Written evidence from The Association for Child and Adolescent Mental Health (CMH197)
The Association is committed to multi-disciplinary research and practice within child and adolescent mental health. It does this through publication of new research findings and dissemination of innovative practices. We are a membership organisation that brings together professionals from a range of disciplines to advance standards and support the professional development of all those working to support the mental health of children and young people.
About this Response
This response was led for the Association for Child and Adolescent Mental Health by:
Professor Kathy Sylva, OBE, FBPS, FAcSS, University of Oxford
With contributions by:
Professor Stephen Scott, CBE, FRCP FRCPsych, Kings College London
Dr Julia Hardy, British Psychological Society Division of Educational and Child Psychology
Aghogho Omonigho, University of Oxford
Introduction: mental health and schools
This century has seen a marked increase in mental health difficulties (Collishaw, Maughan, Natarajan & Pickles, 2010), with schools now viewed as ideal settings for reaching vulnerable/ undiagnosed children and young people. Schools should be the centre for prevention of poor mental health, the place where individual wellbeing is fostered and referrals are made for those who require more specialised services.
1. Promoting emotional wellbeing and building resilience, and establishing and protecting good mental health
1.1 Rationale for promoting good mental health in children and young people
There is a strong case for investing in the mental health of children and young people. ‘ The long term cost to our economy of mental health problems has been estimated to be as high as £105bn per year and three quarters of these problems emerge by the age of 18’ (Educational Policy Institute, 2016). These costs include:
There is increasing evidence of a gender gap, with boys more likely to demonstrate ‘externalising’ problems (conduct disorder or ADHD) and girls demonstrating ‘internalised’ conditions such as depression and anxiety (EPI 2016; Sammons et al. 2014).
Children spend more time in school than in any other institutional structure. Next to the family, schools play the largest role in children’s development, including their skills at problem-solving and teamwork, emotional regulation, social inclusion and citizenship. Education can make a major contribution to supporting wellbeing and resilience in all young people, and identifying those in need of specialist services.
1.2 The Effective Pre-school, Primary and Secondary Education study (EPPSE) study on 3,000 secondary students in England (Sylva et al, 2014) found that a ‘positive school climate’ led to increased mental well-being as well as higher academic attainment in GCSEs. Improving mental health is a ‘win-win’ strategy.
1.3 Wellbeing for all students – promoting positive relationships in mentally health schools
For every child with a recognised mental health problem there are many others struggling with serious family problems, often leading to truancy or bullying, or a combination of these. A mentally healthy school is a first and powerful step in prevention of more serious illness and promotion of high achievement. The EPPSE (Sammons et al., 2014) showed that young people had higher levels of mental well-being in school where there was an emphasis on positive relationships between students and between teachers and students, in terms of trust, respect and fairness. This same study showed that schools with a higher scores on ‘positive relationship’ had students who scored lower on hyperactivity and also on anti-social behaviour. Clearly investing in positive relationships has beneficial effects on both well-being and attainment in GCSE scores.
1.4 The curriculum for all children and young people
A school curriculum that fosters good mental health can be a powerful tool to prevent the development of serious mental health challenges. Personal Social and Health Education (PSHE) provides an opportunity for teaching of social emotional skills such as coping with peer pressure, ‘talking about problems’, building emotional and social resilience in the face of adversity.
The Department for Education prioritised PSHE through its ‘Social and Emotional Aspects of Learning’ (SEAL) programme, widely implemented a decade ago. SEAL is for students 11–16 years; it is a whole-school approach designed to improve learning and attainment, positive behaviour, regular attendance, and the emotional well-being of all staff and pupils (Department for Education & Skills, 2007; Kidger et al., 2010). SEAL was designed to be flexible, to allow schools to tailor it to their own contexts and needs (Weare, 2010) and this is reflected in a lack of prescribed instructions, specific lessons or a fixed model for implementation. The national evaluation of SEAL in found that there was no significant impact on pupil outcomes in terms of social and emotional skills, mental health difficulties and behavior (Lendrum et al., 2012). Although teachers were favourable about the SEAL ‘open’ approach, its implementation was variable. There is an urgent need to re-think PSHE, focussing on programmes with a strong research base in terms of proven effectiveness and avoiding the light touch of SEAL. Making a difference requires intensive and structured approaches.
