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• Volume 76, Issue 5
• Research priorities for mental health in schools in the wake of COVID-19
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• http://orcid.org/0000-0001-7854-6810 Rhiannon Barker 1 ,
• http://orcid.org/0000-0001-9153-7126 Greg Hartwell 1 ,
• http://orcid.org/0000-0002-6253-6498 Chris Bonell 2 ,
• Matt Egan 1 ,
• Karen Lock 1 ,
• http://orcid.org/0000-0003-3047-2247 Russell M Viner 3
• 1 SPHR , London School of Hygiene & Tropical Medicine , London , UK
• 2 PHES , London School of Hygiene & Tropical Medicine , London , UK
• 3 Institute of Child Health , University College London , London , UK
• Correspondence to Dr Rhiannon Barker, SPHR, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; rhiannon.barker{at}lshtm.ac.uk

Children and young people (CYP) have suffered challenges to their mental health as a result of the COVID-19 pandemic; effects have been most pronounced on those already disadvantaged. Adopting a whole-school approach embracing changes to school environments, cultures and curricula is key to recovery, combining social and emotional skill building, mental health support and interventions to promote commitment and belonging. An evidence-based response must be put in place to support schools, which acknowledges that the mental health and well-being of CYP should not be forfeited in the drive to address the attainment gap. Schools provide an ideal setting for universal screening of mental well-being to help monitor and respond to the challenges facing CYP in the wake of the pandemic. Research is needed to support identification and implementation of suitable screening methods.

• mental health
• public health
• child health
• health policy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/jech-2021-217902

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COVID-19 has had significant impacts on the physical and mental well-being of children and young people (CYP) around the world. 1 Schools provide essential structure, routine and support for many students, particularly the most vulnerable. Growing evidence suggests a strong link between mental health and academic attainment 2 ; a recent English study suggests mental health at ages 11–14 predicts attainment at age 16. 3 This relationship is likely bidirectional, with data suggesting that exam anxiety is more significant in those who perceive their academic ability as low. 4 Additionally, analysis from a large longitudinal cohort of parents and children in Bristol, UK, indicates that low attainment at 16 predicts increased depressive symptoms at age 18. 5

The pandemic has presented enormous challenges, creating crises in both academic attainment and CYP’s mental health. As education sectors worldwide try to return to normality following periods of lockdown, there are dual imperatives: to provide effective support to address student mental health and well-being, while also addressing gaps and inequalities in academic progress. We argue that, following the upheaval of the pandemic, schools must be supported to address the mental health and well-being of both students and staff. This can be most effectively achieved via delivery of whole-school initiatives and promotion of positive whole-school culture by school leaders. Specifically, we highlight the importance of routine screening of student well-being in schools, and outline evidence demonstrating that both mental health and attainment can be addressed through a range of interventions relating to school culture including social and emotional learning, school mental health provision and work to promote a sense of commitment and belonging.

The impact of COVID-19 on CYP’s mental health

Approximately half of adult mental health disorders begin during adolescence. 6 International evidence indicates that CYP’s mental health was already deteriorating before pandemic, with increasing proportions of teenagers experiencing symptoms of distress or anxiety, or engaging in self-harm. 7 This is concerning given that poor mental health in these age groups is associated with adverse socioeconomic and mental health outcomes in later life. Results from a meta-analysis show that adolescents who suffer depression are 76% more likely to fail to complete secondary school and 66% more likely to be unemployed. 8 The burden is furthermore socially patterned, with socioeconomically disadvantaged CYP more likely to experience mental health problems and self-harm, 9 10 while being less likely to receive referrals into mental health services. 9

The long periods of isolation and uncertainty that the pandemic has forced on CYP have generated additional challenges. Systematic reviews examining impacts of school closures conclude that they have significantly harmed health and well-being in CYP. 11 The isolation and upheaval created by closures are most likely to have impacted adversely on CYP from lower socioeconomic groups for whom school can be a crucial source of support. 12 Adolescents from black, Asian and minority ethnic (BAME) groups show similar patterns to the adult BAME population, for whom pre-existing inequities have been exacerbated. 3 13

The pandemic’s impact is however not uniform; some studies note a protective effect with certain students reporting mental health benefits from reduced school-based academic pressures and more relaxed timetables. 14 A systematic review 15 examining COVID-19’s impact on adolescent mental health identifies several protective factors such as awareness of transmission routes, good parent–child relationships and strong family structure. It appears that those children receiving less stability and support from their home environment are at heightened risk. Commentators have also conjectured that the ability to stay in touch with peers, through good internet availability and access to social media, may have helped guard against loneliness and isolation. 14

Promising interventions for the school sector’s recovery

Work to build support for improving the mental health of CYP in schools needs to learn from the range of promising interventions that have been shown to be effective in improving measures of student well-being. In particular, many successful behavioural interventions have focused on developing social and emotional competencies which can positively impact on student mental health and academic and behavioural development. 16

Yet challenges have been highlighted around the implementation and embedding of classroom-based interventions to improve health and well-being. 17 Notably, there have been tendencies to overlook the specific context of the school or failure to consider the wider system that may create barriers. 18 Emphasis has now turned from the adoption of programmes targeting health-related behaviours to more comprehensive system-wide approaches. The focus on a whole-school approach to positive mental health is particularly urgent following the almost ubiquitous rise in need during the pandemic and the imperative to provide more generic well-being awareness. Practitioners are looking beyond classroom-based initiatives to interventions that impact on the ‘whole-school’, such as the Learning Together Programme, 19 focusing on reducing school-based bullying and aggression, and improving mental health. While the need for more rigorous evidence has been highlighted, an association is apparent between the school-level environment and mental health. 20 In addition, several studies have reported positive impacts of whole-school interventions on student well-being and mental health. 20 21 Systematic reviews have also considered whole-school approaches to tackling health-related behaviours. 22–24 Despite methodological challenges, these show promising findings linking school ethos and culture to positive mental health outcomes.

Central to a clear understanding of student outcomes is an insight into the mechanisms responsible for CYP engagement, the impact of school culture and the way students negotiate social networks. Greater clarity regarding how change is brought about will support the building of social and emotional skills, shown to be protective against behaviours which impact negatively on mental health. 17 This may help, for instance, with growing anxieties around the areas of harmful social media use, image sharing and sexual harassment, as highlighted by Ofsted’s recent report. 25 Work to foster positive school culture can aim to denormalise such harmful behaviours.

School environments are complex and the way a school impacts on those who study or work within it is influenced by a wide range of causal mechanisms, all of which need to be considered in a whole-school strategy. The Anna Freud Centre sets out a strategic framework for achieving improved mental health and well-being in schools: strong leadership promoting a supportive culture; working together at all levels (staff, students, parents and wider communities); understanding need through routine measurement and monitoring; promoting well-being through a range of whole-school initiatives and interventions; and supporting staff with their own well-being. 26

Moving forward

The temptation to adopt practices which react to immediate crises rather than to invest in longer term support based on best evidence must be avoided. Positive results emerging from whole-school interventions 22 27 28 can guide future work to strengthen school culture and point towards the particular importance of aspects such as student/teacher relationships, bullying reduction and student participation and engagement. The danger is that pressures on schools to focus on academic attainment and ‘curriculum catch-up’ will over-ride the need to address student well-being and mental health. This may in turn adversely impact those aspects of school culture which have been shown to have protective effects on mental health, such as the participation of CYP in school governance. Crucially, a system-wide commitment to the teaching of social and emotional skills and the provision of mental health support is required, as well as interventions to promote commitment and belonging. 27 Together, these have the potential not just to improve student mental health, but to increase attainment and lead to healthier, happier adult lives. Positive correlations found between good mental health and improved academic outputs 2 3 add further support to the importance of working, synergistically, on both these goals.

Leadership strategies that recognise the importance of staff and student mental health in COVID-19 recovery will be key. These should recognise the inequalities that have been exacerbated by lockdowns, improve schools’ physical environments, foster staff/student relationships and address bullying. Evidence from studies of school mental health initiatives is relevant here, given they suggest the effects of interventions are higher when targeting higher risk children. 29 Parallel to this is the need for adequate regulatory leverage, delivered through organisations such as Ofsted, to continue to support and incentivise mental health promotion in schools.

While schools collect multiple data relating to attainment, standardised information on the mental health and well-being of their students is rarely collected. Yet commentators suggest that, given their universality and extensive engagement with CYP, schools provide ideal settings for identifying those at risk of developing mental health difficulties. We recommend, that to monitor rising mental health challenges in our schools, a more standardised system of screening be implemented backed by increased research funding to explore and guide how to make best use of existing resources. All proposals should acknowledge the existing pressures on staff time and school resource, focusing on identifying a viable and pragmatic working model.

Within these future plans, a range of complex factors need to be considered including: an agreed definition of mental health (holistic well-being vs absence of clinical symptoms); reliability and validity of selected tools; design and implementation of screening (including staff training); cultural appropriateness and diversity; and costs and benefits. 30 Processes to seek informed consent from students and parents should be established, while recognition is needed that screening for mental health issues should be backed by the resources to enable appropriate responses to identified need. Intense pressures on finite resources require that, once need is identified, the most appropriate ‘response route’ is followed. The establishing of Mental Health Support Teams, 31 intended to provide extra capacity to deliver evidence-based interventions in schools and create better links to existing services, is an encouraging step. However, research is needed to monitor how support is delivered and to test new approaches such as the colocation of mental health staff in schools.

We propose that the complexity of school-based mental health research benefits from the guidance of a conceptual framework which acknowledges the interaction and influence of a wide range of factors at all system levels. The Systems View of School Climate 32 framework is one such model which adopts a system perspective and demonstrates the importance, both of factors within the school microsystem such as beliefs, values and relationships, as well as more distal ones in the mesosystem and macrosystem, which can all contribute towards creating an environment that works to build positive mental health in students and staff.

Finally, the importance of identifying interventions which address priorities articulated by CYP should not be overlooked, with students themselves involved in this work. Enabling this may require the development of new measures which consider concepts of ‘positive mental health’ and ‘flourishing’. Useful results should begin to emerge, for instance, from ongoing innovative projects 33 where students are collaborating as ‘active co-researchers’ using participatory approaches to measure well-being and respond to the rising mental health challenges faced by CYP.

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Twitter @BarkingMc, @russellviner

Contributors RB wrote the initial article which was scoped during the initial phase of work for an NIHR-funded Public Mental Health Programme. The draft was commented on by GH, CB, ME, KL and RMV.

Funding This article was compiled as part of a scoping study undertaken within the National Institute for Health Research (NIHR) School for Public Health Research (SPHR)-funded Public Mental Health Programme (grant reference: SPHR-PROG-PMH-WP6.1&6.2). NIHR SPHR is a partnership between the Universities of Sheffield; Bristol; Cambridge; Imperial; and the University College London; the London School of Hygiene & Tropical Medicine (LSHTM); LiLaC–a collaboration between the Universities of Liverpool and Lancaster; and Fuse–the Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland and Teesside Universities.

Disclaimer The funders had no role in the design of the study, or collection, analysis and interpretation of the data, or in the decision to publish, or in writing the manuscript.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 30 March 2022

School culture and student mental health: a qualitative study in UK secondary schools

• Patricia Jessiman   ORCID: orcid.org/0000-0002-5805-2415 1 ,
• Judi Kidger 1 ,
• Liam Spencer 2 ,
• Emma Geijer-Simpson 2 ,
• Greta Kaluzeviciute 3 ,
• Anne–Marie Burn 3 ,
• Naomi Leonard 1 &
• Mark Limmer 4  

BMC Public Health volume  22 , Article number:  619 ( 2022 ) Cite this article

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There is consistency of evidence on the link between school culture and student health. A positive school culture has been associated with positive child and youth development, effective risk prevention and health promotion efforts, with extensive evidence for the impact on student mental health. Interventions which focus on socio-cultural elements of school life, and which involve students actively in the process, are increasingly understood to be important for student mental health promotion. This qualitative study was undertaken in three UK secondary schools prior to the implementation of a participative action research study bringing students and staff together to identify changes to school culture that might impact student mental health. The aim was to identify how school culture is conceptualised by students, parents and staff in three UK secondary schools. A secondary aim was to explore which components of school culture were perceived to be most important for student mental health.

Across three schools, 27 staff and seven parents participated in in-depth interviews, and 28 students participated in four focus groups. The Framework Method of thematic analysis was applied.

Respondents identified elements of school culture that aligned into four dimensions; structure and context, organisational and academic, community, and safety and support. There was strong evidence of the interdependence of the four dimensions in shaping the culture of a school.

Conclusions

School staff who seek to shape and improve school culture as a means of promoting student mental health may have better results if this interdependence is acknowledged, and improvements are addressed across all four dimensions.

Peer Review reports

Schools are key settings for health promotion, and the concept of a health promoting school has been supported globally [ 1 ]. This holistic approach involves not only health education via the curriculum but also having a school environment and ethos that is conducive to health and wellbeing, and by engaging with families and the wider community, recognising the importance of this wider environment in supporting children and young people’s health. There is evidence of positive effects on physical health (including weight, physical activity and diet), and limited evidence for the impact of the health promoting school approach on student mental health [ 2 ]. This matters; approximately half of adult mental disorders begin during adolescence [ 3 ], making these early years of life a key time at which to intervene to support good mental health, and to prevent or reduce later poor mental health outcomes.

Discreet mental health interventions delivered in schools often focus on improving individual students’ capacity for resilience, empathy, and communication skills and less on school-level factors [ 4 , 5 , 6 ]. A systematic review of school-based stress, anxiety and depression interventions in secondary schools found that while those aimed at reducing anxiety and depression were often successful, effect-sizes were mediated by student demographics and dosage, and effects were not long lasting. There was no evidence that interventions targeting stress were effective [ 7 ]. The limited impact of discreet mental health interventions may be because they do not address aspects of the school context or system that are determinants of poor mental health, or prevent the intervention becoming embedded [ 8 ]. Interventions which focus on socio-cultural elements of school life, and which involve students actively in the process, are increasingly understood to be important for student health and wellbeing [ 9 , 10 , 11 , 12 ]. Mental health promotion, defined by the World Health Organisation as actions to create an environment that supports mental health [ 13 ] is likely to be best achieved in schools that offer a continuum of interventions, including a focus on social and emotional learning, and the active involvement of students [ 14 , 15 ]. Markham and Aveyard’s theory of health promoting schools proposes that health is rooted in human functioning, which itself is dependent on essential capacities, the most important of which are practical reasoning and affiliation (human interactions and relationships) [ 16 ]. These, alongside other (less essential) capacities, make autonomy possible, and allow individuals to maximise their health potential. This is further supported by a systematic review of theories of how the school environment influences health which concludes that for young people to make healthy decisions, they must have autonomy, be able to reason, and form relationships. These capacities are better developed in schools where students are engaged, have good relationships with teachers, and feel a sense of belonging and participation in the school community [ 17 ].

The school environment is often termed ‘school culture’ or ‘school climate’; both are used in education literature but neither are well defined and both often encompass many differing and nebulous aspects of the school ethos and environment [ 12 , 18 , 19 , 20 , 21 ]. Some authors use the terms interchangeably; conversely they are also described as separate but overlapping concepts [ 22 ]. Van Houtte and Van Maele conclude that ‘climate’ is the broader of the two constructs, encompassing infrastructure, social composition, physical surroundings and culture itself, while ‘culture’ is focused on the shared assumptions, beliefs, norms and values within the school [ 23 ]. Rudasill and colleagues propose a Systems View of School Climate (SVSC) as a theoretical framework for school climate research, itself heavily influenced by Ecological Systems Theory [ 24 , 25 ]. They define school climate as “composed of the affective and cognitive perceptions regarding social interactions, relationships, safety, values, and beliefs held by students, teachers, administrators, and staff within a school.” Wang and Degol reviewed the existing literature and consulted with expert scholars to construct a conceptualization of school climate that includes four dimensions: academic (teaching and learning, leadership, professional development); community (quality of relationships, connectedness, respect for diversity, partnerships); safety (social and emotional safety, physical safety, discipline and order); and institutional environment (environmental adequacy, structural organisation, availability of resources) [ 21 ]. In our study, we use the term culture rather than climate deliberately; in a UK context, the term “culture” is far more commonly associated with school environment than “climate” [ 26 ]. We use “culture” to capture the broad sense of shared norms, values and relationships specific to each school, and also how student feelings of belonging, safety and support are impacted by the infrastructure and social composition of schools (considered by Van Houtte and Van Maele as part of the broader construct of ‘climate’ [ 23 ]).

A positive school culture has been associated with positive child and youth development, effective risk prevention and health promotion efforts, with extensive evidence for the impact on student mental health [ 23 ]. Two evidence reviews report strong associations between the student perceptions of the quality of interpersonal relationships within the school, and school safety, and student mental health [ 18 , 21 ]. School culture may be particularly important to the mental health of Lesbian, Gay, Bisexual and Transgender students who may be more likely to perceive it less positively and be at greater risk of poor mental health, feeling unsafe, and absenteeism [ 27 , 28 , 29 , 30 ].

Given the evidence base highlighting the importance of school culture and active participation of students in school life on mental health promotion [ 9 , 10 , 31 ], we developed a participatory action research (PAR) approach [ 32 ] to understanding and improving school culture in UK secondary schools. Participatory Action Research seeks to enable action within a specific research context by involving study participants as co-researchers. Undertaken in three English secondary schools, our study involves bringing together a small group of students and school staff, facilitated by an external mental health practitioner, to develop a shared understanding of the culture in their own school, and identify changes that might impact student mental health. Participants consider school culture and student mental health, implement changes and/or interventions intended to improve both, and reflect on whether these changes have had an impact. This means that participants are involved in a cycle of data collection, reflection, and action (Act-Observe-Reflect-Plan cycles; [ 33 ]. Further information about the PAR study is available elsewhere, including the study protocol [ 34 ] and the use of PAR as a research method [ 34 , 35 ]. At the launch of the PAR intervention, staff and students were asked to reflect on their conceptualisation of school culture in order to develop a shared understanding. Alongside this, the research team undertook qualitative research in each of the intervention schools. Given the differences in the definition and conceptualisation of school culture identified in the literature, we wanted to better understand how it is conceptualised by those most closely impacted by it. The aim of the current study is to identify how school culture in conceptualised by students, parents and staff in three UK secondary schools. A secondary aim is to explore which elements of school culture are perceived to be most important to student mental health.

This was a qualitative study using semi-structured interviews and focus groups as the primary data collection method. We have followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [ 36 ].

Research team

The study research team comprised academics from public health centres at four English universities. The development of data collection tools was led by PJ; data collection was led by PJ, LS, and EGT; all of the research team were involved in analysis and reporting.

Sampling and recruitment

We used a purposeful sampling approach to select schools with variability in school performance (using Ofsted inspection outcomes as a proxy measure for this), and diversity of student intake across ethnicity, and eligibility for free school meals. Three secondary schools were recruited in October 2020, one of which agreed to run two PAR intervention groups. A lead staff contact in each of the schools supported the recruitment of school staff, parents, and students to take part in an interview (adults) or focus group (students), prior to the PAR groups beginning. We worked with this contact to identify school staff with insight into school culture and student mental health and wellbeing. Participants were drawn from the senior management team, teaching staff, other support staff, particularly those with responsibility for student wellbeing (e.g. pastoral support staff, Personal, Social, Health and Economic education (PSHE) lead, head of year, form tutor). For parent participants, we asked for parents with particular insight into the school, for example parent governors, parent volunteers, or those whose children had required extra pastoral support or similar. Potential interviewees were sent a Participant Information Sheet (PIS) that detailed the objectives of the study, interview length and summary of topics covered, recording arrangements, confidentiality, and data protection details, and use of data for reporting. Participation in interviews was voluntary. A consent form was sent to participants by email in advance of an online interview and consent recorded at the start.

