MEDICINE

REVIEW ARTICLE

Mental Health Problems in a School Setting

in Children and Adolescents
Gerd Schulte-Körne

he global prevalence of mental health problems

SUMMARY
Background: 10–20% of children and adolescents have a
T affecting children and adolescents is 10–20% (1).
According to the German Health Interview and Exam-
mental health problem of some type. Manifestations such ination Survey for Children and Adolescents (KiGGS),
as attention deficits, cognitive disturbances, lack of the prevalence of mental health problems in Germany
motivation, and negative mood all adversely affect
is stable and high, at 10% (2). These problems include
scholastic development. It is often unclear what factors
anxiety disorders, depression, conduct disorders, and
associated with school affect children’s mental develop-
hyperkinetic disorder. However, only about one-third
ment and what preventive measures and interventions at
of acutely and chronically mentally ill children and
school might be effective.
adolescents are receiving medical treatment. The low
Methods: This review is based on systematic reviews, uptake of healthcare services by mentally ill children
meta-analyses, and randomized and non-randomized con- and their families is a problem that is known inter-
trolled trials that were retrieved by a selective search in nationally (3). The reasons are manifold:
the PubMed, PsycInfo, and Google Scholar databases. ● Specialist healthcare is not sufficiently accessible
Results: The prevalence of hyperkinetic disorder is 1–6%. ● Fear of having a mental disorder and being
Its main manifestations are motor hyperactivity, an atten- stigmatized
tion deficit, and impulsive behavior. Learning disorders ● Uncertainty among children and parents about
such as dyscalculia and dyslexia affect 4–6% of children whether the behavioral or mood changes actually
each, while 4–5% of children and adolescents suffer from require treatment
depression, which is twice as prevalent in girls as in boys. ● Little or no awareness of available healthcare ser-
Mental health problems increase the risk of repeating a vices
grade, truancy, and dropping out of school. The risk of ● Language barriers or cultural obstacles in families
developing an internalizing or externalizing mental health from a migration background.
problem can be lessened by changes in the school One of the tasks of schools is to support children’s
environment and by the implementation of evidence- mentally healthy development while growing up (3), as
based school programs. school is where children and adolescents spend a large
Conclusion: Physicians, in collaboration with school social part of their time (4)—combined with social experi-
workers and psychologists, should help teachers recog- ences and challenges, learning demands and mental
nize and contend with mental health problems among the overload, and psychological stress. On the basis that
children and adolescents whom they teach, to enable the 11.1 million children and adolescents attended general
timely detection of stress factors at school and the initi- and vocational schools in Germany in 2014/15 and that
ation of the necessary measures and aids. In particular, the prevalence of mental health problems is 10% (5),
the school-entrance examination and screening for risk some 1.1 million of school-age children and adoles-
factors at school can make a positive contribution. cents have mental health problems requiring treatment.
Evidence-based preventive programs should be imple- To date in human medicine, it remains unknown
mented in schools, and beneficial changes of the school which school-related factors increase the risk for devel-
environment should be a further goal. oping mental health problems and which factors are
►Cite this as: protective and help children and adolescents grow up
Schulte-Körne G: Mental health problems in a school mentally healthy. The fundamental question that arises
setting in children and adolescents. Dtsch Arztebl Int is how medicine and pedagogy can work together more
2016; 113: 183–90. DOI: 10.3238/arztebl.2016.0183 closely in order to lower the risk of developing mental
health problems and to look after and provide treatment
for mentally ill children and adolescents from a holistic
perspective. In view of the high rates of mental health
problems, using preventive methods in school to reduce
the risk of developing mental illness or its recurrence is
Department of Child and Adolescent Psychiatry, Psychosomatics,
and Psychotherapy, Ludwig-Maximilians-Universität München: Prof. Dr. med. an interdisciplinary challenge that cannot be met by
Schulte-Körne using methods of pedagogy alone.

