Use of a Nomination Strategy to Identify Mental Health Help-Seeking Patterns by High School Students and Their Association With Mental Health Service Use
by Jennifer Greif Green, Melissa K. Holt, Javier Guzmán , Rachel Oblath, Chelsey Bowman & Shanee Abouzaglo - November 27, 2018
Background: There are high rates of unmet mental health need among adolescents, but youth who seek help from informal adult sources (e.g., parents, teachers) are more likely to access formal mental health services than their peers.
Objective: This research note provides an example of a simple nomination strategy that can be used by schools to ask students to identify the school staff who they are most likely to approach for help when they are experiencing emotional problems.
Research Design: Participants were students (N = 1,312) at two high schools engaged in a university-district partnership. Students completed an anonymous survey assessing mental health need and service use. Students were also asked to nominate up to three school staff who they would go to for help with emotional problems.
Results: Most students nominated at least one staff member, though almost half of those with elevated mental health problems nominated no one. Students nominating at least one teacher had substantially greater odds than their peers of receiving mental health services.
Conclusions: The nomination process described in this research note has the potential to inform school leaders about patterns of help-seeking among students. In addition, it can identify highly nominated school staff who might then be provided more intensive mental health training. Results also indicate school-specific trends in help-seeking, suggesting that school leaders might benefit from considering their unique study body and school staff members to best inform the selection of trainings and supports for school staff.
In the context of high rates of untreated emotional and behavioral disorders among adolescents (Costello et al., 2014; Hunt & Eisenberg, 2010; Kataoka, Zhang, & Wells, 2002), studies identifying pathways to mental health service use highlight the importance of adults who serve as potential sources of referral (Stiffman, Pescosolido, & Cabassa, 2004). In particular, youth who seek help from informal adult sources (e.g., parents and teachers) are more likely to access mental health services than their peers (Zwaanswijk et al., 2003). Further, research indicates that schools are one of the top settings for mental health service provision to youth (Costello et al., 2014; Ringeisen et al., 2016) and, as such, researchers and policy-makers have increasingly encouraged school staff to actively participate in identifying and supporting youth with mental health needs (Lane et al., 2008; White House, 2013).
Most teachers have limited preparation to identify and support student mental health and do not feel confident in this role (Freeman et al., 2014; Reinke et al., 2011). Therefore, a number of training programs have been developed for school staff, which generally focus on increasing knowledge of mental health problems, providing strategies for offering initial supports, and teaching steps to initiate mental health services referrals (Hadlaczky, Hokby, Mkrtchian, Carli, & Wasserman, 2014; Hampton, 2013; Kitchener & Jorm, 2008). Trainings vary considerably in their cost and depth. For example, the American Psychiatric Foundation Typical or Troubled? program can be implemented in a two-hour session (Hampton, 2013); whereas Youth Mental Health First Aid USA offers an 8-12 hour program (Hadlaczky, Hokby, Mkrtchian, Carli, & Wasserman, 2014; Kitchener & Jorm, 2008).
As such, school leaders are tasked with selecting the intensity of training programs and, relatedly, determining whether to provide training to all staff, or a subset of staff in their school. Prior research has suggested that it may be most important to provide training to the subgroup of staff who are already likely to interact with students when they are in distress either by function of their position (e.g., counselor) or personality traits (e.g., empathy; Wyman et al., 2008). An unanswered question, however, is how to identify the staff who students rely on the most when they experience psychological distress.
In this research note, we provide an example of a simple staff nomination strategy that can be used to identify the school staff who students are most likely to approach for help. We piloted this strategy at two high schools as part of university-district partnerships. In the current study we address two questions: First, can schools identify individual staff who students are most likely to reach out to for support? Second, can schools use staff nomination data to identify patterns in student help-seeking that are associated with mental health service use? Given that students who seek mental health support from teachers and other informal sources are more likely to access formal services (Zwaanswijk et al., 2003), we examine this question in order to identify whether school staff are connecting students most in need of supports with those services.
In the two partner school districts, high school students were asked to nominate adults within their school who they would talk to if they experienced a personal or emotional problem. The names of top-nominated school staff were provided to school leaders, so the school could ensure that highly-nominated staff received needed resources and training. In particular, highly-nominated staff in one school district were encouraged to participate in an intensive and expensive teacher mental health training offered to a limited number of staff. We present data from these schools as an example of how a nomination process has the potential to inform school leaders about patterns of help-seeking among students and guide the allocation of staff training resources.
