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Assessing school employees' abilities to respond to children's mental health needs: implications for school social work.

Mental health disorders are widely prevalent among children and adolescents. Current estimates indicate that approximately 1 in 5 children will experience a mental health disorder severe enough to impair functioning and increase risk for a variety of deleterious academic and social outcomes (Merikangas et al., 2010). Because they are associated with difficulty forming friendships and an increased risk of becoming involved in bullying either as a perpetrator or victim, mental health disorders interfere with children's ability to develop healthy relationships with peers in school settings (Kaltiala-Heino, Rimpela, Rantanen, & Rimpela, 2000). Children with mental health disorders are also more likely than their peers without mental health disorders to experience academic difficulties and often perform at least one year below grade level (Trout, Nordness, Pierce, & Epstein, 2003).

In recognition of the severe impact of mental health disorders on children's academic success and social well-being, the U.S. Public Health Service (2001) declared a public health crisis, and as a result, a variety of national policy initiatives have called for efforts to improve the mental health status of America's children. A key feature of these initiatives is a focus on the central role that schools can play in the prevention, identification, and intervention of children's mental health disorders. The President's New Freedom Commission on Mental Health (2003) emphasized the need for increased public education about children's mental health and illness and specifically called for an expansion of mental health programming in schools. A more recent initiative, Healthy People 2020 (U.S. Department of Health and Human Services, 2010) also prioritized the role of educational settings in preventing and identifying mental health disorders and set additional mental health screening and treatment referral in schools as a primary objective. Consequently, studies are needed to assess the level of preparedness among school personnel and hence elucidate ways in which school staff can be adequately trained to adhere to these initiatives. To that end, the present study explores self-efficacy beliefs to recognize and intervene with student mental health issues among public school personnel in elementary schools and, to the authors' knowledge, is the first study to examine both certified staff (e.g., teachers and counselors) and classified staff (e.g., paraprofessionals).

The Important Role of Schools

As Rones and Hoagwood (2000) have noted, schools are well suited to act as a primary intervention site for children's mental health services because of their nearly universal contact with all children and families. Indeed, schools often act as the crucial bridge connecting family and community (Cappella, Frazier, Atkins, Schoenwald, & Glisson, 2008) and, by virtue of the significant amount of time children spend there, schools provide a setting with the natural capacity to support children's mental health (Allen-Meares, 2006). Yet research has demonstrated that many schools face significant barriers to the successful adoption and implementation of school-based mental health prevention and intervention services (Mendenhall, Iachini, & Anderson-Butcher, 2013). Those barriers include adaptation to the shifting roles and responsibilities required to implement school mental health services, lack of buy-in and support from district and school administrators, time constraints, and depletion of resources needed to provide effective mental health services (Anderson-Butcher et al., 2010; Mellin & Weist, 2011; Suldo, Friedrich, & Michalowski, 2010).

A limited body of evidence has also identified the lack of adequate training and preparation of professionals working in schools as a significant barrier to the implementation of effective school-based mental health services (Flaspohler, Anderson-Butcher, Bean, Burke, & Paternite, 2008). Consequently, many teachers may lack the knowledge necessary to address children's mental health and may feel unprepared to identify and intervene with mental health issues in the classroom. In other words, some educators may have low mental health literacy. As a component of the overarching field of health literacy, mental health literacy has been defined as "knowledge and beliefs about mental disorders which aid their recognition, management, or prevention" (Jorm et al., 1997, p. 182). The results are preliminary, but it appears that mental health literacy holds promise as one mechanism for reducing mental health stigma and increasing access to high-quality mental health care among children and adolescents (Mendenhall, Fristad, & Early, 2009). As noted, school personnel are in a prime position to identify mental health distress in children and connect them to appropriate services.

