Improving teachers’ mental health literacy, a timely need

  • For early diagnosis, classroom management, referral to professional care

BY Ruwan Laknath Jayakody

Improving the mental health literacy of teachers will pave the way for early diagnosis through the identification of the features of childhood behavioural, emotional, and neuro-developmental problems, appropriate classroom management through guidelines, and, if necessary, the referral of children and adolescents with mental health problems for professional care.

This was found in the first study conducted locally to evaluate an interactive training workshop conducted based on the “Sisu Sitha Noridawa” (SSN), or “not hurting the students’ feelings”, training programme to improve teachers’ mental health literacy.

This finding was made by P. Ginige (senior lecturer attached to the Department of Psychiatry of the Faculty of Medicine at the University of Peradeniya), I.B.R.U. Perera (consultant child and adolescent psychiatrist attached to the Peradeniya Sirimavo Bandaranaike Specialised Children’s Hospital), S.C.A. Arambepola (consultant psychiatrist at the Kandy Teaching Hospital), K.A.P.R. Kuruwita, and E.R.N.D. Gunawardena (both temporary lecturers at the same aforementioned Psychiatry Department) in an original research titled “The impact of a specialised training programme on teacher mental health literacy in Central Sri Lanka”, which was published on 1 July 2021 in the Sri Lanka Journal of Medicine’s 30th Volume’s First Issue.

According to the World Health Organisation (WHO); “Child and adolescent mental health worldwide: Evidence for action” by C. Kieling, H. Baker-Henningham, M. Belfer, G. Conti, I. Ertem, O. Omigbodun, and A. Rahman; and “Mental health of young people: A global public health challenge” by V. Patel, A.J. Flisher, S. Hetrick, and P. McGorry, 20% of children and adolescents will contract an emotional and/or behavioural disorder during their lifetime, which can in turn have a drastic impact on their academic and social life.

In this regard, the role of teachers has been highlighted in studies such as R.D. Mendonsa and I. Shihabuddeen’s “Mental health literacy among elementary school teachers in rural South India”, where it was found that especially in rural community settings in developing countries, teachers usually have a fair awareness of the students’ family backgrounds and are capable of advising the family on various issues including health-related problems.

This is where the importance of mental health literacy comes in. In “Mental health literacy: A survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment” by A.F. Jorm, A.E. Korten, P. Jacomb, H. Christensen, B. Rodgers, and P. Pollitt, mental health literacy is defined as the knowledge and beliefs about mental disorders that aid their recognition, management, and prevention. Jorm further notes in “Mental health literacy: Public knowledge and beliefs about mental disorders” that the lack of knowledge of such on the part of the public can in turn hinder evidence-based mental healthcare.

With regard to the lack of knowledge of the same among teachers, it was found by A.G.S. Soares, G. Estanislau, E. Brietzke, F. Lefevre, and R.A. Bressan in “Public school teachers’ perceptions about mental health” that the lack of reliable sources of education to acquire knowledge in this regard in turn creates a lack of confidence on the part of teachers in managing everyday situations involving mental health problems.

Ginige et al. have noted instances where many schoolchildren and adolescents with mental health problems have faced adverse situations involving teachers owing to the latter’s poor level of mental health literacy manifest in the failure to detect the problem or by managing it adversely, which has in turn led to the deterioration of such mental health conditions, poor school performance, and the worsening of emotional and behavioural problems (refusal to attend school, withdrawal, and irritability).

The improvement of the mental health literacy of teachers, as noted by M. Fazal, K. Hoagwood, S. Stephan, and T. Ford in “Mental health interventions in schools in high-income countries” and S. Kutcher, H. Gilberds, C. Morgan, M. Udedi, and K. Perkins’s “Malawi educators assessment of student mental health outcomes”, helps in the early detection of students suffering from mental disorders and also aids in their early referral to professional care. Further, Kutcher et al., S. Kutcher, Y. Wei, and C. Morgan’s “Successful application of a Canadian mental health curriculum resource by the usual classroom teachers in significantly and sustainably improving student mental health literacy” and S. Kutcher, Y. Wei, H. Gilberds, A. Brown, O. Ubuguyu, T. Njau, and K. Perkins’ “The African Guide: One-year impact and outcomes from the implementation of a school mental health literacy curriculum resource in Tanzania” elaborate that school-based programmes and mental health and high school curriculum guides improved knowledge, decreased stigma, and enhanced help-seeking efficacy among teachers where students with potential mental health issues were identified and referred for professional care, following a training programme to improve mental health literacy.

