Mental Health Stigma Prevention - Wiley Online Library

RESEARCH ARTICLE

Mental Health Stigma Prevention: Pilot Testing a Novel, Language Arts Curriculum-Based Approach for Youth HANNAH L. WEISMAN, MAa MARYAM KIA-KEATING, PhDb ANN LIPPINCOTT, PhDc ZACHARY TAYLOR, MAd JIMMY ZHENG, BAe

ABSTRACT BACKGROUND: Researchers have emphasized the importance of integrating mental health education with academic curriculum. The focus of the current studies was Mental Health Matters (MHM), a mental health curriculum that is integrated with English language arts. It is taught by trained community member volunteers and aims to increase knowledge and decrease stigma toward individuals with mental health disorders. METHODS: In Study 1, 142 sixth graders participated in MHM and completed pre- and postprogram measures of mental health knowledge, stigma, and program acceptability. Teachers also completed ratings of acceptability. Study 2 (N = 120 seventh graders) compared participants who had participated in MHM the previous year with those who had not using the same measures. RESULTS: Sixth grade students and teachers rated the program as highly acceptable. Participants significantly increased their knowledge and decreased their levels of stigma. Seventh graders who had participated in MHM had significantly more mental health knowledge than peers who had not, but there were no differences in stigma. CONCLUSIONS: The model appears to be acceptable to students and teachers. Future research is needed to assess the long-term effectiveness of integrating mental health education with other academic curriculum such as language arts or science. Keywords: mental health; curriculum; child and adolescent health; school health instruction; stigma. Citation: Weisman HL, Kia-Keating M, Lippincott A, Taylor Z, Zheng J. Mental health stigma prevention: pilot testing a novel, language arts curriculum-based approach for youth. J Sch Health. 2016; 86: 709-716. Received on May 2, 2015 Accepted on April 4, 2016

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pproximately 22% of children will develop a mental health disorder with severe impairment or distress by age 18,1 suggesting that the vast majority of adolescents will encounter a peer with a mental health disorder. Unfortunately, negative attitudes toward individuals with mental health disorders are developed as early as kindergarten and are relatively stable into adolescence.2,3 Children often have limited knowledge about mental health disorders and confuse mental

illness with physical illness or mental retardation.4 A lack of knowledge can contribute to stigmatizing attitudes, which in turn are associated with the exclusion of peers who are thought to have mental illness.5 Stigmatizing attitudes can have additional negative effects on those with mental health disorders. Stigma prevents adolescents from seeking help for mental health problems,6,7 which can reduce general

a Doctoral Candidate in Counseling, Clinical, and School Psychology, ([email protected]), Department of Counseling, Clinical, and School Psychology, Gevirtz School, University of California, Santa Barbara, CA 93106-9490. b Associate Professor of Clinical Psychology, ([email protected]), Department of Counseling, Clinical, and School Psychology, Gevirtz School, University of California, Santa Barbara, CA 93106-9490. c Emeritus Faculty, Teacher EducationProgram, ([email protected]), Department of Education, Gevirtz School, Universityof California, SantaBarbara, CA93106-9490. dCounselor, ([email protected]), Department of Counseling, Clinical, and School Psychology, University of California, Santa Barbara, CA 93106-9490. e Graduate Student in Industrial Organizational Psychology, ([email protected]), Department of Psychology, University of Central Florida, 4111 Pictor Lane, Psychology Bldg 99, Ste. 320, Orlando, FL 32816; University of California, Santa Barbara, CA 93106-9490.

Address correspondence to: Hannah L. Weisman, Doctoral Candidate in Counseling, Clinical, and School Psychology, ([email protected]), Gevirtz School, University of California, Santa Barbara, CA 93106-9490. The corresponding author is grateful for the support of the 2012 American Psychological Foundation Violet and Cyril Franks Scholarship.

