Journal of Child & Adolescent Mental Health
ISSN: 1728-0583 (Print) 1728-0591 (Online) Journal homepage: http://www.tandfonline.com/loi/rcmh20
Teachers' perspectives of mental health needs in Nigerian schools Patricia Ibeziako , Tolulope Bella , Olayinka Omigbodun & Myron Belfer To cite this article: Patricia Ibeziako , Tolulope Bella , Olayinka Omigbodun & Myron Belfer (2009) Teachers' perspectives of mental health needs in Nigerian schools, Journal of Child & Adolescent Mental Health, 21:2, 147-156, DOI: 10.2989/JCAMH.2009.21.2.6.1014 To link to this article: http://dx.doi.org/10.2989/JCAMH.2009.21.2.6.1014
Published online: 17 May 2012.
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Journal of Child and Adolescent Mental Health 2009, 21(2): 147–156 Printed in South Africa — All rights reserved
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JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/JCAMH.2009.21.2.6.1014
Teachers’ perspectives of mental health needs in Nigerian schools Patricia Ibeziako1*, Tolulope Bella2, Olayinka Omigbodun2,3 and Myron Belfer1 Department of Psychiatry, Children’s Hospital Boston/Harvard Medical School, Boston MA, 02115, USA Department of Psychiatry, University College Hospital, Ibadan, Oyo State, Nigeria 3 Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria * Corresponding author, email: [email protected]
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Objective: This study assessed teachers’ perspectives on children’s mental health needs and the development of school-based mental health programmes in South-West Nigeria. Method: Focus group discussions were held with teachers from randomly selected urban and rural primary schools in Ibadan, Nigeria. Data were analysed using interpretative phenomenological analysis. Results: Teachers identified significant mental health problems in school-age children and described a variety of bio-psychosocial contributing factors. These ranged from problems with primary support systems to poverty, spiritual factors, medical illnesses and genetic vulnerability. The school environment was recognised as an ideal place for dealing with child mental health issues despite deficiencies in teachers’ knowledge, skills and resources. A school mental health programme that would provide training for teachers and awareness campaigns as well as human, material and financial resources was proposed. Conclusions: The findings from this study provide a background for understanding the current state of interventions to address child mental health problems in a resource poor country in sub- Saharan Africa and specific areas where future program development is most likely to have an impact.
Introduction Resource-poor countries have the highest proportion of children living in very difficult circumstances and in dire need of mental health care (Robertson et al. 2004) and there is sufficient evidence to demonstrate significant morbidity from child mental health disorders in the developing world (Rahman et al. 2000). Many resource-constrained countries do not have a mental health policy, let alone a child mental health policy (WHO 2005) and Nigeria, which is the most populous country south of the Sahara, is no exception. Research shows that half of adult mental disorders began before the age of 14 (Kessler et al. 2005), and that early intervention can prevent and reduce more serious consequences later in life (WHO 2004). In many developing countries, trained mental health professionals often number less than one per million of the population and the vast majority of people with mental health problems cannot be reached through centralised care (Rahman et al. 2000). The situation is even more critical for children and adolescents, as there is an extreme shortage of professionals in the child mental health service sector (Dogra and Omigbodun 2004). This makes creative partnerships with other child-serving sectors a necessity if the needs of young people are to be met. Research suggests that school-based mental health services are effective in preventing a range of mental and behavioral problems (Durlak and Wells 1997, US DHHS 1999, 2001). Mental health and psychosocial problems are now being addressed within many school systems worldwide in order to facilitate learning (Kury and Kury 2006) and there is substantial evidence Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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indicating that school-based mental health programmes can produce positive effects on children’s behavioural and emotional functioning (Durlak and Wells 1997). In 2005, worldwide, 84% of all children of primary school age were enrolled in primary school; 59% of all children of secondary school age (boys as well as girls) were enrolled in secondary school (UIS 2005). Schools are accessible to children and families, and may be less intimidating and stigmatising than hospitals or clinics. Moreover, providing mental health services in schools can facilitate the removal of emotional and behavioral barriers to learning, thereby enhancing the students’ potential for academic success (Walter, Gouze and Lim 2006). Schools that provide school-based mental health services overwhelmingly report fewer course failures and higher grade point averages compared to schools without such programmes. (CSMHA 2003). In addition, numerous studies have found that skills-based health education can equip young people to manage relationships, cope with stress, and resolve conflicts (Greenberg et al. 2003). Importantly, students who acquire these skills and learn in a supportive school climate perform significantly better academically (Durlak and Wells 1997). When students feel connected to their school as a caring community, they are less likely to engage in risk behaviors such as smoking, drinking, drug use and early sexual initiation, and perform better academically (Blum and Ellen 2002). Schools can also positively influence student mental health by encouraging open communication and by promoting equal opportunities for all students (WHO 2003). Teacher-student relationships have been shown to be among the most influential school psychosocial influences on student mental health (Undheim and Sund 2005). WHO has defined a Health Promoting School as ‘a school that constantly strengthens its capacity as a healthy setting for living, learning and working and which fosters health and learning with all measures at its disposal’ (WHO 2008: online) A Health Promoting School unites policy, skills-based health education, a healthy physical and psychosocial school environment, and access to services to provide a comprehensive approach. There is considerable emphasis on engaging health, mental health and education officials, teachers, teachers’ unions, students, parents, health providers and community leaders in planning and designing the policies and interventions to make the school a healthy place. Schools and ministries of education, working with ministries of health (including mental health), require certain capacities and know-how to implement this comprehensive approach. An important first step in the development of school-based mental health services is a needs assessment (Walter et al. 2006). This serves to ensure that services are planned based on the identified needs of the local population. Needs assessment involves the synthesis of views about the mental health needs of children from stakeholders involved in their care. These include educational departments, teachers, parents, pediatricians, social services and children themselves. It is likely that each of these sources of information will bring different perspectives, with schoolteachers being more likely to view mental health needs not only from the child’s perspective, but also from the perspective of the impact that the child’s problems many have on the school, other pupils or both (Rahman et al. 2000). Most schools in Nigeria do not have school nurses, but teachers and staff may have knowledge about the health needs of students that the family is unaware of, and they could be trained to carry out simple psychosocial interventions and act as sources of referral. As a preliminary first step in the development of school-based mental health services in Nigeria, this study aimed to obtain information on perceived mental health needs in primary (elementary) schools using focus group discussions with school teachers. Method This study was carried out in Ibadan, a semi-urban city located in South-West Nigeria. Ibadan has a population of about two million (NPC 1999). This was a cross-sectional qualitative study and part of a larger study consisting of both key informant interviews and focus group discussions. Only the focus group discussions are reported in this manuscript. Approval for the study was obtained from
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the Oyo State Ethical Research Committee in the Ministry of Health, and the Oyo State Ministry of Education. Sample There are a total of 11 local government areas (districts) in Ibadan and every local government has a Local Inspector of Education (LIE). In order to ensure representation of the population of primary school teachers in the study site, one rural and two urban local government areas were randomly selected. From these, the respective LIE’s submitted names of schools and head teachers within their district. Six urban public, Six urban private and five rural public schools were randomly selected, making a total of 17 schools. The head teachers from the selected schools were contacted and informed about the project. Each head teacher then randomly selected teachers to participate in the focus group. There were six focus groups in all and each lasted about two hours. Every focus group had eight to ten teachers from three different schools making a total of 56 focus group participants. In the urban areas, teachers from public schools were interviewed separately from those in private schools. No teacher received more than 24 hours notice about the project and many were informed only on the morning of the focus group and accepted the invitation to participate in discussions about child mental health issues in schools. The objective of the project was provided at the beginning of each focus group and teachers were provided with consent forms as well as the opportunity to withdraw. The interviews were held at the selected schools to make it easier for teachers to participate. Instrument A focus group question guide was used for all the interviews. Over 30 questions were originally developed and then narrowed down to 12, which were reviewed with a primary school teacher who helped develop probes for each question. A few adjustments were made to the question guide based on responses from the first focus group, which served as a pilot, and eventually 11 selected questions were discussed during every interview. All the urban focus group discussions were conducted primarily in English and the rural focus groups were conducted primarily in the local language (Yoruba). The question guide aimed to assess the teachers’ perspectives on the following: 1. Mental health problems in primary school children. 2. Resources currently available to tackle mental health problems in primary schools. 3. Resources needed to address mental health problems in primary school children 4. Barriers to children receiving mental health care. Data analysis The interviews were transcribed and reviewed independently by the researchers. Statements were analysed using interpretative phenomenological analysis (Smith and Osborn 2004). This analysis involved reviewing all the interviews to identify and extract emergent themes, which were categorised and coded. Recurrent themes were identified and explored by the investigators. Potential sources of researcher bias were identified and addressed by maintaining a reflective journal, reflecting on presuppositions, and conducting the full literature review after completing the data analysis. Results Demographic data There were 36 (64.3%) female and 20 (35.7%) male teachers who participated in the study. Each focus group had more males than females, which is representative of the distribution of teachers in most primary schools in Ibadan.The mean age of the teachers who participated in the focus groups was 39.5 years (SD = 8.9 years), with an age range of 23 to 57 years. The average number of years of teaching was 13.93 years (SD = 8.3 years) with a range of 2–34 years. See Table 1 for the demographic information of the focus group participants.
