Written evidence submitted by Mrs Fran Bailey (CYP0004)
I have been a teacher for 20 years and have spent the last 10 years working one to one with young people who have been out of school with anxiety-based school attendance barriers and their families. This work led me to retrain as an occupational therapist, as I felt that this profession is best placed to work with young people with mental health difficulties, in order to prevent these mental health difficulties establishing in the first place. Occupational therapists are trained to work inter-professionally with all staff involved with an individual’s mental and physical health, in order to plan and implement interventions that enable an individual to reach their full potential. I am in my final year, and this is my service improvement plan for children and young people’s mental health provision:
Occupational Therapy Service Improvement Plan Proposal: Early intervention primary school-based occupational therapy mental health provision.
The following 3 statistics from the Department of Health and Social Care and the Department of Education (DHSC and DfE)’s 2017 Green Paper on transforming children and young people’s mental health provision are the basis for this service improvement plan. ‘One in 10 children and young people have a diagnosable mental health condition. Only 25% of young people with mental health issues can access adequate mental health provision. Half of all mental health conditions begin before the age of 14.’ (DHSC and DfE 2018)
In 2017, the DHSC and DfE worked together to explore mental health (MH) provision for children and young people (YP). Their response was the Green Paper: ‘Transforming Children and Young People’s Mental Health Provision.’ (DHSC and DfE 2017) This was then followed up in 2018 by their consultation response. Thirteen weeks of public consultation highlighted the need for ‘better joining up between health and education and providing earlier support. Intervene early and prevent mental health problems arising in the first place.’ (DHSC and DfE 2018) Teachers working with YP out of school with school attendance barriers were relieved to see the DHSC and DfE working together on this as part of the barriers to student attendance has been that Education and Health and Social Care were not working inter-professionally and this fragmentation in services was allowing YP with MH difficulties to fall through the system. This ‘disjointed care’ was also highlighted in Care Quality Commission’s (CQC) ‘Are we listening?’ (2018 p. 27) They recommended use of Sustainability and Transformation Partnerships (STPs) to create ‘joined up mental health support’. (CQC, 2018 p. 47) The Children and Families Act 2014 (The Children and Families Act 2014) set the requirement on local authorities to set out a ‘local offer’ of all services and to jointly deliver MH provision.
The Green Paper (DHSC and DfE 2017) proposed that schools ‘identify a Designated Senior Lead for Mental Health to oversee the approach to mental health and wellbeing’ and that Clinical Commissioning Groups (CCGs) fund ‘new Mental Health Support Teams whose work will be managed jointly by schools, colleges and the NHS. These teams will be linked to groups of primary and secondary schools and to colleges, providing early interventions to support those with mild to moderate needs and supporting the promotion of good mental health and wellbeing’. Anna Freud from the National Centre for Children and Families set up a PG Diploma in Educational Mental Health Practitioner (EMHP) which is now being used to train this workforce. The new EMHP role evidences the government’s ‘ambition for earlier intervention and prevention.’ (DHSC and DfE 2017) CQC (2018) reviewed children and YP’s MH services and reinforce the view that focus should be on prevention, and ‘increased support for young people with lower-level mental health problems to help prevent problems from escalating, and earlier interventions for children with emerging mental health problems’ (CQC, 2018 p. 34). Clinical Governance stresses the importance of ‘prevention’ in Chapter 2 of the NHS 2019 long term plan. Teachers commonly work with children as young as 5 years old, who have been referred to alternative school provision. Therefore work on preventing MH issues from establishing needs to begin as soon as children start school. Children’s Mental Health Week 2021, Place2Be and more than 30 other leading MH charities and organisations have supported the Evening Standard’s Young London SOS campaign for investment in ‘prevention rather than cure’. (Place2Be’s Children’s Mental Health Week 2021) noting that the COVID Pandemic has made an already bad situation even worse. This campaign highlights that CCGs currently ‘spend less than 1% of their overall budget on children’s mental health services and 14 times more on adult mental health services.’
