School-based research related to mental health

Mental health issues are highly prevalent - one in five persons will experience mental health issues in their lifetime with most cases likely to emerge between the ages of 16 and 24 (Andrews et al., 2014). Approximately 241 million young people (13.4%) worldwide are affected by some form of mental health issue (Owens et al., 2012). Variety of disorders are observed among students, including anxiety disorders (6.5%), conduct disorders (5.7%), ADHD (3.4%), and depressive disorders (2.6%) (Owens et al., 2012). Similarly, a recently published systematic review and meta-analysis reported 15.5% prevalence of mental disorders among children and adolescents aged 5 to 18 years in Europe. Consistent with previous findings, anxiety disorders and ADHD were identified as the most prevalent conditions (Radanović et al., 2022). Furthermore, it is shown that the prevalence of mental disorders among young people aged 10 to 24 years in European countries is rising (Cain, 2015). Schools are increasingly regarded as critical community settings for the identification and provision of mental health support among youth, frequently serving as the primary access point for mental health screening and intervention. Evidence from a cross-national study involving schools in ten European countries demonstrates that a substantial proportion of schools perceive their current mental health support for students as insufficient (McLaughlin & Black-Hawkins, 2007). When it comes to the level of priority given to mental health provision in their school, only 25.7% of schools in Serbia indicated high or essential priority (McLaughlin & Black-Hawkins, 2007).

Despite the increasing amount of research on mental health in school settings, a substantial gap persists between scientific findings and their practical application within educational environments (Atkins et al., 2010). Walker (2004) discussed that the field of mental health has one of the widest research-practice gaps, with a significant time lag between empirical validation and implementation. Most of the research on mental health in schools focuses on raising awareness within the community about the prevalence of these issues, which could lead to improving students’ mental health outcomes in the school context (Marshal, et al., 2017; Rossen & Cowan, 2014; Sanchez, et al., 2018). However, such research can be expensive, time-consuming, and often less effective than anticipated (Radanovic et al., 2025). Policies and public health initiatives (Adelman & Taylor, 1999; 2006) are frequently overlooked, inconsistently followed or primarily focused on teachers’ perspectives on mental health (Rossen & Cowan, 2014) which, while important, are not always implemented in practice. Moreover, there is a link between students’ mental health and school performance (e.g. Owens et al., 2012). However, research that directly examines the impact of mental health in school settings often treats mental health and school behavior as separate issues (Heath et al., 2020). In other words, instead of looking at these areas independently, school performance and student mental health should be viewed as interrelated goals, though it is rarely the case. This suggests that effective education must incorporate the emotional well-being of students, as it plays an important role in supporting academic achievement (Atkins et al., 2010).

Teachers are often recognized as key figures in promoting and supporting students’ mental health (e.g., Fortier et al., 2016), but they usually lack proper training and overall support for this kind of role (e.g., Radanović et al., 2025). One source of support comes from the data of the academic research on topics related to students’ mental health. However, when it comes to teachers using research to enhance their practice, some studies suggest that while teachers show positive attitudes towards academic-type research (I.B.M., 2022), they are less prone to use this kind of resource in their school decision-making (Burn et al., 2025). Improving the relevance of academic research findings could be especially important for mental health problems such as non-suicidal self-injury (NSSI), since early manifestations of self-injurious behaviour are most likely to surface in everyday classroom interactions, and teachers, positioned as frontline observers, need concise, practice-oriented evidence to recognize warning signs, respond safely and empathetically, and facilitate timely referral to specialized support (Riggi et al., 2017).

