Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Strong partnerships involving schools, community systems, and families are critical in moving toward comprehensive and high-quality mental health programs and services for all students (Weist, 1997). Such partnerships are a foundational value in school mental health (SMH), with strong emphasis on the critical role of students in building, sustaining, and continuously improving programs and services (Christenson & Sheridan, 2001). There are many benefits to partnerships that emphasize strong family and youth participation in SMH, including enhanced collaborative decision-making, family engagement, and positive developmental outcomes for students (Epstein & Van Voorhis, 2010; Henderson & Mapp, 2002). Involving youth and families as partners in SMH is also consistent with federal priorities (U.S. Department of Education, Planning, & Evaluation, Policy Development, 2010), which emphasize consumer- and family-driven mental health care that encourages meaningful involvement of families in all aspects of service provision as recipients of care.

Documented efforts to engage families in SMH has received considerable attention (e.g., Epstein, Coates, Salinas, Sanders, & Simon, 1997; Lowie, Lever, Ambrose, Tager, & Hill, 2003); however, efforts to involve youth directly in shaping programs and services need further consideration. This is in spite of the recognition that, as service recipients, students should also be involved in influencing SMH programs and services (Friensen, Koroloff, Walker, & Briggs, 2011). National organizations have also identified youth involvement and leadership as a key priority (e.g., National School Boards, 2011), yet little evidence exists to provide guidance on how youth can and should be involved as unique partners and a critical voice in developing and implementing SMH programming. One important way to engage students is to solicit and value their perspectives on youth mental health issues, including needs, supports, and services to inform the development of SMH programs and services.

In this chapter, we discuss the impetus for involving youth in SMH and a unique method for obtaining their perceptions. Further, in imploring this approach to engaging youth to inform SMH efforts, we present qualitative data from a survey developed to obtain the perspective of high school youth around SMH services and resources, as well as facilitators and barriers to existing services. Specifically, the youth survey provides information about the problems they face in schools, their awareness of resources, suggestions for school mental health programming, and willingness to use services. We highlight how such data can be used to better address the needs of students, reduce stigma, and increase involvement of youth in programs and services in schools.

Call for Youth Involvement

As reflected in other chapters in this book, SMH has gained momentum in recent decades, transforming child and adolescent mental health services in many ways. In particular, SMH has facilitated a commitment to a much stronger focus on school-family-community partnerships characterized by authentic, mutually beneficial, collaborative relationships (Weist, 1997; Weist, Paternite, & Adelsheim, 2005). These partnerships are intended to ensure that youth and families help to guide programs and services toward enhanced relevance and effectiveness. However, as mentioned above, literature on key aspects of these partnerships, specific strategies that promote success, and challenges faced in developing and sustaining strong partnerships is extremely limited. As a result, strong youth and family engagement in SMH remains more of an aspiration rather than a well-operationalized everyday practice.

The National Assembly on School-Based Health Care (see nasbhc.org) and the National Community of Practice (NCOP) on Collaborative School Behavioral Health (see http://www.ideapartnership.org/) are two organizations that were the impetus to the development of guidelines on promoting strong family and youth collaboration in SMH programs and services. NASBHC supports the development, expansion, and improvement of school-based health centers (SBHCs) in the USA (see www.nasbhc.org). These SBHCs offer a range of health care in schools including medical physicals, treatment of acute illness, and assistance for student management of chronic illnesses and increasingly include mental health services, with emotional/behavioral problems representing the most frequent reason for referral for services (Weist, Goldstein, Morris, & Bryant, 2003). Recently NASBHC participated in and led a School-Based Health Care School Mental Health Capacity Building Partnership (SMH-CBP), funded for 5 years through a cooperative agreement with the Centers for Disease Control and Prevention (Stephan et al., 2010). This work focused on development of strategies to enable educational systems and community partners to operate in a more comprehensive, responsive, and effective way with development and implementation of SMH programs and services. The SMH-CBP strategies include provision of training, technical assistance, information sharing, materials development, technology transfer, or funding. An early phase of the SMH-CBP work involved completion of a qualitative focus group study with a diverse array of stakeholders in four states (MD, MO, OH, OR) to identify critical factors of SMH capacity building. Four distinct focus groups were conducted in each state, with three of the groups including diverse professionals from the fields of education, family advocacy, health professions, mental health and social services, youth development/advocacy, and business. A fourth group in each state consisted of youth. Findings from the focus groups with adult professionals (Stephan et al., 2010) highlight 10 critical factors of SMH capacity building, with one of the 10 factors directly emphasizing family and youth engagement, specifically that “young people and families from diverse backgrounds must be engaged in all aspects of SMH policy and program development” (p. 53). In order to address this critical factor, Stephan et al. made specific strategy recommendations based on analysis of the focus group findings, including the following: (a) expanding the roles for families in schools as strong partners in the education of their children; (b) engaging culturally diverse family and youth organizations as collaborative partners in SMH programs and services; (c) inviting youth and families as strong participants in all SMH efforts; (d) offering incentives for youth and families to participate in SMH efforts; (e) ensuring leadership and decision-making roles for youth and families in SMH efforts; (f) ensuring that SMH professionals and educators fully understand the value and processes of effectively engaging youth, families, and community partners; and (g) increasing youth engagement through their participation in mentorship activities, speakers’ bureaus, and youth leadership initiatives.

