Association of Mental Health Problems with Academic Achievement in High-School Students

Abstract

The research uses a quantitative study design in order to determine the range of symptoms in students and its impacts on educational outcomes. The research questions include the following: Does diagnosis of mental health problems during high school impact high-school students’ abilities to achieve higher academic attainment including high-school diplomas, college education and higher? Do the school mental health service providers provide high quality services in order to improve academic performance outcomes in high-school going children? Do sub-optimal knowledge and skills by school mental health providers negatively impact the higher academic achievement of high-school going children? Mental health problems have impacts on the social, behavioral patterns of children and adolescents as well as on their academic achievement. The role of evaluating the current state of mental health services in schools is critical to ascertain and reduce potential adverse effects on educational achievements of school-going children. The proposed research investigations allow for evaluation of two independent associations with academic outcomes in school-going children. Potential stakeholders for the research include the students, educational systems, federal and state government, and key members of school administration. Students will face outcomes for the rest of their lives if they are not able to gain adequate educational achievements. Due to limited resources offered by state and federal government policies, it is difficult to successfully implement a sustainable system of mental health service provision across schools. It is expected that mental health patterns have impacts on academic achievements in school-going children.

Keywords: [Mental health problems, educational achievement, SDQ, high-school, adolescents, children, quantitative]

Table of Contents

CHAPTER 1. INTRODUCTION…………………………………………………………………………… 5

Background of the Problem…………………………………………………………………………………. 5

Statement of the Problem…………………………………………………………………………………….. 6

Purpose of the Study…………………………………………………………………………………………… 6

Significance of the Study……………………………………………………………………………………… 6

Research Questions……………………………………………………………………………………………… 7

Definition of Terms……………………………………………………………………………………………… 8

Research Design………………………………………………………………………………………………….. 8

Summary……………………………………………………………………………………………………………. 9

CHAPTER 2. LITERATURE REVIEW………………………………. ……………………….10

Theoretical Orientation for the Study…………………………………………………………………. 10

Review of the Literature……………………………………………………………………………………. 11

Synthesis of the Research Findings…………………………………………………………………….. 19

Critique of Previous Research Methods……………………………………………………………… 20

Summary………………………………………………………………………………………………………….. 20

CHAPTER 3. METHODOLOGY………………………………………………………………………… 22

Purpose of the Study…………………………………………………………………………………………. 22

Research Question and Hypotheses…………………………………………………………………….. 23

Target Population and Sample…………………………………………………………………………… 24

Procedures………………………………………………………………………………………………………… 25

Ethical Considerations……………………………………………………………………………………….. 28

CHAPTER 4. EXPECTED FINDINGS/RESULTS……………………………………………….. 30

CHAPTER 5. DISCUSSION………………………………………………………………………………. 32

Implications………………………………………………………………………………………………………. 32

Methodological Strengths and Weaknesses…………………………………………………………. 32

Suggestions for Future Research………………………………………………………………………… 33

 

CHAPTER 1. INTRODUCTION

Coping with mental health illness may be challenging for families with many barriers identified. Children and adolescents may not receive appropriate mental health care services in the community or at school; effective coordination of mental health services has proven to be difficult, which has created a need for mental health intervention programs (Puddy, Roberts, Vernberg, & Hambrick, 2012). Schools have been identified to be a viable source for students with mental health problems. Mental health problems have impacts on the social, behavioral patterns of children and adolescents as well as on their academic achievement. Schools are focusing primarily on academic achievements and their indicators with limited focus on the mental health of students. It is known that mental health plays significant roles in academic outcomes and the mental health problems are aggravated with academic achievement and social support. Often, students are identified with internalized symptoms that go unnoticed.

Background of the Study

Children and adolescents are more vulnerable due to the neglect for mental health services in schools. Mental health is declining in children and adolescents of school-going age with 10-20% of them being affected (Kieling et al., 2011). The United States spends financial resources for education in the United States and the role for providing first-class education. The inclusion of diversity in students is expected to include students at risk of mental health problems due to multi-factorial causes. The role of addressing gaps in achievement lies with school systems, social support groups including families and national and state policies implemented by the government (US Department of Education, 2010). Barriers for academic attainment are often psychiatric or financial with additionally identified limitations related to financial shortcomings of families (Young &Murray, 2004). The role of mental health providers, including teachers, counselors and psychologists, needs to be formally assessed in order to provide sustainable implementation of EBPs across school systems. Effects may be witnessed by families due to changing behavioral and emotional factors. Additionally, sociologists may benefit from increased exploration of social theories impacting educational achievement due to compromised mental health.

Statement of the Problem

While there is a developed infrastructure to provide mental health services across schools in the US, not much information is available for the quality of services available. Policies encourage the use of evidence-based practice across the student mental health infrastructure (Owen et al., 2014). However, there is evidence indicating the poor implementation of national policies (Atkins et al., 2003). The role of evaluating the current state of mental health services in schools is critical to ascertain and reduce potential adverse effects on educational achievements of school-going children.

Purpose of the Study

Obstacles have been identified that impact the successful implementation of school mental health provision across schools (New Freedom Commission on Mental Health, 2003). President Bush identified multiple gaps in the mental health service provision and the roles of federal and state government policies are unspecific as to how to tackle to lack of successful implementation. The quality of life of children and adolescents is directly affected by service providers in school and not enough quantitative evidence is available to ascertain deficits in the knowledge and skills of service providers.

Significance of the Study

The proposed research investigations allow for evaluation of two independent associations with academic outcomes in school-going children. The factors being explored include the mental health status of adolescents and the knowledge and practices of student counselors in school systems. The research explores two different quantitative methods, both being closely linked. No prior study has conducted the dual analysis of school mental health (SMH) services and mental health status on academic outcomes. Findings may draw attention towards the lack of focus on mental health care service providers and their gap in knowledge while providing their services to students.

Research Question

The research uses a quantitative study design in order to determine the range of symptoms in students and its impacts on educational outcomes. In order to categorize data, the use of quantitative questions becomes necessary. The research questions include the following:

  1. Does diagnosis of mental health problems during high school impact high-school students’ abilities to achieve higher academic attainment including high-school diplomas, college education and higher?
  2. Do the school mental health service providers provide high quality services in order to improve academic performance outcomes in high-school going children?
  3. Do sub-optimal knowledge and skills by school mental health providers negatively impact the higher academic achievement of high-school going children?

The following hypotheses have been identified and were developed for the research including:

H1: Higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children are lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade.

H2: Improvements in academic performance is observed when school mental health service providers are able to provide high quality mental health services to students of high schools.

H3: Lack of adequate mental health service providers’ skills and knowledge has adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade.

Definition of Terms

  1. Mental health problems: It is a dependent variable and is quantified using the Strengths and Difficulty Questionnaire (SDQ).
  2. Mental health service providers: These are identified as student counselors and psychologists hired by school administrations to offer students with mental health services.
  3. Quality of care: Enrolled student counselors will be screened for their knowledge and skills using a validated questionnaire to determine their knowledge and practices regarding mental health
  4. Academic achievement: It is identified by the grade point average (GPA) of the students in the current semester they are enrolled in during the course of the research.

Research Design

The study is a series of cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively. The participants will be enrolled with a request via email and interviews will be conducted once they respond to the emails. The identification of students and their email IDs will be provided by schools enrolled in the research. Schools in California will be identified and their principals will be informed of relevant details for the ongoing research. For ensuring variation, student counselors who have worked with students for longer periods of time will be given preference for enrollment. The APA code of ethics is applicable and will be implemented and include five principles namely: `) beneficence and nonmaleficence, fidelity and responsibility, integrity, justice and respect for people’s rights and dignity.

Summary

Mental health problems have adverse effects on academic achievements in school-going children. Previous literature indicates the association of attention problems, hyperactivity, anxiety and depressive symptoms with lowered scores across standard exams and overall educational attainments. Identification of self-reported symptoms of poor mental health in adolescent girls is indicative of gender-based differences for mental health problems and outcomes. There is also an identified role of social contexts and peer pressures for development and aggravation of mental health disorders. The role of mental health providers in schools is critical for the improvement of internalized and externalized symptoms of mental health. The following research is a series of two cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively.

 

 

CHAPTER 2. LITERATURE REVIEW

Theoretical Orientation for the Study

The impact of mental health problems affects social, emotional and behavioral problems in school-going children and adolescents. Children and adolescents suffering from mental health problems may not achieve higher academic levels of education and it is pertinent to address these concerns. The socio-cultural theory proposed by Vygotsky identifies the inter-dependence of social and cultural processes to aid in obtaining knowledge (John-Steiner & Mahn, 1996). The theory is especially important for determining interactions of identified factors that have strong impacts on cognitive development. Vygotsky proposed the crucial aspect of collaboration for obtaining knowledge and education. The theory explains multi-factorial contributors for academic achievements in children, adolescents and young adults. It supports the implementation of appropriate and supportive mental health provision in schools for promoting better cognitive development in school-going children and adolescents. The theory explains the how school systems serve as support systems and extended families. The school support systems as well as provision of mental health services serve as positive influencers for higher academic achievement.

Vygotsky assumes an integral socialism related to human development and considers cultural mediation as an opportunity to bridge the gap of mental health and cognitive abilities. Instead of focusing on the overarching innate ability of humans to achieve academic credibility, Vygotsky identified the importance of giving and receiving in social contexts, including peer support and hygiene of mental health (Matusov & Hayes, 2000) The dualism of socialism and individuals was described by Vygotsky and led to the identification of three key concepts used by human developmental sciences to explain mental health in the last few decades of the 20th century and the 21st century. The first concept explains the role of deconceptualization in promoting developmental skills independent of their use. The second concept outlines the practices of claiming deficits of other communities based on their specific attributes, known as ethnocentric. The last concept identifies the role of parents claiming deficits of their own children’s attributes, skills and values. The last concept identifies the inability of humans to act in such manners when their own children are not comprehensible (Matusov & Hayes, 2000).

Review of the Literature

Labeling Theory and its Consequences on Mental Health

Labeling theory identifies and evaluates social circumstances and its impacts on mental health illnesses (Gove, 1982). It acknowledges the role of social rejection and how pertinent individuals are affected by anticipation and active rejection. It is debated upon whether the stigma and sequelae of mental health illnesses present with additional concerns. The following study explores these non-cognitive traits on educational achievement and academic performances across schools to identify the role of the labeling theory. Data was obtained from a longitudinal survey of the National Longitudinal Study of Adolescent Health (McLeod, Uemura & Rohrman, 2012). Adolescents in the U.S. were followed throughout school with 80 high schools and 52 middle schools enrolled in the survey. Key questions that the study aimed to answer were to identify which factors strongly impacted academic achievement and which combination of factors adversely impacted academic achievement in the students. The study hypothesized that various mental and behavioral problems presented with different outcomes in students in school settings. Mental health traits that represent a lack of response and interest are less likely to elicit negative responses from peers and teachers. Therefore, mental health problems that pose with higher disruption are more likely to be associated with academic achievements for students. 20,725 students were selected from the survey conducted by the National Longitudinal Survey of Adolescent Health in the U.S. and 54% of the enrolled subjects were women. Whites formed the major racial group at 54% with comparable samples of African-American and Latino students. 25% of the study subjects lived with a single parent and 87% of the parents of these study subjects had received a high school diploma or higher.

The study was conducted in multiple stages with an in-home survey being the first. The sub-sample selected took part in an in-home survey and was known as Wave I. This was also accompanied by an interview with either parent. Wave II was conducted a year after Wave I whereby the participants were interviewed again. Wave III was conducted in 2001 and interviews were conducted again. Wave IV was conducted in 2008 and included participants who were enrolled in wave I in-home surveys. Instruments used to measure academic achievement were grade point average (GPA) and highest educational degree received. Mental health and behavioral problems were also measured using a revised 19-item Center for Epidemiologic Studies- Depression Scale. The Swanson, Nolan and Pelham Rating Scale (SNAP-IV) was used to identify subjects with attention deficit hyperactivity disorder (ADHD). The measure of delinquency was self-reported with 14 identified items. Substance abuse was also self-reported and screened for the last year for alcohol use. It included additional questions including cigarette smoking, marijuana and other drug use in the past thirty days as well. For assessing the combination of mental health and behavioral problems, the following variables were examined: depression alone, attention problems alone, and depression and attention problems. Academic aptitude was measured using the scores obtained for wave I study participants using vocabulary test results (McLeod et al., 2012).

Additionally, students who were either receiving special educational services or were diagnosed with a learning disability in the past year were identified as a separate variable. Regression analysis was conducted with two dependent variables: 1) ordinary least squares for GPA scores and 2) ordinal logistic for highest level of education obtained. The Imputation by Chained Equations (ICE) and MICROMBINE were utilized to estimate results using STATA 11.1. Results demonstrated that ADHD, delinquency and substance abuse had greater impacts on academic achievement than depression. Additionally, a combination of two mental health conditions had greater impacts on academic achievement including decline in GPA and highest attained educational achievement. Substance abuse had a strong correlation with a decline in GPA and educational achievement. Findings demonstrate essential findings for mental health practitioners as the study offers a broad range of dysfunctions in school-going students. While the findings are limited due to informal diagnostic assessment of certain variables, it focuses on non-cognitive traits based on behavioral and emotional factors. There is limited evidence regarding teachers’ ability to evaluate these variables despite teachers conducting evaluation for them. The study offers insight on a plethora of mental health problems and correlates it with sociological factors and offers diversity in the variables analyzed. It is, however, not elaborated by the study as to how ethical dilemmas of the survey will be tackled including breach of confidentiality (McLeod et al., 2012).

Onset of Mental Health Problems

            Timely identification of symptoms is critical for preventing occurrence of mental health illnesses in the youth. Trends are worrisome with increased incidences of self-reported internalizing symptoms, more commonly in adolescent girls (Bor et al., 2014). A population-based cross-cohort study was conducted with data obtained from two birth cohorts, for which each twin participant was enrolled in either cohort (Durbjeej et al., 2019). This time trends were explored with identification of two time points: 1) 9-year old children and 2) 15-year old adolescents. The aim of the longitudinal study being conducted in Sweden was to identify mental and somatic health during childhood and teenage years. The study poses important questions pertaining to: 1) the correlations between the two birth cohorts and internalizing symptoms and 2) changes in trends of internalizing symptoms based on changes in scores for clinical parameters for depression and anxiety. The study hypothesized the rise in trends of internalizing issues pertaining to mental health illnesses including depression and anxiety, especially in adolescent girls. Study participants were obtained from the Child and Adolescent Twin Study in Sweden (CATSS) to include all twins born in the country after July, 1992. Once the twins turned 9 years old, parents were interviewed via phone to assess the socio-psychological status of the twins. Later, on turning 15, the same study participants and their parents filled in a questionnaire. At 9 years, the Screen for Child Anxiety Related Emotional Disorders (SCARED) was used to screen for symptoms of anxiety.

The instrument was calibrated according to a 3-point likert scale. The Short Mood and Feelings Questionnaire (sMFQ) was also used to assess the same cohort for symptoms of depression. At age 15, the twin cohort was assessed again using the Strength and Difficulties Questionnaire (SDQ), both parents and children. The SDQ was self-reported by the adolescents and included screening of mental health illnesses on educational symptoms. The internalizing symptoms were identified for depression, anxiety and self-worth. Descriptive statistics and linear regressions were used using Cohen’s measure of effect size. The scores of all questionnaires were used as dependent variables whereby defining characteristics within the cohort were taken as independent variables including gender. Results were indicative of the time trends for enrolled participants and demonstrated data for internalizing symptoms. 9 years-old participants showed an increased pattern of anxiety symptoms and 15-year old subjects self-reported trends for increased internalizing symptoms, with gender-based differences with girls self-reporting higher. Gender-based differences were observed for parent-administered surveys in adolescent girls as well but were less significant than self-reported internalizing symptoms. There were mild similarities amongst twins enrolled in the cross-cohorts. The study provides comprehensive information for twins, and gender-based differences. It sheds light to the critical importance of individual assessments for both depression and anxiety as well as provides valuable evidence using its methodological strength by conducting repeated assessments cross-sectional. Enrolled participants were provided with written consents to ensure ethical parameters were considered and the study participants were selected based on one defining characteristic, being twins (Durbjeej et al., 2019)

Role of Early Life Deprivation in Mental Health Problems

            The effects of deprivation in early life and childhood have been a significant focus for mental health problems. Ethically, it is not permissible to evaluate effects of imposed deprivation on children and conclusive evidence is limited. However, Kumsta et al. (2016) suggested a occurrence of re-modeling of epigenetics, suggestive of biological changes, when children were subjected to abuse. It is, therefore, critical to understand the pathogenesis of mental health with the help of observational studies. A study was conducted across adopted children living with UK families and adopted from Romania in the 1990s. Most of the study participants had suffered from moderate to extreme global deprivation until 3 years of age. A quantitative study design was used and questionnaires were administered at the subjects’ households and six different clinical manifestations were screened: 1) autism spectrum disorder, 2) inability to pay attention and hyperactivity, 3) disinhibited engagement socially, 4) problems pertaining to conduct, 5) emotional symptoms and 6) cognitive impairment. Self-administered questionnaires for study participants were also administered to get an improved understanding of their mental health problems. The Revised Rutter Scale was used twice, once at 6 and at 11 years to understand symptoms related to inattention and hyperactivity. The Strengths and Difficulties Questionnaire was used at 15 years and the Conners Comprehensice Behavior Rating Scales was used for adults. To measure disinhibition, perceptions of the interviewers were required and scored consequently. Autism spectrum disorder was assessed using the Social Communication Questionnaire (SCQ). Cognition was assessed using standard IQ assessments including Children’s Abilities General Cognitive Index at 6 years and a modified version of the Weschsler Intelligence Scale for Children for the next three assessments.