Powers et al. (2016) and Meagher et al. (2019) explored school-based early MH interventions and found that ‘early education settings play a critical role in the identification and treatment of mental health symptoms.’ The Committee on School Health (2014) noted that schools are ‘well positioned to recognise signs and symptoms of MH needs for students and that research is overwhelmingly finding that schools are an effective environment for addressing them.’ The government response document (DHSC and DfE, 2018 p. 15) also highlighted the need to support the identification of ‘at risk children exhibiting signs of mental ill health’. These signs are listed as ‘mild or moderate conditions including: anxiety, low mood and common behavioural difficulties’. Public Health England (2016 p. 5), Tomb et al. (2004), Donavan and Spence (2000) and Greenberg et al. (2001) all list protective factors that can cause MH difficulties and risk factors for anxiety as: communication difficulties, low self-esteem, poor attachment, parents with mental illness, emotional difficulties, parental anxiety, interpersonal problems and Trauma.’
Tomb and Hunter (2004) talk of a 3-tiered prevention model to treat anxiety disorders, ‘Universal, selected and targeted levels of prevention.’ (Greenberg et al. 2001) The ‘Universal’ level of prevention is a whole school approach and aims to minimise the stigma risk. The ‘Selected’ level of prevention ‘targets a subgroup with biological or social risk factors, whose risk of developing a mental health disorder is significantly higher than average and who may not respond to a universal intervention.’ The ‘Targeted’ level of prevention targets individuals and their families and focuses on ‘social skills training or parent-child interaction training.’ (Greenberg et al. 2001) The Green Paper’ (DHSC and DfE 2017) discusses whether ‘in school mental health provision’ was stigmatising, but consensus was that
‘the school environment is well suited to a graduated approach to children’s mental health, where children at risk can be identified and interventions can be offered to address problems. As the school environment can present triggers for many difficulties (such as social anxiety), it is therefore also a good place to find support to manage them. The school environment is non-stigmatising, making interventions offered in this context more acceptable to children and young people, and their parents’.
The CQC (2018 p. 24) also discuss whether early MH intervention should take the form of whole school, targeted small group or individual interventions. In Southwark, a primary school piloted a whole school approach by working collaboratively with the Maudsley NHS foundation trust to ‘improve pupil’s emotional resilience, strengthen their academic performance, reduce their anxiety and help them manage interpersonal relationships effectively.’ The school then saw a reduction in referrals to MH services. The ‘Thrive Framework’ (Wolpert et al. 2019) has a whole school approach training programme in which teachers are trained to do whole class provision on building emotional resilience. Thrive have also designed the ‘Link Programme’ which is a national initiative being rolled out over the next 4 years, which has been ‘designed to enable collaboration between education and mental health professionals’ funded by DfE and supported by NHS England and led by the Anna Freud Centre. (Wolpert 2018)
The House of Commons Health Committee (2014 p. 15) described interventions to manage anxiety as ‘targeted work with small groups of children to develop problem-solving approaches.’ It lists specific approaches as: group based cognitive interventions; behaviour focussed interventions; and play based approaches to develop a more positive child/parent relationship. Public Health England (2016 p. 8) also talks of the importance of building resilience, which it breaks down into building social, self-regulation, problem-solving and positive relationship skills, as well as developing stronger family relationships. Public Health England (2019 p. 9) set up a special interest group to research ‘universal approaches to improving children and young people’s mental health and wellbeing’. It identified key prevention evidence and how that can be used to support every school’s designated senior lead for mental health and the new mental health support teams. The research identified the key universal intervention aims as ‘preventing behavioural difficulties, promoting resilience, preventing emotional difficulties and promoting subjective wellbeing.’ The Department of Health and Social Care (DHSC) and NHS England (2015) ‘Future in Mind’ document recommends programmes of intervention and support to ‘strengthen attachment between parent and child, build resilience and improve behaviour.’(2015 p. 15) Tomb et al. (2004) discuss ‘protective factors’ to prevent children developing anxiety. They see ‘resilience’ building as the core protective factor, so teaching coping skills to children as early as possible. DHSC and DfE (2017) highlight secure attachment with a parent or carer as a protective factor, ‘babies with insecure or disorganised attachment issues are at a greater risk of encountering a range of emotional and behavioural problems as they develop and a subset of these children are more likely to be diagnosed with a mental health problem in early adulthood’. The Green Paper (DHSC and DfE 2017) aims to commission ‘further research into interventions that support parents and carers to build and/or improve the quality of attachment relationships with their babies’. ‘Theraplay’ is specifically a play-based intervention that focuses on parent-child interaction training. Siu (2009) describes Theraplay as a play therapy that aims to ‘reduce internalising problems’. In her study children described as ‘at risk’ for developing internalising problems ‘showed significant differences in their internalising symptoms’ post Theraplay interventions. Rye (2008) found that children in play therapy gain a more secure attachment with their parents, which leads to the child forming more satisfying peer relationships, and learning the ability to self-regulate. Chinekesh et al. (2013) studied the effect of group play therapy on social-emotional skills in pre-school children and found that it ‘enhanced the self-awareness, self-regulation, social communication, empathy and adaptability in children.’
