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Research Article                                                                                                                      Open Access

## Does School Functioning Matter in Patients of Child and Adolescent Mental Health Services?

Einar S. Stødle 1 &Thomas Jozefiak 1,2*

1  Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway;  2 Department for Child & Adolescent Psychiatry, St. Olavs Hospital, University Hospital in Trondheim, Norway

* Corresponding Author:

einarstodle@yahoo.no

## Abstract

Objective: General population studies have demonstrated that good school functioning protects children and adolescents against mental health problems. However, no such studies of clinical populations have been conducted. Therefore, we explored the association  between school functioning and mental health  in  patients referred to child and adolescent mental health services (CAMHS). We also examined whether good school functioning and general social competence at referral predicted better mental health outcomes after six months of outpatient treatment .

Method: Of 345 patients, aged 8-15.5 years, referred as outpatients to CAMHS in a Norwegian county, 192 were eligible for  a  six-month  follow-up  study.  Parents  filled  out  the  Child  Behavior  Checklist  (CBCL)  for  120  of  these  children  and teachers completed the Teachers' Report Form (TRF) for 122 children .

Results: Teacher-reported  adaptive  functioning  (r  =  -0.65)  and  academic  skills  (r  =  -0.42),  and  parent-reported  social competence (r = -0.35) and school competence (r = -0.27) were significantly ( p <  0.01)  negatively associated with total emotional and behavioral problems at baseline. Parent-reported school competence and the total level of emotional and behavioral problems at referral significantly ( p < 0.05) predicted the total level of emotional and behavioral problems six months after referral .

Conclusion : Both teacher- and parent-reported school functioning were associated with mental health in CAMHS patients. Only parent-reported school competence predicted total levels of emotional and behavioral problems six months after referral. Therapists, teachers, and parents should cooperate closely when planning and conducting child and adolescent psychiatric treatments, and school should be considered an important area for intervention.

Key Words: School functioning; Child; Mental Health Services; CBCL; TRF

## Introduction

This study explored the association between school functioning and mental health among patients who were referred for child and adolescent mental health services  (CAMHS). School is important as a social and learning environment that affects not only the academic  achievements  of  students  but  also  their present  and  future  health  and  well-being  (1).  Belonging is a fundamental psychological need (2), and school represents an important arena in which relationships with peers who have a positive influence are possible.

A wide variety of concepts have been used to describe the feelings of connection and belonging that occur  in  a  school.  A  widely  used  definition  of  the term school  connectedness is  'the  extent  to  which  students  feel  personally  accepted,  respected,  included, and  supported  by  others  in  the  school  environment'  (3).  Catalano  and  colleagues  presented  another concept of school connectedness called school bonding that  consists  of  two  components:  1) attachment, which  is  characterized  by  close  emotional bonds with others in the school environment; and 2) commitment, which  is  characterized  by  cognitive, emotional,  and  academic  investment  in  the  school (4).  Libbey  reviewed  the  application  of  these  concepts  and  concluded  that  some  researchers  study 'school  engagement',  others  examine  'school  attachment,'  and  still  others  analyze  'school  bonding'  (5).  According  to  Libbey,  these  various  terms 'have created an overlapping and confusing definitional spectrum'.   A total of 21 concepts have been used to describe the topic of school connectedness, and  even  authors  using  the  same  data  have  used different concepts. Although there is a wide variety of concepts in use, there are some variables that are common to most of these concepts: the feeling of belonging, the degree of care and support received from  teachers,  the  presence  of  close  friends,  engagement  in  personal  academic  performance  and progress,  fair  and  efficient  discipline  in  the  school setting,  and  participation  in  activities  outside  of school (5).

A  positive  feeling  toward  and  relationship  with school  has  been  shown  to  reduce  the  number  of negative  life  events  experienced  by  children  and adolescents  (6);  such  a  connection  may  also  act  to buffer  the  potential  negative  effects  of  certain  risk factors  (1).  Previous  research  among  the  general population has shown that a good relationship with school protects children and adolescents from negative  life  events,  such  as  violence,  smoking,  and drugs (6); such feelings also correlate negatively with mental  health  problems,  including  anxiety  and  depression (2;7-9).

Studies have shown that the level of school connectedness  predicts  later  mental  health  problems with both internalizing and externalizing symptoms (9-11).   School connectedness also predicted a lower level  of  behavioral  problems  one  year  later  (12) among  children  in  the  sixth  and  seventh  grades. Other  researchers  have  examined  the  relationship between connectedness to school and both internalizing and externalizing symptoms among sixth- and seventh-grade students with the use of the problem section of the Achenbach Youth Self-Report. Those authors  found  that  perceptions  of  the  school  climate  (a  construct  similar  to  school  functioning) accounted for 2% and 5% of the variance in internalizing and externalizing symptoms, respectively, 1 year  later  (9).  Shochet  and  colleagues  showed  that the  covariation  between  school  connectedness  and depression  was  38%  to  55%  and  the  covariation between  school  connectedness  and  anxiety  symptoms  was  9%  and  16%  (10).  Their  study  also demonstrated  that  school  connectedness  predicted depressive  symptoms  one  year  later; this  indicates that a low level of school connectedness is not only a  marker  of  depressed  mood  but  also  a  potential risk factor for later depressive symptoms. Ross and colleagues  also  pointed  out  that  school  connectedness may be the most important mediator between low  social  competence  and  later  depressive  symptoms  (7).  A  recent  systematic  review  of  school, learning, and mental health concluded  there is strong evidence for the association between school functioning  and  mental  health  (13).  However,  the report further concluded that there has been limited research  conducted  regarding  how  organizing  factors,  educational  factors,  activities  in  the  school setting,  and  pedagogical  support  for  students  with special needs affect mental health.

