School Teachers’ Knowledge and Attitude towards Mental Disorders among School-going Children: A Cross-sectional Study

1. MBBS Final Year Student, Karwar Institute of Medical Sciences, Karwar, Karnataka, India. 2. Associate Professor, Department of Psychiatry, Karwar Institute of Medical Sciences, Karwar, Karnataka, India.

Abstract

Introduction: Mental disorders in children can present with non specific behavioural issues, like irritability and procrastination. These issues are often neglected, which can negatively affect academic performance and overall development. Teachers hold a unique position to promote mental health and facilitate early identification of mental disorders, leading to timely referrals for early intervention.

Aim: To examine the knowledge and attitude of school teachers towards mental disorders in school-going children.

Materials and Methods: A cross-sectional study was conducted in Karwar city over a period of two months (July and August 2019) at the Karwar Institute of Medical Sciences, Karnataka, India. A total of 121 primary and high school teachers from 11 schools participated in the study. Purposive sampling was used, as all schools in Karwar city were approached for the study. A self-designed questionnaire consisting of 20 questions (10 questions on knowledge and 10 questions on attitude towards children with mental disorders) was used. Descriptive statistics, such as percentages, were used for data analysis.

Results: The study revealed that teachers had moderate knowledge about child mental disorders. However, there was a lack of awareness about the treatment and care of such children. Sixty-three (52.07%) teachers believed that mental disorders result from incorrect thinking. Seventy-nine (65.29%) teachers were of the opinion that sleeping pills are not the only available treatment. Attitude towards children with mental disorders were both positive and negative. 82 (67.77%) teachers believed such children to be less intelligent, while 76 (62.81%) teachers did not believe mentally ill children indulge in violence. Many teachers were aware that these children can be vulnerable to bullying and discrimination by their peers.

Conclusion: The study concluded that there is moderate knowledge and mixed attitude among school teachers regarding mental disorders in school-going children. This highlights the need for proper training programs that can aid in early identification, timely referrals for mental health evaluation, and the promotion of child mental health.

Academic performance, Evaluation, Mental illness, Treatment

Childhood and adolescence are crucial age groups for learning, personality development, and social skill development. However, they are also vulnerable periods when factors like physical illness or mental illness can have long-lasting consequences on learning and development. Mental illnesses are often neglected, and symptoms are attributed to laziness or indiscipline. The common mental disorders seen in children and adolescents are developmental problems like mental retardation and autism spectrum disorders, disruptive disorders including oppositional defiant disorder and conduct disorder, Attention Deficit Hyperactivity Disorder (ADHD), depressive disorders, anxiety disorders, and eating disorders (1). These disorders often present with non specific behavioural and emotional symptoms like withdrawn behaviour, irritability, procrastination, declining academic performance, and school refusal. The prevalence of mental disorders in children and adolescents is estimated to be 10-20%, as per World Health Organisation (WHO) (2). Such children often face bullying, stigma, isolation, discrimination by their peers, and sometimes even by teachers (3).

School-going children spend a significant portion of their time in schools interacting with peers and teachers (4). Thus, teachers are in a unique position to identify and help children with behavioural problems (5),(6). In many cases, they are the first ones to recognise such conditions in an affected student (7),(8). Teachers can also educate parents of such children and guide them. However, a glaring lack of awareness about mental disorders among teachers is a major limiting factor in this regard (9). If awareness is created among school teachers, they can serve as a crucial link in identifying children with mental disorders, spreading awareness about mental health, and reducing stigma, bullying, and discrimination.

There is a paucity of child mental health services in India, leading to poor care for children with mental disorders (10). Additionally, there is a lack of psychologists and counselors in schools where mental disorders can be identified early. Hence, the role of teachers becomes even more important. According to the WHO, mental disorders are the single most common cause of disability in young children and adolescents (2). This makes this age group a critical period in which mental health can be promoted and mental disorders can be addressed. If left untreated, mental disorders can impede all aspects of health, including emotional well-being, social and personality development. Addressing these problems early in life can lead to improvements in social and behavioural adjustment, learning outcomes, and school performance.

This study aimed to assess the knowledge of child mental disorders among school teachers. The objective was to understand the attitude of teachers towards children with mental disorders, as negative attitude can lead to discrimination and poor outcomes. This information can help in formulating effective school mental health programs.

Material and Methods

This cross-sectional study was conducted at Karwar Institute of Medical Sciences, Karwar, Karnataka, India, between July and August 2019. The study received approval from the Institutional Ethics Committee (IEC) (Reference number-IEC/KRIMS/O/05/2018). Written informed consent was obtained from all participating teachers.

