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Students with poor mental health: The student health team should be the very first line of support

Elisabeth Fernell, Christopher Gillberg, Karin Amrén & Joakim Westerlund's latest blog entry

[Posted on 20 February, 2018 by Christopher Gillberg, Elisabeth Fernell, Joakim Westerlund & Karin Amrén]

Children’s mental health and its reported deterioration in Sweden in recent years is currently a hotly debated subject. We at the GNC, in collaboration with school physician Karin Amrén in Falkenberg, have carried out a study that we have summarised in an article in Läkartidningen (–forstarkt-elevhalsoteam-kravs/). Here is a more detailed account of what the Falkenberg study showed.


In Sweden, young people’s health is monitored through National school health surveys. Most municipalities also carry out local health surveys in accordance with recommendations from the The National Board of Health and Welfare. In the present study, pupils in grade 8, age 14-15 years in one representative municipality, had completed forms detailing health and well-being in connection with their regular visit to the school health nurse during the years 2012-2017. About 400 pupils had completed the forms each school year. Five questions were analysed; attention problems, perceived stress related to schoolwork, feelings of sadness, anxiety, and irritability. Girls reported more problems than boys and there was a time trend towards increasing problems over the period in question. There is a need to evaluate whether the new school curriculum from 2011, making higher demands on cognitive/executive functions, may be one factor behind the observed negative trend with regard to mental Health.

In Sweden, there are continuous studies of mental health in children and adolescents at the national level. A study carried out in one of the Swedish state’s public investigations (i.e. SOU, short for “Statens Offentliga Utredningar”, this particular case being SOU 2006:77) resulted in the report “Adolescents, stress and poor mental health” [1]. It brings attention to the fact that there have been several reports over the last 10-20 years showing an increased rate of adolescents feeling dejected and stressed out. The report, nearly 400 pages long, highlights the lack of a nation-wide system to measure adolescent mental health, specifically one which produces reliable information and high retention rates.
A large survey was performed by Sweden’s National Board of Health and Welfare in collaboration with the Centre for Health Equity Studies (CHESS) and the Faculty of Medicine and Health Sciences in Linköping (“The impact of school on mental health in children and adolescents – a study based on the national comprehensive survey in years 6 and 9 in autumn of 2009” [2]). The report emphasises, among other things, the importance of school context-related conditions with regard to students’ mental health, quality of life and exposure to bullying.
The Public Health Agency of Sweden monitors aspects of health development in 11-, 13- and 15-year-olds and the latest report was published in 2014 (“Health habits of school children in Sweden 2013/14” [3]). The study has been carried out every four years since 1985/86 in more than 40 countries as a collaborative project for the World Health Organization (WHO). The latest Swedish report, for the period 2013-2014, comprising around 8,000 students, found that self-reported physical and mental problems had increased among both boys and girls, and especially among 13- and 15-year-old girls. It also turned out that the proportion of 13-year-old girls experiencing stress from schoolwork had doubled over the last four years [3].
Apart from national surveys, information can also be drawn from surveys performed by school health services, as well as from health forms filled out by students in connection with regular visits to the school health nurse in the different municipalities of Sweden. The purpose of the health form is to create an understanding of the student’s health, habits and everyday life situation. The health visits are carried out according to recommendations from the National Board of Health and Welfare and take place three times in primary and lower secondary school, and once in upper secondary school [6]. The health forms, followed by individual talks with the school nurse, provide opportunities to identify children with different types of mental problems and thus also an opportunity to start taking appropriate measures at both an individual level and a general school and community level.
We will here present data regarding symptoms related to mental health, from health forms for students in grade 8, distributed over five academic years (2012-2017) in a West Sweden municipality.


Study population At the time of the study, the municipality examined had a population of about 43,800 inhabitants (2016) and socioeconomically representative status. In 2016, 19% of the children had foreign backgrounds (foreign-born or born in Sweden with two foreign-born parents). There were 20 municipal lower secondary schools and around 400 children in each birth cohort in the municipality.