Although there are a number of initiatives to expand and improve school-based mental health services, limited emphasis has been given to the pressing need to educate school staff about children's mental health, thereby overlooking a central component to achieving optimal service implementation and outcomes (Flaspohler et al., 2008). As a result, a dearth of research exists on the level of preparedness and the self-efficacy beliefs of school personnel regarding student mental health issues. Moreover, to the authors' knowledge, no research to date has included school support staff members (e.g., paraprofessionals and hallway monitors) despite their presence in the classroom and other school locations where students may display mental health symptoms. The policy efforts identified above will have limited success without sufficient mental health literacy among school personnel.

Mental Health Literacy among Teachers and Other School Staff

Children and their families are in frequent contact with various community professionals, particularly those in educational settings such as teachers and other school staff, and recognize them as a potential source of support with mental health concerns (Jorm, Wright, & Morgan, 2007; Pinto-Foltz, Hines-Martin, & Logsdon, 2010). However, with a few exceptions, limited research to date has investigated mental health literacy among educators. In a study of primary school teachers' ability to recognize children's mental health disorders, Loades and Mastroyannopoulou (2010) found that teachers were generally able to recognize the existence and severity of symptoms of mental health disorders when presented in a vignette. In contrast, Walter, Gouze, and Lim (2006) discovered a limited amount of mental health knowledge among the elementary school teachers they surveyed. In addition, surveys have revealed a lack of confidence among early childhood and elementary school teachers regarding their preparation and ability to recognize mental health disorders among their students (Reinke, Stormont, Herman, Puri, & Goel, 2011; Walter et al., 2006). Teachers typically express greater concern when a child presents with behavioral rather than emotional symptoms (Loades & Mastroyannopoulou, 2010) and believe that disruptive behaviors are the greatest mental health issue facing schools (Walter et al., 2006). Because externalizing symptoms are more readily recognized and of greater concern to teachers, it appears internalizing behaviors may be overlooked in educational environments (Williams, Horvath, Wei, Van Dorn, & Jonson-Reid, 2007).

This evidence is somewhat inconclusive and is limited to the experiences of teachers in spite of the numerous interactions of a variety of professionals and paraprofessionals who work with children in school settings on a daily basis. Thus, further studies are needed to assess a wider range of school personnel, including both certified and classified staff, in elementary school settings. Understanding self-efficacy beliefs among elementary school staff, in particular, is vital in light of evidence that mental health prevention and intervention at an early age reduces the risk of continued mental health difficulties in later life (Levitt, Saka, Romanelli, & Hoagwood, 2007). Consequently, early identification and intervention are critical to children's successful development into adolescence and adulthood. Moreover, studies involving school support staff are needed because many of them work with students in situations where mental health needs may be revealed, and recent evidence indicates that successful school mental health interventions adopt a whole-school approach (Wells, Barlow, & Stewart-Brown, 2003).

The Present Study

The present study begins to fill an important gap in our knowledge base by including classified employees (e.g., paraprofessionals, teachers' aides, and custodial and lunchroom staff), who also interact frequently with children and can observe warning signs and symptoms of mental health distress, but may lack the knowledge and skills needed to appropriately intervene. Thus, the purpose of this study is to explore self-efficacy beliefs of both certified and classified staff members in elementary schools with regard to recognizing and intervening with children's mental health issues. Broadly, studies are needed to identify current training needs and to inform efforts to promote mental health literacy among teachers and other school personnel. Of great concern is evidence indicating that, even when specialized mental health services are made available to students, they are often not accessed and used appropriately when school personnel lack the ability to recognize and place children with mental health issues into those services (DeSocio & Hootman, 2004). Thus, the promotion of mental health literacy among educators is clearly relevant to the field of social work because social workers are the primary providers of mental health services in the United States (National Association of Social Workers, 2006). School social workers have specialized knowledge of the ecological climate of school settings and experience in engaging with educational professionals. Thus, they are in a prime position to collaborate with clinical social workers, whose expertise in children's mental health and intervention at multiple system levels qualifies them to provide the training and outreach needed to increase the mental health literacy of educators. The results from this exploratory study and related implications for direct practice stand to make an important contribution to this prominent area of school social work.