Data on students mental health and their help-seeking behavior were collected from 590 9th-12th grade students in School A (87.4% response rate, 53.2% female) and from 722 9th-12th grade students in School B (80.2% response rate, 54.4% female; total N=1,312). Data were collected as part of district-wide assessments of students mental health and use of school-provided mental health services. All students were invited to complete an anonymous, voluntary, online self-report survey at school to inform school- and district-level mental health service provision; it was not possible to identify individual students needing mental health services and all results were presented to the district in aggregate. The University Institutional Review Board approved analysis of data for this research study. School districts were predominantly comprised of non-Latino White and middle/high-income students. According to state data, in School A, 95.4% of students identified as non-Latino White and 4.1% received government assistance. In School B, 94.9% of students identified as non-Latino White and 7.9% received government assistance.
Mental Health Needs
To assess mental health needs, students completed the Strengths and Difficulties Questionnaire (SDQ), a brief measure of social and emotional functioning (Goodman, 2001). The SDQ utilizes five subscales that assess emotional problems, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behaviors. The first four of these scales were summed to create a Total Problems scale. Scores were summed in each of five domains and on the total scale. Students were identified as high-risk if their score was above a predetermined cut-point on each of the subscales (Goodman, 2001). Prior research has demonstrated the reliability (Bourdon et al., 2005) and validity of the SDQ (Bourdon et al., 2005; Goodman & Scott, 1999).
Students were asked to nominate school staff using the following question: Please list the names of the 3 adults at school who you are most likely to reach out to for help when you are upset or having a personal or emotional problem. Write no one if there is no one at school who you reach out to. In School A, 492 students (83.4% of sample) provided a response to the nomination question. In School B, 508 students (70.4% of sample) provided a nomination responses. Nominations were categorized by name and job title.
Mental Health Services
Students were asked to indicate whether they currently received any counseling services or used medication for an emotional, behavioral, or substance use problem.
Students reported their gender and grade in school.
Eight percent (n=49) of students in School A and 14.6% (n=73) of students in School B reported high-risk SDQ scores. Among students in School A, 21.2% (n=116) reported that they received individual or group counseling at school; 10.7% (n=54) of School B students reported that they received counseling. Two thirds of students in each school nominated at least one adult and one third wrote in that they would nominate no one (School A=31.1%; n=141; School B=32.1%, n=163).
First, we examined the extent to which individual school staff serving in supportive roles could be identified by the nomination procedure. An example of nomination data for individual school staff in School A are presented in Figure 1 as a function of high-risk SDQ total score responses.
Figure 1. Number of nominations assigned to each school staff in School A as a function of SDQ Total Score
Note: This figure includes only school staff who received at least one nomination.
There was substantial variability in the number of nominations that staff received from students. In particular, one teacher was more frequently nominated than any other staff member in the school (nominated by n=74, 12.5% of students, in comparison to other staff who were nominated by an average of 4.98, or 1.1% of students). Nominations from students with high-risk SDQ scores (indicated in black in Figure 1) were fairly evenly distributed across staff members, though as expected school health and mental health providers (e.g., nurse, school psychologist, social worker) were nominated by a disproportionate number of students with high-risk scores. Nomination data for School B (available on request) indicate predominant nomination of one guidance counselor who was nominated by n=83, 11.5% of students.
Second, to identify patterns in staff nomination, we entered SDQ subscale scores, student gender, and grade level into multiple logistic regression models that estimated their association with categories of school staff nominated. As presented in Table 1, in both schools females were more likely to nominate guidance counselors than males and older students were more likely than younger students to nominate at least one teacher.
Patterns in the association of specific social-emotional profiles with nominations differed across the two schools. For example, in School A, students with high prosocial skills were more likely than their peers to nominate teachers and administrators, whereas in School B, students with conduct problems were more likely than their peers to nominate an administrator.
Third, we looked specifically at students who nominated no one. Among students with high-risk SDQ scores, almost half nominated no one (47.0%, n=17, in School A and 39.7%, n=29, in School B). In School A, students with low prosocial skills were more likely than their peers to nominate no one (OR=0.83, CI=0.73-0.95). In School B, students were more likely to nominate no one if they had high emotional problems (OR=1.17, CI-1.07-1.29), were male (OR=0.58, CI=0.37-0.91), and younger (OR=0.67, CI=0.55-0.80).
