School Psychiatry: Charting the

landscape of school-based

mental-health interventions.

Ramkumar G S

Psychiatry Specialist

Carithas Hospital, Kottayam.

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Outline.

• Outlining what is already happening in the

school-setting around us.

• Review-series published this month in

Lancet-Psychiatry on school based mental

health interventions and other literature.

• Critical focus on some local interventions.

• Summarising discussion points.

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Dr Mina Fazel,

Department of

Psychiatry, University

of Oxford

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• Outlining what is already happening in the

school-setting around us.

• Review-series published this month in

Lancet-Psychiatry on school based mental

health interventions and other literature.

• Critically overview of local interventions.

• Summarising discussion points.

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DMHP. The “Thalir’ program from

TVPM.

Other prog. with mental health

components….LEAP, Dial A doctor

Health sector

Life skills education module by state

education board (SCERT).

“Ullasaparavakal”

‘Souhrida club' project of higher

secondary education dept.

Sarva Shiksha Abhayan (SSA) for

primary education and (IEDC) for

integrated education of disabled

children.

Special schools.

Education sector

“Clean Campus, Safe Campus” …by

Home ministry ..

NGOs

Private agencies

Buds schools -Kudumbashree

Other sectors

Psycho social service program for

adolescent girls……by SJD (Social

justice)

DEICs –District early intervention

centres

Social sector

The ecology of mental health services in School context

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Lancet-Psychiatry review “Back to school”

Oct 2014.

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Background.

• The number of school-aged children and youngpeople experiencing mental health problems hasbeen estimated at between 8 to 18%.

• Series examines the unique role that schoolscan play in delivering treatment for mental healthproblems to children, as well as universal mentalhealth promotion.

• Both ethical and scientific justification for suchintegration

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Challenges

• The risks of over diagnosis when universal

interventions are offered.

• Insufficient uptake of services if students

perceive that they might be stigmatised or

bullied or the services might not be of help.

• Professionals delivering new care

stategies might not ‘buy-in’ to them either.

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Review 1 on High-Income

Countries.• Epidemiology- Point prevalence 8-18% disorders

• Disruptive behaviors and anxiety disorders.

• Primary school (4-10)….separation anxiety and ODD

• Secondary school (11-18)...generalized anxiety, conduct disorder and depression

• ADHD and autism spectrum disorders…

• Eating disorders and psychosis increase from mid adolescence..

• 36% at least one disorder by 16yrs..

• 40% report bullying…

• Poor relationships between teachers and pupils

• Burn out among teachers….

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School Personnel

• Improved training and support of staff within schools is a coherent and practical model that seems feasible and sustainable from a resource perspective and in view of the expanding literature about the model’s effectiveness.

• Teachers are able to electively identify mental health problems in students, making them good gatekeepers and referral sources for mental health care

• Utilising the natural supports in schools such as special education staff and school nurses.

• School psychologists, counselors, community mental health teams…

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• However, because of the demands placed on teachersto support the academic success of their students,introduction of an additional role of supporting studentmental health is less feasible unless teachers are givensufficient training and time to do these responsibilities.

• Counsellors and social workers are more likely toprovide school-based mental health services than theirpsychology or psychiatry counterparts.

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Three Broad models of integration.

Lancet-review.

individuals from an outside agency are contracted to work within a school,

the school includes a mental health clinic staffed by professionals who deliver mental health services,

and the school has a health centre with mental health as a subspecialty

Parallel in our state.

Situation in private

schools?

DMHP/SJD -

“counseling rooms” in

school

Cotton Hill School, Tvpm

has in-house doctor, nurse

under NRHM support.

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Intervention Types.

• The IOM (Institute Of Medicine) framework differentiates between interventions that promote positive aspects of mental health and those that address prevention and treatment of mental disorders.

• Some interventions span mental health promotion, prevention, and treatment.

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School strategy

• A public health and tiered approach which balances intensity and type of school strategy … includes

universal strategies for all students,

followed by interventions to assist selected students who face particular risks,

and finally a tier with treatment interventions for those with the greatest needs

• The ultimate aim is to promote student wellbeing, prevent the development or worsening of mental health problems, and improve the effectiveness of education.

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Promotion

• In whole-school and classroom- based interventions,universal promotion programmes are often delivered bythe school’s own staff and are done in both primary andsecondary schools

“MindMatters” in Australia

“I Can Problem Solve” and “Good Behavior Game” inUSA

Positive Behavior Interventions and Supports (PBIS)offers a framework for multitiered interventions.