Journal of School Health

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October 2016, Vol. 86, No. 10

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© 2016, American School Health Association • 709

well-being and academic performance.8,9 Research indicates that by fifth grade, students are able to conceptualize mental illness in a more sophisticated manner, suggesting that middle childhood is a developmentally opportune time to provide psychoeducation and reduce stigma.10 Mental health education and stigma reduction is important to decrease the shame of mental illness and to encourage help-seeking behaviors among those with mental health problems.11

This approach has the potential to be cost-effective, sustainable, and to create an ongoing partnership between schools and local community members or an organization. The current program, Mental Health Matters (MHM), utilizes community member facilitators to prevent mental health stigma and simultaneously meet core language arts academic requirements in sixth grade classrooms. The MHM Curriculum and Teaching Model The MHM curriculum is an adaptation of the material from the Breaking the Silence: Teaching the Next Generation About Mental Illness curriculum, an existing stigma-reduction program shown to significantly improve middle school students’ knowledge and attitudes about mental illness when compared with a control group.19,20 Mental Health Matters utilizes language arts pedagogy to impact stigma reduction.10 To disseminate the program and reduce burden on teachers, volunteers were drawn from a communitybased agency focusing on support, housing, advocacy, and education for Santa Barbara area community members and families affected by mental illness. To implement the program, an ‘‘education committee’’ made up of community members works to continually update materials as needed, and offer personal and professional support related to the teaching practices and/or content of the program. The committee meets at least 1 time per month. There has been some research demonstrating the effectiveness of peer-facilitated mental health education for families with members suffering from mental illness,21 but to the authors’ knowledge the use of community members who have personal/family experience with mental illness in mental health education for children has not been examined. Table 1 provides an overview of the education committee and teaching teams. The MHM curriculum takes place over five 45-60minute periods in the classroom. On the first day, facilitators self-disclose that either they or a loved one has a mental health disorder diagnosis. This strategy decreases the stigma of discussing mental illness and is intended to make the curriculum more personal and engaging for the students. Although there may be slight variations in the way material is presented based on the facilitators present, all facilitators ensure that they adhere to the curriculum presented in Table 2.

The Role of Schools in Mental Health Education In addition to academic subjects, schools play a central role in teaching youth ethical behaviors, social skills, and positive mental health practices.12 Studies suggest that students who have participated in comprehensive, long-term social and emotional programs demonstrate a higher level of skills necessary to be successful in life than students who do not participate in such programs. These skills include emotion regulation, goal-setting, conflict resolution, improved self-esteem, and pro-social attitudes.13 In addition, such programs enhance students’ academic performance,13 linking mental health education with academic success in other areas. Many researchers have called for an integrated approach to mental health and educational goals, rather than trying to address these goals separately.12-16 Little research exists overall on interventions that aim to decrease mental illness stigmatization among children in secondary education.17 To the authors’ knowledge, only one such program integrated mental health and academic goals. The intervention, implemented by school teachers,18 targeted middle school students using a biology curriculum and found increased knowledge and decreased negative attitudes at postprogram. This paper presents a pilot test of another such program, a novel, language arts curriculum-based program to reduce stigma toward individuals with mental health disorders. Programs run by school personnel (such as teachers) may be more sustainable than programs run by university-based researchers or outside consultants since researchers often have to discontinue the program when the funding runs out or the study is completed.14 However, school-based resources are not always available or sufficient to enact universal prevention efforts. Teacher training may be timeconsuming, and programs may be difficult to sustain once the training team has exited. Teachers are often overburdened and may not have the support or motivation to learn and continue to implement a new curriculum, particularly if they already have one that works and meets core state and national academic standards. An alternative approach is to train community member volunteers to offer school-based programs. 710 •


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The Current Studies The current studies aimed to examine the acceptability of the MHM program to students and teachers, and pilot test program effectiveness in changing mental health knowledge and stigma. Increasing knowledge is an important component of stigma-reduction programs and is most effective when combined with other strategies to decrease stigma (eg, exposure to •

© 2016, American School Health Association

Table 1. Key Components of the Community Member Teaching Model Component

Definition

Time Commitment

Committee Leader(s)