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Table 1: Focus group participant demographic data (n = 56) Demographic data Districts Akinyele (rural) Ibadan North (urban) Ibadan North-West (urban) School type Urban private Urban public Rural public Religion Christian Islam Educational level Post-secondary University degree Teaching qualification Yes No
n (%) 17 (30.4) 18 (32.1) 21 (37.5) 19 (33.9) 20 (35.7) 17 (30.4) 46 (82.1) 10 (17.9) 39 (69.6) 17 (30.4) 51 (91.1) 5 (8.9)
Focus groups 1. What comes to your mind when you hear about ‘mental illness’ or ‘mental health problems’ in children? The most striking theme was the tendency of participants to use terms that associated mental illness with learning problems. Focus group participants (FGPs) described their first thoughts of mental illness with terms like, ‘low IQ’, ‘mentally retarded’, ‘imbecile’, ‘insane’, ‘moron’, ‘learning disability’, ‘psychological problems’, ‘abnormal behaviour’, and ‘lack of proper reasoning capacity’. FGP’s from some of the urban private schools were less likely to use these terms when asked about mental illness in children. 2. What are the causes of ‘mental illnesses’ in children? The most common theme that emerged from all the focus groups was that mental health problems resulted from contextual factors and only secondarily from genetic predisposition. Poverty, spiritual causes and problems with family supports were among the more common themes to emerge from the focus groups. Poverty leading to poor nutrition, child labour and poor quality of the living environment was seen as an important contributor to mental illness. ‘Most problems we are having in this country can be based on poverty. When a child lacks food to eat, clothes to wear, all these worries can cause mental illness.’ Problems with family supports included family disruption and conflicts, parental neglect, polygamous families, emotional problems in parents (including maternal mental health problems), and the status of being a foster child. Teachers identified spiritual forces as one of the main etiologies of mental illness in children and stressed the importance of this in the African setting. Both urban and rural FGPs discussed this in detail although some were initially reluctant to reveal their thoughts. FGPs believed that spiritual forces could be used to inflict mental illness in a child especially in polygamous families due to rivalries among the wives/mothers. ‘I believe that the root cause of mental imbalance in children is the curse from the family. We have polygamous families … you see the wife trying to make her own children better and go to the extent of doing some juju [supernatural power] to make the children of the other wife look dull or mentally imbalanced. That is the major cause [of mental illness].’
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Psychoactive substance use, genetic transmission, perinatal problems, head trauma, medical illnesses, peer influences, sexual abuse, teachers’ attitudes and religious practices were also described as causes of mental illness. 3. How would you identify children in your class or school who have mental illness or mental health problems? Teachers discussed different signs and symptoms of mental illness in children. The common theme described in every focus group was poor academic performance. Children who are inattentive, do not respond to teachers, fail to do their homework, do not follow instructions and have difficulty concentrating in class were given as examples. Some felt these were signs of laziness in children and not mental health problems. The description of different behaviours was another common theme. A wide range of behaviours were described as evidence of mental illness by the FGPs; such as a dull, unhappy look and being socially withdrawn and extremely quiet. Other behaviours, such as bullying, restlessness, impulsivity, aggressive behaviours, stealing, telling lies and truancy, were described. Talking irrationally or excessively and talking to self were described as manifestations of mental illness by the FGPs. Other manifestations included smiling and laughing inappropriately. Physical appearance such as untidy appearance and abnormal shape of the head were described as ways to identify mental illness in children. ‘If you see the shape of the head, you will know that something has gone wrong with the boy. The mother told me she gave birth to him at home and the child fell and smashed his head. So this affected the poor boy.’ FGPs attempted to classify mental illnesses in children and described differences between major and minor mental illnesses. Minor mental illness was amenable to their interventions at school, while major disorders were not. Some FGPs felt mental retardation should be handled in special schools, while the minor issues such as poor concentration and low interest could be tackled in regular schools. 4. What approaches and resources currently exist to address mental illness or mental health problems in your school? FGPs identified three key areas of intervention focusing on the parent, child, or the school/class environment. Parent-focused intervention was the most common theme in all the focus groups. Virtually all participants described involving parents by inviting them to school, informing them about the child’s problems and in some cases providing advice and counselling. Child-focused interventions ranged from keeping the child busy, providing extra assistance, praising good behaviours, encouragement, individual counselling, prayers, religious counselling, general moral instruction, disciplinary measures and provision of financial assistance. Corporal punishment was mentioned as a tool to address mental illness and mental health problems in schools. Most FGPs utilised this method and felt that the cane was a multipurpose tool and an effective intervention. ‘We cannot do without cane. The child we think is about to be insane and is getting wild, we threaten with sticks or cane. You beat the nonsense out of him and leave common sense.’ Some of the FGPs from urban private schools were not too keen on the use of the cane as they felt it could have adverse consequences on school performance. One of the FGPs identified some of the limitations of the cane to control behavious problems. ‘From my own experience I discovered I was able to curtail the activity of the pupil temporarily with my cane for that period. Immediately I finished the lesson they picked up the attitude again.’ 5. What resources are available in your community to address mental health issues in children? FGPs generally agreed that most of their communities had no resources to address mental health problems. A few mentioned special schools, juvenile remand homes (correctional facilities), teaching hospitals, churches and mosques.