To understand consequences of early life trauma, contextual factors and use of mental health services were determined. Parental factors were assessed using the Parental Attachment Questionnaire to understand the participants’ support systems. Subjects were also asked to answer the Inventory of Parent and Peer Attachment to score their relationship with their parents. Data was categorized as either of the following: 1) lived in an institution for less than 6 months, and 2) lived in an institution for more than 6 months, 3) a control group of adoptees who did not face deprivation. A mixed-effects regression model was used to assess intensity of trends.  The study hypothesized that adoptees who spent less than 6 months would present with less symptoms across all time points. Second, occurrence of autism spectrum disorder, increased severity of inattention and hyperactivity, and impairment in cognition could not be reversed for those children who spent more than 6 years at respective institutions. Last, children who were at institutions for more than 6 months were more likely to suffer from a range of emotional problems with manifestations occurring in late teenage years and early adulthood. Results indicated that children who lived in institutions for less than 6 months had comparable symptoms as the control group’s subjects. Those who lived for longer than 6 months had higher rates of symptoms, especially for cognitive impairment. Findings suggest significant contribution to the mental health well-being of children and how early influencers such as early childhood abuse and trauma impact them throughout the entire length of their lives.

Barriers and Facilitators for Implementation of Mental Health Services in Schools

            For successful implementation of school mental health (SMH), it is important to consider the following components: 1) formal training for professional mental health service providers according to evidence-based practice (EBPs), 2) integrity of implemented SMH, and 3) sustainability of specific EBPs for SMH (Owens et al., 2014). Evidence available to address social and behavioral challenges relies on short-term assessment and often by highly-trained staff. The evidence available for standard SMH is limited and influencing factors for successful implementation are less known. It is difficult to develop standard EBPs for generalizations across schools. Identified gaps include compatibility, training for better implementation and sustainability may be explained by limited EBPs uses across school mental health service providers (Evans et al., 2013). Owens et al. (2014) identified the use of implementation sciences (IS) to address the gaps in literature and the goals were identified as essential for SMH. Organizational factors including internal and external impact interventional success for SMH. Broader factors including political and financial especially influence implementation processes such as state-level mandates impacting education law. Similarly, diversity in the type of professionals available for implementation also affect IS. For instance, SMH with available counselors, psychologists and teachers aiming to aid in implementation may prove sustainable. These professionals, especially teachers and the principal may provide better insight on policies and social networks in schools.

Teachers may provide feedback based on performances of students in schools. Additionally, the school calendars often present with spikes of mental health symptoms and need to be identified for successful longevity of SMH protocols. Professional development is crucial for providing highly integral IS in SMH. This may include workshops, manuals and active-learning guides for professionals. Owen et al. (2014) present services that may have significant impacts on professional development of service providers and include: 1) adopted strategies, 2) models for coaching, 3) length of training, and 4) their role of motivation and social stigma. The study poses pertinent questions for implementation barriers and facilitators and includes the role of coaching in producing desirable outcomes for students. Secondly, the role of strategies and its effect on improving the knowledge and skills of service providers is explored. Thirdly, the models that best suit coaching are reviewed for providing essential skills to aid in professional development. Lastly, the study poses questions for the impact of motivations and perceptions provided by service providers and predict its impact on skill development of the facilitators. The study proposes key areas that may help in successful implementation of EBPs for SMH and addresses the concern for availability of numerous principles governing the IS (Owen et al., 2014).

A study was conducted by Langley et al. (2010) to determine factors affecting the successful implementation of an EBP, called the Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Data was obtained via phone interviews with 35 administrators and service providers across the United States. The professionals had received training and were evaluated 6-18 months after receiving their training. While results indicated differences in the process of implementation, the barriers were similar. Those schools that were able to overcome the barriers were identified as having better organizational structure including robust systems to accommodate implementation. The study demonstrated important findings for aiding in successful implementation for EPBs in SMH by facilitation from necessary professionals and peer support.

Synthesis of the Research Findings

It has been identified that genetic and social factors dictate the onset of mental health problems. Many screening tools have been standardized for obtaining relevant information for students enrolled in school. Academic achievement is often adversely affected with increased mental health problems. Additionally, peer pressure also adds to the burden of mental health illnesses. The stigma surrounding mental health is important to identify for appropriate use of resources. It is important for future researchers to understand the complexities surrounding childhood trauma and biological and psychological effects on the affected children.The role of social factors and peer pressures was identified by the labeling theory in order to understand the roles of social factors. It is expected that students who are facing mental health problems report higher in perceived social and peer pressures. Implementation of SMH is essential to ensure the integrity and sustainability of the programs is possible. However, it may not be possible to conduct implementation of EBPs in our research. Gaps have been identified across school mental health service provisions whereby sub-optimal care is being provided. It is expected to find similar results in our research owing to the lack of standard EBPs for schools. Additionally, organizational factors also play a critical role in the continued implementation of competent SMH services across schools.

Critique of Previous Research Methods

Previous research methods often incorporate the use of either qualitative or quantitative study designs. Due to the validation of questionnaires for screening, the use of qualitative study designs are now limited. However, the use of questionnaires presents problems due to the rigidity of the grading system in many circumstances. The results may be skewed due to biases and the lack of prospective cohorts for implementing SMH changes has not been identified yet. The research designs are often cross-sectional with limited data on day-to-day struggles of students in schools. The role of student counselors has not been identified accurately and there are no formal guidelines for determining their roles in schools. The effects of childhood abuse is factored in but it may also be pertinent to review the role of parents in providing emotional and other support to their children.

Summary

Mental health problems have adverse effects on academic achievements in school-going children. Previous literature indicates the association of attention problems, hyperactivity, anxiety and depressive symptoms with lowered scores across standard exams and overall educational attainments. Identification of self-reported symptoms of poor mental health in adolescent girls is indicative of gender-based differences for mental health problems and outcomes. There is also an identified role of social contexts and peer pressures for development and aggravation of mental health disorders. The role of mental health providers in schools is critical for the improvement of internalized and externalized symptoms of mental health. Previous studies have also identified the role of childhood trauma on mental health later in life. Its impacts have been determined on biological changes including epigenetics. The role of social determinants was outlined by many researchers and pose important consequences for the mental health of children, adolescents and young adults.

 

 

CHAPTER 3. METHODOLOGY

Purpose of the Study

The focus of the research is to explore the impact of mental health problems on academic achievement statuses of adolescents in high school in order to obtain a better understanding of the effects of mental health problems. It is essential to demonstrate an understanding of the longevity of clinical and sub-clinical manifestations of mental health problems before they are recognizable by health care providers. Students spend the longest time periods in school and it amounts to over 6 months of time spent at schools. Adolescents enrolled in high school witness an array of emotional and behavioral alterations throughout their days at school, including exploration of self-identity away from caretakers and family members as well as pubertal development. In the case that students are made to feel safe in schools, it is possible that their mental health problems are reduced. This may only be possible with adequately managed school mental health (SMH) systems in educational institutions including high school. The use of academic achievement is the identification of a single effect of mental health problems on factors directly related to the students’ emotional and behavioral health. The chapter outlines how the research will be implemented. It provides information for the research design and implementation process. It also identifies the target population and sample, procedures, and ethical considerations taken before the research is implemented. The research questions include the following:

  1. Does diagnosis of mental health problems during high school impact high-school students’ abilities to achieve higher academic attainment including high-school diplomas, college education and higher?
  2. Do the school mental health service providers provide high quality services in order to improve academic performance outcomes in high-school going children?
  3. Do sub-optimal knowledge and skills by school mental health providers negatively impact the higher academic achievement of high-school going children?

Research Question and Hypotheses

The research questions pose whether mental health problems and their manifestations affect academic outcomes in high-school going children; additionally, the current knowledge and skills available by mental health service providers is also screened to determine the abilities of SMH to aid in the maximally attained educational achievement in these students. The independent variable is academic achievements and the dependent variables are mental health problems and quality of care provided by school mental health service providers. Screening for mental health problems will be possible by administration of the Strengths and Difficulties Questionnaire (SDQ). It will be used and it screens for social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures. For the ease of statistical analysis for the research questions, the hypotheses were developed for the research and include:

H1: Higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children are lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade.

H2: Improvements in academic performance is observed when school mental health service providers are able to provide high quality mental health services to students of high schools.

H3: Lack of adequate mental health service providers’ skills and knowledge has adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade.

Target Population and Sample

The aim for the target population is 300 high-school students, taking into account loss to follow up and other contextual factors. Based on the power analysis with confidence interval of 95% an accepted margin of error at 5%, the predicted outcome factor hypothesis was set at 20%. OpenEpi software was used to determine the target sample size and 246 participants was identified as the minimum acceptable sample with estimates of sample size to be 100,000 high-school going children enrolled in schools across California. The student counselors will also be enrolled for understanding their role in academic achievement and tackling mental health problems in the students. In order to obtain the target sample size for the student counselors, OpenEpi software was used again and the sample size estimate is 94. The confidence interval was set at 95% and the calculation took into account a 20% non-response rate. The margin of error was set at 10%. They have the highest exposure with students in a personal capacity in schools and a formal analysis of their knowledge and skills is essential to draw meaningful results. Students who were enrolled in eleventh or twelfth grade were enrolled and were included if they had received mental health services at any time in the two years of high school. Student counselors were included who had exposure to students of respective schools for at least 6 months. In order to ensure that the target sample is obtained, the goal is to maintain the response rate above 80% for both students and the counselors and collaboration with schools before-hand is important to promote better recruitment strategies.

Principals of respective schools across California will be contacted and they will provide information for better implementation and improving response rates to achieve the target sample size. Staff recruited for the research will be selected after screening for their performance and the students’ willingness to participate will also be taken into consideration. While the study design is a series of cross-sectional studies, the data will aim to be diverse by not excluding participation of any gender, race or culture. Students will only be selected based on their enrollment in high-school and their receiving of mental health services in schools. Questionnaires will be self-administered and are an efficient means to obtain data from high-school students. However, the research will use phone-based interviews to complete the questionnaires in order to ensure completeness of obtained data. Additionally, participants may be better able to comprehend components of the questionnaires if they are interviewed by a knowledgeable interviewer. Student counselors will also be interviewed over phone for their skills and knowledge of providing high-quality mental health service provision. Participants will be enrolled voluntary via verbal consent in order to obtain a good rapport between interviewers and the study participants. In order to ensure that there is no breach of confidentiality, the student ID codes on questionnaires will be changed before being entered for data entry and the names will be omitted before entry of data.

Procedures

Study Design

The study is a series of cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively. The participants will be enrolled with a request via email and interviews will be conducted once they respond to the emails. The identification of students and their email IDs will be provided by schools enrolled in the research. Schools in California will be identified and their principals will be informed of relevant details for the ongoing research. For ensuring variation, student counselors who have worked with students for longer periods of time will be given preference for enrollment.

Materials and Instruments

Materials to be used for data collection include selection of interviewers and the units of analysis are high-school students and school counselors. Screening of mental health problems will be conducted by telephonic administration of the Strengths and Difficulties Questionnaire (SDQ) by trained interviewers using age-appropriate versions of the questionnaire. The SDQ contains 25 items and it consists of 5 categories with 5 items each. The scores for each item are anywhere between 0 till 2, using the three-band scoring system. The total score is called the total difficulty score and will be categorized, ranging from 0 to 40 total points. It will be used and it screens for social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures. The categories for results include: 1) abnormal being anywhere between 17 till 40 points, 2) borderline being between 14 till 16 points and 3) normal being any score below and including 13 points.

Enrolled student counselors will be screened for their knowledge and skills using a validated questionnaire to determine their knowledge and practices regarding mental health (Abdulkadir & Abdulkadir, 2017). The questionnaire was developed based on items identified by Anderson et al. in 1980 (Bisi-Onyemaechi et al., 2018). It consists of four key components: 1) demographic information, 2) 8 items for current status of SMH services, 3) 5 items for protocols of SMH services, 4) multiple items identifying factors contributing to school environments and 5) knowledge of SMH. For understanding the current knowledge and practices of the student counselors, the answers for the questions were pre-determined and the recorded answers by mental health providers are identified as either correct or incorrect. For categorizing the knowledge as good, the answers are to be correctly identified across three or more of the identified components, excluding demographical data. Average knowledge is categorized as correct answers for one or two of the identified components. Poor knowledge is categorized as no correct identification across all components of the questionnaire. The time required for data collection is 3 months in order to obtain the target sample size.

Data Collection Process

The data will be obtained in a systematic manner using the following steps. Firstly, the schools located in California will be identified and it will be cross-checked for the presence of SMH service provision in these schools. Next, emails will be sent with relevant information regarding the research in order to obtain written consent from the principals. This will be followed by a request for identification of high school students who are enrolled in eleventh and twelfth grades and who have been to a student counselor at least once in their time at high school. Additionally, their contact information including email IDs and phone numbers will be obtained. They will be sent emails to ensure their consent is taken and they are informed about relevant information of the research. The student counselors will then be identified and their duration of employment and relevant contact details will be obtained. Student counselors who have worked for longer durations will be preferred and any student counselor who has been employed for less than 6 months will be excluded. Once consent is obtained according to the target sample size, interviews will be conducted via phone over the span of three months. The interviews will be conducted for obtaining answers for the relevant sections on the questionnaires. This poses the benefit of ensuring complete information for the questionnaires but is slower to conduct than self-administered questionnaires. Next, the data will be entered in SPSS V.20 in order to conduct the analysis.

Analysis

Data will be entered in SPSS, version 20. The variables will be analyzed and results will be presented using descriptive statistics for variables. Dependent variables include identified variables in the SDQ and questionnaires administered to student psychologists. The independent variable is the academic outcomes for the enrolled students currently in high school. Regression analysis will be used for both dependent variables including: 1) scores of SDQ questionnaires and 2) scores of questionnaires administered to student counselors. The use of Chi-square tests and student’s t-test will be used and the significance will be set at 0.05 in order to determine effects of dependent variables on the independent variable, academic achievement. In order to produce valid results, the data will be entered manually and will be double-checked to look for missing or double-entered data. Reliability of the findings will also be ensured using correct data and obtaining enough study participants as the estimated sample size calculation. In order to provide generalizable results, students of all races, genders, and socioeconomic classes will be enrolled. Additionally, student counselors who have worked with students longer will be assessed instead of those who have been employed for less than 6 months in schools.

Ethical Considerations

The APA Code of Ethics is applicable for the research being conducted. In order to provide ethical clarity in the profession of psychology, the principle of beneficence and nonmaleficence will be applied to protect the confidentiality of students obtaining mental health services from their schools. The principle encourages elimination of biases and any preformed prejudices available on the end of the student counselors. The principle of fidelity and responsibility ensures that the student counselors help maintain the ethical standards across their profession in the high schools. It is essential to eliminate fabricated and false results so as to reduce the effects of any incorrect findings for future researchers. The principle of integrity will be used to ensure that the student counselors are not fabricating scores of their questionnaires or causing distress to students. The principle of justice ensures that students of different races, cultures and genders receive fair and impartial treatment. The respect for people’s rights and dignities will be ensured as data entry will not constitute revealing the identity of the participants and their IDs will be changed before the entry of data. The APA code of ethics will be implemented due to the nature of the study with enrollment of psychologists as study participants.

 

 

 

CHAPTER 4. EXPECTED FINDINGS/RESULTS

It is expected that mental health patterns have impacts on academic achievements in school-going children. There has been evidence to indicate that attention problems and depressive symptoms directly lower the GPAs and overall educational attainments for those students. Previous studies have indicated the increased frequency of self-reported symptoms of poor mental health in adolescent girls. The association between socio-economic factors and poor mental health has been identified and it is likely that gender-based differences for mental health problems may be identified if examined. However, our research does not examine gender-based differences for self-reported symptoms of mental health problems. The training of clinical practitioners working in schools may be improved by adopting relevant strategies, coaching of counselors and exploring the role of social stigma. Previous studies have also identified the role of childhood trauma on mental health later in life. While our research does not conduct any screening for childhood factors, it is important for future researchers to understand the complexities surrounding childhood trauma and biological and psychological effects on the affected children.

The role of social factors and peer pressures was identified by the labeling theory in order to understand the roles of social factors. The determination of social factors is present in our research using the SDQ measures. It is expected that students who are facing mental health problems report higher in perceived social and peer pressures.

Implementation of SMH is essential to ensure the integrity and sustainability of the programs is possible. However, it may not be possible to conduct implementation of EBPs in our research. Gaps have been identified across school mental health service provisions whereby sub-optimal care is being provided. It is expected to find similar results in our research owing to the lack of standard EBPs for schools. Additionally, organizational factors also play a critical role in the continued implementation of competent SMH services across schools. Expected findings support previous literature regarding the role of mental health problems on educational outcomes. The research evaluates a gap in literature by identifying the shortcomings of student counselors’ knowledge and practices. The expected findings are sub-optimal quality of care provided by student counselors having adverse impacts on educational outcomes including the GPAs for enrolled students. It is not possible to monitor study subjects for longer durations but the GPAs will be obtained as parameters of academic achievement.

 

 

CHAPTER 5. DISCUSSION

Implications

Potential results point towards the increased tendency for students with mental health problems to perform lower academically. Potential stakeholders for the research include the students, educational systems, federal and state government, and key members of school administration. Students will face outcomes for the rest of their lives if they are not able to gain adequate educational achievements. The educational system of the country will also be affected due to the potentially increased risk of dropouts in students in college or after high school. The government has a crucial role to play in the current SMH services. Due to limited resources offered by state and federal government policies, it is difficult to successfully implement a sustainable system of mental health service provision across schools. The human development is addressed using a wide array of emotional and behavioral patterns that may have been consolidated during childhood trauma and abuse. Additionally, sociology may benefit from the behavioral aspects of students suffering from mental health problems.

Methodological Strengths and Weaknesses

The research identifies key concerns related to mental health problems across teenagers and presents findings for academic achievement. The use of two questionnaires aims to strengthen findings for future development of approaches. The study screens adolescents that have already received at least one session of mental health service provision. This allows for isolation and selection of concerned study population. Additionally, the enrolled participants are administered surveys due to their ability to comprehend and answer relevant items in the questionnaires. This allows for better reporting of symptom as opposed to parents reporting symptoms for their children. The use of interviewers to fill in the questionnaires also ensures that the study participants are aware of what exactly the questions represent and mean. The weaknesses of the research include the study design and the lack of a standard questionnaire for the student counselors. The study design does not allow for long-term monitoring of data and it may not be possible to screen subjects until they obtain college degrees. The study design allows for screening of participants up until the obtainment of GPAs for the concerned semester to ensure that the study is conducted within 3 months. The lack of available standardized questionnaires for student counselors also presents as a significant weakness for the outcomes and findings of the research.