An individual (or 2 individuals) with knowledge of applicable pedagogical and 20-40hours per month mental health concepts; recruits classrooms, facilitates scheduling, organizes meetings, and creates subcommittees as needed to address specific tasks. Education Committee A diverse group of adult volunteers who are invested in mental health 2-5hours per month per person, including the meeting and prevention/promotion. Meet at least once per month as a committee. Must any assigned outside tasks or subcommittee work include some individuals with an education background and some with a mental health professional background. May also include community members with a personal interest in teaching mental health concepts to children/adolescents. The committee is charged with updating the curriculum in an organic fashion (in response to issues that arise in the classroom) or when otherwise called for (eg, when the DSM-5 came out and shifted some categories of mental health disorders). Teaching Team The education committee members who are present in the classroom to teach 5-20hours per month, depending on the individual’s the curriculum. Each teaching teammember has observed the full curriculum availability and the number of classrooms currently before teaching and has received adequate training in basic teaching skills participating (using a loud voice, engaging students, etc) as well as program content.

Table 2. Mental Health Matters Topics and Activities by Day Day

Topic/Activities

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-Members of the teaching team introduce themselves and disclose either their own or a loved one’s mental health disorder diagnosis -The day is focused on providing an introduction and overview of mental illness -Students are exposed to facts about mental illnesses via 3 interactive language arts activities -Students post what they know and what they want to learn about mental illnesses to a board -Program facilitators answer students’ questions from Day 1 -Students perform a readers’ theater play about stigma at school -A handout on stigmatizing words and using ‘‘person-first language’’ is reviewed -Students respond to play for homework -Students divide into groups and plan a poster on a mental health disorder (eg, Schizophrenia) or a group of mental health disorders (eg, eating disorders) -Students review criteria of a good oral presentation and present their posters -Students practice note-taking -The teaching team facilitates a Jeopardy review game (students use their notes from Day 4) -Students complete a ‘‘what I learned’’ exit card

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3 4 5

individuals with mental illness).22 Acceptability refers to ‘‘consumers’ judgments about treatment procedures’’ and is important to assess because programs with low acceptability may not be sustainable even if they are highly effective.23 Acceptability by teachers is key to maintaining a good working relationship between the school and community partner.24 In Study 1, self-report data were collected from sixth grade students in 20 classrooms before and after participating in the MHM program. The prepost, uncontrolled design assessed student perceptions of the program and changes in knowledge and stigma. The hypothesis was that students would find the program to be acceptable (helpful, interesting, and fun), and that their levels of knowledge and stigma would significantly improve after participating in the program. The classroom teachers were also recruited to provide feedback on the acceptability of the program and their perception of how well the program integrated language arts skills. Journal of School Health

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The purpose of Study 2 was to use a naturalistic design to assess whether seventh grade students who completed MHM in sixth grade had more knowledge and less stigmatizing attitudes than peers who had not completed MHM. The students who participated in Study 2 were a different cohort than the students who participated in Study 1 (the 2 studies were completed during the same school year). We hypothesized that students who had participated in MHM the previous year would have more knowledge and less stigma than students who had not participated in MHM, which would suggest sustained effects of the program.

METHODS Participants Study 1 participants were recruited from sixth grade public school classrooms that were signed up to participate in the MHM program. Four of 7 schools consented to participate in the research. A sample of 142 sixth grade participants (52%


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male, Mage = 11.4 years, age range = 11-13 years; 65% consent rate) gave parental consent and participant assent. In terms of race and ethnicity, 45% of participants identified as Caucasian, 34% as Hispanic or Latino/a, 4% as Asian, 1% as Pacific Islander, 1% as black or African-American, 1% as Native American, and 13% as mixed or other ethnicity. In addition, 7 teachers completed a survey on their experience with the program. Demographic information was not collected for the teachers. Participants in Study 2 (N = 120, 50% boys, Mage = 12.7 years, age range 12-14 years; 73% consent rate) were seventh graders enrolled in a science class. About 58% identified as Caucasian, 14% as Hispanic or Latino/a, 6% as Asian, and 22% as mixed or other ethnicity. About one-third of participants (N = 37) had participated in MHM as a sixth grade student.

