Review Reports - Stakeholder Attitudes Toward the Implementation of School-Based, Universal, Mental Health Screening: Student, Caregiver, and Teacher Perspectives

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the manuscript titled “Stakeholder attitudes toward the implementation of school based universal mental health screening: Student caregiver and teacher perspectives”. This paper reports on student caregiver and educator perspectives of school mental health screening in grades 4 through 12. The data are drawn from two separate universal mental health screening studies where feedback questions for stakeholders involved in screening could provide their feedback. The introduction is extremely well written and appropriately cited justifying the importance of this study especially to include student perspectives. Attitudes are overwhelmingly positive with a few important caveats that are clearly noted in the results and discussion. The primary limitation is the use of an opt-in procedure for student and caregiver samples which could have positively biased the results. However, authors note this clearly in the limitations section. There are minor revisions which could further strengthen the clarity and impact of this manuscript which are listed below:

Introduction

The literature reviewed suggests overall positive attitudes toward screening among the studies conducted. My experience in practice, at least in the US, is that there is a wider range of positive to negative attitudes about school mental health screening, including school systems who feel their community and parents are NOT supportive of mental health screening at all. Mention of variation in support of screening due to stigma, especially among some cultural groups, and concern about public school overreach to mental health. Perhaps this is more US centric and especially recently in our divisive political climate which is instigating distrust and disinvestment in public education. Mention of these variations among public opinion by geographic region, cultural identity, access to mental health care, and political views on is left up to the author’s discretion and expertise.
Page 2 line 111 – for clarity, it would help to state that study 1 includes student perspectives and study 2 includes caregiver and clinician perspectives in the second sentence of the ‘current studies’ paragraph
Page 2 lines 112-116 the authors describe hypotheses (and lack thereof) for school staff and educators, but do not include any specific hypotheses about student attitudes or if non-specific/exploratory given literature gap. I think this could strengthen the current study paragraph as a whole.

Methods

For both study 1 and 2, it may provide more clarity if the authors move information regarding each sample (currently located at the very beginning of the procedure sections) to a recruitment section at the introduction of each study method. Including the details about the samples first may help provide more context to subsequent participants and measures sections. It may also help to move the procedure section before measures.
Page 3 – Participants - Consider adding brief detail about Governmental and non-Government schools (e.g., private? Parochial) for those unfamiliar with Australian school systems.
Were the feedback questions in both studies derived from existing attitude measures or developed by the study team? If developed, please provide a bit more information on that process and whether the questions were piloted before use.
In addition, the authors stated questions were developed about self-harm and suicide in study 1 for high school students (p.2 line 33). Brief context about this would be helpful as well.

Results

Some results were surprising and could warrant further interpretation or hypotheses in the discussion, as follows:
- Table 1 – Suicide/self-harm significantly more upsetting to grades 7+. This seems to be an unexpected direction
- Table 1 - Victimization/peer relations significantly more upsetting to grades 4-6; why might this be?
- Table 1 – Body image was a concern across both groups, and slightly more in grades 4-6; is this expected or not?
- Table 2- Only 33.3% educators agreed students are capable of self-report, compared to 75.1% of parents. Why might educators be more skeptical of student self-report than caregivers? Is there any literature that has looked at this?
- Table 2 – Only 54.5% of educators agreed parents should be provided with all screening feedback. Might this be because educators think parents should only be notified of positive screens?
- Page 7 – Positive attitudes toward screening are somewhat surprising in the context of half the educators expressing concern about lack of referral sources. Perhaps there is a belief that regardless of access to care, students should be screened and parents notified? To what extent might educators have concern that schools are responsible to address mental health concerns identified during screening? This is a common concern in US schools especially when referral resources are limited.

Discussion

Page 8 line 314 – Older students were slightly more accepting of screening than younger students. Could this be due in part to age and potential increased exposure/education on what mental health is and why it is important?
Page 8 lines 339-340 - Adding some context about this limitation is appropriate. Specifically, it would make sense to note the location of schools in Study 1 being in middle- and upper-income areas and students with largely Caucasian identity. Additionally, if this limitation is being addressed as primary, might it be beneficial to include information on income/SES status and/or identity in the participants section for study 2 and address alongside this point in the discussion (if this information is available)? See comments about more information needed for both study samples, above.

Minor Comments

Typo on title page, line 39 “identity” should be “identify”
Revise contractions throughout (e.g., page 1 line 67 and page 8 line 349 “don’t” should be “do not” )

Author Response

Reviewer 1

The literature reviewed suggests overall positive attitudes toward screening among the studies conducted. My experience in practice, at least in the US, is that there is a wider range of positive to negative attitudes about school mental health screening, including school systems who feel their community and parents are NOT supportive of mental health screening at all. Mention of variation in support of screening due to stigma, especially among some cultural groups, and concern about public school overreach to mental health. Perhaps this is more US centric and especially recently in our divisive political climate which is instigating distrust and disinvestment in public education. Mention of these variations among public opinion by geographic region, cultural identity, access to mental health care, and political views on is left up to the author’s discretion and expertise.

