained from all individuals before participating. Participants were asked to fill out a brief
demographic questionnaire at the beginning of the session about their age and length of
 6

teaching experience (summarised in Table 1). Participants were all teachers in the school where
the interview was conducted and so knew each of the other members of the group.
A semi-structured topic guide was used to direct the focus group. Questions were based
on previous qualitative research of teachers’ experiences and opinions about mental health in
schools (Kidger et al. 2009; Shelemy et al. under review). This guide was piloted with four
secondary school teachers to ensure clarity and validity (accessed via Appendix B).
Each focus group discussion addressed three aims: (1) teachers’ needs and opinions
regarding mental health provision within school, (2) teachers’ views on three independent
mental health online resources online, and (3) methodology of mental health training and a
review of the online resources. Focus groups lasted between 1.5 to 2 hours with a break,
including 20 minutes to access the online resources.
The three online resources were selected because they all provided teaching on mental
health in schools, are good exemplars of different learning mediums (text, video and an
interactive programme), and had no affiliation to any of the researchers. MindEd, a UK
government-funded educational free online resource for professionals working with teachers is
a text-based programme available throughout the UK (MindEd, n.d.). FutureLearn Cognitive-
Behavioural Therapy (CBT) Anxiety and Depression course is a massive open online course
(MOOC) designed by and delivered through the University of Reading and involves a mixture
of video-based learning and text (FutureLearn, n.d.). The final resource was the demo version
of Kognito (Kognito, n.d.), an animated interactive program that aims to train teachers on how
to support and have a conversation with students about their mental health.
Data Analysis

Focus groups were audio-recorded and transcribed by the lead author. The computer
software package NVivo 10 (NVivo 10 2014) was used to facilitate coding of the transcribed
data. Data analysis followed guidelines for thematic analysis from Braun and Clarke (2013).
The lead researcher (LS) read and re-read each transcript and field notes to ensure a high level
of familiarisation with the data. Transcripts were then annotated and coded into nodes. Two
undergraduate placement students also added nodes to several of the transcripts which were
compared with the lead author’s analysis to ensure important nodes were not missed. Following
this stage, nodes were grouped into key presenting themes by the lead author. A consultation
and meeting with the two further researchers (KH, an experienced qualitative researcher and
PW, an experienced researcher into young people’s mental health and a clinician) helped
classify the data into more functionally distinct and independent subordinate and superordinate
themes.

Results

Four superordinate themes were generated via analysis and are presented in Table 2.
The superordinate and subordinate themes are presented in two broad areas: teacher training
and external changes. These represent how the focus groups were structured, with the first
emphasising what should be done to improve teacher training, and the other focusing on the
external changes that can help participants cope with students’ mental health difficulties within
school. Broadly across the groups there was unanimity for each of the themes. The themes are
explored in greater depth below.

[Table 2 here]
 7

Identifying and preventing rather than solving

Many participants wanted advice on how to identify mental health problems in their students
and how to prevent a situation from worsening, rather than training in how to provide long-
term support for students. When comparing the field notes of focus groups, participants in
schools with a dedicated counselling service appeared to be less enthusiastic about receiving
mental health training than the other groups.

Learning how to identify students’ difficulties

Participants discussed the need for training to identify whether a student is at risk and whether
their mental health or behaviour is a cause for concern. Whilst many participants felt
comfortable with identifying clear visible signs, such as self-harm scars, many wanted
guidance on noticing more subtle indications of mental health problems in their students.

The warning signs, I'd like to learn a lot more because some mental health issues
are quite obvious to spot, but then others less so. You might see positive traits in
somebody but really they're masking something that's wrong. - State-funded,
urban, co-educational

A repeated suggestion across the focus groups was to have a list of key indicators to help with
identifying warning signs.

I think it is quite good to have a print out of a crib sheet actually with a reminder
of what you're looking out for. Something that you and other teachers can put in
their planners, just something there to refer to. - State, urban, girl’s school

Desire to prevent students’ mental health from worsening

When faced with a student who is struggling, many of the participants described how they
would use their common sense and instinct to try and help. Some participants were unsure
whether they do the right thing in these situations and argued that that without guidance or
training, they could be worsening a students’ mental health. Collectively participants wanted
advice on the correct and incorrect things to say and do to help students.

At the same time, we don't know when to leave things or when to let things go
or when to intervene. Do we make things worse? Are we making something out
of which is in fact a natural progression? - State, urban, co-educational

Participants asked for advice about the right thing to do in circumstances where a student is in
immediate risk of distress or harm, such as during a panic attack. Participants wanted guidance
and training on how to contain and support a student prior to expert help being provided.

In the same way first aid training is about trying to stop a situation worsening …
I would like to know two or three key things that would not let a situation
escalate, which would be a holding position until the right people can be brought
along. - Private, urban, co-educational

Not wanting to take on the role of therapist

 8

Participants from the focus groups consistently spoke about a societal expectation that they will
have responsibility over the wellbeing of their students. Despite this, many of the participants
argued that they consider their role a purely academic one and felt that it would be preferable
for “experts" with appropriate training to provide support to their students around mental health
All of the focus groups emphasised how training should not include therapeutic strategies to
improve a young person’s mental health, and that the role of the teacher should not be seen as
that of a therapist or social worker.

I don't see it as a responsibility to advise them on how to improve it, I think

someone else has the expertise to do that and I would feel uncomfortable doing
that … I think that clearly in school we have to deal with things at an initial level.
– State-funded, urban, co-educational

Participants mentioned that their role should be viewed as educational and preventative.
Training should focus on how to educate students around mental health, ideally before
problems begin.

I think we have a duty of care, not a duty of cure. Within that duty of care we
have a duty, not put out the fire but to educate them first, which is what we're
trying to do. We have been trying to teach them and help them and how to
recognise them [mental health problems] early on and I think that's really
something that needs to be improved. - State-funded, urban, co-educational

The need for training that has a real-world application

Participants emphasised the importance of mental health training being focused on providing
resources and examples that are applicable to the classroom. They recommended that training
should contain relevant case studies, resources and strategies that can be easily adapted and
used within the school environment.

Training that teaches practical strategies

Participants in all groups emphasised the need for training to be focused on practical strategies
that can be implemented in their classroom. Whilst some participants found previous mental
health training to be useful, others disagreed and found that talks they have attended have
commonly focused on descriptive explanations of mental health issues, to the detriment of
providing useful and practical advice.

I think with any trained teachers, they want to come away with practical,
achievable things they can do in their classroom that'll make a difference. The
frustration is always from wishy-washy talks where you come away thinking
“there's no way that's relevant to me and there's no way that'll have any impact
in my classroom”. – State, urban, co-educational

Participants described wanting a concrete list of strategies that can be used and that teachers
can easily refer to.

One of the things I would think about is having what strategies to use so … a
definitive list with something like if this happens then you could do this. - State,
rural, co-educational
 9

Receiving adaptable resources and training

In some of the focus groups, participants described the need for teachers to be able to adapt any
resources and lesson plans to make it relevant to the mental health issues faced by their
students, as well as ensuring the content is age-appropriate for the specific year groups.

It can't be a one-size-fits-all but maybe tailor-made for different

years, dependent on what children are potentially likely to experience in those.
Because otherwise year 10 and year 11 will put it off they'll say “it's not for me,
this is little kids stuff". - State, rural, co-educational

Adaptable materials enable teachers to feel comfortable with the material that they are
delivering.

I don't think that I've ever downloaded the lesson plan from any sort of charity
or anything, or even an assembly that I haven't personalised, to make it suitable
for our school and so actually, I know exactly what I'm talking about. - State,
rural, co-educational

Incorporation of illustrative case studies

In several groups, especially those in which individuals had been critical of previous mental
health training, participants described case studies as being a useful tool to understand how to
find practical solutions to help students within a school environment.

I want case studies around issues that have happened in schools and learn how
they have been dealt with. What has the outcome been for the student involved,
the family? What have the staff learnt from dealing with it? That would be really
useful, what have staff that have been involved picked up from that experience
and what would they do differently next time. If we had those case studies
looking at all the different angles that would be great. - State, urban, co-
educational

These participants described how they would like to have real stories from young people to
better understand the nature of their mental health problems and what they are going through.

I think it's also good to have example of people who are suffering from whatever
the issue is, talking about it and what made a difference to them. So videos,
somebody actually talking about what worked for them. - State-funded, urban,
co-educational

The need for training to be engaging and active

The accessibility of training is crucial to enable teacher engagement, retention and interest.
There was a high level of discrepancy amongst participants within each group as to which style
of learning they preferred (e.g. interactive, audio/visual, group discussions). Participants
typically resolved these differences by agreeing that training should contain a mix of teaching
styles to appeal to different learners. Generally, the training courses that they valued most were
 10

interactive, simple and led by someone who participants considered to be an expert in mental
health.

Interactive training

Participants recommended all training should be interactive, promote discussion and require
feedback from the audience.

I think if you have the expert talking to you in front of you, giving you some
video clips of a mocked up class … then you've got an opportunity to stop and
discuss at certain points with the group with the professionals around you, I think
that would be a useful thing to do. - State, urban, co-educational

If delivered online or through videos, some participants recommended including compulsory

questions to check that the person had understood the material and to encourage them to pay
attention.

I think a quick video and some way of checking you've understood it. Even for
me just watching that video, I would have liked a few questions just to check I
have understood what the key learning points were. - State, urban, co-
educational

Simplicity and variation in training method

Participants spoke about how online mental health training should have variation in the style
and allow users to have the option of choosing their preferred form of learning.

I think that’s the only way you're going to hit teachers, is a combination: have
all of them. Have multiple avenues, have the kind of stuff that we put into our
lessons. It’s got to be interactive and audio-visual. - Private, urban, co-
educational

There was debate amongst participants about the three resources shown, with some finding
online learning difficult, whilst others finding content engaging and useful.

For me, online training doesn't work, that's just my personal view. I can't be
trusted to go onto a computer in the evenings or any other point and stay focused
on that one bit of information on the screen and the activities, it just doesn't
work. I need to be in a room with people doing it interactively. – State, rural, co-
educational

The time and work constraints that teachers face meant that training resources need to be short
and direct, with educational resources being to the point and not allowing teachers’ attention
to wander.

You know just 30 second clips. We like to move on. We don't have a lot of time.
We won't want to be sat there for 10 minutes watching a video. Teachers are like
children really, we have to be entertained. – State, urban, girl’s school

Training that is expert led, evidence-based and accredited

 11

Some participants described being unsure about the quality of the training programmes they
had previously received. When shown resources delivered by individuals with a clinical or
professional qualification, participants responded well and found the content more engaging.

Having an expert come in, I always prefer. Actually being able to speak to
someone who you know has experience with dealing with students that age is
essential. - State, urban, co-educational

Similarly, many participants felt that all training and resources should be backed up by
evidence showing the previous effectiveness and relevance of the training.

I think it has to be backed up by evidence, you need to prove why it is worth

doing otherwise we won't do it. We need evidence as to what this is and how it
can improve your teaching and your lessons and the student's grades etc. Hard
facts as evidence. - State, urban, girl’s school

Several participants spoke about the interest in training that resulted in an accreditation or
certificate as part of their continued professional development (CPD) as a motivation for
receiving and being more attentive during training.

The certificate part is important because we have to log training and it just means
that you have that evidence and you have your professional portfolio that is
transferable from school to school. - State, urban, co-educational

Changes that are needed outside the classroom

The following themes represent areas beyond the classroom that participants felt needed to be
in place in order to provide good support to students. The discussions focused mainly on having
clearly defined referral routes and guidance for what to do when passing on concern about a
student.

Clear within-school mental health communication strategy

The majority of the schools in the study had a well implemented mental health communication
strategy, including clear reminders of procedures for signposting students to appropriate
services. Participants in these schools emphasised the importance of understanding how to refer
a student to other members of staff within the school for support around their mental health
difficulties, such as pastoral staff or heads of house.

It's all the little things, like on all the back of our lanyards, a very clear instruction
to members of staff about what they might do if a child discloses … I don't think
there would be a single member of staff that wouldn't know that. - State-funded,
urban, co-educational

Approachable pastoral school staff

In contrast to safeguarding procedures, participants often felt unsure whether they had done the
right thing when informing other school staff about a student they were worried about.
 12

Participants across all groups emphasized the need and usefulness of pastoral staff that are
known to everyone and are available to speak to.

And the SENCOs [Special Educational Needs Coordinator] are very visible,
they're all in an office together, they're not office bound, they are out and about
all the time. The people are very comfortable, and trust making referrals to them
or just seeking advice from them. They're very well-established members of
staff, very approachable. - State, rural, co-educational

Similarly, many participants mentioned the need for acknowledgement and reassurance from
the member of staff they have referred the student to.

You want that immediate recognition that you've done the right thing. - State,
urban, co-educational

Training and informing parents/carers

Several participants emphasised the need for parents to be informed in young people’s mental
health. Parents were described as often dismissive of their child’s mental health problems. The
teachers wanted to learn how they themselves might educate and inform parents, in a manner
that was not patronising or blaming.

One of the challenges I think is to get parents on board. We have conversations

with parents and they're not necessarily keen to engage and they don't see it as a
mental health problem. And you try and word it as well as you can and the
parents aren't taking it seriously, like saying "Oh she's just being a drama
queen". It becomes very challenging because there's a limit to what you can do.
I think it's how we educate parents and families as well. - State, urban, co-
educational

Improved communication with Child and Adolescent Mental Health Services (CAMHS)

A frequent frustration expressed by participants was the lack of communication from CAMHS.
Many of the discussions mentioned how CAMHS staff are often perceived to be unable to
provide useful information or advice to staff about their students.

Very often we don't get that much feedback that often. When you know a child
has been diagnosed with mental health concern issue, then they've been given
therapeutic support … what impact is that going to have on them? And how as
a school can we support them? It's a big gap. We don't get that advice. I don't
recall ever really having free form communication with CAMHS. … There
needs to be more sharing of information. - State-funded, urban, co-educational

Discussion

There is a demand from both teachers and governmental bodies for school staff to be trained
in how to support young people around mental health (Department of Health 2015; Rothì et al.
2008; Shelemy et al. under review). This study describes findings from nine focus groups with
49 secondary school teachers across the UK. Participants were asked to describe what mental
health training, support and resources they would need in order to successfully support students
 13

around mental health difficulties. The main themes that arose were that training should be
focused on preventing rather than solving a students’ problem, be engaging and active, and
have a real world application. Participants also commented on the need for better
communication with external CAMHS services, as well as guidance on what makes a
successful within-school mental health communication strategy. Many of the focus groups
discussed the need to also educate parents about mental health.
Several of these themes are consistent with those found in previous studies of teachers’
attitudes towards mental health. Participants’ recognition of the need for teacher training in
mental health is consistent with findings from previous studies (e.g. Graham et al. 2011; Walter
et al. 2006). Many participants described not wanting to take on the role of therapist and did
not feel qualified to speak to young people in depth about their problems. This is echoed in
previous consultations of teachers’ experiences of mental health in the classroom (Department
of Health and Department of Education 2018; Shelemy et al. under review). Previous studies
have also found that teachers want discussions of real case studies paired with practical
guidance on how to help students who are struggling or disruptive (Vieira et al. 2014) and
expert-led training from a trusted and certified source (Walter et al., 2006).
Whilst participants in each of the focus groups disagreed over the ideal style of learning,
particularly when looking at online resources, the consensus was training that is expert-led with
a mix of teaching methods is most likely to appeal to a broad group of teachers. Mental health
training for teachers should be focused heavily on practical strategies and relevant case studies
and less centred on vague information that cannot be applied to the classroom.
These findings are particularly relevant in light of the recent Green Paper in the UK
announcing future funding for mental health awareness training for “every secondary school”
and for ‘Designated Senior Leads’ (Department of Health and Department of Education 2017).
Whilst this initiative is promising, responses to the paper have expressed concerns that the
training should be “high quality”, “based on evidence and good practice” and include
“manageable ways that are adaptable to different types and sizes of schools” (Department of
Health and Department of Education 2018). For this training to be successful, it is crucial that
the concerns of teachers are considered. As such, we have generated a checklist (Table 3) that
arises directly from the findings of the current study. This can be used to ensure mental health
training meets the needs of teachers, thus increasing their likely engagement.

[Table 3 here]

The strength of this study is that it is a valid exploration of the needs and wants of
teachers regarding mental health in schools; the research was conducted by experienced
qualitative researchers and closely followed guidance by Braun and Clarke (2013). The study
meets the criteria of the COREQ guidelines for rigorous reporting of qualitative research
(Appendix A) (Tong, Sainsbury, and Craig 2007). All of the participants were current teachers
with experience of the challenges faced supporting students in a school environment. Whilst
there was some variation in opinions within and across groups, the themes described were
consistent across all those who participated. Purposive sampling resulted in school variation
on three key dimensions; geographical location within the UK; urban and rural areas, state-
funded and privately-funded.
There are several limitations of the present research that should be acknowledged.
Whilst a variety of schools were contacted about the study, with the hope of recruiting schools
with varying Ofsted ratings, the schools that participated were all rated by Ofsted as ‘Good’ or
‘Outstanding’, thus representing schools that are performing well on academic, social and
behavioural outcomes. The mental health and behavioural problems presented in these schools
may differ in schools with lower Ofsted ratings and teachers in these schools may have different
 14

training requirements. Participants were selected by the pastoral leads within each school and
it is plausible that many of the participants in this study were teachers who were known to have
an interest in mental health and believed that training played a crucial role in school staff
professional development. The views of teachers who do not feel that mental health is part of
their role may not have been captured in this study, resulting in data that is shaped around the
presumption that mental health in schools is a relevant topic.
It is important to acknowledge the biases of the researchers and their potential to shape
the analysis. The analysis was conducted, compared and contrasted by several different
researchers whose varying background and experience will have informed their opinions and
beliefs about mental health training in schools. For example, the lead author believes that
mental health training should be provided for school staff and collaborates with a charity
focused on young people’s mental health training, while the second author (KH) is an academic
health psychologist with an interest in psychological wellbeing and intervention, and the third
author (PW) is a clinical psychologist with an interest in young people’s mental health.
Field notes from the current study indicate that teachers from schools with funding for
a dedicated counselling support service were not as passionate about receiving training
compared to other schools. It is possible that these schools are in less need of training than
schools, perhaps because they have more readily available resources and additional staff to
help young people with mental health problems. Future studies should investigate similarities
and differences between different school types, areas, academic outcomes and socio-economic
status to identify additional needs faced by schools regarding more specific vulnerabilities.

Conclusion

Mental health training for teachers must be practical, simple and interactive. We have
identified key factors from focus groups with teachers that highlight the main areas that school
training interventions should cover and have presented them as a checklist that can easily be
applied by developers to interventions. Future mental health programmes should use these
criteria to ensure that training is directly relevant and pragmatic for schools.

Acknowledgments

We would like to thank the teachers who took part in this research for their help. The research
materials can be accessed by contacting the corresponding author.

Declaration of interest and funding details

The PhD of the lead researcher is funded by The Charlie Waller Memorial Trust, a charity
aiming to improve mental health in young people. The Trust had no involvement in the research
process, from study design to submission. The authors report no conflicts of interest. The
authors alone are responsible for the content and writing of this article.

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Table 1: Overview of focus group characteristics and demographics of participants.

Age category Gender Years spent teaching

Focus School 21-29 30-49 50-60 NR Female Male 0-5 6-15 16+ NR
Group description
G1 Private, 0 2 2 2 2 4 0 3 2 1
urban, co-
educational

G2 State, urban, 0 0 0 6 6 0 0 5 1 0
co-
educational

G3 State, urban, 0 1 1 3 3 2 1 1 1 2
co-
educational

G4 State, rural, 1 3 1 1 4 2 3 2 1 0
co-
educational

G5 State, urban, 2 2 1 3 6 2 2 2 4 0
co-
educational

G6 State, urban, 0 2 1 1 4 0 1 2 1 0
co-
educational

G7 State, rural, 0 2 1 1 4 0 0 1 3 0
co-
educational

G8 State, urban, 1 2 1 1 5 0 1 2 2 0
girl’s school

G9 State, rural, 0 3 0 2 4 1 0 2 3 0
co-
educational
4 17 8 20 38 11 7 21 18 3
NR = Not Reported; participants were asked but did not write answer. G = group.
20
 21

Table 2: Superordinate and subordinate themes are presented under descriptive areas and
category labels.
Teacher Training

Category Superordinate Themes Subordinate Themes

Content of Identifying and preventing Learning how to identify students’

Training rather than solving difficulties

Desire to prevent students’ mental health

from worsening

Not wanting to take on the role of therapist

Style of Training The need for training that Teaching that teaches practical strategies
has a real-world
application

Receiving adaptable resources and training

Incorporation of illustrative case studies

Accessibility of The need for training to be Interactive training

Training engaging and active

Simplicity and variation in training

method

Training that is expert-led, evidence-based

and accredited

External Changes

Category Superordinate Theme Subordinate Themes

School and Changes that are needed Clear within-school mental health
Services outside the classroom communication strategy

Approachable pastoral school staff

Training and informing parents/carers

Improved communication with Child and

Adolescent Mental Health Services
(CAMHS)
22
 23

Table 3: A checklist based on participants’ expressed wants and needs of mental health training

Does your school staff mental health training include ...

How to identify mental health problems and warning signs

How to prevent a situation from worsening

The right and wrong things to say to a student with a mental health problem

How to help a student in the short term

Practical strategies over information about different diagnoses

Resources that can be adapted and tailored by teachers

Materials that are relevant for the issues faced by a targeted age group

Case studies of what worked in different situations

Experiences of actual young people with mental health difficulties

Interactive methods and testing of participants

Engaging and mixed-medium methods of learning

Expert-led material that is evidence-based

How to set up a successful within-school referral system

How to ensure pastoral staff are approachable

How to advise and talk to parents about mental health

How to improve communication with external services

Certification and accreditation

 International Education Studies; Vol. 15, No. 5; 2022
ISSN 1913-9020 E-ISSN 1913-9039
Published by Canadian Center of Science and Education

Teachers’ Experiences with and Helping Behaviour Towards Students

with Mental Health Problems
Michelle Dey1, Laurent Marti1,2, Anthony F. Jorm3
1
Swiss Research Institute for Public Health and Addiction, University of Zurich, Zurich, Switzerland
2
Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, United
Kingdom
3
Centre for Mental Health, University of Melbourne, Melbourne, Australia
Correspondence: Michelle Dey, Swiss Research Institute for Public Health and Addiction, University of Zurich,
Konradstrasse 32, 8005 Zurich, Switzerland. Tel: 41-44-448-1190. E-mail: michelle.dey@isgf.uzh.ch

Received: April 28, 2022 Accepted: July 22, 2022 Online Published: September 26, 2022
doi:10.5539/ies.v15n5p118 URL: https://doi.org/10.5539/ies.v15n5p118

Abstract
The aim of the current study was to examine secondary school teachers’ experiences with and helping behaviour
towards students with mental health problems. Data from 176 teachers were analysed. Altogether, 91.5% of
participating teachers reported that they already had students with a mental health problem (particularly mood
disorders) in their classes. About ¾ of teachers (74.7%) were also willing to help a student with a mental health
problem, particularly by listening attentively or by recommending professional help. The self-rated mental health
literacy of teachers was significantly and positively associated with help provision and with the assessment that
‘asking students about suicidal thoughts’ is helpful. In contrast, the perception of not having the necessary
experience/training to help or that other people are better suited to help were seen as barriers to providing help.
Based on the results, it is concluded that increasing teachers’ mental health literacy and the confidence in their
ability to help (including asking students about suicidal thoughts) might increase their helping behaviour directed
towards students with mental health problems.
Keywords: helping behaviour, mental health first aid, mental health problems, secondary school, students,
teachers
1. Introduction
Mental disorders account for a large proportion of the burden of disease in adolescents and young adults (Gore et
al., 2011; Patel, Flisher, Hetrick, & McGorry, 2007) and several conditions typically first emerge during the high
school years (De Girolamo, Dagani, Purcell, Cocchi, & McGorry, 2012; Kessler et al., 2007). However, the
majority of young people with an impairing mental health condition do not receive specialized mental health
treatment (Costello, Egger, & Angold, 2005; Lambert et al., 2013). This is regrettable because receiving effective
professional treatment might help to prevent more severe illness trajectories (including suicide; Gould,
Greenberg, Velting, & Shaffer, 2003; Pelkonen & Marttunen, 2003). Addressing mental health problems is also
crucial, because of their potential negative impact on students’ learning and academic performance, social
networks and developmental transitions (Froese-Germain & Riel, 2012; Johnson, Eva, Johnson, & Walker,
2011).
Schools might help to close the treatment gap by addressing the mental health problems of students and by
acting as gatekeepers to mental health services, as well as fostering students’ mental health more generally
(Froese-Germain & Riel, 2012; Hedren, Weisen, & Orley, 1994; Hoover & Bostic, 2021; Kutcher, Venn, &
Szumilas, 2010; Lynn, McKay, & Atkins, 2003; Rones & Hoagwood, 2000; Trussell, 2008). Due to the close and
frequent contact between teachers and students, some authors have suggested that teachers are important for
detecting a mental health crisis or problem in their students, for supporting affected individuals, and – if
necessary – referring them to mental health professionals (Johnson et al., 2011; Lynn et al., 2003; Mihalas et al.,
2009; Whitley, Smith, & Vaillancourt, 2013). Accordingly, teachers are often perceived by themselves and others
as having some responsibility for the mental well-being of their students (Andrews, McCabe, &
Wideman-Johnston, 2014; Beames et al., 2022; Dimitropoulos et al., 2021; Ekornes, 2015, 2017; Mazzer &

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Rickwood, 2015; Roeser & Midgley, 1997; Rothì, Leavey, & Best, 2008; Shelemy, Harvey, & Waite, 2019a;
Zumbrunn, Zinniker, & Kunz Heim, 2017). However, this responsibility might particularly involve activities that
can directly be integrated into teachers’ daily working routine, such as promoting an anxiety-free atmosphere for
learning (Zumbrunn et al., 2017), ensuring a stable, safe, supportive and non-stigmatizing environment
(Dimitropoulos et al., 2021; Shelemy et al., 2019a), or providing general support (Beames et al., 2022). In
contrast, other tasks, such as screening students for mental disorders or personally addressing students’ mental
health issues (through to taking on the role of a ‘therapist’), might be less often perceived as top responsibilities
of teachers (Collins & Holmshaw, 2008; Dimitropoulos et al., 2021; Ekornes, 2015; Reinke, Stormont, Herman,
Puri, & Goel, 2011; Shelemy, Harvey, & Waite, 2019b; Shelemy et al., 2019a; Zumbrunn et al., 2017).
In order to support students with mental health problems, it is not only essential that teachers feel responsible,
but also that they have the necessary competencies to do so. However, studies around the world have found
limited mental health literacy (hereafter, MHL) among a significant proportion of teachers (Aluh, Dim, &
Anene-Okeke, 2018; Frauenholtz, Mendenhall, & Moon, 2017; Kurumatani et al., 2004; Parikh et al., 2016;
Prabhu et al., 2021; Walter, Gouze, & Lim, 2006). Correspondingly, teachers might be or feel inadequately
trained, prepared, and knowledgeable regarding students’ mental health issues. This includes uncertainties in
recognizing pupils’ mental health problems (especially more subtle ones), in assessing the severity of such
problems (including the need for treatment), or in personally counselling those pupils with (significant) mental
health problems (Andrews et al., 2014; Beames et al., 2022; Dimitropoulos et al., 2021; Ekornes, 2015, 2017;
Koller & Bertel, 2017; Mazzer & Rickwood, 2015; Moon, Williford, & Mendenhall, 2017; Reinke et al., 2011;
Ross, Kõlves, & Leo, 2017; Rothì et al., 2008; Shelemy et al., 2019b, 2019a; Sisask et al., 2014; Walter et al.,
2011, 2006). Lacking competencies might also decrease teachers’ readiness to help affected students (Sisask et
al., 2014) and – if paired with feeling responsible to handle pupils’ mental health problems – also induce stress in
teachers (Ekornes, 2017). Other significant barriers to teachers supporting their students include limited
personal, school or external resources (Dimitropoulos et al., 2021; Ekornes, 2015, 2017; Graham, Phelps,
Maddison, & Fitzgerald, 2011; Mazzer & Rickwood, 2015; Reinke et al., 2011; Roeser & Midgley, 1997; Ross et
al., 2017; Shelemy et al., 2019a; Walter et al., 2006). Teachers’ perceptions that others (e.g., school
psychologists) are more responsible and better equipped to manage students’ mental health problems (Graham et
al., 2011; Mazzer & Rickwood, 2015; Reinke et al., 2011; Shelemy et al., 2019b, 2019a) might also hinder their
helping behaviour. Additionally, providing help is impeded when a student is reluctant to express his/her
emotional needs towards another person, such as his/her teacher (Johnson et al., 2011). With students who are
willing to open up about their mental health problems, it can be difficult for teachers to balance the privacy of
any information revealed and the necessity to communicate certain information (e.g., regarding at-risk students)
to others (Mazzer & Rickwood, 2015). Lastly, it can be challenging for teachers to find a balance between
offering support to a student with a mental health problem and facing the consequences of being too close to
him/her (Shelemy et al., 2019a). In sum, teachers might be in a position to provide initial support to students
with mental health problems, but various factors might hinder such helping behaviour.
While there have been previous studies of various important prerequisites for teachers to help students with
mental health problems (e.g., feeling responsible, being competent), there is a lack of studies looking at actual
helping behaviours of teachers (with a few exceptions: Jorm, et al. 2010; Long, Albright, McMillan, Shockley, &
Price, 2018; Masillo et al., 2012). The current article aimed to fill this gap by describing the helping behaviour of
teachers of secondary school students with mental health problems in Switzerland and elaborating on the factors
that might foster or hinder their helping behaviour. Help was conceptualized broadly and included various
mental health first aid strategies (Jorm, Morgan, & Wright, 2008), including listening to a student in an
understanding way or recommending professional care. Secondary aims involved assessing additional aspects of
MHL, viz. teachers’ perception of mental health problems (problem recognition) and their understanding of the
helpfulness of asking students about suicidal thoughts. Lastly, an overall assessment of teacher’s self-rated MHL
and its predictors were studied. In sum, the article provides valuable insights on teachers’ MHL, with a particular
focus on their actual helping behaviour.
2. Method
2.1 Procedure
The ‘Swiss Youth Mental Health Literacy and Stigma Survey’ (SYMHLSS) surveyed approximately 5000 students
from 314 classes of 105 randomly selected schools that offered either general (GE; including high schools) or
vocational education/training (VET). The study protocol of this survey has been approved by the ethics
committee of the University of Zurich (approval number: 17.4.9; for more details: Dey, Marti, & Jorm, 2018).

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All principals and teachers who were involved in this youth survey (e.g., by being present during data collection)
were asked to fill out a short online questionnaire after the SYMHLSS was concluded. Of the 338 people
contacted, 255 filled out the questionnaire (response rate = 75.4%). However, for the current article, only those
teachers are considered who answered at least the core questions relevant for the current article (n=176 from 88
schools). Answers from principals were not analysed since their area of responsibility and expertise within the
school context was not the focus of the current article. According to the checklist concerning the ethical safety of
studies of the Faculty of Arts and Social Science (University of Zurich), no ethical approval was necessary for
this survey. However, all participants confirmed that they had 1) read and understood the information about the
scientific study; and 2) participated voluntarily.
2.2 Questionnaire
The survey consisted of questions on teachers’ experiences with students suffering from mental health problems,
their assessment of the helpfulness of asking students about suicidal thoughts, their self-rated MHL, as well as
demographic variables. Furthermore, teachers were asked about the existence of school resources that might be
used by students with mental health problems. Figure 1 details the questions used in the current article.

Figure 1. Questionnaire for teachers

Note. Only the questions that were used for the current paper are depicted in the figure. *The answer format was
not only ‘yes’ or ‘no’, but included more detailed predefined options (e.g. why participants would (not) provide
help if a student had a mental disorder). Besides selecting these predefined categories, participants also had the
option of writing down additional reasons in an open answer format. ** If participants already had several students
with mental disorders in their classes, they were asked to focus on the most recent case while answering these
questions. *** The term ‘mental health literacy’ was defined in the questionnaire as ‘knowledge and beliefs about
mental disorders which aid their recognition, management or prevention.’ (Jorm et al., 1997)

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2.3 Analyses
Descriptive statistics were calculated for all variables depicted in Figure 1. All additional analyses are described
below in the order they occur in the paper.
2.3.1 Problem Recognition
Chi-square tests were used to assess associations between years working as a teacher and teachers’ answers to
question 1 (ever had a student with a mental disorder in class). The qualitative data from question 2 (specifying
the mental disorder of an affected student) were categorized according to ICD-criteria (World Health
Organization, 1992). The frequencies of mentioning particular ICD-10-blocks (e.g., ‘F30-39 mood disorders’)
were listed.
2.3.2 Helping Behaviour
Univariate and multivariate logistic regression analyses were used to study predictors of teachers’ helping
behaviour. Specifically, the outcome ‘providing help to students with mental health problems’ was built by
summarizing questions 3a and 3b (see Figure 1) into one dichotomous variable with the categories ‘no’ (has not
provided help/would not provide help; coded as 0) vs. ‘yes’ (has provided help/would provide help; coded as 1).
The following predictors were considered: gender, number of years working as teacher, school services available
(e.g., counselling service) for students with a mental health problem (0 = not existing/existence is unknown; 1 =
existing), school type (0 = GE; 1 = VET) and self-assessed MHL (continuous variable, ranging from 0 ‘very bad’
to 10 ‘very good’). Teachers who did not answer questions 3a or 3b (n=16) or with missing values in any of the
predictors (n=6) were excluded from these analyses. Hence, data from 154 individuals were available. Crude and
adjusted odds ratio (OR) were calculated.
2.3.3 Helpfulness of Asking About Suicidality
Univariate and multivariate logistic regression analyses were also used for the outcome ‘asking about
suicidality’, which was dichotomized into 0 ‘not perceived as being helpful’ (including the following answer
categories: ‘neither helpful nor harmful’, ‘harmful’ and ‘do not know’) vs. 1 ‘perceived as being helpful’. The
same predictors that were described in Section 2.3.2 were used for these analyses. The analytical sample
consisted of 152 participants.
2.3.4 Self-Rated MHL
Simple and multiple linear regression analyses were calculated with MHL as dependent and gender, number of
years working as teacher, and school type as independent variables (analytical sample=170 participants).
3. Results
Sample characteristics and teachers’ experiences with and helping behaviour towards students with mental health
problems are shown in Table 1. Over 90% of all participating teachers reported that they had already had a
student with a mental health problem in their class. By far the most frequently mentioned ICD-10-block was
F30-39 ‘mood disorders’, with ‘depression’ reported particularly often (by 67 teachers). Teachers with more
years of experience in their job were more likely to report that they already had a student with a mental health
problem in their class (p<.01).

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Table 1. Teachers’ demographics and descriptive statistics on teachers experience with and helping behaviours for
students suffering from mental disorders
If not otherwise specified: n (%)
Total = 176
Gender (n=171)
Male 100 (58.5)
Female 71 (41.5)
Age (n=171)
Up to 39-years old 53 (31.0)
40-49-years old 42 (24.6)
50-59-years old 59 (34.5)
60-years old 17 (9.9)
Years working as teacher (n=173)
Up to 5 years 24 (13.9)
5-10 years 49 (28.3)
11-20 years 58 (33.5)
21 years or more 42 (24.3)
Question 1: Did you ever have a student with a mental disorder in your class (n=176)
No 6 (3.4)
Yes, I assume (mental health problem not confirmed, but assumed) 39 (22.2)
Yes, I am sure (mental health problem confirmed) 122 (69.3)
Do not know 9 (5.1)
Question 2: Mental disorder of the affected student (multiple answers possible) (n=154)
F10-19 Mental and behavioural disorders due to psychoactive substance use 2 (1.3)
F20-F29 Schizophrenia, schizotypal and delusional disorders 10 (6.5)
F30-F39 Mood disorders 68 (44.2)
F40-F48 Neurotic, stress-related and somatoform disorders 16 (10.4)
F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors 24 (15.6)
F60-F69 Disorders of adult personality and behaviour 16 (10.4)
F80-F89 Disorders of psychological development 8 (5.2)
F90-F98 Behavioural/emotional disorders with onset usually occurring in childhood and adolescence 16 (10.4)
Question 3a: Did you help the affected student with a mental disorder? (n=151)
No: n (%), because… (multiple answers were possible for subsequent answer categories) 40 (26.5)
…the affected student was already in treatment a, b 29 (74.4)
…I do not have the necessary experience/training to do so a, b 21 (53.8)
…other people are better suited to help a student with a mental health problem a, b 11 (28.9)
…it would be a transgression of the boundaries of privacy/personal boundaries a, b 4 (10.5)
…this is not one of my duties as a teacher a, b 3 (7.9)
… I do not have time for such additional task in my function as a teacher a, b 2 (5.3)
…I have had bad experiences trying to help students in private patterns a, b 1 (2.6)
Yes: n (%), by… (multiple answers were possible for subsequent answer categories) 111 (73.5)
…listening attentively and giving personal tips a, c 64 (58.2)
…recommending professional school-internal help a, c, d 52 (46.8)
…recommending professional external help (outside of the school context) a, c, d 49 (44.5)
…helping to find professional internal/external help a, c, d 29 (26.4)
Question 3b: Would you help a student with a mental disorder? (n=9)
No e 1 (11.1)
Yes e 8 (88.9)
Question 4: Did her/his situation improve due to your help? (n=108)
Yes, definitely 26 (24.1)
Yes, probably 49 (45.4)
No 10 (9.3)
Do not know 23 (21.3)

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Question 5: Would it be harmful/helpful to ask a student about suicidal thoughts? (n=154)

Helpful 79 (51.3)
Neither helpful nor harmful 18 (11.7)
Harmful 9 (5.8)
Do not know 48 (31.2)
Question 6: Does your school have an internal service that can be used by students with a mental
health problem? (n=173)
No 16 (9.2)
yes 152 (87.9)
do not know 5 (2.9)
Question 7: How would you rate your mental health literacy? (n=174): mode 8
Note. The percentages refer to those people who answered a particular question (missing values excluded); Figure
1 details the structure of the questionnaire (including filter questions).
a
These answer options were pre-given and multiple answers could be chosen. Only those answer options that have
been chosen by at least one participant are mentioned.
b
The following options were not selected by anyone as reasons for not helping: ‘I perceived the student as being
dangerous’; ‘I perceived the student as being unpredictable’; ‘his/her problem was a sign of personal weakness’;
‘this problem is not a real medical illness’; ‘he/she could have behaved ‘normally’ if he/she wanted to’; ‘I did not
want to get emotionally involved with the student's mental health problems’; ‘I was afraid it might make the
situation worse’; ‘such students do not want to be helped by a teacher’; ‘people with psychiatric problems
generally do not want anyone to help them’. The most frequent reason for not helping besides the predefined
criteria was that the person was not the classroom teacher, because other teachers were in closer contact/more
familiar with the affected student or because the participant was only a substitute teacher (n=7).
c
The most frequently mentioned way of helping besides the predefined suggestions was an adaptation of one’s
behaviour in relation to the student or an adaptation of the school requirements (approach him/her regularly,
support him/her, give positive feedback, be understanding, reducing stress by individually setting academic goals,
etc.) (n=17).
d
Altogether, 10 participants mentioned that the affected student was already in treatment. Hence, there was no
need to recommend or organize help for the student.
e
Due to the small numbers, no differentiation was carried out for the subcategories

Among those who have already had a student with a mental health problem in their class, 26.5% mentioned that
they did not help the affected student. The most frequently selected reasons for not providing help were that the
affected student was already in treatment, that the teacher did not have the necessary experience/training to help,
and the perception that other people are better suited to help a student with a mental health problem. Among the
remaining 73.5% who had helped the student with the mental health problem in their class, the following
pre-given helping strategies were most frequently selected: listening to the student attentively or recommending
professional help (within or outside the school environment). Most teachers who had helped an affected student
assumed that the situation of the student had improved because of their help. Also, approximately 90% of the
teachers who reported that they did not yet have a student with such a condition in their class expressed their
hypothetical willingness to help in any future case. ‘Asking about suicidal thoughts’ was assessed as being
helpful by about half of all participants. Roughly 90% indicated that the school has a school service that could be
used by students with a mental health problem.
Lastly, most teachers seemed to be confident regarding their MHL: the mode was 8 on a scale ranging from 0
‘very bad’ to 10 ‘very good’. Of all included predictors, self-rated MHL was the only one that trended towards
statistical significance (in the unadjusted analysis) or significantly predicted (in the adjusted analysis) teachers’
provision of help (Table 2). The positive assessment of ‘asking about suicidality as being helpful’ was slightly
lower among teachers from VET-schools (vs. schools providing GE), but increased significantly with an
increasing self-rated MHL in the multivariate analyses (see Table 3). For MHL as the outcome, only female
gender was identified as a significant predictor in the multivariate analyses (with a trend found in the simple
regression analysis; see Table 4).

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Table 2. Logistic regression models of providing help predicted from sociodemographic variables, mental health
literacy, school services available for students with a mental health problem and school type
Has provided help/would provide help
% yes (if not stated
Total (n= 154) Adjusted OR
otherwise) Crude OR (CI)
(CI)a
Total = 74.7
Gender teacher
male 73.9 1 1
female 75.8 1.11 (0.52-2.34) 0.85 (0.39-1.83)
Years working as teacher
Up to 5 years 68.4 1 1
5-10 years 76.2 1.48 (0.45-4.84) 1.52 (0.46-5.05)
11-20 years 84.6 2.53 (0.75-8.62) 2.36 (0.69-8.10)
21 years and more 63.4 0.80 (0.26-2.48) 0.64 (0.20-2.07)
Existence of school services available for students with a mental health
problem
No/do not know 72.2 1 1
Yes 75.0 1.15 (0.41-3.24) 1.38 (0.49-3.88)
School type
Schools providing general education 76.9 1 1
Schools providing vocational education/training 74.2 0.86 (0.39-1.89) 0.83 (0.37-1.87)
Self-rated mental health literacy teacher: mean among those who 7.70b 1.19 (0.98-1.46)# 1.25 (1.03-1.52)*
provided help/would provide help
Note. OR = odds ratio; CI = 95% confidence interval; # p<.10 (trend); * p<.05; ** p<.01; *** p<.001; a all
predictors included in the model; b The mean among those who did not provide help/would not provide help = 7.13
(0.32).

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Table 3. Logistic regression models of the assessment of the helpfulness of ‘asking about suicidality’ predicted
from sociodemographic variables, mental health literacy, school services available for students with a mental
health problem and school type
Perceiving asking about suicidality as helpful
% yes (if not
Total (n= 152)
stated otherwise) Crude OR (CI) Adjusted OR (CI) a
Total = 51.3
Gender teacher
male 47.1 1 1
female 56.9 1.48 (0.73-3.02) 1.38 (0.67-2.84)
Years working as teacher
Up to 5 years 47.6 1 1
5-10 years 51.2 1.15 (0.40-3.35) 1.61 (0.54-4.81)
11-20 years 50.0 1.10 (0.37-3.23) 1.24 (0.43-3.59)
21 years and more 55.6 1.38 (0.45-4.16) 1.58 (0.51-4.96)
Existence of school services available for students with a mental health
problem
No/do not know 57.9 1 1
Yes 50.4 0.74 (0.25-2.19) 0.58 (0.19-1.76)
School type
Schools providing general education 68.2 1 1
Schools providing vocational education/training 48.5 0.44 (0.16-1.19) 0.33 (0.10-1.09)#
Self-rated mental health literacy teacher: mean (sd) among those who 7.8b 1.25 (1.05-1.48)* 1.27 (1.06-1.52)**
provided help/would provide help
Note. OR = odds ratio; CI = 95% confidence interval; # p<.10 (trend); * p<.05; ** p<.01; *** p<.001; a all
predictors included in the model; b The mean among those who did not perceive asking about suicidality as helpful
= 7.1.

Table 4. Linear regression analyses on mental health literacy

Simple linear regression Multiple linear regression a
Total (n= 170)
B SE B β B SE B β
Gender teacher: female 0.47 0.28 .13# 0.55 0.28 .15*
Years working as teacher (reference = up to 5 years)
5-10 years -0.04 0.56 -.01 -0.03 0.56 -.01
11-20 years 0.35 0.55 .09 0.43 0.55 .11
21 years and more 0.74 0.55 .17 0.85 0.55 .20
School type: vocational education/training 0.15 0.43 .03 .28 0.41 .06
Note. # p<.10 (trend); * = p ≤ .05; ** = p ≤ .01 *** = p ≤ .001. a In the multiple regression analysis, all independent
variables were included. b a residual category including all missing values was built for these variables in order to
not loose cases in the multivariate analyses. (Standardized) betas are not reported for these residual groups, since
they always only included a couple of cases. A non-significant regression equation was found (F(5, 82)=2.34,
p=.05), with an R2 of .05.

4. Discussion
The majority of the secondary school teachers in this study already had students with a mental health problem in
their classes, with mood disorders (especially depression) perceived as particularly common. A large proportion
of teachers were willing to help a student with such a condition, particularly by listening attentively or by
recommending professional help. Self-rated MHL, which was higher in females compared to males, was
positively associated with the provision of help to a student with a mental health problem as well as with the
assessment that ‘asking students about suicidal thoughts’ is helpful. The relatively small number of teachers who
did not help their student with a mental health problem mostly justified their decision by stating that the affected
student was already in treatment, that they did not have the necessary experience/training to help, and the belief
that other people are better suited to help affected pupils.

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About one out of every four or five adolescents and young adults suffers from at least one mental disorder in any
given year (Patel et al., 2007). Due to this high prevalence, it is not surprising that the majority of teachers,
especially those with more years of working as a teacher, have already had experiences with students suffering
from mental health problems. This finding is in line with other studies that targeted secondary school teachers
(e.g. Andrews et al., 2014), as well as with another Swiss study that surveyed teachers of younger students
(mandatory school level) (Robin, Messerli, Mehdiyeva, Albermann, & Dratva, 2021). However, it must also be
taken into account that not all of the mental health problems mentioned by the teachers in the current study fully
comply with diagnostic criteria. Particularly in those cases where the condition was not confirmed by a mental
health specialist, the classification of a mental health problem has probably been deduced from the presence of
some isolated symptoms. Furthermore, some mental health or related problems might have been under- or
overestimated.
The strong willingness to help students with a mental health problem is in line with the finding that teachers are
often perceived or perceive themselves as having some responsibility for the mental well-being and mental
health needs of students (Andrews et al., 2014; Beames et al., 2022; Dimitropoulos et al., 2021; Ekornes, 2015,
2017; Mazzer & Rickwood, 2015; Roeser & Midgley, 1997; Rothì et al., 2008; Shelemy et al., 2019a; Zumbrunn
et al., 2017). The most frequently selected helping strategies – i.e. listening attentively or recommending
professional care – also belong to the steps of the action plan suggested by the Mental Health First Aid-program,
which was developed for lay people in order to enable them to provide an early intervention to people with
mental health problems (https://mhfa.com.au/about/our-activities/what-we-do-mental-health-first-aid). Another
important element of this action consists in ‘approaching, assessing and assisting with any crisis’, which also
includes an assessment of a person’s risk of suicide or harm. However, only about half of all participants
assessed ‘asking a student about suicidal’ thoughts as helpful in the current study. The uncertainty concerning
this question was also reflected by the fact that about 30% of teachers were unsure whether asking about suicidal
thoughts would be helpful or harmful. This finding also corresponds to the results of another Swiss study, which
identified ‘suicidality’ as one of the gaps in knowledge among teachers of younger students (Robin et al., 2021).
The reluctance to ask students about suicidal thoughts might have been caused by the teachers’ general concern
that they could further negatively influence the mental health of already struggling students if they do not say or
do the right thing (Ekornes, 2015; Shelemy et al., 2019b, 2019a). More specifically, the uncertainty regarding the
helpfulness of asking about suicidal thoughts in the current study might have been induced by the concern of
teachers that such questions might themselves evoke suicidal thoughts. However, this fear seems to be
unfounded (Gould et al., 2005). Rather, it can be assumed that a conversation with a person with suicidal
thoughts might be a starting point for the person to feel understood and supported, and to motivate him/her to
seek professional help.
Self-rated MHL was positively associated with helping behaviour in the current study. Hence, the competencies
of teachers in this field and/or their confidence in their ability might have promoted their provision of help. The
finding that most teachers self-rated their MHL as being rather high is in line with a study from Australia that
found that teachers typically feel confident in supporting students’ mental health, in particular in terms of
providing a basic level of support (e.g., talking to students about their concerns) (Mazzer & Rickwood, 2015).
Furthermore, another Swiss study that surveyed teachers of students from mandatory schooling concluded that
teachers generally had a high level of MHL in most domains (except for some areas, such as suicidality; see
above; Robin et al., 2021). However, several other studies have reported contrasting results and suggested that
teachers were inadequately trained, prepared and knowledgeable/competent regarding students’ mental health
issues (i.e. limited MHL) or felt incompetent in this regard (e.g. knowing when a referral is needed) (Aluh et al.,
2018; Andrews et al., 2014; Beames et al., 2022; Dimitropoulos et al., 2021; Ekornes, 2015, 2017; Frauenholtz et
al., 2017; Koller & Bertel, 2017; Kurumatani et al., 2004; Mazzer & Rickwood, 2015; Moon et al., 2017; Parikh
et al., 2016; Prabhu et al., 2021; Reinke et al., 2011; Ross et al., 2017; Rothì et al., 2008; Shelemy et al., 2019a,
2019b; Sisask et al., 2014; Walter et al., 2011, 2006). This lack of confidence might particularly concern
activities that require more advanced skills, for example, by assuming the full responsibility for the student with
the mental health problem (Mazzer & Rickwood, 2015). More advanced skills might also be necessary to ask a
person about suicidal thoughts. Accordingly, the current study indicated that the odds of perceiving such
questions as helpful were higher among teachers with a higher self-rated MHL.
One possible explanation for the relatively high self-rated MHL in the current study is sample bias, as teachers
who participated in the survey may have been particularly interested and therefore competent in this field.
Furthermore, teachers might have overestimated their actual MHL. However, the fact that some earlier research
also found that the MHL is better among females (including female teachers) even when other measures were

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used (Chen, Chen, Wang, Wang, & Li, 2021; Parikh et al., 2016; Reavley, Morgan, & Jorm, 2014) suggests that
the self-rated MHL in the present study not only reflects teachers’ confidence in their ability, but to some extent
also their actual competencies. Furthermore, the fact that those teachers with a higher MHL were also more
likely to (correctly) identify ‘asking about suicidality’ as a helpful strategy also indicates that the self-rated MHL
might serve as a proxy to measure and discriminate between teachers with higher versus lower (actual) mental
health competencies in this area.
Only a relatively small number of the surveyed teachers indicated that they did not help students with a mental
health problem. A common reason not to help was that the affected student was already in treatment. Another
frequently mentioned reason for not providing any help was the self-perceived lack of experience or training to
help. This is in line with previous research showing that a lower ability to understand students’ mental health
problems might also decrease teachers’ readiness to help them (Sisask et al., 2014). Lastly, the perception that
others are better suited to help a student with a mental disorder (in particular, experts in the field) was also
described in previous studies (Graham et al., 2011; Reinke et al., 2011; Shelemy et al., 2019a, 2019b).
Stigmatizing attitudes towards students with mental health problems were not endorsed by anyone in the present
study as a justification for refusing help. However, such attitudes might still exist and influence some teachers’
perception of students with particular mental disorders or their social interaction with them (Frauenholtz et al.,
2017).
The present study has several limitations. Firstly, the analyses were based on self-reports of teachers, which
might have been biased. Furthermore, it must be considered that some teachers might have disregarded the
instruction to focus on the last student with a mental health problem, but rather listed all mental conditions that
they encountered over the years, or they either reported the most dominant type of condition or most severe case
that left a lasting impression on them. It must also be acknowledged that some aspects were only covered with a
single item, such as the self-rated MHL. Lastly, it must be considered that – despite the relatively high response
rate in the present survey – teachers with less interest in this field might have been less likely to participate.
5. Conclusions
MHL seemed to foster the helping behaviour of teachers in secondary schools, whereas lacking experience or
training to help, or the perception that other people are better suited to help, might act as barriers. Hence, it could
be argued that courses aiming at increasing teachers’ MHL and related skills might positively influence their
actual helping behaviour. The involvement of teachers in supporting students with mental health problems
described here indicates that they feel a responsibility to contribute to the mental health of students. Hence, they
might also be willing to further educate themselves on the topic. Several programs exist that are targeting
teachers to improve their competencies. A review that examined the effectiveness of mental health training
programs for secondary school teachers indicates that such programs improve mental health knowledge and
attitudes at post-intervention (Anderson et al., 2019). Additionally, some of the few existing RCTs show further
promising results such as an increased confidence in and willingness to provide help to students among teachers
after having completed the respective program (Jorm et al., 2010; Ueda et al., 2021). However, the
aforementioned review article suggests that there is little evidence that mental health training programs can also
improve teachers’ actual helping behaviour or students’ mental health (Anderson et al., 2019). Hence, there is
still a need for research on whether and how these aspects can be improved. Furthermore, it would need to be
established what type of program might be most useful and practicable for Swiss secondary teachers to optimally
prepare them for supporting students with mental health problems. To achieve this, aspects of the program, such
as the resources needed for its implementation (e.g., teachers’ time needed to complete the program), the content
and the effectiveness on particular outcome measures, need to be taken into account. Besides fostering individual
competencies of teachers, further facilitators of the broader school context (e.g. providing adequate mental health
resources within schools; Dimitropoulos et al., 2021) should be considered in order to optimally address the
mental health problems of students. Due to the importance of pupils’ mental health, the general topic of
supporting students’ mental health should be given a higher priority in the education of teachers.
Acknowledgments
The Swiss Youth Mental Health Literacy and Stigma Survey was supported by the Swiss National Science
Foundation (10001C_173235) and the follow-up survey presented here was based on this youth survey and
therefore part of the overall project. We thank the participants who fillead out the questionnaire and shared their
experiences. We would also like to thank Laura Helbling for her valuable input in terms of data analyses.

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Copyrights
Copyright for this article is retained by the author(s), with first publication rights granted to the journal.
This is an open-access article distributed under the terms and conditions of the Creative Commons Attribution
license (http://creativecommons.org/licenses/by/4.0/).

131
Received: 16 December 2021  |  Accepted: 19 September 2022

DOI: 10.1111/bjep.12553

ARTICLE

Teachers' perceptions of the barriers to assessment

of mental health in schools with implications for
educational policy: A systematic review

Pia O'Farrell1   | Charlotte Wilson2  | Gerry Shiel 3

1
Dublin City University, Dublin 9, Ireland
2
Trinity College Dublin, Dublin, Ireland Abstract
3
Educational Research Centre, Dublin City Background: Assessment of mental health in schools has
University, Dublin 9, Ireland
garnered increased interest in recent years. Children spend a
Correspondence large proportion of their waking hours in schools. Teachers
Pia O'Farrell, Dublin City University, St. Patrick's
Campus, D09Y0A3, Dublin 9, Ireland. can act as gatekeepers by playing a key role in identifying
Email: pia.ofarrell@dcu.ie
children with mental health difficulties in the classroom and
Funding information making the necessary onward referrals to external services.
Dublin City University
The prevalence of mental health difficulties, their impact
on schooling (and beyond) and the importance of early in-
tervention means that it is incumbent on schools to identify
and support potentially affected children.
Aims: Previous reviews focused on mental health interven-
tions in schools; however, this review focuses on the assessment
of mental health in schools and on teachers' perceptions of
this, as such a review is still lacking. Therefore, the study
fills a gap in the existing literature while also providing new,
highly relevant evidence that may inform policy making in
this area.
Composition of studies included in this review: This re-
view included 19 studies. Five studied teachers exclusively
at primary/elementary level, and seven focused on second-
ary level, while six included both primary and secondary

This review was conducted across two universities (Dublin City University and Trinity College Dublin).

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial License, which permits use, distribution
and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2022 The Authors. British Journal of Educational Psycholog y published by John Wiley & Sons Ltd on behalf of British Psychological Society.

|
262    
wileyonlinelibrary.com/journal/bjep Br J Educ Psychol. 2023;93:262–282.
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HEALTH IN SCHOOLS WITH IMPLICATIONS FOR EDUCATIONAL POLICY |
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teachers. Three studies employed mixed methods, ten

were primarily qualitative studies, and five were primarily
quantitative.
Methods: Bronfenbrenner's (The ecolog y of human development:
Experiments by nature and design, Harvard University Press,
1979) framework, adapted by Harvest (How can EPs best sup-
port secondary school staff to work effectively with children and young
people who experience social, emotional and mental health difficul-
ties? 2018), which includes the mature version of the theory
(Tudge et al., 2009, J. Fam. Theory Rev., 1, 198), was used to
analyse the literature.
Results: Results found that lack of training in assessment
of mental health and ‘role conflict’ were key barriers; some
teachers attributed this to their lack of knowledge, skills and
confidence in the area.
Conclusion: Implications for practice and research are dis-
cussed in relation to the importance of sustained training
both pre-­service and in-­service.

K EY WOR DS
assessment, barriers, mental health, teachers

I N T RODUC T ION

A large number of children globally may be at risk of developing social, emotional and be-
havioural difficulties (SEBD), and this has received increased attention in recent years. Loades and
Mastroyannopoulou (2010) highlight that, internationally, children and adolescents with SEBD make
up approximately 20% per cent of the school-­age population. For these children, early identification
has the potential to mitigate against adverse outcomes both in school and beyond (Carr, 2015; Cook
& Ruhaak, 2014; Landrum et al., 2014; Mundschenk & Simpson, 2014). Considering the proportion of
their waking hours that children spend there, schools have a crucial role in identifying children with
SEBD (Levitt et al., 2007). Furthermore, there is an increasing body of literature which states that
emotional well-­being and academic performance in schools are not mutually exclusive and that emo-
tional well-­being provides the foundation from which effective learning can be built (Cefai et al., 2016;
Moilanen et al., 2010).
This review examines teachers' perceptions of the barriers to assessment of children who may be
experiencing SEBDs, an important topic, considering their centrality to the process. According to the
Gateway Provider Model (GPM; Stiffman et al., 2004), the teacher can be the ‘gateway provider’, who
identifies children in need of external services. Therefore, teachers can play a key role in identifying
children with mental health difficulties in the classroom and making the necessary onward referrals
to external services as well as providing the appropriate in-­school supports (Meldrum et al., 2009; Ní
Chorcora & Swords, 2021).
Little is known about how schools are identifying children with mental health difficulties in order
to liaise with and referring them on to external services. In several countries, the role of schools in
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264  |    O'FARRELL et al .

mental health is also unclear and changes to policies in this area suggest the school's role is changing
(Cefai et al., 2021). This report also acknowledges that the school system needs to play a central role
given that children's and young peoples ‘mental health needs are becoming more evident and demand-
ing’ and that social and emotional education for these children is essential (p. 5). Furthermore, this
report outlines that children and young people have a right to physical and mental health and that a
whole school approach to mental health is necessary to accommodate this. However, recent research
shows that there are a wide variety of assessment practices, both structured (e.g., checklists and rating
scales) and unstructured (e.g., observation), which are employed by schools (Dwyer et al., 2006; Ford &
Finning, 2020). For the purpose of this review, all such practices which aim to formally or informally
identify mental health needs of children are included.

Teachers understanding of health and their training

In order to identify and support children with SEBDs, teachers need to understand how they present in
school and the classroom, how to assess them and how to support them. Debattista and Mangion (2019)
study found that ‘teachers who supported students with SEBD were more aware of strategies to be used
in the classroom than those who never supported such students’ (p. 300). This suggests that teacher
training can increase teachers' confidence in assessing mental health in the classroom. For example, in
one Australian study, researchers asked primary and secondary pre-­service teachers to complete a 13-­
week training unit on dealing with sensitive issues, including mental health. Of this cohort of students,
(N = 164), seventy-­t wo completed pre and post measures. Prior to the course, only 29% of the partici-
pants felt confident and competent in identifying those presenting with mental health difficulties; how-
ever, this increased to 80% post-­course (Lynagh et al., 2010). Furthermore, pre-­service teacher training
on mental health is not consistent across countries (Koller & Bertel, 2006). If the curricula of teacher
education courses are reviewed, then it is apparent that identifying and working with children with
SEBD is conceptualized differently as well as being given different weight. This kind of work can be
conceptualized as just dealing with children who need ‘Special and Inclusive Education’ (DCU, Ireland,
and Macquarie and Griffith University, Australia), or as part of general well-­being (Cardiff Metropolitan
University, Wales), or understanding individuals (Aberdeen, Scotland). The training for this work might
focus on the positive aspects, such as positive behaviour support (Leigh University, United States) or
creating a positive learning environment (University of Malta, Malta). Furthermore, credits for these
modules vary from 2.5 to 15 credits. State et al. (2019) US study further illustrates the inconsistencies
that exist in mental health across courses, even within countries. This research sought to gather data
from a random sample of 41 US colleges, although N = 26 participated and agreed to share their syllabi
on social, emotional and behavioural (SEB) topics in pre-­service teacher training. A startling 14% of
the sample had no SEB topics on their syllabi. The research found that overall SEB was not taught in
in a comprehensive manner. This shows that inconsistencies that exist are not just across countries but
within countries also.

Rationale for this systematic review

Early intervention is crucial when identifying children with SEBDs. Governments are rolling out nu-
merous mental health initiatives for schools. However, it is unclear in what proportion of schools as-
sessment of mental health and identification of children with mental health difficulties are occurring
and which procedures are followed. Williams et al. (2007) state that ‘there is a limited understanding
of how children are referred in schools for further treatment and conversely what barriers prevent the
identification and the referral process from being more effective’ (p. 97). Furthermore, there has been
a lack of research in this area since their article was published over a decade ago. For example, there is a
dearth of research, which examines teachers' knowledge of children with SEBDs and their perceptions
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HEALTH IN SCHOOLS WITH IMPLICATIONS FOR EDUCATIONAL POLICY |
       265

of identifying and working with children with mental health difficulties. This was noted, for instance,
in Shillingford and Karlin's (2014) US study with pre-­service teachers, which found that more work
needed to be done to improve pre-­service teacher's knowledge of SEBD and to provide strategies for
identifying and working with children with SEBDs. Previous reviews have focused on teachers' im-
plementation of mental health interventions (Franklin et al., 2012), the use and feasibility of universal
screening programmes (Anderson et al., 2017; Soneson et al., 2020) and teachers' perceptions of chil-
dren who present with mental health difficulties in schools (Armstrong, 2013). The above reviews focus
on interventions, school resources/programmes and on how children with mental health difficulties are
perceived by teachers; what is still lacking is a systematic review, which focuses on teachers' perceptions
of the assessment of children's mental health in schools. Therefore, a systematic review of the literature
on the barriers to assessment of mental health is timely. A systematic review was chosen as one of the
goals of this research is to provide evidence to inform policy making and identify gaps in the existing
literature (Temple University Libraries, 2022). This was also done to ensure all scholarly research in this
area was included. According to Temple University Libraries, this allows the review to be transparent,
replicable and rigorous which is important from a policy perspective and to contribute to the research
in this area (Temple University Libraries, 2022).
There are multiple personnel in a school, but teachers, especially at primary level, have the most
contact with the children and know them best. It is therefore germane to start with exploring these
issues from the perspective of teachers. The current review focuses on the assessment of mental health
in schools, focusing solely on teachers' perceptions of this. This review takes a systematic approach to
identifying the relevant literature (Moher et al., 2009).

Theoretical framework

Bronfenbrenner's (1979) framework, adapted by Harvest (2018), which includes the mature version of

the theory (Tudge et al., 2009) was used to analyse the literature. Harvest's framework places the teacher
at the centre, unlike Bronfenbrenner's (1979), which places the child or young person at the centre;
however, the same systems are referred to in both frameworks. It is acknowledged in the literature
that Bronfenbrenner's Process-­Person-­Context-­Time ‘involves the interplay of the theory's crucial con-
cepts’ (Tudge et al., 2016, p. 422). This allows us to understand the synergistic relation between these
proximal processes (i.e., the individual (teacher)) and the context (e.g., school, other teaching colleagues,
parents and children). This framework is used to illuminate the dynamic relationship between teachers'
perceptions of assessment of mental health in schools and the different systems which influence this
(Harvest, 2018). It also promotes an understanding of the wider school ecology and its impact on teach-
ers' ability to identify and work with children with SEBD, and, in turn, the impact of interventions on
the child (Armstrong, 2013, p. 741).

Purpose of current review

The purpose of this paper is to report on a systematic review of the literature, which examines teachers'
perceptions of the barriers to assessment of mental health in schools.

M E T HOD

Nature and scope of the review and databases used

The search terms used in this review are outlined in Table 1. This review focused on scholarly literature
(i.e., peer-­reviewed articles, books and published and unpublished theses) from a range of international
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266  |    O'FARRELL et al .

T A B L E 1   Search strategy

Teachers' perceptions of the barriers and enablers to assessment of mental health in schools
((anxiety OR "selective mutism" OR "panic disorder" OR phobia OR "mental health" OR "internalising disorder" OR
"internalizing disorder" OR "behavioral disorder" OR "behavioural disorder" OR "behavioral emotional and social
difficulties" OR "behavioural emotional and social difficulties" OR "social emotional and behavioral difficulties"
OR "social emotional and behavioural difficulties") AND ((TITLE-­A BS KEY (assess* OR identif* OR recogni*
OR screen OR "screening measure" OR "test")) AND (TITLE-­A BS-­K EY (child* OR pupil* OR student* OR kid*)
AND (TITLE-­A BS-­K EY) ("Primary School" OR "Elementary School" OR "primary education" OR "Elementary
Education" OR teacher* OR teacher* OR tutor* OR class* OR "School-­based" OR "School based")) AND (TITLE-­
ABS-­K EY) (barrier* OR problem* OR difficult* OR challenge* OR enabler*)) AND (TITLE-­A BSKEY (perception
OR attitude OR belief OR opinion OR expectation))) AND (LIMIT-­TO (LANGUAGE, "English"))

sources. In order to ensure all the key literature was identified, the following specific journals were
hand-­searched, given their specific relevance to this review: School Mental Health and Emotional Behavioural
Difficulties. The primary database used was ScopusEBSCOhost (within this, the ERIC APA Psycinfo and
APA PsycArticles databases were searched). These were used because of the need for literature, which
spans both education studies and the social sciences.

