Comparative child mental health and academic outcomes after primary school teachers deliver task-shifted mental health care in India

Abstract

Teachers are promising lay counselors but have limited time for traditional therapy. To viably leverage teachers to deliver care, we developed Teachers Leading the Frontlines (Tealeaf), where teachers deliver a novel therapy, “education as mental health therapy” (Ed-MH); measures are an extension of classroom management, not an added task. We investigated whether Tealeaf teachers improved child mental health symptoms and academic achievement versus teachers delivering an enhanced usual care (EUC) comparator, Responding to Students' Emotions through Education (RE-SEED), a truncated version of Tealeaf. We conducted a pragmatic, mixed methods, post hoc analysis using data from 2019 of an open trial of Tealeaf running in parallel with the all-EUC first step of a stepped wedge cluster randomized controlled trial (SW-CRCT). We compared postintervention child mental health symptom scores and academic achievement. Semi-structured interviews and focus groups were analyzed using inductive content analyses. Tealeaf teachers observed lower mental health symptom severity (n = 23 children in Tealeaf, n = 104 in RE-SEED; Cohen’s d = 0.70; p = 0.024). Students in Tealeaf (n = 26, n = 183 in RE-SEED) performed better in math (d = 0.63; p = 0.0006) and reading (d = 0.83; p = 0.001). Caregivers of children in RE-SEED (n = 177), the comparator condition, reported lower severity of overall mental health difficulties and internalizing difficulties for their children compared to caregivers’ reports of their children in Tealeaf (n = 25). Tealeaf teachers displayed a greater depth in mental health understanding in mixed methods findings. Evidence supports teachers' potential to improve child mental health and academics in school while underscoring the need for additional home‐based supports. Tealeaf Clinical Trials Registry—India (CTRI) Reg. No. CTRI/2018/01/011471, Ref. No. REF/2017/11/015895; date of registration 2018-01-01. RE-SEED TRN NCT04723277; date of registration 2021-01-25.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-025-00217-2.

Introduction

Globally, up to 90% of children with mental health conditions do not receive care, creating a need for low-cost, accessible, novel mental health interventions to support them outside traditional care systems [1, 2]. As more children attend school than have access to mental health care, schools may facilitate the delivery of mental health interventions [3]. Teachers in particular are well-positioned to deliver such interventions due to their understanding of child development and access to children [3]. Task-shifting models of intervention involve training of lay professionals, such as teachers, to deliver care [4, 5]. Such task-shifted models of care have been shown to be effective in educational contexts across a variety of low- and middle-income country (LMIC) settings [3, 6, 7].

Tealeaf (Teachers Leading the Frontlines—Mansik Swastha [Mental Health in Nepali]) is one such teacher-led, task-shifted intervention designed to improve mental health outcomes for primary school children in the Darjeeling Himalayas of West Bengal, India [8, 9]. India has a wide care gap, with demand far exceeding available care [10]. In Tealeaf, teachers learn about child mental health and therapeutic techniques and then target children in their classrooms with mental health concerns for care [8, 9]. A 2018 pilot trial of Tealeaf provided evidence for Tealeaf’s feasibility and early signals of efficacy [9], leading to the implementation of two trials in 2019 to explore Tealeaf’s potential impact. The first, a year-long open trial, used a single-group, pre-post design to explore the acceptability and preliminary impact of Tealeaf [11]. The second, a multi-year, stepped-wedge cluster randomized controlled trial (SW-CRCT), was set to compare a Tealeaf intervention group to an ethical comparator group receiving enhanced usual care (EUC) called Responding to Students' Emotions through Education (RE-SEED), a truncated version of Tealeaf. The SW-CRCT was discontinued after one year due to the COVID-19 pandemic, but initial quantitative and qualitative data for participants in RE-SEED were collected.

Due to the complications of the COVID-19 context, the impact of Tealeaf versus a comparator group, RE-SEED, has yet to be explored. Such an exploration could provide a meaningful baseline understanding of how the impact of the full Tealeaf intervention on child mental health status and academics may compare to that of RE-SEED. This type of exploration could yield insights into the most impactful components of the Tealeaf intervention required to facilitate academic and child mental health outcomes, informing future intervention efforts with the potential to reduce the mental health care gap in India and other LMICs.

The current study utilizes a pragmatic mixed methods analysis to compare Tealeaf to RE-SEED from the data gathered in 2019. It is hypothesized that the full Tealeaf intervention will have a more significant impact on child outcomes than RE-SEED.

Methods

Setting

Both study trials took place in primary schools in the Darjeeling Himalayas of West Bengal, India. Darjeeling is a diverse, agricultural setting with a largely Nepali-speaking population [12]. Most residents work on tea plantations and earned approximately 176 Indian Rupees (INR; $2.40) in daily wages at the time of the trials [12]. Despite these circumstances, many families send their children to low-cost private (LCP) schools for the perceived high-quality English education that is offered for a modest tuition rate [13]. Low-cost private schools have become increasingly present in financially-disadvantaged urban and rural parts of LMICs [13]. In the rural schools of West Bengal, the prevalence of child and adolescent mental health disorders is estimated to be as high as approximately 30% [14].

Participants

During the 2019 academic school year, teachers (n = 19), students (n = 28), and caregivers (n = 29) from 9 rural LCP schools in Darjeeling participated in Tealeaf in a yearlong open trial. Of the 19 teachers who participated in the open trial, thirteen teachers completed all study activities including quantitative and qualitative measures, while seven engaged in qualitative semi-structured interviews. ‘Caregivers’ were chosen as the involved family as many children in this study (and in Darjeeling) lived with extended family members (e.g., grandparents, aunts, uncles) rather than parents [15]. These other relatives often served as the primary caretakers. Simultaneously, 99 teachers and 188 students and their caregivers from 43 different schools participated in RE-SEED in the SW-CRCT. Select teachers (n = 27) in RE-SEED participated in 10 focus group discussions (FGDs), composed of 2 to 4 participants each, following the trial.

Teachers eligible for participation in either trial had at least one year of prior experience teaching primary school, were aged 18 years or older, and had no prior convictions of child related maltreatment or misconduct. Written informed consent was obtained from all participating teachers and caregivers in both trials. For all participants younger than 18 years old in both trials, parental or legal guardian consent was secured, and children over seven years of age provided verbal assent. All participants completed written informed consent in English or Nepali for their participation or their child’s participation in the study. CONSORT figures are in Supplementary File 1.