Finally, among students with high-risk SDQ scores, those who nominated at least one teacher were significantly more likely to report receiving counseling services at school than their peers (School A, OR=14.94, CI=1.59-140.62; School B, OR=8.53, CI=1.56-46.82). High-risk students who nominated no one were significantly less likely to report receiving counseling services at school than their peers (School A, OR=0.09, CI=0.01-0.87; School B, OR=0.16, CI=0.03-0.90).
DISCUSSION AND CONCLUSION
Data from these two schools provide an example of how a simple nomination strategy could be used to identify the school staff who are most likely to support all students, as well as students in distress. Other studies have found that school-based interventions disseminated through teachers nominated by their colleagues were more effective than interventions disseminated by mental health providers only (Atkins et al., 2008). The results of the current study raise similar questions about the ideal methods for disseminating mental health supports to students in schools. In particular, highly nominated school staff might be targeted for more intensive mental health training (as suggested by Wyman et al., 2008) or, in the least, school leaders might ask if these staff have the support and resources that they need.
One question raised by the current study is why some staff are more highly nominated than others. For example, in the case of School A, the high nomination of an English teacher raises questions about whether there might be particular qualities of individuals likely to teach English (e.g., an interest in personal narrative) or particular activities used in classes that are likely to facilitate student-teacher connection (e.g., journaling). Further, the teacher who was most highly nominated was a teacher of both 9th and 11th grade students, indicating that she likely had contact with students across multiple points in their high school trajectory (as compared to a teacher who taught only upper-grade classes). These types of local patterns can provide important information for school leaders who might be able to identify natural subgroups of school staff (e.g., English teachers or 9th grade teachers) who bear the weight of supporting students in distress.
In addition, our analysis of data from these two schools indicated that the majority of students perceived there to be an adult whom they could reach out to for help. However, a substantial minority of the full population, and almost half of those with high-risk SDQ scores, nominated no one. The finding that many adolescents with mental health needs do not seek help is consistent with the extant literature (Rickwood, Deane, & Wilson, 2007) and suggests the need for increasing the number of mental health service providers in schools and using innovative interventions to improve student-teacher relationships (for example, Gehlbach et al., 2015; Gregory, Clawson, Davis, & Gerewitz, 2016). Results also indicate school-specific trends in help-seeking, suggesting that school leaders might benefit from considering their unique student body and school staff members to best inform the selection of trainings. For example, in School A, students with higher prosocial skills were more likely to nominate school staff, suggesting the importance of staff making explicit efforts to connect with the students who might already have the most trouble seeking help from peers and adults. In School B, results indicated the need for greater staff connection to students with emotional problems. In both schools, data indicate that students with elevated (or high-risk) scores on the SDQ who nominated teachers had eight to fifteen times the odds of receiving counseling services compared to their high-risk peers who did not nominate teachers. This finding is encouraging because it suggests that teachers at these schools might be connecting students most in need of supports with services.
Of note, both schools in this sample are primarily comprised of non-Latino White students, few of whom require government assistance. Research suggests that racial, ethnic, and cultural factors are associated with mental health problem recognition, the decision to seek help, and the selection of sources of support by youth with mental health problems (Cauce et al., 2002). For example, studies have found that non-Latino Black students indicate they are less willing to seek help from adults at school for bullying than students of other races/ethnicities (Eliot, Cornell, Gregory, & Fan, 2010). Students of color may similarly be less likely to reach out to school staff for assistance with mental health problems. Replicating this study in schools with more diverse populations of students might answer questions about whether there are racial/ethnic differences in the school staff who students reach out to for help and whether those differences might be associated with the likelihood of mental health service receipt.
This study has several limitations. First, as noted above, data are from only two schools with similar demographic characteristics within one state. However, results are not intended to be generalizable, as we are using data from these two schools to demonstrate the use of a nomination method that could utilize local data to identify unique patterns within schools. Second, in several instances our research team was unable to code nomination responses due to the use of teacher nicknames, incorrect spelling, or teachers with duplicate names within the school. As a result, these responses were removed from the analyses. In the future, students could be provided a drop-down menu of names to select, although this would potentially limit the staff who would be identified (e.g., in School B a custodian was frequently nominated). Third, the SDQ provides screening data on students emotional and behavioral strengths and challenges, but is not a diagnostic tool or measure of impairment that could be used to dictate the necessity of mental health services. Therefore, results only indicate whether students are at high-risk for emotional and/or behavioral challenges.