In each participating school, all students in the selected year group were invited to take part in the PAR group. School staff shared an information sheet about the PAR group and encouraged students who wanted to take part to contact school staff and also send a short paragraph detailing why they wanted to take part and what skills and attributes they would bring to the group. School staff selected students with guidance and support from the research team (prioritising diversity across gender and ethnicity and those students who were not already involved in any student councils or similar in the school). Students who had volunteered to take part in the PAR intervention, but not selected, were asked if they would participate in the focus group. An information sheet was sent to both students and their carers and consent sought from both to participate (in one school, parents were informed but consent not sought as students were aged 16 years or over). Signed consent forms were collected prior to the focus group and the researchers reaffirmed that consent was informed and voluntarily given verbally at the start of the focus group.

Data collection

Semi-structured interviews support a structured and flowing interview whilst allowing some flexibility to ensure the respondent can engage with the subject, maintaining more autonomy in how they choose to respond to the topic areas in comparison to a more structured survey method (Adams 2015). Topic guides for the interviews were developed following a rapid review of the research literature on school culture to develop a comprehensive list of components that may impact on student mental health, as well as potential mechanisms through which this may happen (see Additional file 1 : Appendix 1). Interviews lasted 30–45 min and guides were used flexibly, using prompts and probes where appropriate. A similar approach was used to develop the topic guide for student focus groups, which included participatory methods to facilitate a discussion about school culture. Focus groups lasted around 45 min.

Data collection took place between December 2020 and April 2021, coinciding with school mitigation measures in place in response to the COVID19 pandemic. These included social distancing, face masks, and year group ‘bubbles’. Although schools were open to all students when data collection began, they were closed to all but vulnerable students and those with key worker parents from the beginning of January until March 2021. As a result, all data collection with school staff and parents took place online. Student focus groups occurred after schools re-opened were a mixture of face to face (3 groups), and online (1 groups) depending on what the school allowed.

All data collection activity was recorded using an encrypted digital recorder and transcribed verbatim. We used the Framework Method of thematic analysis [ 37 , 38 ]. One of the researchers (PJ) developed a thematic framework after reading several transcripts to familiarise herself with the data and referring to the research questions and topic guide to inform an initial coding stage. This framework was augmented by subthemes that emerged in further transcripts. A short summary of each subtheme was developed to describe the data that it was designed to capture. This initial framework was shared with the whole research team and the thematic framework was further refined until the team were confident that it encompassed all the data in the transcripts, the data within each subtheme was coherent, and that there were clear distinctions between subthemes. The final thematic framework is included in Additional file 2 : Appendix 2. PJ then developed a matrix framework, using the subthemes as column headings and participant transcripts as rows. The matrix cells were populated with verbatim and summarised data from the transcripts, as well as analytical notes made by the researchers (‘charting’). Charting reliability was tested by all six researchers charting the same two transcripts independently, and comparing the contents of each cell to ensure that we were applying the subthemes consistently and capturing and summarising the data consistently across all team members. This data management approach produced a data matrix showing data from every respondent under each subtheme, thus providing a detailed and accessible overview of the qualitative dataset. The Framework Method makes possible the capacity to explore the dataset through themes and subthemes, and also by respondent type. A summary of the data under each subtheme was developed to inform the next stage of the analysis, moving up the analytical hierarchy to explore patterns and associations between themes in the data [ 38 , 39 ].

Information about the sample schools and participants is shown in Table 1 .

Across all three schools, 27 school staff participated in an interview for the study. Staff interviewed included members of the senior leadership teams, teaching staff, learning and support assistants, pastoral support staff, and staff with particular responsibility for the Year group which was taking part in PAR in each school. The parent sample was comprised of seven parents of students in the relevant year groups across the three schools (five mothers, two fathers).

Four student focus groups were held in total; one from each of the year groups participating in PAR across the three schools. Twenty-eight students took part across the four groups; student demographics and online/in school data collection method are outlined in Table 2 .

The findings are presented under four overarching dimensions of school culture that emerged from the data and were perceived by respondents to impact on student mental health. These are structure and context, organisational and academic, community, and safety and support (see Fig.  1 ). Anonymised quotations are included from a wide range of participants in order to illustrate the responses rather than indicate representativeness. Where differences between participant groups were apparent (e.g. parents, school staff and students) we highlight these in the findings.

Dimensions of school culture

Dimension 1. Structure and context

Local environment and geography.

School staff noted the impact of geographical location on school culture, with pupils often not living in the immediate locality. This resulted in students living socially deprived areas attending a school in an affluent area, and vice versa. As a result any sense of a school sited within a ‘neighbourhood’ or ‘local community’ setting was depleted. However the impact of the wider locality was recognised. Public events and demonstrations that had occurred in the South-West of England in the 12 months preceding the study generated publicity and awareness amongst the students at all three schools, which staff tried to reflect and respond to.

“So, being in a city centre, if there’s a protest, it’s on our doorstep. So, the student strikes, on our doorstep, Greta Thunberg, when she came, on our doorstep, Black Lives Matter protests, on our doorstep…[]…So, all these issues, our students are even more exposed to, and, you know, in shaping our culture at school, that’s what we’ve tried to move towards. Not just focussing on inclusivity and care, but also in terms of they’re going to be engaged and informed citizens.” School B staff 8

Student diversity

Almost all respondents referred to the three schools as having a very ethnically diverse student body, bringing both opportunities and challenges. Ethnic diversity was perceived by most respondents as one of the key influences over school culture. Parents often spoke of valuing it as a learning opportunity for their children, and a source of high cultural capital. Many staff shared this view and enjoyed working with such a diverse cohort.

“The cultural mix at [School A] was really important for me...So culturally, I think the diversity in [School A] is amazing and although it brings with it many challenges, that was a really important thing for me. That my children could see the struggles. I think it is more of a reflection of society…modern society, multicultural society.” School A parent 1

Many staff noted however that while students may integrate during school hours, they often fell back into homogenous groups at the end of the school day, reflecting the reality of the wider community.

“This is a diverse school, and the city is sometimes perceived to be a diverse melting pot but it is not, it is still very segregated. There is a lot of work to be done between communities.” School C staff 5

There was also diversity across the socio-economic status of students. Staff reflected on the severe poverty faced by many of their students, exacerbated during the COVID19 pandemic, and the efforts made to ensure that students were able to access the same educational and wider opportunities as more affluent students. Staff also reported examples of where ethnicity and socio-economic status intersect, impacting the engagement of students and their families with the school.

“For some BAME families, education is the highest priority. For others who are possibly asylum seekers or who have not really had an education themselves because of issues back home in their own countries, education is much further down the list. You’ve got other families, massive poverty in the families, and so education is the last thing they can think about.” School C staff 4

Finally staff also noted the influence of students with SEND on school culture. Two schools in particular were perceived to have a high proportion of students with SEND, and staff adapted the curriculum and employed additional support staff to ensure the school environment and offer was inclusive. This included working with all students to promote greater awareness and acceptance of disability.

Physical environment

Many staff spoke about the impact of the physical environment of the school on student interactions and wellbeing, and in particular the impact of being quite constrained in a small space. Although efforts were made to create private and safe spaces during break times, often both the number of people, and building and grounds design made it difficult for students to find quiet or perceived safer places to be. This finding emerged in all schools, despite one being an older, traditional building and two being more recently rebuilt to incorporate more light and space.

“Students do struggle with the building sometimes - a big long tin, built around previous ideas of supervision. So offices are glass, toilets are open, they are non-gendered toilets which are open aside from cubicles, but does mean we are restricted on indoor space - not many places where kids can just sit and relax in social time…So, I think that that’s something they do struggle with.” School C staff

Students’ capacity to navigate school buildings was further constrained during the pandemic by social distancing measures. Students were often confined to one classroom all day while teachers moved round the school, one-way systems were put in place, and dining areas and school grounds segregated by year group to limit social mixing. Staff perceived this impacted on the school culture, making small incidents amongst students more likely to escalate, and removing teachers’ sense of control in classrooms that no longer felt like their own.

“All of a sudden they’re crammed, 30 students, into [one] classroom [all day] and I think that’s had a negative influence on a lot of students….[]… As a result small things escalate fairly quickly, which isn’t helping the dynamic within the school. …[]… Before, every time I ever had a class, I would be at the door. I would welcome them into my room, and there’s an automatic element of control and influence where, if there is something, you can address it before you come into the room and the room is the area of control. There isn’t that available anymore, and I thought that that does have an impact.” School A staff 7

Dimension 2. Organisational and academic

Leadership and management of school culture.

The role of the school senior leadership team in shaping school culture was mediated through their support for staff, visibility and transparency to students, and active management of school culture. School staff reported that having a leadership team that listened to and empowered staff was important. This was especially important during the pandemic and related mitigation measures resulting in schools being closed to most pupils and a move to online learning, although for some staff this made the leadership teams less visible. Visibility to students was also seen as key to promoting a welcoming culture in schools; availability and presence during the school day was frequently mentioned by both staff and students.

“The senior leadership team are very visible to students. They’re out every single lunch and break, every lesson changeover, they’re very hands-on, and I would say that’s probably, I think that’s quite a good sign.” School A staff respondent 3

The importance of senior staff being present and welcoming students to school each morning was also perceived by student focus group participants as a reason for valuing their school.

Culture emerged as a key priority amongst the leadership team in all three schools, which all take a proactive stance on leading and shaping it, including having senior leaders responsible for it. Stated reasons for prioritising culture included to reflect the needs of a diverse student intake (particularly across ethnicity and socioeconomic status); mitigate the impact of Covid mitigation measures on student wellbeing; and in response to the UK national government’s push for better mental health provision in schools. There was also a sense that newer staff, and staff recently promoted to managerial posts, were more likely to prioritise culture (and student wellbeing).

“I am aware of how important [mental health in schools] is at the moment from the government.” School A Parent 1 “It can be alienating, but they [new leadership team] spoke a lot about culture - something that people say is important, and in general staff are happy…[]...he [Principal] he would start using these quotes from people, and one of the ones that always sticks in my head is ‘culture eats strategy for breakfast’, is one he loved which, again, is on culture.” School C staff respondent 9

Despite the active management of school culture, there were staff in all schools who questioned whether a narrative of prioritising school culture was tokenistic, without implementing real changes or having noticeable impact.

Staff composition

School staff composition was perceived to influence the culture of the school, and mental health of students, through dedicated pastoral and inclusion roles, their ethnic and gender diversity (or lack of), and staff turnover rates.

All three schools had non-teaching staff with roles dedicated to supporting student mental health and wellbeing, including safeguarding (promoting child welfare and protection from harm), pastoral support, mental health support (counsellors), and support and inclusion for pupils with special educational needs and disabilities (SEND). Staff and parents from two schools perceived the wellbeing teams as unusually large compared to other secondary schools. These staff were especially busy monitoring and supporting students during school closures. The importance of staff dedicated to mental health and wider wellbeing support was recognized by all stakeholder groups, including parents.

“The fact that she [pastoral support lead] doesn’t teach any of them and that they know they can just drop in and they can just go and sit down and say, “I’m having a rubbish day today.” Sometimes that’s what you need. You don’t always need someone to come up with an answer. You just sometimes need somebody to listen.” School B Parent 1

Beyond dedicated non-teaching staff, many school respondents recognised the role that staff diversity had in shaping and informing school culture. Respondents in all schools were conscious that school staff did not reflect the ethnic diversity of students. Gender representation across teaching subjects and leadership roles was also of concern. There was recognition amongst school teaching staff and leadership teams that students need to see ethnic minority and female role models in all roles, and effort is needed to address this through better recruitment practice.

“It's the best leadership team I’ve ever worked in [but] If we're talking about representation in there, I am the only non-white person in our leadership team...[]… It's only really in our pastoral teams where we start to see some diversity. That's a real problem in schools that I've always found, is that any kind of black or ethnic minority staff tend to be in the pastoral teams rather than in the teaching and learning teams.” School C staff 5

Parent respondents highlighted staff turnover and consistency as important. When staff consistency was low, this had a negative impact on students’ wellbeing and school culture as they struggled to build relationships with ever-changing staff. This was particularly important to students who needed additional pastoral and/or inclusion support for SEND or mental health reasons, and also impacted on parents’ ability to build trust and confidence with their child’s key staff contacts in school.

Staff development and training

Few respondents mentioned staff development and training as an important aspect of school culture, although some school staff did raise training in specific areas that would influence their capacity to support student mental health and wider wellbeing (including on safeguarding, mental health promotion and prevention, inclusion, and support for students with SEND). Some reported training in new behaviour management policies specifically intended to impact school culture, including restorative justice and holistic approaches. In one school effort had been made to train staff in anti-discriminatory practice, to give them greater confidence in addressing diversity-related issues and supporting students.

“We need to make sure that, on every bit of our culture that we want to work on, we have staff that are educated in that. I know we've done a lot of work on this year’s staff feeling scared to broach certain subjects, especially with our anti-discriminative practice… They're worried about saying the wrong thing and being accused of being a racist, or being accused of being a homophobe, or being accused of saying something. There's a real fear of that, which I think leads to disengagement, potentially, from trying to be an active participant in the change [to school culture].” School C staff 5.

Respondents across all schools described ongoing changes towards a more inclusive, holistic curriculum, reflective of the diverse student body. The most prominent changes to emerge from interviews were efforts to decolonialise the curriculum across all taught subjects, the inclusion of more content about Black history, and inclusive and diverse content with regard to gender and sexuality. In one school, changes to the curriculum were informed by feedback from student Black and Minority Ethnicity (BAME) and lesbian, gay, bisexual, transgender (LGBTQ +) groups. Staff respondents noted the importance of embedding minority role models across all subject areas, and not simply providing one-off lessons about minority groups. The lack of diversity amongst staff increased the difficulties of delivering a diverse and inclusive curriculum as many reported lacking expert insight, knowledge and confidence. There was consensus however that continuing to work on the curriculum offer was likely to facilitate a more supportive school culture.

“So, we’re working at the moment unit of work by unit of work by just inputting BAME and female role models and careers. So, that it’s not a tokenistic lesson, it’s actually… it just becomes part of the normal conversation at [School C], and no matter what ethnic group a pupil is from or what their sexuality is, there should be, within the curriculum somewhere, role models popping up…, it becomes part of the day to day conversation.” School C staff 2

PSHE education was highly valued by both staff and students as an important means of addressing diversity, inclusion, and health. PSHE time was used to deliver universal mental health provision including education, advice, and interventions such as meditation or mindfulness. Students reported that alongside Relationships and Sex Education (RSE), this helped them to develop an understanding of different cultures and to be mindful and respectful of them.

“I think RSE, PSHE are good because they teach about other people’s cultures and I think it is important since that- say if you don’t know something about another person’s culture you might offend them.” School C student focus group

For some students, the opportunity to discuss mental health during PHSE was welcomed but could feel tokenistic, without enough time to cover issues in depth, and some stigma around discussing mental health remained.

“We had a PSHE assembly quite recently and this is going back to the whole 'surface level' thing, because even though the assembly itself was good, it was, like, all the students [in year 12] in one Zoom. So, it was very difficult for us to have actual, proper, discussions. So, it felt quite, "See, we need to have a PSHE lesson at some point, therefore we'll have one big, fat assembly, so we can tick that off our quota," instead of having smaller groups where people can actually discuss their problems and really learn.” School B student focus group

Staff, parents and students all discussed the importance of non-academic subjects such as Physical Education (PE), Music, Dance and Art, and the ability for students to access these formally through lessons and through lunchtime and after-school clubs. The noted benefits of these include providing an opportunity for self-expression and creativity, a focus on processes rather than outcomes (an important part of mental health), and ‘safe’ spaces to take risks and use failures as opportunities. Staff perceived that having a wider range of music, arts and sports on offer to students allowed them an opportunity to find something they enjoy and may excel in, which may be particularly important for the self-esteem of less academically able students. Respondents across all schools noted that although schools make efforts, there was still not enough emphasis on these wider curriculum areas, and this was exacerbated by the curtailment of after-school and extra-curriculum activities during the pandemic.

Teaching and learning

Most respondents’ comments on teaching styles focused on teachers’ attitudes to discipline in the classroom. Where teachers were perceived as overly strict, students and parents worried that this had a detrimental effect on student mental health. Some students and parents perceived that teachers’ focus on academic performance meant they were more likely to overlook student anxiety and stress.

“For some reason I think [daughter] overthinks things maybe and she second guesses everything she does…[]… They’d set the essay and then she’d spend another week researching which she didn’t need to do. Then she’d start writing the essay by which time other work was coming in, so it got on top of her….[]…She was scared of failing. She was scared of letting them down.” School B Parent 1

The COVID-19 pandemic may have alleviated this problem and encouraged teaching staff to afford greater consideration of student mental health. Staff were aware that not all students coped well with the closure of schools and move to online teaching and learning for extended periods of time alongside the other stressors of the pandemic.

“I’ve spent a lot of time on the phone with parents, and sometimes their kids are having a really tough time and they are ditching the distance learning thing. I’m just like, “You know what? Your kid needs to feel better and then we’ll look at the learning again.” School C staff 3

Academic performance

Pressure on schools to be ‘high performing’ was driven both by external regulators and national performance measures (Office for Standards in Education, Children's Services and Skills (Ofsted); Progress 8 scores (progress a pupil makes from the end of primary school to the end of secondary school), and school staff’s ambition to equip individual students with the skills and qualifications for later life. Respondents also noted the impact of schools’ local and historical context; comparisons with other schools in the area (e.g. higher performing schools more attractive to prospective students and parents) and prior status (e.g. as a grammar school, private school or under-performing school) also influenced how the schools’ current academic performance was perceived by parents and staff. All of this influenced how ‘high performance’ was conceptualised. In one school, staff and parents describe the school as highly academic with an expectation that most students would achieve high academic grades and proceed to higher education. In contrast, staff from a school with lower academic outcomes noted that they are driven to maintain year on year improvements in Progress 8 scores, (a ‘value added’ measure) and equip students for a wider range of next steps, including further education, and vocational routes.

“It is a very high-end sixth form. So you are working with a lot of young people that want to be doctors, vets, quite high-end.” School B staff 4 “We were one of the only schools of our kind, really, to see a… I think it for six years, an improvement in our progress 8 scores, which I know are not everything, but actually are quite a good measure for us. We’re an academy that is massively based around progress, and equal progress.” School C staff 2

Respondents of all types were aware of the impact of high academic expectations on school culture and consequently, student mental health. In school B, which is known for high academic standards, staff reported high levels of anxiety and stress-related disorders amongst students, including eating disorders and self-harming behaviour. School staff acknowledged that expectations of high achievement can cause students stress and anxiety, but addressing this is challenging because it is not always driven by the school culture but by parents or the students themselves.

“There is a big, big drive for students to apply to Oxford or medicine degrees, dentistry, and in my experience this has caused some significant mental health issues in the students. It’s not necessarily a school issue, I would say it’s more due to the demographics of the students that attend the school. They tend to come from very supportive families, often families that actually want the students to attend Oxford or want the students to be doctors... So there is still this sort of competition with their peers and maybe the frustration of not meeting expectations that come from the parents.” School B staff 6

Dimension 3: Community

Quality of relationships in school.

