From recognition to follow-up: A mixed-methods study of care coordination for students at elevated mental health risk...

Adolescent mental health needs are increasing, yet schools vary in how effectively they translate early concerns into coordinated support for students at elevated risk. This qualitative-dominant sequential exploratory mixed-methods study examined higher-tier school mental health support in Chinese junior secondary schools. Interviews with 40 adult stakeholders from six schools in Zhejiang Province, supplemented by 27 school documents and 24 reconstructed support pathways, informed a follow-up survey of 198 respondents across ten schools. Adult stakeholder accounts indicated that variation in ecological support capacity was accompanied by differences in information sharing, role coordination, referral processes, and continuity of support. Two fragile transitions were especially evident: from family contact to referral decision-making and from external referral to school follow-up. Survey data were treated as secondary descriptive evidence rather than as a basis for defining or statistically confirming qualitative school profiles. The study reframes higher-tier support as a cross-boundary implementation pathway involving recognition, family engagement, referral, and follow-up, and identifies continuity of support as a distinct implementation outcome.