The Psychology School Mental Health Initiative

Abstract

French

Evidence suggests that schools have, by default, become the primary mental health system for students in Canada. The goal of the present study was to design, implement, and evaluate the Psychology School Mental Health Initiative (PSMHI). The PSMHI is an innovative attempt to increase the capacity of school-based psychology staff to deliver evidence-based mental health intervention to children and adolescents with mental health concerns. The conceptualization, implementation, and initial outcomes of the PSMHI are outlined. Advantages and challenges of delivering cognitive–behavioural intervention in a school setting are discussed. Preliminary data indicated that participation in the initiative increased the capacity of school psychology staff in the provision of mental health service. Furthermore, results revealed that a higher number of students with mental health issues received evidence-based intervention. Finally, recommendations for enhancing effective service delivery and the expanding role of psychology with the school system are highlighted.

Keywords

child adolescent school psychology mental health capacity building cognitive–behavioural intervention

Introduction

Mental health issues are increasingly recognized as a priority among students. Studies suggest that 14% of Canadian children and adolescents aged 4 to 17 years have serious mental health problems (Leadbeater, 2010), with a staggering 70% of mental health problems having their onset during childhood or adolescence (Government of Canada, 2006). Research indicates the prevalence rates of mental health issues increases across childhood and adolescence, making the teenage years a particularly vulnerable period (Roberts, Atkinson, & Rosenblatt, 1998). According to Statistics Canada (2002), teenagers and young adults aged 15 to 24 years experience the highest incidence of mental disorders of any age-group in Canada; and adolescents also exhibit the highest levels of distress (Stephens & Joubert, 2001).

The social, emotional, and behavioural components of mental health issues can negatively affect virtually all aspects of child development, including school readiness, attendance, academic achievement, familial relationships, and school- and peer-based connections (Fergusson & Woodward, 2002; Fleming, Boyle, & Offord, 1993). Mental health concerns have also been linked to a compromised ability to attend and focus, the exacerbation of physical complaints, and increased morbidity rates (Osborn, 2001).

The impact of mental illness also carries significant costs. For example, suicide is currently the second leading cause of death among young people between the ages of 15 and 24 years (Canadian Mental Health Association, 2007). In Canada, the second highest hospitalization rates for mental illness are among young people aged 15 to 24 years (Government of Canada, 2006). In Canada, only 5% of children receive any form of psychological care, and of those who do, only 1% to 2% are seen by mental health specialists (French & Mureika, 2002). When intervention does occur, it is typically in adulthood, suggesting that key opportunities for early intervention and prevention are lost (Kessler et al., 2005; Wang, Berglund, Olfson, Pincus, & Kessler, 2005).

Low intervention rates may be, in part, because of the limited availability of publicly funded mental health services in Canada. Although mental illnesses constitute more than 15% of the burden of disease in Canada, such illnesses receive only 5.5% of our health care dollars (Lim, Jacobs, & Dewa, 2008). Van Acker and Mayer (2009) predict that by 2020, neuropsychiatric disorders will increase by 50% globally, while parallel increases in terms of mental health services are not projected to occur.

Treatment-seeking behaviour is related to a number of factors. For example, the perception of symptoms may be perceived as normative rather than representing a mental health concern. In some cases, the symptoms themselves may interfere with help-seeking behaviour (Health Canada, 2002). Furthermore, families may have difficulty accessing services, with barriers such as transportation, incidental fees, and/or time away from work. Lastly, mental health issues continue to be associated with a level of stigma, which poses a barrier to both diagnosis and the provision of intervention (Public Health Agency of Canada, 2008).

