School psychiatry

School Psychiatry: Charting the
landscape of school-based
mental-health interventions.
Ramkumar G S
Psychiatry Specialist
Carithas Hospital, Kottayam.

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Outline.
• Outlining what is already happening in the
school-setting around us.
• Review-series published this month in
Lancet-Psychiatry on school based mental
health interventions and other literature.
• Critical focus on some local interventions.
• Summarising discussion points.

Dr Mina Fazel,
Department of
Psychiatry, University
of Oxford
Slide 3 of 76

• Critically overview of local interventions.
Slide 4 of 76

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The ecology of mental health services in School context
DMHP. The “Thalir’ program from
TVPM.
Other prog. with mental health
components….LEAP, Dial A doctor
Health sector
Life skills education module by state
education board (SCERT).
“Ullasaparavakal”
‘Souhrida club' project of higher
secondary education dept.
Sarva Shiksha Abhayan (SSA) for
primary education and (IEDC) for
integrated education of disabled
children.
Special schools.
Education sector
“Clean Campus, Safe Campus” …by
Home ministry ..
NGOs
Private agencies
Buds schools -Kudumbashree
Other sectors
Psycho social service program for
adolescent girls……by SJD (Social
justice)
DEICs –District early intervention
centres
Social sector

Lancet-Psychiatry review “Back to school”
Slide 7 of 76
Oct 2014.

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Background.
• The number of school-aged children and young
people experiencing mental health problems has
been estimated at between 8 to 18%.
• Series examines the unique role that schools
can play in delivering treatment for mental health
problems to children, as well as universal mental
health promotion.
• Both ethical and scientific justification for such
integration

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Challenges
• The risks of over diagnosis when universal
interventions are offered.
• Insufficient uptake of services if students
perceive that they might be stigmatised or
bullied or the services might not be of help.
• Professionals delivering new care
stategies might not ‘buy-in’ to them either.

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Review 1 on High-Income
Countries.
• Epidemiology- Point prevalence 8-18% disorders
• Disruptive behaviors and anxiety disorders.
• Primary school (4-10)….separation anxiety and ODD
• Secondary school (11-18)...generalized anxiety, conduct
disorder and depression
• ADHD and autism spectrum disorders…
• Eating disorders and psychosis increase from mid
adolescence..
• 36% at least one disorder by 16yrs..
• 40% report bullying…
• Poor relationships between teachers and pupils
• Burn out among teachers….

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School Personnel
• Improved training and support of staff within schools is
a coherent and practical model that seems feasible and
sustainable from a resource perspective and in view of
the expanding literature about the model’s effectiveness.
• Teachers are able to electively identify mental health
problems in students, making them good gatekeepers
and referral sources for mental health care
• Utilising the natural supports in schools such as special
education staff and school nurses.
• School psychologists, counselors, community mental
health teams…

• However, because of the demands placed on teachers
to support the academic success of their students,
introduction of an additional role of supporting student
mental health is less feasible unless teachers are given
sufficient training and time to do these responsibilities.
• Counsellors and social workers are more likely to
provide school-based mental health services than their
psychology or psychiatry counterparts.
Slide 12 of 76

Three Broad models of integration.
Slide 13 of 76
Lancet-review.
individuals from an
outside agency are
contracted to work within
a school,
the school includes a
mental health clinic staffed
by professionals who
deliver mental health
services,
and the school has a
health centre with mental
health as a subspecialty
Parallel in our state.
Situation in private
schools?
DMHP/SJD -
“counseling rooms” in
school
Cotton Hill School, Tvpm
has in-house doctor, nurse
under NRHM support.

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Intervention Types.
• The IOM (Institute Of Medicine) framework differentiates
between interventions that promote positive aspects of
mental health and those that address prevention and
treatment of mental disorders.
• Some interventions span mental health promotion,
prevention, and treatment.