We accept this point and have added a brief acknowledgement on p. 8 as follows: “Of course our results were conducted within a single country, with relatively small cultural variation and so it is possible that these results will not generalize across cultures and different school systems.”

In addition in response to this point and the corresponding point from the editor, we have added the following sentences to the end of the discussion: “It should also be noted that the current research in addition to the broader research literature is largely restricted to middle socio-economic populations from mostly Western countries and with little to no comparison between differing school systems or communities. Therefore, future research that broadens the research base to encompass far greater diversity would be warranted.”

Page 2 line 111 – for clarity, it would help to state that study 1 includes student perspectives and study 2 includes caregiver and clinician perspectives in the second sentence of the ‘current studies’ paragraph

We have added the following words to the sentence on p. 2: “– study 1 assessed students’ perspectives while study 2 reports on caregiver and clinician perspectives”.

Page 2 lines 112-116 the authors describe hypotheses (and lack thereof) for school staff and educators, but do not include any specific hypotheses about student attitudes or if non-specific/exploratory given literature gap. I think this could strengthen the current study paragraph as a whole.

We added the following sentence to p 2: “We did not hold specific hypotheses about students’ perspectives, given the very limited prior evidence base.”

For both study 1 and 2, it may provide more clarity if the authors move information regarding each sample (currently located at the very beginning of the procedure sections) to a recruitment section at the introduction of each study method. Including the details about the samples first may help provide more context to subsequent participants and measures sections. It may also help to move the procedure section before measures.

We appreciate the reviewer’s thoughts here, however, while we agree that moving the early paragraph of the procedure will provide some greater clarity in Study 1, it seems a little more complicated for Study 2. Therefore, given that our current format is consistent with methods in many other papers, we have decided to retain the original.

Page 3 – Participants - Consider adding brief detail about Governmental and non-Government schools (e.g., private? Parochial) for those unfamiliar with Australian school systems.

Thank you – we have added the terms “general public” and “Catholic or independent/ private” to clarify the Australian schooling system.

Were the feedback questions in both studies derived from existing attitude measures or developed by the study team? If developed, please provide a bit more information on that process and whether the questions were piloted before use.

We added the following explainer on pp 2 and 3: “questions for this and the next study were developed by the authors based on personal experience and were not derived from existing measures.”

In addition, the authors stated questions were developed about self-harm and suicide in study 1 for high school students (p.2 line 33). Brief context about this would be helpful as well.

These were just a few questions developed by the authors from their clinical experience. The question structure is a little complicated (ie the suicide section includes three nested questions where the subsequent question only appears if someone answers affirmatively to the previous). Given that the content and development of these questions is not relevant to this study (which is about students’ reactions to the questions) and the amount of space that would be required to describe them, we have decided not to expand this section.

Some results were surprising and could warrant further interpretation or hypotheses in the discussion, as follows:

Table 1 – Suicide/self-harm significantly more upsetting to grades 7+. This seems to be an unexpected direction

We thank the reviewer for pointing to this complicated result. We had a look and were also quite confused for a while until it became clear that this result comes from only 276 students. As already described in the results text: “When asked whether any questions upset them, 4321 students (70.9%) responded “not at all”; 1303 students (21.4%) responded “slightly”’ and the remaining 468 students (7.7%) reported moderate or greater distress. However, among students who reported moderate distress or greater, 96 (20.5%) did not describe any specific questions that distressed them and 117 (24.9%) referred to non mental health aspects of the survey or provided nonsense responses. The specific sources of distress among the remaining 276 students (4.5% of the total sample) are shown in Table 1.”

Given that this result appears a little confusing, we have tried to clarify even further by adding the following section to p 4: “(i.e., those who a; reported that an item made them upset and b; specifically described a mental health item in the open-ended question)”. We also added an additional footnote to remind readers that “Suicide/ self harm questions for grades 4-6 were only reported by students in grade 6.”

Table 1 - Victimization/peer relations significantly more upsetting to grades 4-6; why might this be?

Similarly to the previous clarification – the 25.9% figure does not indicate the absolute number of students who were distressed. Rather it is a relative number pointing out that 25.9% of the grade 4-6 students who reported feeling distressed (only 6%) AND described a specific item that distressed them, reported this item to be victimisation.

Table 1 – Body image was a concern across both groups, and slightly more in grades 4-6; is this expected or not?

While we certainly have personal experience and clinical reasons to expect certain questions to be slightly more distressing, we didn’t have any literature on which to make predictions. Therefore, we have decided not to expand on this issue any more than it has already been discussed.

Table 2- Only 33.3% educators agreed students are capable of self-report, compared to 75.1% of parents. Why might educators be more skeptical of student self-report than caregivers? Is there any literature that has looked at this?
Table 2 – Only 54.5% of educators agreed parents should be provided with all screening feedback. Might this be because educators think parents should only be notified of positive screens?