During the past 10 years, there has been a call for interventions in schools that will reduce the number of  children  who  develop  mental  health  problems (14;15).  Numerous  studies    have  shown  that  increasing school functioning among children who are at  high  risk  of  developing  mental  health  problems by  raising  their  academic,  cognitive,  and  relational capacities  through  early  intervention  programs  reduces  the  risk  of  these  children  later  developing mental  health  problems  and  behavioral  disorders (16-19). Programs  have  also  been  developed  for general  school  populations  that  focus  on  training children to cope with everyday adversity and negative  life  events.  One  such  program,  entitled Zippy's Friends, is used by 30,000 children worldwide (20). A recent  randomized  controlled  trial  evaluated  the effects  of  this  program  and  concluded  that Zippy's Friends had a small but positive effect on children's coping skills as well as on the impact that possible classroom difficulties may have on them (21). However, long-term results are lacking.

In this study, we define the concept of school functioning as  a  child's  academic  and  social/relational functioning  at  school.  General  social  competence will  also  be  investigated.  Thus,  the  idea  of school functioning includes most of the variables covered by other  constructs;  the  conclusions  drawn  from  research based on similar concepts (e.g., school connectedness,  school  bonding)  and  their  effects  on mental  health  should  also,  at  least  to  some  extent, be relevant to our concept  of school functioning . School functioning was operationalized by the school competence subscale of the Child Behavior Checklist  (CBCL)  and  the  academic  performance and  total adaptive functioning  subscales  of  the Teacher's Report Form (TRF). We also operationalized the idea of general social competence with the social competence subscale of the CBCL; see Figure 1 for the conceptual map that was used. In our study, the concept of mental health problems was defined by the number and degree of reported emotional and behavioral  problems  observed  from  the  perspectives of  different  informants  (i.e.,  teacher  and  parents) and  operationalized  with  the  total  problem  scales Concept Variables School Functioning Social- and relational functioning from  the  problem  sections  of  the  TRF  and  the CBCL. Social Academic School

(TRF)

Competence

(CBCL)

(TRF)

Academic functioning

Performance Competence

(CBCL)

Figure 1. Conceptual map including operationalization of included variables in the present study*

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*TRF  (Teacher's  Report  Form)  indicates  teacher's  ratings,  CBCL (Child Behavior Checklist) indicates parent's ratings

As discussed previously, prior research has shown that  there  is  a  clear  association  between  school functioning  and  mental  health.  Conversely,  mental health  problems  have  a  negative  effect  on  school functioning  (12;22).   Given  the  high  prevalence  of mental health problems among children and adolescents (23), the important role of schools in dealing with  these  problems  (22;24),  and  the  considerable effort that has been invested into the prevention of mental  health  problems  in  the  general  population (20), it is remarkable that we have not found a study that addresses the association between school functioning and  mental health among  recipients of CAMHS. Previous studies of the reciprocal relationship between school functioning and mental health problems have focused on samples from the general population;  this  also  applies  to  studies  that  have addressed  how  school  functioning  predicts  later mental health problems in children and adolescents. There is growing evidence that systematic interventions  involving  mental  health  services  should  be given  in  the  patient's  own  environment;  this  environment includes the school as an important arena, because  effective  interventions  at  the  clinic  and  at home showed no generalization effects to peer relationships  in  day  care  or  school  (25).  At  present, mental health work in schools is mainly initiated by external  agents  (e.g.,  public  health  organizations, social  services),  which  often  results  in  insufficient systematization and continuity.

A  study  that  addresses  these  topics  in  CAMHS should,  importantly,  have  clinical  implications  for the  planning  and  implementation  phases  of  child and adolescent psychiatric treatments. If there exists a strong association between school functioning and mental health among clinical pediatric populations, then assessment and treatment should include school functioning as an important subject to consider in addition to emotional and behavioral issues.

## Aims of the study

The  overall  aim  of  this  study  was  to  explore  the strength  of  the  association  between  school  functioning and mental health problems among patients between  the  ages  of  8  and  15.5  years  who  were receiving CAMHS. We also examined whether good school functioning and general social competence at the  time  of  referral  to  CAMHS  (T1)  predicted  a better mental health outcome after six months (T2).

The specific research questions were as follows:

- 1) Does school functioning as reported by parents or  teachers  at  referral  correlate  significantly  with mental  health  problems?  If  so,  how  strong  is  this correlation?
- 2)  Does the reported level of school functioning at referral (T1), in addition to emotional and behavioral  problems,  predict  emotional  and  behavioral problems  after  six  months  (T2)  when  controlling for  possible  confounder variables such as age, sex, and socioeconomic status?

## Methods

Participants

In  an  earlier  study  (26),  consecutive  children  and adolescents  between  the  ages  of  8  and  15.5  years who were referred for the first time to one of three geographical  sites  of  the  outpatient  clinic  of  the Department of Child and Adolescent Psychiatry at St. Olav University Hospital in Sør-Trøndelag County, Norway, between July 2003 and December 2005 were asked to participate. The exclusion criteria  were  insufficient  competence in the Norwegian language  (i.e.,  refugees,  n  =  11)  and  children  and parents  who  had  attended  more  than  two  visits before  being  asked  to  participate  in  the  study.  Of the 501 eligible patients, the parents of 82 patients (16.4%)  did  not  give  their  informed  consent,  and the clinical  staff  did  not  follow  the  appropriate research procedures for 74 patients (14.8%). Ultimately,  345  patients  were  included  in  the  earlier  study, which constituted a response rate of 68.9% among the eligible patients. There was no significant difference between the included and excluded patients in terms of the child's living conditions (i.e., with one or  both  biological  parents)  or  psychosocial  functioning  as  measured  by  the  Axis  VI  scale  of  the World  Health  Organization's  tenth  revision  of  the International  Classification  of  Diseases;  this  is  discussed in more detail later in this article. The types of  problems  described  in  the  physicians'  referrals for both participants and non-participants are shown  in  Table  1,  but  there  were  no  significant differences seen.