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School strategy
• A public health and tiered approach which balances
intensity and type of school strategy … includes
 universal strategies for all students,
 followed by interventions to assist selected students who
face particular risks,
 and finally a tier with treatment interventions for those
with the greatest needs
• The ultimate aim is to promote student wellbeing,
prevent the development or worsening of mental health
problems, and improve the effectiveness of education.

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Promotion
• In whole-school and classroom- based interventions,
universal promotion programmes are often delivered by
the school’s own staff and are done in both primary and
secondary schools
 “MindMatters” in Australia
 “I Can Problem Solve” and “Good Behavior Game” in
USA
 Positive Behavior Interventions and Supports (PBIS)
offers a framework for multitiered interventions.

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“Mind Matters”
• Strategies to help students include
 social and emotional learning programmes,
 increasing students’ connection to school,
 building student skills in understanding
 and management of emotions,
 effective communication,
 and stress management.
• Teachers participate in various professional
development opportunities to support their learning in
these curricular domains

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Prevention
Three-tiered approach
• universal,
• selective,
• and indicated interventions.

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Universal Prevention.
• Universal approaches have been studied for a broad
range of presentations,
 including behavioural management,
 risky behaviours,
 and mood and anxiety disorders
• A wide range of universal interventions have been tried
in schools in children of various age ranges, and with
various therapists and therapeutic modalities such as
cognitive behavioural approaches (CBT) and stress
reduction techniques.
• Several systematic reviews of CBT- based interventions
in schools have been done with a main focus on
prevention of anxiety disorders and depression

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“Beyondblue”
• One of the largest studies of universal interventions for
prevention of depression was Beyondblue.
• This study showed that an Australian classroom CBT-based
curriculum of 30 sessions delivered by teachers
did not reduce levels of depressive symptoms in
adolescents.
• This result might emphasise the difficulties faced in
attempts to implement large-scale school-based
universal interventions, with training of teachers in a
new technique, and with engaging of adolescents in
prevention programmes.

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Selective Prevention
• Interventions to decrease substance misuse in adolescents who score
highly on certain personality measures, suggesting an increased risk of
problems with substance misuse.
• The interventions promote
 awareness of personality- associated cognitive distortions
 and alternative coping strategies,
 and ultimately reduce development of some problem behaviors.
• Prevention programmes are often delivered in classrooms or small
groups—eg, the Coping Power Program for students at high risk of
aggressive behaviours, drug misuse, and delinquency.
• An evidence base is also emerging for provision of school-based services
to specific populations, such as young people from low-income urban
regions and refugees.
• Evidence for selective school-based prevention and early intervention
programmes is strong for specific behavioural difficulties, for students with
risks (such as parental divorce), and for students with anxiety or
depressive disorders

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African white…

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Indicated prevention
• Many studies have assessed indicated
school-based programmes for anxiety or
depression, deliberate self- harm, and
post-traumatic stress disorder.
• Indicated programmes generally show
stronger outcomes for depression and a
greater reduction in symptoms of
depression than universal or selective
programmes

Community based mental health treatment in
Slide 24 of 76
schools…
• Consultation in mainstream schools by mental health specialists can assist
with case conceptualisation, differential diagnosis, or considerations for
community care.
• Some schools employ or have links with community-based partners to
provide on- site individual, family, and group treatment for students with
identifi ed problems such as anxiety, depression, disruptive behaviour
disorders, and traumatic stress.
• Intensive treatment often takes place during the school day, which can be
more time effi cient for both students and parents.
• Increasingly, school-employed staff are enhancing their capacity to deliver
specialised mental health treatment for students.
• A study of interpersonal therapy given in school-based health centres
showed that the therapy eff ectively treated adolescent depression.
• Additional service developments in schools include treatment of serious
emotional disturbances and reduction of the duration of untreated
psychosis.

Community based mental health treatment in
Slide 25 of 76
schools…
• Special educational schools or classrooms (for
children with severe emotional and behavioural
di ffi culties) are at one end of the range of
mental health needs in schools and are found to
variable extents in high-income countries.
• Such establishments might have a high
proportion of children with both treated and
untreated mental illness. Alignment of these
schools or classrooms with community mental
health services is often needed, but not
universally available.