Methods

Sample

Six elementary schools in a large suburban school district in the Midwest were recruited to participate in a project to enhance bullying prevention practices within the district. Principals at these schools volunteered to participate in this project, and both they and the district's general administration approved collecting baseline data from staff as part of this broader effort to improve staff responses to bullying and the common mental health issues resulting from bullying exposure (see the Procedures section). A total of 251 school staff members from these schools--85 classified staff members (34%) and 166 certified staff members (66%)--participated in the study Table 1 presents demographic characteristics broken down by certified and classified staff status. Overall, the study sample was 90 percent female and 84 percent white non-Hispanic, with approximately 56 percent attending school beyond college (e.g., graduate school). The average age across the sample was 43.6 years (SD = 10.7). Staff reported that on average they had been at their current school for 6.5 years (SD = 4.6). These demographic characteristics are comparable to district-wide statistics showing that most staff are female, white, and non-Hispanic and have a master's degree.

Measures

A measure was developed for the present study by modeling similar questions posed in previous surveys of school personnel in the literature. School employees were asked to respond to the following three items:

1. I am confident in my ability to recognize children experiencing mental health symptoms.

2. I am confident in my ability to intervene with children experiencing mental health symptoms.

3. I have received adequate training to work with children who have mental health needs.

These five-point Likert items used ratings ranging from strongly agree to strongly disagree. The Cronbach alpha for this scale was .79.

Procedures

After the human subjects committees at the sponsoring university and the participating school district approved the study, school staff were recruited to participate in a one-time anonymous survey created online in Qualtrics, a survey software program. Data for the present study were taken from the larger approved study that assessed school staff attitudes, perceptions, and self-efficacy beliefs relative to intervening with bullying and peer victimization among students. Children who are involved in bullying experience a number of negative developmental outcomes, including mental health issues (Juvonen, Graham, & Shuster, 2003; Nakamato & Schwartz, 2010; Reijntjes, Kamphuis, Prinzie, & Telch, 2010). Consequently, the authors were interested in assessing staff members' perceptions of their own preparedness to address student mental health issues.

Three of the participating schools invited research staff to attend staff meetings where the survey purpose and procedures were described. The principals then allowed staff members who volunteered to participate to adjourn to their classrooms, offices, or computer labs to complete the survey. The other three participating schools could not accommodate research staff attendance at the schools' staff meetings. In these schools, a survey link and description of the study's purpose were e-mailed to the principals for distribution. Principals then sent several follow-up e-mails to prompt staff to complete the survey The overall response rate was 64 percent. However, the response rate was on average 71 percent in schools where research staff attended meetings as compared to 57 percent in schools where research staff did not attend meetings.

Results

Means and standard deviations of the three survey items across the entire sample are reported in Table 2. Significant differences between classified and certified staff are noted. In response to the question about whether staff had received adequate training, only 5.3 percent (n = 5) of classified staff strongly agreed and 14.9 percent (n = 14) agreed that their previous training had been adequate. Other classified staff indicated that they disagreed (30.9%, n = 29), strongly disagreed (8.5%, n = 8), or neither agreed nor disagreed (26.6%, n = 25). Among certified staff, 8.3 percent (n = 14) strongly agreed, 21.3 percent (n = 36) agreed, 30.8 percent (n = 52) neither agreed nor disagreed, 29.6 percent (n = 50) disagreed, and 7.7 percent (n = 13) strongly disagreed that their past training had been sufficient.