Suggestions for Future Research

For improving mental health in schools, it is important to realign current policies and practices pertaining to dealing with mental health. Future researchers need to identify the role of expanded school mental health services. The postulation that schools are the most critical places for children and adolescents to develop and overcome mental health problems may be proven true with similar researches being conducted. It is also recommended to screen what factors are preventing or facilitating successful implementation of the health service programs in schools. Studies should focus on organizational factors, sustainability and overall procedures for implementing EBPs across schools. Another important factor to explore further is the role of social stigma in expressing the ongoing clinical manifestations of mental health problems in the students. Without adequate support, these children and adolescents may not be able to express their status of mental health. Additionally, the role of parents and social support systems, especially in schools, need to be evaluated amongst participants who have been identified with significant mental health problems.

References

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Atkins, M. S., Frazier, S. L., Adil, J. A., & Talbott, E. (2003). School-based mental health services in urban communities. In Handbook of school mental health advancing practice and research (pp. 165-178). Springer, Boston, MA.

Bisi‑Onyemaechi, A. I., Akani, N. A., Ikefuna, A. N., Tagbo, B. N., & Chinawa, J. M. (2018). Evaluation of the school environment of public and private schools in Enugu to ensure child health promotion. Nigerian journal of clinical practice21(2), 195-200.

Bor, W., Dean, A. J., Najman, J., & Hayatbakhsh, R. (2014). Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Australian & New Zealand journal of psychiatry48(7), 606-616.

Durbeej, N., Sörman, K., Selinus, E. N., Lundström, S., Lichtenstein, P., Hellner, C., & Halldner, L. (2019). Trends in childhood and adolescent internalizing symptoms: results from Swedish population based twin cohorts. BMC psychology7(1), 50.

Evans, S. W., Koch, J. R., Brady, C., Meszaros, P., & Sadler, J. (2013). Community and school mental health professionals’ knowledge and use of evidence based substance use prevention programs. Administration and Policy in Mental Health and Mental Health Services Research40(4), 319-330.

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Association of Mental Health Problems with Academic Achievement in High-School Students

Abstract

The research uses a quantitative study design in order to determine the range of symptoms in students and its impacts on educational outcomes. The research questions include the following: Is higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade? Are improvements in academic performance observed when school mental health service providers are able to provide high quality mental health services to students of high schools? Does the lack of adequate mental health service providers’ skills and knowledge have adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade? Mental health problems have impacts on the social, behavioral patterns of children and adolescents as well as on their academic achievement. The role of evaluating the current state of mental health services in schools is critical to ascertain and reduce potential adverse effects on educational achievements of school-going children. The proposed research investigations allow for evaluation of two independent associations with academic outcomes in school-going children. Potential stakeholders for the research include the students, educational systems, federal and state government, and key members of school administration. Students will face outcomes for the rest of their lives if they are not able to gain adequate educational achievements. Due to limited resources offered by state and federal government policies, it is difficult to successfully implement a sustainable system of mental health service provision across schools. It is expected that mental health patterns have impacts on academic achievements in school-going children.

Keywords: [Mental health problems, educational achievement, SDQ, high-school, adolescents, children, quantitative]

Table of Contents

CHAPTER 1. INTRODUCTION…………………………………………………………………………… 5

Background of the Problem…………………………………………………………………………………. 5

Statement of the Problem…………………………………………………………………………………….. 6

Purpose of the Study…………………………………………………………………………………………… 6

Significance of the Study……………………………………………………………………………………… 6

Research Questions……………………………………………………………………………………………… 7

Definition of Terms……………………………………………………………………………………………… 8

Research Design………………………………………………………………………………………………….. 8

Summary……………………………………………………………………………………………………………. 9

CHAPTER 2. LITERATURE REVIEW………………………………. ……………………….10

Theoretical Orientation for the Study…………………………………………………………………. 10

Review of the Literature……………………………………………………………………………………. 11

Synthesis of the Research Findings…………………………………………………………………….. 19

Critique of Previous Research Methods……………………………………………………………… 20

Summary………………………………………………………………………………………………………….. 20

CHAPTER 3. METHODOLOGY………………………………………………………………………… 22

Purpose of the Study…………………………………………………………………………………………. 22

Research Question and Hypotheses…………………………………………………………………….. 23

Target Population and Sample…………………………………………………………………………… 24

Procedures………………………………………………………………………………………………………… 25

Ethical Considerations……………………………………………………………………………………….. 28

CHAPTER 4. EXPECTED FINDINGS/RESULTS……………………………………………….. 30

CHAPTER 5. DISCUSSION………………………………………………………………………………. 32

Implications………………………………………………………………………………………………………. 32

Methodological Strengths and Weaknesses…………………………………………………………. 32

Suggestions for Future Research………………………………………………………………………… 33

 

CHAPTER 1. INTRODUCTION

Coping with mental health illness may be challenging for families with many barriers identified. Parents who suffer from mental illness pose additional risks for children, with 15% having developed mental health problems and 27% having observed behavioral disturbances (Mowbray et al., 2004). Children and adolescents may not receive appropriate mental health care services in the community or at school; effective coordination of mental health services has proven to be difficult, which has created a need for mental health intervention programs (Puddy, Roberts, Vernberg, & Hambrick, 2012). Schools have been identified to be a viable source for students with mental health problems. Bullying victimization is witnessed in school cultures and it remains prevalent, causing public health policies to promote intervention and prevention strategies (Arseneault, Bowes & Shakoor, 2010).However, it has been observed that only 18-34% of young people suffering from severe depression or anxiety avail psychiatric services (Gulliver, Griffiths & Christensen, 2010). Highest prevalence of mental health problems are observed in individuals aged 16-24 years (Slade et al., 2007). Mental health problems have impacts on the social, behavioral patterns of children and adolescents as well as on their academic achievement. For instance, patients with Attention-Deficit/Hyperactivity Disorder (ADHD) cause social and emotional impairment for themselves and their families inadvertently affecting their quality of lives (Wehmeier, Schacht & Barkley, 2010). Schools are focusing primarily on academic achievements and their indicators with limited focus on the mental health of students. Marques, Pais-Ribeiro & Lopez (2011) explored the effects of constructive positive psychology on academic achievement in young children and adolescents and it confirmed the benefits of positive reinforcement on academic outcomes. It is known that mental health plays significant roles in academic outcomes and the mental health problems are aggravated with academic achievement and social support (Marques, Pais-Ribeiro & Lopez, 2011). Often, students are identified with internalized symptoms that go unnoticed. Schools are commencing to take action for students in order to support pro-social behaviors and reduce internalizing (Kramer et al. (2014).

Background of the Study

Children and adolescents are more vulnerable due to the neglect for mental health services in schools. Mental health is declining in children and adolescents of school-going age with 10-20% of them being affected (Kieling et al., 2011). The United States spends financial resources for education in the United States and the role for providing first-class education. The inclusion of diversity in students is expected to include students at risk of mental health problems due to multi-factorial causes. The role of addressing gaps in achievement lies with school systems, social support groups including families and national and state policies implemented by the government (US Department of Education, 2010). Barriers for academic attainment are often psychiatric or financial with additionally identified limitations related to financial shortcomings of families (Young &Murray, 2004). The role of mental health providers, including teachers, counselors and psychologists, needs to be formally assessed in order to provide sustainable implementation of EBPs across school systems. Effects may be witnessed by families due to changing behavioral and emotional factors (Arseneault, Bowes & Shakoor, 2010). Additionally, sociologists may benefit from increased exploration of social theories impacting educational achievement due to compromised mental health.

Statement of the Problem

While there is a developed infrastructure to provide mental health services across schools in the US, not much information is available for the quality of services available (Arseneault, Bowes & Shakoor, 2010). Policies encourage the use of evidence-based practice across the student mental health infrastructure (Owen et al., 2014). However, there is evidence indicating the poor implementation of national policies (Atkins et al., 2003). The role of evaluating the current state of mental health services in schools is critical to ascertain and reduce potential adverse effects on educational achievements of school-going children.

Purpose of the Study

Obstacles have been identified that impact the successful implementation of school mental health provision across schools (New Freedom Commission on Mental Health, 2003). President Bush identified multiple gaps in the mental health service provision and the roles of federal and state government policies are unspecific as to how to tackle to lack of successful implementation. The quality of life of children and adolescents is directly affected by service providers in school and not enough quantitative evidence is available to ascertain deficits in the knowledge and skills of service providers.

Significance of the Study

The proposed quantitative research investigations allow for evaluation of two independent associations with academic outcomes in school-going children. The factors being explored include the mental health status of adolescents and the knowledge and practices of student counselors in school systems. The research explores two different quantitative methods, both being closely linked. No prior study has conducted the dual analysis of school mental health (SMH) services and mental health status on academic outcomes. Findings may draw attention towards the lack of focus on mental health care service providers and their gap in knowledge while providing their services to students.

Research Question

The research uses a quantitative study design in order to determine the range of symptoms in students and its impacts on educational outcomes. In order to categorize data, the use of quantitative questions becomes necessary. The research questions include the following:

  1. Is higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade?
  2. Are improvements in academic performance observed when school mental health service providers are able to provide high quality mental health services to students of high schools?
  3. Does the lack of adequate mental health service providers’ skills and knowledge have adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade?

The following hypotheses have been identified and were developed for the quantitative research including:

H1: Higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children are lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade.

H2: Improvements in academic performance is observed when school mental health service providers are able to provide high quality mental health services to students of high schools.

H3: Lack of adequate mental health service providers’ skills and knowledge has adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade.

Definition of Terms

The following operational definitions will be used to categorize and provide information for data collection (Cummings & Worley, 2015).

  1. Mental health problems: Categorized by variables of the Strengths and Difficulties Questionnaire (SDQ): social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures and will be scored according to pre-determined scales.
  2. Mental health service providers: These are identified as student counselors and psychologists hired by school administrations to offer students with mental health services.
  3. Quality of care: Determined by screening for knowledge and skills using a validated questionnaire to determine the knowledge and practices of healthcare of mental health practitioners
  4. Academic achievement: Categorized by the grade point average (GPA) of the students in the ongoing semester they are enrolled in during the course of the research.

Research Design

The quantitative study is to be implemented by administering questionnaires to the target population. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively. The participants will be enrolled with a request via email and interviews will be conducted once they respond to the emails. The identification of students and their email IDs will be provided by schools enrolled in the research. Schools in California will be identified and their principals will be informed of relevant details for the ongoing research. For ensuring variation, student counselors who have worked with students for longer periods of time will be given preference for enrollment. The APA code of ethics is applicable and will be implemented and include five principles namely: beneficence and nonmaleficence, fidelity and responsibility, integrity, justice and respect for people’s rights and dignity.

Summary

Mental health problems have adverse effects on academic achievements in school-going children. Previous literature indicates the association of attention problems, hyperactivity, anxiety and depressive symptoms with lowered scores across standard exams and overall educational attainments. Identification of self-reported symptoms of poor mental health in adolescent girls is indicative of gender-based differences for mental health problems and outcomes. There is also an identified role of social contexts and peer pressures for development and aggravation of mental health disorders. The role of mental health providers in schools is critical for the improvement of internalized and externalized symptoms of mental health. The following research is a series of two cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively.

 

 

CHAPTER 2. LITERATURE REVIEW

Theoretical Orientation for the Study

The impact of mental health problems affects social, emotional and behavioral problems in school-going children and adolescents. Children and adolescents suffering from mental health problems may not achieve higher academic levels of education and it is pertinent to address these concerns. The socio-cultural theory proposed by Vygotsky identifies the inter-dependence of social and cultural processes to aid in obtaining knowledge (John-Steiner & Mahn, 1996). The theory is especially important for determining interactions of identified factors that have strong impacts on cognitive development. Vygotsky proposed the crucial aspect of collaboration for obtaining knowledge and education. The theory explains multi-factorial contributors for academic achievements in children, adolescents and young adults. It supports the implementation of appropriate and supportive mental health provision in schools for promoting better cognitive development in school-going children and adolescents. The theory explains the how school systems serve as support systems and extended families. The school support systems as well as provision of mental health services serve as positive influencers for higher academic achievement.

Vygotsky assumes an integral socialism related to human development and considers cultural mediation as an opportunity to bridge the gap of mental health and cognitive abilities. Instead of focusing on the overarching innate ability of humans to achieve academic credibility, Vygotsky identified the importance of giving and receiving in social contexts, including peer support and hygiene of mental health (Matusov & Hayes, 2000) The dualism of socialism and individuals was described by Vygotsky and led to the identification of three key concepts used by human developmental sciences to explain mental health in the last few decades of the 20th century and the 21st century. The first concept explains the role of deconceptualization in promoting developmental skills independent of their use. The second concept outlines the practices of claiming deficits of other communities based on their specific attributes, known as ethnocentric. The last concept identifies the role of parents claiming deficits of their own children’s attributes, skills and values. The last concept identifies the inability of humans to act in such manners when their own children are not comprehensible (Matusov & Hayes, 2000).

Review of the Literature

Labeling Theory and its Consequences on Mental Health

Labeling theory identifies and evaluates social circumstances and its impacts on mental health illnesses (Gove, 1982). It acknowledges the role of social rejection and how pertinent individuals are affected by anticipation and active rejection. It is debated upon whether the stigma and sequelae of mental health illnesses present with additional concerns. The following study explores these non-cognitive traits on educational achievement and academic performances across schools to identify the role of the labeling theory. Data was obtained from a longitudinal survey of the National Longitudinal Study of Adolescent Health (McLeod, Uemura & Rohrman, 2012). Adolescents in the U.S. were followed throughout school with 80 high schools and 52 middle schools enrolled in the survey. Key questions that the study aimed to answer were to identify which factors strongly impacted academic achievement and which combination of factors adversely impacted academic achievement in the students. The study hypothesized that various mental and behavioral problems presented with different outcomes in students in school settings. Mental health traits that represent a lack of response and interest are less likely to elicit negative responses from peers and teachers. Therefore, mental health problems that pose with higher disruption are more likely to be associated with academic achievements for students. 20,725 students were selected from the survey conducted by the National Longitudinal Survey of Adolescent Health in the U.S. and 54% of the enrolled subjects were women. Whites formed the major racial group at 54% with comparable samples of African-American and Latino students. 25% of the study subjects lived with a single parent and 87% of the parents of these study subjects had received a high school diploma or higher.

The study was conducted in multiple stages with an in-home survey being the first. The sub-sample selected took part in an in-home survey and was known as Wave I. This was also accompanied by an interview with either parent. Wave II was conducted a year after Wave I whereby the participants were interviewed again. Wave III was conducted in 2001 and interviews were conducted again. Wave IV was conducted in 2008 and included participants who were enrolled in wave I in-home surveys. Instruments used to measure academic achievement were grade point average (GPA) and highest educational degree received. Mental health and behavioral problems were also measured using a revised 19-item Center for Epidemiologic Studies- Depression Scale. The Swanson, Nolan and Pelham Rating Scale (SNAP-IV) was used to identify subjects with attention deficit hyperactivity disorder (ADHD). The measure of delinquency was self-reported with 14 identified items. Substance abuse was also self-reported and screened for the last year for alcohol use. It included additional questions including cigarette smoking, marijuana and other drug use in the past thirty days as well. For assessing the combination of mental health and behavioral problems, the following variables were examined: depression alone, attention problems alone, and depression and attention problems. Academic aptitude was measured using the scores obtained for wave I study participants using vocabulary test results (McLeod et al., 2012).

Additionally, students who were either receiving special educational services or were diagnosed with a learning disability in the past year were identified as a separate variable. Regression analysis was conducted with two dependent variables: 1) ordinary least squares for GPA scores and 2) ordinal logistic for highest level of education obtained. The Imputation by Chained Equations (ICE) and MICROMBINE were utilized to estimate results using STATA 11.1. Results demonstrated that ADHD, delinquency and substance abuse had greater impacts on academic achievement than depression. Additionally, a combination of two mental health conditions had greater impacts on academic achievement including decline in GPA and highest attained educational achievement. Substance abuse had a strong correlation with a decline in GPA and educational achievement. Findings demonstrate essential findings for mental health practitioners as the study offers a broad range of dysfunctions in school-going students. While the findings are limited due to informal diagnostic assessment of certain variables, it focuses on non-cognitive traits based on behavioral and emotional factors. There is limited evidence regarding teachers’ ability to evaluate these variables despite teachers conducting evaluation for them. The study offers insight on a plethora of mental health problems and correlates it with sociological factors and offers diversity in the variables analyzed. It is, however, not elaborated by the study as to how ethical dilemmas of the survey will be tackled including breach of confidentiality (McLeod et al., 2012).

Onset of Mental Health Problems

            Timely identification of symptoms is critical for preventing occurrence of mental health illnesses in the youth. Trends are worrisome with increased incidences of self-reported internalizing symptoms, more commonly in adolescent girls (Bor et al., 2014). A population-based cross-cohort study was conducted with data obtained from two birth cohorts, for which each twin participant was enrolled in either cohort (Durbjeej et al., 2019). This time trends were explored with identification of two time points: 1) 9-year old children and 2) 15-year old adolescents. The aim of the longitudinal study being conducted in Sweden was to identify mental and somatic health during childhood and teenage years. The study poses important questions pertaining to: 1) the correlations between the two birth cohorts and internalizing symptoms and 2) changes in trends of internalizing symptoms based on changes in scores for clinical parameters for depression and anxiety. The study hypothesized the rise in trends of internalizing issues pertaining to mental health illnesses including depression and anxiety, especially in adolescent girls. Study participants were obtained from the Child and Adolescent Twin Study in Sweden (CATSS) to include all twins born in the country after July, 1992. Once the twins turned 9 years old, parents were interviewed via phone to assess the socio-psychological status of the twins. Later, on turning 15, the same study participants and their parents filled in a questionnaire. At 9 years, the Screen for Child Anxiety Related Emotional Disorders (SCARED) was used to screen for symptoms of anxiety.