Children and adolescents spend the majority of their waking hours in schools, and families are increasingly turning to schools for support with mental health issues. Studies now suggest that schools are emerging as a common and even preferred location for mental health service delivery (McLennan, Reckord, & Clarke, 2008). Seventy-five percent of children who currently receive mental health services access them through the education system (Farmer, Burns, Phillips, Angold, & Costello, 2003). School-based settings offer several advantages for mental health services, such as an optimal environment for prevention, early identification, and early intervention (Lean & Colucci, 2010). School-based mental health services may promote increased communication, collaboration, and consultation among professionals involved with students and allow for the sharing of information that may be unavailable in other intervention settings (McLennan et al., 2008; Van Acker & Mayer, 2009). Furthermore, school-based services offer an improved ability to connect with students as compared with community-based settings, and accessing students in schools may be more acceptable and less stigmatizing to some families (Van Acker & Mayer, 2009). Evidence supports increased service utilization in schools as compared with community-based clinics (Crisp, Gudmundsen, & Shirk, 2006).

School-based mental health services may also have a positive impact on other professionals working within the school system. The provision of mental health services may have a trickle-down effect (e.g., classroom management issues for teachers), leading to decreased demands on other school professionals. Research supports a reduction in referral rates to special education for behavioural problems and a decrease in reliance on school suspensions as a discipline measure when mental health services are available (Bruns, Walrath, Glass-Siegel, & Weist, 2004). School-based mental health services have the potential to positively influence all students by fostering a school climate that promotes mental wellness (McLennan et al., 2008; Van Acker & Mayer, 2009). In summary, school-based mental health services have the potential to address both structural barriers and financial barriers that may inhibit treatment seeking.

There is a dearth of research examining the role of schools and school-based mental health professionals in identifying and treating mental health problems (Tramonte & Willms, 2010). Although most schools provide some level of social–emotional support, the available supports vary from one school to another. Few schools have adequately developed services that address the continuum from primary prevention (with schoolwide activities) to tertiary intervention (for students with serious or chronic disorders, Lean & Colucci, 2010).

The Psychology School Mental Health Initiative

The Psychology School Mental Health Initiative (PSMHI) was developed to address the increasing need for school-based mental health services. The conceptualization and development of the initiative, its implementation, and its evaluation will be discussed.

Conceptualization

During the conceptualization of the PSMHI, several key factors were considered that shaped its development, including the following: the target population, intervention selection, practitioner factors, organizational characteristics, and sustainability (Esposito, 1999; Schoenwald & Hoagwood, 2001).

Target population

Careful consideration was given to the client group within the school setting that could be targeted for empirically based mental health intervention. Prevalence rates with respect to mental health concerns across the developmental trajectory were examined. A review of the epidemiological literature indicates anxiety disorders to be the most prevalent mental health issue experienced by children and adolescents (Hirshfled-Becker, et al., 2008; Mazzone et al., 2007). Prevalence rates of childhood anxiety disorders range from 6% to 20% across several large-scale studies (Costello, Musillo, Erkanli, Keeler, & Angold, 2003). In Canada, prevalence rates of anxiety disorders in children and adolescents range from 2% to 12% (Tramonte & Willms, 2010) and increase with age. It is important to note that these studies reflected rates of anxiety disorders meeting formal diagnostic criteria, and if children and adolescents experiencing subclinical or emerging anxiety disorders were included, rates would likely have been much higher. Anxiety disorders often go undiagnosed. Data indicate that less than 50% of patients with anxiety disorders are recognized as having a psychological problem by their primary care physicians and less than one third receive the correct diagnosis (Anxiety Disorders Association of Canada, 2003). Within the school system, anxiety disorders tend to be identified less often when compared with externalizing disorders (e.g., attention deficit hyperactivity disorder), which may be more readily apparent and disruptive in the school setting (Albano, Chorpita, & Barlow, 2003; Kendall et al., 2007).

As with other childhood and adolescent mental health concerns, the negative sequelae of childhood anxiety disorders are significant. They include increased risk for comorbid diagnoses, psychopathology in adulthood, and social/emotional, family, and academic impairments (Hirshfled-Becker et al., 2008; Kendall, 2005; Last, Hansen, & Franco, 1998; Woodward & Fergusson, 2001).