Staff were also asked how confident they felt in their ability to recognize children experiencing mental health symptoms. Of the classified staff responding, 8.5 percent (n = 8) expressed strong confidence in their ability, 33 percent (n = 31) agreed that they felt confident, 36.2 percent (n = 34) neither agreed nor disagreed, 11.7 percent (n = 11) disagreed that they felt confident, and 1.1 percent (n = 1) strongly disagreed. Roughly 12 percent (12.4%) of certified staff (n = 21) strongly agreed that they felt confident in recognizing a child experiencing mental health symptoms, 51.5 percent (n = 87) agreed, 24.3 percent (n = 41) neither agreed nor disagreed, 8.3 percent disagreed, and 1.8 percent (n = 3) strongly disagreed.

Finally, in response to the question about their confidence in their ability to intervene with children experiencing mental health symptoms, 7.4 percent (n = 7) of classified staff strongly agreed they felt confident to intervene, 28.7 percent (n = 27) agreed, 27.7 percent (n = 26) neither agreed nor disagreed, 23.4 percent (n = 22) disagreed, and 2.1 percent (n = 2) strongly disagreed. Among certified staff, 10.1 percent (n = 17) strongly agreed, 40.8 percent (n = 69) agreed, 27.2 percent (n = 46) neither agreed nor disagreed, 17.8 percent (n = 30) disagreed, and 2.4 percent (n = 4) strongly disagreed.

Analyses were conducted to determine any significant differences between the responses of certified and classified staff. Two-tailed independent samples t tests were conducted on each item, with only one item yielding a significant difference. Results revealed that certified staff (M = 3.66, SD = .876) felt significantly more confident than classified staff [M = 3.40, SD = .872, t(249) = 4.00, p = .028] in their ability to recognize a child with mental health symptoms.

Discussion

This exploratory study used a brief survey to assess the perceptions of both certified and classified elementary school staff related to their previous experiences with children's mental health training and their confidence in their ability to identify potential mental health disorders in students and intervene effectively. Results suggest that school staff generally believe they have not received sufficient training related to children's mental health. Although some staff reported confidence in their abilities to recognize and work with children experiencing mental health symptoms, many staff did not. A significant difference was found between classified and certified staff members, favoring certified staff, in their level of confidence to recognize children in mental health distress. Results and implications for training efforts are discussed below.

Survey results revealed that approximately 64 percent (63.9%) of certified staff felt confident in their ability to recognize children experiencing mental health symptoms, whereas just over half (50.9%) reported confidence in their skills to intervene with a child who might have a mental health disorder. However, less than half (41.5%) of classified staff felt confident in their ability to recognize children experiencing mental health symptoms, and only 36 percent indicated that they felt confident in intervening. A possible explanation for this reported lack of confidence is that only about 30 percent (29.6%) of certified staff and just over 20 percent (20.2%) of classified staff believed that they received adequate children's mental health training.

Further, a significant difference was found between classified and certified staff members in their reported level of confidence in recognizing children experiencing mental health symptoms. Although the difference was nonsignificant, certified staff indicated greater confidence in intervening with children experiencing mental health symptoms as compared to classified staff members. Taken as a whole, these results provide further evidence of the need for continued efforts to increase mental health literacy among teachers and other school staff. Moreover, greater inclusion of school support staff members, such as paraprofessionals and teachers' aides, in training efforts is needed. School support staff likely work with and/or encounter students in situations where mental health needs may be revealed. Recent evidence has also indicated that the most successful mental health interventions adopt a whole-school approach. Thus, involving all school staff is critical to the success of these intervention efforts (Wells et al., 2003).

Study Limitations

Several noteworthy limitations exist in the present study. First, the sample of respondents was drawn from an elementary school in the suburban Midwest; therefore, their perceptions regarding previous training experiences and confidence in their ability to identify and intervene with children experiencing mental health disorders may not be reflective of school personnel in other locations across the country. Second, participation in the survey was voluntary and therefore those choosing to participate in the survey could differ in some meaningful way from those choosing not to participate. Third, this study is exploratory; thus, no definitive conclusions can be drawn. Fourth, several measurement issues are key considerations when interpreting these results. The items used in these analyses were developed for the present study and were not subjected to any psychometric testing beyond an examination of internal consistency. These items also may not be reflective of the staff's current levels of mental health literacy. Thus, conclusions regarding this sample's level of mental health literacy cannot be made.

