 
Week 2 - Healthy School Communities
|  | Mental Health in Schools:
Identification and Management of 'At Risk' Secondary Students |
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Listing of Papers | |
MS KERIN WILLIAMS
South Australia, Australia
THE TEENAGE YEARS are often ones of challenge and great joy. But for others they represent a period of great sadness and for some this is the time when the onset of mental health problems can occur.
Secondary schools can do a lot to reduce the onset of mental health problems by putting in place preventative strategies and making schools mentally healthy places for students.
- Twenty percent of all children and adolescents in Australia are affected by mental health problems, with half of these showing impaired schooling and social development.
- It is estimated that one in five Australians will experience a mental illness at some stage in their lives. This will vary from mild or temporary to severe and prolonged.
- Depression is the most common mental health problem for young people, with up to 24% having an episode by age 18. If depression in young people is not accurately diagnosed and treated, it can cause more harmful effects later in adult life. Depression in adolescence can put a young person at greater risk of suicide and self-harm.
- Behavioural and mental health problems of depression, suicidal behaviours, eating disorders and the abuse of alcohol and drugs have increased in young people.
- Students with mental health problems are five times more likely to have below-age academic competence when compared with students who do not (42% compared to 13%).
- Self-esteem problems and major depression are among the key health concerns identified by young people themselves.
- The World Health Organization has estimated that depression alone will constitute one of the greatest health problems worldwide by the year 2020.
Need for Deliberate Strategies
There is increasing awareness that schools can engage in deliberate strategies to build a secure and supportive school environment and to promote health enhancing attitudes and behaviours. In addition, there is awareness that mental health problems in students are associated with higher rates of truancy, suspension, exclusion, school alienation and lower educational achievement. Child and adolescent mental health problems are frequently first identified at school and parents with concerns about their children are likely to consult teachers and other student services as their first step in seeking help.
There is also evidence that mental health problems in childhood and adolescence are associated with heightened risk of mental illness in adulthood and increased vulnerability to a range of other problematic health and education outcomes. Early detection and intervention with young people who exhibit signs of mental health problems can stave off more serious problems in adult life.
Despite mental health problems being reasonably common, the stigma, and worrying about 'what people will think' about them, can mean that young people or their families keep problems a secret and fail to seek help.
Redefining the Stereotype
Schools can play a large role in challenging and redefining the stereotypes about mental health and mental illness held by the general community, and in assisting with the identification of students who are vulnerable to a mental health problem.
The confronting behaviour demonstrated in the classroom or the schoolyard or the problem the student presents with to the school counsellor may, in fact, indicate a deeper mental health issue or a traumatic life experience.
Everything that occurs in a person's life has some impact on their mental health. The kinds of issues negatively impacting on a young person's mental health and well being are:
- experience of loss/failure;
- substance abuse;
- sexual, physical, emotional abuse;
- body image;
- violence;
- bullying;
- isolation/loneliness;
- anxiety;
- range of emotions (e.g., anger, depression);
- stress;
- a sense of worthlessness;
- poor self-image;
- a feeling of having no future;
- family conflict;
- relationship problems; and,
- learning difficulties.
So when a teacher encounters a student exhibiting any of these signs, he or she must consider their 'risk' status.
What Do We Mean by the Term 'At Risk'?
'At risk' is usually understood as being in danger to yourself or to others or in danger of exploitation. Therefore, young people can be at risk through their own acts, or at risk from others, or at risk to others. One of the most frequent and serious reasons for young people being 'at risk' is because they suffer from depression and/or suicidal ideation.
Depression
Depression is a serious yet common illness that attacks the mind and the body at the same time. It affects up to 20% adolescents. Fifty per cent of those have one episode and never have a recurrence. Six per cent will develop a major disorder and from that six per cent, fifteen per cent will commit suicide.
Depression is the single most significant risk factor for suicidal behaviours. Clearly, this is why, as a society, we need to be able to recognise young people who are struggling and have appropriate methods of communication for referral to a suitable professional for assessment and management.