Intervention characteristics

Following the identification of childhood anxiety disorders as a potential target population, consideration was given to treatment amenability, efficacy issues, and transferability to the school setting. The process was informed by both the clinical and research literature and by the unique characteristics of service delivery within the school setting.

There is substantial evidence to indicate that childhood anxiety disorders are highly amenable to psychological intervention (Butler, Chapman, Forman, & Beck, 2006; Chambless & Ollendick, 2001; Grossman & Hughes, 1992; Kendall, Hudson, Choudhury, Webb, & Pimentel, 2005; Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008; Mychailyszyn et al., 2011). In particular, cognitive–behavioural intervention (CBI) has received substantial support as an effective intervention for childhood and adolescent anxiety disorders (Deacon & Abramowitz, 2004). When intervention integrity is maintained, CBI promotes long-term positive effects on the management of anxiety symptoms (Borkovec & Costello, 1993; Compton et al., 2004), reduces the persistence of anxiety disorders into adulthood, and helps prevent secondary disorders (Kendall, 2005).

There is an emerging body of research to support the transfer of CBI for anxiety into the school environment (Creed, Reisweber, & Beck, 2011). For example, Bernstein, Layne, Egan, and Tennison (2005) investigated the effectiveness of school-based interventions for anxious children (separation anxiety, generalized anxiety, and social phobia) aged 7 to 11 years across three different elementary schools. The results indicated that CBI was successful in reducing symptom severity. A follow-up study demonstrated that school-based CBI continued to be effective in decreasing anxiety symptoms for children at 12 months postintervention (Bernstein, Bernat, Victor, & Layne, 2008). A further study by the Queensland Early Intervention and Prevention of Anxiety Project examined a CBI skills training program targeting children and parents at risk of developing anxiety problems (Kendall & Suveg, 2005). Both the intervention and monitored groups showed improvement immediately following the intervention period. However, at 6- and 24-month follow-up, only the CBI group maintained improvements in terms of reduced anxiety symptoms. Research on the FRIENDS program, an early intervention and prevention program addressing anxiety in children and adolescents, has consistently demonstrated reduced anxiety and depressive symptoms following intervention and at 12, 24, and 36 months follow-up (Barrett, Farrell, Ollendick, & Dadds, 2006).

In the school setting, anxiety disorders are less often identified and treated than externalizing disorders (Albano et al., 2003; Kendall et al., 2007). Research posits that this is because of differences in the behavioural expression of anxiety versus the range of externalizing disorders, which may garner externalizing disorders more resources (Beidel, Turner, & Morris, 1999).

Evidence suggests that the efficacy of school-based mental health services is significantly enhanced when they are provided by school-based mental health professionals (Crisp et al., 2006). This is likely related to the connections that school-based professionals share with both students and school staff and their knowledge of the unique culture, implicit rules, and realities that affect the day-to-day lives of people working in the education system. Thus, interventions offered by school-based staff may garner greater acceptance. Improve the sustainability and coordination of services (Crisp et al., 2006; Massey, Armstrong, Boroughs, Henson, & McCash, 2005).

School psychology staff have much to offer, particularly with regard to students who are struggling with their mental health needs (French & Mureika, 2002). Psychology staff are typically the most highly trained mental health professionals present in the school system. They are educated in best practices, child and adolescent development and psychopathology, assessment, diagnosis, and program planning for children and adolescents with exceptionalities (French & Mureika, 2002). Most importantly, many school psychology staff have training and experience with CBI. However, it is recognized that not all psychology staff share this background and that, even among those who do, many have roles within the school system that focus primarily around assessment. Consequently, their recent experience with CBI may have been limited, and in order to provide effective intervention, the skills of some staff may require updating and/or expansion.

