School mental health program in India: Need to shift from a piecemeal approach to a long-term comprehensive approach with strong intersectoral coordination.

School mental health program (SMHP) has been recognized worldwide as key to improve the mental health and wellbeing of school going children. Unfortunately, in India, SMHP is badly neglected. There is no comprehensive SMHP that covers all school children (from rural and urban areas) across the country. A few sporadic activities that occur are praiseworthy; however, they lack a long-term approach. Major reasons for such neglect of SMHP in India could be lack of a steering body, poor intersectoral coordination, and minimal stakeholders' involvement. India, as any other country, needs to implement countrywide SMHP on the model of mental health promotion, prevention, and early intervention (PPEI). This paper outlines the deplorable state of SMHP in India and the needed steps to implement an effective countrywide SMHP on the PPEI model. Copyright:

INTRODUCTION

School mental health program (SMHP) has proven efficacy in the holistic growth of children.[1] It strengthens abilities, such as resilience and stress tolerance, that are needed for the overall growth of children. Furthermore, it helps children with psychological problems at the critical juncture so that their formative years are not affected by the presence of these problems. Moreover, a few activities that can be part of SMHP, such as bully control and gatekeepers training for suicide prevention, may prevent many undesirable happenings, for example, extreme violence and suicide among school children. However, SMHP is badly neglected in India.[2] Barring a few sporadic activities, there is no comprehensive SMHP in India.

The felt need for a strong SMHP in India is palpable. For example, various stakeholders, such as the school boards, often express concerns about the mental health of children.[3] In addition, in case of any extreme violence in schools, the need for immediate implementation of psychological services is discussed vehemently.[4] Unfortunately, all these have failed to result in the implementation of any systematic countrywide SMHP. Various programs and policies, including the National Mental Health Program (NMHP), have emphasized the implementation of SMHP.[2] The draft rule for the implementation of the new national mental health-care bill proposes a few steps to deal with the mental health issues of school children.[5] However, in spite of the strong felt need, the SMHP in India is running with a piecemeal approach for decades without having a clear perspective.[2] For example, in general, schools either do not have any structured program for the psychological wellbeing of children or do some activities that may not have a comprehensive promotive, preventive, and interventional approach to SMHP. Likewise, often the mental health professionals conduct some short-term sensitization programs (such as workshops for teachers) which have limited effects.[6] Besides, more often than not, these sensitization programs are illness oriented (e.g., what are the childhood psychiatric problems) than mental health oriented.[78] Further, the NMHP, though envisages various activities (such as programs to reduce substance abuse problems among children, imparting awareness about mental health, and providing intervention for children with mental illnesses), a specific framework to run a long-term and comprehensive SMHP is not evident.[5] Thus, the fact of the matter is that there is no comprehensive mental health program under which all school children are uniformly covered.

WHY SUCH PIECEMEAL APPROACH?

Literature shows that the SMHP activities are happening in India for the past 40 years.[910] However, these are mostly individual specific or institution specific endeavors.[2] There is lack of a comprehensive nationwide program with long-term outlook having the involvement of all the stakeholders and strong intersectoral coordination. Over the years, whatever little has been done in the field of SMHP in India, amply reflects that there is extremely poor intersectoral coordination and stakeholders' involvement. Any effort, such as inclusion of life-skills training module in curriculum by the school boards,[11] cannot be successful unless all the stakeholders wholeheartedly try in unison for its implementation. Otherwise, it remains just a part of curriculum instead of becoming part of life.

WHAT NEEDS TO BE DONE

The World Health Organization (WHO) recommends that mental health intervention in schools should be at four levels: the level one should be promotion of psychosocial competence which needs to be integrated in the school curriculum, the level two should focus on mental health education and should be part of the general health curriculum, the third level should have focus on those children who may need additional psychosocial interventions in school, and level four should be specifically for those children who are in need of professional help due to their mental health issues.[12] This multi-level program, thus, underscores that (a) each child in school must be covered under the SMHP (it is not only for those who may have some mental health issues); and (b) the activities related to promotion of mental health need to be part of the wider school system. Along these lines, a successful SMHP in any country must follow a public health approach based on the promotion, prevention, and early intervention (PPEI) model. Schools should create an environment which is facilitative of enhancing resilience, cooperation, and other such virtues in children. In addition, children should be involved in such activities that promote life-skills (e.g., empathy, critical thinking, creative thinking, problem solving, healthy interpersonal relationship, and effective communication). In other words, all the components of school such as the playground activities, structure of the class, teaching method, and curriculum should be promoting mental health.[12] Further, there should be a mechanism to identify and help children with mental health problems. There are recommendations to have a two-pronged approach to SMHP in India with a universal program for all children focused on mental health promotion and a targeted program for children with any mental health issues;[13] however, there is not much evidence that these recommendations have been acted on at a large scale.

