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Guest Editorial
Neuropsychiatry: Grasping the Body–Mind and Mind–Body Problems
Trevor A Hurwitz
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In Review
The Neuropsychiatry of Multiple Sclerosis
Anthony Feinstein
(PDF)

Non-Alzheimer’s Disease Dementias: Anatomic, Clinical, and Molecular Correlates
Craig E Hou, Danielle Carlin, Bruce L Miller
(PDF)

Somatization and Conversion Disorder
Trevor A Hurwitz
(PDF)

Original Research
Psychiatric Comorbidity and Eating Disorder Inventory (EDI) Profiles in Eating Disorder Patients
Gabriella Milos, Anja Spindler, Ulrich Schnyder
(PDF)

Family Background and Genius
Albert Rothenberg, Grace Wyshak
(PDF)

Barriers to Acess to Mental Health Services for Ethnic Seniors: The Toronto Study
Joel Sadavoy, Rosemary Meier, Amoy Yuk Mui Ong
(PDF)

Review Paper
The Assessment and Management of Antipsychotic-Associated Metabolic Disturbances from a Psychiatric Perspective
Pierre Chue
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Brief Communication
The Feasibility of a Mental Health Curriculum in Elementary Schools
Bianca A Lauria-Horner, Stan Kutcher, Sarah J Brooks
(PDF)

Book Reviews
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Crisis Intervention and Counseling by Telephone. 2nd edition. Reviewed by
George Voineskos, MD

La IIIe révolution du cerveau. Psychobiologie de la personnalité.
Reviewed by
Joanne Cyr, MD, FRCPC

Letters to the Editor
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Level of Functioning in Hypomania of Bipolar II Disorder

Premenstrual Complaints Before and After 40 Years of Age

Norwalk Precipitates Severe Lithium Toxicity

SARS or Not SARS: Outbreak of Fever in a State Mental Institute in Singapore

Conversion Disorder in a Patient With Diffuse Axonal Injury

Brief Communication

The Feasibility of a Mental Health Curriculum in Elementary School

Bianca A Lauria-Horner, MD¹, Stan Kutcher, MD, FRSPC², Sarah J Brooks, PhD³

Most mental health disorders have onset in childhood and adolescence (1). Depression, anxiety, and behavioural disorders such as attention-deficit hyperactivity disorder (ADHD) collectively affect 15% to 20% of youngsters (2). Unresolved mental health problems lead to learning problems, decreased academic performance, more truancy and dropping out, and special education referral (3). Early identification and early effective intervention can improve short- and long-term outcomes (4–7). However, available data indicate that most youngsters with treatable mental disorders are not correctly identified and not appropriately treated (8–11).

Stigma surrounding mental illness remains a significant barrier to help-seeking behaviour, case recognition, and effective treatment (12,13). Dispelling stigma requires community education programs, including school programs, that improve early recognition of the problem, that encourage early help-seeking behaviour, and that create a supportive environment for the individual (14). Extracurricular inter- ventions in elementary schools have been found to decrease the use of special education and conduct problems, to improve academic skills, and to increase positive peer interactions and parent involvement in school (15).

Our project assessed the feasibility of incorporating a mental health curriculum at the elementary level to be taught by schoolteachers. We describe the development, delivery, and short-term impact of this pilot project on children’s knowledge and attitudes. We chose a francophone rural community within a predominantly anglophone province because the community has less access to valid mental health information.

Method

Sample
The sample consisted of all students of a francophone elementary school in rural Nova Scotia, except for 3 fifth graders whose parents denied consent for their participation (n = 158, distributed evenly across the 7 grades). All participating students in school on the allotted assessment days took part in baseline and postcurriculum assessments.

Procedure
The steering committee consisted of 2 of the authors and invited representatives of the target community: a francophone teacher consultant, the principal and vice principal of the participating school, a parent, 3 high school students, and local representation from 6 regional and national health and education organizations. The curriculum was developed in English and translated into French by professional translators. The content was refined to be age- appropriate for 4 grade groups: Grades 1 and 2, Grade 3, Grades 4 and 5, and Grades 6 and 7.

The teachers attended a full-day training workshop at the September 2001 professional development day. The project’s main objectives, the students’ key learning objectives, and the curriculum were detailed.