There are many projects that have been set up recently in the UK to run primary afterschool or in school groups in developing emotional and social resilience, or to set up whole schools that employ teachers alongside health care professionals: Unlocking Potential (Unlocking Potential 2021) is a local pilot scheme; Pyramid Club (University of West London 2021), and Thrive Outreach (Thrive Education 2020) are paid for by schools or parents. There have been pilot projects internationally that have explored a variety of school-based interventions and measured the effects on social-emotional problems, but these have not been OT focused and no projects have yet led to a whole system provision. Although the Thrive ‘Link Programme’ (Wolpert 2018) seeks to make a system change to how education and health professionals work together.
Kendall (1994) developed the CBT ‘Coping Cat’ anxiety program which gets children to ‘develop, implement and plan their own gradual exposure to people, places or things that they fear, using cognitive, behavioural and physiological coping techniques.’ (Tomb and Hunter, 2004 p. 97) This intervention is a 16 session approach for treating anxiety disorders in children, and uses CBT as a prevention rather than as a treatment method. Public Health England (2019 p. 39) listed interventions that their research showed to be ‘promising’. ‘Fun Friends’ (Early Intervention Foundation 2017) is a ‘selected’ (Greenberg et al. 2001) small group session for children aged 4-7. It is a play-based experiential learning approach to provide cognitive behavioural skills. It aims to increase coping and problem-solving skills through stories, games, videos and activities and involves regular group sessions for parents also. Pahl and Barrett (2010) evaluated the Fun Friends program and found that it had a significant impact on preventing anxiety and improving social and emotional skills. This intervention was the only international small group/family intervention that Public Health England found to be promising. Most of its other promising interventions were whole school ‘universal’ (Greenberg et al. 2001) programs. The ‘Penn Prevention Program’ (Public Health England, 2019 p. 39) was designed to ‘build up resilience, promote realistic and adaptive coping skills, and to develop decision making and problem solving skills’. ‘Promoting Alternative Thinking Strategies (PATHS) (Public Health England, 2019 p. 40) promotes ‘emotional and social competencies’ and aims to ‘reduce aggression and behaviour problems’ for primary aged children.
The CQC review document highlighted the problem that ‘only 50% of the children referred to Children and Adolescent Mental Health Services (CAMHS) are accepted for treatment’ (CQC, 2018 p. 19) Teachers find that YP who have been out of school for 2-3 years have not been able to engage with or access CAMHS support as either their needs were not deemed severe enough, or their agoraphobia led to them being unable to visit the CAMHS support worker within the 4 session window. If the student could not engage within this time frame, they would be discharged from this support. During a conversation with a CAMHS lead, it was stated that ‘this cohort is difficult to engage, so prevention and early intervention is vital.’ The House of Commons Health Committee reported on CAMHS (2014 p. 9) and stated that ‘the focus of investment in CAMHS should be on early intervention.’ This document also reports that ‘early intervention avoids YP falling into crisis and avoids expensive and longer term interventions in adulthood’ (House of Commons Health Committee, 2014 p. 10) CAMHS support is deemed as Tier 2. The current structure dictates that specialist mental health professionals only work with YP who have been referred to their services once mental health issues have become established. They do not have a base in schools and support is either in the family home or in CAMHS property. School staff and GPs are Tier 1. They identify that the YP has a MH problem and refer to Tier 2. If that YP’s needs are not deemed severe enough, then the YP has no support other than the Tier 1 teacher outreach provision. They therefore have no access to MH support and their problems can then escalate to needing higher tier support in the form of inpatient MH support. The Green Paper (DHSC and DfE 2017) discusses a change in the tier system. ‘Almost half the country is considering adoption of the ‘i-Thrive’ model, through which services and professionals focus on the needs of the individual, rather than condition or diagnosis. This is helping move away from the traditional ‘tiers’ of support for mental health based on service boundaries.’