health disorder.’’ This scale has demonstrated internal consistency (.73 < α < .77) and validity in previous work with adolescents.27 Cronbach’s alpha in the current sample was .67. Attitudes Toward Serious Mental Illness Scale— Adolescent Version (ATSMI-AV).28 The ATSMI-AV is a 21-item scale that assesses 5 dimensions of stigma: threat from mentally ill persons, mental illness as a social construction/concern, wishful thoughts about mental illness, categorical thinking (such as ‘‘us versus them’’), and mentally ill persons as out of control. The measure was developed for use with high school students. Users respond to each item on a scale from 1 (completely disagree) to 5 (completely agree). The term ‘‘mentally ill person(s)’’ was changed to ‘‘person/people with mental health disorder(s)’’ in accordance with the terminology used in the MHM curriculum. The internal consistency of the subscales in this sample was quite low (α < .65) except for the Threat subscale (α = .70 and .74 among sixth and seventh graders, respectively), but the global score was acceptable (α = .69 and .76). Findings with the subscales were examined but should be considered exploratory. Open-ended items. Students were asked to respond to the open-ended prompt: ‘‘This is what I know about mental health disorders . . . .’’ At posttest, the prompt was: ‘‘I used to think . . . Now I know . . . ’’ with reference to mental health disorders. Teacher acceptability. At the conclusion of the program, teachers indicated how much they liked MHM, how important they thought the topic was, and how likely they were to include the curriculum in their classroom the following year. In addition, teachers indicated how valuable the curriculum was for teaching language arts skills. Each question was rated on a scale from 1 to 5, with higher scores indicating more positive feedback. Teachers could also provide written feedback on the MHM curriculum. Student acceptability (given at posttest only). Likert scales ranging from 1 to 5 were used for students to rate how helpful, fun, and interesting they found the MHM program.

Instruments Measures in Studies 1 and 2 were identical, except that measures of program acceptability were not included in Study 2. Demographics. Participants were asked to report their sex, age, and ethnicity. Knowledge. Knowledge of mental illness and specific disorders was assessed with a 19-item multiplechoice exam-style measure written expressly for this study. The items were constructed using guidelines for creating fair multiple-choice questions that assess the targeted construct.25 Questions assessed students’ general knowledge of mental illness and stigma, as well as broad definitions of the disorders covered in MHM. Students were instructed to make a ‘‘best guess’’ if they didn’t know the answer. Total correct answers were calculated and ranged from 0 to 19. Revised Attribution Questionnaire (rAQ).26 The rAQ is a shorter, adolescent version of the Attribution Questionnaire.18 The rAQ was developed for use with a diverse group of over 300 adolescents, ages 13-19 years.26 The rAQ presents a brief hypothetical vignette about a new classmate who is mentally ill. The participant rates the degree to which they agree with 7 statements about the new student that map onto attributions of responsibility, pity, anger, dangerousness, fear, help, and avoidance.18 The rAQ also has an item on how likely the user would be to seek help if he or she thought they might have a mental health disorder. In this study, students could respond on a scale from 1 (completely disagree) to 9 (completely agree) and the average of responses was calculated. The prompt was slightly adapted. Instead of, ‘‘Brandon is a new student in your class. Before his first day, your teacher explained that Brandon is mentally ill and is transferring from a special school,’’ the prompt was, ‘‘Brandon is a new student in your class. Before his first day, you find out that Brandon has a mental 712

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Procedure In Study 1, participants completed the self-report measures during class within a week before and after the MHM program. Someone from the research team was present to answer any questions. In Study 2, participants also completed the self-report measures during class with their teacher overseeing measure completion. The seventh grade participants indicated on their survey whether they did, or did not, receive MHM as a sixth grader. They also wrote the name of their sixth grade teacher so that the researchers could verify their response. •


Data Analysis Descriptive statistics were used to examine baseline levels of knowledge and stigma and program acceptability. Independent t tests were used to compare baseline responses between sexes and the 2 largest ethnic groups (Caucasian and Latino/a), and the subsequent analyses (repeated measures t tests or ANOVAs) were chosen accordingly to compare responses before and after the program (Study 1) and between seventh graders who had or had not received the program (Study 2). Responses to the open-ended questions were grouped into the following categories: responses that included incorrect or stigmatizing statements, responses suggesting that the student had no knowledge at all about mental health disorders (‘‘I don’t know anything’’), or responses that were primarily factual and nonstigmatizing.

