F E A T U R E

Devvarta Kumar
Department of Clinical Psychology, Central Institute of
Beginning Steps in
Psychiatry, Ranchi, India
School Mental Health
Indu Dubey
Department of Clinical Psychology, Central Institute of in India: A Teacher
Psychiatry, Ranchi, India

Dipanjan Bhattacharjee
Workshop
Department of Psychiatric Social Work, Central
Institute of Psychiatry, Ranchi, India
Narendra Kumar Singh
Department of Psychiatric Social Work, Central
Institute of Psychiatry, Ranchi, India

Kainaz N Dotiwala
Department of Clinical Psychology, Central Institute of
Psychiatry, Ranchi, India

Shazia Veqar Siddiqui

Department of Clinical Psychology, Central Institute of
Psychiatry, Ranchi, India

Nishant Goyal
Centre for Child and Adolescent Psychiatry, Central
Institute of Psychiatry, Ranchi, India

Key words: school mental health; workshop; teachers;
psychological problems
Introduction
Childhood and adolescence are periods of significant
development and transitions in physiological, cognitive,
emotional, moral, social and other domains. These
phases are also vulnerable to higher level of stresses
and the onset of psychological problems. Various stud-
ies have reported the presence of psychological prob-
lems needing immediate attention in at least 10–12%
children (Fombonne, 1994; Bilenberg et al, 2005).
This percentage further increases if all the psychological

A B S T
As emphasised by this journal, school mental health (SMH)
programmes and services, when done well, lead to valued
outcomes for students and systems focused on children and
adolescents. However, SMH is nearly non-existent in India.
Acute scarcity of trained manpower is the main stumbling block.
It is therefore imperative to facilitate the process of SMH with
some alternative measures, and one way is to enable the primary
stakeholders. Towards this end, at the Central Institute of
R A C T
Psychiatry, Ranchi, India a workshop for teachers was conducted
which focused on various aspects of SMH. The effectiveness
of the workshop was assessed with the help of pre-post and
five-month follow-up assessments which showed increased
understanding by teachers of psychological problems in children
from participation in the workshop. Admittedly, this is a very
early step, but we hope that our experiences will be helpful
in moving SMH forward in developing nations.

Advances in School Mental Health Promotion VOLUME 2 ISSUE 4 - October 2009 © The Clifford Beers Foundation & University of Maryland 29
 F E A T U R E
problems are counted, since one in every five children
has some emotional/behavioral problem at some
time (Hendren et al, 1994). If not managed, these
problems can have negative consequences from various
perspectives and the most important is the loss of
productive years. Psychological problems often start as
benign and mild problems which, if identified and
managed properly, end without leaving any long-term
consequences. On the other hand, an unidentified
mild psychological problem may not only take the
shape of grave psychiatric illness, but also can lead to
multiple other problems.
Early identification and intervention are therefore
imperative, and school mental health (SMH) is playing
a critical role in many nations, as exemplified in this
journal (Weist & Murray, 2007; Teich et al, 2007).
However, in India, where mental health facilities are
quite limited (in terms of mental health professionals,
mental health care centres and availability of psychiatric
beds) (Jacob et al, 2007), SMH services seem a far-off
goal. Although, at policy level, there is realisation that
SMH should be a national emphasis (Agarwal, 2004;
Malhotra, 2004; Jacob et al, 2007), very little move-
ment in this direction has occurred, and there is a
need for concrete examples of progress. At the same
time, the mental health problems of school-age chil-
dren have become such a major concern that various
agencies related to education are taking steps on their
own. For example, the Central Board of Secondary
Education (CBSE) is emphasising the need to strengthen
the mental health of school children, as well to give
support to children stressed by examinations or other
factors (CBSE, 2009a). Various steps, such as providing
information in the form of videos and booklets about
ways to face examination stress and providing list of
counsellors whom students can contact, have been initi-
ated by the CBSE. This board has also recommended
that all secondary and senior secondary schools should
employ a counsellor and engage in exercises in building
student self-concept, self-image, acceptability, ability to
withstand pressures, sense of enterprise, and so on as
central aspects of the learning process (CBSE, 2009b).
In India another problem in this area is that there is
a dearth of literature on SMH services. This leads to
lack of communication between clinicians, researchers
and service providers. It is possible that some sporadic
activities are being done by individuals and institutes
but, without proper scientific communication, these efforts
remain limited in impact. If the efforts are properly
communicated they can serve as models for future
30 Advances in School Mental Health Promotion VOLUME 2 ISSUE 4 - October 2009 © The Clifford Beers Foundation & University of Maryland
programmes in terms of advantages, obstacles, gaps
and so forth.
Keeping in view the gap between the need and the
availability of comprehensive SMH services, it is important
to have alternative approaches that can enable the
primary caretakers of these children to identify and
intervene at the level of minor psychological problems
and refer for professional help in cases of more serious
problems. They can also take some steps to strengthen
the mental health of children (such as enhancement of
coping abilities and positive self-image).
Teachers are among the primary caretakers of school
children. A child spends almost a third of a normal
day at school, so teachers play as important role in
their development as any other primary caretaker.
Being close to the children, teachers can easily identify
any change in the child’s behaviour and, at the same
time, since the school environment is more structured
than home, teachers are in a better position to help
these children with their guidance and support. If iden-
tified in the beginning, many of the major psychiatric
problems can be averted.
The Central Institute of Psychiatry, Ranchi, India began
an initiative in training teachers from various schools
in the Jharkhand State of India, with the objectives of:
 sensitising the teachers to the role of positive
mental health in children’s lives
 providing information about emotional and
behavioural problems in children and adolescents
so that they can identify children with problems
 sensitising them to principles of psychological
interventions.
The purpose of this article is to share the experience of
this workshop and the results and feedback at workshop
completion and at a five-month follow-up, to spotlight
one early example of SMH in India, in the hope that it
will help to spur communication and action between
educators, mental health staff, families, policy makers
and researchers to advance the developmental trajec-
tory of the field.
Details of the workshop
The workshop was organised at the Central Institute of
Psychiatry by the collaborative efforts of faculty members
from the Department of Clinical Psychology, the
Department of Psychiatric Social Work and the Centre
for Child and Adolescent Psychiatry. Heads of the schools

