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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).  

Teacher Nominations

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).


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.


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The authors would like to thank Brian Mayville, Melody Eaton, Noah Segal, and Gerrit DeYoung for their assistance with this project.

Cite This Article as: Teachers College Record, Date Published: November 27, 2018
https://www.tcrecord.org ID Number: 22576, Date Accessed: 4/22/2021 2:29:42 PM

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About the Author
  • Jennifer Green
    Boston University
    E-mail Author
    JENNIFER GREIF GREEN is an associate professor of education at Boston University. Her research examines supports for students with emotional/behavioral disorders, school-based mental health services, and disparities in mental health service access.
  • Melissa Holt
    Boston University
    E-mail Author
    MELISSA K. HOLT is an Associate Professor of Counseling Psychology at BU Wheelock. Her research focuses on how victimization of youth in schools, at home, and in the community affects functioning across multiple domains (e.g., psychological, academic). Further, she engages in evaluation studies of school-based programs designed to reduce bullying and harassment, and to improve student social-emotional well-being.
  • Javier Guzmán
    Boston University & Universidad del Desarrollo
    E-mail Author
    JAVIER GUZMÁN was a doctoral student in Applied Human Development at the Wheelock College of Education & Human Development, Boston University. He was also an instructor and researcher at the School of Psychology of Universidad del Desarrollo. Previously, Javier worked for ten years in a public preventive program of school mental health called “Skills for Life” of JUNAEB (Ministry of Education). His research focused on school mental health and subjective well-being.
  • Rachel Oblath
    Boston University
    E-mail Author
    RACHEL OBLATH is a Ph.D. student in Applied Human Development at the Wheelock College of Education and Human Development, Boston University. She is interested in mental health service provision for children and adolescents with mental health challenges, and particularly those who experience peer victimization. A particular focus is student’s access to social and emotional support services during the summer, when school is not in session. Rachel also studies power dynamics in the context of school bullying. Her focus is on understanding heterogeneity of bullying experiences to inform tailored prevention and intervention.
  • Chelsey Bowman
    Boston University
    E-mail Author
    CHELSEY BOWMAN is a fourth year Counseling Psychology doctoral student at Boston University Wheelock School of Education and Human Development. Chelsey researches the impact of a range of victimization forms (e.g., sexual assault, dating violence, bullying) on the health and well-being of K-12 and college students. She has a particular research interest in the well-being of collegiate student-athletes. She has also been a coauthor on other papers, including Peer victimization and sexual risk taking among adolescents (in press) and The trouble with bullying in high school: Issues and considerations in its conceptualization (2016).
  • Shanee Abouzaglo
    Boston University
    E-mail Author
    SHANEE ABOUZAGLO is an Undergraduate Research Assistant. Her research interests include the social determinants of adolescent mental health and health disparities experienced by racial/ethnic and sexual and gender minorities.  
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