Table 3. Changes in Scores Among Sixth Graders (N = 124 With a Pretest and Posttest) Possible Pretest Posttest Range Mean (SD) Mean (SD)

Instrument Knowledge rAQ ATSMI-AV Subscales Threat From Mentally Ill Persons Mental Illness as a Social Construction Wishful Thoughts About Mental Illness Categorical Thinking Mentally Ill Persons as Out of Control

t

0-19 1-9

13.6 (3.0) 2.4 (1.0)

16.0 (2.7) 2.3 (1.0)

−10.7** 1.4

1-5

2.2 (.75)

2.0 (.73)

4.3**

1-5

1.9 (.67)

1.8 (.73)

3.0*

1-5

3.1 (.77)

3.6 (.78)

−6.3**

1-5 1-5

2.2 (.68) 2.3 (.96)

1.9 (.64) 1.9 (.91)

4.5** 3.4*

*p < .01; **p < .001. rAQ, Revised Attribution Questionnaire.

RESULTS Sixth Grade Sample Characteristics at Baseline Table 3 contains mean scores at baseline. The t tests showed no significant differences between sexes on knowledge (t[140] = .28, p = .78) or stigma (.28 |t| 1.3, .20 < p < .58) at baseline. Independentsamples t tests revealed significant differences between Caucasian (N = 64) and Latino/a (N = 48) participants. A Holm adjustment was used to control for familywise error for this group of tests.29 The results indicated that Caucasian participants had significantly more knowledge at baseline (M = 15.0, SD = 2.8) than Latino/a participants (M = 11.8, SD = 3.8; equal variances not assumed, t[82.8] = 4.8, p < .001). In addition, on the ATSMI-AV, Caucasian participants had lower scores (less stigmatizing attitudes) on the Social Construction/Concern subscale (equal variances not assumed, t[81.0] = −6.3, p < .001) as well as on the Wishful Thinking subscale (t[108] = −2.9, p = .004) than Latino/a participants. Knowledge In Study 1, a total of 124 students (87%) completed both pre- and postmeasures. Participants answered significantly more (84%) questions correctly at posttest than at pretest (74%; t[123] = −8.6, p < .001; Table 3). A repeated measures ANOVA using only the Caucasian and Latino/a participants showed that the interaction between time point and ethnic group for levels of knowledge was not significant, F(1, 95) = .02, p = .88. In Study 2, an independent samples t test showed a significant difference in knowledge between those who had not received MHM in sixth grade (M = 15.5, SD = 2.6) and those who did (M = 16.4, SD = 17), equal variances not assumed, t(100.8) = −2.1, p = .04. Stigma Among the sixth graders, there were significant changes on the global score (t[122] = 3.2, p = .002) Journal of School Health

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and each subscale of the ATSMI-AV from pretest to posttest. Four of the subscales changed in the hypothesized direction (a decrease in stigma; 2.7 ≤ t ≤ 4.7, all p’s < .01), but wishful thinking increased significantly (t = −6.3, p < .001). An independent samples t test showed no significant difference in rAQ scores, t(188) = .11, p = .92. There was no significant interaction effect between time point and ethnic group (Caucasian or Latino/a) for the global score or the subscales of the ATSMI-AV (all p’s > .05). However, there was a significant interaction between time point and ethnic group for the rAQ, F(1, 96) = 5.0, p = .03, although neither main effect was significant. The Latino/a participants decreased their levels of stigma (as assessed by the rAQ) from pre (M = 2.7, SD = 1.2) to post (M = 2.3, SD = 1.2), whereas Caucasian participants had a very slight increase from pre (M = 2.2, SD = .96) to post (M = 2.3, SD = .91). Table 3 shows changes in stigma measures among sixth graders. In Study 2, there were no significant differences in levels of stigma between seventh graders who had and had not received MHM the previous year, all p’s > .05. Differences between ethnic groups were not examined due to small sample size. Open-Ended Responses The open-ended item ‘‘This is what I know about mental health disorders . . . ’’ offered an opportunity to gauge levels of knowledge and stigma at pretest in a more individualized way, and revealed higher levels of stigma than seen in the quantitative survey measures. Many participants demonstrated a lack of knowledge and/or stigma about mental health disorders in their open-ended responses. For example, one participant wrote, ‘‘A lot of people with mental health disorders can be more dangerous and it usually is harder for them to learn. Most of them can’t hear, see, or walk.’’ Another student wrote, ‘‘They do not know much