India is a geographically vast country with diverse socioeconomic conditions. Schools can substantially differ in terms of resources, socioeconomic background of children, educational level of parents, and so on. Further, the schools come under various school boards such as the central boards and the state boards. Moreover, various central and state ministries have their roles and responsibilities related to child health and development. Framing a comprehensive SMHP that covers the whole country and takes care of all these diversities is a complex task, if not impossible. As per the WHO,[12] an effective SMHP takes into account the relationship between the school and the community, pays attention to the relevant socio-political conditions likely to have role in the initiation and successful running of comprehensive SMHP, involves families and other stakeholders at all the stages (planning, implementation, and evaluation), utilizes the available skills and expertise, for example, available with schools and the community (such as the mental health professionals), has possibility of multi-level interventions, trains the stakeholders, and evaluates the effectiveness of the program. We need to ponder how in the backdrop of these suggestions, a comprehensive SMHP based on the PPEI model for India can be developed while addressing various socioeconomic realities of the country.

India has federal structure in which there is division of responsibilities between the central government and the state governments. Education comes under concurrent list which means the responsibilities are shared between the center and the states. Therefore, a national SMHP will require strong coordination between center and all the states. Moreover, as mentioned earlier, there are factors related to geographical vastness and socioeconomic diversities that must be taken into account while planning a comprehensive SMHP. Therefore, a few things must be attended to while designing the SMHP. These are:

How to coordinate and monitor the program to be run in the whole country?

How to bring all the stakeholders and agencies on board?

How to sustain the program in long-run?

How to assess the effectiveness of the program?

THE NEEDED STEPS

Establishment of a steering body

Implementation of any nationwide program, that has to sustain in long-run, requires an organization or steering body that can centrally regulate, coordinate (with various agencies and stakeholders), and monitor the program. Various stakeholders such as educationists; representatives of ministries related to health, education and child development; and representatives of parent groups, teachers, and school administrators should be part of this group. This body should be effectively coordinating between central and state agencies related to health, education, and child development and in consultation with all the stakeholders and concerned agencies decide the process of implementation of SMHP on the PPEI model. Various important concerns such as the steps to bring uniformity in the program, to address the issues of differences in language and habitat of children, and to develop a SMHP program that is self-sustainable as part of the school system can be addressed to a large extent if there is one coordinating body. This body can also coordinate research related to need and outcome assessment, publication of resource materials, and training of workforce.

Strong intersectoral coordination and active involvement of the stakeholders

A truly comprehensive SMHP is possible only when all the stakeholders (the school boards, school leaders, teachers, mental health professionals, parents and policy makers) are on board. Proactive involvement of all the stakeholders and strong intersectoral coordination can be achieved only when different sectors and the stakeholders perceive the shared goals and the need for a concerted effort. Further, there ought to be a clear outlook on what can be achieved by having involvement of the stakeholders and establishment of intersectoral coordination.

Various stakeholders and agencies can perceive their role in running a comprehensive SMHP only when they feel that their larger goals will be supplemented by their active participation in the SMHP. For example, the Ministry of Women and Child Development is likely to be forthcoming in participating in SMHP activities if there is realization that SMHP can be augmentative in achieving their mission of “well nurtured children with full opportunities for growth and development in a safe and protective environment,”[14] that it can help in effective implementation of the Integrated Child Development services, and that the problem of juvenile delinquency can be prevented in a substantial way if schools run mental health promotion programs where children and adolescents spend significant amount of time. Likewise, the Department of School Education and Literacy can play a major role in SMHP if it assists in achieving the goals of programs such as Samagra Shiksha.[15] In addition, the schools can be more proactively participative if they are presented with factual data pertaining to various components of SMHP that help in overall growth of school children and are facilitative in running the schools effectively. In other words, the intersectoral coordination is possible only when the SMHP is in tune with the goals and missions of the individual sectors, stakeholders and agencies. Setting up of core action teams for SMHP in the key ministries such as the Ministry of Health and Family Welfare, the Ministry of Women and Child Development and the Ministry of Education (under which the Department of School Education and Literacy comes) is indispensable to ensure the smooth coordination among the sectors and for monitoring by the main steering body.