of rural, semi-urban and urban areas in Jharkhand
State were sent letters and requested to send one
teacher (from each school) to participate in the pro-
gramme. Overall, a total of 34 schools responded
(seven rural, six semi-urban, 21 urban; 12 primary
grades, 22 secondary grades) with one participant per
school, or 34 participants (10 male, 24 female).
The workshop was interactive and was conducted
for three consecutive days. Details of each day in the
programme are given in Box 1, below.
All sessions were conducted by an interdisciplinary
team of senior psychologists, psychiatrists and psychi-
atric social workers. Each session was divided into two
parts, the first part involving lectures, and the second
focusing on teacher discussion of their experiences in
school, previous understandings, new inputs and so on.
At the end of days 1 and 2, teachers were divided into
four groups and given a problem to discuss, followed
by presentation of the discussion by a group leader
and reactions from other participants.
Assessment
To assess the effectiveness of the workshop in training
the teachers, an objective measure was prepared in
BOX 1 The Programme
Day 1
Psychological problems in childhood and adolescents, need for
and benefits of understanding them
Biopsychosocial factors contributing to psychological problems
in children and adolescents
The role and impact of stress on child and adolescent functioning
Factors contributing to the positive mental health of children and
adolescents
Group discussion
Day 2
Identification and management of cognitive and academic
problems
Identification and management of learning disabilities
Substance abuse in children and adolescents
Disruptive behaviour problems in children and adolescents
Case vignette presentation and discussion
General issues in promoting mental health and managing emo-
tional and behavioural problems in children and adolescents
Group discussion
Day 3
Identification and management of emotional problems in children
and adolescents
Case vignette presentation and discussion
Dealing with examination stress
Life skills education
Adolescent sexuality: a psychological perspective
Panel discussion
Advances in School Mental Health Promotion VOLUME 2 ISSUE 4 - October 2009 © The Clifford Beers Foundation & University of Maryland
F E A T U R E
the form of a case vignette. The questionnaire was
developed in relation to the Attitudes to Mental Illness
Questionnaire (Luty et al, 2006). In the questionnaire,
a case vignette of a child with attention-deficit/
hyperactivity disorder was presented, followed by five
questions to be answered using a three-point scale
(1 = Disagree, 2 = Don’t know, 3 = Agree). The case
vignette and questions are presented in Box 2, below,
and were administered both pre- and post-workshop
(before the first and after the third sessions).
In addition, a follow-up evaluation was conducted
five months after the workshop. In the follow-up assess-
ment the teachers were interviewed on the phone by one
of the authors, using a semi-structured schedule. The
schedule covered three domains: first, how comfortable
the teachers felt in identification and management of
children after attending the workshop, second, how
others (colleagues, parents, students) perceived them
in relation to their understanding of the mental health
issues of the students, and third, their perceived need
for further training in this area.
Results
Table 1, overleaf, shows a substantial shift in percentage
from pre- to post-workshop on items 1 and 2 of the case
vignette questionnaire. On the rest of the items there
was not much change. It is evident that, compared
with the position prior to the workshop, following it,
the majority of teachers agreed that Ramesh had a
psychiatric problem and they felt comfortable in having
him in their class. No changes were observed in the
other three items.
As far as the follow-up assessment (five months
after the workshop) is concerned, the responses of the
BOX 2 Case Vignette and Questions*
Read the statement and answer following items
Ramesh is an eight-year-old boy who keeps on fidgeting, does not
sit in one place and does not pay attention to the instructions given
to him.*
1. Ramesh may have a psychiatric problem
2. I would be comfortable having Ramesh in my class
3. It is likely that his parents have not taught him discipline and
that is why he is such a problem
4. Strict discipline can reduce his problem behaviours
5. Children like Ramesh are bad influences on other children and
therefore should not be kept in class
* Before they answered the questionnaire, a discussion was held with the
teachers on aspects of Ramesh’s problems, including the persistence and
pervasiveness of his inattentiveness, hyperactivity and restlessness, and
their impact on his day-to-day activities, including school performance.
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TABLE 1 Number and Percentage of Teachers who Agreed on the Case Vignette Items pre- and post- Workshop