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90 183
MEDICINE

TABLE 1

School career, support measures and disciplinary measures, and the costs of measures in hyperkinetic disorder

School career of children Frequency and duration of school Frequency of disciplinary incidents Estimated cost of a school
with HKD (e2) measures in HKD (10) across grades involving children disciplinary act (9, 10)
with HKD (10)
Lower school leaving level 0 years: 47.6% 5.8% of children with HKD Additional annual costs of attending a
once a week different school ($ 4181)
(0.0% of controls)
Grade retention (e3) 1–3 years: 18% 29.6% of children with HKD For repeating a year ($ 222)
once a month
(2.5% of controls)
Suspension and expulsion from 4–6 years: 12.2% 45.5% of children with HKD For disciplinary measures ($ 604)
school once a quarter
(7.9% of controls)
Absenteeism/truancy >7 years 22.2% 19.1% of children with HKD Additional annual costs incurred to the
less than once a quarter school system in the USA by HKD
(89.6% of controls) $ 13.4 billion
School drop-out £ 4155,03 per year school-related
costs (compared with total costs
from healthcare expenditure of
£ 5492.63) incur 75% of the total cost
of HKD (9)

HKD, hyperkinetic disorder

TABLE 2

School-based intervention in children with hyperkinetic disorder*

Symptom Informant Number of studies/sample Cohen’s d 95% confidence interval p value

(total)
Inattention Parent 7 (384) 0.13 [–0.14; 0.40] 0.33
Teacher 12 (548) 0.60 [0.14; 1.06] <0.001
Child 7 (292) 0.44 [0.18; 0.70] 0.32
Hyperactivity/impulsivity Parent 7 (285) 0.16 [–0.07; 0.39] 0
Teacher 16 (700) 0.23 [–0.03; 0.49] 0.08
Child 8 (411) 0.33 [0.13; 0.53] 0.001
HKD symptoms combined Parent 3 (110) 0.14 [–0.46; 0.75] 0.65
Teacher 6 (218) 0.16 [–0.22; 0.54] 0.42

* Effect sizes of randomized controlled studies on measures of hyperkinetic disorder (14)

HKD, hyperkinetic disorder

This review article aims to explain factors in setting. Our review is based on—where available—
the school setting that affect mental health and the systematic reviews, meta-analyses, randomized
importance of mental health problems for students’ controlled trials, and controlled trials. We searched
school development. On the basis of a selective the databases PubMed, PsycINFO, and Google
review we will review examples of empirical findings Scholar for the time period 1990–2015. The search
in common mental health problems (hyperkinetic terms covered the specialisms of mental health and
disorder, specific developmental disorders of mental illness (depression, dyslexia, dyscalculia,
scholastic skills, depression) that show the association disorder of arithmetic skills, hyperkinetic disorder,
of school-related factors and mental health problems. and attention deficit-hyperactivity disorder), school-
Furthermore, we will explain the options of diagnostic related factors, prevention, support, treatment, and
evaluation, prevention, and intervention in the school children and adolescents.

184 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90
 MEDICINE

FIGURE Developmental
model of depres-
sive symptoms in
academic failure
Discrepancy
between school performance
requirement and ability

Depressive False cognition and attribution:

syptoms, “I fail because I learn too little
truancy, suicidal thoughts /don’t work hard enough”

Amplification of the false cognition

Increasing failure to perform,
by negative feedback:
with the result of having to repeat
“You’re just refusing to/not trying
the year
hard enough…”

