School Mental Health Program in India—Issues and Possible Practical Solutions

Worldwide, an estimated 13% of youth under 18 years of age have significant mental health problems.^{1, 2} Also, a significant percentage of mental health issues have their onset below 25 years of age. Globally, during this period, the children spend much of the time in school. Hence, it stands to reason that children and adolescents can be reached early in schools than in any other setting for health promotion, prevention of disease, and interventions.

School Mental Health Program (SMHP) Models Globally

Several preventive school-based mental health interventions have proven to have some level of efficacy. Some examples are the Positive Behavior Interventions and Supports (PBIS) ³ , Skills for Life (SFL)^4, and MindMatters. ⁵ Two of these interventions were developed in high-income countries (the United States and Australia), and the third (SFL) was developed in a lower-middle income country (Chile). The outcomes in all of these were positive, though the long-term outcome has to be evaluated. In addition, the School-Based Support (SBS) program was begun in the United States with the goals of increasing the capacity to recognise and meet the mental health needs of children and improve academic and social/ behavioral outcomes. ⁶

A series of SMHPs initiatives by the Australian government aimed at the promotion of mental health and prevention of and early intervention for psychiatric problems This is now a single national education-based initiative to support the mental health and wellbeing of children and young people from birth to school-leaving. ⁷ Evaluations indicated that these programs probably work best in the long run if they are integrated into the school system and run with the support of both the school management and the local community.

SMHPs in India: An Introduction

India has the largest number of children and adolescents in the world. ⁸ The Government of India has given emphasis to developmental delays and developmental disorders as part of the School Health Program under the ‘Ayushman Bharat’ scheme. This document specifically mentions behavior disorder (Autism), Learning Disorders, and Attention Deficit Hyperactivity Disorder. In the health promotion section, substance use, internet safety and literacy, meditation, and yoga are covered along with a broad category of mental health. ⁹

The Central Board of Secondary Education (CBSE) recommends that all secondary and senior secondary schools should employ a counselor and engage in psychological exercises toward building students’ self-concept, self-image, and the ability to withstand pressures. It also suggests developing a sense of curiosity in students – both of the self and the environment – as a central aspect of the learning process. ¹⁰

There have been several reviews of the Indian SMHPs that discuss the issues and possible solutions^{11, 12} Some specific issues about children in schools include their inability to seek help for themselves, their difficulty in trusting adults to help them (especially if they have had bad experiences with adults at home), and, of course, the reluctance to divulge issues in the school setting for fear of being victimised. In addition, in India, there are additional considerations of language, culture, geopolitical issues, and family diversity. This paper attempts to evaluate the current programs with a view to offer practical solutions that can be implemented more easily in order to improve outcomes.

A comprehensive review concluded that SMHP in India ‘is running with a piecemeal approach’, and for all practical purposes, it is non-existent for most school-going children. The authors opined that “the sporadic efforts (such as conducting some sensitisation program for school teachers) are praiseworthy; however, they are insufficient for a comprehensive and sustainable SMHP.” ¹³

Some Current SMHPs

The Help Desk Program under Sarva Shiksha Abhiyan (SSA) ¹⁴ offers a dropbox facility (where children can get support for their problems confidentially) and trained teachers to identify psychological issues and counselling.

The Life Skills Training Program ¹⁵ initiated by the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, involved training secondary school teachers as “life skill facilitators” for teaching life skills to students and a teachers’ orientation program in which they were taught the skills to identify psychological problems, counsel, as well as refer the students to mental health professionals (MHPs) when required. However, the Life Skills module was not implemented by schools for various reasons, including lack of human resources, interest among the school managements, and cooperation of parents and children alike.

Zippy’s friends program, adapted from the United Kingdom for use in Goa, was launched in 2004 with the partnership of a Non-Governmental Organization Sangath. Pre-schoolers (5-7 year olds) were taught problem-solving, coping, and to identify emotions, integrate emotional and language development. Teachers were trained to carry out this program in schools. ¹⁶

Unarv, in Thiruvananthapuram, Kerala, is a district-level adolescent SMHP with a three-tier approach, where two teachers from every high school and higher secondary school are trained annually through workshops. A study found that this is a sustainable model in a low- resource setting. ¹⁷

SHAPE (School HeAlth Promotion and Empowerment) program was designed by Sangath, an NGO in Goa, for 5th to 12th class students. ¹⁸ This intervention was found to be feasible and acceptable in the school setting, with positive outcomes in health-related behaviors.

