Teachers’ Perceived Barriers To Mental Health Assessment In Schools: A Systematic Review

Schools play a crucial role in children’s mental health development, as they form a significant part of a child’s microsystem in Bronfenbrenner’s ecological systems theory.

Teachers, who interact daily with students, are uniquely positioned to identify early signs of mental health issues and provide initial support.

Schools can implement mental health education, offer counseling services, and create a supportive environment that promotes emotional well-being.

By collaborating with families and external services, schools can facilitate a comprehensive approach to student mental health.

This aligns with Bronfenbrenner’s theory, which emphasizes the importance of interactions between different systems in a child’s life for their overall development.

O'Farrell, P., Wilson, C., & Shiel, G. (2023). Teachers' perceptions of the barriers to assessment of mental health in schools with implications for educational policy: A systematic review. British Journal of Educational Psychology, 93(1), 262-282. https://doi.org/10.1111/bjep.12553

Key Points

• The primary barriers to assessment of mental health in schools identified by teachers include lack of training, role conflict, lack of knowledge/skills/confidence, inadequate external services, and parental factors.
• Factors like school ethos, national policies emphasizing academic testing, and teachers’ own mental health experiences significantly affect teachers’ ability and willingness to engage in mental health assessment of students.
• The research, while informative, has limitations such as small sample sizes in some studies, potential selection bias, and a lack of representation from many countries.
• This topic has universal relevance as schools play a crucial role in early identification and support for youth mental health issues, which impact academic outcomes and lifelong wellbeing.

Rationale

This systematic review aimed to examine teachers’ perceptions of barriers to assessment of mental health in schools. The rationale for conducting this review stems from several key factors:

1. High prevalence of youth mental health issues: Approximately 20% of school-age children and adolescents experience social, emotional and behavioral difficulties (SEBD) (Loades & Mastroyannopoulou, 2010). Early identification and intervention for these issues is crucial to mitigate adverse outcomes both in school and beyond (Carr, 2015; Cook & Ruhaak, 2014; Landrum et al., 2014; Mundschenk & Simpson, 2014).
2. Schools as a key setting: Children spend a large proportion of their waking hours in schools, making them an ideal setting for identifying mental health concerns (Levitt et al., 2007). There is increasing recognition that emotional wellbeing and academic performance are interconnected (Cefai et al., 2016; Moilanen et al., 2010).
3. Teachers as “gateway providers”: According to the Gateway Provider Model, teachers can play a crucial role in identifying students in need of mental health support and facilitating referrals to appropriate services (Stiffman et al., 2004; Meldrum et al., 2009; Ní Chorcora & Swords, 2021).
4. Lack of clarity on current practices: While governments are implementing mental health initiatives in schools, there is limited understanding of how children are actually being identified and referred for mental health support in school settings (Williams et al., 2007). Assessment practices vary widely between schools.
5. Gap in existing literature: Previous reviews have focused on mental health interventions in schools, universal screening programs, and teachers’ perceptions of students with mental health difficulties. However, a systematic review specifically examining teachers’ perspectives on barriers to mental health assessment was lacking.
6. Policy implications: Understanding teachers’ perceptions of barriers can inform educational policies and practices to improve early identification and support for student mental health needs.

Given these factors, a systematic review of teachers’ perceived barriers to mental health assessment in schools was deemed timely and valuable for advancing knowledge in this area and informing policy and practice.

Method

This systematic review adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Moher et al., 2009).

Databases searched:

• ScopusEBSCOhost (including ERIC, APA PsycInfo, and APA PsycArticles databases)

Additionally, two specific journals were hand-searched due to their relevance:

• School Mental Health
• Emotional Behavioural Difficulties

Search strategy and terms:

The search strategy used a combination of terms related to:

1. Mental health conditions (e.g., anxiety, selective mutism, panic disorder, phobia, internalizing/externalizing disorders)
2. Assessment processes (e.g., assess*, identif*, recogni*, screen*)
3. School settings (e.g., primary school, elementary school, teacher*, class*)
4. Barriers or enablers (e.g., barrier*, problem*, difficult*, challenge*, enabler*)
5. Teacher perceptions (e.g., perception, attitude, belief, opinion)

The full search string is provided in Table 1 of the paper.