The instrument was calibrated according to a 3-point likert scale. The Short Mood and Feelings Questionnaire (sMFQ) was also used to assess the same cohort for symptoms of depression. At age 15, the twin cohort was assessed again using the Strength and Difficulties Questionnaire (SDQ), both parents and children. The SDQ was self-reported by the adolescents and included screening of mental health illnesses on educational symptoms. The internalizing symptoms were identified for depression, anxiety and self-worth. Descriptive statistics and linear regressions were used using Cohen’s measure of effect size. The scores of all questionnaires were used as dependent variables whereby defining characteristics within the cohort were taken as independent variables including gender. Results were indicative of the time trends for enrolled participants and demonstrated data for internalizing symptoms. 9 years-old participants showed an increased pattern of anxiety symptoms and 15-year old subjects self-reported trends for increased internalizing symptoms, with gender-based differences with girls self-reporting higher. Gender-based differences were observed for parent-administered surveys in adolescent girls as well but were less significant than self-reported internalizing symptoms. There were mild similarities amongst twins enrolled in the cross-cohorts. The study provides comprehensive information for twins, and gender-based differences. It sheds light to the critical importance of individual assessments for both depression and anxiety as well as provides valuable evidence using its methodological strength by conducting repeated assessments cross-sectional. Enrolled participants were provided with written consents to ensure ethical parameters were considered and the study participants were selected based on one defining characteristic, being twins (Durbjeej et al., 2019)

Role of Early Life Deprivation in Mental Health Problems

            The effects of deprivation in early life and childhood have been a significant focus for mental health problems. Ethically, it is not permissible to evaluate effects of imposed deprivation on children and conclusive evidence is limited. However, Kumsta et al. (2016) suggested a occurrence of re-modeling of epigenetics, suggestive of biological changes, when children were subjected to abuse. It is, therefore, critical to understand the pathogenesis of mental health with the help of observational studies. A study was conducted across adopted children living with UK families and adopted from Romania in the 1990s. Most of the study participants had suffered from moderate to extreme global deprivation until 3 years of age. A quantitative study design was used and questionnaires were administered at the subjects’ households and six different clinical manifestations were screened: 1) autism spectrum disorder, 2) inability to pay attention and hyperactivity, 3) disinhibited engagement socially, 4) problems pertaining to conduct, 5) emotional symptoms and 6) cognitive impairment. Self-administered questionnaires for study participants were also administered to get an improved understanding of their mental health problems. The Revised Rutter Scale was used twice, once at 6 and at 11 years to understand symptoms related to inattention and hyperactivity. The Strengths and Difficulties Questionnaire was used at 15 years and the Conners Comprehensice Behavior Rating Scales was used for adults. To measure disinhibition, perceptions of the interviewers were required and scored consequently. Autism spectrum disorder was assessed using the Social Communication Questionnaire (SCQ). Cognition was assessed using standard IQ assessments including Children’s Abilities General Cognitive Index at 6 years and a modified version of the Weschsler Intelligence Scale for Children for the next three assessments.

To understand consequences of early life trauma, contextual factors and use of mental health services were determined. Parental factors were assessed using the Parental Attachment Questionnaire to understand the participants’ support systems. Subjects were also asked to answer the Inventory of Parent and Peer Attachment to score their relationship with their parents. Data was categorized as either of the following: 1) lived in an institution for less than 6 months, and 2) lived in an institution for more than 6 months, 3) a control group of adoptees who did not face deprivation. A mixed-effects regression model was used to assess intensity of trends.  The study hypothesized that adoptees who spent less than 6 months would present with less symptoms across all time points. Second, occurrence of autism spectrum disorder, increased severity of inattention and hyperactivity, and impairment in cognition could not be reversed for those children who spent more than 6 years at respective institutions. Last, children who were at institutions for more than 6 months were more likely to suffer from a range of emotional problems with manifestations occurring in late teenage years and early adulthood. Results indicated that children who lived in institutions for less than 6 months had comparable symptoms as the control group’s subjects. Those who lived for longer than 6 months had higher rates of symptoms, especially for cognitive impairment. Findings suggest significant contribution to the mental health well-being of children and how early influencers such as early childhood abuse and trauma impact them throughout the entire length of their lives.

Barriers and Facilitators for Implementation of Mental Health Services in Schools

            For successful implementation of school mental health (SMH), it is important to consider the following components: 1) formal training for professional mental health service providers according to evidence-based practice (EBPs), 2) integrity of implemented SMH, and 3) sustainability of specific EBPs for SMH (Owens et al., 2014). Evidence available to address social and behavioral challenges relies on short-term assessment and often by highly-trained staff. The evidence available for standard SMH is limited and influencing factors for successful implementation are less known. It is difficult to develop standard EBPs for generalizations across schools. Identified gaps include compatibility, training for better implementation and sustainability may be explained by limited EBPs uses across school mental health service providers (Evans et al., 2013). Owens et al. (2014) identified the use of implementation sciences (IS) to address the gaps in literature and the goals were identified as essential for SMH. Organizational factors including internal and external impact interventional success for SMH. Broader factors including political and financial especially influence implementation processes such as state-level mandates impacting education law. Similarly, diversity in the type of professionals available for implementation also affect IS. For instance, SMH with available counselors, psychologists and teachers aiming to aid in implementation may prove sustainable. These professionals, especially teachers and the principal may provide better insight on policies and social networks in schools.

Teachers may provide feedback based on performances of students in schools. Additionally, the school calendars often present with spikes of mental health symptoms and need to be identified for successful longevity of SMH protocols. Professional development is crucial for providing highly integral IS in SMH. This may include workshops, manuals and active-learning guides for professionals. Owen et al. (2014) present services that may have significant impacts on professional development of service providers and include: 1) adopted strategies, 2) models for coaching, 3) length of training, and 4) their role of motivation and social stigma. The study poses pertinent questions for implementation barriers and facilitators and includes the role of coaching in producing desirable outcomes for students. Secondly, the role of strategies and its effect on improving the knowledge and skills of service providers is explored. Thirdly, the models that best suit coaching are reviewed for providing essential skills to aid in professional development. Lastly, the study poses questions for the impact of motivations and perceptions provided by service providers and predict its impact on skill development of the facilitators. The study proposes key areas that may help in successful implementation of EBPs for SMH and addresses the concern for availability of numerous principles governing the IS (Owen et al., 2014).

A study was conducted by Langley et al. (2010) to determine factors affecting the successful implementation of an EBP, called the Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Data was obtained via phone interviews with 35 administrators and service providers across the United States. The professionals had received training and were evaluated 6-18 months after receiving their training. While results indicated differences in the process of implementation, the barriers were similar. Those schools that were able to overcome the barriers were identified as having better organizational structure including robust systems to accommodate implementation. The study demonstrated important findings for aiding in successful implementation for EPBs in SMH by facilitation from necessary professionals and peer support.

Synthesis of the Research Findings

It has been identified that genetic and social factors dictate the onset of mental health problems. Many screening tools have been standardized for obtaining relevant information for students enrolled in school. Academic achievement is often adversely affected with increased mental health problems. Additionally, peer pressure also adds to the burden of mental health illnesses. The stigma surrounding mental health is important to identify for appropriate use of resources. It is important for future researchers to understand the complexities surrounding childhood trauma and biological and psychological effects on the affected children.The role of social factors and peer pressures was identified by the labeling theory in order to understand the roles of social factors. It is expected that students who are facing mental health problems report higher in perceived social and peer pressures. Implementation of SMH is essential to ensure the integrity and sustainability of the programs is possible. However, it may not be possible to conduct implementation of EBPs in our research. Gaps have been identified across school mental health service provisions whereby sub-optimal care is being provided. It is expected to find similar results in our research owing to the lack of standard EBPs for schools. Additionally, organizational factors also play a critical role in the continued implementation of competent SMH services across schools.

Critique of Previous Research Methods

Previous research methods often incorporate the use of either qualitative or quantitative study designs. Due to the validation of questionnaires for screening, the use of qualitative study designs are now limited. However, the use of questionnaires presents problems due to the rigidity of the grading system in many circumstances. The results may be skewed due to biases and the lack of prospective cohorts for implementing SMH changes has not been identified yet. The research designs are often cross-sectional with limited data on day-to-day struggles of students in schools. The role of student counselors has not been identified accurately and there are no formal guidelines for determining their roles in schools. The effects of childhood abuse is factored in but it may also be pertinent to review the role of parents in providing emotional and other support to their children.

Summary

Mental health problems have adverse effects on academic achievements in school-going children. Previous literature indicates the association of attention problems, hyperactivity, anxiety and depressive symptoms with lowered scores across standard exams and overall educational attainments. Identification of self-reported symptoms of poor mental health in adolescent girls is indicative of gender-based differences for mental health problems and outcomes. There is also an identified role of social contexts and peer pressures for development and aggravation of mental health disorders. The role of mental health providers in schools is critical for the improvement of internalized and externalized symptoms of mental health. Previous studies have also identified the role of childhood trauma on mental health later in life. Its impacts have been determined on biological changes including epigenetics. The role of social determinants was outlined by many researchers and pose important consequences for the mental health of children, adolescents and young adults.

 

 

CHAPTER 3. METHODOLOGY

Purpose of the Study

The focus of the research is to explore the impact of mental health problems on academic achievement statuses of adolescents in high school in order to obtain a better understanding of the effects of mental health problems. It is essential to demonstrate an understanding of the longevity of clinical and sub-clinical manifestations of mental health problems before they are recognizable by health care providers. Students spend the longest time periods in school and it amounts to over 6 months of time spent at schools. Adolescents enrolled in high school witness an array of emotional and behavioral alterations throughout their days at school, including exploration of self-identity away from caretakers and family members as well as pubertal development. In the case that students are made to feel safe in schools, it is possible that their mental health problems are reduced. This may only be possible with adequately managed school mental health (SMH) systems in educational institutions including high school. The use of academic achievement is the identification of a single effect of mental health problems on factors directly related to the students’ emotional and behavioral health. The chapter outlines how the research will be implemented. It provides information for the research design and implementation process. It also identifies the target population and sample, procedures, and ethical considerations taken before the research is implemented.

Research Questions and Hypotheses

The research questions pose whether mental health problems and their manifestations affect academic outcomes in high-school going children; additionally, the current knowledge and skills available by mental health service providers is also screened to determine the abilities of SMH to aid in the maximally attained educational achievement in these students. The independent variable is academic achievements and the dependent variables are mental health problems and quality of care provided by school mental health service providers. Screening for mental health problems will be possible by administration of the Strengths and Difficulties Questionnaire (SDQ). It will be used and it screens for social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures. The research questions include the following:

  1. Is higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade?
  2. Are improvements in academic performance observed when school mental health service providers are able to provide high quality mental health services to students of high schools?
  3. Does the lack of adequate mental health service providers’ skills and knowledge have adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade?

For the ease of statistical analysis for the research questions, the hypotheses were developed for the research and include:

H1: Higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children are lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade.

H2: Improvements in academic performance is observed when school mental health service providers are able to provide high quality mental health services to students of high schools.

H3: Lack of adequate mental health service providers’ skills and knowledge has adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade.

Target Population and Sample

The aim for the target population is 300 high-school students, taking into account loss to follow up and other contextual factors. Based on the power analysis with confidence interval of 95% an accepted margin of error at 5%, the predicted outcome factor hypothesis was set at 20%. OpenEpi software was used to determine the target sample size and 246 participants was identified as the minimum acceptable sample with estimates of sample size to be 100,000 high-school going children enrolled in schools across California. The student counselors will also be enrolled for understanding their role in academic achievement and tackling mental health problems in the students. In order to obtain the target sample size for the student counselors, OpenEpi software was used again and the sample size estimate is 94. The confidence interval was set at 95% and the calculation took into account a 20% non-response rate. The margin of error was set at 10%. They have the highest exposure with students in a personal capacity in schools and a formal analysis of their knowledge and skills is essential to draw meaningful results. Students who were enrolled in eleventh or twelfth grade were enrolled and were included if they had received mental health services at any time in the two years of high school. Student counselors were included who had exposure to students of respective schools for at least 6 months. In order to ensure that the target sample is obtained, the goal is to maintain the response rate above 80% for both students and the counselors and collaboration with schools before-hand is important to promote better recruitment strategies.

Principals of respective schools across California will be contacted and they will provide information for better implementation and improving response rates to achieve the target sample size. Staff recruited for the research will be selected after screening for their performance and the students’ willingness to participate will also be taken into consideration. While the study design is a series of cross-sectional studies, the data will aim to be diverse by not excluding participation of any gender, race or culture. Students will only be selected based on their enrollment in high-school and their receiving of mental health services in schools. Questionnaires will be self-administered and are an efficient means to obtain data from high-school students. However, the research will use phone-based interviews to complete the questionnaires in order to ensure completeness of obtained data. Additionally, participants may be better able to comprehend components of the questionnaires if they are interviewed by a knowledgeable interviewer. Student counselors will also be interviewed over phone for their skills and knowledge of providing high-quality mental health service provision. Participants will be enrolled voluntary via verbal consent in order to obtain a good rapport between interviewers and the study participants. In order to ensure that there is no breach of confidentiality, the student ID codes on questionnaires will be changed before being entered for data entry and the names will be omitted before entry of data.

Procedures

Study Design

The study is a series of cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively. The participants will be enrolled with a request via email and interviews will be conducted once they respond to the emails. The identification of students and their email IDs will be provided by schools enrolled in the research. Schools in California will be identified and their principals will be informed of relevant details for the ongoing research. For ensuring variation, student counselors who have worked with students for longer periods of time will be given preference for enrollment.

Materials and Instruments

Materials to be used for data collection include selection of interviewers and the units of analysis are high-school students and school counselors. Screening of mental health problems will be conducted by telephonic administration of the Strengths and Difficulties Questionnaire (SDQ) by trained interviewers using age-appropriate versions of the questionnaire. The SDQ contains 25 items and it consists of 5 categories with 5 items each. The scores for each item are anywhere between 0 till 2, using the three-band scoring system. The total score is called the total difficulty score and will be categorized, ranging from 0 to 40 total points. It will be used and it screens for social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures. The categories for results include: 1) abnormal being anywhere between 17 till 40 points, 2) borderline being between 14 till 16 points and 3) normal being any score below and including 13 points.

Enrolled student counselors will be screened for their knowledge and skills using a validated questionnaire to determine their knowledge and practices regarding mental health (Abdulkadir & Abdulkadir, 2017). The questionnaire was developed based on items identified by Anderson et al. in 1980 (Bisi-Onyemaechi et al., 2018). It consists of four key components: 1) demographic information, 2) 8 items for current status of SMH services, 3) 5 items for protocols of SMH services, 4) multiple items identifying factors contributing to school environments and 5) knowledge of SMH. For understanding the current knowledge and practices of the student counselors, the answers for the questions were pre-determined and the recorded answers by mental health providers are identified as either correct or incorrect. For categorizing the knowledge as good, the answers are to be correctly identified across three or more of the identified components, excluding demographical data. Average knowledge is categorized as correct answers for one or two of the identified components. Poor knowledge is categorized as no correct identification across all components of the questionnaire. The time required for data collection is 3 months in order to obtain the target sample size.

Data Collection Process

The data will be obtained in a systematic manner using the following steps. Firstly, the schools located in California will be identified and it will be cross-checked for the presence of SMH service provision in these schools. Next, emails will be sent with relevant information regarding the research in order to obtain written consent from the principals. This will be followed by a request for identification of high school students who are enrolled in eleventh and twelfth grades and who have been to a student counselor at least once in their time at high school. Additionally, their contact information including email IDs and phone numbers will be obtained. They will be sent emails to ensure their consent is taken and they are informed about relevant information of the research. The student counselors will then be identified and their duration of employment and relevant contact details will be obtained. Student counselors who have worked for longer durations will be preferred and any student counselor who has been employed for less than 6 months will be excluded. Once consent is obtained according to the target sample size, interviews will be conducted via phone over the span of three months. The interviews will be conducted for obtaining answers for the relevant sections on the questionnaires. This poses the benefit of ensuring complete information for the questionnaires but is slower to conduct than self-administered questionnaires. Next, the data will be entered in SPSS V.20 in order to conduct the analysis.

Analysis

Data will be entered in SPSS, version 20. The variables will be analyzed and results will be presented using descriptive statistics for variables. Dependent variables include identified variables in the SDQ and questionnaires administered to student psychologists. The independent variable is the academic outcomes for the enrolled students currently in high school. Regression analysis will be used for both dependent variables including: 1) scores of SDQ questionnaires and 2) scores of questionnaires administered to student counselors. The use of Chi-square tests and student’s t-test will be used and the significance will be set at 0.05 in order to determine effects of dependent variables on the independent variable, academic achievement. In order to produce valid results, the data will be entered manually and will be double-checked to look for missing or double-entered data. Reliability of the findings will also be ensured using correct data and obtaining enough study participants as the estimated sample size calculation. In order to provide generalizable results, students of all races, genders, and socioeconomic classes will be enrolled. Additionally, student counselors who have worked with students longer will be assessed instead of those who have been employed for less than 6 months in schools.

Ethical Considerations

The APA Code of Ethics is applicable for the research being conducted. In order to provide ethical clarity in the profession of psychology, the principle of beneficence and nonmaleficence will be applied to protect the confidentiality of students obtaining mental health services from their schools. The principle encourages elimination of biases and any preformed prejudices available on the end of the student counselors. The principle of fidelity and responsibility ensures that the student counselors help maintain the ethical standards across their profession in the high schools. It is essential to eliminate fabricated and false results so as to reduce the effects of any incorrect findings for future researchers. The principle of integrity will be used to ensure that the student counselors are not fabricating scores of their questionnaires or causing distress to students. The principle of justice ensures that students of different races, cultures and genders receive fair and impartial treatment. The respect for people’s rights and dignities will be ensured as data entry will not constitute revealing the identity of the participants and their IDs will be changed before the entry of data. The APA code of ethics will be implemented due to the nature of the study with enrollment of psychologists as study participants.