Inclusion and exclusion criteria

Due to limited time and resources, only English language studies were reviewed. Studies, which were
conducted in countries classified as developing economies, were also excluded, given that mental health
care is often very different in those countries (World Health Organization, 2019). Studies were excluded
where data from teachers were amalgamated with those of other school practitioners, including psy-
chologists and social workers. These were removed as it was difficult to disentangle which information
related to teachers and which related to other school participants. They were also excluded if they did
not specifically examine teachers' perspectives on assessment for mental health, for example if a study
only compared teacher's ratings to students and did not gather information on their perspectives on
the barriers to assessment of mental health, it was removed. Studies focusing on principals, pre-­service
teachers, pre-­school teachers, review/discussion papers and studies focusing on mental health inter-
vention in schools were also excluded. The decision was made to focus on in-­service teachers for the
following reasons. First, this cohort spends much of the school day with the children. Secondly, a large
number of countries both in the EU and North America use a tiered approach to mental health identi-
fication (i.e., where the teacher plays a key role in this first tier by identifying mental health difficulties
and escalating them), which places teachers as gatekeepers to these external services (Cefai et al., 2018).
Thirdly, the GPM states that for a teacher to identify ‘at risk’ children to external services, the process
may be influenced by three key factors ‘their perception of need, and their knowledge of resources, and
their environment’, and therefore, examining teachers perceptions is crucial (Stiffman et al., 2004, p.
189). In some cases, it was not initially clear whether a research paper focusing on teachers supporting
students' mental health in schools included assessment and intervention or only assessment. To shed
light on the research question, a careful review of full texts was conducted to ensure that they answered
this question (i.e., in relation to assessment of mental health).

Methodological framework

The review was guided by a methodological framework (Moher et al., 2009) for conducting scoping
studies, which was last updated on 5 April 2021. This ‘PRISMA’ framework was used due its systematic
nature and is outlined in Figure 1.
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HEALTH IN SCHOOLS WITH IMPLICATIONS FOR EDUCATIONAL POLICY |
       267

Identification of studies via databases and registers

Records removed before

screening:
Identification

Records marked as ineligible

Records identified from*: by automation tools (n=3907)
Databases (n=8533) Duplicate records removed
Registers (n=0) (n=98)
Records removed for other
reasons (n=4395)

Records screened Records excluded**

(n=133) (n =75)

Reports sought for retrieval Reports not retrieved

(n =58) (n=0)
Screening

Reports excluded:
Reports assessed for eligibility Reason 1: The data was
(n=58) amalgamated from several
studies and therefore teachers’
perspectives of assessment for
mental health was not
specifically examined (n=15)
Reason 2: The focus was not
on assessment but
intervention (n=24)
Included

Studies included in review

(n=19)

F I G U R E 1   Adapted preferred reporting items for systematic reviews and meta-­a nalyses (PRISMA) flowchart of review
process and study selection

R E SU LT S

Overview of included papers

Thirty-­n ine abstracts met the initial inclusion criteria, and of these, 19 met the final inclusion criteria.
Those studies which were excluded primarily due to the fact that data from teachers were amalgamated
with other school practitioners. Several of these studies are small-­scale and qualitative in their orienta-
tion (three mixed methods, eleven qualitative and five quantitative studies) in their orientation; however,
when these findings are considered together, a more coherent picture of the current international land-
scape emerges. The literature, which met the final inclusion criteria, is set out in Table 2. The number
of participants ranged from 8 to 771, eight of the studies were carried out in the United Kingdom, four
in the United States, three in Australia, with and one each from Norway, Turkey and the Netherlands.
 T A B L E 2   Literature which satisfied the inclusion criteria for this review
268 

Application of Harvest's ecological framework

Stated methodology and to teachers' perceptions of barriers to
|   

Author(s) Location research method Sample size who participated assessment of mental health in schools
Childs-­Fegredo et al. (2021) UK Qualitative: n = 26 teachers (this included teaching INDIVIDUAL: Fear over expectation of their
Semi-­structured interviews assistants, class teachers and head role. Lack of confidence
teachers) across four primary schools MACROSYSTEM: Training-­burden on teachers.
Lack of time and resources. Reliability of
universal screening
MICROSYSTEM: Poor sign posting to services
MESOSYSTEM: Parental stigma and parental
consent
Corcoran and Finney (2015) UK Qualitative: n = 15 secondary school teachers with INDIVIDUAL: Role conflict. Fear over
Semi-­structured interviews a focus on senior staff (i.e., Social expectation of their role
and Emotional Aspects of Learning MACROSYSTEM: Lack of training
coordinators, head teachers, a Special
Educational Needs Coordinator
SENCO)
Danby and Hamilton (2016) UK Mixed methods: semi-­structured n = 18 from two primary schools INDIVIDUAL: Role conflict. Lack of knowledge
interviews and a questionnaire Nine teachers, seven teaching assistants MACROSYSTEM: Lack of training
and two additional learning needs EXOSYSTEM: Mixed consensus –­some found
coordinators external services ‘easy’ or ‘moderately easy’ to
access while some did not
Ekornes (2015) Norway Mixed methods: electronic survey n = 15 teachers from three different INDIVIDUAL: Lack of knowledge
and focus groups secondary school participated in the MACROSYSTEM: Lack of training. Training
focus groups. n = 771 completed needed on confidentiality procedures
the survey (172 of these worked in MESOSYSTEM: Parental stigma
primary schools while the rest of the
responses were from teachers working
in secondary schools)
Goodman and Burton (2010) UK Qualitative: n = 8 secondary school teachers, teaching MACROSYSTEM: Training is inadequate. Little
(published) Semi-­structured interviews across four regions of England or no specialist training
EXOSYSTEM: Lack of availability of external
services to conduct further assessment.
Difficulties obtaining information about
students
O'FARRELL et al .

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 T A B L E 2   (Continued)

Application of Harvest's ecological framework

Stated methodology and to teachers' perceptions of barriers to
Author(s) Location research method Sample size who participated assessment of mental health in schools
Gowers et al. (2004) UK Quantitative: electronic survey n = 148 primary school teachers' in a rural MACROSYSTEM: Lack of training. Mixed
district. All teachers were the SENCO consensus over the helpfulness of training
in their school INDIVIDUAL: Lack of knowledge
EXOSYSTEM: Children Adolescents Mental
Health service (CAMHS) and its referral
system viewed as inadequate
Graham et al. (2011) Australia Quantitative: electronic survey n = 508 teachers from both primary (49%) INDIVIDUAL: Role conflict
and secondary school (46%) and some MACROSYSTEM: Inadequate pre-­service teacher
teachers teaching across both training
Hackett et al. (2010) UK Quantitative: online questionnaire n = 403. Nine primary schools were MACROSYSTEM: The need for supporta with
randomly selected from a large urban primarily externalizing difficulties, however
area they also addressed internalizing difficulties
(e.g., emotional withdrawal)
Harvest (2018) (unpublished) UK Qualitative: n = 14 school staff across two mainstream INDIVIDUAL: Lack of knowledge and skills. Role
HEALTH IN SCHOOLS WITH IMPLICATIONS FOR EDUCATIONAL POLICY

Two focus groups secondary schools conflict. Stress from taking on the student's
TEACHERS' PERCEPTIONS OF THE BARRIERS TO ASSESSMENT OF MENTAL

mental health difficulties.

MACROSYSTEM: Lack of training
MICROSYSTEM: School ethos
Hinchliffe and Campbell (2016) Australia Qualitative: n = 20 teachers from two primary schools INDIVIDUAL: Role conflict
Semi-­structured interviews MACROSYSTEM: Societal expectations
Mooij and Smeets (2009) Netherlands Qualitative: n = 35 teachers, from primary and MACROSYSTEM and EXOSYSTEM: Insufficient
Semi-­structured interviews secondary schools, from five different knowledge given to teachers about children
regions of the Netherlands
|        269

(Continues)

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 T A B L E 2   (Continued)
270 

Application of Harvest's ecological framework

Stated methodology and to teachers' perceptions of barriers to
|   

Author(s) Location research method Sample size who participated assessment of mental health in schools
Papandrea and Winefield (2011) Australia Mixed methods: online n = 152 secondary teachers from 17 South MACROSYSTEM: Lack of training, particularly in
questionnaire (closed and Australian schools identifying internalizing symptoms in children.
open-­ended questions) Policy (pressure to test)
EXOSYSTEM: Inadequate available and sustained
access to mental health supports
INDIVIDUAL: Lack of knowledge. Role conflict
(uncomfortable with the expectation to identify
children without training). Teacher stress in
managing difficulties
Reinke et al. (2011) United Quantitative: online questionnaire n = 292 elementary teachers across five MACROSYSTEM: Lack of training
States of school districts (rural suburban and MICROSYSTEM: Lack of school funding
America urban) EXOSYSTEM: Insufficient number of mental
(USA) health professionals
MESOSYSTEM: Lack of parental support
INDIVIDUAL: Lack of confidence and
knowledge
Rothi et al. (2008) UK Qualitative: semi-­structured n = 30 teachers Eight participants taught INDIVIDUAL: Role conflict. Stress, and
interviews in primary schools, 13 in secondary frustration due to lack of knowledge
schools, 8 in special schools and one MACROSYSTEM: Lack of training in assessment
in a Montessori school (particularly in identifying less visible
disorders). Inadequate training for pre-­service
teachers
Sezer (2017) Turkey Qualitative: n = 24 teachers, teaching in primary, INDIVIDUAL: Teacher stress due to lack of
Case study secondary and high school confidence and knowledge in understanding
the problem
O'FARRELL et al .

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 T A B L E 2   (Continued)

Application of Harvest's ecological framework

Stated methodology and to teachers' perceptions of barriers to
Author(s) Location research method Sample size who participated assessment of mental health in schools
Shelemy et al. (2019) UK Qualitative: n = 49 teachers from nine secondary MACROSYSTEM: Societal expectations. Lack
Nine focus groups schools of training. No consensus over the quality of
training received.
INDIVIDUAL: Role conflict. Fear of making
things worse.
MESOSYSTEM: Frustration with parents who are
dismissive and difficult to get on board
EXOSYSTEM: Lack of communication from
CAMHS
Walter et al. (2006) USA Quantitative: electronic survey n = 119 elementary teachers across six MACROSYSTEM: Lack of training, large class
schools sizes and lack of time in the school day.
Inadequate pre-­service teacher training
INDIVIDUAL: Lack of confidence
MESOSYSTEM: Lack of parental involvement
Westling (2010) USA Quantitative: questionnaire (hard n = 70 teachers (38 special education and MACROSYSTEM: Mixed views over the adequacy
HEALTH IN SCHOOLS WITH IMPLICATIONS FOR EDUCATIONAL POLICY

copy delivered by post) 32 general education teachers) from of professional preparation training they
TEACHERS' PERCEPTIONS OF THE BARRIERS TO ASSESSMENT OF MENTAL

one south-­eastern state in the United received in assessment

States. This included those teaching in
kindergarten, primary and secondary
schools
Williams et al. (2007) USA Qualitative: n = 19 teachers from two elementary INDIVIDUAL: Teachers spoke about feeling
Two focus groups schools overwhelmed. Fear over societal expectations
MESOSYSTEM: Frustration with parents
MICROSYSTEM: School ethos. Lack of time in
the school day for mental health assessment
a
Although training is not mentioned explicitly, this is implied.
|        271

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272  |    O'FARRELL et al .

Of the 19 studies, six studied teachers exclusively at primary/elementary level and seven focused on
secondary level, while six included both primary and secondary teachers. Each system (Harvest's, 2018)
is presented and analysed separately in order to highlight the individual nature of different barriers.

Synthesizing analyses

Macrosystem

Training
In terms of the macrosystem, lack of training was considered a barrier in 15 studies (Corcoran &
Finney, 2015; Danby & Hamilton, 2016; Ekornes, 2015; Reinke et al., 2011). Of these, six were cross-­
sectional studies using questionnaires, six were qualitative studies involving interviews and focus
groups, and three studies used a mix of qualitative and quantitative methods. In the overwhelming ma-
jority of the studies, teachers were keen to receive further training. In one large-­scale US study, teachers
were asked to list the top three areas they identified for additional training. The first was strategies for
working with children with externalizing behaviour problems, the second was training in recognizing
and understanding mental health issues in children, and the third was training in classroom manage-
ment (Reinke et al., 2011). This is noteworthy, given the range of potential areas across education which
could have been chosen. An Australian study (Papandrea & Winefield, 2011), in which a random sample
of teachers (n = 152) from 28 secondary schools completed an online questionnaire, sought to explore
why referral rates for internalizing problems are so low. In this study, four main categories of concern
emerged: ‘Insufficient mental health-­related training’ (n = 63), ‘Inadequate available and sustained sup-
ports’ (n = 49); referrals prioritized instead to children who are ‘More disruptive in classrooms’ (i.e.,
externalizing problems; n = 36) and ‘Teacher stress’ (n = 21, p. 227).
Diversity of opinion on training was identified in one US study by Westling (2010) where 70 teachers
completed a questionnaire. The results showed mixed views on the adequacy of professional preparation
training the teachers had received in ‘data collection and assessment’, with 60% of special education
teachers and 39% of general education teachers reporting that they had adequate or extensive prepara-
tion in this area (Westling, 2010). This study did not draw a distinction between primary and secondary
teachers. Furthermore, the questionnaire used in this study looked exclusively at challenging behaviour.
This raises questions as to whether those working with children with special educational needs received
more training in this area and were more adequately prepared. Although the overwhelming majority of
studies address lack of training as a barrier, some studies identified specific needs in relation to further
training and these are outlined below.
Some studies noted that the quality of training was not sufficiently specialized. Participants ex-
plained that training needed to include information on warning signs or risk factors (Ekornes, 2015;
Goodman & Burton, 2010; Shelemy et al., 2019). There were also calls from participants in one of the
UK studies for this training to be accredited (Shelemy et al., 2019). Some studies criticized pre-­service
teacher training for not equipping them with the necessary skills to identify children who were experi-
encing mental health difficulties (Graham et al., 2011; Rothi et al., 2008; Walter et al., 2006). In other
studies, there were mixed views on whether teachers had received sufficient professional pre-­service or
in-­service training to deal with mental health difficulties in the classroom (Goodman & Burton, 2010;
Papandrea & Winefield, 2011; Westling, 2010). Rothi et al. (2008) noted that teachers need training in
self-­assessment of their own mental health. One study also called for training in confidentiality pro-
cedures (Ekornes, 2015). Other studies, however, noted that teachers require support specifically with
identifying internalizing difficulties (Papandrea & Winefield, 2011; Rothi et al., 2008).

National policy guidelines

In total, six studies raised specific concerns about increased pressure on academic testing due to
national policies (Corcoran & Finney, 2015; Papandrea & Winefield, 2011; Reinke et al., 2011; Rothi
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et al., 2008; Walter et al., 2006; Williams et al., 2007) and argued that this left no time for assess-
ing mental health (Walter et al., 2006; Williams et al., 2007). The above studies were conducted in
the United Kingdom, the United States and Australia. They highlight that challenges imposed by
national policy are not limited to one specific country. Of these, two were cross-­sectional studies
using questionnaires, three were qualitative studies involving interviews and focus groups, and one
used a mix of qualitative and quantitative methods. Corcoran and Finney (2015) found that teach-
ers reported a constant professional challenge in ‘trying to make sense of competing legislative and
policy pressures’ in the context of mental health promotion and early intervention (p. 111). Reinke
et al. (2011) commented that there needs to be calls for government polices to mandate this training
to address this.

Individual

Role conflict
Ten articles incorporated discussion on the teacher's role. Of these, two were cross-­sectional stud-
ies using questionnaires, six were qualitative studies involving interviews and focus groups, and two
used a mix of qualitative and quantitative methods. A key issue that emerged from teachers' narratives
in seven of these studies was the fear that solving mental health problems was becoming their role
(Childs-­Fegredo et al., 2021; Corcoran & Finney, 2015; Danby & Hamilton, 2016; Graham et al., 2011;
Harvest, 2018; Hinchliffe & Campbell, 2016; Papandrea & Winefield, 2011; Rothi et al., 2008; Shelemy
et al., 2019). In their eyes, they were teachers and their role was purely academic (Shelemy et al., 2019).
As one teacher remarked, ‘I certainly didn't sign up for this. I'm totally out of my depth. We receive no
training but are expected to deal with so many problems’ (Papandrea & Winefield, 2011, p. 227). Six of
the ten studies were from the United Kingdom, while two were conducted in Australia. In contrast to
this, in two of the US studies, the majority of teachers believed monitoring that mental health to be part
of their role (Reinke et al., 2011; Walter et al., 2006). This would suggest teachers' attitudes to their role
in mental health differ across countries.
Harvest's (2018) UK study found that many teachers see their role as more holistic, including mental
health promotion and early intervention, and believe they have a duty of care towards children. As one
teacher from this UK study put it: ‘we're teachers of young people who need support in all ways because
I never come to school just to sit and teach lessons’ (Harvest, 2018, p. 110). There were mixed views,
not just between studies but also even within studies. As Harvest noted, ‘all teaching staff at School
2 endorsed the sentiment that we foster that kind of idea of caring about them as individuals not just
as like kind of exam stats’. In contrast to this, another teacher remarked, ‘I'm expected to teach, I'm
expected to deliver really good lessons, I'm expected to, you know; look after the educational needs of
my children. And as much as I'd love to support them pastorally, I physically don't have the capacity’
(Harvest, 2018, pp. 109–­110).
However, it is clear that many teachers still view the teaching of core curricular subjects as their
primary focus. In one study, for example, teachers acknowledged that it is important to make an onward
referral, if anxiety was affecting the students academically. This makes one wonder if students who are
still achieving academically, but who are experiencing high levels of anxiety may slip through the cracks
(Hinchliffe & Campbell, 2016).

Teachers' mental health

Two studies demonstrate that opinions were divided in terms of the impact of a teacher's own mental
health on their ability to identify children with mental health difficulties in the classroom. Of these, one
was a cross-­sectional study conducted in Australia using questionnaires, and the other was a qualitative
study from the United Kingdom involving focus groups. One study commented on how, if a teacher
had experienced mental health difficulties, they may be more aware of the signs or risk factors to look
out for (Harvest, 2018). In contrast to this, a different study stressed the importance of teachers' own
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274  |    O'FARRELL et al .

sense of mental health as an important factor in their ability to identify and support these students with
difficulties (Graham et al., 2011).

Knowledge, skills, confidence and fears of teachers

Fifteen studies referred to knowledge, skills, confidence and fears of teachers as barriers to assessment
of mental health needs of children. Of these, four were cross-­sectional studies using questionnaires,
seven were qualitative studies involving interviews and focus groups, one was a case study (using inter-
views), and three used a mix of qualitative and quantitative methods, suggesting that it is a robust find-
ing. Teachers also consistently reported feelings of ‘incompetence, frustration and helplessness’ (Rothi
et al., 2008, p. 1227). Their feelings of incompetence were often referred to indirectly, as teachers spoke
about their lack of knowledge and skills in this area, their lack of understanding of mental health and
their low confidence in their skills in this area. One study outlined that many teachers felt that they did
not have the knowledge (41%) or the skills (36%) to meet the mental health needs of children in their
class (Reinke et al., 2011), although in this study, teachers' knowledge and skills are spoken about more
broadly, and not specifically in relation to assessment.
Sezer (2017) examined the views of teachers with less than 3 years' experience (these were referred to
as novice teachers in this study). The results demonstrated that novice teachers struggled with disruptive
behaviour and this caused stress and anxiety in almost half of such teachers. Some also acknowledged
that trying to understand the problem was challenging. Moreover, a Norwegian study found that, irre-
spective of teaching experience, teachers found it difficult to disentangle what constitute ‘normal mood
swings’ from more severe problems (Ekornes, 2015, p. 200). In contrast to these studies, one study in
the United States which used two focus groups (across two schools) found that most teachers were com-
fortable identifying children with mental health problems (particularly externalizing difficulties) but felt
they did not have enough time to do so (Williams et al., 2007).
Teachers spoke about a fear of making things worse, noting, for instance, that ‘we don't know when
to leave things or when to let things go or when to intervene’ (Shelemy et al., 2019, p. 104). The fear
of having the ‘responsibility over the well-­being of their students’ was also addressed in several studies
(Shelemy et al., 2019, p. 106). Another fear that was noted by teachers was the expectation that ‘we
should have all the answers’ (Williams et al., 2007, p. 100).

Mesosystem

Parents
Nine studies referred to parents as an important component of the assessment process as they can not
only act as barriers to assessment (given they are the gatekeepers for giving consent) but also as enablers
by identifying their child as presenting with difficulties, prompting the need for onward referral. These
results were found across quantitative (n = 2), qualitative (n = 6) and mixed methods studies (n = 1).
Several studies expressed frustration with parents who were dismissive and difficult to get on board
(Reinke et al., 2011; Shelemy et al., 2019; Walter et al., 2006; Williams et al., 2007). One Norwegian study
highlighted that parents could act as barriers if they are reluctant to address mental health difficulties
due to their own stigma (Ekornes, 2015), while a US study spoke directly about how parents were a
barrier, due to the difficulty in obtaining consent and getting them to follow-­up and attend the services
(Williams et al., 2007).

Microsystem

School ethos
Four studies, all qualitative utilizing focus groups, identified school ethos as important. There was
a ready acknowledgement from teachers in these studies that the school culture and school ethos
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can act as a barrier if mental health resources are not prioritized or if time during the school day
is not set aside for mental health (Childs-­Fegredo et al., 2021; Harvest, 2018; Shelemy et al., 2019;
Williams et al., 2007).

Exosystem

External mental health services

Six studies referred to the role of external services. Of these, one was a cross-­sectional study using
questionnaires, four were qualitative studies involving interviews and focus groups, and one used a
mix of qualitative and quantitative methods. External services were viewed by the participants in a
majority of these studies as inadequate (Goodman & Burton, 2010), and reference was made to lack of
clear sign posting to allow teachers to navigate within available services (Childs-­Fegredo et al., 2021).
Some teachers commented that there was a lack of ‘appropriate and prompt assessment’ (Goodman
& Burton, 2010, p. 226). Teachers were unsure when they were ‘allowed access’, particularly where a
further assessment may have been warranted (Gowers et al., 2004, p. 229). Several studies stated that
information on students can be difficult to access (Goodman & Burton, 2010; Mooij & Smeets, 2009;
Shelemy et al., 2019). This highlights that challenges for teachers in assessment of mental health go
beyond the school setting and that difficulties accessing external services may make teachers less likely
to make onward referrals in the future.

Summary

There are some clear trends in the literature, which provide worthwhile insights on understanding the
barriers to assessment of mental health in schools, as identified by teachers. The overwhelming major-
ity of studies found that lack of training was a barrier and studies outlined different recommendations
for this training (e.g., training in confidentiality procedures and in identifying risk factors). Another
key finding was the divided opinion among teachers on their role in the assessment of mental health in
schools, with some feeling they had an important role to play, and others seeing it as something outside
their core duties. In several studies, teachers spoke about their lack of knowledge, skills and confidence
in this area and their fear of making things worse. There were also mixed views on the adequacy of
external services. Finally, both parents and schools (through their ethos) were identified as clear barriers
to the assessment process.

DIS C US SION

This review explored teachers' perceptions of the barriers to assessment of mental health in schools.
This review is particularly timely given the psychosocial impact that the SARS-­CoV-­2 (coronavirus
disease 2019; previously 2019-­nCoV) pandemic has had on children, including the increasing diffi-
culties faced by children with pre-­existing SEBDs (Ghosh et al., 2020; Youngminds, 2020). Despite
the paucity of studies, a number of key themes emerged across different educational systems. At
the individual level, the key factors outlined were role conflict, fear, teachers own mental health
experiences, lack of knowledge, and the need for skills and confidence. Within the microsystem, the
school ethos emerged as important while both parents and colleagues played important roles within
the mesosystem. Studies also demonstrated the inadequacy of external services (an element of the
exosystem) and the lack of training, the importance of policies and the impact of societal expecta-
tions (macrosystem).
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276  |    O'FARRELL et al .

Role conflict

A significant issue addressed by Ekornes (2015) was that teachers are becoming an underutilized
resource in schools if they are unable to identify the students who are at risk and make appropri-
ate referrals. However, this review demonstrated that there were mixed views over ‘this apparent
expansion of the role of teachers around mental health’ (Kidger et al., 2009, p. 11). Corcoran and
Finney (2015) outline that some teachers view mental health as ‘peripheral to the purpose of edu-
cation’ (p. 105). Kidger et al. (2009) argue that educating pupils about ‘good emotional health and
identifying and referring on those who need specialist support, may be viewed as newer additions
to the traditional teaching role’ (p. 12). Given that the lines for some teachers are blurred around
their perceived role in mental health, this suggests the need for policy to explicitly clarify the role
of teachers.

Lack of teacher confidence

A key theme that emerged was the lack of teachers' confidence in their knowledge and skills in assess-
ment of mental health. Teachers felt that the ultimate impact of mental health education programmes is
dependent on a number of teacher-­specific characteristics. In line with (Bandura, 1977) beliefs on self-­
efficacy, a teachers' beliefs, ‘about a students' mental health, together with perceptions of their own ca-
pability to recognise and deal with mental health-­related issues, will potentially influence their responses
and hence the success or otherwise of mental health education programmes’, (Graham et al., 2011, p.
481). Kidger et al.'s (2009) study found that when teachers' own mental health has been at risk or in
danger, such teachers may be less able and/or willing to respond to (recognize or support) pupils with
mental health difficulties. This is interesting given that this review found that there were mixed views
between studies as to whether a teacher's own state of mental health may hinder or assist in the assess-
ment process. In Kidger et al.'s (2009) study, a teacher reported having a mental health difficulty (in the
past), which made them more in-­t une in identifying children with difficulties. However, it is clear that
there is a distinction between research on teachers with a mental health difficulty (current) and those
that have had one in the past. Furthermore, the stigma attached to mental health difficulties may be
different in different countries, which again may affect teachers' attitudes to mental health (Krendl &
Pescosolido, 2020).

Parental consent and confidentiality

It is important that schools obtain ‘active parental consent’ from all families during the assessment
process (Levitt et al., 2007, p. 183), and in most countries, this is a legal requirement. Furthermore, an
important consideration for teachers and mental health professionals is that the data that are shared with
parents are clearly outlined and presented to them in ways that foster understanding. This appears to
be paramount, as it may influence not just parental awareness of children's possible difficulties but also
whether parents' access or give consent for the referral pathways to be followed (Dvorsky et al., 2014).
Connecting with mental health services is often a long process for parents, and this may act as a barrier
to engaging with available services (Cohen et al., 2012; Iskra et al., 2015). However, some scholars have
suggested a possible solution and recommended that services ‘engage with families placed on a waiting
list rather than just requiring them to confirm their intention to continue waiting for services [as this]
is an effective strategy to increase an uptake of initial appointment and subsequent engagement with
services’ (Anderson et al., 2017, p. 171). Policies, which are aimed at promoting the mental health of
parents, are also salient (Ford et al., 2007).
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Lack of training and National Policies

Government policies were identified as barriers to assessment of mental health in a number of coun-
tries. In particular, reference was made to the increased pressure brought on by academic testing. The
overwhelming majority of studies found that lack of training was a barrier, and this training may also
assist by building on teachers' confidence in assessment of mental health. It is evident from this review
that this barrier was not unique to one education system but is apparent in teachers working in differ-
ent education systems at different levels within those systems. Furthermore, the three studies which
criticized pre-­service teacher training were not unique to one country, and they were based on research
in the United Kingdom, the United States and Australia. This highlights the importance of teachers'
perspectives, as they are on the front line, working with children with mental health difficulties.

Assessment of the quality of the literature

It is beyond the scope of this review to provide a detailed commentary on all aspects of each study re-
viewed. Moreover, only six countries were represented across the 18 studies. Due to the small number of
studies found, it is difficult to draw definitive conclusions. Furthermore, some of the studies' methods
were lacking in detail and should be interpreted with caution. For example, survey questions had re-
sponse items, which could be considered to be somewhat limiting. In one US study, teachers were asked
to rank their beliefs about the biggest mental health problems (Walter et al., 2006); however, this scale
used solely focused on externalizing problems. Another study outlined that nine schools were invited to
participate in interviews and of these seven declined, suggesting difficulties in generalizing the results
even within countries (Danby & Hamilton, 2016).
Although two qualitative studies spoke about how teachers' mental health affects their assessment of
children's mental health, none of the studies in this review explicitly asked this question. The majority of
studies in this review used convenience (Danby & Hamilton, 2016), or purposive sampling (Goodman
& Burton, 2010). Although some studies drew from a random sample (Hackett et al., 2010; Papandrea
& Winefield, 2011), these were the exception. Teachers may be more likely to participate if they have a
more positive attitude towards mental health in schools. Four studies in this review (22%) used focus
groups. The results from these studies need to be interpreted with caution given that participants may
be reluctant to voice their own opinions, if they are working within a specific school culture (Barbour
& Kitzinger, 1998; Gibbs, 1997).

Limitations of the literature review

Cultural differences are likely to impact on how different countries and indeed different areas within
countries view mental health and this may have impacted the findings of this review. Furthermore, it
is likely that there may be cultural differences in determining the role that assessment of mental health
plays in initial teacher education programmes. This review excluded studies, which included data from
practitioners (e.g., counsellors and psychologists) alongside teachers, as these results were amalgamated.
It is possible that studies, which included these teachers, may have had relevant findings. Given that a
small number of articles met the inclusion criteria for this search, it is difficult to make generalizations
from this review. Furthermore, there may have been unpublished work, which was overlooked.

Further research

It is clear from the literature that schools play an important role in mental health and that school
staff ‘are at the nexus between education and psychology’ (Corcoran & Finney, 2015, p. 98). In light
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278  |    O'FARRELL et al .

of this, there is a need for further research in this area. This review demonstrates that there are few
(English language) studies from a teacher's perspective and there is a need for research across a range
of countries. Further investigation into specific barriers or enablers to mental health, which distinguish
between research at primary and secondary level, are needed. In several studies, which included teach-
ers working in primary and secondary schools, the results were often combined, making it difficult to
disentangle specific challenges within sectors. Only one of the papers that met the inclusion criteria for
this review outlined that assessment measures/screeners/available tests (in schools) were a barrier to
their assessment of mental health. It is noteworthy that this study asked teachers about universal screen-
ing specifically, whereas the other studies did not. This is surprising given that universal school-­based
screening is a hotly debated topic in recent years (Dowdy et al., 2010; Humphrey & Wigelsworth, 2016;
Lane et al., 2012). Therefore, further research should explore what measures teachers are using and their
perception of these. Teacher require education not just in supporting children but also in supporting
their own social and emotional competence and resilience (Cefai et al., 2021). Given that teachers can
act as gatekeepers, by potentially playing a key role in identifying children with mental health difficul-
ties and making the necessary onward referrals, further research needs to be conducted on how best the
school system can support teachers. Yoder (2014) recommends educators engage in self-­assessment and
develop their own mental health skills. However, little is known about how (if at all) a teacher's well-­
being may influence their role in the assessment process.

Educational and clinical implications

These findings highlight the need for compulsory training in assessment of mental health, which spans
both pre-­service and in-­service teachers. As Conway (2014) has noted, ‘professional development for
teachers needs to be sustained, not a one off occurrence’ (p. 434). One of the main recommendations for
Educational Psychology practice arising from this review is the need to empower teachers by providing
training in identifying mental health difficulties. Psychologists are well placed to deliver this training at
school level. This training may empower teachers to engage on a more equal basis in consultation, when
referring a child who may need further help, as some teachers may not see assessment of mental health
as part of their role (O'Farrell & Kinsella, 2018, p. 325). Harding et al. (2019) found that better teacher
well-­being was associated with fewer psychological difficulties among students. Investing in training in
assessment (including providing teachers with an understanding of self-­assessment of their own mental
health) is likely to increase teacher confidence in this area and is likely to have a positive impact on chil-
dren. Spiker and Hammer (2019) highlight that ‘a lack of mental health knowledge is viewed as a driver
of prejudice towards individuals with mental illness, which then leads to discriminatory behaviour’. The
GPM highlights the important role of the teacher. Training in mental health literacy (MHL) can have a
useful impact by providing the teacher with knowledge on mental health while also providing informa-
tion on referral pathways and relevant resources. This is line with previous research, which found that
training positively affected teachers' MHL and capacity to support these ‘at risk’ children (Mansfield
et al., 2021; Ní Chorcora & Swords, 2021).
Bearing in mind the consequences of MHL, collaboration between psychologists who are working
with teachers (e.g., through consultation or in-­service training) and parents may be particularly import-
ant. Furthermore, a lack of MHL may cause stigma among parents and/or teachers and may lead them
to disengagement from the assessment process. However, this could be tackled by educational work-
shops delivered by psychologists.
External services need to improve how they communicate with schools to ensure that all stake-
holders are kept informed and involved. Furthermore, external services would benefit from engaging
with families on long wait lists as this may affect that likelihood that parents will access these services.
Finally, as Mehrens (1998) states, it is ‘unwise, illogical and unscholarly to just assume that assessments
will have positive consequences; there is the potential for both positive and negative consequences’ (p.
28). Therefore, further research should be conducted into teachers', principals' parents' and children's'
TEACHERS' PERCEPTIONS OF THE BARRIERS TO ASSESSMENT OF MENTAL

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HEALTH IN SCHOOLS WITH IMPLICATIONS FOR EDUCATIONAL POLICY |
       279

perceptions of assessment of mental health in schools and the assessment resources used to support
decision-­making.

C ONC LUSION

This review's findings are relevant as they provide an overview of the studies completed in this area
and the various perspectives held by teachers with respect to assessment of children's mental health
in schools. This review gives teachers and policy makers food for thought, in particular in terms of
the professional training that is been sought by teachers and the need to develop and/or improve
existing policies which more clearly outline teachers' roles in the assessment of mental health in
schools.

AU T HOR C ON T R I BU T ION S
Pia O'Farrell: Conceptualization; data curation; formal analysis; funding acquisition; investigation;
methodology; project administration; software; validation; visualization; writing –­original draft;
writing –­review and editing. Charlotte Wilson: Conceptualization; data curation; formal analysis;
investigation; methodology; supervision; validation; visualization; writing –­original draft; writing
–­review and editing. Gerry Shiel: Conceptualization; data curation; formal analysis; investigation;
methodology; supervision; validation; visualization; writing –­original draft; writing –­review and
editing.

AC K NOW L E D G E M E N T S
This work is part of a PhD in the School of Psychology at Trinity College Dublin, funded by School of
Policy and Practice, DCU Institute of Education, Dublin City University. This funding has included the
provision of research materials to support this research. I would also like to acknowledge the guidance
and support of my supervisors Dr. Charlotte Wilson and Dr. Gerry Shiel and both my previous Heads
of School, Dr. Brendan Walsh and Dr. Elaine McDonald, and my current Head of School, Dr. Martin
Brown. Open access funding provided by IReL.

C ON F L IC T OF I N T E R E S T
All authors declare no conflict of interest.

DATA AVA I L A BI L I T Y S TAT E M E N T

Data sharing is not applicable to this article as no datasets were generated or analysed during the cur-
rent study.

ORC I D
Pia O’Farrell  https://orcid.org/0000-0001-5010-4623

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How to cite this article: O’Farrell, P., Wilson, C., & Shiel, G. (2023). Teachers' perceptions of the
barriers to assessment of mental health in schools with implications for educational policy:
A systematic review. British Journal of Educational Psycholog y, 93, 262–­282. https://doi.org/10.1111/
bjep.12553
Policies and Practices to Support School
Mental Health

Katie Eklund, Lauren Meyer, Joni Splett, and Mark Weist

Policies and Practices to Support School Mental Health

Providing mental health services to children and youth in schools has been found to
be an effective and innovative approach to reaching at-risk or hard-to-reach youth
(Sklarew, Twemlow, & Wilkinson, 2004; Zirkelback & Reese, 2010). A rich history
of literature and research supports the use of mental health services in schools.
School-based programs that support the mental well-being of children and youth not
only promote wellness but have been linked to improved academic achievement and
behavioral functioning among school-aged youth (Crespi & Howe, 2002; Owens &
Murphy, 2004). The failure of the nation’s child mental health system to fully
address the mental health needs of children and adolescents has been well docu-
mented and highlights the urgency to reconsider current policy and practice (Burns
et  al., 1995; Kataoka et  al., 2003; Simon, Pastor, Reuben, Huang, & Goldstrom,
2015). Furthermore, the need for school mental health services is detailed in special
education regulations and national reports indicating that schools should provide
services that target the mental health needs of youth (National Academies of
Sciences, Engineering, & Medicine, 2018a, 2018b; President’s New Freedom
Commission on Mental Health, 2003; U.S. Department of Education, 2018).
Research indicates that of the small percentage of children and adolescents who
receive mental health services, schools are the most common setting in which
­children access this care (Carta, Fiandra, Rampazzo, Contu, & Preti, 2015; Demissie,

K. Eklund (*)
School Psychology Program, University of Arizona, Tucson, AZ, USA
e-mail: keklund@u.arizona.edu
L. Meyer
University of Arizona, Tucson, AZ, USA
J. Splett · M. Weist
University of South Carolina, Columbia, SC, USA

© Springer Nature Switzerland AG 2020 139

B. L. Levin, A. Hanson (eds.), Foundations of Behavioral Health,
https://doi.org/10.1007/978-3-030-18435-3_7
140 K. Eklund et al.

Oarker, & Vernon-Smiley, 2013; Farmer, Burns, Phillips, Angold, & Costello, 2003;
Office of the Surgeon General, 2000). Further, data indicate these services are
indeed reaching youths, including students from ethnic minority groups and those
with less obvious problems, such as depression and anxiety, who are unlikely to
access services in specialty mental health settings (Foster & Connor, 2005; Kataoka
et al., 2003; Ramos & Alegría, 2014).
School mental health (SMH) services provide youth increased access to services
by reducing many of the barriers to seeking traditional services, such as transporta-
tion, cost, and stigma (Weist, Lever, Bradshaw, & Sarno Owens, 2013). Providing
services within schools can provide a neutral environment whereby youth learn that
seeking out help and support is commonplace and exists within a continuum of
provided supports (e.g., academic supports, physical health services). Offering a
broad range of universal, targeted, and intensive mental health support services to
youth in schools has been supported by a public health framework that recognizes
the diverse needs of children and families (Kleiver & Cash, 2005; Short, 2003).
Many states have implemented such multitiered systems of support so that chil-
dren and youth quickly and effectively can access a diverse range of services,
requiring individuals other than those solely at the highest level of risk receive atten-
tion (Doll & Cummings, 2008). By providing a range of services, schools are able
to help address many of the barriers to learning that children and youth may experi-
ence at some point throughout their school trajectory.
Evidence indicates that more comprehensive SMH, involving community-based
and school staff increasing the intensity and comprehensiveness of services,
improves children’s outcomes. It increases the likelihood of first appointment after
referral (Catron, Harris, & Weiss, 2005), subsequent retention in services (Atkins
et al., 2006), and more effective outreach to underserved communities (Anyon, Ong,
& Whitaker, 2014; Armbruster & Lichtman, 1999; Atkins et al., 2015), particularly
for those children presenting less observable “internalizing” disorders like depres-
sion and anxiety (Atkins et  al., 2006; Weist, Myers, Hastings, Ghuman, & Han,
1999). There is also an evidence base for research-supported prevention and inter-
vention programs in schools (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger,
2011; Elliott & Mihalic, 2004; Mihalic & Elliott, 2015). However, we must caution
there needs to be solid empirical literature showing that mental health services
delivered in schools are superior to those delivered in other settings.

Review of the Literature

Children’s Mental Health Concerns

Approximately 20% of children experience significant mental, emotional, or

behavioral symptoms that would qualify them for a psychiatric diagnosis at
both national and global levels (National Research Council & Institute of
Policies and Practices to Support School Mental Health 141

Medicine, 2009). Not only does the prevalence of those conditions and indica-
tors increase with age (Perou et al., 2013), behavioral disorders are the leading
causes for years lived with a disability for children and adolescents (Baranne &
Falissard, 2018; Mokdad et al., 2016).
Furthermore, 9–13% of young people will experience a serious emotional distur-
bance with substantial functional impairment, while 5–9% will experience a serious
emotional disturbance with extreme functional impairment (Friedman, Katz-Leavy,
& Sondheimer, 1996). Unfortunately, only 15–30% of the children who demon-
strate mental health concerns receive any type of help or support.
In order to address the gap in providing mental health services to children and
youth, the President’s New Freedom Commission on Mental Health (2003) called
for a transformation in the delivery of mental health services in this country. School
mental health services were suggested as one strategy in beginning to address many
of the unmet mental health needs of children and youth (Atkins, Hoagwood, Kutash,
& Seidman, 2010). As children currently receive more services through schools
than through any other system, school- and community-employed clinicians are
well positioned to provide mental health supports in schools (Larson, Spetz, Brindis,
& Chapman, 2017).

History of School Mental Health

The provision of school mental health services originates from four co-occurring
initiatives. First was the placement of nurses in schools as a public health approach
to detect and treat illness that evolved into the establishment of school-based health
centers across the United States. Second was the creation of child guidance clinics
that evolved into community mental health centers with the passage of the
Community Mental Health Act of 1963 (Public Law 88-164). Third was the passage
of Public Law 94-142  in 1975 and its reauthorization as the Individuals with
Disabilities Education Act (IDEA) in 1997 that resulted in the hiring of school-­
employed mental health professionals. The final initiative was the emergence of the
expanded school mental health movement which brought community-based mental
health professionals into schools to not only consult with teachers but provide direct
services to children and families.

School Nursing and School-Based Health Centers

Employing nurses in the school setting largely resulted from the overwhelming
number of eastern European immigrants moving to urban areas of the United States
in the early part of the twentieth century without access to basic healthcare. In the
early years, school nurses were effective at addressing health problems that inter-
fered with student’s learning. In fact, rates indicate that the percentage of students
who missed school due to illness substantially declined from 10,567 in 1902–1101 in
142 K. Eklund et al.

1903 (Hawkins, Hayes, & Corliss, 1994). However, the school nurses’ role was
limited to physical health promotion and prevention of illness and injury. At that
time, children’s emotional well-being in relation to mental disorders was not recog-
nized as affecting student’s academic and social functioning.
By the 1960s, school-based health centers (SBHCs) started to emerge from what
had previously been termed public health clinics and through the provision of ser-
vices delivered via school nurses. SBHCs began to flourish in the 1980s, growing
from 200 centers in 1990, to 1380 in 2001, and 1909 centers in 45 states by 2010
(U.S. Government Accountability Office, 2010). The SBHCs primarily employed
nurse practitioners and/or physician’s assistants. With the emerging recognition that
many of the visits to the SBHC were related to mental health concerns (Lear,
Gleicher, St. Germaine, & Porter, 1991), the SBHCs expanded their role to include
mental health counseling provided by a master’s level mental health clinician.

Child Guidance Clinics and Community Mental Health Centers

Child guidance clinics began as community-based centers that provided psycho-

logical therapeutic and assessment services for children with mental health con-
cerns and their families. Originating in Chicago in 1909, the clinics embraced an
interdisciplinary approach to service provision by employing social workers, psy-
chologists, and psychiatrists to best meet the needs of children with mental health
concerns (Witmer, 1940). The implementation of the Community Mental Health
Centers (sCMHC) Construction Act of 1963 (Pub. Law 88-164) initiated the deliv-
ery of mental health consultation and intervention services to children and adoles-
cents via CMHCs. The Walter P.  Carter Center in Baltimore, MD, served as a
seminal provider of school mental health services by establishing relationships with
local schools in the community. The Carter Center provided on-site consultation
with educators and discussed children receiving services at the centers’ four clinics.
These clinics established a foundation for the later development of expanded school
mental health (ESMH) programs.

 ublic Law 94-142 and the Individuals with Disabilities Education Act

P
(IDEA)

Originally passed as Public Law 94-142 in 1975, the IDEA mandates that schools
serve all students, including those with learning or emotional disabilities. From its
inception, IDEA facilitated the hiring of school mental health professionals, such as
psychologists and social workers, to provide mental health supports to students. For
example, schools hired school psychologists to conduct IDEA-required student
evaluations to determine the degree of disability and necessary educational accom-
modations (Flaherty & Osher, 2003). The shift of mental health professionals from
the community to employment as school staff members included providing services
to students with emotional and behavioral challenges (Flaherty & Osher, 2003).
Policies and Practices to Support School Mental Health 143

While early provisions of IDEA outlined service provisions to youth who met set
criteria, it failed to address an organized and systemic approach to providing school
mental health services. For example, students identified as emotionally disturbed
(ED) had especially poor outcomes compared to students under other eligibility
criteria, which may have been a primary driver in the development and expansion of
SMH programming (Osher & Hanley, 1996).
In 1997, IDEA amendments further expanded the educational opportunities and
support for students with ED.  These revisions provided a broader role for both
school- and community-employed practitioners to assist with delivery of services to
youth via individualized educational plans. These amendments represent the grow-
ing recognition of the need to provide prevention services to intervene when youth
display at-risk behaviors rather than postponing intervention until students’ symp-
toms require more intensive placement or supports. IDEA provided a solid founda-
tion for not only expanded service delivery but also expanded school mental health
(ESMH) programs.

Expanded School Mental Health Programs

In the 1990s, the concept of “expanded” SMH emerged with early successes defined
by the building of the child guidance clinic and CMHC models. This idea involved
augmenting pre-existing school-based programs and roles that had been primarily
focused on special education and crisis response services, toward a broad-based role
of mental health supports (Weist, 1997). CSMH services included individual, fam-
ily, and group psychotherapy, consultation with teachers and families, as well as
mental health promotion and education. Several cities, including Baltimore,
Maryland, demonstrated early success related to ESMH and brought about the
receipt of significant federal funding in 1995 to establish the Center for School
Mental Health (CSMH) at the University of Maryland as a national training and
technical assistance center. The CSMH was funded by the Maternal and Child
Health Bureau’s Mental Health of School-Age Children and Youth Initiative, which
also provided funding to the University of California at Los Angeles’ Center for
Mental Health in Schools, as well as five state infrastructure grants to Kentucky,
Maine, Minnesota, New Mexico, and South Carolina.
Since 1995, the field of ESMH has grown significantly because of several efforts,
including a national conference hosted by the CSMH, collaboration with the IDEA
Partnership, and federal investment by the US Department of Education Office of
Special Education Programs. These results have created a national Community of
Practice on Collaborative School Behavioral Health, as well as 12 practice groups
and 17 state groups, and a number of books and journals (Weist et al., 2013).
With this growth, the field came to represent more than just the original concep-
tualization of community-employed professionals providing mental health services
in schools. As the emphases on public health frameworks, prevention science, and
interdisciplinary collaboration emerged, the field of ESMH became known simply
as school mental health (SMH). The change in acronyms better represented a
144 K. Eklund et al.

school- and community-wide approach inclusive of a team of school and commu-

nity mental health professionals partnering with youth and families to provide a
public health continuum of promotion, prevention, early intervention, and treatment
services.

Public Health Models that Support a Multitiered Framework

Conversations regarding the provision of school mental health services have been
prominent in educational policy dialogues in recent years. Legislative acts continue
to address the need for a collaborative focus on mental health in schools, such as the
School Safety and Mental Health Services Improvement Act (2018), with an empha-
sis on preventative measures that deter the seemingly increasing incidence of crisis
events in educational settings (Birkland & Lawrence, 2009; Crepeau-Hobson,
Sievering, Armstrong, & Stonis, 2012). However, conversations among SMH prac-
titioners examining the importance of an integrated mental health model of service
delivery predate contemporary comments by legislators on service implementation
methods (Cowen & Lorion, 1976; Windle & Woy, 1983). These early discussions
referenced the ineffective nature of traditional reactive methodologies, which are
designed to provide services only when concerns arise, echoing a “wait-to-fail”
model of service delivery (Albers, Glover, & Kratochwill, 2007). Consequently,
students who do not manifest robust externalizing behaviors, for example, may not
be identified with missed opportunities for early intervention.
This gap in service has resulted in research to address the short- and long-term
deleterious effects (e.g., academic, social, emotional) that may emerge from unmet
mental health concerns among children and youth (Perou et al., 2013). The 1999
Surgeon General’s Report on Mental Health first highlighted the need for preventa-
tive measures to effectively decrease the negative impact mental health concerns
may have on youth (Office of the Surgeon General, 1999). Alternative models of
service delivery are warranted, including those that reinforce the importance of
­collaboration between parents, educators, and mental health practitioners in schools
and communities (Weist, Lowie, Flaherty, & Pruitt, 2001).
The public health approach incorporates an ecological framework in addressing
children’s mental health by acknowledging the influence of multiple systems on
children’s difficulties. This includes integrating systems of care for youth, including
but not limited to child welfare, education, health, juvenile justice, mental health,
and social services (Blau, Huang, & Mallery, 2010; Stiffman et al., 2010).
Although the public health model is holistic in nature, its goals do not oppose
those in public education. The public health model goals are designed to supple-
ment the current educational structure, build a bridge between school- and
community-­based services, promote partnerships between family systems and the
school, and organize formative research that reflects the climate of the school so
that the model can be tailored to students’ needs (Nastasi, 2004). This approach
is strength-based and culturally and environmentally sensitive and prescribes a
Policies and Practices to Support School Mental Health 145

continuum of mental health services ranging from activities that support and
maintain positive mental health to prevention and treatment efforts (Blau et al.,
2010; Office of the Surgeon General, 1999). Emerging research highlights a few
examples, such as multitiered system of supports, that illustrate the effectiveness
of the public health model in children’s mental health services (Miles, Espiritu,
Horen, Sebian, & Waetzig, 2010).
Similar in design, a multitiered system of support (MTSS) framework aims to
provide a continuum of care that combines the efforts of communities, families, and
schools. The MTSS framework, however, is defined by the application of high-­
quality interventions and positive behavioral supports at various levels or “tiers.”
Extant literature describes response to intervention (RtI) and positive behavioral
interventions and supports (PBIS) as MTSS approaches that target specific barriers
to learning while amplifying the integration of evidence-based interventions and
supports until the obstacles to learning are addressed (Batsche et  al., 2005;
Sulkowski, Wingfield, Jones, & Alan Coulter, 2011).
These systems underscore the role of prevention and wellness through the activa-
tion of multiple tiers (i.e., primary, secondary, tertiary) and progress monitoring.
Organizing services in this way allows stakeholders to engage in a systematic data-­
based decision-making process that promotes the implementation of programming
and services that meet the mutable needs of students.
However, despite the multitiered design of PBIS, a common concern in these
systems is the insufficient development of Tier 2 and 3 systems and practices, result-
ing in unaddressed behavioral and emotional needs for students with more complex
mental health concerns. In addition, PBIS Tier 1 systems, although showing success
in social climate and discipline, do not typically address broader community data
and mental health prevention (Barrett et al., 2017). Newer models, whose principles
parallel those within the MTSS framework, aim to address these gaps.
The Interconnected Systems Framework (ISF), for example, borrows from the
strengths of PBIS, implementation science, and RtI to create a healthy merger with
school mental health (Eber, Weist, & Barret, 2014). At its core, ISF capitalizes on
the use of (1) effective collaborations between community and mental health
­providers; (2) data-based decision-making; (3) formal evaluation and implementa-
tion of evidence-based practices (EBP); (4) early access via comprehensive screen-
ings; (5) rigorous progress monitoring for both fidelity and effectiveness; and (6)
ongoing training and coaching at system and practice levels. The benefits of this
model are influential in both economic and social schemes: children and adoles-
cents will gain earlier access to high-quality EBPs; professional roles will be
clearly defined, particularly among school- and community-employed mental
health staff; and cross-­training will endorse common language, communication,
and engagement among all parties: students, parents, community members, and
school staff.
146 K. Eklund et al.

School Mental Health Services in Multitiered Systems of Support

Within the public health framework of a multitiered system of support, such as the
Interconnected Systems Framework, a collaborating team of education and mental
health professionals provides a range of services across a continuum of assessment,
intervention, and consultation services (Andis et al., 2002). This includes anything
from accessing accommodations in the classroom (e.g., extended time, a quiet
workspace, break cards) to more targeted and intensive services, such as the provi-
sion of individual and small group counseling services.
Universal strategies, often referred to as Tier 1 supports, traditionally provide a
platform for promotion and prevention activities. They may also include social-­
emotional learning programs, welcoming and social support programs for new stu-
dents and their families, staff development on positive behavior supports, violence
prevention, coordination of a universal screening program, efficient referral mecha-
nisms, and/or the development of crisis prevention and response procedures (Elliott
& Tolan, 1998).
The second level of support often is referred to as targeted services, or Tier 2
interventions. This may include small group counseling for issues such as social
skills, anger control, or depressive symptoms, psychoeducation and consultation
with parents and families for issues related to bullying and peer conflicts, and/or
daily behavior report cards to teach and reinforce positive replacement behaviors
(National Association of School Psychologists, 2015).
The most intensive level of support services are offered at Tier 3 to selected indi-
viduals. Services commonly include psychological, psychoeducational, and/or
functional behavioral assessments, individual and family counseling, a coordinated
system of care, referrals to community service agencies, crisis intervention and
response, and/or home-based programs (Andis et al., 2002; Splett, Fowler, Weist,
McDaniel, & Dvorsky, 2013).
Across these tiers, SMH services include data-based decision-making, imple-
mentation support, and consultation and collaboration. Data-based decision-making
includes using data to determine what services are needed and are working for an
entire school (Tier 1), small group of students (Tier 2), and individual students (Tier
3). This includes formative and summative evaluation to monitor progress of
­prevention and intervention activities, as well as evaluate their overall efficacy and
implementation fidelity.
Implementing evidence-based programs and practices as intended is an essential,
yet often ignored, aspect of delivering an effective continuum of mental health ser-
vices in schools. Research indicates the need for access to implementation supports
such as coaching, training, and technical assistance to promote high-quality imple-
mentation of evidence-based programs in “real-world” settings (Fixsen, Naoom,
Blase, Friedman, & Wallace, 2005).
Thus, a conduit for providing effective mental health services in schools is cer-
tainly access to a strong infrastructure of implementation supports. Similarly, con-
sultation and collaboration with parents, youth, teachers, school administrators,
other mental health professionals, and key community stakeholders are critical to
Policies and Practices to Support School Mental Health 147

effective SMH services (Weist et al., 2005). Consultation and collaboration promote
engagement and service quality across the continuum of services.

Critical Issues in School Mental Health

Providing School Mental Health Services

A critical challenge in the field is effectively addressing the question of why mental
health services should be provided in schools. Often times, schools may view men-
tal health services as “add-ons” that are not central to the academic mission of
schools (School Mental Health Alliance, 2004), and traditional school reform efforts
focus on student learning, teaching strategies, and non-cognitive barriers to devel-
opment (Burke, 2002; Koller & Svoboda, 2002). While educators may be willing to
address barriers to student learning, they often do not recognize that social-­emotional
well-being is essential to academic success (Klem & Connell, 2004). National
efforts, such as the No Child Left Behind Act (NCLB, 2001), the President’s
Commission on Excellence in Special Education (2002), and the Every Student
Succeeds Act (ESSA, 2015), place priority on academic goals and may minimize
attention to the social-emotional or mental health needs of students. There are pro-
visions in national legislation that focus on health promotion and risk reduction
(e.g., safe and drug-free schools in the NCLB Act and reducing risk for serious
emotional disturbance in the New Freedom Commission on Mental Health report,
2003). However, policy reform still is needed at the local, state, and federal levels to
include a focus on how behavioral and academic outcomes can be highly correlated
(Nastasi, 2004).
Providing school mental health services within a public health model differs from
traditional service delivery models as the explicit focus is on a community or society
as opposed to any one individual. Theoretically, this perspective is well aligned with
ecological systems perspectives, as proposed by Bronfenbrenner (1979), in which
individuals and systems are mutually influential. Within an e­ cological framework,
each student is at the center of a series of concentric circles, which represent increas-
ingly expanding, mutually influential systems. For lasting impact to occur, change
must occur at a broader level than just within an individual.
If the focus of school mental health services is to provide prevention, interven-
tion, and response services to children and youth, the educational context by which
services are delivered must also be a core consideration. Namely, teachers spend
countless hours with students each day and often become intimately familiar with
children’s behavior, routines, and abilities. As many disorders often arise for the
first time in adolescents or young adults, early recognition and treatment increases
the chances of better long-term outcomes. However, identification and help-seeking
behaviors can only occur if young people and their support systems (e.g., families,
teachers, friends) know about early changes produced by mental disorders and how
to access help.
148 K. Eklund et al.

Universal Screening

Universal screening is a proactive approach of using brief and efficient measures to

identify students at risk for future difficulties (Eklund & Dowdy, 2014; Jenkins,
Hudson, & Johnson, 2007). A primary purpose of universal screening pertains to the
identification of individual students who have not responded to universal prevention
efforts and are likely in need of targeted or intensive supports (Eklund & Tanner,
2014; Levitt, Saka, Romanelli, & Hoagwood, 2007).
Research suggests schools provide an ideal setting for identifying at-risk stu-
dents due to the large number of youth in school and the ability to provide follow-up
care within schools (Glover & Albers, 2007; Levitt et al., 2007). For example, pro-
viding behavioral supports in schools allows for the modification of environmental
contingencies toward the disruption of problem behavior development. On the basis
of research that shows positive outcomes may be achieved through early identifica-
tion and intervention, recent educational policy and legislation place an increasing
focus on data-based decision-making and universal assessment in schools (IDEA,
2004; (Lane, Robertson Kalberg, Lambert, Crnobori, & Bruhn, 2010; Reschly,
2008). Indeed, children with childhood behavioral difficulties who are identified
early and receive intervention are likely to make significant gains in positive emo-
tional and behavioral functioning (Brophy-Herb, Lee, Nievar, & Stollak, 2007;
Eklund & Dowdy, 2014).
Despite this research and screening’s status as an essential component of MTSS
service delivery, many schools have not begun to adopt universal screening (Bruhn,
Woods-Groves, & Huddle, 2014; Romer & McIntosh, 2017). Although reasons for
such limited implementation of universal screening abound (Chafouleas, Kilgus, &
Wallach, 2010), more understanding of how screening is implemented and whether
or not they achieve intended outcomes is needed. While initial research demon-
strates that screening identifies a group of at-risk students previously unknown to
school staff and/or not receiving services (Eklund & Dowdy, 2014), additional
research on treatment utility is needed to demonstrate students are receiving
improved access to care and ultimately, positive response to early intervention
services.

Parent and Community Partnerships

One of the greatest strengths of school mental health models is the emphasis on
building an alliance between those who have a shared responsibility for the child,
particularly models that invite and encourage parent, school, and community
involvement. However, efforts to develop links between stakeholders have illumi-
nated the inadequacy of services and holes in delivery, which subsequently produce
a lack of enthusiasm for participation in dialogues on SMH. One qualitative study
(Ouellette, Briscoe, & Tyson, 2004) reported that while parents would like to par-
ticipate in community events and services, the absence of public and private trans-
portation made following through with these commitments difficult. Furthermore,
Policies and Practices to Support School Mental Health 149

parents reported that too few organizations offer the services they need to build
partnerships with the community. The limited availability of after-school program-
ming and tutor services may contribute to this resistance.
Service provider’s concerns echoed those of parents, citing the importance of
transportation services. An increase in public transportation availability may help
address these concerns.
Communication was another noted weakness, as the discourse used by human
service workers may fail to convey useful information and strategies for interven-
tions adequately (Ouellette et al., 2004). Faith-based organizations contributed to
the conversation as well, expressing concerns for safe home environments and
resources for crisis situations (e.g., clothing, employment, food, shelter).
Ecological models designed to facilitate conversation between parents, teachers,
and community members are gaining recognition. The Positive Attitudes for
Learning in School (PALS) model, for example, encourages clinicians and commu-
nity members to work collaboratively on school-based teams to address concerns
unique to the community, in addition to issues arising in academic achievement,
behavior management, and social support for parents, teachers, and children
(Frazier, Abdul-Adil, Atkins, Gathright, & Jackson, 2007).
Variations in geographic landscapes may also inform the development of mental
health services. The limited availability of services and their proximity to individu-
als in need, for example, may act as barriers to those in rural communities.
Reinforced by restrictions in transportation and the less than desirable fiscal obli-
gations, families residing in these small rural communities may feel less inclined
to pursue services, even if needs are demonstrated (Girio-Herrera, Owens, &
Langberg, 2013).
Alternatively, researchers examining the bridge between mental health and edu-
cation in urban communities identified socioeconomic status and disconnects
between community resources and school supports as major challenges in the
implementation of effective services (Cappella, Jackson, Bilal, Hamre, & Soulé,
2011).
Mobilization of SMH services requires a network of practitioners and research-
ers who are willing to share jurisdiction over the development, implementation, and
evaluation of interventions. Programs like Bridging Education and Mental Health in
Urban Schools (BRIDGE) are an example of such a partnership (Cappella, Frazier,
Atkins, Schoenwald, & Glisson, 2008). This particular program capitalized on
teacher consultation to increase pro-social interactions between students with
behavioral difficulties and their classmates. It was designed to connect mental
health practitioners with educators so that students receive the most effective form
of service delivery possible. Individualized support and teacher observations were
at the core of this framework.
School mental health practitioners are in a unique position to connect parents
with community services. School psychologists and school counselors, for exam-
ple, may lead the task of identifying culturally and environmentally sensitive
resources that bridge the two contexts for the child (Nastasi, 2004; Nastasi, Varjas,
& Moore, 2010). Additionally, SMH providers may find it appropriate to implement
150 K. Eklund et al.

training programs for parents, teachers, and community members that prioritize
learning goals and address concerns voiced by all parties while empowering each
group to contribute to the implementation and monitoring of interventions (Cappella
et al., 2008; Nastasi, 2004).

Evidence-Based, Culturally Sensitive Interventions

Building partnerships across settings is critical to balancing evidence-based ser-

vices with cultural sensitivity. While research has demonstrated positive outcomes
when evidence-based interventions are tailored to meet culturally diverse needs
(Harachi, Catalano, & Hawkins, 1997; Wang-Schweig, Kviz, Altfeld, Miller, &
Miller, 2014), other findings indicate the outcomes can be weakened or reduced
when unexpected or ill-advised changes occur (Kumpfer, Alvarado, Tait, & Turner,
2002; Milburn & Lightfoot, 2016).
Evidence-based interventions in SMH that allow for cultural adaptation through
partnerships with local communities during the dissemination, planning, and imple-
mentation stages have shown positive outcomes and greater buy-in (Ngo et  al.,
2008). For example, exposure to violence is a significant national concern and par-
ticularly prevalent among minority and ethnically diverse youth (Carothers, Arizaga,
Carter, Taylor, & Grant, 2016; Weist & Cooley-Quille, 2001). In recognition of this
concern, violence prevention and trauma response have been prioritized by national
initiatives and federal funding associated with President Obama’s Now is the Time
Initiative (The White House, 2013, January 16).
One evidence-based intervention focused on treating youth exposed to violence
from a culturally sensitive framework is Cognitive Behavioral Intervention for
Trauma in Schools (CBITS; Jaycox et  al., 2007). CBITS prioritizes partnerships
with local schools and communities, including stakeholders from parents, ­clinicians,
community organizations, and faith-based groups throughout all stages of the pro-
gram. It was developed for and with diverse children and families in mind and has
shown positive outcomes in randomized control studies and dissemination evalua-
tions with Mexican and Central American youth, urban African American students,
Native American children, and children in rural communities (Kataoka et al., 2003).
CBITS includes formal and informal feedback mechanisms, as well as multi-­
stakeholder planning committees, during local program development and imple-
mentation planning to ensure the consultation, outreach, training/supervision,
evaluation, and service delivery models meet the cultural context while keeping the
core cognitive behavioral therapy components intact (Ngo et  al., 2008). Tailoring
implementation to be culturally sensitive and respectful of the local community is
supported by collaboration with cultural liaisons, who have both knowledge of the
cultural context and clinical intervention (Ngo et  al., 2008). SMH practitioners
implementing CBITS or any other evidence-based practice should (1) develop part-
nerships across stakeholder groups; (2) familiarize themselves with the local cultural
context and any individual issues that may arise; (3) stay vigilant in their attention to
Policies and Practices to Support School Mental Health 151

the unique needs of their students; and (4) work with others who have cultural
knowledge and clinical expertise for collaboration, training, and supervision.
From a research perspective, more efforts are needed to invite open dialogues
and use the cultural experiences of youth to inform the development and delivery of
culturally sensitive and specific interventions. Dialogue among a wide range of cul-
turally diverse stakeholders in SMH is needed to improve the service delivery, con-
sultation, and evaluation models currently employed in the field. Given issues of
disparity and collaboration with parents and families, more dialogues around meth-
ods to break through these barriers are needed. Additionally, in developing cultur-
ally specific interventions and/or tailoring existing evidence-based interventions to
be more culturally sensitive, ethnographic research is needed to better understand
the cultural experience of youth (Anyon et al., 2014).
Similar to CBITS, other interventions have been developed because of ethno-
graphic research, which aimed to expand the literature on students’ cultural experi-
ences and in what ways these experiences affect behavioral and academic
functioning. In one particular study, four culture-specific themes emerged—adult-­
sanctioned behaviors and practices, adolescents’ perspectives about the present,
adolescents’ aspirations for the future, and societal factors (Varjas, Nastasi, Moore,
& Jayasena, 2005). The authors argue these factors should guide the development
and implementation of culture-specific interventions and conclude that these factors
will intersect in different domains of the ecological framework, including school,
family, peer, and community contexts.

Mental Health Literacy

Mental health literacy has been recognized as one strategy in facilitating early inter-
vention for mental health concerns. In this approach, young people and their support
systems are taught how to provide appropriate mental health first aid and how to
support help-seeking behaviors upon first recognition of a mental health concerns.
These interventions can include community campaigns aimed at both youth and
adults; school-based interventions that teach help-seeking behavior, mental health
literacy, or resilience; and programs training individuals on how to intervene in a
mental health encounter or crisis (Kelly, Jorm, & Wright, 2007).
While there is no standardization of mental health education in schools, initial
research suggests mental health literacy can be improved with planned interven-
tions. Key components may include campaigns tailored to the specific needs and
preferences of the intended community that will appeal to different groups (e.g.,
youth, teachers, parents); ensuring the availability of trusted and established help-­
seeking pathways among youth; and providing education and accurate information
on what to expect when seeking help and obtaining professional support (Kelly
et al., 2007; Rickwood, Deane, Wilson, & Ciarrochi, 2005). Gatekeepers, such as
teachers, parents, and other important adults, play an important role in offering help
to those who need it most.
152 K. Eklund et al.