Health form In grade 8, the students fill out the health form on their own in school, after which each student discusses their respective responses with the school nurse, as part of their individual health visit. The school nurse decides whether specific measures are needed. The interviews conducted locally in the municipalities by student health care services thus entail a personal encounter with each student, which in turn creates an opportunity to address even more sensitive problems, and to discuss individual solutions for help and support.
The “Guidance for student health services” directive, issued by the National Board of Health and Welfare and the Swedish National Agency for Education [6], emphasises that one of the advantages of health forms is the ability to normalise uncomfortable questions by creating a situation where everyone is expected to answer them. The health form, which is addressed to the student, covers questions concerning everyday school environment, bullying, concentration difficulties, mental health, diet, sleep, physical activity, leisure time, pain, medical conditions/illnesses, physical development, relationships, alcohol, narcotics and tobacco.
For this study, data was compiled from five academic years; 2012-13, 2013-14, 2014-15, 2015-16 and 2016-17 for students in grade 8 (ages 14-15), divided into boys and girls. Five health questions in the form were analysed: 1) “I am able to concentrate in class”, 2) “I feel stressed out about schoolwork”, 3) “I have felt sad and dejected over the last three months”, 4) “I have felt worried and afraid over the last three months” and 5) “I have felt irritated or been in a bad mood over the last three months”. Each statement has five possible responses, and for each respective item, the two responses indicating the highest problem severity were tallied up across all questionnaires. For the statement “I can concentrate in class”, we calculated the proportion who answered “rarely” and “never”. For the other four statements, we calculated the proportion who answered “often” and “always”.


Concentration difficulties in class Significantly more girls (9.9%) than boys (6.9%) reported concentration difficulties (measured over the entire time period) , χ21 = 5.60, p = 0.018, Odds ratio = 1.48, 95% CI = 1.07-2.04. There were also significant differences between the academic years regarding the proportion of individuals reporting that they could rarely or never concentrate during class, χ24 = 17.90, p = 0.001. The proportion of individuals with concentration difficulties increased gradually for each academic year (from 4.3% in 2012-2013 to 12.3% in 2016-2017), except for the fourth of the five years examined, when the proportion temporarily decreased.

Perception of schoolwork-related stress Significantly more girls (37.8%) than boys (17.1%) reported that they felt stressed out, often or always, about their schoolwork (measured over the entire time period), χ21 = 105.64, p < 0.001, Odds ratio = 2.94, 95% CI = 2.39 – 3.63. There were significant differences between the academic years with regard to reported stress, χ24 = 16.80, p = 0.002. Schoolwork-related stress increased gradually for each academic year examined, except for the last one, when it decreased slightly.

Having felt sad and dejected over the last three months Significantly more girls (13.2%) than boys (2.5%) reported that they often or always felt sad and dejected (measured over the entire time period), χ21 = 77.42, p < 0.001, Odds ratio = 5.87, 95% CI = 3.78-9.10. There were also significant differences between the academic years, χ24 = 12.38, p = 0.015. The proportion of individuals who reported that they often or always felt sad and dejected increased gradually for each academic year (from 4.0% in 2012-2013 to 10.6% in 2016-2017).

Having felt worried and afraid over the last three months Significantly more girls (8.6%) than boys (1.2%) reported that they had often or always felt worried and afraid (measured over the entire time period), χ21 = 58.01, p <0.001, Odds ratio = 7.70, 95% CI = 4.18-14.20. Significant differences between the academic years were observed here as well, χ24 = 10.45, p =0.033. The proportion of individuals who reported that they were worried and afraid increased over the three academic years 2012-2013, 2013-2014, 2014-2015 (from 2.3% in the 2012-2013 academic year to 7.1% in the 2014-2015 academic year), before it eventually decreased slightly in the following two academic years.

Having felt worried or been in a bad mood over the last three months Significantly more girls (22.5%) than boys (7.8%) described that they had felt irritated or been in a bad mood, often or always, measured over the entire time period, χ21 = 83.24, p <0.001, Odds ratio = 3.45, 95% CI = 2.61-4.55. There were also significant differences between the academic years, χ24 = 28.08, p <0.001. The proportion of individuals who reported irritability and bad mood increased for each academic year (from 9.3% in the 2012-2013 academic year to 21.1% in the 2016-2017 academic year).


The results indicate an increase in cases of poor mental health over the last five years. Girls report poor mental health significantly more often than boys. Similar results have been reported in Swedish national surveys [1-3]. This difference between girls and boys might be an expression of poorer mental health in girls, but might also reflect that boys generally find it harder to admit to such problems.

One of the strengths of our municipality-based study is that the results hopefully will be more concrete and thus create a starting point for intervention, both at the individual level and in terms of general school policy. One limitation of the study is that we do not have access to individual data and therefore are unable to analyse connections between different variables on an individual level – e.g. between reported concentration problems and perceived schoolwork-related stress.
The directive “Guidance for Student Health Services”, issued by the National Board of Health and Welfare and the National Agency for Education [6], states that the goal of student health services is to create as positive a learning situation as possible for the student. One question we ask ourselves is how our results – with a large and increasing proportion of students, and with a majority of girls, with reported concentration problems, schoolwork-related stress, anxiousness and fear, dejection and irritability – should best be used in order to lead to individual and general analyses of underlying factors and, last but not least, appropriate measures. Based on the national surveys we have available in Sweden, we can assume that the results are not entirely unique to the municipality examined in this study.