 

 

 

CHAPTER 4. EXPECTED FINDINGS/RESULTS

It is expected that mental health patterns have impacts on academic achievements in school-going children. There has been evidence to indicate that attention problems and depressive symptoms directly lower the GPAs and overall educational attainments for those students. Previous studies have indicated the increased frequency of self-reported symptoms of poor mental health in adolescent girls. The association between socio-economic factors and poor mental health has been identified and it is likely that gender-based differences for mental health problems may be identified if examined. However, our research does not examine gender-based differences for self-reported symptoms of mental health problems. The training of clinical practitioners working in schools may be improved by adopting relevant strategies, coaching of counselors and exploring the role of social stigma. Previous studies have also identified the role of childhood trauma on mental health later in life. While our research does not conduct any screening for childhood factors, it is important for future researchers to understand the complexities surrounding childhood trauma and biological and psychological effects on the affected children.

The role of social factors and peer pressures was identified by the labeling theory in order to understand the roles of social factors. The determination of social factors is present in our research using the SDQ measures. It is expected that students who are facing mental health problems report higher in perceived social and peer pressures.

Implementation of SMH is essential to ensure the integrity and sustainability of the programs is possible. However, it may not be possible to conduct implementation of EBPs in our research. Gaps have been identified across school mental health service provisions whereby sub-optimal care is being provided. It is expected to find similar results in our research owing to the lack of standard EBPs for schools. Additionally, organizational factors also play a critical role in the continued implementation of competent SMH services across schools. Expected findings support previous literature regarding the role of mental health problems on educational outcomes. The research evaluates a gap in literature by identifying the shortcomings of student counselors’ knowledge and practices. The expected findings are sub-optimal quality of care provided by student counselors having adverse impacts on educational outcomes including the GPAs for enrolled students. It is not possible to monitor study subjects for longer durations but the GPAs will be obtained as parameters of academic achievement.

 

 

CHAPTER 5. DISCUSSION

Implications

Potential results point towards the increased tendency for students with mental health problems to perform lower academically. Potential stakeholders for the research include the students, educational systems, federal and state government, and key members of school administration. Students will face outcomes for the rest of their lives if they are not able to gain adequate educational achievements. The educational system of the country will also be affected due to the potentially increased risk of dropouts in students in college or after high school. The government has a crucial role to play in the current SMH services. Due to limited resources offered by state and federal government policies, it is difficult to successfully implement a sustainable system of mental health service provision across schools. The human development is addressed using a wide array of emotional and behavioral patterns that may have been consolidated during childhood trauma and abuse. Additionally, sociology may benefit from the behavioral aspects of students suffering from mental health problems.

Methodological Strengths and Weaknesses

The research identifies key concerns related to mental health problems across teenagers and presents findings for academic achievement. The use of two questionnaires aims to strengthen findings for future development of approaches. The study screens adolescents that have already received at least one session of mental health service provision. This allows for isolation and selection of concerned study population. Additionally, the enrolled participants are administered surveys due to their ability to comprehend and answer relevant items in the questionnaires. This allows for better reporting of symptom as opposed to parents reporting symptoms for their children. The use of interviewers to fill in the questionnaires also ensures that the study participants are aware of what exactly the questions represent and mean. The weaknesses of the research include the study design and the lack of a standard questionnaire for the student counselors. The study design does not allow for long-term monitoring of data and it may not be possible to screen subjects until they obtain college degrees. The study design allows for screening of participants up until the obtainment of GPAs for the concerned semester to ensure that the study is conducted within 3 months. The lack of available standardized questionnaires for student counselors also presents as a significant weakness for the outcomes and findings of the research.

Suggestions for Future Research

For improving mental health in schools, it is important to realign current policies and practices pertaining to dealing with mental health. Future researchers need to identify the role of expanded school mental health services. The postulation that schools are the most critical places for children and adolescents to develop and overcome mental health problems may be proven true with similar researches being conducted. It is also recommended to screen what factors are preventing or facilitating successful implementation of the health service programs in schools. Studies should focus on organizational factors, sustainability and overall procedures for implementing EBPs across schools. Another important factor to explore further is the role of social stigma in expressing the ongoing clinical manifestations of mental health problems in the students. Without adequate support, these children and adolescents may not be able to express their status of mental health. Additionally, the role of parents and social support systems, especially in schools, need to be evaluated amongst participants who have been identified with significant mental health problems.

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Association of Mental Health Problems with Academic Achievement in High-School Students

Abstract

The research uses a quantitative study design in order to determine the range of symptoms in students and its impacts on educational outcomes. The research questions include the following: Is higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade? Are improvements in academic performance observed when school mental health service providers are able to provide high quality mental health services to students of high schools? Does the lack of adequate mental health service providers’ skills and knowledge have adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade? Mental health problems have impacts on the social, behavioral patterns of children and adolescents as well as on their academic achievement. The role of evaluating the current state of mental health services in schools is critical to ascertain and reduce potential adverse effects on educational achievements of school-going children. The proposed research investigations allow for evaluation of two independent associations with academic outcomes in school-going children. Potential stakeholders for the research include the students, educational systems, federal and state government, and key members of school administration. Students will face outcomes for the rest of their lives if they are not able to gain adequate educational achievements. Due to limited resources offered by state and federal government policies, it is difficult to successfully implement a sustainable system of mental health service provision across schools. It is expected that mental health patterns have impacts on academic achievements in school-going children.

Keywords: [Mental health problems, educational achievement, SDQ, high-school, adolescents, children, quantitative]

Table of Contents

CHAPTER 1. INTRODUCTION…………………………………………………………………………… 5

Background of the Problem…………………………………………………………………………………. 5

Statement of the Problem…………………………………………………………………………………….. 6

Purpose of the Study…………………………………………………………………………………………… 6

Significance of the Study……………………………………………………………………………………… 6

Research Questions……………………………………………………………………………………………… 7

Definition of Terms……………………………………………………………………………………………… 8

Research Design………………………………………………………………………………………………….. 8

Summary……………………………………………………………………………………………………………. 9

CHAPTER 2. LITERATURE REVIEW………………………………. ……………………….10

Theoretical Orientation for the Study…………………………………………………………………. 10

Review of the Literature……………………………………………………………………………………. 11

Synthesis of the Research Findings…………………………………………………………………….. 19

Critique of Previous Research Methods……………………………………………………………… 20

Summary………………………………………………………………………………………………………….. 20

CHAPTER 3. METHODOLOGY………………………………………………………………………… 22

Purpose of the Study…………………………………………………………………………………………. 22

Research Question and Hypotheses…………………………………………………………………….. 23

Target Population and Sample…………………………………………………………………………… 24

Procedures………………………………………………………………………………………………………… 25

Ethical Considerations……………………………………………………………………………………….. 28

CHAPTER 4. EXPECTED FINDINGS/RESULTS……………………………………………….. 30

CHAPTER 5. DISCUSSION………………………………………………………………………………. 32

Implications………………………………………………………………………………………………………. 32

Methodological Strengths and Weaknesses…………………………………………………………. 32

Suggestions for Future Research………………………………………………………………………… 33

 

CHAPTER 1. INTRODUCTION

Coping with mental health illness may be challenging for families with many barriers identified. Parents who suffer from mental illness pose additional risks for children, with 15% having developed mental health problems and 27% having observed behavioral disturbances (Mowbray et al., 2004). Children and adolescents may not receive appropriate mental health care services in the community or at school; effective coordination of mental health services has proven to be difficult, which has created a need for mental health intervention programs (Puddy, Roberts, Vernberg, & Hambrick, 2012). Schools have been identified to be a viable source for students with mental health problems. Bullying victimization is witnessed in school cultures and it remains prevalent, causing public health policies to promote intervention and prevention strategies (Arseneault, Bowes & Shakoor, 2010).However, it has been observed that only 18-34% of young people suffering from severe depression or anxiety avail psychiatric services (Gulliver, Griffiths & Christensen, 2010). Highest prevalence of mental health problems are observed in individuals aged 16-24 years (Slade et al., 2007). Mental health problems have impacts on the social, behavioral patterns of children and adolescents as well as on their academic achievement. For instance, patients with Attention-Deficit/Hyperactivity Disorder (ADHD) cause social and emotional impairment for themselves and their families inadvertently affecting their quality of lives (Wehmeier, Schacht & Barkley, 2010). Schools are focusing primarily on academic achievements and their indicators with limited focus on the mental health of students. Marques, Pais-Ribeiro & Lopez (2011) explored the effects of constructive positive psychology on academic achievement in young children and adolescents and it confirmed the benefits of positive reinforcement on academic outcomes. It is known that mental health plays significant roles in academic outcomes and the mental health problems are aggravated with academic achievement and social support (Marques, Pais-Ribeiro & Lopez, 2011). Often, students are identified with internalized symptoms that go unnoticed. Schools are commencing to take action for students in order to support pro-social behaviors and reduce internalizing (Kramer et al. (2014).

Background of the Study

Children and adolescents are more vulnerable due to the neglect for mental health services in schools. Mental health is declining in children and adolescents of school-going age with 10-20% of them being affected (Kieling et al., 2011). The United States spends financial resources for education in the United States and the role for providing first-class education. The inclusion of diversity in students is expected to include students at risk of mental health problems due to multi-factorial causes. The role of addressing gaps in achievement lies with school systems, social support groups including families and national and state policies implemented by the government (US Department of Education, 2010). Barriers for academic attainment are often psychiatric or financial with additionally identified limitations related to financial shortcomings of families (Young &Murray, 2004). The role of mental health providers, including teachers, counselors and psychologists, needs to be formally assessed in order to provide sustainable implementation of EBPs across school systems. Effects may be witnessed by families due to changing behavioral and emotional factors (Arseneault, Bowes & Shakoor, 2010). Additionally, sociologists may benefit from increased exploration of social theories impacting educational achievement due to compromised mental health.

Statement of the Problem

While there is a developed infrastructure to provide mental health services across schools in the US, not much information is available for the quality of services available (Arseneault, Bowes & Shakoor, 2010). Policies encourage the use of evidence-based practice across the student mental health infrastructure (Owen et al., 2014). However, there is evidence indicating the poor implementation of national policies (Atkins et al., 2003). The role of evaluating the current state of mental health services in schools is critical to ascertain and reduce potential adverse effects on educational achievements of school-going children.

Purpose of the Study

Obstacles have been identified that impact the successful implementation of school mental health provision across schools (New Freedom Commission on Mental Health, 2003). President Bush identified multiple gaps in the mental health service provision and the roles of federal and state government policies are unspecific as to how to tackle to lack of successful implementation. The quality of life of children and adolescents is directly affected by service providers in school and not enough quantitative evidence is available to ascertain deficits in the knowledge and skills of service providers.

Significance of the Study

The proposed quantitative research investigations allow for evaluation of two independent associations with academic outcomes in school-going children. The factors being explored include the mental health status of adolescents and the knowledge and practices of student counselors in school systems. The research explores two different quantitative methods, both being closely linked. No prior study has conducted the dual analysis of school mental health (SMH) services and mental health status on academic outcomes. Findings may draw attention towards the lack of focus on mental health care service providers and their gap in knowledge while providing their services to students.

Research Question

The research uses a quantitative study design in order to determine the range of symptoms in students and its impacts on educational outcomes. In order to categorize data, the use of quantitative questions becomes necessary. The research questions include the following:

  1. Is higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade?
  2. Are improvements in academic performance observed when school mental health service providers are able to provide high quality mental health services to students of high schools?
  3. Does the lack of adequate mental health service providers’ skills and knowledge have adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade?

The following hypotheses have been identified and were developed for the quantitative research including:

H1: Higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children are lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade.

H2: Improvements in academic performance is observed when school mental health service providers are able to provide high quality mental health services to students of high schools.

H3: Lack of adequate mental health service providers’ skills and knowledge has adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade.

Definition of Terms

The following operational definitions will be used to categorize and provide information for data collection (Cummings & Worley, 2015).

  1. Mental health problems: Categorized by variables of the Strengths and Difficulties Questionnaire (SDQ): social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures and will be scored according to pre-determined scales.
  2. Mental health service providers: These are identified as student counselors and psychologists hired by school administrations to offer students with mental health services.
  3. Quality of care: Determined by screening for knowledge and skills using a validated questionnaire to determine the knowledge and practices of healthcare of mental health practitioners
  4. Academic achievement: Categorized by the grade point average (GPA) of the students in the ongoing semester they are enrolled in during the course of the research.

Research Design

The quantitative study is to be implemented by administering questionnaires to the target population. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively. The participants will be enrolled with a request via email and interviews will be conducted once they respond to the emails. The identification of students and their email IDs will be provided by schools enrolled in the research. Schools in California will be identified and their principals will be informed of relevant details for the ongoing research. For ensuring variation, student counselors who have worked with students for longer periods of time will be given preference for enrollment. The APA code of ethics is applicable and will be implemented and include five principles namely: beneficence and nonmaleficence, fidelity and responsibility, integrity, justice and respect for people’s rights and dignity.

Summary

Mental health problems have adverse effects on academic achievements in school-going children. Previous literature indicates the association of attention problems, hyperactivity, anxiety and depressive symptoms with lowered scores across standard exams and overall educational attainments. Identification of self-reported symptoms of poor mental health in adolescent girls is indicative of gender-based differences for mental health problems and outcomes. There is also an identified role of social contexts and peer pressures for development and aggravation of mental health disorders. The role of mental health providers in schools is critical for the improvement of internalized and externalized symptoms of mental health. The following research is a series of two cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively.

 

 

CHAPTER 2. LITERATURE REVIEW

Theoretical Orientation for the Study

The impact of mental health problems affects social, emotional and behavioral problems in school-going children and adolescents. Children and adolescents suffering from mental health problems may not achieve higher academic levels of education and it is pertinent to address these concerns. The socio-cultural theory proposed by Vygotsky identifies the inter-dependence of social and cultural processes to aid in obtaining knowledge (John-Steiner & Mahn, 1996). The theory is especially important for determining interactions of identified factors that have strong impacts on cognitive development. Vygotsky proposed the crucial aspect of collaboration for obtaining knowledge and education. The theory explains multi-factorial contributors for academic achievements in children, adolescents and young adults. It supports the implementation of appropriate and supportive mental health provision in schools for promoting better cognitive development in school-going children and adolescents. The theory explains the how school systems serve as support systems and extended families. The school support systems as well as provision of mental health services serve as positive influencers for higher academic achievement.

Vygotsky assumes an integral socialism related to human development and considers cultural mediation as an opportunity to bridge the gap of mental health and cognitive abilities. Instead of focusing on the overarching innate ability of humans to achieve academic credibility, Vygotsky identified the importance of giving and receiving in social contexts, including peer support and hygiene of mental health (Matusov & Hayes, 2000) The dualism of socialism and individuals was described by Vygotsky and led to the identification of three key concepts used by human developmental sciences to explain mental health in the last few decades of the 20th century and the 21st century. The first concept explains the role of deconceptualization in promoting developmental skills independent of their use. The second concept outlines the practices of claiming deficits of other communities based on their specific attributes, known as ethnocentric. The last concept identifies the role of parents claiming deficits of their own children’s attributes, skills and values. The last concept identifies the inability of humans to act in such manners when their own children are not comprehensible (Matusov & Hayes, 2000).

Review of the Literature

Labeling Theory and its Consequences on Mental Health

Labeling theory identifies and evaluates social circumstances and its impacts on mental health illnesses (Gove, 1982). It acknowledges the role of social rejection and how pertinent individuals are affected by anticipation and active rejection. It is debated upon whether the stigma and sequelae of mental health illnesses present with additional concerns. The following study explores these non-cognitive traits on educational achievement and academic performances across schools to identify the role of the labeling theory. Data was obtained from a longitudinal survey of the National Longitudinal Study of Adolescent Health (McLeod, Uemura & Rohrman, 2012). Adolescents in the U.S. were followed throughout school with 80 high schools and 52 middle schools enrolled in the survey. Key questions that the study aimed to answer were to identify which factors strongly impacted academic achievement and which combination of factors adversely impacted academic achievement in the students. The study hypothesized that various mental and behavioral problems presented with different outcomes in students in school settings. Mental health traits that represent a lack of response and interest are less likely to elicit negative responses from peers and teachers. Therefore, mental health problems that pose with higher disruption are more likely to be associated with academic achievements for students. 20,725 students were selected from the survey conducted by the National Longitudinal Survey of Adolescent Health in the U.S. and 54% of the enrolled subjects were women. Whites formed the major racial group at 54% with comparable samples of African-American and Latino students. 25% of the study subjects lived with a single parent and 87% of the parents of these study subjects had received a high school diploma or higher.

The study was conducted in multiple stages with an in-home survey being the first. The sub-sample selected took part in an in-home survey and was known as Wave I. This was also accompanied by an interview with either parent. Wave II was conducted a year after Wave I whereby the participants were interviewed again. Wave III was conducted in 2001 and interviews were conducted again. Wave IV was conducted in 2008 and included participants who were enrolled in wave I in-home surveys. Instruments used to measure academic achievement were grade point average (GPA) and highest educational degree received. Mental health and behavioral problems were also measured using a revised 19-item Center for Epidemiologic Studies- Depression Scale. The Swanson, Nolan and Pelham Rating Scale (SNAP-IV) was used to identify subjects with attention deficit hyperactivity disorder (ADHD). The measure of delinquency was self-reported with 14 identified items. Substance abuse was also self-reported and screened for the last year for alcohol use. It included additional questions including cigarette smoking, marijuana and other drug use in the past thirty days as well. For assessing the combination of mental health and behavioral problems, the following variables were examined: depression alone, attention problems alone, and depression and attention problems. Academic aptitude was measured using the scores obtained for wave I study participants using vocabulary test results (McLeod et al., 2012).