Gaps in research and challenges in
Slide 26 of 76
implementation.
• research on fidelity of treatment…..
• embedded process assessments…
• cost effectiveness…
• Additionally, not all interventions done in
schools have produced positive results
and the potential for adverse effects from
psychological interventions should be
acknowledged and monitored.

• Development of the scientific base is important
to avoid the typical trajectory of mental health
practices in schools, commonly characterised
by incomplete implementation, restricted
sustainability, and narrow spread.
• Poorly assessed interventions are often used in
schools, and when schools do use evidence-based
Slide 28 of 76
interventions, they are often
implemented with poor fidelity.

• A common barrier to the implementation of evidence-based
interventions in schools is poor engagement of all
levels of school staff —ie, teachers, counsellors, and
support staff .
• A challenge for both research and practice will be to test
strategies to implement and sustain integrated whole-school,
Slide 29 of 76
classroom-level, and individual-level
interventions.
• The EPIS model (exploration, preparation,
implementation, sustainability) identifies different
implementation phases and aspects of the outer and
inner context that are salient at different phases.

• Service systems that support educational
and mental health promotion, prevention,
and treatment are administratively,
legislatively, and politically separate.
Slide 30 of 76
Health
sector
Education
sector
Others
Social
sector

• Tensions between mental health and other
school priorities have prevented some schools
and education services from placing resources
in mental health provision.
• Agreement about which entity or organisation
owns or is responsible for mental health
services (schools vs the community) is a debate
that is being replaced by models of shared
ownership
• Improved collaboration between education and
health sectors would be enhanced by mutual
contributions to basic professional training.
Slide 31 of 76

Review2- Low income countries
• A key systematic review of mental health
promotion interventions in LMICs, but
because no similar reviews exist for
prevention and treatment interventions,
Slide 32 of 76

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Teachers?
• The capacity to manage any additional child needs
within the LMIC school context will need to address the
potential burden on school staff who have few oppor-tunities
for professional development in the face of the
challenges of teaching in low-resource contexts.
• This absence of development might, for example, make
teachers less equipped to manage the emotional and
behavioural diffi culties presenting in their classrooms
unless properly supported and could signal the need for
non-teaching professionals to deliver mental health
interventions within schools.

• Compared with their high-income counterparts, children in LMICs
are likely to have some broad differences in risk exposures and
protective factors for psychological difficulties
• Unfortunately, Schools can sometimes be places where
 children experience abuse and violence, either from peers, teachers,
Slide 35 of 76
or outside groups..
 example, peer and teacher victimisation
 and bullying,
 corporal punishment,
 and sexual abuse have all been reported within the school context,
 and forced recruitment of children into armies has also been seen.
• School cannot necessarily be assumed to be a safe and healthy
place for children

• Data suggest that bullying in school is
widespread across many LMICs
Slide 37 of 76
• school refusal?

• Fewer systems are in place in LMICs than
HICs to support the increasing number of
children who are surviving with physical
disabilities and neurodevelopmental
disorders,
• including autism spectrum and learning
disorders, many of whom might have
additional difficulties in school
Slide 38 of 76

School models in LAMICs
• Models in LAMICs have used peer and community-based partners,
the internet, cash incentives, and extra- curricular activities.
Slide 40 of 76
• Health-promoting schools (HPS) represent one of the most
prominent of these strategies, adopted by schools worldwide and
promoted by international organisations such as WHO. HPS
represent a holistic whole-school is supported by improvements in
the physical and social environment of the school, and a school
ethos that supports such activities.
• Schools adopting the HPS framework have shown better child
emotional and physical health. The HPS framework also has the
potential to develop a mechanism of closer integration with
healthcare systems