Depression is grossly under-recognised in young people. The reason for this is that adolescents' symptoms are often masked or not acknowledged; behavioural indicators often being labelled as 'just a bad case of adolescence' or 'a stage they are going through' . This is often because parents and teachers do not recognise behaviours seen at school or in the home as a sign that the young person is finding life difficult. Signs of depression include:
- sleep disturbance;
- appetite disturbance;
- loss of interest or pleasure;
- decreased energy;
- agitation;
- sense of worthlessness or guilt;
- impaired ability to think (poor concentration and memory);
- irritability;
- brooding;
- obsessive thoughts;
- anxiety;
- phobias;
- tearfulness;
- excessive worry about physical health;
- complaints of pain (headaches, stomach pains); and,
- for some, the extreme end of a depressive illness is suicide.
Not Out of the Blue
Suicidal behaviours do not occur out of the blue; they occur in the context of community problems, family dysfunction, poor parenting, academic failure, interpersonal difficulty, and all kinds of abuse and recent loss. Many of the risk factors are similar to the list of those issues that negatively affect a young persons' life or for the symptoms of depression. There is no single explanation, no single personality structure nor any single social reason that predisposes to suicidal behaviour. Suicide is a multi-dimensional problem.
Although suicide rates are alarmingly high in this country, with the figures for the 15-24 year age range being 16.4 per 100,000, suicide is still a relatively rare event. It is difficult to predict, as there are so many variables, including the fact that individuals cope with life events differently. However, research has consistently identified four factors that distinguish suicide 'attempters' from other young people. They are young people whose lives are plagued by:
- social and emotional disadvantage;
- unhappy, dysfunctional families;
- recognisable mental health or adjustment disorders; and,
- a life event that is perceived as stressful just prior to a suicide attempt, which commonly revolves around the breakdown of a significant relationship.
Signs that may indicate suicidal behaviour in a young person include:
- anxiety;
- obsessional behaviours;
- impulsivity;
- loss of control;
- physical, sexual, alcohol, drug abuse;
- knowledge of death of a friend, relative from suicide;
- demographic;
- lack of family closeness;
- parenting style; and,
- academic pressures.
What is the School's Role in Dealing with Mental Health Issues?
The school's role is fundamentally about good mental health promotion. The provision of a safe and supportive learning environment, where personal skills are enhanced by including modules in the curriculum that promote positive attitudes, coping strategies and healthy life options, with the encouragement of help-seeking behaviours are advocated. Students need the provision of a pastoral care and counselling service, as well as being informed about support services they can contact themselves. The school has a responsibility to develop and maintain effective partnerships with community. Within the school, there should be processes for notifying welfare staff about worrying statements or behaviours.
A School Community that Takes Action
A health promoting school is a school community that takes action and places a priority on creating an environment that will have the best possible impact on the health of students and staff, and recognises that a broad range of factors influence our health. These factors include the physical and the social environments. A health promoting school aims to create an environment that is safe, stimulating, satisfying and enjoyable for all. The desired effect is to positively link the student with the family, the school, and the community, through the formal school curriculum, the school atmosphere and making the learning that occurs at school practical and relevant to what is happening in the wider community.
Programs which incorporate a whole-of-school approach to promoting a safe and healthy environment are a first step in the prevention process. Policies to sit alongside this education, so that the best pathways to care are established, are considered essential to augment the process described.
Teachers are known to lack confidence when dealing with mental health issues, therefore inservice education and a whole-of-school approach is essential in order to obtain better outcomes for students. Teachers need to feel comfortable in their working environment, realising their important role in shaping the lives and attitudes of the students they come into contact with.
Discussing Suicide in the Classroom
The topic of suicide is considered interesting and topical and frequently arises as a subject for discussion in the classroom. The advice is not to undertake a specific 'suicide awareness' unit or to make suicide a focus for research or project work. However if, for example, the subject arises in an English text, it is not appropriate to dismiss the issue without any meaningful attention being given to it. Attention in class to the issue of suicide can be distressing for those with suicidal ideation and may make the option more viable for vulnerable students.