Additionally, students who were either receiving special educational services or were diagnosed with a learning disability in the past year were identified as a separate variable. Regression analysis was conducted with two dependent variables: 1) ordinary least squares for GPA scores and 2) ordinal logistic for highest level of education obtained. The Imputation by Chained Equations (ICE) and MICROMBINE were utilized to estimate results using STATA 11.1. Results demonstrated that ADHD, delinquency and substance abuse had greater impacts on academic achievement than depression. Additionally, a combination of two mental health conditions had greater impacts on academic achievement including decline in GPA and highest attained educational achievement. Substance abuse had a strong correlation with a decline in GPA and educational achievement. Findings demonstrate essential findings for mental health practitioners as the study offers a broad range of dysfunctions in school-going students. While the findings are limited due to informal diagnostic assessment of certain variables, it focuses on non-cognitive traits based on behavioral and emotional factors. There is limited evidence regarding teachers’ ability to evaluate these variables despite teachers conducting evaluation for them. The study offers insight on a plethora of mental health problems and correlates it with sociological factors and offers diversity in the variables analyzed. It is, however, not elaborated by the study as to how ethical dilemmas of the survey will be tackled including breach of confidentiality (McLeod et al., 2012).

Onset of Mental Health Problems

            Timely identification of symptoms is critical for preventing occurrence of mental health illnesses in the youth. Trends are worrisome with increased incidences of self-reported internalizing symptoms, more commonly in adolescent girls (Bor et al., 2014). A population-based cross-cohort study was conducted with data obtained from two birth cohorts, for which each twin participant was enrolled in either cohort (Durbjeej et al., 2019). This time trends were explored with identification of two time points: 1) 9-year old children and 2) 15-year old adolescents. The aim of the longitudinal study being conducted in Sweden was to identify mental and somatic health during childhood and teenage years. The study poses important questions pertaining to: 1) the correlations between the two birth cohorts and internalizing symptoms and 2) changes in trends of internalizing symptoms based on changes in scores for clinical parameters for depression and anxiety. The study hypothesized the rise in trends of internalizing issues pertaining to mental health illnesses including depression and anxiety, especially in adolescent girls. Study participants were obtained from the Child and Adolescent Twin Study in Sweden (CATSS) to include all twins born in the country after July, 1992. Once the twins turned 9 years old, parents were interviewed via phone to assess the socio-psychological status of the twins. Later, on turning 15, the same study participants and their parents filled in a questionnaire. At 9 years, the Screen for Child Anxiety Related Emotional Disorders (SCARED) was used to screen for symptoms of anxiety.

The instrument was calibrated according to a 3-point likert scale. The Short Mood and Feelings Questionnaire (sMFQ) was also used to assess the same cohort for symptoms of depression. At age 15, the twin cohort was assessed again using the Strength and Difficulties Questionnaire (SDQ), both parents and children. The SDQ was self-reported by the adolescents and included screening of mental health illnesses on educational symptoms. The internalizing symptoms were identified for depression, anxiety and self-worth. Descriptive statistics and linear regressions were used using Cohen’s measure of effect size. The scores of all questionnaires were used as dependent variables whereby defining characteristics within the cohort were taken as independent variables including gender. Results were indicative of the time trends for enrolled participants and demonstrated data for internalizing symptoms. 9 years-old participants showed an increased pattern of anxiety symptoms and 15-year old subjects self-reported trends for increased internalizing symptoms, with gender-based differences with girls self-reporting higher. Gender-based differences were observed for parent-administered surveys in adolescent girls as well but were less significant than self-reported internalizing symptoms. There were mild similarities amongst twins enrolled in the cross-cohorts. The study provides comprehensive information for twins, and gender-based differences. It sheds light to the critical importance of individual assessments for both depression and anxiety as well as provides valuable evidence using its methodological strength by conducting repeated assessments cross-sectional. Enrolled participants were provided with written consents to ensure ethical parameters were considered and the study participants were selected based on one defining characteristic, being twins (Durbjeej et al., 2019)

Role of Early Life Deprivation in Mental Health Problems

            The effects of deprivation in early life and childhood have been a significant focus for mental health problems. Ethically, it is not permissible to evaluate effects of imposed deprivation on children and conclusive evidence is limited. However, Kumsta et al. (2016) suggested a occurrence of re-modeling of epigenetics, suggestive of biological changes, when children were subjected to abuse. It is, therefore, critical to understand the pathogenesis of mental health with the help of observational studies. A study was conducted across adopted children living with UK families and adopted from Romania in the 1990s. Most of the study participants had suffered from moderate to extreme global deprivation until 3 years of age. A quantitative study design was used and questionnaires were administered at the subjects’ households and six different clinical manifestations were screened: 1) autism spectrum disorder, 2) inability to pay attention and hyperactivity, 3) disinhibited engagement socially, 4) problems pertaining to conduct, 5) emotional symptoms and 6) cognitive impairment. Self-administered questionnaires for study participants were also administered to get an improved understanding of their mental health problems. The Revised Rutter Scale was used twice, once at 6 and at 11 years to understand symptoms related to inattention and hyperactivity. The Strengths and Difficulties Questionnaire was used at 15 years and the Conners Comprehensice Behavior Rating Scales was used for adults. To measure disinhibition, perceptions of the interviewers were required and scored consequently. Autism spectrum disorder was assessed using the Social Communication Questionnaire (SCQ). Cognition was assessed using standard IQ assessments including Children’s Abilities General Cognitive Index at 6 years and a modified version of the Weschsler Intelligence Scale for Children for the next three assessments.

To understand consequences of early life trauma, contextual factors and use of mental health services were determined. Parental factors were assessed using the Parental Attachment Questionnaire to understand the participants’ support systems. Subjects were also asked to answer the Inventory of Parent and Peer Attachment to score their relationship with their parents. Data was categorized as either of the following: 1) lived in an institution for less than 6 months, and 2) lived in an institution for more than 6 months, 3) a control group of adoptees who did not face deprivation. A mixed-effects regression model was used to assess intensity of trends.  The study hypothesized that adoptees who spent less than 6 months would present with less symptoms across all time points. Second, occurrence of autism spectrum disorder, increased severity of inattention and hyperactivity, and impairment in cognition could not be reversed for those children who spent more than 6 years at respective institutions. Last, children who were at institutions for more than 6 months were more likely to suffer from a range of emotional problems with manifestations occurring in late teenage years and early adulthood. Results indicated that children who lived in institutions for less than 6 months had comparable symptoms as the control group’s subjects. Those who lived for longer than 6 months had higher rates of symptoms, especially for cognitive impairment. Findings suggest significant contribution to the mental health well-being of children and how early influencers such as early childhood abuse and trauma impact them throughout the entire length of their lives.

Barriers and Facilitators for Implementation of Mental Health Services in Schools

            For successful implementation of school mental health (SMH), it is important to consider the following components: 1) formal training for professional mental health service providers according to evidence-based practice (EBPs), 2) integrity of implemented SMH, and 3) sustainability of specific EBPs for SMH (Owens et al., 2014). Evidence available to address social and behavioral challenges relies on short-term assessment and often by highly-trained staff. The evidence available for standard SMH is limited and influencing factors for successful implementation are less known. It is difficult to develop standard EBPs for generalizations across schools. Identified gaps include compatibility, training for better implementation and sustainability may be explained by limited EBPs uses across school mental health service providers (Evans et al., 2013). Owens et al. (2014) identified the use of implementation sciences (IS) to address the gaps in literature and the goals were identified as essential for SMH. Organizational factors including internal and external impact interventional success for SMH. Broader factors including political and financial especially influence implementation processes such as state-level mandates impacting education law. Similarly, diversity in the type of professionals available for implementation also affect IS. For instance, SMH with available counselors, psychologists and teachers aiming to aid in implementation may prove sustainable. These professionals, especially teachers and the principal may provide better insight on policies and social networks in schools.

Teachers may provide feedback based on performances of students in schools. Additionally, the school calendars often present with spikes of mental health symptoms and need to be identified for successful longevity of SMH protocols. Professional development is crucial for providing highly integral IS in SMH. This may include workshops, manuals and active-learning guides for professionals. Owen et al. (2014) present services that may have significant impacts on professional development of service providers and include: 1) adopted strategies, 2) models for coaching, 3) length of training, and 4) their role of motivation and social stigma. The study poses pertinent questions for implementation barriers and facilitators and includes the role of coaching in producing desirable outcomes for students. Secondly, the role of strategies and its effect on improving the knowledge and skills of service providers is explored. Thirdly, the models that best suit coaching are reviewed for providing essential skills to aid in professional development. Lastly, the study poses questions for the impact of motivations and perceptions provided by service providers and predict its impact on skill development of the facilitators. The study proposes key areas that may help in successful implementation of EBPs for SMH and addresses the concern for availability of numerous principles governing the IS (Owen et al., 2014).

A study was conducted by Langley et al. (2010) to determine factors affecting the successful implementation of an EBP, called the Cognitive Behavioral Intervention for Trauma in Schools (CBITS). Data was obtained via phone interviews with 35 administrators and service providers across the United States. The professionals had received training and were evaluated 6-18 months after receiving their training. While results indicated differences in the process of implementation, the barriers were similar. Those schools that were able to overcome the barriers were identified as having better organizational structure including robust systems to accommodate implementation. The study demonstrated important findings for aiding in successful implementation for EPBs in SMH by facilitation from necessary professionals and peer support.

Synthesis of the Research Findings

It has been identified that genetic and social factors dictate the onset of mental health problems. Many screening tools have been standardized for obtaining relevant information for students enrolled in school. Academic achievement is often adversely affected with increased mental health problems. Additionally, peer pressure also adds to the burden of mental health illnesses. The stigma surrounding mental health is important to identify for appropriate use of resources. It is important for future researchers to understand the complexities surrounding childhood trauma and biological and psychological effects on the affected children.The role of social factors and peer pressures was identified by the labeling theory in order to understand the roles of social factors. It is expected that students who are facing mental health problems report higher in perceived social and peer pressures. Implementation of SMH is essential to ensure the integrity and sustainability of the programs is possible. However, it may not be possible to conduct implementation of EBPs in our research. Gaps have been identified across school mental health service provisions whereby sub-optimal care is being provided. It is expected to find similar results in our research owing to the lack of standard EBPs for schools. Additionally, organizational factors also play a critical role in the continued implementation of competent SMH services across schools.

Critique of Previous Research Methods

Previous research methods often incorporate the use of either qualitative or quantitative study designs. Due to the validation of questionnaires for screening, the use of qualitative study designs are now limited. However, the use of questionnaires presents problems due to the rigidity of the grading system in many circumstances. The results may be skewed due to biases and the lack of prospective cohorts for implementing SMH changes has not been identified yet. The research designs are often cross-sectional with limited data on day-to-day struggles of students in schools. The role of student counselors has not been identified accurately and there are no formal guidelines for determining their roles in schools. The effects of childhood abuse is factored in but it may also be pertinent to review the role of parents in providing emotional and other support to their children.

Summary

Mental health problems have adverse effects on academic achievements in school-going children. Previous literature indicates the association of attention problems, hyperactivity, anxiety and depressive symptoms with lowered scores across standard exams and overall educational attainments. Identification of self-reported symptoms of poor mental health in adolescent girls is indicative of gender-based differences for mental health problems and outcomes. There is also an identified role of social contexts and peer pressures for development and aggravation of mental health disorders. The role of mental health providers in schools is critical for the improvement of internalized and externalized symptoms of mental health. Previous studies have also identified the role of childhood trauma on mental health later in life. Its impacts have been determined on biological changes including epigenetics. The role of social determinants was outlined by many researchers and pose important consequences for the mental health of children, adolescents and young adults.

 

 

CHAPTER 3. METHODOLOGY

Purpose of the Study

The focus of the research is to explore the impact of mental health problems on academic achievement statuses of adolescents in high school in order to obtain a better understanding of the effects of mental health problems. It is essential to demonstrate an understanding of the longevity of clinical and sub-clinical manifestations of mental health problems before they are recognizable by health care providers. Students spend the longest time periods in school and it amounts to over 6 months of time spent at schools. Adolescents enrolled in high school witness an array of emotional and behavioral alterations throughout their days at school, including exploration of self-identity away from caretakers and family members as well as pubertal development. In the case that students are made to feel safe in schools, it is possible that their mental health problems are reduced. This may only be possible with adequately managed school mental health (SMH) systems in educational institutions including high school. The use of academic achievement is the identification of a single effect of mental health problems on factors directly related to the students’ emotional and behavioral health. The chapter outlines how the research will be implemented. It provides information for the research design and implementation process. It also identifies the target population and sample, procedures, and ethical considerations taken before the research is implemented.

Research Questions and Hypotheses

The research questions pose whether mental health problems and their manifestations affect academic outcomes in high-school going children; additionally, the current knowledge and skills available by mental health service providers is also screened to determine the abilities of SMH to aid in the maximally attained educational achievement in these students. The independent variable is academic achievements and the dependent variables are mental health problems and quality of care provided by school mental health service providers. Screening for mental health problems will be possible by administration of the Strengths and Difficulties Questionnaire (SDQ). It will be used and it screens for social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures. The research questions include the following:

  1. Is higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade?
  2. Are improvements in academic performance observed when school mental health service providers are able to provide high quality mental health services to students of high schools?
  3. Does the lack of adequate mental health service providers’ skills and knowledge have adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade?

For the ease of statistical analysis for the research questions, the hypotheses were developed for the research and include:

H1: Higher academic achievements including obtaining a high-school diploma, college education and higher in high-school going children are lowered following the diagnosis of mental health problems in students enrolled in eleventh and twelfth grade.

H2: Improvements in academic performance is observed when school mental health service providers are able to provide high quality mental health services to students of high schools.

H3: Lack of adequate mental health service providers’ skills and knowledge has adverse impacts on academic achievements of high-school going students enrolled in eleventh and twelfth grade.

Target Population and Sample

The aim for the target population is 300 high-school students, taking into account loss to follow up and other contextual factors. Based on the power analysis with confidence interval of 95% an accepted margin of error at 5%, the predicted outcome factor hypothesis was set at 20%. OpenEpi software was used to determine the target sample size and 246 participants was identified as the minimum acceptable sample with estimates of sample size to be 100,000 high-school going children enrolled in schools across California. The student counselors will also be enrolled for understanding their role in academic achievement and tackling mental health problems in the students. In order to obtain the target sample size for the student counselors, OpenEpi software was used again and the sample size estimate is 94. The confidence interval was set at 95% and the calculation took into account a 20% non-response rate. The margin of error was set at 10%. They have the highest exposure with students in a personal capacity in schools and a formal analysis of their knowledge and skills is essential to draw meaningful results. Students who were enrolled in eleventh or twelfth grade were enrolled and were included if they had received mental health services at any time in the two years of high school. Student counselors were included who had exposure to students of respective schools for at least 6 months. In order to ensure that the target sample is obtained, the goal is to maintain the response rate above 80% for both students and the counselors and collaboration with schools before-hand is important to promote better recruitment strategies.

Principals of respective schools across California will be contacted and they will provide information for better implementation and improving response rates to achieve the target sample size. Staff recruited for the research will be selected after screening for their performance and the students’ willingness to participate will also be taken into consideration. While the study design is a series of cross-sectional studies, the data will aim to be diverse by not excluding participation of any gender, race or culture. Students will only be selected based on their enrollment in high-school and their receiving of mental health services in schools. Questionnaires will be self-administered and are an efficient means to obtain data from high-school students. However, the research will use phone-based interviews to complete the questionnaires in order to ensure completeness of obtained data. Additionally, participants may be better able to comprehend components of the questionnaires if they are interviewed by a knowledgeable interviewer. Student counselors will also be interviewed over phone for their skills and knowledge of providing high-quality mental health service provision. Participants will be enrolled voluntary via verbal consent in order to obtain a good rapport between interviewers and the study participants. In order to ensure that there is no breach of confidentiality, the student ID codes on questionnaires will be changed before being entered for data entry and the names will be omitted before entry of data.

Procedures

Study Design

The study is a series of cross-sectional studies using quantitative study design protocols. Students and student counselors will be selected based on their current status as high-school students and affiliation with school for their service provision, respectively. The participants will be enrolled with a request via email and interviews will be conducted once they respond to the emails. The identification of students and their email IDs will be provided by schools enrolled in the research. Schools in California will be identified and their principals will be informed of relevant details for the ongoing research. For ensuring variation, student counselors who have worked with students for longer periods of time will be given preference for enrollment.

Materials and Instruments

Materials to be used for data collection include selection of interviewers and the units of analysis are high-school students and school counselors. Screening of mental health problems will be conducted by telephonic administration of the Strengths and Difficulties Questionnaire (SDQ) by trained interviewers using age-appropriate versions of the questionnaire. The SDQ contains 25 items and it consists of 5 categories with 5 items each. The scores for each item are anywhere between 0 till 2, using the three-band scoring system. The total score is called the total difficulty score and will be categorized, ranging from 0 to 40 total points. It will be used and it screens for social behavioral patterns, emotional symptoms, conduct behavioral problems, over-activity and peer pressures. The categories for results include: 1) abnormal being anywhere between 17 till 40 points, 2) borderline being between 14 till 16 points and 3) normal being any score below and including 13 points.

Enrolled student counselors will be screened for their knowledge and skills using a validated questionnaire to determine their knowledge and practices regarding mental health (Abdulkadir & Abdulkadir, 2017). The questionnaire was developed based on items identified by Anderson et al. in 1980 (Bisi-Onyemaechi et al., 2018). It consists of four key components: 1) demographic information, 2) 8 items for current status of SMH services, 3) 5 items for protocols of SMH services, 4) multiple items identifying factors contributing to school environments and 5) knowledge of SMH. For understanding the current knowledge and practices of the student counselors, the answers for the questions were pre-determined and the recorded answers by mental health providers are identified as either correct or incorrect. For categorizing the knowledge as good, the answers are to be correctly identified across three or more of the identified components, excluding demographical data. Average knowledge is categorized as correct answers for one or two of the identified components. Poor knowledge is categorized as no correct identification across all components of the questionnaire. The time required for data collection is 3 months in order to obtain the target sample size.

