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Weaknesses of School-Based Approach to Mental Health Programmes

School-based mental health services also have some disadvantages. According to UNICEF’s (2012) State of the World’s Children, school enrolment is as low as 63% in Nigeria and similarly low in most other developing countries. Therefore, SBMHPs will first have to contend with getting more children to attend schools before it can have far-reaching impact in developing countries such as Nigeria. Out-of-school children are also likely to be at greater risk of mental health problems (McCarty et al. 2008). Receiving mental health services within the school presents its own challenges, one of which is the risk of stigmatisation by peers (AAP Committee on School Health 2004). The organisation of SBMHPs within the continuum of other health services and ensuring discretion on the part of service providers and general confidentiality can ameliorate this challenge.

Furthermore, locating health services of any kind within the school and involving teachers in its implementation present a situation of competing responsibilities. In schools, research has shown that SBMHPs are often poorly implemented (Atkins et al. 2003). One of the identified barriers is the poor buy-in of teachers (Langley et al. 2010) often related to perceived increased work burden and competing responsibilities (Forman et al. 2009). This is especially important in a setting like Nigeria where teachers are poorly motivated and overburdened with a large student-teacher ratio (Bennell and Akyeampong 2007; Tilak 2009). However, this can be addressed by clear and concise programme modules with clear role assignment (Langley et al. 2010). Buy-in can also be promoted by active engagement and general improvement in teacher motivation, including specific incentives for participation and uptake of SBMHPs.

More importantly, SBMHPs will naturally increase the volume of mental health-related discourses associated with initiatives aimed at enhancing mental health service provision and increasing mental health literacy. This will create a demand for persons with competence in mental health education and mental health service design and delivery. These developments may come with unintended effects. In a region like Nigeria (and most countries in sub-Saharan Africa) where there is rich indigenous knowledge of parenting and community childcare (Pence and Shafer 2006), the introduction of ‘child mental health practitioners’ within the school environment may lead to local beliefs and practices being undermined by ‘expert’ and globalised knowledge systems (Said 1993). This could lead to the erosion of valuable knowledge and practice such as kith and kin care, kith and kin fostering, community storytelling (as a form of enculturation, social learning and group therapy) and other local remedies for various physical and psychological disturbances in childhood.

Also, the very availability of mental health services within the school can create a situation in which children with otherwise normal variants of mood and behaviours are diverted into school mental health services. Some critics have argued that the global increase in the diagnosis and treatment of childhood mental health problems may not necessarily reflect increased incidence but a change in the way we view ‘normal’ childhood (Timimi and Leo 2009; Timimi 2010). This medicalising approach to child mental health may also train children to relegate or forgo their own locally derived personal agency and coping strategies in favour of ‘expert’ advice (Timimi and Leo 2009; Timimi 2010). The care, attention and support provided to school children, identified with mental health problems or risk, could undermine the children’s confidence and sense of personal agency. This is particularly important in a setting like Nigeria where there is a high premium on personal responsibility, and the ability to overcome adversities among children and youth. These are protective factors that have been found to enhance youth mental health in Africa (Meintjes and Giese 2006).

In the same vein, an SBMHP which is not a particularly nuanced approach may create a situation whereby the complex dynamics of the school environment are interpreted by teachers solely from mental health perspectives. As such, ordinary events like ‘noise-making’, which teachers previously understood as routine infractions, may then assume a higher disruptive value in line with the medicalising approach. The introduction of SBMHPs and the professionalisation and specialisation of skills for management of emotional and behavioural issues within a mental health framework might undermine teachers’ existing confidence and skills in dealing with these issues and with the day-to-day complexities of the school environment (Timimi and Leo 2009; Timimi 2010).

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