Inclusion criteria: School teachers from primary and high schools in Karwar city and teachers who agreed to participate were included in the study.

Exclusion criteria: Teachers from schools that declined to participate or did not provide consent were excluded from the study.

Sampling method: Purposive sampling was used, approaching all school teachers in Karwar city for the study.

Sample size calculation: A total of 121 teachers were included in the study through complete enumeration, which means all teachers who satisfied the inclusion and exclusion criteria were included in the study.

Study Procedure

Data was collected using a self-designed questionnaire in English and Kannada, comprising 20 questions about knowledge and attitude towards mental disorders in school-going children. The questionnaire was developed based on prevailing social and cultural attitudes and existing research (11),(12). It comprised of two parts: Part A with 10 questions for knowledge assessment and Part B with 10 questions to assess attitude towards children with mental disorders.

To test the reliability of the questionnaire, a pilot study was conducted with 30 responses. The calculated Cronbach’s Alpha value was 0.718, which was considered acceptable. Each question was scored on a 5-point Likert scale ranging from strongly agree, agree, don’t know, disagree, to strongly disagree. After data collection, response categories were combined to simplify the results. The percentage of respondents reporting agreement includes both “agree” and “strongly agree” responses, while the percentage reporting disagreement includes both “disagree” and “strongly disagree” responses. A total of 121 teachers from 11 schools agreed to participate in the study. The purpose and methodology were explained to them, and confidentiality was assured. Any questions about the study raised by the teachers were addressed. The responses were collected and taken to the parent institute for further analysis.

Statistical Analysis

After complete data collection, a master chart was prepared, and descriptive statistics, such as percentages, were used to categorise the data.

Results

Out of the 13 schools approached, two schools declined to participate in the study. One school cited a busy schedule, while the other felt it served no useful purpose. Among the remaining 11 schools, only 121 out of 160 teachers consented to participate in the study, while the remaining 39 did not consent.

Responses to knowledge items are summarised in (Table/Fig 1). The results showed that 114 teachers (94.21%) were knowledgeable about the fact that mental disorders can occur at any age, and 107 teachers (88.43%) responded positively that mental health services should be sought for persistent behavioural problems in children. Twenty-eight teachers (23.14%) believed that mental disorders do not affect academic performance. Ten teachers (8.27%) believed there is no treatment for mental disorders in children, eight teachers (6.61%) did not know, and the remaining teachers were aware that treatment was available. Twenty-seven teachers (22.31%) believed children with mental disorders have low chances of recovery, 15 teachers (12.4%) did not know about the prognosis, and 79 teachers (65.29%) did not agree that all children with mental disorders had low recovery chances. Ninety-three teachers (76.86%) were aware that mental disorders in children can occur due to stressful life events, while 12 teachers (9.92%) were not aware of this fact. About 88 teachers (72.73%) were aware that not all mental disorders in children are due to external stressors. About 63 (52.07%) teachers attributed mental disorders in children to incorrect thinking, while 25 teachers (20.66%) did not know whether incorrect thinking contributed to mental disorders. Thirty-three teachers (27.27%) were aware that incorrect thinking patterns are not the cause of all mental disorders in children. Seventy-nine teachers (65.29%) were of the opinion that sleeping pills are not the only treatment available for mental disorders. Ninety-six teachers (79.34%) were aware that not all mental disorders in children are inherited.

Responses to attitude items are summarised in (Table/Fig 2). The results revealed that teachers had both positive and negative attitudes towards children with mental disorders. About 28 teachers (23.14%) believed that children with mental disorders are violent, while 76 (62.81%) disagreed. Eighty-two teachers (67.77%) believed that children with mental disorders are not as smart as other children. Fourteen teachers (11.57%) believed that children have mental disorders because of their upbringing. Seventy-eight teachers (64.46%) disagreed that such children are mentally weak and should be blamed for their condition. The majority of the teachers, 101 (83.47%), were of the opinion that such children should not be discouraged from attending school. Eighty-nine teachers (73.55%) had no problem in dealing with parents of children with mental disorders. Forty-four teachers (36.36%) were not aware that other children tend to discriminate against children with mental disorders. Seventy teachers (57.85%) were of the opinion that it would be difficult for them if they had a child with a mental disorder. Ninety-four teachers (77.68%) had no problem with their children having friends with mental disorders. Ninety-seven teachers (80.16%) responded positively that the management of children with mental disorders was not a waste of time and resources.