The quality of interactions and relationships with others in school was perceived as another key element of school culture important to student mental health. Staff respondents distinguished between ‘staff’ and ‘student’ culture, though also recognized that the relationships between staff and students would impact on the school culture overall. Relationships amongst staff were generally described as friendly, supportive and collaborative. This was especially important during the past months when school closures necessitated the move to online teaching, with repercussions for students through better practice, and better support.

“It’s really noticeable that no matter what department you’re in, what level of teaching, if you’ve got your head around something that other departments or individuals haven’t, people have voluntarily made tutorial videos and just sent them to all staff, it’s not that you have to go knocking and asking all the time, actually people are just pulling together and trying to promote best practice.” School C staff 2

There was some disagreement over the role of the senior leadership team in reinforcing positive staff culture. Some respondents described working with an empowering leadership team that actively supported good staff relationships. For others, leadership influence over high workloads, pressure to maintain high academic performance, pandemic-related changes and recent staffing decisions (including redundancies) had damaged relationships amongst staff. There was also some stigma around disclosing mental health concerns, particularly those caused or exacerbated by work pressures, although this may be improving.

“Lots of people are worried about the consequences [of disclosing] and they’re worried about having the label of someone who cannot cope, there’s a lot of that.” School B staff 6

The quality of interactions between students and staff were perceived as highly influential over how students experienced school culture, and to their mental health. There was recognition amongst school staff that while those in pastoral or other support roles would prioritise maintaining good relationships with students, teaching staff may differ in their perception of their role; some would focus on teaching and learning only, while others would see the creation of positive and trusting relationships with students as important and conducive to better learning and healthy development. Other influences on the quality of relationships between staff and students included pressure on staff and students to maintain high academic standards. Staff willingness to be accessible and approachable to students was also important, and this had been adversely been affected by school closures and subsequent social distancing measures in place in school.

“Relationships between student and staff are really important, because if you don't really have a good relationship with your teacher, you may feel uncomfortable with asking them for help. It can cause a lot of stress if you're beginning to struggle and you don't get any help.” School B student focus group

Inclusion and diversity-related factors were key; staff from schools with a more ethnically diverse student intake reported that the lack of diversity amongst staff damaged relationships with students from minority groups. There was also concern that Black and Minority Ethnicity students were over-represented in disciplinary statistics, possibly a result of unconscious bias or prejudice from staff.

“In our school, when almost all staff are White and then you’ve got an over-representation of Black students in our behaviour data, race becomes an issue. Not just for the students, but for parents as well. That is something we’re continually trying to overcome and work on.” School A staff 1

Friendships with peers and the quality of interactions between students in school were also recognized as having an important influence on school culture and student mental health by all stakeholders. Respondents across all schools generally described peer relationships as positive, though there was recognition that individual students would have different experiences.

“If you have good relationships with other students, then your mental health will just, overall, feel better. You'll have someone to talk to, someone to rely on and you'll just, overall, have a better experience at school.” School B student FG

Diversity, particularly ethnic diversity, was seen as very influential over peer relationships by staff and parent respondents. As noted earlier, it is valued as a key attribute of a school and there is an expectation amongst staff and parents that students will benefit from relationships with peers from different backgrounds. They also report that peer support is strong amongst minority groups, and students with SEND and minority ethnic groups looking out for and supporting each other. However, where problems arise in student relations this is generally attributed to differences across ethnicity, age, gender or disability (with SEND students at particular disadvantage). Respondents describe concerns with discrimination amongst peers in all three schools, which can manifest in a lack of integration during social and break times, and bullying.

Efforts to promote inclusion were apparent in all schools, as this was perceived to be another key influence on school culture and student mental health. Across all schools, respondents describe a diverse student intake with regard to ethnicity, socio-economic status, geography, and religion. This was highly valued; forming peer relationships across these divides is seen as an opportunity for students to learn from each other and encourage acceptance and valuing difference. Staff from all schools reported an emphasis on inclusive practices, driven by both the need to ensure that all students felt safe and welcomed in school, and by recent Black Lives matters protests that have highlighted awareness of prejudice and discrimination amongst students.

School staff were conscious that for many students, time in such a diverse environment was limited, and hence the opportunity to gain the most advantage should be optimised.

“We don't want people to tolerate each other…[]…We want to teach you to celebrate, actually, differences, and learn from each other and be able to have high cultural capital, based on you've got this experience to come to this environment every day where you're mixing with so many different people that maybe, once you leave school, you're not going to be able to access.” School A staff 5

Staff were keen to emphasise the activities undertaken promote inclusion, such as running groups for under-represented or minority students, (e.g. BAME and LGBTQ + students), increased pastoral support for minority groups, events/displays to celebrate diversity and difference; ‘stamping down’ on issues of intolerance and bullying, and the provision of unisex toilets. There was some recognition of the intersectionality of race, gender and sexuality.

“Quite often, we find that if you belong to a BAME community, talking about or being open about your sexuality can sometimes be a big no-no…[]…We’ve got a lot of children, students from the BAME community that aren’t out, but actually want to go to the LGBTQ club group to learn and talk and debate and discuss and learn more about themselves. So, you know, making sure they do that in a safe place.” School C staff 4

School staff perceived some improvements were still to be made, including increasing the ethnic diversity of staff, and addressing potential staff bias that may result in BAME groups being over-represented in disciplinary actions. Staff also report increasing incidences of misogynistic language and bullying amongst students, and this may be the next inclusion issue to be targeted. Students recognise the work that schools are doing around inclusion and value it, although agree that there is still some progress to be made.

“The school discourse is specifically- I feel like the school used to be a very majority white school and it is slowly integrating and becoming a more culturally diverse school. So, I think the school, in itself, is still learning how to make different cultural identities more heard, more safe, more whatever, but I think the school definitely has a lot more to learn and to do.” School B student FG

Student voice

Student voice and empowerment mechanisms and the success of these varied across the schools and again, were impacted by the pandemic mitigation measures. There was consensus amongst school staff that the degree to which students felt listened to was a key aspect of school culture which would impact on student-staff relationships and student mental health. All schools had systems in place for consultation with and engagement of students (for example student councils). Staff also reported using surveys as a regular means of monitoring student health and wellbeing and gaining feedback on specific issues. There were examples of student-led groups, for example BAME or gender equality groups, being involved in changes to the curriculum or school rules that which particularly affected these groups.

School staff varied in their perception of effectiveness of these mechanisms, with some reporting that school leadership teams were responsive to student feedback and willing to reflect student views. Student councils and surveys had been disrupted during school closures, although respondents across all schools reported that changes had been made to practice (for example, how online learning was delivered), as a result of student feedback. This was a minority view however; the majority of respondents perceived that student views were often ignored and had little tangible impact on the how the school was run. Some attributed this to a lack of staff resource devoted to facilitating and supporting student engagement; conversely other staff report that too much engagement work is staff-led, rather than student-led.

The overwhelming perception of students and parents is that school leadership teams are unwilling to engage with and reflect student views.

“My personal experience of school councils is that they are a bit of a- we all have a school council because we know it’s the only thing to do but actually when it comes to decision making they kind of ignore it or they’ll steer the kids in a direction they want to go.” School A parent 1 'I feel like they try to say that they do a lot [around student voice], especially with student leaders and stuff, but a lot of the ideas and rules that we might want to change get shut down real quick.' School A student FG

Parent engagement

Parental engagement was perceived as good across all three schools. Mechanisms included parent forums, parent teacher association (PTA), email newsletters and social media groups. School staff also liaised with parents of students over specific issues (typically about academic, behavioural, health or SEND support). The degree of communication and engagement with parents increased during the pandemic, as staff conducted additional and regular welfare checks while most students were not attending school in person.

There was recognition that some parents were more willing and easier to engage with than others; factors influencing this include parents’ motivation for their child’s academic success, concern about student support needs, and ‘second generation’ students whose parents also attended the school. The relationship with some parents could be challenging for school staff, either because parents are reluctant to engage, may blame school staff for their child’s behavioural issues or be critical over the perceived lack of support for their child. Engagement was also perceived to vary across socio-demographic status and ethnicity. Some staff reported that higher earning families may have greater expectations of their child’s academic success and will seek out opportunities to engage with school staff to facilitate this. In one school, concerns about problematic disengagement of parents from one particular community was addressed by the employment of a family support worker to liaise between families and schools to help overcome language and cultural barriers.

Most parents were pleased with the level of engagement they had with school staff, particularly where their child had additional needs or existing mental health issues. They report feeling listened to by school staff, who were quick to respond to issues and make necessary changes, making parents feel like they are working together with staff in the child’s best interests.

“I feel they always know who I am, they know, when I talk about my children they seem to know everything that I’m talking about, and they’re always quick to respond. They actually take you seriously - they sort of think: “Well you’re the parent, you must know your child so tell us what we can do to help.” And I just find that really helpful.” School A parent 3

Students were aware of parental communication, especially where this was concerned with behaviour or achievement. Many appreciated school staff contacting their parents with positive feedback about them. Students were clear about the links between positive feedback from the school, their parents, and their mental health.

“Keeping in touch with parents is really important - I would say keeping in touch with parents as when they tell your parents that you’ve been excellent it raises your self-esteem and makes you feel like your parents are proud of you which makes you feel proud of yourself.” School C student focus group

Dimension 4: Safety and support

Pastoral support.

As previously noted, schools all had designated staff for student wellbeing and pastoral support.

Most staff were confident that students would know who to approach, usually a tutor or a member of the pastoral support team. Pastoral staff report being especially busy during school closures, conducting regular welfare checks on all students, and providing additional support for those in need. The pandemic mitigation measures made providing pastoral support harder, by limiting in-person contact while schools were closed, and use of face masks making communication harder.

“It’s been harder this year because of closures and mask wearing - there’s still a swathe of other [students] that don’t have a connection. You only need a strong connection with one staff member to feel like you’re supported, valued and have someone that you can go to.” School B staff 8

Parents were universal in their praise for the pastoral support provided to their children, with staff seen as skilled and responsive to both student and parental needs. Students’ views were more mixed, with concerns about anonymity, embarrassment about raising mental health issues in school, unwillingness to approach pastoral staff where they were also teaching staff, and having better support systems in peer groups or at home.

“There are pretty much only one or two people that I would tell private stuff to, and it definitely isn’t any of the teachers.” School A Student focus group

Primary prevention

Most school staff describe two main mechanisms for mental health promotion; speaking often about the importance of good mental health, and ensuring students in need of support know who to approach for help and guidance at the earliest opportunity. Mental health is addressed during assemblies, as part of the PHSE curriculum. and in tutor time. School staff also used these opportunities to communicate support available to students both within the school from external agencies (via face to face, telephone or online). Teaching staff also have a role in promoting good mental health by having an accessible ‘open door’ policy for students, and being aware of, and not putting further pressure on, students with known mental health issues. Schools also frequently used noticeboards, websites and student newsletters to communicate about mental health.

“We do things like toilet door campaigns in our school. The inside of toilet doors are just covered in different posters and stuff like that. They’re unisex open-plan toilets. So, we’re targeting everyone with everything”. School C staff 4

Respondents often commented on the stigma attached to mental health difficulties, and like staff, students may be reluctant to talk about them in school. This was perceived as particularly true for students from some ethnic minority communities. Staff believed that talking often about the important of mental health would encourage students to ask for support if they needed it. Some staff report that as mental health awareness increased, students were becoming more likely to report issues about themselves, or for other students.

“In terms of preventative support, I want to say the kids really have each other’s back. I would say they really do. There have been lots of cases in the past of friends of students coming to me or going to [Name] or [Name] to say, “So and so is having a panic attack,” or, “So and so is having a tough time.” School B staff 6

All schools had processes in place to monitor student mental health though the degree to which this was formally structured varied. One had a range of pre-emptive measures in place including regular face-to-face monitoring by safeguarding leads or tutors, and monitoring through proxy measures such as attendance and engagement. School staff also mentioned the importance of staff communication to spot and support students needing support. Student feedback on this was mixed; not all students agreed that it is the role of teaching staff to monitor student mental health.

“I don't think it’s the teacher’s job to look after people’s mental health. I think their job is just to teach.” School A student focus group “There’s a survey asking you how well do you feel out of one to ten, do you need to talk to someone, how is it going, and all these questions….[]…I think that’s pretty good because then you can just answer it, even though it says your name, no one else is going to see it except the teacher which is fine because they’re the ones who help you.” School C focus group

Targeted support

Targeted mental health support was mainly comprised of access to a school counsellor or a mentor. School respondents often said they would have more targeted support available but this was unaffordable. Staff from two schools also mentioned targeted group interventions for anger management, stress and anxiety, body image, and understanding emotions. Again it was stated than this would be useful for all students as health promotion activities, but the resources were not available. Other barriers to accessing targeted support included pressure on curriculum time; staff reported difficulty in removing a child from a taught class to take part in a mental health intervention. Learning support assistants (LSA) for students with SEND were also perceived to provide high levels of mental health support. Students in all schools were aware of these support systems.

“Someone that has issues with mental health or wellbeing, they go to their mentor and that would be passed on. Or they could go to the mental health/SEN support teachers for their issues”. School A focus group.

There were some inequalities in which students are more likely to request, or be offered, targeted support. Staff respondents perceived that BAME groups are under-represented amongst students who access counselling, while white, middle-class students may be more likely to come forward and ask for help with stress or anxiety. There may also be differences in school support provided that are dependent on how the mental health issue manifests; one parent noted that her child may be more likely to receive support because she is ‘likeable and polite’ and hence perceived by school staff as more deserving of support than students with mental health needs that manifest themselves in more challenging behaviours.

School staff also reported signposting or referring students for support from external agencies though waiting lists were often long and may have worsened during the pandemic.

“Because of funding cuts and things, to actually get referred to CAMHS [Child and Adolescent Mental Health Services]I think you have to meet a very high threshold of maybe being a harm to yourself or others before you get referred. Where, earlier in my teaching career, it was much easier to get support from CAMHS and intervention outside. I think some of it now is just that schools are dealing with so many mental health issues as teachers and staff that, maybe at other times, might have been dissipated to other organisations and things like that. I guess that’s been exacerbated in COVID maybe.” School B Staff 1

Parents mostly reported satisfaction with the level of support put in place by schools for their children, many of whom had required targeted mental health support. For some, there was a preference to manage mental health support within the school where possible to benefit from existing trusted relationships, even if this meant some delay.

“I did ask for him to be referred [to the counsellor], but what was interesting is there’s a very, very long list of people. …[]… I’ll see how long it takes, because I will seek it in a different way, privately, if necessary. But I think again there’s a sense of safety. I think [Son] does trust the school, I’m not saying he likes all the teachers or anything, because he doesn’t, but he trusts the school. So, I figured if it came through the school, it’s joined up; he would feel safer.” School C parent 1

Safeguarding

Safeguarding was prioritised by staff, but did not emerge as a prominent element of school culture. All schools had designated safeguarding leads and protocols in place. There were some differences between school staff and students in the understanding around safeguarding protocols. Some believed that students understood the importance of safeguarding, and if disclosures (of risk or harm) are made, then staff had a duty of care to act upon them. However this had the potential to damage trust and limit how much students were willing to share with school staff.

“The school counsellors have a reputation of saying it’s confidential but then still telling your parents and stuff.”

“Some people just want to talk to the teacher without having any consequences, and they’re not in any danger, but then they feel like their information will be [shared].” School A student focus group

For many school staff, issues with bullying were closely linked with diversity and inclusion. Misogyny, and prejudice against students with SEND were perceived to be the more pressing underlying causes of bullying. As such, many anti-bullying initiatives in schools were also inclusion initiatives, such as support groups for minority and vulnerable students, addressing inclusion and diversity in the curriculum, and celebrating diversity during tutor time and assemblies. Students often perceived these approaches to bullying as too simplistic, and not addressing the more coercive types of behaviour they experienced.

“I think there’s quite a lot of assemblies and stuff, but I think it’s not always presented in the right … it’s like very stereotypical bullying… rather than there’s lots of different types of bullying and sometimes not all of it is covered, like manipulative people and people who try and get you to do stuff, but that’s not [discussed]. Whereas that is actually bullying if they’re trying to get you to do stuff….[]…sometimes if you’re being targeted, you don’t realise that they’re bullying you because it hasn’t been shown in anything and you haven’t seen that as bullying.” School A student focus group

Staff described anti-bullying messages displayed around the school, and students were taught about bystander apathy and to challenge bullying behaviour. One school had anonymous reporting for students to report bullying. For many students however, recognizing and reporting bullying to school staff remained problematic.

“I feel like sometimes yes, we go and talk to the teacher about it but sometimes some students might feel that peer pressure into not doing it …[]… because they’re like, “Don’t do this or I’ll do this to you.” School C Student focus group

Staff respondents discussed changes in disciplinary procedures over recent years, with a shift away from punitive disciplinary systems which appeared to no longer work (or have an even more negative outcome on existing behavioural issues) towards restorative approaches and building relationships/rapport between staff and students.

As noted, some staff reported concerns that BAME students were more likely to be subject to disciplinary measures, which may be due to real differences in behaviour or, conscious or unconscious bias amongst (predominantly) white staff. Two schools had adopted systems emphasising ‘rewards before sanctions’; students could win points through positive behaviours. Students with challenging and disruptive behaviours at risk of sanctions were also offered additional contact, monitoring and support from staff, to promote positive relationships. Staff reported some implementation issues, with staff training on restorative justice approaches disrupted by the pandemic, and some inconsistency in how discipline was applied. Some staff perceived that students themselves have a key role to play in maintaining discipline and modelling good behaviour.

“If a student doesn't hold open a door for someone else, that is something you pull them up on. Any kind of bad language you hear, whether it is in a classroom or whoever it is directed at, is challenged. Uniform is absolutely 100%. Every single member of staff challenges it. So then the students become role models for anyone coming in because I think, particularly teenagers, although there are lots of exceptions to this, but generally speaking they don't really want to stick out too much. They don't want to be the one who is doing the role or a different thing from their peers.” School B staff 2

There are many examples and conceptualisations of school culture in the literature emerging from reviews of school culture research, and its measurement [ 12 , 20 , 21 ]. The aim of this study was to identify how school culture is conceptualised by staff, students and their parents in three UK secondary schools. It adds to the literature by providing a conceptualisation that is grounded in the experience of those within UK secondary schools: staff, students, and their parents.

Respondents from three schools identified elements of school culture that align into four dimensions; structure and context, organisational and academic, community, and safety and support. Structure and context includes physical aspects of the school buildings, the geographical setting, and the diversity of these on the student intake, particularly around ethnicity and socio-economic status. The academic and organisational dimension includes how culture is led and prioritised by school leaders, pedagogical aspects including teaching and learning styles and the curriculum, academic performance, and staff composition . Community refers to the quality of the relationships within and across key stakeholders in any school; students, parents (or carers), and school staff. Safety and support primarily refers to how schools support student emotional and psychological wellbeing, including through the provision of both primary and targeted support for mental health, although some aspects of physical safety (for example, bullying) may also be important.