Organizational characteristics, culture and climate

Although there are advantages to offering CBI for anxiety disorders in the school setting, there are also potential challenges. These include practical issues, such as the timing of sessions (e.g., the need to work around students’ schedules, school events, and school holidays) and balancing prescheduled appointments with the inevitable crises that frequently arise within schools (Creed et al., 2011). Furthermore, students receiving intervention in schools are often expected to return to class following sessions, and they need to be emotionally ready to do so. Also, there may be difficulties maintaining communication with parents as they need not attend every session. In addition, workload issues (i.e., managing the extremely large caseloads most school-based support staff already experience) also need to be addressed. Finally, school professionals often face limited resources with which to carry out their duties (e.g., space).

School administrators have traditionally used psychology staff as “testers” and gatekeepers to special education services. Administrators may not embrace a reallocation of what they already perceive to be a limited resource. Furthermore, Adelman and Taylor (2008) note that school administrators often do not recognize the role that mental health plays in student achievement and school success. Research suggests that a supportive organizational context is essential if meaningful change in terms of role expansion and related service delivery is to occur (Cummings & Doll, 2008; Forman & Barakat, 2011).

Implementation

Securing funding

The psychology department in a large, predominately urban school board based in the Greater Toronto Area conducted a systematic grant scan. The department applied for and received a Group Professional Development Grant from the Ontario Centre of Excellence in Child and Youth Mental Health. This grant was directed toward allowing staff to refresh, retool, and expand their capacity to deliver CBI to students with anxiety as the primary presenting concern.

Training

Once funding was secured, a program of training was developed. As an initial step, members of the psychology department were asked to self-select their preferred level of involvement with the PSMHI. This was based on their interests, education, experience (i.e., skills and competence with mental health interventions), and the relevant regulatory requirements. After careful consideration, 34 of 45 psychology staff members (76%) opted to participate in the professional development training.

Expert trainers were then selected based on their expertise in school-based mental health and CBI. Areas of training included the theoretical background of CBI, the evidence supporting the efficacy of CBI for children and adolescents, as well as the CBI techniques necessary to deliver high-quality intervention within the school system. A range of training activities and opportunities were planned to take place over a 1½-year period. The timeline was tailored to events taking place throughout the school year (e.g., school closures for holidays), as well as the workload demands and schedules of participating staff.

Training was broken down into three separate phases. Phase 1 involved a period of self-study in preparation for working with expert trainers. Each member of the PSMHI was asked to carry out a program of guided readings relevant to the training, which were directed and monitored by the expert trainers (see Appendix A). Relevant materials were purchased from grant funding for each staff participating, and included both theoretical and practical (both individual and group) resources. Such materials were intended to form a library of resources for staff to use regularly for both assessment and intervention. Three half-day self-study group sessions were also scheduled to supplement this individual learning. Expert trainers directed the content of the self-study groups via e-mail and telephone consultation. Two 2-day face-to-face training sessions with expert trainers took place following the self-study phase. Psychology staff, who felt ready to begin working with students requested referrals for CBI within their school settings. Staff who did not yet feel they could deliver effective intervention continued their self- and group study activities.

Phase 2 consisted of remote consultations with the expert trainers, as well as on-site peer consultation activities and continued self-study activities such as directed readings (see Appendix B). Peer consultation groups were formed to support staff as they began delivering CBI, and each group was led by a participant with prior experience and expertise in CBI. Staff not yet delivering CBI in schools also participated, as it was anticipated that the case discussions regarding formulation of presenting problems, suitability of candidates for intervention, and ongoing descriptions of actual intervention sessions would enrich their knowledge of CBI.

Phase 3 consisted of a 2-day, face-to-face, advanced clinical workshop (direct instruction, problem solving, and case presentations) with an expert trainer to refine and solidify clinical skill development. Staff continued to participate in peer consultation, as well as to expand their knowledge of CBI through directed readings.