Slow working style,

low willingness to exert oneself,
low efficiency

Hyperkinetic disorder significant performance impairments for reading

Hyperkinetic disorder (HKD) (6) is one of the most (d=0.73), arithmetical skills (d=0.67), and spelling
common mental health problems, with a prevalence of (d=0.55). In view of the high rate of school dropouts
1–6% (7, 8). The key symptoms include pronounced (10–12%) and the increased risk of such youngsters for
hyperactivity, attention deficit disorder, and increased further mental health problems—for example, conduct
impulsivity. Children with HKD are easily distracted, disorders in combination with delinquent behaviors
jump up in class, shout out into the classroom, are able (12)—it is necessary for children with HKD to receive
to focus their attention for a short timespan only, miss treatment from a medical specialist. The complexity of
important information in class, disrupt their fellow the disorder with the most common comorbidities will
students, drop class materials, or topple over with their need to be taken into account for the diagnostic evalu-
chairs. The basic school requirement of being able to ation and treatment.
adhere to structured behavior over several hours and to The school report or the teacher’s diagnostic
focus their attention is asking too much from children assessment should have a special role in the medical
with HKD. Teachers experience and describe hyper- specialist’s diagnostic evaluation of HKD. The Inter-
kinetic behavior as disruptive and stressful. Children national Classification of Diseases (ICD-10) requires
with HKD suffer greatly when they notice that they are for the purposes of a diagnosis that the symptoms occur
“different” and not able to control their behavior. They in more than one situation—for example, at home and
are teased by their fellow students and get into rows. If at school. Thus, the teacher’s observations are a vital
the symptoms persist, such children often become so- ingredient in the diagnostic process. Qualitative
cially isolated; their fellow students do not invite them (descriptions of a child’s attention, motor restlessness,
to play, and adults punish them for their behavior. In the impulsivity, performance ability, and social compe-
school entry examination, parents and children should tence) and quantitative standardized behavior and ob-
be given advice on the diagnostic and therapeutic servation sheets at school—such as the Child Behavior
options if there are indications of HKD. Checklist (CBCL)—are used (13).
The school career of children with HKD is notably Many teachers are uncertain about how to deal with
impaired (9) (Table 1). The support and disciplinary children with HKD. Because of their hyperactive
measures incur substantial costs (9, 10), which in the behavior during lessons and breaks, children with HKD
school setting are clearly higher than in the healthcare require treatment that includes the school. A recently
sector. A meta-analysis (11) with a focus on the school published systematic review of 54 studies (14) shows
success of children and adolescents with HKD found the methods that can be used at school and that are

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90 185
MEDICINE

TABLE 3

School climate: School-related factors that influence students’ mental health development

Factor Examples Importance for mental health development

Safety at school Adherence to social rules, Poor safety increases the risk for experiencing
(social-emotional and physical safety [e4] owing to Control of availability of weapons and drugs in violence, violence against fellow students (bullying/
standards and rules) schools, mobbing), disciplinary measures taken against
Teaching and monitoring behavioral rules and students, absenteeism/truancy, and less success at
standards, school.
Managing conflict and strengthening students’
problem solving skills
Connectedness to school (29, e5) I am happy to be at this school! Low school connectedness increases the risk (e5)
I think I am a part of this school! for depressive symptoms, anxiety, violence, and
I feel safe at this school! bullying/mobbing whereas high school connected-
I feel attached to my fellow students! ness reduces that risk. A close social bond with
The teachers treat me with fairness! fellow students further reduces the risk of devel-
oping mental health problems.
High school connectedness supports students’
individual successful learning.
Relationship/interaction between teacher and How strongly do you feel that your teacher takes If a teacher cares about a student this correlates
student care of you/worries about you? with fewer symptoms of depression in students
How often during this school year have you had (29). A conflicted relationship between teacher and
trouble/conflict with your teacher? student increases the risk for abnormal behaviors
and learning problems.
A teacher’s emotionally supportive, committed, and
responsible attitude towards their student results in
less disruptive behavior and fewer internalizing dis-
orders (e6).
Learning environment at school (e7) Collaborative group work with a common aim, Great willingness to cooperate and achieving aims
Feelings of belonging and attachment are shaped together improve the climate in the classroom and
by mutual trust in the group of students yield greater learning success.

effective. The studies investigated the effectiveness of orders (DSM-5) (16). These learning disorders occur at
school-based interventions for the key symptoms of a rate of 4–6%, respectively. In specialist medical
HKD, social skills, children’s self-awareness, and practice, children often present with severe headache or
teachers’ perceptions of school success. Overall the abdominal pain, for which no physical correlate is
effects are small (Table 2). The analysis of whether identified during the subsequent examination. In a pro-
different intervention methods have a differential effect nounced developmental disorder, affected students
did not yield a significant result. This includes behavior often avoid attending school, with the result that
modification by means of reward/punishment with or several weeks of absence may accrue. A meta-analysis
without amplification, cognitive-behavioral self (17) focusing on the rates of anxiety in children and
instruction with problem-solving strategies, social adolescents with learning disorders (reading and/or
skills training, and encouraging children to recognize spelling disorder, disorder of arithmetic skills) showed
and control their own feelings. During childhood, that anxiety was significantly more common (d=0.61;
social competence training was found to be effective; in P<0.001), independently of sex or grade. Furthermore,
adolescence, strategies for structuring work and learn- the meta-analysis showed higher rates of comorbidities
ing were found to deliver the best results. Methods for with depressive disorders, HKD, conduct disorders,
the direct modification of behaviors by the teacher, by and emotional disorders. The disease course is charac-
using a daily report card, on which the designated terized as follows:
changes were described, were effective on the whole ● A stubborn persistence of the key symptoms
(15). ● Notably worse school exit examination results
than might have been expected on the basis of a
Specific developmental disorders of student’s cognitive performance ability
scholastic skills ● A need to repeat school years
The ICD-10 and the Diagnostic and Statistical Manual ● Frequent dropping out of school
of Mental Disorders (DSM-5) classify substantial prob- ● Changing schools
lems in learning to read, arithmetic skills, and spelling ● Psychological stress
under the specific developmental disorders of ● A higher risk for depressive disorders and anxiety
scholastic skills (ICD-10) and specific learning dis- disorders (18).