Non-suicidal self-injury and school-based research

It is expected that, within the school context, the most frequently studied mental health issues are those that occur most often, such as anxiety and depression, which are the most prominent disorders among children and adolescents (Child and Adolescent Health Measurement Initiative [CAHMI], 2021–2022). However, one of the increasingly recognized issues that is receiving more attention and poses a particular risk during this developmental period is NSSI. As defined by the International Society for the Study of Self-Injury (International Society for the Study of Self-Injury, 2024), NSSI is the deliberate, self-directed damage of body tissue without suicidal intent and for reasons not socially or culturally sanctioned. Although NSSI is different from suicidality, and it does not imply a suicidal motive, research has shown that it correlates robustly with suicidality (Hamza & Heath, 2018), which is one of the reasons why it is so important to pay attention to it. Although cutting skin is the most common method of NSSI used among adolescents, some studies have shown that girls are more likely to use cutting while boys more often engage in hitting and burning themselves (e.g., Barrocas et al., 2012; Sornberger et al., 2012). Meta-analysis showed that global NSSI prevalence among adolescents is approximately 17 to 18% (Swannell et al., 2014). Teachers are often the first to notice signs of NSSI. Not only do more than a half of teachers in many studies report dealing with NSSI, but they also perceive it as an increasing issue (Berger et al., 2014)(Berger et al., 2014)(Hasking et al., 2021). They often report being concerned, frustrated by lack of support, lacking knowledge and confidence and have limited professional support (Berger et al., 2014; Elyoseph & Levkovich, 2024). Importantly, teachers often report willingness to help and get involved, but they emphasize the need for additional education, training and guidance (Berger et al., 2015; Elyoseph & Levkovich, 2024; Heath et al., 2006; Radanović et al., 2025; Simundic et al., 2024). In response to that, many international guidelines for addressing NSSI in schools have been published over the last decade (De Riggi et al., 2017; Hamza & Heath, 2018; Heath et al., 2020; Hasking et al., 2019, 2021). Last year, a proposed protocol for procedures in schools in Serbia was published (Radanović et al., 2025).

Why exploring this topic in Serbia: research objectives

Our previous studies (Radanović, 2025) have shown that Serbian schools are generally unprepared to address mental health issues. The findings of the Health Behaviour in School-aged Children (HBSC) study in the Republic of Serbia highlight the need for targeted interventions at both the school and community levels to enhance social support within the school environment, alleviate academic pressure, and prevent bullying (Sanchez et al., 2018). There are no mental health specialists employed in schools in Serbia. Mental health is not frequently discussed within the school context, and prevention or intervention programs are typically implemented by NGOs - and none of these programs specifically address NSSI. No school or national-level guidelines or official protocols are established on how to adequately respond to NSSI among students. Epidemiological studies on NSSI in Balkan countries are rare. In Serbia, there is still no nationally representative data on the prevalence of NSSI among adolescents, although the first such study is expected to be published soon. However, it is shown that the lifetime prevalence among adults is about 4% when measured using a yes/no question, and 14.5% when using a checklist of NSSI behaviors (Radanović et al., 2022). Given the impression that school staff are largely left to manage these issues on their own with minimal external support, an important question arises - what can educational researchers, one of the key actors in the process of improving education, do to help? We have recently proposed an NSSI protocol tailored to Serbian schools (Radanović et al., 2025) to help school staff respond to NSSI more effectively. However, like any other protocol, its implementation and practical use will largely depend on close collaboration between researchers and practitioners. This research aimed to better understand the attitudes of teachers towards the research of the NSSI in schools, a problem which can consequently help us identify barriers to implementation, improve the practical relevance of academic findings, and support the development of more effective, context-sensitive interventions in Serbian educational settings.

Sample. We invited all schools in Serbia to participate in this research, using a comprehensive national list (school sampling frame) of schools. A database of all state and private primary and secondary schools in Serbia was compiled, including publicly available email addresses. An email was sent to inform principals about the study, and informed consent was requested from each principal and school staff member. A poster summarizing key information about the research project was also attached. As the study was part of a larger project on mental health literacy and introduced with a focus on general mental health topics, it likely attracted a more diverse sample, including participants beyond those specifically interested in NSSI. Although all schools in Serbia were invited to participate, only 61 elementary school principals and 32 high school principals gave consent to distribute questionnaire links to their staff members. The remaining schools either declined or did not respond to our calls. The final sample consisted of 556 school staff members (84.2% female), 24 to 70 years old (M=45.51, SD=9.75).

