The role of schools in promoting mental health · • Risk and resilience framework ( Masten, 2014) ... – Increase in emotional difficulties among adolescents, especially girls

The role of schools in promoting mental health

Professor Neil Humphrey Manchester Institute of Education [email protected]

@neilhumphreyUoM

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Mental health by the numbers

50% of lifetime cases of mental health difficulties begin by

age 142 10%

of children aged 5-16 experience clinically

significant mental health difficulties1

Teenage girls are nearly

3x more likely to experience emotional problems than

teenage boys3

Children living in the most deprived areas are

4.5x more likely to experience mental

health difficulties than those living in least deprived areas4

£105 billion per year Wider economic costs of mental health difficulties5

6% of total NHS expenditure on mental health for child and

adolescent services6

£13 Average return for every £1 invested in evidence-based interventions for

adolescents with conduct disorder7

Overview

• What is mental health and why does it matter? • What factors are associated with variability in mental

health? • Are mental health difficulties among children and young

people increasing? • Why have schools become a central focus in this area? • What can schools do to support children’s mental

health?

Some foundations

What is mental health and why does it matter?

• What comes to mind when you think about ‘mental health’?

What is mental health and why does it matter?

• Complete mental health model (Keyes, 2005) – Mental health simultaneously comprises our experience of symptoms of psychological

distress and wellbeing

• Mental health difficulties = changes in how we think, feel and/or behave that impact negatively on our everyday lives (Murphey, Barry & Vaughn, 2013)

• Wellbeing – Subjective (hedonic) = affective (e.g. positive affect) and cognitive (e.g. life satisfaction)

components – Psychological (eudaimonic) = self-acceptance, positive relationships, autonomy (Children’s

Society, 2017)

What is mental health and why does it matter?

• Mental health difficulties and wellbeing are not simply polar opposites – For example, we can experience low wellbeing in the absence of mental health difficulties – Mental health difficulties and wellbeing have distinct correlates (Patalay & Fitzsimons, 2016)

What is mental health and why does it matter?

• Mental health difficulties lead to reduced quality of life, lost economic productivity, destabilisation of communities, and higher rates of health, education and social care utilisation (Belfer, 2008)

• Mental health difficulties cost over £100 billion annually in England (Centre for Mental Health, 2010) – Human costs, output losses, health and social care

• By 2030, depression alone will yield the highest disease burden in high-income countries, accounting for nearly 10% of disability-adjusted-life-years (Mathers & Loncar, 2006)

• By contrast, people who report higher levels of wellbeing tend to live longer (Chida & Steptoe, 2008)

What is mental health and why does it matter?

• Approximately 13% of children and young people worldwide experience difficulties severe enough to warrant professional intervention (Polanczyk et al, 2015)

• Two recent large scale studies suggest high prevalence rates in early adolescence (Patalay & Fitzsimons, 2017; Deighton et al, 2018)

Prevalence of emotional symptoms and conduct problems in 11-14 year-olds

(drawn from HS3 project, Deighton et al, 2018)

Prevalence of mental health difficulties in 7-9 year-olds (drawn from Manchester PATHS trial, Humphrey

et al, 2018)

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Mental health difficulties (teacher SDQ)

What factors are associated with variability in mental health?

• Risk and resilience framework (Masten, 2014) • Risk factor = “a measurable characteristic in a group of individuals

or their situation that predicts a negative outcome on a specific outcome criteria” (Wright, Narayan & Masten, 2013, p.17)

• Empirically validated risk factors for mental difficulties in childhood and adolescence (Patel et al, 2007) include (but not limited to): – Toxin exposure (e.g. alcohol) in pregnancy – Sexual abuse – Inconsistent care-giving – Bullying in school – Exposure to violence in the community

• Not everyone exposed to a given risk factor is destined to experience a negative outcome. Risk is about probability, not certainty (Zolkoski & Bullock, 2012)

What factors are associated with variability in mental health?

• Resilience = “positive adaptation in the face of risk or adversity; [the] capacity of a dynamic system to withstand or recover from disturbance” (Wright, Narayan & Masten, 2013, p.17)

• Protective factor = “a predictor of positive outcomes particularly in situations of risk or adversity” (Wright, Narayan & Masten, 2013, p.17)

• Both risk and protective factors operate at multiple ecological levels: individual, familial, school, community

What factors are associated with variability in mental health?