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“Mind Matters”

• Strategies to help students include

social and emotional learning programmes,

increasing students’ connection to school,

building student skills in understanding

and management of emotions,

effective communication,

and stress management.

• Teachers participate in various professionaldevelopment opportunities to support their learning inthese curricular domains

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Prevention

Three-tiered approach

• universal,

• selective,

• and indicated interventions.

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Universal Prevention.• Universal approaches have been studied for a broad

range of presentations,

including behavioural management,

risky behaviours,

and mood and anxiety disorders

• A wide range of universal interventions have been triedin schools in children of various age ranges, and withvarious therapists and therapeutic modalities such ascognitive behavioural approaches (CBT) and stressreduction techniques.

• Several systematic reviews of CBT- based interventionsin schools have been done with a main focus onprevention of anxiety disorders and depression

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“Beyondblue”

• One of the largest studies of universal interventions forprevention of depression was Beyondblue.

• This study showed that an Australian classroom CBT-based curriculum of 30 sessions delivered by teachersdid not reduce levels of depressive symptoms inadolescents.

• This result might emphasise the difficulties faced inattempts to implement large-scale school-baseduniversal interventions, with training of teachers in anew technique, and with engaging of adolescents inprevention programmes.

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Selective Prevention• Interventions to decrease substance misuse in adolescents who score

highly on certain personality measures, suggesting an increased risk of problems with substance misuse.

• The interventions promote

awareness of personality- associated cognitive distortions

and alternative coping strategies,

and ultimately reduce development of some problem behaviors.

• Prevention programmes are often delivered in classrooms or small groups—eg, the Coping Power Program for students at high risk of aggressive behaviours, drug misuse, and delinquency.

• An evidence base is also emerging for provision of school-based services to specific populations, such as young people from low-income urban regions and refugees.

• Evidence for selective school-based prevention and early intervention programmes is strong for specific behavioural difficulties, for students with risks (such as parental divorce), and for students with anxiety or depressive disorders

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African white…

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Indicated prevention

• Many studies have assessed indicated school-based programmes for anxiety or depression, deliberate self- harm, and post-traumatic stress disorder.

• Indicated programmes generally show stronger outcomes for depression and a greater reduction in symptoms of depression than universal or selective programmes

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Community based mental health treatment in

schools…• Consultation in mainstream schools by mental health specialists can assist

with case conceptualisation, differential diagnosis, or considerations for community care.

• Some schools employ or have links with community-based partners to provide on- site individual, family, and group treatment for students with identifi ed problems such as anxiety, depression, disruptive behaviour disorders, and traumatic stress.

• Intensive treatment often takes place during the school day, which can be more time effi cient for both students and parents.

• Increasingly, school-employed staff are enhancing their capacity to deliver specialised mental health treatment for students.

• A study of interpersonal therapy given in school-based health centres showed that the therapy eff ectively treated adolescent depression.

• Additional service developments in schools include treatment of serious emotional disturbances and reduction of the duration of untreated psychosis.

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Community based mental health treatment in

schools…

• Special educational schools or classrooms (for children with severe emotional and behavioural di ffi culties) are at one end of the range of mental health needs in schools and are found to variable extents in high-income countries.

• Such establishments might have a high proportion of children with both treated and untreated mental illness. Alignment of these schools or classrooms with community mental health services is often needed, but not universally available.

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Gaps in research and challenges in

implementation.

• research on fidelity of treatment…..

• embedded process assessments…

• cost effectiveness…

• Additionally, not all interventions done in schools have produced positive results and the potential for adverse effects from psychological interventions should be acknowledged and monitored.

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• Development of the scientific base is important

to avoid the typical trajectory of mental health

practices in schools, commonly characterised

by incomplete implementation, restricted

sustainability, and narrow spread.

• Poorly assessed interventions are often used in

schools, and when schools do use evidence-

based interventions, they are often

implemented with poor fidelity.

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• A common barrier to the implementation of evidence-based interventions in schools is poor engagement of all levels of school staff —ie, teachers, counsellors, and support staff .

• A challenge for both research and practice will be to test strategies to implement and sustain integrated whole-school, classroom-level, and individual-level interventions.

• The EPIS model (exploration, preparation, implementation, sustain- ability) identifies different implementation phases and aspects of the outer and inner context that are salient at different phases.

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• Service systems that support educational

and mental health promotion, prevention,

and treatment are administratively,

legislatively, and politically separate.

Health

sector

Education

sector

Others

Social

sector

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• Tensions between mental health and other school priorities have prevented some schools and education services from placing resources in mental health provision.