Within the SMH-CBP partnership, youth engagement was modeled by inviting youth in each of the four states noted above to participate in the focus group study. Specifically, in each of the four states (MD, MO, OH, OR), focus groups with youth were conducted to gain their perspectives on what schools can do to better address the mental health needs of all students. Through their responses, these youth highlighted a number of key themes including confidentiality when helping students, strong trusting relationships between students and adults in school, school staff openness to learn about students’ backgrounds and cultures, staff training in mental health issues, a positive school environment, opportunities for participation in curriculum development cocurricular participation, and active youth engagement in development of SMH programs and policies. A detailed summary of lessons learned from youth through the focus groups is available on the NASBHC website (http://ww2.nasbhc.org/RoadMap/Public/MH_What%20Students%20Say.pdf).

In 2004, the NCOP was developed via collaboration between the IDEA Partnership, a national initiative to improve learning supports for youth in special education, and the Center for School Mental Health (CSMH), one of two national centers focused on the advancement of SMH.Footnote 1 The NCOP works with 22 national organizations, 9 technical assistance centers, leaders in 16 states, and other interested stakeholders to facilitate a “shared agenda” across education, mental health, and families. The work of NCOP is implemented significantly through 12 “practice groups” each focused on a specific issue or theme (e.g., quality and evidence-based practice, building a collaborative culture for student mental health). In response to the lack of specific guidance on involving youth in SMH programs and services, the NCOP developed a Youth Involvement and Leadership in SMH practice group (see www.sharedwork.org). The aims outlined by the group are to (1) expand youth leadership, participation, and input at all levels, including in local, state, and national efforts; (2) advance the development and implementation of strategies that promote involvement in service delivery systems; (3) support efforts to promote meaningful involvement of youth as an important stakeholder; (4) organize discussion around the inclusion of youth in SMH in meaningful ways; (5) develop and promote best practices for youth involvement and leadership in all aspects of SMH programming; and (6) serve as a resource for educators and practitioners to develop strategies and approaches to teach new skills to promote youth involvement in schools and communities.

The work of NASBHC, including their SMH-CBP initiative in collaboration with the CDC, and the work of the NCOP are encouraging. However, the guidelines have not been empirically evaluated; thus, specific, empirically supported strategies for engaging youth as recipients of care or as guiders of programming decisions are not yet available. For example, SMH professionals lack specific guidance on determining how to help youth and families articulate their perspectives, how to balance youth and family input with that of the professionals, and how to obtain perspectives from educators on student functioning while maintaining confidentiality. In order to establish such guidelines, additional data are needed. Schools may take initial steps toward building partnerships with students by obtaining their perceptions of common problems and needs, services to address those needs, and methods through which students could contribute ideas for enhancing the relevance and effectiveness of school-based mental health services.

To advance our own understanding of the needs of the students we were working with in our state, we conducted a study focused specifically on obtaining high school youth perspectives on effective SMH programs and services. In the United States, youth in 9th–12th grade are engaging in behaviors that place them at risk for morbidity and mortality. These behaviors include unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors contributing to unexpected pregnancy and sexually transmitted diseases, unhealthy diet, and lack of exercise (Centers for Disease Control and Prevention [CDC], 2012). As these behaviors impede students’ ability to achieve successful academic standards, many SMH efforts are targeting this population to prevent school dropout and promote school success to graduation. In our own efforts to improve family, school, and community supports for high school students with emotional/behavioral problems, we found it critically important to conduct this study with a sample of high school students to better understand their emotional, behavioral, and social needs, their knowledge about what services and resources they needed, and their access to resources and services provided in their school. We conceptualized this study based on a review of the fairly limited literature on partnering with youth to inform SMH programs. A description of the study and its findings highlighting key themes from students’ responses and specific recommendations for increasing youth engagement and leadership in SMH follow.