The ‘resilience short-list’ (protective and promotive factors) (Wright et al, 2013, p.21)

What factors are associated with variability in mental health?

• Cumulative and multiple risk perspectives (Evans, Li & Whipple, 2013) • Risk and health inequality: risk factors as markers/proxies for inequalities (e.g. Reiss,

2013) • Number of people reporting mental health difficulties is almost twice as high for those living in deprived

areas compared to those living in less deprived areas (Mental Health Foundation, 2016)

Risk Protection

Multiple disadvantage and low wellbeing (Children’s Society, 2017)

What factors are associated with variability in mental health?

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Whole sample (N=5027)

0-2 assets (N=385)

3-5 assets (N=1271)

6+ assets (N=3371)

The intersection between cumulative risk exposure and developmental assets as predictors of externalising problems (Humphrey et al, in preparation)

• Has the prevalence of mental health difficulties among children and young people changed in the last 10 years?

Are mental health difficulties among children and young people increasing?

• Social changes – Rising affluence but increased income

inequality – Changes in family environment (increased

rate of single parenting, family conflict, parental mental health problems)

– Changes in parenting styles, increased exposure to screen time, internet and social media, increased pressure in school (Murphy & Fonagy, 2012)

• Recent policy changes: expansion of academies and free schools, raising of participation age, changes to academic assessment procedures, increase in University fees (Lessof et al, 2016)

• Socio-economic disadvantage, impact of digital technologies, changes to family structure (Thorley, 2016)

Income inequality and mental health difficulties (Wilkinson & Pickett, 2010)

Are mental health difficulties among children and young people increasing?

• 1974-1999: significant increases in conduct problems and emotional difficulties among young people (Collishaw et al, 2004)

• 1999-2004: no significant change (Green et al, 2005) – ONS survey repeated in 2016 (findings pending: Oct 18)

• 2009-2014: significant increase in prevalence of anxiety in female adolescents (Fink et al, 2015)

• Systematic review by Borr et al (2014) using international studies – review of time trends into the 21st century

– No change for toddlers and children – Increase in emotional difficulties among adolescents, especially girls

• 2005-2014: increases in psychological distress among adolescent girls (Lessof et al, 2016)

• 1995-2014: increases in prevalence of long-standing mental health conditions across 4-24 year olds (Pitchforth et al, 2018)

– Proportion of 4-12 year olds reporting high general distress decreased somewhat

– Proportion of 4-12 and 13-15 year olds reporting high emotional symptoms decreased somewhat

– Variation by gender and nation (England, Wales, Scotland)

Are mental health difficulties among children and young people increasing?

• 1974-1999: significant increases in conduct problems and emotional difficulties among young people (Collishaw et al, 2004)

• 1999-2004: no significant change (Green et al, 2005) – ONS survey repeated in 2016 (findings pending: Oct 18)

• 2009-2014: significant increase in prevalence of anxiety in female adolescents (Fink et al, 2015)

• Systematic review by Borr et al (2014) using international studies – review of time trends into the 21st century

– No change for toddlers and children – Increase in emotional difficulties among adolescents, especially girls

• 2005-2014: increases in psychological distress among adolescent girls (Lessof et al, 2016)

• 1995-2014: increases in prevalence of long-standing mental health conditions across 4-24 year olds (Pitchforth et al, 2018)

– Proportion of 4-12 year olds reporting high general distress decreased somewhat

– Proportion of 4-12 and 13-15 year olds reporting high emotional symptoms decreased somewhat

– Variation by gender and nation (England, Wales, Scotland)

Time trends in hospital admissions for self-harm among 0-17 year olds (NHS Digital, 2017)

Are mental health difficulties among children and young people increasing?

Why have schools and colleges become a central focus in this area?

• The ‘turn’ to schools….

• The notion of schools as central sites for promoting mental health and wellbeing is not new (e.g. TaMHS, 2008; SEAL, 2005; Every Child Matters, 2003), but it has arguably reached an unprecedented level of exposure and intensity in the last 5 years

• Green paper (2017) highlights – Systematic evidence review suggests an important role for schools and teachers (e.g. in identification and early

intervention) – Designated senior lead for mental health in schools – Mental health support teams to bridge education and health services – Reduced waiting times for specialist child and adolescent mental health services – Go to MIE BEE blog to read a summary of criticisms of the Green Paper

Why have schools become a central focus in this area?