• Barry and colleagues despite the large number of
interventions in use worldwide, only 14 studies from
LMICs satisfied their inclusion criteria.
• Robust evidence exists that mental health promotion
interventions have positive effects,which are improved
with increased structure and duration
• School-based interventions were mainly trying
 to prevent anxiety,
 depression,
 or negative sequelae after exposure to potentially
Slide 41 of 76
traumatic events.
• Three studies reported negative effects of the
interventions done

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• whole school approach for lifeskills and resilience…
• Both universal and selected interventions have been shown to
• successfully reduce symptoms of PTSD; however, more
• caution needs to be used for other disorders.
• These disorders include behavioural difficulties in primary school
populations and depression and anxiety disorders, which have a
greater prevalence in secondary school populations.
• Delivery of mental health interventions in schools can potentially
draw on
 Professionals including school counsellors and teachers,
 and lay community members
 and student peers;
• the studies available show the diversity of people who have
delivered these interventions.

Life skills education in LSMICs (not part
Slide 43 of 76
of the review)
• NIMHANS module develpoed by WHO
aid.
• Unicef also promote life skills deucation in
schools.

• Gaps in knowledge also exist with regard to
how best to translate HIC evidence into policy
and practice in LMICs.
• as against PTSD….authors have called for a
stronger focus on the importance of ongoing
(daily) stressors for mental health, such as
domestic violence, chronic poverty, and social
exclusion, which are seen, to varying degrees,
in many diff erent LMIC communities.
Slide 44 of 76

• In LMICs, however, the role of teachers needs to be considered in a
Slide 45 of 76
broad context.
• Constraints with use of teachers exist because of the many roles
they need to play in low-resource settings. The importance of
teachers as a local resource has been further emphasised because
some have been trained to deliver psychological interventions even
outside of the school setting.
• However, the School HeAlth Promotion and Empowerment
(SHAPE) programme intervention has shown how lay community
members can be trained to deliver eff ective health promotion
interventions in schools.
• Role of the field of humanitarian mental health.

• Similar to evidence from HICs suggests
that teachers can successfully deliver
many different mental health promotion
interventions, although further evidence is
needed to assess teacher-delivered
preventive interventions.
Slide 46 of 76

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Research gap
• How schools in LMICs can reach out to families
suffering economic distress and domestic violence in a
non-stigmatising way; parent–teacher associations can
promote communication.
• About children’s mental health; and schools can promote
reconciliation between peers of previously warring
ethnic or religious factions.
• A need therefore exists to assess school-based
interventions not only as standalone approaches, but
also as components of multilayered interventions
addressing broad social complexities

• Success in studies adopting a common-elements and
transdiagnostic treatment approach provides promise
for and relevance to development of potential
interventions for children in LMICs.
Slide 48 of 76
• These approaches have, for example, used lay
counsellors to deliver flexibly tailored treatments, with
options open to the counsellor to address depression,
traumatic stress, anxiety, and substance misuse,
dependent on what each individual presents

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Outline.
• Critically focus on some of local
interventions.

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The ecology of mental health services in School context
DMHP. The “Thalir’ program from
TVPM.
Other prog. with mental health
components….LEAP, Dial A doctor
Health sector
Life skills education module by state
education board (SCERT) …..
“Ullasaparavakal”
‘Souhrida club' project of higher
secondary education dept.
Sarva Shiksha Abhayan (SSA) for
primary education and (IEDC) for
integrated education of disabled
children
Special schools..
Education sector
“Clean Campus, Safe Campus” …by
Home ministry ..
NGOs
Private agencies
Buds schools -Kudumbashree
Other sectors
Psycho social service program for
adolescent girls……by SJD (Social
justice)
DEICs –District early intervention
centres
Social sector

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“Thaliru” DMHP
• ‘Thalir’ is a “targeted intervention” programmes launched
by the DMHP in the district. It has covered over 22,000
students in 112 schools. The programme aims at
 the holistic development of schoolchildren
 by making them aware of the importance of mental health
 along with physical well-being,
 offering them counselling,
 and addressing behavioural issues.
• The programme works in “coordination” with the
Adolescent Reproductive and Sexual Health programme
and the School Health Programme being implemented in
schools by the National Rural Health Mission.