In the case of Sri Lanka, where the prevalence of child and adolescent mental health problems is a considerable health issue, M. Perera’s “Mental health of adolescent schoolchildren in Sri Lanka – a national survey” and P. Ginige, S.U.B. Tennakoon, W.H.M.K.J. Wijesinghe, L. Liyanage, P.S.D. Herath, and K. Bandara’s “Prevalence of behavioural and emotional problems among seven to 11-year-old children in selected schools in the Kandy District” found that 18.9% of the adolescents aged 13-18 years showed some abnormality in emotional and behavioural parameters, while 15.5% and 12.4% of them were severely affected in educational functioning and peer relationships, respectively. In Central Sri Lanka, 13.8% of schoolchildren aged seven to 11 years have also shown emotional and behavioural problems.

Also, N. Samarasekara, M.L.M. Davies, and S. Siribaddana have noted in “The stigma of mental illness in Sri Lanka: The perspectives of community mental health workers” that stigma in relation to mental health is high and constitutes a barrier to promoting mental health, which, according to Ginige et al. in the instant study, likely contributes to the poor conceptualisation of mental health literacy in general.

Teachers, as Ginige et al. mention, only learn certain aspects of child psychology principles, albeit briefly, at teacher training schools. The Open University has a Diploma in Early Childhood and Primary Education programme which offers diploma-level courses on the same with sub-courses on social and personality psychology.

Subsequently, to remedy the status quo of the absence of organised, regular, islandwide/national, hands-on skills training programmes for teachers on emotional and behavioural disorders among children and adolescents, a teacher training programme on how to improve mental health literacy concerning emotional and behavioural disorders of childhood and adolescents named SSN was developed and delivered in the Sinhala language.

The participant teachers for this study conducted in the Central Province were selected by the principals of government schools (with science, arts, and commerce streams for the Advanced Level [A/L], Grades One to 11, primary classes from Grades One to Five to Eight) from a convenient sample of 251 primary teachers from the educational zones of Kandy, Dewinuwara and Katugasthota in the Kandy District. The majority were females (205 – 81.7%), Buddhists (98%), and educated up to A/L (48.2%). The largest group (36.7%) was from primary schools with classes from Grades One to Five to Eight. Further, 33.9% had a basic degree, 8.8% had a diploma, 6.4% had a doctorate, and 2.8% had a Master of Arts degree. The majority (185 – 73.7%) revealed that they had encountered children with emotional and behavioural problems. A total of 12.4% of the teachers revealed that they too had children of their own who suffered from some mental health issue.

The common childhood behavioural, emotional, and neuro-developmental problems that were considered were oppositional defiant disorder (ODD), conduct disorder, attention deficit hyperactivity disorder (ADHD), autism, dyslexia, mental retardation, depression, separation anxiety disorder, anxiety around sexuality, and anxiety around bullying.

The impact of the training programme was assessed by way of pretest and post-test self-administered questionnaires on knowledge-related and attitudinal aspects pertaining to mental health problems in children and adolescents.