Financing for School Mental Health Services

It is estimated that childhood emotional and behavioral disorders cost the public
$247 billion annually (National Research Council & Institute of Medicine, 2009).
Other estimates suggest that in 2012, $13.9 billion was spent for the treatment of
mental disorders in children, which was the highest of any children’s healthcare
expenditures exceeding asthma, trauma-related disorders, acute bronchitis, and
infectious disease (Soni, 2015, April). As an estimated 20% of children have a diag-
nosable mental, emotional, or behavioral disorder, treatment remains one of the
most prevalent and costly of all chronic illness in youth.
Historically, as many as one in seven adolescents have been without health insur-
ance and therefore have been unable to receive third-party reimbursable mental
health services in the private sector (Crespi & Howe, 2002). Reports by the US
Department of Health and Human Services indicated that a disproportionate num-
ber of children with mental health problems in the United States do not receive
mental health services due to a lack of insurance (Maternal and Child Health Bureau,
2010, 2018, October). An estimated 2.8 million children are eligible for Medicaid
or the Children’s Health Insurance Program but are not enrolled currently in either
(Kenney, Jennifer, Pan, Lynch, & Buettgens, 2016, May). Sole reliance on providers
outside the school environment has placed considerable burden on families without
such insurance.
It is projected that implementation of the Patient Protection and Affordable Care
Act (PPACA), Public Law 111-148 (June 2010), will have a significant impact on
the way that healthcare services are delivered, as many youth who were previously
uninsured or underinsured will gain access to services. With the expansion of health
insurance coverage, many of the most vulnerable populations, such as young chil-
dren, youth aging out of foster care, and children living in poverty, will have
increased access to preventive services, as well as mental health treatment (English,
2010). In addition, the authorization of funding for home visitation programs to
promote improvements in areas such as child development, parenting, and school
readiness will provide opportunities for families who are in the greatest need. The
provision of the PPACA to authorize funding to establish and expand school-based
health centers has the potential to significantly increase and enhance mental health
education, prevention, and early intervention efforts within schools.
While school mental health programs have grown over the past two decades, iden-
tifying and securing sustainable funding sources continues to be a concern. Recent
studies suggest 70% of school districts reported an increase in need for services but
saw funding remain stagnant or decreased (Foster & Connor, 2005). As education
systems provide limited funding for SMH services, schools traditionally look to
grants or other fee for service programs (e.g., Medicaid). However, sole reliance on
these mechanisms may not provide sufficient revenue and can be highly bureaucratic
and difficult to obtain (Center for Health and Health Care in Schools, 2003; Evans
et  al., 2013; Freeman, 2011). In addition, fee-for-service approaches have created
concerns about overdiagnosis, limited time for prevention activities, and an inability
Policies and Practices to Support School Mental Health 153

to serve students without Medicaid (Lever, Stephan, Axelrod, & Weist, 2004; Mills
et al., 2006). As a result, schools are called upon to explore collaborative and unique
funding arrangements to sustain SMH services and programs.
Sustainable funding is needed to support SMH services. Although there are some
potential funding sources that are underutilized (e.g., from Early and Periodic
Screening, Diagnosis, and Treatment, Safe and Drug-Free Schools, Title I), access
to such funds and continued sustainability continue to be a concern for many
schools. In order to address these barriers, many programs and services have blended
or “braided” funding, by deriving funding from multiple sources, including grants,
contracts, and private agencies (Lever et  al., 2004). Fee-for-service revenue has
served as a primary source of funding for many mental health services provided in
schools. Third-party payers (e.g., Medicaid, State Children’s Health Insurance
Programs, private insurance) provide reimbursement for mental health services pro-
vided to children. However, reimbursement is typically limited to those students
who have a clinical diagnosis from the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; APA, 2013) for traditional mental health services (e.g., indi-
vidual and group counseling, family counseling) versus broader SMH services (e.g.,
teacher consultation, parent consultation, prevention services, case management).
Sole or primary reliance on fee-for-service models provides a number of barriers
to school districts and agencies, including significant paperwork, administrative
duties, and managerial responsibilities. Although larger school districts and ­agencies
may have mechanisms in place to be able to hire and train staff to manage Medicaid
billing and services, rural communities and smaller agencies may be at a disadvan-
tage. Many of these same barriers are placed upon clinicians, who face substantial
paperwork that can become burdensome when the primary focus should be on pro-
viding direct clinical services and preventative care.

Implications for Behavioral Health

The SMH field has grown significantly since its beginning days in child guidance
clinics and primary focus on expanded models inclusive only of community provid-
ers. The opportunity to provide mental and behavioral health services within the
school setting has been an ongoing goal for many mental health professionals (e.g.,
social workers, psychologists, counselors) who desire to improve access to care by
providing evidence-based interventions to a greater number of children and
families.
Service delivery models that emphasize teaming and collaboration across school,
community, and family stakeholders within the system of a multitiered public health
continuum of promotion, prevention, early intervention, and treatment are increas-
ingly showing positive outcomes for children in need. This includes the aforemen-
tioned Interconnected Systems Framework that combines implementation science,
school-based response to intervention models, and PBIS to streamline services for
children, families, and educators. This framework provides concrete examples of
154 K. Eklund et al.

interdisciplinary collaboration among school- and community-based mental health

providers as being essential to delivering high-quality evidence-based mental and
behavioral health services in schools.
Furthermore, schools continue to utilize public health models that emphasize
prevention through screening and early intervention practices that can eliminate or
reduce the severity of behavioral and emotional symptoms when combined with
early intervention. However, more work is needed, and critical issues remain.
The field must continue to emphasize the critical role of mental health in the
academic mission of schools and should consider how to intertwine behavioral and
academic standards for student success. For example, Illinois Learning Standards
now include three social/emotional development standards that students should
know and be able to do to varying degrees in grades K-12 (Illinois State Board of
Education, 2018). This includes the development of self-awareness and self-­
management skills, as well as the use of social-awareness and interpersonal skills to
establish and maintain positive relationships. These types of educational policies
can be instrumental in continuing to advance mental health promotion in the school
setting.

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School Mental Health
DOI 10.1007/s12310-015-9147-y
ORIGINAL PAPER
Teacher Perspectives on Their Role and the Challenges
of Inter-professional Collaboration in Mental Health Promotion
Stine Ekornes1,2
 Springer Science+Business Media New York 2015
Abstract This paper explores the teacher role in inter-
professional collaboration in mental health promotion and
identifies teachers’ perceived challenges to collaborative
work in this field. Data are derived from a mixed method
design, with three focus group interviews (n = 15) and
survey research (n = 771) conducted with Norwegian
K-12 teachers. The findings show that teachers perceive
their gatekeeping role to be prominent, in that they are
front line professionals to identify students’ mental health
problems and, if necessary, make referrals to mental health
services. However, teachers realize that mental health
promotion encompasses more than the assessment of dif-
ficulties, and they call for more support and information
through inter-professional collaboration in order to extend
their engagement in student mental health beyond the
gatekeeping role. Based on this, six main challenges to
inter-professional collaboration are identified. These are
the challenges of: (1) communication and confidentiality,
(2) time constraints, (3) contextual presence and under-
standing, (4) cross-systems contact, (5) school leadership
and (6) teacher competence in mental health.
Keywords Inter-professional collaboration
Mental
health promotion
School mental health
Mixed methods
design
& Stine Ekornes
stinee@hivolda.no
1 The Norwegian Context
Department of Teacher Education and School Research,
Faculty of Educational Sciences, University of Oslo, Moltke
Moes vei 35, Blindern, P.O. Box 1099, 0851 Oslo, Norway
2
Faculty of Humanities and Education, Volda University
College, P.O. Box 500, 6100 Volda, Norway
Introduction
Existing research indicates that most teachers clearly rec-
ognize that mental health promotion is a part of their
professional role and responsibility (Graham, Phelps,
Maddison, & Fitzgerald, 2011; Roeser & Midgley, 1997).
However, teachers are bound by limited training, time and
resources, which makes it very difficult to address the
challenges of mental health promotion alone (Hornby &
Atkinson, 2003). Therefore, inter-professional collabora-
tion is of critical importance to meet the mental health
needs of students (Berzin et al., 2011; Burke & Paternite,
2007; Franklin, Kim, Ryan, Kelly, & Montgomery, 2012;
Viggiani, Reid, & Bailey-Dempsey, 2002). Furthermore, as
school is the most common point of entry for accessing
mental health services and the only arena capable of
reaching all students on a daily basis, the role of teachers
and schools becomes essential in collaborative work on
mental health promotion (Langley, Nadeem, Kataoka,
Stein, & Jaycox, 2010; Lynn, McKay, & Atkins, 2003;
Ringeisen, Henderson, & Hoagwood, 2003; Stephan,
Mulloy, & Brey, 2011; Stormont, Reinke, & Herman,
2011). This paper aims to investigate teachers’ perceptions
of their role in inter-professional collaboration on mental
health promotion, and what they perceive to be their main
challenges to such collaborative work. Data are provided
from Norwegian K-12 teachers through a sequential mixed
method design, which uses three focus groups followed by
survey research.
In Norway, the mental health service system in child and
adolescent mental health consists of health care services
such as school nurse and medical doctors, municipal
123

mental health services such as Educational Psychology
Services (EPS) and specialized mental health services such
as Child and Adolescent Mental Health Services
(CAMHS), located at region hospitals (Norwegian Minstry
of Health & Care Services, 2005). In addition, the child
welfare service is included as part of the mental health
service system. The majority of mental health services are
located outside of school, except from school nurses and
EPS, which are normally present at school on regular, if not
daily, basis. According to numbers obtained from the
Norwegian Ministry of Education and Research (2009),
2 % of K-12 schools have EPS located in school as part of
the school organization, 23 % have EPS present at school
on regular basis, 52 % have a regular EPS contact, but no
regular in-school service, and 21 % of the schools lack
even a regular contact. School nurses represent ap-
proximately 50 % of all full time equivalents in school
health services, whereas medical doctors represent 5 %,
and school psychologists only 1 % (Kjelvik, 2007; Statis-
tics Norway, 2013). In reality, this means that an average
lower secondary school has school nurse present only
2–3 h per week, and very few schools have access to
campus school psychologists. However, school counsel-
lors/social teachers are present at most schools on a daily
basis, but these are teachers, not mental health profes-
sionals, and only 50 % have additional education in psy-
chology, sociology or other subjects relevant to mental
health (Norwegian Ministry of Education & Research,
2009).
Inter-professional Collaboration at Different Levels
of Intervention
Mental health promotion encompasses both the promotion
of good mental health in general and the prevention of
mental problems and illness (Greacen et al., 2012). Inter-
professional collaborative work to promote student mental
health would, therefore, include a wide range of interven-
tion strategies at universal, targeted/selected and indicated
levels (Askell-Williams & Lawson, 2013; Franklin et al.,
2012; Levitt, Saka, Hunter Romanelli, & Hoagwood,
2007). Given this conceptualization of mental health,
Wells, Barlow, and Stewart-Brown (2003) categorize uni-
versal intervention primarily as the promotion of mental
health, and targeted/selected and indicated intervention
primarily as the prevention of mental illness.
The ultimate goal of universal intervention strategies is
to promote positive mental health for all students, for ex-
ample, by providing anti-bullying programs and by making
efforts to enhance the psychosocial environment. This in-
cludes class-based interventions as well as interventions to
change the school ethos and raise the collective awareness
on mental health issues amongst students and teachers.
123
School Mental Health
Reviews of universal intervention programs clearly show
their effectiveness (Durlak, Allison, Taylor, Weissberg, &
Kriston, 2011; Wells et al., 2003), but it is of great im-
portance that teacher training in program implementation is
followed up by support from school administration and
mental health professionals (Andersson, Bungum, Kas-
persen, Bjørngaard, & Buland, 2010; Langley et al., 2010).
Targeted/selected intervention strategies are directed at
student cohorts with known risk factors that make them
vulnerable to the development of mental health difficulties.
Collaboration at this level primarily involves mental health
professionals offering assessments of problems and sug-
gestions for different types of school-based interventions.
Mental health professionals can also be involved in the
consultation and training of teachers, such as in their work
with classroom management techniques and the implemen-
tation of behaviour plans. As Reinke, Stormont, Herman,
Puri, and Goel (2011) pointed out, it is important that mental
health professionals keep teachers well informed about the
existence of different evidence-based interventions and,
thus, enable them to make informed decisions in the class-
room. As the students’ mental health problems become more
severe and persistent, indicated intervention strategies are
needed. This level of intervention involves specialist ser-
vices such and intensive interventions; in the most severe
cases, these are given as residential psychiatric treatments.
Even though the teachers are not directly involved in therapy
sessions, they play an important role in helping the students
to reintegrate into school after treatment. There is also evi-
dence that psychological well-being and academic
achievement are strongly interrelated, and by helping stu-
dents to improve their academics, teachers can complement
and strengthen the effects of psychotherapy (Baskin, Slaten,
Sorenson, & Glover-Russel, 2010). Thus, based on the un-
derstanding of mental health promotion as involving inter-
ventions at the universal, targeted/selected and indicated
levels, the teacher role in inter-professional collaboration has
many aspects which correspond to the levels of intervention.
However, this paper gives special attention to teachers’ role
in the referral process and their gatekeeping function in
identifying and assessing the students’ need for help, in
agreement with Ball, Anderson-Butcher, Mellin, and Green
(2010) who point out that teachers have a critical role in inter-
professional collaboration as key professionals in the iden-
tification and referral process.
The Gatekeeper Role in Collaborative Work
A wide range of research shows that teachers serve an im-
portant role as gateway providers/gatekeepers, in that they
are front line professionals who identify students’ mental
health needs and, if necessary, make referrals to mental
health services (Nadeem et al., 2011; Stiffman, Pescosolido,
School Mental Health
& Cabassa, 2004; Williams, Horvath, Wei, Van Dorn, &
Jonson-Reid, 2007). This role is based on teachers’ unique
position, in which they can discover problems at an early
stage, due to their day-to day contact with students (Langley
et al., 2010; Ringeisen et al., 2003; Stephan et al., 2011;
Stormont et al., 2011). Thus, teachers are active observers of
students’ mental health on a daily basis.
As Weare and Markham (2005) argue, mental health
problems are widespread, and if the focus of inter-profes-
sional intervention is reduced only to the targeted/selected
levels, many students with minor mental health problems
or no known risk factors will be ignored. Therefore, it is
necessary for those in the gatekeeper role to possess good
knowledge about warning signs, risk factors and indicators
of mental health difficulties, but many teachers face chal-
lenges in filling this role, due to their inadequate educa-
tional training in mental health promotion. This makes
teachers feel professionally unprepared, as they do not
possess the necessary skills to make informed decisions
about what is age-appropriate behaviour, what are normal
variations in mental health and what is abnormal and needs
intervention and help (Atkinson & Hornby, 2002; Kidger,
Gunnell, Biddle, Campbell, & Donovan, 2010). According
to the survey data referred to by Weist and Paternite
(2006), 70 % of teachers expressed an interest in additional
training in this field. Survey data collected from a Nor-
wegian context has found that teachers receive minimal
knowledge about mental health through their professional
training (Ekornes, Hauge, & Lund, 2012). Similar findings
from an international context are reported in Koller,
Osterlind, Paris, and Weston (2004).
A possible consequence of poor preparation and training
is that teachers become an underutilized resource in inter-
professional collaboration on mental health as long as they
feel ill-equipped to engage in this work (Powers, Bower,
Webber, & Martinson, 2010). Following this, there is a risk
of so-called ‘‘drain’’, in which collaboration exists pri-
marily in name alone and is dominated by rhetorical
communication and formal protocols, as opposed to shared
decision-making and the mutual exchange of information
(Feinstein, Fielding, Udvari-Solner, & Joshi, 2009). Based
on focus group data collected from inter-professional team
meetings, Ødegård (2005) also raises the question of
whether teachers are seen as true collaborative partners to
be systematically included in treatment programs, or
whether they are considered to be just important informa-
tion providers for other services.
Identifying Possible Challenges to Collaboration
Through a Contextual Organizational Perspective
A significant number of research papers identify difficulties
in inter-professional collaborative work due to
organizational and contextual issues, such as the lack of time
and resources, vaguely defined roles and problems with
communication between the professions due to confiden-
tiality issues and different professional vocabularies (Ball
et al., 2010; Choi & Pak, 2007; Hall, 2005; Holmesland,
Seikkula, Nilsen, Hopfenbeck, & Arnkil, 2010; Lynn et al.,
2003; Ødegård, 2005). Teachers are often unfamiliar with
the psychiatric classifications, and mental health termi-
nology that are used by mental health professionals (Gott,
2003; Kidger et al., 2010). These profession-based differ-
ences, combined with different practices regarding confi-
dentiality, could cause problems with information exchange
and communication (Feinstein et al., 2009). From a teacher
perspective, inter-professional communication is further
complicated due to other services’ lack of understanding of
and knowledge about the school context (Burke & Paternite,
2007; Rowling, 2009). Like Rothi, Leavey, and Best (2008)
pointed out, teachers unanimously state their need for ‘hands
on’ training provided by mental health experts, something
that requires contextual understanding in order to give fea-
sible and relevant advice.
Finally, time constraints are an important contextual
factor (Powers et al., 2010). Limited time resources in
mental health services can lead to slow case processing,
which leaves teachers and students to their own devices,
while they wait for help and support. In school, time
constraints lead to frustration and feelings of insufficiency
due to the perceived gap between individual students’ need
for support and teachers’ opportunity to provide it within
their busy day-to-day routines (Poulou & Norwich, 2002).
Additionally, teachers perceive that the logistical demands
of collaborative work in mental health often come at the
expense of instructional tasks (Jordfald, Nyen, & Seip,
2009). Altogether, many challenges to inter-professional
collaboration are rooted in and affected by such contextual
factors as time resources, service access and other services’
presence and involvement in classroom settings, and it is,
therefore, important to recognize and identify the impact of
these factors.
Aims and Research Questions
Various researches have explored the roles of school
nurses, school social workers and school clinicians in inter-
professional collaboration on mental health (Berzin et al.,
2011; DeSocio & Hootman, 2004; Langley et al., 2010).
This paper takes the perspective of teachers, their per-
ceived role and their perceptions of what they consider to
be the challenges of collaborative work. Based on this, two
main research questions were developed:
1. How do teachers perceive their role in inter-profes-
sional collaboration in mental health promotion?
123

2. What do teachers perceive to be the main challenges to
inter-professional collaboration in mental health
promotion?
The first question addresses the teacher role and what
teachers perceive to be their main tasks and responsibilities
in inter-professional collaboration for mental health pro-
motion. The second question addresses possible barriers to
inter-professional collaboration as seen through a contex-
tual organizational perspective, which focuses on how
service access, time resources, perceived professional
competencies, practices of confidentiality and school
leadership issues affect collaborative efforts.
Methods
The present study adopts a sequential mixed method design
(Creswell, 2012), utilizing focus group interviews followed
by survey research. The reason for using a mixed method
approach is to provide a more holistic picture than
qualitative or quantitative approaches can give separately
or individually. Additionally, the two data sources provide
complementary and divergent information about related
aspects of the same phenomenon (Tashakkori & Teddlie,
2008). In order to achieve interpretative rigour of the two
strands of the study, the data are constantly compared and
contrasted with one another, as well as with existing the-
ories and the present state of knowledge in the field. Ac-
cording to Teddlie and Tashakkori (2009), design quality is
comprised of four aspects: design suitability, design fi-
delity, internal consistency and analytic adequacy. In this
paper, brief narrative descriptions of the construction of the
focus group protocol and survey questionnaire are given in
order to make the design quality of the study more trans-
parent and reliable.
Sampling and Sample Characteristics
Three different focus group interviews with a total of fifteen
teachers from grades 8–13 were conducted in December
Table 1 Focus group sample characteristics
Groups: School type Gender Years of age
School size (range)
M = 46.2
Group 1: Lower secondary school 1 Male 38–59
[400 students 4 Females
Group 2: Lower secondary school 2 Males 34–50
\300 students 2 Females
Group 3: Upper secondary school 1 Male 34–66
[500 students 5 Females
123
School Mental Health
2011 through January 2012 in three different municipalities
in the western part of Norway. The schools were located in
both urban and rural areas. Eleven women and four men in
total volunteered to participate and gave their informed
consent after having received written and oral information
about the study at a meeting for teacher practice supervisors.
The sample characteristics are displayed in Table 1.
Group members were from the same school, which
made the groups homogenous in their organizational con-
text, and the group members were familiar to one another,
which was intended to inspire reflection on everyday ex-
periences and more open sharing of attitudes and opinions
(Kitzinger & Barbour, 1999; Williams et al., 2007).
The survey data were collected from April to June 2012,
in three different counties in the western part of Norway. In
total, 51 state schools were selected by simple random
stratified sampling, and the total number of respondents
were n = 1575. The response rate was 49 % (n = 771).
All participants received e-mail information about the
study and were granted confidentiality protection. Table 2
gives an overview of the independent (background) vari-
ables and the number of respondents in each category.
Measures
The focus group protocol and its interview categories were
mainly derived from a review of existing research and
literature on school mental health. Based on this, the pro-
tocol contained a total of eight themes; (1) conceptual
understanding of mental health, (2) perceived competence
in mental health, (3) tension between policy and profes-
sion, (4) school organization, (5) inter-professional col-
laboration, (6) collaboration with parents, (7) school
culture and (8) future perspectives. In this paper, the theme
of inter-professional collaboration was selected for further
analysis. Even though the interview guide was semi-
structured, the theme of inter-professional collaboration
contained four explicit questions:
1. When you suspect that one of your students is having
mental health problems and not coping well, is it easy
Educational Additional education Years of experience
background in special education (range) M = 19.2
4 BA level 3 No 11–31
1 MA level 2 Yes
2 BA level 4 No 8–20
2 MA level 0 Yes
3 BA level 6 No 7–38
3 MA level 0 Yes
School Mental Health

Table 2 Survey sample Independent variables Categories n (%)

characteristics
Gender Males 276 (35.8 %)
Females 486 (63.0 %)
Years of experience 0–5 116 (15.1 %)
6–10 146 (18.9 %)
11–15 144 (18.7 %)
16–20 97 (12.6 %)
21–25 96 (12.5 %)
26–30 70 (9.1 %)
[30 99 (12.8 %)
School size Small \ 100 students 61 (7.9 %)
Medium 100–300 students 268 (34.8 %)
Large [ 300 students 436 (56.5 %)
School type Primary school 172 (22.5 %)
Lower secondary school 274 (35.5 %)
Upper secondary school 319 (41.1 %)
Participation in mental health training programs Yes 193 (25.2 %)
No 493 (64.3 %)
Don’t know 80 (10.4 %)
Additional education in psychology and/or special education Yes 200 (25.9 %)
No 553 (71.7 %)
Educational background Bachelor level (BA) 614 (79.7 %)
Master level (MA) 113 (14.6 %)
Vocational education 17 (2.2 %)
No teacher education 21 (2.7 %)
Note. For analytical purposes, seven subgroups of educational background in the original questionnaire
were collapsed into four main groups based on educational level

or hard to provide early help and interventions? Can
you suggest some possible reasons for why it is so?
2. Is the teacher role clearly or vaguely defined regarding
your professional responsibility towards students with
mental health difficulties?
3. Do you consider yourself as central in following up
with students also after referrals are made and other
professionals are involved?
4. How do you perceive your ability to help students
within the classroom context?
Three out of four questions were closed-ended, indicating
a highly structured approach to focus group interviewing.
This offers the researcher a better opportunity to follow the
same order of topics and questions from group to group and
provides basic control over the content and direction of
discussion (Morgan, 1997). Given the sequential design, in
which focus group data guided the construction of survey
questions and items, a highly structured approach was re-
garded best suited to obtain design quality.
The survey measured different aspects of the teachers’
role and responsibility in mental health promotion and the
questionnaire contained a total of 10 Likert scale questions
(84 items), three open response categories and 10 back-
ground variables. Out of these, eight individual items, one
question measuring the quality of collaboration and one
open response category measuring teachers’ perceived
barriers to collaboration were selected for analysis in the
present paper. These individual items do not amount to
reliability-tested indexes or scales, indented to measure
defined constructs, but provide descriptive data on different
thematic aspects of collaboration. The eight items are
presented in Table 3.
The survey item construction, with regard to inter-pro-
fessional collaboration, was inspired by recent research
from an effect evaluation of mental health training pro-
grammes in Norway (Kaspersen et al., 2009), paying at-
tention to teachers’ perceptions of their access to mental
health services and their need for inter-professional col-
laboration as well as its outcomes. Furthermore, the quality
of inter-professional collaboration was frequently dis-
cussed by the focus group participants. Based on the se-
quential and explorative nature of the design, this issue of
quality was, therefore, included as a survey question, which
asked teachers to assess the quality of collaboration with

123
 School Mental Health

Table 3 Eight individual survey items with Likert scaled responses

Individual items Likert scaled responses

The school is uniquely positioned to discover mental health difficulties at an early stage 1. Strongly disagree
2. Somewhat disagree
3. Neutral
4. Somewhat agree
5. Strongly agree
It is hard to identify students’ mental health difficulties
It is hard to know how severe the students’ mental health difficulties are 1. Strongly disagree
I often doubt what is considered as normal variations and what needs help 2. Disagree
Our school collaborates well with mental health services 3. Somewhat agree
Our school has good access to child and adolescent mental health professionals 4. Agree
5. Strongly agree
My ability to help students with mental health difficulties totally depend on support from mental health services
I have gained knowledge about mental health through collaboration with mental health services

different services/groups of professionals on a Likert scale
ranging from 1 = very bad to 5 = very good. The open
response category explored teachers’ perceived reasons for
poor quality of collaboration.
Procedures
The focus group interviews were conducted, tape-recorded
and transcribed by the author. The coding was done in the
NVivo.10 software, providing exact counts of all the
mentions of a given code, both at the individual and group
levels. The initial coding started out with seven main
coding categories and 30 subcategories. Out of these, four
main coding categories and 15 subcategories were selected
for the purpose of this paper. These coding categories are
presented in Fig. 1.
The coding categories in Fig. 1 were created based on
theoretical assumptions and existing research in the field,
whereas the subcategories were mainly derived from
‘group-to-group validation’, in which the frequency and
attention given to the issues served as the selection criteria
for relevant coding categories (Morgan, 1997, p. 63). Thus,
the analytical process was a combination of data-driven
and concept-driven approaches (Gibbs, 2002), using ab-
ductive coding to combine deductive and inductive rea-
soning. The type of analysis applied can also be identified
as constant comparison analysis, the main aim of which is
to reduce data to codes and develop themes based on these
codes (Onwuegbuzie & Combs, 2010).
The survey was piloted by six K-12 teachers, two from each
school type. The questionnaire was also thoroughly reviewed
by two different research groups and representatives from the

Fig. 1 Overview of main

2. Perceived 3. Cross-systems
coding categories and 1. Percepons of 4. Role of School
Professional Collaborave
subcategories in focus group Professional Role Organizaon
Competence Experiences
data
Need for
Assessment of
refinement - Collegial
own Accessibility
the gatekeeper support
competence
role

Understanding
Subjecve role Need for
of school Frame factors
understanding knowledge
context

The challenge
Descripve role
of knowing School
- what it is in Confidenality
what leadership
reality
(indicators)

The challenge
Normave role Formal
of knowing
- what it is procedures and
how
expected to be rounes
(intervenons)

123
School Mental Health
national cooperative project of Mental Health in Schools. The
survey data were analysed through simple descriptive statis-
tics, showing the distribution of answers to the different
questions. In addition, ANOVA and t tests were performed to
identify variance between groups. When analysing the open
response category, classical content analysis was applied.
Here, the number of codes was counted in order to identify the
most cited concepts throughout the data (Leech & Onwueg-
buzie, 2008), and through axial coding, six main challenges to
collaboration were identified. Recognizing the danger of de-
contextualization (Bergman, 2010), the statistical results were
interpreted in conjunction with quotations displayed in full
length in the paper.
An Integrative Mixed Method Framework
In order to obtain a quality design in mixed method re-
search, integration of the different strands of the study is
important in all aspects of the design (Tashakkori & Ted-
dlie, 2008). Table 4 illustrates how the two data sources of
this study are intended to address the two main research
questions and how they provide complementary informa-
tion (see also Table 3; Fig. 1 for a detailed presentation of
survey items and focus group coding categories).
Results
Based on the research design and integrative framework
presented in Table 4, the results are presented by mixing
qualitative and quantitative data in order to address the two
Table 4 Overview of research questions and source data
Research questions
1. How do teachers perceive their role in inter-professional
collaboration in mental health promotion?
2. What do teachers perceive to be the main challenges to inter-
professional collaboration in mental health promotion?
main research questions of this paper, exploring teachers’
perceived role in and barriers to inter-professional col-
laboration in mental health promotion.
Exploring Teacher Role in Inter-professional
Collaboration: ‘That is My Task I Feel—To Refer
Them to Mental Health Services’
In the administered survey, teachers were asked to mark
their agreement to the statement: The school is uniquely
positioned to discover mental health difficulties at an early
stage. The Likert scale ranged from 1 = strongly disagree to
5 = strongly agree, with a neutral mid-point. Teachers’
recognition of their unique position in the identification and
referral system was clearly indicated, as 79.7 % of teachers
somewhat or strongly agreed with this statement (M = 4.08,
SD = .85, n = 757). However, focus group data high-
lighted teachers’ need to define themselves as educators, not
psychologists. Thus, teachers seemed to perceive their main
role in inter-professional collaboration in mental health
promotion as that of the ‘gatekeeper’, whose responsibility
is to identify and observe mental health needs and, if nec-
essary, make referrals to mental health services. The fol-
lowing focus group quote is quite illustrative:
Let me put it this way; I don’t want to be my stu-
dents’ psychologist. I am not a psychologist, but I do
want to get them to take their problems seriously.
That is my task, I feel, to refer them to mental health
services….Because, pretending to be a psychologist
and believing that teachers can cure students of
Explored by
Focus group interviews
Coding category 1: Perceptions of professional role
Coding category 2: Perceived professional competence
Survey data
One item measuring teachers’ perceptions of the schools’ position to
discover mental health difficulties at an early stage
Three individual items measuring perceived challenges to teacher
competence in mental health
Focus group interviews
Coding category 3: Cross-systems collaborative experiences
Coding category 4: The role of school organization
Survey data
Four individual items measuring different aspects of inter-professional
collaboration at individual and organizational levels
One question measuring the perceived quality of collaboration with
different services/professionals
One open response category identifying barriers to inter-professional
collaboration
123

severe depression and things like that, is not some-
thing I believe in. I believe all we can do is to keep
our eyes open, observe and report to our superiors.
(Female, 66, upper secondary school)
Related to this, the issue of teacher competence in
mental health comes forth as teachers’ perceived ability to
fulfil the ‘gatekeeper’ role greatly depended on their per-
ceived ability to assess the nature and severity of problems.
Survey data addressed the issue though three different
items and the descriptive statistics are presented in Fig. 2.
As Fig. 2 indicates, the vast majority (68.6 %) of the
teachers agree that it is hard to assess the severity of the
students’ mental health difficulties. To some extent, it also
seemed to be difficult for teachers to actually identify the
issues and the need for help. These findings are supported
by focus group data, in which the teachers, regardless of
teaching experience, sometimes found it difficult to sepa-
rate what they called ‘normal teenager mood swings’ from
more severe problems in order to identify potential mental
health issues and assess their severity. This competence
problem was mainly attributed to limited professional
training on mental health during their undergraduate
preparation, like a young teacher described it:
I am thinking about the role you have as a newly
qualified novice teacher. You are professionally
trained in pedagogy and teaching, right? Not to look
for what sort of mental health problems you might be
faced with. ‘You feel you are on thin ice here, re-
garding all that sort of thing…. Because you don’t
have professional expertise in that field. You’re just
using normal common sense, when you can see that
there is something wrong. But we can’t start making a
diagnosis. We can only say what we think it might be.
But we must sort of realize our limitations, and then
make it clear that someone else has to take over.
(Male, 34, lower secondary school)
I oen doubt what is considered as normal variaons
and what needs help (M = 3.09, SD = .83, n = 762)
2.00%
It is hard to assess the severity of the students` mental
health difficules (M = 3.84, SD = .75, n = 765)
0.30%
2.60%
It is hard to idenfy students` mental health difficules
(M = 3.04, SD = .78, n = 763)
Fig. 2 Percentage distribution of answers to individual items measuring teachers’ perceived challenges to their competence in mental health
123
School Mental Health
Additionally, it can be difficult for teachers to discover
mental health problems at an early stage, even if they
consider themselves to be uniquely positioned to do so.
Often, the students’ mental problems can be very well
hidden for different reasons: for example, the parents’ fear
of stigmatization. This situation is described by a female
teacher (59) at a lower secondary school: ‘If you show your
concern, there are parents that do not want us to…It is not
often, but it has to do with being given a diagnosis and the
fear of their child being stigmatized’. In other cases, the
students are good at keeping up appearances and show few
warning signs:
Sometimes it is obvious, and it is written all over
them that there is something wrong. But with others, I
have to say that perhaps I wouldn’t have noticed
anything, if it wasn’t for their frequent absence from
school…. Some are very good at hiding their prob-
lems, I think! (Female, 53, lower secondary school)
There are hidden mental illnesses that they would
rather not divulge - and then they have a meltdown, and
everything falls apart and you are completely shocked.
‘Cause it might be very clever students, and suddenly
they just… (Female 63, upper secondary school)
In sum, the gatekeeper role is regarded as a prominent yet
difficult role for teachers in inter-professional collabora-
tion, as mental health problems can be hard to discover,
identify and assess. This is not only due to limited teacher
knowledge about warning signs and risk factors, but
equally because problems can be very well hidden.
Exploring Perceived Challenges to Collaboration
In this paper, the gatekeeper role, as described above, and
its respective demand for competency serve as a point of
departure for exploring challenges to inter-professional
4.30% Strongly agree
24.50%
48.70%
20.50% Agree
Somewhat agree
17.90%
50.70% Disagree
28.60%
2.50%
Strongly disagree
18.70%
62.10%
13.10%
3.40%
School Mental Health
collaboration, but the present data also identify challenging
aspects of collaboration with regard to the implementation
of interventions and how to follow-up with students in a
classroom setting after referrals are made. In the open re-
sponse categories in the survey, teachers gave multiple
reasons for poor collaboration, indicating, from their points
of view, what factors hinder the best possible provision of
assistance to students with mental health needs. The results
are presented in Fig. 3.
Through axial coding, the single coding categories/n-
odes in Fig. 3 were collapsed into six analytical categories
that identify the main challenges to collaboration: com-
munication and confidentiality, time constraints, contextual
presence, cross-systems contact, school leadership and
teacher competence in mental health. All of the challenges
were ranked by their importance, which was based on the
number of references in each coding category. The six
main challenges, their original coding categories and their
illustrative quotes are presented in Table 5.
The six challenges identified above are elaborated on
below, combining focus group data and survey data from
the open response category. Answers from survey respon-
dents are referred to throughout as ‘SR’, whereas answers
from the focus group informants are referred to by gender,
age and school type.
The Challenge of Communication and Confidentiality
Confidentiality was the issue most frequently mentioned as
an obstacle to communication in inter-professional col-
laboration, in both the survey data and focus group data.
The problem was independent of services. Confidentiality
was frequently described as ‘unidirectional’, in which
teachers gave extensive information about students without
receiving any information in return. Thus, teachers often
felt ‘left in the dark’ after interventions or treatment were
Fig. 3 Teachers’ perceived
reasons for poor quality of inter-
professional collaboration based
on open response answers in
survey data. The number of
CODING CATEGORIES
Little Focus on MH Promotion in School Context
respondents in open survey
category was n = 196.
However, due to the complexity
MH Promotion as Beyond Teacher Responsibility
of the answers, some of the
responses were coded in more
than one category, giving a total
number of references n = 215.
MH mental health
initiated, making it difficult for them to follow-up with
students through the day-to day routine. The expressions
‘hide behind the confidentiality’ and ‘bound by confiden-
tiality’ are often recurring in the data, and the problem of
information exchange was well described by one of the
survey respondents:
Of course, as a teacher I do not need to know ev-
erything that is talked about, but I often feel like I’ve
been dealt the poorest hand, knowing little or noth-
ing, and therefore I’m not able to provide help when
it’s really needed either as teacher or a fellow human
being. (SR)
The importance of being informed to be able to help the
students was also clearly stated by the focus group par-
ticipants, and as a female teacher (59) in lower secondary
school said: ‘It is not easy, because it’s so confidential. To
my mind, if you are supposed to be something to a person,
you have to be involved’. Although teachers clearly respect
confidentiality, they also find the need for a pragmatic
approach to it, in which practices of confidentiality are
guided by what is perceived to be good for the students.
The following quote is representative for this view:
We fear confidentiality a bit too. Sort of, what are the
boundaries? Often, you need to discuss with others
(…) I believe it is in the best interest of the student
that we can discuss things with each other. Therefore,
we choose to have more of a pragmatic approach to
this. (Female, 42, upper secondary school)
The Challenge of Time Constraints
Second after confidentiality, the lack of time is the most
frequently mentioned as a source of poor collaboration
(Fig. 3). This is mainly due to limited resources, heavy
Incompetence in MH Services 3
Lack of School Routines 3
Personal Factors 5
MH Services` Disclaims of Responsibility 5
5
Teachers` Poor Knowledge of MH Promotion
6
Difficult to Get in Contact with MH Services 8
10
Weak School Leadership 15
Unavailable In- School Services 16
Poor Contextual Understanding 16
Poor Communication and Information Flow 18
Weak Traditions for Collaboration 22
Limited Resources in MH Services 23
Teachers` Lack of Time 23
Confidentiality Issues 37
0 10 20 30 40
NUMBER OF REFERENCES
123

Table 5 Six main challenges to inter-professional collaboration—with illustrative quotations from survey data
Type of challenge (n = number of
references)
(1) Communication and confidentiality
(n = 55)
Collapsed nodes
Confidentiality issues
Poor communication and information
flow
(2) Time constraints (n = 46)
Collapsed nodes
Limited resources in mental health
services
Teachers’ lack of time
(3) Contextual presence and
understanding (n = 32)
Collapsed nodes
Unavailable in-school services
Poor contextual understanding
(4) Cross-systems contact (n = 30)
Collapsed nodes
Difficult to get in contact with mental
health services
Weak traditions for collaboration
(5) School leadership (n = 23)
Collapsed nodes
Lack of school routines
Weak School Leadership
Little focus on mental health promotion
in school context
123
School Mental Health
Illustrative quotations from the open response category in survey data
‘We rarely get any information in return from CAMHS and Child Welfare Services. Without some
degree of information exchange, you cannot call it collaboration. Hiding behind confidentiality is
all too easy. And that leaves you in no position to collaborate’
‘Confidentiality results in a gap in the communication and the transfer of information. In my opinion,
the various professionals should exchange information to a much greater extent than is the case
today. I have never got to talk to medical doctors or Child Welfare Services about students, because
they always claim that they cannot comment on these things’
‘The school nurse is bound by confidentiality, and as a teacher you receive very little information
from her in cases regarding students’ mental health’
‘The Child Welfare Services are largely bound by confidentiality. They are fine to collaborate with at
meetings, focusing on prevention and discussions about students, but we often lack information
about how the case has been handled after the school has made a referral. The school receives very
little information on whether measures have been taken or whether the case is closed. All
professional instances need to collaborate and exchange information in order to achieve a best
possible holistic approach to help the student’
‘CAMHS often takes their confidentiality so seriously that it is harmful to the students. It is us who
have to deal with the students in all lessons, and we receive no information on how to handle
different situations, unless the parents themselves give us some’
‘CAMHS and Child Welfare Services (and other health care services) give us no access to
information. We have students who are ill, but we don’t know why—or how to help. We are asked
to assess students and write long reports, but we seldom or never receive anything in return.
Moreover, we are the ones who have these students on an everyday basis. Therefore, situations can
easily arise where we are scared of making things worse—because of a lack of information. We are
bound by confidentiality in our profession too—and that should be used in the best interests of the
child—not to create firewalls between the professions’
‘I believe the reason is that it is very resource-consuming. There are few possibilities to give special
attention to individual students within the time available’
‘You make a referral, and then it takes a long time before assessments are made. Then still more
waiting for the report. You get the report, and no or very few resources are allocated, and you’re left
on your own with the challenges. A great deal depends on money’
‘The students see that little action is taken, and time goes by. In this waiting period, the students are
struggling!’
‘The school has no school nurse. This increases the strain on the social teacher and contact teacher’
‘It is difficult to follow up advice from the EPS. There are many fine words, but it doesn’t feel as
though they help much in the day-to-day routines at school. To my mind students need closer
following up from those who have expertise on the issue’
‘The threshold for taking contact is high. It feels like it is the teacher who has to take responsibility
for the individual student’
The doctors are nowhere to be seen. In all my years as a teacher, I have never seen a doctor using his/
her knowledge to do preventive work amongst children and adolescents
‘There are no initiatives from other services to include the school as an active partner’
‘It is not common that medical doctors contact teachers. CAMHS is fairly peripheral for teachers’
‘The Child Welfare Services is not involved in schools. The medical doctors are not very engaged in
the students’ school situation either’
‘I have never heard the concept of mental health being mentioned either orally by the school
administration or in writing in any school policy documents’
‘Teacher don’t take this seriously, and give it little priority. There is a lack of guidelines and follow
up systems in cases where the teachers don’t do their job or lack expertise. There are no
consequences if teachers ignore or postpone work involving mental health issues’
‘The school administration does not consider this as their area of responsibility’
‘There is no plan for this work at my school. Interventions are random, and it is the teacher that has to
take the initiative and do the following up’
School Mental Health

Table 5 continued
Type of challenge (n = number of Illustrative quotations from the open response category in survey data
references)

(6) Teacher competence in mental health
(n = 16)
Collapsed nodes
Teachers’ poor knowledge of mental
health promotion
Mental health promotion as beyond
teacher responsibility
‘As a teacher I will accept and follow clear guidelines drawn up by professionals on how to handle
individual students in class. As a human being, I care about my students, but this is not my
responsibility as a teacher, because I am not competent enough. ‘Pseudo-competence’ or just a little
knowledge about mental health is not good enough for students who are struggling. My experience
is that it is not always easy for young people to accept help in time from the mental health services.
It is this service that needs to be reinforced and quality assured. The responsibility for mental health
must lie with the mental health services!’
‘This should not be a part of the teachers’ area of responsibility. Let mental health professionals and
parents take care of this. We have more than enough to do in the daily teaching!!!’

workloads and the shortage of staff in school as well as in
other services. As for mental health services, limited re-
sources lead to case processing delays, which teachers find
highly frustrating in case of urgent problems, and teachers
often feel left to their own devices to cope.
Other services are very positive when we contact
them and call for a meeting, and there is a quick
response to initiate one. But of course, they too are
short of resources, aren’t they? So the questions of
what next and where to go from here are often up to
us to figure out. We get some advice on how to do
things, but in the end, it’s left to us to do something
about it. This is a challenge! (Male, 38, lower sec-
ondary school)
The same teacher also elaborated on the conflict of in-
terest in prioritizing between mental health issues and
teaching tasks. He described it as ‘parallel driving’, jug-
gling time spent on academic demands versus personal
relations. Giving special attention to one student necessi-
tates lessening attention to the other 20–25 students in
class, and this dilemma is likely to cause a constant feeling
of shortcoming. One teacher in the survey data actually felt
that ‘not having the time you need to follow-up’ was the
worst thing about being a teacher.
The Challenge of Contextual Presence and Understanding
understanding of the nature of the problem. In general, the
teachers call for more ‘hands on’ advice from psy-
chologists and doctors on how to relate to students with
mental health needs. In order to give relevant and useful
advice, mental health professionals need to spend more
time in schools. One survey respondent reasoned like this:
‘the other professionals often don’t know the child as well
as those of us who work closely with them and they are
therefore not able to give relevant advice’.
Additionally, teachers believe that inter-professional
collaboration is strongly affected by service availability
and state their clear concerns for the schools’ poor access
to mental health professionals. For example, at one of the
schools of the focus group sample, the school nurse was
present approximately only 2 h per week. One of the
teachers found this very unsatisfactory:
I miss having a much larger team of experts in pas-
toral care at the school. I just do not understand how
it can be legal to have a school with over 400 students
without a school nurse present at least two days a
week or so… That mental health issues are not taken
more seriously! (Male, 38, lower secondary school)
The survey data support that this is a representative si-
tuation for the schools in the study sample, as poor access
to school nurse is frequently mentioned in the open re-
sponse category as a major challenge to collaboration.

As the quotes in Table 5 indicate, teachers are unanimous
in their need for mental health professionals to visit their
school more often and gain more understanding of the day-
to day routine and daily life of students. A female teacher
(53 years old) at lower secondary school described col-
laborative problems with CAMHS due to being in ‘two
separate worlds’, in which CAMHS have not observed the
student in the classroom setting and thus have a limited
The Challenge of Cross-Systems Contact
This challenge is closely related to that of contextual
presence and understanding but is more focused on weak
professional traditions for collaboration, indicating that
much of the contact between school and services like
doctors and child welfare services, seems to be crisis-dri-
ven and not orientated towards collaboration at universal

123

intervention levels. One survey respondent put the chal-
lenge plainly:
The only time we are in contact with the doctor is in
the case of a crisis. There should have been better
collaboration in terms of the doctors making them-
selves more visible to students and, for example,
coming to school to inform about mental health. This
is also the case for CAMHS and child welfare ser-
vices. (SR)
With regard to the need for more collaboration at uni-
versal intervention levels, one of the teachers in the focus
group data also suggested creating a ‘mental health mentor’
arrangement as part of inter-professional collaboration:
In the business world, they have mentors. I wish we
could have had something similar here, where you
could talk to someone, be observed and get feedback.
We should have had professional mentors that could
convey this kind of simple thing. (Male, 38, lower
secondary school)
The key point is the teachers’ need for practical advice
from mental health professionals in a classroom context as
well as enhanced cross-systems contact beyond crisis
management.
The Challenge of School Leadership
The essence of this challenge is that weak school leader-
ship often represents a poor integration of mental health
promotion in school routines and policy, relying too much
on the individual teachers’ abilities and engagement to
provide help when problems occur. A survey respondent
made the following claim, pointing to the need for inter-
professional collaboration to provide high-quality inter-
ventions: ‘The school relies on the teacher as a ‘hobby-
psychologist’ and believes that is good enough. If we are to
do any preventive work in school, this must be quality
assured by properly qualified experts’. Focus group data
support the claim of high pressure on the individual
teachers, but underscore, at the same time, the impact that
strong school leadership can have in supporting teachers in
their daily efforts to promote student mental health:
There is a pressure upon us, and if you feel you can’t
manage, the administration plays a very important
role. I believe this is so much more important than
having lecturers and projects and all other sorts of
things. In other words, the daily follow-up is quite
essential! (Male 34, lower secondary school)
This teacher also highlighted the importance of school
administration to initiate and facilitate inter-professional
123
School Mental Health
collaboration, through creating what he called ‘tight
bounds’ between the school and other services.
The Challenge of Teacher Competence in Mental Health
Finally, as the findings in Fig. 2 previously indicated,
uncertainty with regard to what are ‘normal variations’ and
what needs help is identified as a prominent challenge to
teacher competence, and to their gatekeeping role in par-
ticular. If teachers make the wrong judgments here, it can
hinder the student’s opportunity to receive appropriate
help. Furthermore, teachers commonly express a fear of
making things worse if they say or do the wrong things and
are, therefore, reluctant to intervene. One of the survey
respondents described the challenge: ‘In school, it’s the
lack of expertise that makes collaboration difficult, both
before and after referrals are made. You don’t know what
to look for and are afraid of making things worse if you
intervene’. This quote shows that the teachers’ need for
knowledge not only regards warning signs and risk factors,
but also encompasses evidence-based knowledge about
how to implement interventions and follow-up with stu-
dents after referrals are made.
Exploring the Challenges of Inter-professional
Collaboration Further Through Descriptive
Statistics and Analysis of Variance
The administered survey contained four items that mea-
sured teachers’ perceptions of: (a) knowledge outcomes of
inter-professional collaboration, (b) the importance of in-
ter-professional collaboration to enhance teachers’ ability
to help students with mental difficulties, (c) their schools’
access to mental health services and (d) the overall quality
of the cross-systems collaboration at their school. The
descriptive results are presented in Fig. 4.
The teachers’ perceived knowledge outcomes of inter-
professional collaboration seem to be moderate as 34.8 %
disagree and 41.8 % only somewhat agree that they have
gained knowledge about the issue of mental health through
collaboration with mental health services. Still, 39.7 % of
the teachers agree or strongly agree that their ability to help
students with mental health difficulties totally depends on
receiving support from the mental health services. How-
ever, the schools’ access to these services varies and
45.5 % of the teachers only somewhat agree that their
school has good access to child and adolescent mental
health professionals. In spite of this, the vast majority of
teachers (66.6 %) agree or strongly agree that their school
collaborates well with mental health services. However, the
respondents were also asked to give a differentiated ac-
count for their perceived quality of collaboration with the
School Mental Health
4.30%
I have gained knowledge about mental health through
collaboraon with mental health services (M = 2.82,
SD = 1.00, n = 764)
My ability to help students with mental health
difficules totally depends on support from mental
health services (M = 3.27, SD = 1.00, n = 754)
4.20%
Our school has good access to child and adolescent
mental health professionals (M = 3.33, SD = .86, n =
763)
1.70%
Our school collaborates well with mental health
services (M = 3.75, SD = .78, n = 764)
3.80%
0.90%
Fig. 4 Individual and organizational aspects of inter-professional
collaboration. Percentage distribution of answers to single items
measuring individual aspects such as teachers’ need for support in
order to provide help and their perceived knowledge outcomes of
different groups of professionals involved in mental health
services. The descriptive results are presented in Table 6.
As Table 6 indicates, the majority of teachers experi-
enced the quality of inter-professional collaboration as
good or very good, especially with regard to school nurses
and Educational Psychological Services. The poorest
quality of collaborative experiences seems to be with
medical doctors, rated as good or very good by only
17.7 % of the teachers. In addition, a high percentage of
the teachers (33.3 %) also reported having no experience
with this kind of collaboration at all. The same situation
somewhat applied to child welfare services, but here the
quality of existing collaboration was generally perceived as
better.
Finally, in order to explore the impact of different
background variables on the items in Fig. 4, a series of one-
way analysis of variance (ANOVA) was conducted with the
independent variables of school type, school size, years of
experience, educational background and participation in
mental health training programs. For the background
variables of additional education and gender, independent
t tests were conducted. The one-way ANOVA, F(2,
170) = 4.13, p = .018, g2 = .008, demonstrated sig-
nificant between group differences in school size on the
dependent variable of ‘Our school collaborates well with
mental health services’. Post hoc comparisons using the
Tukey HSD test indicated that the mean score for small
schools (M = 3.97, SD = .68) was significantly different
from that of large schools (M = 3.70, SD = .75). On the
dependent variable of ‘Our school has good access to child
and adolescent mental health professionals’, there were
significant differences between groups on the independent
variables of school type, F(2, 454) = 10.39, p \ .001,
g2 = .025, and educational background, F(3, 754) = 4.71,
19.10%
41.80%
24.20%
10.60%
11.80%
27.90%
40.20% Strongly agree
15.90%
Agree
8.10% Somewhat agree
32.50%
Disagree
45.50%
12.20% Strongly disagree
14.10%
52.50%
28.70%
collaboration, and organizational aspects such as the schools’ access
to help services and how well the school collaborates with these
services in general
p = .003, g2 = .018. Tukey HSD indicated that the mean
score for upper secondary schools (M = 3.49, SD = .87)
differed significantly from that of lower secondary schools
(M = 3.26, SD = .87) and primary schools (M = 3.16,
SD = .76). Furthermore, the mean score for teachers
educated at bachelor level (M = 3.28, SD = .85) differed
significantly from teachers educated at master level
(M = 3.51, SD = .89) and teachers with no formal teacher
education (M = 3.76, SD = .77). Finally, ANOVA showed
significant between group differences in school type, F(2,
458) = 5.95, p = .003, g2 = .013, and participation in
mental health training programs F(2, 757 = 17.90),
p \ .001, g2 = .037 on the dependent variable of ‘I have
gained knowledge about mental health through collabora-
tion with mental health services’. The results from the
Tukey HSD demonstrated that the mean score for teachers
at primary school (M = 3.03, SD = .88) differed sig-
nificantly from the mean score for teachers at lower sec-
ondary school (M = 2.78, SD = .98) and upper secondary
school (M = 2.75, SD = 1.10). t tests also showed sig-
nificant gender differences on this dependent variable, in
the score for females (M = 2.91, SD = .98) and males
(M = 2.69, SD = 1.01; t(557) = -2.84, p = .005) and in
the scores for teachers with (M = 3.10, SD = 1.03) and
without additional education in psychology and/or special
education (M = 2.73, SD = .97; t(745) = -4.53,
p \ .001. However, the effect sizes (Cohens’ d) were small
(d = .22 and d = .38, respectively). On the dependent
variable: ‘My ability to help students with mental health
difficulties totally depends on support from mental health
services’, t tests showed significant gender differences in
scores for males (M = 3.12, SD = .95) and females
(M = 3.35, SD = 1.03; t(587.354) = -3.10, p = .002),
but the magnitude of the difference was small (d = .23).
123
 School Mental Health

Table 6 Teachers’ perceived quality of collaboration in mental health promotion with different services/groups of professionals. Percentage
distribution of answers (%)
Very good Good Neutral Bad Very bad No such experiences

With teacher colleagues 23.5 44.6 23.0 3.7 .8 4.5

(M = 4.00, SD = .93, n = 762)
With school counsellor 35.5 26.5 17.8 4.3 1.4 14.5
(M = 4.34, SD = 1.14, n = 736)
With principal/school adm. 27.1 33.7 20.8 7.3 1.9 9.3
(M = 4.05, SD = 1.14, n = 756)
With school nurse 31.4 32.0 16.2 4.7 3.1 12.6
(M = 4.22, SD = 1.18, n = 752)
With EPS 20.9 38.6 22.6 6.0 1.6 10.2
(M = 4.02, SD = 1.11, n = 761)
With medical doctors 4.8 12.9 31.2 8.7 9.2 33.3
(M = 3.95, SD = 1.69, n = 751)
With CAHMS 14.8 29.0 27.4 7.4 4.2 17.1
(M = 3.94, SD = 1.36, n = 755)
With child welfare services 8.1 23.5 30.6 8.1 4.6 25.2
(M = 3.98, SD = 1.46, n = 742)
Note. EPS Educational Psychology Services, CAMHS Child and Adolescent Mental Health Services

Taken together, these results suggest that teachers at
small schools perceive the quality of cross-systems col-
laboration as better than teachers at larger schools do, and
teachers at upper secondary schools report better access to
mental health professionals than teachers at primary and
lower secondary schools do. However, teachers at primary
schools report greater knowledge outcomes on mental
health through inter-professional collaboration than teach-
ers at higher grades do. Similar significant positive
knowledge outcomes were found for female teachers and
for teachers who have participated in mental health training
programs. Finally, the results indicate that females, more
than males perceive themselves as totally dependent on
support from mental health services in order to help stu-
dents with mental health problems.
Summary of Findings
Teachers often feel they are just providers and not receivers
of information, which makes them feel ‘left in the dark’
after referrals are made and not fully included as partners in
inter-professional interventions. Furthermore, teachers’
perceived quality and frequency of collaboration vary
greatly across services, in which school nurses and EPS are
given the highest ratings, while doctors and child welfare
services are given the lowest. The availability and presence
of mental health professionals in schools are a significant
challenge, and teachers unanimously call for more in-ser-
vice training and advice from these professionals—
although they recognize the problem of resource avail-
ability in mental health services, which is similar to the
challenge of time constraints in school. Finally, strong
school leadership is regarded as essential to support
teachers and to facilitate inter-professional collaboration to
meet students’ different mental health needs.

The gatekeeper role, which is responsible for the identifi- Discussion

cation and assessment of mental health needs as a basis for
referral to mental health services, is a prominent role of
teachers in inter-professional collaboration. This role can
be a challenging one, because teachers lack training and
have been poorly prepared in the identification of warning
signs and risk factors. Thus, the need for improved teacher
competency in mental health promotion was identified as
one of the six challenges to inter-professional collabora-
tion. However, the single greatest challenge to collabora-
tion was that of communication and confidentiality issues.
Challenges to inter-professional collaboration in mental
health are well documented in previous research but are
most commonly considered through the perspective of
implementing mental health programs or through the per-
spective of school-based mental health services. This pa-
per’s unique contribution to the research field is in the
identification of the teacher role with regard to inter-pro-
fessional work and perceived challenges to collaboration as
seen from the teachers’ perspective. Based on data

123
School Mental Health
provided by Norwegian K-12 teachers, the teacher role in
inter-professional collaboration is explored, and six main
challenges to collaborative work are identified.
The vast majority of teachers recognize their unique
position to discover child and adolescent mental health
difficulties at an early stage. This makes the gatekeeper
role prominent to them. However, teachers also realize that
mental health promotion encompasses more than the
assessment of issues, and they recognize the importance of
inter-professional collaboration at all levels of intervention
to prevent mental illness and to promote mental health for
all students. In fact, 39.7 % of the surveyed teachers, and
females significantly more than males, responded that their
ability to help students with mental health difficulties to-
tally depends on receiving support from mental health
services. Further research is needed to explore these gender
differences, but the main point is that teachers consider
inter-professional collaboration as highly necessary in
school mental health promotion. Therefore, as Langley
et al. (2010) pointed out, to enhance inter-professional
collaboration and provide the best possible interventions,
we need to identify collaborative barriers and what factors
that enhance the likelihood for these barriers to be
surmounted.
Multiple Challenges to Inter-professional
Collaboration
The present data identifies six main challenges to col-
laboration. These are the challenges of communication and
confidentiality, time constraints, contextual presence and
understanding, cross-systems contact, school leadership
and teacher competence in mental health. Based on the
contextual organizational perspective of this study, school
leadership is considered to be an overriding challenge,
which is important for facilitating inter-professional col-
laboration through the provision of clear guidelines for re-
ferrals, effective resource allocation, and day-to-day support
for teachers in their efforts to implement interventions and
meet the mental health needs of students. However, all six
challenges somewhat overlap and interrelate, indicating the
complexity of inter-professional collaboration.
In interview data reported by Rothi et al. (2008),
teachers cited poor training and a lack of information as
major barriers for them to engage in mental health pro-
motion and follow-up with students with regard to their
mental health needs. These barriers are mirrored in the
findings presented in this paper, which show that many
teachers feel professionally ill-equipped to identify early
warning signs and to decide whether or not problems that
they have identified need professional help. Teachers are
also afraid of worsening the situation by saying or doing
the wrong things. These results are well supported by
international research (Graham et al., 2011; Kidger et al.,
2010). Thus, when students start to develop mental health
problems, teachers’ need for proper information, guidance
and in-service training from mental health professionals
increases. In the present data, teachers who have par-
ticipated in mental health training programs report sig-
nificantly better knowledge outcomes than other teachers.
However, the overall knowledge outcomes from inter-
professional collaboration seem to be rather moderate, as
only 23.4 % of the teachers agree or strongly agree that
they have gained knowledge about mental health through
such work. Furthermore, primary school teachers report
having significantly greater knowledge outcomes than
teachers at higher grades, something which might be at-
tributed to case that inter-professional collaboration takes
place more widely in primary schools at the universal in-
tervention level, in which the provision of general infor-
mation on mental health issues is central. As students grow
older, mental health problems become more persistent and
severe, which calls for more collaboration at the select-
ed/targeted and indicated intervention levels, in which
confidentiality issues often are perceived to obstruct com-
munication and information exchange. The findings in this
paper show that teachers commonly describe mental health
professionals as ‘hiding behind’ confidentiality and blame
it for creating ‘firewalls’ between professions (Table 5).
This is supported by findings reported in Holen and Waa-
gene (2014), showing that confidentiality issues are a par-
ticular barrier for collaboration with specialist services
such as CAMHS.
Obviously, as Ball et al. (2010) argue, teachers and
mental health professionals have different expectations
regarding confidentiality, which are based on their differ-
ences in work context and educational training. The present
findings, however, clearly suggest that teachers have no
desire or need to know everything about their students, but
they do need to know something regarding students’ con-
ditions in order to help them in the classroom. This
‘pragmatic’ approach to confidentiality is in line with the
aim to improve quality of care and treatment as an im-
portant reason for sharing personal information (Baker,
2008). Therefore, as Feinstein et al. (2009) pointed out, it is
crucial to clarify what can and cannot be communicated
and, thus, define the possible areas of conversation. By
doing so, confidentiality no longer needs to be equal to
silence. However, this requires regular meetings between
teachers and mental health professionals, in which the
communication process itself can be discussed. In general,
further research is needed to examine differences in inter-
professional communication challenges that depend upon
intervention levels.
Although regular and frequent meetings between
teachers and social workers have clearly proven to
123

facilitate communication and help effectiveness (Viggiani
et al., 2002), the challenges of time constraints and poor
cross-systems contact make regular communication diffi-
cult to implement. This is highly supported by the present
findings. At the universal levels of intervention, limited
time resources prevent teachers from engaging in mental
health issues or giving priority to them in the day-to-day
routine, whereas at indicated/selected and targeted levels,
time constraints make it difficult, for example, to follow-up
on students’ mental health needs and to attend inter-pro-
fessional team meetings. Likewise, Forman, Olin, Hoag-
wood, Crowe, and Saka (2009) reported the dearth of time
as a significant barrier for teachers’ engagement in mental
health promotion. In addition, limited time resources in
other services lead to case processing delays and leave
teachers and students to their own devices long after re-
ferrals are made.
In general, as Powers et al. (2010) pointed out, teachers
often feel isolated in their work with students’ mental
health needs. As the present data clearly suggest, teachers
call for more in-service support and training from mental
health professionals, such as psychologists and doctors.
However, they often find advice from mental health pro-
fessionals to be unfeasible and irrelevant, due to these
professionals’ limited presence in and knowledge of the
school and classroom settings. As the survey data indicate
(Table 6), teachers’ perceived quality of inter-professional
collaboration seems to be affected by service access, and
the services that are least present in schools, including
doctors, child welfare services and CAMHS, are given the
lowest quality scores. These findings are supported by
Andersson et al. (2010), who found that organizational
differences are likely to affect the quality of inter-profes-
sional collaboration. However, cross-cultural studies are
needed to examine the differences in teachers’ perceptions
of inter-professional collaboration as a function of the
service delivery system.
Regarding the challenge of little cross-systems contact,
the present data show that medical doctors are the profes-
sional group with whom teachers have the least collabora-
tive experience and the poorest quality of collaboration. In
general, doctors are described by teachers as difficult to
contact, disinterested in preventive work, minimally in-
volved in schools and only then in the event of a crisis.
Similar findings were reported by the Norwegian Board of
Health Supervision (2009), which found that doctors are
often poorly represented in responsibility groups1 and that
there are weak traditions for collaboration between schools
and doctors. A partial explanation for this might be the
1 constraints present a major challenge in both school and in
In Norway, 83 % of municipalities use inter-professional ‘respon-
sibility groups’ to coordinate services for children and adolescents
with mental health needs (Helgesen & Myrvold, 2009).
123
School Mental Health
tendency of schools to be too crisis-driven and to have too
little of a focus on preventive work in inter-professional
collaboration on mental health (Langley et al., 2010).
However, research shows that teachers’ involvement in
school-based interventions that aimed at breaking down
stigmas and barriers is a significant factor in motivating
students with severe mental health problems to seek help
from doctors (Mariu, Merry, Robinson, Watson et al., 2012;
Wilson, Deane, Marshall, & Dalley, 2008). Thus, greater
contact between schools and doctors is warranted in order to
provide the best possible help to students with mental health
needs. Nonetheless, as Feinstein et al. (2009) pointed out,
even if the importance of collaboration is widely recognized,
many mental health professionals are unfamiliar with the
nature of the roles of school staff and struggle to identify
effective collaborative liaisons in schools. This would seem
to call for better pre-service training of all professionals
involved in mental health promotion, as to how they can
better establish and maintain positive inter-professional re-
lations. It is also important that the process of seeking help
and establishing inter-professional collaboration is not
relegated as the responsibility of individual teachers, but
something that is supported at the organizational level as an
integrated part of school leadership.
School Leadership as the Linchpin for Inter-
professional Collaborative Efforts
Based on the contextual organizational perspective of this
paper, it is important to discuss challenges to inter-profes-
sional collaboration in the light of school leadership and its
role in facilitating collaboration. The present data show that
support from school administration is of crucial importance
for teachers in their efforts to promote student mental health
and to deal with different sorts of student mental health
difficulties. These findings are thoroughly supported by
other research, identifying a lack of institutional support,
unclear roles and minimal shared knowledge as major bar-
riers for inter-professional mental health promotion in
schools (Ball et al., 2010; Choi & Pak, 2007; Lynn et al.,
2003; Ødegård, 2005). Therefore, weak school leadership,
with regard to poorly articulated policies on mental health
promotion and missing guidelines regarding the referral
process, clearly represents challenges to inter-professional
collaboration and increases the risk that interventions would
become arbitrary and left to the individual teacher’s personal
abilities and engagement. As Weare and Nind (2011)
pointed out in their review of mental health interventions in
schools, the effectiveness of interventions strongly depends
on coordinated work with other services. Given that time
other services, the effective allocation of existing resources,
therefore, becomes an important leadership task.
School Mental Health
Nonetheless, the most important aspect of school lead-
ership in inter-professional collaboration on mental health
seems to be schools’ ability to be proactive in their ap-
proach. According to Feigenberg, Watts, and Buckner
(2010), proactive schools recognize how mental health
affects students’ learning outcomes and are able to take
action and intervene before these problems occur or esca-
late. In addition, as Rowling (2009) pointed out, leadership
in health promotion includes providing formal means for
mental health promotion in school documents as well as
efforts to clarify referral pathways, support teamwork and
strengthen school-based resources allocated for the pre-
vention and treatment of mental health issues. Thus, as
Weare and Markham (2005) argued, schools’ ability to
consider several organizational aspects simultaneously,
including ethos, communication, policies and relations
with other services, are all key elements in a ‘whole school
approach’ to mental health promotion. The importance of
these aspects of school leadership is well supported by the
findings presented in this paper, which indicates that school
leadership serves both a symbolic function in raising
awareness of mental health as an important issue in school
context and a practical function in facilitating collaborative
work through the provision of support and guidelines for
referrals and interventions.
Conclusion
This paper has identified six challenges to collaboration:
communication and confidentiality, time constraints, con-
textual presence and understanding, cross-systems contact,
school leadership and teacher competence in mental
health. These are all somewhat interrelated, and the main
takeaway is the teachers’ need for support from mental
health professionals as well as from the school adminis-
tration, in their daily efforts to promote student mental
health. The challenges also highlight the importance of
mutual information exchange between teachers and mental
health services as well as greater access to mental health
professionals in schools. Additionally, it is of critical im-
portance, based on teachers’ central gatekeeping role, to
provide teachers with enhanced knowledge of warning
signs and risk factors for mental health problems, as well as
knowledge about evidence-based interventions and advice
on how to follow-up with students in the classroom setting.
This knowledge can, to some extent, be gained through
participation in mental health training programs and in-
service guidance, but there is still a need to strengthen the
knowledge base on mental health promotion in the pre-
service training of teachers. Finally, there is a need for a
greater focus on the establishment of inter-professional
liaisons and confidentiality practices in the educational
training of all professionals involved in mental health
promotion in schools.
Limitations of the Study
Although this study provides some insights into how teachers
perceive their role in inter-professional collaboration and
into what they identify as the main challenges to collabora-
tion, several limitations must be taken into consideration
when interpreting the results. First, as this study takes on the
teachers’ perspective, it is a one-sided view of collaboration.
Thus, the assessments of the quality of collaboration are not
balanced with the views of the other parties. Second, the use
of classical content analysis for the open response data, such
as counting the number of references, calls for cautious in-
terpretation regarding the most prominent challenges. The
number of references in each node and in each category of
nodes is affected by the coding criteria. Sometimes, an open
response answer can be multifaceted and difficult to interpret
and code. Therefore, in order to minimize the risk of de-
contextualization and the fragmentation of meaning, the
node count is supplemented by full-length quotations. The
use of a mixed method design also strengthens the inter-
pretation of the open response data, as the focus group
provide complementary information. Finally, there is a
methodological limitation related to the representativeness
and generalizability of the study. Those who are the most
engaged in the mental health issues are also those who are
most likely to respond to the survey in general, and to the
open response categories in particular, which could alter the
representation of the population in the study. Additionally,
differences in how the mental health service system is or-
ganized in different countries affect, to some extent, how
much the data can be generally applied. Nonetheless, the
findings are likely to have international relevance, as they
address universal challenges to inter-professional col-
laboration with regard to confidentiality issues, knowledge
demands, time constraints and school leadership.
Acknowledgments The research presented in this paper was funded
by grants from Volda University College, (Project No. 75019). I
would like to acknowledge the six teachers who piloted the survey,
the 771 teachers who took part in the survey, and the 15 teachers who
provided insight into teachers’ lives through their participation in
focus group interviews. I would also like to thank the reviewers for
their insightful comments on the manuscript, and Dr Trond Eiliv
Hauge and Dr Ingrid Lund for their valuable support.
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 Scandinavian Journal of Educational Research

ISSN: 0031-3831 (Print) 1470-1170 (Online) Journal homepage: https://www.tandfonline.com/loi/csje20

Helping Teachers Support Pupils with Mental

Health Problems Through Inter-professional
Collaboration: A Qualitative Study of Teachers and
School Principals

Ellen Nesset Mælan, Hege Eikeland Tjomsland, Børge Baklien & Miranda
Thurston

To cite this article: Ellen Nesset Mælan, Hege Eikeland Tjomsland, Børge Baklien & Miranda
Thurston (2019): Helping Teachers Support Pupils with Mental Health Problems Through Inter-
professional Collaboration: A Qualitative Study of Teachers and School Principals, Scandinavian
Journal of Educational Research, DOI: 10.1080/00313831.2019.1570548

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SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH
https://doi.org/10.1080/00313831.2019.1570548

Helping Teachers Support Pupils with Mental Health Problems

Through Inter-professional Collaboration: A Qualitative Study of
Teachers and School Principals
Ellen Nesset Mælan, Hege Eikeland Tjomsland, Børge Baklien and Miranda Thurston
The Faculty of Public Health, Inland Norway University of Applied Sciences, Elverum, Norway

ABSTRACT ARTICLE HISTORY

A qualitative study conducted in four lower secondary schools in Norway Received 18 March 2018
explored teachers’ and school principals’ experiences of collaboration with Accepted 14 December 2018
a variety of extended services (ES). Particular attention was directed to the
KEYWORDS
ways (if any) they perceived collaboration to be relevant to helping Pupils’ mental health;
teachers support pupils with mental health problems through their teachers’ roles; inter-
everyday social and pedagogic practices. Findings of the study indicated professional collaboration;
that teachers valued initiatives that could help develop mutual extended services
understandings of teachers’ and ES professionals’ roles and
responsibilities. Initiatives to build inter-professional relationships were
perceived as laying the foundation for more productive collaboration.
However, to be able to provide coherent, sustained support in the
classroom, teachers needed guidance from ES professionals. This
required a shift in collaborative processes away from a focus on
individualized pupil support towards helping teachers support pupils
through their classroom-based social and pedagogical practices.
Implications for policy and practice are discussed.