Sensitization of the stakeholders

To bring all the stakeholders on board, it is important that large scale sensitization programs are conducted for sensitizing all the stakeholders. It is not uncommon to meet with resistance toward SMHP from stakeholders, such as parents and teachers, because of either their unawareness about its importance or each of them having different priorities (often with the feeling that mental health is not their business).[16] Through consultative meets of the stakeholders and large-scale media coverages, the stakeholders need to be communicated the significant advantages of a comprehensive SMHP. In other words, there needs to be strong advocacy for SMHP by communicating a few robust advantages of this program to the stakeholders; such as:

Mental health and wellbeing of pupil can determine the educational outcomes in a significant way

Life-skills training, as part of the school environment, can be an important step towards inculcating qualities such as resilience and creative thinking in children

Building resilience, stress tolerance, and other such abilities can protect children in a significant way from mental health problems.

A careful observation in schools can detect children with mental health problems at an early stage which saves their formative years.

In this connection, conducting a pilot need assessment is imperative to understand specific issues and concerns (in view of the socioeconomic realities of the country) of the stakeholders. For example, understanding the resource constraints with parents and schools and their suggestions about designing SMHP keeping these constraints in view is important to run the program in a sustained manner.

A clearly defined system of implementation of school mental health program

It is important that (a) the schools are motivated and supported to build an in-house team to run the SMHP services and (b) there should be specialized training programs which cater to the needs of schools to have specialist professionals to help in running SMHP. A first step toward this goal can be initiation of a well monitored and regulated school psychologists training program (such as a diploma) which generates manpower specifically for running SMHP. As of now, there is no specific guideline about who can work as a school mental health professional in India. More often than not, individuals with postgraduate degree in psychology are employed as school psychologists/counselors. For instance, the Central Board of Secondary Education (CBSE) mandates all the affiliated secondary and senior secondary schools to recruit a “wellness teacher” who may have qualification of either of three: (a) graduate or postgraduate in psychology, (b) postgraduate in child development, (c) graduate/postgraduate with diploma in career guidance and counseling.[17] Although this is a welcome effort by CBSE toward ensuring wellness of pupil, it has some inherent difficulties as well. For example, a graduate in psychology, without any formal training in child and adolescent mental health, will have difficulty in working toward the promotive, preventive, and interventional aspects of mental health. While formulating such guidelines, it is critical to bear in mind that children can have (a) serious mental health issues and if not dealt properly, can have extreme repercussions, sometimes leading to suicide and homicide and (b) it is absolutely unadvisable to recruit people who have not got any formal training in child and adolescent mental health (which includes understanding of child development, importance of enhancing life-skills, understanding child and adolescent mental health problems, theoretical and practical exposure to skills to conduct counseling and crisis intervention, and so on). It will not be an exaggeration to say that not being counseled is better than counseling conducted by an untrained person. It has risk of ill-informed and nonempirical advices which can have serious implications.

A structured school psychologist training program will be able to ensure availability of such professionals for the schools who will be equipped to run the SMHP services (as well as carry out other activities such as coordinating with other team members in the school, stakeholders, and agencies). The core skills (pertaining to promotive, preventive and interventional aspects of child and adolescent mental health) required in these school mental health professionals need to be clearly defined and there should be proper assessments to ensure the minimum level of competency in these professionals. In addition, there should be well-regulated licensure process for these professionals. Further, the schools can be directed to recruit, at least, one such professional mandatorily.

Empirically tested and objectively defined content as well as clearly defined expected outcome of school mental health program

To ensure uniformity, it is imperative that the content of SMHP is clearly defined. Moreover, there should be clarity on what would constitute the promotive components of mental health which would cover all the children as part of universal program. There are inherent difficulties in using all-encompassing word like “wellbeing.”[18] As the meaning and components of 'wellbeing' can vary for different individuals, there can be disparities in the programs conducted at different schools. Taking this into account, it is important that the steering body defines and specifies the contents of SMHP clearly to ensure uniformity across schools and school boards. Further, it is crucial that the effectiveness of a program is empirically tested before it is rolled out on a national level. The outcome of SMHP needs to be assessed on a range of proximal and distal variables such as the emotional well-being of children, control of destructive activities such as bullying, number of referrals for children requiring specialist mental health assistance, and the like.

