Acceptability of screening for mental health difficulties in primary schools: a survey of UK parents

Role of schools in identifying children at risk of poor mental health outcomes

Schools can play a unique role in the early identification of MHD, particularly as they are the setting in which most mental health related service contacts currently occur [24, 26–29]. From a practical standpoint, schools reach the vast majority of CYP in the UK [23], including CYP from marginalised populations, who experience MHD at higher rates than their peers and access care less readily [2]. Furthermore, the large number of contact hours means that teachers and other school staff are well placed to notice changes in behaviour and demeanour that may signal that a student is experiencing MHD [30]. Finally, the majority of all lifetime mental disorders will begin during the schooling years [31], emphasising the opportunity that schools offer for early identification and intervention.

The UK government has emphasised the role of schools in identifying CYP with MHD and linking them with care and support [32]. The National Institute for Health and Care Excellence and the Commission on Children and Young People’s Mental Health expect teachers to be able to identify and assess early signs of MHD in their pupils [33, 34]. The UK Education and Health Committees further note that schools have a unique insight into pupils and are well placed to recognise difficulties, including those not identified at home or to complement what is observed at home [35]. However, despite these expectations, teachers often feel ill-equipped to recognise signs of MHD [12, 36], especially as mental health is poorly covered in most teacher training curricula.

School-wide screening for MHD

School-wide screening programmes have received significant attention for their potential to identify MHD in CYP [13, 24, 27, 37]. These programmes feature systematic identification of pupils at-risk for poor mental health outcomes, as identified by the presence of symptomatology or functional impairment. School-wide screening programmes show some promise in terms of enhancing identification and linking CYP with appropriate support [38].

In addition to effectiveness, acceptability must be a key consideration in the development and evaluation of school-based identification programmes. The World Health Organization identifies acceptability as a cornerstone of any successful screening programme [39]. Similarly, the UK National Screening Committee cites acceptability as one of the key criteria that must be met before a screening programme can be implemented [40]. Acceptability is particularly important in the context of screening for MHD due to associated stigma [27, 37] and significant difficulties surrounding schools’ communication and cooperation with mental health services [41].

Current study

The current study reports results of a cross-sectional survey of parental attitudes towards school-wide screening for emotional and behavioural difficulties in four UK primary schools. The survey is part of the DEAL (Developing Early Identification and Access in Learning Environments) study, which aims to develop an evidence-based prototype school-based programme for the identification of and response to MHD in primary school children. DEAL focuses on primary schools for epidemiological, policy, and pragmatic reasons. First, many lifetime mental disorders begin during the primary school years (for example, anxiety and impulse control disorders each have a median age of onset of 11 years [31]). Second, national UK guidelines have set forth expectations for the identification of MHD in primary schools [33]. Finally, from a practical standpoint, there are often stronger links between schools and parents of primary school aged children compared with those of secondary school aged children [42].

In order to inform programme design, the survey sought to (1) assess whether school-wide MHD screening was acceptable ‘in principle’ to parents of primary school children, (2) determine some of the preferred characteristics of an acceptable screening programme, and (3) identify anticipated benefits and harms of screening. The results from this survey, in combination with other components of the DEAL study (i.e. evidence reviews and in-depth parent and school staff interviews surrounding the strengths and limitations of multiple identification methods) will inform the design of an identification model. Furthermore, the findings from the survey are among the first published from UK data on the acceptability of screening in primary school settings, and can inform the debate on the practical role that schools can potentially play in delivering the UK public mental health response.

Participants

Instrumentation

Due to the lack of an existing measure of parental attitudes toward MHD screening, we collaborated with experts in school-based mental health to develop a questionnaire to measure the acceptability of screening. We used findings from a review of the literature and known uncertainties about the acceptability of the screening process to develop the questionnaire. Questionnaire items aimed to understand parents’ opinions regarding early identification of MHD, schools’ role in MHD identification, anticipated harms and benefits of screening, and key components of acceptable screening programmes. Patient and Public Involvement (PPI) groups, an occupational psychologist, heads of participating schools, and other school staff reviewed the questionnaire. PPI members suggested simplifying wording, shortening the questionnaire, highlighting information about the participation incentive, and excluding two questions on family life and parent educational qualifications. All stakeholders approved the final version of the questionnaire. We did not compute a generic reliability estimate for the questionnaire given that it had no overall score or underlying construct.

The first page of the anonymous questionnaire (Additional file 1: Appendix C) explained the purpose of the questionnaire, defined emotional health and emotional health difficulties, explained what was meant by ‘screening’ and ‘emotional health checks’ (used synonymously throughout the questionnaire), and gave instructions for completion. The questionnaire explained screening as ‘the collection of information about the emotional health and wellbeing of all children in a school’ in order to ‘detect people with early signs of a problem so that they can be offered help at the earliest opportunity.’ As this study aimed to understand parents’ attitudes toward the general concept of screening rather than toward a specific screening programme, we purposely did not give detailed information on how data would be collected, who would fill out screening questionnaires, etc., and instead included questions to determine parents’ preferences regarding these types of programme components.

