Written evidence from University of Bristol (CMH0117)
This written evidence was prepared by Dr Judi Kidger and submitted on behalf of the WISE (Wellbeing in Secondary Education) study team.
Dr Kidger is a Research Fellow in Public Health at the School of Social and Community Medicine, University of Bristol. She has led on a number of research studies exploring the connection between the school environment and student mental health and wellbeing, focusing particularly on secondary schools and the teenage years. Dr Kidger is currently the Chief Investigator of an NIHR funded randomised controlled trial (the WISE study), which is an evaluation of an intervention that seeks to improve the mental health support and training available to secondary school teachers, using Mental Health First Aid as a training package (http://www.bris.ac.uk/social-community-medicine/projects/wise/).
Executive Summary
Main Submission
1. There are a range of ways in which schools can contribute to improving resilience, promoting mental health and wellbeing, and supporting children and young people with mental health problems. Several programmes have been developed for use within the classroom, primarily aiming to develop coping skills or to educate about various mental health issues, and young people themselves generally favour the idea of lessons in which they can learn more about emotional health and wellbeing [1]. However, evaluations of such programmes to date have only provided limited evidence of effectiveness in improving mental health outcomes [2, 3, 4]. Further, schools struggle to allocate time to focus explicitly on this topic within the curriculum, and teachers report a lack of training in how to address it, particularly as it is often left to tutors to cover during tutor time, rather than more specialist PHSE teachers [1]. A baseline audit of 25 schools in England and Wales participating in the WISE study found that just under half did not provide any curriculum content on emotional or mental health and wellbeing. Making personal, social and health education (PSHE) statutory, and including mental health and wellbeing as a core element, would help ensure it was given curriculum time, and that teachers with the right expertise were delivering the lessons. However, careful planning is needed when deciding how to address mental and emotional health related topics in the curriculum; young people express concerns about the stigma of discussing emotions in the public forum of the classroom, which might undermine any value of such lessons, particularly if delivered by teachers whom they would they encounter at other points in the school day [1]. An alternative way to make use of the curriculum is the scope that exists to learn about mental health and wellbeing more implicitly through other curriculum subjects. Young people report that a whole range of subjects from the humanities, through the arts to sport enable them to explore and develop their understanding of emotions, and even to find relief from difficult feelings, in a relatively ‘safe’ way [1]. If initial teacher training included consideration of the importance of supporting student mental health and wellbeing, and reflection on how different disciplines might do this, then such opportunities could be capitalised on.
2. Any work within the curriculum focused on mental health and wellbeing must be within the context of consideration of the wider school environment. Evidence from longitudinal studies shows that the school environment has the potential to have a significant impact, positive or negative, on children and young people’s mental health and wellbeing. Previous studies have found that perceiving school staff to be supportive, and feeling happy and connected to school predicts lower rates of depression and self-harm during the teenage years [5, 6]. Conversely, difficult teacher-student relationships in secondary school have been found to predict childhood psychiatric disorder and exclusion from school three years later [7]. Young people themselves identify relationships with teachers as having a significant impact on how they are feeling, with treatment from teachers that is perceived to be unsympathetic or unfair potentially adding to emotional distress that they are already experiencing [1]. Other aspects of the school environment identified by students as triggers for emotional distress are bullying from peers and pressure of school work. Conversely, young people also discuss ways in which schools might support their mental health, for example through the provision of ‘safe’ spaces to work through emotions, small support groups and where staff role model more positive relationships [1]. Recent relevant government initiatives such as the Healthy Schools Programme and SEAL (Social and Emotional Aspects of Learning) have included a strong focus on the school environment through the application of a whole school approach to addressing health and wellbeing needs. Such an approach, as well as addressing key features of school-life likely to impact on mental health and wellbeing, is also likely to be more sustainable, as it creates an appropriate context and norms within which more specific work supporting mental health and wellbeing can be developed.
3. Although the quality of day to day relationships between teachers is important for student mental health, young people also report that they would value having someone they can talk to in confidence who is not related to their schooling in any other way. A majority of secondary schools provide counsellors, but this is not a universal provision, and even where counsellors are employed they are often part time, and not always easily accessed by students. What young people say they want is an adult whom they can approach directly and in confidence, without needing a referral, who will listen to them non-judgementally, and be able to provide useful information and advice [1]. Various staff members in schools can and do fulfil this role – including school nurses, counsellors, learning mentors and chaplains – but provision is variable, with some students unable to access such help if needed. It is crucial that such an individual has strong links to the local Child and Adolescent Mental Health (CAMHS) team, to gain advice and also make referrals, as this could be one important way of identifying students at risk of developing a mental disorder and ensuring they receive appropriate, timely support from mental health services. Many schools currently have very limited contact with CAMHS workers, therefore even if staff members are approached by a vulnerable student, they do not always have the knowledge or resources to establish what help is needed, and to secure that help. The CASCADE training organised by the Anna Freud centre (http://www.annafreud.org/service-improvement/service-improvement-in-schools/cascade-schools-and-camhs-partnership-training/), aims to build stronger links between schools and CAMHS teams. This is a relatively new initiative, and the extent to which this aim has been met successfully is not yet clear.