186 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90
 MEDICINE

An integrated medical-pedagogical approach for BOX

treating such young people is therefore urgently
needed. If a comorbid psychological disorder is present
the therapy should consider pedagogical support and Evidence and recommendation for school-based
psychosocial integration, in addition to the relevant prevention and intervention*
child and adolescent psychiatric and psychotherapeutic
treatment guidelines (19). ● Topics
In instructing students with learning disorders it is of Recommendations for changes to a school’s climate (attitudes, convictions, and
great importance to identify anxieties, low mood, or values); strengthening of social and emotional competencies combined with
negative thoughts in students, and to initiate support positive feedback if students achieve their learning objectives, universal and
measures, in a timely manner. Identifying any potential selective prevention in order to reduce the risk of developing internalizing dis-
school-related links to the mental health problems is orders (anxiety, depression) and externalizing disorders (conduct disorders,
greatly important (20). The school-based support sys- violence, bullying/mobbing).
tems include—in addition to teachers—school social
workers and school psychologists. Medical specialists’
central task is to coordinate the different support ● Advanced and extended training
systems for every child and to supervise them. This Specific advanced training in prevention and intervention measures is required,
includes giving advice on the symptoms and on how to to raise awareness of mental health and illness in children and adolescents. Such
deal with mental health problems at school. training should be delivered by qualified experts—for example, school psycholo-
gists, school social workers, and teachers. Cooperation and collaboration with
Depressive disorders health professionals is recommended.
Worldwide, the prevalence of depressive disorders in
childhood and adolescence is 4–5% (21). Girls are
affected twice as often as boys (22). The main symptoms ● Methods
include difficulties in concentrating, lack of self worth, Interventions based on the methods of cognitive-behavioral therapy; interactive,
low mood, joylessness, a loss of activities and interests, class-based, and group-based methods, measures directed at target groups;
social withdrawal, giving up leisure activities, changes in strengthening of individual resources, exclusively information-based methods not
appetite, sleep disruption, and—in moderate to severe recommended.
forms—suicidal thoughts and acts. Depression in
adolescence is one of the greatest risk factors for
suicide in this age group (23). Depression affects the
● Networking
psychosocial and school-related development of Close cooperation with parents, authorities, and partners from the social, educa-
adolescents in a major way. They increase the risk of tional, and healthcare sectors is recommended.
having to repeat a year, dropping out of school, and being
placed in special education (24, 25). The reasons may be ● Implementation
the neurocognitive impairments that often accompany
depression—such as reduced attention, an impaired Programs should have a clear structure, clearly formulated objectives, verifiable
ability to organize one’s work, and impaired memory benchmarks to assess whether they are being conducted at a high quality level,
function (26). These reinforce the changed self- and achieving objectives, clear instructions, quality assurance, and an implemen-
perception regarding one’s own capability that tation plan; monitoring of implementation and achieving of objectives is strongly
accompanies the depression (Figure). Affected students recommended.
experience their inability to perform as a personal failure,
and having to repeat a year is interpreted as punishment, ● Temporal aspects
which triggers additional stress. Because of their Measures should start early and should be initiated in primary school children;
depression, such students cannot compensate for the Interventions should be undertaken for the long term (longer than a year);
learning impairment. This cycle is amplified by the booster sessions are recommended to make the effects of the intervention
fact that adolescents are less likely to seek help (27); permanent or even strengthen them.
consequently, support and relief regarding their school-
related demands mostly comes too late for those affected.
School-based factors that moderate the mutual * For the purposes of promoting mental health and reducing the risk of developing mental health
influence between depressive disorder and school problems (according to 39).
career include the school climate and a student’s school
connectedness (Table 3). If both factors are weakly
expressed then the risk of developing a depressive
disorder is increased (12, 28). In a representative longi-
tudinal study from the US, which included 11 852
adolescents, significant associations were seen between
a poor attachment to the school (r=-0.33), a poor attach- Depressive disorders in childhood and adolescence
ment to teachers (r=-0.20), and more pronounced should be treated according to the current S3 guidelines
depressive symptoms (29). (30). Evidence based treatment methods include