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6. Do you think that teachers know about mental illness and mental health problems presently? The overwhelming majority of FGPs felt teachers did not know enough about mental illness or mental health problems. Some reported that they could handle ‘psychological problems’, but not ‘mental health problems’.
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7. Would you feel comfortable asking a child about mental illness or mental health problems? FGPs generally expressed a comfort level talking to children about mental health issues. 8. How do you think parents would feel about mental health issues being addressed in schools? The majority of FGPs from all the schools sectors felt most parents would be receptive to school mental health programmes because of the high regard they have for teachers, and felt only a few parents would be apprehensive about the programme. ‘They will appreciate it if it will not cost them money.’ ‘Most of them will appreciate it while some may not. You may not be able to give advice to some parents because of their traditions and beliefs. All they want is that you teach their child and have nothing to do with their health.’ 9. What resources do you feel would be necessary in order to address mental health issues in school? The FGPs described human and material resources they perceived would be important for a successful school mental health programme. Training of teachers and availability of child mental health specialists within schools were identified by FGPs as important. Availability of health centres close to or within schools was also felt to be important. 10. What barriers exist which prevent children receiving mental health treatment in schools and the community? Poverty, ignorance, stigma and a lack of resources were the major themes that evolved as the predominant barriers preventing children from receiving mental health care. ‘Some parents would rather get herbs for treatment than seek medical treatment.’ ‘Nowadays we have many churches around. When a child is sick they will take the child for deliverance. I’m not saying that our churches are not trying, but deliverance might not be the first solution. Such a child can go to the hospital first.’ 11. If you were in charge of creating a school mental health programme, what suggestions would you have for school administrators and policy-makers? The FGPs gave key recommendations for a successful school mental health programme. They discussed government policies, training, awareness campaigns, accessible facilities and the involvement of all stakeholders. ‘I will like the government to put health care in the school curriculum.’ ‘NGO or governmental organisations can organise training on weekends or during vacation for teachers.’ ‘Public awareness is also very essential on radio, television, posters, etc.’ ‘There should be a programme like the immunisation program going from house to house to vaccinate children with mental illness.’ Discussion Perceptions of mental health problems in children The views of Nigerian primary school teachers on mental health problems in children are very similar to that of school administrators and head teachers (Ibeziako, Omigbodun and Bella 2008). Like the administrators, teachers used a wide variety of outdated and stigmatising expressions to express their understanding of mental illness in children. Teachers from urban private schools were less likely to use these terms and their responses were indicative of greater awareness of
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mental illness in children. This may be due to a higher level of education attained by these teachers compared with those from rural schools. Many FGPs used the term ‘mental illness’ interchangeably with ‘mental retardation’. Terms like ‘laziness’, ‘wickedness’ and ‘extrovert’ were used to describe problematic behaviours, which were not seen as illness. The term ‘mental health problems’ also elicited a broader and more inclusive response than ‘mental illness’ across the board and there was some resistance among respondents to identify certain behaviours as illness. A wider range of aetiological factors were elicited by the teachers than the school administrators and head teachers (Ibeziako et al. 2008). These include psychoactive substance use, peer influence and harmful religious practices, as well as problems with primary supports, poverty, spiritual causes and genetic transmission. This observation may be due to the larger number of participants in the focus group discussions. In addition, group dynamics may have facilitated broader discussions among the participants, thus yielding a wider variety of ideas about possible aetiological factors. School administrators and head teachers were interviewed on their own. While administrators mentioned poor academic performance as one of the signs of mental illness in children, teachers focused on it as the most important sign. Studies have shown that teachers are likely to highlight problems which interfere with the learning process (Mansour et al. 2002). Teachers in this study also went further to classify mental illnesses into major and minor according to their own ability to deal with them. A similar needs assessment for urban elementary schools in a major city in midwestern United States revealed that academic difficulties were the second most common mental health problem identified by teachers after disruptive behavioural disorders (Walter et al. 2006). Poverty was highlighted by the majority of teachers not only as a cause of mental illness but also an important barrier to care. A theme that emerged during the interviews was that children of educated and wealthy parents have a greater advantage and are less likely to have mental health problems. Respondents described the effects of poverty as far-reaching and contributing to parental neglect, child labour, poor nutrition, poor quality of living environment, poor maternal health, poor perinatal care, and lack of adequate school materials. The relationship between poverty and mental illness has long been established. In a recent study, Corrigall et al. (2008) use a more encompassing definition of poverty and argue that health deprivation and adverse events are not just mediators of the poverty–mental illness relationship, but are in fact facets of poverty itself. There is a danger that the role of mental ill-health in maintaining poverty is minimised, and mental health continues to be ignored by governments (Corrigall et al. 2008). Cultural influences were also evident during interviews, as teachers highlighted spiritual problems as contributing to mental illness in children. This is an aspect deeply ingrained in the cultural and spiritual beliefs of the environment. Ohaeri and Fido (2001) report that the majority of families of sufferers of mental illness believed it was caused by spiritual forces. Perceptions about school mental health programmes The majority of teachers were of the opinion that schools are an important avenue for addressing mental health problems in children, and that they (teachers) are in the best position to identify these issues. They reported that children spend more time with teachers at school than with their own parents since the current financial situation in the country necessitates parents spending a large part of their day trying to make ends meet in order to provide for their families. Importantly it was emphasised that many parents look up to teachers and defer to their authority, as happens even in the developed world. A US national study on public knowledge of mental health problems in children reported that over 80% of respondents would choose to approach teachers for help on mental health issues in children (Pescosolido et al. 2008) Respondents in this study described the current role of primary school teachers as educators, counsellors, surrogate parents and even spiritual ministers as part of their routine work. They also described a wide variety of parent-, child- and environmentally-centred interventions currently being used to manage mental health problems in the primary school setting. They were able to identify the limitations of some techniques, such as the use of the cane. This is a form of corporal punishment which is widely accepted in Nigeria and based on strong cultural and religious beliefs, but which has also been associated with risks for child abuse (Ebigbo 1993). In this study, some teachers