Involving Youth in SMH: A Qualitative Analysis of High School Age Students’ Perceptions of SMH

We conducted a qualitative study examining youths’ perspectives and knowledge of SMH, including their perception of the problems that students are confronted with, the resources and types of SMH services delivered at their school, and ways to improve these services. The study focused on high school-age youth given our efforts to improve evidence-based SMH interventions for these youth to prevent school dropout and improve student outcomes. We also sought to understand what problems, facilitators, and barriers to effective SMH were salient for these youth.

Sixty youth, ranging in age from 14 to 19 years, were recruited through a study hall course in one high school in a rural area of South Carolina. The high school was selected for the study because of an interest by school personnel X in developing and implementing SMH services, which the school did not currently provide. A convenience sampling strategy was used, with administrators selecting three study hall classes that included students in all grade levels. Student participants were given a packet of measures and an open-ended survey on student needs, resources, and perceptions of SMH, which are the data used for this analysis. Given the timeline for data analysis, only 25 participants completed the survey, and qualitative analysis was conducted with a subset of the sample (N = 25), who were participating (N = 60) in the larger study.

After obtaining study approval from the Institutional Review Board at the University of South Carolina and from the school district, parents and students were informed about the project and parents consented; students assented to participation. In study hall classes, students received a structured and open-ended survey written in English that lasted approximately 10–12 min. Participants were given a $5 gift card as an incentive for participating. The survey included seven open-ended items and one Likert scale item. Six of the items assessed student (1) perceptions of the problems that students face in their school; (2) the types of facilitators that make it easy for students to get help and (3) to use resources; (4) individual(s) who students turn to when they experience problems; (5) the types of barriers that exist that prevent students from receiving help; and (6) the types of resources that are presently available to students in their school. On the seventh question, participants reported their willingness to use resources or programs at their school if they were in need of them and they were available, using a five-point response (1 = least willing to 5 = most willing). To understand students’ attitudes regarding SMH, on the last open-ended item, participants were asked to define what the words “school mental health” meant to them.

Thematic analysis was conducted, using the in vivo software utility, to examine students’ responses to the open-ended survey items. Identification of themes emerged through immersion in the data, including data sorting, coding, and comparison. Analyses were performed by two researchers (a middle-class African American woman and a middle-class Caucasian American woman). Each researcher read the entire set survey responses and identified important themes. Initial codes for responses were created and then each response was grouped into these larger themes (Charmaz, 2006). Then data were coded to examine each sentence, individual word, and phrase (Strauss & Corbin, 1990). This process allowed for the identification of categories, properties, and dimensional aspects of the data. The two researchers separately identified themes and then compared the themes that emerged from each other. After the themes were discussed, a third rater was brought in to resolve discrepancies of themes upon the two researchers. This iterative process occurred until all surveys were analyzed and coded and all major themes were identified.

Themes from High School Age Students’ Perceptions of SMH

Description of Daily Psychosocial Difficulties

Participants identified several difficulties that affected their psychological and social functioning, reporting problems both at school and at home. They reported experiencing difficulties in their peer relationships at school. These difficulties included forms of physical and relational violence. Several participants, for example, reported that they were bullied or teased to the extent of getting into fights. Other participants reported that they experienced peer pressure that overwhelmed them.

Some participants reported that academic pressures impaired their psychosocial functioning because they felt that they had to “…make the best grades to get into a good college.” Another academic stressor was the amount of pressure students experience from their families regarding grades. As reported by one participant “…families bother you about grades.”