Avoid increasing knowledge of means/methods during any conversation on the topic and attempt to debunk myths surrounding suicidal behaviour, especially the romanticism of death by suicide.
What Can Schools Do to Help 'At Risk' Students?
Assisting 'at risk' students means adopting a whole school approach to mental health promotion (Health Promoting Schools Framework), where the students' well being is viewed holistically and they are encouraged to involve themselves with a school where they are encourage and supported as individuals. They participate in the learning process in an environment that is safe, and the curriculum is designed to incorporate all kinds of subjects.
Good communication channels within the school are important in the identification and support for students at risk. By sharing concerns in a respectful manner, it is often possible for teachers to collectively put the various clues to the 'jigsaw' together, thus detecting a student requiring support.
If policies and guidelines are in place, they serve to provide direction to deal with a range of issues that arise in any school, e.g., bullying and harassment, grief and loss, critical incident management, drug and alcohol rules, etc. These policies assist staff in defining their roles and responsibilities, which enable them to manage a crisis with greater efficiency. It is necessary to review these policies to keep pace with changing management structures and relate experience to policy review and practices.
What Should Teachers Say?
School staff ask what they should do, and what they can say to a student they are concerned about. Do they come right out and say, 'What's wrong?' or more importantly, if they have heard or suspect the student to be in imminent risk, do they say, 'Are you thinking of killing/harming yourself?'
The guiding principles are as follows:
| seek to gain students' trust; |
| show interest and concern; |
| be sensitive to their thoughts and feelings; |
| don't judge the nature and severity of the problem; |
| ask if they are thinking of hurting or killing themselves; |
| avoid debating suicide as an option; |
| inform caregivers (counsellor, parents, professionals); |
| put supervision in a safe place; |
| don't be sworn to secrecy but maintain privacy; |
| make support programs available to help deal with grief, depression or other mental illnesses or problems; |
| take any incident of self-harm seriously; |
| follow up any indication of suicidal ideation; |
| make counsellors available & accessible; |
| define help-seeking pathways for staff, students and parents pro-actively; |
| refer to appropriate professional; |
| ensure young people know how to access school and community services; |
| build links with community organizations, parents, Aboriginal and Torres Strait Islander communities and ethnic groups to provide culturally appropriate services; |
| school monitors outcome and maintains ongoing support; |
| school requests feedback/advice; |
| school assists with reintegration; |
| support peers/ friends/ siblings & others affected (e.g., staff, other vulnerable students). |
Suicide is difficult to predict but it is possible to recognise changes in behaviour and crises, and this recognition may help prevent a suicide. The way in which schools can help is to develop environments that encourage young people to share their feelings with family and friends and seek help.
The bottom line, however, is to teach young people how to cope with problems before they reach a critical stage.
MindMatters is a resource for placing mental health on the agenda in secondary schools throughout Australia. The resource kit forms the core component of the program and provides advice to schools about how to adopt a whole-of-school approach to mental health. The curriculum materials cover a number of important topics for use in pastoral care programs and in several learning areas. The topics range from a planning framework for implementing the process, understanding mental illness, a guide for preventing and addressing self-harm and suicide, dealing with bullying, loss and grief, enhancing resilience and managing challenges and change.
Schools are Not Clinicians
This does not mean that schools should take on the role of clinicians. Far from it, schools are places of learning not treatment institutions. But by reducing risk factors and taking a whole school approach to establishing a mentally and physically healthy place, mental illness problems can be reduced. The MindMatters resource will help secondary schools to formulate plans, look at what they are already doing and to include some well-researched and trialed curriculum materials where appropriate.