Training of the teachers

In order to ensure that the teachers have an understanding of the importance of SMHP and are able to actively participate in its delivery, it is important that there is an inbuilt system of training the teachers for this purpose. It can be at two levels: first, inclusion of topics related to SMHP, such as child and adolescent development and various life-skills, in the curriculum of Bachelor of Education (B. Ed.) program and second, provision for intensive in-service training for teachers in conducting life-skills related programs such as enhancing resilience, emotional regulation, problem-solving, and healthy interpersonal relationship. In addition, the teachers should be sensitized to various child and adolescent mental health issues, ways to work as gatekeepers for suicide prevention and steps to conduct preliminary crisis intervention. As of now the B. Ed. curriculum has just a small component on child development.[19] As suggested above, it should be more inclusive of topics related to child and adolescent development, mental health, and life-skills.

Better utilization of resources

It is important that all the stakeholders work together for better utilization of resources. For example, the District Mental Health Program (DMHP) team can be involved in a major way by (a) running the sensitization programs for the stakeholders and (b) to support those children who have been identified to have diagnosable psychological problems. Under the NMHP, a facilitators' manual titled “Living Life Positively”[20] has been prepared for the DMHP professionals for imparting training in the domains of life-skills, stress-management and suicide prevention (with a gatekeepers approach). The DMHP staff can use this manual to run these programs and also to train the school teachers in these domains.

AN EXAMPLE OF A COMPREHENSIVE APPROACH

In many countries, SMHP has come up in a major way in the past 20 years[1] and we can take lessons from their experiences. For example, the MindMatters, KidsMatter and KidsMatter early childhood programs of Australia exemplify how SMHP on PPEI model can be executed effectively if there is systematic planning and involvement of all the stakeholders.[21] MindMatters, was started in 1990s after a careful planning and involvement of various stakeholders. From the beginning, a few things were kept in view to make the program successful, for example, it was ensured that all the stakeholders are involved in such a way that they understand the relevance of the program and participate actively. Also, a proactive approach of school as facilitator of emotional wellbeing was adopted. Further, outcome assessment was an integral part of the program. With the success of the MindsMatter, which was meant for adolescents, two more programs were rolled out – the KidsMatter (for children of primary school) and KidsMatter early childhood. Later, it was felt that all these initiatives could be much more effective if they were integrated into one single national program. It resulted in the Australian Government's National Support for Child and Youth Mental Health Program.[22] In 2017, an organization named Beyond Blue was given the responsibility to run this program. The new program is named “Be You” and integrates all the earlier running programs such as MindMatters and KidsMatters.[22] There are similar examples from many other countries such as Ireland, New Zealand, and Singapore.[23]

CONCLUSION

SMHP in India is running with a piecemeal approach and for all practical purposes, it is nonexistent for the majority of school going children. The sporadic efforts (such as conducting some sensitization program for school teachers) are praiseworthy; however, they are insufficient for a comprehensive and sustainable SMHP. Neglect of mental health of children has significant short- and long-term negative repercussions. Therefore, a countrywide comprehensive SMHP (covering both urban and rural areas) based on the PPEI model is urgently required. It can happen only if there is proper intersectoral coordination and stakeholders' involvement. A cohesive effort should lead to framing of a long-term SMHP, keeping the socioeconomic realities of the country in mind. Often, it is argued that resource constraints could be a major stumbling block in having a comprehensive SMHP.[23] However, the fact of the matter is that there is no alternative to the PPEI based comprehensive approach to SMHP. We need to ensure that SMHP is delivered in a way that it takes care of the resource constraints as far as possible. It is important that the school leaders and teachers are communicated that a PPEI approach to promotion of mental health in school is essentially revamping and tuning the existing system in a manner that it becomes more conducive to support the wellbeing of school as a community. It may need some extra resources; nevertheless, many important aspects of a wellbeing promoting school system, such as, healthy and open communication, warm relationship among students (and between staff and students), a cohesive environment, noncriticality, and life-skills promoting discussions and activities fundamentally need proactive efforts from teachers, schools administration, parents and students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.