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90 187
MEDICINE

psychotherapy and psychopharmacotherapy; both are systematic reviews (Box). Global school concepts that
recommended. In a mild depressive episode, outpatient includes the changes in school life—including the
treatment is the preferred option. If the patient is atmosphere/climate, architectural aspects, extracurricu-
managing in everyday life, supportive counseling with lar support systems, and acceptance in the city or
regular controls may be offered. Cooperation and col- municipality—have, in spite of their increasing popu-
laboration between medical specialists and schools/ larity, shown hardly any effects or none at all (39, e8).
teachers can contribute substantially to achieving a Possible reasons may be unclear and unfocused
supportive and stress-reducing attitude of teacher to objectives, an absence of clear guidelines for imple-
student, by means of psychoeducation and advice on mentation, a lack of instruction manuals, insufficient
how to handle suicidal ideation from/in students. instruction and training of those in positions of
responsibility for undertaking the program, and lacking
Screening in schools implementation and quality controls (40). The effect
The diagnostic quality of screening methods for psy- sizes of the school-based prevention and intervention
chological stress—for example, emotional problems, programs in terms of strengthening mental health,
attention deficit disorders and hyperactivity, problems reducing psychological pressures/stress, reducing
in dealing with peers, and abnormal behaviors—has bullying/mobbing, and promoting prosocial behavior
been repeatedly studied in schools (31–33). The are low to moderate. Universal programs to reduce
strengths and difficulties questionnaire (SDQ) is a violence and improve conflict resolution in the context
popular screening instrument (34–36) that is used in the of bullying/mobbing had a very low effect size. This is
previously mentioned settings of teachers, parents, and notably higher when the prevention and intervention
professionals in the healthcare sector (37). In an epi- method target students with an increased risk for men-
demiological sample (37) of 7984 students aged 5–15 tal health problems, such as anxiety or depression, or
years, 70% of students with conduct disorders, hyper- target groups of students who display violent
activity, depressive symptoms, and anxiety disorders behaviors. It should be emphasized that only a
were correctly diagnosed by using the SDQ, compared sustained implementation of programs with quality
with the ICD-10 diagnoses. The specificity for mental assurance, qualified advanced and extended training for
health problems was 94.6% (95% CI [94.1%; 95.1%]), those conducting the programs, and an improvement of
the sensitivity was 63.3% [59.7%; 66.9%]. Comparing a school’s atmosphere/climate will lead to sustained
the teacher’s rating with the parental one showed that success in prevention and intervention in schools. A
teachers identified HKD more often and parents were summarized overview of German-language programs
better at identifying anxiety disorders and depression. for preventing mental health problems and behavioral
The best screening result was reached by combining the problems in children and adolescents was presented by
parents’ and teachers’ ratings. In specialist medical Röhrle (e1).
care, questionnaires are time-saving instruments for
assessing—in a valid and reliable manner—in at-risk Challenges and solutions
children or adolescents with unexplained symptoms In view of the high prevalence rates of mental health
whether they are experiencing the symptoms of a de- problems in children and adolescents and their impor-
pressive disorder or HKD (31, 38). For the school entry tance for young people’s scholastic development, and
exam (32), screening instruments could be useful in in view of the low uptake of the relevant services pro-
identifying early exposures that may trigger mental vided by the healthcare system, the risks of mental
health problems. For the examination between the ages health problems should be identified at an early stage
of 7 and 8 years, it would be necessary to extend the and reduced by means of preventive measures.
screening areas by including emotional stress and Children, adolescents, and their families should be in-
symptoms of depression. In this way, early stress fac- formed about the options available in the healthcare
tors for the child—which occur in school in some system, and access to such services should be
cases—can be identified and the required help and improved. The school as a central institution in the
treatment can be initiated in a timely manner. The use education system, with its support systems in the
of questionnaires in schools should remain the preserve psychosocial area (school social workers, school psy-
of school psychologists or school doctors, who can rec- chologists) can take a central role in this, in cooperation
ommend and initiate the necessary measures depending with services provided by the healthcare system (public
on the result. health services; general practitioners; outpatient, part-
inpatient, and inpatient child and adolescent psychiatric
School-based prevention and intervention and psychosomatic services, as well as psychothera-
Under the title “Mental Health Program or Promotion,” peutic and medical services for children and adoles-
prevention and intervention measures have been con- cents) and by youth welfare services, by implementing
ducted in schools worldwide, at different levels, with the following measures:
the entire school, at class level, or with risk groups, in ● Screenings
order to strengthen children and adolescents’ mental ● Preventive measures
health in general and in the school setting in particular ● Changes in class and school climate
(39). Weare and Nind (39) summarize the results of 52 ● Advanced training for teachers.