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from urban schools expressed a disinclination to use the cane ,even though they still engage in this practice. This reluctance of urban teachers compared with rural teachers may be a result of greater exposure to ideas from the Western world about the consequences of corporal punishment coupled with reduced influence from cultural beliefs. Teachers also recognised their limitations in terms of knowledge, skills and resources to manage mental health problems in children. This was at variance with the views of some school administrators and head teachers who felt teachers had adequate skills and knowledge to handle these issues (Ibeziako et al. 2008).The administrators may have been more reluctant to reveal limitations in the training and skills of their staff; however, limitations in knowledge and skills of teachers are not unique to the developing world. Walter et al. (2006) report that teachers in the US expressed a limited amount of overall mental health knowledge and a lack of confidence in managing mental health problems in their classrooms. Similarly, when tested, only 56% of pre-school teachers in Singapore had a pass mark on the knowledge of childhood developmental and behavioural disorders (Lian et al. 2008) Proposed solutions The willingness of elementary school teachers to deal with mental health issues in schools despite their limitations creates a favourable climate for the development of school-based mental health programmes in Nigerian schools. In Africa, functional school mental health programmes have been reported in only a few countries, such as Tunisia and Egypt (Gaddour 2007) and these have made use of physicians, nurses, health visitors and social workers. This study revealed that Nigerian elementary schools are not equipped with such resource persons; hence teachers currently constitute the only existing resource base for developing elementary school mental health programms. With collaboration and training opportunities, Nigerian school teachers would be able to act as invaluable community mental health resources for child and adolescent mental health. Using teachers for these programmes would also facilitate the implementation and sustainability, as both factors have been linked with use of already existing resources rather than introducing new ones (Han and Weiss 2005). School-based mental health programmes all over the world have been associated with reduction in the stigma of having to attend a psychiatry service (Sinha, Kishore and Thakur 2003) and in the Nigerian context psycho-education would be particularly useful in combating the high level of illiteracy, ignorance and deeply rooted traditional beliefs (Ohaeri and Fido 2001, Omigbodun 2004). In this study, because of teachers’ understanding that mental illness is widely misunderstood in the society, they suggested ways to reduce the influence of stigma by appropriate packaging of the programme, careful selection of words to minimise negative labels and emphasis on going beyond mere public awareness to public enlightenment. The first was described as simply notifying the public about programmes and resources, while the latter involves actually spending time educating the public about the nature of the problem and the need for treatment (psycho-education). There is evidence that school mental health policies incorporated the following components, all of which contribute to mental health promotion in schools: raising public awareness to create demand, building collaborative relationships, addressing stakeholder concerns, generating funding, providing adequate teacher training and support, forming a steering committee, and implementing services (Adelman and Taylor 2006, Weist and Paternite 2005). One limitation of a Nigerian school mental health programme is that many of the most vulnerable Nigerian children are not in school for reasons such as family and national poverty, coupled with an increasingly fragile social support system (Olley 2006). However, it is encouraging to note that the south-west of Nigeria, where this study was carried out, still has the highest rate (86%) of school attendance in the country (Orc Macro 2004) and the majority of children in this sub-region would therefore benefit from a school mental health programme which could later be disseminated to other parts of the country. Thus it is important not to neglect the needs of those who are now accessible in the hope that in future other populations can be served as resources expand.
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Conclusion The findings from this study provide a background for understanding the current state of addressing child mental health problems through school interventions. Key findings from this study reveal that while there are fundamental gaps in the knowledge of elementary school teachers about mental illness in children, these issues are present in schools and there was an overwhelmingly positive response for the development of school-based mental health programmes. The need for training of personnel at many levels of the system, the inclusion of parents in the educational process and involvement of all stakeholders including the government were all highlighted. The study was carried out in South-Western Nigeria and the small sample size may limit the ability to generalise for the rest of the country. The study did not include the perspectives of parents, children and healthcare providers who could potentially provide additional insight into the mental health needs of children. As far as the authors are aware, this is the first needs assessment identifying primary school mental health needs as perceived by teachers in a Nigerian context. The benefit to communities and to the nation will be evident as demonstrated worldwide in other settings. References Adelman HS and Taylor L (2006) The Status of Mental Health in Schools: A Policy and Practice Brief. Los Angeles: UCLA School Mental Health Project Blum RW and Ellen J (2002) Work group V: increasing the capacity of schools, neighborhoods, and communities to improve adolescent health outcomes. Journal of Adolescent Health. 31: 288–292 CSMHA (Center for School Mental Health Assistance) (2003) Outcomes of Expanded School Mental Health Programs. Available at: http://csmha.umaryland.edu/resources.html/resource_packets/download_files/ outcomes_ESMHP_2003.pdf [Accessed 7 January 2008] Corrigall J, Lund C, Patel V, Plagerson S and Funk MK (2008) Poverty and mental illness: fact or fiction? Social Science and Medicine 66: 2061–2066 Dogra N and Omigbodun O (2004) Partnerships in mental health are possible without multidisciplinary teams. British Medical Journal 329: 1184–1185 Durlak JA and Wells AM (1997) Primary prevention mental health programs for children and adolescents. American Journal of Community Psychology 26: 775–802 Ebigbo PO (1993) Child abuse and neglect in Nigeria – a situation analysis: Nigeria’s population. Quarterly Journal of Population Activities in Nigeria 10: 4 Gaddour N (2007) Child and adolescent mental health Profile in Tunisia. Paper presented at IACAPAP Study Group, 16–20 March, Nairobi, Kenya Greenberg MT, Weissberg RP, O’Brien MU, Zins JE, Fredericks L. Resnik H and Elias MJ (2003) Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist 58: 466–474 Han SS and Weiss B (2005) Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology 33: 665–679 Ibeziako PI, Omigbodun OO and Bella TT (2008) Assessment of need for a school-based mental health programme in Nigeria: perspectives of school administrators. International Review of Psychiatry 20: 271–280 Kessler RC, Berglund P, Demler O, Jin R, and Walters EE (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 593–602 Kury KW and Kury G (2006) An exploration into the internal dynamics of a school-based mental health collaboration. Journal of School Health 76: 164–168 Lian WB, Ying SH, Tean SC, Lin DC, Lian YC and Yun HL (2008) Pre-school teachers’ knowledge, attitudes and practices on childhood developmental and behavioural disorders in Singapore. Journal of Paediatrics and Child Health 44: 187–194 Mansour ME, Kotagal UP, DeWitt TG, Rose B and Sherman SN (2002) Urban elementary school personnel’s perceptions of student health and student health needs. Ambulatory Pediatrics 2: 127–131 NPC (National Population Commission) (1999) Nigeria Demographic and Health Survey. Nigeria: National Population Commission Ohaeri JU and Fido AA (2001) The opinion of caregivers on aspects on schizophrenia and major affective disorders in a Nigerian setting. Social Psychiatry and Psychiatric Epidemiology 36: 493–499 Olley BO (2006) Social and health behaviours in youth of the streets of Ibadan, Nigeria. Child Abuse and
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Neglect 30: 271–282 Omigbodun OO (2004) Psychosocial Issues in a Child and Adolescent Psychiatric Clinic Population in Nigeria. Social Psychiatry and Psychiatric Epidemiology 39: 667–672 Orc Macro (2004) DHS EdData Education Profile: Nigeria. Calverton, MD: Orc Macro Pescosolido BA, Jensen PS, Martin JK, Perry BL, Olafsdorttir S and Fettes D (2008) Public Knowledge and Assessment of Child Mental Health Problems: Findings From the National Stigma Study-Children. Journal of the American Academy of child and Adolescent Psychiatry 47: 339–349 Rahman A, Mubbashar M, Harrington R and Gater R (2000) Annotation: Developing child mental health services in developing countries. Journal of Child Psychology and Psychiatry 41: 539–546 Robertson B, Mandlhate C, Seif El Din A and Seck B (2004) Systems of care in Africa. In: Remschmidt H, Belfer ML, Goodyer I (eds), Facilitating Pathways: Care, Treatment and Prevention in Child and Adolescent Mental Health. Berlin: Springer. pp 71–88 Sinha V, Kishore M and Thakur A (2003) A school mental health program in India. Journal of the American Academy of Child and Adolescent Psychiatry 42: 624 Smith J and Osborn M (2004) Interpretative phenomenological analysis. In: Glynis M Breakwell (ed.), Doing Social Psychology Research. Oxford: Blackwell. pp 232–234 Undheim AM and Sund AM (2005) School factors and the emergence of depressive symptoms among young Norwegian adolescents. European Child and Adolescent Psychiatry 14: 446–453 UIS (UNESCO Institute for Statistics) (2005) Global Education Digest 2005. Montreal: UNESCO Institute for Statistics Walter HJ, Gouze K and Lim KG (2006) Teachers’ beliefs about mental health needs in inner city elementary schools. Journal of the American Academy of Child and Adolescent Psychiatry 45: 61–68 Weist M.D and Paternite CA (2005). Building an interconnected policy-training-practice-research agenda to advance school mental health. Education and Treatment of Children 29: 173–196 WHO (World Health Organization) (2003). Creating an Environment for Emotional and Social Well-being: An Important Responsibility of a Health Promoting and Child-Friendly School. Information Series on School Health, Document 10. Geneva: World Health Organization WHO (2004). Prevention of Mental Disorders: Effective Interventions and Policy Options – Summary report. Geneva: World Health Organization WHO (2005) Global Concerns: Implications for the Future. Atlas of Child and Adolescent Mental Health Resources. Geneva: World Health Organization WHO (2008) What is a Health-Promoting School? Available at: http://www.who.int/school_youth_health/gshi/ hps/en/index.html [Accessed 4 January 2008]