Introduction
In recent years, the role of schools in general, and teachers in particular, in supporting young people
with mental health problems has been increasingly emphasized by policy makers in Norway as else-
where. In part, this reflects the increasing visibility of mental health problems in the school setting:
not only do these problems tend to emerge during the secondary school years as young people begin
the transition towards young adulthood, trends indicate that more young people are reporting a var-
iety of mental health-related problems (Patalay et al., 2016). In Norway, for example, 15–20% of
young people are estimated as being affected by mental health problems (Bakken, 2016; Skogen
et al., 2015). Moreover, an increasing proportion of Norwegian young people report mental health
problems in the form of stress connected to various aspects of schooling (Lillejord, Børte, Ruud, &
Morgan, 2017), a finding that is consistent with research in other countries (Sweeting, West, Young,
& Der, 2010). Overall, these patterns point towards the increasing complexity and expansion of tea-
chers’ roles in their everyday work in schools.
Given the well-established reciprocal relationship between mental health and academic achieve-
ment (Gustafsson et al., 2010), the capacity of schools to respond to pupils’ mental health problems
and keep them engaged in learning is important if schools are to help pupils realize their potential.
Early recognition and intervention has the potential to prevent mental health problems worsening
and avoid a crisis, which is often the point at which support is first offered (Angold et al., 2002).

CONTACT Ellen Nesset Mælan ellen.malan@hihm.no; ellen.malan@inn.no Inland Norway University of Applied Sciences,
Postboks 400, Elverum 2418, Norway
© 2019 Scandinavian Journal of Educational Research
2 E. N. MÆLAN ET AL.

Being responsive to the early signs of problems can also help reduce the risk of stigmatizing pupils
who experience such challenges (Cossu et al., 2015). In spite of increasing needs among pupils,
research suggests that they are unlikely to access mental health services beyond schools on their
own initiative (Patalay et al., 2016). As Graham, Phelps, Maddison, and Fitzgerald (2011) have
argued, this means that it often falls to teachers to provide links to mental health support services.
As a consequence, they are drawn into a network of “extended services” (ES) in which they are
expected to play a role in early identification and referral of pupils, liaise with a variety of mental
health professionals and support pupils. Supportive teacher relationships have been shown to
have a moderating effect on negative life-events, and reduce the risk of depressive symptoms
among adolescents (De Wit, Karioja, Rye, & Shain, 2011; Murberg & Bru, 2009; Roorda, Koomen,
Spilt, & Oort, 2011). However, teachers seem to interact less supportively with pupils with mental
health problems compared to those without such problems (Holen, Waaktaar, & Sagatun, 2017).
As Phillippo and Kelly (2014) point out, while secondary school teachers are likely to encounter
pupils with mental health problems, they are unlikely to address them if they feel unsure of their
role or have little confidence in how to support them. This has particular implications for under-
standing how teachers, through collaboration with ES, can support pupils within the social and ped-
agogical environment of the classroom, which, to the best of our knowledge, has not been empirically
researched.

Aim and Research Question

This paper focuses on inter-professional work between lower secondary school teachers and a range
of professionals involved in supporting pupils who either are at risk of, or already experiencing, men-
tal health problems. The specific research questions asked were:

(i) how do teachers experience and understand their involvement with ES

(ii) in what ways (if any) do teachers perceive their involvement in ES as relevant to helping them
support pupils through their everyday social and pedagogic practices?

We start by reviewing the extant literature with regard to teachers’ involvement in inter-pro-
fessional processes relating to providing support for pupils with mental health problems. Although
in places we use the word “collaboration”, in keeping with much of the research in this domain we
recognize that its meaning is ambiguous (Ødegård & Strype, 2009) as well as being underpinned by a
number of normative connotations (Easen, Atkins, & Dyson, 2000). We also provide an overview of
the formal arrangements for working with ES in Norway in order to contextualize the study.

Teachers’ Experiences of Working with ES Professionals

Research on inter-professional work in a variety of settings is extensive and consistently reveals the
difficulties of working together effectively (see, for example, Easen et al., 2000; Hesjedal, Hetland,
Iversen, & Manger, 2015; Phillippo & Kelly, 2014). In this regard, teachers’ experiences of working
with ES are no different. Research from a number of countries has emerged in recent years that has
shown that, for a variety of organizational (for example, structural and resource constraints) and
professional (for example, differences in values, culture and language) reasons, inter-professional
work tends to be poorly co-ordinated, a consequence of which is the marginalization of teachers
(Ekornes, 2015; Patalay et al., 2016; Phillippo & Kelly, 2014). In particular, teachers’ involvement
in inter-professional work tends to unfold in a way that leads to parallel practices rather than inte-
gration (Phillippo & Kelly, 2014). Even in situations where ES professionals work alongside teachers
in universal mental health initiatives in schools, they seem not to involve teachers to the same extent
when supporting pupils with mental health problems (Berzin et al., 2011; Franklin, Kim, Ryan, Kelly,
& Montgomery, 2012). According to Weist et al. (2012), limited resources in schools and intense
 SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH 3

academic pressures may lead to a situation whereby teachers leave the responsibility for supporting
pupils’ mental health to ES professionals, particularly if they are unsure how to contribute. However,
Ekornes (2015) found that although teachers viewed their primary role as identifying pupils with
mental health problems and, if necessary, making referrals, they recognized that better inter-pro-
fessional collaboration could be a vehicle for helping them extend their role in providing mental
health support. Moreover, expanding their role beyond “gatekeeping” was something the teachers
in this study said they wanted. However, Graham et al. (2011) found that teachers tended to look
primarily to outside “experts” in ES to assist them with pupils’ mental health problems even
when they were school-related. While views vary on how far teachers should be involved in mental
health support of pupils, the potential for teachers to augment support from ES professionals
through their classroom practices in a sustained way over time has been noted (Adi, Killoran, Jan-
mohamend, & Stewart-Brown, 2007). If this is to be effective, however, research has shown that tea-
chers themselves need support from ES professionals and, moreover, that inter-professional working
relationships need to be based on trust and respectful communication through open exchanges of
information (Moran & Bodenhorn, 2015; Rothì, Leavey, & Best, 2008). Moreover, these kinds of
inter-professional processes contribute to relationship-building that can lead to a better understand-
ing of teachers’ roles and those working in ES (Mellin, Ball, Iachini, Togno, & Rodriguez, 2016;
Moran & Bodenhorn, 2015). School principals also play a critical role in facilitating teachers’ invol-
vement through organizational support, particularly in supporting collaboration through communi-
cating with and advocating on behalf of ES professionals (Mellin et al., 2016). Research has shown
the importance of inter-professional processes of interaction: simply basing mental health pro-
fessionals in school, however, is unlikely in itself to facilitate collaboration and may even lead tea-
chers to think they have little role in providing school-based support (Spratt, Shucksmith, Philip,
& Watson, 2006). Furthermore, studies of the Educational Psychological Services (EPS) in Nordic
countries indicated that even though teachers and school leaders experience professionals in EPS
as highly competent, they perceive a need for those in EPS to develop better understanding of tea-
chers’ social and pedagogic practices (Ahtola & Niemi, 2014; Fylling & Handegård, 2009; Hustad,
Strøm, & Strømsvik, 2013).
Research from many countries has shown that teachers report having limited knowledge and few
skills in supporting pupils’ mental health, either in terms of universal strategies for mental health
promotion or prevention (Askell-Williams & Cefai, 2014; Askell-Williams & Lawson, 2013; Graham
et al., 2011; Reinke, 2011). In particular, teachers reported feeling unsure how best to support pupils
with mental health problems (Ekornes, 2015; Mælan, Tjomsland, Baklien, Samdal, & Thurston,
2018; Mazzer & Rickwood, 2015). Furthermore, neglecting teachers’ mental health may be a factor
in making them reluctant to engage with pupils’ mental health problems (Kidger, Gunnell, Biddle,
Campbell, & Donovan, 2010). This is worthy of note as teacher stress has been shown to be related to
a perceived gap between feeling responsible for, and being able to support, pupils with mental health
problems (Ball & Anderson-Butcher, 2014; Ekornes, 2016).
This brief review of research indicates that joint working between teachers and ES professionals is
often difficult and fragmented. Perhaps more importantly, it gives rise to teachers feeling unsure
about how to support pupils who are struggling in order to keep them engaged in school and learn-
ing. As a consequence, they become an underused resource in supporting pupils (Phillippo & Kelly,
2014). Better inter-professional collaboration has the potential, however, to improve teachers’ every-
day social and pedagogical practice with regard to supporting pupils with mental health problems.
Thus, further exploration of how collaboration with ES is experienced, and the relevance of ES col-
laboration to teachers’ practice in the classroom, is needed.

The Norwegian Context

Norwegian reforms (for example, Norwegian Ministry of Education and Research, 2016–2017; Nor-
wegian Ministry of Health and Care Services, 2010–2011) emphasize the importance of developing
4 E. N. MÆLAN ET AL.

co-ordinated, collaborative, community-based approaches to prevention and early intervention.

However, the majority of mental health services are located outside of schools, either in the munici-
pality or regionally. The mental health service system for children and adolescents in Norway
involves services on two different levels. On the first level, the system consists of health care services
(such as school nurses, medical doctors and EPS) in the municipalities. On the second level, are the
specialized mental health services, such as Child and Adolescent Mental Health Services, located at
regional hospitals (Norwegian Ministry of Health and Care Services, 2005). In the current article,
school nurses, professionals in mental health services on both levels, and professionals in wider com-
munity services involved in supporting pupils’ mental health are referred to as ES professionals.
Inter-professional teams are described by the Norwegian Directorate of Health as a way of pro-
moting collaboration. Such teams are organized – usually by the head or other school representa-
tive – at the majority of schools in Norway, but the frequency of meetings, the professions involved
and the number of participants vary with the size of the municipality and the school. If teachers
want to discuss mental health problems related to a particular pupil or group of pupils with the
members of the team, they can ask to attend a meeting. Likewise, team members can propose dis-
cussing mental health problems relating to a particular pupil or group of pupils, and ask for rel-
evant teachers to attend and participate. Pupils who are going to be the subject of discussion and
their parents may also be invited to participate in these meetings. If they do not attend, consent
from the pupil and the parents are needed (The Norwegian Directorate of Health, 2007). If no con-
sent is forthcoming, then discussions take place anonymously If the conclusion of the discussion is
that further collaboration would be beneficial, an agreement of the form and frequency, as well as
who is going to participate, is usually decided during the meeting. This is in line with national
guidelines which specify routines to encourage coordination of services (The Norwegian Directo-
rate of Health, 2007).

Method
This study is located within a larger project concerned with schools, learning and mental health, in
which 10 lower secondary schools in Norway were recruited. The current article reports from a
qualitative study conducted in four lower secondary schools in four different Norwegian municipa-
lities drawn from the pool of schools included in the larger project. The preferred methodological
approach was qualitative.

Data Collection
In order to address the research questions, teachers’ and School principals’ experiences of collabor-
ation with ES were explored through focus groups and individual interviews respectively. The focus
groups were conducted in a meeting room at each school with a moderator present, and lasted 60–
75 min. The researcher allowed the conversation to flow and rich descriptions and examples of how
collaboration with ES was experienced, as well as the perceived relevance for teachers’ practice, were
generated. The individual interviews were conducted at the School principal’s office and lasted
between 45 and 60 min. A guide for both focus groups and interviews was developed with all par-
ticipants being asked the same key questions, as follows: “How do you collaborate with ES to support
pupils’ mental health?”; “what expectations do you have for your work with ES?”; and “Is there any-
thing you miss in your collaboration with ES today, and if so, what is preventing it from happening?”.
In order to gain a better understanding of the context of teachers’ collaboration with ES, the
researcher participated in inter-professional team meetings at each of the four schools in the period
of October 2016 – April 2017. The researcher observed the meetings and recorded field notes without
taking part in the discussion. (Data from these observations are, however, not included in the
analysis).
 SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH 5

Schools and Informants

The field work was conducted in four lower secondary schools in four different Norwegian munici-
palities. Schools were selected on the basis of differences in location and size. Although routines for
coordinated support of a particular pupil in need of assistance from several services was developed in
all of the municipalities, the schools differed in how they organized collaboration with ES and which
extended services they collaborated with on a regular basis. This held out the possibility of exploring
collaborative processes that might differ across schools and shed light on what might facilitate or
constrain such work. Table 1 shows the arrangements made in each school at the time the research
took place.
Six focus groups with a total of 36 teachers from the four schools were conducted in January-
June 2016. The focus groups were composed of 3–8 teachers. The teachers were recruited by the
school principal at each school based on specific criteria provided by the researcher, to ensure
that the groups were composed of those with different work experience, teaching in different
subjects at different levels. As a result, 17 male and 19 female teachers participated in the inter-
views, teaching at 8th. 9th, and 10th grade, and their teaching experience varied from 1 to 18
years. In the same period, individual interviews were conducted with each of the school
principals.

Table 1. Descriptions of participating schools, the municipalities in which they are located, and routines for collaboration with ES.
School 1 School 2 School 3 School 4
Area Eastern part of Norway Western part of Norway
Size of 30.000 residents 6000 residents 275 000 residents 5000 residents
municipality
Pupils (aged 360 230 420 200
13–16)
Teachers 31 28 34 27
employed
School School principal and School principal School principal and School principal
leadership assistant School three department
principal heads
Social workers Full time Full time Part time (80%) No social worker
employed at
school
School nurse’s 2 days a week 1 day a week 3 days a week 1 day a week
presence at
school
Weekly School principal (team School principal (team School principal, No weekly extended
extended leader), Psychiatric leader), Social worker department heads, school staff meeting
school staff nurse, School nurse, and School nurse special education
meetings Crime prevention needs teacher, social
involving: coordinator worker and School
nurse
Inter- Psychiatric nurse (team School principal (team School principal (team Special education needs
professional leader), Representatives leader), Social worker, leader) school nurse, teacher (team leader),
meetings of different social special education representatives of EPS, School nurse,
involving: services in the teacher, School nurse, police and child care representatives of child
municipality (incl. child representatives of child attending. Specific welfare and EPS,
welfare), police and welfare and EPS teachers invited when psychologist employed
EPS. (Psychiatric nurse is attending. Specific needed in the municipality.
the link between school teachers invited when Specific teachers
staff and participants in needed invited when needed
inter-professional
meetings)
Frequency of Weekly 4 times a year 4 times a year Every 5th week
inter-
professional
meetings:
6 E. N. MÆLAN ET AL.

Data Analysis
The individual interviews and focus groups were recorded and transcribed verbatim, and the data
were imported into NVivo-11. The coding process started with reading the transcripts and listening
to the audio files from interviews and focus groups, while noting down initial thoughts and reflec-
tions. In the next phase, meaningful units of text were identified and coded descriptively by the first
author (Kvale, 1996). To strengthen the validity of the coding process, transcripts were also read by
one of the co-authors. Descriptive codes were discussed on the basis of whether they analytically cov-
ered the data in the transcripts. Examples of meaningful units and codes related to each of the main
themes are included in the table below (Table 2).
The first author developed extracts of meaningful units and discussed initial codes with one of the
co-authors. Both transcripts and initial codes were written in Norwegian. The codes were discussed
and organized into themes, and translated into English. No new codes were added in the process of
discussing meaningful units and initial codes, however the initial codes were modified, expanded and
reorganized in order to move from descriptive codes to more analytic themes, inspired by the process
of first and second cycle coding by Saldaña (2013). Patterns between the initial codes were mapped in
the process of developing themes.

Ethical Considerations
The study was approved by the Norwegian Centre for Research Data (NSD). Written consent for
participation and for the use of audio recording was obtained from all the participants prior to
the interviews and the observations. The participants were informed that their participation was
voluntary and that they were free to withdraw from the study at any time. The teachers and school
principals attending the interviews were informed that their names and the school’s name would be
anonymized.

Findings
The section begins by providing an overview of how teachers viewed inter-professional work with
ES, focusing on their own involvement and relevance for their role as classroom teachers. Teachers
referred to how ES professionals asked them to provide information about their concerns relating
to how pupils were functioning at school, either by filling out questionnaires or referral forms, or
by participating in meetings with ES. School-based inter-professional meetings were set up to

Table 2. Meaningful units, initial codes and themes.

Meaningful unit: Initial code: Theme:
“Even after working in school for some years, I Need of more information on how to share Developing an understanding of
still need to be better informed of how responsibility teachers’ and ES professionals’
collaboration works: what the school is contributions
supposed to do and what to expect of
extended services”
“We know each other and that makes it easier Becoming familiar eases the process of Laying the foundations for inter-
to get in touch with professionals in contact professional collaboration
different ES”
“It is difficult for some pupils to build Teacher and mental health professionals Supporting pupils with mental
relationships with new people, and they working together to support pupils in the health problems in the
may find it difficult to talk to a mental health classroom by sharing knowledge and classroom
provider. If they have a trusting relationship expertise
with one of their teachers, the teacher could
support a young person with mental health
problems with guidance from a mental
health professional … that’s something I
really miss!”
 SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH 7

facilitate collaboration, by, for example, allowing participants to become familiar with the different
mental health services supporting schools and clarify “who does what”. Teachers and school prin-
cipals viewed the meetings as having this role, at least in theory. When it worked well, it was
because the meetings presented opportunities for teachers and school principals to discuss with
ES professionals how they could keep pupils with mental health problems engaged in school in
general and in their learning in particular. Such discussions tended to promote reflection on
how they could facilitate pupils’ everyday life in school in ways that could promote their recovery,
reduce pressure and re-engage them in learning. Nonetheless, in practice, because professionals’
participation in meetings varied and not all ES were represented, the full potential of meetings
was often not realized. While teachers found inter-professional work time consuming in a busy
school day with many tasks and demands, both teachers and school principals expressed a need
to collaborate with ES if they were to be able to support pupils effectively. On their own, teachers
struggled to keep pupils with mental health problems engaged in learning or prevent their pro-
blems from deteriorating, which was often the point at which they sought support from ES pro-
fessionals. However, referring a pupil to ES did not always give rise to the form of collaboration
they wanted.
Alongside these overarching concerns, teachers tended to view collaboration with ES as a way of
helping them broaden their own knowledge and skills in how to support pupils, because, as they saw
it, ES professionals had specialist expertise that they did not have but wanted to develop. Teachers
and School principals referred in particular to teachers’ need of better skills in supporting pupils who
were anxious, unhappy, or who were withdrawn in some way. Such skills were seen as relevant to
keeping pupils engaged in learning as well as preventing problems developing into more severe
difficulties and possibly leading to school absence. Teachers viewed ES professionals as wanting to
collaborate with them because of their familiarity with pupils and their everyday life in school.
They expressed the view that ES professionals needed to know about a pupil’s school situation if
they were to plan and implement initiatives that were likely to be helpful. In this regard, teachers
viewed inter-professional work as involving them in supporting the work of ES professionals as
well as seeing how ES professional could support them in their social and pedagogical work in
the classroom. This two way process – if and when it worked well – would support pupils and
keep them engaged in learning, they felt. Nevertheless, teachers did not always experience contact
with ES as productive in these ways, as we elaborate further in relation to three themes: (1) devel-
oping an understanding of teachers’ and ES professionals’ contributions, (2) laying the foundations
for inter-professional collaboration, and (3) supporting pupils with mental health problems in the
classroom.

Developing an Understanding of Teachers’ and ES Professionals’ Roles and

Responsibilities
In the first theme, teachers and School principals talked about how the teachers’ role in supporting
pupils’ mental health was experienced as diffuse and complex. Teachers said that they might hesitate
to engage in collaboration with ES professionals because they felt unsure of the different ES pro-
fessionals’ roles and responsibilities. In particular, they were concerned how they, as teachers,
could support a pupil with mental health problems alongside relating to services working with a par-
ticular pupil. Teachers were eager to develop a better understanding of the role of the different ES
and how they could contribute to supporting pupils in contact with ES, as Hans, a teacher in math-
ematics at school three, explained:
When I started to work as a teacher, I missed information about the role of the different services. When I was
responsible for a pupil with mental health problems for the first time, I had to learn this as part of the process of
supporting this particular pupil … And even after working in school for some years, I still need to be better
informed of how collaboration works: what the school is supposed to do and what to expect of extended
services.
8 E. N. MÆLAN ET AL.

In school one, where extended school staff meetings and inter-professional meetings were held on a
weekly basis, teachers could see that these organizational arrangements had both advantages and dis-
advantages. Pupil support could be provided quickly because the extended team was responsible for
referrals and knew who would be the appropriate ES professional to refer a pupil to. Furthermore,
teachers realized that a consequence of not having to attend these meetings was that it was more of a
challenge to work effectively alongside ES professionals, when they were unaware of the form, con-
tent and duration of the interventions provided for a pupil. In these circumstances, because they were
not sure what, if any, role they were expected to have, they said that they tended to assume that, hav-
ing identified the need for a referral and having made it, pupils’ mental health was being taken care of
by others. A consequence of this was that they also felt unsure about how they could contribute to
supporting pupils themselves in the classroom. This was also the likely outcome if ES professionals
did not directly ask for a teacher to contribute to the process of providing support. This notion of
“leaving it to someone else” is reflected in the quotation from Tone, a language teacher at school
three. It also illustrates how leaving a young person’s support to others was recognized as perhaps
not the most useful thing for a teacher to do, because it meant that they were then excluded from
knowing about pupils’ needs and how best to support them:
Sometimes we teachers think: “OK, at least other professionals are in contact with the pupil now. The problems
will be handled by someone who actually is a mental health professional, so I can focus on other tasks.” But this
attitude is actually not beneficial …

The inter-professional team was perceived as being an arena where they discussed and were
advised by ES professionals on how they (as teachers) could contribute to keeping a young per-
son who was being supported engaged in learning. However, the balance of the discussion tended
towards using most time on ES professionals’ contribution, rather than, for example, discussing
how teachers could provide a supportive learning climate for the young person. For teachers,
clarification of both the role and responsibilities of themselves and ES professionals with regard
to any particular young person was needed: if that happened then they could actively support a
young person they said.

Laying the Foundations for Inter-professional Collaboration

Teachers and school principals viewed collaboration with ES professionals as being more likely if
some time had already been spent developing and building relationships through processes above
and beyond specific case work with pupils. Familiarity with each other’s work, alongside the oppor-
tunity to simply get to know each other, was seen as the basis for a good inter-professional relation-
ship. Teachers valued knowing the person in ES to contact if they had a particular concern as it made
it easier to ask for support from them. Teachers talked about building such relationships through
working together on universal mental health initiatives. School two and four invited ES professionals
to contribute to initiatives such as mental health education or working to enhance the psychosocial
environment. Working together on these initiatives was described as a way of getting to know pro-
fessionals in different ES, as well as becoming more familiar with their knowledge and skills. In the
same way, ES professionals’ involvement in universal initiatives in school was also described as a way
they could become more familiar with the everyday life of school, have a chance to meet pupils and
school staff, and, in so doing, better understand teachers’ roles and responsibilities in the classroom.
This was viewed as beneficial for any subsequent liaison when a teacher referred a young person. An
especially beneficial outcome of this type of generic work in the minds of teachers and School prin-
cipals was that it made it more likely that ES professionals could better appreciate how teachers
might contribute to the support of a young person through the social and pedagogical environment
of the classroom. For example, teachers viewed collaborating with ES professionals as easier if they
felt they were familiar with teachers’ experiences and competence, as illustrated by Tore, a teacher in
science and mathematics at school four:
 SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH 9

Teachers’ have different experiences, depending on how many years they have worked as a teacher, and they
differ in how competent they feel they are in different situations. I collaborate better with a professional who
knows a bit about what kind of situations I feel I can manage, and the competence I have achieved through
working with pupils for several years.

Building relationships through various school-based processes such as those discussed above was
often undermined by staff turnover in ES. Talking specifically about the school nurse, Ingunn, a
language teacher at school one, explained how this had challenged relationship-building among tea-
chers and school principals, as well as having implications for how well pupils seeking support from
the school nurse could be supported:
The situation with the school nurse has not been optimal. How many have left their job at this school in the past
year? Two or three? Because it has been unstable, we have not been able to build a relationship with her before
she quits and another one is taking over her duties. And we encourage pupils to go and talk to the school nurse,
but after two conversations there is another change.

Although building inter-professional relationships was viewed by teachers and school principals as
important for improving collaboration, it was seen as taking time in a busy, hectic school day. Turn-
over among ES professionals, as well as reorganization of services was viewed as making things more
time consuming because recently established relationships could well be broken through such organ-
izational processes necessitating the re-forming of new relationships.

Supporting Pupils with Mental Health Problems in the Classroom

Teachers viewed the building of a trusting relationship with pupils as the foundation on which they
could work collaboratively with ES professionals. An ES professional could work with a teacher on
how to support a pupil in the classroom. This might be more effective as pupils are more likely to be
receptive and at ease with a known teacher compared to an unfamiliar ES professional. Teachers also
had the opportunity to integrate support into the daily life of the classroom. They argued that some
teachers were in a better position to support pupils’ mental health than others, based on the degree of
trust between them, which was viewed as an important aspect of providing support. An added benefit
of working in this way, was the reciprocal sharing of knowledge between teachers and ES pro-
fessionals. Stig, the school principal of school four, referred to pupils who had not managed to estab-
lish a relationship with an ES professional, and therefore had not been able to benefit from their
support. He described how a trusting relationship between a pupil and a teacher could be helpful:
It is difficult for some pupils to build relationships with new people, and they may find it difficult to talk to a
mental health provider. If they have a trusting relationship with one of their teachers, the teacher could support
a young person with mental health problems with guidance from a mental health professional … that’s some-
thing I really miss!

Teachers viewed their role in providing support in the classroom as being undermined because they
were not always informed how a young person in their class was being supported by ES professionals.
Teachers were eager to be informed about the content and form of what support was being provided,
as they thought it would help them think about how to engage the pupil in learning processes in a
way that was consistent and supportive of any other intervention being received. Knowing how to
support a pupil with anxiety was discussed in one focus group, as a specific example of how better
collaboration with ES – in particular, through better exchange of information and specific advice
from ES professionals – would be beneficial to teachers. In the absence of such alliances, teachers
felt themselves to be in somewhat of a dilemma about the extent to which such pupils could be
allowed to avoid situations in the classroom that might raise their levels of anxiety. While such
an approach might have some short term benefits, in the longer term this was seen as perhaps
not being in the best interests of pupils because it might exacerbate their anxiety. In the same
vein, they saw that feedback from ES was important if they were to monitor progress and adapt
their work, alongside making sure that their work was consistent with what was happening with
10 E. N. MÆLAN ET AL.

ES. Moreover, they wanted to be sufficiently informed about what was going on so that they could
consider their actions and their likely effects. For example, Anne, a teacher involved in special edu-
cation at school one said:
Let’s say that a pupil is having weekly conversations with the school nurse or a psychologist which is experi-
enced as helpful for improving the pupil’s self-esteem. However, if the pupil at the same time experiences being
overlooked and ignored by his teacher, the support from professionals is not likely to succeed. The teacher may
be afraid of exposing the pupil, but how can the pupil be helped to improve his self-esteem, if he gets an
impression of not even being liked by his teacher?

The lack of feedback regarding the content and form of support pupils were receiving was a recurring
feature of the teachers’ and school principals’ reflections on their experiences of working with ES,
which, in their view, limited how well the school in general and teachers in particular could collab-
orate with ES. Mari, for example, an art and language teacher in school three, said:
In inter-professional team meetings we usually talk about how things are going and what kind of mapping of
the pupil’s mental health problems is required. I do miss some guidance from extended services, as there is
usually not much time left to talk about how we can provide support for the pupil at school.

A consequence of this limited feedback, was that communication was perceived to be predominantly
one way, whereby teachers provided information for ES professionals without receiving anything in
return. In addition to lack of time for information exchange, teachers and School principals saw con-
fidentiality concerns as an explanation for the limited flow of information. However, Finn, a teacher
and social worker at school two explained that these could be overcome by involving parents in the
process:
When a pupil is referred to a mental health provider, we can ask the parents for their consent to the school’s
involvement in the process. We ask them to tell the mental health provider that the school wants to be involved,
so that our support of the pupil corresponds with support from the mental health provider.

Even when feedback was forthcoming from ES professionals, teachers and school principals found
the advice difficult to implement within the school context. For example, removing school – and
classroom-related stressors for a particular pupil was felt to be very difficult to fulfil. By way of illus-
trating this further, teachers in one school discussed how difficult it was to create a classroom climate
that did not emphasize academic achievement – as they had been advised by ES professionals – in
order to support a pupil who found this focus stressful. Trying to avoid discussions in class of pupils’
grades was difficult because, at least in part, pupils themselves compared grades and focused on their
achievements. A further dilemma was discussed in relation to the advice for meeting the needs of a
specific pupil and the tension this created in terms of teachers’ obligations towards the whole class.
This was understood generally as ES professionals not being fully cognizant of teachers’ professional
responsibilities. These notions relating to the challenge of implementing advice from ES pro-
fessionals is illustrated in the quotation from Elisabeth, a teacher in social studies and religion at
school three: “We cannot just drop everything and say that it (what they suggest we should do) is
okay. They, sort of, have an insufficient understanding of our profession”. Adapting advice to the
reality of the classroom was a particular challenge for teachers, as illustrated by this quotation
from Christian, a science teacher at school three: “After participating in meetings with ES, I’m
often thinking: ‘How on earth can I try to fix this in the classroom?’”.

Discussion
The specific contribution of this study was to explore how teachers and school principals experienced
collaboration with ES, and in what ways (if any) they perceived it as relevant to helping teachers sup-
port pupils through their everyday practices. Two processes were recognized as important for their
collaboration with ES. First, teachers valued initiatives that could help develop mutual understand-
ings of teachers’ and ES professionals’ roles and responsibilities. Second, they thought that initiatives
 SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH 11

to build inter-professional relationships could lay the foundation for inter-professional collabor-
ation. However, they also emphasized that ES professionals needed to adapt to teachers’ needs by
offering them appropriate help to support pupils in the classroom. Together these processes were
viewed as having the potential to enhance teachers’ capacity to support pupils in the classroom in
a consistent and sustained manner.

Experiences of Collaboration with ES: The Emphasis on Building Understandings of Roles

and Responsibilities and Inter-professional Relationships
The findings indicate that inter-professional relationships at both an organizational and an inter-
personal level were important for teachers’ collaboration with ES. First, inter-professional teams
were recognized as arenas for building relationships at an inter-organizational level. In particular,
these teams provided a mechanism for developing understandings of teachers’ and ES professionals’
roles and responsibilities. These findings are similar to those of earlier studies of ES professionals’
perceptions of collaboration (Ødegård & Strype, 2009; Ødegård & Willumsen, 2011). In each school,
school managers were involved in coordinating meetings and communicating with different ES pro-
fessionals, which has been recognized as promoting teachers’ involvement in inter-professional col-
laboration (Mellin et al., 2016). The findings from our study, however, indicate that even with
organizational support from school principals and frequent meetings, differing cultural values and
ambiguity over professional roles tended to prevail. These differences where likely to influence the
content, direction and outcomes of meetings. However, the findings of the current study indicate
that participants in school-based inter-professional meetings tended to spend more time discussing
how ES professionals could support pupils with mental health problems, rather than discussing how
teachers could support them. This is in line with previous studies indicating that teachers tend to
understand their primary role in mental health promotion as gatekeepers (Ekornes, 2015; Mellin
et al., 2016). The findings are also consistent with studies showing that teachers tend to consult
ES about pupils’ mental health needs rather than on how to support a pupil in the classroom (Berzin
et al., 2011; Franklin et al., 2012).
However, teachers participating in this study recognized the importance of keeping pupils
engaged in learning to prevent problems deteriorating, and wanted to enhance their capacity to sup-
port pupils’ referred to ES. The fact that inter-professional discussions rarely focused on teachers
providing support in the classroom, might be due to teachers’ lack of knowledge and skills in adapt-
ing their teaching to pupils’ needs (Ekornes, 2015; Nordahl & Hausstätter, 2009). Perhaps more
likely, is a knowledge gap for both teachers and ES professionals regarding how teachers can contrib-
ute to supporting pupils in the classroom (Phillippo & Blosser, 2017). School-based inter-pro-
fessional meetings were spoken of as collaborative meetings. They seemed, however, to primarily
be concerned with ensuring pupils were supported by ES professionals rather than be a forum for
promoting collaborative processes between teachers and ES professionals. The limited focus on
how teachers could support pupils through practices of teaching and learning might reflect the
long tradition of providing individualized support among different ES (Fasting, 2015). This illus-
trates cultural differences in how participants in school-based inter-professional meetings under-
stand their roles, as well as differences in understanding and conceptualizing collaboration (Easen
et al., 2000). The challenge for teachers is to integrate suggestions for individualized support within
an everyday context in which teaching a whole class takes precedence.
Second, processes for developing familiarity between teachers and ES professionals were empha-
sized as a way of building a foundation for collaboration. The findings of this study suggest that tea-
chers might tend to leave the responsibility for supporting a pupil with mental health problems to ES
professionals in a busy school day. This is consistent with previous studies indicating that the pres-
ence of ES professionals in schools (Spratt et al., 2006), as well as schools’ limited resources and
intense academic pressures (Weist et al., 2012) can lead teachers to prioritize other tasks. However,
this study found that teachers and ES professionals were more likely to collaborate when they were
12 E. N. MÆLAN ET AL.

able to develop a relationship based on respect and trust, a finding that is consistent with other
research (Mellin et al., 2016; Moran & Bodenhorn, 2015; Rothì et al., 2008). Furthermore, when
both teachers and ES professionals were familiar with each other’s work experiences and skills,
they could exploit their combined competence, and discuss how teachers could support a pupil
through their social and pedagogical practices.

Relevance of ES Collaboration for Teachers’ Practice: Integration or Working in Parallel to

Support Pupils?
Teachers in this study wanted to enhance their capacity to support pupils with mental health pro-
blems, and collaboration with ES professionals was viewed as a way to increase their knowledge
and skills. They also emphasized the importance of consistency in teachers’ and ES professionals’
support of a pupil. In order for this to happen, they emphasized the importance of feedback from
ES, as well as guidance relevant to teachers’ practice in the classroom. However, the limited feedback
from ES professionals that teachers often experienced suggests some uncertainty about whether or
not providing feedback and guidance for teachers is part of ES professionals’ responsibility. Further-
more, in line with previous studies (Ahtola & Niemi, 2014; Fylling & Handegård, 2009; Hustad et al.,
2013), the findings indicate that teachers and school principals experience professionals in EPS, as
well as professionals in other ES, as somewhat distanced from teachers’ social and pedagogical prac-
tices. Although EPS has a specific responsibility for developing knowledge and skills in schools
(Opplæringslova [Education Act], 1998, § 5–6), under the current organizational arrangements
they seemed limited in their capacity to adapt to the teachers’ needs in terms of helping them support
pupils in the classroom. The challenge for teachers seems to be to integrate suggestions for indivi-
dualized support within an everyday context in which teaching a whole class takes precedence. Pla-
cing more emphasis on pupils’ everyday life in school during school-based inter-professional
meetings could increase teachers’ ability to support pupils in the classroom, as well as reduce tea-
chers’ perceived stress related to the gap between their own competence and pupils’ needs (Ekornes,
2016).
Confidentiality concerns have been identified in previous studies as being a potential impediment
to ES professionals giving feedback to teachers (Phillippo & Kelly, 2014; Spratt et al., 2006; Weist
et al., 2012). However, in this study teachers thought this could be solved through gaining consent
from parents for sharing information among teachers and ES professionals. What was viewed as
more important for teachers, was that they received feedback and guidance from ES professionals
that they were able to implement in the classroom. This was more likely to happen when they
had established an inter-professional relationship with ES professionals who had become familiar
with the teachers’ experiences and competence, as well as pupils’ school context. Although establish-
ing inter-professional relationships are viewed as time consuming (Mellin et al., 2016; Ødegård &
Strype, 2009), it seemed to promote collaborative processes. It also gave ES professionals opportu-
nities to anchor their work in a trusting relationship between a pupil with mental health problems
and his/her teacher.

Methodological Limitations and Strengths

This study has a number of limitations that future research will need to address. Three points should
be noted about the study. First, the data were transcribed, coded and themes identified by the first
author. To enhance this process the transcriptions were reviewed by one of the co-authors, and a
detailed description of the processes of collecting and analyzing data was included to enhance trust-
worthiness. Second, the study was conducted in four Norwegian lower secondary schools with a rela-
tively small sample of informants. In keeping with a qualitative approach, the selection of schools
and participants was purposiveThe third limitation of the study is the recruitment of participants.
The teachers participating in the focus groups were recruited by the school principals, and there
 SCANDINAVIAN JOURNAL OF EDUCATIONAL RESEARCH 13

may have been some selection bias introduced with participants having an interest in pupils’ mental
health being more likely to have been chosen and/or agree to participate.

Implications for Policy and Practice

National guidelines identify the need for collaboration between teachers and ES professionals if the
goal of comprehensive and coherent services for pupils with mental health problems is to be achieved
(The Norwegian Directorate of Health, 2007). The findings of this study indicate that to achieve this
goal it would be beneficial if time was invested in building relationships during collaborative meet-
ings. Clarification of values and roles as part of an ongoing process of inter-professional familiariz-
ation also seemed important. This would require a shift in emphasis away from a primary focus on
ES-led discussion of individual pupil support towards a focus on inter-professional working prac-
tices. Furthermore, this shift could also create some space for teachers and ES professionals to
explore how teachers could support pupils with mental health problems in the classroom alongside
teaching. Organizational support from school principals to shift the purpose and focus of collabora-
tive meetings in these ways could be particularly advantageous. The current study did not differen-
tiate between different support services. In Norway, the EPS has more competence and a stronger
obligation to offer practical pedagogical guidance to teachers, while the competence and obligation
of mental health services are more directed towards therapeutic interventions. However, the EPS
tends to give priority to pupils with learning difficulties rather than mental health problems. If
this latter group of pupils is to be better supported, then it is likely that changes to the current organ-
ization of support systems and/or a shift of competence within the different systems will be required.
Given the limited empirical research examining schools’ work with ES, especially in Norway, further
research is needed to explore how school-based inter-professional collaboration could be improved.
In particular, ES professionals’ experiences of school-based work could be elaborated in future
research, especially in relation to different support services.

Disclosure Statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by Norges Forskningsråd: [Grant Number 238212/F60].

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 Advances in School Mental Health Promotion

ISSN: 1754-730X (Print) 2049-8535 (Online) Journal homepage: http://www.tandfonline.com/loi/rasm20

Teachers’ experiences collaborating in expanded

school mental health: implications for practice,
policy and research

Elizabeth A. Mellin, Annahita Ball, Aidyn Iachini, Nicole Togno & Ana Maria
Rodriguez

To cite this article: Elizabeth A. Mellin, Annahita Ball, Aidyn Iachini, Nicole Togno & Ana Maria
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 Advances in School Mental Health Promotion, 2017
VOL. 10, NO. 1, 85–98
http://dx.doi.org/10.1080/1754730X.2016.1246194

Teachers’ experiences collaborating in expanded school

mental health: implications for practice, policy and research
Elizabeth A. Mellina, Annahita Ballb, Aidyn Iachinic, Nicole Tognod and
Ana Maria Rodrigueza
a
College of Community and Public Affairs, Binghamton University, Binghamton, NY, USA; bSchool of Social
Work, University at Buffalo, Buffalo, NY, USA; cCollege of Social Work, University of South Carolina, Columbia,
SC, USA; dCollege of Education and Human Development, George Mason University, Washington, DC, USA
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ABSTRACT ARTICLE HISTORY

Teachers are critical partners in expanded school mental health Received 15 March 2016
(ESMH) collaborations that aim to bring educators, community mental Accepted 27 July 2016
health professionals and families together to leverage expertise and
KEYWORDS
resources for addressing non-academic barriers to learning. Although Teachers; collaboration;
teachers are in a unique position to observe the day-to-day mental expanded school mental
health needs of students, their roles in ESMH collaborations have been health; social capital;
largely ignored leaving little research-based guidance for maximizing community mental health
this practice strategy. To address this gap, this study explored 384 professionals
teachers’ experiences with ESMH collaboration including the types
of collaborations they are engaged in, what influences those
relationships and what they perceive to be the benefits of this practice
strategy. The findings support previous conceptual and research
contributions focused on collaboration, as well as suggest some
specific influences on collaborative relationships between teachers
and community mental health professionals. Implications for practice,
policy and research are offered.

The relationship between student mental health and academic outcomes is well documented
(Baskin, Slaten, Sorenson, & Glover-Russel, 2010). Teachers, by nature of their role, have day-
to-day interactions with students and are in an exceptional position to observe and identify
their mental health needs (Ball & Anderson-Butcher, 2014; Ekornes, 2015; Weston, Anderson-
Butcher, & Burke, 2008). Pre-service and in-service preparation for teachers in this area,
however, is limited (Koller & Bertel, 2006), despite the increasing reliance on teachers as
gatekeepers for identifying and accessing mental health services for students (Ball, Anderson-
Butcher, Mellin, & Green, 2010). As a result, teachers are often aware of the non-academic
barriers to learning that their students experience, yet report feeling overwhelmed, conflicted,
stressed and unsure of how to support students experiencing difficulty (Anderson-Butcher,
2006; Graham, Phelps, Maddison, & Fitzgerald, 2011; Koller, Osterlind, Paris, & Weston, 2004).
Insufficient preparation coupled with conflicting feelings about m ­ ental health concerns may
limit teachers’ involvement in the identification and access to services for their students.

CONTACT  Elizabeth A. Mellin  emellin@binghamton.edu

© 2016 The Clifford Beers Foundation
 86    E. A. Mellin et al.

Expanded school mental health (ESMH), however, is a service model that has the potential
to address these barriers. ESMH builds on the combined resources and assets of schools and
communities to offer comprehensive mental health promotion, early intervention and treat-
ment programmes for students (Weist, 1997). Collaboration between school professionals
(e.g. teachers, administrators and/or nurses) and community mental health professionals
(e.g. counsellors, psychologists and/or social workers) is a key feature of ESMH (Weist, 1997).
Although research on ESMH collaboration is increasing (Ekornes, 2015; Iachini, Anderson-
Butcher, & Mellin, 2013; Mellin, Anderson-Butcher, & Bronstein, 2011; Mellin, Taylor, & Weist,
2014; Mellin, Taylor, Weist, & Lockhart, 2015; Mellin & Weist, 2011; Mellin et al., 2010), the
experiences of teachers in these collaborations have largely been understudied. Using a
social capital lens, this paper aims to examine the ways in which teachers are collaborating
in ESMH, what influences those collaborative relationships and what they perceive to be the
benefits of this practice strategy.
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Conceptual framework for ESMH collaboration

Social capital refers to the kind of relationships that are established among members of a
group who share common goals (Putman, 2000). These relationships are based on trust and
on the creation of effective networks that can mobilize ideas and resources for addressing
shared goals (Putman, 2000), such as student mental health needs. In the context of ESMH,
social capital is typically mobilized through collaborations among schools, families and com-
munities (Mellin & Weist, 2011) to address non-academic barriers to learning. From a social
capital perspective, these collaborations also foster social closure (Coleman, 1988), or
­contexts in which important adults in the lives of children know each other and can coor-
dinate their actions (Warren, 2005). Social closure ensures that non-academic barriers to
learning can be approached holistically with a unified set of expectations (Warren, 2005). In
addition to social closure, social capital theory also suggests three types of collaborative
relationships that are critical for mobilizing necessary expertise and resources to address
student needs (Forbes, 2009; Mellin, 2010; Mellin & Weist, 2011).
Bonding social capital focuses on the quality of relationships and connections among
people of similar groups (Putman, 2000). This form of collaboration is typically characterized
by strong, horizontal ties that facilitate the exchange of available resources among members
of a homogeneous group (Putman, 2000), for example, among teachers within a school
(Forbes, 2009). The trust established in bonding social capital is a necessary precursor to
bridging social capital that establishes connections to professionals and organizations out-
side of the school (Forbes, 2009; Mellin, Belknap, Brodie, & Keim, 2015). Bridging social capital,
which is characterized by weaker, horizontal ties, connects people from varying professional
and organizational groups who have access to different expertise and resources (Forbes,
2009). For example, community mental health professionals may develop strong collabora-
tive partnerships with teachers (Jaycox et al., 2010) in order to deliver specific intervention
programming based on school needs. Bridging social capital facilitates the diversification
of resources and expertise to address ESMH issues (Mellin & Weist, 2011; Mellin et al., 2016).
Lastly, linking social capital seeks to establish vertical relationships among people in different
power or status positions with a wider access to new ideas and resources (Halpern, 2005)
for addressing the needs of students across systems. In schools, linking social capital is
 Advances in School Mental Health Promotion   87

typically generated through collaborative relationships between teachers and families

(Mellin & Weist, 2011; Mellin et al., 2016; Warren, 2005).
Social capital provides a framework to conceptualize ESMH collaboration (see Mellin &
Weist, 2011 for a more complete discussion of social capital theory as a conceptual framework
for ESMH collaboration). Bonding, bridging and linking social capital facilitate the under-
standing of the different kinds of relationships that take place among professionals and
families, inside the school and outside of the school walls, as well as ideas about what shapes
those relationships and associated outcomes. These collaborative relationships can lead to
more focused, coordinated and efficient approaches for addressing non-academic barriers
to learning. This conceptual framework, therefore, provides a starting place for understand-
ing teachers’ experiences with various types of ESMH collaborations, influences on those
relationships and perceptions of how they relate to student-level outcomes.
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Teachers, ESMH collaboration and social capital

Given that collaboration among varying professional groups and families is a key feature of
ESMH (Mellin, 2009), much of the literature can be conceptualized from a social capital
perspective. In ESMH practice, community mental health professionals work in and with
schools to augment services provided by traditional school mental health professionals (e.g.
school counsellors, school psychologists and school social workers). This helps expand the
supports available to students who are especially in need of targeted or indicated interven-
tions to address more significant mental health problems (Weist, 1997). In this practice
model, collaboration is believed to generate the expertise and resources (or social capital)
necessary to prevent or address complex, non-academic barriers to learning, such as depres-
sion, substance use or interpersonal violence, that often cross multiple systems (e.g. schools,
mental health and juvenile justice; Mellin & Weist, 2011). As a part of ESMH practice, teachers
routinely collaborate to build social capital with other school professionals (bonding social
capital), community mental health professionals (bridging social capital) and/or families
(linking social capital) to address mental health needs of students. Such collaborations hap-
pen in a variety of different contexts including informal or formal identification and referral
systems (Ball et al., 2010), consultations (Michael, Bernstein, Owens, Albright, & Anderson-
Butcher, 2014) or participation on school-based teams (e.g. student assistance teams, teacher
assistance teams and/or school improvement teams; Iachini et al., 2013; Markle, Splett, Maras,
& Weston, 2014).
Although there are multiple ways in which teachers might collaborate in ESMH, there
are a number of potential challenges to this seemingly simple, and commonly assumed
beneficial, practice strategy. Several scholars have identified challenges to collaboration,
or the generation of different types of social capital. With space limitations being a practical
concern for schools, community mental health providers often struggle to find private
meeting places (Mellin et al., 2014; Weist et al., 2012) or are relegated to offices in corners
of the school where they are largely invisible to teachers and other collaborators. Visibility
issues, combined with a frequent lack of understanding of school culture among commu-
nity mental health providers (Ekornes, 2015; Paternite, Weist, Axelrod, Anderson-Butcher,
& Weston, 2006) may be obstacles to the development of bridging social capital with
teachers. Ekornes (2015) and Mellin and Weist (2011) both found that different expectations
regarding communication and confidentiality, along with insufficient support for focusing
 88    E. A. Mellin et al.

on student mental health by school administrators, challenge the ability of school and
community mental health professionals to build bridging social capital. Other authors
have indicated that trust and mutual respect (Mellin & Weist, 2011; Mellin et al., 2010) are
important aspects of ESMH collaboration. Lastly, although ESMH literature often positions
families as important partners in collaborative research, more recent research suggests
that practitioners may not view families as members of their collaborations (Mellin et al.,
2010). Although more research is needed to understand whether and how families are
included in ESMH collaborations, the gap between rhetoric and research signals an impor-
tant impediment to the development of linking social capital between teachers and
families.
ESMH scholars have also discussed the benefits of collaboration; however, most appear
to be specific to school outcomes (Mellin, 2009) rather than youth, family or community
outcomes. Collaboration, according to Weist, Proescher, Prodente, Ambrose, and Waxman
(2001), can provide support to school systems that are overwhelmed by accountability
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demands and the escalating needs of students. Improved accessibility (Mellin & Weist, 2011)
and increased resources (Porter, Epp, & Bryant, 2000) are also hypothesized benefits of col-
laboration. Another study highlights the relationship between ESMH and declines in referrals
to special education (Walrath, Bruns, Anderson, Glass-Siegal, & Weist, 2004). These outcomes
seem to suggest the important role of social capital for school systems and, perhaps, teachers.
In addition to system-level outcomes, some have suggested that collaboration could actually
improve functional outcomes for youth (Lever et al., 2003) and increase family engagement
in schools (Anderson-Butcher & Ashton, 2004; Bickham, Pizarro, Warner, Rosenthal, & Weist,
1998). More recent research indicates that school professionals, including teachers, do
perceive collaboration, or social capital, as contributing to school-, youth- and family-level
outcomes (Mellin & Weist, 2011). These outcomes seem to reflect the potential benefits of
social capital to ESMH efforts to support youth.

The current study

Although teachers are considered important collaborators in ESMH, the literature is domi-
nated by conceptual contributions while research-informed strategies for strengthening
collaboration are lacking. Studying the experiences of teachers as collaborators in ESMH
through a social capital lens is particularly important for three reasons. First, collaboration
is critical to ESMH practice, yet relationships between teachers and their collaborators have
received little attention. Although anecdotal accounts and practice experience provide some
insights into the variety of ways teachers collaborate in ESMH, more research is needed in
this area. Second, interventions for strengthening collaboration rest on research-based
understandings of what influences this practice strategy. Applied research that provides
practical suggestions for maximizing collaboration across professional groups is critical for
advancing practice and supporting pre- and in-service teachers. Lastly, understanding the
perceived benefits of collaboration between teachers and community mental health pro-
fessionals in ESMH may highlight likely pathways between this practice approach and
improvements in student-level outcomes. To address this need and to contribute to the
growing literature on the teaching workforce in ESMH, this manuscript presents the results
of an exploratory (i.e. there were no a priori hypotheses) quantitative study that examined
the following research questions:
 Advances in School Mental Health Promotion   89

(1)  How are teachers collaborating in ESMH?

(2)  What influences teachers’ participation in ESMH collaboration?
(3)  What do teachers perceive as the benefits of collaboration?

Methods
Participants
The sample for this study included 384 teachers involved in ESMH collaborations. Females
accounted for 77% (n = 292) of the respondents. The average age of participants was 43 years
old with a range from 22 to 70 years old. The level of school participants reported working
in included 47% (n = 167) elementary schools, 7% (n = 25) elementary/middle schools, 15%
(n = 53) middle schools and 31% (n = 111) high schools. The average number of total years
of experience working in schools for this sample was 16 with the average years of experience
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at their current school being 11. Lastly, participants reported that their schools were located
in diverse communities: 56% (n = 201) reported working in rural communities, 16% (n = 57)
reported working in suburban communities and 28% (n = 99) reported working in urban
communities.

Instrument
The ESMH Collaboration Instrument, School Version (ESMHCI [SV]; Mellin et al., 2014) was
used to examine teachers’ experiences with collaboration. This instrument measures per-
ceptions of collaboration between school professionals and mental health professionals
from collaborating agencies. The ESMHCI [SV] includes 70 items that make up three scales
(Types of Collaboration, Influences on Collaboration and Perceived Benefits of Collaboration).
The Types of Collaboration scale includes three subscales organized by the different types
of social capital: Collaboration with Other School Colleagues (Bonding Social Capital);
Collaboration with Community Mental Health Professionals (Bridging Social Capital); and
Collaboration with Families (Linking Social Capital). Subscales and items for the Influences
on Collaboration (outreach and approach by mental health professionals from collaborating
agencies, interpersonal processes, school outreach to communities and families and school
administrator support) and Perceived Benefits of Collaboration scales (support for students
and teachers, increased mental health programming, improved access for students and
families and improved family–school relationships) were developed based on focus groups
with ESMH professionals (Mellin & Weist, 2011). Sample items for each of the three scales
include, ‘In my role as a school professional, I coordinate efforts to increase family involve-
ment with community mental health professionals’ (Types of Collaboration); ‘Community
mental health professionals who work in this school make an effort to build relationships
with teachers’ (Influences on Collaboration); and ‘During the past year as a result of collab-
oration between school and community mental health professionals, stress among teachers
has decreased’ (Perceived Benefits of Collaboration). Each scales uses one of two, four-point
Likert-type response ranges (1 = Never to 4 = Often for Types of Collaboration; 1 = Strongly
Disagree to 4 = Strongly Agree for Influences on Collaboration and Perceived Benefits of
Collaboration). Cronbach’s alpha for the scales and subscales of the ESMHCI [SV] are pre-
sented on the diagonal (bold print in Table 1). Content validity and pilot testing of the
 Downloaded by [University of Florida] at 11:42 07 August 2017

90 
  E. A. Mellin et al.

Table 1. Descriptive statistics and bivariate correlations (N = 384).

Variable M (SD) 1 2 3 4 5 6 7 8 9 10 11
1. Outreach and approach 3.22 (.51) .935
2. Interpersonal processes 3.32 (.63) .766** .966
3. School outreach 3.49 (.55) .422** .471** .935
4. School administrator support 3.26 (.55) .507** .525** .550** .922
5. Collaboration with CMH prof. 2.73 (.79) .408** .361** .197** .276** .948
6. Collaboration with families 2.58 (.76) .135** .183** .284** .194** .427** .888
7. Collaboration with school clgs 3.36 (.53) .178** .231** .203** .219** .545** .540** .771
8. Support for students and tchrs 2.87 (.55) .651** .633** .418** .490** .339** .196** .168** .900
9. Increased mental health prgm 2.98 (.58) .529** .459** .349** .393** .234** .165** .151** .759** .923
10. Improved access 3.08 (.53) .558** .510** .378** .409** .291** .214** .145** .656** .721** .831
11. Improved family–school rel 2.86 (.58) .551** .538** .459** .425** .232** .227** .150** .735** .685** .634** .902
Note: The range for all variables was 1–4, with higher scores indicating more positive responses.
**p < 0.01. Internal consistency estimates (α) are presented on the diagonal in bold type.
 Advances in School Mental Health Promotion   91

instrument were based on the well-established guidelines of DeVellis (2012) and resulted
in the deletion of 15 items, revision of 3 items and addition of 11 items. For complete details
about this process, please see Mellin et al., 2014.

Procedures
An Institutional Review Board (IRB) granted Human Subjects approval for this study. The
instrument was distributed via an online data collection tool to a self-identified and voluntary
sample of teachers through the listserv of the University of Maryland Center for School
Mental Health (CSMH). A link to the informed consent, instrument and invitation to enter a
drawing to win a $15 gift card was distributed via email. Follow-up messages were sent 7
and 14 days after the initial recruitment message was emailed. Other colleagues also
­forwarded the recruitment email to professionals involved in ESMH collaborations and
­additional school districts collected data associated with their collaborative programmes
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(IRB approved). Eligibility criteria for this study included being 18 years of age or over and a
self-identified practising teacher involved in ESMH collaboration.

Data analysis
Data management and analysis was completed using SPSS 21.0 for Mac. Descriptive statistics
were completed, as well as bivariate correlations examined, for each of the study variables.
Additionally, this study used canonical correlation (Tabachnick & Fidell, 2007) to examine the
relationship between factors on Influences on Collaboration and Types of Collaboration scales.
CCA is a statistical technique that creates two linear combinations, or canonical variates, of
the study variables. The predictor variables form the first set while the criterion variables form
the second set. The correlation between the two sets of variables is then maximized by the
canonical analysis allowing for the concurrent examination of several dependent and inde-
pendent variables (Sherry & Henson, 2005). CCA also reduces the likelihood of Type I error
(Sherry & Henson, 2005). The sample size of 384 was adequate for these types of analyses, as
approximately 10 cases per variable are recommended (Tabachnick & Fidell, 2007).

Results
Summary descriptive data and bivariate correlations are presented in Table 1. For clarity, the
following results are organized by research question.

(1)  How are teachers collaborating in ESMH?

Overall, across the three types of collaboration subscales, teachers in this study indicated
they most often engage in Collaboration with other School Colleagues. Teachers reported
collaborating with other school colleagues (M = 3.76, SD = .47), community mental health
professionals (M = 3.00, SD = .85) and families (M = 3.27, SD = .80) as they consult about
student needs. Collaboration with other School Colleagues (M = 2.98, SD = .79) as well as
Collaboration with Families (M = 2.28, SD = .94) were less frequently focused on intervening
in student crises. Lastly, Collaboration with Community Mental Health Professionals that cen-
tred on the delivery of student mental health services (e.g. group counselling; classroom
prevention activities; M = 1.95; SD = .86) was reported least frequently.
 92    E. A. Mellin et al.

(2)  What influences teachers’ participation in ESMH collaboration?

Descriptive statistics and the CCA provided insight related to the influences of teachers’
participation in ESMH collaboration. Teachers in this study indicated higher levels of agree-
ment with the four subscales included within the Influences on Collaboration scale. In terms
of Outreach and Approach by Community Mental Health Professionals, teachers agreed that
the extent to which these professionals are visible in schools (M = 3.43; SD = .64), support
the collaboration of families and school staff (M = 3.38; SD = .63) and act like they belong in
the school (M = 3.38; SD = .65) influence collaboration. Teachers in this study also indicated
that mutual respect (M = 3.47; SD = .66), liking one another (M = 3.43; SD = .63) and having
similar priorities (M = 3.37; SD = .71) are important Interpersonal Processes that influence
collaboration. In terms of School Outreach to Communities and Families, teachers expressed
higher levels of agreement that welcoming community involvement (M = 3.55; SD = .61),
having a friendly environment (M = 3.54; SD = .64) and valuing family involvement (M = 3.52;
SD = .64) influence ESMH collaboration. Finally, teachers in this study agreed that School
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Administrator Support, particularly as it relates to supporting (M = 3.46; SD = .57), commu-

nicating with (M = 3.37; SD = .60) and advocating on behalf of (M = 3.33; SD = .64) community
mental health professionals, influences ESMH collaboration.
The relationships among the major scales (Types of Collaboration, Influences on
Collaboration and Perceived Benefits of Collaboration) were statistically significant and in
the positive direction. In addition, the influences on collaboration were significantly and
positively related to each of the other influences; the same was true for the types of collab-
oration and benefits of collaboration. Notably, none of the statistically significant correlations
in the preliminary analysis reached a level of concern for potential multicollinearity
(Tabachnick & Fidell, 2007), yet it will be important to consider the effects of multicollinearity
when further interpreting the canonical correlation analysis.
The CCA additionally identified important influences on ESMH collaboration. Outreach
and Approach by Community Mental Health Professionals, Interpersonal Processes, School
Outreach and School Administrator Support served as the predictor variables and the three
types of collaboration (Collaboration with Community Mental Health Professionals,
Collaboration with School Colleagues and Collaboration with Families) served as the criterion
variables. The CCA revealed two statistically significant functions (p < .001) with squared
canonical correlations of .17 (Rc = .42) and .07 (Rc = .28). Only the squared canonical correlation
value of the first function met the 10% criterion for overlap in variance deemed as meaningful
by Tabachnik and Fidell (2007). As such, only the first function was interpreted.
Across both functions, the full model was statistically significant (Wilk’s λ = .75,
F(12, 992.45) = 9.46, p < .001). Because 1 – λ yields the full model effect size, the Wilk’s λ
represents the variance unexplained by the model. The two canonical functions explained
25% of the variance shared between the variable sets.
Canonical loadings indicate the contribution of each variable to the multivariate relation-
ships in Function 1. Table 2 presents the standardized canonical function coefficients, structure
coefficients, as well as the squared structure coefficients for the function. Structure coefficients
above .45 are noted in bold type to show the variables deemed useful for interpretation
(Sherry & Henson, 2005). In addition, Tabachnik and Fidell (2007) indicate that structure coef-
ficients greater than .30 are acceptable for interpretation. The canonical loadings indicated
that Collaboration with Community Mental Health Professionals (rs = 1.34) was the only criterion
variable that contributed to the multivariate relationship, while Outreach and Approach by
 Advances in School Mental Health Promotion   93

Table 2. Canonical solution for influence on collaboration predicting types of collaborations for function
1 (N = 384).
Variable Coef rs rs2 (%)
Predictor variables
Outreach and approach .77 1.50 225.00
Interpersonal processes .21 .33 10.89
School outreach −.11 −.21 4.41
School administrator support .34 .35 12.25
Rc2 17.76
Criterion variables
Collaboration with CMH professionals 1.06 1.34 179.56
Collaboration with families −.07 −.10 1.00
Collaboration with school colleagues −.06 −.12 1.40
Note: Structure coefficients (rs) greater than |.45| are in bold. Coef  =  standardized canonical function coefficient;
rs = structure coefficient; rs2 = squared structure coefficient.

Community Mental Health Professionals (rs = 1.50), School Administrator Support (rs = .35) and
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Interpersonal Processes (rs = .33) were meaningful predictor variables in the set. These relation-
ships were all in the positive direction, indicating that teachers who reported greater outreach
and approach by community mental health professionals, greater school administrator sup-
port and higher quality interpersonal processes also reported more collaboration with com-
munity mental health professionals. Still, Outreach and Approach by Community Mental Health
Professionals was the most relevant predictor variable in the set (rs2 = 179.56).

(3)  What do teachers perceive as the benefits of collaboration?

Lastly, responding to the Perceived Benefits of Collaboration scale, teachers in this study
agreed that this practice strategy contributes to support for teachers and students, increased
mental health programming, improved access for students and families, as well as improved
family–school relationships. Responding to the Support for Teachers and Students subscale,
teachers expressed higher levels of agreement that these relationships may contribute to
more consistent expectations for students (M = 3.01; SD = .67), students being less likely to
slip through the cracks (M = 2.98; SD = .66) and more support for teachers (M = 2.95; SD = .71).
In terms of Increased Mental Health Programming, teachers agreed that they have observed
improvements in service quality (M = 3.07; SD = .64) as well as increases in mental health
programming (M = 3.02; SD = .64) and resources (M = 3.01; SD = .68) as a result of their ESMH
collaborations. Responding to the Increased Access for Students and Families scale, teachers
agreed that increased student access to mental health programming (M = 3.12; SD = .64)
was a likely outcome of their collaborations in ESMH. Finally, in terms of Improved Family–
School Relationships, teachers indicated they have observed that families feel more empow-
ered to support their children’s school behaviours (M = 2.92; SD = .64) as an outcome of
ESMH collaboration.

Discussion
This study explored teachers’ experiences with ESMH collaboration including the types of
collaborations they are engaged in, what influences those relationships and what they per-
ceive to be the benefits of this practice strategy. The findings support previous conceptual
and research contributions focused on these aspects of collaboration and suggest specific
influences on collaborative relationships between teachers and community mental health
professionals.
 94    E. A. Mellin et al.

Teachers’ experiences collaborating in ESMH

Teachers in this study reported routinely collaborating, or building social capital, with a
number of professionals and families as they address students’ mental health concerns.
Teachers reported most frequently collaborating with other school colleagues (bonding
social capital), community mental health professionals (bridging social capital) and families
(linking social capital) as they consulted about student needs; this finding is consistent with
previous literature citing the role of teachers as gatekeepers to identifying and accessing
mental health services for youth (Ball et al., 2010; Ekornes, 2015). Teachers in this study also
reported less frequent collaboration in the delivery of mental health services (including crisis
intervention); this finding appropriately reinforces professional roles, especially based on
the limited training teachers are given as it relates to student mental health (Koller & Bertel,
2006). Overall, teachers in this study reported stronger ties to other school colleagues and
weaker ties to community mental health professionals and families. Consistent with social
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capital theory (Coleman, 1988; Putman, 2000), it is likely that the strong relationships among
teachers and other professionals within a school (bonding social capital) provide the foun-
dation of trust necessary to bridge out to other professionals in the community as well as
to link to families.
This study also indicated that the outreach and approach of providers substantially
­influenced teachers’ perceptions of their collaboration with community mental health pro-
fessionals. Both schools and community mental health agencies must be attuned to the
implicit and explicit processes and assumptions that undergird ESMH collaboration, as is
also highlighted in previous research (e.g. Ekornes, 2015; Paternite et al., 2006). Notably,
results also indicated that interpersonal influences and school administrator support are
related to teachers’ collaborations with community mental health professionals, pointing to
the importance of trust, communication and respect, findings which are consistent with
other studies on ESMH collaboration (Mellin et al., 2010, 2011; Mellin & Weist, 2011). It is also
notable that findings revealed collaboration with families and collaboration with school
colleagues were not significant criterion variables in this investigation. Lastly, existing
research points to the critical role that teachers have in collaborating with families and school
colleagues (e.g. Bickham et al., 1998); yet, it is possible that other factors influence these
relationships, such as those more specifically related to teacher–family relationships and
inter-school politics.
Teachers in this study also agreed with many of the benefits of ESMH collaboration
advanced in the literature. In particular, teachers identified the contribution of these collab-
orations to family engagement (Anderson-Butcher & Ashton, 2004; Bickham et al., 1998),
increased access to and quality of services (Burns et al., 1995), along with support for teachers
and students (Mellin & Weist, 2011; Walrath et al., 2004). These findings highlight that teachers
perceive a variety of reported benefits to multiple stakeholder groups when engaging in
ESMH collaboration.