Inclusion and exclusion criteria:

Inclusion criteria:

• English language studies
• Peer-reviewed articles, books, published and unpublished theses
• Studies focused on in-service teachers’ perspectives
• Studies specifically examining barriers to mental health assessment (not just intervention)

Exclusion criteria:

• Studies conducted in countries classified as developing economies
• Studies where teacher data was amalgamated with other school practitioners (e.g., psychologists, social workers)
• Studies focusing only on principals, pre-service teachers, or pre-school teachers
• Review/discussion papers
• Studies focusing solely on mental health intervention (not assessment)

Statistical measures:

This review primarily synthesized qualitative findings. No meta-analysis or other statistical analyses were conducted.

The review used Bronfenbrenner’s ecological systems theory (adapted by Harvest, 2018) as a framework for organizing and analyzing the findings.

Results

The systematic review identified 19 studies that met the inclusion criteria. The findings were organized according to Bronfenbrenner’s ecological systems theory:

Macrosystem:

1. Training: 15 out of 19 studies identified lack of training as a major barrier. Teachers expressed a need for more specialized training in recognizing mental health issues, understanding warning signs/risk factors, and navigating confidentiality procedures. Some studies critiqued pre-service teacher training as inadequate in this area.
2. National policy: 6 studies highlighted how increased pressure on academic testing due to national policies left little time for mental health assessment. This issue was noted across studies from the UK, US, and Australia.

Individual level:

1. Role conflict: 10 studies discussed teachers’ perceptions of their role in mental health assessment. Many teachers expressed fear that addressing mental health issues was becoming part of their job despite feeling unprepared. Views on this varied between and within studies.
2. Teachers’ mental health: Two studies presented mixed findings on how teachers’ own mental health experiences influenced their ability to identify students’ mental health needs.
3. Knowledge, skills, and confidence: 15 studies reported on teachers’ lack of confidence, knowledge, and skills in mental health assessment. Teachers often felt incompetent, frustrated, and helpless when faced with students’ mental health needs.

Mesosystem:

1. Parents: 9 studies identified parental factors as both potential barriers and enablers in the assessment process. Issues included difficulty obtaining parental consent, parental stigma, and challenges in getting parents to follow up with referrals.

Microsystem:

1. School ethos: 4 studies highlighted the importance of school culture in prioritizing mental health resources and time for assessment.

Exosystem:

1. External mental health services: 6 studies reported on inadequacies in external services, including lack of clear referral pathways, difficulties accessing information, and long wait times.

Insight

This systematic review provides valuable insights into the complex barriers teachers face when assessing students’ mental health needs in school settings. Key findings include:

1. Widespread need for training: The near-universal identification of inadequate training as a barrier suggests this is a critical area for improvement. Both pre-service and in-service training programs need to better equip teachers with the knowledge and skills to recognize mental health issues and navigate assessment processes.
2. Role ambiguity: The mixed views on whether mental health assessment should be part of a teacher’s role highlight a need for clearer policies and expectations. This ambiguity likely contributes to teachers’ stress and reluctance to engage in mental health assessment.
3. Systemic challenges: Barriers exist at multiple levels of the education system, from individual teacher factors to school culture, parental involvement, and external service provision. This underscores the need for comprehensive, multi-level approaches to improve mental health assessment in schools.
4. Cross-cultural similarities: While the review included studies from only six countries, many barriers were consistently identified across different educational systems. This suggests some universal challenges in integrating mental health assessment into schools.
5. Impact of academic pressures: The finding that national policies emphasizing academic testing create barriers to mental health assessment highlights potential unintended consequences of education reforms. Policymakers need to consider how to balance academic and mental health priorities.

These findings extend previous research by providing a comprehensive overview of barriers specifically related to mental health assessment, rather than intervention.