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Teachers' perspectives of mental health needs in Nigerian schools Patricia Ibeziako , Tolulope Bella , Olayinka Omigbodun & Myron Belfer To cite this article: Patricia Ibeziako , Tolulope Bella , Olayinka Omigbodun & Myron Belfer (2009) Teachers' perspectives of mental health needs in Nigerian schools, Journal of Child & Adolescent Mental Health, 21:2, 147-156, DOI: 10.2989/JCAMH.2009.21.2.6.1014 To link to this article: http://dx.doi.org/10.2989/JCAMH.2009.21.2.6.1014
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Journal of Child and Adolescent Mental Health 2009, 21(2): 147–156 Printed in South Africa — All rights reserved
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JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/JCAMH.2009.21.2.6.1014
Teachers’ perspectives of mental health needs in Nigerian schools Patricia Ibeziako1*, Tolulope Bella2, Olayinka Omigbodun2,3 and Myron Belfer1 Department of Psychiatry, Children’s Hospital Boston/Harvard Medical School, Boston MA, 02115, USA Department of Psychiatry, University College Hospital, Ibadan, Oyo State, Nigeria 3 Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria * Corresponding author, email: [email protected]
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Objective: This study assessed teachers’ perspectives on children’s mental health needs and the development of school-based mental health programmes in South-West Nigeria. Method: Focus group discussions were held with teachers from randomly selected urban and rural primary schools in Ibadan, Nigeria. Data were analysed using interpretative phenomenological analysis. Results: Teachers identified significant mental health problems in school-age children and described a variety of bio-psychosocial contributing factors. These ranged from problems with primary support systems to poverty, spiritual factors, medical illnesses and genetic vulnerability. The school environment was recognised as an ideal place for dealing with child mental health issues despite deficiencies in teachers’ knowledge, skills and resources. A school mental health programme that would provide training for teachers and awareness campaigns as well as human, material and financial resources was proposed. Conclusions: The findings from this study provide a background for understanding the current state of interventions to address child mental health problems in a resource poor country in sub- Saharan Africa and specific areas where future program development is most likely to have an impact.
Introduction Resource-poor countries have the highest proportion of children living in very difficult circumstances and in dire need of mental health care (Robertson et al. 2004) and there is sufficient evidence to demonstrate significant morbidity from child mental health disorders in the developing world (Rahman et al. 2000). Many resource-constrained countries do not have a mental health policy, let alone a child mental health policy (WHO 2005) and Nigeria, which is the most populous country south of the Sahara, is no exception. Research shows that half of adult mental disorders began before the age of 14 (Kessler et al. 2005), and that early intervention can prevent and reduce more serious consequences later in life (WHO 2004). In many developing countries, trained mental health professionals often number less than one per million of the population and the vast majority of people with mental health problems cannot be reached through centralised care (Rahman et al. 2000). The situation is even more critical for children and adolescents, as there is an extreme shortage of professionals in the child mental health service sector (Dogra and Omigbodun 2004). This makes creative partnerships with other child-serving sectors a necessity if the needs of young people are to be met. Research suggests that school-based mental health services are effective in preventing a range of mental and behavioral problems (Durlak and Wells 1997, US DHHS 1999, 2001). Mental health and psychosocial problems are now being addressed within many school systems worldwide in order to facilitate learning (Kury and Kury 2006) and there is substantial evidence Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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indicating that school-based mental health programmes can produce positive effects on children’s behavioural and emotional functioning (Durlak and Wells 1997). In 2005, worldwide, 84% of all children of primary school age were enrolled in primary school; 59% of all children of secondary school age (boys as well as girls) were enrolled in secondary school (UIS 2005). Schools are accessible to children and families, and may be less intimidating and stigmatising than hospitals or clinics. Moreover, providing mental health services in schools can facilitate the removal of emotional and behavioral barriers to learning, thereby enhancing the students’ potential for academic success (Walter, Gouze and Lim 2006). Schools that provide school-based mental health services overwhelmingly report fewer course failures and higher grade point averages compared to schools without such programmes. (CSMHA 2003). In addition, numerous studies have found that skills-based health education can equip young people to manage relationships, cope with stress, and resolve conflicts (Greenberg et al. 2003). Importantly, students who acquire these skills and learn in a supportive school climate perform significantly better academically (Durlak and Wells 1997). When students feel connected to their school as a caring community, they are less likely to engage in risk behaviors such as smoking, drinking, drug use and early sexual initiation, and perform better academically (Blum and Ellen 2002). Schools can also positively influence student mental health by encouraging open communication and by promoting equal opportunities for all students (WHO 2003). Teacher-student relationships have been shown to be among the most influential school psychosocial influences on student mental health (Undheim and Sund 2005). WHO has defined a Health Promoting School as ‘a school that constantly strengthens its capacity as a healthy setting for living, learning and working and which fosters health and learning with all measures at its disposal’ (WHO 2008: online) A Health Promoting School unites policy, skills-based health education, a healthy physical and psychosocial school environment, and access to services to provide a comprehensive approach. There is considerable emphasis on engaging health, mental health and education officials, teachers, teachers’ unions, students, parents, health providers and community leaders in planning and designing the policies and interventions to make the school a healthy place. Schools and ministries of education, working with ministries of health (including mental health), require certain capacities and know-how to implement this comprehensive approach. An important first step in the development of school-based mental health services is a needs assessment (Walter et al. 2006). This serves to ensure that services are planned based on the identified needs of the local population. Needs assessment involves the synthesis of views about the mental health needs of children from stakeholders involved in their care. These include educational departments, teachers, parents, pediatricians, social services and children themselves. It is likely that each of these sources of information will bring different perspectives, with schoolteachers being more likely to view mental health needs not only from the child’s perspective, but also from the perspective of the impact that the child’s problems many have on the school, other pupils or both (Rahman et al. 2000). Most schools in Nigeria do not have school nurses, but teachers and staff may have knowledge about the health needs of students that the family is unaware of, and they could be trained to carry out simple psychosocial interventions and act as sources of referral. As a preliminary first step in the development of school-based mental health services in Nigeria, this study aimed to obtain information on perceived mental health needs in primary (elementary) schools using focus group discussions with school teachers. Method This study was carried out in Ibadan, a semi-urban city located in South-West Nigeria. Ibadan has a population of about two million (NPC 1999). This was a cross-sectional qualitative study and part of a larger study consisting of both key informant interviews and focus group discussions. Only the focus group discussions are reported in this manuscript. Approval for the study was obtained from
