Department of Psychiatric Social Work, National Institute of Mental Health Neuro Sciences (NIMHANS), Bengaluru- 560 029, India
Received Date: April 09, 2015; Accepted Date: May 31, 2015; Published Date: June 07, 2015
Citation: Vranda MN (2015) Promotion of Mental Health and Well-Being of Adolescents in Schools- A NIMHANS Model. J Psychiatry 18:303 doi: 10.4172/2378-5756.1000303
Copyright: © 2015 Vranda MN. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
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Promotion of mental health and psychological wellbeing of adolescents in schools is a novel program initiated with an aim to develop a comprehensive a model school mental for children and adolescents. Towards this the need assessments were conducted with teachers, students and their parents, policy makers and mental health experts. Based on the need assessment and in triangulation with literature a manual was prepared, field-tested with 299 school teachers. The paper discuss methodology adopted in developing and standardizing promotive school mental health model using existing resources - teachers as facilitators.
Promotion, Mental health; Adolescents; Well-being; Model
It is estimated that around 20% of the world’s adolescents have a mental health or behavioural problem. Upto 50% of mental, behavioural and psychological problems have their onset during adolescence period . The stress faced by the children and adolescents in current situation is enormous. The empowerment of children adolescents is very essential in today’s context in India as there is rapid globalization and urbanization with breaking up of joint families and the traditional social support systems. There is growing evidence of increased psychological problems in children and adolescents especially behaviour problems and suicides. The prevalence rate of psychiatric disorders in India is 12.5% among children aged 0-16 years and 12% among the 4-16 year’s children . Suicide death rates in India are among the highest in the world .
Most of the risk taking behaviours and psychological problems among children and adolescents emerge during adolescent period which can be preventable through universal preventive and promotive school mental health programme. Crime, violence, sexual permissiveness, drug abuse, academic competition, bullying and school dropout are on the rise among the youth. These problems have strong impact on their participation in the classroom, scholastic achievement, relationship issues, mental health and psychological wellbeing. Promoting competencies has the potential to prevent high risk behaviours, psychological problems and enhance resilience among the children and adolescents. World Health Organization  defines Child and Adolescent Mental Health as the ‘capacity to achieve and maintain optimal psychological functioning and wellbeing. It is directly related to the level reached and competence achieved in psychological and social functioning’.
Worldwide increasing attention has been given on primary prevention of mental illness and risk reduction to vulnerability to mental illness. The existing program in the west have shown promising results in enhancing skills of adolescents including positive youth development; prevention of violence; decreased bullying; self-esteem; peer relations; student-teacher relations; improved problem solving; emotional and social awareness [5-9]. In India, there is no separate comprehensive policy to deal with child mental health issues. The existing policies such as National Health Policy, Integrated Child Development Scheme and National Mental Health Program for India [6,7] stress the need for developing comprehensive child mental health program and services at various levels. However, in reality much work needs to be done as the existing program restricted to urban setting where it addresses the psychiatric needs of the adolescents in government hospital setting. Many of the mental, behavioural and psychological problems, among children and adolescents can be prevented if it is intervened at an early stage. School-based interventions possess a great potential in reducing the risk factors and increasing the protective factors to promote the mental health and well-being of children and adolescents. A well-timed comprehensive program in the schools using teachers as a facilitators have the potential for building competencies results in yielding high long term returns on investment on children and adolescent. The program was intended with the aim of promoting the mental health of adolescents. The present project ‘Promotion of Mental Health and Psychological Well-Being of Adolescents in Schools’ was a novel project initiated with the funding from the District Administration, Kolar, Government of Karnataka (GoK). The current program adopts life skills competency building approach, resiliency, and experiential framework of promoting mental health of adolescents in schools. The aims of the project were to develop a comprehensive school mental health model programme to promote mental health and well-being of adolescents in schools’ using teachers as facilitators; to develop a manual for the teachers; test out the manual by training teachers as facilitators to implement program in the schools.