188 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90
 MEDICINE

7. Polanczyk G, Willcutt E, Salum G, Kieling C, Rohde L: ADHD preva-

KEY MESSAGES
lence estimates across three decades: an updated systematic re-
view and meta-regression analysis. Int J Epidemiol 2014; 1–9.
● Stress factors at school—such as unempathetic and un-
supportive teacher-student relationships and a poor 8. Schuber I, Köster I, Lehmkuhl G: The changing prevalence of
attention-deficit/hyperactivity disorder and methylphenidate
classroom or school climate—increase the risk for
prescriptions: a study of data from a random sample of insurees of
children and adolescents of developing mental health the AOK Health Insurance Company in the German State of Hesse,
problems. 2000–2007. Dtsch Arztebl Int 2010; 107: 615–21.
● Mental health problems in young persons—for example, 9. Telford C, Green C, Logan S, Langley K, Thapar A, Ford T: Estimating
hyperkinetic disorder, depressive episodes, and specific the costs of ongoing care for adolescents with attention-deficit hy-
peractivity disorder. Soc Psychiatry Psychiatr Epidemiol 2013; 48:
developmental disorders of scholastic skills (specific
337–44.
reading and/or spelling disorder, specific disorder of
arithmetic skills)—impair children’s and adolescents’ 10. Robb J, Sibley M, Pelham W, et al.: The estimated annual cost of
ADHD to the US education system. School Ment Health 2011; 3:
performance and notably increase the risk for absentee- 169–77.
ism/truancy from and dropping out of school.
11. Frazier T, Youngstrom E, Glutting J, Watkins M: ADHD and achieve-
● By cooperating with schools and by seeking support ment: meta-analysis of the child, adolescent, and adult literatures
from and collaborating with school social workers and and a concomitant study with college students. J Learn Disabil
school psychologists, doctors can help teachers to 2007; 40: 49–65.
identify stress factors in the school setting and reduce 12. Kuperminc G, Leadbetter B, Blatt S: School social climate and indi-
risks for children and adolescents in that setting. vidual differences in vulnerability to psychopathology among middle
school students. J School Psychol 2001; 39: 141–59.
● School-based prevention programs have low to mod- 13. Döpfner M, Plück J, Kinnen C: CBCL/6–18R, TRF/6–18R,
erate effect sizes in reducing young persons’ risk for YSR/11–18R. Deutsche Schulalter-Formen der Child Behavior
developing mental health problems. Checklist von Thomas M. Achenbach. Elternfragebogen über das
Verhalten von Kindern und Jugendlichen (CBCL/6–18R), Lehrer-
● Mental health programs in school have so far shown fragebogen über das Verhalten von Kindern und Jugendlichen
very little effect or none at all. Qualified advanced (TRF/6–18R), Fragebogen für Jugendliche (YSR/11–18R).
training of teachers at all types of schools on the sub- Göttingen: Hogrefe 2014.
ject of mental health problems and disorders in children 14. Richardson M, Moore D, Gwernan-Jones R, et al.: Non-
and adolescents with mental health problems is recom- pharmacological interventions for attention-deficit/hyperactivity