• Why could/should schools play a central role in preventing the onset, maintenance or progression of mental health difficulties? (Greenberg, 2010) – Broad reach – Prolonged engagement (“15,000 hours” – Rutter et al, 1979) – Central hub in most communities

• School is the primary developmental context after the family (Bronfenbrenner, 2005)

• Teachers are the most commonly contacted mental health ‘service’ (Ford et al, 2007)

• Children’s learning and their mental health are inter-related (Panayiotou & Humphrey, 2017)

Why have schools become a central focus in this area?

Panayiotou & Humphrey (2017)

Why have schools become a central focus in this area?

Panayiotou & Humphrey (2017)

Four Five key things that schools and can do to promote CYP’s mental health

• Taken from NatCen & NCB (2017) – Responses from 2,780 schools and colleges in England – 15 in depth case studies to explore models of delivery and

experiences of different approaches

1. Create an environment where CYP feel safe and happy 2. Identify those YP with specific mental health needs 3. Provide support for mental health needs 4. Refer to and/or deliver specialist provision

... Plus! 5. Promote staff wellbeing

• What impacts on your wellbeing at school/college?

Promote staff wellbeing

Promote staff wellbeing

• 84% of those working in the education sector report having experienced mental health problems in the last 2 years, of whom 81% felt their workload was a principal underpinning factor (Education Support Partnership, 2015)

• 10% of teachers have been prescribed anti-depressant drugs to cope with job pressure (NASUWT, 2016)

• 13% increase in days lost due to mental health difficulties among the teaching workforce in Scotland in the last 3 years (BBC, 2016)

• 90% of teachers have considered leaving the profession in the last two years (NUT, 2014)

Promote staff wellbeing

• Teacher-student interpersonal relationships found to be the strongest predictor of teachers’ joy (Hagenauer, Hascher & Volet, 2015)

• Young people’s perception of interpersonal teacher behaviour predicts their wellbeing Petegem et al (2007)

– e.g. when students viewed their teacher as ‘tolerant yet exacting discipline’, this is positively associated with wellbeing

• Thus, when it comes to the link between teacher wellbeing and student outcomes, relationships matter (Klem & Connell, 2004)

• Teacher wellbeing matters for school success (Driner & Dewberry, 2007)

– Positive association between average levels of teacher wellbeing and primary school SATs results

– Average level of teacher wellbeing accounted for 8% of the variance in SATs results

Promote staff wellbeing

“Self-care is not selfish. You cannot serve from an empty vessel” (Eleanor Brown)

Promote staff wellbeing

• Six things schools can do (Lamb, 2017)

1. Identify staff concerns 2. Get all staff involved 3. Ensure leadership support 4. Preach about the benefits 5. Stay positive 6. Make staff wellbeing integrated

• Making changes (Education Support Partnership, 2017)

– Workload – Support – Structure – Control – Relationships – Change

Create an environment where CYP feel safe and happy

• Some basic principles – Relationships, relationships, relationships – Addressing bullying – Reducing the stigma of mental health – Giving young people a voice – Signposting

Create an environment where CYP feel safe and happy

• Reducing the stigma of mental health

Create an environment where CYP feel safe and happy

Mental health literacy framework (Mansfield, forthcoming)

Create an environment where YP feel safe and happy

• A case study in developing a mental health curriculum – Oldham Sixth Form College (Marshall & Smith, 2018)

• Tutorial programme focusing on – Mental health stigma reduction – Identifying depression – Stress management – Past and present students share their experiences

• Transition video focusing on – Resilience – Managing anxiety – Recognising the signs of mental health difficulties – Accessing support

• Embedding resilience training in the wider curriculum (e.g. strategies to cope with failure or under-achievement)

• Targeted skills sessions for students with identified needs – e.g. lunchtime sessions by Positive Steps on positive mindset

Identify those YP with specific mental health needs

• Schools and colleges as sites for early identification – 82% use ad hoc identification by staff – Only 15% make use of universal screening approaches (NatCen

& NCB, 2017) • ‘Refer-test-place’ and ‘wait to fail’ models

– Highly variable and result in under-referral and late-referral (Dvorsky et al, 2014)

• Universal screening: a population based approach (Humphrey & Wigelsworth, 2016) – All members of the student population in a school/college

undergo brief assessments designed to identify those at-risk of (or already experiencing) mental health difficulties

