The pursuit of happiness: a new ambition for our mental health
Perceptions of wellbeing and mental health in English secondary schools: a cross sectional study
Holly Taggart Stephen Lee Laura McDonald
THE PURSUIT OF HAPPINESS: A NEW AMBITION FOR OUR MENTAL HEALTH
December 2014
A CENTREFORUM COMMISSION
About the Commission
CentreForum launched an independent, evidence‐based Commission in May 2013 under the chairmanship of Rt Hon Paul Burstow MP. The Commission launched its final report, ‘the pursuit of happiness: a new ambition for our mental health’ in July 2014. The Commission members included: : Lord Victor Adebowale CBE, Chief Executive, Turning Point; : Professor Dame Sue Bailey, Chair, Children and Young People’s Coalition; : Paul Farmer, Chief Executive, Mind; : Angela Greatley OBE, Chair, Tavistock and Portman NHS Foundation Trust; : Paul Jenkins OBE, Chief Executive, Tavistock and Portman NHS Foundation Trust (formerly Rethink Mental Illness); : Dr Alison Rose‐Quirie, Chief Executive, Swanton Care and Community (formerly Care UK). The Commission calls for five big shifts in policy and practice: 1. The mental wellbeing of the nation or the ‘pursuit of happiness’ should be a clear and measurable goal of government. 2. Roll out a National Wellbeing Programme led by Public Health England to foster mutual support, self‐care and recovery. 3. Prioritise investment in the mental health of children and young people right from conception. By scaling up what works, we can transform the life chances of hundreds of thousands of children and reduce the costs to society of low educational attainment, negative behaviour, worklessness, crime, and antisocial behaviour. 4. Make our places of work mental health friendly. 5. Close the treatment gap that leaves almost one in ten of the adult population needlessly suffering from depression and anxiety and 1‐2 per cent of the adult population experiencing a severe mental illnesses such as schizophrenia. This cross‐sectional study forms part of the ongoing work of the Commission.
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About the Authors
Holly Taggart is Policy Research Officer at CentreForum and the lead researcher on the Mental Health Commission. Before working in public policy, she studied global mental health (MSc) at King’s College London and the London School of Hygiene and Tropical Medicine. She is also a registered mental health nurse. Professor Stephen Lee is Chief Executive of CentreForum and Professor of Voluntary Sector Management at Cass Business School, City University. Having undertaken degrees at Huddersfield University, the London School of Economics and later taught at Lancaster University, Professor Lee entered the voluntary sector in 1982 as Deputy Chief Executive at the Charities Advisory Trust and Directory of Social Change. Professor Lee has published widely in the fields of non‐profit and fundraising management; reputation management and corporate governance. Laura McDonald interned at CentreForum from August 2013 to January 2014. During this time, she assisted with the work associated with the Mental Health Commission.
Acknowledgments
The authors would like to thank Professor Dame Sue Bailey, Andy Bell, Rt Hon Paul Burstow MP, Paul de Kort, Natasha Kutchinsky, Chris Leaman, Tom Rathborn and Anthony Rowlands.