Measures

Teacher report form

Teachers completed the Achenbach System of Empirically Based Assessment (ASEBA) Teacher Report Form (TRF), a teacher-report measure of child mental health symptoms that has been validated in an Indian context [16, 17]. The measure includes 113 items that yield overarching T-score sums of child internalizing, externalizing, and total mental health problems, along with several subscale measures. For Total Problem, Internalizing, and Externalizing scores, a T-score < 60 is considered to be “normal”, indicating typical functioning; a T-score of 60–63 is considered to be “borderline”, indicating likely having symptoms needing diagnostic criteria; and a T-score of above 63 is considered to be “clinical”, indicating more definitively meeting diagnostic criteria. A score of at least borderline was set as the threshold for needing care [9, 18]. The TRF was administered in Nepali and took participants about 20 minutes to complete. All teachers filled out the TRF post-intervention (‘POST’) for children receiving care.

Strengths and difficulties questionnaire

Caregivers completed the Strengths and Difficulties Questionnaire (SDQ), a measure of child mental health symptoms as observed by caregivers [19, 20]. The SDQ has not yet been validated within an Indian context; still, this measure was selected due to its brevity (reducing the research burden on caregivers), validation across other similar contexts, and potential for use with culturally diverse populations [21]. The SDQ has 25 items with five symptom subscales: emotional, hyperactivity, conduct, social, and pro-social. The SDQ Impact Score is used to assess functional impairment and distress, examining how symptoms may interfere with the ability of the individual to perform daily living tasks. Caregivers filled out SDQs for their children POST. The measure was administered in Nepali and took participants roughly 10 minutes to complete.

Annual status of education report

The Annual Status of Education Report (ASER) is a brief assessment of reading and math skills validated in an Indian context [22]. The ASER was used to assess student academic achievement and was delivered orally in Nepali by an independent rater (research assistant) at the end of each intervention. Assessment items involved 4 reading questions assessing word and sentence meaning and 7 math questions assessing math abilities ranging from number recognition to math word problem completion. A higher score on the ASER indicates a greater degree of ability in the corresponding subject area, with one additional point corresponding with gaining one additional substantial skill and improving by one grade level.

Intervention framework: Tealeaf

Tealeaf is a task-shifting intervention that teaches primary school teachers (K-4) to use transdiagnostic techniques, applying the same principles across disorders without focusing on specific diagnoses, to support any student with any diagnosis in real classroom situations. Interactions with students with mental health needs are guided by psychological principles; teachers use Education as Mental Health Therapy (Ed-MH) techniques in their interactions. Ed-MH is based on behavior theory, removing the need to know diagnoses and allowing use of transdiagnostic measures to address mental health. Teachers learn to interpret behavior as one would for a crying baby, identifying if the need is for attention (e.g, comfort), escape (e.g., from discomfort), tangible (e.g., hunger), or sensory (e.g., wet diaper). They also receive psychoeducation on behavior types of "nervous", "disagreeable", and "withdrawn" as these correspond to the common mental disorders that manifest in children (i.e., anxious, disruptive, and depressive disorders) [23, 24]. Teachers then pick measures from a menu of Ed-MH options to meet the identified need. Measures are adapted from Cognitive Behavioral Therapy/Play Therapy (CBT/CBPT), Dialectical Behavior Therapy (DBT), and Behavioral Activation, allowing measures to be evidence-backed but selected to align with practices teachers already use (e.g., small group work, student leadership roles) [23, 24]. Measures are a natural extension of existing classroom management, not an added task. For example, small group work addresses social anxiety; student leadership roles can boost self-esteem in withdrawn students. Even subtle changes in phrasing or expectations (Fig. 1) embed these principles into everyday classroom interactions. Overall, teachers are empowered to better manage their classroom. The support they provide is so well-targeted, though, it effectively serves as care, with pre-post improvements demonstrated in two pilot trials [9, 18, 23, 24].

Fig. 1.

Examples of teaching as usual versus education as mental health therapy

Tealeaf consists of six components: teacher training, identifying students who need mental health support, behavior analysis, behavior plans, one-on-one interaction with students, and relationship building with caregivers. Participants in Tealeaf first attend a 10-day professional development workshop that presents information on basic child behavior, behavior theory, behavior plans, and learning of Ed-MH transdiagnostic therapeutic techniques. Following the workshop, teachers receive ongoing coaching from social worker staff (called coaches) on the research team, the equivalent of supervision that trainees in mental health professional programs receive [25, 26]. Topics discussed include the accurate selection of students in need of mental health care as based on behavioral assessment; behavior plan development; behavior plan implementation using evidence-based techniques; and collaborating with families. Teachers work with coaches to select from their classrooms, with a high degree of accuracy, students at-risk of or currently experiencing diagnosable mental or behavioral health concerns [27, 28]. Teachers then create individualized plans for students and provide targeted intervention using evidence-backed Ed-MH techniques throughout the school year, with ongoing supervision and support from coaches. Described briefly above, a separate publication describes these measures in detail [9]. The supervision is structured and involves biweekly phone calls and monthly in-person visits. As relationship-building is emphasized as a core component of Tealeaf, teachers also strive to communicate with caregivers and encourage caregivers to engage in therapeutic techniques in the home to create a holistic, ecological approach to intervention [29, 30]. Tealeaf has been delivered with fidelity and positive acceptability and feasibility [8, 9, 11]. It has improved children’s mental health symptoms, as measured on the TRF, PRE-POST in two different pilot trials [9, 18, 23, 24].

Intervention framework: RE-SEED

RE-SEED is a truncated version of Tealeaf. It is designed to be the most viable form of Tealeaf that can be implemented without requiring significant additional resource investment; accordingly, RE-SEED contains the basic components of Tealeaf and does not include supervision. A separate publication shows qualitative evidence that teachers found RE-SEED acceptable and perceived students improving in behavior and academics [31]. RE-SEED was developed with input from a local ethics committee to serve as a comparison group for Tealeaf, such that a valid comparison could be made between an intervention group (Tealeaf) with a control group (RE-SEED), while children in need of support in the control group still received it.

In RE-SEED, teachers receive a 2- to 3-day rather than a 10-day training. This training teaches teachers basic knowledge on child behavior, along with a limited number of simple strategies to address classroom behavior based in cognitive-behavioral techniques. The training omits psychoeducation on anxiety, disruptive, and mood disorders, instead focusing on the broad basics of behavior and intervention. It also provides less of an emphasis on collaborating with families. Post-training, coaches support teachers as they select students in their classrooms for targeted intervention. Following the selection process, however, teachers are left to deliver care independently. Structured meeting times with the team are not built into the intervention; instead, teachers are encouraged to contact the team when in need of additional support.