Eligible patients: 501

No informed consent: 82

Attrition due to procedures: 74

Urban site

excluded: 153

Table 1. Type of problems in the physician referrals for included outpatients and attrition by four subgroups (26)

follow-up

Participated in follow-up: 158

| Group problems       | of   | Physician's reason of referral                             |   Partici- pants (%) n=331 a |   Non- Partici- pants (%) n=148 b |
|----------------------|------|------------------------------------------------------------|------------------------------|-----------------------------------|
| Emotional problems   |      | Depressive, suicidal, anxious, compulsive, eating disorder |                         42.0 |                              48.6 |
| Behavioural problems |      | Hyperactivity/attention and conduct problems               |                         44.4 |                              35.8 |
| School problems      |      | Learning, language- and speech problems and school-phobia  |                          4.8 |                               6.8 |
| Other                |      | Autistic or psychotic symptoms, visual/auditory problems   |                          8.8 |                               8.8 |

None of the observed differences were significant by Pearson Chi-Square. a 345 totally included outpatients and b 156 drop-outs; the difference to N is due to 'no problem specified' or physician referral sheet

## Present study

The  current  study  is  a  six-month  follow-up  study involving the sample that was described previously. However,  it  was  conducted  in  only  the  two  rural geographic sites of the three sites of the outpatient clinic, so it included only 192 of the 345 previously studied patients. The third urban site was excluded as a result of administrative changes, relocation, and reorganization,  which  made  the  follow-up  study impractical  to  conduct.  The  patients  seen  at  the rural  location  had significantly  lower  scores on  the CBCL  total  problems  scale  (t[324]=  -3.39, P = .001)  as  reported  by  parents  (mean,  45.2;  standard deviation, 24.3) as compared with the urban excluded  patients  (mean,  54.7;  standard  deviation,  25.9); more  details  are  given  about  these  results  later  in this article. However, there were no significant differences observed between rural included and urban excluded  patients  with  regard  to  TRF  academic achievement  scores  and  TRF  total  adaptive  scores as  reported  by  teachers;  this  is  addressed  in  more detail  later  in  this  article.  In  the  present  follow-up study, of the 192 patients who were eligible at baseline  (T1),  158  patients  participated.  No  significant differences  were  observed  with  regard  to  CBCL total problems scores, TRF Academic achievement scores,  or  TRF  total  adaptive  scores  at  baseline between participants and non-participants at the 6month follow up. Parents filled out the CBCL for 120  patients  and  teachers  completed  the  TRF  for 122  patients  for  the  6-month  follow-up.  For  an overview, see Figure 2.

Figure 2. Inclusion of patients in the follow-up study

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## Procedures

The therapists who met with each patient and his or her  parent  or  parents  informed  them  about  the project  and  gave  them  written  information.  The therapists stressed that patient confidentiality would be  observed,  and  they  responded  to  any  questions from the  patients  and  their  parents.  They  also  determined whether the patient fulfilled any exclusion criteria  and  scored  the  patient  on  the  psychosocial functioning scale described later in this article. For more  details  of  this  process,  see  the  article  by Jozefiak and colleagues (26).

## Instruments

CBCL. The CBCL is part of the Achenbach System of Empirically Based Assessment, which is a multiinformant  package  of  standardized  scores  and  descriptive information that addresses children's functioning  (27).  The  CBCL  has  a  competence  section and a problem section. Parents are asked to report their children's competence with the use of 20 questions about how often and the extent to which the child is engaged in sports, hobbies, activities, work, duties, and friendships. On the basis of these questions, the following three subscales are calculated: 1) social  competence,  which  is  based  on  number  of friends;  relationships  with  peers,  siblings,  and  relatives; and the ability to play alone; 2) school competence, which is based on the child's level of performance  in  academic  subjects,  his  or  her  need  for special  services,  and  the  total  number  of  school problems;  and  3)  activities,  which  is  based  on  the child's total number of activities and hobbies. Finally, a total competence score can be calculated on the basis  of  these  three  subscales.  For  this  study,  we only used the social competence and school competence  subscales,  because  the  number  of  activities and  hobbies  was  not  considered  relevant  for  our assessment  of  social  competence. In  the  problem part of the CBCL, parents are asked to score their responses  to  120  statements  about  their  children's emotional and behavioral problems on a scale that ranges from 0 to 2 (0 = Not True; 1 = Somewhat or Sometimes  True;  2  =  Very  True  or  Often  True). Thus, the range of the  total  problem  score  is  0  to 240.  The  Norwegian  version  of  the  CBCL  was translated  in  accordance  with  international  standards and showed satisfactory reliability and validity, and normative data were available (28-30).