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Contents
About the Commission .......................................................................................................... 1 About the Authors ................................................................................................................. 2 Acknowledgments ................................................................................................................. 2
Contents ................................................................................................................................ 3 Acronyms and Glossary ......................................................................................................... 4 Executive summary ............................................................................................................... 6 Objective: .......................................................................................................................... 6 Methods: ........................................................................................................................... 7 Key Findings: ...................................................................................................................... 7 Conclusion: ...................................................................................................................... 11 Recommendations: ......................................................................................................... 11 Introduction ......................................................................................................................... 13 Prevalence ....................................................................................................................... 13 Associated outcomes and costs ...................................................................................... 14 Adversity, risk and vulnerability ...................................................................................... 15 Protective factors and psychosocial resilience ................................................................ 16 Interventions and services .............................................................................................. 18 Commissioning and funding ............................................................................................ 19 Policy ............................................................................................................................... 20 Rationale .......................................................................................................................... 20 Departmental Advice ....................................................................................................... 21 Methods .............................................................................................................................. 22 Research questions.......................................................................................................... 22 Design .............................................................................................................................. 22 Participants ...................................................................................................................... 22 Instrument ....................................................................................................................... 23 Data collection ................................................................................................................. 23 Analysis ............................................................................................................................ 23 Findings ................................................................................................................................ 24 Descriptive characteristics ............................................................................................... 24 Mental health related demand and need in secondary school pupils ............................ 26 Mental health and wellbeing strategies in English secondary schools ........................... 28 Interventions to promote positive mental health in pupils ............................................ 32 Interventions to support pupils with complex needs ..................................................... 36 Referring severe cases ..................................................................................................... 37 Schools commissioning services directly ......................................................................... 39 Discussion ............................................................................................................................ 41 Conclusion and recommendations ...................................................................................... 44
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Acronyms and Glossary
Acronym CAMHS CYP CYP IAPT DfE HWB JHWS JSNA PRU PSHE SDQ SEN
Meaning Child and adolescent mental health services Children and young people Children and Young People’s Improving Access to Psychological Therapies Department for Education Health and Wellbeing Board Joint Health and Wellbeing Strategy Joint Strategic Needs Assessment Pupil referral unit Personal, social, health and economic education Strengths and Difficulty Questionnaire Special educational needs
Term Academy, converter
Definition 1 2 3 All schools that have chosen through Governing Body Resolution and application to the Secretary of State to become an Academy under the Academies Act 2010. Academies are all‐ability, state‐funded schools established and managed by sponsors from a wide range of backgrounds, including high performing schools and colleges, universities, individual philanthropists, businesses, the voluntary sector, and the faith communities. Behavioural problems include problems such as hyperactivity, aggression, bullying, self‐injurious behaviour, truancy, abuse of alcohol or drugs, defying authority, stealing or damaging property. The Local Authority employs the school's staff, owns the school's land and buildings and is the admissions authority (it has primary responsibility for deciding the arrangements for admitting pupils). A clinical diagnosed disorder comprising of behaviour that may include stealing, defiance, fire‐setting, aggression and anti‐social behaviour. Demand is a term used here to describe those pupils who do not have a diagnosed mental health problem but are displaying risk factors or symptoms of mental health problems. Disorders that include a delay in acquiring certain skills such as speech, social ability or bladder control, primarily affecting children with autism and those with pervasive developmental disorders. Emotional problems include problems such as the inability to cope with daily problems and activities, long lasting negative moods and tearfulness, loss of interest in friends and activities they usually enjoy, significant increase in time spent alone, excessive worrying or anxiety. Clinically diagnosed phobias, anxiety states and depression disorders. Foundation schools the governing body is the employer and the admissions authority. The school's land and buildings are either owned by the governing body or by a charitable foundation. Number of pupils known to be eligible for and claiming free school meals who have full time attendance and are aged 15 or under, or who have part time attendance and are aged between five and 15.
Academy, sponsor led Behavioural problems Community schools Conduct disorder Demand Developmental disorders Emotional problems
Emotional disorders Foundation school Free school meals
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Department for Education (DfE), ‘Glossary’, 2014, available from: http://www.education.gov.uk/edubase/glossary.xhtml?letter=A 2 DfE, ‘Private schools’, 2014, available from: https://www.gov.uk/types‐of‐school/private‐schools. 3 Citizen Advice Bureau, ‘Voluntary Controlled Schools’, 2014, available from: http://www.adviceguide.org.uk/england/education_e/education_school_education_ew/types_of_school.htm.
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Free schools
Hyperkinetic disorders Independent schools
Free schools are funded by the government but aren’t run by the local council. They have more control over how they do things. They’re ‘all‐ability’ schools, so can’t use academic selection processes like a grammar school. Free schools can set their own pay and conditions for staff and change the length of school terms and the school day. They don’t have to follow the national curriculum. Disturbance of activity and attention.