Like the reviewer, our interpretations of the above would be that caregivers will often say that their own personal child is open and honest, while educators, when describing the student body as a whole, are more experienced with students who may be less than honest. Similarly, educators may feel as though they need to filter information before sending it all back to caregivers. However we have chosen not to expand on these ideas in the current report because they seem quite speculative and are very difficult to support with evidence.

Page 7 – Positive attitudes toward screening are somewhat surprising in the context of half the educators expressing concern about lack of referral sources. Perhaps there is a belief that regardless of access to care, students should be screened and parents notified? To what extent might educators have concern that schools are responsible to address mental health concerns identified during screening? This is a common concern in US schools especially when referral resources are limited.

Our own experience in working with school systems is that educators at the higher levels (ie education bureaucrats or district supervisors) are very concerned about schools’ duty of care and subsequent legal risk. They are therefore more concerned about the lack of referral sources. Educators on the ground (ie the sample in the current study) are much more concerned about students’ wellbeing and are therefore positively disposed toward screening despite the lack of referral sources. Again, we feel that these points are somewhat speculative and lacking in any supportive evidence and we therefore decided not to include them in a formal discussion. We could do so if the editor wishes.

Page 8 line 314 – Older students were slightly more accepting of screening than younger students. Could this be due in part to age and potential increased exposure/education on what mental health is and why it is important?

Yes we think this is very likely. However, the context of this paragraph in the discussion is more about making the point that there were relatively few predictors of attitudes and we point to the very small correlations (all r’s < .1). In line with the point made by Reviewer 2 about the small relationships (see below), we don’t wish to highlight these differences any more than we have already. What we have done in response to this and the next reviewer’s comments, is to add the word “very” into the sentence stating “(very) slightly more accepting of screening …”

Page 8 lines 339-340 - Adding some context about this limitation is appropriate. Specifically, it would make sense to note the location of schools in Study 1 being in middle- and upper-income areas and students with largely Caucasian identity. Additionally, if this limitation is being addressed as primary, might it be beneficial to include information on income/SES status and/or identity in the participants section for study 2 and address alongside this point in the discussion (if this information is available)? See comments about more information needed for both study samples, above.

We have added the following sentence to the limitations section (p. 9): “In addition, schools within this study were mostly from middle income areas or above and the majority of participants identified as Caucasian.”

Unfortunately, we don’t have detailed demographic information on the caregivers or educators.

As noted above, we also added the following sentence to the discussion (p. 8): “ Of course our results were conducted within a single country, with relatively small cultural variation and so it is possible that these results will not generalize across cultures and different school systems.”

Typo on title page, line 39 “identity” should be “identify”

Thank you – we have fixed this.

Revise contractions throughout (e.g., page 1 line 67 and page 8 line 349 “don’t” should be “do not” )

Despite the fact that we disagree with the APA guidelines about reducing contractions and believe that in most cases that facilitate ease of reading, we have removed the few contractions in the current paper.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses an important and understudied area—stakeholder attitudes toward mental-health screening in schools. As someone involved in developing school-based mental-health assessment tools, I found the insights presented here genuinely useful, and many of them are not readily available elsewhere.

The paper is clearly written and generally easy to follow. Methodologically, I have relatively few concerns. The authors appropriately identify the primary limitation—the use of an opt-in sampling approach. While this is a notable weakness, it is explicitly acknowledged in the discussion and does not, in my view, undermine the overall contribution.

One issue I would encourage the authors to address is the presentation of response distributions. The tables in the main text report cumulative percentages toward agreement, which is acceptable, but not fully transparent. Because cumulative reporting can be influenced by how categories are grouped, the manuscript would benefit from including the full distribution of responses (i.e., raw percentages for each response option) in an appendix.

I also have some reservations regarding the interpretation in the discussion, specifically the statement that “…it was disheartening to see that students reporting greater emotional distress were, if anything, more accepting of school screening.” This conclusion seems stronger than warranted by the data. The reported correlation between anxiety and endorsement of school screening is r = 0.064, which achieves statistical significance primarily due to the large sample size; however, the shared variance is negligible. As such, the interpretation should be tempered to reflect the limited practical significance of this association.

Overall, this is a valuable and informative manuscript, and with minor adjustments to data presentation and interpretation, it will make a solid contribution to the literature on school-based mental-health screening.

Author Response

Reviewer 2

We have created three additional tables describing the data in full and will present that to the journal to place in an online supplement. We have added the following statement to the end notes for each Table: “Data broken down by the full set of response options are presented in the online supplement.”

As noted above in response to Reviewer 1, the gist of this paragraph was supposed to highlight the very minimal relationships identified (in full agreement with the reviewer). To make this clearer, we have added a few words to the discussion to highlight the very small size of the correlations.