Limitations
There are several limitations to this research study. First, this study relied on self-report
measures and, as such, may not reveal the tangible ways teachers are (or are not) collabo-
rating in ESMH and what influences those relationships. Without directly observing teachers
in collaboration with other professionals in ESMH, it is difficult to know if their responses are
 Advances in School Mental Health Promotion   95

accurate reflections of their conditions or if other types of collaboration are occurring.

Additionally, social network analysis, which is congruent with the theoretical propositions
of social capital and which allows for more accurate measurement of interdependent rela-
tionships, could more accurately capture influences on collaborative relationships in ESMH
(Mellin & Weist, 2011). Future research studies that incorporate direct observation, or social
network analyses, of collaborative relationships are encouraged. Second, most of the par-
ticipants in this study were recruited through the CSMH listserv, and given the focus of the
listserv, could be people who believe collaboration is an important component of ESMH
practice. Future studies in this area should seek samples that may be less biased to confirm
whether these results can be replicated. Finally, this study did not include the collection of
qualitative data that could have provided important context for the results. Interviews with
teachers, for example, could have clarified the less frequent collaborations with families
observed in this study. In spite of these limitations, the findings provide early support for
the types of ESMH collaborations teachers are engaged in, what likely influences those
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relationships and the perceived benefits of engaging in ESMH collaboration. It also signals
initial implications for practice, policy and research.

Implications for practice, policy and research

Understanding teachers’ involvement in ESMH, including their perceptions of ESMH collab-
orations, is critical to improving services for students in schools. Teachers in this study
reported engagement in several types of collaborations, and also indicated that outreach
and approach were related to their collaboration with community mental health profession-
als. This information is valuable for community mental health professionals attempting to
build bridging social capital with teachers; the initial efforts to build relationships with teach-
ers may potentially shape future collaboration. Additionally, school administrator support
was also related to teachers’ collaboration with community mental health professionals. It
is likely that a concerted and collaborative effort between school administrators and com-
munity mental health professionals focused on building meaningful relationships with
teachers, engaging teachers in ESMH teams and fostering bridging social capital may have
a positive impact on these collaborations, and ultimately improve ESMH service delivery.
Along with practice, this study also suggests some implications for policy in ESMH. The
findings of this study suggest that teachers primarily collaborate with community mental
health professionals and families when they consult about student needs. As ESMH pro-
grammes seek to build opportunities for the development of bridging and linking social
capital, for example, they may want to provide some structure for other types of collabora-
tions that may support students with mental health needs. Teachers and community mental
health professionals, for example, could be required to participate in shared training expe-
riences that will help address knowledge gaps for both groups of professionals – teachers
as it relates to student mental health and community mental health professionals as it relates
to school policies and procedures – that may open a wider pipeline of opportunities for
shared work. Additionally, the results of this study suggest the important role of policy in
establishing ESMH programmes. As ESMH programmes are developed, attention should be
given to the visibility and outreach of community mental health professionals in schools as
well as to the important role of school administrators in communicating their support of
this approach. Policies that address these important influences on bridging social capital in
 96    E. A. Mellin et al.

ESMH may promote collaborative relationships between teachers and community mental
health professionals.
This study also has important implications for research. Given the limited empirical
research examining teachers’ involvement in ESMH, continued research is needed that
explores the types of collaborations that teachers engage in along with what influences
those collaborative efforts. This study represents an important step in this line of research,
but additional research studies that employ social network analysis or mixed method
approaches are needed. In addition, it may also be important to explore whether types of
ESMH collaborations, along with perceived influences and benefits, differ by level or type
of school community (i.e. elementary, middle or high and rural, suburban or urban). Research
that also quantitatively examines the relationship between strength of ESMH collaboration
and a range of student, family, school and teacher outcomes is needed (Mellin, 2009).
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Conclusion
Teachers, through their daily contact with students, are in a unique position to identify
mental health concerns, yet typically have little preparation for identifying and managing
these issues (Koller & Bertel, 2006). Lacking this preparation, teachers may feel overwhelmed
and unsure about how to help students who are experiencing difficulties (Anderson-Butcher,
2006; Graham et al., 2011; Koller et al., 2004). ESMH programmes emphasize collaborative
relationships among professionals and families to mobilize expertise and resources for
addressing student mental health concerns (Weist, 1997). Despite the important role of
teachers in identifying and accessing student mental health services (Ball et al., 2010; Ekornes,
2015), and the well-documented challenges to collaboration across professions and with
families (Mellin & Weist, 2011; Mellin et al., 2010), the experiences of teachers have largely
been ignored leaving a lack of research-based suggestions for maximizing this practice
strategy. This study examined the experiences of 384 teachers involved in ESMH programmes
and found that they most often collaborate with other school professionals while reporting
similar, but less frequent, collaboration with community mental health professionals and
families. Across professional groups and families, teachers report they most frequently col-
laborate when they are consulting about student needs. The results of this study also suggest
the importance of outreach and approach by community mental health professionals, sup-
port from school administrators, as well as interpersonal aspects like mutual respect and
liking one another to the frequency of collaboration between teachers and community
mental health professionals. Lastly, increased access to mental health services for students
and families may be one important benefit of teachers’ involvement and collaboration in
ESMH.

Disclosure statement
No potential conflict of interest was reported by the authors.

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The Australian Educational Researcher
https://doi.org/10.1007/s13384-022-00558-9

Supporting children’s mental health in primary schools:

a qualitative exploration of educator perspectives

Alison Giles‑Kaye1,3   · Jon Quach1,3   · Frank Oberklaid1,2,4 ·

Meredith O’Connor1,3   · Simone Darling1,4 · Georgia Dawson1,3   ·
Ann‑Siobhan Connolly1

Received: 25 October 2021 / Accepted: 18 July 2022

© The Author(s) 2022

Abstract
Schools are often seen as a key setting for the provision of mental health support
for children. This study aimed to explore the professional perspectives of primary
school educators in Victoria, Australia, regarding how schools can support the men-
tal health of their students. Semi-structured interviews and focus groups were con-
ducted with 17 primary school educators, from four schools. Thematic analysis was
used to generate themes from the data. This study indicates that educators report
significant concerns about the complexities of their role and their capacity to sup-
port children’s mental health due to a lack of resources, overwhelming demands,
and inadequate training. Educators highlighted the importance of partnership and
communication with families and of a school culture that prioritises mental health.
This study provides insights into external factors that can undermine effective sup-
port of children’s mental health within primary schools and indicates a need for a
more integrated approach to supporting children’s mental health across education
and healthcare.

Keywords  Child mental health · School · Educators · Primary · Qualitative

* Alison Giles‑Kaye
al.gileskaye@student.unimelb.edu.au
* Jon Quach
jon.quach@unimelb.edu.au
1
Centre for Community Child Health, Murdoch Children’s Research Institute, Children’s
Hospital, RoyalMelbourne, VIC, Australia
2
The Royal Children’s Hospital, Melbourne, VIC, Australia
3
Melbourne Graduate School of Education, University of Melbourne, Melbourne, VIC, Australia
4
Department of Pediatrics, University of Melbourne, VIC, Australia

13
Vol.:(0123456789)
 A. Giles‑Kaye et al.

Introduction

Good mental health is defined by the World Health Organization as “a state of

wellbeing in which every individual realises his or her own potential, can cope
with the normal stresses of life, can work productively and fruitfully and is able
to make a contribution to her or his community” (World Health Organization &
Calouste Gulbenkian Foundation, 2014). This understanding of mental health
speaks to the presence of functional skills and strategies as well as emotional
states. According to a large national survey of parents and adolescents, over half
a million (13.6%) Australian 4- to 11-year-olds experience a diagnosable mental
health disorder each year, and many more children are estimated to experience
subclinical mental health difficulties (Johnson et al., 2018; Lawrence et al., 2015).
Left unaddressed, the early life experience of mental illness is associated with
later recurrence, compromised social relationships, unemployment and general
ill-health (Danby & Hamilton, 2016; Goldstein & Morewitz, 2011; Green et al.,
2013).
The recent Australian Productivity Commission (2020) and the Royal Com-
mission into Victoria’s Mental Health System (2021) have revealed a system that
is crisis driven and overwhelmed, where appropriate support is too often inacces-
sible (Productivity Commission, 2020; State of Victoria, 2021). This is particu-
larly the case for children’s mental health. Both commissions advocate shifting to
a focus on mental health promotion and prevention and focussing on schools as a
setting for identifying and supporting children’s mental health needs (Productiv-
ity Commission, 2020; State of Victoria, 2021). It is well established that early
intervention is more effective than treatment once symptoms become entrenched
and that the first few years of primary school are a key period when risk and pro-
tective factors can profoundly impact the trajectory of children’s mental health
(Cefai & Camilleri, 2015; Centre for Community Child Health, 2006, 2012;
Marryat et  al., 2018). The knowledge that half of adult mental health disorders
emerge before 14 years of age (Birleson & Vance, 2008; Fernando et al., 2018),
further  speaks to the importance of addressing children’s mental health needs
during their early primary school years so that they can experience optimal learn-
ing and wellbeing throughout their lives.
Motivation to address children’s mental health difficulties early, coupled with
the fact that nearly all children attend a primary school (Lawrence et al., 2015),
has meant that primary schools have increasingly been seen as a key commu-
nity setting in which to support children’s mental health (Burns & Rapee, 2019;
Fabiano & Evans, 2019; Patalay et al., 2014, 2017; Werner-Seidler et al., 2017).
However, a theme throughout previous research is the lack of training and sup-
port teachers in general receive and the low confidence they feel about supporting
children’s mental health (Anderson et al., 2019; Andrews et al., 2014; Yamaguchi
et  al., 2020). Teachers have concerns that the mental health needs of children
in primary schools far outweigh their professional capabilities and the resources
available to support them (Australian Education Union, 2019; Graham et  al.,
2011; Hussein & Vostanis, 2013; Kratt, 2017; Yamaguchi et  al., 2020). While

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Supporting children’s mental health in primary schools: a…

previous literature conceptualises schools as an ideal venue to support children’s

mental health, there is limited understanding of what that might look like within
schools and for educators. If primary schools are to be charged with the respon-
sibility of supporting children’s mental health, then, to inform and sustain pol-
icy direction, it is important to ascertain primary school educators’ views in this
regard.
In Victoria, 41% of primary school teachers have reported that they have students
with mental health difficulties in their class (Australian Education Union, 2019).
These children experience a range of symptoms that inhibit their daily functioning
and wellbeing (Fabiano & Evans, 2019; Forns et al., 2011; Tandon et al., 2009). In
a school setting, these difficulties impact not only the individual child but also their
peers and school staff, inhibiting learning and teaching.
Some research in the United Kingdom and Australia has been undertaken to
explore educators’ perspectives. However, these have mainly focussed on second-
ary schools (Graham et al., 2011; Kidger et al., 2010; Mazzer & Rickwood, 2015;
Shelemy et  al., 2019). Generally, these data indicated that educators thought it
was important to support student mental health but felt constrained because they
lacked effective training, experienced low confidence, and were frustrated by inac-
cessible child mental health services. While the perspectives of secondary school
teachers may well resonate with primary school educators, there is a lack of quali-
tative empirical data to confirm this. Primary school educators may have different
challenges, especially as the students are younger and may have different functional
characteristics to indicate differences in mental wellbeing as well as different types
of developmentally appropriate responses and supports available. The role of a sec-
ondary school teacher, who teaches subject-specific cohorts, differs substantially
from the primary school teacher, who teaches year level cohorts across all subjects
and therefore spends substantially more time with their students, likely gaining a
different perspective. Results from survey data provide quantitative insights into
educator perspectives; however, these data to date lack the rich insights that can be
gained from qualitative investigation. Quantitative data are restrained by the ques-
tions asked by the survey, with forced options and little opportunity to expand on
responses, whereas qualitative methods allow for a more exploratory approach to the
topic where participants can initiate discussion on issues. Further, it is important to
explore primary school educators’ views in order to sustain policy and practice in
primary schools regarding universal and targeted prevention and intervention strate-
gies. For these reasons, it is highly complementary to have the addition of qualita-
tive data. This study was designed to elicit qualitative perspectives from educators
in primary schools in Australia to understand their views on how they think schools
can best support children’s mental health.

Methods

This study aimed to generate insights into the perspectives of primary school educa-
tors about how schools can support children’s mental health, focussing on Founda-
tion to Grade 3. This was a qualitative inquiry using interviews and focus groups

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 A. Giles‑Kaye et al.

to explore the professional experiences and perspectives of Victorian state primary

school educators, experienced in teaching Foundation to Grade 3. Thematic analysis
was employed to generate themes and subthemes. Ethical approval for the study was
granted by the Royal Children’s Human Research Ethics Committee (HREC 57,564)
and the Department of Education and Training, Victoria (2019_004161). The
study was guided by the Consolidated Criteria for Reporting Qualitative research
(COREQ): A 32-item checklist for interviews and focus groups to support rigour
and transparency (Tong et al., 2007)(Appendix 1).

Participants

We used a purposive sampling technique to recruit educators in mainstream Victo-

rian state primary schools, and convenience sampling for pragmatic reasons of geo-
graphic location, time and accessibility (Kervin et al., 2006). Primary school leaders
and classroom teachers were eligible to participate in the study if they had current
or recent experience in Foundation to Grade 3. Recruitment was focussed in one
region of the Victorian Department of Education and Training (DET). The study
was advertised by DET to all primary schools in two areas of the region. Eligible
participants contacted the researcher to express their interest and were provided with
further written information about the study.
Four schools participated in data collection between November 2019 and March
2020. In total, 17 educators participated in the study—six school leaders and 11
classroom teachers. Nine classroom teachers were working within Foundation to
Year 3 and two within Year 4–6. Participants included two men and 15 women;
teaching experience ranged from four to 30  years. Six in-person interviews with
school leaders and four focus groups with classroom teachers were conducted. The
sample size enabled the collection and analysis of in-depth data to generate themes
and subthemes. One school was located in the inner city, two were suburban metro-
politan and one was semi-rural.

Procedure

Data collection was via semi-structured interviews and focus groups which were
informed by a question guide (Appendix 2), written by the lead author in consulta-
tion with the research team. The question guide was piloted with several educators
and researchers before it was finalised and comprised open ended questions designed
to engage participants, moving from general to specific questions (Krueger & Casey,
2015). The questioning was designed to elicit participants’ general views on chil-
dren’s mental health, and support of children’s mental health needs, along with bar-
riers and enablers to support within schools. The lead author and participant inter-
viewer is a female PhD candidate at the University of Melbourne, who is a qualified
social worker and primary school teacher. The broader research team involved in
the study was multi-disciplinary and included educators, psychologists, a paediatri-
cian and an experienced qualitative researcher. To mitigate any power imbalances

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Supporting children’s mental health in primary schools: a…

between leaders and teachers, school leaders were offered individual interviews, and
teachers were given the option of an interview or a small focus group. The authors
had no prior relationship with any of the participants. Participants provided their
informed written consent before any data collection began, and data collection was
conducted in a private room in the educator’s school by the lead author, with no
non-participants present. Interviews and focus groups lasted between 20 and 79 min
and were audio-recorded then transcribed verbatim by a transcription company.

Data analysis

This article aimed to explore educator perspectives of how schools can support chil-
dren’s mental health, and therefore, this analysis focussed on data related only to
that topic. Thematic analysis was conducted inductively commencing after initial
data collection (Pope et al., 2000). The lead author read and re-read each transcript
to de-identify the data, check for accuracy and ensure familiarity. De-identified tran-
scripts were imported into NVivo12 (QSR International, 2021) to support coding.
The coding process was iterative with codes, categories and themes being generated
through data immersion, reflection and writing (Braun & Clarke, 2019, 2021) with
transcripts being coded and recoded as new codes were generated from ongoing data
collection. Participant perspectives were checked by the interviewer throughout the
data collection via verbal clarification techniques; however, returning transcripts
for member checking was not undertaken after data collection or analysis to avoid
excessive demands on participant time. To support rigour, two researchers were
involved in the coding process and six in overall thematic analysis. Two researchers
(AGK, ASC) independently cross-checked the codes, categories and themes. Cat-
egories and themes were discussed by the research team until the authors thought
the data were effectively represented.

Results

Four themes, each with subthemes were generated from the data: complexities of
the educator role; partnership with families; school culture that prioritises mental
health; and external factors that influence school capacity (Table 1).

Complexities of the educator role

A theme from all participants was concern around the complexities of the educator’s
role regarding the support of children’s mental health. There was repeated discus-
sion about the uneasiness that educators felt that while they were trained to teach,
they were increasingly being required to engage in supporting children’s mental
health.

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 A. Giles‑Kaye et al.

Table 1  Themes and Subthemes generated from the data

Themes Subthemes

Complexities of the educator role Motivation to prioritise students’ social-emotional

Importance of partnership with families
A school culture that prioritises mental health
External factors that influence school capacity
learning
Feeling pressured and overwhelmed
Informal strategies for identification of mental health
difficulties
Being flexible and responsive
Clear and regular communication
Complexities in the communication and engagement
with families
Family factors
Importance of whole-school approach
Developing relationships with children
Provision of school-based resources
Impact on staff wellbeing
Inaccessibility of support services
Insufficient support staff in schools
The need to improve child mental health literacy

Motivation to prioritise students’ social‑emotional learning

All educators described high levels of motivation to support their students’ men-
tal health, citing the significant impact mental health difficulties have on student
learning in the classroom. Educators described the disruption to learning, for all
students, when a child in the class is experiencing mental health difficulties and
therefore the need to prioritise explicit teaching of social-emotional wellbeing
skills and strategies to all students.
I think that’s the biggest thing, that’s the most important thing. If they’re
feeling happy and they’re engaged and they’re going to learn better. [class-
room teacher]
... I guess, also students with poor mental health would also—can also stop
other children from learning. So, it’s pretty critical that we get that right I
think. [classroom teacher]

Feeling pressured and overwhelmed

Most educators consistently reported feeling significant pressure regarding their

dual role. They expressed concern about the difficulties of balancing their teach-
ing responsibilities with their need to support students’ mental health. Many felt
that they would benefit from mental health training but said that time pressures
mean they were not able to do or implement training and that students need indi-
vidual mental health support that educators are not able to provide.

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Supporting children’s mental health in primary schools: a…

...we do need training, but we also don’t have time to do it...we can’t be trained
in everything and be able to do everything. ...we also need someone to just
come in and intervene for us sometimes. [classroom teacher]
We need more help. We’re not psychologists. So, when the kids come and say
... ‘I will kill myself,’ and we don’t know how to handle that. We don’t know
what to do... [school leader]

Informal strategies for identification of mental health difficulties

All participants reported that they tended to rely on informal strategies such as rela-
tionship building, intuition and observation of behaviour to identify and support the
mental health needs of their students. Getting to know their students was seen as
vital so that educators could identify when children were struggling. However, edu-
cators spoke about lacking confidence and commonly thought that effectively iden-
tifying children’s mental health needs is a complex task for which they were not
trained.
...when you build a relationship with the students from your class you can kind
of see when they’re having an off day—you can just tell when they’re not quite
feeling right that day. [classroom teacher]

Being flexible and responsive

A common view among several participants was the need to be flexible and respon-
sive to student needs, particularly regarding lesson plans and schedules. Educators
spoke about the need to change plans in response to student needs, often adjusting
teaching plans at very short notice if they judge that students are not coping.
...sometimes you would’ve read your class and gone, you know what, I was
going to do maths today, we can’t do maths today because you just are not
going to be able to cope with that ... [classroom teacher]

Clear and regular communication

Participants typically reported that clear and regular communication with stake-
holders was key in identifying and supporting the mental health of their students.
Systems in schools to record and promote communication about children’s needs
between colleagues and from year to year were seen as vital to enable a consistent
approach to support individual students.
During our staff meetings, we usually have a section of that dedicated to well-
being of the students, so that’s the time that we bring up any students that we’re
having any concerns about and then we’ll discuss them. [classroom teacher]

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 A. Giles‑Kaye et al.

Importance of partnership with families

A view common to all participants was the importance of partnering with families
to support children’s mental health and the complexities and challenges involved in
communication and family engagement. Participants advocated the need to develop
partnerships with families to facilitate open communication and consistency in sup-
porting students, as well as to expedite the provision of external services if needed.

Complexities in communication and engagement with families

Educators typically spoke about the complexities of communicating and engaging

with families and the need for increased literacy around children’s mental health, to
support school–home partnerships and to facilitate children accessing support. Par-
ticipants expressed concern about the challenges they face when families have lim-
ited understanding of children’s mental health and that this hampers their endeav-
ours to support their students.
People come from so many different places and not everyone’s got the same
culture, upbringing, values or even knowledge of what to do... Seminars and
workshops for students with their parents or just the parents would be helpful.
[classroom teacher]

Family factors

Participants generally described the economic, work, health, social and emotional
pressures families experience as having an influence on effective partnerships
between the school and home. Educators who have been practising for many years
felt that pressures on families have become more intense over that time.
...the pressures of life I think [there] seems to be much more pressure on fami-
lies these days than it was back then. [school leader]

A school culture that prioritises mental health

A common view among participants was that a school culture that prioritises mental
health is vital to enable educators’ support of children’s mental health in classrooms.
Educators highlighted a range of issues they saw as important, including a whole-
school approach, schools valuing staff relationships with children, the provision of a
range of school-based resources and prioritising staff wellbeing.

Importance of a whole‑school approach

All participants spoke about the necessity of a whole-school approach to support

effective communication between colleagues and with families, the teaching of
social-emotional skills and strategies and planning for each student. Participants

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Supporting children’s mental health in primary schools: a…

proposed that a whole-school approach to social-emotional learning enables them

to provide students with consistency thereby improving the overall support students
receive.
So, each week we have a professional learning meeting... and one of the
agenda items is always student welfare. And so, we talk about how kids are
going and if anyone else needs to be added and discussed. [school leader]

Developing relationships with children

Several educators spoke about the need for a school culture that values staff devel-
oping relationships with children and encourages educators to be hands-on, acces-
sible and tuned-in to children. Participants reported that a school culture that
places importance on school leaders and classroom teachers knowing their students
enhances their capacity to see when individual children are struggling and therefore
better support them.
Because I spend a lot of time with the kids too, I know them well enough
to know—it’s a quick, ‘Hi, how you going?’ and, ‘See you later, get back to
class,’ or, ‘I can see you need some space. I’ll let you sit, and we’ll talk in a lit-
tle bit about what’s going on’. [school leader]

Provision of school‑based resources

All educators spoke about the value of prioritising school-based services and
resources to support children’s mental health and described a range of profession-
als and programmes that their schools had engaged to supplement what educators
were able to do in classrooms. Participants’ schools had garnered a range of services
and resources to support children’s mental health. Some had therapeutic services
that came to the school site, others had implemented social-emotional learning pro-
grammes while others had on-site play, art or animal therapy for students. Some par-
ticipant schools prioritised these strategies in their budget, others had engaged with
support services that were eligible for subsidies from the government, and others
had raised funds through community groups to subsidise their endeavours.
We do have an art therapist who comes in that works with some children. We
pay for the ones that we believe are disadvantaged or the ones that the parents
can’t afford, but there’s also a user-pay as well, so parents pay to work with
him. [school leader]

Impact on staff wellbeing

Another subtheme from several participants was how schools address the emotional
impact experienced by educators working with children who have mental health dif-
ficulties. Participants spoke about the benefits of a school culture where educator
wellbeing was prioritised, and that this improves their capacity to support children.

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 A. Giles‑Kaye et al.

Educators also spoke about the difficulties of working in a school where they receive
very limited wellbeing support and that this compounds the pressures and difficul-
ties of supporting students.
So, if there’s a child that’s disclosed something, it doesn’t just stop there. [The
educators] carry that. [school leader]
...we’ve set up a really cool relaxation room... For the staff where they can
just—if they need five minutes, they go and collect the key from the staff cen-
tre and they’ve got massage chairs and there’s just a bit of downtime, and then
they get back into it... [school leader]

External factors that influence school capacity

A theme among all participants was that a range of factors external to schools inhib-
its their capacity to support children’s mental health. Concerns included the inacces-
sibility of timely community-based and in-school child mental health support ser-
vices and low child mental health literacy in the wider community.

Inaccessibility of support services

All participants expressed frustration and concern about long waiting lists for
assessment and intervention for children with mental health difficulties. Support ser-
vices were consistently described as inaccessible; therefore, families were required
to travel long distances to access help or were unable to afford private timely men-
tal health services for their children in lieu of public services that had long waiting
lists. Educators reported that a family’s inability to access professional mental health
support is detrimental to the school’s capacity to effectively support children in the
classroom. This is because they are left, with limited understanding, to care for chil-
dren who may be experiencing significant mental health difficulties and exhibiting
challenging internalising or externalising symptoms.
...even for them to get assessments done and things like that so that we can
then help them so that we’ve got more knowledge. But 18 months on a waiting
list sometimes it’s really hard... [classroom teacher]
...the waiting list is like a year plus. It’s a long time. And for us as a school,
sometimes you can’t proceed with anything until you have a paediatrician. It’s
not easy, you have to just—it’s a waiting game. [school leader]

Insufficient support staff in schools

Another subtheme from most participants was the lack of access to allied health staff
for assessment, intervention and support. Educators spoke of high allied health staff
turnover, leading to frustration, inconsistency and miscommunication. Participants
indicated that all primary schools should have ready access to support services,

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Supporting children’s mental health in primary schools: a…

particularly to counsellors for children, but also health and allied health staff to
assess and provide timely support and intervention.
Well, we lost our ed psych—they moved, and we were supposed to get a new
one and they’ve just never eventuated. So, since the middle of the year, we
probably haven’t had one allocated to us. So—which is interesting given that
mental health is so prominent in the media and there’s so much about looking
after children’s mental health. [classroom teacher]

The need to improve child mental health literacy

Many participants reported that they thought child mental health literacy needs to
be improved in the wider community. Educators reported that the stigma and lack of
understanding about children’s mental health inhibit educators’ capacity to support
children in the classroom because the lack of a common language around children’s
mental health inhibits family engagement. Educators reported that when families are
not engaged about their child’s mental health, it compromises what educators can do
and means that some children may not get the support they need.
Just to bring the awareness ... So, the parents are not just saying, ‘Well, that’s
just my child. He’s just grumpy all the time’. Well, because I mean, we see 20
of them and we can compare and we know the difference, whereas, that person
might only have one child or two, so, and they only spend a couple of hours
with them. [classroom teacher]
I think one of the biggest problems with kids with mental health issues is in
primary schools. There’s still not really a huge recognition that kids can have
[mental health issues]. [school leader]

Discussion

This study indicates that despite being motivated to support children’s mental health,
educators are feeling overwhelmed and pressured, out of their depth and frustrated
by the complexities of their role. However, they have developed a range of informal
strategies, using observation and relationship building, to identify and support chil-
dren’s mental health needs. Educators provided insights into what they perceived as
important for schools’ support of children’s mental health, such as school culture
and partnering with families, while also indicating there are external influences that
inhibit this support and expressing a need for a more effective approach to support-
ing children’s mental health.
While primary schools are increasingly viewed as a key community setting where
children’s mental health can be supported, this study signals that educators have con-
cerns about what this means for the complexities of their role, echoing research from
secondary schools (Graham et al., 2011; Kidger et al., 2010; Mazzer & Rickwood,
2015; Shelemy et al., 2019). Indeed, the ‘complexities of the educator role‘ was a
theme woven throughout all the focus groups and interviews. Similar to studies of

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 A. Giles‑Kaye et al.

educator perspectives in secondary schools, all participants thought it was important

that schools address children’s mental health needs (Danby & Hamilton, 2016; Gra-
ham et al., 2011; Mazzer & Rickwood, 2015). However, educators felt overwhelmed
by the needs of children’s mental health in their schools and classrooms (Walter
et al., 2006). All participants had undertaken some child mental health professional
development and were open to further training, but they felt they had too little time
to do this because their teaching responsibilities meant they were time poor.
Educators consistently expressed concern about the pressures families are expe-
riencing and the impact this has on children’s mental health, and on the school’s
ability to engage and partner with families. While some participants had positive
experiences of communication and collaboration with families, others had struggled
because of the complexities of language, socio-cultural issues and low child mental
health literacy among parents. This echoes other Australian studies about the con-
cerningly low child mental health literacy levels among parents in the general com-
munity (Tully et  al., 2019). This study indicates that child mental health literacy
levels among parents not only affect children’s access to support services but impor-
tantly also inhibit the school’s capacity to provide support to children. Strategies to
increase child mental health literacy in the community could support the identifica-
tion of children’s mental health needs and the provision of appropriate support.
Participants commonly reflected on the importance of a school culture that priori-
tises mental health and takes a whole-school approach to social-emotional learning.
However, participants spoke about a range of factors external to schools that inhib-
ited their capacity to support the mental health needs of students. Concern about
the long waiting lists for paediatric assessments wove through discussions of edu-
cator challenges about identifying and supporting children’s mental health needs.
Participants spoke about many families who had waited over 12 months for an initial
assessment of their child or faced prohibitively expensive private consultations. Par-
ticipants expressed concern that when children do not get this help, educators, with
limited capacity, are left to support these children in schools. This echoes the litera-
ture about the pressures on educators who grapple with being time poor and having
limited mental health training (Shute & Slee, 2016). Educators felt that professional
assessments of children’s mental health needs are invaluable to schools’ support
of their students. However, they raised concerns that the school-based support ser-
vices that exist for mental health needs are often inaccessible for children—either
untimely or too expensive—and that this places significant pressures on educators
to fill the gap. There was general agreement that school support services were often
inaccessible or inadequate, characterised by frequent changes in allied health staff,
who were limited in what they could provide.
Educators spoke about feeling uncertain about their skills for identifying chil-
dren’s mental health difficulties (Graham et  al., 2011; Kratt, 2017) stating that
child mental health training would be useful, but that pressures in the classroom
and school meant they often didn’t have time to do training or to implement train-
ing content. Rather, they saw improving child mental health literacy in the broad

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Supporting children’s mental health in primary schools: a…

community, reducing waiting lists for professional children’s mental health assess-
ments and providing better and more consistent access to allied health staff as vital
to empowering schools to support children’s mental health.
This study raises implications for policies and practices within the wider educa-
tion and health systems as well as in schools. Schools, and educators, require stra-
tegic support, by way of sufficient qualified support staff, if they are to effectively
support children’s mental health. Addressing the mental health training needs of
educators could build schools’ capacity to identify and support children’s mental
health needs. However, this should not be done without addressing the time-poor
nature of the primary school teacher role. Likewise, the health sector needs reform
so that children and families can access mental health assessments and interventions
in a timely manner, rather than waiting excessive amounts of time to get the help
they need. When these concerns are addressed in parallel then the educator capacity
to initiate care pathways for children can be supported so children can get the help
they need.

Strengths and limitations

The qualitative study design enabled exploration of the perspectives of primary

school educators regarding supporting children’s mental health in schools. A ques-
tion guide was used with flexibility, and open questions were asked to prompt depth
of discussion. This enabled participants to express their views with latitude, not
restricted to answering specific questions, and elicited a range of salient and poign-
ant perspectives from participants that a more structured design might not have
achieved (Kervin et al., 2006).
Because of the recruitment strategy where educators had to be proactive and
contact the research team, only educators who were particularly interested in the
topic participated. All participants were practising primary school educators who
were interested in supporting children’s mental health and volunteered their time to
the study. While the four participating schools varied geographically, they were all
within a single region of the Department of Education and Training, Victoria. The
results of this study were not intended to be generalisable to the wider population,
and future research should be done in other areas to explore whether the themes gen-
erated from this study are shared by educators in other parts of Victoria.
This study was impacted when, because of the COVID-19 pandemic, the Depart-
ment of Education and Training, Victoria suspended all research in schools within
Melbourne for most of 2020. This meant that 12 schools, each with multiple partici-
pants, were withdrawn from the study. However, 17 participants is a suitable sample
size for the study design and is comparable with other studies (Garvey et al., 2020;
Shelemy et al., 2019).

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 A. Giles‑Kaye et al.

Suggestions for future research

Educators in this study spoke about the importance and complexities of engaging
and partnering with families. Future exploration of families’ perspectives could con-
tribute to clarifying and mitigating inhibitors to home–school partnerships and to
elucidating how families see the role of schools regarding children’s mental health.
Children’s voices are often absent in research that affects them and school mental
health research is no exception (Fazel & Hoagwood, 2021). Research with child par-
ticipants is important to give them a voice in matters that concern them, and so that
school policies and practices can be sustained, informed and accepted by these piv-
otal stakeholders (Fazel & Hoagwood, 2021).

Conclusion

While schools are increasingly viewed as an ideal setting to address children’s men-
tal health needs (Patalay et al., 2017; Werner-Seidler et al., 2017), this study indi-
cates that, despite being motivated, educators felt overwhelmed, pressured and out
of their depth, and expressed a need for a more effective approach to supporting
children’s mental health. This study elucidates primary school educator perspec-
tives, including several suggestions to enhance primary schools’ capacity to sup-
port the mental health needs of children. These are as follows: that educators should
receive pre-service, as well as ongoing, training in early identification of children’s
mental health difficulties so that they can initiate care pathways for children; waiting
lists for professional mental health assessments need to be addressed, so children
and educators get appropriate and timely support; schools need access to regular,
on-site, and ongoing support staff that can work with children and staff; and mental
health literacy levels in the community need to be improved, to promote partner-
ships between schools and families by having a common language.

13
Supporting children’s mental health in primary schools: a…

Appendix 1

Consolidated criteria for reporting qualitative studies (COREQ): 32

Item checklist (Tong et al., 2007)

No Item Guide questions/description Reported on page #

Domain 1: Research team and reflexivity

Personal characteristics
1 Interviewer/facilitator Which author/s conducted the inter- p. 8
view or focus group?
2 Credentials What were the researcher’s creden- p. 8
tials? E.g. PhD, MD
3 Occupation What was their occupation at the time p. 8
of the study?
4 Gender Was the researcher male or female? p. 8
5 Experience and training What experience or training did the p. 8
researcher have?
Relationship with participants
6 Relationship established Was a relationship established prior p. 8
to study commencement?
7 Participant knowledge of the inter- What did the participants know about n/a
viewer the researcher? e.g. personal goals,
reasons for doing the research
8 Interviewer characteristics What characteristics were reported n/a
about the interviewer/facilitator?
e.g. Bias, assumptions, reasons, and
interests in the research topic
Domain 2: study design
Theoretical framework
9 Methodological orientation and What methodological orientation was p. 6
Theory stated to underpin the study? e.g.
grounded theory, discourse analy-
sis, ethnography, phenomenology,
content analysis
Participant selection
10 Sampling How were participants selected? e.g. pp. 6–7
purposive, convenience, consecu-
tive, snowball
11 Method of approach How were participants approached? pp. 6–7
e.g. face-to-face, telephone, mail,
email
12 Sample size How many participants were in the p. 7
study?
13 Non-participation How many people refused to partici- p. 25
pate or dropped out? Reasons?

13
 A. Giles‑Kaye et al.

No Item Guide questions/description Reported on page #

Setting
14 Setting of data collection Where was the data collected? e.g. p. 8
home, clinic, workplace
15 Presence of non-participants Was anyone else present besides the p. 8
participants and researchers?
16 Description of sample What are the important character- pp. 6–7
istics of the sample? e.g. demo-
graphic data, date
Data collection
17 Interview guide Were questions, prompts, guides pp. 7–8
provided by the authors? Was it
pilot tested?
18 Repeat interviews Were repeat interviews carried out? If n/a
yes, how many?
19 Audio/visual recording Did the research use audio or visual p. 8
recording to collect the data?
20 Field notes Were field notes made during and/or n/a
after the interview or focus group?
21 Duration What was the duration of the inter- p. 8
views or focus group?
22 Data saturation Was data saturation discussed? n/a
23 Transcripts returned Were transcripts returned to p. 8
participants for comment and/or
correction?
Domain 3: analysis and findings
Data analysis
24 Number of data coders How many data coders coded the p. 9
data?
25 Description of the coding tree Did authors provide a description of pp. 9–10
the coding tree?
26 Derivation of themes Were themes identified in advance or p. 9
derived from the data?
27 Software What software, if applicable, was p. 9
used to manage the data?
28 Participant checking Did participants provide feedback on p. 8
the findings?
Reporting
29 Quotations presented Were participant quotations presented Yes
to illustrate the themes/findings? pp. 10–20
Was each quotation identified? e.g.
participant number
30 Data and findings consistent Was there consistency between the Yes
data presented and the findings?
31 Clarity of major themes Were major themes clearly presented Yes
in the findings? pp. 10–20
32 Clarity of minor themes Is there a description of diverse cases Yes
or discussion of minor themes? pp. 10–20

13
Supporting children’s mental health in primary schools: a…

Appendix 2

Question guide for interviews and focus groups

When I say the term “child mental health” what does that mean to you?
Thinking about the school context, please tell me about what good mental health looks like in children?
What about children experiencing mental health concerns? Tell me about what that looks like, in a
school context?
How do you identify if a child may need support for their mental health?
How do you determine what kinds of support children need, to develop good mental health?
How do you work with your students’ families to support the mental health of their children?
Thinking about the school context, in your experience, what do you think works well, in supporting
children’s mental health?
Within the school context, what are the most common things you see getting in the way of children’s
good mental health?
If you could change anything about the school system to better care for children’s mental health, what
would you do?

Acknowledgements  We thank the school leaders and teachers who participated in this study, for their
time and commitment.

Author contributions  All authors contributed to the study conception and design. Data collection and
analysis were performed by AGK and ASC. The first draft of the manuscript was written by AGK and
all authors commented on previous versions of the manuscript. All authors read and approved the final
manuscript.

Funding  Open Access funding enabled and organized by CAUL and its Member Institutions. The study
was supported by the authors’ affiliated organisations listed above.

Data availability N/A.

Code availability N/A.

Declarations 

Conflict of interest  The authors have no conflict of interest to declare that are relevant to the content of
this article.

Ethical approval  Ethics approval for the study was granted by the Royal Children’s Human Research Eth-
ics Committee (HREC 57564) and the Department of Education and Training, Victoria (2019_004161).

Consent to participate  Informed consent was obtained from all individual participants included in the
study.

Consent to publish  Informed consent to publish was obtained from all individual participants included in
the study.

Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as

13
 A. Giles‑Kaye et al.

you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is
not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​
ses/​by/4.​0/.

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Publisher’s Note  Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

Alison Giles‑Kaye  is a PhD candidate at The Melbourne Graduate School of Education, Melbourne Uni-
versity. She has a Masters in Education and is a qualified social worker and primary school teacher. The
focus of her PhD is on understanding how primary schools can support the development of children’s
mental health in the early years (Foundation—Grade 3).

Jon Quach  is a senior research fellow at the Royal Children’s Hospital, Centre for Community Child
Health. His overarching research agenda focusses on the health and education interface. Drawing upon
the fundamental understanding that children’s health and development are intrinsically linked, he aims
to determine how children’s academic outcomes are shaped by common health problems during the
early years of school and how best to address these problems within the traditional school setting. He has
worked on over 12 community and school-based intervention studies which have examined how schools
and the workforces that work within the education. These interventions have focussed on areas such as
child mental health, behaviour, learning and cognition. As part of this research, and recognising the inter-
sect between a child’s health and education, he has also aimed to understand how best to ensure services
across the education and health systems are best aligned to ensure optimal outcomes for children. In addi-
tion to his intervention research, he has also utilised a number of longitudinal datasets to understand how
children’s developmental trajectories over time, to ultimately identify areas where interventions may lead
to the greatest benefit for children and their families. Through his research, he has published over 50 peer-
review journals in leading journals in the field of child health (e.g. Paediatrics, JAMA Paediatrics) as well
as over 12 reports for federal and state government education and health departments.

Frank Oberklaid  AM, MD, FRACP was the Foundation Director of the Centre for Community Child
Health at The Royal Children’s Hospital for over 25 years. He is Co-Group Leader, Policy, Equity and
Translation, at the Murdoch Children’s Research Institute and an Honorary Professor of Paediatrics at
the University of Melbourne. He is a co-Chair of a steering committee and expert advisory group tasked
with developing a National Children’s Mental Health and Wellbeing Strategy on behalf of the Federal
Government. He is also Chair of the Victorian Children’s Council, which advises the Premier and Min-
isters on child health policy. He also chairs or is a member of several other important national policy
committees. He is especially interested in child mental health, prevention and early intervention, and the
use of research findings to inform public policy and service delivery. He is an internationally recognised
researcher, author, lecturer, and consultant, and has written two books and over 200 scientific publica-
tions. His work has been acknowledged in the form of a number of prestigious awards and many invited
international lectureships and visiting professorships.

Meredith O’Connor  BA(Hons), DEdPsych is an educational and developmental psychologist. Her research
investigates the development of optimal mental health over the life course. This includes both mental health
challenges, and the mental health strengths and assets that allow people to thrive. She has a particular focus
on how adversity undermines the development of optimal mental health, and what schools can do to pro-
mote it. To investigate how mental health unfolds, she uses powerful data from longitudinal cohort studies,
including the Longitudinal Study of Australian Children and Australian Temperament Project.

13
Supporting children’s mental health in primary schools: a…

Simone Darling  nee Hearps is a Research Fellow and Programme Manager at the Murdoch Children’s
Research Institute, Honorary Research Fellow at the University of Melbourne and Associate Fellow of the
Australian Institute of Digital Health. His work focusses on typical and atypical childhood development,
with a particular interest in social, emotional and cognitive outcomes in community and clinical settings.
He has attracted over $5.3 million in government and competitive funding to build the capacity of primary
schools to support student mental health and wellbeing, including the development and delivery of a state-
wide training programme for educators. He also has expertise in evidence-based digital health innovation,
and has attracted over $1.4 million in competitive government and venture capitalist funding to support
the development and implementation of digital health solutions. Most recently, he co-authored an inter-
nationally patented technology for the assessment of paediatric social skills (PEERSTM). In 2018, he was
nominated for the Inaugural Schmidt Science Fellowship Programme, a prestigious programme offered in
partnership with the Rhodes Trust to enhance the ability of the world’s most promising new scientists. In
2019, he was awarded a prestigious Quebec Health Research Fund Postdoctoral Fellowship.

Georgia Dawson  is a research fellow with the Melbourne Graduate School of Education (MGSE), manag-
ing a range of education-based research and evaluation projects spanning mental health, social-emotional
learning and literacy and numeracy at the programme and policy level. He also lectures in child develop-
ment, exceptionalities and learning interventions for several Masters courses at MGSE. He has a Masters
and a PhD in Educational Psychology and is a practising psychologist currently working in private practice.

Ann‑Siobhan Connolly  BMSc, MPH is a public health researcher at the Royal Children’s Hospital Cen-
tre for Community Child Health. Her research explores avenues for optimising children’s mental health.
Employing qualitative approaches, she explores caregiver perspectives on the barriers to existing school
and community-based mental health supports for children. This includes parental experiences of access-
ing child mental health services in the community and primary school staff’s views on supporting student
emotional health. Her research findings are intended to inform and shape current policy and service deliv-
ery to ultimately improve the mental health and wellbeing of children and their families.

13
 Teaching and Teacher Education 60 (2016) 312e320

Contents lists available at ScienceDirect

Teaching and Teacher Education

journal homepage: www.elsevier.com/locate/tate

School mental health content in state in-service K-12 teaching

standards in the United States
Annahita Ball a, *, Aidyn L. Iachini b, Jill Haak Bohnenkamp c, Nicole M. Togno d,
Elizabeth Levine Brown e, Jill A. Hoffman f, Melissa W. George g
a
School of Social Work, University at Buffalo, 685 Baldy Hall, Buffalo, NY 14260, United States
b
College of Social Work, University of South Carolina, 332 Hamilton, Columbia, SC 29208, United States
c
Center for School Mental Health, Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Office 422, 737 W. Lombard St.,
Baltimore, MD 21201, United States
d
College of Education and Human Development, George Mason University, 4400 University Drive, 2101 West Building, Fairfax, VA 22030, United States
e
College of Education and Human Development, George Mason University, 4400 University Drive, 1804 Thompson Hall, MS4B3, Fairfax, VA 22030, United
States
f
College of Social Work, The Ohio State University, 1947 College Rd., Columbus, OH 43210, United States
g
Prevention Research Center, Colorado State University, 439 Behavioral Sciences Building, 410 West Pitkin Street, Fort Collins, CO 80523, United States

h i g h l i g h t s

Content analysis was used to examine content in state K-12 teaching standards.

All states included content on school mental health, but content varied.

No statistically significant differences were noted across geographic regions.

Personal and professional growth was the least represented in the standards.

The collection and use of data was the most represented in the standards.

a r t i c l e i n f o a b s t r a c t

Article history: Teachers are integral to addressing children's mental health needs in schools, and they are often
Received 4 February 2016 members of child-serving teams focused on school mental health. Still, teachers report limited training in
Received in revised form mental health and behavior management in the classroom. This study used content analysis procedures
12 August 2016
to examine state K-12 teaching standards in the United States to understand the extent to which stan-
Accepted 22 August 2016
dards reflected teacher competencies for school mental health. Results revealed that all states included
content on school mental health, yet the content and extent of the content varied considerably across the
country. Implications are suggested for teaching policy, practice, and training.
Keywords:
Teaching standards
Published by Elsevier Ltd.
School mental health
In-service
Professional development
Behavior management
Content analysis

Current estimates suggest that one out of five children in the
United States has a mental health disorder and suicide is the
leading cause of death among adolescents (Centers for Disease
* Corresponding author.
E-mail addresses: annahita@buffalo.edu (A. Ball), iachini@mailbox.sc.edu
(A.L. Iachini), jbohnenk@psych.umaryland.edu (J.H. Bohnenkamp), ntogno@gmu.
edu (N.M. Togno), ebrown11@gmu.edu (E.L. Brown), Hoffman.800@osu.edu
(J.A. Hoffman), melissa.george@colostate.edu (M.W. George).
Control and Prevention, 2013; Merikangas et al., 2010). Moreover,
in some communities in the United States, up to two-thirds of
youth have experienced a traumatic event before age 16 (American
Psychological Association, 2008). Unaddressed, these issues can
result in difficulties at school, including poor academic functioning,
chronic absenteeism, and disciplinary concerns (DeSocio &
Hootman, 2004). Schools are increasingly identified as primary
access points and service delivery contexts for children's mental
health care, offering a range of services designed to address

http://dx.doi.org/10.1016/j.tate.2016.08.020
0742-051X/Published by Elsevier Ltd.
 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320
students' mental health needs (Wei, Kutcher, & Szumilas, 2011) and
promote social and emotional learning (Durlak, Weissberg, &
Dymnicki, 2011). Schools in the United States also face substantial
consequences for leaving children's emotional and behavioral dis-
orders unaddressed, as the Individuals with Disabilities Education
Act (IDEA, 2004) mandates appropriate services for all children
identified with disabilities, including those who have an emotional
disturbance or another mental health concern that may inhibit
learning.
Unfortunately, despite the prominent role for schools in
addressing students' mental health needs, teachers report that they
are largely unprepared for handling mental health in the classroom
(Williams, Horvath, Wei, Van Dorn, & Jonson-Redi, 2007). The is-
sues of professional development are not unique to the United
States. Globally, student behavioral concerns is a high-priority need
for teacher professional development (Schleicher, 2012). Current
research and policy underscore the controversy around if, and how,
teachers should support children's mental health. For instance,
standards-based accountability policies pinpoint curriculum and
instruction as the primary focus of teaching, despite students'
mental health being a contributor to teacher's everyday practice in
the classroom (Walter, Gouze, & Lim, 2006). Many other countries
also are struggling to identify the best ways to support teachers as
they engage with students' mental health concerns (e.g., Kutcher
et al., 2015; Pereira et al., 2012).
Teachers often are integral in providing a number of mental
health services, including early identification, referral, and
classroom-based support strategies (Anderson-Butcher, 2006;
Rothi, Leavey, & Best, 2008). Moreover, several existing school-
based mental health interventions rely on teachers for classroom-
based implementation and instruction (Franklin, Kim, Ryan, Kelly,
& Montgomery, 2012). Yet, teachers report stress related to stu-
dents' mental health needs (Ball, 2011; Ball & Anderson-Butcher,
2014) and they receive little focused training on students’ mental
health (Koller & Bertel, 2006).
Professional teaching standards serve an important role in
defining the scope of teacher practice. Teaching standards in the
United States articulate knowledge, skills, and dispositions that
states, professional associations, and consortia identify as critical to
the success of public school teachers. The United States is not alone
in attempting to identify and apply professional teaching standards,
as both the UK and Australia have put policy initiatives in place to
develop and refine standards for teachers as well (Ryan & Bourke,
2013). These standards are frequently used to establish profes-
sional development priorities for in-service teachers and serve as
guideposts for teacher evaluations. In the United States, each state
is responsible for creating professional teaching standards, but this
leaves the potential for inconsistency in expected teacher compe-
tencies, and specifically competencies in supporting student
mental health. The national Council of Chief State School Officers
(CCSSO), through its Interstate Teacher Assessment and Support
Consortium (InTASC), offers a model for core professional practice
standards that are designed to help states identify the knowledge,
skills, and dispositions that all K-12 teachers, regardless of grade or
content area, should possess to be effective in today's complex
classrooms (Council of Chief State School Officers, 2011). Still, states
have autonomy to design standards based on their own priorities,
models, and needs.
No study to date has examined the extent to which teaching
standards reflect competencies necessary for implementing pro-
grams and practices included in multi-disciplinary models of
school mental health. A better understanding of teaching standards
related to student mental health is critical to inform policymakers
about the professional development needs of teachers in this area
and in turn potentially support the overall developmental and
313
academic outcomes for students. The purpose of this study was to
address this gap and explore the extent to which state-level pro-
fessional K-12 teaching standards reflect competencies critical for
school mental health, and explore whether variability exists across
states within the US. Implications for educational policy, teacher
education, and teacher practice are discussed.
1. Literature review
1.1. School mental health
The notion that schools can and should serve as an important
context for providing mental health supports is gaining global
attention. After all, schools are where children spend much of their
time, and offer an environment in which children have regular
opportunities to experience academic and social success (Stephan,
Sugai, Lever, & Connors, 2015; Weist & Murray, 2007). In addition,
schools provide a single point of access for mental health inter-
vention for a majority of children, many of whom would otherwise
not receive these needed services (Kutash, Duchnowski, & Lynn,
2006). As such, school mental health (SMH) systems are integral to
address children's mental health needs and increase access to these
services. SMH systems often include a broad range of programs and
services that include the prevention, early intervention, and
treatment of students' emotional and behavioral problems, as well
as strategies that enhance the learning environment and promote
social and emotional development for all students.
The comprehensive scope of SMH requires multiple pro-
fessionals to share in service delivery, including teachers (Ball,
2011; Mellin, Anderson-Butcher, & Bronstein, 2011). Teachers
across social contexts play a critical role in the healthy development
and academic success of children (Anderson-Butcher, 2006; Pianta,
Hamre, & Allen, 2012), as well as in addressing students’ mental
health needs (Adelman & Taylor, 2011; Burke & Paternite, 2007).
For instance, teachers provide universal promotion and prevention
supports for students, implement classroom-based management
strategies, foster positive school climate, develop caring and sup-
portive relationships, and enhance other protective factors among
students (Pianta et al., 2012; Weston, Anderson-Butcher, & Burke,
2008). It is also common for teachers to collaborate with families
and other child-serving agencies to improve outcomes for children
with, or at risk of, social and emotional difficulties (Franklin et al.,
2012). Thus, the work of the teacher in addressing a diverse range
of social and emotional needs is demanding and complex, and
these demands are reported in other countries as well (Graham,
Phelps, Maddison, & Fitzgerald, 2011).
1.2. Teacher professional development in SMH
The body of research regarding teacher professional develop-
ment is vast, yet the niche of teacher competencies related to SMH
is largely unexplored. The majority of literature on teacher educa-
tion (both for pre-service and in-service teachers) has focused on
curriculum and instruction rather than teacher preparation to
address and support student mental health (Phillippo & Kelly,
2014). As such, evidence continues to suggest that teachers do
not feel adequately prepared to address students' social-emotional
and mental health issues in the classroom. Koller and Bertel (2006)
found that teacher training programs provide little, if any, specific
competence-based training regarding teachers’ ability to identify or
respond to a wide variety of mental health issues faced by many
students today. Indeed, a 2002 review of mental health content in
several commonly used educational psychology textbooks found
that information about mental health, social-emotional develop-
ment, and personality had steadily declined since the early 1950s
314 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320
(Oddone, 2002). While researchers are beginning to study the
effectiveness and impacts of teacher professional development in
SMH (e.g., Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010;
Powers, Wegmann, Blackman, & Swick, 2014), there are still few
empirically-based training curricula for teachers in this area.
Although teachers may view supporting students' mental and
emotional health to be a part of their role, research conducted
within the U.S., as well in the United Kingdom and Australia, in-
dicates that they may be reluctant to engage in this work (Kidger,
Gunnell, Biddle, Campbell, & Donovan, 2010; Mazzer & Rickwood,
2015). Teachers also frequently report feeling unprepared to
address student mental health needs in the classroom because they
are not provided with comprehensive training and professional
development opportunities (Phillippo & Kelly, 2014; Rothi et al.,
2008; Williams et al., 2007). Further, Roeser and Midgley (1997)
found that teachers' stress may exacerbate the “burden” they feel
related to students' mental health needs. Kidger et al. (2010) found
support to suggest teachers are less able to consider the mental
health needs of students when their own emotional and mental
health needs are neglected. Similarly, Ball's (2011) study of teach-
ers' readiness to adopt SMH programs found that teachers who
experienced more stress were also more likely to report readiness
to engage in SMH. Yet, teacher professional development rarely
includes skills and knowledge that aids teachers' involvement in
the range of social, emotional, behavioral and mental health chal-
lenges faced by their students (Begeny & Martens, 2006; Rollin,
Subotnik, Bassford, & Smulson, 2008).
Effective SMH service delivery relies on the high-quality
implementation of evidence-based and best practices (Ringeisen,
Henderson, & Hoagwood, 2003). Domitrovich et al. (2008)
describe a theoretical framework that highlights the critical com-
ponents of SMH implementation, including the macro context as a
primary influencer of SMH implementation. Specifically, they
identify two distinct components at play during implementation:
the intervention and the support system. In the case of SMH,
teachers sit within the support system, among other critical factors
such as professional development, training, coaching, and macro-
level policies related to mental health and the intervention.
Domitrovich and colleagues note that the support system's purpose
is to provide the means and context for quality implementation.
Thus, per their framework, teachers are not only essential to
implementing quality SMH programming, but the policies that
establish educational priorities and teacher professional develop-
ment are essential as well. Further, Domitrovich et al.’s framework
highlights the interplay of macro-level context, school-level factors,
and individual-level factors in the implementation of effective
programs. School-level factors, such as schools' available resources,
culture, leadership and decision-making structures, and climate
may all influence implementation. The factors have been studied in
relation to teacher engagement in SMH (see Ball & Anderson-
Butcher, 2014 for an example). Likewise, researchers have already
highlighted numerous individual-level factors that influence
teachers' implementation of SMH, such as knowledge (Mazzer &
Rickwood, 2015) and stress (Ball, 2011).
This study is focused on policies situated within the macro-level
that influence teachers’ understanding and implementation of
SMH. Policies at the federal, state, and district level have tremen-
dous influence on implementation processes, yet few studies
examine state-level teacher policy in relation to SMH. It is possible
that teachers who are positioned within a supportive policy context
that influences their preparation and professional development
may better understand the mental health concerns facing their
students and may be better able to reduce the impact of mental
health-related barriers to student learning, thus improving student
academic outcomes.
1.3. SMH competencies for teachers
To advance teachers' preparation and professional development
related to SMH, Weston et al. (2008) identified a set of SMH com-
petencies for teachers. Their work was the first attempt to provide a
foundation for teacher professional development and pre-service
training that focused on SMH. Since their publication in 2008,
these competencies have been highlighted by SMH researchers
(e.g., Phillippo & Kelly, 2014) and have been used to develop new
training models for teachers as well (Kumar et al., 2009). We
focused our attention in this area on Weston et al.’s competencies,
as they are the only comprehensive framework available to assess
teachers’ preparation and professional development related to
SMH.
Weston et al.’s competencies include six broad domains and 17
specific competencies for teachers' knowledge and skills related to
SMH. Table 1 lists each of the six domains as well as the compe-
tencies within each domain. The six domains include (1) key pol-
icies and laws (e.g., knowledge of the Individuals with Disabilities
Act or Family Educational Rights Privacy Act), (2) provision of
learning supports (e.g., understanding of risk and protective factors
and use of differentiated learning supports), (3) data collection and
use (e.g., use of data-driven decision-making, progress monitoring),
(4) communications and relationship building (e.g., verbal and non-
verbal communication, culturally responsive practice), (5) multiple
system engagement (e.g., connecting and engaging community
resources, cross-system collaboration), and (6) personal and pro-
fessional development and well-being (e.g., use of reflective prac-
tices, understanding of stress and burnout). To date, no study has
explored the extent to which professional teaching standards
reflect these SMH competencies. An analysis of the existing content
related to SMH within teaching standards will illuminate possible
opportunities for teacher education that support students’ mental
health and academic success.
1.4. Purpose of the study
Teachers are integral to SMH, but the extent to which profes-
sional teaching standards, which define the scope of teacher
practice, are reflective of SMH is unknown. This study sought to
address this gap in the literature by exploring the extent to which
state standards and the InTASC standards for teachers include the
competencies for SMH identified by Weston et al. (2008). We
sought to examine differences and similarities in content across
state standards for teachers, given the increasing trend toward
centralizing critical aspects of public education (e.g., Common Core
State Standards, Council of Chief State School Officers, 2012).
2. Methodology and methods
Content analysis procedures (Neuendorf, 2002) were employed
to examine and quantify the content related to SMH that was
evident in state standards for professional teaching. Specifically,
quantitative content analysis (Berelson, 1952; Holsti, 1969) was
chosen to systematically and objectively quantify the manifest SMH
content within the state standards documents by segmenting the
documents into units, assigning the units to categories, and then
counting categories. This analysis allowed us to identify and mea-
sure SMH content so that comparisons could be made across states,
as well as in relation to the InTASC standards.
2.1. Sample
The sample was composed of standards documents for 48 states
in the United States. The documents were limited to those
 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320 315

Table 1
SMH Competency Content included in State Standards Documents and InTASC.

Teacher competencies for SMH % (n) of state standards documents that Content included
included competency in InTASCb

Domain 1: Key Policies and Laws 60.4 (29) X

The teacher demonstrates understanding and application of key policies and laws that foster delivery of
effective and ethical learning supports in schools.
a Identifies and analyzes key policies driving educational reform and provision of learning supports in schools. 27.1 (13) X
b Explains how addressing “non-academic barriers” to learning (e.g., emotional problems) contributes to 37.5 (18) X
healthy development and school success.
c Uses effective confidentiality guidelines that govern practice in schools, adn applies strategies that are 39.6 (19) X
respectiful to student and family rights and privacy.
Domain 2: Provision of Academic, Social Emotional, and Behavioral Learning Supports 89.6 (43) X
The teacher demonstrates knowledge and skills related to the provision of learning supports that promote
academic achievement, healthy development, and overall school success.
a Identifies and explains the risk and protective factors that influence academic achievement and healthy 37.5 (18) X
development.
b Demonstrates understanding of a range of evidence-based and differentiated learning supports e from 87.5 (42) X
prevention, early identification and referral, and intervention e that promote academic achievement and
healthy development for all students.
Domain 3: Collection and Use of Data 100 (48)
The teacher demonstrates knowledge and skills in the collection and use of data measuring student behaviors,
affect, and attitudes, as they relate to academic, social, and emotional needs and outcomes.
a Identifies and explains the early signs and symptoms of mental health problems or atypical social-emotional 20.8 (10)
development among students.
b Identifies and explains the characteristics of positive, safe, and supportive classrooms, school climate, and 77.1 (37) X
culture.
c Uses assessment information to guide teaching, instruction, student referrals, and provision of social and 93.8 (45) X
emotional learning supports for students.
Domain 4: Communication and Collaboration 70.8 (34)
The teacher possesses and demonstrates the skills to communicate effectively and build relationships with
students, families, and colleagues.
a Identifies and uses effective verbal and non-verbal communication patterns. 53.1 (25) X
b Identifies and explains multiple barriers to effective communication. 8.3 (4)
c Demonstrates an ability to build trusting relationships with individuals of different backgrounds, cultures, 60.4 (29) X
languages, behaviors, attitudes, and beliefs.
Domain 5: Engagement in Multiple Systems and Cross-System Collaboration 91.7 (44) X
The teacher engages multiple systems and people in practices that maximize students' academic achievement,
healthy development, and overall school success.
a Identifies and explains the various school and community resources available to support academic 31.3 (15) X
achievement, healthy development, and overall school success.
b Participates effectively in teams and structures for provision of learning supports (pre-referral, intervention, 91.7 (44)a X
and evaluation assistance).
c Identifies and explains the principles of collaboration and group process that are necessary when working 91.7 (44) X
with others.
Domain 6: Personal and Professional Growth 58.3 (28)
The teacher demonstrates knowledge and skills that facilitate personal and professional growth, development,
and overall well-being.
a Identifies and explains the factors that lead to stress and burnout, as well as the negative outcomes 0 (0)
associated with their occurrence.
b Applies ongoing reflective practices by monitoring affect, values, beliefs, self-perceptions, and assumptions, 58.3 (28) X
and evaluating the impact of these influences on others and self.
c Identifies and applies coping strategies to combat stressors or resolve tensions between personally held 2.1 (1)
values, idealss, aspirations, and professional role expectations.