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the Oyo State Ethical Research Committee in the Ministry of Health, and the Oyo State Ministry of Education. Sample There are a total of 11 local government areas (districts) in Ibadan and every local government has a Local Inspector of Education (LIE). In order to ensure representation of the population of primary school teachers in the study site, one rural and two urban local government areas were randomly selected. From these, the respective LIE’s submitted names of schools and head teachers within their district. Six urban public, Six urban private and five rural public schools were randomly selected, making a total of 17 schools. The head teachers from the selected schools were contacted and informed about the project. Each head teacher then randomly selected teachers to participate in the focus group. There were six focus groups in all and each lasted about two hours. Every focus group had eight to ten teachers from three different schools making a total of 56 focus group participants. In the urban areas, teachers from public schools were interviewed separately from those in private schools. No teacher received more than 24 hours notice about the project and many were informed only on the morning of the focus group and accepted the invitation to participate in discussions about child mental health issues in schools. The objective of the project was provided at the beginning of each focus group and teachers were provided with consent forms as well as the opportunity to withdraw. The interviews were held at the selected schools to make it easier for teachers to participate. Instrument A focus group question guide was used for all the interviews. Over 30 questions were originally developed and then narrowed down to 12, which were reviewed with a primary school teacher who helped develop probes for each question. A few adjustments were made to the question guide based on responses from the first focus group, which served as a pilot, and eventually 11 selected questions were discussed during every interview. All the urban focus group discussions were conducted primarily in English and the rural focus groups were conducted primarily in the local language (Yoruba). The question guide aimed to assess the teachers’ perspectives on the following: 1. Mental health problems in primary school children. 2. Resources currently available to tackle mental health problems in primary schools. 3. Resources needed to address mental health problems in primary school children 4. Barriers to children receiving mental health care. Data analysis The interviews were transcribed and reviewed independently by the researchers. Statements were analysed using interpretative phenomenological analysis (Smith and Osborn 2004). This analysis involved reviewing all the interviews to identify and extract emergent themes, which were categorised and coded. Recurrent themes were identified and explored by the investigators. Potential sources of researcher bias were identified and addressed by maintaining a reflective journal, reflecting on presuppositions, and conducting the full literature review after completing the data analysis. Results Demographic data There were 36 (64.3%) female and 20 (35.7%) male teachers who participated in the study. Each focus group had more males than females, which is representative of the distribution of teachers in most primary schools in Ibadan.The mean age of the teachers who participated in the focus groups was 39.5 years (SD = 8.9 years), with an age range of 23 to 57 years. The average number of years of teaching was 13.93 years (SD = 8.3 years) with a range of 2–34 years. See Table 1 for the demographic information of the focus group participants.
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Table 1: Focus group participant demographic data (n = 56) Demographic data Districts Akinyele (rural) Ibadan North (urban) Ibadan North-West (urban) School type Urban private Urban public Rural public Religion Christian Islam Educational level Post-secondary University degree Teaching qualification Yes No
n (%) 17 (30.4) 18 (32.1) 21 (37.5) 19 (33.9) 20 (35.7) 17 (30.4) 46 (82.1) 10 (17.9) 39 (69.6) 17 (30.4) 51 (91.1) 5 (8.9)
Focus groups 1. What comes to your mind when you hear about ‘mental illness’ or ‘mental health problems’ in children? The most striking theme was the tendency of participants to use terms that associated mental illness with learning problems. Focus group participants (FGPs) described their first thoughts of mental illness with terms like, ‘low IQ’, ‘mentally retarded’, ‘imbecile’, ‘insane’, ‘moron’, ‘learning disability’, ‘psychological problems’, ‘abnormal behaviour’, and ‘lack of proper reasoning capacity’. FGP’s from some of the urban private schools were less likely to use these terms when asked about mental illness in children. 2. What are the causes of ‘mental illnesses’ in children? The most common theme that emerged from all the focus groups was that mental health problems resulted from contextual factors and only secondarily from genetic predisposition. Poverty, spiritual causes and problems with family supports were among the more common themes to emerge from the focus groups. Poverty leading to poor nutrition, child labour and poor quality of the living environment was seen as an important contributor to mental illness. ‘Most problems we are having in this country can be based on poverty. When a child lacks food to eat, clothes to wear, all these worries can cause mental illness.’ Problems with family supports included family disruption and conflicts, parental neglect, polygamous families, emotional problems in parents (including maternal mental health problems), and the status of being a foster child. Teachers identified spiritual forces as one of the main etiologies of mental illness in children and stressed the importance of this in the African setting. Both urban and rural FGPs discussed this in detail although some were initially reluctant to reveal their thoughts. FGPs believed that spiritual forces could be used to inflict mental illness in a child especially in polygamous families due to rivalries among the wives/mothers. ‘I believe that the root cause of mental imbalance in children is the curse from the family. We have polygamous families … you see the wife trying to make her own children better and go to the extent of doing some juju [supernatural power] to make the children of the other wife look dull or mentally imbalanced. That is the major cause [of mental illness].’
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Psychoactive substance use, genetic transmission, perinatal problems, head trauma, medical illnesses, peer influences, sexual abuse, teachers’ attitudes and religious practices were also described as causes of mental illness. 3. How would you identify children in your class or school who have mental illness or mental health problems? Teachers discussed different signs and symptoms of mental illness in children. The common theme described in every focus group was poor academic performance. Children who are inattentive, do not respond to teachers, fail to do their homework, do not follow instructions and have difficulty concentrating in class were given as examples. Some felt these were signs of laziness in children and not mental health problems. The description of different behaviours was another common theme. A wide range of behaviours were described as evidence of mental illness by the FGPs; such as a dull, unhappy look and being socially withdrawn and extremely quiet. Other behaviours, such as bullying, restlessness, impulsivity, aggressive behaviours, stealing, telling lies and truancy, were described. Talking irrationally or excessively and talking to self were described as manifestations of mental illness by the FGPs. Other manifestations included smiling and laughing inappropriately. Physical appearance such as untidy appearance and abnormal shape of the head were described as ways to identify mental illness in children. ‘If you see the shape of the head, you will know that something has gone wrong with the boy. The mother told me she gave birth to him at home and the child fell and smashed his head. So this affected the poor boy.’ FGPs attempted to classify mental illnesses in children and described differences between major and minor mental illnesses. Minor mental illness was amenable to their interventions at school, while major disorders were not. Some FGPs felt mental retardation should be handled in special schools, while the minor issues such as poor concentration and low interest could be tackled in regular schools. 4. What approaches and resources currently exist to address mental illness or mental health problems in your school? FGPs identified three key areas of intervention focusing on the parent, child, or the school/class environment. Parent-focused intervention was the most common theme in all the focus groups. Virtually all participants described involving parents by inviting them to school, informing them about the child’s problems and in some cases providing advice and counselling. Child-focused interventions ranged from keeping the child busy, providing extra assistance, praising good behaviours, encouragement, individual counselling, prayers, religious counselling, general moral instruction, disciplinary measures and provision of financial assistance. Corporal punishment was mentioned as a tool to address mental illness and mental health problems in schools. Most FGPs utilised this method and felt that the cane was a multipurpose tool and an effective intervention. ‘We cannot do without cane. The child we think is about to be insane and is getting wild, we threaten with sticks or cane. You beat the nonsense out of him and leave common sense.’ Some of the FGPs from urban private schools were not too keen on the use of the cane as they felt it could have adverse consequences on school performance. One of the FGPs identified some of the limitations of the cane to control behavious problems. ‘From my own experience I discovered I was able to curtail the activity of the pupil temporarily with my cane for that period. Immediately I finished the lesson they picked up the attitude again.’ 5. What resources are available in your community to address mental health issues in children? FGPs generally agreed that most of their communities had no resources to address mental health problems. A few mentioned special schools, juvenile remand homes (correctional facilities), teaching hospitals, churches and mosques.