A mental health promotion programme for young people can only be successful if it is centred on their felt needs and concerns; age specific, flexible and culturally appropriate. The first and the foremost relevant step towards this was the recognition of the need to involve the end-users and care providers as partners in the identification of the mental health issues, problems and concerns of adolescents in schools. Towards this we conducted three focus group discussions with teachers, parents their students and eleven in-depth interviews with mental health experts, bureaucrats, policy makers, educationalists, and personnel’s of non-governmental organizations. The agenda of the need assessment was to understand the perspectives of these groups regarding the promotion of positive mental health practices within a school health context. The issues, needs and concerns of the adolescents as well as the skills and competencies that need to be integrated in the programme in order to enhance the mental health and wellbeing of adolescents were discussed. The logistics of promoting mental wellbeing program within a school system was also discussed. The needs of the groups were varied where students focussed on issues related to overcoming academic difficulties, handling exam fears and stress, improving self-image, confidence, peer pressure and handling too much parental pressure on academic felt extremely stressful by students. Few girls expressed being discriminated by having more restrictions on compared to boys. Their teachers and parents focussed more academic performance, handling boy-girl relationship, teaching problem solving and coping skills to handle academic related stressors. Mental health experts, policy makers, educationalists, bureaucrats and NGO’s stressed more program and policies related issues. Considering the growing number of mental and behavioural problems, increased suicides and substance abuse among children and adolescents, all opined the need to have separate policies and programmes to integrate preventive and promotive school mental health in the educational system as there is no national policy on school mental health in the country. The existing polices such as National Health Policy, National Education Policy and National Mental Health Programme for India highlight the need for developing comprehensive child mental health services and programmes at various levels. However, in practice there is no programme as such in the educational system to cater to the mental health needs of children and adolescents. The main needs that emerged from the content analysis with few quotes below are summarized in Table 1.
|1||Positive Mental Health||• Information on how to have a positive state of mind
• Skills for self-confidence and self-esteem
• Overcoming inferiority complex
• Information on how to overcome stressful situation using problem solving and coping skills
• Managing negative feelings such as sadness, anger anxiety, and worries.
“Why we become moody sometimes? Is it normal to be moody sometimes?”- Student “Now a day’s children think about each and everything in a negative way. They are anxious.In our time we used to be positive and discuss our problems with our parents. But today’s generation children consider sharing difficulties as a weakness” - Parent “School environment needs to be changed. Teachers need to mingle with students in a friendly way......There is a lot of gap between teachers and students which need to be changed, then only we will be able to understand the minds of the children” - Teacher
|2||Suicide Prevention||• Prevention ofsuicide due to exam failure,love failure or otherpersonal life events
“Suicidal thoughts are common among children. They are impulsive and not mentally ill. Situations make them think and act impulsively. We are scared to scold them………we do not know how they take it. They do not know the positive way of taking failures. The only thing they know is either running away from home or committing suicide”- Parent. “Children need to be taught how to take failure and success in positive ways. Due to pressure from parents and higher expectations, children are unable to take failures in a positive way. For them failure means weakness” - Mental Health Expert.
|3||Awareness about Mental Illness||• Information to the students about recognizing early signs of psychological problems.
• Information to the teachers about common psychological and behavioural problems among adolescents
• Information about how to identify and help students with psychological problems
• Information on myths and misconceptions about mental illness to prevent stigma.
“We never tell our personal problems which makes us sad. We are good in hiding stuff” – Student. “Teachers need to be sensitized about psychological issues of adolescents” – Educationalist.
|4||Exam Pressure and School Related Issues||• Handling exam fear, failureand stress
• Teaching skills to improve motivation, study habits, concentration and memory
• Prevention ofschool dropout
“Though I read everything, I forget everything in examination hall– Student. “All parents want ‘A’ grade. We take special class for 10th standard students from 8 am and evening again we take extra class. We will not allow them to play or take a break. We are forced by the school administration to get good results. We are also pressurized and stressed out.How can we expect the children to concentrate and study? They need rest. Some children drop out of school or run away from home due to this. Somewhere we, parents and the system are responsible for such things” - Teacher. “Parents always compare their children to brighter students which affect their mind result is suicide or depression or inferiority complex - NGO Personnel “The system needs to be changed as focus is only on academics with encouragement being given only to good students and not to every student. The educational approach should become skills oriented rather than grade oriented. Every child has potentials and talents; we need to identify and enhance it- Bureaucrat
|5||Self-Image||• Information on how to overcome negative self-image and analyse the media’s stereotypical images.