mended. disorder (ADHD) delivered in school settings: systematic reviews of
quantitative and qualitative research. Health Technol Assess 2015;
19: 1–470.
15. Fabiano, G, Vujnovic R, Pelham W, et al.: Enhancing the effective-
ness of special education programming for children with ADHD
using a daily report card. School Psychol Rev 2010; 39: 219–39.
Conflict of interest statement 16. Schulte-Körne G: Spezifische Lernstörungen. Z Kinder-
The author declares that no conflict of interest exists. Jugendpsychiatr Psychother 2014; 42: 369–74.
17. Nelson J, Harwood H: Learning disabilities and anxiety: a meta-
Manuscript received on 12 August 2015, revised version accepted on analysis. J Learn Disabil 2011; 44: 3–17.
2 December 2015.
18. Wilson A, Armstrong C, Furrie A, Walcot E: The mental health of
Canadians with self-reported learning disabilities. J Learn Disabil
Translated from the original German by Birte Twisselmann, PhD. 2009; 42: 24–40.
19. Galuschka K, Schulte-Körne G: Clinical practice guideline: Diag-
REFERENCES nosing and treating reading and spelling disorders in children an
adolescents. Dtsch Arztebl Int 2016; in press.
1. Kieling C, Baker-Henningham H, Belfer M, et al.: Child and adoles-
cent mental health worldwide: evidence for action. Lancet 2011; 20. Schulte-Körne G: The prevention, diagnosis, and treatment of dys-
378: 1515–25. lexia. Dtsch Arztebl Int 2010; 107: 718–26.
2. Ravens-Sieberer U, Otto C, Kriston L, et al.: The longitudinal BELLA 21. Costello E, Egger H, Angold A: 10-year research update review: the
study: design, methods and first results on the course of mental epidemiology of child and adolescent psychiatric disorders: I. Meth-
health problems. Eur Child Adolesc Psychiatry 2015; 24: 651–63. ods and public health burden. J Am Acad Child Adolesc Psychiatry
3. Green J, McLaughlin K, Alegría M: School mental health resources 2005; 44: 972–86.
and adolescent mental health service use. J Am Acad Child
Psychiatry 2013; 52: 501–10. 22. Hyde J, Mezulis A, Abramson L: The ABCs of depression: Integrating
affective, biological, and cognitive models to explain the emergence
4. Rutter M: Fifteen thousand hours: secondary schools and their of the gender difference in depression. Psychol Rev 2008; 115:
effects on children. Cambridge, MA USA: Harvard University Press 291–313.
1982.
5. Statistisches Bundesamt: Zahl der Schüler im Schuljahr 2014/2015 23. Windfuhr K, While D, Hunt I, et al.: National confidential inquiry into
um 0,7 % gesunken. www.destatis.de/DE/PresseService/Presse/ suicide and homicide by people with mental illness. Suicide in ju-
Pressemitteilungen/2015/03/PD15_093_211pdf (last accessed on veniles and adolescents in the United Kingdom. J Child Psychol
3 November 2015). Psychiat 2008; 49: 1155–65.
6. World Health Organization: The ICD-10 classification of mental and 24. Quiroga C, Janosz M, Lyons J, Morin A: Grade retention and sev-
behavioral disorders: clinical discriptions and diagnostic guidelines: enth-grade depression symptoms in the course of school dropout
World Health Organization 1992. among high-risk adolescents. Psychology 2012; 3: 749–55.