We obtained written consent of parents or guardians prior to students’ participation in the curriculum. Local committee members played a critical role in obtaining consent by addressing hesitant parents’ concerns regarding this controversial subject. The teachers implemented the curriculum in 4 hourly sessions each week for 16 weeks, replacing the usual health program.

We assessed students’ baseline and postintervention knowledge and attitudes, using age-appropriate individual questionnaires (Grades 4 to 7) containing self-rated and objective assessments of knowledge and attitudes, and by leading focus group discussions (Grades 1 to 7). We repeated baseline assessments of students’ knowledge and attitudes 1 to 2 weeks postcurriculum. Committee members led midcurriculum discussions with teachers and a postcurriculum discussion with teachers and parents to explore observed changes in students’ knowledge and attitudes. An independent evaluator compiled and analyzed the data.

The Curriculum
The curriculum contained 4 modules: expected emotional development, depression, anxiety disorders, and ADHD. Key messages were imparted didactically and through interactive activities designed to elicit thinking and discussion about the issues and to reinforce new information. Key messages included new terminology, information to dispel common misconceptions, warning signs and symptoms related to each disorder, and guidelines on what to do when such symptoms are recognized.

Results

Grades 1 to 3
Students in Grades 1 to 3 who voiced opinions at baseline could provide examples of when they might feel particular emotions (such as sadness or fear) or act in particular ways (that is, doing something inappropriate without thinking). At baseline, students in Grade 1 indicated that they would talk with an adult about feeling scared more readily than about feeling sad. We noted qualitative postcurriculum improvements in first graders’ reported attitudes toward seeking immediate help from a trusted adult when feeling sad and in all 3 grades when having trouble learning (this suggests improvement when compared with baseline responses of waiting until they were in trouble and punished). Qualitative comparison of the 3 grades’ baseline responses suggested that first-grade students were more likely to talk to an adult about problem feelings or behaviours than were second- or third-grade students and that students in Grade 2 would seek help more quickly than would students in Grade 3. Postcurriculum responses reinforced these impressions.

Grades 4 to 7
Of the students in Grades 4 to 7, a total of 92 and 84 were present for baseline and postcurriculum assessments, respectively; those absent, presumably because of illness, were not assessed.

Postcurriculum questionnaires revealed that most students (80% to 89%) self-rated their knowledge of 4 aspects of mental health and mental illness as improved or much improved. Postcurriculum response rates to all questions were significantly higher than at baseline (when nonresponses were common). Further, significantly more correct responses (chi-square tests, P < 0.05) were obtained postcurriculum in questions probing the following facts regarding anxiety and ADHD: the occurrence of these disorders in children, the recovery of people with these disorders, characteristic symptoms, and appropriate actions to take when symptoms are recognized. Knowledge of anxiety and ADHD prevalence rates did not change significantly. Prevalence (unpaired t-test, P < 0.05) was the only aspect of knowledge about depression that showed statistically significant improvement.

Compared with baseline, significantly more students responded and agreed that it was important to know about each of the disorders (chi-square tests, P < 0.05). Likewise, significantly more students at postcurriculum indicated that they would befriend someone with either anxiety or ADHD than indicated at baseline, and fewer students indicated that they would not befriend such a person. The only tested attitude that did not show change was whether students would befriend someone with depression. This null result was attributable partly to compassionate attitudes being fairly common at baseline but also to some residual stigma surrounding depression.

Teachers’ Midcurriculum Feedback
Teachers reported that students in Grades 1 to 3 learned keenly about mental health and showed no reticence in discussing their feelings with teachers. Students in Grades 4 to 7 were also receptive to learning about mental health but were less open to discussing their feelings with teachers. One teacher reported that a child with a disorder featured in the curriculum now felt less shame about the disorder and about taking medication for it and that the classmates were now more accepting of this student.

Parents’ Feedback
Some parents reported noticing improvements in their childrens’ knowledge or attitudes. For example, one parent reported that the child realized, unaided, that an aunt had panic attacks, and several parents confirmed that classmates were more accepting of the aforementioned child with the disorder.