Additional difficulties involved relationship problems at home, such as divorcing parents, unfair treatment by stepparents, poor communication, and general challenges manifested as fighting with parents. Additionally, alcohol, drug, and cigarette use were noted as concerns of youth

Getting Help for Problems

Participants were asked to describe what would make it easier for teens to get help with problems at their school and what stops them from getting help. Participants overwhelmingly reported that they would like more connections to resources, including access to trusted relationships with others in the school and structures for promoting the development of trusted relationships. They reported a preference for regular, ongoing opportunities to talk with counselors and others at school, but at the same time reported numerous challenges that make this impossible. Challenges included not knowing of someone who understood, absence of school staff who had experienced similar problems, staff who conveyed disinterest, and staff who were unavailable because of workload or lack of time. Several students reported that if they were experiencing problems, they would deal with the problem alone and not tell anyone. Fear seemed to be a motivation for wanting to avoid disclosure. Whether perceived or real, participants’ fears included retaliation by the person who the participant had problems with, consequences or punishment if problems were revealed, mistreatment if undesired people learned of their “business,” and not receiving help for their problems either because they were “hopeless” or others would be incapable of helping.

Barriers to Getting Help

When asked to identify barriers that deter students from accessing school resources, they identified past negative emotional experiences, their perceptions of how other people viewed them, consequences they faced, and lack of support from other people. Participants described feeling afraid and threatened from other students about sharing their problems or seeking help from authority figures. The participants construed “telling” as “snitching,” which is viewed very unfavorably. For example, one participant reported “snitches deserve stitches and should be found in ditches.” This phrase represents the harmful effects youth may face if they seek help from authority figures. By refusing to get help, these youth remain vulnerable, duplicitously shielding and protecting the individuals who are troubling them from consequences. These conflicting experiences contribute to participants’ feeling unsafe, unprotected, and incapable of stopping things that are out of their control. Unfortunately, participants’ fear of potential reprisal for exposing their problems may, in fact, exacerbate their inability to access resources because no one knows they are suffering.

Additionally, participants’ perceived lack of support and helplessness deterred them from accessing resources. They reported feeling that there was no one available to help them, that “nothing would help,” or that “no one knows how I feel.” Students’ feelings of embarrassment and pride regarding admitting and exposing their problems may be exacerbated if adults reach out to students poorly, leading students to never seek help and suffer in silence. According to (Yalom & Leszcz, 2005), universalization and normalization are strong therapeutic concepts that help people cope and manage fear and hardships. Participants experiencing problems within a silo may begin to believe they are the only ones experiencing a particular problem, and they may experience the problem for a prolonged time, unnecessarily. Participants also reported worries about fitting in. For example, one participant reported “if other people knew what I experienced I wouldn’t fit-in…and people would say something bad about me.” Fear of fitting in and fear of additional negative consequences were common themes deterring participants from accessing school resources.

Ease of Using School Resources

Participants also were asked to identify school resources. Several participants responded that they did not know of any resources or they were unsure about the existence of any resources. There are several plausible interpretations for these responses. It may be that some participants had experienced few problems and had no need to seek resources. They did not need resources; hence they did not have any knowledge about existing resources. Alternately, it may be that participants had experienced problems, but were unsure about using resources because of the previously mentioned fears regarding accessing them. Thus, they were fearful of accessing resources and felt uncertain using them. Further, it may be that participants had experienced problems, but did not know of existing resources. Thus, knowledge of and need for resources may vary depending on several factors, including participants’ need for resources, degree of industriousness regarding finding resources, availability of resources, ability to overcome fear of using resources, and ability to access identified resources.

Some participants also explicitly recognized a need for resources, such as extracurricular activities, and the importance of being able to access those resources, to help take their mind off problems. They listed a variety of activities they would appreciate accessing, such as the library, gym, and computer labs at school. However, they reported that there were not many activities available to them in their area. Participants wanted time to participate in programs during school hours, given that in rural communities transportation is problematic for some families. Youth may not have parents who can transport them to after-school activities. If participants cannot participate in activities during school hours, they may be denied altogether, especially if they are totally dependent on school buses to get home (Weist, 1997).

Willingness to Use School Resources

Participants also rated their willingness to use school resources and programs if they had a problem (1 = least willing to 5 = most willing). Participants’ scores were skewed toward feeling less willing (M = 2.12, SD = .88, range 1–4). No participants indicated that they would be most willing to use school resources if they had a problem.