Despite these limitations, the results of the current study suggest it is possible to collect simple nomination data to identify both the school staff most likely to support students with mental health needs and also to determine local patterns in student help-seeking.
Bourdon, K. H., Goodman, R., Rae, D. S., Simpson, G., & Koretz, D. S. (2005). The Strengths and Difficulties Questionnaire: US normative data and psychometric properties. Journal of the American Academy of Child & Adolescent Psychiatry, 44(6), 557564.
Cauce, A. M., Domenech-Rodríguez, M., Paradise, M., Cochran, B. N., Shea, J. M., Srebnik, D., & Baydar, N. (2002). Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70(1), 4455.
Costello, E., He, J., Sampson, N., Kessler, R., & Merikangas, K. (2014). Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatric Services, 65(3), 35966.
Eliot, M., Cornell, D., Gregory, A., & Fan, X. (2010). Supportive school climate and student willingness to seek help for bullying and threats of violence. Journal of School Psychology, 48(6), 533553.
Freeman, J., Simonsen, B., Briere, D. E., & MacSuga-Gage, A. S. (2014). Pre-service teacher training in classroom management: A review of state accreditation policy and teacher preparation programs. Teacher Education and Special Education, 37(2), 106120.
Gehlbach, H., Brinkworth, M. E., King, A. M., Hsu, L. M., McIntyre, J., & Rogers, T. (2016). Creating birds of similar feathers: Leveraging similarity to improve teacher-student relationships and academic achievement. Journal of Educational Psychology, 108(3), 342.
Goodman, R., & Scott, S. (1999). Comparing the Strengths and Difficulties Questionnaire and the Child Behavior Checklist: Is small beautiful? Journal of Abnormal Child Psychology, 27(1), 1724.
Goodman, R. (2001). Psychometric properties of the Strengths and Difficulties Questionnaire. Journal of the American Academy of Child & Adolescent Psychiatry, 40(11), 13371345.
Gregory, A., Clawson, K., Davis, A., & Gerewitz, J. (2016). The promise of restorative practices to transform teacher-student relationships and achieve equity in school discipline. Journal of Educational and Psychological Consultation, 26(4), 325353.
Hunt, J., & Eisenberg, D. (2010). Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health, 46(1), 310.
Jorm, A. F., Kitchener, B. A., Sawyer, M. G., Scales, H., & Cvetkovski, S. (2010). Mental health first aid training for high school teachers: A cluster randomized trial. BMC Psychiatry, 10(1), 51.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among US children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), 15481555.
Lane, K. L., Kalberg, J., Robertson, P., Robin, J., & Carter, E. W. (2008). Student Risk Screening Scale: Initial evidence for score reliability and validity at the high school level. Journal of Emotional and Behavioral Disorders, 16(3), 178190.
Phillippo, K. L., & Kelly, M. S. (2014). On the fault line: A qualitative exploration of high school teachers involvement with student mental health issues. School Mental Health, 6(3), 184200.
Reinke, W. M., Stormont, M., Herman, K. C., Puri, R., & Goel, N. (2011). Supporting children's mental health in schools: Teacher perceptions of needs, roles, and barriers. School Psychology Quarterly, 26(1), 113.
Rickwood, D. J., Deane, F. P., & Wilson, C. J. (2007). When and how do young people seek professional help for mental health problems? Medical Journal of Australia, 187(7 Suppl), S35S39.
Rickwood, D., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2005). Young peoples help-seeking for mental health problems. Australian e-journal for the Advancement of Mental health, 4(3), 218251.
Ringeisen, H., Miller, S., Muñoz, B., Rohloff, H., Hedden, S. L., & Colpe, L. J. (2016). Mental health service use in adolescence: Findings from the National Survey on Drug Use and Health. Psychiatric Services, 67(7), 787789.
Stiffman, A., Pescosolido, B., & Cabassa, L. (2004). Building a model to understand youth service access: The gateway provider model. Mental Health Services Research, 6(4), 18998.
White House. Presidential proclamation: National Mental Health Awareness Month, 2013. Retrieved from http://www.whitehouse.gov/the-press-office/2013/04/30/presidential-proclamation-national-mental-health-awareness-month-2013
Zwaanswijk, M., Verhaak, P., Bensing, J., Van Der Ende, J., & Verhulst, F. (2003). Help seeking for emotional and behavioural problems in children and adolescents: A review of recent literature. European Child & Adolescent Psychiatry, 12(4), 153161.