Doctoral dissertation: The mental health of children is influenced by the context and the ratings affected by the subjectivity of the assessor

At 16:00 on 15 December 2021, Karin Streimann from Tallinn University’s School of Governance, Law and Society will defend her doctoral thesis “Preventing Mental Health Problems in Elementary Schools: Effectiveness of a Universal Classroom-Based Preventive Intervention (PAX GBG) in Estonia" („Vaimse tervise probleemide ennetus algkoolides: universaalse klassis elluviidava ennetava sekkumise (VEPA Käitumisoskuste Mäng) tulemuslikkus Eestis“).

Karin Streimann

This doctoral thesis looked at ways of preventing mental health issues in elementary school children and studied the effects of one preventative intervention used in Estonian schools (PAX Good Behaviour Game) on the mental health of first grade students and the self-efficacy of teachers. Because children might display different mental health problems at home than they do at school, and because the interpretation of the problems themselves can be influenced by the background of the assessors, associations between the data were also studied to understand which background factors predict parent-teacher agreement.

The two-year-long study showed that the intervention had a positive effect on both the students and the teachers and based on the results, the broader implementation of the PAX GBG program can be recommended in Estonian schools. Teachers reported that in classrooms where the preventative intervention was used, children experienced less conduct problems, hyperactivity, and inattention. In addition, students from the PAX GBG group experienced less mental health issues in general in both the first and second school year. Parents noticed changes in the prosocial behaviour of the children (they became more caring and helpful) during the second school year and they reported reduced emotional symptoms (e.g. stress, anxiety, sadness) in children who studied in PAX GBG classrooms. The intervention supported the mental health of boys and girls equally well, but worked especially well for students at risk for mental health issues. These kinds of changes were not reported in the control classes where PAX GBG was not used.

Karin Streimann also looked at how PAX GBG affects the self-efficacy of teachers, which is connected to burnout, stress and retention. “The results showed that the teachers’ efficacy in student engagement, instructional practice, and classroom management improved significantly in GBG classes during both school years,” said Streimann. “The results did not change in the control group, which tells us that the method is not only useful for supporting the mental health of the students, but also has a positive effect on the well-being of the teachers.”
The study indicated that the mental health assessment of a child is influenced by the context and the perspective of the person assessing the child – children might experience different problems at school and at home and behave differently, some environments might trigger certain issues more than others and the assessor might perceive some issues to be more serious than others.   Parents and teachers agreed on the child’s risk status for mental health issues in about 70% of children. A greater level of agreement was found on externalizing behaviours, where parents and teachers agreed more often on the risk status of the child. The biggest differences emerged regarding emotional symptoms: 22.1% of parents believed their child to be at risk for emotional problems that went unnoticed by the teachers.

Streimann said, “The difficulty of assessing child’s mental health is not talked about very often. The current study also showed how assessments of a child’s mental health are influenced by sociodemographic factors as well as contextual expectations of the child’s behaviour and abilities. For example, teachers and parents of the children in the PAX GBG classes noticed different changes in the mental health of the children: teachers saw changes in the behaviour, specifically in concentration and self-control, while parents noted that the prosocial behaviour and emotional wellbeing of the children improved.”

Another interesting tendency the study uncovered was that the parents’ and teachers’ assessments of children’s mental health and behaviour were more similar when it came to girls. This might allude to parents and teachers having more similar expectations regarding girls’ behaviour and coping mechanisms, compared to that of boys. This result somewhat differs from previous studies, where the child’s gender influenced only the ratings about externalizing behaviours and might indicate that the cultural context affects the inter-rater agreement about mental health problems among girls and boys differently. A number of other sociodemographic factors predicted inter-rater agreement about children’s mental health, like family structure or the financial situation of the family. This can indicate that parenting practices or stress levels might affect the ratings about children’s mental health.

Children are the most vulnerable target group for interventions as they do not have the ability to decide whether to take part in an activity or not, nor do they have the capacity to evaluate whether an activity might involve unpredictable consequences for them. This is why it is vital to ensure that the intervention does not increase the risk for developing mental health problems and that it will produce gaugeable positive effects on the well-being of children. This can primarily be done through experimental studies that will enable to compare the results of the control group with the results of the intervention group and thus make reliable conclusions about the effects of the intervention.

We cannot presume prevention is always useful and will lead to positive change – there are several studies in the world describing the adverse effects or ineffectiveness of preventative interventions. So, application of preventative interventions always comes with ethical dilemmas: how much will the intervention improve people’s lives and is there any chance that the intervention will cause harm for some participants.

The public defence will take place in auditorium M648 at Tallinn University.
The defence can also be watched through Zoom.
The supervisors of the dissertation are professor Merike Sisask from Tallinn University and professor Karmen Toros from Tallinn University.
The opponents are senior lecturer Jeremy Segrott from Cardiff University and lecturer and researcher Geertje Leflot from Thomas More University of Applied Sciences.
The doctoral thesis is available in the ETERA digital environment of the Tallinn University Academic Library.