Discussion

Childhood and adolescence are periods characterised by rapid development not only in the physical domain but also emotionally and cognitively. Most people go through this period without significant mental health problems, but almost everyone experiences some emotional distress. Approximately one in five children display signs of poor mental health and meet the criteria for a mental illness at any given time (13). About half of all mental illnesses begin in childhood and adolescence. Schools provide a great opportunity to identify and support children who are experiencing emotional difficulties and promote overall emotional well-being, social development, and moral development. School experiences are important for both intellectual development and psychological well-being, and the close connection between emotional health and academic achievement, hence, schools enhance school achievement by attending to issues such as self-esteem and social well-being (14),(15). Strengthening student protective factors and resilience within schools reduces negative risks and outcomes for vulnerable children. Promoting school mental health helps decrease violence and juvenile crime.

Children spend a significant amount of time in schools and face various challenges in academics, social interactions, sports, and extracurricular activities. Psychological problems make it difficult for children to cope with these challenges. Teachers have a significant responsibility for educating their students, and working with children who have mental health problems can be both rewarding and challenging. Often, it is the teachers who identify behavioural problems in children. However, due to a lack of awareness about the nature of mental disorders, children are subjected to punishments and are often put down in front of their peers. This further worsens psychological problems, leads to bullying, discrimination, and isolation. Learning about school mental health will help teachers and not just be one more thing to do.

Many teachers express the need for assistance in promoting well-being within the classrooms and in recognising and aiding students facing mental health issues. When teachers feel more capable of supporting students’ mental health, it becomes simpler for them to handle challenging classroom behaviour and facilitate students’ academic achievements. If teachers are knowledgeable about mental disorders in children and adolescents, they can play a key role in identifying and guiding children with mental disorders. Previous research done in this field has revealed that teachers often lack adequate knowledge about ADHD, specific learning disorders, and autism spectrum disorder (3),(11),(16),(17),(18),(19),(20). Present study assessed knowledge about child mental disorders in general. In present study, 114 (94.21%) teachers were knowledgeable about the fact that mental disorders can occur at any age. A study done by Parikh N et al., concluded that the majority of teachers had poor knowledge about signs and symptoms of mental disorders (3). Similarly, another large study done by Kamel A et al., in Saudi Arabia, involving teachers from 420 schools, reported that a considerable number of teachers had low awareness about risk factors, causes, and signs and symptoms of mental disorders (21). Alshammari SA et al., found that 40% of teachers believed that mental disorders like depression are rare in adolescents (9).

In present study, 107 (88.43%) teachers positively responded that mental health services should be sought if needed. Similarly, in a study done by Latifeh Y et al., 71% of teachers agreed that referring children with behavioural issues for psychotherapy is advantageous (22). A study done by Akpan MU et al., showed that overall academic scores of pupils (12.9%) with behavioural disorders were significantly low compared to others (9.1%) without behavioural disorders (23). Mental disorders in school-going children can lead to an inability to concentrate in the classrooms, a lack of stamina, difficulty in managing assignments, and difficulty in communicating with students and teachers. In present current study, 28 (23.14%) teachers believed that mental disorders do not affect academic performance. In a study done by Alshammari SA et al., 99% of teachers were aware that mental disorders like depression can affect academic grades (9). In present study, 10 (8.27%) teachers were of the view that there is no treatment for mental disorders in children, while 8 (6.61%) believed that the only treatment available was sleeping pills. Studies by Ghanizadeh A et al., and Brook U et al., also showed that teachers lacked knowledge about the medications available for mental disorders (17),(24). Similarly, Parikh N et al., concluded that teachers had poor knowledge about the treatment aspects of mental disorders (3). In the study done by Kamel A et al., more than half of the participants were unaware of psycho-behavioural interventions for mental disorders (21).

A study done by Low NCP et al., Adrian C, and Hammen C and Hammen C showed that stressful life events and external stressors like family disruptions (divorce/separation, new family), interpersonal relationship stress (parents, siblings, friends), personal stress (romantic break-ups, health issues, weight, school work), etc., lead to mental disorders in children (25),(26),(27). Ninety-three (76.86%) teachers in present study were aware that stressful life events can lead to mental disorders in children. Eighty-eight (72.73%) teachers in present study were aware that not all mental disorders in children are due to stress alone. To support this, a study by Youseff MK et al., showed that 33.2% of teachers believed that ADHD is inherited (18). Teacher’s awareness of stress in the causation of mental disorders in children has not been adequately researched. Ninety-six (79.34%) teachers in present study were of the view that not all mental disorders in children are inherited in the family, while a study by Kamel A et al., showed that 44.4% of the participating teachers believed that inheritance played a role in mental illnesses (21).