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6. Do you think that teachers know about mental illness and mental health problems presently? The overwhelming majority of FGPs felt teachers did not know enough about mental illness or mental health problems. Some reported that they could handle ‘psychological problems’, but not ‘mental health problems’.
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7. Would you feel comfortable asking a child about mental illness or mental health problems? FGPs generally expressed a comfort level talking to children about mental health issues. 8. How do you think parents would feel about mental health issues being addressed in schools? The majority of FGPs from all the schools sectors felt most parents would be receptive to school mental health programmes because of the high regard they have for teachers, and felt only a few parents would be apprehensive about the programme. ‘They will appreciate it if it will not cost them money.’ ‘Most of them will appreciate it while some may not. You may not be able to give advice to some parents because of their traditions and beliefs. All they want is that you teach their child and have nothing to do with their health.’ 9. What resources do you feel would be necessary in order to address mental health issues in school? The FGPs described human and material resources they perceived would be important for a successful school mental health programme. Training of teachers and availability of child mental health specialists within schools were identified by FGPs as important. Availability of health centres close to or within schools was also felt to be important. 10. What barriers exist which prevent children receiving mental health treatment in schools and the community? Poverty, ignorance, stigma and a lack of resources were the major themes that evolved as the predominant barriers preventing children from receiving mental health care. ‘Some parents would rather get herbs for treatment than seek medical treatment.’ ‘Nowadays we have many churches around. When a child is sick they will take the child for deliverance. I’m not saying that our churches are not trying, but deliverance might not be the first solution. Such a child can go to the hospital first.’ 11. If you were in charge of creating a school mental health programme, what suggestions would you have for school administrators and policy-makers? The FGPs gave key recommendations for a successful school mental health programme. They discussed government policies, training, awareness campaigns, accessible facilities and the involvement of all stakeholders. ‘I will like the government to put health care in the school curriculum.’ ‘NGO or governmental organisations can organise training on weekends or during vacation for teachers.’ ‘Public awareness is also very essential on radio, television, posters, etc.’ ‘There should be a programme like the immunisation program going from house to house to vaccinate children with mental illness.’ Discussion Perceptions of mental health problems in children The views of Nigerian primary school teachers on mental health problems in children are very similar to that of school administrators and head teachers (Ibeziako, Omigbodun and Bella 2008). Like the administrators, teachers used a wide variety of outdated and stigmatising expressions to express their understanding of mental illness in children. Teachers from urban private schools were less likely to use these terms and their responses were indicative of greater awareness of
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mental illness in children. This may be due to a higher level of education attained by these teachers compared with those from rural schools. Many FGPs used the term ‘mental illness’ interchangeably with ‘mental retardation’. Terms like ‘laziness’, ‘wickedness’ and ‘extrovert’ were used to describe problematic behaviours, which were not seen as illness. The term ‘mental health problems’ also elicited a broader and more inclusive response than ‘mental illness’ across the board and there was some resistance among respondents to identify certain behaviours as illness. A wider range of aetiological factors were elicited by the teachers than the school administrators and head teachers (Ibeziako et al. 2008). These include psychoactive substance use, peer influence and harmful religious practices, as well as problems with primary supports, poverty, spiritual causes and genetic transmission. This observation may be due to the larger number of participants in the focus group discussions. In addition, group dynamics may have facilitated broader discussions among the participants, thus yielding a wider variety of ideas about possible aetiological factors. School administrators and head teachers were interviewed on their own. While administrators mentioned poor academic performance as one of the signs of mental illness in children, teachers focused on it as the most important sign. Studies have shown that teachers are likely to highlight problems which interfere with the learning process (Mansour et al. 2002). Teachers in this study also went further to classify mental illnesses into major and minor according to their own ability to deal with them. A similar needs assessment for urban elementary schools in a major city in midwestern United States revealed that academic difficulties were the second most common mental health problem identified by teachers after disruptive behavioural disorders (Walter et al. 2006). Poverty was highlighted by the majority of teachers not only as a cause of mental illness but also an important barrier to care. A theme that emerged during the interviews was that children of educated and wealthy parents have a greater advantage and are less likely to have mental health problems. Respondents described the effects of poverty as far-reaching and contributing to parental neglect, child labour, poor nutrition, poor quality of living environment, poor maternal health, poor perinatal care, and lack of adequate school materials. The relationship between poverty and mental illness has long been established. In a recent study, Corrigall et al. (2008) use a more encompassing definition of poverty and argue that health deprivation and adverse events are not just mediators of the poverty–mental illness relationship, but are in fact facets of poverty itself. There is a danger that the role of mental ill-health in maintaining poverty is minimised, and mental health continues to be ignored by governments (Corrigall et al. 2008). Cultural influences were also evident during interviews, as teachers highlighted spiritual problems as contributing to mental illness in children. This is an aspect deeply ingrained in the cultural and spiritual beliefs of the environment. Ohaeri and Fido (2001) report that the majority of families of sufferers of mental illness believed it was caused by spiritual forces. Perceptions about school mental health programmes The majority of teachers were of the opinion that schools are an important avenue for addressing mental health problems in children, and that they (teachers) are in the best position to identify these issues. They reported that children spend more time with teachers at school than with their own parents since the current financial situation in the country necessitates parents spending a large part of their day trying to make ends meet in order to provide for their families. Importantly it was emphasised that many parents look up to teachers and defer to their authority, as happens even in the developed world. A US national study on public knowledge of mental health problems in children reported that over 80% of respondents would choose to approach teachers for help on mental health issues in children (Pescosolido et al. 2008) Respondents in this study described the current role of primary school teachers as educators, counsellors, surrogate parents and even spiritual ministers as part of their routine work. They also described a wide variety of parent-, child- and environmentally-centred interventions currently being used to manage mental health problems in the primary school setting. They were able to identify the limitations of some techniques, such as the use of the cane. This is a form of corporal punishment which is widely accepted in Nigeria and based on strong cultural and religious beliefs, but which has also been associated with risks for child abuse (Ebigbo 1993). In this study, some teachers