Pre Post 2
No. Item N % N % c df=1

1 Ramesh has a psychiatric problem 11 32.35 31 91.17 9.52**

2 I would be comfortable having Ramesh in my class 14 41.17 27 79.41 4.12*
3 It is likely that his parents have not taught him discipline and that is why he is
such a problem 6 17.64 7 20.58 0.7
4 Strict discipline can reduce his problem behaviours 5 14.70 2 5.88 1.29
5 Children like Ramesh are a bad influence on other children and should therefore
not be kept in class 3 8.82 2 5.88 0.20

**p ≤.01, *p ≤.05

teachers were qualitatively analysed under three headings:
 self-perception about competency in dealing
with children with psychological problems
 perceived perception of others about their
(teacher) competency in dealing with children
with psychological problems
 need for further training.
workshop were a reference source that they were using
frequently to guide their interactions with students.
Teachers also reported enhanced understanding of
the need for confidentiality and acceptance without
being judgmental, which made children more comfort-
able with them. In turn, it empowered the teachers to
start and participate in more personal discussions with
students.

The reason for qualitative analysis was the nature of
the questionnaire. Barring one or two questions, the
items had to be responded to in an open-ended manner
and scores could not be generated. Agreement or non-
agreement could not be taken as the basis of coding,
as almost all the respondents agreed on various items
favouring the impact of the workshop. However, their
elaborated responses highlighted advantages of the
training, benefits, constraining factors and so forth
which were important to understand their experience.
Self-perception about competency in dealing with
children with psychological problems
After attending the workshop, the teachers felt more
comfortable in dealing with children with psychological
problems. They reported that now they could under-
stand the nature of the problem in relation to specific
details and felt equipped to initiate basic interventions.
For example, one of the teachers in a rural school
commented that before the workshop every problem
child for her was either ‘hyperactive or dull’, but now
she could infer the nature of the problem more clearly.
A number of the teachers commented that they felt they
had enhanced abilities to consider categories of emotional
and behavioural problems being presented by children,
whereas before these assessments were more crude.
They said that the study notes provided to them in the
Perception of others about their (teacher)
competency in dealing with children with
psychological problems
Overall, teachers felt that their colleagues, as well as
the parents of the students, perceived them as more
competent in identifying and dealing with psychological
problems in children following workshop participation.
A few teachers reported that, following the workshop,
they were given additional assignments by the school
authorities, for example in developing a brief manual
on mental health issues for teachers and parents, being
asked to be in occasional meetings with other teachers
to sensitise them to psychological problems in children,
being asked to arrange and co-ordinate visits of the
mental health team from the Central Institute of
Psychiatry and so forth.
Interestingly, some of the teachers reported that,
though they were not being assigned more mental
health-related duties, they themselves took the initiative
in taking on such responsibilities. For example, one of
the teachers reported that she had extracted information
from the handouts of the workshop and prepared a brief
write-up for distribution to parents and other teachers.
Asked whether they were better able to help the
parents of children, most of the teachers responded
that the parents were not very receptive to their sug-
gestions. They usually denied that their children had

