The mental health of children and adolescents is a significant concern in Australia and around the world. Current estimates are that approximately one in four to five young people will experience a mental health disorder across their lifetime.1 Moreover, recent data from the Australian Child and Adolescent Survey of Mental Health and Wellbeing found that one in seven children aged 4–17 years had experienced a mental health disorder in the previous 12 months.2 Perhaps the finding of greatest concern from this report was that almost half of young people with mental health disorders had not used services for emotional and behavioural problems in the previous 12 months.2
Parents will often consult with their general practitioner (GP) as a first point of contact for concerns about their child’s emotional or behavioural wellbeing and, consequently, GPs have a pivotal role to play in the management of mental health issues in children and adolescents.3 Although a GP will sometimes have sole responsibility for the management of a young person’s emotional and behavioural disorders, best practice usually requires a collaborative approach.4,5 Such collaboration includes working with psychiatrists, paediatricians and psychologists. Given that children in Australia spend more than 10,000 hours of their time at school during their primary and lower secondary years alone,6 it makes sense that any mental health collaboration includes the young person’s school. Experiences at school influence a young person’s mental health, and a young person’s mental health influences their school experience.
This paper addresses the largely ignored benefits of GPs collaborating with school psychologists to bring about good health outcomes for children and adolescents.
Who are school psychologists?
It is important to make a distinction between school counsellors and school psychologists – these terms are not synonymous or interchangeable. In Australia, defining the difference becomes complex as different titles are common, not only across different states and territories of Australia but also across different education sectors (state, Catholic and independent). Generally speaking, ‘school counsellor’ is a generic term that refers to those who provide counselling in schools. School counsellors often have a background as teachers, but can be psychologists, social workers, chaplains or generic counsellors. While it is true that some school psychologists call themselves school counsellors, it cannot be assumed that all school counsellors are psychologists.
The title of psychologist in Australia is reserved for those legally registered with the Psychology Board of Australia, which operates under the Australian Health Practitioner Regulation Agency (AHPRA). Government registration provides the GP with confidence to know that when they collaborate with a school psychologist, they are working with a professional who has a mandatory six years training prior to registration, is required to adhere to the Australian Psychological Society’s Code of Ethics (including strict regulations about confidentiality), engages in regular continuing professional development (CPD), and must be available for a formal audit process of their CPD and professional practice. By contrast, there is no regulation or minimum standards required for the use of the term ‘counsellor’. An implication of this is that GPs may need to ask questions to understand the level of mental health training that a counsellor in a school has.
The focus of this paper is on the specific collaboration between GPs with psychologists, rather than the more generic group of school counsellors, for whom it is more difficult to make general comments. Most Australian schools now have, at least part-time, either a psychologist or counsellor on staff. A GP can clarify the type and extent of psychological support available in their local schools (government and non-government) by a phone call to the schools.
School psychologists, GPs and information sharing
Sharing of information between GPs and school psychologists is bound by all the same regulations and restrictions as that of a GP with any other health professional. Importantly, the GP can trust that the school psychologist, as an AHPRA-registered health professional, will be guided by strict ethical guidelines about consent and confidentiality in the sharing of information. A school psychologist will only speak to a GP with the direct consent of the young person (or the parents, in the case of a minor). Similarly, a GP can trust that any information shared with a school psychologist will not be made public across the entire school. Rather, the GP, psychologist and patient (or their parents if a minor) can work together to determine what and how information is disseminated more broadly within the school system. For so-called ‘mature minors’, there will be times when a school psychologist and a GP could consult without the need for parental involvement. For example, a school psychologist may encourage an older student to seek advice from a GP for situations they are reluctant to discuss with their parents, such as having contracted a sexually transmitted infection. By no means does this negate the vital role that parents have in the lives of their children, and the responsible GP and school psychologist will be seeking to involve a young person’s parents whenever possible.
What can a school psychologist offer a GP?
Given that GPs will already have a knowledge of local psychologists and mental health providers in their community, it is important to differentiate between what a school psychologist can contribute to patient care as opposed to a community‑based psychologist. In fact, in some rural and regional areas, there may not be a psychologist practising in the area, and so a school psychologist who visits the school may become a valuable resource for the GP.