The questions in the knowledge questionnaire included the following: 1) Only adults have mental health disorders; 2) children and adolescent brains are not developed enough to have mental health problems; 3) medication is the only answer in the majority of the emotional and behavioural disorders in children; 4) mental health problems do not affect students behaviour; 5) mental health problems do not affect the students performance; 6) children with anxiety disorders may panic in situations that they fear; 7) children with phobias can be helped by making them relaxed and feeling supported; 8) a child who does not speak at school all the time but speaks well at home may be doing so due to defiance; 9) depression is sadness; 10) only weak-minded children develop depression; 11) common symptoms of childhood depression are getting angry and being disobedient; 12) childhood depression may cause poor school performance and refusal to attend school; 13) children with ADHD can concentrate on their work for at least for 20 minutes; 14) children with ADHD are more impulsive, disorganised, and forgetful; 15) reasonable punishment can cure ADHD; 16) difficulty in reading, writing, and doing mathematics are not mental health problems; 17) students with specific learning disorders may have normal or superior intelligence; 18) if a child shows less intelligence, there is nothing a mental health professional can do about that child; 19) children with mental retardation appear to forget what is taught; 20) children with mental retardation are poor in all school-related performances; 21) children with autism have poor social interactions; 22) children with autism could be highly intelligent or have low Intelligence; 23) children with autism later on develop psychosis; 24) children with ODD have a less severe condition than children with conduct disorder; 25) children with ODD and conduct disorder often bully, threaten, or intimidate others; 26) children with ODD and conduct disorder deliberately annoy others; 27) children with ODD and conduct disorder may not be angry and resentful; 28) it is mainly unknown persons that sexually abuse children; 29) sexually abused children often feel guilty thinking that they were abused because they were at fault; 30) alcohol and other substances of abuse have a less addictive effect on the developing brain; 31) having a balanced diet and adequate sleep can improve the mental health wellbeing of students; 32) giving praise improves the mental health wellbeing of students; 33) talking about problems with students helps to build better mental health; 34) physical exercise helps to improve the mental health wellbeing of students; and 35) having a positive relationship with students and doing something that students enjoy improves the mental health wellbeing of both teachers and students.

The questions in the questionnaire on attitudes included the following: 1) Having high mental health literacy makes life easy for a teacher; 2) having a mental illness ruins one’s life; 3) people with mental illnesses never get better; 4) seeking help for a mental illness is a sign of weakness; 5) seeking help for a mental illness is not good for the record of a child’s future; 6) mental illnesses are caused by personal weaknesses or character flaws; 7) the role of the special education teacher is less important than that of a science or mathematics teacher; 8) the role of the counselling teacher is less important than that of a science or maths teacher; 9) children with mental illness should not be sent to school; 10) children with mental illnesses are dangerous; 11) media gives a reasonable idea about mental health problems; 12) homosexual orientation is a mental health disorder; 13) a female child behaving and thinking like a male child is a disgrace to a girls school; and 14) it is alright to criticise children to correct them as opposed to criticising adults as adults get hurt and having a falling out with teachers.

The mean pretest score of the knowledge component, it was found, significantly improved after the workshop with the percentage of accurate responses to most of the components in the knowledge questionnaire increasing following the programme. The change of the outcomes was deemed statistically significant.

The mean pretest score in the attitude component too improved by the time the post-test was conducted with the percentage of the most favourable response for each sentence increasing following the programme. Again, the change of outcomes was considered statistically significant.

In short, the results indicated that the training programme had a significant positive impact on improving both the knowledge and attitude components of teachers regarding child and adolescent mental health issues.

This type of an interactive approach with the participation of fellow teachers and psychiatrists helps to alleviate many self-identified yet unanswered questions that teachers have on child mental health problems encountered on a daily basis and supports their willingness to enhance their knowledge and ability to manage them better as has also been noted by B. Forese-Germain and R. Riel in “Understanding Teachers’ Perspectives on Student Mental Health”.

As per Kutcher and Gilberds et al., S.M. Gaiha, G.A. Sunil, R. Kumar, and S. Menon’s “Enhancing mental health literacy in India to reduce stigma: The fountainhead to improve help seeking behaviour”; T.D. Daniszewski’s “Teachers Mental Health Literacy and Capacity towards Student Mental Health”; C.M. Kelly, A.F. Jorm, and A. Wright’s “Improving mental health literacy as a strategy to facilitate early intervention for mental disorders”; and S. Kutcher, A. Bagnell, and Y. Wei’s “Mental health literacy in secondary schools: A Canadian approach”, knowledge improves both the understanding and acceptance of mental health issues and decreases stigma, which in turn have a long-term positive impact on students as the mental health literacy of students too will improve when teachers impart their knowledge and attitudes which could also lead to self-identification and help-seeking behaviour on the part of students, thus reducing child and adolescent mental health morbidity and mortality.

Kutcher, Wei, and Gilberds et al. and Kelly et al. have recommended the incorporation of mental health literacy-related training into the existing school curriculum structure and the teacher training curriculum. Ginige et al. further recommended the conduct of regular booster training programmes on the SSN within the teacher training curriculum of training colleges and in the context of in-service training. Furthermore, the SSN can be upgraded to a didactically familiar classroom-based training programme as has elsewhere been recommended by Kutcher, Wei, Gilberds, and Ubuguyu.