Conduct of SMHP by trained lay counsellors have also been found to be well implemented, like in the ‘Strengthening Evidence-base on scHool-based intErventions for pRomoting adolescent health program’ (SEHER) ¹⁹ in Bihar, which is a low-cost approach utilising the service of a trained teacher and lay counsellor. This study found no significant differences between lay counsellors and professionals in improving social skills among adolescents.

In Kerala, in recent years, many interventions have been made available that specifically focus on the mental wellbeing of children. A review revealed over 15 programs providing mental health services at various levels. ²⁰ This included government, private, and non-government organisations. Some programs included universal prevention (e.g., Clean Campus Safe Campus that focused on reducing access to drugs; Thangu project that oriented teachers to providing psychological support; Santhavanam project that empowered parents, teachers, and students; Souhrida Clubs that provided leadership training; Ullasaparavakal that focused on life skills lessons by teachers; Thalir program that focused on sensitisation on mental health/ ill health, by mental health professionals, for parents, teachers, and children; and Nallapadam that published model student-led activities with social messages in newspapers). Some [e.g., Gurukulam Project and Our Responsibility to Children (ORC)] looked at selective prevention. This review also identified some indicated prevention programs such as the Childline program, Help Desk program, and Jyothirgamaya project. All these programs have had reasonable success, according to the authors of the review but the lacunae continue to be in the domain of human resources for sustaining the programs and the lack of inter-agency coordination in carrying out the plans.

In 2021, the Indian Psychiatric Society, Kerala Branch, launched a training program christened ‘Sneha Kavacham’ to address digital addiction, with the target audience being students, teachers, and parents. ²¹

Another review of SMH activities in Maharashtra traced its origins to the early 1930s. ²² The paper discusses various programs and facilities available for mental health education in the state, including awareness programs, camps, and early intervention. It recommends that there is an acute need to work on the existing setup and available resources by enriching SMH activities.

All the above programs had a preventive and treatment approach, with a long-term promotive component woven into some of them. Some of them have been formally evaluated for their efficacy, and it would be interesting to know the long-term outcome of these initiatives.

Possible Barriers to Implementation

Often, when students are identified in schools as potentially struggling with mental health issues, they are referred out to professionals in the community for treatment. While well-intended, this approach is largely unsuccessful if families face challenges such as language barriers, cost, lack of transportation, or lack of flexibility with their jobs leaving them unable to make appointments.

The Indian mental health system has an acute shortage of trained mental health professionals to deal even with severe mental illness. They are also mostly located in cities and larger towns, making them inaccessible to most children and families.

Schools in India are also somewhat reluctant to be involved in running these programs. The reasons may be many, such as the lack of personnel for such activities and a conflict for the school across the different roles it sets for itself. Also, not being funded for these activities gives them less motivation to conduct such programs.

Stigma is often cited as a reason for not seeking mental health treatment or fully participating in it. Other barriers such as lack of dedicated physical space, non- cooperation of the school management, the reluctance of teachers to refer children in need of help, non-availability of a counsellor regularly on campus, and lack of privacy are all possible reasons.

Some Practical Suggestions to Overcome the Stumbling Blocks

Involvement of Mental Health Professionals in SMH-Related Activities

It would be helpful for mental health professionals at all levels to involve themselves in SMH-related activities by publicising them on social media, writing articles for laypeople in the lay press, and giving talks on the radio, television, and in virtual media as well. This would play a major role in sensitising people about mental health issues and promote acceptance of consultations and treatments with mental health professionals. Often, such plans remain either as a theoretical concept in an individual’s mind or on paper as a document that records the proceedings of a meeting.

A proactive approach is needed in the form of commitment to helping schools at the individual level and also incorporating SMH into the agenda for the state, zonal, and national bodies. ²³ Physical presence of professionals may be difficult, but sharing expertise is not. Being on the advisory boards of schools and colleges could be a good starting point. Sharing of information, capacity building, and peer supports should help decrease stigma in schools as well.