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and they are weak.’’ Many participants also expressed wishful thinking, such as ‘‘I think that when people are depressed, love from their family can cure them’’ and, ‘‘Just because someone has a mental health disorder doesn’t mean they are different than me.’’ Finally, a common response was for students to write that they did not know anything at all about mental health disorders. At posttest, the majority of participants’ responses to the prompt, ‘‘I used to think . . . Now I know . . . ’’ indicated a perception of positive change from a stigmatizing or incorrect thought as a result of their participation in the program. One participant wrote: ‘‘I used to think that people with mental health disorders are the ones to blame for their disorder. Now I know that it is not the person’s fault and they have not done anything wrong.’’ Another participant noted, ‘‘I used to think mental health disorders are contagious. Now I know they are not.’’ The qualitative responses suggest that (1) students did hold some stigmatizing attitudes before participating in MHM, and (2) the program increased participants’ awareness of their own stigmatizing or incorrect thoughts about mental health disorders.

mental health information with language arts core academic standards. In addition, this study was important because it highlighted the utility of qualitative measures of stigma, which were more sensitive to participants’ stigmatizing attitudes than quantitative measures used. Overall, the results of Study 1 indicated that the program is acceptable to both teachers and youth participants. Program participants increased their knowledge about mental health disorders and generally decreased their stigmatizing attitudes, although the changes were small. The qualitative data provided a more in-depth look at changes in participants’ stigmatizing beliefs before and after the program and provides evidence for program effectiveness in reducing mental health stigma. The results of Study 2 indicated that students who received MHM had significantly more knowledge a year later than students who did not. It is worth noting that there was only a 1-point difference in knowledge scores between the 2 groups, leaving some question about the meaningfulness of these longitudinal findings. No differences were seen in levels of stigma; levels of reported stigma were low among both groups. There are several possible interpretations of this finding. First, self-report bias or social desirability makes stigma difficult to measure, with other studies with children finding generally low levels of stigma.18 The qualitative measures may have done a better job capturing stigma. Future studies may want to give more consideration to choosing qualitative methods to assess stigma, or having qualitative reports inform the development of measures which better capture experiences of mental health stigma among youth. Second, Study 1 suggests that students may not be aware of their own stigmatizing attitudes or beliefs until going through an educational program such as MHM. Indeed, when compiling the measurement instruments we wrestled with whether to provide a definition of ‘‘mental health disorder’’ at pretest because many youths have misconceptions about the term.4 Similarly, they may not be aware of their own stigmatizing attitudes. The retrospective component of the qualitative question we included at posttest (‘‘I used to think . . . ’’) was fruitful in identifying stigmatizing attitudes that the participants held preprogram. A third possibility is that the effects of MHM may not be sustained and followup programming may be necessary to maintain and continue to reduce stigmatizing attitudes. Stigmatizing attitudes are difficult to change, even when an individual has knowledge that contradicts these attitudes.22 Mental Health Matters may be a useful curriculum to include alongside other stigma-reduction efforts throughout childhood and adolescence. The significant increase in wishful thinking from pre- to postprogram was unexpected. Items from this subscale of the ATSMI-AV include ‘‘People with

Student and Teacher Acceptability Overall, students rated the program as highly helpful (M = 4.2, SD = .85), interesting (M = 4.0, SD = .92), and fun (M = 3.9, SD = 1.0). Teachers reported that they liked the MHM curriculum (M = 4.9, SD = .38), found the topic important (M = 4.9, SD = .38), were likely to include the curriculum in their classroom the following year (M = 5.0, SD = 0), and found the curriculum valuable for teaching language arts skills (M = 4.0, SD = .82). Importantly, 100% of participating teachers did indeed include the curriculum in their classroom the following year. In terms of teacher feedback, the open-ended responses generally indicated satisfaction with the MHM curriculum. For example, one teacher wrote: ‘‘The integration of language arts skills (note-taking, summarizing) is valuable. The students positively received the content. Very well organized/presented!’’ Many teachers commented on the salience of the topic to students’ lives: ‘‘I was amazed at how many of these kids have some sort of experience with mental health issues [such as] through family members or friends. The kids loved the program and were very engaged.’’