The questionnaire contained 20 questions. Thirteen statements relating to the acceptability of screening featured a 5-point Likert-type scale (where 1 = strongly disagree and 5 = strongly agree) and included the additional answers of don’t know and prefer not to say. The questions were heterogeneous, so we did not calculate an overall score. Open-text boxes where parents could provide additional comments followed two questions about the perceived harms and benefits of screening. In addition, a final open-text box invited parents to share thoughts or comments about screening that were not addressed by other questions. Four final questions asked parents for their age, gender, ethnicity, and the number of children they had in each school year.

Procedures

We collected questionnaires between 17 July 2017 and 12 January 2018. Schools communicated initial information about the DEAL study to parents via mailings, letters in book bags, video clips, in-person communications, Facebook posts, and information presented on school websites, and sent regular reminders to complete the questionnaire. Furthermore, members of the research team attended schools’ parents’ evenings to encourage participation and answer any questions about the study. Questionnaire packs were distributed to parents through various routes, including in-person at school parents' evenings and via children’s book bags. Each pack contained an invitation letter, a participant information sheet, and a questionnaire (including an explanation of content and instructions for completion) (see Additional file 2: Appendix A, Additional file 3: Appendix B, Additional file 1: Appendix C). The participant information sheet (Additional file 3: Appendix B) included detailed information on the study and participation. We indicated on this sheet that participation was voluntary and anonymous, explained the advantages and disadvantages of participating, and described how data would be used. We further explained that parents could give contact details to participate in an interview, and provided information about confidentiality, data storage, and advantages/disadvantages of participating in the interview. We provided contact details for further questions or concerns and ascertained parents’ informed consent by a ticked box on the online version of the questionnaire, or the receipt of a completed paper version.

Questionnaires were also available online through Qualtrics’ online survey platform (www.qualtrics.com). Heads of schools received school-specific links for the electronic version of the questionnaire to distribute via their preferred communication routes (e.g. email, text message, Facebook). To minimise response burden, we instructed parents to fill out only one survey (either hard copy or electronic) per family, regardless of the number of children enrolled in the school. Parents could return completed questionnaires via their child or mail them to the research team using a free post envelope. Parents could also indicate they were not interested in participating in the study by not returning a questionnaire or by returning a blank questionnaire.

Parents from each school who participated in the study were entered into a prize draw for £50 of shopping vouchers. Hard copy questionnaires contained a raffle ticket, and online versions contained randomly-generated raffle numbers that could be printed out or written down. Parents could also enter into the prize draw without completing the questionnaire by returning a blank copy. We also awarded a £50 voucher to the school with the highest response rate.

Analysis

Parent characteristics

Questionnaire responses

Means and frequencies of responses to the 13 Likert-type statements are presented in Fig. 1.

Role of schools in early identification

On the questionnaire, 254 parents (98%) agreed or strongly agreed that it is important to identify MHD early in life (mean = 4.71, SD = 0.63), and 251 (97%) agreed or strongly agreed that schools have an important role in promoting pupils’ emotional health (mean = 4.54, SD = 0.62). The majority of parents (N = 229; 88%) agreed or strongly agreed that schools are well placed to detect emotional health difficulties (mean = 4.32, SD = 0.73).

Benefits of screening

Most parents saw value in school-based screening. The majority of parents (N = 213; 82%) agreed or strongly agreed that screening would be helpful (mean = 4.15, SD = 0.89) but it is worth noting that some parents (N = 13; 5%) disagreed or strongly disagreed with this statement. A sizeable proportion of parents neither agreed nor disagreed that screening was helpful (N = 26; 10%).

Harms of screening

In total, 165 parents (63%) disagreed or strongly disagreed that screening would be harmful to children (mean = 2.33, SD = 1.13). Importantly, 34 parents (13%) agreed or strongly agreed that screening would be harmful, and 39 (15%) neither agreed nor disagreed.

Table 4 shows the themes relating to harms of screening, as included in any of the three open-ended responses. Comments can be divided into harms of MHD screening for the child, harms associated with screening accuracy/reliability, and harms associated specifically with identification in the school setting. Of the perceived harms to children, some were more minor and temporary than others, for example children feeling uncomfortable during screening or not understanding the process. More significant and lasting harms related to the singling out and potential stigmatisation of children and the lack of support available for identified pupils.

There were many concerns regarding the accuracy and reliability of screening. Parents were worried about the effects of false positive and false negative results. Some parents felt that it was difficult to identify MHD in children, and that schools could misunderstand children’s answers. There were also concerns about children giving false answers in order to please adults, or, more seriously, adults leading children into giving certain answers.