Data Collection Process

The data will be obtained in a systematic manner using the following steps. Firstly, the schools located in California will be identified and it will be cross-checked for the presence of SMH service provision in these schools. Next, emails will be sent with relevant information regarding the research in order to obtain written consent from the principals. This will be followed by a request for identification of high school students who are enrolled in eleventh and twelfth grades and who have been to a student counselor at least once in their time at high school. Additionally, their contact information including email IDs and phone numbers will be obtained. They will be sent emails to ensure their consent is taken and they are informed about relevant information of the research. The student counselors will then be identified and their duration of employment and relevant contact details will be obtained. Student counselors who have worked for longer durations will be preferred and any student counselor who has been employed for less than 6 months will be excluded. Once consent is obtained according to the target sample size, interviews will be conducted via phone over the span of three months. The interviews will be conducted for obtaining answers for the relevant sections on the questionnaires. This poses the benefit of ensuring complete information for the questionnaires but is slower to conduct than self-administered questionnaires. Next, the data will be entered in SPSS V.20 in order to conduct the analysis.

Analysis

Data will be entered in SPSS, version 20. The variables will be analyzed and results will be presented using descriptive statistics for variables. Dependent variables include identified variables in the SDQ and questionnaires administered to student psychologists. The independent variable is the academic outcomes for the enrolled students currently in high school. Regression analysis will be used for both dependent variables including: 1) scores of SDQ questionnaires and 2) scores of questionnaires administered to student counselors. The use of Chi-square tests and student’s t-test will be used and the significance will be set at 0.05 in order to determine effects of dependent variables on the independent variable, academic achievement. In order to produce valid results, the data will be entered manually and will be double-checked to look for missing or double-entered data. Reliability of the findings will also be ensured using correct data and obtaining enough study participants as the estimated sample size calculation. In order to provide generalizable results, students of all races, genders, and socioeconomic classes will be enrolled. Additionally, student counselors who have worked with students longer will be assessed instead of those who have been employed for less than 6 months in schools.

Ethical Considerations

The APA Code of Ethics is applicable for the research being conducted. In order to provide ethical clarity in the profession of psychology, the principle of beneficence and nonmaleficence will be applied to protect the confidentiality of students obtaining mental health services from their schools. The principle encourages elimination of biases and any preformed prejudices available on the end of the student counselors. The principle of fidelity and responsibility ensures that the student counselors help maintain the ethical standards across their profession in the high schools. It is essential to eliminate fabricated and false results so as to reduce the effects of any incorrect findings for future researchers. The principle of integrity will be used to ensure that the student counselors are not fabricating scores of their questionnaires or causing distress to students. The principle of justice ensures that students of different races, cultures and genders receive fair and impartial treatment. The respect for people’s rights and dignities will be ensured as data entry will not constitute revealing the identity of the participants and their IDs will be changed before the entry of data. The APA code of ethics will be implemented due to the nature of the study with enrollment of psychologists as study participants.

 

 

 

CHAPTER 4. EXPECTED FINDINGS/RESULTS

It is expected that mental health patterns have impacts on academic achievements in school-going children. There has been evidence to indicate that attention problems and depressive symptoms directly lower the GPAs and overall educational attainments for those students. Previous studies have indicated the increased frequency of self-reported symptoms of poor mental health in adolescent girls. The association between socio-economic factors and poor mental health has been identified and it is likely that gender-based differences for mental health problems may be identified if examined. However, our research does not examine gender-based differences for self-reported symptoms of mental health problems. The training of clinical practitioners working in schools may be improved by adopting relevant strategies, coaching of counselors and exploring the role of social stigma. Previous studies have also identified the role of childhood trauma on mental health later in life. While our research does not conduct any screening for childhood factors, it is important for future researchers to understand the complexities surrounding childhood trauma and biological and psychological effects on the affected children.

The role of social factors and peer pressures was identified by the labeling theory in order to understand the roles of social factors. The determination of social factors is present in our research using the SDQ measures. It is expected that students who are facing mental health problems report higher in perceived social and peer pressures.

Implementation of SMH is essential to ensure the integrity and sustainability of the programs is possible. However, it may not be possible to conduct implementation of EBPs in our research. Gaps have been identified across school mental health service provisions whereby sub-optimal care is being provided. It is expected to find similar results in our research owing to the lack of standard EBPs for schools. Additionally, organizational factors also play a critical role in the continued implementation of competent SMH services across schools. Expected findings support previous literature regarding the role of mental health problems on educational outcomes. The research evaluates a gap in literature by identifying the shortcomings of student counselors’ knowledge and practices. The expected findings are sub-optimal quality of care provided by student counselors having adverse impacts on educational outcomes including the GPAs for enrolled students. It is not possible to monitor study subjects for longer durations but the GPAs will be obtained as parameters of academic achievement.

 

 

CHAPTER 5. DISCUSSION

Implications

Potential results point towards the increased tendency for students with mental health problems to perform lower academically. Potential stakeholders for the research include the students, educational systems, federal and state government, and key members of school administration. Students will face outcomes for the rest of their lives if they are not able to gain adequate educational achievements. The educational system of the country will also be affected due to the potentially increased risk of dropouts in students in college or after high school. The government has a crucial role to play in the current SMH services. Due to limited resources offered by state and federal government policies, it is difficult to successfully implement a sustainable system of mental health service provision across schools. The human development is addressed using a wide array of emotional and behavioral patterns that may have been consolidated during childhood trauma and abuse. Additionally, sociology may benefit from the behavioral aspects of students suffering from mental health problems.

Methodological Strengths and Weaknesses

The research identifies key concerns related to mental health problems across teenagers and presents findings for academic achievement. The use of two questionnaires aims to strengthen findings for future development of approaches. The study screens adolescents that have already received at least one session of mental health service provision. This allows for isolation and selection of concerned study population. Additionally, the enrolled participants are administered surveys due to their ability to comprehend and answer relevant items in the questionnaires. This allows for better reporting of symptom as opposed to parents reporting symptoms for their children. The use of interviewers to fill in the questionnaires also ensures that the study participants are aware of what exactly the questions represent and mean. The weaknesses of the research include the study design and the lack of a standard questionnaire for the student counselors. The study design does not allow for long-term monitoring of data and it may not be possible to screen subjects until they obtain college degrees. The study design allows for screening of participants up until the obtainment of GPAs for the concerned semester to ensure that the study is conducted within 3 months. The lack of available standardized questionnaires for student counselors also presents as a significant weakness for the outcomes and findings of the research.

Suggestions for Future Research

For improving mental health in schools, it is important to realign current policies and practices pertaining to dealing with mental health. Future researchers need to identify the role of expanded school mental health services. The postulation that schools are the most critical places for children and adolescents to develop and overcome mental health problems may be proven true with similar researches being conducted. It is also recommended to screen what factors are preventing or facilitating successful implementation of the health service programs in schools. Studies should focus on organizational factors, sustainability and overall procedures for implementing EBPs across schools. Another important factor to explore further is the role of social stigma in expressing the ongoing clinical manifestations of mental health problems in the students. Without adequate support, these children and adolescents may not be able to express their status of mental health. Additionally, the role of parents and social support systems, especially in schools, need to be evaluated amongst participants who have been identified with significant mental health problems.

References

Abdulkadir, M. B., & Abdulkadir, Z. A. (2017). The survey of head teachers of private schools regarding knowledge and implementation of the school health program in Ilorin. Journal of Clinical Sciences14(3), 126.

Arseneault, L., Bowes, L., & Shakoor, S. (2010). Bullying victimization in youths and mental health problems:‘Much ado about nothing’?. Psychological medicine40(5), 717-729.

Atkins, M. S., Frazier, S. L., Adil, J. A., & Talbott, E. (2003). School-based mental health services in urban communities. In Handbook of school mental health advancing practice and research (pp. 165-178). Springer, Boston, MA.

Bisi‑Onyemaechi, A. I., Akani, N. A., Ikefuna, A. N., Tagbo, B. N., & Chinawa, J. M. (2018). Evaluation of the school environment of public and private schools in Enugu to ensure child health promotion. Nigerian journal of clinical practice21(2), 195-200.

Bor, W., Dean, A. J., Najman, J., & Hayatbakhsh, R. (2014). Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Australian & New Zealand journal of psychiatry48(7), 606-616.

Cummings, T. O., & Worley, P. (2015). Skill Biased Organisational Change? Evidence from British and French Establishments. Quarterly Journal of Economics3(9), 1449-1492.

Durbeej, N., Sörman, K., Selinus, E. N., Lundström, S., Lichtenstein, P., Hellner, C., & Halldner, L. (2019). Trends in childhood and adolescent internalizing symptoms: results from Swedish population based twin cohorts. BMC psychology7(1), 50.

Evans, S. W., Koch, J. R., Brady, C., Meszaros, P., & Sadler, J. (2013). Community and school mental health professionals’ knowledge and use of evidence based substance use prevention programs. Administration and Policy in Mental Health and Mental Health Services Research40(4), 319-330.

Gove, W. R. (1982). The current status of the labeling theory of mental illness. Deviance and mental illness, 273-300.

John-Steiner, V., & Mahn, H. (1996). Sociocultural approaches to learning and development: A Vygotskian framework. Educational psychologist31(3-4), 191-206.

Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., … & Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet378(9801), 1515-1525.

Kramer, T. J., Caldarella, P., Young, K. R., Fischer, L., & Warren, J. S. (2014). Implementing Strong Kids school-wide to reduce internalizing behaviors and increase prosocial behaviors. Education and treatment of children37(4), 659-680.

Kumsta, R., Marzi, S. J., Viana, J., Dempster, E. L., Crawford, B., Rutter, M., … & Sonuga-Barke, E. J. (2016). Severe psychosocial deprivation in early childhood is associated with increased DNA methylation across a region spanning the transcription start site of CYP2E1. Translational psychiatry6(6), e830.

Langley, A. K., Nadeem, E., Kataoka, S. H., Stein, B. D., & Jaycox, L. H. (2010). Evidence-

based mental health programs in schools: Barriers and facilitators of successful implementation. School mental health2(3), 105-113.

Marques, S. C., Pais-Ribeiro, J. L., & Lopez, S. J. (2011). The role of positive psychology

constructs in predicting mental health and academic achievement in children and adolescents: A two-year longitudinal study. Journal of Happiness Studies12(6), 1049-1062.

Matusov, E., & Hayes, R. (2000). Sociocultural critique of Piaget and Vygotsky. New Ideas in

Psychology18(2-3), 215-239.

 McLeod, J. D., Uemura, R., & Rohrman, S. (2012). Adolescent mental health, behavior

problems, and academic achievement. Journal of health and social behavior53(4), 482-497.

Mowbray, C. T., Bybee, D., Oyserman, D., Allen-Meares, P., MacFarlane, P., & Hart-Johnson,

  1. (2004). Diversity of outcomes among adolescent children of mothers with mental illness. Journal of emotional and behavioral disorders12(4), 206-221.

New Freedom Commission on Mental Health. (2003, April). Retrieved October 26, 2019 from

http://www.mentalhealthcommission.gov/mission.html

Owens, J. S., Lyon, A. R., Brandt, N. E., Warner, C. M., Nadeem, E., Spiel, C., & Wagner, M. (2014). Implementation science in school mental health: Key constructs in a developing research agenda. School mental health6(2), 99-111.

Puddy, R., Roberts, M., Vernberg, E. M., & Hambrick, E. P. (2012). Service

Coordination and Children’s Functioning in a School-Based Intensive Mental Health Program. Journal of Child and Family Studies , 21 (6), 948-962.

Slade, T., Johnston, A., Oakley Browne, M. A., Andrews, G., & Whiteford, H. (2009). 2007

National Survey of Mental Health and Wellbeing: methods and key findings. Australian and New Zealand Journal of Psychiatry43(7), 594-605.

  1. S. Department of Education. (2010, March). ESEA Blueprint for Reform. In A Blueprint for Reform (Office of Planning, Evaluation and Policy Development, pp. 1-33).

Young, T. & Murray, R. (2004, June). American academy of pediatrics policy statement: Organizational principles to guide and define the child health care system and/or improve the health of all children (Vol. 13). Retrieved November 3, 2010 from American Academy of Pediatrics Committee on School Health: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;113/6/1839.pdf

Survivance and sovereignty on turtle island: Engaging with Contemporary Native American Art

Survivance and sovereignty on turtle island: Engaging with Contemporary Native American Art

The “Survivance and sovereignty on Turtle Island” is an exhibition show that is on view at the Kupferberg Holocaust Center (KHC). The exhibition aims at addressing the histories and the current realities of the first people of America, using contemporary art. The Anishinabek and the Lenape are some of the indigenous North American tribes, who named the region “Turtle Island.” The name originated from the Lenape creation story, which elaborates on how the world was created on the back of a turtle. The exhibition tells the story of the survival and sovereignty of the indigenous people who lived on Turtle Island. These tribes faced significant challenges, which include genocides and mass atrocities for centuries, and it is only through detailed artwork that contemporary society can understand these challenges.

The organizing principle and thesis of the show are to educate the masses on the issues faced by the indigenous people and how they overcame these challenges and still managed to preserve their culture. Moreover, the show focused on showcasing the rich indigenous culture, which most people have forgotten or do not think that it exists. Through the 16 pieces of art featured in the exhibition, one gets to reflect on the first people’s culture, understand aspects that were of importance to them, and how the cultures have evolved.

The indigenous people suffered from instances of genocide for over a hundred years. This genocide did not only occur physically, but it was also enforced culturally. The first people were brought together by their culture, and they cherished it, even in times when they were forced by their colonizers to abandon them. Through contemporary art in the exhibition, such as a piece of art by Nadema Agard, one understands how influential culture and heritage is to the indigenous people. The artwork, called Wampum Moon of Change includes words in the Munsee dialect, which was mainly spoken by the Lenape people, and original New Yorkers still speak some of its words. Language was an essential element of culture for the indigenous people as it provided a sense of belonging. Other than the inclusion of language in the painting, the purple and white color palettes used in the artwork are based on the wampum. The wampum was made from the shell of a clam (Quahog) and was valued by the people as it was used as a form of currency. It was also used as a form of adornment, and as a form of transportation to the spiritual world, aspects that are still present in Lenape and Algonquin countries. Through this piece of work, the survival of the culture of Turtle Island is showcased, where it was not only present in the previous generations, but it still is practiced by the current generation.

The exhibition further elaborates on the cultural survival and resistance of the indigenous people through the artwork of Mario Martinez. Martinez, through Brooklynscape #3 showcases how the indigenous people came to accept and integrate the western culture in their culture. The painting is a combination of colors and aspects of both the native and western cultures. Martinez combines elements from his pre-Christian Yaqui beliefs, aspects in the natural world, and activities currently ongoing in his life in Brooklyn. Through the painting, the survival of the indigenous people’s culture and the importance of western culture in preserving this native culture is demonstrated. Even though the two cultures differed significantly centuries ago with mass atrocities being committed, modern society has allowed them to bond. The piece of work further addresses the present realities of the first people, where most of them do not currently live in North America but have diversified to other cities. For instance, Martinez is from the Pascua Yaqui tribe that initially resided in Mexico, but he has however lived in the US for the most prolonged period. Through his artwork, one can understand how the culture of the indigenous people has traveled and is being accepted in different regions.

I became aware of variety of aspects of the first people’s culture and experiences from the exhibition. For instance, I learned of how elements such as the moon, clamshells, beans, windmills, and tobacco meant a lot to these people. They symbolized an essential aspect of their culture. Moreover, from the exhibition, I learned that even though there were a variety of tribes, they had a united culture. The exhibition further educated me on the ability to use contemporary art to teach indigenous cultures. These cultures are complex to understand and comprehend, but with the use of modern art, they are easily understandable.

In conclusion, the exhibition show was not only interesting but also informative. I would recommend any individual interested to learn about the indigenous cultures to attend the exhibition before it finally closes on May 2020. The exhibition provides an opportunity to reflect and learn about the first people’s cultures and experiences.