“You are constantly being shown what beauty is – you must be thin, pretty and fair without pimples on the face. It is disgusting the way they show girls”- Student “Girls are very much conscious of their body image. They imitate whatever they see on TV and practice unhealthy diet to keep slim and thin” - Teacher
|6||Parents Related Issues||• Dealing with gender issues
• Bringing down parental expectations on academic
• Understandingadolescents’ growing up issues
“Why do they (parents) control us so much?They treat us like prisoners and do not allow us to do things on our own. I have grown up now; I know what is right and what is wrong. I am no more a small child” - Student
|7||Sexual abuse and harassment||• Skills to handlesexual abuse, sexual harassment, bullying, and eve teasing
“They(boys) call me Dummi (Fatty), it hurts. I don’t feel like goingto school” – Student. “I travel by bus, I feel scared to travel alone, some men look at me in a dirty way” – Student.
|8||Peer Pressure||• Teaching assertiveness skills tohandle peerpressure and prevention of negative peer influence
“Why do they (parents) always control us?It is normal to have friends and go out with them. They(parents) do policing to know with whom we are going” - Student “Now a days it has become a fashion that students smoke or watch pornography under the influence of their friends. We need to channelize them and build healthy behaviour” - Teacher
|9||Adolescent issues and Sexuality||• Helping adolescents how to pubertal issues which includes menstrual issues in boys and night emission in boys for healthy transitions.
• Handling boy-girl relationship
“Suddenly after attaining menarche, my mother does not allow me to wear a short frock; I have to wear Langa (Long Skirt). I love to wear frocks”- Student “They (parents) tell me I have grown up, don’t do this and don’t do that. I get angry”- Student “ Some girls have boyfriends and few eloped with them” – Teacher
|10||Sexual Abuse||• Information on how to protect oneself in public places
• Safety skills to prevent sexual abuse
“I am the only one to get down from bus at the last stop; while getting down from the bus the conductor looks at me in a dirty way and sings dirty movie songs. I get scared and do not know how to handle him. I am scared to tell my parents about this as they will stop me going to school and blame me only” – Student
|11||Substance Abuse and Alcohol||• Information on negative impact of smoking and drinking
• Skills to say ‘No’ to smoking
• Information on how to analyze media information especially advertisements
“In TV advertisement actor Upendar encouraged people to drink beer. How can he do like that? Will he tell same things to his own small children?At least lady actress Tara is better; she promotes youngsters to drink Nandini Milk” – Student
|12||HIV and AIDS and Sexuality||• Information on HIV and AIDS
“Curiosity about sex is common. They (students) get misleading information through friends and few try to experiment it due to peer influence and curiosity. We have to educate them” – Educationalist
|13||Values and Life Skills||• Building values and life skills
“Children need moral and value educations as values are decreasing in the present days………….. Children who are in 5th or 6th grade talk about sex openly and seem to know everything.They do not have fear, even if they do wrong things”. – Parent
|14||Making a Career Plan||• Time management skills, setting goals and career planning
“I like commerce and I want to become an accountant.My parents want me to become an engineer. They want me to work in the IT sector and earn lots of money” - Student
|15||Gender related Issues||• Why boys are treated differently from girls?