Discussion

We examined the implementation feasibility of a mental health curriculum in a linguistically and geographically isolated francophone community in Nova Scotia by assessing the short-term impact on elementary schoolchildren’s (Grades 1 to 7) knowledge and attitudes regarding mental health and common mental illnesses.

Involving local community members in the project from start to finish was critical to the project’s success. Cooperation of the school staff was excellent. We obtained objective, subjective, and anecdotal evidence indicating improvements in knowledge and attitudes of students in Grades 4 to 7, particularly regarding anxiety and ADHD. We also observed improved knowledge of help-seeking behaviour strategies (in students Grades 4 to 7). We observed qualitative indications that, with increasing age across all 7 grades, children were more reluctant to ask for help, more inhibited when discussing their emotions, and more inclined to harbour negative baseline attitudes about mental health disorders. If school programs on mental health were started at entry level, attitudes of stigma could be lessened.

Long-term goals are to incorporate mental health information into regular school curricula, along with an expanded school-based mental health service (16,17), primary care education, and (or) other care continua where children would have ready access to appropriate resources.

Acknowledgements

This project was sponsored by Health Canada through the Population Health Fund, Rural and Remote Innovations Initiative (project # 6788-03-2000/1890023).

References

1. Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E. Ages of onset of psychiatric disorders in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry 1994;33:706–16.

2. Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab-Stone ME, and others. The NIMH diagnostic interview schedule for children. Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA study. J Am Acad Child Adolesc Psychiatry 1996;35:865–77.

3. Adelman HS, Taylor L. Mental health in schools and system restructuring. Clin Psychol Rev 1999;19:137–63.

4. Casey RJ, Berman JS. The outcome of psychotherapy with children. Psychol Bull 1985;98:388–400.

5. Kazdin AE, Weisz JR. Identifying and developing empirically supported child and adolescent treatments. J Consult Clinical Psychol 1998;66:19–36.

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8. Surgeon General’s Report on Mental Health. Available: http://www.surgeongeneral.gov/topics/cmh/default.htm. Accessed 2002 June (updated May 27, 2003).

9. Bijl RV, de Graaf R, Hiripi E, Kessler RC, Kohn R, Offord DR, and others. Health Aff (Millwood). The prevalence of treated and untreated mental disorders in five countries 2003;22:122–33.

10. McCarthy J, Boyd J. Mental health services and young people with intellectual disability: is it time to do better? J Intellect Disabil Res 2002;46:250–6 (part 3).

11. National Institute of mental health. Available: http://www.nimh.nih.gov/publicat/childnotes.cfm. Accessed 2002 June (updated October 2003).

12. Starr S, Campbell LR, Herrick CA. Factors affecting use of the mental health system by rural children. Issues Ment Health Nurs 2002;23:291–304.

13. Wahl OF. Mental health consumers’ experience of stigma. Schizophr Bull 1999;25:467–78.

14. Health Canada. A report on mental illnesses in Canada. Ottawa: Health Canada; 2002. Mental illnesses in Canada: an overview (chapter 1). Available: www.hc-sc.gc.ca/pphb-dgspsp/publicat/miic-mmac. Accessed 2002 June.

15. American Psychological Association. School-based interventions with successful academic outcomes 2003. Available: http://mirror.apa.org/ppo/issues/pschoolbased.html Accessed 2003 July.

16. Flaherty LT, Weist MD. School-based mental health services: the Baltimore models. Psychology in the Schools 1999;36:379–89.

17. Noam GG, Hermann CA. Where education and mental health meet: developmental prevention and early intervention in schools. Dev Psychopathol 2002;14:861–75.

Author(s)

Manuscript received March 2003, revised, and accepted June 2003.

Previously presented in part at the 3rd International Forum of Mood and Anxiety Disorders; November 27 to 29, 2002; Monte Carlo. Previously presented in part at the Association Canadienne d’Éducation de Langue Française; October 2002; Halifax (NS). Previously presented in part at the Mental Health Conference; October 4, 2001; Moncton (NB).

1. Lecturer, Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia.

2. Professor and Head, Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia.

3. Research Associate, Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia.

Address for correspondence: Dr BA Lauria-Horner, Lecturer, Department of Psychiatry, Dalhousie University, Halifax, NS B3H 2E2.

e-mail: hornerb@is.dal.ca

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