Mental health needs emerging in the school system
Prevalence of mental health emerging in childhood
Mental illness and suicide risk are growing public health concerns in Australia – almost half of all Australians experience a mental illness in their lifetime (ABS 2018), and indigenous rates of psychological issues and suicide are nearly 3 times greater than the national average (ARACY, 2013). There have been substantial efforts to address this issue with numerous new initiatives and investments increasing resources directed to treatment agencies such as Headspace, Beyond Blue and others, but concerns remain about the rate of suicide and the frequency of mental health issues being presented in hospital emergency centres (APS White Paper, 2019). This sits in the context of increasing family breakdown, violence, mobility of families, lack of family support where it is most needed, vulnerabilities, reduced local social cohesion and in schools increased numbers of children in out of home care, and growing school absentee rates.
Concerns about young people are reflected in news headlines such as ‘Mental health system fails children’, The Age August 1, 2019 and ‘The Age of Anxiety’, The Age, August 11, 2019. Figures indicate that children and young people are impacted negatively by experiencing a mental health disorder. One in 5 adolescents experience depression by the age of 18 years, (WHO, 2019), 1 in 7 children aged 4-17 years are affected by mental health disorders, with anxiety disorders being the most prevalent, and major depressive disorders present in 1 in 20 adolescents from 12-17 years (Lawrence et al, 2015). Almost 10 per cent of children aged 6-7 are reported to show signs of social-emotional stress, and up to 1 in 5 young people live with a family where a parent has a mental illness, with consequent impact on their own development (Mayberry, Reupert, Patrick & Goodyear, 2009; Goodsell, Lawrence, Ainley, Sawyer, Zubrik & Maratos, 2017). 50 per cent of lifelong mental health issues start before the age of 14 years (Sawyer, et al., 2010) so early intervention is crucial for ameliorating suffering and building strengths for future adult life.
Experiencing mental health problems can affect the development and adaptation of young people, as they are associated with lower educational achievement, poor school attendance and engagement (Patel, Flisher, Hetrick & McGorry, 2007; Lamb& Rice, 2008), and increased risk of suicide and suicidal behaviour. Childhood difficulties have been associated with increased risk of social exclusion and physical ill health and development of psychiatric disorders, depression, anxiety and substance use in adulthood (WHO, 2018, Lester, Waters & Cross, 2013). Children with mental health disorders, conduct disorder and ADHD have been found to have lower scores on national testing, miss more days at school and have lower scores on connectedness (APS Submission to the Productivity Commission, 2019). Learning and conduct issues also come with wellbeing risks, and can be associated with later mental health problems. Remote areas are underserviced by health professionals, and families must travel significant distances to gain treatment (APS Submission to the Productivity Commission, 2019).
With new developmental and community demands, the school is often the first focus of interest when these issues arise. With the concerns about mental health presentations increasing, schools are a seen as major provider of mental health services and referral sources (Lawrence et al., 2015) and a target for Mental Health promotion (WHO, 2018). The school is considered an ideal venue to nurture the skills for developing positive life skills and the capacity to be resilient in face of diversity. The collaborative program developed in partnership with Beyond Blue and Early Childhood Australia titled Be You is a new program that has grown out of evidence based programs developed for schools to use to enhance coping skills and thereby reduce mental ill-health (Be You, 2019). The Be You program provides a range of resources for schools to build capacity in students that will contribute to prevention, early intervention and mental health promotion. Schools are encouraged to build positive support structures for students and school-community environments to nurture belonging, engagement, resilience and connectedness. Be You is one of many initiatives, and it is up to schools to select appropriate approaches to its student needs. There is an abundance of programs and on-line information to access, which can be confusing and overwhelming for schools hoping to do the best for their students. It is difficult to select and sustain these programs when there is no specific person to maintain the interest and ongoing support in the school. Experience in schools demonstrates that teachers are often keen to work on these programs but need advice and guidance in implementing them over time.
While building the strengths of the schools to support students, there remains a high need for close work between schools and appropriate clinicians: to interpret this material, help identify students in need of early intervention, and pick up the challenge of working with the complex day to day student presentations that arise.
The service providers in schools
There are many professions contributing to the wellbeing of children in schools, and they may have different titles. For example, there may be Educational Psychologists, Clinical Psychologists, Counselling Psychologists or General Psychologists. There might also be School Counsellors (no registration needed), School Guidance workers (no registration needed), School teachers, School Principals, School Chaplains (code of practice but no registration needed), School Social Workers, Mental Health workers, and a range of others. Some of these professionals are required by law to be registered and are subject to professional standards, others are not.
Psychologist, counsellor, clinician, and practitioner: what importance rests on a professional title? In fact the title a service provider uses is extremely important. It is important to the practitioner so that they can clearly advise on the service they can provide. It is essential to the client that they can understand that the person treating them has expertise in the area of concern, and be reassured that expertise can be corroborated in professional documentation or professional registration. Understanding of the professional area of expertise is also key information needed by the person recommending consultation, whether it be a teacher or general practitioner, as their recommendation will hold weight. It is also necessary information for funding bodies, employers and other health professionals, as it allows clarity and verification as to what service is based on, what training has been undertaken, and what experience has been gained.