Procedures

Teachers were recruited and enrolled in the Tealeaf open trial December 2018 and January 2019. Teachers completed a 10-day training in February 2019. Following the training, teachers observed students and their behaviors in preparation for choosing two students to provide care to [27, 28]. Teachers selected two students each for intervention based on their perceptions of students’ needs for mental health support, pragmatically limited [27, 28]. All teachers delivered targeted interventions to selected students from May to December 2019. Following the intervention at POST, quantitative measures were completed by teachers (TRF), caregivers (SDQ) and children (ASER); and teachers, caregivers, and students participated in semi-structured, qualitative interviews. Relevant qualitative teacher findings are reported here, while all qualitative findings are reported in a separate publication [11].

Participants in RE-SEED followed the same timeline of procedures as participants in Tealeaf but with the protocol distinctions detailed above. RE-SEED participants were enrolled in the SW-CRCT and completed a 3-day training independently of Tealeaf participants in March and April of 2019. Baseline data collection was initially planned for RE‐SEED. However, resource limitations precluded administering two waves of data collection. Consequently, we chose to prioritize a high‐fidelity intervention and focused our efforts on a single, post‐intervention assessment. Teachers observed students and selected two children for targeted care. In December 2019 at POST, quantitative measures were completed by teachers (TRF), caregivers (SDQ), and children (ASER). Teachers participated in FGDs.

For both Tealeaf and RE-SEED, we also collected the TRF from a secondary teacher who was Tealeaf‐trained but not directly caring for the child to serve as an additional rater on the Teacher Report Form (TRF). This secondary rater was introduced to reduce potential bias from the primary teacher delivering the intervention.

All methods were carried out in accordance with all relevant ethical guidelines and regulations.

Quantitative analysis and comparison

Due to the unanticipated suspension of the SW-CRCT during the COVID-19 pandemic, the comparison pursued required use of data already collected, i.e., a smaller Tealeaf intervention group and a larger RE-SEED comparator group. As per Dumville and colleagues, unbalanced designs (including control-to-intervention ratios of approximately 4:1) can still preserve adequate power when practical constraints limit one arm’s size [32]. We therefore first conducted post-hoc power analyses to confirm that, despite the smaller-than-planned intervention group, the study retained acceptable power to detect moderate effect sizes. For the entire sample (188 in EUC, 28 in intervention), with α = 0.05 and a two-tailed test, we had 80% power to detect an effect size of 0.57. In the final sample analyzed for the Teacher Report Form (TRF; 104 in EUC, 23 in intervention), power calculations indicated an 80% power to detect an effect size of 0.65. Similarly, power remained at 80% to detect effect sizes of 0.60 for the Strengths and Difficulties Questionnaire (SDQ; 177 in EUC, 25 in intervention) and 0.59 for the Annual Status of Education Report (ASER; 183 in EUC, 26 in intervention). These calculations suggested that our analyses could reliably detect clinically meaningful group differences in child mental health and academic outcomes.

Demographics of Tealeaf and RE-SEED participants were then compared using independent sample t-tests. Data were analyzed with an intention to treat protocol. Mean scores were calculated at POST for the TRF (Total Problem, Externalizing, and Internalizing scores), SDQ (Total Difficulties, Externalizing Difficulties, Internalizing Difficulties, and Impact scores), and ASER (Math and Reading). Independent sample t-tests were first used to compare Tealeaf and RE-SEED POST scores to understand the raw data. Then, as teachers rated up to two students each on the TRF, we employed univariate generalized estimating equations (GEE) with an exchangeable working correlation structure for the difference in TRF scores to adjust standard errors for the within‐teacher clustering.

Exploratory multivariable modeling was then used to determine whether intervention (Tealeaf or RE-SEED) predicted test scores, adjusting for the following relevant confounders that were selected a priori via review of the literature, purposeful statistical variable selection, and clinical judgment: child age, child gender, and teacher formal training. Specifically, older children typically demonstrate higher academic and mental health skill levels, gender differences are well-established in mental health symptomatology and learning trajectories, and teacher credentials have long been associated with differential classroom practices and student performance [33–35]. GEE-adjusted scores were used for the multivariable modeling for TRF scores while raw scores were used for the SDQ and ASER multivariable modeling. Effect sizes (Cohen’s d) were also calculated.

To estimate the relative risk (RR) of remaining in the borderline/clinical range while accounting for teacher-level clustering, TRF total, externalizing, and internalizing scores were converted into a dichotomous variable designating normal (< 60) vs borderline/clinical (≥ 60) and then analyzed using GEE models. Covariates were the same as in the continuous models.

Finally, we also compared the primary teacher’s post-TRF ratings to the secondary teacher’s post-TRF ratings using paired t-tests, with statistical significance set at p < 0.05.

All analyses were completed using SAS 9.4 Language Reference: Concepts. Cary, NC: SAS Institute Inc, 2023. [37].

Qualitative and mixed methods analysis and comparison

Researchers used inductive content analysis, aimed at a qualitative description of the data, following established guidelines [38, 39]. Interview and FGD guides were developed with targeted questions on the broad evaluation theme of impact. Trained qualitative research assistants in Darjeeling, Nepal, conducted all data collection in Nepali. Interviews and FGDs were recorded and transcribed verbatim into English.

Following transcription, transcripts were imported into ATLAS.ti version 8.4.15 (ATLAS.ti Scientific Software Development GmbH, 2019) for coding and theme abstraction [40]. For Tealeaf interviews, three individuals pursued analyses: two qualitative researchers (one with an MSW and one with an MA in Psychology) coding and the PI (CMC) for discussions and consensus. The coders used an iterative coding process: they read and re-read transcripts, discussed initial open codes, refined a codebook in group sessions, and arrived at final coding by consensus. Codes were then aggregated into categories to abstract themes, determined by consensus among the same three researchers and finalized by corresponding authors CMC and MM. Key illustrative quotations were identified, and the results were linked to the specific research questions on program impact. The RE-SEED data were analyzed by three researchers (one with an MA in Psychology [coder], one a medical student [coder], and the PI [discussions & consensus]) following these same inductive content analysis steps. Saturation was determined to have been reached for both Tealeaf and RE-SEED using Guest’s 2006 principles [41]: no additional revisions to the codebook were needed, and no new themes emerged. Subsequently, CMC and MM conducted a mixed methods analysis per Bazeley [42], organizing results into a side-by-side, joint-display matrix comparing impact-focused themes from RE-SEED and Tealeaf.

Results

Demographics

For students, participants were similar across all demographics, including age, gender, and members of household, except for language, with more children in the RE-SEED group speaking Hindi than in the Tealeaf group (66% versus 10.7%; p < 0.0001; Table 1). For teachers, results indicated that the groups were similar across most variables, including age, number of years spent teaching, and gender (Table 1). Significant differences included formal training, with more Tealeaf teachers having received formal training than RE-SEED teachers (38.5% versus 11.3%; p = 0.02), as well as language differences, with more teachers in RE-SEED speaking Nepali (97.9%, p < 0.0001) and English (67.0%, p = 0.02). School level variables, including the number of students enrolled, number of teachers, and monthly fees, did not differ significantly between the two groups.