Implications for Social Work Practice

Despite these limitations, the results of this study have several noteworthy implications for school social work practice. In principle, because educational staff report a general lack of confidence in their ability to identify children who may be experiencing a mental health disorder and intervene appropriately, it is reasonable to assert that targeted training efforts to increase their mental health knowledge could result in increased confidence. Consequently, increased confidence could lead to appropriate intervention, thus reducing some of the negative outcomes frequently experienced by children with mental health issues. This support might then reduce out of classroom time and behavioral problems that impede the learning environment, thereby improving the academic outcomes. Moreover, given the universal access to youth in schools, teachers and other school staff play an important role in communicating with parents about their children's needs. It is likely that enhancing self-efficacy among school staff may help to improve communication with parents on behavioral and mental health needs for children. Such improved communication could result in increased referrals and access to mental health services.

To that end, school and clinical social workers, with their shared person-in-environment perspective and training in providing interventions from the micro to macro level, are in an ideal position to play a leadership role in efforts to enhance school employees' mental health literacy. A variety of approaches may be useful. For example, intervention strategies may range from the interpersonal level to improve individual mental health literacy up to broader school and even community level efforts to create a more positive school mental health climate, reduce stigma, and increase identification and treatment access for children with mental health disorders. It is important to note that these efforts are not intended to qualify school staff, whether acting in a classified or certified capacity, to act as mental health professionals and make diagnoses. Instead, the goal of such training is to increase general understanding of children's mental health disorders among school staff and enhance their ability to identify children experiencing mental health distress so that the appropriate level of services by licensed mental health professionals can be accessed.

At the interpersonal level, psychoeducation has demonstrated effectiveness in increasing understanding of mental health diagnoses and care management. Typically used with children and their families, psychoeducation provides training regarding how to cope with a particular diagnosis, emphasizing the unique strengths and skills of the child and family (Fristad, Goldberg-Arnold, & Gavazzi, 2003). In the role of consultants, school social workers can provide individual education to teachers and other school staff, in addition to the child and family, regarding how a child's diagnoses may affect his or her classroom performance and behavior, as well as how to manage that behavior. Through the use of psychoeducation, school social workers can also reduce misunderstandings about a child's disorder and increase empathy, thus reducing stigma.

At the broader level, training interventions have been developed to increase mental health literacy about children's mental health disorders. However, these interventions have not been extensively tested in school settings. Of note, because previous research has discovered that they are an important resource for addressing the emotional, mental, and behavioral needs of students (Early & Vonk, 2001; Franklin, Kim, & Tripodi, 2009), particularly in collaboration with classroom teachers (Lynn, McKay, & Atkins, 2003), school social workers have assumed a vital role in mental health literacy efforts. Therefore, school social workers may similarly play an important role in staff training efforts (Kelly et al., 2010). In fact, previous research has noted the success of educational workshops targeting knowledge, attitudes, and beliefs within the context of child abuse prevention when delivered to school staff by school social workers (Abrahams, Casey, & Daro, 1992). Moreover, Kelly and colleagues have observed that building the capacity of schools, via professional development for school staff, is a key school social work function.

An important role for school social workers, identified by previous research, is not only supporting the emotional, mental, and behavioral needs of students (Early & Vonk, 2001; Franklin et al., 2009), particularly in collaboration with classroom teachers (Lynn et al., 2003), but also building the capacity of schools via professional development for school staff (Kelly et al., 2010). As noted above, educational workshops to prevent child abuse have been found effective when delivered to school staff by school social workers (Abrahams et al., 1992). Thus, considering ways in which school social workers can promote mental health literacy among school staff may be an important future direction for school social work practice and research.