The’ FRIENDS for Life programme’ is a targeted , 10 session cognitive behavioural intervention delivered to children in small groups using role play and interactive activities. It is aims to reduce anxiety while developing self-esteem and resilience through improving coping skills, e.g., teaching children to relax, identify unhelpful thoughts and then change these thoughts to overcome everyday problems (Stallard et al., 2007). When compared to a control group, participants in the FRIENDS for Life programme show a significant reduction in anxiety (Barret et al., 2006). The World Health Organisation (2004) support the programme as it ‘appears to be efficacious across the entire spectrum, as a universal prevention programme, as a targeted prevention programme and as a treatment’.
1.5 Classroom management
There are several well evidenced programmes that train teachers in effective classroom management. These include ‘The Incredible Years Teacher Classroom Management Course’ (Reinke et al., 2012) and ‘The good Behaviour Game’ (Kellam et al., 2011). Investing in training of teachers in positive ways to promote good behaviour will lead to enhanced peer skills and emotional regulation, which in turn will have positive effects on academic performance.
1.6 Designated leads for Mental Health in every school
Every school should have a designated lead for mental health. In primary school this might be the SENCO (but with enhanced training in mental health). It is proposed that all secondary schools should have a specially designated person with responsibility for mental health, sharing responsibility for ‘behaviour’ and perhaps leading on the PSHE curriculum. The designated Mental Health Lead would be the named liaison person with CAMHS and could facilitate quicker and a more ‘triaged’ referral to CAMH for those with the greatest need.
1.7 Inspection
The largest driving force in school practice is the Ofsted inspection system. If Ofsted criteria are detailed and strict on mental health in school, then heads/managers (and governing bodies) will invest in it. There is growing pressure from Ofsted to use ‘evidence-based approaches’ when spending the Pupil (poverty) Premium; similar pressure could be applied to schools for adopting evidence based mental health curricula and interventions.
2. Targeted Support for young people with more serious mental problems
2.1 Psychological therapies in school settings
Behavioural and cognitive-behavioural interventions are particularly promising; yielding effects sizes twice those achieved by other preventive programmes (Stallard et al, 2007). Some are led by outside professionals and others by a member of school staff who has received intensive training in a manualised programme. Locating parent programmes in school buildings improves attendance at sessions and reduces potential stigma associated with mental health issues (Stallard et al. 2007).
Some schools employ their own counsellors to support students ‘at risk’ but not suitable for the specialist services of CAMHS. One well known programme of in-school counselling is run by Place2Be (Lee, Tiley & White, 2009) which trains counsellors who provide care for children, based on the assessed needs of the child. This programme has shown some promise in studies without a control group, but more rigorous evidence is needed.
There is scarce evidence that school counselling is effective for moderate or severe anxiety or depression. Similarly, there is scarce evidence that counselling reduces moderate to severe disruptive behaviour, whereas there have been scores of randomised controlled trials proving the effectiveness of evidence-based parenting programmes. Therefore, we argue that efforts to increase Educational or Health provision for moderate/severe emotional and behavioural difficulties should include access to skilled interventions for anxiety and depression such as CBT, and equally, well-managed parenting programmes, not just individual counselling.
2.2 Links between schools, CAMHS and local authority teams
Better awareness of emotional behavioural difficulties at school will lead to more recognition of difficulties that require more specialist intervention, such as ADHD, eating disorders, more severe depression, autistic tendencies, etc. This will require a good link with CAMHS services and there will be an increased demand for assessment and treatment, since at present less than a quarter get such specialist treatment.
A recent study of health professionals and local authority staff responsible for welfare (EPI, 2014) reports a recurring concern about engagement with schools. They found a range of barriers to effective engagement, such as the recent changes to the education system, with a reduced role of local authorities and a proliferation of multi-academy trusts, each with different governance structures. This made it difficult for health staff to know how best to engage with schools and for school staff to collaborate on a mental health issue with a neighbouring school belonging to a different chain.
3. Building skills for professionals
3.1 School staff and those from children’s centres report feeling ill-equipped to deal with mental health problems (Sylva et al. 2013). Workforce difficulties are a key barrier to the implementation of the vision set out in Future in Mind (EPI, 2016). ‘Conceptualisations of the same child can vary according to the professions, such that a child with depression can be perceived to be failing academically, disengaged, or even cognitively impaired, or alternatively might be regarded as having poor motivation or low self-esteem’ (Fazel et al., 2014). Substantial differences exist between mental health services and educational services, including professional qualifications, funding mechanisms, and the criteria by which a child's eligibility for access to services and outcomes are judged. The problems of staff from different professions working together could benefit from further focus in the government’s forthcoming workforce strategy (EPI, 2016; Civil Service, 2016).