Table 1.

RE-SEED and Tealeaf demographic comparison

Children	RE-SEED (n = 188)	Tealeaf (n = 28)	p-value*
	Mean (SD)	Mean (SD)
Age	7.97 (1.58)	8.29 (1.65)	0.33
	N (%)	N (%)
Gender = male	114 (60.6%)	20 (71.4%)	0.27
Lives with:
Mother	154 (81.9%)	24 (85.7%)	0.79
Father	147 (78.2%)	23 (82.1%)	0.63
Uncle	32 (17.0%)	8 (28.6%)	0.14
Aunt	33 (17.6%)	5 (17.9%)	0.99
Brother	56 (29.8%)	7 (25.0%)	0.60
Sister	73 (38.8%)	12 (42.9%)	0.68
Grandmother	91 (48.4%)	16 (57.1%)	0.39
Grandfather	60 (31.9%)	10 (35.7%)	0.69
Cousin	1 (0.5%)	0 (0%)	0.99
Language
Nepali	188 (100%)	28 (100%)	nc
Bengali	2 (1.1%)	0 (0%)	0.99
English	175 (93.1%)	26 (92.9%)	0.99
Hindi	124 (66.0%)	3 (10.7%)	< 0.0001
Other	1 (0.5%)	0 (0%)	0.99
Mother education			0.29
Some Primary	32 (17.3%)	1 (3.6%)
Finished primary	23 (12.4%)	2 (7.1%)
Some secondary	98 (53.0%)	17 (60.7%)
Finished secondary	22 (11.9%)	6 (21.4%)
Some senior secondary	2 (1.1%)	0 (0%)
Finished senior secondary	5 (2.7%)	1 (3.6%)
Some undergrad	2 (1.1%)	0 (0%)
Finished undergrad	1 (0.5%)	1 (3.6%)
Some grad/postgrad	0 (0%)	0 (0%)
Father education			0.94
Some Primary	21 (11.9%)	3 (10.7%)
Finished primary	18 (10.2%)	3 (10.7%)
Some secondary	91 (51.7%)	15 (53.6%)
Finished secondary	29 (16.5%)	3 (10.7%)
Some senior secondary	6 (3.4%)	1 (3.6%)
Finished senior secondary	5 (2.8%)	1 (3.6%)
Some undergrad	2 (1.1%)	1 (3.6%)
Finished undergrad	2 (1.1%)	1 (3.6%)
Some grad/postgrad	2 (1.1%)	0 (0%)

Teachers	n = 97	n = 13
	Mean (SD)	Mean (SD)
Age	30.7 (9.6)	29.8 (5.9)	0.77
Years teaching	6.5 (7.1)	7.4 (5.8)	0.66
Years at school	5.3 (5.8)	5.0 (5.0)	0.82
	N (%)	N (%)
Gender = male	16 (16.5%)	3 (23.1%)	0.55
Language
Nepali	95 (97.9%)	5 (38.5%)	< 0.0001
Bengali	3 (3.1%)	0 (0%)	0.99
English	65 (67.0%)	4 (30.8%)	0.02
Hindi	38 (39.2%)	2 (15.4%)	0.13
Other	0 (0%)	0 (0%)	Not compared
Formal training	11 (11.3%)	5 (38.5%)	0.02

School variables	N = 43	N = 7
	Mean (SD)	Mean (SD)
Number of students enrolled primary	42.0 (34.0)	57.1 (28.8)	0.27
Number of teachers	6.8 (4.0)	9.7 (5.1)	0.097
Monthly Fees (rupees)	453.7 (305.9)	375.8 (90.7)	0.21
Grades taught	N (%)	N (%)
0	38 (88.4%)	6 (85.7%)	0.99
1	38 (88.4%)	6 (85.7%)	0.99
2	38 (88.4%)	6 (85.7%)	0.99
3	38 (88.4%)	6 (85.7%)	0.99
4	37 (86.0%)	6 (85.7%)	0.99
5	10 (23.3%)	3(42.9%)	0.36
6	9 (20.9%)	2 (28.6%)	0.64
7	5 (11.6%)	2 (28.6%)	0.25
8	5 (11.6%)	1 (14.3%)	0.99
9	5 (11.6%)	1 (14.3%)	0.99
10	5 (11.6%)	1 (14.3%)	0.99

*p-value for t-test for continuous variables and chi-square test or fisher’s exact test for categorical variables, as appropriate for expected cell size; significance level set to p < 0.05

Quantitative comparison

Tealeaf and RE-SEED were compared on teacher-rated mental health scores (TRF), caregiver-rated mental health scores (SDQ), and academics (ASER; Table 2). For the TRF, students in Tealeaf had a lower severity level of broad mental health symptoms per the GEE-adjusted multivariable (i.e., adjusting for relevant confounders) comparisons of the Total Problems score (beta = − 6.73, d = 0.70; p = 0.024) and Internalizing Problems score (beta = − 7.30, d = 0.69; p = 0.016) at POST, as compared to children who participated in RE-SEED. As betas represent TRF score changes, these results are clinically meaningful since they could correspond to a child moving from a clinical level of symptoms to a normal level of symptoms (skipping over the middle category of ‘borderline’) as defined by the TRF [16]. Externalizing Problems were significantly lower for students in Tealeaf for raw and GEE-adjusted univariate comparisons, but not for the GEE-adjusted multivariable comparison. Of note, because most teachers contributed TRF ratings for one or two students, the impact of clustering was minimal; indeed, confidence intervals widened slightly, and p‐values changed marginally. Estimates of effect size and overall interpretations were similar to those from the unadjusted analyses.

Table 2.