A secondary aim was to explore which elements of school culture are perceived to be most important to student mental health. While elements across all four dimensions have influence, respondents were most likely to discuss diversity (across ethnicity, socio-economic status, gender and sexuality) in both the student and staff population as a key element of school culture likely to influence student mental health. This is supported by a recent study of over 28,000 adolescents in England which found gender, ethnicity and deprivation were risk factors for experiencing mental health difficulties [ 40 ]. Other elements of school culture that emerged as key influencers of student mental health were inclusive practice as an important element of mental health promotion, pastoral support, the quality of relationships and interactions in the school, and student voice, although mechanisms to promote student voice were regarded as unsatisfactory by most respondents, particularly students.

This study also demonstrates how culture was prioritised by staff in the participating schools. Senior leaders recognised the importance of culture and took a proactive stance on leading and shaping it. This was driven by their belief that it will influence student mental health, and the UK Government’s emphasis on the role of schools in supporting mental health [ 41 ]. It is also apparent in our data how school staff were influenced by wider events, including the COVID19 pandemic and the subsequent impact on mental health, and the Black Lives Matters protests of 2020. School leaders (and all school staff) reflected on the impact of these events on student mental health and the need to respond and adapt aspects of school culture in response.

The four dimensions identified in our study closely align with those identified in Wang and Degol’s conceptualisation of school climate [ 21 ], though there are some differences. Their ‘institutional environment’, referring to the physical school building and allocation of resources, is replaced in our study with ‘structure and context’. Participants in our study placed little emphasis on the quality of the physical environment (school buildings, maintenance, cleanliness etc.) although building design did feature. Instead, this dimension included greater emphasis on contextual factors including the school’s geographical setting and the diversity of the student cohort. In particular, stakeholders in our study perceived that the ethnicity, socio-economic status and to a lesser extent, intellectual disability (SEND) characteristics of the student intake had a profound effect on the culture of the school and staff efforts to manage it. Unlike other models of school culture (or climate), which consider the social composition of the student body as outside the construct of school culture but hugely influential over it [ 23 , 24 ], in our study the social demographics of the student intake was one of the defining features both of the school culture and of efforts to manage and improve it.

How might the dimensions of school culture as conceptualised in our study influence student mental health promotion? Wang and Degol’s dimensions of community (in particular, the quality of interpersonal relationships within the school) and safety, which largely overlap with those dimensions in our study, were found to be key determinants of students’ emotional wellbeing [ 21 ]. Much less research has been undertaken on the impact of academic and organisational factors on psychological outcomes (though more has been done on their influence over academic outcomes). Markham and Aveyard’s theory of health promoting schools suggests that schools can promote (or inhibit) the capacities essential for human functioning, and therefore health, through ‘framing’ and ‘classification’ [ 16 ]. ‘Framing’ refers to pedagogic practice, and ‘weak’ framing is that which enhances student involvement in their own learning and opportunity to influence the curriculum, thus increasing capacity for practical reasoning. This is reflected in our study through respondents’ accounts of curriculum development and efforts to enhance student voice and engagement. ‘Classification’ refers to the boundaries between students, their peers, school staff, and the outside world. Drawing on Bernstein’s theory of cultural transmission [ 42 ], the authors advocate that strong boundaries ‘insulate’ students and prevent opportunities for both forming relationships (affiliation) and practical reasoning, the two capacities most essential to mental health optimisation. In our study, efforts to promote better relationships between peers and with staff, engage with parents and develop the curriculum to better reflect the wider world and incorporate diversity could be interpreted as efforts to weaken these boundaries and hence promote affiliation.

Studies which focus on the influence of one aspect of school culture on student mental health are useful, but may miss the wider effects of school culture. The boundaries between the four dimensions identified in our study are not distinct, but factors within each one have influence across all dimensions. Diversity of the student intake, in particular ethnicity, is a key factor in the structure and context dimension but also hugely influential over factors in the other three dimensions. It was particularly salient to our respondents when describing delivering and adapting the curriculum (including efforts to decolonialize it), and their concerns about staff composition. Ethnicity also influences community factors; lack of minority representation amongst staff is seen to damage relationships with BAME students, and drives the emphasis on inclusive practice evident in all three schools. Staff were also cognisant of the influence of ethnicity on disciplinary practice, and student perception of the equity of this. Another illustration of influence across dimensional boundaries is how efforts to create a safe and supportive environment influence factors within the academic and organisational domain, such as staff training on inclusive practice and the inclusion of mental health in the curriculum. This study makes clear the interdependence of the four dimensions in shaping the culture of a school. School staff who seek to shape and improve school culture as a means of promoting student mental health may have better results if this interdependence is acknowledged, and improvements are addressed across all four dimensions rather than prioritising one or two.

A strength of this study is the inclusion of the student voice, and of students across a range of ages and ethnicities. This is unusual in school culture literature. However we are limited in the generalisability of our findings given that participants were drawn from only three schools, from one geographical area, during a global health emergency. We are also limited by the selection of parents for this study, as gatekeeping effects of school staff may have resulted in the exclusion of parents with a more critical appraisal of the schools. Further work is required to determine if this conceptual model of school culture is transferable to other schools in different contexts (with within the UK and beyond).

As the PAR intervention is implemented in our study schools, we plan further research with school-based participants to explore how the active involvement of students as co-researchers working to improve school culture for the benefit of student mental health works in practice. This methodology reflects the importance identified in the literature of active engagement and the promotion of autonomy in health promoting schools [ 9 , 14 , 16 , 17 ]. Studies are also needed that identify effective ways in which to influence all the different dimensions of school culture, to ensure safe and inclusive environments that are supportive of and not detrimental to student mental health.

Availability of data and materials

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Acknowledgements

We would like to thank Off the Record for ongoing support with our study, and ARC West’s Young People’s Advisory Group for reviewing data collection methods and tools.

This study is funded by the National Institute for Health Research (NIHR) School for Public Health Research (Grant Reference Number PD–SPH–2015). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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PJ, JK, ML contributed to the study conception and design. Material preparation, data collection and analysis were performed by PJ, JK, ML, EGS, LS and GK. The first draft of the manuscript was written by PJ and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Jessiman, P., Kidger, J., Spencer, L. et al. School culture and student mental health: a qualitative study in UK secondary schools. BMC Public Health 22 , 619 (2022). https://doi.org/10.1186/s12889-022-13034-x

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• Review Article
• Published: 07 May 2024

Mechanisms linking social media use to adolescent mental health vulnerability

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• Adrian Meier   ORCID: orcid.org/0000-0002-8191-2962 2 ,
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Research linking social media use and adolescent mental health has produced mixed and inconsistent findings and little translational evidence, despite pressure to deliver concrete recommendations for families, schools and policymakers. At the same time, it is widely recognized that developmental changes in behaviour, cognition and neurobiology predispose adolescents to developing socio-emotional disorders. In this Review, we argue that such developmental changes would be a fruitful focus for social media research. Specifically, we review mechanisms by which social media could amplify the developmental changes that increase adolescents’ mental health vulnerability. These mechanisms include changes to behaviour, such as sharing risky content and self-presentation, and changes to cognition, such as modifications in self-concept, social comparison, responsiveness to social feedback and experiences of social exclusion. We also consider neurobiological mechanisms that heighten stress sensitivity and modify reward processing. By focusing on mechanisms by which social media might interact with developmental changes to increase mental health risks, our Review equips researchers with a toolkit of key digital affordances that enables theorizing and studying technology effects despite an ever-changing social media landscape.

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Introduction.

Adolescence is a period marked by profound neurobiological, behavioural and environmental changes that facilitate the transition from familial dependence to independent membership in society 1 , 2 . This critical developmental stage is also characterized by diminished well-being and increased vulnerability to the onset of mental health conditions 3 , 4 , 5 , particularly socio-emotional disorders such as depression, and eating disorders 4 , 6 (Fig. 1 ). Notable symptoms of socio-emotional disorders include heightened negative affect, mood dysregulation and an increased focus on distress or challenges concerning interpersonal relationships, including heightened sensitivity to peers or perceptions of others 6 . Although some risk factors for socio-emotional disorders do not necessarily occur in adolescence (including genetic predispositions, adverse childhood experiences and poverty 7 , 8 , 9 ), the unique developmental characteristics of this period of life can interact with pre-existing vulnerabilities, increasing the risk of disorder onset 10 .

Meta-analytic proportion of age of onset of anxiety (red), obsessive-compulsive disorder (purple), eating disorders (orange), personality disorders (green), schizophrenia (grey) and mood disorders (blue). The peak age of onset (dotted lines) is 5.5 and 15.5 years for anxiety, 14.5 years for obsessive-compulsive disorder, 15.5 years for eating disorders and 20.5 years for personality disorders, schizophrenia and mood disorders. Adapted from ref. 258 , CC BY 4.0 ( https://creativecommons.org/licenses/by/4.0/ ).

Over the past decade, declines in adolescent mental health have become a great concern 11 , 12 . The prevalence of socio-emotional disorders has increased in the adolescent age range (10–24 years 2 ) 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , leading to mounting pressures on child and adolescent mental health services 16 , 21 , 22 . This increase has not been as pronounced among other age groups when compared with adolescents 20 , 22 , 23 (measured in ref.  20 , ref.  22 and ref.  23 as age 12–25 years, 12–20 years and 18–25 years, respectively), even if some studies have found increases across the entire lifespan 24 , 25 . Although these trends might not be generalizable across the world 26 or to subclinical indicators of distress 15 , similar trends have been found in a range of countries 27 . Declines in adolescent mental health, especially socio-emotional problems, are consistent across datasets and researchers have argued that they are not solely driven by changes in social attitudes, stigma or reporting of distress 28 , 29 .

Concurrently, adolescents’ lives have become increasingly digital, with most young people using social media platforms throughout the day 30 . Ninety-five per cent of UK adolescents aged 15 years use social media 31 , and 50% of US adolescents aged 13–17 years report being almost constantly online 32 . The social media environment impacts adolescent and adult life across many domains (for example, by enabling social communication or changing the way news is accessed) and influences individuals, dyads and larger social systems 33 , 34 , 35 , 36 . Because social media is inherently social and relational 37 , it potentially overlaps and interacts with the developmental changes that make adolescents vulnerable to the onset of mental health problems 38 , 39 (Fig. 2 ). Thus, it has been intensely debated whether the increase in social media use during the past decade has a causal role in the decline of adolescent mental health 40 . Indeed, rapid changes to the environment experienced before and during adolescence might be a fruitful area to explore when examining current mental health trends 41 .

During adolescence, the interaction between genetic programming (yellow), social determinants (red) and environmental factors (blue), as well as the developmental changes discussed in this Review, increases the risk for onset of mental health conditions. Digital environments, mediated behaviours and experiences, and the impact that this technology has on society and economy more generally, are one aspect of the complex forces that might lead to the declines in adolescent mental health observed in the last decade. Adapted from ref. 259 , Springer Nature Limited.

Although there are many environmental changes that could be relevant, a substantial body of research has emerged to investigate the potential link between social media use and declines in adolescent mental health 42 , 43 using various research approaches, including cross-sectional studies 44 , longitudinal observational data analyses 45 , 46 , 47 and experimental studies 48 , 49 . However, the scientific results have been mixed and inconclusive (for reviews, see refs. 43 , 50 , 51 , 52 , 53 ), which has made it difficult to establish evidence-based recommendations, regulations and interventions aimed at ensuring that social media use is not harmful to adolescents 54 , 55 , 56 , 57 .

Many researchers attribute the mixed results to insufficient study specificity. For instance, the relationship between social media use and mental health varies notably across individuals 45 , 58 and developmental time windows 59 . Yet studies often examine adolescents without differentiating them based on age or developmental stage 60 , which prevents systematic accounts of individual and subgroup differences. Additionally, most studies only rely on self-reported measures of time spent on social media 61 , 62 , and overlook more nuanced aspects of social media use such as the nature of the activities 63 and the content or features that users engage with 52 . These factors need to be considered to unpack any broader relationships 35 , 64 , 65 , 66 . Furthermore, the measurement of mental health often conflates positive and negative mental health outcomes as well as various mental health conditions, which could all be differentially related to social media use 52 , 67 .

This research space presents substantial complexity 68 . There is an ever-increasing range of potential combinations of social media predictors, well-being and mental health outcomes and participant groups of varying backgrounds and demographics that can become the target of scientific investigation. However, the pressure to deliver policy and public-facing recommendations and interventions leaves little time to investigate comprehensively each of these combinations. Researchers need to be able to pinpoint quickly the research programmes with the maximum potential to create translational and real-world impact for adolescent mental health.

In this Review, we aim to delineate potential avenues for future research that could lead to concrete interventions to improve adolescent mental health by considering mechanisms at the nexus between pre-existing processes known to increase adolescent mental health vulnerability and digital affordances introduced by social media. First, we describe the affordance approach to understanding the effects of social media. We then draw upon research on adolescent development, mental health and social media to describe behavioural, cognitive and neurobiological mechanisms by which social media use might amplify changes during adolescent development to increase mental health vulnerability during this period of life. The specific mechanisms within each category were chosen because they have a strong evidence base showing that they undergo substantive changes during adolescent development, are implicated in mental health risk and can be modulated by social media affordances. Although the ways in which social media can also improve mental health resilience are not the focus of our Review and therefore are not reviewed fully here, they are briefly discussed in relation to each mechanism. Finally, we discuss future research focused on how to systematically test the intersection between social media and adolescent mental health.

Social media affordances

To study the impact of social media on adolescent mental health, its diverse design elements and highly individualized uses must be conceptualized. Initial research predominately related access to or time spent on social media to mental health outcomes 46 , 69 , 70 . However, social media is not similar to a toxin or nutrient for which each exposure dose has a defined link to a health-related outcome (dose–response relationship) 56 . Social media is a diverse environment that cannot be summarized by the amount of time one spends interacting with it 71 , 72 , and individual experiences are highly varied 45 .

Previous psychological reviews often focused on social media ‘features’ 73 and ‘affordances’ 74 interchangeably. However, these terms have distinct definitions in communication science and information systems research. Social media features are components of the technology intentionally designed to enable users to perform specific actions, such as liking, reposting or uploading a story 75 , 76 . By contrast, affordances describe the perceptions of action possibilities users have when engaging with social media and its features, such as anonymity (the difficulty with which social media users can identify the source of a message) and quantifiability (how countable information is).

The term ‘affordance’ came from ecological psychology and visuomotor research, and was described as mainly determined by human perception 77 . ‘Affordance’ was later adopted for design and human–computer interaction contexts to refer to the action possibilities that are suggested to the user by the technology design 78 . Communication research synthesizes both views. Affordances are now typically understood as the perceived — and therefore flexible — action possibilities of digital environments, which are jointly shaped by the technology’s features and users’ idiosyncratic perceptions of those features 79 .

Latent action possibilities can vary across different users, uses and technologies 79 . For example, ‘stories’ are a feature of Instagram designed to share content between users. Stories can also be described in terms of affordances when users perceive them as a way to determine how long their content remains available on the platform (persistence) or who can see that content (visibility) 80 , 81 , 82 , 83 , 84 . Low persistence (also termed ephemerality) and comparatively low visibility can be achieved through a technology feature (Instagram stories), but are not an outcome of technology use itself; they are instead perceived action possibilities that can vary across different technologies, users and designs 79 .

The affordances approach is particularly valuable for theorizing at a level above individual social media apps or specific features, which makes this approach more resilient to technological changes or shifts in platform popularity 79 , 85 . However, the affordances approach can also be related back to specific types of social media by assessing the extent to which certain affordances are ‘built into’ a particular platform through feature design 35 . Furthermore, because affordances depend on individuals’ perceptions and actions, they are more aligned than features with a neurocognitive and behavioural perspective to social media use. Affordances, similar to neurocognitive and behavioural research, emphasize the role of the user (how the technology is perceived, interpreted and used) rather than technology design per se. In this sense, the affordances approach is essential to overcome technological determinism of mental health outcomes, which overly emphasizes the role of technology as the driver of outcomes but overlooks the agency and impact of the people in question 86 . This flexibility and alignment with psychological theory has contributed to the increasing popularity of the affordance approach 35 , 73 , 74 , 85 , 87 and previous reviews have explored relevant social media affordances in the context of interpersonal communication among adults and adolescents 35 , 88 , 89 , adolescent body image concerns 73 and work contexts 33 . Here, we focus on the affordances of social media that are relevant for adolescent development and its intersection with mental health (Table  1 ).

Behavioural mechanisms

Adolescents often use social media differently to adults, engaging with different platforms and features and, potentially, perceiving or making use of affordances in distinctive ways 35 . These usage differences might interact with developmental characteristics and changes to amplify mental health vulnerability (Fig.  3 ). We examine two behavioural mechanisms that might govern the impact of social media use on mental health: risky posting behaviours and self-presentation.

Social media affordances can amplify the impact that common adolescent developmental mechanisms (behavioural, cognitive and neurobiological) have on mental health. At the behavioural level (top), affordances such as permanence and publicness lead to an increased impact of risk-taking behaviour on mental health compared with similar behaviours in non-mediated environments. At the cognitive level (middle), high quantifiability influences the effects of social comparison. At the neurobiological level (bottom), low synchronicity can amplify the effects of stress on the developing brain.

Risky posting behaviour

Sensation-seeking peaks in adolescence and self-regulation abilities are still not fully developed in this period of life 90 . Thus, adolescents often engage in more risky behaviours than other age groups 91 . Adolescents are more likely to take risks in situations involving peers 92 , 93 , perhaps because they are motivated to avoid social exclusion 94 , 95 . Whether adolescent risk-taking behaviour is inherently adaptive or maladaptive is debated. Although some risk-taking behaviours can be adaptive and part of typical development, others can increase mental health vulnerability. For example, data from a prospective UK panel study of more than 5,500 young people showed that engaging in more risky behaviours (including social and health risks) at age 16 years increases the odds of a range of adverse outcomes at age 18 years, such as depression, anxiety and substance abuse 96 .

Social media can increase adolescents’ engagement in risky behaviours both in non-mediated and mediated environments (environments in which the behaviour is executed in or through a technology, such as a mobile phone and social media). First, affordances such as quantifiability in conjunction with visibility and association (the degree with which links between people, between people and content or between a presenter and their audience can be articulated) can promote more risky behaviours in non-mediated environments and in-person social interactions. For example, posts from university students containing references to alcohol gain more likes than posts not referencing alcohol and liking such posts predicts an individual’s subsequent drinking habits 97 . Users expecting likes from their audience are incentivized to engage in riskier posting behaviour (such as more frequent or more extreme posts containing references to alcohol). The relationship between risky online behaviour and offline behaviour is supported by meta-analyses that found a positive correlation between adolescents’ social media use and their engagement in behaviours that might expose them to harm or risk of injury (for example, substance use or risky sexual behaviours) 98 . Further, affordances such as persistence and visibility can mean that risky behaviours in mediated and non-mediated environments remain public for long periods of time, potentially influencing how an adolescent is perceived by peers over the longer term 39 , 99 .

Adolescence can also be a time of more risky social media use. For most forms of semi-public and public social media use, users typically do not know who exactly will be able to see their posts. Thus, adolescents need to self-present to an ‘imagined audience’ 100 and avoid posting the wrong kind of content as the boundaries between different social spheres collapse (context collapse 101 ). However, young people can underestimate the risks of disclosing revealing information in a social media environment 102 . Affordances such as visibility, replicability (social media posts remain in the system and can be screenshotted and shared even if they are later deleted 39 ), association and persistence could heighten the risk of experiencing cyberbullying, victimization and online harassment 103 . For example, adolescents can forward privately received sexual images to larger friendship groups, increasing the risk of online harassment over the subject of the sexual images 104 . Further, low bandwidth (a relative lack of socio-emotional cues) and high anonymity have the potential to disinhibit interactions between users and make behaviours and reactions more extreme 105 , 106 . For example, anonymity was associated with more trolling behaviours during an online group discussion in an experiment with 242 undergraduate students 107 .