Identify those YP with specific mental health needs

• Potential advantages of universal screening

• Universal reach • A baseline for future

monitoring, assessment and evaluation

• Cost savings over time • Different options: Use of mental health

screening measures, risk indices, and/or simple nomination approaches

• More generally, high quality routine monitoring and assessment is a crucial component of school mental health provision (e.g. to take a snapshot, screen/identify, evaluate; Deighton. et al 2016)

Provide support for mental health needs

• Universal prevention: “An ounce of prevention is worth a pound of cure” (Benjamin Franklin)

• Universal school-based interventions can influence outcomes for children and young people who would not otherwise access the support they need through usual care pathways – Estimate of unmet need for those with significant mental health

difficulties is 75% (Kelvin, 2014) – More inclusive and less stigmatizing? (Humphrey, 2013; Stallard

et al, 2012)

• What do schools and colleges do to promote mental health? – 64% mental health promotion integrated into the school day – 73% used skills development sessions – 53% used mental health literacy/awareness approaches – Primary schools (16%, compared to 63% of colleges) least likely

to use activities to address mental health stigma (NatCen & NCB, 2017)

• Social and emotional learning (SEL) is one approach to universal school-based prevention that has become a dominant orthodoxy in education

• SEL is, “a process for helping children and even adults develop the skills for life effectiveness. SEL teaches the skills we all need to handles ourselves, our relationships and our work effectively and ethically. These skills include recognising and managing our emotions, developing caring and concern for others, establishing positive relationships, making responsible decisions, and handling challenging situations constructively and ethically. They are the skills that allow children to calm themselves when angry, make friends, resolve conflicts respectfully, and make ethical and safe choices” (www.casel.org)

Provide support for mental health needs

Provide support for mental health needs

• PATHS - Promoting Alternative Thinking Strategies • PATHS is a universal social-emotional learning

curriculum that helps children to manage their behaviour, understand their emotions and work well with others

• Based on the Affective-Behavioral-Cognitive-Developmental model of development, which emphasizes the developmental integration of affect, emotion language, behavior and cognitive understanding to promote social-emotional competence

• Series of twice weekly lessons covering topics such as identifying and labelling feelings, controlling impulses, reducing stress and understanding other people’s perspectives

• Three main components: • Taught curriculum • Generalisation activities • Parent materials

• Delivered by class teacher

Refer to and/or deliver specialist provision

• How do schools and colleges work with external services to support students’ mental health?

– 73% work with local public health and/or local authorities – 73% work with specialist mental health services – 93% refer to CAMHS, 73% to GPs and 53% to VCSO or independent services – 19% have a single point of contact for external agencies (NatCen & NCB, 2017)

• What support do schools and colleges offer for pupils with identified needs? – 61% educational psychology and/or counselling services – 18% cognitive behavioural therapy – 14% clinical psychology support – 94% sought to monitor the impact of the support offered (NatCen & NCB, 2017)

Refer to and/or deliver specialist provision

• Interagency collaboration in children and young people’s mental health (Cooper, Evans & Pybis, 2016)

– Systematic literature review of outcomes, facilitating factors and inhibiting factors (N=33 studies)

– Mixed findings – some studies demonstrating associations between interagency collaboration and greater service use, equity of provision, et cetera, but others highlighting negative effects on service quality

– Facilitating factors included: communication, joint training, understanding across agencies, named link person

– Inhibiting factors included: inadequate resources, differing perspectives, confidentiality issues

Conclusion

• What challenges to schools and colleges face? – 74% difficulties in commissioning local services – 71% lack of funding – 59% lack of internal capacity

• What do schools and colleges think is the key to success in this area? – Shared vision and understanding – Mental health needs of staff as well as students – Senior member of staff as mental health lead – Clear processes for identification and referral – Staff-pupil relationships based on trust – Training – Government support (e.g. funding, directory of local services) (NatCen & NCB,

2017)

Resources

• Mind Ed here• Anna Freud Centre ‘You’re never too young to talk about mental

health’ here• The Mix here• The Early Intervention Foundation Guidebook here• Collaborative for Academic, Social and Emotional Learning

programme guide here• Kidsmatter programme guide here• EEF SPECTRUM measures database• Anna Freud Centre and Public Health England wellbeing monitoring

toolkit here• Youth Wellbeing Directory here• Mentally Healthy Schools here

Thanks for listening!

“It is easier to build strong children than to repair broken men” (Frederick Douglass)