Comparison of Tealeaf and RE-SEED child mental health symptoms and academic achievement

Child Mental Health Symptoms Reported by Teacher Delivering Care (TRF)
	Tealeaf n = 23	RE-SEED (EUC) n = 104	Raw (unadjusted for clustering)			GEE-adjusted, univariate			GEE-adjusted, multivariable5
	Raw (unadjusted for clustering)		Difference as a Beta Estimate (95% CI)1	p-value2	Effect Size3	Difference as a Beta Estimate (95% CI)1	p-value4	Effect Size3	Difference as a Beta Estimate (95% CI)1	p-value4	Effect Size3
Total problem unadjusted mean (SD)	54.57 (10.16)	61.44 (9.48)	− 6.88 (− 12.55, − 1.20)	0.02	0.70	− 6.95 (− 12.27, − 1.63)	0.01	0.72	− 6.73 (− 12.56, − 0.90)	0.024	0.70
Externalizing problem unadjusted mean (SD)	53.70 (9.19)	58.31 (9.00)	− 4.61 (− 9.41, 0.19)	0.06	0.51	− 4.72 (− 9.33, − 0.10)	0.045	0.52	− 4.08 (− 9.14, 0.99)	0.115	0.45
Internalizing problem unadjusted mean (SD)	54.96 (10.24)	61.91 (10.60)	− 6.96 (− 12.79, − 1.12)	0.02	0.67	− 6.67 (− 12.26, − 1.08)	0.019	0.63	− 7.30 (− 13.22, − 1.38)	0.016	0.69

Child Mental Health Symptoms Reported by Caregiver (SDQ)
	Tealeaf n = 25	RE-SEED (EUC) n = 177	Crude			Adjusted (multivariable5)
			Difference as a Beta Estimate (95% CI)1	p-value2	Effect Size3	Difference as a Beta Estimate (95% CI)1	p-value2	Effect Size3
Total difficulties mean (SD)	20.16 (3.35)	16.60 (5.12)	3.56 (1.50, 5.62)	0.0007	− 0.82	3.79 (1.07, 5.86)	0.0005	− 0.88
Externalizing difficulties mean (SD)	9.32 (3.13)	9.63 (3.35)	− 0.31 (− 1.70, 1.07)	0.66	0.1	− 0.25 (− 1.67, 1.16)	0.73	0.08
Internalizing difficulties mean (SD)	10.84 (1.72)	6.97 (3.90)	3.87 (2.33, 5.42)	< 0.0001	− 1.28	4.05 (2.47, 5.62)	< 0.001	− 1.35
Impact score mean (SD)	2.86 (0.56)	4.91 (4.21)	− 2.05 (− 4.06, − 0.05)	0.04	0.68	− 2.32 (− 4.25, − 0.39)	0.03	0.77

Academic Achievement Obtained by Independent Rater (ASER)
	Tealeaf n = 26	RE-SEED (EUC) n = 183	Crude			Adjusted (multivariable5)
			Difference as a Beta Estimate (95% CI)1	p-value2	Effect Size3	Difference as a Beta Estimate (95% CI)1	p-value2	Effect Size3
Math score sum mean (SD)	5.77 (2.80)	3.80 (2.14)	1.97 (1.06, 2.89)	0.002	0.79	1.58 (0.70, 2.47)	0.0006	0.63
Reading score sum mean (SD)	3.69 (0.74)	2.74 (1.41)	0.95 (0.40, 1.51)	< 0.0001	0.84	0.94 (0.38, 1.49)	0.001	0.83

Relative Risk of Child Still Having Mental Health Symptoms After 1 Year of Tealeaf Care
TRF GEE-adjusted (dichotomous: normal (ref) vs borderline/clinical)	Crude Univariate RR (95% CI) (RE-SEED is reference group)	p-value4	Multivariable adjusted RR (95% CI) (RE-SEED is reference group)	p-value4
Total problem GEE-adjusted	0.70 (0.55, 0.89)	0.0036	0.38 (0.16, 0.92)	0.032
Externalizing problem GEE-adjusted	0.81 (0.65, 1.02)	0.0716	0.74 (0.37, 1.49)	0.4019
Internalizing problem GEE-adjusted	0.81 (0.62, 1.05)	0.1148	Did not converge	n/a

Abbreviations: Teacher Report Form (TRF); Strengths & Difficulties Questionnaire (SDQ); Annual Status of Education Report (ASER); Generalized Estimating Equations (GEE)

(1) Calculated as Tealeaf minus RE-SEED score

(2) p-value for t-test for continuous variables and chi-square test or fisher’s exact test for categorical variables, as appropriate for expected cell size; significance level set to p < 0.05

(3) Calculated as Cohen's d; positive effect size means children in Tealeaf improved scores; negative effect size means children in RE-SEED had improved scores

(4) p-value for z-test in the GEE output; significance level set to p < 0.05

(5) multivariable analyses accounted for child age, child gender, and teacher formal training

Caregiver-rated SDQ outcomes displayed an opposite trend, with caregivers in RE-SEED reporting lower severity of mental health difficulties for their children on the adjusted Total Difficulties comparison (beta = 3.79, p = 0.0005) and the Internalizing Difficulties scale (beta = 4.05, p < 0.001) of the SDQ (Table 2). These score changes may be clinically meaningful as they can represent moving from abnormal to borderline symptom severity levels or borderline to normal levels as defined by the SDQ [20]. Academically, students participating in Tealeaf performed better on adjusted analyses in math (beta = 1.58, d = 0.63; p = 0.0006) and reading (beta = 0.94, d = 0.83; p = 0.001) on the ASER (Table 2). One-point changes in ASER scores correspond to an improvement in grade level, which is academically meaningful.

When examining dichotomous TRF scores, children in Tealeaf had a significantly lower risk of persisting borderline/clinical total problem scores (adjusted RR = 0.38, p = 0.032; Table 2). The RRs for externalizing and internalizing problems did not reach significance, likely reflecting fewer children meeting clinical thresholds in these domains. The multivariable GEE model for the internalizing dichotomous outcome did not converge due to low cell counts across covariate strata, so no stable estimate was obtained for that measure. The dichotomous results show that children in Tealeaf were less likely to remain above borderline thresholds, consistent with the continuous data. However, the nonsignificant RRs in other domains may reflect smaller cell sizes and the complex, variable path from subthreshold to fully diagnosable disorders, as described by Angold et al. [43]. The secondary teachers' TRF ratings (Table 3) were largely congruent with those of the primary rater. Mean scores differed only minimally between the two raters, with no statistically significant differences for any domain.

Table 3.

Comparing POST mental health symptom scores reported by primary teacher raters versus secondary teacher raters

	RE-SEED			Tealeaf
	Primary rater n = 104	Secondary rater n = 97	Paired t-test p-value	Primary rater n = 23	Secondary rater n = 23	Paired t-test p-value
	Mean (SD)	Mean (SD)		Mean (SD)	Mean (SD)
TRF total problem score	61.44 (9.48)	60.54 (10.01)	0.84	54.57 (10.16)	56.1749 (11.0)	0.40
TRF externalizing problem score	58.31 (9.00)	58.48 (9.42)	0.42	53.70 (9.19)	53.04 (10.98)	0.74
TRF internalizing problem score	61.91 (10.60)	60.90 (9.83)	0.73	54.96 (10.24)	55.96 (11.10)	0.68

Abbreviation: Teacher Report Form (TRF)

p-value significance level set to p < 0.05

Qualitative and mixed methods results

Themes on the impact of the Tealeaf and RE-SEED programs were examined side-by-side to understand why teachers may have rated children receiving Tealeaf to have improved mental health symptoms versus teachers rating children in RE-SEED (Table 4).