Thus, social media might drive more risky behaviours in both mediated and non-mediated contexts, increasing mental health vulnerability. However, the evidence is still not clear cut and often discounts adolescent agency and understanding. For example, mixed-methods research has shown that young people often understand the risks of posting private or sexual content and use social media apps that ensure that posts are deleted and inaccessible after short periods of time to counteract them 39 (even though posts can still be captured in the meantime). Future work will therefore need to investigate how adolescents understand and balance such risks and how such processes relate to social media’s impact on mental health.

Self-presentation and identity

The adolescent period is characterized by an abundance of self-presentation activities on social media 74 , where the drive to present oneself becomes a fundamental motivation for engagement 108 . These activities include disclosing, concealing and modifying one’s true self, and might involve deception, to convey a desired impression to an audience 109 . Compared with adults, adolescents more frequently take part in self-presentation 102 , which can encompass both realistic and idealized portrayals of themselves 110 . In adults, authentic self-presentation has been associated with increased well-being, and inauthentic presentation (such as when a person describes themselves in ways not aligned with their true self) has been associated with decreased well-being 111 , 112 , 113 .

Several social media affordances shape the self-presentation behaviours of adolescents. For example, the editability of social media profiles enables users to curate their online identity 84 , 114 . Editability is further enhanced by highly visible (public) self-presentations. Additionally, the constant availability of social media platforms enables adolescents to access and engage with their profiles at any time, and provides them with rapid quantitative feedback about their popularity among peers 89 , 115 . People receive more direct and public feedback on their self-presentation on social media than in other types of environment 116 , 117 . The affordances associated with self-presentation can have a particular impact during adolescence, a period characterized by identity development and exploration.

Social media environments might provide more opportunities than offline environments for shaping one’s identity. Indeed, public self-presentation has been found to invoke more prominent identity shifts (substantial changes in identity) compared with private self-presentation 118 , 119 . Concerns have been raised that higher Internet use is associated with decreased self-concept clarity. Only one study of 101 adolescents as well as adults reviewed in a 2021 meta-analysis 120 showed that the intensity of Facebook use (measured by the Facebook Intensity Scale) predicted a longitudinal decline in self-concept clarity 3 months later, but the converse was not the case and changes in self-concept clarity did not predict Facebook use 121 . This result is still not enough to show a causal relationship 121 . Further, the affordances of persistence and replicability could also curtail adolescents’ ability to explore their identity freely 122 .

By contrast, qualitative research has highlighted that social media enables adolescents to broaden their horizons, explore their identity and identify and reaffirm their values 123 . Social media can help self-presentation by enabling adolescents to elaborate on various aspects of their identity, such as ethnicity and race 124 or sexuality 125 . Social media affordances such as editability and visibility can also facilitate this process. Adolescents can modify and curate self-presentations online, try out new identities or express previously undisclosed aspects of their identity 126 , 127 . They can leverage social media affordances to present different facets of themselves to various social groups by using different profiles, platforms and self-censorship and curation of posts 128 , 129 . Presenting and exploring different aspects of one’s identity can have mental health implications for minority teens. Emerging research shows a positive correlation between well-being and problematic Internet use in transgender, non-binary and gender-diverse adolescents (age 13–18 years), and positive sentiment has been associated with online identity disclosures in transgender individuals with supportive networks (both adolescent and adult) 130 , 131 .

Cognitive mechanisms

Adolescents and adults might experience different socio-cognitive impacts from the same social media activity. In this section, we review four cognitive mechanisms via which social media and its affordances might influence the link between adolescent development and mental health vulnerabilities (Fig.  3 ). These mechanisms (self-concept development, social comparison, social feedback and exclusion) roughly align with a previous review that examined self-esteem and social media use 115 .

Self-concept development

Self-concept refers to a person’s beliefs and evaluations about their own qualities and traits 132 , which first develops and becomes more complex throughout childhood and then accelerates its development during adolescence 133 , 134 , 135 . Self-concept is shaped by socio-emotional processes such as self-appraisal and social feedback 134 . A negative and unstable self-concept has been associated with negative mental health outcomes 136 , 137 .

Perspective-taking abilities also develop during adolescence 133 , 138 , 139 , as does the processing of self-relevant stimuli (measured by self-referential memory tasks, which assess memory for self-referential trait adjectives 140 , 141 ). During adolescence, direct self-evaluations and reflected self-evaluations (how someone thinks others evaluate them) become more similar. Further, self-evaluations have a distinct positive bias during childhood, but this positivity bias decreases in adolescence as evaluations of the self are integrated with judgements of other people’s perspectives 142 . Indeed, negative self-evaluations peak in late adolescence (around age 19 years) 140 .

The impact of social media on the development of self-concept could be heightened during adolescence because of affordances such as personalization of content 143 (the degree to which content can be tailored to fit the identity, preferences or expectations of the receiver), which adapts the information young people are exposed to. Other affordances with similar impacts are quantifiability, availability (the accessibility of the technology as well as the user’s accessibility through the technology) and public visibility of interactions 89 , which render the evaluations of others more prominent and omnipresent. The prominence of social evaluation can pose long-term risks to mental health under certain conditions and for some users 144 , 145 . For example, receiving negative evaluations from others or being exposed to cyberbullying behaviours 146 , 147 can, potentially, have heightened impact at times of self-concept development.

A pioneering cross-sectional study of 150 adolescents showed that direct self-evaluations are more similar to reflected self-evaluations, and self-evaluations are more negative, in adolescents aged 11–21 years who estimate spending more time on social media 148 . Further, longitudinal data have shown bidirectional negative links between social media use and satisfaction with domains of the self (such as satisfaction with family, friends or schoolwork) 47 .

Although large-scale evidence is still unavailable, these findings raise the interesting prospect that social media might have a negative influence on perspective-taking and self-concept. There is less evidence for the potential positive influence of social media on these aspects of adolescent development, demonstrating an important research gap. Some researchers hypothesize that social media enables self-concept unification because it provides ample opportunity to find validation 89 . Research has also discussed how algorithmic curation of personalized social media feeds (for example, TikTok algorithms tailoring videos viewed to the user’s interests) enables users to reflect on their self-concept by being exposed to others’ experiences and perspectives 143 , an area where future research can provide important insights.

Social comparison

Social comparison (thinking about information about other people in relation to the self 149 ) also influences self-concept development and becomes particularly important during adolescence 133 , 150 . There are a range of social media affordances that can amplify the impact of social comparison on mental health. For example, quantifiability enables like or follower counts to be easily compared with others as a sign of status, which facilitates social ranking 151 , 152 , 153 , 154 . Studies of older adolescents and adults aged, on average, 20 years have also found that the number of likes or reactions received predict, in part, how successful users judge their self-presentation posts on Facebook 155 . Furthermore, personalization enables the content that users see on social media to be curated so as to be highly relevant and interesting for them, which should intensify comparisons. For example, an adolescent interested in sports and fitness content will receive personalized recommendations fitting those interests, which should increase the likelihood of comparisons with people portrayed in this content. In turn, the affordance of association can help adolescents surround themselves with similar peers and public personae online, enhancing social comparison effects 63 , 156 . Being able to edit posts (via the affordance of editability) has been argued to contribute to the positivity bias on social media: what is portrayed online is often more positive than the offline experience. Thus, upward comparisons are more likely to happen in online spaces than downward or lateral comparisons 157 . Lastly, the verifiability of others’ idealized self-presentations is often low, meaning that users have insufficient cues to gauge their authenticity 158 .

Engaging in comparisons on social media has been associated with depression in correlational studies 159 . Furthermore, qualitative research has shown that not receiving as many positive evaluations as expected (or if positive evaluations are not provided quickly enough) increases negative emotions in children and adolescents aged between age 9 and 19 years 39 . This result aligns with a reinforcement learning modelling study of Instagram data, which found that the likes a user receives on their own posts become less valuable and less predictive of future posting behaviour if others in their network receive more likes on their posts 160 . Although this study did not measure mood or mental health, it shows that the value of the likes are not static but inherently social; their impact depends on how many are typically received by other people in the same network.

Among the different types of social comparison that adolescents engage in (comparing one’s achievements, social status or lifestyle), the most substantial concerns have been raised about body-related comparisons. One review suggested that social media affordances create a ‘perfect storm’ for body image concerns that can contribute to both socio-emotional and eating disorders 73 . Social media affordances might increase young people’s focus on other people’s appearances as well as on their own appearance by showing idealized, highly edited images, providing quantified feedback and making the ability to associate and compare oneself with peers constantly available 161 , 162 . The latter puts adolescents who are less popular or receive less social support at particular risk of low self-image and social distress 35 .

Affordances enable more prominent and explicit social comparisons in social media environments relative to offline environments 158 , 159 , 163 , 164 , 165 . However, this association could have a positive impact on mental health 164 , 166 . Initial evidence suggests beneficial outcomes of upward comparisons on social media, which can motivate behaviour change and yield positive downstream effects on mental health 164 , 166 . Positive motivational effects (inspiration) have been observed among young adults for topics such as travelling and exploring nature, as well as fitness and other health behaviours, which can all improve mental health 167 . Importantly, inspiration experiences are not a niche phenomenon on social media: an experience sampling study of 353 Dutch adolescents (mean age 13–15 years) found that participants reported some level of social media-induced inspiration in 33% of the times they were asked to report on this over the course of 3 weeks 168 . Several experimental and longitudinal studies show that inspiration is linked to upward comparison on social media 157 , 164 , 166 . However, the positive, motivating side of social comparison on social media has only been examined in a few studies and requires additional investigation.

Social feedback

Adolescence is also a period of social reorientation, when peers tend to become more important than family 169 , peer acceptance becomes increasingly relevant 170 , 171 , 172 and young people spend increasing amounts of time with peers 173 . In parallel, there is a heightened sensitivity to negative socio-emotional or self-referential cues 140 , 174 , higher expectation of being rejected by others 175 and internalization of such rejection 142 , 176 compared with other phases in life development. A meta-analysis of both adolescents and adults found that oversensitivity to social rejection is moderately associated with both depression and anxiety 177 .

Social media affordances might amplify the potential impact of social feedback on mental health. Wanting to be accepted by peers and increased susceptibility to social rewards could be a motivator for using social media in the first place 178 . Indeed, receiving likes as social reward activated areas of the brain (such as the nucleus accumbens) that are also activated by monetary reward 179 . Quantifiability amplifies peer acceptance and rejection (via like counts), and social rejection has been linked to adverse mental health outcomes 170 , 180 , 181 , 182 . Social media can also increase feelings of being evaluated, the risk of social rejection and rumination about potential rejection due to affordances such as quantifiability, synchronicity (the degree to which an interaction happens in real time) and variability of social rewards (the degree to which social interaction and feedback occur on variable time schedules). For example, one study of undergraduate students found that active communication such as messaging was associated with feeling better after Facebook use; however, this was not the case if the communication led to negative feelings such as rumination (for example, after no responses to the messages) 183 .

In a study assessing threatened social evaluation online 184 , participants were asked to record a statement about themselves and were told their statements would be rated by others. To increase the authenticity of the threat, participants were asked to rate other people’s recordings. Threatened social evaluation online in this study decreased mood, most prominently in people with high sensitivity to social rejection. Adolescents who are more sensitive to social rejection report more severe depressive symptoms and maladaptive ruminative brooding in both mediated and non-mediated social environments, and this association is most prominent in early adolescence 185 . Not receiving as much online social approval as peers led to more severe depressive symptoms in a study of American ninth-grade adolescents (between age 14 and 15 years), especially those who were already experiencing peer victimization 153 . Furthermore, individuals with lower self-esteem post more negative and less positive content than individuals with higher self-esteem. Posted negative content receives less social reward and recognition from others than positive content, possibly creating a vicious cycle 186 . Negative experiences pertaining to social exclusion and status are also risk factors for socio-emotional disorders 180 .

The impact of social media experiences on self-esteem can be very heterogeneous, varying substantially across individuals. As a benefit, positive social feedback obtained via social media can increase users’ self-esteem 115 , an association also found among adolescents 187 . For instance, receiving likes on one’s profile or posted photographs can bolster self-esteem in the short term 144 , 188 . A study linking behavioural data and self-reports from Facebook users found that receiving quick responses on public posts increased a sense of social support and decreased loneliness 189 . Furthermore, a review of reviews consistently documented that users who report more social media use also perceive themselves to have more social resources and support online 52 , although this association has mostly been studied among young adults using social network sites such as Facebook. Whether such social feedback benefits extend to adolescents’ use of platforms centred on content consumption (such as TikTok or Instagram) is an open question.

Social inclusion and exclusion

Adolescents are more sensitive to the negative emotional impacts of being excluded than are adults 170 , 190 . It has been proposed that, as the importance of social affiliation increases during this period of life 134 , 191 , 192 , adolescents are more sensitive to a range of social stimuli, regardless of valence 193 . These include social feedback (such as compliments or likes) 95 , 194 , negative socio-emotional cues (such as negative facial expressions or social exclusion) 174 and social rejection 172 , 185 . By contrast, social inclusion (via friendships in adolescence) is protective against emotional disorders 195 and more social support is related to higher adolescent well-being 196 .

Experiencing ostracism and exclusion online decreases self-esteem and positive emotion 197 . This association has been found in vignette experiments where participants received no, only a few or a lot of likes 198 , or experiments that used mock-ups of social media sites where others received more likes than participants 153 . Being ostracized (not receiving attention or feedback) or rejected through social media features (receiving dislikes and no likes) is also associated with a reduced sense of belonging, meaningfulness, self-esteem and control 199 . Similar results were found when ostracism was experienced over messaging apps, such as not receiving a reply via WhatsApp 200 .

Evidence on whether social media also enables adolescents to experience positive social inclusion is mostly indirect and mixed. Some longitudinal surveys have found that prosocial feedback received on social media during major life events (such as university admissions) helps to buffer against stress 201 . Adult participants of a longitudinal study reported that social media offered more informational support than offline contexts, but offline contexts more often offered emotional or instrumental support 202 . Higher social network site use is, on average, associated with a perception of having more social resources and support in adults (for an overview of meta-analyses, see ref. 52 ). However, most of these studies have not investigated social support among adolescents, and it is unclear whether early findings (for example, on Facebook or Twitter) generalize to a social media landscape more strongly characterized by content consumption than social interaction (such as Instagram or TikTok).

Still, a review of social media use and offline interpersonal outcomes among adolescents documents both positive (sense of belonging and social capital) and negative (alienation from peers and perceived isolation) correlates 203 . Experience sampling research on emotional support among young adults has further shown that online social support is received and perceived as effective, and its perceived effectiveness is similar to in-person social support 204 . Social media use also has complex associations with friendship closeness among adolescents. For example, one experience sampling study found that greater use of WhatsApp or Instagram is associated with higher friendship closeness among adolescents; however, within-person examinations over time showed small negative associations 205 .

Neurobiological mechanisms

The long-term impact of environmental changes such as social media use on mental health might be amplified because adolescence is a period of considerable neurobiological development 95 (Fig.  3 ). During adolescence, overall cortical grey matter declines and white matter increases 206 , 207 . Development is particularly protracted in brain regions associated with social cognition and executive functions such as planning, decision-making and inhibiting prepotent responses. The changes in grey and white matter are thought to reflect axonal growth, myelination and synaptic reorganization, which are mechanisms of neuroplasticity influenced by the environment 208 . For example, research in rodents has demonstrated that adolescence is a sensitive period for social input, and that social isolation in adolescence has unique and more deleterious consequences for neural, behavioural and mental health development than social isolation before puberty or in adulthood 206 , 209 . There is evidence that brain regions involved in motivation and reward show greater activation to rewarding and motivational stimuli (such as appetitive stimuli and the presence of peers) in early and/or mid adolescence compared with other age groups 210 , 211 , 212 , 213 , 214 .

Little is known about the potential links between social media and neurodevelopment due to the paucity of research investigating these associations. Furthermore, causal chains (for example, social media increasing stress, which in turn influences the brain) have not yet been accurately delineated. However, it would be amiss not to recognize that brain development during adolescence forms part of the biological basis of mental health vulnerability and should therefore be considered. Indeed, the brain is proposed to be particularly plastic in adolescence and susceptible to environmental stimuli, both positive and negative 208 . Thus, even if adults and adolescents experienced the same affective consequences from social media use (such as increases in peer comparison or stress), these consequences might have a greater impact in adolescence.

A cross-sectional study (with some longitudinal elements) suggested that habitual checking of social media (for example, checking for rewards such as likes) might exacerbate reward sensitivity processes, leading to long-term hypersensitization of the reward system 215 . Specifically, frequently checking social media was associated with reduced activation in brain regions such as the dorsolateral prefrontal cortex and the amygdala in response to anticipated social feedback in young people. Brain activation during the same social feedback task was measured over subsequent years. Upon follow-up, anticipating feedback was associated with increased activation of the same brain regions among the individuals who checked social media frequently initially 215 . Although longitudinal brain imaging measurements enabled trajectories of brain development to be specified, the measures of social media use were only acquired once in the first wave of data collection. The study therefore cannot account for confounds such as personality traits, which might influence both social media checking behaviours and brain development. Other studies of digital screen use and brain development have found no impact on adolescent functional brain organization 216 .

Brain development and heightened neuroplasticity 208 render adolescence a particularly sensitive period with potentially long-term impacts into adulthood. It is possible that social media affordances that underpin increased checking and reward-seeking behaviours (such as quantifiability, variability of social rewards and permanent availability of peers) might have long-term consequences on reward processing when experienced during adolescence. However, this suggestion is still speculative and not backed up by evidence 217 .

Stress is another example of the potential amplifying effect of social media on adolescent mental health vulnerability due to neural development. Adolescents show higher stress reactivity because of maturational changes to, and increased reactivity in, the hypothalamic–pituitary–adrenal axis 218 , 219 . Compared with children and adults, adolescents experience an increase in self-consciousness and associated emotional states such as self-reported embarrassment and related physiological measures of arousal (such as skin conductance), and heightened neural response patterns compared with adults, when being evaluated or observed by peers 220 . Similarly, adolescents (age 13–17 years) show higher stress responses (higher levels of cortisol or blood pressure) compared with children (age 7–12 years) when they perform in front of others or experience social rejection 221 .

Such changes in adolescence might confer heightened risk for the onset of mental health conditions, especially socio-emotional disorders 6 . Both adolescent rodents and humans show prolonged hypothalamic–pituitary–adrenal activation after experiencing stress compared with conspecifics of different ages 218 , 219 . In animal models, stress during adolescence has been shown to result in increased anxiety levels in adulthood 222 and alterations in emotional and cognitive development 223 . Furthermore, human studies have linked stress in adolescence to a higher risk of mental health disorder onset 218 and reviews of cross-species work have illustrated a range of brain changes due to adolescent stress 224 , 225 .

There is still little conclusive neurobiological evidence about social media use and stress, and a lack of understanding about which affordances might be involved (although there has been a range of work studying digital stress; Box  1 ). Studies of changes in cortisol levels or hypothalamic–pituitary–adrenal functioning and their relation to social media use have been mixed and inconclusive 226 , 227 . These results could be due to the challenge of studying stress responses in adolescents, particularly as cortisol fluctuates across the day and one-point readings can be unreliable. However, the increased stress sensitivity during the adolescent developmental period might mean that social media use can have a long-term influence on mental health due to neurobiological mechanisms. These processes are therefore important to understand in future research.