They highlight the interconnected nature of these barriers and the need for coordinated efforts to address them.

Further research is needed to:

• Evaluate the effectiveness of different training approaches in improving teachers’ mental health assessment skills and confidence
• Explore how to best clarify and support teachers’ roles in mental health assessment
• Investigate strategies for improving collaboration between schools, parents, and external mental health services
• Examine how cultural factors influence teachers’ perceptions of mental health assessment across a wider range of countries

Strengths

The study had several methodological strengths:

1. Systematic approach: The review followed PRISMA guidelines, ensuring a comprehensive and transparent search strategy.
2. Theoretical framework: The use of Bronfenbrenner’s ecological systems theory provided a structured approach to organizing and analyzing findings across multiple levels of influence.
3. Mixed methods synthesis: The review included qualitative, quantitative, and mixed-methods studies, allowing for a rich, nuanced understanding of the topic.
4. Focus on teachers’ perspectives: By centering teachers’ voices, the review provides valuable insights from those on the front lines of student mental health support.
5. Cross-cultural comparison: Including studies from multiple countries allowed for identification of both common and context-specific barriers.
6. Practical implications: The findings have clear relevance for informing policy and practice in teacher training and school mental health programs.

Limitations

The review has several limitations that should be considered:

1. Limited geographical scope: Only six countries were represented in the included studies, with a heavy emphasis on English-speaking countries. This limits the generalizability of findings to other cultural and educational contexts.
2. Small sample sizes: Some of the included studies had very small sample sizes, which may limit the reliability of their findings.
3. Potential selection bias: Many studies used convenience or purposive sampling, which may have resulted in participants with more positive attitudes towards mental health being overrepresented.
4. Lack of distinction between school levels: Several studies combined data from primary and secondary school teachers, making it difficult to identify sector-specific challenges.
5. Focus on barriers: The review primarily examined barriers rather than enablers or successful practices in mental health assessment. This may present an overly negative picture of the current situation.
6. Limited exploration of assessment tools: Only one study specifically addressed teachers’ perceptions of mental health screening tools or measures used in schools.
7. Exclusion of non-English language studies: Relevant research published in other languages may have been missed.

These limitations suggest a need for caution in generalizing the findings and highlight areas for future research to address.

Implications

The findings of this review have significant implications for educational policy, teacher training, and school mental health practices:

1. Teacher training: There is a clear need for more comprehensive and ongoing training in mental health assessment for both pre-service and in-service teachers. This training should cover recognition of mental health issues, understanding of assessment processes, and strategies for supporting students and collaborating with families and external services.
2. Policy development: Educational policies need to more clearly define teachers’ roles and responsibilities in mental health assessment. Policies should also address how to balance mental health support with academic priorities.
3. School culture: School leaders should work to create a culture that prioritizes student mental health and provides time and resources for assessment and support.
4. Collaboration: Improved communication and collaboration between schools, families, and external mental health services is crucial. This may involve developing clearer referral pathways and strategies for engaging families throughout the assessment process.
5. Teacher wellbeing: Given the potential impact of teachers’ own mental health on their ability to support students, schools should prioritize teacher wellbeing and provide resources for self-care and stress management.
6. Cultural competence: Training and assessment practices need to be culturally sensitive and adaptable to different educational contexts.
7. Resource allocation: Schools may need additional funding and staffing to adequately support mental health assessment and follow-up support for students.
8. Research funding: More research is needed to develop and evaluate effective strategies for overcoming the identified barriers. Funding should be allocated to support larger-scale, cross-cultural studies in this area.

Implementing these recommendations could significantly improve early identification and support for students with mental health needs, potentially leading to better academic outcomes and long-term well-being.

References

Primary reference

O’Farrell, P., Wilson, C., & Shiel, G. (2023). Teachers’ perceptions of the barriers to assessment of mental health in schools with implications for educational policy: A systematic review. British Journal of Educational Psychology, 93(1), 262-282. https://doi.org/10.1111/bjep.12553

Other references

Carr, A. (2015). The handbook of child and adolescent clinical psychology: A contextual approach. Routledge.