Table 4.

Comparing themes and illustrative quotes between tealeaf and RE-SEED

Key Theme	Tealeaf Theme	Tealeaf Quote	RE-SEED Theme	RE-SEED Quote
Overall Impact	Effort to implement is justified by children improving	“It has benefitted the children. The children are doing better with it. I spent a lot of my time on this, but when I see the children are improving through this, then I feel it was worth it.”	Limited progress and frustration	“We really tried to help children who showed certain behavioural characteristics but we have not been able to make much progress in this field. Either we are not getting through…or either these children are really difficult.”
Training	Learned new classroom approaches and skills	“Even though we have had many years of teaching experience, I know that our techniques were sometimes flawed. We learnt a lot of new skills in the training, we learnt how to handle, behave, treat and react to the children.”	Positive but basic orientation	“The training was really wonderful; we learnt new things and new approaches on how to work with the children.”
Understanding	Greater awareness of a child's agency and motives	“Earlier we would treat all the children in the same way… We never considered that the academically weaker students needed more attention… These things were brought into our awareness during the training… When we started doing it this way, it helped the students.”	Greater awareness of a child's agency and motives	“ ...there are better ways of handling it, such as talking to the child and making the child listen and understand... .”
Beliefs about Mental Health	Mental health may be affected by teacher actions	“Oftentimes, I would punish the child in front of the entire class… I stopped doing that because I came to learn that treating children in this way would negatively affect their self-esteem… I try to figure out the reason behind the child’s lack of interest…”	Perceived ineffectiveness of non-punitive strategies	“…We would begin by adopting your methods, but then…it wouldn’t go according to what you had told us, and then we would go back.”
Teacher Engagement	Enjoyment and deeper connection with students	“I am enjoying my time with the kids, getting close to them and learning about child psychology… There were a few children in my class who fell in the ‘withdrawn’ category. I would give them various tasks to keep them busy…”	Engagement centered on concrete strategies	“You had also suggested that we drew colourful pictures while teaching the child and also to talk and behave in a friendly manner. I really liked these suggestions.”
Caregiver Engagement	Mixed responses but active parent–teacher dialogue	“The parents come and talk to me about their children…Every parent thinks their child is good; no one wants to consider that their child might be a bit weaker… Some parents said they are grateful and happy that the teachers…are trying to upgrade their child.”	Minimal parental understanding of mental health	“I feel none of the parents understood what mental health is and what was going on in this programme.”
Time	Increased workload	“Since I am multi-tasking, I have not been able to give proper time to the children and the program. I am not giving my 100% to the children because it is very difficult for me.”	Increased workload	“Feels like our workload has increased…We have to come even during our holidays… Finally when we get time to sit and take a break we come and work again.”
Stigma	Guardians resistant to “mental health” labels	“They obviously did not take it positively. The guardians came to me and said my child isn’t mentally challenged so I don’t think my child should do this program.”	Guardians resistant to “mental health” labels	“The parents would cringe at the word ‘mental health’ so we had to approach the topic with alternative names.”

Teachers in both Tealeaf and RE-SEED discussed the impact of the training on their professional development; the impact of the program on their own classroom behaviors and understanding of child mental health; the impact of the program on caregivers; and barriers that influenced program impact, including lack of time and stigma around mental health in the community. The interview commentary was overall consistent between groups.

There were, however, a few distinctions between the experiences of the RE-SEED and Tealeaf groups. Overall, there were more critiques of the program in the RE-SEED group as compared to the Tealeaf intervention group. Teachers in RE-SEED noted that difficulty applying learned therapeutic techniques resulted in a return to previous methods (e.g., traditional punishment techniques), a topic that was not discussed among Tealeaf teachers. By contrast, Tealeaf teachers were more likely to comment on specific therapeutic strategies related to supporting child mental health and on detailed discussions they would have with caregivers as compared to teachers in RE-SEED. Finally, RE-SEED teachers did not mention behaviors related to disorders, something Tealeaf teachers did mention.

Discussion

This study presents the results of a pragmatic, mixed-methods comparison between two teacher-led, task-shifted interventions implemented in India: Tealeaf, an intervention involving a 10-day training and continued supervision/coaching, and its counterpart, RE-SEED, involving a 3-day training with no coaching follow-up. Although the comparison arises from two separate studies, the similarity of the participant cohorts and procedures, with teachers in each arm selecting children to care for whom they perceived had the greatest mental health needs all in 2019, lends itself to a preliminary comparison. Overall, teacher ratings indicate moderate‐to‐large improvements in child mental health in school and academic outcomes relative to the comparator. RE-SEED caregivers, though, reported less severe internalizing symptoms at home. (Of note, the comparator included a level of intervention for the ethical conduct of research; effect sizes may have been greater versus a comparator without intervention.)

Both mental health symptoms at school and academic achievement improved for children in Tealeaf. Though primary teachers rated their students mental health symptoms on the TRF, we interpret this improvement to be genuine. Tealeaf teachers, after a ten‐day training plus supervision, may have been more motivated to see and report positive changes. This motivation, sometimes described as an “investment bias”, could bias teacher ratings toward improvement [44, 45]. However, a comparison between primary and secondary teacher observers showed no difference in scores (Table 3). Though still with a potential for bias, the secondary observer is likely to be less biased, and their scores being no different from primary observer scores lends credence to the primary observer reports [44]. Further, both mental health symptoms in school and academic achievement improved at the same time, and academic achievement was assessed by an independent rater. Because these two outcomes come from distinct sources, with one less prone to the same biases as the teacher, their parallel improvements suggest the mental health changes are not solely an artifact of teacher perceptions [47].

TRF findings are consistent with pre-post improvements in both areas for children in two pilot trials [9, 18]. As described in these publications, the mechanism of action for Tealeaf improving child mental health symptoms is through teachers guiding children to consistently practice coping skills and emotion regulation for long periods of time (a school day) and in real time. Tealeaf teachers interact with children the way a therapist would direct them to if a therapist were available. Here though, teachers learn themselves to determine how therapeutically interact with children as, in most places globally, there are no therapists to guide their interactions. In these publications, teachers also went into more detail about how they used measures such as academic accommodations or teaching lessons differently as their chosen Tealeaf therapeutic measures. Their use of academic measures likely underlies the marked improvement in academic achievement seen in Tealeaf children.