3.2. Recent Education Policy Institute (2016) research has highlighted that teachers in England work longer hours than in most other countries, and that this hindered teachers’ access to continuing professional development. One health leader explained to the EPI Team that school staff had not time to attend their meetings. Teaching is a stressful profession and managing difficult behaviour in the class is a large factor contributing to stress, burn-out and teachers leaving the profession. Programmes such as the Incredible Years Teacher Classroom Management Course’ could lower teacher stress and a current trial is underway (Ford et al., 2012).
3.3 There is growing acknowledgement of an expanded role for Educational Psychologists (EPs; Squires, 2010; Squires & Caddick, 2012). Actively working with the child is only one element within a wider educational system which hinders or supports the person receiving psychological therapies. EPs have an important role in changing the educational system, not just the child. EPs aim to change perceptions of mental health and emotional wellbeing through awareness-raising activities in schools and communities (Psychological Therapies in School Settings, BPS, 2016). They provide training for school staff to increase their knowledge of mental health and help schools create environments where children and young people are supported to be resilient and mentally healthy.
3.4 The curriculum of initial teacher education (ITE) is crowded and contested. However time devoted to promotion of a positive school climate will lead to dividends in mental health and also in academic attainment. ITE programmes need to incorporate curricula targeted at the most common mental health issues present in schools. These curricula include mental health screening and identification of common presentations of mental health problems. Similarly, training teachers in mental health promotion can help teachers feel less overwhelmed by the emotional and behavioural challenges in their classrooms as well as assist in identification and referral (Fazel et al., 2014) . Just as the programmes implemented in schools need to be evidence based, initial teacher training (ITT) needs a strong evidence base too. The recent Carter Review of ITT recommended that future training should provide a foundation in child and adolescent development, including emotional and social development, which will underpin their understanding of mental health provision (EPI, 2016). This will required changes in the teacher training curriculum, followed by rigorous evaluation of their impact.
3.5 Serving teachers need to develop skill at the early identification of mental health problems; this will be the basis for addressing them though effective classroom management techniques, support from specialised school staff, or referral for specialist health services. Training should cover topics such as adolescent depression or anxiety and, practical ways to address Emotional Health and Wellbeing (EHWB). Interview research with teachers (Kidger et al., 2010) shows the importance of formal (e.g. timetabled) and regular support for school staff. Additionally, the dominant culture needs to change to one that is accepting of the need to seek help and support.
4. Social media and the internet
4.1 Worries over teenage mental health problems are growing with misuse of social media cited as the biggest cause (Headmasters’ and Headmistress’ Conference, 2015). Many other organisations, including the police, will submit evidence about the risks to mental health and safety of social media. Empowering young people to live safe digital lives should focus on developing resilience and critical thinking skills in the face of online threats; this should form a vital part of PSHE described above.
4.2 We concentrate now on the potential for the internet to contribute positively to mental health. Here we include the potential for positive benefits such as online counselling and support. High quality information for use by teachers and other school staff as well as parents and young people can be found at:
5. Funding specialist services – school referrals that get results
5.1 Finally, the issue of funding cannot be ignored. Schools need to refer children and young people to adequately staffed services. Children from aged 0 to 18 years form around a third of our population, yet only 7% of the whole of the £11bn a year spent by the NHS on mental health is given to children - despite the fact that 70% of people who develop mental health disorders start with them under the age of 18. Nearly half of this expenditure goes on inpatient units, leaving approximately £45 per year for outpatient CAMHS. This means that current CAMHS services can take only the most severe cases who are at risk of dying through self-starvation, self-harm and suicide, or have severe disorders such as autism.
5.2 Unfortunately a large proportion the £250 million increase a year promised to child mental health has been spent elsewhere by CCGs, as revealed by freedom of information requests by “The Times” newspaper, amongst others. Therefore we propose that CAMHS services need to have some mechanism by which money allocated to them does indeed reach them, and the total amount needs to be increased; the current CY-IAPT initiative is much too small to address this.