• Education to the parents to treat both (boys and girls) equally
“Why more rule for girls? Why do they (parents) give more importance to my brothers? Why do I have to do all the work at home? I feel sad” – Student
“If a boy baby is born parents are very happy but if it’s a girl baby then they start crying” -Student. “After marriage girls go to their in-laws house and do not take care of parents, we (boys) are the ones who take care of our parents, they (girls) belong to others after marriage, they (girls) are not going to live with us forever. Why should we (boys)treat them equally? As a boy I have to earn money, take the responsibilities of get her married off......... after marriage they (girls) do not belong to our family”- Student
Table 1: Needs in the Area of Promotive Mental Health of Adolescents in Schools Identified by the Groups.
Based on the information collected through the analysis of qualitative data and in triangulation with existing literature a comprehensive manual was developed. 15 areas were identified. To avoid overlap between the themes and activities, the issues were grouped into 12 major modules/units with 52 activities. Some of the themes such as awareness about mental illness (3) and self-image (5) were brought under module- 1 (promotion of positive mental health), parent related issues (6) and gender related issues (15) were brought under module-9 (developing healthy relationships), peer pressure (8) was brought under module-10 (prevention of substance abuse). The manual designed to strengthen student abilities or skills using teachers as the facilitators in the schools in the following areas: promotion of positive mental health, enhancing resilience, handling academic stressors, practicing healthy life styles, reproductive health issues, developing healthy sexuality, prevention and handling sexual abuse, harassment and bullying, developing healthy relationships, prevention of substance abuse, goal setting and career planning, prevention of suicide and developing values and life skills. This program is designed as a universal promotive programme for use in schools to promote psychosocial competencies of the students to handle demands and challenges of life successfully. It is not designed as a mental health intervention to provide counselling services to students although for some students such services may be required. The goal of the program is the reduction or elimination of unhealthy behaviour or health problems by intervening before such problems occur. Interactive and activity-based classroom sessions give students the opportunity to enhance their knowledge, attitudes and skills essential for promotion mental health and resilience in an experiential manner, the results of which are expected to be sustained. Young people need to be taught how to regulate their emotions, deal with frustrations and failures, handle peer pressure and problems related to development, school and family in a healthier way which in turn would promote their mental health and resiliency. The ideal place for such a programme is the school where there is ample opportunity to promote the mental health of young people. School is not just a place of educational learning, but also an important environment where children make friends, develop social networks and are introduced to adult role models. The current programme takes school as a platform to implement the activities using teachers as facilitators. The school setting, being a place of learning and modelling, has the potential to contribute positively to students’ mental health and well-being. All the activities of the manual were planned with the teachers as facilitators to implement the program. Students’ participation in the class was given more importance as part of this program. The modules were designed for use in upper primary and higher secondary schools settings, for the students of 7th, 8th, 9th and 10th standards/grades. The modules had a common structure, with materials organized according to the developmental age of the students. Each standard/grade had about 15 modules (activities). Modules were activity based but had allocated sufficient time for the students to think and articulate about the skills and content. A balance between the activities/games on the one hand and introspection/thinking on the other hand was envisaged. The activities were designed in such a way that they would be simple and could be carried out by the teacher by reading the instructions before the class. Cultural sensitivity was maintained. Activities were arranged in a specific order for each class. It was expected that the teacher would do the activities over the entire span of the academic year, once a week for one hour either as part of the physical training class or moral education class.
The manual was field tested with 288 upper primary and secondary school teachers of Kolar District (data not presented). The teachers were trained as facilitators to implement the program in their respective classes. A follow-up evaluation conducted on 200 teachers after 2 months training showed that a majority had carried out various activities in the modules and had found the program feasible. The feedback from the teachers shows that the program was a feasible one using them as facilitators if trained. More than 60-70% of these teachers were able to do the activity, satisfied with the discussions by the small groups, felt that the students participated actively and confident about doing the activities with students. Most of the teachers were able to complete the activity within an hour and reported active student participation. Most teachers were satisfied with the small group discussions and their role as facilitators, and were confident of their ability to conduct the activities in the class. Some of the teachers reported procedural difficulties pertaining to small space and difficulty completing the session on time due to larger number of students. With regard to the students’ responses to the activities, it was reported that majority of them were curious, participated with high enthusiasm and enjoyed doing the activities. Teachers reported that students responded well to the interactive techniques and issues offered for exploration. Teachers reported that they enjoyed doing the activities with students and their relationship with them also changed as many students started sharing their personal difficulties with them. Students started to see them as a friend than as teacher. Some of the behavioural changes observed in the students by the teachers during and after program were: improved confidence, leadership skills, increased classroom participation, increased self-esteem and improved communication skills. The feedback from the teachers it was found that the model is acceptable and feasible.