DISCUSSION This study was one of the first to examine the acceptability of a curriculum-based mental health stigma prevention program. This program was novel in its use of community members as sustainable intervention facilitators and its integration of the 714

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mental health disorders can get well if they are treated with love and kindness’’ and ‘‘People who have mental health disorders could be well enough if they tried hard enough.’’ Watson and colleagues cautioned that ‘‘while optimism about recovery is desirable, this construct suggests the belief that people should just get over it and could result in blaming individuals who continue to struggle.’’28 It is possible that the MHM program may overly emphasize the possibility of recovery from mental health disorders. Finally, the MHM program offers interesting and innovative areas to consider for future mental health education or stigma-reduction programs. The curriculum begins with facilitators briefly sharing their own or a family member’s experience with mental illness. Based on these personal experiences, or on students’ personal experiences (eg, if a student shares that he/she has a certain disorder), facilitators might emphasize or expand on specific topics. It is possible that different classrooms participating in MHM might emphasize slightly different aspects of mental health, but the primary components of the curriculum, especially around mental health stigma reduction, are covered in all classrooms. The role of personal testimonies such as these in preventing stigma and impacting change is an important area for further study. It is notable that allowing for personal testimonies challenges the scientific study of a program because, while each can touch on similar overarching themes, personal testimonies are unique, and strict adherence to a protocol is sacrificed for the benefit of potentially powerful influence of sharing an individual’s real-world experience. Continued research is needed to examine the utility of personal testimonies and differences in treatment integrity and learning between classes.30 Limitations This study showed significant changes in knowledge and stigma from pretest to posttest, but the major limitation was the lack of a control group. Study 2 attempted to partially address this shortcoming via a naturalistic follow-up with seventh grade students who had or had not completed MHM in sixth grade. However, there was no random assignment and there may have been preexisting differences between the seventh graders that had participated in MHM and those that had not. Although there was no formal control group, the study provided initial support for the MHM program in accomplishing its stated goals, and demonstrated its acceptability in the classroom. Results suggested that the quantitative measures were not extremely sensitive to stigmatizing attitudes, and they also had low internal consistency with this sample. It is possible that students were less aware of their own stigmatizing attitudes. Future studies might Journal of School Health

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benefit from pilot testing measures of stigma to assess sensitivity and specificity. One limit to the generalization of this work is the potential for challenges that can arise when building school-community partnerships. The current program overcame these types of barriers in previous years, but other community groups trying to establish similar program might encounter commonly faced challenges such as resistance from school staff, concerns raised regarding parent reactions toward discussing the topic of mental illness at school, or difficulty recruiting community member volunteers.31 Conclusions In sum, this paper offers a new model integrating mental health with other academic curricula such as language arts. This study demonstrated initial acceptability of the model, although it was not clear how long the effects of the program sustain. In theory, this approach could be applied to many other combinations of mental health and academic material.

IMPLICATIONS FOR SCHOOL HEALTH Schools have the difficult task of passing on academic, social, and emotional knowledge to children.12 It can be challenging to find the time to include mental health education and stigma-reduction efforts, although it is important to do so to enhance students’ personal and academic outcomes. It may be ideal to integrate mental health education with academic core requirements. Findings suggest that mental health education and stigma reduction can feasibly be accomplished through a language arts curriculum. These preliminary results also indicate that the effects of MHM may need to be reinforced in order to maintain program gains. In the long term, it is important to reduce stigma toward individuals with mental health disorders in order to facilitate help-seeking behaviors, reduce shame among those with mental health problems, and ensure that these students remain academically and socially engaged.11 Human Subjects Approval Statement This protocol was approved by the Institutional Review Board at the University of California, Santa Barbara (protocol #15-0280) and by the participating school districts.

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