Box 1 Digital stress

Digital stress is not a unified construct. Thematic content analyses have categorized digital stress into type I stressors (for example, mean attacks, cyberbullying or shaming) and type II stressors (for example, interpersonal stress due to pressure to stay available) 260 . Other reviews have noted its complexity, and categorized digital stress into availability stress (stress that results from having to be constantly available), approval anxiety (anxiety regarding others’ reaction to their own profile, posts or activities online), fear of missing out (stress about being absent from or not experiencing others’ rewarding experiences) and communication overload (stress due to the scale, intensity and frequency of online communication) 261 .

Digital stress has been systematically linked to negative mental health outcomes. Higher digital stress was longitudinally associated with higher depressive symptoms in a questionnaire study 262 . Higher social media stress was also longitudinally related to poorer sleep outcomes in girls (but not boys) 263 . Studies and reviews have linked cyberbullying victimization (a highly stressful experience) to decreased mental health outcomes such as depression, and psychosocial outcomes such as self-esteem 103 , 146 , 147 , 264 , 265 . A systematic review of both adolescents and adults found a medium association ( r  = 0.26–0.34) between different components of digital stress and psychological distress outcomes such as anxiety, depression or loneliness, which was not moderated by age or sex (except for connection overload) 266 . However, the causal structure giving rise to such results is still far from clear. For example, surveys have linked higher stress levels to more problematic social media use and fear of missing out 267 , 268 .

Thus, the impact of digital stress on mental health is probably complex and influenced by the type of digital stressor and various affordances. For example, visibility and availability increase fear of negative public evaluation 269 and high availability and a social norm of responding quickly to messages drive constant monitoring in adolescents due to a persistent fear of upsetting friends 270 .

A range of relevant evidence from qualitative and quantitative studies documents that adolescents often ruminate about online interactions and messages. For example, online salience (constantly thinking about communication, content or events happening online) was positively associated with stress on both between-person and within-person levels in a cross-sectional quota sample of adults and three diary studies of young adults 271 , 272 . Online salience has also been associated with lower well-being in a pre-registered study of momentary self-reports from young adults with logged online behaviours. However, this study also noted that positive thoughts were related to higher well-being 273 . Furthermore, although some studies found no associations between the amount of communication and digital stress 272 , a cross-sectional study found that younger users’ (age 14–34 years and 35–49 years) perception of social pressure to be constantly available was related to communication load (measured by questions about the amount of use, as well as the urge to check email and social media) and Internet multitasking, whereas this was not the case for older users aged 50–85 years 274 . By contrast, communication load and perceived stress were associated only among older users.

Summary and future directions

To help to understand the potential role of social media in the decline of adolescent mental health over the past decade, researchers should study the mechanisms linking social media, adolescent development and mental health. Specifically, social media environments might amplify the socio-cognitive processes that render adolescents more vulnerable to mental health conditions in the first place. We outline various mechanisms at three levels of adolescent development — behavioural, cognitive and neurobiological — that could be involved in the decline of adolescent mental health as a function of social media engagement. To do so, we delineate specific social media affordances, such as quantification of social feedback or anonymity, which can also have positive impacts on mental health.

Our Review sets out clear recommendations for future research on the intersection of social media and adolescent mental health. The foundation of this research lies in the existing literature investigating the underlying processes that heighten adolescents’ risk of developing socio-emotional disorders. Zooming in on the potential mechanistic targets impacted by social media uses and affordances will produce specific research questions to facilitate controlled and systematic scientific inquiry relevant for intervention and translation. This approach encourages researchers to pinpoint the mechanisms and levels of explanation they want to include and will enable them to identify what factors to additionally consider, such as participants’ age 60 , the specific mental health outcomes being measured, the types of social media being examined and the populations under study 52 , 228 . Targeted and effective research should prioritize the most promising areas of study and acknowledge that all research approaches have inherent limitations 229 . Researchers must embrace methodological diversity, which in turn will facilitate triangulation. Surveys, experience sampling designs in conjunction with digital trace data, as well as experimental or neuroimaging paradigms and computational modelling (such as reinforcement learning) can all be used to address research questions comprehensively 230 . Employing such a multi-method approach enables the convergence of evidence and strengthens the reliability of findings 231 .

Mental health and developmental research can also become more applicable to the study of social media by considering how studies might already be exploring features of the digital environment, such as its design features and perceived affordances. Many cognitive neuroscience studies that investigate social processes and mental health during adolescence necessarily design tasks that can be completed in controlled experimental or brain scanning environments. Consequently, they tend to focus on digitally mediated interactions. However, researchers conceptualize and generalize their results to face-to-face interactions. For example, it is common across the discipline to not explicitly describe the interactions under study as being about social processes in digital environments (such as studies that assess social feedback based on the number of ‘thumbs up’ or ‘thumbs down’ received in social media 232 ). Considering whether cognitive neuroscience studies include key affordances of mediated (or non-mediated) environments, and discussing these in published papers, will make studies searchable within the field of social media research, enabling researchers to broaden the impact of their work and systematically specify generalizations to offline environments 233 .

To bridge the gap between knowledge about mediated and non-mediated social environments, it is essential to directly compare the two 233 . It is often assumed that negative experiences online have a detrimental impact on mental health. However, it remains unclear whether this mechanism is present in both mediated and non-mediated spaces or whether it is specific to the mediated context. For instance, our Review highlights that the quantification of social feedback through likes is an important affordance of social media 160 . Feedback on social media platforms might therefore elicit a greater sense of certainty because it is quantified compared with the more subjective and open-to-interpretation feedback received face to face 151 . Conducting experiments in which participants receive feedback that is more or less quantified and uncertain, specifically designed to compare mediated and non-mediated environments, would provide valuable insights. Such research efforts could also establish connections with computational neuroscience studies demonstrating that people tend to learn faster from stimuli that are less uncertain 234 .

We have chosen not to make recommendations concerning interventions targeting social media use to improve adolescent mental health for several reasons. First, we did not fully consider the bidirectional interactions between environment and development 35 , 235 , or the factors modulating adolescents’ differential susceptibility to the effects of social media 45 , 58 . For example, mental health status also influences how social media is used 47 , 58 , 59 , 236 , 237 (Box  2 ). These bidirectional interactions could be addressed using network or complexity science approaches 238 . Second, we do not yet know how the potential mechanisms by which social media might increase mental health vulnerability compare in magnitude, importance, scale and ease and/or cost of intervention with other factors and mechanisms that are already well known to influence mental health, such as poverty or loneliness. Last, social media use will probably interact with these predictors in ways that have not been delineated and can also support mental health resilience (for example, through social support or online self-help programmes). These complexities should be considered in future research, which will need to pinpoint not just the existence of mechanisms but their relative importance, to identify policy and intervention priorities.

Our Review has used a broad definition of mental health. Focusing on specific diagnostic or transdiagnostic symptomatology might reveal different mechanisms of interest. Furthermore, our Review is limited to mechanisms related to behaviour and neurocognitive development, disregarding other levels of explanation (such as genetics and culture) 34 , and also studying predominately Western-centric samples 239 . Mechanisms do not operate solely in linear pathways but exist within networks of interacting risk and resilience factors, characterized by non-linear and complex dynamics across diverse timescales 9 . Mechanisms and predisposing factors can interact and combine, amplifying mental health vulnerability. Mental health can be considered a dynamic system in which gradual changes to external conditions can have substantial downstream consequences due to system properties such as feedback loops 240 , 241 , 242 . These consequences are especially prominent in times of change and pre-existing vulnerability, such as adolescence 10 .

Indeed, if social media is a contributing factor to the current decline in adolescent mental health, as is commonly assumed, then it is important to identify and investigate mechanisms that are specifically tailored to the adolescent age range and make the case for why they matter. Without a thorough examination of these mechanisms and policy analysis to indicate whether they should be a priority to address, there is insufficient evidence to support the hypothesis that social media is the primary — or even just an influential and important — driver of mental health declines. Researchers need to stop studying social media as monolithic and uniform, and instead study its features, affordances and outcomes by leveraging a range of methods including experiments, questionnaires, qualitative research and industry data. Ultimately, this comprehensive approach will enhance researchers’ ability to address the potential challenges that the digital era poses on adolescent mental health.

Box 2 Effects of mental health on social media use

Although a lot of scientific discussion has focused on the impact of social media use on mental health, cross-sectional studies cannot differentiate between whether social media use is influencing mental health or mental health is influencing social media use, or a third factor is influencing both 51 . It is likely that mental health status influences social media use creating reinforcing cycles of behaviour, something that has been considered in the communication sciences literature under the term ‘transactional media effects’ 58 , 236 , 237 . According to communication science models, media use and its consequences are components of reciprocal processes 275 .

There are similar models in mental health research. For example, people’s moods influence their judgements of events, which can lead to self-perpetuating cycles of negativity (or positivity); a mechanism called ‘mood congruency’ 276 . Behavioural studies have also shown that people experiencing poor mental health behave in ways that decrease their opportunity to experience environmental reward such as social activities, maintaining poor mental health 277 , 278 . Although for many people these behaviours are a form of coping (for example, by avoiding stressful circumstances), they often worsen symptoms of mental health conditions 279 .

Some longitudinal studies found that a decrease in adolescent well-being predicted an increase in social media use 1 year later 47 , 59 . However, other studies have found no relationships between well-being and social media use over long-term or daily time windows 45 , 46 . One reason behind the heterogeneity of the results could be that how mental health impacts social media use is highly individual 45 , 280 .

Knowledge on the impact of mental health on social media use is still in its infancy and studies struggle to reach coherent conclusions. However, findings from the mental health literature can be used to generate hypotheses about how aspects of mental health might impact social media use. For example, it has been repeatedly found that young people with anxiety or eating disorders engage in more social comparisons than individuals without these disorders 281 , 282 , and adolescents with depression report more unfavourable social comparisons on social media than adolescents without depression 283 . Similar results have been found for social feedback seeking (for example, reassurance), including in social media environments 159 . Specifically, depressive symptoms were more associated with social comparison and feedback seeking, and these associations were stronger in women and in adolescents who were less popular. Individuals from the general population with lower self-esteem post more negative and less positive content than individuals with higher self-esteem, which in turn is associated with receiving less positive feedback from others 185 . There are therefore a wide range of possible ways in which diverse aspects of mental health might influence specific facets of how social media is used — and, in turn, how it ends up impacting the user.

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Acknowledgements

A.O. and T.D. were funded by the Medical Research Council (MC_UU_00030/13). A.O. was funded by the Jacobs Foundation and a UKRI Future Leaders Fellowship (MR/X034925/1). S.-J.B. is funded by Wellcome (grant numbers WT107496/Z/15/Z and WT227882/Z/23/Z), the MRC, the Jacobs Foundation, the Wellspring Foundation and the University of Cambridge.

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ORIGINAL RESEARCH article

Development of an implementation plan for a school-based multimodal approach for depression and suicide prevention in adolescents.

• 1 GGZ Oost Brabant, Boekel, Netherlands
• 2 113 Suicide Prevention, Amsterdam, Netherlands
• 3 Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
• 4 Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam, Netherlands
• 5 Department of Public and Occupational Health, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
• 6 Amsterdam Public Health Research Institute, Health Behaviors & Chronic Diseases, Amsterdam, Netherlands
• 7 Pro Persona, Nijmegen, Netherlands

Strong Teens and Resilient Minds (STORM) is a multimodal, school-based approach for depression and suicide prevention in adolescents that is currently implemented in a region in the Netherlands. The STORM approach will be implemented in new regions in the coming years. This study used the implementation mapping protocol to report on the development of the STORM implementation plan. First, a needs assessment was conducted through semi-structured interviews with stakeholders and brainstorming sessions with regional programme leaders in the two regions that started implementing STORM in 2023. This led to the identification of six main barriers to implementation: high level of demands for schools, insufficient understanding of the programme content, insufficient network collaboration, no perceived relative advantage of STORM by stakeholders, lack of attention to sustainability, and high work pressure. Second, performance and change objectives were formulated based on these barriers. For example, a performance objective for potential providers was that they felt supported by STORM. Third, implementation strategies were selected from theory and translated into practical applications through brainstorming sessions with programme leaders. The following strategies were included in the implementation plan: collaborate with similar initiatives within the region, free up time for STORM tasks, tailor strategies, identify and prepare STORM champions, and promote network weaving. Last, a plan to evaluate the implementation of STORM and the application of the STORM implementation plan was formulated. Planned evaluation research will provide more insight into the usefulness and impact of the STORM implementation plan.

Introduction

Globally, depression and suicide prevalence in adolescents is high and appears to be increasing ( 1 – 8 ). Adolescent depression is associated with poor social well-being, poor school attendance, failure to complete secondary school, depression recurrence, and the onset of other psychiatric disorders ( 9 – 12 ). Moreover, suicide is the fourth leading cause of death among adolescents aged 15–29 worldwide ( 13 ). This stresses the need to implement evidence-based depression and suicide prevention programmes.

Educational settings offer opportunities to reach a large number of adolescents, since most adolescents attend school. Several review studies have found small effects and moderate effects on students’ mental health for universal and indicated school-based depression prevention interventions, respectively ( 14 – 17 ). School-based suicide prevention interventions have shown small positive effects on suicidal ideation and behaviours ( 18 , 19 ). Katz et al. ( 20 ) and Hofstra et al. ( 21 ) have suggested combining several interventions to further increase the efficacy of depression and suicide prevention.

Such an approach has been developed in the Netherlands and is called Strong Teens and Resilient Minds (STORM) ( 22 , 23 ). Currently, the STORM approach consists of four interventions ( 22 , 23 ): (1) universal prevention through mental health lessons in schools, (2) a gatekeeper training (GKT) for school personnel to create a support network around adolescents, (3) early detection of depressive symptoms and suicidality and further assessment and referral when needed, and (4) Op Volle Kracht (OVK, which translates to “at full force”), an indicated depression prevention intervention based on cognitive behavioural group therapy. The STORM approach is science-based, and several programme components have been found to be effective ( 22 , 23 ): The GKT has been found effective at increasing knowledge of suicide prevention and confidence to discuss suicidality ( 24 ). The OVK training has been found effective at reducing depressive symptoms in adolescent ( 25 , 26 ).

Despite the existing evidence on the effectiveness of interventions for mental health promotion, prevention, and treatment, most people affected by mental health problems do not receive appropriate intervention ( 27 ). Therefore, scaling up effective prevention approaches is warranted. As part of the Dutch National Agenda Suicide Prevention 2021–2025 ( 28 ), which states national-level goals and activities in the context of suicide prevention, STORM will be scaled up to a national level. STORM is currently implemented in one region in the Netherlands that has about 250,000 inhabitants. Several new Dutch regions will be financially supported to also implement the approach in the coming years. Higher levels of implementation in various implementation outcomes, such as fidelity or dose, are related to better programme outcomes ( 29 – 31 ). This requires applying strategies that fit the context of new user settings ( 32 ). Therefore, developing an implementation plan in collaboration with stakeholders is essential to enhance the level of implementation and the potential programme outcomes.

The current study reports on the development of an implementation plan for STORM using the implementation mapping protocol, a systematic approach to developing an implementation plan by combining theory and co-creation with stakeholders in practice ( 32 ). Studies reporting on the development of an implementation plan for school-based mental health approaches in preparation for implementation are scarce. While we studied the example case of STORM, our approach to identifying these strategies and our outcomes could inform other school-based mental health approaches as well. This case is of particular interest to others, because of the complexity of STORM considering the multiple components, and because many stakeholders are involved in providing and implementing the approach.

The current study used a qualitative case study design to develop an implementation plan for STORM that was co-created with stakeholders in practice, and was guided by thematic analysis ( 33 ). The report followed the Standards for Reporting Qualitative Research formulated by O’Brien et al. ( 34 ), which was filled in and included in Supplementary File 1 . All participants in this study signed an informed consent form before participation. This study was approved by the Ethics Commission Social Sciences of Radboud University, approval number ECSW-LT-2023-2-2-33415.

The STORM approach

First, mental health lessons are offered by mental healthcare professionals in schools to improve mental health literacy. Second, schoolteachers can undergo GKT, through which they learn to identify adolescents who show signs of suicidal behaviours and how to respond to those students. Third, a screening of students’ depression and suicide risk is conducted by the Public Health Service (PHS, in Dutch: GGD) using the Childhood Depression Inventory 2 ( 35 ) and the Questionnaire Assessing Suicide and Self Injury ( 36 ). Students identified as at risk for suicide are seen within 48 h by Child and Youth Health (CYH) professionals from the PHS for further assessment and referral, if necessary. Students with elevated depressive symptoms based on the Child Depression Inventory 2 are offered the indicated depression prevention intervention called OVK, which is based on cognitive behavioural group therapy ( 23 ). This intervention is usually provided by a duo of a care professionals within the school and a care professional in the youth care domain.

An integral part of STORM is collaboration within the network of care and education for adolescents ( 22 , 23 , 37 ). There are four main partners in this network: secondary and vocational schools, municipalities, PHS, and mental health professionals. Secondary and vocational schools are the settings for all interventions that are part of STORM ( 23 ). Within a region, these schools collaborate with municipalities in educational partnerships in supporting and caring for youth ( 38 ). Also, municipalities financially facilitate the implementation of STORM in practice ( 23 ). While regions can apply for a start-up budget through the Dutch National Agenda Suicide Prevention 2021–2025 subsidised by the Ministry of Health, Welfare, and Sports ( 28 ), municipalities still have to be involved for sustained financing after 2025. A team of mental health professionals provides consultation, training and personnel for carrying out the interventions ( 23 ).

An overview of the regional STORM programme structure, including the tasks of each partner, is provided in the second and third columns of Figure 1 . Stakeholders from education, the PHS, mental health services, and municipalities collaborate in each part of the programme structure. For the current study, we defined four stakeholder categories: regional management, regional programme leaders, policymakers, and service providers. These are also indicated in the first column of Figure 1 .

Figure 1 . Overview of regional STORM programme structure.

National scaling up of STORM

As part of the Dutch National Agenda Suicide Prevention 2021–2025 ( 28 ), STORM is being scaled-up to new regions in the Netherlands between 2021 and 2025. Interested regions could apply for a start-up implementation budget. The first two regions to receive this budget were selected in December 2022 and started implementing STORM in the academic year of 2023–2024 ( 39 ). To apply for the budget, the regions had to prepare for implementation and had thus already initiated several implementation strategies before the start of the current study. Furthermore, existing STORM regions have already introduced several implementation strategies in recent years. These strategies have already been formulated and provided to the new regions. An overview of the existing implementation strategies can be found in Supplementary File 2 . The current study seeked to identify additional strategies from the literature that can help to overcome implementation barriers.

Theoretical background

The tasks of implementation mapping (IM) described by Fernandez et al. ( 32 ) offer a systematic approach to developing an implementation plan by combining theory and co-creation with stakeholders in practice. IM has previously helped to identify implementation strategies for various preventive interventions and programmes ( 40 – 46 ). The five tasks of IM are the following: (1) conduct an implementation needs assessment to identify barriers and facilitators for implementation, (2) identify adoption and implementation outcomes, performance objectives, and change objectives, (3) select theoretical methods and design implementation strategies, (4) produce implementation protocols and materials, and (5) evaluate implementation outcomes ( 32 ).