Screening in Schools

A study from Gujarat concluded that mental health screening should be incorporated into the school health program protocol. ²⁴ Such screening needs to be done with the involvement of the family, school, and community and requires a transformed mental health system. In India, we may not be ready for this as yet. We also do not have screening tools that are acceptable for use all over the country.

Scarcity of Human Resources and Trained Force (Alternatives to Overburdening Teachers)

Many long-term SMH projects overcame the difficulty of lack of enough trained force by training the teachers to conduct the programs^25,,. However, teachers may perceive this as an additional responsibility with the existing academic and related activities. Hence, it would be unfair to add this extra burden on them. Child and adolescent psychiatrists have an important role to play in developing human resources and training laypersons and other paraprofessionals to do the onerous job of identifying, treating, and also preventing mental health issues in the school-going children.

In addition, usually students do not prefer to discuss their issues with teachers, due to difficulties for both the parties: Teachers have to play the dual role of teacher and counsellor, while it is difficult for students to perceive them in a role other than the authoritarian one they usually play. Teachers can be trained, however, to recognise the early warning signs like school absenteeism, poor self-care, a decline in academic performance, poor social interaction, etc., as these may indicate the beginning of major child and adolescent psychiatric disorders. As already discussed, some emerging programs use trained laypersons with good acceptability and accessibility. ²⁶

Form Strong Parent–Teacher Associations

In the West, parents are encouraged to be volunteers in their children’s schools. Parental engagement with the school, which has primarily been studied about children’s school achievement, has generally shown a positive association between the two. ²⁷

A study in the Caribbean countries found an association of parental involvement with lower levels of loneliness, anxiety, suicidal ideation, and depression among school-going adolescents. ²⁸

Given the constraints in human re- sources for implementing mental health programs in Indian schools, the possibility of parental involvement as volunteers must be attempted, and parents can be provided training according to the roles they are expected to play. It is also a fact, however, that poverty and lack of education prevent parents from being active partners with schools.

Use Other Professionals

We propose that a nurse may be appointed to deal with both the medical and psychological needs of children in the school setting. It will serve to destigmatise mental health issues. There are some suggestions that this will be acceptable to the children, parents, teachers, and school management. ²⁹ A manual has been developed to describe a school nurse’s role in mental health. This provides various options, including screening and assessment, identifying problems and providing an appropriate response, and playing preventive roles by sensitising children, parents, and teachers about mental health promotion. ³⁰ They can also play a role in obtaining consent for treatment, processing the child’s and family’s access to mental health care, and ensuring confidentiality, which will enhance compliance. To facilitate mental health work, school nurses need to be trained and supported to develop interpersonal skills and networks. They will also need access to a local mental health team to refer.

There are school health programs in India that use school health nurses for general health awareness and intervention and these have been varyingly successful. One study showed that services to address the school environment – including preventive, promotive, therapeutic and rehabilitative services - are supposedly available in Government schools on paper, but these are not utilized by either the students or the school personnel. Shortage of staff and a lack of awareness of such facilities being available are often cited as reasons. ³¹ Including pediatricians in this endeavor will be helpful as they are probably the first point of contact for any health, including mental health, concerns. The stigma will also be far less if a pediatrician is involved in sharing information, sensitising children and their parents, and even giving talks in schools including mental health aspects to general physical health.

Address Stigma

It is important to remember that much of the resistance to seeking help for mental health problems is due to misinformation. In one study, about 70% of higher secondary school teachers who were shown a case vignette on depression acknowledged having personal and perceived stigma toward the case. The negative attitude toward people with mental illness was quite evident. Teachers who were younger, male, or in urban schools or had less teaching experience had higher stigma. ³² It is important to provide accurate information in the form of holding poster, quiz, and essay writing competitions on themes to do with mental health to sensitise children, teachers, and parents. This would encourage children and adolescents who need help to reach out. Getting mental health professionals to speak to children and parents during annual day programs or parent-teacher meetings may also serve the purpose of sensitisation. In the current scenario, online sessions can also be planned as part of the school day. Liaising with the media to promote positive mental health education and close interaction of mental health professionals with parents and teachers in a common forum, wherein a mental-health-oriented approach rather than an illness-oriented approach is adopted, are also suggested. Sharing of information, capacity building, and peer supports should help decrease stigma in schools as well.