The manual was reviewed and validated by panel of experts from child and adolescent mental health. Their suggestions were incorporated in the final version of the manual. The modules were edited for language, grammar and uniformity. Pictures were added in the beginning of each of the modules to break the monotony and modified where necessary. Few activities related to sexuality were scrutinized and culturally appropriate messages were added. Apart from this clear instruction for doing certain activity related to sexuality separately for the boys and girls were given on the top of the activities. Content of the some of the modules which had overloaded information in the fact sheets were reduced e.g. healthy life style practices, STD, HIV etc. Final version of the manual was printed manual and handed over to all the trained teachers and implementation of the program for the forthcoming academic year was planned.
School based interventions program have been increasingly recognized as effective means of promoting mental health of students and prevent the development of unhealthy behaviour. Programs focussed on competence enhancement of children and adolescents produced long lasting positive effects on mental, social, and behavioural domains [7-9]. The current Promotive Mental Health and Well- Being (PMHWB) programme is a universal comprehensive school promotive mental health programme designed to reduce risks and enhance psychosocial competencies and resiliency of adolescents in schools found to be feasible and acceptable by teachers. It is universal as it applies to all students. The program is a novel one which focuses on comprehensive mental health of the adolescents using preventive approach through experiential learning using the already available resources-teachers as facilitators in the school. The program is cost effective as it used exiting teachers to integrate the program in the classroom. The findings from the study suggest that trained teachers can effectively deliver mental health promotion intervention in schools. Further evaluations of program are needed to determine the long-term impact on various multi-component aspects of mental health and psychological well-being. The health professionals who are working in the area of child and adolescents mental health has significant role in promoting mental health of children. The current model may be replicated in their settings which would help in integration of program in schools. The contribution and highlights of the PMHWB model are:
• Using teachers as FACILITATORS to implement the programme in the schools.
• Using structured program and activities with participatory experiential approach.
• Promoting Mental Health and Well-Being of adolescents through enhancing psychosocial skills and resiliency as outcomes.
Support of Dr. D.S.Vishwanath, IAS, Deputy Commissioner and District Magistrate, Kolar District, Karnataka for funding and active involvement in implementation of the program in school system is greatly acknowledged.
The author acknowledge the expert contributions by: Dr. R. Parthasarathy, Professor, Department of Psychiatric Social Work; Dr. Jayashree Ramakrishna, Professor and Head, Department of Mental Health Education; Dr. Gururaj.G, Professor and Head, Centre for Public Health and Epidemiology; Dr.K.Sekar, Professor and Head, Department of Psychiatric Social Work; Dr. Murulidharan. K, Associate Professor, Department of Psychiatry; Dr. K.S. Meena, Assistant Professor, Department of Mental Health Education; Dr. N. Girish, Department of Epidemiology, Mr. Prabhudev, Editor, Department of Publication (all are from NIMHANS, Bengaluru), Dr. Rajaram Subbaiah, International Expert in Psychosocial Care, ANTHARANG, Bengaluru; Dr. Sonykutty George, Child Protection Specialist, United Nations Children’s Fund, UNICEF, Hydreabad; Dr. Divya Ravindran, Research and Training Consultant, Child Protection Unit, UNICEF, Bengaluru; Dr. Bala Shanthinikethana, Assistant Professor, Christ University, Bengaluru; Dr. Atique Ahmed, Assistant Professor, Central University, Rajasthan and Dr. Anish Cherian, Assistant Professor, Department of Psychiatry, K S Hegde Medical Academy, Mangaluru.