Cefai, C., Bartolo, P. A., Cavioni, V., & Downes, P. (2018). Strengthening social and emotional education as a core curricular area across the EU: A review of the international evidence.

Cook, B. G., & Ruhaak, A. E. (2014). Causality and emotional or behavioral disorders: An introduction. In P. Garner, J. Kauffman, & J. Elliott (Eds.), The sage handbook of emotional behavioural difficulties (pp. 97–108). Sage Publications.

Harvest, H. (2018). How can EPs best support secondary school staff to work effectively with children and young people who experience social, emotional and mental health difficulties? (Doctoral dissertation, UCL (University College London)).

Landrum, T. J., Tankersley, M., & Kauffman, J. M. (2003). What is special about special education for students with emotional or behavioral disorders?. The Journal of Special Education, 37(3), 148-156. https://doi.org/10.1177/00224669030370030401

Levitt, J. M., Saka, N., Romanelli, L. H., & Hoagwood, K. (2007). Early identification of mental health problems in schools: The status of instrumentation. Journal of School Psychology, 45(2), 163-191. https://doi.org/10.1016/j.jsp.2006.11.005

Loades, M. E., & Mastroyannopoulou, K. (2010). Teachers’ recognition of children’s mental health problems. Child and Adolescent Mental Health, 15(3), 150-156. https://doi.org/10.1111/j.1475-3588.2009.00551.x

Meldrum, L., Venn, D., & Kutcher, S. (2009). Mental health in schools: How teachers have the power to make a difference. Health & Learning Magazine, 8(1), 3-5.

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Annals of Internal Medicine, 151(4), 264–269. https://doi.org/10.7326/0003-4819-151-4-200908180-00135

Moilanen, K., Shaw, D. S., & Maxwell, K. L. (2010). Developmental cascades: Externalizing, internalizing and academic competence from middle childhood to early adolescence. Development and Psychopathology, 22, 637–655. https://doi.org/10.1017/S0954579410000337

Mundschenk, D., & Simpson, R. (2014). Defining emotional or behavioral disorders: The quest for affirmation. In P. Garner, J. Kauffman, & J. Elliott (Eds.), The sage handbook of emotional behavioural difficulties (pp. 43–54). Sage.

Ní Chorcora, E., & Swords, L. (2021). Mental health literacy and help-giving responses of Irish primary school teachers. Irish Educational Studies, 1–17. https://doi.org/10.1080/03323315.2021.18990

Stiffman, A. R., Pescosolido, B., & Cabassa, L. J. (2004). Building a model to understand youth service access: The gateway provider model. Mental Health Services Research, 6(4), 189–198.

Williams, J. H., Horvath, V. E., Wei, H. S., Van Dorn, R. A., & Jonson-Reid, M. (2007). Teachers’ perspectives of children’s mental health service needs in urban elementary schools. Children & Schools, 29(2), 95–107. https://doi.org/10.1093/cs/29.2.95

Keep Learning

Socratic questions for a college class to discuss this paper

1. How might cultural differences influence teachers’ perceptions of their role in mental health assessment? What factors should be considered when comparing findings across different countries?
2. Given the identified barriers, what strategies could schools implement to better support teachers in mental health assessment without overburdening them?
3. How might the increasing focus on academic testing and standardized assessments impact schools’ ability to prioritize mental health assessments? Are these goals necessarily in conflict?
4. What ethical considerations should be taken into account when involving teachers in mental health assessment? How can schools balance the need for early identification with concerns about labeling or stigmatization?
5. How might teachers’ own mental health experiences influence their approach to assessing students’ mental health needs? What support should be provided to teachers to address this?
6. What role should parents play in the mental health assessment process in schools? How can schools better engage parents who may be resistant or difficult to reach?
7. How might the barriers to mental health assessment differ between primary and secondary school settings? What unique challenges might each level face?
8. Given the limitations of this review, what additional research would be most valuable to further our understanding of this topic? How would you design a study to address some of the gaps identified?