Several factors may contribute to the greater impact of Tealeaf on child mental health in the school setting and academic outcomes. For instance, coaching, present in the Tealeaf intervention but not in RE-SEED, may be a critical component in the greater success observed in the Tealeaf group. Longitudinal coaching relationships have been established as an important component of task-shifting interventions [25, 48]. RE-SEED teachers reported more difficulty implementing program tools, which is an issue potentially addressed by coaching. Indeed, in a separate publication, RE-SEED was predominantly seen by teachers as a psychoeducational intervention that reframed teachers’ beliefs [31]. Thus, coaching may be the component that can transform a psychoeducational program (RE-SEED) into a care intervention (Tealeaf). Coaches can help navigate teachers’ use of strategies and any ongoing difficulties in understanding mental health concepts, creating fewer barriers overall and more implementation success than that which was observed in the RE-SEED group [25, 48].

Another key divergence were differences in teacher understanding of mental health. This may be attributed to differences in Tealeaf and RE-SEED training and the lack of longitudinal support in RE-SEED. Teachers in RE-SEED only received basic information about the significance of mental health and child behavior. The discrepancy in scope of training could be conceptualized as RE-SEED representing a foundational exploration of child mental health needs for teachers and with general communication on support strategies [31]. Meanwhile, Tealeaf conveyed this general framework while further offering highly specific, interpersonal, evidence-based mental health strategies for teachers to apply in the classroom setting [9]. The greater psychoeducational training & coaching and transdiagnostic therapeutic techniques available to Tealeaf teachers may have led to a deeper level of mental health understanding and appreciation for evidence-based care.

Along with these indirect measures of impact, the two groups demonstrated differing degrees of direct impact on both students and teachers in qualitative findings. In the RE-SEED group, the most significant observed impact on children were observed behavioral changes such as increased classroom participation and student willingness to share thoughts with instructors. By contrast, Tealeaf teachers communicated significant shifts in teaching mentality. Tealeaf teachers were able to elucidate the importance and impact of specific strategies such as giving constructive feedback to students in private meetings, and in doing so, communicated an advanced understanding of child mental health, child assessment, and the provision of individualized, child-centered mental health support. This is consistent with task-shifting literature where shorter trainings and less support in stepped levels of care leads to differential levels of understanding [49, 50].

As in the qualitative results, there was a reversion to traditional punishment in the RE-SEED group that was not present in the Tealeaf intervention group. This outcome may be a result of differences in “buy-in” to methods taught in training and how these new approaches support child mental health. This also relates to previously discussed deeper mental health understanding Tealeaf teachers gained; a more advanced comprehension of training may correlate with greater program “buy-in” [51]. In addition, as various cultures differentially promote and discourage specific child behaviors [17, 52, 53], a culturally appropriate coaching relationship may prove beneficial in helping strengthen new perspectives and taught methodologies. This rapport is crucial when program goals involve redefining the role of teachers and schools in supporting an aspect of children’s health that is typically stigmatized [3, 45].

Of note, participants in Tealeaf and RE-SEED did not differ from each other demographically except for a greater proportion of Tealeaf teachers having more of a formal education background. This difference is less likely to meaningfully contribute to Tealeaf and RE-SEED outcome differences in the context of the literature. In education literature, teachers with formal education backgrounds and/or more experience adopt and use new skills less than those with less training or experience [55, 56]. Further, Tealeaf teachers with less formal education were more accurate in nominating students for mental health care [27]. Given the smaller sample of teachers in Tealeaf, whether a difference in teacher education influences Tealeaf or RE-SEED outcomes should be further explored in a powered trial.

In contrast to the observed teacher‐rated improvements, Tealeaf caregivers reported higher internalizing symptoms in their children than RE‐SEED caregivers. Several dynamics may explain this difference. First, in the qualitative data, teachers in Tealeaf noted more of a focus on “withdrawn” children, aligning with a difference in Tealeaf versus RE-SEED training and suggesting they may have chosen students with higher baseline needs & that tend to require more intensive intervention. This may account for children in RE-SEED appearing to have less intense internalizing symptoms at home than children in Tealeaf. Resource constraints prevented the collection of pre-intervention data in RE-SEED to investigate this difference (see Limitations) but may be examined in a future powered, definitive trial. Further, early task-shifting studies showed that individuals with depressive symptoms required more intensive intervention to improve versus other common mental health concerns such as anxiety [57, 58]. If children in Tealeaf were more likely to have withdrawn symptoms, then their symptoms may appear worse at home where supports do not match what is at school. This may account for the difference in symptom severity between home and school contexts for children in Tealeaf. As with the difference between RE-SEED caregiver and Tealeaf caregiver reports, future data collection with pre-intervention data will allow for exploration of this difference.

Second, children in Tealeaf may have had more of a “restraint collapse” at home after working harder therapeutically at school versus children in RE-SEED [59]. That is, they may have had less patience and energy to “hold it together” at home, particularly if no parallel supports are in place there [60, 61]. A known clinical phenomenon, symptoms at home would be expected to also improve over time [60, 61]. Resource limitation prevented follow-up data collection after the trials (see Limitations). This too may be examined in a future trial with resources for follow-up.

Lastly, there may be reporting biases underlying these findings. As above, Tealeaf teachers may have had an “investment bias” influencing their TRF ratings [44, 45]. Teacher report was pursued due to limited resources and mitigated by having a secondary teacher rater, as above. On the other hand, Tealeaf caregivers had more frequent and in‐depth conversations with teachers per teacher qualitative data (e.g., “The parents come and talk to me about their children”), which can spark a caregiver “awareness shift” that caregivers in RE-SEED would not have experienced [29, 44, 62]. As Tealeaf caregivers learned to spot subtle internalizing behaviors and expect more progress, they may have become more likely to report persistent symptoms. Such an effect may have further been magnified by their own “social desirability bias” if they felt compelled to emphasize challenges in order to validate receiving continued support for their child [44, 45]. Teacher and caregiver report was pursued based on limited resources and as validated measures for child self-report of symptoms under age 11 are rare [63]. Future studies with enhanced resources may allow for independent rating of children’s mental health symptoms. In sum, these findings do not necessarily imply that Tealeaf caused worse internalizing symptoms at home. Instead, they underscore the importance of additional home‐based supports and extended investigation to ensure that classroom gains effectively extend beyond the school setting. Further, both teacher and caregiver reports may be shaped by awareness and bias, reinforcing the need to triangulate data across informants, clarify expected outcomes in each context, and strengthen caregiver engagement.

Implications

As noted previously, the SW-CRCT for the RE-SEED group in 2019 was terminated when schools closed due to the COVID-19 pandemic. Considering the greater burden placed on existing mental health providers in LMICs during the pandemic, task-shifting has become critical in providing the same level of care available pre-pandemic [64]. While post-hoc, these analyses may help shape the development of interventions that seek to leverage teachers to address children’s mental health as educational systems must confront new, post-pandemic realities in youth mental health prevalence on a global scale.