Measures. Based on the example of previous studies (e.g., Berger et al., 2014), participants had to read the definition of NSSI before answering questions (direct and deliberate damage of bodily tissue without suicidal intent such as cutting, head or hand banging, severe scratching, etc.). As in previous studies (Berger et al., 2014), definition was outlined to ensure participants’ answers are indeed related to NSSI in case they are not familiar enough with the concept. The questionnaire consisted of structured introductory questions and a single unstructured open-ended question. Introductory questions are related to participants’ age, gender, and years of professional experience. To explore staff’s perception of scientific research related to NSSI and the importance of exploring their experiences, we asked Why do you think it is important for researchers in this field to explore your experience with students engaged in NSSI?

Procedure. School principals forwarded a link to the online consent form and online questionnaire to all school staff members. The questionnaire was launched online using SoSci Survey (International Society for the Study of Self-Injury, 2024). Staff members completed the questionnaire anonymously and voluntarily. At the end of the survey, participants were provided with authors’ email addresses and websites containing detailed information about the research project. Following data collection, all participants received a debriefing.

Debriefing. The debriefing was provided in the form of a written text prepared by researchers and mental health experts, focusing on the mental health of children and adolescents. As the study was presented as part of a broader mental health literacy project, the debriefing included information not only on NSSI but also on mental health issues more generally. The debriefing emphasized the importance of collaboration between researchers and practitioners in addressing students’ mental health challenges. Finally, references and recommendations for further reading were provided.

Qualitative analysis. Answers to the open-ended question were organized and quantified using qualitative content analysis (Shelemy et al., 2019) and software MAXQDA 2024 (Software, 2004). Following data familiarization, two independent coders developed and named the categories through multiple rounds of discussion. Then, each of the two researchers independently applied the agreed-upon categories to all responses. To assess the level of agreement, the Intraclass Correlation Coefficient (ICC) was calculated using IBM SPSS Statistics, version 29.0. There was no character limit for responses to the open-ended questions. The number of coded responses exceeded the number of participants, as some answers contained multiple distinct ideas or perceptions. These were accordingly coded into more than one category.

All responses unrelated to the question were excluded from the analysis. In total, 423 responses from 400 participants were categorized. The interrater reliability was .93, indicating an excellent level of agreement between the coders. Final categories, subcategories, their frequency, and examples for each are presented in Table 1. Four overarching categories emerged: NSSI knowledge, Prevention, Identificationand early intervention, and Treatment. Responses within the NSSI knowledge category reflected participants' interest in understanding the phenomenon of NSSI among students, specifically, its prevalence, characteristics, and underlying causes. School staff emphasized that researching NSSI in school settings helps to gain a clearer understanding of why students engage in NSSI and to identify those in need of support. The Prevention category included responses highlighting the importance of raising awareness and educating both staff and students, as NSSI remains a rarely discussed topic in schools. Participants indicated that exploring the issue within schools can guide the development of effective prevention strategies and help assess teachers’ training needs and schools’ preparedness to respond appropriately. The Identification and early intervention category encompassed three main subcategories: Teachers as gatekeepers, Mapping school resources for mental health support, and providing a protocol for school staff response. These responses underscored the role of teachers and school systems in recognizing warning signs, mobilizing existing resources, and ensuring that staff have clear guidance for action. Finally, the Treatment category comprised ideas related to offering help and support to students struggling with NSSI. Responses that addressed broader factors affecting students’ or teachers’ mental health were grouped under category Other.

This study aimed to explore school staff’s perceptions of the NSSI research within school context – an issue that is increasingly present in school settings but remains under-researched, particularly within the Serbian education system. Our findings provide insight into how school staff perceive the necessity and potential implications of scientific research related to NSSI.