TRF. The TRF, which is also part of the Achenbach  System  of  Empirically  Based  Assessment, is completed by a teacher or another school staff  member  who  has  known  the  child  in  the school setting for more than two months. Like the CBCL, the TRF also consists of two parts. The first part measures the child's academic performance and adaptive functioning. To  evaluate the  academic functioning  of  the  patients, their  teachers  were asked  to  rate  each  student's  performance  in  five academic  subjects  and  to  compare  them  with  the performance  of  typical  students  of  the  same  age using  a  scale  from  1  to  5,  where  1  indicated  well below average  and  5  indicated  well  above  average. The  academic  subjects  that  were  assessed  were Norwegian, mathematics, English, science, and history,  and  the  scores  for  each  subject  were  then averaged  to  form  an  academic  performance  score. The teachers also used a 7-point Likert scale, with 1 indicating well below average and 7 indicating well above average to rate the child's adaptive functioning and to compare the child with a typical student in  terms  of  how  hard  he  or  she  worked,  how  appropriately he or she behaved, how much he or she learned, and how happy he or she appeared to be. These scores were summarized to form a total adaptive score, which was a measure of the child's total adaptive  functioning  in  the  school  environment. The second part of the TRF, the problem section, is similar  to  the  problem  section  of  the  CBCL.  Normative data for the Norwegian versions are available (31). The Norwegian TRF has also shown satisfactory internal consistency (32)

Sociodemographic  and  clinical  information. Information about  the  child's  age,  sex,  number  of  caregivers, physician's referral, and clinical diagnosis according to the International Classification of Diseases, 10th revision, was obtained through the electronic medical record system. The parents' highest educational level was used as a measure of socioeconomic status and was rated on a standard 7-point scale (33).

Psychosocial functioning. International Classification of Diseases,  10th  revision, Axis  VI:  Global  Assessment  of Psychosocial  Disability  (GAPD). The  Global  Assessment of Psychosocial Disability assesses psychological,  social,  and  occupational  functioning  with  a psychiatric disorder, without regard for the presence or  absence  of  psychiatric  symptoms,  in  children between  the  ages  of  0  and  18  years.  It  has  nine codes that range from 0 to 8, with no steps in between; 0 indicates superior/good functioning or no disability. The lowest level of functioning must have been  recorded  within  the  3  months  preceding  the assessment.

## Statistics

SPSS  Statistics  17.0  software  was  used  to  analyze the data. Correlations between continuous variables were  calculated  with  Pearson's r coefficient.  We used a multivariate linear regression analysis to predict emotional and behavioral problems at 6 months after  referral.  For  regression  analysis  I,  using  the CBCL total problems score at T2 as the dependent variable,  the  independent  variables  were  entered blockwise  in  the  following  steps:  1)  CBCL  total problems score at T1; 2) CBCL school competence and social competence scores at T1; and 3) age, sex, and  socioeconomic  status.  For  regression  analysis II, using the TRF total problems score at T2 as the dependent variable, the independent variables were entered  blockwise  in  the  following  steps:  1)  TRF total problems score at T1; 2) TRF academic competence and adaptive functioning scores; and 3) age, sex, and socioeconomic status. An alpha level of P < .05 indicated statistical significance.

## Ethics

Before  a  child  was  allowed  to  participate  in  the study,  his  or  her  parents  had  to  provide  written informed consent. In addition, the Norwegian Ethical  Committee  of  Medical  Research  approved  this study (reference # 140-02).

## Results

School functioning and teacher's report of mental health

There were moderate but significant ( P < .01) negative correlations between the child's academic functioning  (TRF  academic  scale; r =  -0.42)  and  the child´s  total  emotional  and  behavioral  problems (TRF total problems), and between the total adaptive score (TRF total adaptive score; r = -0.65) and the child's total emotional and behavioral problems (TRF total problems), as reported by the teacher at referral (T1) (Table 2). A negative correlation means that  the  poorer  the  school  functioning,  the  more emotional and behavioral problems were measured. On the subscale level, 'working hard' and 'appropriate  behavior'  showed  strong  negative  correlations with teacher-reported total  emotional  and behavioral problems (TRF total problems; see Table 2).

Table 2. Pearson Correlations between various scales measuring school function and emotional/behavioral problems on the CBCL and TRF at referral. N=135-181

|                   |   TRF tot problems | CBLC tot problems   | TRF Academic   | Working hard   | Appr. behavior   | Learning   | Happy   | TRF tot adaptive   | CBCL School comp   | CBCL Social comp   |
|-------------------|--------------------|---------------------|----------------|----------------|------------------|------------|---------|--------------------|--------------------|--------------------|
| TRF tot problems  |                  1 | 0.26**              | -0.42**        | -0.63**        | -0.68**          | -0.33**    | -0.47** | -0.65**            | -0.43**            | -0.18              |
| CBCL tot problems |                    | 1                   | -0.15          | -0.23**        | -0.17*           | -0.11      | -0.28** | -0.26*             | -0.27**            | -0.35**            |
| TRF               |                    |                     | 1              | 0.61**         | 0.40*            | 0.71       | 0.28**  | 0.64**             | 0.71**             | 0.32**             |
| Working hard      |                    |                     |                | 1              | 0.69**           | 0.48**     | 0.36**  | 0.84**             | 0.55**             | 0.18*              |
| Appr. behavior    |                    |                     |                |                | 1                | 0.34**     | 0.46**  | 0.78**             | 0.36**             | 0.10               |
| Learning          |                    |                     |                |                |                  | 1          | 0.15    | 0.62**             | 0.57**             | 0.18*              |
| Happy             |                    |                     |                |                |                  |            | 1       | 0.60**             | 0.25**             | 0.31**             |
| TRF tot adaptive  |                    |                     |                |                |                  |            |         | 1                  | 0.56**             | 0.22**             |
| CBCL School       |                    |                     |                |                |                  |            |         |                    | 1                  | 0.31**             |
| CBCL Social comp  |                    |                     |                |                |                  |            |         |                    |                    | 1                  |

Variables in bold are major scales, variables in italic are subscales. *=p<0.05, **=p<0.01

Table 3. Pearson correlations between involved variables in multiple regression analysis with CBCL total problem score at T2 as dependent variable. N=105-178

|                                |   Total Problems (CBCL), T2 |   Total Problems (CBCL), T1 |   School Competence (CBCL), T1 |   Social Competence (CBCL), T1 |
|--------------------------------|-----------------------------|-----------------------------|--------------------------------|--------------------------------|
| Total Problems (CBCL), T2      |                        1.00 |                        0.73 |                          -0.41 |                          -0.38 |
| Total Problems (CBCL), T1      |                             |                        1.00 |                          -0.33 |                          -0.44 |
| School Compe- tence (CBCL), T1 |                             |                             |                           1.00 |                           0.39 |
| Social Compe- tence (CBCL), T1 |                             |                             |                                |                           1.00 |

All correlations were significant (p<0.05). T1: At referral, T2: Six months after referral.