Race Discussion 2 Name Institution   Race Discussion 2 Discussion 1: Key legislation that has influenced the rights and provisions offered to the physically and mentally challenged individuals (459 words) Particular significant statutes safeguard privileges for physically challenged individuals. Usually, parents who have children with disabilities are supposed to engage in learning of laws that protect the rights of people with disabilities. The American constitution provides rules and regulations that safeguard the privileges of the people with disability. Even though human rights are protected under various laws, three distinct pieces of legislation are precisely applied to people with disabilities (Hanser, & Gomila, 2014). The statutes comprise of Americans with disability act, people with disability education act, and the rehabilitation act. The rehabilitation act mainly addresses the privileges of people with disabilities. The rehabilitation laws prohibit illegal programs that receive financial aid to discriminate individuals based on disability. The rehabilitation act defines individuals with a disability as persons who have a mental or physical impairment that interfere with a person’s major life activities. Such complications comprise of impaired speaking, walking, seeing, and hearing (Kayess, & French, 2008). Additionally, people with disabilities are entitled to an appropriate education. The law provides that parents of children with a disability be supposed to be updated about the school progress of their children. Individuals with disability law provide that physically challenged students of age up to twenty-one years be entitled to special education alongside other associated provisions. Disabilities that necessitate children with disability with these provisions comprise of hearing or vision impairment and cerebral palsy. Moreover, low offers that learners with disabilities are privileged to funding that aids educational agencies and nations to meet the needs of physically challenged children. Americans with disabilities law prohibit any form of discrimination against individuals with a disability in several different settings. The Americans with disabilities act comprise of reasonable accommodation that must be offered to workers and students who have a disability. The accommodations may entail the provision of written communication in substitute formats, modifying examinations, and redesigning equipment. The ADA is limited to private schools as opposed to religious organizations or schools. Therefore, to summarize the federal statute dictates that there is no form of disability-inclusive of physical disability, learning disability of mental complications should limit a child from receiving equal and fair entitlement to education. All sorts of disabilities act as barriers to education, but the federal laws advocate for equal and equitable access to education regardless of the effects of the current limitations. Federal regulations ensure people with disabilities have equal access to education through the provision of special accommodations to such students free of charge. The American laws ensure the establishment of disability resource centers and offices, an aspect that enables students with disabilities to know where they can get the accommodation they require. Discussion 2: Compare and Contrast the Static-99 and the SVR-20` (458 words) The static-99 report is a risk examination tool offered in the penal code (Bartol & Bartol, 2017). Generally, it is documented in one to two pages concerning particular male offenders. The main aim of the static-99 report is to examine the perpetrator’s hazard to the community. The story is usually used alongside the registerable sex offense section of the penal code. The story is different from a probation officer’s report or pre-plea report that is present in most felony matters. The demand for the story is determined by several factors like the purpose and the person requesting it. Having this information aids the defense lawyer to have basements of negotiating for a favorable plea for the client. On the other hand, SRV-20 is an examination tool that is applied in both civil and criminal forensic contexts concerning sexual violence-related crimes. The device is used in determining how often an offender has earlier committed sexual violence. The sexual risk examination from SRV-20 is mainly focused on statistical information, but it is limited to the future commitment of a crime. The instrument also covers other elements like frequency of eminence and the victim harm. Both the SRV-20 device and the static-99 report entail an examination of sexual offenses. I believe that the static-99 story is the most appropriate tool because it examines the potential harm of the offender when released back to society. In the year 199, two high school students, Eric Harris and Dylan Klebold, conducted an all-out assault within the middle of the day in Littleton, located in Colorado. The juveniles had planned to kill their peers with the use of a multitude of bombs, knives, and guns. After the massacre, two murderers, one teacher, and twelve students were left dead. Additionally, other twenty-one students were left injured. The sensible choice approach affirms that people apply analytical choice calculations to achieve outcomes and make intelligent choices that rhyme with their personal goals. Findings from the rational choice theory are directly linked with the person’s self-interests. The application of sound choice theory is suggested to yield results that offer individuals with the most excellent satisfaction from the available choices (Clarke, & Felson, 2017). Most mainstream economic theories and assumptions are founded on rational choice theory. The balanced choice approach is linked with the ideas of the rational actors, the invisible hand, self-interest, and the rationality assumption. Sound choice theory suggests that people are rational actors who apply profound knowledge to maximize their merits from a particular situation as they strain to minimize the loses. After the sensible choice actor discovers that the advantages outweigh the disadvantages, the perpetrator is likely to commit that particular crime. Discussion 3 (200 words) The self-interest element of rational choice states that individuals are likely to commit activities that fulfill their particular interests. Moreover, people tend to outweigh the advantages and disadvantages to determine the conceivable reward from one specific act. In the case columbine massacre, the two boys, Klebold and Harris, for a long time they kept on thinking about committing suicide, an aspect that influenced them in planning for the massacre. The boys planned for the killing for one year before they committed the crime. Therefore, it implies that the two were restricted to applying rational choice in their planning. Earlier before the mass killing both, Harris and Klebold were involved in a crime where they broke into a van, although they were arrested. Since the two boys had earlier committed crimes, it implies that they knew to evaluate the reward of a crime. Concerning the element of self-interest, reports about the columbine massacre affirmed that both Harris and Klebold conducted the killings under the influence of hate. The two boys grew up as aggressive teenagers. Klebold and Harris gathered adequate information concerning the recipes for pipe bombs alongside other explosives. Therefore, the massacre was set a satisfaction for their interests.   References Bartol, C. R., & Bartol, A. M. (2017). Introduction to forensic psychology: Research and application. Sage Publications. Clarke, R. V., & Felson, M. (2017). Introduction: Criminology, routine activity, and rational choice. In Routine activity and logical choice (pp. 1-14). Routledge. Hanser, R. D., & Gomila, M. D. (2014). Multiculturalism and the criminal justice system. Pearson Higher Ed. Kayess, R., & French, P. (2008). Out of darkness into light? Introducing the Convention on the Rights of Persons with Disabilities. Human rights law review, 8(1), 1-34.

prescribing and assessing for a asthmatic patient at gp practice

 

 

 

 

 

PRESCRIBING AND ASSESSING FOR ASTHMATIC PATIENT AT GP PRACTICE

 

 

Name

 

 

 

Course

Professor’s Name

Institution

City/State

Date

 

 

 

Prescribing and Assessing For Asthmatic Adult at GP Practice

 

Background Information

Paige J is a joyous mother of three. She is from the Hispanic ethnic group who works as a receptionist at a five-star hotel. Paige J has a huge passion for cats, and she was diagnosed with asthma in the last five years.

Paige J claims that what triggers her Asthma is the exposure to dust, pollen, and animals like dogs and cats, which she likes spending time with when at home. When Paige spends some minutes or hours with her cat, for example, she ends up waking up at the night hours with terrible Asthma and tightness of the chest. She does not talk during asthma attacks because talking makes her struggle a lot. She uses mostly her rescue inhaler, and just in case she does not have it, she tries to get some fresh air or drink some chocolate. She also has prescribed medicine, which she uses in case of an attack. Her attacks happen during the night. Paige denies being a smoker. Her asthma is classified as mild persisted, where the symptoms can reveal themselves twice in a week, but not more than one is a day. Paige J has been referred to me as a general practitioner because I have a good past medical history of treating patients with asthma.

Past Medical history

Paige J Asthma manifested itself in the last five years. She has been using an inhaler in case of attacks. Most of her attacks happen during the night.  She has been using inhaled corticosteroids (Qnasi, Qvar). She also medicated with long-acting beta-agonists serevent. She has never used allergy medications

Subjective Information

Wheezing-high pitched whistling sound when breathing out, airway obstruction syndrome, she experienced panic fear, and she had fatigue signs. After an asthma attack, she is not able to work the following day and do her daily chores. She cannot do tasks that her demanding, and she has added significant weight.

Paige J complains that she has been to many health Centres, and she has not got any significant help, which has increased her psychological problems like stress, anxiety with some point of depression. Paige J also complains that the medication, which she has been using (with long-acting beta-agonists Serevent), has not helped despite spending large amounts on the drugs.

Objective Information

More tests were needed to measure Paige lung function to find out how air moved in and out during breathing. The spirometry test was 69%. The normal range should be more than 80% Paige reacted to methacholine in the first lung function test. The nitric oxide test indicated 50 parts per billion. A normal range should be 25-30 parts per billion. Sputum eosinophils were at 5%. The normal range should be 3%.  From observation, she had hives and itchy skin. Her skin was a bit swollen. From the result, Paige had mild intermittent asthma.

Assessment – Medicines Optimization

The drug-related problems (DRPs) identified in this case were:

  1. The Qvar inhaled corticosteroids made Paige have stomach upsets, stuffy nose, sore throat nausea at some times. The long-acting beta-agonists (Serevent) have little impact on Paige.
  2. There was a need to pre-describe both Qvar inhaled corticosteroids and the long-acting beta-agonists (Serevent).

Change of medicine was needed and the immediate start of allergic medication. I prescribed her Ipratropium (Atrovent) medicine, which acts quickly to immediately relax airways and make it easier to breathe. For long-term medication, I prescribe Paige J the flunisolide inhaled corticosteroids, which have reduced the risk of side effects when used for a very long time. For her allergy medication, I prescribed her allergy shots immunotherapy,  which is very best in reducing the immune system reaction to dust, cats and pollen allergens. The only side effect of allergy shots is swelling at the point of injection. The allergy shots are outstanding in treating allergies, and they consequently prevent the development of new allergies. Paige J had no problems adhering to the medication instructions. The previous medication had been inappropriately prescribed to Paige since it was not helping her.  This was because Qvar inhaled corticosteroids, and Serevent long-acting beta-agonists both solve a similar problem and used together; the result interaction can lead to reduced absorption of either the drugs.

Appraisal

Ipratropium (Atrovent) medicine

Henderson (2017) does a research on 66 asthmatic patients indicated that Ipratropium bromide Atrovent had pharmacology effects leading to a high degree of activity and a specific bronchoselectivity if administered intravenously. Evidence indicates that it is the best for routine administration with small doses, which lead to the opening of airways without resulting in anticholinergic side effects. The pharmacology properties of this drug are that it “blocks the muscarinic cholinergic receptor in the smooth muscles of the bronchi in the lungs.”  This medicine would work for Paige to improve her lung function, which had a Spirometry test which very low than normal. Patients with other co-morbidities like diabetes can use this medication.

Flunisolide inhaled corticosteroids

Evidence indicates that flunisolide is very useful in preventing, controlling asthma symptoms especially the wheezing, and the shortness of breath, which results from asthma (Choby & Lee, 2015). The drug works closely with lungs making breathing easier. “American Academy of Allergy Asthma & Immunology” (AAAAI) has a set guide for the use of this drug. The pharmacological properties of Flunisolide are that it undergoes very quick and intensive first-pass metabolism (Watts et al. 2019).

Allergy shots immunotherapy

Evidence-based studies indicate that allergy shots were effective for treating all year round and indoor allergies (Schroer & Aalberse, 2018). AAAAI has set out the guidelines used for this medication.

Plan

I recommended Paige to stop using her previous medication immediately once she begins using the new prescribed drugs. I also recommend that she should have more air conditioners in her house. I also recommended that she should avoid her cat even though she has a huge passion for cats. The change in asthma symptoms has to monitor closely in the first month and medicine adherence. I agreed with Paige J to have weekly visits at her home as one way to follow up. Phone calls would also be used to determine her progress.

Paige was happy with this treatment plan, especially the idea of treating her allergic conditions, which she never thought was a significant issue that needed medication. This treatment plan was much more than she expected. I kept Paige’s medical chart for a future treatment plan. We agreed that she should call me whenever she had any questions or issue regarding her asthmatic condition. Paige did not have team-based care since she did not have comorbidities related to her asthma.

 

 

Reference List

Choby, G. W., & Lee, S., 2015. Pharmacotherapy for the treatment of asthma: current treatment options and future directions. In International forum of allergy & rhinology (Vol. 5, No. S1, pp. S35-S40).

Henderson, L. 2017. Prehospital use of ipratropium bromide paired with salbutamol as treatment for shortness of breath. [Online] https://emspep.cdha.nshealth.ca/ProtocolImages/LHenderson%20CAT.pdf. Accessed 28 October 2019

Schroer, B. and Aalberse, R.C., 2018. Clinical Allergy at the Interface of Sticky Dust Particles and Crystal-Clear Proteins. The Journal of Allergy and Clinical Immunology: In Practice6(6), pp.1866-1868.

prescribing and assessing for a asthmatic patient at gp practice

 

 

 

 

 

PRESCRIBING AND ASSESSING FOR ASTHMATIC CHILD AT GP PRACTICE

 

 

Student’s Name

 

 

 

Course

Professor’s Name

Institution

State/Course

Date

 

 

 

 

 

Prescribing and Assessing For Asthmatic Child at GP Practice

Background Information

Biodata

Name: James Smith

Age: 5 ½ years

Sex: Male

Ethnicity: Black African

Residence: St. Louis Missouri

Next of Kin: Mary Smith

Relationship with next of kin: Mother

Next of kin cellphone: 0723310923

Subjective Information

Presenting Complains

The patient presented with difficulty in breathing, wheezing, sweating, and lethargy, which had begun in the morning (5 hours before seeking care).

History of Presenting Complain

The patient was well until the morning when he developed the above complaints. He woke up and took breakfast, which comprised an egg, banana and white tea.  Later he visited construction site for a residence the family is building.  He visited the stores to pick a material for one of the construction workers.  After approximately 30 minutes, he returned to the house to bath since they had planned a trip to visit his father at work.  The developed labored breathing on the way out, but her mother opted to continue with the journey and visit a hospital later. However, wheezing worsened, she had to stop the journey and seek a nearby hospital.

Past Medical-Surgical History

The patient has had one episode of asthmatic attack at the age of 2 years, but it resolved within a year of medication. No other chronic illness or allergy has been noted. He has never been operated.

Social History

He is a third born in a family of five. He is in grade KG. His performance in school is impressive; he is playful and active class representative.  He lives with his mother. The other siblings are in boarding schools.

Objective Information

Observation of Vital Signs

Temperature: 37.4Oc (36.2 Oc -37.2 Oc, Pulse rate 83 beats/min (60-110, Respiratory rate 30(20-40) beats/min, Blood pressure 127/67 mmHg.

Focused Assessment

Generally, the patient was ambulating, conscious but strained to walk fast. No abnormalities were noted on the skin. The head and neck showed nothing significant. However, there was labored breathing. Auscultation of the chest showed wheezing on expiration. The abdominal muscles were involved in expiration of air.  Extremities were normal, although there was a tinge of cyanosis on the lower extremities.  Oxygen saturation on the upper extremities was averagely 89.0C.

Diagnosis

The history presented as well as physical assessment findings were indicative of respiratory tract problems associated with narrowing of airways.  Such conditions included Asthma, pneumonia, and bronchiolitis.  Additional tests were conducted to include an X-ray to rule out pneumonia. The test was negative for pneumonia. Exhaled Nitric Oxide test shows 23 parts per billion confirming inflammation of the airway. The acute nature of the condition leads to a conclusion of Asthmatic Attack diagnosis.

Pathophysiology

An asthmatic attack occurs when an allergen activates inflammatory response in the body thus causing inflammation, swelling and accumulation of fluid along the airways. The airways are narrowed by the accumulated fluid and inflammation, necessitating forceful breathing out (expiration), which ought to be effortless in normal circumstances.  This impairs gaseous exchange at the alveoli leading to reduced oxygen saturation in blood and tissues, which is responsible for myalgia and lethargy. If no intervention is done, asthma associated inflammation leads to loss of lung function with time leading to development of comorbidities such as Congestive Pulmonary Disease and bronchiectasis.  Public health considerations involve removal of allergens from the environment to minimize risks of Asthmatic attack (Holgate, 2011; Morris, 2019).

Assessment

The identified problem was that the patient was not fully informed asthmatic attacks could re-occur in the future. This was the second time the patient was treated for Asthma.  One of the critical approaches to management of Asthma is avoidance of the allergen. But the patient, in this case, believed they were healed and never anticipated another episode of attack would occur with another exposure.  A visit to the construction store, which often is dusty and houses cement among other items was the potential source of the allergen that leads to development of Asthma.  Besides, there was inappropriate prescribing and monitoring of patients. Patients diagnosed with Asthma are required to keep inhaler medications and to be conversant with asthma symptoms. This is meant to ensure they can assess emergency care wherever the condition happens.  In this case, they lacked the expertise as well as the drugs to manage the situation at home.

Option Appraisal

Evidence

Guidelines for the management of Asthma require a systematic approach to ensure quality care and effective management. The first approach is correct diagnosis of Asthma patients and identification of allergens.  The second step is management of the acute phase with medications that reduce inflammation of the airway as well as reduce secretions on the airway. The third step is education of the patient to improve their knowledge on the causes, pathophysiology, management, and prevention of Asthma.  Lastly is removal of the allergen and educating the patient on identification and avoidance of the allergen (Global Initiative for Asthma, 2019; Morris, 2019).

Concordance

The development of concordance relationship with the client begins on clear education of the problem they are suffering from and developing an open connection on the nature of the condition and how it can be managed and/or prevented. Besides, establishing an agreement for regular clinic visits to provide follow up and encourage regular discussion would improve the relationship. I will promote self-care by educating the client to have an inhaler medication in the house for use during such episodes. Besides, I will share hospital contact information to enable client seek help from home by way of phone consultation.

Pharmacoeconomics

There are no cheaper drugs for managing Asthma. However, it is necessary to ensure the child has an insurance cover. Secondly, prevention of allergen is the best approach to minimize costs associated with Asthma attack. Moreover, self-medication with inhaler medications can reduce hospital consultation costs

Clinical Governance

Quality management of Asthma requires identification of the allergen, treatment of attacks, and development of approaches to enable the client avoid allergens. This ought to have been emphasized. Besides, self-treatment is necessary in this case because asthmatic attacks can occur anywhere, anytime (Global Initiative for Asthma, 2019).

Legal Aspects

The legal aspects involved in the case was the treatment of a minor. Besides, inhaler drugs were prescribed for use at home. The drug would be administered by the patient’s guardian.

Ethical Aspects

Ethical aspects included respecting the patient’s right to full information regarding their treatment and condition.  In this case, educating the patient to prevent future attacks was a vital component of the care. It would improve wellbeing of the patient and reduce healthcare costs for the patient.

Plan

Recommendations

I recommend that the management of Asthmatic patients to be broadened to include more education on prevention of non-allergens. I recommend that Asthmatic patients should be allowed to consult from their homes to manage acute episodes because transfer to hospital consumes more time.  The patient follows up after the first episode of attack is necessary. A bi-annual visit to the clinic, even in the absence of asthma signs and symptoms is essential to allow evaluation of client progress and knowledge of the condition.

Communication

We agreed with the client to continue with a follow-up clinic the following week.  I kept records of the history and physical assessment that was done, cardex and a clinic appointment copy.  Moreover, records of the treatment sheet and prescribed drugs were kept. To ensure seamless communication with the previous hospital, the patient was given a discharge summary to indicate what was done in our hospital. This would provide if he visits the next hospital, there would be clarity on what was done in another hospital. Besides, the patient was encouraged to bring discharge summary from the other hospital in the follow-up clinic.

 

 

References List

Global Initiative for Asthma, 2019. Global strategy for asthma management and prevention. [Online] URL https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf. Accessed 27 October 2019.

Holgate, S.T., 2011. Pathophysiology of asthma: What has our current understanding taught us about new therapeutic approaches? Journal of Allergy and Clinical Immunology 128, 495–505. https://doi.org/10.1016/j.jaci.2011.06.052

Morris, M.J., 2019. Asthma guidelines: Guidelines Summary, classification guidelines, management guidelines. Medscape. [Online] https://emedicine.medscape.com/article/296301-guidelines. Accessed 27 October 2019.