The totality of our data suggests children did indeed improve, as elaborated above. However, the discrepancy in reports between teachers and caregivers highlights the need to extend therapeutic strategies into the home. Still, given the known challenges with engaging families in both schools and school mental health interventions [65], findings support continued evaluation of Tealeaf as a school-based intervention with the ability to (1) improve mental health in at least one setting as this may lead to positive outcomes for care recipients, even if imperfect, and (2) improve academics, a known area of struggle for children with mental health needs and a key indicator for future well-being and success [47].

Limitations

The methods involve the post-hoc comparison of participants from two separate trials, an approach that could lead to discrepancies or biases in enrolled participants or analyses. However, the populations under study were similar in baseline characteristics (Table 1). Further, teachers and students were enrolled with the same criteria. Results were relatively consistent across the selected outcomes and in alignment with the expected group differences, lending credence to the analysis. In addition, the intervention group was smaller than the control group. Power calculations, however, indicated that moderate effect sizes could be detected with these sample sizes. The effect sizes found were larger than what was projected to be detected in our power calculations. We were unable to include a no-intervention arm due to local ethical constraints, and thus cannot fully disentangle study outcomes from any background influences (e.g., community events or policy changes). However, both arms occurred in parallel using identical teams and recruitment procedures. Thus, external factors would likely affect both groups similarly, suggesting that the observed differences are robust. Because of resource constraints, only post‐intervention measures were collected for RE‐SEED, limiting our ability to account for any pre‐existing differences in child mental health symptoms. Although baseline data were originally planned, we chose to preserve staff capacity to ensure high‐fidelity program delivery. Further, our POST comparison relied on data we had collected before COVID, precluding assessing whether these improvements persist long-term. Finally, we incorporated a secondary teacher observer to help reduce bias from data from primary teacher observers, but independent raters, not feasible due to resource constraints, would have been ideal. Still, our findings suggest that, although some degree of bias is inherent whenever intervention providers rate their own students, using a second teacher observer mitigated that concern. Future studies should address these limitations and build on the findings presented here.

Conclusions

Results suggest that Tealeaf may have a greater impact on child mental health in school settings and academic outcomes as compared to a shorter version of the program. Results also point to the need to bolster in-home supports to ensure improvements in school translate to the home setting.

Of note, qualitatively, teachers indicated that both iterations of the intervention were impactful and associated with changes in teacher behavior and knowledge around mental health, along with positive changes in child behavior. This may mean that RE-SEED may have a role as a standalone intervention or as a part of a stepped-model of care and that both interventions may be used to improve child mental health.

Although in need of a confirmatory comparison, overall, these results indicate that teachers may be able to have great impact on child mental health and academic achievement in at least one setting by addressing the mental needs of their students through changing their everyday interactions to be therapeutic. This model may thus increase child mental health care access dramatically, everywhere there are teachers and students, and substantially change the trajectory of the many children with mental health needs globally who would otherwise never receive care.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

CMC, KH, and MM designed the study. BNG was involved in study design. CMC, PG, and MM created the teacher training, intervention materials, and intervention and research protocols. PG, SB, and AT delivered the teacher training, provided supervision to teachers, and collected data. CD, RL, and CCS collected data. CMC, MM, and RL provided umbrella supervision for the supervision of teachers by PG, SB, and AT. MML, BW, CMC, and AKR performed quantitative data analysis while RL, JV, SE, CD, MM, and CMC performed qualitative and mixed methods data analysis. CMC, MML, BW, AKR, KH, PG, SB, AT, JV, CD, SE, VCF, RL, and MM were involved in data interpretation. PG, MML, VCF, CD, JV, RL, MM, and CMC drafted the manuscript. All authors revised and approved the final version of the manuscript before submission.

Funding

The results in this publication regarding RE-SEED data was made possible through the Mariwala Health Initiative (MHI); its contents are the responsibility of the authors and do not necessarily reflect the official views of MHI. The results in this publication regarding caregivers’ and students’ Tealeaf data was made possible through the American Academy of Child and Adolescent Psychiatry (AACAP) Junior Investigator Award, supported by Pfizer and Sunovion Pharmaceuticals; its contents are the responsibility of the authors and do not necessarily reflect the official views of AACAP nor the companies listed above.

The results in this publication regarding teachers’ Tealeaf data was made possible through the Early Career Award Program of the Thrasher Research Fund; its contents are the responsibility of the authors and do not necessarily reflect the official views of the Thrasher Research Fund.

Data analysis for this publication was possible in part through generous support from the Doris Duke Foundation Grants #2020-143, #2021-264 and #2023-0238. This publication’s contents are the responsibility of the authors and do not necessarily reflect the official views of the Doris Duke Foundation.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the connectedness of the Darjeeling community, the relatively small sample size of teachers, caregivers, and students included where families may be able to connect which children they know received services, and with mental health continuing to be stigmatized in the Darjeeling area. Participants did not agree to share their data publicly. Requests for data will be reviewed case-by-case by the corresponding authors upon reasonable request.   

Code availability

Requests for code will be reviewed case-by-case by the corresponding authors upon reasonable request.

Declarations

Ethics approval and informed consent to participate

The research protocols and all informed consent forms were approved by the University of North Carolina at Chapel Hill Institutional Review Board and a Darjeeling-based Ethics Committee. Schools: PG, a psychiatric social worker, called principals of area schools to gauge interest. Interested principals discussed with their teachers their interest in intervention delivery and study participation. Teachers: All eligible teachers in participating schools were invited to meet with study representatives (PG) to review study protocols individually and privately. Those interested in participating in the study voluntarily signed a written informed consent. Caregivers: Study representatives (PG) individually privately met with each caregiver to review study protocols for their children and themselves. Those interested in participating and in having their children participate signed a written informed consent. Children: Children greater than 7 years of age were verbally assented individually and privately by PG for participating in the study and were allowed to refuse to participate. As part of our consent form for teachers and caregivers (for themselves and their children) and as part of assenting the children, teachers, caregivers, and children were made aware that findings from the study would be submitted for peer review with the possibility of publication. Any data presented in this manuscript has been de-identified.

Trial registration

The trials were registered on January 01, 2018 with Clinical Trials Registry – India (CTRI), reg. no. CTRI/2018/01/011471, ref. no. REF/2017/11/015895 and on January 25, 2021 on clinicaltrials.gov, TRN NCT04723277 http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27

Competing interests

CMC, PG, and MM hold the copyright to the training materials, decision support tools, and intervention materials for the teacher-led task-shifted alternative systems of children’s mental health care at the center of this manuscript. They have disclosed this interest fully to the publisher.