6. Recommendations
‘Future in Mind’ (DoH, 2015) proposes a five-year plan for a complete overhaul of mental health services for children and young people. We recommend a high profile, national government programme to ensure a stronger focus on mental health and wellbeing within schools and education. This will need to be cross-cutting and involve high level involvement of ministers and senior officials. It will focus on:
Post-script for the Select Committee: It is also worth noting the great benefit of involving children and young people in deliberations of the Committee. Young people will bring creativity and new ideas to committee deliberation, helping the committee to consider new approaches such as involving peer support or youth workers rather than relying solely on professionals (EPI 2016).
Selected References (full list available on request)
Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M. (2006). Long-term outcomes of an Australian universal prevention trial of anxiety and depression symptoms in children and youth: an evaluation of the friends program. Journal of clinical child and adolescent psychology, 35(3), 403-411.
Boswell, J., Kraus, D., Miller, S. & Lambert, M. (2013) Implementing routine outcome monitoring in clinical practice: Benefits, challenges and solutions. Psychotherapy Research. Doi: 10.1080/10503307.2013.817696
Department for Education (2011). Me and My School: Findings from the National Evaluation of targeted Mental health in School 2008-2011. London: Author
Department of Health (2015). Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing. London: Author
Educational Policy Institute (2016). Children and Young People’s Mental Health: Time to Deliver. London: Author
Educational Policy Institute (2016). Children and Young People’s Mental Health: State of the Nation. London: Author
Fazel, M., Hoagwood, K., Stephan, S., & Ford, T. (2014). Mental health interventions in schools in high-income countries. The Lancet Psychiatry, 1(5), 377-387.
Ford T, Edwards E, Sharkey S, Okoumunne O, Byford S, Norich B & Logan S. (2012). Supporting Teachers And children in Schools: The effectiveness and cost-effectiveness of the Incredible Years Teacher Classroom Management programme in primary school children: a cluster randomised controlled trial, with parallel economic and process evaluations. BMC Public Health, 12(1)719
Hardy, J. & Dunsmuir, S. (2016). Delivering Psychological Therapies in Schools and Communities. Leicester, UK: British Psychological Society.
Kellam, S. G., Mackenzie, A. C., Brown, C. H., Poduska, J. M., Wang, W., Petras, H., & Wilcox, H. C. (2011). The good behavior game and the future of prevention and treatment. Addiction Science Clinical Practice, 6, 73-84.
Kidger, J., Gunnell, D., Biddle, L., Campbell, R., & Donovan, J. (2009). Part and parcel of teaching? Secondary school staff’s views on supporting student emotional health and well‐being. British Educational Research Journal, 36(6), 919-935.
Lee, R. C., Tiley, C. E., & White, J. E. (2009). The Place2Be: Measuring the effectiveness of a primary school-based therapeutic intervention in England and Scotland. Counselling and Psychotherapy Research, 9(3), 151-159.
Lendrum, A., Humphrey, N., & Wigelsworth, M. (2013). Social and emotional aspects of learning (SEAL) for secondary schools: implementation difficulties and their implications for school‐based mental health promotion. Child and Adolescent Mental Health, 18(3), 158-164.
Reinke, W. M., Stormont, M., Webster‐Stratton, C., Newcomer, L. L., & Herman, K. C. (2012). The Incredible Years Teacher Classroom Management program: using coaching to support generalization to real‐world classroom settings. Psychology in the Schools, 49(5), 416-428.
Ruttledge, R., Devitt, E., Greene, G., Mullany, M., Charles, E., Frehill, J., & Moriarty, M. (2016). A randomised controlled trial of the FRIENDS for Life emotional resilience programme delivered by teachers in Irish primary schools. Educational & Child Psychology, 33(2), 69-89.
Sammons, P., Sylva, K., Melhuish, E., Siraj, I., Taggart, B., Smees, R., Toth, K. (2014). Influences on students’ social-behavioural development at age 16. Effective Pre-school, Primary and Secondary Education (EPPSE 3-16). London: Department for Education Stallard, P., Simpson, N., Anderson, S., Hibbert, S., & Osborn, C. (2007). The FRIENDS emotional health programme: Initial findings from a school‐based project. Child and Adolescent Mental Health, 12(1), 32-37
Sylva, K. , Melhuish, E., Sammons, P., Siraj, I., Taggart, B., Smees, R … Hollingworth, K(2014). Students’ educational and developmental outcomes at age 16. Effective Pre-school, Primary and Secondary Education (EPPSE 3-16). London: Department for Education
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