• Agreement about which entity or organisation owns or is responsible for mental health services (schools vs the community) is a debate that is being replaced by models of shared ownership

• Improved collaboration between education and health sectors would be enhanced by mutual contributions to basic professional training.

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Review2- Low income countries

• A key systematic review of mental health

promotion interventions in LMICs, but

because no similar reviews exist for

prevention and treatment interventions,

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Teachers?

• The capacity to manage any additional child needs within the LMIC school context will need to address the potential burden on school staff who have few oppor-tunities for professional development in the face of the challenges of teaching in low-resource contexts.

• This absence of development might, for example, make teachers less equipped to manage the emotional and behavioural diffi culties presenting in their classrooms unless properly supported and could signal the need for non-teaching professionals to deliver mental health interventions within schools.

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• Compared with their high-income counterparts, children in LMICs are likely to have some broad differences in risk exposures and protective factors for psychological difficulties

• Unfortunately, Schools can sometimes be places where

children experience abuse and violence, either from peers, teachers, or outside groups..

example, peer and teacher victimisation

and bullying,

corporal punishment,

and sexual abuse have all been reported within the school context,

and forced recruitment of children into armies has also been seen.

• School cannot necessarily be assumed to be a safe and healthy place for children

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• Data suggest that bullying in school is

widespread across many LMICs

• school refusal?

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• Fewer systems are in place in LMICs than HICs to support the increasing number of children who are surviving with physical disabilities and neurodevelopmental disorders,

• including autism spectrum and learning disorders, many of whom might have additional difficulties in school

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School models in LAMICs

• Models in LAMICs have used peer and community-based partners, the internet, cash incentives, and extra- curricular activities.

• Health-promoting schools (HPS) represent one of the most prominent of these strategies, adopted by schools worldwide and promoted by international organisations such as WHO. HPS represent a holistic whole-school is supported by improvements in the physical and social environment of the school, and a school ethos that supports such activities.

• Schools adopting the HPS framework have shown better child emotional and physical health. The HPS framework also has the potential to develop a mechanism of closer integration with healthcare systems

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• Barry and colleagues despite the large number of interventions in use world- wide, only 14 studies from LMICs satisfied their inclusion criteria.

• Robust evidence exists that mental health promotion interventions have positive effects,which are improved with increased structure and duration

• School-based interventions were mainly trying

to prevent anxiety,

depression,

or negative sequelae after exposure to potentially traumatic events.

• Three studies reported negative effects of the interventions done

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• whole school approach for lifeskills and resilience…

• Both universal and selected interventions have been shown to

• successfully reduce symptoms of PTSD; however, more

• caution needs to be used for other disorders.

• These disorders include behavioural difficulties in primary school populations and depression and anxiety disorders, which have a greater prevalence in secondary school populations.

• Delivery of mental health interventions in schools can potentially draw on

Professionals including school counsellors and teachers,

and lay community members

and student peers;

• the studies available show the diversity of people who have delivered these interventions.

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Life skills education in LSMICs (not part

of the review)

• NIMHANS module develpoed by WHO

aid.

• Unicef also promote life skills deucation in

schools.

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• Gaps in knowledge also exist with regard to

how best to translate HIC evidence into policy

and practice in LMICs.

• as against PTSD….authors have called for a

stronger focus on the importance of ongoing

(daily) stressors for mental health, such as

domestic violence, chronic poverty, and social

exclusion, which are seen, to varying degrees,

in many diff erent LMIC communities.

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• In LMICs, however, the role of teachers needs to be considered in a broad context.

• Constraints with use of teachers exist because of the many roles they need to play in low-resource settings. The importance of teachers as a local resource has been further emphasised because some have been trained to deliver psychological interventions even outside of the school setting.

• However, the School HeAlth Promotion and Empowerment (SHAPE) programme intervention has shown how lay community members can be trained to deliver eff ective health promotion interventions in schools.

• Role of the field of humanitarian mental health.

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• Similar to evidence from HICs suggests

that teachers can successfully deliver

many different mental health promotion

interventions, although further evidence is

needed to assess teacher-delivered

preventive interventions.

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Research gap

• How schools in LMICs can reach out to families suffering economic distress and domestic violence in a non-stigmatising way; parent–teacher associations can promote communication.

• About children’s mental health; and schools can promote reconciliation between peers of previously warring ethnic or religious factions.