Special role of teachers
Being with children and adolescents every day is a great training ground in how young people grow, change and cope. The teacher is a privileged person observing this development, and watching and working with young people as they work through their life stage tasks – learning, relating, problem solving, fitting in, setting goals are some of these. Teachers are encouraged to take note of this role in their work, being asked to build wellbeing and resilience while also succeeding in enabling their students to learn and achieve. As a potential referrer to services, teachers have been shown to be competent identifiers of children’s difficulties, they are in an ideal situation to assist with early intervention, and evidence indicates that young people in difficulty are more likely to approach someone they know and trust than search out professional help (Rickwood, Dean & Wilson, 2007). Teachers find that they need to be able to work with parents and families collaboratively, help young people deal with their reluctance to seek help, and modify their classroom practices to the diverse needs of their groups.
Whenever a new difficulty emerges, the community looks to the school to respond. The role of educational institutions has expanded from teaching essential academic skills to greater focus on overall development, and, in particular, fostering skills that will protect children when under pressure. Teachers are being trained in mental health first aid, and are to some extent expected to be able to identify students who need therapeutic services. At the same time they are expected to improve student performance on national assessments, keep up with demands of an expanding curriculum, and prepare students for tertiary education and future employment.
However, teachers are not trained clinicians and may be uncertain about which professionals have the training for working with the mental health needs of young people. How are teachers and school leadership to know who to engage to work with their students? A recent report by the Australian Psychological Society suggests that there is a highly variable skill base in the current mental health workforce in schools (2019). All young people need to be able to access high quality mental health support, and the school is the obvious accessible source of information as to who will provide this. Teachers need opportunities to fulfil their primary teaching role and not be expected to do work beyond their area of training. Schools need appropriately qualified personnel to assist them both in providing service or referring young people to the correct clinical service, and in working with the school to build capacity and connectedness in wellbeing and prevention programs.
There are presently no national standards for school support in Australia. The ratios of psychologists in schools to student numbers vary by State, and it is difficult to gain a clear picture of this. The APS reports that in a 2011 study there were 3,076 psychologists working in schools with a school population of 3,541,809, which indicates an estimated ratio of 1:1151. This is contrary to the APS recommended of 1:500, with a psychologist in each primary and secondary school (APS, Submission to the Productivity Commission, 2019).
An added complexity comes from the sharing of health and education responsibilities between state and federal governments, and balancing between the two levels of government can create inefficiencies and missing links in service (APS, White Paper, 2019). This is evident in schools referring students to private practitioners (funded through Medicare) in place of using a school based service, and the shift of disability support to the Commonwealth NDIS system. The consequences are that fewer positions are offered in state public services, and numbers of psychologists in private practice have grown. This impacts school services, as in some cases well trained psychologists move to work privately, leaving school systems to employ those less experienced or qualified, thereby reducing services within the schools that work closely with teachers.
In a recent survey, Bell and McKenzie(2013) found that psychologists working in schools were keen to work with schools on preventative programs but the demand for direct assessment services left them little time to contribute systemic and prevention services. There were also inconsistent expectations of services expressed by psychologists, teachers and parents, highlighting how necessary it is to clarify the specific training and service offered by a health professional engaged by the school.
There are many excellent professionals involved with schools; however the clinical work with vulnerable young people and their families needs to be done with appropriately qualified professionals. Psychologists are required to be registered and update their work on a yearly basis with professional development and supervision. Their role in mental health is important and needs to be available in schools to support students and their teachers. Some registered psychologists are specifically trained to work in schools with young people, and with teachers.
With a Royal Commission into Mental Health underway in Victoria, there are welcome changes being proposed and implemented. Some states have committed to a psychologist in each secondary school. It is becoming clear that the current mental health workforce is not adequate and highlights the need for more training places (APS media releases 9th May 2019, 21st June. www.psychology.org.au).
There are already psychologists employed in the public school system in Victoria, but they have been hindered by the demands created between numbers of referrals and available staff, and their work brief has evolved from direct work with schools to a consultancy model (DET). The introduction of a psychologist being based in all schools is a welcome one, but it is has not been established that the best model is to leave it to the schools to employ these practitioners, rather than employ more psychologists in the School Support Service teams that already work closely with schools.
Where to from here?
The employment of registered psychologists in schools allows onsite support for school teachers and school programs. There are excellent programs looking at wellbeing and healthy relationships that can be utilised in collaborative work between teachers and psychologists. Use of appropriately qualified people and building constructive interventions are important steps to building a comprehensive program of intervention, early intervention and prevention in school settings. Noting that some psychologists are trained specifically to work in the education sector, an excellent channel for funding would be to support increased places in Universities in these Master courses and to provide training scholarships to encourage growth in the availability of educational psychologists. Professionals working with vulnerable children in schools can have significant impact on the individual and their future.
The important target is gaining the best service for the client – which is promoted when there is good understanding of the distinctive professional areas of knowledge and expertise that are available to support learners, teachers, parents, leadership teams and general wellbeing.
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Vicki McKenzie is Associate Professor at the University of Melbourne and is Coordinator of the Master of Educational Psychology, and Master of Educational Psychology/PhD programs. Dr McKenzie also has experience as the leader of a multi-disciplinary team of school support personnel working with schools on systemic intervention in the areas of student and community wellbeing. She has written on the resources, resilience and coping skills of disengaged students, and has presented at national and international conferences on building coping skills and resilience in young people. Training psychologists for professional practice in schools has been a central component of Dr McKenzie's professional career. She is currently Chair of the Australian Psychological Society (APS) College of Educational and Developmental Psychologists, and is a Fellow of the Society.
This article appears in Professional Voice 13.1 Mental health, reporting and education futures.