Upon completion of the formal training period, a professional learning community was established for ongoing consultation and support. A rubric was developed to support this community (see Appendix C). Using this rubric, staff were asked to rank their current level of clinical competence and independence. The results were used to help link participants to teams for peer consultation support, problem solving, and case disccusion. Meetings and updates with the PSMHI team as a whole also continued to discuss progress, barriers to service delivery, and the ongoing needs of the team.

Treatment fidelity

Treatment integrity is too often ignored in child and youth mental health intervention. School based pracitioners may lack sufficient time and the support required to measure treatment integrity. Furthermore, feasible and effective measures of treatment integrity are not readily available and most existing measures are specific to particular interventions (Sanetti & Kratochwill, 2011). Treatment fidelity was addressed by audio taping one CBI session in a random sample of 10% of the PSHMI team. These confidential audiotapes were examined by the expert trainer for treatment adherence and efficacy. Feedback was provided in writing and addressed areas such as rapport, session structure and use of CBI strategies. Feedback was positive, with overall satisfactory ratings. Specific remarks included comments about outlining the connection between thoughts, feelings and behaviour, the likelihood of feared outcomes, providing practice in the session and how comfortable the students felt in the session.

Knowledge exchange

Systemic knowledge exchange activities aimed at the broader school community were undertaken which were aligned to the board’s system goals and current mental health initiatives. Knowledge exchange activities were undertaken to increase awareness and potential success of the PSMHI. A series of presentations to key stakeholders, specifically board level leadership, administrators, auxiliary school staff, and special education consultants were completed. Presentations included general aspects of mental health, identification of mental health concerns in the classroom, and relevant aspects related to the PSMHI intervention. Written material outlining mental health and the value of the PSMHI and CBI was distributed to those in board-wide leadership roles and school administrators.

Progress Monitoring

At the end of the grant period, a survey focused on capacity building was administered to PSMHI participants to evaluate their experience with the training program provided. Results indicated that 67% of psychology staff who participated in the PSMHI felt that they had increased their knowledge and confidence with regard to CBI. Furthermore, 74% of trainees reported feeling competent in their ability to design and implement a CBI based intervention targeting anxiety within a school setting. Lastly, 67% of participants reported they were now implementing CBI strategies with students to address anxiety in a school setting.

Anecdotal information provided by teachers indicated that they were aware of the increased availability of intervention services and school administrators reported satisfaction with the school adjustment of students who received intervention. Furthermore, school psychology staff reported a favourable reception by many teachers, administrators, and guidance counselors with regard to the expanding role of school psychology. Finally, anecdotal parental reports indicated a greater willingness to participate in school-based intervention services as compared to accessing supports through a community-based setting.

Future Directions

Several measures were taken to ensure the quality and sustainability of the PSMHI, and to support its continued expansion and growth. To monitor the fidelity and validity of the intervention provided, on-going individual case supervision is being carried out with the expert trainer. The peer-consultation groups and the PSMHI professional learning community also continue to function and are a source of support and problem-solving for all psychology department staff. Currently, tools are being developed for the psychology department to better select, evaluate, and monitor the impact of interventions offered through the PSMHI. In addition, a more thorough examination of the available data is currently underway. Finally, knowledge exchange activities, within the board’s current mental health initiatives, are ongoing, including the merits of high quality, empirically validated intervention by trained professionals.

Presently, the Psychology Department is developing a specialty psychology mental health service as part of the school board’s mental health initiatives. The Psychology Diagnostic and Intervention Mental Health Team(s) (PDIMH) receive referrals from psychology department staff regarding students who present with mental health issues requiring specific assessments and diagnosis. The PDIMH team(s) will be available to offer brief intervention (usually CBI) for students and to provide consultation to school staff and families. A final goal of the PDIMH team(s) is to support psychology staff in the continued development of their assessment and intervention skills.