Meaning of School Mental Health

Recognizing that the construct mental health carries some degree of stigma and that delivery of mental health services in schools is not standardized and universal, participants were asked what the words “school mental health” meant to them. This was in effort to understand the implicit association and connotations associated with the phrase. Participants listed a range of responses including identifying school personnel, the idea of helping, and indicators of the presence or absence of physical and mental health and well-being, as well as components of academics. Participants also indicated ideas that were consistent with perspectives of mental health that reflect deficits-based approaches, abnormalities, and stigma. In general participants listed the following words that came to their minds: school staff (e.g., “nurses, guidance, and teachers”), helping (e.g., “talking, thinking, caring individuals”), and physical health and well-being (e.g., “stress, headaches, crazy, emotions, safe, self-control, self-confidence, healthy mind-set regarding school, brain, and problems”). Other items that were listed were “academics, people think something’s wrong with you, institution.” Because the survey was anonymous, we could not conduct follow-up interviews to further explore these responses.

Discussion, Limitations, and Recommendations

This chapter reviewed the call for youth involvement as a national priority in service provision and as an important practice in advancing efforts in SMH. Central to involving youth is developing equitable mutually beneficial partnerships, but models for partnering with youth and specific strategies for involving youth in SMH cannot advance if the perspective of youth is omitted. Given previous efforts documented by the NASBHC to incorporate youth voice on issues related to SMH, we conducted a survey as an initial step to understand the perspectives of the population of youth that we are seeking to help in improving SMH programs and practices in South Carolina. This demonstrates one way in which researchers, practitioners, and school professionals may approach involving youth to inform and advance SMH efforts.

The findings of the study highlight the importance of soliciting the voice of youth for the promotion of improved SMH service delivery. As indicated by the survey results, there were youth who expressed that even if they had problems and if services existed, they would still be unwilling to use them. Further understanding the specific barriers that impede SMH use for students is a critical step toward removing them. This reflects the theme in this chapter on the need for purposeful outreach by education and SMH staff to students on emotional, behavioral, and academic challenges they are facing and requesting their recommendations on the best approaches to help them with these challenges. Student responses then can help guide programming at universal, selective, and indicated levels of prevention, consistent with the increasing emphasis on multi-tiered systems of promotion and support as in school-wide positive behavior support (and reflected in a number of chapters in this book).

Other themes that emerged from our qualitative analyses indicated that youth were fearful of experiencing negative consequences from seeking services or help, that they felt disconnected from school and possible programs or services offered at school, and that there was a lack of resources and availability of services that they knew about within their schools. By identifying these concerns and continuing to ask youth about their perspectives on these issues, we may begin to develop specific strategies and practices that promote greater youth involvement and partnerships in SMH and potentially more effective programs and services.

Clearly, the findings of this study are not generalizable to all high school youth. In addition, the survey methodology has limitations, in that it was not possible to conduct follow-up interviews to gain deeper understandings of the youth responses to survey questions. Nonetheless, the results do shed light on important dimensions to consider in engaging youth in SMH more broadly. For example, efforts might focus on strategies that reduce youth’s fear of consequences of others knowing of their own emotional and behavioral difficulties. SMH professionals might also develop strategies for improving relationships and connections between students and other peers and adults in schools. Attending to these issues and continuing to ask youth about their needs, awareness of resources, perceptions of stigma, and suggestions for improving SMH programming may prove useful in developing additional strategies to inform the development of SMH programs, practices, and policies.

Education and SMH professionals should focus on building relationships with youth, assessing their skills, and building on their strengths and assets while marketing SMH services. As emphasized by the study participants, youth are not willing to share their problems with professionals if trust, privacy, and confidentiality are compromised. Professionals must refrain from giving the appearance that they are untrustworthy or gossipers. Youth are fearful that if they disclose about their problems, others will find out and begin mistreating them. This fear is a barrier to SMH services and one that staff should continuously be mindful of.

Another strategy SMH professionals should use to build relationships with youth is to communicate “unconditional, positive regard” (Rogers, 1995, p. ix). This type of communication conveys empathy, acceptance, and opportunities for growth and personal development. As suggested in the survey results, youth did not believe that adults could help them or that they were interested in hearing what they had to say. Youth can be distrusting of adults, especially if they perceive that adults have failed them previously. SMH professionals can offer youth opportunities to establish positive, healthy relationships with trusting and caring adults. Given the survey responses, youth want this type of relationship, but are unsure of how to find or create it.

Youth involvement is essential to the success and effectiveness of SMH programs, but often youth voice is not sought or seriously considered in shaping these programs. Rather than a supplemental activity that programs may or may not engage in, we hope the clear message from this chapter is that youth voice is absolutely essential to effective programs.