School staff emphasized the relevance of conducting research towards enhancing knowledge on NSSI for understanding its prevalence, phenomenology, and underlying risk factors, as well as for the knowledge base for further research. In relation to prevention, participants highlighted the need for raising awareness and targeted education, noting that NSSI remains insufficiently addressed within the school context and that additional teacher training is essential. They viewed themselves as key actors in the early identification and intervention process, stressing the importance of timely detection, systematic mapping of available resources, and the establishment of clear response protocols. Regarding treatment, staff underlined the necessity of providing appropriate support to students who engage in self-injury, while also recognizing the significant role of the family and other systems in addressing and managing these behaviors.

Participants from the present study shared understanding on the importance of gathering NSSI knowledge base, including the importance of exploring prevalence rate, e.g. “To find out how many cases of NSSI are present in student population”. Although the is still no nationally representative data for adolescents in Serbia, what we do know, based on studies conducted among adults, is that the prevalence of NSSI ranges from 4% to 14.5%, depending on how the questions are framed (Radanović et al., 2022). Based on the respondents’ answers, it is reasonable to question to what extent these findings are known to those for whom they are relevant, as well as how effectively research results are disseminated and shared with the groups they are intended to benefit. School staff also emphasized the importance of examining NSSI phenomenology and risk factors of NSSI, noting that such insights could be helpful to them. Research evidence indicates that a wide range of risk factors, including mental disorders, low health literacy, adverse childhood experiences, bullying, problem behaviors, negative attitudes toward school, low academic achievement, and female gender, are associated with NSSI (Baetens et al., 2021)(Vanderlinde & Braak, 2010). Among these, school-related factors are particularly noteworthy, underscoring the relevance of the school context for understanding NSSI. Knowledge about factors contributing to NSSI is often derived from research conducted with students in school settings, which teachers appear to have recognized well.

The need for prevention efforts related to NSSI is also recognized. School staff members believe that greater emphasis on awareness-raising initiatives would yield stronger benefits for schools. One of the participants stated Because it is something that happens, yet is not spoken about enough, and as is often the case when it comes to mental health, it is frequently concealed. Awareness efforts are contributing to this reported increase in mental health problems. Due to prevalence inflation hypothesis (Foulkes, & Andress, 2023), it is expected that mental health awareness efforts will contribute to the rise in reported NSSI cases which is a beneficial outcome. Greater public awareness of NSSI perceived by students include creating websites and social networking pages, petitions, online support groups, and campaigns to raise funds and knowledge of NSSI (Berger et al., 2014). At school level, NSSI prevention programs based on psychoeducation show evidence on reducing the likelihood of students' future NSSI engagement (Baetens et al., 2020). Interestingly, participants emphasized that effectively addressing NSSI in Serbia goes beyond awareness-raising initiatives. Many participants identified education and professional development as important, suggesting that research on NSSI in schools should inform the design of staff training to strengthen their capacity to support students’ mental health, for example to provide a foundation for planning staff training aimed at developing the skills necessary to promote students’ mental health within the school setting. Different forms of NSSI education for teachers and other members of school staff could be offered. In recent years, online learning modules have emerged as an accessible and effective option. For example, Burn et al. (2025) developed and evaluated an e-learning module titled Supportive Response to Self-Harm, while Price et al. (2022) provided an online training program for secondary school teachers. However, in Serbia there are still no official mandatory training programs on NSSI for primary and secondary school teachers. Teachers may attend such programs outside the school system and typically have to finance them themselves, while the number of available programs remains very limited. Within the Prevention category, participants emphasized several systemic factors that influence how schools and society respond to NSSI. They highlighted the need for comprehensive, multi-level approaches such as whole-school prevention programs, peer-based initiatives, and collaboration with families and the wider health and social care systems. Evidence supporting these approaches can be found in recent studies, for instance, whole-school NSSI prevention programs (Aspeqvist et al., 2025), peer-based NSSI prevention programs (Cipriano et al., 2022), and intersystem cooperation models involving schools and other support networks (Berger et al., 2015). These findings indicate that teachers are indeed able to identify effective strategies for preventing NSSI, but they also recognize that these strategies are not implemented in their school environments. They call on relevant stakeholders, including researchers, to engage in addressing this issue.