Total problems: The total problem score as reported by the parents through CBCL

Table 4. Multiple regression analysis with CBCL

Total Problem scores at T2 as dependent variable. N=85

|                              |   Beta |   SE Beta | Standardized Beta   |
|------------------------------|--------|-----------|---------------------|
| Constant                     | 22.709 |     17.43 |                     |
| Total Problems (CBCL), T1    |  0.700 |     0.088 | 0.670**             |
| School Competence (CBCL), T1 | -3.809 |     1.797 | -0.183*             |
| Sex                          |  3.881 |     3.813 | 0.078               |
| Age, T1                      | -0.866 |     0.934 | -0.070              |
| Age, T1 SES                  | -0.403 |     1.348 | -0.024              |

R 2 = 0.581. R 2 Total Problems=0.559 (p<0.05), * p<0.05, ** p<0.01.

T1: At referral, T2: 6 months after referral. SES: Socio-economical status

## School functioning and parent's report of mental health

There  were  low  to  moderate  significant  ( P <  .01) negative  correlations  between  the  child's  school functioning (CBCL school comp; r = -0.27) and the total  emotional  and  behavioral  problems  (CBCL

total problems), and between the child's social functioning  (CBCL  social  competence;  r  =  -0.35),  and the total emotional and behavioral problems (CBCL total problems), as reported by the parents at referral (T1) (see Table 2).

Predictors  of  total  emotional  and  behavioral  problems  after six months of treatment as reported by parents via the Child Behavior Checklist

Before conducting the linear regression analysis, we calculated  the  correlations  between  the  possible predictors  and  the  total  emotional  and  behavioral problems  six  months  after  referral  (Table  3).  The strongest  predictor  of  the  child's  total  emotional and  behavioral  problems  six  months  after  referral (T2) was the total level of emotional and behavioral problems at referral (T1) as reported by the parents (  =  0.670, P <  .01;  Table  4).  The  child's  school competence as reported by the parents at T1 (CBCL school  competence  T1)  also  significantly  predicted the total  emotional and behavioral problems at T2 (CBCL total problems at T2;  = -0.183, P <  .05; see  Table  4).  Reported  social  competence  at  T1 (CBCL social competence T1) did not significantly predict  the  child's  total  emotional  and  behavioral problems at T2. In addition, the possible confounding variables of sex, age, and socioeconomic status were  not  significant  predictors  in  this  model.  The total  emotional  and  behavioral  problems  at  T1 (CBCL total problems at T1) explained 53.7% ( R 2 = 0.537)  of  the  variance  in  the  total  emotional  and behavioral  problems  6  months  after  referral  for CAMHS  (CBCL  total  problems  at  T2).  The  final model explained 58.1% ( R 2 = 0.581) of the variance in  the  total  emotional  and  behavioral  problems  at T2 (see Table 4).

Predictors of total emotional and behavioral problems after 6 months of treatment as reported by teachers via the Teacher's Report Form

The only significant predictor of the total emotional and  behavioral  problems  reported  by  the  teachers after  6  months  was  the  children's  total  emotional and behavioral problems reported by the teachers at referral (  = 0.729, p < 0.001).

## Discussion

Teachers  reported  a  significant  moderate  negative association between the child's total adaptive functioning  in  the  school  environment  and  the  child's total emotional and behavioral problems at referral. We also found a significant moderate negative association between the child's academic skills as reported by the teacher and the child's total emotional and behavioral problems. Parents reported a significant low  to  moderate  negative  association  between  the child's school competence and the child's total emotional  and  behavioral  problems  at  referral.  Social competence as reported by the parents also showed a significant moderate negative association with the child's  total  emotional  and  behavioral  problems. The  child's  school  competence  as  reported  by  the parents at referral significantly predicted the child's total  emotional  and  behavioral  problems  at  six months after referral.

## Parents' and teachers' reports: different perspectives

In  this  study,  we  gathered  information  about  children's competence and their emotional and behavioral problems from both their teachers' (TRF) and their  parents'  (CBCL)  perspectives.  The  TRF  and CBCL share similar problem sections, but the correlation  between  the  teachers'  and  parents'  problem ratings  was  low  (0.26).  This  is  a  well-recognized phenomenon  that  occurs  as  part  of  the  multiinformant  assessment  of  mental  health  problems (34), and it is cited as one of the most robust findings  in  psychopathology  (35).  In  addition,  the  ratings  of  the  two  informant  sources  at  T1  (baseline) did not predict each other's outcomes at T2. However, the aim of this study was not to compare the two  informant  sources  but  rather  to  exploit  the advantages of using such a multi-informant perspective  to  explore  the  reciprocal  relationship  between school functioning and mental health problems.

