Teacher-student relationships and mental health help seeking behaviors among elementary and secondary students in Ontario Canada

Abstract

This study examined associations between teacher-student relationship quality at school and teachers' responsiveness to students' emotional concerns in a classroom and (a) students' intention to seek help at school for mental health concerns and (b) mental health-related service use. Data for analyses came from the School Mental Health Survey, a cross-sectional survey of 31,120 grade 6–12 students, in 1968 classrooms, attending 248 schools in Ontario, Canada. Three-level (student, classroom, school) binary logistic regression was used to address the study objectives. Student ratings of the quality of teacher-student relationships and teachers' responsiveness were included as predictors, both at the individual student level and aggregated to represent a contextual level characteristic at the school and classroom level, respectively. At the student level, both teacher-student relationship quality and teacher responsiveness were positively associated with intentions to seek help at school among both elementary and secondary students (ORs ranged from 1.14–1.19 for relationships and 1.06–1.08 for responsiveness). Aggregated to the school level, teacher-student relationship quality was positively associated with mental health service use for secondary students (OR = 1.36, 95% CI [1.10, 1.69]). Positive and responsive teacher-student relationships were associated with help-seeking behaviors among students. Longitudinal studies are warranted to disentangle the temporality of these associations.

Introduction

Early intervention and treatment for mental health concerns play an important role in reducing the severity and persistence of illness across the life-course (De Girolamo, 2012). In Ontario, Canada, less than one-third of children and adolescents with a mental illness received care from a mental health professional (i.e., psychiatrist, psychologist, social worker) (Georgiades, Duncan, Wang, Comeau, & Boyle, 2019). Similar estimates have been reported in Australia (Johnson et al., 2016) and the United States (Costello, He, Sampson, Kessler, & Merikangas, 2014). Across the many settings in which children and adolescents have mental health related service contacts, schools are the most common (Costello et al., 2014; Georgiades et al., 2019; Green et al., 2013; Merikangas et al., 2011; Ryan, Toumbourou, & Jorm, 2014), yet little is known about the interpersonal processes occurring within schools that may facilitate access to care.

The objectives of the present study were to examine associations between the nature of teacher-student relationships at school and in the classroom and student help seeking intentions and behaviors. Help seeking typically refers to the active behavior of seeking out and communicating need for support from other people (Rickwood, Deane, Wilson, & Ciarrochi, 2005). Rickwood, Deane, and Wilson (2007) proposed that the conceptualization of mental health help-seeking behaviors should include multiple “processes”, based on the theory of planned behavior, which include (a) attitudes towards seeking help, which predict (b) intentions to seek help, which in turn predict, (c) actual observable help-seeking behaviors. This study examined intentions, which are not direct measures of help-seeking but may predict later help-seeking behaviors, and actual professional mental health service use.

Two complementary conceptual models - Andersen's behavioral model (Andersen, 1995) and McLeroy's ecological model (McLeroy, Bibeau, Steckler, & Glans, 1988) — were used to inform our study objectives and hypotheses. Andersen's model focuses primarily on individual characteristics that serve to facilitate access and use of health services (Andersen, 1995), whereas McLeroy's ecological model integrates broader socio-contextual level factors (McLeroy et al., 1988). Andersen's model classifies the main predictors of health service utilization into (a) predisposing characteristics, which include socio-demographic characteristics; (b) enabling resources, which include the availability of resources, knowledge of resources, and social relationships that facilitate or impede service use; and (c) need, which includes indices of the severity of illness and perceived need for help (Andersen, 1995). Andersen's model acknowledges the importance of the social context, though it mainly focuses on individual characteristics and processes. In contrast, ecological models have been developed to focus more explicitly on the role of socio-contextual factors on health-related outcomes. In the context of schools, socio-contextual factors can be classified according to (a) institutional factors, which refer to schools' physical structure, rules and regulations; (b) community factors, which include school climate and school-level relationships; and (c) public policy factors, which refer to local, provincial, and national laws and policies that govern the availability of mental health resources in schools (McLeroy et al., 1988). The integration of these conceptual frameworks provides a holistic approach to understanding help-seeking behaviors among students by incorporating both individual- and socio-contextual factors that shape these behaviors. On the basis of these frameworks, we hypothesized that social interactions between teachers and students in school would be associated with student mental health help-seeking behaviors, over and above predisposing characteristics and indicators of mental health need.

