Do school teachers and primary contacts in residential youth care institutions recognize mental health problems in adolescents?

Compared with other children, adolescents in contact with the Child Welfare System (CWS) tend to be less successful later in life across a wide range of areas [1, 2]. These adolescents experience problems with mental health, drug addiction, crime, poor education, and unemployment [3, 4]. According to Harpin et al. [5], out-of-home youth in Ireland had greater risks (suicidal risk, mental health distress) and fewer protective factors (feeling that parents and other adults care about them and a sense of school connectedness) than those in the comparison group. Several studies have confirmed that CWS clients have more mental health problems than others [6, 7]. A recent Norwegian study reported that 76.2 % of the youth living in residential youth care (RYC) in Norway fulfilled the symptoms, onset, duration and impairment criteria for at least one DSM-IV diagnosis. That study reported higher prevalence rates for depressive and anxiety psychiatric disorders than for behavioral disorders [8]. The most frequent diagnoses or diagnostic categories observed were depression and dysthymia (37.3 %), followed by any anxiety disorder (34.9 %), Attention Deficit Hyperactivity Disorder (ADHD) (32.3 %) and Asperger’s Syndrome (AS) (23.2 %); however, only 37 % reported receiving help for these diagnoses. According to Levitt [9], there is a significant gap between children in the CWS population who need services and children who receive services, as the majority of child welfare agencies do not systematically screen children in the CWS for mental health problems.

Adolescents who have been removed from home because of a lack of adequate parental care rarely have access to consistent educational support, which is a resource that is taken for granted by most adolescents who live with their parents [10]. There is no reason to think that adolescents in RYC are better off in this area. In general, adolescents in out-of-home care are at a high risk of having poor educational outcomes [11‐13], and they have lower rates of school attendance [14], more cases of drop-outs [15] and lower grades compared to children living at home [16].

School failure is one of the more serious negative outcomes for young people in CWS. International studies have consistently shown that they score significantly below their peers on a range of school outcome measures [17]. In a Norwegian study by Clausen and Kristofersen [12], 35 % of former CWS clients had completed high school, compared to 80 % of a non-client sample. Similar results have also been found in Sweden [13]. Jaffee and Gallop [18] found that relatively few CWS adolescents (approximately 40 %) function normally in school and that even fewer are resilient across several domains, i.e., school achievement, mental health, and social competence. In addition, caregivers’ attitudes towards school may influence children’s success in school [19]. Marginalization and social exclusion are considered to be outcomes of a lack of coping in school [20, 21], as education plays a major role in an individual’s ability to successfully settle into adult life.

It has also been reported that adolescents’ secondary school careers are negatively affected by the presence of acute psychosocial health problems [22]. Kessler et al. [23] have reported that in the United States, adolescents with psychiatric disorders account for 14.2 % of high school dropouts. Furthermore, externalizing problems are reported to impair educational attainment [24]. Poor educational attainment has also been found to predict the onset of schizophrenia spectrum disorders [25].

Adolescents in RYC do not have parents to attend to their needs, and they depend more on other people, for example on primary contacts in RYC institutions or teachers, to disclose their problems. Adolescents spend a substantial amount of time in school, and it is therefore important for teachers to help detect serious problems. However, because of residential instability, adolescents in care tend to experience multiple school transfers [26], which makes it difficult for teachers to observe symptoms over time. On the other hand, for some adolescents in RYC, teachers may be among the more stable persons in their life.

Studies have shown that teachers in Scandinavia generally report relatively low levels of emotional/behavioral problems among school-aged children [27]. However, we do not know how well teachers detect mental health problems in children living in RYC, who, according to studies, suffer from far more mental health problems than the general population [6].

Teachers are reported to be more accurate in identifying children who are at risk of externalizing disorders than those at risk of internalizing disorders [28]. Internalizing problems such as feelings of depression or loneliness are presumably less observable and depend more on interpretation by informants than externalizing problems such as fighting or teasing. Recognizing mental health problems, however, is very important among adolescents living in RYC, in which more than 70 % of adolescents have been found to meet the criteria for at least one psychiatric disorder [8, 29].

Previous studies on teacher’s reports of adolescent mental health problems most often included adolescents living with families and often focused on younger children. To our knowledge, no studies have focused on adolescents living in RYC institutions and their situations at school. Earlier studies tended to include children in the CWS system in general.

The aim of the present study which is part of a larger study on adolescents in RYC was to explore whether mental health problems, as assessed by The Child and Adolescent Psychiatric Assessment (CAPA) [30], among adolescents living in RYC institutions were detected by primary contacts at their institutions and their teachers. The research question was whether adolescents’ internalizing (affective and anxiety) disorders, conduct disorder (CD) and ADHD problems as reported by teachers and primary contacts were consistent with the diagnostic categories identified in CAPA [30]. As the symptoms of externalizing (CD) problems and ADHD are more easily identified as disruptive, we hypothesized that teachers and primary contacts would more easily detect these two categories than internalizing problems.

This paper focused on how well teachers and primary contacts in RYC institutions identified adolescents’ mental health problems as determined by the CAPA diagnostic interview. We observed that there was a significant gap between the mental health problems diagnosed by the CAPA interviews and the problems reported by the primary contact on the CBCL and by the teachers on the TRF. In general, we observed that the reports from the primary contacts showed a higher sensitivity across all diagnostic categories than those of the teachers. This indicates that when adolescents do have a psychiatric disorder, primary contacts are better at identifying this than teachers. Teachers’ ratings showed a higher specificity across all diagnostic categories than those of primary contacts. This indicates that when adolescents do not have a psychiatric disorder, teachers are better at recognizing this than the primary contacts. Ideally, when using any screening instrument, both sensitivity and specificity should be high, thus ensuring that the right individuals are identified with a diagnosis and avoiding overdiagnosis.