Note.
a
Competencies 5b and 5c were coded together as one competency due to their similarity.
b
An “X” for the entire domain indicates that all sub-domains were present in the InTASC standards document.

describing the standards for in-service K-12 teachers that were
passed by legislation. We excluded from this study those standards
in debate or in process, as well as standards for licensure and
teacher preparation programs. Standards for licensure and teacher
preparation programs were excluded to allow for a more thorough
investigation of in-service standards, given the research team's
resources.
2.2. Data collection
In 2014, the research team obtained in-service teaching stan-
dards documents from state department websites, including de-
partments of education, boards of education and teacher
associations, using search terms within the websites (i.e., “teacher
standards,” “professional standards,” “standards”). Although state
standard documents are public information, we tracked and noted
the difficulty in locating and obtaining these documents. The ma-
jority of standards documents (n ¼ 40) were available via state
department websites. Eight states, however, required personal
communication to obtain the standards documents. For these eight
states, we first e-mailed requests to the departments of education,
which resulted in obtaining the standards documents for four
states, three of which required multiple attempts through various
offices in state government. For the remaining four states, we
determined three had professional teaching standards boards. Each
board was contacted via e-mail, but we did not receive any return
responses. Next, we contacted university faculty members located
in colleges of education at each of the four remaining states. One
faculty member indicated the state was in the process of refining
their standards and was working through the policy process of
316 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320

adopting the InTASC standards; at their recommendation, we used
the InTASC standards. Faculty from a second state directed us to
another contact in state government, whom we e-mailed and ob-
tained the document for that state. Final attempts to secure the
documents for the two remaining states were made via e-mails to
state teachers’ associations. In one instance, we were redirected to
the state department of education website that we examined at the
start of the process; thus, we were unsuccessful in obtaining the
standards document for this state. We received no reply from the
other association. After this process of search and inquiry, which
occurred over the duration of approximately one year, we were
ultimately unable to locate standards documents for two states
(Pennsylvania and Wyoming).
2.3. Codebook development & data analysis
The researchers developed a codebook based on the established
Weston et al. (2008) teacher competency framework, the recom-
mendations of Neuendorf (2002), and coding schemes used in
studies employing similar procedures (e.g., Centers for Disease
Control and Prevention, 2011; Hindjua & Patchin, 2008). The
included SMH content that aligned with at least one domain.
Table 1 illustrates the percentage of the 48 state standards docu-
ments that included each of the six SMH competency domains.
Table 2 provides this information by each of the 48 states included
in the sample. Twenty (20) states included content from every SMH
domain in their standards document (Alabama, Arizona, Arkansas,
California, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana,
Kansas, Michigan, Nebraska, North Dakota, Ohio, Oklahoma, Ore-
gon, Tennessee, Utah, Vermont), while a minority of states, with the
lowest amount of SMH content, included content from two do-
mains (Alaska, Georgia, South Dakota). Results are summarized
next according to these six domains.
3.1. Domain 1- key policies and laws
Over half (60.4%; n ¼ 29) of the sampled states included at least
Table 2
Representation of the six SMH competency domains within each in-service state
teaching standards document.

codebook contained definitions of each of the six domains identi- State (standards document) Domain
fied by Weston et al. (2008). Additionally, the codebook contained 1 2 3 4 5 6
operational definitions for each of the 17 specific sub-domains
e e e e e e
within the six broader domains. A code of 0 was given for each
competency item that was not included in the document and a code Alabama X X X X X X
of 1 was given to each competency item that was included in the Alaska X X
document. Two pioneering researchers with expertise in teacher Arizona X X X X X X
Arkansas X X X X X X
education and SMH reviewed the codebook and provided feedback California X X X X X X
on face validity, content validity, and instrument structure. We Colorado X X X
refined the language within the codebook as a result of this Connecticut X X X X X X
feedback. Delaware X X X X X X
Florida X X X X
We then conducted a pilot test of the codebook using a random
Georgia X X
sample of 10 state standard documents (20% of the final sample). Hawaii X X X X X X
Six members of the research team independently coded the 10 Idaho X X X X X X
standards documents with one coder serving as the master coder to Illinois X X X X X X
determine reliability. An agreement rate was calculated by dividing Indiana X X X X X X
Iowa X X X
the number of times the coder agreed with the master coder by the Kansas X X X X X X
number of coding possibilities. The agreement rate for the initial Kentucky X X X X X
pilot test was adequate at 0.76. Still, to ensure that the codebook Louisiana X X X X
allowed for a reliable measurement of content in the documents, Maine X X X X
Maryland X X X X
we held discussions to identify and discuss areas of disagreement.
Massachusetts X X X X
Then, the team coded an additional five states with an agreement Michigan X X X X X X
rate of 0.86, which exceeds the recommended rate of 0.81. Each Minnesota X X X X
coder was assigned one SMH content domain and reviewed and Mississippi X X X X
coded the remaining 33 standards documents for that domain and Missouri X X X X X
Montana X X X X
entered the codes in a datafile using the Statistical Package for the Nebraska X X X X X X
Social Sciences (IBM SPSS, v. 22). Nevada X X X X X
Descriptive statistics were calculated to summarize the data. New Hampshire X X X X
Specifically, the frequency of SMH content by domain was calcu- New Jersey X X X X X
New Mexico X X X X X
lated for the entire sample. A state standard document was coded
New York X X X X X
as including content in each domain if at least one competency item North Carolina X X X X
for that domain was present in the standard document. The fre- North Dakota X X X X X X
quency of the presence of each domain in the state standards Ohio X X X X X X
documents for the entire sample was calculated by dividing the Oklahoma X X X X X X
Oregon X X X X X X
number of individual state standard documents that included Rhode Island X X X X X
content in that domain by the total number of states included in South Carolina X X X
this analysis (n ¼ 48). The breadth of competencies in each domain South Dakota X X
was also calculated for the entire sample by calculating the fre- Tennessee X X X X X X
Texas X X X X
quency of each competency item across the 48 states included in
Utah X X X X X X
this analysis. Vermont X X X X X X
Virginia X X X
3. Results Washington X X X X X
West Virginia X X X X
Wisconsin X X X X X
All of the 48 state professional teaching standards documents
 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320
one specific competency reflective of key policies and laws. Within
this domain, competency 1(a), “identifies and analyzes key policies
driving educational reform and provision of learning supports in
schools,” was the least represented (27.1%). Competency 1(c), “uses
effective confidentiality guidelines that govern practice in schools,
and applies strategies that are respectful to student and family
rights and privacy,” was the most represented (39.6%).
3.2. Domain 2- provision of academic, social emotional, and
behavioral learning supports
Almost all (89.6%; n ¼ 43) of the states in the sample included at
least one competency reflective of the provision of academic, social
emotional, and behavioral learning supports. Within this domain,
competency 2(b), “demonstrates understanding of a range of
evidence-based and differentiated learning supports … that pro-
mote academic achievement and healthy development for all stu-
dents,” was represented considerably more than competency 2(a),
“identifies and explains the risk and protective factors that influ-
ence academic achievement and healthy development” (87.5% and
37.5% respectively).
3.3. Domain 3- collection and use of data
Every state (100%; n ¼ 48) included at least one competency in
Domain 3; however, just 20.8% of the states included competency
3(a), “identifies and explains the early signs and symptoms of
mental health problems,” while 93.8% included competency 3(b),
“uses assessment information to guide student supports.
3.4. Domain 4 - communication and collaboration
This domain, which focused on teachers’ competencies related
to effective communication and relationship-building with stu-
dents, families, and colleagues, was represented in 70.8% (n ¼ 34) of
the sample. Competency 4(b), “identifies and explains multiple
barriers to effective communication,” was represented in only 8% of
the sampled states; however, competency 4(c), “demonstrates an
ability to build trusting relationships with individuals of different
backgrounds,” was represented in over 60% of the sampled states.
3.5. Domain 5- engagement in multiple systems and cross-system
collaboration
Over 90% of the states (n ¼ 44) included at least one competency
in engagement in multiple systems and cross-system collaboration,
with 31.3% of states including competency 5(a), “identifies and
explains the various school resources to support academic
achievement, healthy development and overall school success,”
and 91.7% include both 5(b), “participates effectively in teams,” and
5(c), “identifies and explains principles of collaboration.”
3.6. Domain 6- personal and professional growth
Domain 6 was the least represented of all domains, with just
over half (58%; n ¼ 28) of the states including at least one com-
petency related to personal and professional growth. There was
notable variability across the sub-domains, with competency 6(b),
“applies ongoing reflective practices by monitoring affect, values,
beliefs, self-perceptions, and assumptions, and evaluating the
impact of these influences on others and self,” represented by over
half of the states (58.3%). No state standards documents included
content on 6(a), “identifies and explains factors that lead to stress
and burnout.”
317
3.7. InTASC standards
We also examined the InTASC standards document, as it serves
as a benchmark for states to either use as their own standards or to
guide state-specific standards. In our study, six of the states used
the InTASC standards as the state's teacher standards document.
Table 1 summarizes those domains and competencies that were
represented in the InTASC standards. Domains 1 (key policies and
laws), 2 (provision of learning supports), and 5 (cross-system
collaboration) were the only domains in which all competencies
were included in the InTASC standards. While the InTASC standards
included some competencies from domains 3, 4, and 6, the domains
were not represented entirely in the standards. It is notable that
domain 6 (personal and professional growth) was the least evident
in the InTASC standards.
4. Discussion
Teachers are instrumental and frequently engaged in addressing
student mental health concerns in the classroom. However, little is
known about the extent to which state teaching standards reflect
this. As such, this study sought to understand whether state pro-
fessional in-service standards for teaching reflected competencies
critical for teachers within SMH (Weston et al., 2008). Overall, from
this study, there is evidence that these standards documents do
reflect priorities around teachers’ involvement in SMH, particularly
in relation to the collection and use of data, engagement in cross-
system collaboration and communication, and the provision of
academic, social, emotional, and behavioral learning supports.
These findings are encouraging, particularly as many of the com-
plex issues facing students today require teachers to possess these
critical competencies. These particular SMH competencies also are
reflective of broader trends in education around data-informed
decision-making, collaboration, and learning supports (Ball, 2011;
Mellin, 2009). As Domitrovich et al. (2008) highlight, the macro
context lays the groundwork for program implementation. In this
case, a number of U.S. educational policies emphasize these prior-
ities and thus state standards do as well, suggesting perhaps that
schools are implementing these strategies more.
Although the SMH competency domains of collection and use of
data, engagement in cross-system collaboration and communica-
tion, and the provision of academic, social emotional, and behav-
ioral learning supports were most represented across standards
documents, it should be noted that the competencies focused on
academic support were more frequently represented than those
with a specific focus on social and emotional development and
mental health. These results highlight that many of the compe-
tencies necessary to support student mental health are already
required of teachers as they relate to academic learning supports.
As these competencies are generally connected to providing aca-
demic learning supports and exist in teaching standards across
states, it may be a natural point of entry for increasing mental
health competencies for educators. Moreover, this is consistent
with U.S. federal policy (e.g., IDEA) priorities situated within the
macro context that focus teachers' efforts on ensuring all students
have an equal opportunity to receive an education by reducing
barriers to students' learning. Mental health problems pose such a
barrier, therefore any effort of teachers to engage in strategies to
support students’ mental health reflects directly back to that goal.
The competency domain least reflected in the standards docu-
ments was that of personal and professional growth. This is an
interesting finding given that teacher stress has critical implica-
tions for teacher turnover (Rothi et al., 2008). It is possible that
states include content in this area in other professional policy
documents, but this study revealed that in-service state teaching
318 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320
standards largely do not cover information on personal and pro-
fessional growth. As increasing numbers of teachers worldwide
express frustration and stress related to students' behavioral and
mental health (Kidger et al., 2010; Rothi et al., 2008), states within
the U.S. and other countries might consider how teachers may
obtain knowledge and skills to prepare them to cope with these
demands of teaching. For example, community organizations in
some states provide training and support for teachers that integrate
academic and social and emotional learning. Greater adoption of
these strategies at a state level may influence professional teaching
standards. Further, teachers' stress and emotional exhaustion is
often related to student's behavioral difficulties (Skaalvik &
Skaalvik, 2011), and is a key contributor to increasing teacher
turnover in U.S. schools (Ingersoll, Merrill, & Stuckey, 2015). More
and more professional development programs target teachers'
understanding of the early signs and symptoms of mental health
disorders, such as those developed by Jorm et al. (2010) and Powers
et al. (2014), but it may be equally important to remain attuned to
teachers' own mental health needs as well (Ball, 2011; Kidger et al.,
2010). An increased focus on teachers' personal and professional
growth, particularly in relation to self-care, may prove beneficial in
addressing teacher turnover and, ultimately, student outcomes. An
increased emphasis in state standards for in-service teaching is one
way to begin to address the pressing self-care needs of U.S.
teachers.
Another finding with important policy and practice implications
is that only one-fifth of the state standard documents included
language related to teachers being able to identify and explain the
early signs and symptoms of mental health problems. Teachers, by
nature of their role, are often the first to witness the signs and
symptoms of student distress or challenges in the classroom. The
importance of their role in early identification has been widely
discussed, including a specific call by President Obama (The White
House, 2013); however, it appears as though this specific compe-
tency is not reflected in documents that often guide and define
teacher practice and professional development. Indeed, teachers
report a global lack of experience and training for supporting
mental health (Mazzer & Rickwood, 2015; Reinke, Stormont,
Herman, Puri, & Goel, 2011) and further attention to inclusion of
this competency in professional standards may be warranted.
An exploration of the InTASC standards resulted in the identi-
fication of similar trends found in the individual state documents.
Collection and use of data, engagement in cross-system collabora-
tion and communication and the provision of academic, social
emotional, and behavioral learning supports were the most rep-
resented and personal and professional growth was represented
less often. This is not surprising given that the InTASC standards
offer a model of core professional practice. The findings of this
study indicate that many states are developing their teaching
standards documents in alignment with the standards delineated
by InTASC, which is consistent with Domitrovich et al.’s framework
as well, which points to the influence of external macro policies and
initiatives. As such, the InTASC standards document is an important
lever by which change in teacher competencies in relation to SMH
may occur.
4.1. State variability
The most variability among states was evident in the domains of
key policies and laws, communication and collaboration and per-
sonal and professional growth. Key policies and laws were less
represented across the entire sample, yet Alabama included con-
tent in this domain more frequently than any other state. Similarly,
personal and professional growth was less represented across the
entire sample, but state standards documents in California included
the most content pertaining to this domain. These states have the
potential to serve as examples for how standards documents may
reflect additional standards in these areas. A close look at the re-
sults, however, indicates that variability is evident across each state.
Federalism in the United States roots educational and mental
health policy decisions at the state-level, often leading to sub-
stantial differences in service delivery across states. This study
underscores how educational, mental health, and teacher educa-
tion policy may be attuned to local needs and priorities.
4.2. Limitations
Several limitations of this study are important to note. First, we
used the SMH competency framework offered by Weston et al.
(2008) to guide this study. There may be other competency
frameworks that also may be important to examine as it relates to
teachers’ competencies around SMH (e.g. social emotional learning
standards). Second, this study adopted a quantitative approach to
understanding the extent to which SMH competencies were re-
flected in these standards documents. As such, some of the rich
detail is lost by reducing the data in this way. However, we believed
a quantitative approach was an important first step in this research
to provide a broad comparison across states.
4.3. Implications and future research
This review provides a critical first step in understanding the
national landscape of what is required of in-service teachers with
regards to SMH. Implications for policy from this study relate to
how to expand and build from the SMH competencies already re-
flected in many of these documents. For example, it may be
important to consider how personal and professional growth might
be further incorporated into in-service standards. This is especially
important given current research pointing to the connection be-
tween teachers' comfort and efficacy in implementing social-
emotional learning practices and teacher stress (Collie, Shapka, &
Perry, 2012). In fact, emphasis on addressing teachers' own com-
fort levels with SMH, beginning with greater focus in the K-12
teaching standards, may prove beneficial for addressing teacher
stress and improving students’ developmental and academic
outcomes.
Another implication from this study is the need to continue
bridging the policy to practice gap, which is essential for effective
SMH implementation (Domitrovich et al., 2008). Scholars continue
to note that despite policy reform efforts, changes in teaching
practices may be more difficult to achieve and will require inno-
vative, collaborative partnerships among policymakers, re-
searchers, and teachers (Cohen, McCabe, Michelli, & Pickeral, 2009;
Greenwood & Abbott, 2001). These partnerships bridge the levels
identified in Domitrovich et al.’s framework, linking macro-,
school-, and individual-level characteristics to improve imple-
mentation quality. Our findings point to several areas of shared
priority across the state teaching standards, and the development
of national InTASC standards also are an indicator of the potential
for newly-developed collaborations that guide teaching. It will be
important to consider how existing collaborative partnerships may
be leveraged to spur innovation in teaching and teacher education.
This is especially needed as change must span macro-, school-, and
individual-levels to influence not only policy, but also teachers'
professional development and in-service training. Collectively,
these changes in the support system create the context for SMH
interventions to improve students’ outcomes.
Future research should investigate how the SMH competencies
that are included in the standards documents are translated to
teacher preparation, professional development and evaluation.
 A. Ball et al. / Teaching and Teacher Education 60 (2016) 312e320
Although the inclusion of SMH competencies in state standards
documents is an important step in supporting both student mental
health and teacher well-being, it is only as meaningful as the
impact of these policies on teacher training and practice. A review
of how standards are utilized across the nation to support teacher
practice, especially as it relates to SMH, will allow for potential
action steps with regard to additional supports necessary for
teachers to achieve these competencies. Likewise, it is possible that
states and districts still provide content on SMH in professional
development programs for teachers, regardless of the standards
content. It will be important to continue an investigation of the
ways in which state policy and local educational agencies include
SMH in their ongoing teacher preparation and training.
Future research also should examine the state standards as they
relate to important youth and school-level outcomes, such as aca-
demic and social-emotional indicators. It will be important to know
whether the presence of specific SMH competencies in state stan-
dard documents is related to improved outcomes for students and
schools. Although it is promising that many of the SMH compe-
tencies are included in the teacher state standards documents, a
better understanding of how these state standard policies are
translated to teacher training, practice and student outcomes is an
important next step in this line of inquiry.
States with the highest and lowest levels of SMH content in their
teacher standards may be an important point of entry to better
understanding the landscape of these relevant and related out-
comes. For instance, an important future line of inquiry would be
whether SMH content in teacher standards in high and low content
states are correlated with access to teacher professional develop-
ment resources and/or metrics of teacher stress and burnout.
Additionally, a better understanding of the potential relationship
between high and low levels of SMH content in the teacher stan-
dards and youth mental health statistics have the potential to drive
policy in teacher standards and teacher professional development.
5. Conclusions
Teachers are charged with supporting students’ academic suc-
cess. As this success is increasingly influenced by non-academic
barriers to learning such as mental health concerns (Dix, Slee,
Lawson, & Keeves, 2012; Massey, Armstrong, Boroughs, Henson,
& McCash, 2005), and as K-12 teachers interact with children and
youth on a daily basis, they are increasingly being called upon to
support student social and emotional development (The White
House, 2013). Professional teaching standards identify the knowl-
edge, skills, and dispositions that all in-service teachers should
possess to be effective in the classroom.
This study reviewed the extent to which these state teaching
standards reflect competencies in SMH critical for supporting stu-
dents' academic success and well-being. The presence of SMH
competency requirements in the professional teaching standards
across the United States further highlights the important role that
teachers play in supporting student mental health. These standards
may inform policy decisions about how states and districts can best
support teachers in the development of these critical SMH com-
petencies necessary to bolster student success. Additionally, the
standards in the United States may inform the efforts of other
countries attempting to assist teachers in their efforts to address
students’ non-academic barriers to learning. This study provided an
initial review of the SMH competency content evident in US state
standards, yet additional research is needed to further illuminate
how states and education agencies incorporate SMH content in
professional development for teachers. Still, the findings presented
here point to critical next steps for policy and teacher education.
319
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School-Based Mental Health Interventions and Teacher Involvement: A

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Children and Youth Services Review xxx (2012) xxx–xxx

Contents lists available at SciVerse ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Teacher involvement in school mental health interventions: A systematic review

Cynthia G.S. Franklin a, Johnny S. Kim b, Tiffany N. Ryan a, Michael S. Kelly c, Katherine L. Montgomery a,⁎
a
The University of Texas at Austin, United States
b
University of Kansas, United States
c
Loyola University, United States

a r t i c l e i n f o a b s t r a c t

Article history: Schools are large providers of mental health services for children and adolescents. Recent educational policy
Received 3 November 2011 initiatives at the federal level have ushered in Response to Intervention and school-wide behavior supports
Received in revised form 27 January 2012 that have potential to involve teachers in school mental health interventions. Little research exists investigat-
Accepted 29 January 2012
ing the involvement of teachers in school mental health services or the level of efficacy associated with
Available online xxxx
teachers providing these services. This paper conducts a systematic review to investigate the extent to
Keywords:
which teachers a) are the primary school-based service providers, b) collaboratively work with other profes-
Teacher sionals to provide services, and c) what levels of interventions within the Response to Intervention (RTI)
Mental health framework apply to these interventions. This paper further evaluates how efficacious teachers and school
School-based services mental health professionals are in impacting outcomes in previous studies. Results indicated that out of
Response to intervention the 49 school mental health studies analyzed, teachers were actively involved in 40.8% of mental health in-
Effective terventions evaluated, and were the sole providers of interventions in 18.4% of the studies. It was also
found that many of these school mental health interventions were universal (Tier 1) and took place in the
classrooms. Further examination of findings suggested that different personnel, such as school mental health
professionals and teachers, achieved similar outcomes across the studies.
© 2012 Elsevier Ltd. All rights reserved.

1. Introduction responsible for the delivery of school mental health services.

The 2005–2006 national survey by the Substance Abuse and Men-
tal Health Services Administration (SAMHSA, 2007) revealed that ap-
proximately three million youths received school-based services for
behavioral or emotional problems during the 2005–2006 academic
year. As this national survey indicates, schools often serve as a deliv-
ery point for mental health services for children and adolescents
(Adelman & Taylor, 2010; Hoagwood et al., 2007; Stormont, Reinke,
& Herman, 2011). Adelman and Taylor (2010) suggest, for example,
that over 50% of students from urban districts may have serious learn-
ing, emotional, and behavioral problems that schools must address.
These authors also point out that students' behavioral problems
may be more psychosocial in nature and highlight that all problems
may not warrant a mental health diagnosis. However, the resolution
of emotional and behavior problems has become a necessity for the
improvement of educational outcomes and falls under the auspices
of school-based mental health professionals. School based mental
health professionals (sbmhp), sometimes called Related Services
(i.e. school social workers, psychologists, and counselors), are mainly
⁎ Corresponding author at: The University of Texas at Austin, School of Social Work,
1 University Station, D3500, Austin, TX 78712, United States. Tel.: + 1 512 565 5750.
E-mail addresses: kmontgomery@utexas.edu (C.G.S. Franklin), jkim@ku.edu
(J.S. Kim), tryan@mail.utexas.edu (T.N. Ryan), mkell17@luc.edu (M.S. Kelly),
kmontgomery@utexas.edu (K.L. Montgomery).
Teachers, however, have also become involved in classroom interven-
tions and various learning supports.
1.1. Definitions of school mental health
School mental health is a broad category that describes many dif-
ferent psychosocial interventions and services that are designed spe-
cifically to be learning supports for students with social, emotional,
and learning challenges. School-based mental health services have
been defined very broadly to reflect a diversity of services that may
be used in schools to meet the learning needs of students. School
mental health, for example, has been defined by The National Assem-
bly of School-based Health Care as being an overarching concept that
encompasses many programs and frameworks including, but not lim-
ited to, student assistant teams, Response to Intervention (RTI), posi-
tive behavioral interventions and supports, special education, social
and emotional learning services, Safe Schools and Healthy Students,
school climate and many other initiatives that are meant to address
the social and emotional learning, and behavioral responses of stu-
dents. Weist and Paternite (2006) suggest that school mental health
may focus on all students, general and special education, and include
a full range of programs, strategies, and services ranging from mental
health promotion to mental health intervention.
Adelman and Taylor (2010) also describe the roles of school men-
tal health professionals as including the delivery of mental health

0190-7409/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.childyouth.2012.01.027

Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
2 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx
promotion, prevention programs aimed at resolving psychosocial
problems, enhancing resiliency in students and early interventions,
building the capacity of school staff toward mental health and system-
ic changes in school programs, as well as supporting schools with em-
pirically supported treatments for students that may have one or more
diagnosable mental disorders. Through the lens of an RTI framework,
this manuscript investigates the effectiveness of school mental health
services, with a specific focus on understanding the extent to which
teachers are involved in intervention service delivery.
2. Background
2.1. Response to intervention and school mental health
Recent reauthorizations of IDEA (1997, 2004) have encouraged
the use of RTI, a public health framework that promotes the use of
three tiers of intervention corresponding to primary, secondary, and
tertiary prevention (Fuchs & Fuchs, 2006; Hoover, Baca, Wexler-
Love, & Saenz, 2008). Though RTI began as an initiative rooted in spe-
cial education, goals of the policy have become focused on: 1) an in-
creased direct involvement of regular education teachers in the
assessment of at-risk students and 2) enabling school districts to
use the RTI framework as a tool to develop school-wide strategies
that coalesce around helping all children achieve positive academic
and behavioral outcomes (Vaughn & Fuchs, 2003).
Over the past decade, RTI has been expanded to include two relat-
ed, but distinct, strands of school-based interventions for both
teachers and school-based mental health professionals. RTI has been
offered as a framework to design and implement evidence-based
early intervention strategies for students with specific behavioral inter-
ventions for specific students (Gresham, 2005), though there is little
evidence yet on the efficacy of this approach. Additionally, school-
wide positive behavioral supports aimed at improving the school
climate, and evidence-based mental health practices within schools
are often characterized as RTI (though they are also sometimes de-
scribed by the related term Positive Behavior Supports or PBS). In par-
ticular, many of these interventions have focused on the classroom
management strategies employed by teachers and their abilities to de-
liver social–emotional learning curriculum in their classrooms
(Lindsey, White, & Korr, 2006).
Related service personnel, specifically school-based mental health
professionals (SBMHP) such as school social workers, school coun-
selors, and school psychologists, have begun to adapt their practice
roles to work explicitly within the various facets of the RTI frame-
work. Though this process is far from uniform, recent survey data col-
lected on SBMHP practice indicate that SBMHP participate in RTI in
the following ways:
1) Attending RTI team meetings
2) Identifying students for more intensive tier-based interventions
based on data collected by the SBMHP and the RTI team,
3) Measuring the impact of interventions delivered by the SBMHP to
address student behavioral issues at all three tiers
4) Delivering universal (Tier 1) and more targeted interventions
(Tier 2 and Tier 3)
5) Working collaboratively with classroom teachers to implement
behavior plans
6) Consulting with the administrative team by helping them select
appropriate universal interventions to address behavioral and
socio-emotional problems in the school building (Kelly, Raines,
Stone, & Frey, 2010; Sabatino, 2009).
2.2. Roles of teachers and school mental health professionals within RTI
RTI has changed the way special education and general education
teachers function. For example, it has caused their roles to more
Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
frequently overlap and has also increased the workload of general ed-
ucation teachers through helping children with serious behavioral
challenges and/or mental health disorders (Fairbanks, Simonsen, &
Sugai, 2008; Horner et al., 2009; Simonsen, Shaw, Faggella-lubym
Sugai, Coyne, & Alfano, 2010). In a typical RTI framework, the school
first implements “Tier 1,” universal strategies in every classroom. It
is presumed that general education teachers will learn the best class-
room management strategies, which are based on the principles of
applied behavioral analysis (e.g. setting clear rules and consequences,
contingent praise, and the use of positive reinforcement). Then sec-
ondly, the school offers “Tier 2,” selective interventions that consist
of small group instruction or intervention for children. Progress of
Tier 2 interventions is revealed through continuous progress moni-
toring in data-based assessments to extend help beyond the universal
level. While all students in a school that implements the RTI approach
receive Tier 1 interventions, only approximately 20% may be referred
to a Tier 2 intervention (Frey, Lingo, & Nelson, 2011).
Students that need help beyond the Tier 2 interventions may re-
ceive “Tier 3” (indicated) interventions that involve more intensive in-
dividualized instruction and/or therapeutic approaches (Kelly, 2008).
At the point of needing Tier 3 interventions, many students may be re-
ferred for special education services. RTI approaches that involve spe-
cial education and intensive, individualized therapeutic interventions
are considered to be the last and greatest effort to help a child. While
this may become the exclusive domain of school mental health profes-
sionals, it is conceptualized to only involve approximately 5% of chil-
dren in schools (Kelly, 2008). This means that special educators and
school mental health teams, such as school social workers and psy-
chologists, have an important role to play in providing support to gen-
eral education teachers that are on the front-lines of the Tier 1
interventions and may further work closely with teachers in the deliv-
ery of Tier 2 interventions (Fairbanks et al., 2008).
As Richards, Pavri, Golez, Canges, and Murphy (2007) point out in
actual school settings, the interventions that are delivered across tiers
may become blurred, and general education teachers may also be in-
volved in delivery of the Tier 2 interventions. Frey et al. (2011) also
suggest that Tiers 2 and 3 interventions may be hard to differentiate
from one another. The result being that Tiers 1 and 2 may overlap
and may scaffold on one another, and Tiers 2 and 3 may increase inten-
sity of interventions, but use the same types of interventions in differ-
ent ways. For example, a student assessed by the 3-tier framework and
found to need more intensive social skills instruction may participate in
30 min of small group social skills instruction (Tier 2) delivered by a
classroom teacher or fill out a daily report card while continuing their
current Tier 1 classroom instruction by a teacher. When moving to
Tier 3, social skills interventions may focus more intensively on stu-
dents who continue to receive the same social skills instruction and in-
tensive monitoring interventions as other students (such as a daily
report card) along with other individual, family, and community inter-
ventions that may be delivered by a school mental health team, but
may also involve the student's general education teacher.
2.3. Teamwork between school based mental health professionals
and teachers
Literature suggests that teachers are valuable partners with school
mental health professionals and may take on significant roles in the
delivery of mental health interventions in school settings (Feinstein,
Fielding, Udvari-Solner, & Joshi, 2009; Ringwalt et al., 2010; Smolak,
Harris, Levine, & Shisslak, 2001; Stormont, Lewis, Beckner, & Johnson,
2008; Wolmer, Hamiel, & Laor, 2011). Several authors have also sug-
gested advantages to including teachers on mental health teams. Adi
and colleagues suggested that teachers may be better at sustaining
longer-term effects because interventions may be reinforced in class-
rooms (Adi, Killoran, Janmohamed, & Stewart-Brown, 2007). Similar-
ly, Diekstra (2008) also pointed out that teachers are better at
 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx
integrating social and emotional interventions in ways that may im-
pact academic performance because they are more involved with stu-
dents for prolonged periods of time and across different school
programs and, therefore, may have the largest impact on student
functioning. This is a point that is also echoed by Feinstein et al.
(2009), who suggested that effective delivery of mental health inter-
ventions in schools might not be possible without the collaboration of
teachers, because mental health professionals have substantially less
access to students.
Implementation of an RTI framework within a school suggests that
school-based mental health professionals may work together as a
team with teachers in the delivery of school mental health interven-
tions. When researchers examine the roles of teachers and school
mental health professionals in school mental health services the re-
sults are not as clear concerning how often the two work together
as a team. A national survey of school-based mental health programs
found, for example, that most mental health programs that were once
provided have withdrawn their screening and counseling services
and, further, that there was little time for collaboration between
teachers and mental health professionals (Foster et al., 2005). In an-
other more recent national survey of school social work professionals,
however, Berzin et al. (2011) found that school social workers often
collaborated with teachers to assist with the following: 1) helped
teachers with behavior intervention plans and classroom manage-
ment techniques, 2) conducted joint sessions with teachers and stu-
dents, and 3) improved teacher professional development. Other
collaborative roles with teachers also included those that involved
case management and school-wide reform (Berzin et al., 2011). This
survey suggests that teamwork is occurring between school mental
health professionals and teachers, but more research is needed to
clarify how often teachers may work as a team with mental health
professionals in the delivery of mental health interventions.
2.4. Effective school mental health interventions
Baskin, Slaten, Sorenson, Glover-Russell, and Merson (2010) com-
pleted a meta-analysis of 107 counseling and psychotherapy youth
studies in schools and found an overall medium effect size (0.45)
for youth interventions. This review allowed for studies that were
designed by psychologists and other mental health professionals,
but were delivered by teachers. The study further examined interven-
tion moderators grouping teachers into a paraprofessional category
along with parents. Twenty-three of the 107 studies analyzed were
implemented by the paraprofessionals including both teachers and
parents. Results indicated that licensed mental health professionals
out performed (0.67) the paraprofessionals (0.45) and, further, para-
professionals had better results than graduate students (0.17). It is
worth noting, however, that the teachers and parent deliverers of in-
terventions achieved a medium effect size, which is the same as the
overall study results.
In separate narrative reviews, Rones and Hoagwood (2000) iden-
tified 47 effective mental health interventions, and Hoagwood et al.
(2007) identified 24 effective school-based mental health interven-
tions. Although these empirical reviews did not specifically focus
on the role that teachers might play in the delivery of these inter-
ventions, the results do provide some insights into effective pro-
gram components. For example, Hoagwood et al. (2007)
discovered that the more efficacious interventions included class-
room, family, and school-wide interventions that suggested ecologi-
cal and collaborative approaches are the most effective ways to
impact both mental health and academic outcomes. Other re-
searchers reviewing the school-based intervention literature have
suggested that school mental health professionals work with
teachers who are intricately involved in carrying out many of the
evidence-based, behavioral interventions in schools, especially
Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
3
those delivered at the Tiers 1 and 2 levels (Anderson-Butcher &
Ashton, 2004; Berzin et al., 2011; Frey et al., 2011).
2.5. Teacher effectiveness in school mental health
Teachers may play a central role in the implementation of strat-
egies and interventions rooted in the RTI framework, but their effec-
tive role in the implementation of RTI and mental health
interventions is a point of controversy within the educational litera-
ture (e.g., Chitiyo & Wheeler, 2009; Hawkins & Heflin, 2011;
Ringwalt et al., 2010; Tillery, Varjas, Meyers, & Collins, 2010). For
example, researchers suggest that many teachers lack knowledge
about RTI and others do not understand the core concepts of RTI
well enough to carry them out effectively over time. Reviews of
the research have also indicated that teachers lack knowledge and
training in mental health and are not well equipped to carry out be-
havioral interventions (Frey et al., 2011). On the other hand, re-
search suggests that teacher–student relationships are key to social
and emotional development and the academic achievement of stu-
dents (Helker, Schottelkorb, & Ray, 2007). Teachers may also be
very effective in the implementation of both RTI and evidence-
based mental health practices if teacher efficacy is increased, they
are thoroughly trained, and are provided the appropriate supports
and supervision by administration and mental health professionals
to carry-out and sustain the interventions (Durlak, Weissberg,
Dymnicki, Taylor, & Schellinger, 2011; Easton & Erchul, 2011; Lane,
Weisenbach, Little, Phillips, & Wehby, 2006; Murray, Rabiner,
Schulte, & Newitt, 2008; Pierce, Reid, & Epstein, 2004).
The classroom management practices of teachers are highlighted
the most as an effective behavioral intervention. Effective classroom
management has been shown to decrease children's behavior prob-
lems, as well as offer promising implications regarding the prevention
and development of more serious emotional and behavioral disorders
(Hester et al., 2004; Leflot, van Lier, Onghena, & Colpin, 2010; Myers,
Simonsen, & Sugai, 2011; Pierce et al., 2004).
Although, teachers may obviously have important roles in class-
room management strategies, researchers have not specifically stud-
ied teacher implementation and effectiveness in the delivery of
evidence-based, mental health interventions. In a meta-analysis on
school-based programs for aggressive and disruptive behavior, how-
ever, Wilson, Lipsey, and Derzon (2003) found that “interventions
were generally more effective when implemented well and relatively
intense, used one on one formats and were administered by teachers”
(p. 148). Interventions studied included social competence training,
behavioral interventions, therapy and counseling, multimodal pro-
grams and peer mediation. In a separate but related study Wilson
and Lipsey (2007) also concluded that the interventions delivered
by teachers to prevent violence and aggression were more sustain-
able and cost effective when compared to other interventionists.
3. Purpose of current review
The purpose of this article is to conduct a retrospective systematic
review of the literature on school mental health interventions to
more closely examine the extent to which teachers may be involved
in the delivery of school-based mental health services. The main
focus of this article is twofold: 1) to assess how often teachers are in-
volved in delivering school mental health interventions and 2) to as-
sess at what level of intervention teachers may be involved using the
framework of Response to Intervention. As a supplementary aim, this
article will also examine the efficacy of school mental health inter-
ventions implemented by teachers in conjunction with and compari-
son to other professionals, and in relationship to diverse outcomes
through calculating corresponding effect sizes.
4 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx

4. Method

For this review, we have concentrated our literature search and

study inclusion on specific criteria and recent school mental health
studies for two specific reasons. First, we wish to review school men-
tal health literature that reflects a more recent shift in the ways ser-
vices are being conceptualized and delivered, specifically related to
the framework of Response to Intervention (RTI) and its related
framework SWPBS, because these studies may better reflect the cur-
rent roles of teachers in the delivery of school mental health services.
The RTI framework has become a major emphasis of state and local
school policy initiatives, and many studies conducted in the 1980s
and early 1990s were not conducting school mental health practices
within this framework and, therefore, may not adequately reflect
the programs that are currently being implemented in many schools.
Second, other scholars have examined school-based interventions
from 1980 and beyond (Baskin et al., 2010; Franklin, Kim, & Tripodi,
2009; Rones & Hoagwood, 2000) and we wish to add to this literature
by more carefully examining the changing roles of teachers in the de-
livery of school mental health services. Thus, the following inclusion
criteria were created to most adequately address the aims associated
with this article.

4.1. Study selection

School mental health interventions may be best identified by the

purposes for which they are designed and delivered, and that is to
assist the mental health functioning of students and to support
their social and emotional learning within schools. School mental
health services are not determined by or limited to any specific
mental health diagnosis or intervention but instead are services
that are self-defined as being a school-related, mental health service
with a specific focus on improving the social, emotional and behav-
ioral functioning of students. Since the school mental health litera-
ture is vast and interventions grounded in research evidence are
most critical, we will narrow our examination of the literature to
school-based mental health interventions that have been studied
using experimental and quasi-experimental designs. Fig. 1 depicts
the review process and decisions made that led the final study se-
lection. A computerized search on several databases (ERIC, Psy-
cINFO, MEDLINE, CINHAL, & Social Science Abstracts) was
conducted to locate studies that tested any school-based mental
health services for children. Studies were identified using the key-
words: school*, children or adolescent* or youth, mental health or
mental health service*, and outcome study or effective or efficacy,
with an * on some words to include multiple variations of that
term. Furthermore, other published systematic reviews were
searched to locate additional studies that might be included in this
meta-analysis. In order to meet study inclusion for this systematic
review, primary studies needed to meet the following eligibility cri-
teria: (a) study research design is either a randomized controlled
trials or quasi-experimental involving a comparison between and
intervention and control group; (b) study published between Janu-
ary 1999 and September 2010; (c) study conducted in a school set-
ting; (d) involved a mental health and behavioral service such as
prevention, risk reduction, and intervention/treatment; (e) study
conducted in the United States; and (f) study contained enough sta-
tistical information to calculate effect sizes. Qualitative studies, de-
scriptive case studies, and single-case design were excluded due to
the lack of statistical information to calculate effect sizes.
4.2. Effect size calculation
For each study, one effect size was calculated and entered using
Comprehensive Meta-Analysis software 2.0 (Borenstein, Hedges,
Higgins, & Rothstein, 2005). Hedges's g effect sizes (with small
Fig. 1. Study selection flowchart.
sample size bias adjustment) were calculated for studies reporting
standardized mean differences between treatment and control condi-
tions while odds ratio effect sizes were calculated for dichotomous
outcomes and then converted to Hedges's g effect sizes (Cooper &
Hedges, 1994). One study (Hallfors et al., 2006) reported non-
significant results without providing any detailed statistical informa-
tion; therefore, an effect size of zero was substituted for non-
significant outcomes as recommended by Perry (1997). This provides
a more conservative pooled point estimate of the effect size. All effect
sizes were recorded such that a positive value indicated a better out-
come for the experimental condition regardless of the direction of the
scale used in the original study.
When studies reported multiple follow-up points, the first
follow-up point was selected to help calculate effect sizes
(Corcoran & Pillai, 2007). Several studies contained two different in-
terventions in addition to a control group with results comparing
both interventions to the control as well as between the two inter-
ventions. In these instances, an effect size was calculated for each
comparison between the experimental and control group and then
those effect sizes were averaged together to come up with one ef-
fect size estimate for the study. Effect sizes were interpreted based
on classification by Cohen (1988), with 0.20 indicating a small effect
size, 0.50 indicating medium, and 0.80 and above considered large.
A 95% confidence interval (CI) level was also calculated for each
study effect size measure to indicate the precision of the estimated
effect size (Lipsey & Wilson, 2001), as well as used to indicate statis-
tical significance for a study's outcome measure. If the 95% confi-
dence interval level does not contain zero, then we can reject the
null hypothesis and conclude that the effect size estimate is signifi-
cantly different from zero (Littell, Corcoran, & Pillai, 2008; Shadish &
Haddock, 1994). When a primary study used multiple measures for
a single outcome construct, we followed Lipsey's (1994) suggestion
to calculate individual effect sizes for each of the different measures
in a single study and then average them to come up with one effect
size for that measure.

Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx 5

4.3. RTI coding Table 1

Study characteristics.

After the final selection of studies to be included in this review, Characteristic N (%)
two of the authors independently went through all the studies and
Publication date
coded the RTI levels and then compared their results for agreement. 1999–2004 37 (75.5)
Those studies that were coded differently were double checked and 2005–2010 12 (24.5)
resolved through a consensus agreement between the authors of Research design
Experimental 33 (67.3)
this study. When coding the RTI levels in this study, we delineated
Quasi-experimental 16 (32.7)
the tiers as follows: Type of control
No treatment 57.1
• Universal (Tier 1): An intervention delivered to either at an entire Waitlist control 18.4
school-level or across specific grade-levels within an entire school Alternative treatment 14.3
to all students (e.g., all 3rd–5th grade classrooms get intervention Treatment as usual 10.2
Outcomes examined
or all students in a school learn from a bullying prevention
Internalizing problems 17 (34.7)
curriculum). Externalizing problems 1 (2.0)
• Selective (Tier 2): An intervention delivered at either a classroom or Internalizing and externalizing problems 5 (10.2)
small-group level that identifies a specific group of students who ei- Substance abuse 6 (12.2)
ther are at-risk for certain problems, but have not developed specif- Social skills or psycho-education 7 (14.3)
Academic performance 2 (4.1)
ic diagnostic and behavioral severity within the school (i.e., a Multiple outcomes 11 (22.4)
specific IEP label for special education or a high number of behav- School level
ioral or discipline referrals). Elementary school 19 (38.8)
• Indicated (Tier 3): An intervention that is conducted in individual Middle school 12 (24.5)
High school 14 (28.6)
or small group (or self-contained Special education classroom) set-
Multiple levels 4 (8.2)
tings for students who are already “identified” for specific services Ethnicity of students
within the school or community setting (i.e., an IEP, a DSM diagno- Asian, Black, Hispanic, and White 20 (40.8)
sis, severe behavioral/discipline issues, involvement with juvenile Black, Hispanic, and White 13 (26.5)
justice, etc.) Black only 3 (6.1)
Hispanic only 5 (10.2)
Minority only 3 (6.1)
5. Results Did not specify 5 (10.2)
Classroom setting
General education 46 (93.9)
This study reviewed published articles from January 1999 to Sep-
Special education 3 (6.1)
tember 2010 and found 1443 studies that met the initial inclusion cri-
teria and 49 studies that met the final inclusion criteria. The final
studies included contained 3 published studies by the Conduct Prob- Most of the articles (93.9%) conducted studies on general education
lems Prevention Research Group (CPPRG) group and a decision was classrooms and only 6.1% looked at both general education and spe-
made to treat them as one study since the same sample was used as cial education classrooms.
part of a larger longitudinal study. The studies that were excluded Results compiled in Table 2 reveal that more than half of the study
from the final review sample either did not meet criteria for the re- interventions (59.2%) were conducted by a combination of experi-
search inclusion design or did not have necessary information in the enced clinicians, graduate interns, or other non-teaching profes-
article to calculate an effect size. As seen in Table 1, results show sionals, such as nurses. Studies using only professional clinicians,
three-fourths of the studies were published during 1999–2004, such as school social workers and psychologists, accounted for
while a quarter of the studies were published during 2005–2010. 28.6% of the studies, and 18.4% of the studies had only teachers pro-
The majority of the studies (67.3%) used an experimental design. vide the interventions to the students. As most of the studies were
More than half the final studies (57.1%) used a control group that re- conducted in the classroom, 40.8% of the interventions involved
ceived no treatment, followed by waitlist control group (18.4%), alter- teachers at some level in the delivery of the interventions. The most
native treatment (14.3%), and business as usual (10.2%). Regarding common RTI level targeted was the Tier 1, universal preventative in-
outcomes examined, 34.7% looked at internalizing problems, 2% terventions (40.8%). Only one study (Eron et al., 2002) targeted all
looked at externalizing problems, and 10.2% looked at both internal- three RTI levels, leaving two studies (Conduct Problems Prevention
izing and externalizing problems. Studies in this review also exam- Research Group, 1999, 2002, 2004; Fast, Fanelli, & Salen, 2003) that
ined substance abuse (12.2%), social skills or psycho-education targeted some combination involving 2 of the 3 RTI levels.
(14.3%), academic performance (4.1%), and multiple outcomes Effect size results across all 49 studies ranged from zero (Hallfors
(22.4%). et al., 2006) to a very large effect size of 1.898 (Larkin & Thyer,
The grade levels of student participants in the studies were divid- 1999). When teachers were the sole providers of interventions
ed somewhat equally, with 38.8% only including elementary school (n = 8), study effect sizes ranged from a zero (Hallfors et al., 2006),
aged participants, 24.5% middle school, 28.6% high school, and 8.2% which indicates no treatment effect, to a large effect size of 1.214
studying multiple grade levels. The majority of the studies (40.8%) ex- (Duncan, Duncan, Beauchamp, Wells, & Ary, 2000). More specifically,
amined all students with coded diverse ethnic and racial back- three studies (Cho, Hallfors, & Sánchez, 2005; Hallfors et al., 2006;
grounds. Twenty-six percent of the studies examined a combination Melnyk et al., 2009) had small effect sizes, three studies (Botvin,
of Caucasian, Black, and Hispanic students, and 10.2% did not specify Griffin, Diaz, & Ifill-Williams, 2001; Hennessey, 2007; Robinson,
racial composition of their sample. Noteworthy, we chose to code Smith, & Miller, 2002) had medium effect sizes, and one study
under the term “Black” rather than “African American,” because not (Duncan et al., 2000) that offered a large effect size. For those studies
all Black students identify their ancestors as being from Africa (for ex- where teachers were involved in the delivery of the intervention
ample, some are from Jamaica or Haiti). The remainder of the articles along with others (n = 12), effect sizes ranged from a small effect
identified either one specific group to study or a combination of mi- size of 0.100 (McWhirter & Page, 1999) to a large effect size of
nority groups with 6.1% using a sample of only minority students, 0.706 (Franklin, Moore, & Hopson, 2008). A majority of these studies
6.1% only including Black students, and 10.2% only Hispanic students. reported small treatment effects, with only two studies (Flay, Allred,

Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
6 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx

Table 2
RTI intervention results.

Study Intervention RTI level Intervention deliverers Effect size (95% CI)

Armbruster and Lichtman (1999) School-based mental health service program Indicated Clinical therapists 0.093 (0.27, − 0.09)
Asarnow, Scott, and Mintz (2002) Cognitive behaviors family education intervention Indicated Graduate interns 0.298 (− 0.51, 1.11)
Bauer, Lozano, and Rivara (2007) Olweus Bullying Prevention Program Universal Whole school — teacher, 0.136 (0.06, 0.22)
staff, administration
Bohman, Barker, Bell, Lewis, Holleran, Protecting Me, Protecting You Curriculum Universal Teachers and students 0.278 (0.06, 0.50)
and Pomeroy (2004)
Botvin, Griffin, Diaz, Life skills training to prevent drug and alcohol use Universal Teachers 0.494 (0.25, 0.74)
and Ifill-Williams (2001)
Bruning, Brown, Winzelberg, Abascal, Student bodies program — internet-based eating Universal Clinical therapists 0.354 (− 0.06, 0.76)
and Taylor (2004) disorder prevention program
Carbonell and Partelemo-Barehmi Psychodrama group program Indicated Clinical therapists 0.672 (− 0.10, 1.45)
(1999)
Cho, Hallfors, and Sánchez (2005) Reconnecting Youth class Universal Teachers 0.101 (− 0.05, 0.25)
Cardemil, Reivich, and Seligman (2002) Penn Resiliency Program (Depression Selective Graduate interns and 0.170 (− 0.17, 0.51)
Prevention Program) clinical therapists
Chemtob, Nakashima, and EMDR Indicated Graduate interns 0.172 (− 0.51, 0.85)
Carlson (2002)
Conduct Problems Prevention Research Fast Track and PATH's curriculum Universal and Teachers and 0.113 (0.03, 0.19)
Group (1999, 2002, 2004) indicated Clinical Therapists
DeRosier, 2004 Social skills group intervention Selective Graduate interns and 0.118 (− 0.08, 0.32)
clinical therapists
Donaldson, Thomas, Graham, Au, Adolescent Alcohol Prevention Trial Universal Clinical therapists 0.269 (0.06, 0.48)
and Hansen (2000)
Duncan, Beauchamp, Wells, CD-ROM refuse to use Selective Teachers 1.214 (0.72, 1.71)
and Ary (2000)
Eron, Huesmann, Spindler, Guerra, Yes I Can curriculum — for social skills and conduct Universal, selective, Teachers, interns, and 0.229 (0.01, 0.45)
Henry, and Tolan (2002) and indicated clinical therapists
Fast, Fanelli, and Salen (2003) Mediation curriculum by Yale Child Studies Center Universal and Administrator and 0.589 (− 0.07, 1.25)
selective graduate interns
Flay, Allred, and Ordway (2001) Positive action Universal Whole school- teacher, 0.580 (0.50, 0.66)
staff, administration
Franklin, Moore, and Hopson (2008) Solution Focused Brief Therapy Selective Teachers and 0.706 (− 0.01, 1.42)
clinical therapists
Frey (2002) Social skills classroom meeting program Universal Clinical therapists 0.440 (0.08, 0.80)
Gillham et al. (2007). Penn Resiliency Program Universal Teachers, interns, 0.172 (− 0.02, 0.36)
and clinical therapists
Ginsburg and Drake, (2002) Cognitive behavioral small groups Indicated Graduate interns 0.610 (− 0.48, 1.70)
Gottfredson and Gore (2002) Cognitive behavioral instruction — Social Problem Universal Graduate interns 0.143 (− 0.12, 0.40)
Solving Curriculum
Hallfors, Cho, Sanchez, Khatapoush, Reconnecting Youth class Selective Teachers 0a
Kim, Bauer (2006)
Hardin, Weinrich, Weinrich, Garrison, Catastrophic stress intervention Selective Nurses 0.267 (0.15, 0.39)
Addy, Hardin (2002)
Harris and Franklin, 2003 Cognitive behavioral small groups Indicated Clinical therapists 0.748 (0.28, 1.22)
and students
Hawkins, Catalano, Kosterman, Classroom instruction and management, Universal Teachers and 0.161 (− 0.05, 0.37)
Abbott, and Hill (1999) child skill development, parent intervention Clinical Therapists
Hennessey (2007). Open Circle Program Universal Teachers 0.461 (0.13, 0.79)
Herrmann and McWhirter (2003) Student created aggression replacement Selective Graduate Interns 0.326 (− 0.23, 0.88)
education program
Ialongo, Poduska, Werthamer, Classroom centered intervention and family Universal Teachers and 0.369 (0.15, 0.59)
and Kellam (2001) centered partnership intervention Clinical Therapists
Jaycox et al. (2006) Break the cycle's ending violence curriculum Universal Attorneys 0.191 (0.10, 0.28)
Jenson and Dieterich, (2007) Youth matters Universal Clinical Therapists 0.092 (− 0.06, 0.24)
Kataoka et al. (2003) Group based on the cognitive behavioral Indicated Clinical therapists 0.350 (0.02, 0.68)
intervention for trauma in schools
Ko, S., and Cosden (2001). Child abuse listening and mediation Universal Clinical therapists 0.237 (− 0.36, 0.84)
Kumpfer, Alvarado, Tait Project SAFE — I can problem solve and Universal Teachers and 0.649 (0.35, 0.95)
and Turner (2002) strengthening families clinical therapists
Larkin and Thyer, 1999 Cognitive behavioral small groups Indicated Clinical therapists 1.898 (1.23, 2.57)
McWhirter and Page (1999) Skills for living anger management curriculum Selective Teachers and 0.100 (− 0.37, 0.57)
clinical therapists
Melnyk Jacobson, Kelly, O'Haver, Creating opportunities for personal empowerment, Universal Teachers 0.189 (− 0.76, 1.14)
Small, Mays and (2009) healthy lifestyle and thinking, emotions, exercise
and nutrition
Mufson et al. (2004) Interpersonal therapy amended Indicated Clinical therapists 0.543 (0.05, 1.04)
Murray and Malmgren (2005) teacher student relationship program Selective Teachers 0.271 (− 0.29, 0.83)
Pedro-Carroll et al. (1999) Children of divorce intervention program Selective Clinical Therapists 0.945 (0.31, 1.58)
and Graduate interns
Post, P. (1999). Child centered play therapy Selective Graduate interns 0.252 (− 0.05, 0.56)
Robinson, Smith, and Miller (2002) Anger control curriculum — cognitive behavioral Indicated Teachers 0.526 (− 0.10, 1.15)
Stein et al. (2003) CBT for trauma in schools Indicated Clinical therapists 0.356 (− 0.01, 0.72)
Viggiani et al. (2002) Social worker–teacher classroom collaboration Universal Teachers and 0.378 (− 0.07, 0.83)
graduate interns
Walkeret al. (2006) Motivational enhancement therapy Indicated Clinical therapists 0.208 (− 0.19, 0.60)

Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx
Table 2 (continued)
Study Intervention
Weiss, Harris, Catron, RECAP — a psychosocial intervention
and Han (2003)
Werch et al. (2010) Planned success brief intervention
Yampolskaya, Brown, Youth asset development program and postponing
and Vargo (2004) sexual involvement program
Zubernis et al. (1999) Depression prevention program for children
a
This study did not report enough information to calculate effect sizes but did report non-significant results.
& Ordway, 2001; Kumpfer, Alvarado, Tait, & Turner, 2002) offering
medium effect sizes, and one study (Franklin et al., 2008) reporting
a large effect size.
When examining effect size results for those studies where only
professional clinicians provided the intervention (n = 14), effect
sizes were mostly small, with three studies (Carbonell & Partelemo-
Barehmi, 1999; Frey, 2002; Mufson et al., 2004) offering medium ef-
fect sizes and one study (Larkin & Thyer, 1999) having a very large ef-
fect size. For those studies that only used graduate interns (n = 7) to
provide the intervention, effect sizes were also mostly small, with
only two studies (Ginsburg & Drake, 2002; Zubernis, Cassidy,
Gillham, Reivich, & Jaycox, 1999) reporting a medium effect size. For
those studies that had interventions delivered by non-teaching pro-
fessionals only or by professional clinicians along with graduate in-
terns or other non-teaching professionals (n = 8), most of the effect
sizes ranged in the small category. Only one study had a medium ef-
fect size (Fast et al., 2003), and two studies (Harris & Franklin, 2003;
Pedro-Carroll, Sutton, & Wyman, 1999) had large effect sizes.
Effect size results based on targeted RTI levels primarily revealed
small treatment effects across all three levels. Universal preventative
interventions included in this review revealed that 75% of the studies
had small effect size estimates, five studies (Botvin et al., 2001; Flay et
al., 2001; Frey, 2002; Hennessey, 2007; Kumpfer et al., 2002) offered
medium effect size estimates, and no studies that fell into the large ef-
fect size category. About 71% of the selective preventative interven-
tions also had small effect sizes. Only one selective intervention
study (Zubernis et al., 1999) had a medium effect size estimate, and
three studies (Pedro-Carroll et al.,1999; Duncan et al., 2000;
Franklin et al., 2008) had large effect sizes. Regarding the indicated
preventative intervention studies, 50% included in this review had
small effect sizes. Four studies (Carbonell & Partelemo-Barehmi,
1999; Ginsburg & Drake, 2002; Mufson et al., 2004; Robinson et al.,
2002) at this level had medium effect size estimates, and two studies
(Harris & Franklin, 2003; Larkin & Thyer, 1999) had large effect sizes.
With the three studies that looked at multiple RTI levels, two of them
had small treatment effects (Eron et al., 2002; CPPRG, 1999, 2002,
2004) and one had a medium effect size (Fast et al., 2003).
6. Discussion
The purpose of this article was to assess the frequency with which
teachers are involved in delivering school mental health interven-
tions and to assess at what level of intervention school mental health
interventions are being delivered using an RTI framework. In addi-
tion, the efficacy of school mental health interventions implemented
was also evaluated by comparing different personnel involved in
the delivery of school mental health interventions. This review sys-
tematically identified mental health interventions that were exam-
ined in research studies and that also met the aforementioned
inclusion criteria as a school mental health intervention. Only the
most recent studies were included because scholars have suggested
that school policy changes, and more specifically the RTI movement,
may be increasing the teamwork between teachers and mental health
professionals and increasing teacher involvement in behavioral inter-
ventions (Frey et al., 2011). Even though several authors have
Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
7
RTI level Intervention deliverers Effect size (95% CI)
Selective Clinical therapists 0.220 (− 0.21, 0.65)
Selective Nurses and certified 0.132 (− 0.08, 0.34)
health educators
Universal Clinical therapists 0.361 (0.10, 0.62)
Selective Graduate interns 0.594 (− 0.27, 1.46)
suggested that teachers are actively involved in the delivery of school
mental health interventions (e.g., Anderson-Butcher & Ashton, 2004;
Berzin et al., 2011; Frey et al., 2011), the active participation of
teachers in school mental health interventions has not been widely
investigated in empirical studies. This current study hopes to address
a gap in this knowledge base, specifically aimed at understanding
who is delivering school mental health interventions and how effec-
tive these services may prove to be.
This current review found that out of 49 school mental health
studies analyzed, teachers were actively involved in 40.8% of mental
health interventions evaluated and were the sole providers of inter-
ventions in 18.4% of the studies. It was also found that many of
these school mental health interventions were universal (Tier 1)
and took place in the classrooms. This Tier 1 focus may also partly ex-
plain the active involvement of teachers in a relatively high percent-
age of these interventions. These findings suggest that teachers have
been actively involved in school mental health interventions and
that they are more likely to work as a team with other professionals
than as sole providers of these interventions. However, they may be
the primary deliverer of a smaller percentage of school mental health
interventions. The school-based service literature has suggested that
teachers are increasingly involved in school mental health services
due to the implementation of the RTI framework and school wide be-
havioral supports that support their involvement (Berzin et al., 2011;
Frey et al., 2011; Kelly et al., 2010). While these findings cannot con-
firm or disconfirm how wide spread teacher involvement may be in
school mental health services, the data indicates that out of the stud-
ies examined over the past ten years, that teachers served as collabo-
rators in a respectable percentage of school mental health
interventions (40.8%)
6.1. School mental health outcomes
The overall results of this study suggest that there is no wide var-
iation in outcomes between different school mental health studies,
regardless of which personnel may be implementing the interven-
tions. In this regard, studies involving teachers as sole providers of
mental health services and those studies that involved teachers as
collaborators on mental health teams had fairly equivocal results
with most studies having small effect sizes, and only a few studies of-
fered medium and large effect sizes. The results from studies where
teachers were involved in the implementation of school mental
health interventions were also fairly equivocal with those that were
delivered by mental health professionals, and there did not seem to
be a clear advantage of one type of personnel over another. Even
though this study found no differences between different personnel
that delivered the mental health interventions, the overall findings
for this outcome remain mixed across different studies. Similar to
this study, for example, some researchers have found that teachers
may effectively administer school-based, mental health services (i.e.
Wilson et al., 2003 & Wilson & Lipsey, 2007). In another systematic
review (Baskin et al., 2010), however, researchers found that para-
professionals such as teachers and parents did not achieve as large
of effect sizes as licensed mental health professionals. Furthermore,
results from the Baskin review indicated that studies using graduate
8 C.G.S. Franklin et al. / Children and Youth Services Review xxx (2012) xxx–xxx
interns, whether alone or in combination with professional clinicians,
had fairly equivocally small effect size results. This current study dif-
fers further from Baskin and colleagues' (2010) study in that the out-
comes from students and interns were weaker than those found for
professionals (whether they were teachers or clinicians).
One possibility for why licensed professionals appeared to do bet-
ter in Baskin and colleagues' (2010) study may have been the focus
on psychotherapy verses broader types of psychosocial interventions
and also the grouping of teachers with parents. In this current study,
for example, there was a higher percentage (18.4%) of articles includ-
ed where teachers were the sole providers of the mental health inter-
ventions, and also worked together in teams with other mental health
professionals instead of paraprofessionals or lay people. This differ-
ence may have served to elevate the outcomes of teachers within
the studies. Since different studies offer contradictory results regard-
ing the outcomes of different personnel delivering school mental
health interventions, future studies will have to clarify the effective-
ness of different professionals.
6.2. Professional roles and levels of intervention
This study suggests that the levels of intervention delivered may
differ between professionals, with teachers (alone), delivering almost
exclusively Tiers 1 and 2 interventions (7 studies) and mental health
professionals (alone) delivering more of the Tier 3 selective interven-
tions (7 studies). The greatest crossover between teachers and mental
health professionals is in the universal and indicated categories, with
mental health professionals being most distinguished from teachers
by delivering slightly more indicated interventions, yet usually work-
ing on the first two levels as partners with teachers. This suggests that
when empirically evaluating school mental health studies, it might be
important to assess who is most involved at what level of interven-
tion and also to look more closely at the roles of different profes-
sionals involved in the delivery of school mental health services. In
order to better understand professional roles in school mental health
services and the levels of intervention, future studies will need to
evaluate in more depth the roles of teachers and other professionals
in relationship to the RTI framework.
6.3. Limitations
This study has several limitations including its descriptive nature
and the large number of studies that did not meet the final inclusion
criteria to be included in the review. As the results on Fig. 1 show,
around 1500 studies met our initial criteria for inclusion but only 49
studies met all the necessary requirements for inclusion in our re-
view. While this type of big exclusion of studies is quite common in
systematic reviews, it's clear that there are still potentially important
studies that were not included because of research design issues or
insufficient data to calculate effect sizes. Also, many of the studies in
school settings are using advanced multilevel modeling and structur-
al equation modeling analysis which makes calculating effect sizes
very complicated, if not impossible, depending on the data provided.
Authors of future studies should report effect sizes for between and
within group contrasts. Caution should also be warranted when gen-
eralizing these results because many of the effect size results from the
studies were based on combining multiple outcome measures which
can lead to oversimplified interpretations and mask subtle differences
found between various outcomes. Furthermore, the comparisons of
effect sizes across the various professionals who provided the inter-
ventions were limited statistically, as we were unable to examine
these results through a mixed-effects model using teacher as a pre-
dictor variable. Despite these limitations, the current study looks sys-
tematically at a large number of school mental health studies and
evaluated the participation of teachers in the implementation of men-
tal health interventions and shows important results. Future studies
Please cite this article as: Franklin, C.G.S., et al., Teacher involvement in school mental health interventions: A systematic review, Children and
Youth Services Review (2012), doi:10.1016/j.childyouth.2012.01.027
may wish to conduct a more comprehensive meta-analysis on the ef-
fects of teacher mental health interventions and their specific roles as
the providers of these services.
7. Conclusion
Schools are large providers of mental health services for children
and adolescents Adelman & Taylor, 2010; Hoagwood et al., 2007;
Stormont, Reinke, & Herman, 2011). Recent educational policy initia-
tives at the Federal level have ushered in RTI and school-wide behav-
ior supports that have potential to involve teachers in school mental
health interventions. The results of this ten-year review suggest that
teachers are not only involved in the delivery of school mental health
interventions mostly as team members with other school mental
health professionals, but also less frequently may serve as the sole
providers of these interventions. Consistent with what has been sug-
gested in other literature (Berzin et al., 2011; Frey et al., 2011;
O'Connor, 2003; Tilly, Reschly, & Grimes, 1999) this study indicates
that mental health professionals, such as school social workers and
psychologists, may take on more of a clinical practitioner role in the
delivery of Tier 3 interventions. They may also support teachers or
work as a team with them when delivering school mental health in-
terventions at Tiers 1 and 2 levels. Although this current review con-
tributes empirical knowledge documenting the involvement of
teachers with school mental health services, it also indicates that fur-
ther research is needed to understand and clarify the efficacy associ-
ated with the roles that both mental health professionals and
teachers play in offering the most effective mental health services to
students in school settings.
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Early Childhood Education Journal (2023) 51:851–861
https://doi.org/10.1007/s10643-022-01346-x

Educator Perspectives on Mental Health Supports at the Primary Level

Malena A. Nygaard1   · Heather E. Ormiston1   · Olivia C. Heck1   · Sophia Apgar1   · Maureen Wood1 

Accepted: 31 March 2022 / Published online: 3 May 2022

© The Author(s), under exclusive licence to Springer Nature B.V. 2022

Abstract
During the early years of formal education, young students develop a number of formative academic, motor, behavioral,
and socioemotional skills that lay the foundation for future learning. Since student mental health in the early grades predicts
academic achievement in later grades, mental health interventions are essential at the primary school level. Not only are
teachers expected to provide academic instruction, they are now involved in providing students with mental health services,
despite a lack of training to do so. The current study sought to gather the perspectives of 38 primary-level educators to gain
understanding about mental health knowledge, current approaches to mitigating mental health challenges, and barriers that
prevent them from successfully addressing student mental health issues. Using thematic analysis, three themes developed:
(1) Educators indicate supporting primary students’ mental health is within their role; (2) Systems-level constraints prevent
effective mental health supports; and (3) Staff desire increased mental health resources. Implications for educators and
practice are discussed.