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Thaliru
• “We train school counsellors and School Junior Public Health Nurses to be the link between
students and teachers and the DMHP unit. Thalir is implemented as a total package for teachers,
parents and students,” says P.S. Kiran, nodal officer for DMHP.
• Focus areas‘Thalir’ focusses on addressing
 behaviour and emotional issues among children,
 helping them stay away from substance abuse,
 suicide prevention,
 stress management,
 life-skills education,
 and also managing childhood problems like learning disability and conduct disorder.
• Students are encouraged to seek help from school counsellors.
• As part of scaling up the programme across State, counselling ? centres will be opened in 1,926
schools this year.
• Private schools have not been excluded from the programme, though government schools will
have the priority.
http://www.thehindu.com/news/national/kerala/school-mental-health-scheme-in-all-kerala-districts/
article5913077.ece

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SCERT curriculum
• SCERT has developed and published “life skills modules” titled
'ullaasaparavakal' for standards 1 to 12.
• Seperate modules are available for each standard and yearly 20 hours are
supposed to be devoted to life skills.
• Ullasaparavakal is primarily intended
 as a health and attitude promotion tool,
 but since it also addresses specific issues like substance abuse,
 healthy diet,exercise ,
 learning techniques etc.
 it can also serve as a prevention tool in selected indications.
 it can help in early identification and intervention too.
 it will help to shape up an younger generation who may have much more
clear ideas about health and mental health in our society where culture
bound superstitions exist.
(as communicated by the lead resource psychiatrist who contributed to
developing the module)

Psycho social service program for
Slide 55 of 76
adolescent girls… SJD
• Counsellors(500)…….started as central program
now under state plan budget…
• Evaluation study done …(suggests community
integration and home based provisioning)
• One teacher in each schools given training in
counseling…
• Adolescent clubs in anganwadis
• Family counseling centers under domestic
violence act…..
• District level monitoring has a psychiatrist
included.

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From the news…..
• “Counselling is not compulsory in government
schools but we’ve decided to engage the
services of a counsellor realizing its positive
effect, especially during exams. However, we
found it difficult to get a qualified child
psychologist despite out best efforts”, said Gracy
Joseph, Principal, SRV Government Model High
School.
http://archives.deccanchronicle.com/130312/news-current-affairs/
article/schools-dire-need-counsellors

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From the news..
• According to Dr Gracy Thomas, chairperson of the Adolescence
Committee of Kerala Federation of Obstetrics and Gynaecology,
Thiruvananthapuram and Ernakulam are the only districts in the
state where regular counselling sessions in schools are conducted.
• “Only the adolescent counselling classes organised by the
Directorate of Higher Secondary Education are compulsory in state
schools. These classes, conducted by a physician, a psychologist, a
paediatrician and a gynaecologist, take care of only higher
secondary students, but under-15 students are subjected to more
sexual atrocities”, said Dr Thomas.
• There are also demands to introduce the post of a permanent
counsellor in all institutions, including government, aided and
unaided schools.

• The priest, who has been working to protect the rights of
juveniles in the state said the government has to co-ordinate
Slide 64 of 76
the counselling programmes of different
agencies to get the maximum output.
• “We have counselling sessions organised by the Mental
Health Programme, National Rural Health Mission and
similar agencies. But there are no review meetings
between these agencies to discuss which schools were
covered and what the topics dealt with were.
• Also, we need a scientific study of the needs of Kerala
children”, Fr James added.