We used the Consolidated Framework for Implementation Research (CFIR) from Damschroder et al. ( 47 ) to identify barriers to and facilitators for implementation in Task 1. The CFIR describes constructs in five domains to consider as potential barriers or facilitators. First, the innovation domain, which includes constructs related to the innovation being implemented. Second is the inner setting into which the innovation is implemented. Third is the outer setting within which the inner setting exists. The fourth domain concerns individuals and pertains to the roles and characteristics of individuals involved in the innovation being implemented. The last domain implementation process consists of constructs related to the activities and strategies used to implement the innovation ( 47 ).

For the selection of theoretical implementation strategies in Task 3, Powell, Waltz ( 48 ) compiled a list of 73 implementation strategies based on the results of the Expert Recommendations for Implementing Change (ERIC) study. Recently, this compilation has been adapted to improve its utility in educational settings in the School Implementation Strategies, Translating ERIC Resources (SISTER) Project ( 49 ). This project resulted in a list of 75 school-adapted implementation strategies. Both the ERIC and SISTER compilations guided the selection of strategies in this study.

Below, we specify our study procedures in terms of sample and recruitment, data collection, and data analysis conducted for each of the five IM tasks. An overview of our procedures for each task is described in Figure 2 .

Figure 2 . Overview of procedures and sample per IM task.

Task 1: conduct a needs assessment

The needs assessment helps to identify important actors and potential barriers to and facilitators for implementation ( 32 ). For this, we conducted semi-structured interviews of approximately half an hour in February and March 2023. Study participants were selected from the region that has already implemented STORM (region 1) and two regions that were planning to implement STORM (regions 2 and 3) using purposive snowball sampling. First, we invited the national STORM team and regional programme leaders ( n  = 6) for interviews. Next, they helped to identify and contact other relevant stakeholders within the regions. We aimed to represent all stakeholder groups, and reached out to management and intervention providers from schools ( n  = 9), the PHS ( n  = 5), mental health organisations ( n  = 5), and municipalities ( n  = 4). Additionally, we invited mentors from secondary schools that had already implemented STORM ( n  = 2) for interviews, because mentors from secondary schools in the new regions had not yet been informed about the STORM approach. Participants were included until data saturation was reached, which meant that two researchers (KJ and CG) agreed that the last two interviews did not lead to new information. Researchers met with the national coordinators and regional programme leaders prior to the interviews to discuss which other stakeholders to include in the study. Researchers did not meet with any of the other participants prior to the interviews. The researchers’ characteristics did not influence the research questions, approach, methods, results, or transferability.

The interviews followed an interview guide based on the updated CIFR ( 47 ). The topics included STORM characteristics (example question: what is your perspective on STORM?) and barriers and facilitators (example question: what are things you think could complicate the implementation of STORM?), as well as the sub-topics Outer Setting, Inner Setting, Individuals, and Implementation Process. The full topic list is added in Supplementary File 3 . Interviews were conducted by two researchers (KJ & CG) and audio-recorded. KJ was a PhD student at the time of the study with previous experience in conducting and analysing qualitative research. CG was a bachelor student and intern at the time of the study with no previous experience in qualitative research. The recordings were transcribed verbatim. After the interviews, a short summary was sent to the participants for verification.

To draw up a codebook, three researchers (KJ, CG, and FN) analysed six of the 20 interviews using open coding in Atlas.ti. FN (PhD) has previous experience in conducting and analysing qualitative research. Two researchers (KJ & FN) ordered the codes under the five major domains of the CFIR framework ( 47 ) and then combined them into overarching codes using axial coding. The complete codebook can be found in Supplementary File 4 . Next, two researchers (KJ & CG) separately coded three transcripts, after which the coding was compared and variations in coding were discussed until both researchers agreed. Subsequently, all interview transcripts were analysed using deductive coding. Finally, the researchers analysed the coded data to identify barriers to and facilitators for the implementation of STORM in new regions.

Two researchers (KJ and FN) presented the identified barriers to four programme leaders from regions 2 and 3 and two stakeholders who had been involved in the implementation of STORM in region 1 during a brainstorming session in May 2023. We asked these participants to indicate, on a scale from 1 to 5 per barrier, whether they thought a barrier required immediate action or not using Mentimeter. The results of this brainstorming are available in Supplementary File 5 (in Dutch). Barriers that were scored higher than 3.5 were selected, while barriers that were scored lower than 2.5 were not. For barriers that were scored between 2.5 and 3.5, a group discussion determined whether the barrier was selected.

Tasks 2, 3, and 4: formulate goals, objectives, implementation strategies, and implementation protocols

We formulated performance objectives based on the most important barriers identified in Task 1. For each performance objective, we formulated change objectives across five determinants based on the example of Kang and Foster ( 46 ): knowledge, awareness, skills, outcome expectancy, and self-efficacy. We chose this example, because it was the most complete objectives matrix we found.

Next, we selected theoretical implementation strategies to achieve the change objectives. First, for determinants that match the first-version CFIR constructs ( 47 ), strategies were identified using the CFIR-ERIC tool ( 48 , 50 ). These strategies were then compared to the adapted compilation of ERIC implementation strategies for school-based implementation, SISTER ( 49 ), to identify strategies that are suitable for school-based implementation projects. Then, for determinants that did not fit the first-version CFIR constructs, suitable strategies were selected from the SISTER strategies ( 49 ).

A second round of brainstorming sessions was hosted in May 2023, one session with two national coordinators and one with four regional programme leaders. In both sessions, the main author (KJ) presented identified strategies for the selected barriers. Participants first discussed which of the identified strategies overlapped with existing implementation strategies. For the remaining strategies, participants discussed the extent to which they were realistic and relevant for practice. The implementation strategies that were considered both realistic and relevant for practice by national coordinators and regional programme leaders were selected for the implementation plan. If participants did not reach consensus about how realistic or relevant a strategy would be, the main author (KJ) made the final decision to include or exclude the strategy. A detailed description of our selection process can be found in Supplementary File 2 . Next, the selected strategies were translated into practical applications in collaboration with the programme leaders from regions 2 and 3. The applications were reported following the recommendations for reporting implementation strategies by Proctor et al. ( 51 ). The implementation strategies found in the current study were added to the STORM implementation guide developed by the national STORM team. Besides implementation strategies, this document contains a detailed description of the programme components and programme structure of STORM. All future STORM regions will be offered this guide to aid their implementation efforts.

Task 5: develop an evaluation plan

Based on the implementation plan, KJ and FN developed a plan to evaluate the implementation of STORM, as well as the application of the implementation plan in practice.

Twenty stakeholders were interviewed. Stakeholders were included until data saturation was reached. Their characteristics are presented in Table 1 . Most participants had a coordinating role in the project, followed by providers, management, and policymakers. The number of participants per organisation type were spread evenly, except for municipalities, which were represented by only two participants.

Table 1 . Participant characteristics.

We identified 21 barriers to and 13 facilitators for the implementation of STORM in new regions. An overview of all identified barriers and facilitators can be found in Supplementary File 6 . These determinants include CFIR constructs and barriers that did not match the CFIR constructs. In the first brainstorming session with programme leaders, five barriers were selected for which implementation strategies should be identified. An overview of these barriers is presented in Table 2 .

Table 2 . Barrier descriptions.

Multiple participants mentioned that schools are seen as the ideal setting for prevention, not only regarding mental health, but also for prevention of obesity or smoking. This leads to a high demand for schools. For example, one of the regional program leaders mentioned that “many societal developments are occurring and often it’s the schools who have to solve it .” Related to this, most participants recognised high work pressure in both education and healthcare as an important barrier for implementing a new approach. A school principal indicated that “it is an important theme, but honestly I do not have the people, the time, and the money to properly implement STORM.”

Another important issue raised by participants was that, at the time of the interviews, they, nor their colleagues, sufficiently understood the content of the STORM approach and what it means in practice. A school therapist mentioned, for example, that they “still need to receive a lot of information .” Moreover, participants thought that not all stakeholders saw added value in STORM compared to other interventions. A national coordinator indicated that “[organizations] struggle to de-implement [what they were already doing] to implement of STORM.”

It was also noted by some participants that network collaboration required improvement, especially between schools and mental healthcare services. A manager in mental healthcare mentioned that “education sometimes complains: ‘[mental healthcare organizations] do some test, but they never refer back to us’,” while a school therapist mentions that “collaboration [with mental healthcare organizations] does not exist in our school.”

Additional to the interview results, lack of attention to the sustainability of STORM in the current implementation efforts was identified as a barrier during the brainstorming sessions. Programme leaders felt that long-term sustainability was not receiving enough attention yet from stakeholders involved.

For each barrier selected in Task 1, we formulated performance and change objectives. The performance and change objectives are listed per stakeholder category in Table 3 . For example, a performance objective for programme leaders related to the barrier ‘insufficient network collaboration’ and was that they should stimulate the development of sustainable partnerships between involved organisations. Change objectives for this performance objective were formulated under skills (i.e., able to connect organisations within the STORM network) and self-efficacy (i.e., are confident that they are able to connect organisations within the STORM network).

Table 3 . Matrix of change.

Not all barriers were relevant for each stakeholder category. ‘Partnerships and connections’ and ‘Sustainability’ were relevant for all categories, because all stakeholders are part of the STORM network, and the sustainable implementation of STORM should be achieved for all categories. ‘Relative advantage’ was not relevant for the programme leaders, because this is not a barrier for this stakeholder category based on the interviews. Since only the schools, the PHS, and mental healthcare organisations are involved in implementing STORM, the barriers ‘High demand for schools’ and ‘High work pressure’ were only relevant to these stakeholder categories. Finally, ‘Insufficient understanding of programme content’ was regarded as a relevant barrier for management only, because management has the final decision to participate in STORM, and thus needs to be well informed of the content.

Tasks 3 and 4

To address the performance and change objectives formulated in Task 2, 14 implementation strategies were selected using the CFIR-ERIC tool and SISTER that matched the barriers identified ( 49 , 50 ). Using the second round of brainstorming sessions with national coordinators and regional programme leaders, five implementation strategies were deemed relevant and realistic for practice: ‘pruning competing initiatives’, ‘change/alter environment’, ‘tailor strategies’, ‘identify and prepare champions’, and ‘promote network weaving’ ( 49 ). We translated these to practical applications and report on the strategies in Table 4 following the recommendations of Proctor et al. ( 51 ). The first strategy described is ‘collaborate with similar initiatives’, in which the idea is that regional program leaders actively identify other mental health school-based initiatives that are (being) implemented in their region, and look for ways to collaborate in the implementation process. The goal is to relieve the pressure on schools and minimise extra workload for service providers. Second is ‘free up time for STORM tasks’, in which organisation management allocate time to for implementing and executing STORM, while program leaders reserve budget to support organisations in doing so. Third is ‘tailor strategies’, meaning programme leaders adapt their communication style and message about STORM to the specific needs of various stakeholders, with the aim of improving adoption. Fourth is ‘identify and prepare STORM champions’, which entails both identifying and supporting individuals within involved organisations that are enthusiastic about the approach. The goal is to promote sustainment within those organisations through these individuals. Last is ‘regional network weaving’ through developing a social map of the organisations and individuals involved in STORM, and organising a joint kick-off session for those organisations and individuals.

Table 4 . Implementation strategies

In the final task, we developed a plan to evaluate the implementation of STORM in the new regions, as well as the application of the implementation plan over the course of two academic years. We identified outcomes from the implementation outcomes defined by Proctor et al. ( 52 ) and process evaluation guidelines from Moore at al. ( 53 ) and Saunders et al. ( 54 ). In Table 5 , we summarise the outcomes for the implementation of STORM, including definitions, and how and when the outcomes will be measured. Providers, regional management, and policymakers will be involved in the evaluation of the implementation process through a survey and interviews at multiple time points. The measurement instruments to be used in the survey comprise a shortened version of the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure from Weiner et al. ( 55 ), and the Normalisation Measure Development Questionnaire ( 56 ). In Table 6 , we summarise the outcomes for the application of the implementation plan, including definitions of the outcomes, and how and when the outcomes will be measured. Programme leaders and programme groups (see Figure 1 ) will be involved in the evaluation through a checklist of implementation strategies and focus group sessions. Additionally, we will analyse the administrative data for both evaluations.

Table 5 . Evaluation plan for the implementation of STORM.

Table 6 . Evaluation plan for the application of the implementation plan.

This study aimed to develop an implementation plan for a school-based approach to depression and suicide prevention. To our knowledge, this is the first study reporting on the development of an implementation plan for school-based mental health interventions. The IM tasks from Fernandez et al. ( 32 ) helped us to combine practical needs and perceptions with theoretical strategies. We identified six main barriers to implementation, on the basis of which we formulated performance and change objectives. We found five new implementation strategies to achieve these objectives. Lastly, we developed a plan to evaluate the implementation of STORM in new regions over the course of two school years.

One of the most relevant barriers to implementation of STORM that we found was limited network collaboration within regions, while network collaboration is an essential part of the STORM approach ( 22 , 23 , 37 ). A study into determinants for the screening and subsequent referral to the OVK revealed that even in the region where STORM has been implemented for years, collaboration between organisations involved in STORM is not optimal ( 57 ). This led us to the selection of several ERIC strategies categorised under ‘develop stakeholder interrelationships’ aimed at improving network collaboration ( 58 ). The implementation evaluation will determine whether these strategies indeed helped us increase network collaboration.

Some of the identified barriers were also some of the most frequently mentioned barriers for other school-based mental health interventions ( 59 ), including ‘insufficient understanding among stakeholders of programme content’ and ‘insufficient network collaboration’. However, costs and the availability of resources, which are often reported as barriers to implementation ( 59 ), were not identified as barriers in the current study. The fact that these factors were not discussed in any of the interviews is most likely due to the implementation budget that regions receive to implement STORM ( 28 ). However, this is only a start-up budget that can only be provided to a limited number of regions. Moreover, lack of funding or financial resources was identified as a barrier to sustaining school-based mental health interventions ( 60 ). Therefore, keeping track of implementation costs is relevant and has been included as an outcome in our evaluation plan.

We selected implementation strategies based on how realistic and relevant the STORM programme leaders thought they were. In a study by Lyon et al. ( 61 ), school-based consultants who provided social, emotional, and mental health services rated the feasibility and importance of all SISTER strategies. Most strategies we selected were also rated important in this study ( 61 ). Yet, we included some strategies which were rated low on feasibility in the study from Lyon et al. ( 61 ), including ‘collaboration with similar initiatives’, ‘use advisory boards and workgroups’, and ‘promote network weaving’, because they were considered realistic and relevant by the program leaders. These different perceptions might be explained by the difference in the stakeholders involved: we spoke with programme leaders, whereas Lyon et al. ( 61 ) consulted stakeholders within schools. However, these differences might also indicate the importance of context when considering the feasibility of an implementation strategy. Our evaluation of the implementation strategies should provide more insight into this difference.

The goal of the implementation plan developed in the current study is to improve the level of implementation of STORM in new regions in the Netherlands. We selected several implementation strategies that were found in the literature to have a positive effect on programme adoption and fidelity, including ‘conduct ongoing training’, ‘identify and prepare champions’, ‘use train-the-trainer strategies’, and ‘facilitation/problem solving’ ( 62 ). Still, knowledge about the mechanisms by which implementation strategies target their linked barriers, as well as about the effectiveness of most strategies, is lacking ( 62 – 64 ). Thus, while the IM approach helped us to select strategies that are likely to positively impact the implementation of STORM, our evaluation should confirm whether our selection was accurate.

Strengths and limitations

A strength of the current study is that we systematically developed an implementation plan by following the tasks of IM ( 32 ). We did this in close collaboration with stakeholders who will implement STORM in practice, ensuring that the implementation plan matches the needs in practice. Additionally, we enhanced the credibility and transferability of our results through member checks, data and investigator triangulation, and sampling until we reached data saturation.

We recognise some limitations to our study as well. To begin, we mainly identified determinants related to the adoption and implementation of the intervention, and not to sustaining STORM over time. This is mostly likely because sustainability was not an explicit topic in our interviews and interviewees were in an early stage of pre-implementation. We discussed the lack of determinants with programme leaders and accordingly added a general determinant for sustainability. Furthermore, we reached out to multiple stakeholders and interviewed those who responded. Possibly, this led to selection bias if only participants with strong opinions about STORM, be these negative or positive, responded to our invitation. However, we asked participants to reflect on the perceptions of others in their field to minimise this bias.

Recommendations

Building on our strengths and limitations, we first recommend following the tasks of IM when developing an implementation plan, as this helped us to systematically select appropriate strategies. Furthermore, it encourages close collaboration with practice, which we found to be very helpful for developing a plan that is both achievable and relevant for practice. In doing so, we recommend including sustainability in the needs assessment to identify determinants and strategies for sustainability within the implementation plan.

Second, we recommend consulting multiple sources for the selection of implementation strategies. We found it helpful to first use the CFIR-ERIC tool to get a first idea of possible strategies, and then compare them to the SISTER strategies to identify more suitable strategies for the school context. We recommend others developing an implementation plan to consult such strategy compilations for specific intervention settings, if available.

For new STORM regions, we recommend using this implementation plan as guidance rather than a prescription. Some strategies might prove not to be as relevant and/or feasible as we originally believed. The implementation plan could also be helpful for the implementation of other school-based mental health interventions as these might encounter similar barriers. However, tailoring the implementation strategies to the specific context for these interventions is warranted.

In this study, we followed the tasks of IM, which helped us to develop a STORM implementation plan systematically and in collaboration with practice. The implementation plan offers guidance for new regions implementing STORM. Following the implementation plan could help to improve implementation outcomes and might even lead to better programme outcomes. Moreover, our approach and the strategies we identified could inform the implementation of other school-based mental health programmes, although we recommend tailoring our strategies to the specific context into which it will be implemented. Future research evaluating the implementation of STORM across the Netherlands will provide more insight into the usefulness of the implementation plan.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

This study was approved by the Ethics Commission Social Sciences of Radboud University, approval number ECSW-LT-2023-2-2-33415. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

KJ: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing. SR: Conceptualization, Supervision, Writing – review & editing, Writing – original draft. AP: Conceptualization, Supervision, Writing – review & editing, Writing – original draft. DC: Conceptualization, Supervision, Writing – review & editing, Writing – original draft. CG: Formal analysis, Investigation, Methodology, Writing – review & editing, Writing – original draft. LV: Investigation, Writing – review & editing, Writing – original draft. SM: Writing – review & editing, Writing – original draft. JS: Writing – review & editing, Writing – original draft. FN: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing, Writing – original draft.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was funded by a subsidy of the Ministry of Health, Welfare, and Sport in the programme of the National Agenda Suicide Prevention 2021–2025.

Acknowledgments

We would like to thank the national and regional STORM teams from 113 Suicide Prevention, Groningen, Nijmegen and East Brabant for helping us to recruit study participants and for helping us select implementation strategies that are relevant for practice. We also thank all study participants for participating in an interview.

Conflict of interest

SR and DC were involved in the development of the STORM approach. SR, DC, and LV were involved in the national scale-up of STORM. LV was involved as an interview participant and was therefore not involved in revising, reading and approving the results section.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2024.1386031/full#supplementary-material

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Keywords: implementation mapping, implementation, adolescents, prevention, depression, suicide

Citation: Jenniskens K, Rasing S, Popma A, Creemers D, Ghalit C, van Vuuren L, Mérelle S, Spijker J and van Nassau F (2024) Development of an implementation plan for a school-based multimodal approach for depression and suicide prevention in adolescents. Front. Public Health . 12:1386031. doi: 10.3389/fpubh.2024.1386031

Received: 14 February 2024; Accepted: 12 April 2024; Published: 10 May 2024.