In the present study, 82 (67.76%) teachers believed that children with mental disorders are less smart compared to other children. Additionally, 70 (57.85%) teachers felt that it would be difficult for them to cope if they had children with mental disorders. Fourteen (11.57%) teachers were of the view that children have mental disorders because their parents did not raise them properly. A study done by Nur N and Kavakci O and Ghanizadeh A et al., showed that 65.5% and 53.1% of teachers, respectively, believed that ADHD in children is because of bad parenting (11),(17). Latifeh Y et al., also reported that 88% of teachers believed that bad parenting and abuse lead to mental illness (22). A study by Prabhu V et al., showed that 53.8% of teachers had an opinion that such children are not harmful to other children (16). Similar results were found in present study, where 76 (62.81%) disagreed with the fact that children with mental health illnesses can be violent. In present study, 44 (36.36%) teachers were not aware that other children discriminate against children with mental disorders. A study by Wahl O showed that 71% of students had no problem being friends with mentally ill people, 56% were okay with having such classmates, 51% were willing to share their benches in the classroom with such students, and 41% had no issues with doing class projects with such students (12).

In the study done by Parikh N et al., it was found that teachers had a significant negative attitude towards the mentally ill, including poor acceptance of people with mental illness, not wanting to discuss mental issues in the classroom, feeling ashamed of taking psychiatric treatment, and believing that having children with mental illness in the classroom was bad (3). Kamel A et al., found that the majority of teachers had positive attitudes towards people with mental illness, with the majority of teachers showing acceptance of people with mental illness and agreeing that those with mental disorders should be referred to a psychiatrist. However, about 42% of teachers believed that psychiatric medications are addictive, and around 20% of teachers felt that mental illnesses are incurable and that children with mental illness can be dangerous (21).

There were also a few positive attitudes found in present study like, the majority of teachers had no problem dealing with parents of children with mental disorders, believed that such children should not be discouraged from attending school, would allow their children to have friendships with children who have a mental disorder, and believed that it is not a waste of time and resources to care for children with mental disorders.

It is not necessary for teachers to determine whether a child has a mental disorder or to diagnose a child with a mental disorder. Attempting to diagnose children risks inappropriately labelling a child, alienating children and their parents, and requires specialised training. Rather, it is important for teachers to understand how to support the mental health of all students and to determine when mental health problems are severe enough to require additional help from family members and/or a mental health specialist.

Limitation(s)

The limitations of the present study include not considering teachers’ socio-demographic details and the lack of psychometric testing of the self-designed questionnaire. This study has a drawback because it lacked a widely validated assessment tool to measure all aspects of teachers’ knowledge and attitude that were studied. Additionally, since the study was confined to Karwar city, these findings may not be generalisable to other surrounding rural areas. There is a lack of tools for assessing teachers’ perception of mental health issues in children. Hence, further studies are needed to better understand teachers’ knowledge and attitudes about mental health, which can help in understanding the needs of school teachers and training them.

Conclusion

It was found that there is moderate knowledge about the occurrence of child mental disorders, the need for treatment referral, and the effect on academic performance among teachers. There were both positive and negative attitudes towards children with mental disorders. Tolerant attitudes and encouragement by teachers can improve low self-esteem, reduce social isolation, and discrimination. There is a necessity for programs to create awareness among school teachers about mental disorders in children and to create school environments that can promote mental well-being in children. Such programs can aid in the early identification, timely referrals for mental health evaluation and intervention, and the promotion of child mental health. There is a need for future research in the field of school mental health to facilitate and assess the effectiveness of school mental health programs and policies.

DOI and Others

DOI: 10.7860/JCDR/2024/65338.19078

Date of Submission: May 10, 2023
Date of Peer Review: Jul 19, 2023
Date of Acceptance: Dec 01, 2023
Date of Publishing: Feb 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: This study was approved and funded by ICMR under the Short Term Studentship (STS) program, 2019 (Reference No.: 2019-02548).
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 13, 2023
• Manual Googling: Aug 09, 2023
• iThenticate Software: Nov 24, 2023 (11%)

ETYMOLOGY: Author Origin

EMENDATIONS: 7