• A need therefore exists to assess school-based interventions not only as standalone approaches, but also as components of multilayered interventions addressing broad social complexities

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• Success in studies adopting a common-elements and transdiagnostic treatment app- roach provides promise for and relevance to development of potential interventions for children in LMICs.

• These approaches have, for example, used lay counsellors to deliver flexibly tailored treatments, with options open to the counsellor to address depression, traumatic stress, anxiety, and substance misuse, dependent on what each individual presents

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Outline.

• Outlining what is already happening in the

school-setting around us.

• Review-series published this month in

Lancet-Psychiatry on school based mental

health interventions and other literature.

• Critically focus on some of local

interventions.

• Summarising discussion points.

Slide 51 of 76

DMHP. The “Thalir’ program from

TVPM.

Other prog. with mental health

components….LEAP, Dial A doctor

Health sector

Life skills education module by state

education board (SCERT) …..

“Ullasaparavakal”

‘Souhrida club' project of higher

secondary education dept.

Sarva Shiksha Abhayan (SSA) for

primary education and (IEDC) for

integrated education of disabled

children

Special schools..

Education sector

“Clean Campus, Safe Campus” …by

Home ministry ..

NGOs

Private agencies

Buds schools -Kudumbashree

Other sectors

Psycho social service program for

adolescent girls……by SJD (Social

justice)

DEICs –District early intervention

centres

Social sector

The ecology of mental health services in School context

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“Thaliru” DMHP

• ‘Thalir’ is a “targeted intervention” programmes launched by the DMHP in the district. It has covered over 22,000 students in 112 schools. The programme aims at

the holistic development of schoolchildren

by making them aware of the importance of mental health

along with physical well-being,

offering them counselling,

and addressing behavioural issues.

• The programme works in “coordination” with the Adolescent Reproductive and Sexual Health programme and the School Health Programme being implemented in schools by the National Rural Health Mission.

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Thaliru

• “We train school counsellors and School Junior Public Health Nurses to be the link between students and teachers and the DMHP unit. Thalir is implemented as a total package for teachers, parents and students,” says P.S. Kiran, nodal officer for DMHP.

• Focus areas‘Thalir’ focusses on addressing

behaviour and emotional issues among children,

helping them stay away from substance abuse,

suicide prevention,

stress management,

life-skills education,

and also managing childhood problems like learning disability and conduct disorder.

• Students are encouraged to seek help from school counsellors.

• As part of scaling up the programme across State, counselling ? centres will be opened in 1,926 schools this year.

• Private schools have not been excluded from the programme, though government schools will have the priority.

http://www.thehindu.com/news/national/kerala/school-mental-health-scheme-in-all-kerala-districts/article5913077.ece

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SCERT curriculum • SCERT has developed and published “life skills modules” titled

'ullaasaparavakal' for standards 1 to 12.

• Seperate modules are available for each standard and yearly 20 hours are supposed to be devoted to life skills.

• Ullasaparavakal is primarily intended

as a health and attitude promotion tool,

but since it also addresses specific issues like substance abuse,

healthy diet,exercise ,

learning techniques etc.

it can also serve as a prevention tool in selected indications.

it can help in early identification and intervention too.

it will help to shape up an younger generation who may have much more clear ideas about health and mental health in our society where culture bound superstitions exist.

(as communicated by the lead resource psychiatrist who contributed to developing the module)

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Psycho social service program for

adolescent girls… SJD

• Counsellors(500)…….started as central program now under state plan budget…

• Evaluation study done …(suggests community integration and home based provisioning)

• One teacher in each schools given training in counseling…

• Adolescent clubs in anganwadis

• Family counseling centers under domestic violence act…..

• District level monitoring has a psychiatrist included.

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From the news…..

• “Counselling is not compulsory in government schools but we’ve decided to engage the services of a counsellor realizing its positive effect, especially during exams. However, we found it difficult to get a qualified child psychologist despite out best efforts”, said GracyJoseph, Principal, SRV Government Model High School.

http://archives.deccanchronicle.com/130312/news-current-affairs/article/schools-dire-need-counsellors

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From the news..

• According to Dr Gracy Thomas, chairperson of the Adolescence Committee of Kerala Federation of Obstetrics and Gynaecology, Thiruvananthapuram and Ernakulam are the only districts in the state where regular counselling sessions in schools are conducted.

• “Only the adolescent counselling classes organised by the Directorate of Higher Secondary Education are compulsory in state schools. These classes, conducted by a physician, a psychologist, a paediatrician and a gynaecologist, take care of only higher secondary students, but under-15 students are subjected to more sexual atrocities”, said Dr Thomas.