Association between school functioning and mental health in child and adolescent psychiatric patients

Our  findings  indicate  that  there  is  a  relationship between  school  functioning  and  mental  health  in child  and  adolescent  psychiatric  outpatients  at  the time  of  referral.  This  is  consistent  with  previous research  conducted  in  the  general  population  (2;79). The relationship seemed to be stronger between the  mental  health  and  school  functioning  reported by the teacher than between the mental health and school functioning reported by the parents at baseline. On the subscale level, our results indicate that children's adaptive functioning in the school setting as  reported by the teacher and parent-reported social  competence are more closely related to mental health  symptoms  than  academic  functioning  has been found to be. Our results also indicate that the teachers' evaluations of the children's social adaptation  skills  in  the  school  setting  are  more  strongly related  to  mental  health  symptoms  as  compared with  parents'  evaluations  of  their  children's  social competence outside of school.

The strongest association was found between the child's mental health and his or her adaptive skills in the school environment as reported by the teacher. Academic  functioning  as  reported  by  either  the parent  or  the  teacher  showed  a  low  to  moderate association with mental health. These results may be explained by the fact that adaptive skills in a social setting (e.g., the school setting) are closely related to the environmental context. In addition, such adaptive functioning at school may be a measure of the severity  of  the  child's  symptoms  and  behaviors  as they interfere with that environmental context. The teacher  observes  the  child's  adaptive  skills  in  the school setting to a much greater extent than parents do and therefore provides a more realistic picture of the child's actual adaptive skills at school. Another important  point  is  that  the  social  competence  reported by the parents on the CBCL had somewhat different content than the total adaptive score of the TRF, although they covered similar areas of social functioning. For example, the parents reported the child's  number  of  friends,  his  or  her  relationships with peers, and his or her ability to play on his or her own on the social competence subscale, whereas  the  teachers  reported  how  hardworking,  how appropriately  behaved,  how  willing  to  learn,  and how  happy  the  child  appeared  to  be  on  the  total adaptive  score  subscale.  Thus,  the  teacher's  report may  reflect  different  aspects  of  social  functioning (i.e.,  those  that  are  usually  associated  with  symptoms of common psychiatric diseases, such as conduct disorder, depression, and attentiondeficit/hyperactivity  disorder)  than  those  reflected in  the  parent's  report.  The  parents'  and  teachers' ratings of academic functioning are also subjective, although  they  are  based  on  more  objective  information  (e.g.,  the  child's  marks  in  various  school subjects) as compared  with social competence.

= 0.71) between the CBCL school competence subscale and the TRF academic  competence  scale  and  the  quite  similar of  these  two  subscales  with  mental

Therefore, the strong correlation ( r association health were as expected.

School  functioning  as  a  predictor  of  mental  health  in  child and adolescent psychiatric patients at the six-month follow up The  findings  of  our  study  indicate  that  the  child's school competence-measured as the level of performance in academic subjects, the need for special services, and the total levels of school problems as reported  by  the  parents  through  CBCL-was  a significant predictor of the total number of mental health symptoms six months after referral. Previous studies  have  shown  that  the  level  of  school  connectedness  predicted  later  mental  health  problems in the general population (9-12). As outlined in the Introduction section of this article, the school connectedness construct  is  a  measure  of  the  child's  social competence at school rather than of his or her academic  competence.  Because  our  version  of  school functioning, which is partly measured by the school competence subscale of the CBCL, reflects both the child's  academic  competence  and  his  or  her  social competence via his or her need for special services and his or her total number of school problems, our results may be comparable to those of former studies, at least to some degree.

We  were  surprised  to  find  that  teacher-reported adaptive functioning, which correlated most strongly  with  the  child's  total  emotional  and  behavioral problems at referral, did not significantly predict the teacher-reported total emotional and behavioral problems  six  months  after  referral.  However,  this may indicate that, over a period of six months, the most important predictive factors for mental health symptoms  are  not  the  teacher's  perception  of  the child's adaptive functioning (i.e., in a class of up to 30  pupils);  rather,  how  parents  perceive  their  own child's level of problems at school, the child's need for  special  services,  and  the  child's  academic  functioning  at  the  time  of  referral  to  CAMHS  may  be more predictive. As mentioned previously, the correlation  between  parents'  and  teachers'  problem ratings was low, which indicates that the two types of  informants  have  different  perspectives  with  regard  to  children's  emotional  and  behavioral  problems.  Deng  and  colleagues  demonstrated  that  parent-teacher  agreement  was  greater  for  attentional and  externalizing  problems  than  for  internalizing problems  and  that  it  decreased  with  increased  behavioral problems, so correlations can be expected to  be  low  in  a  clinical  population  (36).  Our  study may indicate  that,  in  a  clinical  population  of  child and  adolescent  patients  with  psychiatric  concerns, the  parents'  ratings  of  these  problems  are  more correct  than  the  teachers'  ratings.  Parents  of  children  with  mental  health  problems  observe  their children  in  several  contexts  and  likely  know  them better  than  their  teachers  do.  Thus,  parents  may recognize changes in school functioning as well as in the total levels of emotional and behavioral problems in a more accurate way than teachers do. For example, parents are closely involved in the outpatient  treatment of their children and may therefore be more aware of their children's problems and the changes  that  occur  in  these  problems  throughout the treatment process. Children with levels of emotional and behavioral problems that are so high that they require treatment, such as those in our patient sample, may also be absent from school more often than children in the healthy population. Therefore, it is reasonable to consider that the parents of children who are receiving CAMHS observe their children  more  intensively  than  the  children's  teachers, especially as compared with the parents of children in the healthy population. Our study thus indicates that  mental  health  personnel  in  a  clinical  setting should also pay attention to parents' reports of the school functioning and total emotional and behavioral problems of their children. Therapy should be based on a multimodal approach that includes not only the therapist but also teachers and parents.