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from urban schools expressed a disinclination to use the cane ,even though they still engage in this practice. This reluctance of urban teachers compared with rural teachers may be a result of greater exposure to ideas from the Western world about the consequences of corporal punishment coupled with reduced influence from cultural beliefs. Teachers also recognised their limitations in terms of knowledge, skills and resources to manage mental health problems in children. This was at variance with the views of some school administrators and head teachers who felt teachers had adequate skills and knowledge to handle these issues (Ibeziako et al. 2008).The administrators may have been more reluctant to reveal limitations in the training and skills of their staff; however, limitations in knowledge and skills of teachers are not unique to the developing world. Walter et al. (2006) report that teachers in the US expressed a limited amount of overall mental health knowledge and a lack of confidence in managing mental health problems in their classrooms. Similarly, when tested, only 56% of pre-school teachers in Singapore had a pass mark on the knowledge of childhood developmental and behavioural disorders (Lian et al. 2008) Proposed solutions The willingness of elementary school teachers to deal with mental health issues in schools despite their limitations creates a favourable climate for the development of school-based mental health programmes in Nigerian schools. In Africa, functional school mental health programmes have been reported in only a few countries, such as Tunisia and Egypt (Gaddour 2007) and these have made use of physicians, nurses, health visitors and social workers. This study revealed that Nigerian elementary schools are not equipped with such resource persons; hence teachers currently constitute the only existing resource base for developing elementary school mental health programms. With collaboration and training opportunities, Nigerian school teachers would be able to act as invaluable community mental health resources for child and adolescent mental health. Using teachers for these programmes would also facilitate the implementation and sustainability, as both factors have been linked with use of already existing resources rather than introducing new ones (Han and Weiss 2005). School-based mental health programmes all over the world have been associated with reduction in the stigma of having to attend a psychiatry service (Sinha, Kishore and Thakur 2003) and in the Nigerian context psycho-education would be particularly useful in combating the high level of illiteracy, ignorance and deeply rooted traditional beliefs (Ohaeri and Fido 2001, Omigbodun 2004). In this study, because of teachers’ understanding that mental illness is widely misunderstood in the society, they suggested ways to reduce the influence of stigma by appropriate packaging of the programme, careful selection of words to minimise negative labels and emphasis on going beyond mere public awareness to public enlightenment. The first was described as simply notifying the public about programmes and resources, while the latter involves actually spending time educating the public about the nature of the problem and the need for treatment (psycho-education). There is evidence that school mental health policies incorporated the following components, all of which contribute to mental health promotion in schools: raising public awareness to create demand, building collaborative relationships, addressing stakeholder concerns, generating funding, providing adequate teacher training and support, forming a steering committee, and implementing services (Adelman and Taylor 2006, Weist and Paternite 2005). One limitation of a Nigerian school mental health programme is that many of the most vulnerable Nigerian children are not in school for reasons such as family and national poverty, coupled with an increasingly fragile social support system (Olley 2006). However, it is encouraging to note that the south-west of Nigeria, where this study was carried out, still has the highest rate (86%) of school attendance in the country (Orc Macro 2004) and the majority of children in this sub-region would therefore benefit from a school mental health programme which could later be disseminated to other parts of the country. Thus it is important not to neglect the needs of those who are now accessible in the hope that in future other populations can be served as resources expand.
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Conclusion The findings from this study provide a background for understanding the current state of addressing child mental health problems through school interventions. Key findings from this study reveal that while there are fundamental gaps in the knowledge of elementary school teachers about mental illness in children, these issues are present in schools and there was an overwhelmingly positive response for the development of school-based mental health programmes. The need for training of personnel at many levels of the system, the inclusion of parents in the educational process and involvement of all stakeholders including the government were all highlighted. The study was carried out in South-Western Nigeria and the small sample size may limit the ability to generalise for the rest of the country. The study did not include the perspectives of parents, children and healthcare providers who could potentially provide additional insight into the mental health needs of children. As far as the authors are aware, this is the first needs assessment identifying primary school mental health needs as perceived by teachers in a Nigerian context. The benefit to communities and to the nation will be evident as demonstrated worldwide in other settings. References Adelman HS and Taylor L (2006) The Status of Mental Health in Schools: A Policy and Practice Brief. Los Angeles: UCLA School Mental Health Project Blum RW and Ellen J (2002) Work group V: increasing the capacity of schools, neighborhoods, and communities to improve adolescent health outcomes. Journal of Adolescent Health. 31: 288–292 CSMHA (Center for School Mental Health Assistance) (2003) Outcomes of Expanded School Mental Health Programs. Available at: http://csmha.umaryland.edu/resources.html/resource_packets/download_files/ outcomes_ESMHP_2003.pdf [Accessed 7 January 2008] Corrigall J, Lund C, Patel V, Plagerson S and Funk MK (2008) Poverty and mental illness: fact or fiction? Social Science and Medicine 66: 2061–2066 Dogra N and Omigbodun O (2004) Partnerships in mental health are possible without multidisciplinary teams. British Medical Journal 329: 1184–1185 Durlak JA and Wells AM (1997) Primary prevention mental health programs for children and adolescents. American Journal of Community Psychology 26: 775–802 Ebigbo PO (1993) Child abuse and neglect in Nigeria – a situation analysis: Nigeria’s population. Quarterly Journal of Population Activities in Nigeria 10: 4 Gaddour N (2007) Child and adolescent mental health Profile in Tunisia. Paper presented at IACAPAP Study Group, 16–20 March, Nairobi, Kenya Greenberg MT, Weissberg RP, O’Brien MU, Zins JE, Fredericks L. Resnik H and Elias MJ (2003) Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist 58: 466–474 Han SS and Weiss B (2005) Sustainability of teacher implementation of school-based mental health programs. Journal of Abnormal Child Psychology 33: 665–679 Ibeziako PI, Omigbodun OO and Bella TT (2008) Assessment of need for a school-based mental health programme in Nigeria: perspectives of school administrators. International Review of Psychiatry 20: 271–280 Kessler RC, Berglund P, Demler O, Jin R, and Walters EE (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 593–602 Kury KW and Kury G (2006) An exploration into the internal dynamics of a school-based mental health collaboration. Journal of School Health 76: 164–168 Lian WB, Ying SH, Tean SC, Lin DC, Lian YC and Yun HL (2008) Pre-school teachers’ knowledge, attitudes and practices on childhood developmental and behavioural disorders in Singapore. Journal of Paediatrics and Child Health 44: 187–194 Mansour ME, Kotagal UP, DeWitt TG, Rose B and Sherman SN (2002) Urban elementary school personnel’s perceptions of student health and student health needs. Ambulatory Pediatrics 2: 127–131 NPC (National Population Commission) (1999) Nigeria Demographic and Health Survey. Nigeria: National Population Commission Ohaeri JU and Fido AA (2001) The opinion of caregivers on aspects on schizophrenia and major affective disorders in a Nigerian setting. Social Psychiatry and Psychiatric Epidemiology 36: 493–499 Olley BO (2006) Social and health behaviours in youth of the streets of Ibadan, Nigeria. Child Abuse and
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