As adolescents living in RYC institutions do not have parental educational support, it is up to the institutional staff to meet this need. It is important to identify factors that facilitate healthy adaptation to school for these adolescents to succeed in school. Improving mental health problems is one of these factors, as mental health issues are an important barrier to learning [24]. Teachers were quite good at identifying adolescents who did not meet the criteria for a diagnosis (specificity). This suggests that teachers have a tendency to view these students as healthy and may underestimate the severity of their problems.

On the other hand, adolescents’ primary contacts may overestimate the prevalence of mental health problems and view individuals as more sick than they are. A disadvantage of this perspective is that adolescents may be treated as sick when they are not; they may thus be given fewer responsibilities and fewer demands instead of being encouraged to push themselves and do their best. Underestimating these adolescents and feeling sorry for them because of their previous challenges and experiences is understandable. However, they, more than others, need people to believe in them, encourage them to work, and believe in their ability to succeed. In addition, caretakers’ attitudes towards school have been reported as being important for children to succeed in school [19]. In general, studies have reported that adolescents in out-of-home care are at a high risk for poor educational outcomes [11, 13]. This is a serious problem, as we also know that education plays a major role in successful adult life [38]. Enhancing the educational performance of young people in RYC requires daily and pervasive educational support and encouragement [39]. Both teachers and care persons should work together towards these goals.

Primary contacts were quite good at identifying adolescents who had a diagnosis (sensitivity), whereas teachers had a tendency to underestimate these problems, which is consistent with results from Larsson and Drugli [27] on school-aged children. Adolescents in RYC are dependent on caretakers and teachers to identify their problems. The present study shows that primary contacts detect adolescents’ mental health problems to a certain degree. However, as very few of the adolescents from our study report receiving help for their problems from mental health clinics (37 %, [8]), the institutions do not seem to refer these adolescents to treatment. If RYC personnel or teachers do not act, these adolescents will not receive the help that they need as few adolescents call on medical or other services themselves if they suffer anxiety or feel depressed. This situation is noteworthy. The availability of psychiatric services for this group is further discussed in another paper from the same study [8].

With CBCL sensitivities ranging from 0.60 to 0.82 across the four diagnostic categories based on primary contacts’ reports and sensitivities of the TRF ranging from 0.39 to 0.54 according to teachers, many mental health problems may go undetected. The fact that approximately 76 % of the adolescents in the present study qualified for at least one psychiatric DSM-IV diagnosis [8] shows that there is a gap between the true prevalence of mental health problems (CAPA diagnosis) and the problems reported on the CBCL and TRF.

Suffering from mental health problems prevents individuals from fully focusing on schoolwork. It is therefore very important for caretakers and teachers who see these adolescents every day to recognize their mental health problems and refer them to treatment. These adolescents may also need adjustments in school to promote optimal learning. This is important because education is reported to provide better prospects for an individual’s future [40].

Sensitivity and specificity measure the performance of the cut-off values used to identify adolescents within a borderline range. The fact that the CBCL had a higher sensitivity than the TRF, whereas the TRF had a higher specificity than the CBCL, could be explained by the higher cut-off points for the TRF compared to the CBCL as illustrated in the ROC curves. The area under the ROC curve is a measure of the ability of the value to discriminate between clinical cases and non-clinical cases. This area was similar for the CBCL and TRF for all diagnostic groups.

The hypothesis that externalizing problems would be easier to detect was confirmed, consistent with previous literature [28]. Both primary contacts and teachers classified externalizing problems fairly well such as ADHD in both genders and CD in girls, with AUCs between 0.7 and 0.8, which is considered acceptable [37]. It is understandable that externalizing problems are easier to detect, as some symptoms manifest themselves as disturbing elements that can easily be observed because they may interrupt regular activities. Externalizing problems are also reported to impair educational attainment [24]. Furthermore, learning and behavior problems are often related [41], and these adolescents may be at risk for developing behavioral issues if help is not introduced early enough. It is worth noting that several adolescents had externalizing problems that were undetected by caretakers and teachers, and these adolescents also need help.

Both teachers and primary contacts struggled more in recognizing internalizing problems. They poorly identified affective disorders and anxiety in both genders and CD in boys, with AUCs of their corresponding scales below 0.7, which is considered poor [37]. One exception was the use of the CBCL to detect affective disorders in girls, with an AUC = 0.73, indicating that primary contacts detected these problems at an acceptable level. Internalizing problems, such as depression and anxiety, are more hidden and could be concealed in subtle behavior. These problems are often disguised as withdrawal and passive behavior, and staff and teachers could easily think that adolescents with these problems are shy or want to be left alone. However, it is an important problem that serious diagnoses such as depression and anxiety are so modestly detected by caretakers and teachers. Who else is in a position to identify these problems among these adolescents?

In the present study, there was a mismatch between the DSM-IV diagnoses among adolescents in RYC and the problems reported by their primary contacts and teachers. Primary contacts’ reports showed a higher sensitivity than those of teachers, whereas the teachers’ TRF scores showed a higher specificity in detecting mental health problems in adolescents in RYC than the primary contacts’ CBCL reports. Both primary contacts and teachers recognized externalizing problems such as ADHD fairly well in both genders as well as CD in girls. Both teachers and primary contacts, however, had more problems detecting internalizing problems. It would be important to create interventions with primary contacts, teachers, and youth to educate and raise awareness about emotional problems. Peer identification is another strategy which also has shown effectiveness amongst youth and might be a resource worth considering in the future. Further studies should investigate this topic more carefully to ensure that these vulnerable adolescents receive sufficient help for their problems. CWS should revise their intake procedures so that possible problems are detected early and that the necessary treatment is introduced.