The wide spectrum of definitions that are used to describe a child's connectedness to school makes it difficult  to  compare studies and to identify what is actually  being  measured  (37).  Further  research  is required to unravel the developmental precursors of school connectedness so that this construct may be measured  in  a  proper  way,  although  some  factors (e.g.,  social  skills,  attachment  to  parents,  school environment) have already been shown to be significant  predictors  of school  connectedness (14). The clarification of the concepts and a common definitional framework are vital if research into this topic is to benefit children with mental health problems.

It  is  important to widen our perspective on children's mental health by including the school as an important area for treatment. Interventions that are designed to prevent and treat mental health symptomatology  in  patients  receiving  CAMHS  should target social skills and school functioning in an integrated way. At referral, CAMHS should specifically take advantage of parents' knowledge of their children's  school  functioning.  A  multimodal  approach in which the therapist includes teachers and parents in both the planning and intervention phases of the CAMHS would  provide  a  tailored  and  individualized treatment plan for the child that addresses the relevant  mental  health  problem.  In  this  way,  treatment could be organized to include a school-based intervention  by  recognizing  school  functioning  as an important parameter for the successful treatment of patients receiving CAMHS.

## Limitations

As a result of the exclusion of the urban site of the outpatient department, the patients included in this study  were  only  those  that  live  in  rural  districts  in one county in central Norway, thereby limiting the representativity  of  the  sample.  As  expected,  the included patients showed lower levels of emotional and  behavioral  problems  at  baseline  than  the  excluded  urban  patients  did.  However,  we  did  not observe significant differences with regard to school functioning  between  rural  and  urban  children.  For the present study, 192 patients were eligible. Of the 158 patients  who participated  at  follow  up,  120  of their parents completed the CBCL, and the teachers filled out the TRF for 122 of them. Therefore, there was some attrition, which was mainly attributable to parents  and  teachers  not  filling  out  questionnaires. Another limitation of the study was that we did not include self-reports of mental health, such as those collected  with  the  Achenbach  Youth  Self-Report. The Achenbach Youth Self-Report was not included in this study because it would have considerably reduced  the  size  of  our  clinical  sample,  thereby diminishing the statistical power of the analysis and corrupting the results. The use of additional behavior  rating  scales  and  observational  data  could  have offered more to our multisource approach. We also mainly  focused  on  associations  between  teacherreported  variables and  then  looked  separately  at relationships between parent-reported variables. Any associations may therefore be partly a result of the rater's overall bias toward rating the child positively  or  negatively.  Lastly,  the  information  about children's  emotional  and  behavioral  problems  was obtained with questionnaires rather than with semistructured  clinical  interviews  conducted  by  clinical professionals, the latter of which is acknowledged as the gold standard method. However, the resources available for this study precluded this option.

## Conclusion

Research into the association between mental health and  school  functioning  in  clinical  populations  of outpatients who are receiving CAMHS is very limited.  The results  of  our study  indicate  that  there  is an  association  between  mental  health  and  school functioning in these patients. The strongest association at baseline was between the children's adaptive skills in the school environment and the total levels of  emotional  and  behavioral  problems  as  reported by their teachers. However, for our 6-month followup  study,  only  parent-reported  school  competence and  the  total  level  of  emotional  and  behavioral problems  at  baseline  predicted  the  total  level  of emotional and behavioral problems at T2.

## Implications

Mental health work in schools is mainly initiated by external  agents  (e.g.,  public  health  services,  child care  services,  ideal  organizations),  which  results  in insufficient  systematization  and  continuity.  Therapists, teachers, and parents should cooperate closely when planning and conducting child and adolescent psychiatric  treatments,  and  the  school  should  be included as an important arena for intervention.

## References

1. Anderman  LH,  Freeman  TM.  Students'  sense  of  belonging  in school. Advances in Motivation and Achievement 2004;13:27.
2. Anderman EM. School effects on psychological outcomes during adolescence. J Educ Psychology 2002;94:795-809.
3. Goodenow  C.  The  psychological  sense  of  school  membership among adolescents: scale development and educational correlates. Psychology in the Schools 1993;30:79-90.
4. Catalano R, Haggerty K, Oesterle S, Fleming C, Hawkins J. The Importance of bonding to school for healthy development: findings from the Social Development Research Group. J Sch Health 2004;74(7):252-61.
5. Libbey  HP.  Measuring  student  relationships  to  school:  attachment,  bonding,  connectedness,  and  engagement.  J  Sch  Health 2004;74:274-83.
6. Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones  J,  et  al.  Protecting  adolescents  from  harm:  findings  from the  National  Longitudinal  Study  on  Adolescent  Health,  JAMA 1997;278(10):823-32.
7. Ross  AG,  Shochet  IM,  Bellair  R.  The  role  of  social  skills  and school  connectedness  in  preadolescent  depressive  symptoms.  J Clin Child Adolesc Psychol 2010;39(2):269-75.
8. Bond L, Butler H, Thomas L, Carlin J, Glover S, Bowes G, et al. Social  and  school  connectedness  in  early  secondary  school  as predictors of late teenage substance use, mental health, and academic outcomes. J Adolesc Health 2007;40(4):357.e9-18.
9. Kuperminc GP, Leadbetter BJ, Blatt SJ. School social climate and individual differences to psychopathology among middle school students. J Sch Psychology 2001;39:141-59.
10. Shochet IM, Dadds MR, Ham D, Montague R. School connectedness  is  an  underemphasized  parameter  in  adolescent  mental health:  results  of  a  community  prediction  study . J  Clin  Child Adolesc Psychol 2006;35:170-9.
11.  Jacobson KC, Rowe DC. Genetic and environmental influences on  the  relationship  between  family  connectedness,  school  connectedness and adolescent depressed mood: Sex differences. Dev Psychol 1999;35(4):926-39.
12.  Loukas A, Ripperger-Suhler KG, Horton KD. Examining temporal associations between school connectedness and early adolescent adjustment. J Youth Adolesc 2009;38(6):804-12.
13.  Gustafsson JE, Allodi MW, Åkerman BA, Eriksson C, Eriksson L,  Fischbein S,  et  al.  School,  learning  and  mental  health:  a  systematic review. Stockholm: The Royal Swedish Academy of Sciences,  The  Health  Committee  2010;[Retrieved  15 th   May  2013] Available from

