Schools are a vital way of reaching the 10–20 percent of children and young people across the globe who would benefit from some sort of mental health intervention, according to a new series on mental health interventions in schools published in The Lancet Psychiatry.
Children spend more time in school than in any other formal institution, say the authors, and as such, schools play a huge role in all areas of child development. Peer relationships, social interactions, academic attainment, cognitive process, emotional control, behavioral expectations, physical development, and moral development are all mediated through school experiences, and all of these domains are affected by mental health during childhood and adolescence.
The term childhood mental disorder refers to all mental disorders that can be diagnosed and begin in childhood, including but not limited to: attention-deficit/hyperactivity disorder (ADHD); Tourette syndrome; behavioral disorders; mood and anxiety disorders; autism spectrum disorders; and substance use disorders. (Note: Certain conditions – particularly personality disorders – are characterized by pervasive, long-term symptomatology and therefore cannot be diagnosed in individuals under the age of 18, while other conditions – like oppositional defiant disorder – are defined by their childhood onset and can only be diagnosed if symptoms began before the age of 18).
While symptoms vary widely across different disorders, childhood mental illness is characterized by serious changes in the ways children typically learn, behave, or handle their emotions. Symptoms usually start in early childhood, with half of all mental disorders beginning before age 14; other conditions may develop throughout the teenage years. According to the World Health Organization, around 20 percent of the world’s children – 1 in 5 – suffer from mental disorders or problems.
Childhood mental disorders are among the leading causes of worldwide disability in young people, and experts warn that if such problems are not treated, they can affect many different aspects of a young person’s development – potentially leading to school failure and non-attendance, as well as affecting later relationships and career choices. Unfortunately, regions of the world with the highest percentage of population under the age of 19 have the poorest level of mental health resources. Most low- and middle-income countries have only one child psychiatrist for every 1 to 4 million people.
According to the authors behind the new research, 75 percent of adults who access mental health services had a diagnosable disorder before they reached age 18. Even in high-income countries, estimates show that only 25 percent of children who require a mental health intervention are identified and treated. In total, about 10-20 percent of children and young people worldwide are in need of some form of mental health intervention, the authors say.
School provides ideal setting for equitable mental health care
The Lancet series, led by Dr. Mina Fazel, a child psychiatrist at the University of Oxford in the UK, reviews mental health services and interventions in schools, focusing on high-income countries in one paper, and countries with middle- and low-income in another. The articles highlight that the mental health gap (unmet mental health needs) is far more extreme in low-and middle-income countries, where more than 80 percent of the global population of children and adolescents live. In the second paper, Dr. Fazel and colleagues discuss ways to bridge this gap in countries without the professionals and resources of high-income countries.
The researchers explain how, because almost all young people in high-income countries attend school and the numbers attending in the rest of the world are increasing, this setting provides the ideal opportunity to offer both universal education about mental health issues and specialized help for those who need it.
Implementation of mental health services in schools can provide timely input to children, thereby improving their present well-being—sometimes overlooked in child mental health in favor of longer-term outcomes only, the researchers note. Also, as the authors point out, offering such services to children in a place they are already attending and during the school day democratizes access to services, as being able to receive care is not determined by parental income or work patterns.
In addressing mental health problems in countries with low resources and a scarcity of mental health professionals, the authors point to India’s SHAPE program as an effective initiative. SHAPE uses trained l ay school health counselors to assess both physical and mental health (e.g., screening for visual and weight problems as well as violence and bullying). They work with schools to conduct whole-school interventions, and where necessary, one-on-one counseling for children.
Stigma, gap between research and practice pose challenges
There are still many challenges to overcome with mental health services in schools. For instance, concerns have been raised about the labeling and stigmatizing of young people that could result from widespread screening in schools.
Misunderstanding and stigma surrounding mental illness are widespread; despite the existence of effective treatments for mental disorders, there is a belief that they are untreatable or that people with mental disorders are deficient or less capable than others. This stigma can lead to shame, rejection and isolation, and also contributes to untreated mental illness. However, Dr. Fazel says that shouldn’t get in the way of screening for mental health problems.
“If 10% of children had diabetes,” says Dr. Fazel, “we wouldn’t be saying that screening was a bad thing. Schools provide a platform to access large proportions of young people, and the vast majority of children picked up by screening would not need complex interventions.”
The primary barrier to meeting the mental health needs of young people is the gap between research and practice, says Dr. Fazel. Large numbers of interventions have already been trialled and proven to work in whole schools, classrooms, and among selected individuals, but they haven’t shown the same success in broader applications. “We know what works, but where we fall down is implementing this on a large scale in schools. We also need national policies to help education and mental health services work more closely together,” says Dr. Fazel.
“The evidence shows that children prefer to be seen in school rather than outside school. But right now, health and education are very different systems,” adds Dr. Fazel. “The reality is that we are not maximizing on the opportunities to work in these environments. We need to have an approach that is child focused and to do this health and education must become more closely aligned.”