Teachers in the present study recognize that they should be engaged throughout the research process, as they have direct insight into students’ well-being and mental health which previous studies have similarly indicated (Ching et al., 2024; McLaughlin & Black-Hawkins, 2007; Vanderlinde & Van Braak, 2010). One of the participants in the present study comment that children spend a lot of time daily in school, and it is a setting where signs of self-injury may be detected, and where students may also feel free to share their problems and seek help. In this context, teachers are left to fill roles for which they are neither trained nor adequately supported (Giles-Kaye et al., 2022). Berger and colleagues (2014) described this situation as teachers feeling like they are “working in the dark,” which may reduce both their willingness to engage and students’ intentions to seek help. Many teachers feel overwhelmed and poorly equipped to respond effectively to students’ mental health needs, NSSI included (e.g., Berger et al., 2014, 2015; Elyoseph & Levkovich, 2024). School staff mostly recognize the importance of their role and empathize with students, e.g. one participant says we have the opportunity to notice, to prevent, to help… because we have a relationship with children that is, or should be, based on trust; because we spend time with them; because, after all, we are educators, human beings, and humanists. On the other hand, the absence of mental health professionals in schools and lack of clear protocols leave them uncertain about how to act, while the broader school culture often encourages silence rather than open discussion of difficult topics. Participants from present study shared Because it is silenced - it is a “taboo topic” both in society and in schools. My experience is that it is preferably “not discussed” at staff meetings, since addressing it would require the school to initiate a protocol that is considered “too complicated” and “something we don’t need right now” (in the words of my school principal). Although many participants called for training and educational support, the implication is not that teachers should become therapists, but that they need appropriate tools and protocols to respond to NSSI confidently and effectively (Ching et al., 2024). This finding aligns with data showing that most teachers recognize the importance of mental health in learning, and at the same time feel unprepared to help them (Andrews et al., 2014; Giles-Kaye et al., 2022). Additionally, responses suggest another important point: NSSI is a stigmatized behavior, and it is necessary to address this stigma as part of prevention and intervention efforts.

School staff perceive research on NSSI as important for improving interventions designed for students engaged in NSSI, emphasizing the need for better support to the students. Participants from the present study pointed out that the research is aimed to improve work with students who engage in NSSI, but it is essential to recognize that schools alone cannot be expected to carry the full burden of mental health support. Although this study aimed to explore collaboration between researchers and practitioners, and the question targeted practitioners’ perceptions of their role in our research, the responses largely centered on a different issue - the challenging position of school staff in responding to students’ mental health problems and their calls for support from various stakeholders, including researchers. Several unclassified responses in the present study addressed the challenging position of school staff and feelings of exhaustion. For instance, one teacher described the researchers’ intention to explore NSSI as follows: because you plan to burden already overburdened teachers even further. The response indicates that research is sometimes viewed by school staff as an additional burden, and that the significance of their participation or the data they provide may not always be adequately highlighted or effectively communicated. This serves as a reminder to researchers to invest more effort in the planning and data collection phases of school-based studies. Previous studies have shown that education professionals also require support (e.g., Costa et al., 2020). We should not only attend to their educational needs but also contribute to creating a healthier and more supportive work environment. Even in more developed countries (e.g. Australian) lack of leadership and cohesion from actors such as the Ministry of Education or Ministry of Health with a lack of clarity about solutions to increase access to support services for students, unclear roles and responsibilities and lack of best practice guidance available to schools about managing NSSI (Berger et al., 2015). Proposing a national strategy involved with care of students engaged in NSSI, is recommended to be followed with school autonomy in flexibility of their responses to the needs, available resources and context (Berger et al., 2015). Sanchez and colleagues (2018) demonstrated that some school-based mental health interventions can be expensive, time-consuming, and of limited effectiveness, underscoring the importance of designing interventions that are feasible, cost-effective, and compatible with existing educational structures. Our participants echoed this concern, indicating that research leading to increased administrative burdens without clear benefits will likely face resistance. Therefore, future studies must adopt an applied focus, be co-designed with educators, and aim to produce context-sensitive tools that are straightforward to implement. Methodologies such as action research, design-based research, and participatory approaches are particularly well-suited to these objectives (McLaughlin & Black-Hawkins, 2007).