In addition to the development of this team, plans are ongoing to complement the PDIMH assessment, diagnostic and intervention services with mental health prevention and early intervention programs in the Psychology Department. This is part of the processes currently being developed by the school board with community partners, in alignment with the Board Strategic Plan. In addition, the board is developing mental health initiatives in concert with government direction for child and youth mental health.

Although the PSMHI is a positive first step toward increasing high quality, evidence-based mental health services for students struggling with mental health issues, several concerns about mental health supports in school systems are raised. One concern is that many of the cases referred for services are crisis related. It is important to ensure that cases will be referred to mental health services before reaching a crisis point. In school boards with multidisciplinary support services, it is vital that co-ordination and standards for the various services be established with the goal of ensuring the integrity and fidelity of mental health interventions.

The purpose of this article was to examine the feasibility of training school based psychology staff to provide school based CBI for students with anxiety symptoms. It is important to note the limitations of this process; specifically the impact of the PSMHI needs to be quantified more objectively which would include standardized pre and post measures and the inclusion of a comparison group. In addition, the severity of anxiety symptoms was not controlled and may have influenced PSMHI participants’ self-ratings of their knowledge and confidence to be efficacious in the implementation of CBI.

Conclusion

The PSMHI offered school-based psychology staff the opportunity to build their capacity to provide evidence-based intervention for mental health issues. The initial results indicate the initiative was met with success. Specifically, the capacity of school-based psychology staff to provide high quality mental health intervention was increased. Schools also expressed satisfaction with the services provided and a willingness to consider the expansion of psychology’s traditional role within the system. Lastly and most importantly, the PSMHI increased the number of students and families receiving CBI for mental health concerns in the school setting.

Footnotes

Appendix A

Appendix B

Appendix C

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Ontario Centre of Excellence for Child and Youth Mental Health (Group Professional Development Award).

Author Biographies

Golden M. Millar, PhD, C. Psych. is a school psychologist at the Dufferin-Peel Catholic District School Board, where she provides consultation, assessment and intervention to children, adolescents and their families at both the elementary and secondary school level. She obtained her PhD at the University of Toronto in Counselling Psychology. Areas of professional interest include prevention models aimed at child and adolescent mental health, empirically based intervention strategies for anxiety disorders and addictive behaviours.

Debra Lean, PhD, C. Psych. received her MA and PhD in Clinical Psychology at Concordia University in Montreal. She is currently the Chief Psychologist at the Dufferin-Peel Catholic District School Board. She has an extensive experience in the provision and supervision of clinical and school psychology services. She has co-authored two books on integrating mental health services in schools. Dr. Lean clinical interests include broadening the role of school psychology to include clinical services for both academic and mental health issues at the prevention, early identification and intense intervention levels.

Susan D. Sweet, Ph.D., C. Psych., is a psychologist with the Dufferin-Peel Catholic District School Board in Ontario, Canada, where her clinical practice focuses on consultation, assessment, and intervention among secondary school populations designated as priority/high risk. She is also part of the Psychology Department’s Psychology Diagnostics and Intervention for Mental Health Team, and holds a SPARK Fellowship with the Mental Health Commission of Canada.

Sabrina C. Moraes, PhD, C.Psych, is a school psychologist at the Dufferin Peel Catholic District School Board, Canada, where she conducts both assessments and targeted mental health interventions. She obtained her PhD in School Psychology at the University of British Columbia. Areas of professional interest include evidence-based individual and group interventions for child and youth, specifically Cognitive Behavioural Therapy for depression and anxiety.

Victoria Nelson, PhD, C. Psych. completed her MSc in clinical psychology at McGill University, and her Ph.D. in school psychology at the University of Toronto. She has had extensive experience in individual and group therapy, assessment, and consultation. She is works at the Dufferin-Peel Catholic District School Board as a Senior Psychologist, where she provides services to children and adolescents, trains and supervises psychology staff, and consults with teachers and administrators around mental health issues and coping with tragic events, crisis prevention, and suicide.

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