• There are also demands to introduce the post of a permanent counsellor in all institutions, including government, aided and unaided schools.

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• The priest, who has been working to protect the rights of juveniles in the state said the government has to co-ordinate the counselling programmes of different agencies to get the maximum output.

• “We have counselling sessions organised by the Mental Health Programme, National Rural Health Mission and similar agencies. But there are no review meetings between these agencies to discuss which schools were covered and what the topics dealt with were.

• Also, we need a scientific study of the needs of Kerala children”, Fr James added.

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Action plan in 2013

• An action plan for effective counselling in schools across the state to prevent suicides and all forms of abuse among children is all set to be rolled out by a state government expert committee that held a consultative meeting with UNICEF officials. http://timesofindia.indiatimes.com/city/thiruvananthapuram/Plan-for-effective-student-counselling-ready-to-roll-out/articleshow/11040704.cms

• "The action plan aims at

accreditation and appraisal of the present counsellors,

prioritizing systematic training to the counsellors

with massive orientation programme for teachers and parents before counseling children”

Based on the action plan, it is mandatory to have well-equipped student counselling centres in all schools, be it state syllabus, central syllabus-based, aided or unaided schools, across the state by April 1, 2013, Lida Jacob said.

•

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• Based on recommendations by educationists and social activists at the expert committee meet, the student counsellors will be renamed as 'guidance teachers' or 'mentors', she said.

• "Already, the government has set up counselling centres in 500 schools of the state. Additionally, such centres will be set up in 700 schools across the state with upgradation of facilities and by improving the functioning of existing counsellors," said Maj Dinesh Bhaskaran, regional director of the Kerala Social Security Mission (KSSM).

• That would also include the government plan to reappoint more than 1,000 protected teachers as guidance teachers after providing them a course in counselling, he said.

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From the news…

• Child Development Centre director M K C Nair said the government is expected to take a proactive stand through effective student counselling for the holistic development of the child.

Childline, Trivandrum founder director Fr Phillip Parakkat said the school counselling system needs to be established with a multi-link development programme. The system should take on board a life skills and personality development trainer, a psychotherapist, counsellor teacher and parents who should be given periodic orientation sessions.

Kerala Anti-addiction Committee president Rajan Amboori said awareness needs be created among children on substance abuse at an early age before they get habituated to chewing gums, paan, tobacco products and alcoholism.

http://timesofindia.indiatimes.com/city/thiruvananthapuram/Plan-for-effective-student-counselling-ready-to-roll-out/articleshow/11040704.cms

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• “There are hundreds of protected teachers who

are paid remuneration by the state but are out of

schools with lot of time to spare. We could give

them training and make use of their service for

the counselling programme,”

• “The peer support system should be

implemented under strict supervision,” said M K

C Nair, director of Child Development Centre

who also threw light on the desirable changes in

the role of school counsellors

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From the news• Counsellors should be seen at par with teachers, their

pay should be decent, their training should be planned, infrastructure should be provided in schools to accommodate their service and basically there should be an accreditation/screening process to recruit them, the meeting opined.

• Lida Jacob said

protected and the retrenched teachers need to be given a certificate course in counselling.

After that, the teachers should be reinstated by the government as counsellors or guidance teachers in schools

with a decent salary and not just an honorarium.

http://ibnlive.in.com/news/school-counselling-system--to-be-strengthened/210315-60-116.html

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stake holders

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Childen with special needs.

• Buds schools….Kudubashree

• Special education schools….all private, now getting aid from government.

• Sarva shiksha abhyan (SSA) integrated education for children with special needs…..

• Natural supports in regular schools…. • Adolescent Reproductive and Sexual Health programme (ARSH) • NRHM….School health Program,

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Disability

certification in

SLD

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Summary.

• There is ethical and scientific justification for

school-based mental health services.

• Emerging evidence base. More rigor is emerging

in the conceptualisation of school based mental

health services (eg. IOM frame work)

• Components in the interventions need to be

cleared defined even if it is multi pronged.

• Research gap/ implementation research, fidelity

to program ingredients. Evaluation.

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• A lot of activity happening in our state.

• I have tried to give an overview of the various actors involved and the contours of the landscape.

• There is hardly any evaluation of activities. one exception was evaluation of the Psycho social adolescent scheme for girls by SJD.

• Duplication, overlap, wastage, and lack of coordination.

• Issues in our state are a mix of what is noted in high income and low income countries. Local research?

• Need exploration about interventions in private schools? Role for private-private partnerships?

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• Discussion and comments.