Not another thing for schools to deal with, I hear you say. Why do we now have to include teaching about mental health along with the plethora of new curriculum and other issues schools are meant to include in an already crowded curriculum? Many schools are already embracing aspects of this type of teaching in their curriculum or similarly managing problems with students who are struggling with academic or personal issues, and whose behaviour at school warrants special attention. Therefore, it may be merely a case of more specific tailoring of information, broadening the scope or re-framing the understanding. The curriculum materials kit is the basic resource kit which individual schools can adapt to suit their individual needs. The details of the resource package are as follows:
'School Matters'
This overarching document provides schools with a framework and planning document, and advice about possible structures, strategies, partnerships and curriculum programs to promote and protect the mental health of all members of the school community. The framework is based on the concept of a school core team working collaboratively to bring about a whole school change.
'Understanding Mental Illness'
This curriculum unit for older students aims to increase students' understanding of mental illness, reduce the stigma associated with mental health problems, and increase health-seeking behaviour. A video which accompanies the unit is useful for staff, student or school community members.
'Educating For Life'
'Educating for Life' is a guide for a school-based response to preventing self-harm and suicide. The development of these guidelines was funded as a national project under the National Youth Suicide Prevention Strategy. There was wide-ranging consultation on the development of 'Educating for Life' to ensure that it was suitable for the many different community, cultural, religious and social contexts found in our schools. 'Educating for Life' advocates a five pronged approach to the prevention of suicide:
- primary prevention, including pastoral care and personal development curriculum programs;
- early intervention to identify and support at risk students;
- crisis intervention;
- assessment and treatment - protocols for referring and reintegration of students receiving treatment; and,
- postvention - support for those affected after a critical incident.
'Changes and Challenges'
Curriculum materials have been designed to assist schools in running effective transition programs and are for use with students in their early weeks of secondary school. Three units are provided: 'Getting to Know You' for home group activities, 'Friendship and Belonging', a unit for the English class and 'People, Identity and Culture' for the SOSE classroom.
'Dealing with Bullying'
This booklet guides schools in their attempts to deal with bullying. A comprehensive checklist is a useful device for schools to check their current practice and guide revision. Three curriculum units are also included for use in English, Drama and Personal Development classes.
'Enhancing Resilience'
These materials targeted at students in Years 9-11 discuss ways schools can create a positive school culture and the valuing of school and community. Two curriculum units, 'Coping' and 'Stressbusters', are included for use in health, pastoral care or religious education contexts.
'Loss and Grief'
A sequence of lessons and advice about school practices relevant to dealing with death and loss within the school.
So how will this happen and what will schools gain? All secondary schools will be offered a complete set of the materials around May 2000. In addition, schools will have access to a two-day professional development program. This program will provide an overview of the materials and advice about strategies to create a school environment that is conducive to promoting psychosocial competence and well being. Third, a website has been established to provide ongoing support for schools.
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ABOUT THE AUTHOR
Ms Kerin Williams (BA, Grad.Dip.Soc.Sc., RN) trained as a nurse specialising in intensive care and cardio-thoracic nursing. She later studied psychology, graduating in 1993. Since that time she has been employed as a Research Officer with the Royal Australian College of General Practitioners and for the past five years has worked on several Commonwealth Suicide Prevention Strategy projects, including 'The Early Detection of Emotional Disorder Project', 'Out of the Blues' - a National Demonstration project aimed at the best practice management of mood disorders in young people, and the 'Mental Health Education and Promotion in Schools Project'.
Her work has been closely linked to schools, and she has worked in collaboration with administrators within the education sector, specialising in developing links between health and education.
She has also worked, as a consultant in crisis management in schools, for the Catholic Education Office and the Independent Schools Board, conducting inservice training and counselling for 'at risk' students. Kerin is also a registered provider of professional development on mental health issues to the Department of Education, Training and Development, in South Australia.
Her other involvements include being a Member of the Council of Governors at an independent girls' college and Chairperson of the Communications and Education Committee at that school. She is currently the National School and Community Links Officer for the National 'MindMatters' Program.
For further information about 'MindMatters', and school and community links dealing with 'at risk' students, contact Kerin Williams by email at:
kerinwilliams@ozemail.com.au
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