Implementation of screening programmes

Most parents (N = 222; 85%) agreed or strongly agreed that they would be prepared to fill out questionnaires on their child’s emotional health. Approximately as many agreed or strongly agreed that they would be prepared for teachers (N = 216; 83%) or their children (N = 206; 79%) to fill out questionnaires. About 8% of parents did not have a strong opinion regarding who should fill out emotional health screening measures. There was no clear consensus regarding the way in which parental consent should be sought; 186 parents (72%) endorsed opt-in consent and 209 (80%) endorsed opt-out, signifying that some parents endorsed both options.

The vast majority (N = 245; 94%) of respondents agreed or strongly agreed that parents should receive individualised feedback on their child’s emotional health, but they were divided on whether feedback should be distributed to all parents, or just to those parents whose children were indicated to be at-risk by the screening programme. While approximately half of respondents (N = 135; 52%) believed that parents should receive feedback regardless of screening results, 94 parents (37%) indicated that parents should receive feedback only if their child was identified as at-risk by the screening. All but 11 respondents (less than 5%) agreed or strongly agreed that they would be willing to work with schools or with other organisations to ensure that their child received any necessary support.

Fisher’s exact tests did not indicate any significant differences in responses by gender, ethnicity, or school for any of the thirteen statements (p > 0.05 for all statements). Age and statement responses were weakly correlated (polyserial correlations ranged from − 0.06 to 0.21.)

Strengths and limitations

This study offers new and valuable information in terms of the public mental health response to MHD in CYP. Our focus on primary school aged children is important given the relative lack of school-based identification programmes for this age group as compared to older students [38]. The survey response rate of 61% is higher than those of similar surveys, which all attained response rates of less than 50% [50, 71–73]. Furthermore, the inclusion of open-ended comments allowed parents to explain their views on screening and its potential harms and benefits. The survey was also one of the first to offer UK-based evidence on the acceptability of screening, which is important given that beliefs about MHD identification may vary by context and culture [24].

We also acknowledge several limitations. First, since there was no existing measure of attitudes about MHD screening, we developed a new measure, which may limit the generalisability of results. Second, following PPI and stakeholder feedback, the questionnaire was simplified and key questions about family life and educational qualifications were excluded. This information would have been useful for understanding whether results differed across groups of parents. Third, anonymous participation was incentivised through use of a prize draw, which might have encouraged duplicate entries. Fourth, we only focused on parents of primary school children. Finally, our sample size was relatively small, and our respondents were largely homogenous in terms of key socio-demographic characteristics, which limits the generalisability of our results. Responding parents were from four relatively deprived areas in two UK counties, 95% of respondents were of White British ethnicity, and 80% were mothers or female guardians. The lack of diversity in our sample is a significant limitation because parents of underrepresented groups may hold different views on the acceptability of screening. Indeed, there is wide cultural variation in views on mental health, and any screening programme must be considerate of these differences [24].

Implications for practice

While school-based screening for MHD has the potential to improve psychosocial outcomes for CYP as part of a multi-tiered system of mental health identification and support, it is first necessary to establish evidence of its effectiveness, acceptability, and feasibility. Determining parents’ views on school-based screening represents an important first step for understanding whether screening programmes for MHD could be feasible and sustainable. Currently, 99% of UK schools report taking action to identify pupils with MHD, but most schools rely on ad-hoc identification by school staff [12]. Schools that do systematically screen for MHD often do so with non-validated measures [12], and many currently-implemented school-based mental health programmes are not evidence-based [11]. In providing evidence of parents’ support for systematic identification, this study supports the further development of primary school screening programmes for MHD.

However, acceptability is just one aspect of the screening guidelines as given by the National Screening Committee. In addition to being acceptable, a screening programme should also be effective in reducing morbidity/mortality, balanced in terms of harms and benefits, and economically feasible [40]. It is currently unclear whether school-based MHD screening would fulfil these other criteria, as evidence on the effectiveness, cost effectiveness, and feasibility of screening is mixed [38, 74]. The potential for harm caused by screening must also be further explored: a recent review of school-based screening across all types of MHD [74] found only two studies in the literature that assessed iatrogenic effects of school-based MHD screening (neither of which found an iatrogenic effect) [52, 75]. Furthermore, the National Screening Committee highlights that there should be accessibility to an effective intervention for any identified individuals [40]. Given that many CYP have limited access to mental health care [21], further investigation is needed into this criterion before the wider implementation of school-based MHD screening programmes.

Implications for future research

More evidence on the acceptability of school-based MHD identification programmes is needed before their widespread implementation in the UK. In particular, future studies must seek to understand the acceptability of screening for parents of minority ethnic groups as well as fathers and male guardians, as these views were under-represented in the current study. Also, as this survey only targeted parents, further research is needed to establish acceptability amongst school staff and mental health professionals. Additionally, the survey focused on identification in primary schools and may not generalisable to other age groups, suggesting a need for more research on programmes designed for older pupils. Finally, this study only reported on school-wide screening for mental health difficulties. Researchers should also seek to understand the acceptability of 1) other types of identification models (e.g. curriculum-based or staff training/teacher nomination models), and 2) more targeted identification of specific types of mental health problems (e.g. risk of suicide).