These reports of poor mental health might reflect both non-school-related and school-related factors. Students who are facing an insecure and difficult home environment must be recognised, as must students with developmental difficulties. In addition, students are facing ever greater demands to be perfect from various types of social media. Analysis of the reported increase in schoolwork-related stress should take the new curriculum (2011) [7] into account. The new curriculum places higher demands on students’ cognitive/executive skills. According to our findings, this increased demand level has not been preceded by any analysis whatsoever concerning how the demands in question relate to the cognitive/neurological development level of children and adolescents of different ages [8]. We cannot determine from this survey study alone how much of the school-related stress can be linked with the curriculum’s demand level, but further analysis should give us a better understanding of this point.

During the time period that we have examined, the term school health care has disappeared and been replaced in the new Education Act [9] with the term student health services. Student health services are to provide medical, psychological, psychosocial and special education-based measures. There should also be readily available access to a school physician, school nurse, psychologist and counsellor. However, oddly enough, principals and local chief authorities are free to decide for themselves which resources are actually needed for the medical measures in question [10]. The Swedish school physician association sent out a survey to 600 schools nation-wide [11], which showed major variations in staffing of school physicians, and that in some schools, the school physician virtually never had time to see individual students. In other words, school nurses have thus seen a decrease in support from school physicians in the collective medical efforts of student health services.

Dating back several years, Sweden’s municipalities and counties (SKL, “Sveriges Kommuner och Landsting) are building clinics in municipalities and counties – “the first line of support” – for children and adolescents with poor mental health. However, in many of these clinics it is unclear who is actually responsible for “the first line” and what the responsibility means [12].
Student health services should in their medical efforts aim, in the context of health visits, to quickly identify problems or symptoms in students that might indicate a need for special support or other measures [6]. The student health team should thus be the natural “very first line of support”. The current first-line-teams can then shift their attention towards support and treatment measures once this has been determined to be the primary need.
Resources must be allocated to the student health teams in order to enable interprofessional collaboration, including between school physicians and school psychologists. That way, students with poor mental health can get an initial assessment regarding underlying factors, and decisions can be made regarding potential measures, examination and treatment. So-called poor mental health can also be a partial symptom in underlying neuropsychiatric/neurodevelopmental disorders.

1. Ungdomar, stress och psykisk ohälsa. Statens offentliga utredningar, SOU 2006:77.

2. National Board of Health and Welfare (Swedish Socialstyrelsen) and Centre for Health Equity Studies (CHESS). Skolans betydelse för barns och ungas psykiska hälsa – en studie baserad på den nationella totalundersökningen i årskurs 6 och 9 hösten 2009. Socialstyrelsen: 2012. [In Swedish].

3. Skolbarns hälsovanor I Sverige 2013/14, Folkhälsomyndigheten: 2014. [In Swedish].

4. Currie C, Nic Gabhainn S, Godeau E, Committee IHNC. The Health Behaviour in Schoolaged Children: WHO Collaborative Cross-National (HBSC) study: origins, concepts, history and development 1982–2008. International Journal of Public Health. 2009;54:131-9.

5. Currie C, Zanotti C, Morgan A, Currie D, de Looze M, Roberts C, et al. Social determinants of health and well-being among young people: Health Behaviour in School-Aged Children (HBSC) study: International report from the 2009/2010 survey. Health policy for children and adolescents. Copenhagen: WHO Regional Office for Europe, 2012.

6. Vägledning för elevhälsan. Socialstyrelsen och Skolverket, 2016.

7. Läroplan för grundskolan, förskoleklassen och fritidshemmet) (SKOLFS 2011:19. Stockholm: Skolverket, 2011, Reviderad 2016.

8. Lindblad I, Westerlund J, Gillberg C, Fernell E. Har alla barn i grundskolan förutsättningar att klara nya läroplanens krav? Läkartidningen 2018, accepterad för publikation.

9. Skollagen, Svensk författningssamling (SFS 2010:800). Stockholm 2010.

10. Milerad J, Swensson M, Hallerbäck MU, Alm B, Lagercrantz H, Ludvigsson JF. Läkarbedömning – inte så viktigt för elevhälsan? Skolhälsovården sviker elever som inte mår bra. Lakartidningen. 2015;112. pii: DMZH.

11. Vilken vård du får avgörs av var du bor. Skolläkarföreningens nationella kartläggning av vaccinationstäckning, medicinska hälsokontroller, bedömning av inlärningsproblem, neuropsykiatrisk problematik, omhändertagande av nyanlända och tillgång till förebyggande hälsoprogram. Stockholm: Svenska Skolläkarföreningen; 2015. (Publiceras på Skolläkarföreningens webbplats 10 sep 2015).

12. Första linjen för barn och ungas psykiska hälsa. Uppdrag Psykisk Hälsa, 2017.