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90 189
MEDICINE

25. Robles-Piña A, Defrance E, Cox D: Self-concept, early childhood de- 36. Woerner W, Hasselhorn M, Banaschewski T, Rothenberger A: Vali-
pression and school retention as predictors of adolescent depres- dation of the parent and teacher SDQ in a clinical sample. Eur Child
sion in urban hispanic adolescents. School Psychol Int 2008; 29: Adolesc Psychiatry 2004; 13 (Suppl 2): 11–16.
426–41. 37. Goodman R, Ford T, Simmons H, Gatward R, Meltzer H: Using the
26. Owens M, Stevenson J, Hadwin J, Norgate R: Anxiety and depres- Strengths and Difficulties Questionnaire (SDQ) to screen for child
sion in academic performance: an exploration of the mediating fac- psychiatric disorders in a community sample. Br J Psychiat 2000;
tors of worry and working memory. School Psychol Int 2012; 33, 177: 534–9.
433–49. 38. Pietsch K, Allgaier AK, Frühe B, et al.: Screening for depression in
27. Allgaier AK, Schiller Y, Schulte-Körne G: Wissens- und Einstellungs- adolescent paediatric patients: validity of the new Depression
änderungen zu Depression im Jugendalter: Entwicklung und Evalu- Screener for Teenagers (DesTeen). J Affect Disord 2011; 133:
ation einer Aufklärungsbroschüre. Kindheit und Entwicklung 2011; 69–75.
20, 247–55. 39. Weare K, Nind M: Mental health promotion and problem prevention
28. Ross A, Shochet I, Bellair R: The role of social skills and school con- in schools: what does the evidence say? Health Prom Int 2011; 26:
nectedness in preadolescent depressive symptoms. J Clin Child S1; i29–i69.
Adolesc Psychol 2010; 39: 269–75. Durlak J, Weissberg R, Dymnicki A, Taylor R, Schellinger K: The im-
29. Joyce H, Early T: The impact of school connectedness and teacher pact of enhancing students’ social and emotional learning: a meta-
support on depressive symptoms in adolescents: a multilevel analy- analysis of school-based universal interventions. Child Dev 2011;
sis. Child Youth Serv 2014; 39: 101–7. 82: 474–501.
30. Dolle K, Schulte-Körne G: The treatment of depressive disorders in
children and adolescents. Dtsch Arztebl Int 2013; 110: 854–60. Corresponding author
Prof. Dr. med. Gerd Schulte-Körne
31. Frühe B, Allgaier AK, Pietsch K, et al.: Children’s depression Klinik und Poliklinik für Kinder- und Jugendpsychiatrie,
screener (ChilD-S): development and validation of a depression Psychotherapie und Psychosomatik
screening instrument for children in pediatric care. Child Psychiat Ludwig-Maximilians-Universität
Hum Dev 2012; 43: 137–51. Nußbaumstr. 5a
80336 München, Germany
32. Essex, M, Kraemer H, Slattery M, et al.: Screening for childhood [email protected]
mental health problems: outcomes and early identification. J Child
Psychol Psychiat 2009; 50: 562–70.
33. Pietsch K, Allgaier AK, Frühe B, et al.: Screening for depression in
adolescent paediatric patients: validity of the new Depression
Screener for Teenagers (DesTeen). J Affect Disord 2011; 133:
69–75
34. Goodman A, Goodman R: Strengths and difficulties questionnaire as
a dimensional measure of child mental health. J Am Acad Child
Adolesc Psychiat 2009; 48: 400–3.
35. Woerner W, Becker A, Rothenberger A: Normative data and scale
properties of the German parent SDQ. Eur Child Adolesc Psychiatry
2004; 13 (Suppl 2): 3–10.
@ Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref1116

190 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90
 MEDICINE

Supplementary material to:

Mental Health Problems in a School Setting in Children and Adolescents
by Gerd Schulte-Körne
Dtsch Arztebl Int 2016; 113: 183–90. DOI: 10.3238/arztebl.2016.0183

eReferences
e1. Röhrle B: Prävention und Gesundheitsförderung, Band III für
Kinder und Jugendliche. Tübingen: DGVT-Verlag 2007.
e2. Kent K, Pelham W, Molina B, et al.: The academic experience of
male high school students with ADHD J Abnorm Child Psychol
2011; 39: 451–62.
e3. Langberg J, Molina B, Arnold L, et al.: Patterns and predictors of
adolescent academic achievement and performance in a sample
of children with attention-deficit/hyperactivity disorder. J Clin
Child Adolesc Psychol 2011; 40: 519–31.
e4. Thapa A, Cohen J, Guffey S, Higgins-D’Alessandro A: A review of
school climate research. Rev Educ Res 2013; 83: 357–85.
e5. Bond L, Butler H, Thomas L, et al.: Social and school connected-
ness in early secondary school as predictors of late teenage sub-
stance use, mental health, and academic outcomes. J Adolesc
Health 2007; 40: 357.
e6. Way N, Reddy R, Rhodes J: Students’ perceptions of school
climate during the middle school years: associations with trajec-
tories of psychological and behavioral adjustment. Am J Comm
Psychol 2007; 40: 194–213.
e7. Stewart E: School structural characteristics, student effort, peer
associations, and parental involvement: the influence of school-
and individual-level factors on academic achievement. Educ
Urban Soc 2008; 40: 179–204.
e8. Kidger J, Araya R, Donovan J, Gunnell D: The effect of the school
environment on the emotional health of adolescents: a systematic
review. Pediatrics 2012; 129: 925–949.

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2016; 113: 183–90 | Supplementary material I