Keywords  Student mental health · Educator perspectives · School-based mental health · Primary level

Introduction et al., 2014; Russo et al., 2019; Sabol & Pianta, 2012). For
instance, a longitudinal examination of over 1300 students
The primary grades are foundational for supporting the determined readiness skills upon entry into kindergarten,
development of students’ school readiness across multiple such as language, academic, and socioemotional skills, were
domains (Pace et al., 2019; Sabol & Pianta, 2012). Young found to significantly predict socioemotional and academic
children are rapidly developing academic, behavioral, and performance through fifth grade (Pace et al., 2019). Chil-
socioemotional skills essential for academic success and stu- dren with specific academic and emotional and behavioral
dent well-being (Brovokich & Dirsmith, 2021). Later school challenges in preschool often continue on that problematic
success and positive academic achievement have been found trajectory as they move into middle school and may be at
to depend on early student development of socioemotional higher risk for school dropout (Fitzpatrick et al., 2020; Get-
skills and competencies (Pace et al., 2019; Papadopoulou tinger et al., 2010).
For our present purposes, we define mental health (MH)
in childhood, including children through age 8, as:
* Malena A. Nygaard
mnygaard@iu.edu a broad label that encompasses a range of mental,
emotional, social, and behavioral functioning…[and]
Heather E. Ormiston
ormiston@iu.edu occurs along a continuum from good to poor and var-
ies over time, in different conditions, and at different
Olivia C. Heck
oheck@iu.edu ages. Good mental health in children includes indica-
tors such as the timely achievement of developmental
Sophia Apgar
sapgar@iu.edu milestones, healthy social and emotional development,
and effective regulatory and coping skills…Poor men-
Maureen Wood
mauwood@iu.edu tal health and patterns of symptoms that are severe,
are persistent, and cause impairment or dysfunction
1
Department of Counseling and Educational Psychology, can develop into mental disorders. (Bitsko et al., 2022,
Indiana University School of Education, 201 N Rose Ave, p. 1)
Bloomington, IN 47405, USA

13
Vol.:(0123456789)

852
In young children, the development of socioemotional
skills is associated with executive functioning skills such as
decision-making, planning, and problem-solving; emotional
skills such as emotion recognition and emotion regulation;
social skills such as prosocial skills and establishing peer
relationships; and intra-personal skills such as frustration
tolerance and managing conflict (Papadopoulou et al., 2014).
Unfortunately, young children are not immune to mental
health challenges (Cree, 2018), and increasingly, educators
are reporting higher prevalence rates of students with sig-
nificant socioemotional needs (Danielson et al., 2021) and
an overall lack of readiness for school (Russo et al., 2019).
Student Mental Health in Primary Grades
Based on parent report, approximately 17% of children
between the age of 2 and 8 in the United States (US) have a
mental, behavioral, or developmental disorder (Cree, 2018),
consistent with international prevalence rates (von Klitzing
et al., 2015). Diagnosis and identification of mental health
concerns is difficult for children at a young age (McGorry
& Mei, 2018). Numerous risk factors related to the child,
family, and environment have been identified that may con-
tribute to the mental health challenges displayed by young
children and often have an “additive” effect such that mul-
tiple risk factors lead to increased likelihood of negative
outcomes (Gettinger et al., 2010). Approximately one in six
young children—ages 2–8 years—in rural areas have men-
tal health challenges, a prevalence rate higher than children
in urban areas (Robinson et al., 2017). Additionally, chil-
dren in the child welfare system have significantly higher
rates of mental health disorders as well as trauma exposure
(National Child Traumatic Stress Network, 2013). Parental
stress, mental health challenges, and marital problems have
all been linked to an increased risk for mental health con-
cerns in children as well (American Academy of Child &
Adolescent Psychiatry, 2015). Minoritized youth are also
at an increased risk of mental health concerns (Suldo et al.,
2014). Despite this, few children with mental health chal-
lenges actually receive any type of mental health support in
the US (Costello et al., 2014; Merikangas et al., 2010; U.S.
Department of Education, 2021).
Calls to support early childhood mental health have come
from policy makers (Nelson & Mann, 2011) and the health-
care (Wakschlag et al., 2019) and education fields (Suldo
et al., 2014). These calls focus on the importance of early
screening (Wakschlag et al., 2019), supporting the develop-
ment of early childhood professionals, including educators,
to recognize early warning signs in young children (Nel-
son & Mann, 2011), and early intervention to support early
childhood socioemotional well-being (McGorry & Mei,
2018; Wakschlag et al., 2019). Additionally, implementa-
tion of school-based mental health services via a multi-tiered
13
Early Childhood Education Journal (2023) 51:851–861
system of support, particularly for young children, is gaining
attention (Brovokich & Dirsmith, 2021; National Associa-
tion of School Psychologists [NASP], 2015).
Systems‑Level Approaches to Supporting Student
Mental Health
School-based mental health (SBMH) services are those
delivered by school- and/or community-based personnel
to meet the varying mental health needs of children in the
school setting (Doll et al., 2017). Addressing mental health
needs in schools reduces barriers to access and makes men-
tal health support more accessible for the school community
while also reducing stigma, ensuring consistency in services,
and promoting healthy development (Doll et al., 2017; Little
& Akin-Little, 2013). Early intervention in the school setting
aimed at addressing the effects of risk factors such as trauma
and other adverse childhood events has been found to miti-
gate negative effects by meeting the socioemotional needs
of students (Stegelin et al., 2020). A recent meta-analysis of
forty-three controlled trials examining over 49,000 students
found SBMH services delivered small to medium effect
sizes in decreasing elementary school-aged children’s men-
tal health problems, most notably when the mental health
services were integrated into academic instruction as well as
implemented multiple times per week (Sanchez et al., 2018).
Schools have increasingly begun to adopt a multi-tiered
system of support (MTSS) framework that integrates stu-
dent needs and school services across academic, behavioral,
and socioemotional domains (NASP, 2016). Within MTSS,
socioemotional strategies can be implemented to help youth
acquire the needed knowledge, attitudes, and skills “to
develop healthy identities, manage emotions and achieve
personal and collective goals, feel and show empathy for
others, establish and maintain supportive relationships, and
make responsible and caring decisions” (Collaborative for
Academic, Social, and Emotional Learning [CASEL], 2020,
np). Implementing mental health interventions in a school
setting can lead to long-term improvements in reducing anx-
iety and behavioral problems, and increases in positive atti-
tudes, prosocial behavior, and academic outcomes (CASEL,
2020; Stegelin et al., 2020). Within an MTSS framework,
universal school mental health supports are typically taught
within elementary school classrooms, most often by class-
room teachers (Franklin et al., 2012), and are intended to
provide students opportunities to practice socioemotional
skills.
Primary Teachers’ Role in Meeting Student Mental
Health Needs
An important aspect of the effective delivery of mental
health services in school is the integration of the services
Early Childhood Education Journal (2023) 51:851–861 853
within academic instruction (Sanchez et al., 2018). Indeed,
the role of teacher has expanded beyond creating and deliv-
ering academic lessons to include supporting student men-
tal health needs (Reinke et al., 2011) via the delivery of
classroom-based mental health supports (Franklin et al.,
2012). Research has demonstrated no significant difference
in the effects of an intervention based on the personnel who
delivered the program, such that teachers delivering mental
health interventions produce comparable results to mental
health providers (Franklin et al., 2012). While classroom
teachers are uniquely positioned to understand the needs of
their students and play a critical role in the implementation
of interventions to address those needs (Berzin et al., 2011;
Whear et al, 2013), and they reportedly value implementing
these types of interventions, they do not always feel prepared
to meet the mental health needs of their students due to a
lack of training to support student mental health (Baweja
et al., 2016; Berger et al., 2021; Ohrt et al., 2020; Reinke
et al., 2011), a finding relevant across the US (e.g., Baweja
et al., 2016; Ohrt et al., 2020; Reinke et al., 2011) and abroad
(Berger et al., 2021; Ohrt et al., 2020).
Study Purpose
Although mental health providers such as school psycholo-
gists and school counselors are known as experts in deliver-
ing SBMH services, school staff with various levels of train-
ing and expertise are involved in delivering such services
(Franklin et al., 2012). Thus, this study explored educator
perspectives related to current perceptions of student men-
tal health as well as the perception of existing resources to
address student mental health needs at the primary school
level. For the purposes of the present study, we referred to
primary as children enrolled in kindergarten, first, and sec-
ond grade. We posed the following research questions to be
answered via participant interviews:
1. What are the perceptions of school staff at a primary
school in relation to student mental health?
2. What current resources are in place at the primary
school to address student mental health?
We conducted one-on-one interviews with teachers, staff,
and administrators within the school to understand their per-
spectives and knowledge related to student mental health.
Methods
Setting and Participants
Participants were recruited from a large primary school in
a Midwestern US school district. The National Center for
Education Statistics (2006) classifies the school’s locale
as suburb: midsize. The school serves approximately 600
students and employs approximately 45 teachers. Ninety
percent of the students enrolled identify as White, 5.6% of
students are Multiracial, and 2.8% are Hispanic. Approxi-
mately 35% of students receive free and reduced-price lunch,
and approximately 17% of students are eligible for special
education services.
Thirty-eight school staff members consented to participat-
ing in an interview. Participants included classroom teach-
ers, special education teachers, related arts teachers (e.g.,
music, art), support staff (e.g., instructional assistants),
administrators, and other licensed special education person-
nel (e.g., occupational therapist, speech language patholo-
gist). Informed consent was provided prior to beginning
interviews. All procedures adhered to and complied with
the university’s Institutional Review Board standards and
requirements for the protection of human subjects. Data
analysis was supported by grant funding and the authors do
not disclose any financial conflicts. Given the homogene-
ous population of educators employed by the school and
to protect participant anonymity, we did not collect gender
nor racial demographic information. Participants had been
working at the school between 1 and 22 years with an aver-
age of 8.7 years. Total number of years in the education field
ranged between 1 and 24 years, with an average of 11.6 years
in education. Of the 38 interviewees, 47% were classroom
teachers, 31% were support staff, 16% were special educa-
tion staff (including licensed staff), and 3% were related arts
teachers and administrators, respectively. See Table 1 for
additional information about participants.
Interview Procedure and Instrument
Recruitment was conducted on a volunteer basis via an
online sign-up sheet. The link to the sign-up sheet was sent
to all school staff members, including administrators, gen-
eral education teachers, special education teachers, and other
service providers via an email drafted by the researchers and
delivered by the building’s principal. Interviews took place
in the Fall of 2020 and were conducted via an online video
conference platform (Zoom) due to COVID-19 restrictions.
After sharing a visual copy of the consent form via “screen-
share,” participants provided verbal consent to participate in
the study. Only one person did not consent, in which case the
interview was still conducted and not utilized for research
purposes but included in an executive summary shared with
the school. Of about 45 teachers and staff members invited
to participate, 38 signed up for an interview and consented
to participate in the study (i.e., ~ 85% response rate). Upon
completion of interviews, participants were awarded a
$15.00 Amazon gift card. Interviews were conducted by five
members of the research team, which included four doctoral
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854 Early Childhood Education Journal (2023) 51:851–861

Table 1  Participant identification codes and demographic information graduate students and one school psychology faculty mem-
Participant ID Professional title Years Years in ber. We adopted interview questions from Ormiston et al.
at study educa- (2021), found in the ‘Appendix’, which addressed student
school tion mental health within the primary school, and individual
and systemic practices currently in place to support student
T1 Kindergarten teacher 9 9
mental health concerns. As stated previously, all interview
T2 Kindergarten teacher 11 15
data was collated and shared with school administrators and
T3 Kindergarten teacher 8 15
staff via an executive summary, as a mechanism for member
T4 Kindergarten teacher  < 1  < 1
checking. Participants noted the findings seemed consist-
T5 Kindergarten teacher 6 8
ent with anecdotal evidence obtained from working in the
T6 Kindergarten teacher 13 13
school building.
T7 Kindergarten teacher 7 7
T8 Kindergarten teacher 3 13
T9 Kindergarten teacher 6 13
Research Team
T10 1st grade teacher 19 20
Our research team consisted of one school psychology fac-
T11 1st grade teacher 5 8
ulty member, four doctoral graduate students, and one edu-
T12 1st grade Teacher 9 11
cational specialist student. Four team members identified as
T13 1st grade teacher 3 7
White, one identified as Black/African, and one identified
T14 1st grade teacher  < 1 7
as Filipino/White. According to Braun and Clarke’s (2020)
T15 2nd grade teacher 7 14
recommendation, we acknowledged our positionality and its
T16 2nd grade teacher 18 24
potential impact on this research. All research team mem-
T17 2nd grade teacher 7 7
bers were affiliated with the school psychology program in
T18 Teacher N/A N/A
the same university, which claims a social justice orienta-
T-RA1 Related arts teacher 3 5
tion. Thus, despite our selection of an inductive thematic
T-SPED1 Special education teacher 15 15
analysis design, a method that seeks to minimize potential
T-SPED2 Special education teacher 15 15
T-SPED3 Special education teacher 1 5
bias (Braun & Clarke, 2006), we recognized we viewed the
T-SPED4 Special education teacher 12 21
interviews and resulting data analysis through a school psy-
SPED1 Special education certified 22 23
chology and social justice lens.
staff
SPED2 Special education certified 11 11 Study Design and Procedures
staff
OS1 School administrator 13 24 By using multiple data sources (i.e., teachers, administrators,
SS1 Instructional assistant 13 15 school staff) and multiple researchers, we employed crystal-
SS2 Instructional assistant 4 15 lization to provide a thorough understanding of participants’
SS3 Instructional assistant  < 1 1 perspectives on SBMH practices in their school (Tracy,
SS4 Instructional assistant 16 16 2010). Foundational to quality qualitative research, we
SS5 Instructional assistant 1 1 sought to establish trustworthiness, or credibility, through
SS6 Instructional assistant 1 1 our use of a thick, rich description of our research process
SS7 Instructional assistant 5 5 and findings (Tracy, 2010).
SS8 Instructional assistant 16 16
SS9 Instructional assistant  < 1 6 Thematic Analysis
SS10 Instructional assistant 5 5
SS11 Library assistant 11 15 We conducted an inductive thematic analysis to develop
SS12 Interventionist 14 15 and analyze potential themes. Three of the research team
members were involved in data analysis. We began data
Key: T# = Classroom teacher; T-RA# = Related arts teacher (e.g.,
Physical Education, Music, etc.); T-SPED#  = Special education analysis by familiarizing ourselves with the data, reading
teacher; SPED# = Special education personnel (e.g., Speech Lan- the transcripts of all 38 interviews independently without
guage Pathologist, Occupational Therapist, etc.); OS# = Office staff identifying anything that stood out to us. Once completed,
(e.g., administrator); SS# = Support staff (e.g., instructional assis-
each researcher was assigned 25–26 out of the 38 transcripts
tants; library assistant, interventionist)
to read through again and extract initial “interesting” ideas
and topics (i.e., codes). Each interview was analyzed by two
of the researchers. After extracting codes, we individually
sorted them into potential themes by relevance to each other.

13
Early Childhood Education Journal (2023) 51:851–861 855
Braun and Clarke (2006) recommend to “consider how dif-
ferent codes may combine to form an overarching theme” (p.
19). Subsequently, two of the researchers met to refine their
themes to “form a coherent pattern” and “consider validity
of individual themes in relation to the data set” (Braun &
Clarke, 2006, p. 20–21). We developed sub-themes to further
delineate the scope of each theme, before all three research-
ers met to further refine the themes and finalize them. We
checked to ensure each theme was distinct such that each
code only fit within one theme. In the final phase of the
thematic analysis, we identified and extracted the data from
the interview transcripts that best represented the central
ideas of each theme, excerpts of which are presented below.
Results
Results of the thematic analysis highlighted the following
themes: (1) Educators indicate supporting primary stu-
dents’ mental health is within their role; (2) Systems-level
Fig. 1  Themes and subthemes
constraints prevent effective mental health supports; and
(3) Staff desire increased mental health resources. These
three themes suggest that, although there are various ways
of addressing and approaching mental health at the current
primary school, school personnel desire more opportuni-
ties and resources to be able to provide mental health sup-
port to their young students. All themes and subthemes can
be found in Fig. 1. Please note “school staff” and “school
personnel” are used interchangeably when results encap-
sulate perspectives of diverse roles; when perspectives are
specific to one sub-group (e.g., classroom teachers), the
specific role is reflected in the results discussed.
Although our primary aim is not to quantify the quali-
tative nature of participants’ responses, for the sake of
clarity and consistency we describe our results based on
the frequency with which those ideas were endorsed by
participants as follows: “few” refers to 3 or fewer partici-
pants, “some” refers to 4–9 participants, “many” refers to
10–19 participants, and a “majority” refers to more than
19, or more than half of our 38 participants for whom that
idea was endorsed.
13

856
Educators Indicate Supporting Primary Students’
Mental Health is Within Their Role
Staff members’ interpretation and definition of mental health
and mental health services for students varied based on their
role, responsibilities, and position in the school. For exam-
ple, certified teachers often referred to classroom accommo-
dations and procedures such as offering breaks to students
when needed, and daily check-ins to identify students’ cur-
rent emotional states (e.g., SS3, T10, T-RA1, T-SPED1). A
majority of teachers also described their roles as it relates
to building relationships with students and being a person
students can trust (e.g., T3, T5, T6, T17, SS7).
I think as a kindergarten teacher, I have a very impor-
tant role, where I’m a lot of times, these first kiddos’
contact in school. Or it might be their first experience
just being outside of the home. And so, we’re there
to see—we’re there and we need to know the signs to
look for or help [the] identification of students who
might be experiencing mental health struggles or emo-
tional struggles and that might need those extra sup-
ports. (T2)
In contrast, those who do not work as intimately with stu-
dents (i.e., those who are not classroom teachers), described
their role as implementing interventions or providing
resources for students when asked about mental health (e.g.,
SS1, T-SPED2). For example, “Well, I don’t know for sure
how much it impacts the mental health. But I mean being in
Title I, sometimes the kids I see have a lower reading ability
and the frustration is there” (SS1). Another staff member
indicated her “role could be supporting in books that include
diversity of feelings, current events, past events that affect
us now. Things like that. And then just listening” (SS11).
All staff members, regardless of their relationship with
students, were able to identify ways in which they sup-
port students with mental health issues even though it may
increase their emotional strain. For instance, one teacher
indicated:
Just the other day I had a student come in and like,
hmm, something’s going on…you can just tell in his
face. But I always feel like I’m more of their therapist
and I’m like their caregiver…So that brings a lot of
whatever they’re going through onto me. (T15)
Educators described the ways they support student men-
tal health, indicating that all school personnel contribute,
in one form or another, toward improving student well-
being. Some staff members highlighted district-wide ini-
tiatives (e.g., Connected Learning Assures Successful
Students program) that target professional development,
promoting the use of a universal vocabulary to help stu-
dents articulate their mental health needs (e.g., SPED1),
13
Early Childhood Education Journal (2023) 51:851–861
in turn helping school staff connect students to services
(e.g., T2, T18, T-SPED2). Additionally, many teachers ref-
erenced a collaborative work environment in which staff
work together to provide adequate mental health services
to students (e.g., T11, T-SPED4, SS5, SS6). Classroom
teachers described approaches they implement directly
with students:
In my room I would focus on the mental health needs
of my students, and the students I see every day. We do
a lot of typical [socioemotional learning] type lessons.
Giving them strategies that they can use if they ever
need them. And then there are always those students
that need a little extra support, and one-on-one time.
So I try to do that when I can. (T11)
At the time of conducting interviews, the school district
and the local university had recently begun partnering to
establish an MTSS framework and this effort was reflected
in numerous responses (e.g., SPED2, SS10). Participants
made comments regarding the “SEL [socioemotional learn-
ing] team,” suggesting that initial efforts of the partnership
had been noticed and appreciated by school staff:
We end up discussing SEL needs and referrals. We
make a lot of referrals to the SEL team. I feel like
previously, it was to social work. And now with the
expanding SEL team…I feel like we just—we have a
lot more options, a lot more resources. And just—it’s
great. I feel like we have a lot more options to be able
to refer kiddos. (SPED2)
Many staff members also highlighted the “positive com-
munity” that their school has (e.g., OS1), and the ease of
collaborating with others to ensure each student receives
adequate support (e.g., SS11). One teacher mentioned “for
the most part…we are very collaborative. Each grade level
works really, really well together to try to come up with the
best plan for the kids on a day-to-day basis and long-range
basis” (T16). Similarly, others discussed collaboration and
the strong sense of community that is felt throughout the
school:
We’re big but we’re small. And it’s a small community
that’s growing. I feel like there’s always someone you
can reach out with for those kids. I mean if it’s not
me working with them, then I know that I can talk to
probably three or four other adults in the building for
help for them. (T15)
Within this theme, staff and teachers recognize the impor-
tance and need for supporting the mental health needs of
their students. The collaborative nature of school person-
nel has provided teachers with support in offering students
needed services. Teachers also understood the importance
of development of socioemotional skills in young students,
Early Childhood Education Journal (2023) 51:851–861 857

illustrated by many mentions of socioemotional lessons and Some expressed concern about the number of school- and
referrals to the newly implemented SEL team. district-level initiatives (e.g., T7), resulting in minimal time
to reach out to students they think need help.
Systems‑Level Constraints Prevent Effective Mental
I think sometimes we take on so many new initiatives
Health Supports
that certain things can get left on the back burner. And
I think we also take a lot of initiatives to just improve
Systems-level issues such as funding, lack of personnel, and
how we’re instructing curriculum. We’re very, very
lack of universal metrics to track mental health interventions
curriculum driven. And so some days…I do think
hindered staff’s ability to feel fully competent in their abil-
when I leave at the end of the day, “OK, did I touch
ity to address student mental health needs (e.g., OS1, SS2,
base with every single one of my students?” Because
SS3, SS4, T1, T9, T12, T-SPED-3, SS8). No participant
you just kind of hit the ground running, and it’s like go,
was able to identify specific metrics the school utilizes to
go, go. I’ve got to do this. I’ve got to do this. And so I
track whether a mental health intervention was effective.
think sometimes… certain things might get put on the
This suggests there are unclear guidelines and procedures for
back burner because we have all these other plates we
referring students for and providing mental health support.
are juggling at the same time…we wear many different
Teachers also felt as though the academic demands placed
hats when we’re teaching. (T10)
on themselves as well as students are preventing them from
adequately meeting the persistent mental health issues stu- Meeting academic demands during the COVID-19 pandemic
dents face (e.g., T10). A classroom teacher stated: and trying to adapt to new, district-wide initiatives empha-
size the stress teachers are under. Teachers are, however,
So I feel like we barely have any time in the day to
able to recognize mental health concerns and make attempts
do our instruction for reading, and math, and all the
to provide services to students although teachers perceive
subjects. And then social, emotional, or mental health
they are unable to meet the persisting needs of all the stu-
just kind of falls down through the cracks. So it's not
dents they encounter.
getting handled as much. (T18)
Another stated “teachers are now having to do everything.
Staff Desire Increased Mental Health Resources
We have to figure out the problem. We have to figure out
how to get them help…You have to do everything” (T16).
Although there were a number of positive responses indicat-
Academic demands, coupled with large class sizes
ing teachers and staff utilize current resources and services
and the global pandemic, have left teachers feeling over-
to address student mental health needs, many school person-
whelmed. One teacher stated, “It’s very, very hard in a big
nel still desire more programs designed to address mental
school to really see each kid…because of the size, it’s really
health (e.g., T15). School staff stated they feel “resources are
overwhelming” (T8) and another “started out the year with
thin” (T16) and limited in areas such as programming, time,
37 [students], which was quite a lot to manage, but right
funding, resources, and mental health staff members (e.g.,
now I’m down to 32” (T4). Some teachers indicated the
T9, T14, T-SPED2, SS12). They also indicated it is difficult
additional stress the COVID-19 pandemic placed upon both
to address intensive student needs:
students and teachers:
If we could just have more bodies to help us with talk-
I would say if there’s anything right now, it’s the stress
ing to these kids and helping them sort through their
that teachers are under. Because right now we’re on a
feelings and their situations at home and their—a lot
hybrid schedule. So we are only seeing our students,
of them have seen a lot of things and been through a
some of our students, two days a week. So we see half
lot. And they need as much support as they can get.
of our students on Monday, Tuesday and then the other
So we need the bodies and the people to know how to
half on Thursday, Friday. So we’re having to, for lack
deal with these situations and help these students learn
of a better term, jam this curriculum down their throats
how to cope. (T1)
for two days. And so we have to teach them something
because they were out of school for almost nine weeks Many teachers (e.g., T-RA1) also mentioned the desire to
last school year. (T14) have consistent language across the district to maintain
appropriate supports and have consistent procedures for
A special education teacher indicated “the academic
referring and evaluating students for mental health issues:
requirements are strenuous, the class sizes are large, so the
teacher—classroom teacher, the person that the students feel So it would be nice to have something that is school-
more comfortable with—has the least amount of time to con- wide, whether it’s like terminology or a system or
nect with them daily, one-on-one” (T-SPED1). something so that way if you’ve worked really hard

13

858
with someone that struggles in kindergarten with this
type of thing, when they come to first grade, I’m able
to use the same terminology as like the kindergarten
teacher used to help with that. So maybe we were
all on the same page as far as like ways to cope or
some kind of system, that might be nice to have like a
school-wide thing set in place. (T13)
School personnel are desiring more resources, such as addi-
tional training (e.g., SS9) and supports in hopes to better
serve their students. Teacher perspectives on what is needed
at the district-, school-, and classroom-levels are important
for making improvements in areas of student mental health
to improve the overall well-being of students at the primary
level.
Discussion and Implications for Practice
Obtaining primary school educators’ perspectives related
to SBMH practices provides a valuable contribution to the
existing literature since a teacher’s role is everchanging and
expanding to accommodate student needs (Reinke et al.,
2011; Whear et al, 2013). In the current sample, school
personnel highlight barriers to SBMH initiatives stemming
from the need to balance academic demands, behavior, and
mental health, and the need to meet mental health challenges
with limited funding and a shortage of resources. Teacher
concerns regarding balancing academics and mental health
during the school day is consistent with the extant litera-
ture (Baweja et al., 2016; Willis et al., 2019). Advocates for
student mental health suggest this takes priority in schools
during these early years and emphasize the importance of
providing students with the foundational socioemotional
tools needed for future academic success (Gettinger et al.,
2010; Suldo et al., 2014). Certainly, earlier access to men-
tal health services, such as making referrals for students in
need (e.g., SPED2), lowers the probability of needing long-
term mental health services to address mental health needs
(Okado et al., 2017).
Academic demands dominate a teacher’s role within our
sample yet teachers also indicate supporting student mental
health is within their scope, similar to other findings (Papa-
dopoulou et al., 2014). Teachers are active agents in teaching
socioemotional lessons (Franklin et al., 2012; Reinke et al.,
2011) and connecting students to support within an MTSS
framework (von der Embse et al., 2018). As one partici-
pant noted (T2), teachers, especially kindergarten teachers,
are often a child’s first contact in school and are therefore
responsible for identifying students in need of extra soci-
oemotional support. Since teachers view themselves as the
first line of defense in identifying students in need of sup-
port and providing universal instruction on socioemotional
13
Early Childhood Education Journal (2023) 51:851–861
competencies (Ormiston et al., 2021), teachers should have
the training to identify students with mental health chal-
lenges (Papadopoulou et al., 2014) and are encouraged to
be a regular presence on multi-disciplinary MTSS teams
(Brovokich & Dirsmith, 2021). Universal school-based soci-
oemotional programs delivered by classroom teachers foster
a common language and improve social and emotional skills,
behaviors, and academic achievement (Durlak et al., 2011).
Given the current rate of students with MH needs (Cree,
2018), universal instruction delivered by classroom teach-
ers is an efficient way to ensure students receive at least a
baseline of socioemotional instruction. While this has hap-
pened with some success (Franklin et al., 2012), teachers
consistently report not having enough training or knowl-
edge to know how to best support their students (Baweja
et al., 2016; Berger et al., 2021; Ohrt et al., 2020). Although
teachers in our sample have experienced the added stress of
the COVID-19 pandemic, findings remain consistent with
previous literature in that teachers continue to desire train-
ing in mental health to best support their students (Reinke
et al., 2011). As such, tools such as universal socioemotional
screeners can be used to identify students at risk (von der
Embse et al., 2018) even though fewer than 15% of schools
utilize universal screeners to assist in their SBMH referrals
(Bruhn et al., 2014). Participants from this study reported
no such mechanism, suggesting a need for the continued
expansion of this practice. However, participants caution the
adoption of too many new initiatives, raising a concern for
sustainability, consistent with concerns identified by Splett
et  al. (2018) regarding the implementation of universal
screening and a school’s capacity to serve the number of
students identified.
Preliminary research and data into the impact of the
COVID-19 pandemic suggests mental health needs for
students and teachers have increased (Lizana et al., 2021;
Wang et al., 2020). Teachers have been made responsible
for meeting the needs of their students with limited addi-
tional support and as a result of the sudden shift to a new
learning modality, teachers have experienced an increase
in workload, which contributes to a higher level of distress
(Aperribai et al., 2020). Even though students are back in
school “as normal,” teachers will likely be responsible for
getting students caught up academically and meeting the
increased socioemotional needs of their students for years to
come. In light of these challenges, it is especially important
that teachers are supported, receive the necessary training to
support their students, and ensure their voices are considered
in the development of a plan to meet the needs of so many
students.
Teachers in this study discussed collaboration and the
importance of the student–teacher relationship when it
comes to supporting student mental health. Relationship
building amongst school staff and with students and families
Early Childhood Education Journal (2023) 51:851–861 859
is key in promoting a safe, positive school climate (Cohen
et al., 2009). A positive student–teacher relationship has
often been found to be an important component to support-
ing the emotional and behavioral well-being of children
(Papadopoulou et al., 2014). However, when teacher mental
health is negatively impacted, as indicated by participant
T15, the effects filter down to students such that student
mental health is affected as well. The reverse is also evident,
such that positive teacher mental health has been associated
with improved student well-being and lower rates of men-
tal health concerns (Harding et al., 2019). Even collegial
relationships—as discussed by our current sample—have
been found to impact the mental health of students and staff
(Milkie & Warner, 2011).
Limitations
Several limitations to the current study should be addressed.
First, due to public health concerns related to the pandemic,
interviews were conducted via a web-based platform. The
lack of in-person interviews could have impacted the qual-
ity of the interviewer-interviewee dynamic, thus limit-
ing the responses of participants. Additionally, the school
was already in the initial stages of implementing an MTSS
framework due to a grant the district received. Staff may
have been influenced by the changes already made—albeit
limited given the pandemic and time the interviews took
place during the school year—but this is a confounding fac-
tor that must be considered. Finally, the study took place in
a relatively homogenous, Midwestern US district. Results
from the present study are limited when examining teacher
perspectives related to mental health in other locales and
with more diverse populations.
Conclusion
The current study presents results from interviews with staff
at a Midwestern US primary school. Three themes devel-
oped as a result of thematic analysis: (1) Educators indicate
supporting primary students’ mental health is within their
role; (2) Systems-level constraints prevent effective mental
health supports; and (3) Staff desire increased mental health
resources. Results suggest teachers recognize how mental
health influences student growth and development at the
primary level and feel a responsibility to improve student
mental health yet face barriers in mental health education,
resources, and services. Findings reinforce the need for an
MTSS framework as a means to deliver school mental health
services.
Appendix
Interview Protocol
1. Please tell me about your role in the school/district as it
relates to the mental health needs of students.
2. What approaches, if any (including approaches that you
may not directly be involved with) does SCHOOL take
to support the mental health of its students?
3. What are the existing strengths of SCHOOL, if any, as
it relates to supporting the mental health needs of its
students?
4. What gaps, if any, are there in supporting the mental
health needs of students at SCHOOL?
5. What metrics, if any, are in place to track whether an
individual mental health intervention was successful?
6. What metrics, if any, are in place to track whether
SCHOOL as a school is having a positive impact on the
mental health of its students?
7. Where would you like to see a potential partnership
between SCHOOL and the school psychology program
at UNIVERSITY head?
Acknowledgements  The authors acknowledge Akua Adjeiwaa Asom-
ani-Adem (ajasom@iu.edu) and Keelyn Ingmire (kmingmir@iu.edu)
for their contribution in coding the data.
Author Contributions  All authors contributed to the study conception
and design. Material preparation and data collection were performed
by MAN, HEO, OCH, and MW. Data analysis was performed by MAN,
OCH, and SA. The manuscript was written and prepared by all authors
and heavily revised by HEO. All authors read and approved the final
manuscript.
Funding  This work was supported by the U.S. Department of Educa-
tion Mental Health Professional Demonstration Grant #S184X190033
but the funding source had no such involvement in the study design,
data collection, analysis and interpretation of data, in writing the
report, or in deciding to submit this article for publication.
Declarations 
Conflict of interest  The authors have no conflict of interest to declare
that are relevant to the content of this article.
Ethical Approval  The study was approved by the University Institu-
tional Review Board (Exempt Protocol Number: 1904386118).
Informed Consent  Informed consent was obtained from all individual
participants included in the study.
13

860 Early Childhood Education Journal (2023) 51:851–861

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13
Received: 23 November 2020 | Revised: 31 May 2021
DOI: 10.1002/pits.22582
RESEARCH ARTICLE
Educator perspectives on mental health
resources and practices in their school
Heather E. Ormiston | Malena A. Nygaard | Olivia C. Heck
Maureen Wood | Nicole Rodriguez | Mallory Maze |
Akua A. Asomani‐Adem
David Shriberg
Department of Counseling and Educational
Psychology, Indiana University Bloomington,
Bloomington, Indiana, USA
Correspondence
Heather E. Ormiston, Department of
Counseling and Educational Psychology,
Indiana University Bloomington, 201N, Rose
Ave, Suite 4020, Bloomington, IN 47405,
USA.
Email: ormiston@indiana.edu
Funding information
U.S. Department of Education, Mental Health
Professional Demonstration,
Grant/Award Number: S184X190033
2148 | © 2021 Wiley Periodicals LLC
| Accepted: 1 June 2021
|
| Keelyn Ingmire | Bri Burgess |
Abstract
The need for mental health services in schools is increasing.
Teachers are expected to meet student's academic needs
but may find their role impacted by the need for mental
health support among students (Bruhn et al., 2014;
Kaffenberger & O'Rouke‐Trigiani, 2013). The purpose of
this study is to elicit teacher perspectives on addressing the
mental health needs of students in school. Staff members
from one school in a Midwestern state were interviewed to
examine their perspectives related to student mental
health. Thirteen classroom teachers (n = 13), four related
arts teachers (n = 4), seven special education staff members
(n = 7), three building support personnel (n = 3), two office
staff (n = 2), and four support staff members (n = 4) were
interviewed, for a total of 33 participants (n = 33). Partici-
pant experience ranged from 2 to 37 years in education.
Utilizing an inductive thematic analysis approach (Braun &
Clarke, 2006), information regarding teachers' current
knowledge of, roles, and approaches to support students
with mental health needs in schools is presented across
four main themes. Directions for future research, training,
and practice are described.
KEYWORDS
school staff perspectives, student mental health, teacher
knowledge, teacher training
wileyonlinelibrary.com/journal/pits Psychol Schs. 2021;58:2148–2174.
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ORMISTON ET AL. | 2149

The mental health of children and adolescents has gained more attention in the media, community, and at school
(Kranke & Floersch, 2009; McGinty et al., 2016) in recent years, as the prevalence of mental health disorders rises.
The news has increasingly covered mass shootings, violence, and suicides, exacerbating the social stigma of people
with mental health disorders (McGinty et al., 2016). Popular shows have glorified mental illnesses resulting in a
spike in the monthly suicide rates of adolescents (Bridge et al., 2020). At school, students with a mental health
diagnosis may experience ostracism from their peers (Kranke & Floersch, 2009), lower teacher expectations, and
family distrust (Moses, 2010). These psychosocial stressors can serve as one explanation for the increased attention
to youth mental health, while another explanation is the sheer volume of youth with mental health challenges. To
that effect, the 12‐month prevalence of a major depressive episode in adolescents rose from 8.7% in 2005 to 11.3%
in 2011 (Mojtabai et al., 2016). Anxiety prevalence is also on the rise, reported at 4.1% in 2018 compared to 3.5% in
2008 (Child Mind Institute, 2018). Ghandour et al. (2019) found that among U.S. children “7.1% had current anxiety
problems, 7.4% had a current behavioral/conduct problem, and 3.2% had current depression” (p. 256). Other
reports have found that as many as 20%–25% of school‐aged children are dealing with mental health issues that
could affect their school performance (A. L. Bruhn et al., 2014; Kaffenberger & O'Rorke‐Trigiani 2013).

1 | S C H O O L ‐ BASED M ENTAL HEA LTH SERVICES

Few other places in the community will see as many children, and their mental and emotional needs, like schools.
Although mental health needs are increasingly prevalent among school‐age children, between 50% and 80% of
students who are in need of mental health services are not receiving them (Paulus et al., 2016; Splett et al., 2013).
Of families that receive services within the community, many terminate services prematurely, often after attending
just a few sessions (Kern et al., 2017). Because schools are central features within a community and children spend
a large amount of time at school or engaged in school‐based activities, this makes schools a natural and common
entry point into mental health services (National Association of School Psychologists [NASP], 2015). In fact, up to
80% of students receive mental health support in school (Rones & Hoagwood, 2000). However, this places schools
in the unique, and often challenging, the position of needing to understand and meet the mental health needs of
their students.
School‐based mental health (SBMH) services broadly encompass assessment, prevention, and implementation
of services designed to promote a safe and healthy learning environment to enhance students' academic and
socioemotional success (Doll et al., 2014). Optimally, community‐based mental health services are woven into
SBMH to provide a coordinated and inclusive system of care (Doll et al., 2014; NASP, 2016). In addition, SBMH
programming is best conceptualized when integrated into a multi‐tiered system of support (MTSS). MTSS is a
comprehensive framework that incorporates a response to academic intervention and Positive Behavioral Inter-
ventions and Supports to provide a range of evidence‐based practices for academic, socioemotional, and behavioral
support through progressively intensive tiers of support (McIntosh & Goodman, 2016). MTSS is one “in which
evidence‐based instruction is delivered along a continuum, based on student need, includes both academics and
behavior, and uses data to guide instructional decision‐making” (NASP, 2016, p. 1). MTSS is typically comprised of
universal services that are effective for 80% of students, group‐level services for 15% of students, and intensive
individual services for about 5% of students who do not benefit from universal or small group interventions (von der
Embse, 2018).
SBMH services within an MTSS framework allow for the universal screening of students to identify those in
need of socioemotional and behavioral support and provide increasingly intensive levels of support to address those
needs (Eklund & Dowdy, 2014; McIntosh & Goodman, 2016). Implementation of mental health services within
schools via an MTSS framework increases access to mental health services (Stephan et al., 2007). School psy-
chologists, along with other mental health professionals, have training that is valuable for expanding mental health
 15206807, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22582 by Universidad De Santiago De Chile, Wiley Online Library on [30/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2150 | ORMISTON ET AL.

services in schools. The staff who have training in mental health can play an important role in the development of a
mental health framework (Splett et al., 2013).
Collaboration among all school staff is important for the effective implementation of SBMH services. Sanchez
et al. (2018) conducted a meta‐analysis of the effectiveness of SBMH interventions for elementary‐aged students.
They concluded mental health interventions should be integrated within the school and academic environments to
be more effective. In addition, they found that a large proportion of the mental health services were actually being
implemented by teachers rather than by dedicated mental health professionals. Indeed, while school psychologists
are broadly trained to provide a variety of services to support children in schools (NASP, 2020), including supporting
the implementation of MTSS efforts within a school and district (Eagle et al., 2015), many reports conducting
psychoeducational evaluations (i.e., assessment and report writing) for special education identification continues to
remain their primary role (McNamara et al., 2019). This may also contribute to the reliance on general education
teachers to implement universal socioemotional and mental health programming. Although the district and school
administrators endorse the importance of addressing student mental health, many also report identifying barriers to
successful implementation such as staff resistance to such efforts, concerns with sustainability, and the challenges
of collaboration between school and community‐based systems for successful implementation (Powers et al., 2014).
Within an MTSS framework, teachers are often the ones to implement universal, preventive socioemotional
and mental health programming. To successfully implement this type of programming, teachers need to view
implementation as feasible and desirable (Han & Weiss, 2005). Furthermore, administrative support is fundamental
to the successful “buy‐in” and implementation by teachers (Han & Weiss, 2005). Delivery of universal programming
by teachers is seen as cost‐effective and enhanced by the relationships teachers have with their students (Collins
et al., 2014; Franklin et al., 2012). In a recent systematic literature review conducted by Franklin et al., (2012), over
90% of mental health interventions were delivered in the general education setting. Teachers often report not
having the requisite background knowledge and skills to effectively deliver mental health programming (Collins
et al., 2014; Reinke et al., 2011).

2 | TE A C H E R KN O W LE D G E A ND TR AI NI NG RELATE D TO M ENTAL
H E A L TH

Teachers are in a unique position to recognize and support students with mental health concerns given the amount
of time and interaction they have with students on a daily basis. Their role allows them to notice students who are
struggling or acting differently than usual. The time they get to spend with students also gives them the opportunity
to intervene if there are mental health concerns. Teachers generally recognize the important role they serve in
supporting student mental health (Reinke et al., 2011). However, research in this area has consistently shown
teachers feel they have a lack of knowledge and are inadequately prepared in this area, which leads to a lack of
confidence in their ability to support the mental health needs of students (Frauenholtz et al., 2015, 2017; Reinke
et al., 2011; Walter et al., 2006).
Training in general mental health awareness is beneficial but not sufficient for teachers and other education
professionals to be equipped to deal with the multiple student mental health challenges they will face in their role
(Walter et al., 2006). Education professionals consistently desire more training in role‐specific skills related to
mental health and report the importance of having administration place a priority on supporting student mental
health (Frauenholtz et al., 2017). More training for teachers in areas such as promoting whole class mental well‐
being, identifying students in mental distress, explicit socioemotional teaching strategies, and providing accom-
modations for students with mental health concerns is needed (Fortier et al., 2017). In general, teachers report
having the ability to perceive students experiencing distress but are unsure of the root of the distress, how to
intervene, or even how to refer the child for services (Eklund & Dowdy, 2014). Teachers desire more training in
 15206807, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22582 by Universidad De Santiago De Chile, Wiley Online Library on [30/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ORMISTON ET AL. | 2151

recognition skills for mental health concerns as well as practical strategies and teaching skills that could be used to
address these concerns (Rothì et al., 2008).

3 | S TU D Y P U R PO S E

Teachers are expected to meet student academic needs, as measured by state standardized tests, though data
clearly shows the increasing prevalence of mental health disorders among youth (A. L. Bruhn et al., 2014;
Kaffenberger & O'Rorke‐Trigiani, 2013). This increase in youth with mental health challenges begs for student
mental health needs to be met in the general education school setting. However, teachers feel unprepared to meet
these challenges in their classrooms (Walter et al., 2006). Research related to gaining the perspectives of educa-
tional staff, particularly those that serve in diverse roles (e.g., related arts teachers, building support staff, admin-
istrators) within a school, has been minimally examined (Powers et al., 2014). Gathering teacher perspectives related
to student mental health brings awareness to teachers' current knowledge and approaches to student mental health
challenges. This information may also help to identify the gaps teachers see that hinder their ability to successfully
address mental health concerns in their schools. Within an MTSS framework, this can be especially important for
gleaning insight into what supports may be needed across the tiers of support. Thus, this study aims to answer three
research questions:

1. What are school staff perceptions related to student mental health?

2. What procedures are in place for the school to address student mental health?
3. How has the school staff addressed student mental health?

We conducted one‐on‐one interviews with teachers, staff, and administrators within the school to understand
their perspectives and knowledge related to student mental health.

4 | M E TH O D S

4.1 | Setting and participants

Participants were recruited from an intermediate elementary school in a small, Midwestern school district that
receives Title 1 funding. The intermediate school serves approximately 632 students in grades 3 through 5 with
approximately 75 total school staff. The majority of the student population (∼89.7% of students) is White and about
43.5% of students meet the standards to be described as “economically disadvantaged,” according to the state
department of education (Indiana Department of Education, 2021).
Study participants were school staff members across disciplines and departments. Specifically, participants
included general and special education teachers, related arts staff, custodians, administrators, and more. See
Tables 1 and 2 for a breakdown of participant professional roles and their years in education. Of the 75 total school
staff, 33 staff members participated in the interviews. Informed consent was obtained before conducting staff
interviews. All procedures adhered to and complied with the university's Institutional Review Board's standards and
requirements for the protection of human subjects. The analysis of the data was supported by grant funding and the
authors do not disclose any financial conflicts as part of this study. To protect the anonymity of participants (e.g., so
few males working in the building), we did not collect gender or racial participant demographics. Participant
experience, however, ranged from 2 to 37 years in education, with a mean of 16.79 years in education and 12.29
years at the participating school. Thus, participants had sufficient background regarding the school climate, student
and staff needs, and the current status of mental health supports available in the school.
 15206807, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22582 by Universidad De Santiago De Chile, Wiley Online Library on [30/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2152 | ORMISTON ET AL.

TABLE 1 Participant years in education

Years at study school n = 33 Years in education n = 33

Range 1–37 2–37

Mean 12.29 16.79

Median 6 15

Total 33 33

TABLE 2 Participant demographics by professional title

Years at study Years in Years at study Years in

school education school education

Classroom teachers Related arts teachers

Range 2–37 2–37 Range 2–31 6–31

Mean 14.5 17.5 Mean 10.8 21.5

Median 5 15 Median 5 24.5

Special education certified staff Building support personnel

Range 1–32 2–32 Range 2.5–16 9–16

Mean 10.4 13.4 Mean 7.2 11.7

Median 6 10 Median 3 10

Office staff Support staff

Range 1–23 18–25 Range 5–22 11–23

Mean 12 21.5 Mean 14 17

Median 12 21.5 Median 14.5 17

4.2 | Interview procedure and instrument

Research team members attended an interview training where they reviewed the interview protocol and
learned interview strategies such as querying and leaving silence for participants to elaborate. Interviews were
conducted by six researchers in private offices in the participating school building. Participants were asked
seven questions based on an interview protocol created by a subset of the researchers. The interview protocol,
found in the Appendix, was developed to assess staff members' perspectives on student mental health, ap-
proaches employed to systematically address student mental health concerns in the building, and individual
practices currently used to support students with mental health challenges. Interview questions were created
to address the aforementioned research questions and to gain information about the culture of the school
building as it relates to identifying and supporting students with mental health problems. Interview data was
collated and shared with school administrators and staff via an executive summary, as a mechanism for member
checking. Participants noted the findings seemed consistent with anecdotal evidence obtained from working in
the school building.
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ORMISTON ET AL. | 2153

4.3 | Research team

Faculty members, graduate students, and undergraduate students contributed to this project in some capacity.
The research team consisted of two school psychology professors, seven school psychology graduate stu-
dents, and one undergraduate psychology student, at the time of data collection and analysis. Each research
team member was affiliated with the same university, and the professors and graduate students came from the
same school psychology program that claims a social justice orientation. As a result, it is undeniable that
the researchers viewed the interviews and resulting data analysis through school psychology and social justice
lens, although the inductive thematic analysis was selected to combat this potential bias (Braun &
Clarke, 2006). The research team included seven members who identify as White, one who identifies as Black/
African, one who identifies as Filipino/White, and one who identifies as White/Hispanic. Six of the ten total
team members conducted participant interviews, while nine members participated in data analysis. Biweekly
research meetings took place over the span of 5 months to progress through the data analysis procedures
outlined below.

4.4 | Study design and procedures

This study employed an inductive thematic analysis design (Braun & Clarke, 2006) to identify, analyze, and
report themes within the participant interviews to capture the breadth and depth of participant perspectives
on mental health practices in their school. Thematic analysis is a data analysis method separate from any
theoretical framework (Braun & Clarke, 2006; Maguire & Delahunt, 2017). Therefore, this study design can
reflect the data without the influence of a particular theory. Thematic analysis can be employed in
a wide array of fields and topics (Braun & Clarke, 2012; Castleberry & Nolen, 2018), and is supported
for use in educational (Lehtomäkia et al., 2016; Poulos & Mahony, 2008; Raufelder et al., 2016) and
interview research (Castleberry & Nolen, 2018; Clarke & Braun, 2017; DeSantis & Ugarriza 2000; Morse &
Field, 1995).
The research team selected an inductive thematic analysis approach to avoid researcher bias in the
development of themes and to prioritize participant responses over the researcher's thoughts about the
school's mental health resources. An inductive or “bottom‐up” approach signifies the themes are strongly
linked to the data because the data was coded without trying to fit the data into pre‐existing codes (Braun &
Clark, 2006; Castleberry & Nolen, 2018). The inductive thematic analysis approach included six phases de-
tailed in Table 3. Table 3 defines and outlines how the research team created themes and codes, indicating the
team applied a systematic and empirically‐based approach for analyzing the data. For an example of how the
data analysis team progressed a code from one phase to the next, see Figure 1. After the team transcribed and
reviewed each interview for Phase 1, team members systematically worked through the entire data set
highlighting interesting aspects of the data to form initial codes during Phase 2. In Phase 3, an analysis of
codes took place to begin initial extraction into themes. The end result of this phase was a collection of initial
themes, and subthemes as appropriate. Phase 4 involves the refinement of the initial themes developed in the
previous phase such that initial themes were modified, combined, or deleted to ensure themes were distinct
from one another, and also cohesive. Phase 5 emphasized defining and refining themes and concluded with
theme names that were used in the final analysis. Finally, Phase 6 results in data extract that capture the
essence of the themes (Braun & Clarke, 2006), with the purpose of describing the data pattern and answering
the research questions.
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2154 | ORMISTON ET AL.

TABLE 3 Thematic analysis procedures (Braun & Clarke, 2006)

Phase Purpose Description of our process

1. Familiarizing yourself To immerse oneself in the data Seven research team members transcribed audio
with your data files (which averaged to 9 min and 22 s in
length) and “spot checks” for transcription
accuracy were conducted. Team members read
all the transcripts for which they had not
conducted the interview, transcribed, or spot‐
checked

2. Generating initial To highlight interesting aspects of the
codes data that may later form themes
across the data
Three coders (out of nine total coders) were
assigned to each transcript to code for lines
that stood out as important and/or meaningful.
Groups of three met to reach a consensus on
preliminary codes

3. Searching for themes To sort codes into preliminary themes New coding teams (three teams of three coders)
were created to talk through all codes from
Phase 2 and develop preliminary themes. Each
code was sorted into a preliminary theme (see
Figure 2)

4. Reviewing themes To refine the themes based on One person from each of the Phase 3 teams met
patterns to review the preliminary themes and reach a
consensus on medial themes. Preliminary
themes were modified, combined, and deleted
to ensure themes were distinct from one
another. The preliminary codes were combined
and modified, becoming subthemes (see
Figure 3)

5. Defining and naming To define and refine themes by
themes determining what they are and
are not
All researchers reviewed the medial themes and
determined changes were necessary because
there were too many overlapping subthemes
for the themes to be distinct. A group
discussion led to further refinement and the
development of final themes which were
tested by checking that each code fits within a
given subtheme and that the themes reflect all
data from the participant interviews (see
Figure 4)

6. Producing the report To display final themes that describe The remaining article relays the results of our data
the data pattern as it relates to analysis and a subsequent discussion of said
answering the research questions results

5 | RESULTS

Themes from the interviews that emerged from the qualitative data analysis fell into four categories: (1) Staff roles
and knowledge impact their perspectives on and understanding of student mental health; (2) The school has limited
mental health resources to meet student and staff needs; (3) Home and school environments affect student mental
health; and (4) School staff express desire for additional support and training. While quantifying the frequency of
15206807, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22582 by Universidad De Santiago De Chile, Wiley Online Library on [30/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 2155

Applying the thematic analysis procedures to a sample data extract

ET AL.

FIGURE 1
ORMISTON
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ET AL.
ORMISTON

Continued
FIGURE 1
| 2156
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ORMISTON ET AL. | 2157

FIGURE 2 Searching for themes

each participant response is not the goal of this qualitative study, we include Table 4 to provide a sense of how
often subthemes and themes were identified in participant responses.
Table 5 details participants' professional titles, years at the study school, and total years in education to provide
context for the included quotes.

5.1 | Staff roles and knowledge impact perspectives and understanding of student
mental health

The first theme emerging from the qualitative data analysis focuses on how staff roles and knowledge impact their
perspectives on and understanding of student mental health. This theme encompassed staff roles, how staff
perceives contributing factors to student mental health, staff recognition of the need to meet students' mental
 15206807, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22582 by Universidad De Santiago De Chile, Wiley Online Library on [30/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2158 | ORMISTON ET AL.

FIGURE 3 Reviewing themes

health needs before meeting students' academic needs, and a discussion of how student mental health affects staff
members' mental health.

5.1.1 | Staff roles

The manner in which staff felt they supported and understood student mental health varied by the role the
individual held within the school. Multiple staff (n = 25) reflected on how their roles involved having to support
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| 2159

Defining and naming themes

ET AL.

FIGURE 4
ORMISTON
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2160 | ORMISTON ET AL.

TABLE 4 Frequency of themes and subthemes in participant responses

Theme 1: Staff roles and knowledge impact their perspectives on student mental health

Subthemes Frequency

Staff roles 25

Contributing factors to mental health 9

Recognition of the need to meet student 5

mental health needs before meeting
academic needs

Student mental health affects staff mental 2

health

Theme 2: The school has limited mental health resources to meet student and staff needs

Subthemes Frequency

Metrics 19

Student needs 8

Limited staff knowledge 8

Current services and limitations of 23

resources

Theme 3: Home and school environments affect student mental health

Subthemes Frequency

Positive school environment 14

Factors outside staff control 10

Theme 4: School staff express desire for additional support and training

Subthemes Frequency

Personnel 7

Desire for additional supports 5

Training 15

students in multiple capacities, not just academically, but with behavior and mental health also. Teachers noted
being “the Jack of all trades,” “on the front lines,” the “first line of defense,” or being the first ones to notice or
respond to a student's mental health needs. For instance, one classroom teacher (Participant T2) commented, “I'm in
the trenches every day… you feel like you're the coach, the psychiatrist, a mediator, a judge, a jury, a mom.”
A special education staff member (Participant T‐SPED2) stated, “I'm the first responder to any kind of issues that
our kids are having whether it's just… it's academic, emotional, behavior.”
School personnel differed in how they felt their roles supported student mental health. One related arts
teacher, for example, stated, “I would say like any teacher, uh, I'm constantly watching the students, looking for
signs, where, uh, maybe things are a little out of normal” (Participant T‐RA1). Another indicated their role was more
limited because they only saw students a few times per week and went on to note mental health was “not my area
of expertise” (Participant T‐RA2). One certified member of the special education staff (Participant SPED2) indicated
“I don't have any role in mental health issues other than, um, me working with my students.” Interestingly, one
classroom teacher felt they did not deal much with mental health: “My role does not include, uh, a lot of mental
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ORMISTON ET AL. | 2161

TABLE 5 Participant identification codes and demographic information

Years at study Years in
Participant ID Professional title school education

T1 3rd Grade teacher 4 6

T2 3rd Grade teacher 37 37

T3 3rd Grade teacher 33 33

T4 4th Grade teacher 4 5

T5 4th Grade teacher 2 7

T6 4th Grade teacher 25 28

T7 4th Grade teacher 4 10

T8 4th Grade teacher 5 16

T9 5th Grade teacher 15 15

T10 5th Grade teacher 5 15

T11 5th Grade teacher 31 31

T‐HA1 Teacher (high ability) 21 23

T‐HA2 Teacher (high ability) 2 2

T‐RA1 Related arts teacher 31 31

T‐RA2 Related arts teacher 2 31

T‐RA3 Related arts teacher 2 6

T‐RA4 Related arts teacher 8 18

T‐SPED1 Special education teacher 2 3

T‐SPED2 Special education teacher 6 10

T‐SPED3 Special education teacher 4 6

T‐SPED4 Special education teacher 11 11

SPED1 Special education instructional assistant 1 2

SPED2 Special education certified staff 17 30

SPED3 Special education certified staff 32 32

O1 Cafeteria staff 2.5 10

O2 Custodian 3 9

O3 Custodian 16 16

OS1 School administrator 1 18

OS2 School office staff 23 25

SS1 Instructional assistant 5 11

SS2 Instructional assistant 22 22

SS3 Interventionist 17 23

SS4 Student support interventionist 12 12

Abbreviations: O#, building support personnel (e.g., kitchen supervisor, custodian); OS#, office staff (e.g., administrator,
office staff); SPED#, special education personnel (e.g., school social worker, school psychologist, etc.); SS#, support staff
(e.g., instructional assistants; school community liaison); T#, classroom teacher; T‐HA, high ability classroom teacher; T‐RA,
related arts teacher (e.g., physical education, music, etc.); T‐SPED#, special education teacher.
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2162 | ORMISTON ET AL.

health. Um, honestly, the only mental health issues I really deal with are kids with ADD or ADHD… Students with,
uh, other mental needs, we usually look for support because they're difficult to handle within…the classroom”
(Participant T7).

5.1.2 | Contributing factors related to student mental health

The staff did not have a cohesive definition of mental health. Instead, many (n = 9) provided what appear to be
contributing factors to student mental health concerns. For instance, when asked what school‐wide ap-
proaches are taken to support student mental health, some (n = 5) related mental health to socioeconomic
status and child welfare by listing off child welfare supports such as providing free and reduced‐price lunches,
sending home food for families over the weekend, providing free winter coats to children in need, and free eye
and dental exams coordinated by the school nurse (e.g., Participant SPED2, Participant T2). One instructional
assistant (Participant SS3) stated: “You can't teach children when there are too many other things in the
way… all of those basic needs need to be met before we can dive in and really learn or teach.” In contrast, one
teacher (Participant T‐RA2) suggested schools need to expand their definition of “mental health” beyond
just providing supports for students from low socioeconomic status: “I don't think that mental health is
necessarily a socioeconomic issue. I think it's an issue for low, middle, and high‐income people and to, um,
make sure we don't make the assumption that because they come from a rich family, that maybe they don't
need anything.”
Mental health was identified as manifesting in both externalizing and internalizing behavior. Staff (n = 3)
indicated they are able to notice when “something's off” (Participant T5) when a child's “behavior… needs so
much help you can see” (Participant SS2) or seeing the behavior as “something small that we're able to fix in
the classroom” (Participant T5). One teacher noted it tends to be students with externalizing behaviors that
receive support more often than students with internalizing behaviors: “[W]ith all the kids that do have the
externalizing behavior, the internalizing kids kinda fall through the cracks” (Participant T‐SPED3). Another
teacher commented: “[T]here's also some quiet kids that probably need some services [that] we, that are
you know, that are pushed under the rug or we just don't notice as much” (Participant T5). One of the school's
high ability teachers felt mental health needs were different given the population of students they work
with: “[B]ecause I teach high ability… my emotional concerns are kind of the other spectrum, perfectionism
and anxiety and those kind of things, so I don't personally [pause] umm, have as many issues” (Participant
T‐HA2).

5.1.3 | Recognition of the need to meet student mental health needs before meeting
academic needs

A number of staff (n = 5) noted the need to address student mental health before being able to teach academic
content. One teacher (Participant T6) stated, “I think sometimes they don't need the academics of the classroom;
they just need the comfort and the love of another adult that they trust.” This same teacher also stated: “the bottom
line is if they're not healthy mentally, academics are not going to stick.” Yet another classroom teacher (Participant
T1) stated, “[T]he mental health issues that they bring into the classroom… I'm kind of having to meet those needs
before we can go into the academic stuff.” One classroom teacher (Participant T9) lamented:

[T]hat's the frustration. If I could just sit and chat with them and I didn't have to worry about getting
to this place or that place… I could probably get a lot farther but you're still trying to wear all those
hats… You know, you're making them feel safe here at school. You're trying to teach them. You're
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ORMISTON ET AL. | 2163

trying to support their needs. You're trying to find out what's wrong with them. You're trying,
sometimes you're sending food home with them… You know, they don't have what they need to be
successful.

These statements were endorsed by noncertified staff as well. For instance, an instructional assistant
(Participant SS2) stated, “These kids are trying to learn but there's a bigger picture out there… because these kids,
um, their mindset is not good.”
A special education teacher suggested students' special education area of eligibility may reflect their mental health
needs: “[S]o when you have a student who has an IEP [Individualized Education Plan] for an emotional disability or other
health impairment…I would be more supporting their mental health because they have those others things going on, uh,
mentally, that are preventing them from being able to be successful at school” (Participant T‐SPED3). However, the
certified mental health professional (Participant SPED3) made sure to indicate mental health was not just a “special
education” issue: “I think sometimes there is a prejudice against special education students because they think maybe…
they have more problems than the general population. That is so not true. That is so not true.”

5.1.4 | Student mental health affects staff mental health

Two classroom teachers specifically noted the negative impact student mental health may have on their own mental
health. For example, a teacher (Participant T6) noted the distress felt when having to involve outside agencies: “I've
had to call DCS [Department of Child Services] several times last year, several times…when you have to do it several
times for the same student, its yeah, it's really upsetting.” Another classroom teacher (Participant T3) related their
distress: “to have some of the things these kids are dealing with, it blows my mind every day…and I don't know how
to help 'em… every day I still see something come up that is like 'oh my word' [sigh] and it's not academics, that's the
thing… it's these other home issues and such.”
Others commented that student mental health impacts the teachers' ability to effectively do their jobs. For
instance, one teacher (Participant T‐SPED2) stated, “so if I have a kiddo who's having an issue there's… not always
somebody who can meet with him… unless it's me and then that disrupts whatever I'm supposed to be doing.”
Another classroom teacher (Participant T11) summed it up with this sentiment: “Well, this year particularly I feel
like, um, teaching them academics is way not important to a majority. I mean there is a group of kids that are, you
know, come to school that are ready… But I have kids who… are not ready for the academic because I'm needing to
meet their emotional.” This teacher also noted, “I spend most of my day troubleshooting.”

5.2 | The school has limited mental health resources to meet student and staff needs

This theme reflected staff sentiment of the limitations of resources available within the building while also noting
the needs of students within the building increasing.

5.2.1 | Limited staff knowledge

Several staff members (n = 8) noted their limited knowledge in relation to identifying and supporting student mental health
needs. One classroom teacher (Participant T9) commented: “[Y]ou try to talk to and support kids like if they've had a rough
day coming in but nothing in terms of like actual counseling. You know, we're not trained to counsel.” A different classroom
teacher (Participant T10) expressed how she felt the lack of knowledge was influencing her ability to help students: “[S]o, I
feel like we… are just flying by the [interviewer and Participant T10 laugh] seats of our pants and trying to help however we
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2164 | ORMISTON ET AL.

know how… we are not equipped to handle all the things that are happening and we would love to know how to do that…
we haven't been trained or taught how to help socially and emotionally.”

5.2.2 | Student needs

School personnel (n = 8) recognized the needs of their student population as changing. For instance, the certified
mental health professional for the school (Participant SPED2) stated: “[T]here's a huge need… and a huge gap in
services… and it's just gotten more because the needs have gotten more.” One classroom teacher (Participant T6)
commented: “I just think the numbers are increasing of kids who need these services.” One classroom teacher also
recognized that while student need is increasing, staff awareness of those needs is increasing also: “Well, I think
they're very aware, which is, number one, is just being aware that there is a need” (Participant T5). Another teacher
(Participant T6) commented: “[W]e have a lot of kids that are struggling with behaviors, a lot of behaviors we've
never seen before.”

5.2.3 | Current services and limitations of resources

School staff (n = 23) were able to identify several areas where students did receive support, although the
services did not seem to be coordinated in any way. For instance, some stated the school offers small group
“lunch bunch” services for students provided by local university students in training (e.g., Participant T2).
Others discussed the implementation of behavior plans as a way to support students (e.g., Participant T5). Still,
others mentioned referring families for outside mental health resources (e.g., Participant T‐SPED1), although
some did state the family needed to be willing to follow up on the referral (e.g., Participant T6). Most methods
of support seemed to rely on team collaboration meetings such as “brainstorming” sessions to gather ideas for
supports (e.g., Participant OS1).
When asked what data the school collects to track student progress in relation to mental health support, many
(n = 19) did not know (e.g., Participant SS1, Participant SS3, Participant O3, Participant OS1, Participant T‐RA2,
Participant T‐RA3, Participant T4, Participant T6, Participant T‐HA1). Special education staff reflected on various
data that were collected as part of students' IEPs or behavior plans (e.g., Participant SPED3, Participant T‐SPED2,
Participant T‐SPED3). Others noted they measured progress simply by observing students' behavior: “[W]e have
observations, we meet, we have meetings, umm [pause] we take notes ourselves as we observe our students, um to
use when we meet” (Participant T10). Office discipline referrals were considered by some to be an indicator as well
(e.g., Participant O2, Participant T‐SPED3).
Despite the services staff identified, many noted the limitations present in providing supports to students
and families as well as who can deliver mental health supports. One classroom teacher (Participant T5) stated,
“I feel like right now we're very stretched, we're stretched really thin, and we don't have all the resources that
we need.” As one building administrator (Participant OS1) aptly put it: “[W]e're definitely just in kind of
'putting out fires' mode.” Furthermore, at the school, only students with IEPs received services from the one
certified mental health staff member on campus, and the services were spread across multiple districts and
multiple schools in the special education cooperative: “There's not enough people here and… I can only see
the special ed students. I can't even see the gen‐ed students and gen‐ed students have just as significant
issues as special education students do” (Participant SPED3). One of the office staff (Participant OS2) stated:
“[T]here's a lot of kids that don't have IEPs that need someone to talk to and we don't… have a full‐time
[certified mental health professional]… we need somebody, more than one person, and a full‐time person that
can be able to maybe do groups with them.”
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ORMISTON ET AL. | 2165

5.3 | Home and school environments affect student mental health

Another theme to emerge from the data was comprised of how different environments and contexts can affect a student's
mental health. This theme was made up of a positive school environment and factors outside of the staff's control.

5.3.1 | Positive school environment

Many participants (n = 14) discussed the positive environment in the school and the supportive school staff in terms of
relationships with the students, positive views on the school administration, and the overall culture of caring throughout
the school. One related arts teacher (Participant T‐RA1) stated, “I do like the fact that I do think we have a very caring staff
that I mean very seldom have I ever thought when I brought something up to a teacher that they would just kind of ‘ahh,’
you know, brush it under the rug type thing.” One building support personnel (Participant O2) described: “They get down
to their level, talk eye‐to‐eye, help them get through their issue, they take their walks with them.” Another support person
(Participant O1) echoed this by stating, “I see many times when I am walking through the hallway that [the principal] is out
in the, in the hallway talking to an individual… and [they get] down to their level and [talk] really calmly.” A classroom
teacher (Participant T6) described the following: “teachers here deeply, deeply, care about the students… I think we're all
compelled to try to help that child out and to contact someone on their behalf.” Another teacher (Participant T2) stated,
“Everybody is just kind of willing to step up and do whatever is needed… when… there's a need… they don't just ignore it
and say ‘well not my kid, not my job’ you know, everybody jumps in.” Another classroom teacher (Participant T3) stated,
“the nurse, the [related arts] teachers, the admin, have all, the secretaries, have all been amazing as far as trying to help
each individual kid with whatever problems they have.”
The staff also described how the administration is supportive and open, for both staff and students, allowing for this
positive culture to flourish throughout this school. One classroom teacher (Participant T11) praised the school's admin-
istrative team: “[T]here's support from the administration to the teacher. I know if teachers go to the administration, there's
a lot of support for them and they try to seek out ways to help that teacher deal with issues that are happening in the
classroom.” The certified mental health professional (Participant SPED3) assigned to the building spoke very highly of the
principal:

Well, I think the biggest strength here is the principal… [They are] living it every day, [they are]
compassionate, [they want] to help these students, [they want] to help [the] teachers. [They
recognize] too that the teachers have mental health needs and that they're going to need to be
supported as well as the students and the families… and you know, the principal is the culture
of the school, you know. When you have a principal that's a leader like that… it makes a huge
difference.

5.3.2 | Factors outside staff control

Some participants discussed factors outside of their classroom environment that affect their student's mental health
or their ability to respond appropriately to mental health concerns. The factors most commonly mentioned were
family and home lives and the size of the school.

Familial factors
A few school personnel (n = 3) mentioned students' family dynamics and family stress as contributing to the mental
health challenges of students. For instance, one teacher (Participant T11) compared their job to be a parent and
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2166 | ORMISTON ET AL.

inferred they feel their students' family lives are affecting how they present in the classroom: “[T]his year I felt like I
need to be their mom and not a teacher. I am not in the teaching capacity this year, I am in, I just need to be their
mother.” Another participant discussed the “trickle‐down” effect they see in the school. One participant described
this as “the parents have some, maybe mental health needs so therefore the kids do” (Participant SS4). A building
administrator (Participant OS1) stated, “they just have so much baggage and they just want somebody to talk to.”
Another classroom teacher (Participant T3) felt “parents don't put school, I mean, school is at the bottom of the list
and I know a lot of them, it's, they're trying to get food on the table, they're trying to you know, helping their kid
with a math paper is the last thing on their list.”

Size of the school

Falling under the theme of factors outside of staff's control, school staff (n = 7) discussed the size of the school as
impacting student mental health. One staff member (Participant T11) talked to this point stating, “we're quite a large
elementary… and there's a lot, there's a lot of need there.” This particular staff recognized the size of the school
creates a problem in addressing all the needs of their students. Another teacher (Participant T7) described this as
“[C]lass sizes… are too large to be able to deal with mental health issues in the classroom setting.” Another teacher
(Participant T3) commented, “[T]here are a ton of issues that these kids, I mean we have 600 kids in this building and
I think probably a good half or more need some help, big time.” From these examples, inferences can be made that
the school staff feel there are too many students to give individualized attention and supports when students
present mental health concerns.

5.4 | School staff express desire for additional support and training

The final theme to emerge from the interviews surrounds staff desire for additional resources and training. These
resources varied from personnel to more school‐ and family‐based supports to additional training.

5.4.1 | Personnel

Several staff (n = 7) indicated additional personnel would be helpful to work directly with students. One classroom
teacher (Participant T11) stated, “We really need more. We need the person who can help be that mental health
person, so that teachers can teach and that their mental health is also being met, and it's not just choosing one or
the other.” Another classroom teacher (Participant T6) commented: “Again, I just think the numbers are increasing
of kids who need these services and so that is probably the major, um, obstacle is just not having enough people.”
This sentiment was present from classroom teachers as well as support staff. For instance, one support staff
member (Participant SS4) stated, “And so, you know, we're expected to do so much with so little hands and we, you
know we don't turn kids away… So, if we, bottom line is, we just had more hands to help us, you know, treat kids, I
think we'd be in better shape.”

5.4.2 | Desire for additional supports

School‐wide support
The most common concern (n = 5) expressed about school‐wide supports was the importance of services and
communication being consistent between grade levels and staff members. For instance, one teacher (Participant T8)
stated: “I feel there's some communication gaps. Like year to year what kind of services or what professionals talk
to the students in the school… [I see] inconsistency between years and between teachers and things.” Another
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ORMISTON ET AL. | 2167

classroom teacher (Participant T6) noted the need for consistency in relation to having all staff trained with the
same knowledge regarding mental health: “[T]o have that training so that it carries through grade level to grade
level, so that we all know what to be looking for is really important. [W]hen it comes to mental health we all need to
kind of be on the same page and looking for the same thing.” One related arts teacher (Participant T‐RA3)
specifically mentioned more mental health support for teaching staff: “I think it's really hard to keep morale up as
teachers… And teachers are some of those people that just shove their own feelings so deep down… To focus on
everyone else and I just think it would be helpful to have staff outreach as well.”

Familial support
Additional reference was made to providing support for families in the form of referrals for community mental
health agencies or educating families about mental health (n = 3). For instance, a special education staff member
(Participant SPED2) stated, “[T]o get help for these students, help for their families… I think the parents and
guardians don't always know where to go for resources or don't always know that there's a problem.” This staff
member went on to discuss a need for “[e]ducating the children and the parents about the needs and resources that
they could try or use.” Another teacher (Participant T5) noted it was a building administrator that provided referrals
for families:

I've had students where I've had concerns. Things that were happening at home, or that they were
doing to themselves, or things that I was concerned about… [the administrator] talked to the parents
about, um, helping them get in contact with people that might help them outside of the school.