As a general rule, a local community/clinic-based mental health service will continue to be a GPs first port of call for any general mental health assessment and intervention in a young person, or when there are significant family difficulties. There are, however, three key factors that may become apparent during a GP’s assessment that would alert them to the possibility of collaborating with the school psychologist (Box 1). The first is any emotional health difficulty that may influence the student’s learning. For example, difficulties with mood or anxiety can dramatically affect a young person’s concentration, memory and learning. The GP can alert the school psychologist, who can then help the student navigate their academic challenges in light of their emotional health difficulties.
The second factor involves any difficulty experienced by a young person, whether in the home environment or school setting, that may pose a threat to the young person or other students. This includes patients who are self-harming or suicidal. The school psychologist can then work with the patient and the family to ensure that a safety plan is in place at school. Risk may also come from a patient who is violent, or where there is concern of child abduction.
The third concern relates to any other information from the GP’s assessment that may have school-related implications. This would include any medical condition that may influence a young person’s social and emotional wellbeing at school. Examples may involve conditions that result in the young person requiring prolonged absences from school, such as post-viral syndrome (typically after glandular fever), type 1 diabetes, major surgery or, less commonly, a diagnosis of cancer. These conditions usually require the student to take time away from school to attend multiple appointments with doctors and allied health professionals. Furthermore, the school psychologist would benefit from any specific information that the GP may have about peer relationship difficulties at school or psychosomatic presentations that hinder school attendance.
Box 1. Flags for a GP to consider contacting a school psychologist
Flag 1 – Emotional health problems: A diagnosis of anxiety or depression will impair a student’s ability to apply themselves to school work
Flag 2 – Threat to self or others: A school psychologist can ensure a safety plan is in place for students who are a threat to themselves or others in the school community
Flag 3 – Medical problems that affect schooling: Some medical problems will affect a young person’s academic performance, as well as their social and emotional wellbeing
What can a GP offer a school psychologist?
Just as a GP may seek to involve a school psychologist, there are many situations when a school psychologist may seek to collaborate with a GP about a student they are seeing. This will usually be done through the student’s family, but at times, older students may consult a GP independently of their parents. Such consultations will usually fall into one of two categories. The first relates to medical services that the GP can provide directly. For example, a school psychologist may direct a student to see a GP to exclude physical explanations for lethargy (eg iron deficiency, viruses including glandular fever, chronic rhinitis, poor nutrition or poor sleep habits) before making a diagnosis of depression. Similarly, a school psychologist may enter a collaborative relationship whereby the GP prescribes medication for a student who is depressed while the psychologist provides talking-based therapies. Secondly, a school psychologist and GP may work together to ensure that a suitable referral is made for a student who needs specialist assessment and intervention. Examples include students with attention deficit hyperactivity disorder or an autism spectrum disorder, who would benefit from referral to a paediatrician for specialist assessment and treatment, or a student with a complex psychiatric presentation who needs a referral to a child and adolescent psychiatrist. In this situation, the GP can then take on the role of case manager, ensuring good communication between health professionals, including the school psychologist.
This paper argues for a strengthening of the relationship between GPs and school psychologists. An important first step is for the GP to ascertain whether the school counsellor is a registered psychologist or some other form of counsellor. This can be done through a check of the AHPRA ‘Register of Practitioners’ website
(www.ahpra.gov.au/registration/registers-of-practitioners.aspx). By promoting collaboration between GPs and school psychologists we are not looking to de‑value the important relationship between GPs and social workers or other counsellors in schools but, rather, seeking to educate GPs about the vital assurances that come from working with psychologists in schools.
- Counsellors in schools can come from a wide selection of professionals, including teachers, social workers and chaplains.
- Psychologists in schools are a distinct group of professionals who are registered with the Psychology Board of Australia and AHPRA.
- Stronger collaboration between GPs and school psychologists could assist in improving the health outcomes for children and adolescents.
John R Burns BSW, MLitt, MPsych, MAPS, Clinical Psychologist, SHORE School, North Sydney; Honorary Clinical Supervisor, Department of Psychology, Macquarie University, NSW. firstname.lastname@example.org
Kevin Wong, MBBS, FRACGP. General Practitioner, West Lindfield, NSW; Chair of GP Network Northside, NSW.
Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.