One such intervention, Youth Mental Health First Aid (YMHFA), has recently been adapted from its original Australian model and is being disseminated in the United States. A cluster randomized controlled trial of YMHFA modified for teachers was recently conducted in Australia and revealed promising results (Jorm et al., 2010). These results revealed that teachers who received the YMHFA training had significant gains in mental health knowledge that persisted six months later. Further, students reported that trained teachers were more likely to provide them with mental health information. Although no definitive conclusions can be drawn on the basis of one trial, these results are encouraging and suggest that targeted training may be used to increase school professionals' knowledge of children's mental health and boost their confidence in assisting a student with a mental health disorder. It remains unclear if increased knowledge and confidence alter actual behavior, however. In an effort to increase the likelihood of successful intervention efforts, school social workers would benefit from specialized educational training that prepares them for coordinating efforts with clinical social workers, school staff, students, and their families. Through these efforts, social work stands to make a significant contribution in advancing mental health intervention and supports in school settings consistent with several national initiatives.

Conclusion

As the rates of children and youth experiencing mental health disorders remain high and create detrimental outcomes, national policy initiatives prioritize mental health identification and services in the schools. However, such policies cannot be fully effective if school personnel lack sufficient knowledge or mental health literacy to be confident and active participants in the identification, referral, and treatment process. The findings of this study, though limited, reinforce previous results indicating that school staff lack knowledge of children's mental health and feel insufficiently prepared to address children's mental health concerns in school settings. Additionally, these results enhance our understanding of potential targets via staff training to improve school staff's abilities to address student mental health challenges. Enhancing the confidence of both certified and classified staff members will increase the likelihood that they can effectively support children experiencing mental health symptoms. The inclusion of classified staff members is a strength of this investigation because these staff may also come into regular contact with children experiencing symptoms of mental health disorders. Therefore, efforts to respond to the self-reported need among educational personnel to raise mental health literacy among all school staff should be given top priority and school social workers are in a prime position to guide these efforts.

Susan Frauenholtz, MHRIR, MSW, is a doctoral student at the University of Kansas School of Social Welfare, Lawrence, KS. Anne Williford, PhD, is assistant professor and Amy N. Mendenhall, PhD, is assistant professor at the University of Kansas School of Social Welfare.

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Table 1. Demographic Characteristics by Classified and
Certified Staff Status

                                Classified staff     Certified staff

Participant (n)                        85                  166
  Age
    M                                46.46                41.96 **
    SD                                9.35                11.15
  Gender
    Male                              6.4%                 5.4%
    Female                           93.6%                94.6%
  Ethnicity
    African American                  3.2%                 1.2%
    Latino/Hispanic                  13.8%                 4.2% **
    Other                             4.3%                   0%
    White non-Hispanic               70.2%                92.2% **
    Declined to answer                8.5%                 2.4%
  Number of years at school
    M                                 5.33                 7.16 **
    SD                                4.08                 4.73
  Highest level of education
    M                                 3.04                 4.83 ***
    SD                                1.22                  .38

* p < .05; ** p < .01; *** p < .001.

Table 2. Children's Mental Health Training and Self-Efficacy
Beliefs by Classified and Certified Staff Status

                                        Classified    Certified
                                           staff        staff

I am confident in my ability to
recognize children experiencing
mental health symptoms.

   M                                        3.4          3.66 *
   SD                                        .876         .872

I am confident in my ability to
intervene with children experiencing
mental health symptoms.

   M                                        3.18         3.39
   SD                                        .996         .977

I have received adequate training
to work with children who have
mental health needs.

   M                                        2.74         2.93
   SD                                       1.058        1.085

* p < .05.
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Author:Frauenholtz, Susan; Williford, Anne; Mendenhall, Amy N.
Publication:School Social Work Journal
Article Type:Report
Geographic Code:1USA
Date:Mar 22, 2015
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