Limitations

The first limitation of this study concerns the sample. A much smaller number of schools agreed to participate in the study than expected, so the dropout rate among those initially contacted was high. It is likely that the staff who chose to respond were those already concerned about mental health or NSSI, which may have introduced a self-selection bias. Several factors likely contributed to the low level of engagement, and the feedback from participants in this study provides insight into the reasons for the low response rate. First, there is a notable sense of skepticism toward research among school professionals. Participants in present study reported having taken part in previous studies without ever receiving feedback or observing meaningful change, leading to doubts about the value and purpose of participation. Second, mental health, and especially sensitive topics like NSSI, remains stigmatized and uncomfortable to address within many school environments. Third, administrative overload significantly contributes to low participation. With increasing responsibilities and bureaucratic demands, school staff often view research participation as an added burden. Furthermore, the lack of systemic support and absence of national-level mental health initiatives leave many schools feeling isolated and without clear guidance on how to engage in research collaborations. Finally, open-ended questions provide valuable insights, but they lack the structure needed to systematically assess the prevalence of specific beliefs or attitudes. While our findings offer some understanding of how school staff perceive NSSI research, it would be more useful to conduct interviews to obtain more concrete and detailed responses that would provide clearer insights into how teachers perceive the role of the researchers. These important questions remain open and should be explored further through longitudinal, mixed-method studies that aim to deliver more practical and context-sensitive insights. Involving teachers as active partners through, for example, participatory research, would ensure that proposed interventions are contextually relevant, and sustainable within existing educational frameworks.

In summary, this study offers valuable insights into school staff perceptions of research on understanding and addressing NSSI among students in the Serbian educational context, including their role in it. Results indicate that they recognize the importance of research on NSSI, the valuable information such research provides, and its role in improving school practices related to recognition, prevention, and treatment. Additionally, they expressed a strong interest in professional development and systematic training to enhance their ability to respond effectively to students’ needs, while acknowledging that schools cannot shoulder this responsibility alone. At the same time, they draw attention to the need to protect and support educators, who often feel overburdened and insufficiently equipped to manage such complex challenges.

Insights from this study provide the implication for developing and evaluating structured NSSI education modules for school professionals, which can enhance staff competencies and strengthen schools’ capacity to promote students’ mental health. Importantly, researchers must consider the workload, needs, and well-being of school staff. Understanding teachers’ perspectives can guide researchers in developing context-sensitive, school-based prevention and intervention strategies. These findings revealed the importance of designing research with schools, not merely about them.

Acknowledgements

Authors would like to thank all the school staff who agreed to participate in the research and shared their experiences, concerns and needs with the research team.

Funding

This research was funded by the Ministry of Science, Technological Development and Innovation of the Republic of Serbia (Contract No. 451-03-33/2026-03/ 200018).

Conflict of interests

The authors declare no conflict of interest.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Institutional Review Board Statement

This research has been approved by the Ethics Committee of the Institute for Educational Research (Decision No. 96 dated February 9, 2023).

Author Contributions

Conceptualization, A.R., I.M., M.T., M.K.L., and J.M.; Data curation, A.R., I.M., M.T; Formal analysis, A.R., I.M., and M.K.L.; Investigation, A.R., I.M., M.T., M.K.L., Methodology, A.R., I.M., M.T., and M.K.L.; Project administration, A.R., I.M., M.T., Writing—original draft preparation, A.R., I.M., M.T., M.K.L and J.M.; writing—review and editing, A.R., I.M., J.M., M.T. and M.K.L. All authors have read and agreed to the published version of the manuscript.