5.4.3 | Training

Several school personnel (n = 15) reported wanting additional training to support student mental health. A special
education teacher (T‐SPED4) commented, “I would love to see just more professional development for teachers for
mental health.” One classroom teacher (Participant T10) noted: “[W]e do need training [pause] on how to handle
[pause] all the different aspects of mental health.” Another classroom teacher (Participant T10) stated, “I also think
as educators we would benefit greatly from having, um, tools in which we can use to teach the students.” Yet
another classroom teacher commented, “I think just knowing… being informed on what to look for. Um, it's not just
that we're stretched thin but its sometimes like, just I think we are aware there's a problem but not always able to
identify what the problem is or what steps to take, and yeah, just, yeah, lack of knowledge.” Some teachers also
expressed a desire to help students with more internalizing behaviors as well: “[M]aybe knowledge of how to help
those children that are like, you know, with the internalizing things that you don't see maybe would be helpful.”
(Participant T9).

6 | DISC USSION A ND I MPLICATIONS F OR PRACTIC E

As the mental health needs of students increase (Bruhn et al., 2014; Kaffenberger & O'Rorke‐Trigiani 2013;
Mojtabai et al., 2016), the need for mental health support and resources is also on the rise. Schools are uniquely
positioned and called on to address mental health issues among students (NASP, 2015), particularly through the
implementation of an MTSS (Eagle et al., 2015). The current study sought to examine school staff perspectives and
knowledge related to the mental health of the students in the school. Overall findings indicate that although staff is
aware of the impact of mental health issues on students, the need for mental health training and support is
imperative for the well‐being of students, teachers, and staff.
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2168 | ORMISTON ET AL.

Within the theme Staff roles and knowledge impact their perspectives on and understanding of student mental
health, the lack of consensus when defining and identifying student mental health issues reveals there is no
consistent or universal language or training at any level within the school. This may have emerged because the
varying roles within the school system may result in different interactions and relationships with students. Some
staff conceptualized mental health needs as related to child welfare such as providing food, clothing, and wellness
exams at the school. This is an important component to consider when conceptualizing comprehensive, integrated
services within an MTSS framework such that by meeting basic needs, youth, families, and school personnel can
then prioritize mental health services (Sulkowski & Michael, 2014). Others understood mental health to be related
to both externalizing and internalizing behaviors and recognized the need to ensure students with internalizing
behaviors do not “fall through the cracks” (Participant T‐SPED3). Indeed, a concern with universal screening has
emerged in that universal screening assessment methods may not accurately capture and identify students with
internalizing behaviors (Margherio et al., 2019).
Current results also indicate teachers understand they need to play critical roles in addressing the mental health
needs of students, supporting previous research (Reinke et al., 2011; Walter et al., 2006). Although teachers are
often tapped for providing universal, classroom‐based supports within an MTSS framework (Sanchez et al., 2018),
they often do not feel they can adequately serve the mental health needs of students (Frauenholtz
et al., 2015, 2017; Reinke et al., 2011; Walter et al., 2006), a sentiment reported by several teachers in the current
study. Providing training to teachers and integrating these services through a tiered framework may help maximize
resources within a school. On the other hand, two teachers, in particular, explicitly mentioned they do not play a
role in supporting the mental health of their students, with one citing the “only mental health issues I really deal
with are kids with ADD or ADHD” (Participant T7). While symptomatology related to ADD or ADHD may be
considered a mental health issue, teachers' lack of knowledge related to mental health may contribute to the
perception they do not interact with or serve students with mental health needs (Powers et al., 2014).
Teachers in the current study endorsed feelings that students' mental health challenges were impacting their
own mental health, which may be seen in the form of compassion fatigue (CF; Hupe & Stevenson, 2019; Koenig
et al., 2018). CF is defined as the psychological and physical consequences endured by an individual caring for those
impacted by trauma (Hydon et al., 2015). When teachers care for students with significant mental health needs
related to trauma, as alluded to by the participants in our current study, the compassion and empathy educators
often exude comes at a cost (Figley, 2002) to their own mental health. In addition, as teachers are required to make
reports to child welfare agencies due to mandatory reporting laws (Hupe & Stevenson, 2019), this contributes to CF
as well (Cieslak et al., 2014; Hupe & Stevenson, 2019). Indeed, one of our participants endorsed this sentiment
specifically when they referred to their repeated contact with local child welfare agencies. Additional research in
the education field examining CF in teachers is needed (Hupe & Stevenson, 2019; Koenig et al., 2018).
The themes school staff express desire for additional support and training and the school has limited mental health
resources to meet student and staff needs highlight the necessity and eagerness of teachers and staff to help their
students to not only succeed academically but mentally and emotionally as well. Responses within this theme echo
the results of Rothì et al. (2008) that emphasize the importance of mental health training and support. Like several
general and special education teachers in our sample, teachers report they do not have adequate levels of
knowledge to support the mental health needs of students (Walter et al., 2006) yet have a strong desire to learn
more. When Ohrt et al. (2020) conducted a systematic review of the literature from over 100 years, they only found
a meager 15 articles that “consisted of intervention studies focused on improving K–12 teachers' abilities to identify
and manage student mental health concerns conducted either through a control group comparison or a pre/
posttest evaluation” (p. 835). Their findings and those of this study clearly support the need to research more
specific training programs related to enhancing teachers' knowledge of student mental health. Furthermore, be-
cause resources in schools are limited, we call upon teacher education programs to incorporate mental health
content into the curriculum of preservice educators to provide them with the foundation needed before entering
the workforce (Atkins & Rodger, 2016).
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ORMISTON ET AL. | 2169

Within the theme Home and school environments affect student mental health, many educators shared senti-
ments regarding the impact the positive school climate has on student mental health. The school climate was
described as one of caring and support from the teachers and administration. Allen et al. (2015) highlight the
influence a school leader plays on the culture and climate of the school. School leadership has also been implicated
in teacher satisfaction and reductions in burnout (Pas et al., 2012; Skaalvik & Skaalvik, 2011). In our sample, school
personnel noted how supported they felt by the administration within the school and also how administrators
attempt to provide support to students with mental health needs. It is important to note the contrary has also been
documented: administrative support, or lack thereof, has been identified as a reason why students with mental
health needs “fall through the cracks” (Reinke et al., 2011).
While the positive climate is a clear strength of the school, there are factors perceived to be outside one's
control that may act as a barrier to providing support to children in need. Several educators noted large classes and
overall school size may make it difficult for teachers to identify every student who may be at risk for mental health
concerns. Many participants expressed that while they do the best they can, they are sometimes “wearing too many
hats” and simply do not have the time or resources available. Large class sizes have also been linked to teacher
burnout (Caringi et al., 2015), and when coupled with CF as discussed earlier, this should be an area of consideration
for addressing student mental health. Putting this concern within the context of an MTSS framework, the appli-
cation of a universal screening procedure would help to identify students in need of support (McIntosh &
Goodman, 2016), with an eye toward ensuring those with internalizing concerns are identified as well (Margherio
et al., 2019).
Finally, some staff discussed students whose mental health concerns are related to familial mental health or
unstable home lives. When conceptualizing this theme, we feel it is important to note the need to take a strengths‐
based perspective with students and families. School staff should seek to understand the perspectives of families in
relation to their beliefs about mental health. For instance, many families may be reluctant to share information
related to a student's mental health because of the stigma associated with doing so (Minke & Vickers, 2015).
Adopting a strengths‐based perspective to family engagement focusing on collaboration, positive reframing, re-
spect, and empowerment (Minke & Vickers, 2015), helps students develop skills and knowledge to succeed, feel
valued and have a sense of purpose (J. Bryan & Henry, 2008). Furthermore, the strengths‐based perspective may
help to close the communication gap between families and the school (Minke & Vickers, 2015). By treating parents
and caregivers with respect and care, along with recognizing them as valuable assets and allies in their children's
education, families may be more willing to participate in school‐based activities (Minke & Anderson, 2005; Minke &
Vickers, 2015) and communicate regularly with school staff and teachers.
Overall, a few different implications for practice may be considered. First, educators voiced a critical need for
additional mental health training and support. Providing professional development for school staff could improve
the implementation of tier 1 support within an MTSS framework and offer a foundation from which mental health
services can be carried out and student mental health needs can be identified. Educators with adequate student
mental health knowledge may be better suited to advocate for more intensive services for students within MTSS.
Early identification of mental health needs, whether through universal screening as part of an MTSS framework or
through teacher referral as a result of increased knowledge of student mental health, may result in earlier receipt of
mental health services for students (Splett et al., 2018).
Partnering with community agencies to provide mental health services on‐site may also be a viable option to
provide services to students in need. For instance, we are aware of several local school systems that partner with a
community agency such that mental health providers employed by the agency operating out of the school district.
The agency bills students eligible for Medicaid, thus effectively providing the services for “free” to the school, and
the school is obligated to provide the agency a private space from which the mental health provider can see
students. While logistical issues may need to be worked out, this can be an excellent and viable option for schools
limited in personnel and funds yet offer a way for student needs to be met.
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2170 | ORMISTON ET AL.

Finally, we cannot overemphasize the importance of supporting teachers' mental health and self‐care. Teaching
is a highly stressful occupation (Johnson et al., 2005) compounded by large class sizes, complex student learning,
and behavioral needs, and are often asked to work with limited resources and increasing accountability demands
(Gray et al., 2017). Teachers burdened with their own mental health challenges have a reduced capacity to support
their students (Kidger et al., 2010). Supporting teacher resilience and mental health may help buffer the impact of
burnout and CF that results in teachers leaving the profession (Gray et al., 2017). There is some evidence to indicate
that engaging in self‐care practices such as mindfulness may promote well‐being among educators (Abenavoli
et al., 2013).

7 | L IM I TAT I ONS AND FU TU RE DIREC TION S

The qualitative nature of the present study suggests that the interpretations of interviews are subjective and were
only viewed through the lens of the researchers. However, the researchers selected a qualitative method and
thematic analysis because it is an evidence‐based methodology. In addition, it is possible that the researchers had
preconceived notions about the school due to previous collaborations with the school district. Interview questions
and the interviewers themselves may have shaped the responses as well, resulting in interviewees falling victim to
interviewer effects. Participants were aware that they would be interviewed by the researchers, so they may have
answered in a way that elicited specific reactions of the interviewer. It is also important to note that the sample
selection is not representative of all schools because the school only served three grade levels. Differing attitudes
and perceptions may be found among teachers and staff at different grade levels. Future research should include
interviews with teachers and staff from all grade levels to encompass viewpoints from all levels within a school
system.
Because interviews were strongly encouraged by the school's administrator, yet were ultimately on a
volunteer‐only basis, results may not have encompassed the full scope of what occurs at the school. The
demographics of the school itself may make it difficult for generalization. There is a predominately White
student, teacher, and staff population. The results fail to incorporate multicultural impacts on mental health
(e.g., racism). The perspectives of families, caregivers, and students themselves need to be examined to
triangulate the current results. Moreover, future research needs to include a more diverse sample size. Racially
and ethnically diverse teachers and school staff, as well as teachers and staff who serve racially and ethnically
diverse students need to be included in future research to account for multicultural impacts on student mental
health.

8 | C ONC LUS I ON

The current study examined school staff perceptions of student mental health captured by three research ques-
tions: (1) examining school staff perceptions related to student mental health; (2) school procedures for addressing
student mental health; and (2) how school staff to address student mental health. Through a thematic analysis of
interview data, the following themes emerged: (1) Staff roles and knowledge impact their perspectives on and
understanding of student mental health; (2) The school has limited mental health resources to meet student and
staff needs; (3) Home and school environments affect student mental health; and (4) School staff express desire for
additional support and training. Findings indicate that although many school staff are aware of and understand the
influence of mental health on the well‐being of students, there is a critical need for mental health training and
additional support throughout the school. The current study highlights the voices of teachers and school staff and
emphasizes their concerns.
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ORMISTON ET AL. | 2171

CO NFL I CT OF INTERES T S
The authors declare that there are no conflict of interests.

ORCID
Heather E. Ormiston https://orcid.org/0000-0002-3774-7090

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0000187243.17824.6c

How to cite this article: Ormiston, H. E., Nygaard, M. A., Heck, O. C., Wood, M., Rodriguez, N., Maze, M.,
Asomani‐Adem, A. A., Ingmire, K., Burgess, B., & Shriberg, D. (2021). Educator perspectives on mental health
resources and practices in their school. Psychol Schs, 58, 2148–2174. https://doi.org/10.1002/pits.22582

A P P E N D IX A
Interview Protocol

1. Please tell me about your role in the school/district as it relates to the mental health needs of students.
2. What approaches, if any (including approaches that you may not directly be involved with) does SCHOOL take
to support the mental health of its students?
 15206807, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pits.22582 by Universidad De Santiago De Chile, Wiley Online Library on [30/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2174 | ORMISTON ET AL.

3. What are the existing strengths of SCHOOL, if any, as it relates to supporting the mental health needs of its
students?
4. What gaps, if any, are there in supporting the mental health needs of students at SCHOOL?
5. What metrics, if any, are in place to track whether an individual mental health intervention was successful?
6. What metrics, if any, are in place to track whether SCHOOL as a school is having a positive impact on the mental
health of its students?
7. Where would you like to see a potential partnership between SCHOOL and the school psychology program at
UNIVERSITY head?
School Mental Health (2023) 15:1–18
https://doi.org/10.1007/s12310-022-09535-0

REVIEW PAPER

Roles and Functions of School Mental Health Professionals Within

Comprehensive School Mental Health Systems
Faith Zabek1   · Michael D. Lyons1   · Noor Alwani1   · Julia V. Taylor1 · Erica Brown‑Meredith2 · Melinda A. Cruz3 ·
Vickie H. Southall4

Accepted: 4 July 2022 / Published online: 26 July 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Mental health concerns are on the rise among youth, contributing to a growing need for school-based mental health services.
However, challenges to service provision arise due, in part, to workforce shortages, service fragmentation, and inefficient
allocation of staff time. The current study describes the professional competencies and time allocation of four school-based
mental health professions (i.e., school counselors, school psychologists, school social workers, and school nurses) in order
to demonstrate how schools can leverage the skills of their existing staff to coordinate a comprehensive approach to support
student mental health. First, we identified the core clinical competencies needed to implement the key features of compre-
hensive school mental health systems. Then, we crosswalked these clinical competencies with the training standards of the
four professions. Finally, we conducted a systematic review of the literature to understand how these professionals’ time
is allocated, as well as their responsibilities related to the provision of mental health services. Results demonstrated that,
although all four professions receive training in most of the core competencies needed to implement comprehensive school
mental health services, their skillsets are often underutilized in day-to-day practice. Thus, we concluded that there are at
least two untapped opportunities for school leaders to support student mental health—first, maximize the use of school
mental health professionals through task-shifting (i.e., reassigning tasks less central to mental health service delivery to
other staff), and second, implement an integrated model of school mental health services to efficiently leverage the mental
health training of professionals.

Keywords  School mental health professionals · Professional competencies · Time allocation · Roles and functions · Service
coordination · Interprofessional collaboration

Introduction
Poor mental health can have a serious adverse impact on
youth wellbeing and future success (Clayborne et al., 2019).
Prior to the COVID-19 pandemic, youth mental health con-
cerns (e.g., anxiety and depressive symptoms) were on the
* Faith Zabek
tak9uz@virginia.edu
1
Department of Human Services, University of Virginia,
Charlottesville, USA
2
Department of Social Work and Communication Sciences
and Disorders, Longwood University, Farmville, USA
3
Department of Psychology, Radford University, Radford,
USA
4
Department of Family, Community and Mental Health
Systems, University of Virginia, Charlottesville, USA
rise in the USA and throughout much of the world (Burns
& Gottschalk, 2019; Mojtabai & Olfson, 2020). Since the
pandemic began, rates of psychological distress among
young people have increased further (Racine et al., 2021;
Sharma et  al., 2021). Accordingly, more educators and
health professionals are identifying mental health as one of
students’ greatest needs (American Academy of Pediatrics,
2021; Iachini et al., 2016), and researchers, policy makers,
and global institutions are calling for increased access to
effective school-based mental health supports (Kern et al.,
2017; UNICEF, 2021; U.S. Department of Education [ED],
2021). To support student mental health needs effectively
and sustainably, it is critical to develop and strengthen the
capacity of schools to implement comprehensive school
mental health (SMH) systems. SMH systems coordinate
services to promote the social and emotional development
of students, which can have a positive and lasting impact on

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2 School Mental Health (2023) 15:1–18
youth achievement, behavior, and wellbeing (Sanchez et al.,
2018; Taylor et al., 2017). These services are often provided
by a diverse set of professionals (e.g., school counselors,
psychologists, social workers, and nurses) who function in
both similar and unique ways (Ball et al., 2010). However,
barriers to efficient SMH service provision arise due to (a)
fragmented service delivery across providers (Weist et al.,
2012) and (b) budgetary constraints and workforce shortages
(Whitaker et al., 2019). This study describes the SMH com-
petencies and time allocation of school-based professionals
so that schools can leverage the skills of their existing staff
and coordinate an integrated and comprehensive approach
to support student mental health.
Core Components and Challenges of School
Mental Health Systems
SMH services refer to a continuum of supports and interven-
tions designed to prevent, identify, and treat student mental
health challenges and to promote student wellbeing and suc-
cess. Because of the wide scope of activities that fall within
SMH, researchers and experts document key practices and
strategies that are pertinent to effective service delivery.
Hoover et al. (2019) synthesize the knowledge and guidance
of over 75 SMH experts and leaders, gleaned over multiple
national convenings. They delineated eight core features of
comprehensive SMH systems (e.g., a multitiered system of
support [MTSS] approach for addressing mental health). The
last feature (i.e., funding) is likely to be implemented by school
administrators, while the others are likely to require the support
of SMH professionals. The National Center for School Mental
Health (NCSMH) and the Mental Health Technology Trans-
fer Center (MHTTC, 2019) outline similar features in their
national SMH curriculum, and they identify an additional key
feature of SMH systems: cultural responsiveness and equity.
These eight features (excluding funding) are: (a) well-trained
specialized support personnel, (b) family–school–community
collaboration, (c) needs assessment and resource mapping, (d)
multitiered systems of support (MTSS) approach, (e) mental
health screening, (f) evidence-based practice, (g) effective use
of data, and (h) culturally responsive and equitable mental
health practices (see Table 1 for additional detail). Together,
these features describe the clinical competencies needed by
SMH providers and reflect the need for SMH systems to pre-
vent, assess, support, and monitor student mental health needs
of varying intensities within an MTSS framework. Specifi-
cally, MTSS describes a model of service delivery in which
schools deliver supports and interventions to students in
varying intensities. With respect to SMH, tier one focuses on
mental health promotion and prevention for all students; tier
two focuses on prevention and early intervention for students
identified as at-risk or experiencing mild impairment; and tier
13
three focuses on individualized interventions for students with
more serious concerns (Hoover et al., 2019). When these key
features occur, schools are able to deliver services in a compre-
hensive and coordinated manner that reduces disparities and
responds to the diversity of students and families.
Although there are various barriers to effective and sus-
tainable SMH provision, two pervasive barriers are service
fragmentation and staff shortages (Eiraldi et al., 2015; Weist
et al., 2017). First, service fragmentation occurs when mental
health supports are provided in relative isolation and there is
a lack of coordination and role clarity among SMH provid-
ers (Weist et al., 2012). While there is growing evidence for
the positive impact of interprofessional collaboration on SMH
service provision and student mental health outcomes (Bates
et al., 2019; Reaves et al., 2022), school-based providers report
relatively low rates of service coordination, which may lead
to duplication of services and inadequate service provision
(Santiago et al., 2014). Challenges to effectively coordinating
mental health services include role confusion and disciplinary
differences (Mellin & Weist, 2011). Without a clear under-
standing of the professional mandates and job responsibilities
of distinct SMH disciplines, SMH team members are not likely
to recognize how their roles can complement the expertise of
other providers and disputes or confusion may arise over who
should be responsible for certain tasks (Markle et al., 2014).
Understanding and discussing the roles and responsibilities of
distinct professions can improve the functioning and effective-
ness of SMH teams (Borg & Pålshaugen, 2018).
Second, national workforce shortages and limited funding
to hire and train professionals mean that schools have dif-
ficulty staffing—and subsequently implementing—compre-
hensive SMH services (Shelton & Owens, 2021). Although
SMH services engage a wide range of professionals, national
shortages of SMH providers mean that schools often face
supply shortages of qualified SMH practitioners (Health
Resources and Services Administration [HRSA], 2015).
These shortages likely contribute to an overburdening of
staff, leaving little time for SMH service provision and coor-
dination (Mellin & Weist, 2011). Thus, opportunities may
exist for tasks to be shifted among (or away from) SMH
professionals to increase schools’ capacity to support stu-
dent mental health. A thorough understanding of the men-
tal health competencies of SMH professions along with the
ways their time is allocated may help guide decisions about
how to best allocate tasks to maximize impact on student
mental health.
School Mental Health Professionals
In the subsections below, we provide an overview of the
training and competencies of school counselors, school
nurses, school psychologists, and school social workers.
 Table 1  Crosswalk of SMH professional standards with clinical competencies needed to implement the key features of comprehensive SMH systems
Key features of comprehensive Aligned SMH professional com- School counseling School nursing School psychology School social work
SMH systems petencies

Well-Trained Specialized Instruc-
tional Support Personnel: Com-
prehensive SMH systems must be
adequately staffed with personnel
trained to provide assessment,
diagnosis, counseling, educa-
tion, therapy, and other necessary
a. Conduct and interpret mental
health assessments
b. Identify mental health disabili-
ties
c. Provide mental health counseling
d. Provide mental health education
X Standard 1 Domain 1 Standard 3
X Standard 2 Domain 4 (4th Practice) Core Areas (6th Area)
B-SS 3 Standard 5 (11th Competency) Domain 4 (2nd Practice) Guiding Principle 3: Tier 2
B-SS 5.b Standard 5B Domain 4 (1st Practice) Standard 10
School Mental Health (2023) 15:1–18

mental health services
Family–School–Community
Collaboration: Comprehensive
SMH systems create intentional
structures to meaningfully involve
students, families, and commu-
nity partners in the provision of
mental health care
Needs Assessment and Resource
Mapping: Comprehensive SMH
systems strategically assess SMH
needs and systematically identify
available resources for the provi-
sion of mental health services
Multitiered System of Support
(MTSS): Comprehensive SMH
systems ensure all students have
access to a full array of layered
supports, including universal pro-
motion supports (e.g., schoolwide
programming: Tier 1), targeted
programs (e.g., early intervention
or brief individualized interven-
tions: Tier 2), and treatment
services (e.g., individualized
therapy for significant distress
and functional impairment: Tier
3). Professional development and
support for staff as well as fam-
ily–school–community partner-
ships are foundational elements
of MTSS
e. Provide mental health therapy X X Standard II.3.12 Guiding Principle 3: Tier 3
a. Collaborate with students and B-SS 6 Standard 5 (1st Competency) Domain 7 (6th & 7th Practices) Guiding Principle 2
families
b. Collaborate with community B-SS 6 Standard 18 (5th Competency) Domain 4 (9th Practice) Standard 10
providers and partners
a. Conduct mental health needs B-PF 9.b Standard 18 (8th Competency) Domain 5 (4th Practice) Standard 3
assessments
b. Conduct mental health resource B-SS 4 Standard 16 Domain 6 (2nd Practice) Guiding Principle 2
mapping
a. Facilitate an MTSS approach for X Standard 4 (3rd–6th Competencies) Domain 5 (8th Practice) Guiding Principle 3
supporting mental health
b. Provide mental health profes- B-SS 5.d Standard 5B (9th Competency) Domain 5 (2nd Practice) Standard 10
sional development for staff
c. Establish and maintain family– B-SS 6.a Standard 10 Domain 7 (2nd Practice) Standard 10
school–community partnerships
d. Facilitate Tier 1 universal mental B-PF 9.a Standard 5B Domain 6. (6th Practice) Guiding Principle 3: Tier 1
health promotion supports
e. Provide Tier 2 targeted supports B-SS 3.b Standard 5 (10th–12th Competen- Domain 6. (5th Practice) Guiding Principle 3: Tier 2
and early intervention services cies)
f. Provide Tier 3 individualized X Standard 4 (1st Competency) Domain 4 (2nd Practice) Guiding Principle 3: Tier 3
intervention and treatment
services

13
3
 4

Table 1  (continued)
Key features of comprehensive Aligned SMH professional com- School counseling School nursing School psychology School social work
SMH systems petencies

13
Mental Health Screening: a. Conduct mental health screening X X Domain 5 (7th Practice) Standard 3
Comprehensive SMH systems
use evidence-based processes
and psychometrically validated
screening tools to systematically
identify students in need of addi-
tional mental health supports
Evidence-Based and Emerging a. Use evidence-based and emerg- B-PF 1.c Standard 13 Domain 9 Standard 4
Best Practices: Comprehensive ing best practices
SMH systems select and use
mental health prevention and
interventions strategies that are
research-supported and consistent
with best practices
Data: Comprehensive SMH sys- a. Systematically track and monitor B-SS 1.h Standard 3 Domain 4 (8th Practice) Standard 5
tems use data to plan, monitor, mental health data outcomes
and document the impact of men- b. Use and create data systems to B-PA 2 Standard 1 (1st Competency) Domain 1 (7th Practices) Standard 3
tal health supports and services facilitate SMH data collection
c. Use data-driven decision-making B-PA 3 Standard 6 Domain 1 (4th Practice) Standard 5
to inform SMH planning
Cultural Responsiveness and a. Engage in culturally responsive B-PF 6 Standard 8 Domain 8 (3rd Practice) Standard 9
Equity: All components of mental health practices
comprehensive SMH systems b. Ensure SMH practices are equi- B-PA 2 Standard 8 (11th–12th Competen- Domain 8 (9th Practice) Standard 11
consider and are responsive to the table and reduce disparities cies)
specific cultural values, beliefs,
and behaviors of families and
communities. Comprehensive
SMH systems ensure access to
mental health supports and ser-
vices in a manner that is equitable
and reduces disparities across all
students

SMH school mental health. Examples of professional and ethical standards that reflect the clinical competencies needed to implement the key features of comprehensive SMH systems are pre-
sented for each SMH profession. Competencies that were not reflected in professional standards documents are denoted by “X.” The example standards reference: ASCA (2019; school coun-
seling); ANA and NASN (2017; school nursing); NASP (2020; school psychology); and NASW (2012; n.d.; school social work)
School Mental Health (2023) 15:1–18
School Mental Health (2023) 15:1–18 5
We focus on these four disciplines because they (a) have
professional, often graduate-level training in supporting the
mental health of students; (b) are typically certified at the
national- and/or state-level; and (c) are frequently identified
in SMH policy and guidance (see, e.g., Cowan et al., 2013;
Every Student Succeeds Act [ESSA], 2015). While their
specific roles may vary, these staff are routinely assigned
duties to provide mental health services in schools and
recognized as SMH providers (Whitaker et al., 2019). We
refer to standards set out by leading professional organiza-
tions in the USA to summarize the competencies of each
of these professionals as it relates to mental health service
provision. Finally, because there have been widespread
calls across the four disciplines for increased engagement
in tasks supporting student mental health (see, e.g., Ber-
zin et al., 2011; DeKruyf et al., 2013; Puskar & Bernardo,
2007; Splett et al., 2013), there is a need to examine how
the professional training standards across professionals may
contribute to the provision of SMH service in shared and
unique ways. By understanding how the professional train-
ing backgrounds of diverse service providers align with the
key features of comprehensive SMH systems (Hoover et al.,
2019; NCSMH & MHTTC, 2019), we expect to equip lead-
ers with the knowledge to successfully allocate resources
(e.g., staff expertise and time), coordinate responsibilities,
and implement comprehensive SMH programs. Thus, in the
current study, we aim to support schools’ efforts to meet the
rising mental health needs of youth (American Academy of
Pediatrics, 2021) by linking a national model for effective
SMH (Hoover et al., 2019; NCSMH & MHTTC, 2019) to
the professional competencies of school staff who are likely
to be leading efforts to implement these services.
In the subsections below, we briefly describe the train-
ing and roles of the four mental health professionals but
acknowledge that these professionals may be assigned
duties outside of mental health (e.g., supporting students’
academic, career, or physical health outcomes). In addition,
the requirements to work in these fields vary by state and
may not adhere to professional standards. Therefore, SMH
provider’s competencies may differ based on their training
and credentialing status.
School Counselors
School counselors support the success of all students by
promoting and enhancing student academic, postsecond-
ary, and social–emotional outcomes. They are licensed
(or certified) by the state in which they are employed.
Although licensure requirements vary, most states require
school counselors to graduate from a master’s-level school
counseling program to complete supervised experiences
in school settings, pass a comprehensive examination,
and complete continuing education (American School
Counselor Association [ASCA], n.d.-b). The Council for
Accreditation of Counseling and Related Educational Pro-
grams (CACREP) accredits approved school counseling
training programs, and the National Board of Certified
Counselors offers the specialized National Certified
School Counselor (NCSC) credential to those who qualify.
According to ASCA (2019), school counselors collabo-
rate with others to create a school culture of success for
all, use data to identify needs and evaluate efforts, and
provide direct and indirect services, including: advisement
in large group, classroom, small group, and individual set-
tings; counseling in small group and individual settings;
consultation to support student success; referrals for stu-
dents who require extensive mental health support; and
planning and assessment of school counseling programs.
The 2019 student-to-school counselor ratio was 444:1
(Whitaker et al., 2019), nearly twice as high as the recom-
mendation of 250:1 (ASCA, n.d.-c).
School Nurses
School nurses promote student health, facilitate optimal
development, and advance academic success. Although
most school nurses have a bachelor’s degree in nursing
(BSN; Willgerodt et  al., 2018), some states allow for
licensure at the associate’s level. Licensure as a Regis-
tered Nurse (RN) requires a passing score on the licen-
sure examination and completion of continuing education.
Although there are no specific requirements differentiating
a school nurse from other nurses, the National Association
of School Nurses (NASN) recommends a BSN degree as
the entry-level qualification and encourages school nurses
to seek advanced skills to competently needs within school
settings (American Nurses Association [ANA] & NASN,
2017). Nationally, the Commission on Collegiate Nursing
Education (CCNE) accredits approved nursing programs,
and the National Board for the Certification of School
Nurses (NBCSN) offers the Nationally Certified School
Nurse (NCSN) credential to qualified school nurses.
According to the ANA and NASN (2017), school nurses
bridge health care and education, provide care coordina-
tion, and collaborate to promote student success. They pro-
vide health education and address a wide range of health-
related barriers, including mental health issues; physical
and emotional disabilities; chronic health needs; and social
determinants of health. In addition, school nurses con-
tribute to special education teams by providing expertise
in assessment, diagnosis, and health planning. The 2019
student-to-school nurse ratio was 936:1 (Whitaker et al.,
2019), higher than the recommended 750:1 ratio (ANA &
NASN, 2017).
13
6 School Mental Health (2023) 15:1–18
School Psychologists
School psychologists apply expertise in mental health, learn-
ing, and behavior to help youth succeed. Licensure (or cer-
tification) requirements vary by state; most require at least
a masters or specialist degree plus a 1-year internship from
a school psychology program, completion of school-based
practicum and internship experiences, a passing score on the
school psychology Praxis examination, and completion of
CE (National Association of School Psychologists [NASP],
2020). Nationally, NASP approves training programs and
offers the Nationally Certified School Psychologist (NCSP)
credential to qualified school psychologists. Although not
the focus of this study, the American Psychological Associa-
tion (APA) also accredits doctoral-level school psychologists
who receive more extended training in mental health inter-
vention, assessment, and research. We focus on school psy-
chologists with masters or specialist-level training because
they represent the largest portion of school psychologists
practicing in school settings (83%) relative to doctoral
school psychologists (17%; Goforth et al., 2021).
According to the NASP (2020), school psychologists part-
ner with families, educators, and community stakeholders to
create safe, healthy, and supportive learning environments.
They possess expertise in assessment, psychopathology,
diagnosis, and special education law as well as competen-
cies in 10 domains: (a) data-based decision-making, (b)
consultation and collaboration, (c) academic interventions
and instructional supports, (d) mental and behavioral health
services and interventions, (e) schoolwide practices to pro-
mote learning, (f) services to promote safe and supportive
schools, (g) family, school, and community collaboration,
(h) equitable practices for diverse students, (i) research and
evidence-based practice, and (j) legal, ethical, and profes-
sional practice. The 2019 student-to-school psychologist
ratio was 1382:1, nearly triple the recommended 500:1 ratio
(NASP, 2020). The reasons for severe shortages of school
psychologists are multifaceted and include a shortage of fac-
ulty and financial resources requiring creative solutions for
addressing workforce needs (Bocanegra et al., 2022).
School Social Workers
School social workers coordinate the efforts of schools,
families, and communities to help students. Most states
require school social workers to have a master’s degree in
social work (MSW), although some only require a bachelor’s
(BSW). The generalized Licensed Clinical Social Worker
(LCSW) credential requires an MSW, supervised train-
ing experience, a passing score on a licensure exam, and
completion of continuing education. Although no specific
requirements differentiate a school social worker from other
social workers, the National Association of Social Workers
13
(NASW, 2012) recommends an MSW degree as the entry-
level qualification and encourages school social workers
to seek specialized knowledge of education systems and
approaches to teaching and learning. Nationally, the Coun-
cil on Social Work Education (CSWE) accredits approved
social work training programs, and NASW offers the Certi-
fied School Social Work Specialist (C-SSWS) credential to
qualified school social workers.
According to the NASW (2012), school social workers:
provide schoolwide, small group, and individualized inter-
ventions; implement prevention efforts; and foster school
environments that are safe, fair, and emphasize early inter-
vention and positive behavioral supports. In addition, school
social workers provide crisis intervention and consultation
as well as participate in the special education assessment
process. The 2019 student-to-school social worker ratio was
2106:1 (Whitaker et al., 2019), eight times the recommenda-
tion of 250:1 (NASW, 2012).
Current Study
To address challenges promoting student mental health,
schools must leverage the skills of their current workforce—
whose mental health training is often underutilized (Schaffer
et al., 2021)—in a coordinated and efficient manner. The
present study seeks to facilitate the successful implemen-
tation of comprehensive SMH systems by describing the
relevant knowledge and skills of existing staff as well as
potential untapped resources (e.g., staff expertise and time)
that could be dedicated to SMH service provision (Dam-
schroder et al., 2009). Through a better understanding of
how the professional competencies of school staff, trained in
mental health service delivery, align with the skills needed
to implement comprehensive models of SMH services and
how school staff currently spend their time and provide these
services, schools will be better equipped to plan and execute
effective SMH services by identifying implementation lead-
ers, appropriately allocating resources and expertise, and
aligning roles and responsibilities in an integrated approach.
Specifically, we examined two questions. First, how do the
competencies needed to implement the core features of com-
prehensive SMH services align with the training standards
for the following professions: school counseling, school psy-
chology, school social work and school nursing? To answer
this question, we engaged faculty trainers to crosswalk train-
ing standards against a best practice framework for imple-
menting comprehensive SMH services (Hoover et al., 2019;
NCSMH & MHTTC, 2019). Second, how do SMH profes-
sionals currently employed by schools use their time and
training? To answer this question, we conducted a systematic
literature search examining time use among SMH staff.
School Mental Health (2023) 15:1–18 7
Research Question 1: Crosswalk of SMH
Frameworks with SMH Professional Training
Methods
The core clinical competencies needed to implement the
key features of comprehensive SMH systems were identi-
fied based on two widely used frameworks (Hoover et al.,
2019; NCSMH & MHTTC, 2019) and summarized into
eight domains (see Table 1). Next, we conducted a cross-
walk of these competencies with the standards of practice
for each of the SMH professions. Standards of practice
were identified using the professional and ethical standards
of national organizations (ASCA, 2019; ANA & NASN,
2017; NASP, 2020; NASW, 2012, n.d.). Two research-
ers independently coded each profession to determine
whether each competency was reflected in the standards.
To promote accuracy in our findings and interpretations,
at least one coder for each SMH profession was currently
employed as university faculty in the respective field. Ini-
tial inter-rater reliability (IRR) was established for the
crosswalk (overall IRR = 89%; counseling = 73%; nurs-
ing = 86%; psychology = 100%; and social work = 95%).
Discrepancies in coding were discussed until consensus
was reached.
Results
Results from the crosswalk are presented in Table 1. Find-
ings suggest that each of the four professions shares many
of the clinical competencies needed to implement the key
features of comprehensive SMH systems. Overall, the
standards of each profession reflected 73% (school coun-
selors) to 100% (school psychologists and school social
workers) of the SMH competencies. Results suggest that
100% of the professions included in the review are trained
in each of the competencies associated five of the eight
key features of comprehensive SMH systems: (a) fam-
ily–school–community collaboration, (b) needs assess-
ment/resource mapping, (c) evidence-based practice, (d)
data use, and (e) cultural responsiveness/equity. While
there were discrepancies in training across the remain-
ing three domains, each profession also shares specific
competencies in mental health counseling and education,
staff professional development, SMH partnerships, as well
as Tier 1 and Tier 2 mental health services and supports.
Differences also emerged across the professional train-
ing standards for school counselors, nurses, psycholo-
gists, and social workers. For example, school psychology
and school social work standards included competencies
related to the provision of mental health therapy (i.e.,
longer-term mental health interventions for students with
more severe and/or persistent needs), whereas school
counseling and school nurse standards emphasized train-
ing in short-term, targeted, and/or crisis counseling (i.e.,
brief, problem-focused interventions). In addition, school
psychology and school social work standards included
training standards on the systematic screening for mental
health. Finally, standards for school nursing, psychology,
and social work included training on assessing and iden-
tifying mental health disabilities, facilitating the imple-
mentation of a tiered support system, and providing mental
health services for students identified within Tier 3 (i.e.,
those with indicated mental health needs). In contrast, the
school counseling standards discussed restricted use of
assessment and tiered support principles (i.e., only within
the context of school counseling programs) and empha-
sized making referrals to other school- and community-
based providers for students with long-term mental health
needs.
Research Question 2: Systematic Review
of SMH Professionals’ Time Use and Regular
Duties
Methods
A literature search was conducted on March 29, 2021, to
identify research studies which described how the profes-
sions included in this study used their time in school. To
identify these studies, authors used search terms used the
following search terms and Boolean operators: SU (“school
psycholog*” OR “school counsel*” OR “student coun-
sel*” OR “school social work*” OR “school nurs*”) AND
SU (“workload” OR “caseload” OR “responsibilit*” OR
“time” OR “duties” OR “job characteristics” OR “role*”)
(SU = subject or keyword; *designates allowance of alterna-
tive word endings within search results). Due to the chang-
ing standards of the SMH professions, the search range was
restricted to the earliest year that current standards were
published (NASW, 2012). We used EBSCO to search for
refereed articles published in English between 2012 and
2021 (March) within the following databases: ERIC, APA
PsycINFO, Academic Search Alumni Edition, Educa-
tion Research Complete, and Academic Search Complete.
Additionally, Google Scholar was scanned to identify missed
articles.
Studies were included if they: (a) were published in an
English-language, peer-reviewed journal between 2012
and 2021 (March); (b) were empirical studies; (c) reported
quantitative data about SMH professionals’ time allocation
and/or mental health responsibilities; and (d) reported on
the activities of school counselors, nurses, psychologists,
13
8 School Mental Health (2023) 15:1–18
and/or social workers in US public schools. The following
types of research were considered beyond the scope of this
review and were therefore excluded: (a) investigations of
time allocation and roles with respect to specific populations
or activities (e.g., role within response-to-intervention sys-
tems); (b) participant samples comprised of SMH trainees;
and (c) studies that did not allow for meaningful compari-
sons of time allocation (i.e., time was not operationalized as
hours or percentages).
Identified articles were screened according to Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines (Page et al., 2021). Records retrieved
from the database searches were imported into Endnote and
de-duplicated. Screening and eligibility assessment were
conducted in an un-blinded manner by authors. The titles
and abstracts were screened to exclude any studies that obvi-
ously violate the above criteria. Any studies that potentially
met the inclusion criteria were retrieved and the full text
assessed for inclusion. For each study included in the synthe-
sis, data were collected regarding the study characteristics
(e.g., year published and type of publication), methodology
(e.g., sample size and demographics), and outcomes (e.g.,
time allocation across general activities, specific mental
health responsibilities, and barriers/facilitators to imple-
menting mental health services). Two researchers indepen-
dently reviewed each study and coded information according
to the procedures recommended by Wilson (2009). Initial
inter-rater reliability (IRR) was established for each subsec-
tion of the coding document (overall IRR = 92%; study char-
acteristics = 97%; methods = 88%; time outcomes = 98%;
mental health duty outcomes = 88%, and facilitator/barrier
outcomes = 92%). Discrepancies in coding were resolved by
consensus.
Data Synthesis
Results were organized by profession and outcome (i.e.,
time, SMH duties, and SMH facilitators/barriers outcomes).
When studies disaggregated time results (e.g., reported by
geographic area), the average (for numerical percentages/
hours) or mode (for categorical outcomes) was used. When
studies reported time categorically (e.g., 0–5% or 5–10%),
an average time was computed and assigned (e.g., 0–5% was
transformed to 2.5%).
Time outcomes were organized in six domains: (a) inter-
vention (e.g., direct prevention and intervention); (b) con-
sultation (e.g., indirect consultation and support); (c) assess-
ment (e.g., evaluation to inform service planning); (d) family
(e.g., parent support); (e) related coordination and profes-
sional enhancement (e.g., service coordination and student-
focused meetings); and (f) miscellaneous: paperwork/docu-
mentation (e.g., report writing) and unrelated activities (e.g.,
statewide testing, committee work not related to students,
13
and bus/cafeteria duty). Time results were then summed by
domain, and a percentage with respect to total time reported
was calculated (e.g., if total percentages exceeded 100%,
time was calculated as a percentage of the total).
Results
Study Selection
The EBSCO search identified 1208 articles (see Fig. 1 for
the PRISMA flow diagram). An additional article was identi-
fied through a Google Scholar search. After duplicates were
removed, 975 records were screened to determine eligibility,
resulting in the exclusion of 916 articles. The full texts of
each of the remaining articles (n = 59) were then retrieved
and assessed for eligibility. Of these, 50 were excluded for
the following reasons: (a) did not include quantitative data
describing the general time allocation and/or specific mental
health responsibilities of SMH professionals (n = 23); (b)
were not empirical (n = 16); (c) did not allow for meaningful
comparisons in time allocation (n = 5; e.g., utilized Likert-
type scales with descriptions of time allocation, such as
“I occasionally do this” or “I frequently do this,” and did
not operationalize time as hours or percentages; see, Waal-
kes et al., 2019); (d) only reported qualitative data (n = 3);
and (e) participants were outside of the USA (n = 1) or (f)
were SMH trainees (n = 1). An additional article was later
excluded, as it used the same data as an included study (Mau
et al., 2016). In total, nine articles were included in the final
synthesis: six reported on time allocation and three reported
on specific mental health responsibilities. Across selected
studies, the majority of participants were female (M = 88%
across studies, range = 79–100%) and White (M = 86%
across studies, range = 67–95%).
Time Outcomes
Of the six studies that reported time outcomes, two reported
on school counselors, one reported on school nurses, two
reported on school psychologists, and one reported on school
social workers. Studies used various methods to study time
allocation (e.g., how time was measured and the inclusion,
grouping, and operationalization of various activities), and
time outcomes were categorized according to the domain
that best represented the activities (see Table S1 for the full
delineation of study outcomes into time categories). For
example, Kelly and Whitmore’s (2019) Indirect Services
outcome was categorized within the consultation domain but
included aspects of both consultation and coordination, and
Bahr et al. (2017) Tier 1, 2, and 3 outcomes were categorized
within the intervention domain but included aspects of both
intervention and assessment. In addition, the degree to which
specific domains were represented varied across studies, and
School Mental Health (2023) 15:1–18 9
Fig. 1  Flow diagram of systematic review
some domains were not represented at all. For example, two
studies (Albritton et al., 2019; Willgerodt et al., 2018) did
not include any activities that might fall in the miscellane-
ous category. Similarly, only studies that reported on school
psychologists included assessment activities as individual
categories (excluding statewide testing for counselors). For
example, Kelly and Whitmore (2019) included compliance
assessment activities within their Documentation outcome,
but this outcome was categorized within the miscellaneous:
paperwork/documentation” domain, because it is described
predominantly as writing reports and documenting activi-
ties. Similarly, Neyland-Brown et al. (2019) include needs
assessment, evaluation of student progress, and documenta-
tion activities within their coordination activities outcome,
but this outcome was categorized here within the related
coordination/professional enhancement domain, because it
primarily refers to program coordination and professional
development. In addition, school nurses may have included
screening activities when responding to the direct care out-
come reported by Willgerodt et al. (2018), but this outcome
was categorized here under “intervention.” These methodo-
logical discrepancies should be considered when interpret-
ing the results.
Results suggested variability across professions in the
time spent providing services related to student men-
tal health (see Fig.  2). Findings suggested that school
counselors, school nurses, and school social workers spend
more time implementing interventions (e.g., direct ser-
vices), while school psychologists spend more time con-
ducting assessments (e.g., screening and individual evalu-
ations) and providing consultation (e.g., problem-solving
and data teams). Notably, of the studies that collected
information on miscellaneous activities (n = 4), each SMH
profession spent a significant amount of time (22–41%)
engaged in documentation and paperwork activities as well
as activities unrelated to their field.
With respect to specific activities, Table 2 ranks the
time allocation of SMH professionals according to the
activities they spend the most and the least time conduct-
ing. The top activity for each profession directly related
to supporting student wellbeing. However, miscellaneous
tasks ranked in the top three activities for each of the four
studies that included such outcomes. These results show
that school counselors spend a considerable amount of
their time conducting non-counseling duties (e.g., sched-
uling courses and coordinating schoolwide testing; Mau
et al., 2016; Neyland–Brown et al., 2019); school psychol-
ogists spend a large portion of time writing assessment
reports and completing paperwork (Bahr et al., 2017); and
school social workers spend much of their time on docu-
mentation (e.g., documenting services and writing reports;
13

10
Fig. 2  Time allocation of SMH professionals. Note. SC school coun-
selors. SN school nurses. SP school psychologists. SSW school social
workers. Due to variability in the inclusion and operationalization
of time outcomes across studies, synthesized time allocation results
Kelly & Whitmore, 2019). The only study that reported
on school nurses did not include miscellaneous activities.
Most studies did not differentiate activities that support
student mental health from activities that support student
achievement, physical health, or general success (i.e., Kelly
& Whitmore, 2019; Willgerodt et al., 2018). Among stud-
ies that provided some differentiation regarding the focus
of activities (e.g., academic versus career development),
findings suggested that professionals tend to spend a lim-
ited time addressing mental health needs. Mau et al. (2016),
for example, found that high school counselors spent about
50% of their time providing direct intervention to students,
but only a quarter of direct intervention time focused on
personal or school problems—the majority of interventions
focused on college, career, and academic development. Sim-
ilarly, most of the service-related activities reported by Bahr
et al. (2017) and Albritton et al. (2019) did not differentiate
between mental health and other supports; however, activi-
ties that clearly reflected mental health supports represented
about 14% (Albritton et al., 2019) to 17% by (Bahr et al.,
2017) of school psychologists’ total time. Neyland-Brown
et al. (2019) asked their participants to indicate separately,
with respect to all activities, the percentage of time spent
addressing student mental health. Their results indicated that
13
School Mental Health (2023) 15:1–18
should be considered in context. The delineation of how individual
study time outcomes were organized can be found in the Supplemen-
tal Materials.*Study did not measure activities in the miscellaneous
category
about 36% of school counselors’ time was spent supporting
mental health.
Two studies included in the time outcomes synthesis
also asked participants to rank their preferred activities in
addition to their actual activities. Both studies concluded
SMH professionals would prefer to be engaged in more
mental health services than they currently are conducting.
Bahr et al. (2017) noted that some of the greatest discrepan-
cies were for “mental health interventions (#2 preferred, #9
actual), counseling (#5 preferred, #17 actual), and positive
behavior interventions and supports (PBIS: #10 preferred,
#18 actual). By comparison, “paperwork (#3 actual, #25
preferred) and report writing activities (#2 actual, #21 pre-
ferred) were not strongly preferred yet consumed consider-
able work time” (p. 586). Similarly, Neyland-Brown et al.
(2019) found a significant discrepancy between the actual
and preferred activities of school counselors; they concluded
that “school counselors feel that they are not being used to
address the mental health needs of their student population”
(p. 12). Specifically, school counselors want to spend less
time engaged in non-counseling duties (e.g., bus duty and
class scheduling) and more time providing mental health
services, such as group interventions.
School Mental Health (2023) 15:1–18 11

Table 2  Rankings for time spent conducting specific activities: three highest and three lowest activities
Study  ← Highest Lowest → 
Three highest ranked activities Three lowest ranked activities

School counselors
Mau et al. (2016) College readiness/ High school Personal/aca- Other counseling Job placement/job Non-counseling
selection/appli- course choice/ demic/career activities skill develop- activities
cation scheduling development ment
Neyland–Brown Counseling Other (e.g., test – – Curriculum Coordination
et al. (2019) coordination,
committees)
School nurses
Willgerodt et al. Direct Care Case management – – Administrative/ Professional devel-
(2018)a teacher support opment
School psychologists
Albritton et al. Individual evalua- Consultation (indi- Family Engage- Consultation Assessment of Screening/Progress
(2019)a tions (SpEd) vidual students) ment (schoolwide classroom qual- monitoring
programs) ity
Bahr et al. (2017) Problem-solving Report writing Miscellaneous Tier 2: Progress Research Programmatic
consultation paperwork/ monitoring/ interventions
recordkeeping intervention
School social workers
Kelly and Whit- Direct service Indirect services Documentation School Wide Supervision/Men- Crisis/Non-Case-
more (2019) Prevention toring load

For studies that only reported on five activities, the top and bottom two activities were included in this table. Miscellaneous activities are itali-
cized. SpEd = special education
a
 Study did not collect information regarding time spent conducting miscellaneous activities (e.g., paperwork, test coordination, committees, and
other non-specialized duties)

Primary Mental Health Responsibilities of SMH
professionals
Three additional studies provided insight into the specific
mental health responsibilities of three of the four SMH pro-
fessions (no studies of school social workers were identi-
fied). Most and least frequented responsibilities are sum-
marized in Table 3. Nearly all school counselors reported
providing crisis counseling, coordinating with parents to
support students’ mental health, and making referrals to
outside mental health providers; and more than half pro-
vided mental health counseling and classroom program-
ming. School counselors were least likely to use assessments
to monitor and promote students’ mental health (Fan et al.,
2019). Eklund et al. (2020) found that, on average, school
psychologists spend more time providing universal mental
health supports (5–9 h per week) versus targeted services
(1–4 h per week). While nearly three-quarters of school psy-
chologists reported providing mental health consultation,
only a third reported providing direct mental health services.
Finally, school nurses were observed to most frequently
engage in indirect and medication-related mental health
services; the provision of direct mental health services and
assessment were ranked lowest (Bohnenkamp et al., 2015).
The studies reviewed also provided some insight into
the barriers and facilitators for engaging in responsibilities
associated with SMH care. School nurses reported a lack of
training, tools, methods for obtaining consent, and follow-
up resources as the top barriers to conducting mental health
screenings (Bohnenkamp et al., 2015). Eklund et al. (2020)
reported on factors that may facilitate the provision of men-
tal health services among school psychologists. Adminis-
trator support and improved school psychologist-to-student
ratios were ranked highest, followed by more training and
collaboration among other SMH professionals.
Discussion
As mental health needs of students in K-12 schools
increase, particularly since the COVID-19 pandemic
began, it is critical that schools leverage the training of
their current workforce to provide SMH services in a
coordinated and efficient manner. This review aimed to
help schools facilitate the successful implementation of
comprehensive SMH systems by describing the relevant
knowledge and skills of existing staff as well as exist-
ing resources (e.g., staff time) that could be reallocated
to SMH service provision (Damschroder et  al., 2009).

13

12

13
Table 3  Rankings of specific mental health duties performed by SMH professionals
Profession/Study/  ← Highest Lowest → 
Duty type

School counselors
 Fan et al. (2019)
 General practices Crisis counseling Coordinate with Refer to outside MH One-on-one MH Classroom-based pre- Group MH counseling Psychological assess-
(93.2%) parents to support providers (92.2%) counseling (87.4%) ventions programs (60.7%) ments to promote MH
student MH/ devel- to support MH (31.6%)
opment (93.1%) (72.5%)
School nurses
 Bohnenkamp et al. (2015)
 Screening practices Do not conduct MH Screen for Anxiety Screen for Depres- Screen for Suicide (3) Screen for Behavioral Screen for Substance/ Screen for ADHD
screenings (1) (2) sion (3) Issues (4) Alcohol Abuse (5) (6), Trauma (7), or
Psychosis (8)
 Service practices Communicate with Refer to other SMH Administer (3)/Moni- Refer to community MH consultation (7); MH education (9); Other (12); Substance
parents about MH professionals (2) tor (4) medication MH professionals Brief (1–2 sessions) MH assessment abuse (13)/Extended
(1) (5); Crisis response MH counseling (8) (10); Cognitive- (14) counseling
teams (6) Behavioral interven-
tion (11)
School psychologists
 Eklund et al. (2020)
 General practices Consultation related Crisis intervention Individual counseling Schoolwide preven- Suicide or threat Group counseling Classroom‐wide inter-
to MH (72.1%) (33%) (32%) tion programming assessment (23%) (20%); Universal ventions (7%); Other
(31%) MH screening (6%)
(12%)

MH mental health. Fan et al. (2019) and Eklund et al. (2020) reported the percentage of participants who engaged in each activity. Bohnenkamp et al. (2015) reported the response frequency
rank order for each activity
School Mental Health (2023) 15:1–18
School Mental Health (2023) 15:1–18 13
Results suggest that school counselors, school nurses,
school psychologists, and school social workers share
many of the clinical competencies needed to implement
the key features of comprehensive SMH systems. Each
discipline’s professional standards emphasized common
themes related to evidence-based practice, data use, and
consultation skills, which are necessary for effective men-
tal health service provision (Hoover et al., 2019; NCSMH
& MHTTC, 2019). Unfortunately, it appears that these
skills are un- and under-utilized. In particular, school
counselors, psychologists, social workers, and nurses are
now graduating with professional degrees that emphasize
assessment and intervention services in response to youth
mental health needs. However, our review of time alloca-
tion studies suggests that most of these professionals spend
time in non-mental health related duties (e.g., completing
paperwork or engaging in duties unrelated to their clinical
expertise, as reflected in a large portion of time classified
as “miscellaneous”). This means that, while these profes-
sionals are likely to have the skills necessary to respond
to the mental health needs of students, schools are not
routinely drawing on the specialized mental health knowl-
edge staff possess.
These results are a reason for concern but also opti-
mism. Findings suggest that schools can respond to calls
for increased access to school-based mental health services
for students (see, e.g., UNICEF, 2021; U.S. ED, 2021) by
(a) clarifying and coordinating the roles of distinct SMH
professionals and (b) shifting less specialized tasks away
from SMH professionals to use the breadth and depth of
their mental health training—a move that would align with
widespread calls across professions (DeKruyf et al., 2013;
Splett et al., 2013). For schools with limited access to SMH
providers, results point to two promising considerations
for redeploying SMH staff in ways that effectively and effi-
ciently support student success. First, the results suggest that
a variety of SMH professionals are likely to have the profes-
sional expertise enabling them to support the delivery of
SMH services. Second, current SMH professionals may be
assigned duties that do fully leverage their expertise (e.g.,
administrative of case management duties). Thus, if these
types of tasks were shifted to other staff, current provid-
ers may be able to engage in a wider range of SMH activi-
ties. We conclude that there may be untapped opportunities
for collaboration and coordination across disciplines given
shared expertise in many of the core functions associated
with SMH services. Finally, schools may also consider
leveraging community mental health providers to expand
capacity of school teams to address youth mental health
teams. Although community mental health providers were
not included in this review, the use of community-based
mental health providers in school settings can be an effec-
tive way to expand capacity especially when resources are
devoted to coordinating care across community and school
settings and allow opportunities for community and school
staff to collaborate on student mental health needs (Splett
et al., 2017; Weist et al., 2006). These recommendations
are consistent with integrated models of mental health care
wherein providers from various professional backgrounds
and settings proactively collaborate with each other to ensure
efficient and equitable provision of mental health services
(Eber et al., 2019; Splett et al., 2017).
Professional Training: Common Themes
and Unique Perspectives
As schools struggle to hire qualified SMH professionals
due to national shortages of providers (Whitaker et al.,
2019), the crosswalk of professional training standards
against SMH competencies revealed both common themes
and unique disciplinary perspectives. As school leadership
consider strategies to deploy SMH staff, understanding
these perspectives may be useful for determining how to
staff SMH services. Importantly, results do not provide
insight into an “ideal” ratio or staffing model; instead,
we summarize professional training and alignment with
a comprehensive SMH framework to allow school leaders
to make informed staffing decisions. By delineating the
unique competencies and their overlap with key features of
comprehensive SMH systems, we hope to increase efficient
use of existing SMH professionals and maximize benefits
to students.
Training standards for all the SMH professionals
included in this review emphasized many of the core
competencies needed to implement comprehensive SMH
services (Hoover et al., 2019). Unfortunately, these profes-
sionals also frequently report being assigned job respon-
sibilities that are not aligned with their core set of compe-
tencies—for example, many professionals report spending
a large amount of time on administrative duties (e.g.,
paperwork and scheduling; Bahr et al., 2017; Mau et al.,
2016) that do not directly relate to SMH. Thus, school
leaders may be able to capitalize on elements of training
shared across professionals when considering how to best
implement comprehensive SMH services. For example,
collaborating with families and community partners is a
shared training competency jointly identified across the
professions (ASCA, 2019; ANA & NASN, 2017; NASP,
2020; NASW, 2012). Therefore, depending on availabil-
ity of specific staff in a particular school (or school dis-
trict), leaders may leverage the expertise of counselors,
psychologists, nurses, or social workers when implement-
ing structures to collaborate with families and commu-
nity organizations in support of student mental health.
Similarly, each profession shares competencies in mental
13

14
health counseling; thus, schools facing staff shortages can
utilize the skills of diverse SMH professionals to meet the
increasing mental health needs of youth, particularly post-
COVID (Mojtabai & Olfson, 2020; Racine et al., 2021).
Results also provided insight into additional factors that
school leaders and SMH professionals should consider
when allocating tasks. First, it is important to consider that
different professions may possess distinct skills in certain
domains. For example, with respect to the provision of
Tier 2 mental health services, school counseling standards
emphasize competencies in counseling to address student
needs and promote social-emotional development (ASCA,
2019), whereas school nursing standards emphasize the
provision of responsive counseling and intervention in
areas such as teen pregnancy, death of family members,
and substance abuse. Similarly, at Tier 3, school psychol-
ogy and school social work standards reflect individualized
and long-term mental health counseling and consultation,
whereas school nursing standards reflect medication treat-
ments and health consultation for complex cases. Finally,
the standards of only two professions—school psychology
and school social work—reflected competencies related to
universal mental health screening and mental health ther-
apy, which are critical to effective SMH systems (Dowdy
et al., 2014; Kern et al., 2017). Thus, school leaders should
consider the scope of skills when making hiring decisions
and assigning tasks. Whenever possible, schools should
coordinate the unique expertise of specific professionals
to efficiently meet the mental health needs of students.
Similarly, the degree to which professional standards
reflected each competency varied across fields. For exam-
ple, MTSS is specifically described within the professional
standards of school psychologists and school social work-
ers, whereas school nursing standards refer more generally
to components of a public health approach that promotes
a continuum of services. Although the school counseling
standards discuss using principles of MTSS, the national
school counseling association, ASCA (n.d.-a), specifically
identifies the coordination of a schoolwide MTSS approach
as an inappropriate activity for school counselors. Similarly,
the degree to which individual SMH providers’ competen-
cies align with those reflected in their fields’ professional
standards may vary—providers may possess competencies
not reflected in their standards or vice versa. For example,
identification of mental health disabilities was reflected in
the competencies required to become a C-SSWS; however,
not all individuals employed as social workers in schools
have this certification (Kelly et al., 2015). Similar discrep-
ancies may exist between the standards of professional
organizations and individual professionals’ adherence to
those standards. For instance, while ASCA (2019) discour-
ages school counselors from providing long-term mental
health therapy, some have argued that school counselors are
13
School Mental Health (2023) 15:1–18
well-suited to provide these services (Lambie et al., 2019).
Thus, the crosswalk is meant to provide general guidance
regarding SMH competencies across professions, but it may
not accurately represent the breadth and depth of SMH train-
ing of any particular provider.
Finally, although the competencies identified in this
study were determined using the standards of leading pro-
fessional organizations, this does not ensure that prospec-
tive SMH providers have been trained using these models.
Due to variations across states in professional requirements
and the changes in training requirements over time, current
and prospective hires may have diverse qualifications. Thus,
schools should consider the national certifications held by
SMH professionals, the accreditation status of their training
programs, and their previous experiences when determining
the competencies of current and prospective hires.
Task Shifting: Maximizing the Time of School
Mental Health Staff
Results from this study also suggest that there may be an
opportunity to shift the prioritization of tasks for SMH pro-
fessionals to maximize opportunities for SMH staff to prac-
tice in ways most consistent with their professional train-
ing. For example, school counselor responsibilities related
to non-counseling duties (e.g., test coordination; Wilder,
2018) may be shifted toward supporting student mental
health (DeKruyf et al., 2013). Similarly, school psycholo-
gist duties may be able to be shifted away from an emphasis
on special education eligibility and toward an emphasis on
prevention and the provision of SMH services (Dowdy et al.,
2014; Splett et al., 2013). This task shifting model may be
one way to address concerns that SMH staff express about
a lack of time to address student mental health (Hanchon &
Fernald, 2013).
Strategies for task shifting include both (a) re-allocating
current tasks away from SMH professionals to other indi-
viduals with less extensive qualifications and (b) aligning
the roles of SMH professionals to promote an integrated
approach. Most evidently, miscellaneous tasks (e.g., sched-
uling, test coordination, and record keeping) may be able
to be reassigned to other school professionals or support
can be provided to reduce the demands of the tasks (e.g.,
personnel support or streamlining procedures). Also, some
have suggested that SMH professionals may use their train-
ing in mental health to support or supervise other school
staff (e.g., teachers or paraprofessionals) who could provide
direct intervention supports which focus on either mental
health promotion (Tier 1) or manualized curriculums tar-
geting academic or life skills (Tier 2; Eber et al., 2019).
Finally, the mental health services provided by distinct SMH
professionals, which have traditionally been siloed, may be
School Mental Health (2023) 15:1–18 15
integrated into a single system of delivery. In this integrated
system of tiered supports, multidisciplinary SMH teams col-
lectively select and monitor all interventions, regardless of
who implements it, and clearly delineate roles and respon-
sibilities to prevent overlap (Eber et al., 2019).
Task shifting, however, does require schools to carefully
consider practical, ethical, and legal implications of shifting
staff duties (Eber et al., 2019; McQuillin et al., 2019). Practi-
cally, this approach requires organizational shifts and role
changes for staff (e.g., reallocation of tasks, shifting the role
of all educators to include prevention-based mental health
supports, and integrating the separate responsibilities of
SMH providers into a single, team-based model), which may
be met with resistance and necessitates iterative evaluation
of how these changes impact other school services, as well
as staff wellbeing and workload. Ethically, when planning
to task-shift, it is critical that the personnel who assume new
responsibilities are provided adequate training, supervision,
and oversight to ensure services are provided in a competent
and transparent manner. Legally, clear policies and proce-
dures need to be implemented to protect student privacy and
confidentiality in a manner that does not impede effective
service delivery within an integrated system. In addition,
schools need to make certain that they are complying with
state laws related to organizational staffing requirements.
Limitations and Future Directions
There were important limitations within the current study.
For the crosswalk, we relied on the key components of com-
prehensive SMH systems outlined in Hoover et al. (2019)
and NCSMH and MHTTC (2019) to determine the SMH
professional competencies. These documents may not reflect
all the competencies needed by SMH professionals; how-
ever, we attempted to reduce potential bias by using guid-
ance developed by multidisciplinary teams of experts and
leading national organizations. In addition, we relied on the
standards of leading national organizations, which may not
reflect the competencies and mandates of all individuals
within each respective profession. Future research may con-
sider investigating the perceived competencies of individual
providers to determine alignment with the core components
of SMH systems. Finally, we restricted our crosswalk to four
school-based mental health professions; however, there are
a variety of other professionals who support the emotional
and behavioral health of students (e.g., behavior analysists)
and/or collaborate on expanded SMH teams (e.g., commu-
nity clinicians). We chose to focus on school counselors,
nurses, psychologists, and social workers because these
professionals are often specifically trained and certified to
deliver mental health services to students in schools, and
they are frequently identified in SMH policy and literature
(see, e.g., Cowan et al., 2013; ESSA, 2015; Whitaker et al.,
2019). Still, results should not be considered an exhaustive
review of the competencies of all professionals who may
provide SMH services.
Limitations were also present in the systematic review.
First, the variety of methods used to measure time alloca-
tion did not allow for a perfect comparison of time alloca-
tion. To allow for comparisons across studies, we assigned
numerical percentages to each activity based on the central
tendency of categorized times with respect to the sum of all
activities. Although this method provides insight into time
allocation and promotes interpretability, it is not exact. In
addition, most studies utilized reflective measures of time
allocation (e.g., estimates), which may increase measure-
ment error. Finally, some of the time outcomes included
activities that reflected more than one domain (as defined in
the synthesis), and the activities measured within the studies
reflected the domains to varying degrees—sometimes not at
all. When certain activities were not reflected in a study’s
time outcomes, participants may have disregarded them
when responding or may have included them within other
categories. To better understand time allocation and how it
differs across professions, future research should consider
including all SMH providers in the same participant sample
and use appropriate time study methods.
Conclusions
Results suggest that school counselors, nurses, psycholo-
gists, and social workers share many of competencies needed
to implement comprehensive SMH systems, but that and the
breadth and depth of their unique and specialized skillsets
in mental health are often underutilized. Thus, opportuni-
ties exist for schools to leverage their current workforce to
increase access to SMH services and effectively meet the ris-
ing mental health needs of students. Specifically, there may
be a variety of ways in which schools can staff SMH pro-
grams given the common and unique competencies across
disciplines; schools should clarify and align the responsibili-
ties of distinct SMH professions to ensure comprehensive,
efficient, and effective service provision. For example, all
professions share competencies in mental health counseling;
however, schools could coordinate the unique expertise of
distinct professions by having school nurses respond to
situational stressors, assigning school counselors short-
term counseling cases, and delegating universal screening
and long-term therapy to school psychologists and social
workers. Finally, SMH professions spend a considerable
amount of their time on activities that may not require their
expertise. Thus, opportunities exist for schools to shift those
tasks to staff with less extensive qualifications to maximize
13

16
opportunities for SMH professionals to engage in tasks
that prioritize and leverage their mental health training.
By understanding how the clinical competencies of SMH
professionals align with the key features of comprehensive
SMH systems and how these staff are currently utilized,
schools can efficiently plan and execute effective mental
health services.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 12310-0​ 22-0​ 9535-0.
Declarations  nated school mental health care. Psychology in the Schools, 52(7),
Conflict of interest  We have no conflicts of interest to disclose.
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