RCOT (2018 p. 5) identifies OT as one of the key MH professions. In this document RCOT reiterates the importance of early intervention in mental health and makes a case for OT to be ‘effectively incorporated’ into MH services as a ‘government priority in order to reduce pressure on other parts of the health service’. RCOT advocates OT as a core part of a multi-disciplinary team and key to ‘improving access to services and integrating mental and physical health. Inpatient units with higher OT input, have the shortest lengths of stay by up to 20%.’ (RCOT, 2018 p. 6) OTs are moving out of traditional services and offering OT in new innovative and cost effective ways’. Health Education England states that OTs have a fundamental role to play in the delivery of the 5 Year Forward View of Mental Health, particularly in tackling education.’ (Health Education England 2017) Issues of MH funding in schools were highlighted by DHSC and DfE (2018) as to whether school-based MH services should be paid for by the school or by CCGs. The funding consultation response was 25% to school lead, 24% to charity lead, and 21% to CCG lead. So opinions are split, but all agree that this support should not be another add on to teacher workload. Therefore the Designated Senior Lead for Mental Health should not be a teacher. Their salary could be paid for by both CCGs and Education. CCGs have already agreed to pay for the training and employment of EMHP staff. This would lead to truly ‘joined up’ (CQC, 2018 p. 47) working.
This business plan is for an upstream service improvement project that sets up primary school OT MH provision that aims to prevent MH issues from establishing. There are 2 options for appropriate settings: One is to be employed by the school as the Designated Mental Health Lead; the other is via CAMHS, but as Tier 1 provision. The school setting would require long arm supervision from a CAMHS OT. The CAMHS setting would be role emerging as they only currently do Tier 2-4 provision.
The new ‘Designated Senior Lead for Mental Health’ in primary schools should be an OT with teaching experience. The newly trained ‘Mental Health Support Teams’ staff will be support staff. They will be managed by the Designated Lead, so will not be responsible for decision-making. OTs should have a leadership role to oversee and manage primary school MH provision, as OTs are trained to work as part of a multi-disciplinary team; trained to lead provision; and OTs can work with people in a more stream-lined way because they are uniquely trained to address both mental and physical health at the same time’ (RCOT, 2018 p. 6). Occupational Therapy should increase its ‘scope of practise’ to include MH provision in primary schools as a systems level provision. Currently OT provision for school age children is either through paediatric OT working on physical and sensory development or with CAMHS provision working tier 2-4 with established mental health difficulties. Preventative MH OT provision in schools is a role emerging area. RCOT now has MH occupational therapy as one of its Top 10 research priorities; ‘How can OT services be more inclusive of both mental and physical health?’ (RCOT 2020)
OT MH provision in primary schools, should be established via emotional and social wellbeing play-based ‘selected’ (Greenberg et al. 2001) groups that are underpinned by play therapy, Theraplay and CBT strategies, so focus on building emotional and social resilience, increasing self-esteem, problem-solving and social skills, emotional regulation, and that work through attachment issues and children’s relationships with their families. This provision should also support children through their transition into secondary school, as DHSC and DfE (2018) found that there is a need for ‘greater focus on transition periods in children and young people’s lives.’ Certainly teachers find that most referrals for alternative education provision, follow YPs unsuccessful transition into secondary school.
The Royal College of Occupational Therapy lists the following in its ‘Code of Ethics and Professional Conduct’. ‘Your practice should be focused on enabling individuals, groups and communities to change aspects of their person, the occupation, or the environment to enhance occupational participation’ (adapted from World Federation of Occupational Therapists 2010). This service improvement plan aims to:
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March 2021