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Action plan in 2013
• An action plan for effective counselling in schools across the state to
prevent suicides and all forms of abuse among children is all set to
be rolled out by a state government expert committee that held a
consultative meeting with UNICEF officials.
http://timesofindia.indiatimes.com/city/thiruvananthapuram/Plan-for-effective-student-counselling-ready-to-roll-out/
articleshow/11040704.cms
• "The action plan aims at
 accreditation and appraisal of the present counsellors,
 prioritizing systematic training to the counsellors
 with massive orientation programme for teachers and parents before
counseling children”
Based on the action plan, it is mandatory to have well-equipped
student counselling centres in all schools, be it state syllabus,
central syllabus-based, aided or unaided schools, across the state
by April 1, 2013, Lida Jacob said.
•

• Based on recommendations by educationists and social activists at
the expert committee meet, the student counsellors will be renamed
as 'guidance teachers' or 'mentors', she said.
• "Already, the government has set up counselling centres in 500
schools of the state. Additionally, such centres will be set up in 700
schools across the state with upgradation of facilities and by
improving the functioning of existing counsellors," said Maj Dinesh
Bhaskaran, regional director of the Kerala Social Security Mission
(KSSM).
• That would also include the government plan to reappoint more than
1,000 protected teachers as guidance teachers after providing them
a course in counselling, he said.
Slide 66 of 76

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From the news…
• Child Development Centre director M K C Nair said the government is
expected to take a proactive stand through effective student counselling for
the holistic development of the child.
Childline, Trivandrum founder director Fr Phillip Parakkat said the school
counselling system needs to be established with a multi-link development
programme. The system should take on board a life skills and personality
development trainer, a psychotherapist, counsellor teacher and parents who
should be given periodic orientation sessions.
Kerala Anti-addiction Committee president Rajan Amboori said awareness
needs be created among children on substance abuse at an early age
before they get habituated to chewing gums, paan, tobacco products and
alcoholism.
http://timesofindia.indiatimes.com/city/thiruvananthapuram/Plan-for-effective-student-
counselling-ready-to-roll-out/articleshow/11040704.cms

• “There are hundreds of protected teachers who
are paid remuneration by the state but are out of
schools with lot of time to spare. We could give
them training and make use of their service for
the counselling programme,”
Slide 68 of 76
• “The peer support system should be
implemented under strict supervision,” said M K
C Nair, director of Child Development Centre
who also threw light on the desirable changes in
the role of school counsellors

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From the news
• Counsellors should be seen at par with teachers, their
pay should be decent, their training should be planned,
infrastructure should be provided in schools to
accommodate their service and basically there should be
an accreditation/screening process to recruit them, the
meeting opined.
• Lida Jacob said
 protected and the retrenched teachers need to be given
a certificate course in counselling.
 After that, the teachers should be reinstated by the
government as counsellors or guidance teachers in
schools
 with a decent salary and not just an honorarium.
http://ibnlive.in.com/news/school-counselling-system--to-be-
strengthened/210315-60-116.html

Childen with special needs.
Slide 71 of 76
• Buds schools….Kudubashree
• Special education schools….all private, now
getting aid from government.
• Sarva shiksha abhyan (SSA) integrated
education for children with special needs…..
• Natural supports in regular schools….
• Adolescent Reproductive and Sexual Health programme (ARSH)
• NRHM….School health Program,

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Disability
certification in
SLD

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Summary.
• There is ethical and scientific justification for
school-based mental health services.
• Emerging evidence base. More rigor is emerging
in the conceptualisation of school based mental
health services (eg. IOM frame work)
• Components in the interventions need to be
cleared defined even if it is multi pronged.
• Research gap/ implementation research, fidelity
to program ingredients. Evaluation.

• A lot of activity happening in our state.
• I have tried to give an overview of the various actors
Slide 75 of 76
involved and the contours of the landscape.
• There is hardly any evaluation of activities. one
exception was evaluation of the Psycho social
adolescent scheme for girls by SJD.
• Duplication, overlap, wastage, and lack of coordination.
• Issues in our state are a mix of what is noted in high
income and low income countries. Local research?
• Need exploration about interventions in private schools?
Role for private-private partnerships?

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• Discussion and comments.

School psychiatry

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