Reviewed by:

Copyright © 2024 Jenniskens, Rasing, Popma, Creemers, Ghalit, van Vuuren, Mérelle, Spijker and van Nassau. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Kristel Jenniskens, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Schools Feel Less Equipped to Meet Students’ Mental Health Needs Than a Few Years Ago

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Fewer than half of public schools—48 percent—report that they can effectively meet students’ mental health needs, and that number has dwindled in the past few years even as students’ needs have risen.

Those findings come from the most recent School Pulse survey from the National Center for Education Statistics , which polled 1,683 school leaders in March.

Today’s schoolchildren are dealing with a range of challenges that are impacting their mental health. Social media, the lingering effects of the pandemic, and the opioid crisis are often cited as major reasons.

For Chris Young, the principal of North Country Union High School, a campus of 720 students in Vermont, the ongoing opioid crisis has been a major challenge to his students’ mental health—and to his school’s ability to teach them.

“We live in a rural area that has been hit hard by the opioid crisis. So, we have been experiencing students with severe mental health needs in K through 12 for quite some time,” Young said. “There is significant housing instability, substance abuse, and food insecurity that students are experiencing and that obviously shows up in school.”

These mental health issues present themselves differently depending on the student’s age, he said. In elementary school, students tend to lash out and misbehave. In high school, they tend disengage, leading to chronic absenteeism. The pandemic, Young said, made what was already a tough situation in his community worse.

Fifty-eight percent of schools in the School Pulse survey said that the number of students who sought mental health services from their school increased a little or a lot compared with last year.

Schools face a number of challenges to meeting their students’ mental health needs, according to the School Pulse survey. One big one is a lack of mental health staff and funding—barriers that will likely grow for many schools as federal pandemic aid runs dry. Many schools used those federal funds to hire school counselors, social workers, and psychologists, and contract with outside providers.

Even so, 55 percent of schools in the survey reported they did not have enough mental health staff to manage students’ needs, 54 percent said they struggled with inadequate funding, and 49 percent said they couldn’t find enough licensed mental health professionals.

“We’ve always known that the responsibilities of schools go beyond academics, but these new data shine important light on the demands they face to support students who struggle with mental health issues,” said NCES Commissioner Peggy G. Carr in a statement. “These challenges can be significant obstacles to student learning and well-being if not properly addressed.”

School counselors shoulder most of the burden

School counselors still shoulder most of the responsibility of providing mental health services to students on campus, with three-quarters of schools saying that counselors provide mental health services to students. That’s down 8 percent from last school year.

Despite challenges with staffing, nearly all schools surveyed said they provide some kind of mental health service for students, ranging from telehealth to outreach to making referrals to outside mental health professionals. On average, those schools report that 1 in 5 of their students have used these services.

In many cases, schools are leaning on teachers to help support students’ mental health. Sixty-three percent of schools said they offered professional development to train teachers to support students’ social-emotional and mental well-being.

Among schools that had made changes to their school calendars to support students’ mental health, such as designating time during the school day or giving students days off to focus on mental health, 67 percent have kept those changes.

Forty-four percent of schools said they created or expanded a program to support student social-emotional and mental well-being this year and 27 percent said they created new positions to support these efforts.

At North Country Union High School, Young has focused a lot of attention on social-emotional learning and mental well-being through events, activities, and guest speakers. Teachers also regularly set aside time to address SEL and mental well-being in their advisory periods, or homerooms, with students.

“We have a skit night, and the kids are making fun of how much we talk about mental health,” he said. “Which I think is great, we are beating them over the head with it.”

But, Young said, if the school doesn’t meet students’ mental health needs, then many students do not learn.

Young has also invested in hiring several additional mental health support staff. Two of those positions were paid for initially with federal pandemic aid, and his school will keep those positions permanently.

But hiring someone to support students’ mental well-being often comes with a tradeoff, said Young, and it’s tricky finding a balance between supporting students’ academics and mental health without sacrificing one for the other.

“That is a battle that is constantly playing out in my mind of: ‘Should I be advocating for more intervention teachers, who support students academically, or should I be advocating for another counselor?’” he said.

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Schools Feel Less Equipped to Meet Students’ Mental Health Needs Than a Few Years Ago

• Share article

Fewer than half of public schools—48 percent—report that they can effectively meet students’ mental health needs, and that number has dwindled in the past few years even as students’ needs have risen.

Those findings come from the most recent School Pulse survey from the National Center for Education Statistics , which polled 1,683 school leaders in March.

Today’s schoolchildren are dealing with a range of challenges that are impacting their mental health. Social media, the lingering effects of the pandemic, and the opioid crisis are often cited as major reasons.

For Chris Young, the principal of North Country Union High School, a campus of 720 students in Vermont, the ongoing opioid crisis has been a major challenge to his students’ mental health—and to his school’s ability to teach them.

“We live in a rural area that has been hit hard by the opioid crisis. So, we have been experiencing students with severe mental health needs in K through 12 for quite some time,” Young said. “There is significant housing instability, substance abuse, and food insecurity that students are experiencing and that obviously shows up in school.”

These mental health issues present themselves differently depending on the student’s age, he said. In elementary school, students tend to lash out and misbehave. In high school, they tend disengage, leading to chronic absenteeism. The pandemic, Young said, made what was already a tough situation in his community worse.

Fifty-eight percent of schools in the School Pulse survey said that the number of students who sought mental health services from their school increased a little or a lot compared with last year.

Schools face a number of challenges to meeting their students’ mental health needs, according to the School Pulse survey. One big one is a lack of mental health staff and funding—barriers that will likely grow for many schools as federal pandemic aid runs dry. Many schools used those federal funds to hire school counselors, social workers, and psychologists, and contract with outside providers.

Even so, 55 percent of schools in the survey reported they did not have enough mental health staff to manage students’ needs, 54 percent said they struggled with inadequate funding, and 49 percent said they couldn’t find enough licensed mental health professionals.

“We’ve always known that the responsibilities of schools go beyond academics, but these new data shine important light on the demands they face to support students who struggle with mental health issues,” said NCES Commissioner Peggy G. Carr in a statement. “These challenges can be significant obstacles to student learning and well-being if not properly addressed.”

School counselors shoulder most of the burden

School counselors still shoulder most of the responsibility of providing mental health services to students on campus, with three-quarters of schools saying that counselors provide mental health services to students. That’s down 8 percent from last school year.

Despite challenges with staffing, nearly all schools surveyed said they provide some kind of mental health service for students, ranging from telehealth to outreach to making referrals to outside mental health professionals. On average, those schools report that 1 in 5 of their students have used these services.

In many cases, schools are leaning on teachers to help support students’ mental health. Sixty-three percent of schools said they offered professional development to train teachers to support students’ social-emotional and mental well-being.

Among schools that had made changes to their school calendars to support students’ mental health, such as designating time during the school day or giving students days off to focus on mental health, 67 percent have kept those changes.

Forty-four percent of schools said they created or expanded a program to support student social-emotional and mental well-being this year and 27 percent said they created new positions to support these efforts.

At North Country Union High School, Young has focused a lot of attention on social-emotional learning and mental well-being through events, activities, and guest speakers. Teachers also regularly set aside time to address SEL and mental well-being in their advisory periods, or homerooms, with students.

“We have a skit night, and the kids are making fun of how much we talk about mental health,” he said. “Which I think is great, we are beating them over the head with it.”

But, Young said, if the school doesn’t meet students’ mental health needs, then many students do not learn.

Young has also invested in hiring several additional mental health support staff. Two of those positions were paid for initially with federal pandemic aid, and his school will keep those positions permanently.

But hiring someone to support students’ mental well-being often comes with a tradeoff, said Young, and it’s tricky finding a balance between supporting students’ academics and mental health without sacrificing one for the other.

“That is a battle that is constantly playing out in my mind of: ‘Should I be advocating for more intervention teachers, who support students academically, or should I be advocating for another counselor?’” he said.

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Edweek top school jobs.

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Bullying Prevention and Mental Health Promotion Lab

The Bullying Prevention and Mental Health Promotion Lab conducts research on topics including bullying and bullying prevention, school-based mental health services and prevention of mental health problems, mental health literacy, help-seeking among culturally and linguistically diverse (CLD) students, parenting practices and family involvement. 

Some of our recent projects include:

• Influences of the Coronavirus (COVID-19) Outbreak on Racial Discrimination, Identity Development and Socialization (funded by NSF)
• Racial Discrimination, Identity, Socialization and Civic Engagement among Asian American Families during COVID-19 (funded by Russell Sage Foundation)
• Examining the Feasibility and Effectiveness of a Novel Psychosocial Intervention for Asian American Parents and Youth during COVID-19 (funded by American Psychological Foundation 2020 Visionary Grant)
• Promoting mental health literacy and positive help-seeking attitudes for school-based mental health services among minority adolescents
• The impact of school (e.g., school climate) and family factors (e.g., parenting practice, parental ethnic racial socialization) on students’ involvement in bullying and psychosocial adjustment

If you are a prospective student interested in applying to Dr. Wang's lab, please send an e-mail expressing your interest to [email protected] .  You may also email the lab manager, Ami Patel, with any questions at [email protected] . Applicants with an interest in school-based mental health services, peer relationships, bullying prevention, parenting practice, working with culturally and linguistically diverse (CLD) students, and bridging the gap between research and practice are especially encouraged to apply. 

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Technology-Powered Mental Health Initiatives Save Students’ Lives

Rebecca Torchia is a web editor for  EdTech: Focus on K–12 . Previously, she has produced podcasts and written for several publications in Maryland, Washington, D.C., and her hometown of Pittsburgh.

The  Children’s Internet Protection Act  mandates that schools must use content filters to protect students from explicit content. But Nathan Short, IT director at  Encinitas Union School District  in California, doesn’t care if he gets an alert about students trying to search explicit content. “I just want it to be blocked,” he says. “I started retooling the content filter to trigger on self-harm-related keywords.”

The initiative started as a passion project for Short, who notes that he has lost friends to suicide and finds it invaluable to  keep students safe . “It wouldn’t have been possible without the support of every department; a big focus in our school district is social-emotional health,” he says.

Encinitas Union School District has been  a one-to-one district  for years, and it notifies families at the start of the school year that student activity will be monitored on school-owned devices. “The responses have been overwhelmingly positive,” Short says. When content monitoring has compelled the district to reach out to families, “it’s most often shock from the parents and gratitude because they would have never known their child was struggling,” he says.

Click the banner   for resources to improve your school’s physical safety tech today.

Since first trying to retool the district’s existing content filter six years ago, Short has been able to invest in technologies built for the purpose of monitoring student behavior online for self-harm — and it’s paid off, having saved multiple students’ lives.

Capture and Flag Troubling Student Behavior Online

While some monitoring technologies capture only what students are searching in a web browser,  Lightspeed Systems ’  Lightspeed Alert  — the tool Encinitas Union School District is currently using — works like a keylogger, capturing everything students type. This allows the district to identify potentially harmful content in applications like  Google Docs , which Short says students are using as a communication tool.

Students can share documents with their classmates and type messages to one another in that document, he explains. “They’re pretty good about deleting what they’ve written, but the technology captures everything.”

DISCOVER:   Technology enables collaboration on K–12 student projects.

When the team gets an alert about something potentially harmful, it can look at a document and — even if students have deleted the messages — the version history and the Lightspeed Systems technology have a record of what was typed.

Identify False Positives and Escalate Concerns

The  Student Risk Module , part of the  iboss  zero-trust secure access service edge platform, “proactively identifies risks related to student threats to self-harm, threats to harm others, threats to the school and academic integrity by using advanced data analysis and customizable keyword alerts,” says Richard Quinones, senior vice president public sector at iboss. The company’s platform works in conjunction with Gaggle Safety Management to identify false positives and flag alerts that need immediate attention.

“If the team classifies it as a questionable content search, the alert will be emailed to the school or district,” Quinones says. With the power of 24/7 oversight and human scrutiny, today’s technologies weed out false positives fairly accurately.

At Encinitas Union School District, the team has dealt with everything from the release of the “Suicide Squad” movie to student reports on the death of Vincent Van Gogh.

However, “if anyone has any doubt whatsoever, we escalate it,” Short says.

The first step at the district is to reach out to principals, and sometimes teachers, to find out if the students are researching something that has triggered an alert. “Teachers know their students,” Short says. “Getting that extra little bit of information can let you know if a child might need some help.”

A 2021 report from the U.S. Secret Service’s  National Threat Assessment Center  examined  67 averted school attack plots . Forty-seven percent of plotters researched prior attacks, security measures, other related topics or a combination of those things.

When it’s determined that a student needs assistance or an intervention, the district has a team of psychologists assigned to the school sites. “They’re ready and trained to respond to those types of things,” Short says. “I’m not — I just handle the technical side.”

That team then contacts the parents or guardians of the student to get them help.

Nathan Short IT Director, Encinitas Union School District

Save Students’ Lives with Immediate Intervention

In the past, trying to  reach a student’s family  hasn’t always been easy for the team at Encinitas Union School District. “A child who was being cared for by grandparents was at risk and actually planning to hang themselves,” Short recalls. It was late at night, and the grandparents weren’t answering the school’s calls. “More often than not, nobody’s picking up their cellphone when they’re getting calls late at night from an unidentified phone number.”

Thankfully, a staff member lived nearby and was able to go to the home, knock on the door and alert the grandparents to the situation, saving the student’s life.

“If the response time hadn’t been so rapid, we would have immediately called 911,” Short says. With the alert system the district has in place now, “if a member of the team does not respond to an alert from the 24/7 monitoring service within five minutes, that monitoring service is calling 911.”

LEARN MORE:   These are the three key features of a school alert system.

Short also remembers an incident where the district didn’t have five minutes to spare. “Twenty minutes before dismissal, the child was searching for, first, the fastest way to kill themselves, followed by nearby tall buildings, nearby cliffs,” he says. “Encinitas has a lot of cliffs along the ocean within walking distance of schools. Then they looked up a map route on how to get to a nearby cliff. All this is happening while the clock is ticking.”

Alerted to the student’s alarming searches, the team immediately worked on  tracking down the device  to find out who it was checked out to. They had to find out what school and what classroom the child was in, and they had to get to them before dismissal.

Once again, the immediate actions of the team following an alert saved a student’s life.

Detect and Stop Bullying Among K–12 Students

Bullying prevention is another benefit to the district’s monitoring technologies. In the U.S. Secret Service report, 21 percent of individuals plotting a school attack did so because of bullying by their peers.

“Often, teachers will address a bullying issue without even alluding to the technology,” Short says. They don’t point out to the students where they saw the behavior occurring, and teachers are able to address it in early stages.

The percentage of current and former students whose plans to attack their school because of bullying by peers were averted between 2006 and 2018

The district’s focus on  teaching digital citizenship  and integrating social-emotional well-being into instruction has taught students the value of online and personal safety. “Conversations about how the kids are feeling are commonplace now,” Short says.

The National Center for Education Statistics found that 69 percent of public schools reported that the percentage of  students who had sought mental health services from school  had increased since the start of the coronavirus pandemic. “Without early detection, these issues can escalate and lead to potential tragedies in schools,” Quinones says.

There are resources other  schools can use to implement these safety measures  in their own classrooms and technology. “It’s just a matter of getting school districts to take that first step,” Short notes. “Sometimes there are costs associated with it, and public schools don’t have a lot of money, but the dividends are priceless.”

KEEP READING:   How can the COPS SVPP grant fund school safety?

FBI Involvement Brings Added Protections and Insights

Nathan Short hopes other districts follow Encinitas Union School District’s lead in adopting technologies that prevent student harm. To that end, he’s worked closely with the FBI to support his own district’s initiatives and to spread awareness about the risks and resources.

“The FBI offers support to school districts, but schools don’t tend to take advantage of it,” Short says. He shares how he’s worked closely with Supervisory Special Agent Victor Nguyen in the FBI’s San Diego field office to  address student mental health issues .

This helps the FBI gain a better understanding of how harmful behaviors can escalate in troubled students.

“We maintain a dynamic partnership with the FBI, which provides iboss an updated list of terms that informs our high-risk categories in the monitoring solution,” says Quinones.

These partnerships help the school districts and the technology vendors pinpoint early warning signs to avoid dangerous situations.

“If we can get kids help early, we can prevent a lot of the violence we’re seeing in the news,” Short says.

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Physical Fitness Linked to Better Mental Health in Young People

A new study bolsters existing research suggesting that exercise can protect against anxiety, depression and attention challenges.

By Matt Richtel

Physical fitness among children and adolescents may protect against developing depressive symptoms, anxiety and attention deficit hyperactivity disorder, according to a study published on Monday in JAMA Pediatrics.

The study also found that better performance in cardiovascular activities, strength and muscular endurance were each associated with greater protection against such mental health conditions. The researchers deemed this linkage “dose-dependent,” suggesting that a child or adolescent who is more fit may be accordingly less likely to experience the onset of a mental health disorder.

These findings come amid a surge of mental health diagnoses among children and adolescents, in the United States and abroad, that have prompted efforts to understand and curb the problem.

The new study, conducted by researchers in Taiwan, compared data from two large data sets: the Taiwan National Student Fitness Tests, which measures student fitness performance in schools, and the National Insurance Research Databases, which records medical claims, diagnoses prescriptions and other medical information. The researchers did not have access to the students’ names but were able to use the anonymized data to compare the students’ physical fitness and mental health results.

The risk of mental health disorder was weighted against three metrics for physical fitness: cardio fitness, as measured by a student’s time in an 800-meter run; muscle endurance, indicated by the number of situps performed; and muscle power, measured by the standing broad jump.

Improved performance in each activity was linked with a lower risk of mental health disorder. For instance, a 30-second decrease in 800-meter time was associated, in girls, with a lower risk of anxiety, depression and A.D.H.D. In boys, it was associated with lower anxiety and risk of the disorder.

An increase of five situps per minute was associated with lower anxiety and risk of the disorder in boys, and with decreased risk of depression and anxiety in girls.

“These findings suggest the potential of cardiorespiratory and muscular fitness as protective factors in mitigating the onset of mental health disorders among children and adolescents,” the researchers wrote in the journal article.

Physical and mental health were already assumed to be linked , they added, but previous research had relied largely on questionnaires and self-reports, whereas the new study drew from independent assessments and objective standards.

The Big Picture

The surgeon general, Dr. Vivek H. Murthy, has called mental health “the defining public health crisis of our time,” and he has made adolescent mental health central to his mission. In 2021 he issued a rare public advisory on the topic. Statistics at the time revealed alarming trends: From 2001 to 2019, the suicide rate for Americans ages 10 to 19 rose 40 percent, and emergency visits related to self-harm rose 88 percent.

Some policymakers and researchers have blamed the sharp increase on the heavy use of social media, but research has been limited and the findings sometimes contradictory. Other experts theorize that heavy screen use has affected adolescent mental health by displacing sleep, exercise and in-person activity, all of which are considered vital to healthy development. The new study appeared to support the link between physical fitness and mental health.

“The finding underscores the need for further research into targeted physical fitness programs,” its authors concluded. Such programs, they added, “hold significant potential as primary preventative interventions against mental disorders in children and adolescents.”

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel

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