32 Advances in School Mental Health Promotion VOLUME 2 ISSUE 4 - October 2009 © The Clifford Beers Foundation & University of Maryland

any problem or might need professional help and, as
a result, many of the teachers reported some feelings
of helplessness about their abilities to help these children.
Related to this observation, a number of the teachers
recommended that parents/guardians be included in
workshop training, to increase their knowledge and to
increase co-operative efforts with school staff.
Need for further training
Interestingly, although all the teachers had found the
workshop useful, they felt that in order to work with
children/adolescents with psychological problems in
more concrete and specific ways it was imperative for
them to have more detailed training. In fact many of
them felt that they had become more comfortable in
identifying mental health issues in children, but the
workshop could not make them confident in dealing
with children as they could understand counselling and
therapeutic techniques in general, but this did not
translate to skills to put into practice.
Given the opportunity to make open-ended comments,
teachers said that the handouts distributed during the
workshop were quite useful for them and provided
strategies for increasing the impact of the handouts
(such as turning them into booklet form). As mentioned,
they recommended similar training for parents/guardians,
and some recommended this training for students as well.
Discussion
The workshop was useful in helping teachers to gain
knowledge about positive mental health and psycho-
logical problems (nature, causes and interventions) in
children and adolescents. Pre- to post-workshop gains
in knowledge were evident in the questionnaire, most
prominently for items reflecting knowledge about psychi-
atric problems in children and acceptance of such children
in the classroom. The follow-up assessment showed
that the teachers felt more confident in identifying and,
to some extent, in dealing with children/adolescents
with psychological problems after attending the work-
shop. Follow-up assessment also revealed that either
the teachers themselves took the initiative in dissemi-
nating knowledge to other teachers, parents and
students, or they were given such responsibilities by
the school administration. Thus this workshop had
served the major purpose of knowledge dissemination
and worked as a source of ‘enabling the enablers’.
Although the workshop certainly helped the teachers
Advances in School Mental Health Promotion VOLUME 2 ISSUE 4 - October 2009 © The Clifford Beers Foundation & University of Maryland
F E A T U R E
to gain knowledge, follow-up assessment also revealed
that more detailed training is required to equip teachers
in handling these problems more confidently (beyond
identification). This suggests a number of strategies for
the future, including increasing the length of training
and providing ongoing coaching and support for
teachers to address mental health issues in students
(Fixsen et al, 2005; Weston et al, 2008), as well as
ensuring strong partnerships between education, men-
tal health staff and families (Weist & Murray, 2007).
In addition, the experience of organising and
conducting this workshop provided important insights
into school mental health (SMH) needs to our leadership
group (all mental health professionals). Although
admittedly it is a very early step, we believe that publi-
cising this experience will help promote interest in
advancing SMH efforts in India, and a number of lessons
were learned that will be helpful as the field begins to
develop.
Further efforts are continuing for progression of
SMH efforts, including the following.
 Teachers have been given phone numbers and
e-mail addresses through which they can contact
the mental health professionals to discuss any
problems or issues with students.
 Other awareness raising and training is being
conducted at other schools on a one- or two-
time basis.
 Planning is active for the next intensive workshop.
There are rewarding examples from countries that
neighbour India (such as Pakistan and Sri Lanka) that
small steps towards SMH are worth pursuing (Nastasi et
al, 1998; Rahman et al, 1998), and the positive out-
comes of the present workshop support this conviction.
Limitations and conclusion
There are obviously many limitations to this initial SMH
effort in this region of India. The study is an evaluation
rather than a controlled research study, with all the
attendant potential biases in interpretation. The inter-
vention itself, the workshop, is admittedly a limited ‘dose’
and we acknowledge the need for more intensive
training and ongoing coaching and support, as above.
Follow-up questions were worded in a way that may
have led to biased responding. Finally, the workshop
was too focused on psychiatric problems and, based
on our experiences, we believe it should be altered to
33
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focus more intensively on positive mental health (efforts
are under way to do this). In spite of these and other
limitations, we believe a foothold for SMH is now estab-
lished in this region of India, and we are hopeful that
gains in critical mass will occur in the months and years
to come.
Acknowledgements
We would like to thank Professor SH Nizamie (Director,
Central Institute of Psychiatry, Ranchi) and Professor
VK Sinha (In-charge, Centre for Child and Adolescent
Psychiatry, Central Institute of Psychiatry, Ranchi) for
their guidance and support. We thank anonymous
reviewers and the editor for giving many useful
suggestions, such as the need to conduct workshops
at two levels, reframing the title of the manuscript and
highlighting the need for more emphasis on positive
mental health issues in future workshops.
Address for correspondence
Dr Devvarta Kumar, Department of Clinical Psychology
Satayanand Teaching Block, Central Institute of
Psychiatry, Ranchi, Jharkahnd, India 834006. Tel:
+91-651-2232618 (Ext. 260). Email: devavratakumar@
hotmail.com or devavrata.kumar@gmail.com
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