4. Despite the key contribution teachers can make to bolstering or diminishing student mental health through their day to day interactions, teachers report little or no training in how to support students’ mental health [8, 9]. Evidence shows that teachers are the professionals who have the most contact with children and young people about mental health issues [10]. Introducing training about childhood and teenage mental health during both initial and in-service teacher training, including ways to promote resilience, how to respond to a student who is distressed and how to identify a student at risk of developing a mental disorder, would be a useful way to support teachers in knowing how best to help vulnerable students. In our audit for the WISE study, we found that less than half of the 25 schools provided any training for teachers relating to student mental health and wellbeing. Further, none of the schools had a policy explicitly relating to student mental health and wellbeing, although most had policies on related issues such as safeguarding and bullying. This suggests that any provision to support mental health and wellbeing, be that teacher training, curriculum led work, or one to one and small group support, will at best be piecemeal, rather than part of an overall strategy which is clear to the entire school community.
5. As well as reporting a lack of training in how best to support students, teachers also discuss that they themselves do not always feel well supported with regard to their own mental health and wellbeing needs [8]. Teaching can be a stressful job, involving a great deal of ‘emotional labour’ [11], in which teachers have to engage in careful management and expression of their own emotions, while having to constantly engage, enthuse and motivate students, some of whom may be displaying difficult behaviours or emotions. Teachers have poor rates of wellbeing and high levels of depression compared to the general population [12], therefore ensuring that the mental health of this group of professionals is properly supported represents a valid public health concern in its own right. Further, given the impact teachers can have on student mental health via the quality of their day to day interactions, there is also likely to be a knock on positive effect for student mental health. A recent, unpublished analysis of baseline data collected from the 25 schools participating in the WISE study has shown a moderately strong, positive association exists between teacher and student wellbeing within schools. Although this may be explained in part by shared factors within the school environment impacting on the wellbeing of both, it also suggests a symbiotic relationship may exist between the two.
6. The WISE (Wellbeing in Secondary Education) study is a cluster randomised controlled trial of an intervention that addresses this need for improved teacher mental health training and support. Twelve schools have been randomly selected to receive Mental Health First Aid (MHFA) training for schools and colleges for up to 16 teachers. They will also receive the two day standard MHFA course for up to 16 further staff, who will then go on to provide confidential peer support to colleagues, and a one hour mental health training session for all teaching staff, which raises awareness and provides ideas for increasing resilience and support. A group of 13 schools will continue with usual practice and will act as a comparator. MHFA training for schools and colleges specifically seeks to equip teachers and other staff to support student mental health, and to identify those at risk of developing a mental disorder. MHFA has a good evidence base regarding improvements to knowledge and confidence in helping others, but to date no study has provided evidence of improvements to mental health outcomes [13]. Our study will contribute to this knowledge gap, by examining whether teacher and student wellbeing has improved, and levels of psychological difficulty decreased, following the intervention. These findings will be well placed to inform the recently announced roll out of MHFA for all secondary schools. We are also measuring impact of the intervention on teacher absence and work performance, and student attendance and attainment. We recognise that schools are ultimately most concerned with students reaching their potential academically, and this is what they are judged on. A large international review of over 200 interventions focusing on development of social and emotional learning found such interventions also led to an improvement in academic performance [14]. Another study has shown an association between good quality teacher-student interactions – measured in terms of emotional support as well as classroom organisation and instructional support – and higher levels of student academic achievement [15]. It is vitally important to add to this evidence base, thereby convincing schools of the importance of supporting mental health and wellbeing, by exploring the connections between interventions to improve mental health and wellbeing and student learning outcomes.
In summary there are a number of ways in which schools can improve learning about mental health and wellbeing, support students experiencing distress or difficulty and improve early identification of those at risk of a mental disorder. More evidence is needed regarding the most effective approaches in these areas. Further, it is vital that teachers are provided with sufficient training and support themselves if they are to successfully fulfil their central role in improving student mental health and wellbeing.
References
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