- http://www.kva.se/documents/vetenskap\_samhallet/halsa/utsk ottet/kunskapsoversikt2\_halsa\_eng\_2010.pdf
14.  Shochet IM, Homel R, Montgomery DT, Cockshaw WL. How does school connectedness and attachment to parents interrelate in  predicting  adolescent  depressive  symptoms?  J  Clin  Child Adolesc Psychol, 2008;37:676-81.
15.  Faulkner  GEJ,  Adalf  EM,  Irving  MA,  Allison  KR,  Dwyer  J. School disconnectedness: identifying adolescents at risk in Ontario, Canada. J Sch Health 2009;79(7):312-318.
16.  Hawkins  JD,  Catalano  RF,  Kosterman  R,  Abbott  R,  Hill  KG. Preventing  adolescent  health-risk  behaviors  by  strengthening protection during childhood. Arch Pediatr Adolesc Med 1999;153:226-34.
17.  Campbell FA, Ramey CT, Pungello E, Sparling J, Miller-Johnson S.  Early  childhood  education:  young  adult  outcomes  from  the Abecedarian Project. Applied Developmental Science 2002;6(1):42-57.
18.  Catalano RF, Mazza JJ, Harachi TW, Abbott RD, Haggerty KP, Fleming  CB.  Raising  healthy  children  through  enhancing  social development in elementary school: results after 1.5 years. J Sch Psychology 2003;41(2):143-64.
19.  Hamre BK, Pianta RC. Early teacher-child relationships and the trajectory  of  children's  school  outcomes  through  eighth  grade. Child Dev 2001;72(2):625-38.
20.  Mishara  B,  Ystgaard  M.  Effectiveness  of  mental  health  promotion to improve coping skills in young children: Zippy's Friends. Early Childhood Res Quart 2006;21:110-23.
21.  Holen S, Waaktaar T, Lervåg A, Ystgaard M. The effectiveness of a  universal  school-based  programme  on  coping  and  mental health: a randomised, controlled study of Zippy's Friends. Educational Psychol 2002;32:657-77.
22.  Hoagwood  K,  Johnson  J.  School  psychology:  a  public  health framework  1.  From  evidence-based  pracices  to  evidence-based policies. J Sch Psychol 2003;41:3-21.
23. Mathiesen KS, Karevold E, Knudsen AK. Psykiske lidelser blant barn og unge i Norge. Folkehelseinstituttet; 2010
24.  Rones M, Hoagwood K. School-based mental health services: a research review. Clin Child Family Psychol Rev 2000;3:223-41.
25.  Drugli MB, Larsson B, Clifford G. Changes in social competence in young children treated because of conduct problems as viewed by multiple informants. Eur Child Adolesc Psychiatry, 2007;16:370-8.
26. Jozefiak  T,  Larsson  B,  Wichstrøm  L,  Wallander  J,  Mattejat  F. Quality of life as reported by children and parents: a comparison between students and child psychiatric outpatients. Health Qual Life Outcomes 2010;8:136-44.
27.  Achenbach  TM,  Rescorla  L.  An  integrated  system  of  multiinformant assessment - school-age forms and profiles. USA: Library of Congress; 2001.
28. Nøvik  TS.  Validity  and  use  of  the  child  behavior  checklist  in Norwegian children and adolescents: an epidemiological and clinical  study.  Centre for  Child  and  Adolescent  Psychiatry,  Department Group of Psychiatry, University of Oslo, Oslo;1999.
29.  Nøvik TS. Validity of the child behaviour checklist in a Norwegian sample. Eur Child Adolesc Psychiatry 1999;8:247-54.
30.  Jozefiak T, Larsson B, Wichstrøm L, Rimehaug T. Competence and emotional/behavioural problems in 7-16-year-old Norwegian school  children  as  reported  by  parents.  Nordic  J  Psychiatry 2012;66:311-9.
31.  Larsson B, Drugli MB.  School competence and emotional/behavioral problems among Norwegian school children as rated  by  teachers  on  the  Teacher  Report  Form.  Scand  J  Psychol 2011;52:553-9.
32.  Drugli  MB,  Klöckner  C,  Larsson  B.  Do  demographic  factors, school functioning and quality of student-teacher relationship as rated by teachers predict internalizing and externalizing problems among Norwegian schoolchildren. Evaluation & Research in Education 2011;24:243-54.
33.  Hollingshead  AB.  Two  factor  index  of  social  position.  New Haven: Yale University; 1958
34.  Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: implications of crossinformant  correlations  for  situational  specificity.  Psychol  Bull 1987;101:213-32.
35.  De  Los  Reyes  A,  Kazdin  AE.  Informant  discrepancies  in  the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations  for further study. Psychol Bull 2005;131(4):483-509.
36.  Deng S, Liu X, Roosa M. Agreement Between Parent and Teacher Reports on Behavioral Problems Among Chinese Children. J Dev Behav Pediatr 2004;25:407-14.
37.  Barber  BK,  Schluterman  JM.  Connectedness  in  the  lives  of children and adolescents: A call for greater conceptual clarity. J Adolesc Health 2008;43:209.

## Acknowledgements

The study  was  funded  by  the  National  Council  of Mental  Health/EXTRA  and  the  department  of Child and Adolescent psychiatry/St. Olav University Hospital.