Manage Financial Constraints

Involving governmental and non- governmental agencies and the private sector would be good ways to address financial constraints. Better utilisation of the available resources is another important way to solve the financial crisis. ³³ Looking for different ways to raise funds for the adequate implementation of a program, like approaching members of the local clubs – like the Rotary or Lions clubs - who can conduct some recreational programs or even raise funds through their members would also be helpful.

The issue in India appears not to be a case of paucity of available financial resources but more of a problem with the allocation of available resources and roadblocks at the various levels - from the funding authority to the point of actually disbursing funds for the deserving programs at local levels.

Use Online Resources

With the increased use of technology in all spheres of education, it is only natural that some degree of psychological services can also be provided online. There are definite advantages of this medium as it ensures confidentiality, improves accessibility, and also promotes children’s confidence to confide their difficulties. Their areas of concern may be to do with peers, school (both academics and issues with teachers) or family. Supporting schools to develop websites to share information about mental health and also providing them with details of possible ways to seek help for these concerns could be a logical step for SMHP. ³⁴ While e-counseling should not be construed as the first choice when dealing with severe psychological challenges, it can be a practical and viable adjunct. ³⁵

An Australian study evaluated a web-based mental health service that offered screening, psychological therapy, and monitoring in an attempt to help counselors manage time and provide additional supervision to students. It concluded that, although the service helped reach a larger number of students, greater support and resources are needed to facilitate the already challenging and demanding role of school counsellors. ³⁶

In the wake of the COVID-19 pandemic, some schools have provided avenues to discuss mental health issues online, but this is still very rare. Schools can put together a list of mental health professionals that their students and families can access and display it on their websites and notice boards and even include such information in routine parent-teacher meetings.

Need for Team Effort

Mental health is of concern to all and should not just be restricted to relying on mental health professionals. This is especially important considering the small number of mental health professionals in our country and the enormity of the population needing help. Team effort must be enlisted to support this cause – this should include teachers, parents, paramedical personnel, nurses, doctors, especially pediatricians, psychologists, psychiatrists, psychiatric social workers, counselors, senior alumni of the school, and people in the management. Unless some combination of professionals comes together for this endeavor, it is unlikely to succeed.

Role of Child and Adolescent Mental Health Professionals in School Mental Health

Child and adolescent mental health professionals are uniquely positioned to respond to the growing public health challenges associated with mental disorders arising early in life that will first be observed in the school setting. Some authors recommend that, to meet these challenges, the field must consider some changes. They outline four consensus priorities for child and adolescent mental health over the next decade ³⁷ —increase the workforce, reorient mental health services to incorporate broader public health needs, increase research and training and incorporate newer research findings into practice, and, most importantly, increase efforts at advocacy.

Road Map for Initiating and Expanding SMH Services

It is important to have a clear vision about the scaling of mental health services in the school setting. A tier system will be a helpful guide. Tier 1 could be the universal screening of all children at various time points – like at the time of entry into preschool, primary school, and secondary school. This could be done using simple screening instruments. Tier 2 would include children identified as having difficulty and needing support, but this could be support provided at the school level by a nurse, teacher, or parent and can be provided in an individual or group format. Tier 3 includes children needing professional help and support from locally available mental health professionals. Every school could have a directory of professionals available in their locality, who have been primed to receive referrals from the schools in the area.

Conclusions

Children and adolescents need nurturing, and their mental health is a shared responsibility of all stakeholders, including parents, school authorities, society, governments, policymakers, etc. For any intervention to be effective, there should be adequate resources for its implementation and synergy among the efforts being made to address the issues. Both in developing and developed countries, the impact of SMHPs on children’s holistic growth is studied and well appreciated. Emphasis needs to shift from training teachers alone to including other professionals who can be involved in working with children. Mental health professionals must also go beyond delivering mental health lectures in schools to ensure proper initiation, effective execution, and favorable outcomes of SMHPs. There is enough justification for the integration of mental health into education. If this integration is based on evidence-based practice, it can promote positive mental health in children and adolescents.