Although numerous studies have documented the use of school-based mental health services (Costello et al., 2014; Georgiades et al., 2019; Merikangas et al., 2011; Ryan et al., 2014), few have investigated the extent to which social processes occurring within schools may be associated with help seeking behaviors. Given that teachers may be the first to observe early signs of mental health concerns among students, the quality of their relationships with students and their responsiveness to expressed emotional concerns may represent important social processes that promote student help seeking behaviors. For example, positive teacher-student relationships may facilitate mental health help seeking behaviors among students by fostering trusting relationships that help decrease perceived stigma, fear, embarrassment and shyness some of the most prevalent barriers to youth accessing mental health care (Gulliver, Griffiths, & Christensen, 2010; Yap, Reavley, & Jorm, 2013). Similarly, teachers' ability to identify, respond and engage with students about their emotional concerns, referred to as responsiveness in the present study, may improve communication and facilitate access to mental health supports.

Previous research has demonstrated that a teacher's ability to identify students with mental health concerns is positively associated with utilization of mental health services (Gasquet, Ledoux, Chavance, & Choquet, 1999; Sourander et al., 2001; Wu et al., 1999; Zwaanswijk, van der Ende, Verhaak, Bensing, & Verhulst, 2005). However, to our knowledge, there are only two studies that examined the role of teacher-student relationship quality in help-seeking behaviors: one focused on mental health and the other on bullying behaviors. Mariu, Merry, Robinson, and Watson (2012) found that secondary students were more likely to access mental health services from general practitioners when they felt teachers attempted to “get to know them,” or when they had a non-family adult (such as a teacher) with whom they could talk. These associations persisted over and above socio-demographic characteristics and mental health symptomatology, including depressive and anxiety symptoms, suicidal thoughts, and hallucinations. Eliot, Cornell, Gregory, and Fan (2010) found that Grade 9 students attending schools with more supportive school climates, assessed using student self-reports aggregated to the school level, were more likely to endorse intentions to seek help from teachers for bullying, over and above individual and school demographic characteristics. Supportive school climate was operationalized as having teachers who “care about students, respect them, and want them to do well” (p. 539).

Teacher-student relationship quality can be conceptualized as both a student level characteristic, hereby referred to as individual level, and a classroom- or school level characteristic, hereby referred to as contextual level. Typically, in school-based research, student reported scores are aggregated to the school level to create variables that represent a collective shared experience of the school context. Contextual variables are distinct from individual variables because they capture processes that are hypothesized to exert an influence on all individuals in that particular context (Blakely & Woodward, 2000). Of note, individual perceptions of experiences in a school are, in part, driven by being in a particular school context. The reverse is also true – aggregate measurements of schools are also driven by individual perceptions. Therefore, when effects at the individual and contextual levels are examined independent of one another (i.e., in separate models or not included at all), the estimates may be biased and misleading as they combine effects at both individual and contextual levels (Enders & Tofighi, 2007).

Two studies provide support for examining teacher-student relationship quality at the individual- (Mariu et al., 2012) and contextual levels (Eliot et al., 2010) in relation to help-seeking behaviors. However, to our knowledge, few if any studies have examined both individual and contextual level social processes simultaneously in the context of mental health help-seeking behaviors. Other multi-level, school-based studies have simultaneously examined associations between individual and contextual level indicators of school climate and bullying behaviors and victimization (Konishi, Miyazaki, Hymel, & Waterhouse, 2017) and adolescent depressive symptoms (Briere, Pascal, Dupere, & Janosz, 2013). Modeling individual and contextual level variables simultaneously provides the opportunity to quantify overall effects of school- and classroom level teacher-student relationships, beyond the students' own perceptions of those relationships (Enders & Tofighi, 2007).

The objectives of this study were to examine the associations between teacher-student relationship quality at school and teachers' responsiveness to students' emotional concerns in the classroom and (a) students' intentions to seek help at school for mental health concerns, and (b) students' mental health-related service use. This study simultaneously modeled individual and contextual level measures of teacher-student relationship quality at school and teachers' responsiveness to students' emotional concerns in the classroom on student help seeking behaviors. Findings have the potential to inform educators and mental health service providers about interpersonal processes occurring within schools and classrooms that are associated with student help seeking behaviors, which in turn, can inform whether targets for interventions to promote help seeking behaviors should be at the individual, classroom, and/or school levels.