Independent schools charge fees to attend instead of being funded by the government. Pupils don’t have to follow the national curriculum. All private schools must be registered with the government and are inspected regularly. An Independent School is any school which provides full time education for 5 or more pupils of compulsory school age, which is not maintained by a local authority or a non‐maintained special school. Independent school An independent school approved for SEN pupils is a special school approved for SEN equivalent of an Independent School catering wholly or mainly for children pupils with statutory statements of special educational needs. It has been approved by the DfE for SEN provision. Independent Special An Independent Special School is equivalent to an Independent School School catering wholly or mainly for children with statutory statements of special educational needs. Need Need refers to those pupils who have a known mild, moderate or severe mental health problem. Non‐Maintained Non‐Maintained Special schools are special schools approved by the Special schools Secretary of State for Education and Skills. They are run on a not‐for‐profit basis by charitable trusts and normally cater for children with severe and/or low incidence special educational needs. They get the majority of their funding from local authorities placing children with special educational needs statements at the schools and paying the fees. Pupil referral units A Pupil Referral Unit is established and maintained by a local authority which is specially organised to provide education for children who are excluded, sick or otherwise unable to attend mainstream school and is not a special or other type of school. SEN units SEN Units are special provisions within a mainstream school where the children are taught mainly within separate classes. Units: receive additional funding from the LA specifically for the purpose of the provision; cater for a specific type or types of SEN (e.g. autistic spectrum disorders); are usually for pupils with statements of SEN (but may also provide support for pupils at School Action Plus). Voluntary aided Voluntary‐aided schools are maintained schools and often, but not always, schools have a religious character. These schools are eligible for capital funding by grant from the department. VA schools are paid on a similar basis to other categories of school, but the governing body must usually pay at least 10 per cent of the costs of capital work. Responsibility for work to VA school premises is shared between the school’s governing body and the local authority. The LA has responsibility for the playing fields and the governing body are liable for all other capital expenditure. Voluntary A voluntary controlled school can also be called a religious or faith school. controlled schools In a voluntary controlled school the land and buildings are owned by a charity, often a religious organisation such as a church and the charity appoints some of the members of the governing body, but the local education authority is responsible for running the school the school is funded by the local education authority. The local education authority employs the staff the local education authority provides support services the pupils have to follow the national curriculum, the admissions policy is usually determined and administered by the local education authority.
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Executive summary
The mental health and emotional needs of students is ever prominent in the work we do. It impacts greatly on a child’s ability to engage with their learning and the social aspects of school. Progress Centre Manager, Foundation School.
Objective: The CentreForum Mental Health Commission believe that government should set a new ambition for our society’s mental health where the wellbeing and mental and social capital of the nation is promoted, there is a reduction in the misery experienced, and there is delivery of effective interventions for people with existing mental health problems. One of the core principles underpinning this ambition is the need to invest in the prevention of mental health problems, and the promotion of mental wellbeing. We find these issues to be extremely resonant in this research. The primary focus of schools should be to cultivate a personal disposition to learn, work and relate, with the skills to live in society. It is vital that schools provide an environment that offers the opportunity for all children and young people (CYP) to learn and develop, regardless of need. 4 In order to achieve this, we must recognise that teachers, teaching assistants and other members of staff are facing increasing challenges relating to a growing proportion of pupils presenting with mental health and behavioural problems. In England, ten per cent of CYP are experiencing poor mental wellbeing and a further ten per cent have a clinically diagnosable mental health problem. This equates to three young people in every classroom.5 The number of CYP admitted to hospital for self‐harm has been rising for the past five years. In fact, 43 per cent of 15‐year‐olds say that they self‐harm at least once a month.6 Adversity, risk and vulnerability all contribute to the development of mental health problems; yet protective factors and resilience in CYP mean that some individuals do not experience poor mental health. Addressing these issues is crucial as the associated poor mental and physical health outcomes as well as reduced attainment, attendance and productivity have far reaching consequences into later life. Child and adolescent mental health problems are also very costly to society with an estimated £11,030 to £59,130 spent annually per individual.7 Ensuring CYP have access to appropriate, effective and timely support is essential in preventing a further deterioration in mental health, which can often result in more complex and difficult to treat cases. However, we are far from achieving this goal. Half of all lifetime cases of mental health problems have developed by the age of 14 and three quarters have
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CentreForum Mental Health Commission, ‘The Pursuit of happiness: a new ambition for our mental health’, CentreForum, July 2014. 5 H Green, A McGinnity, H Meltzer et al., ‘Mental health of children and young people in Great Britain’, Office of National Statistics, 2004. 6 YoungMinds, ‘Children’s admission to hospitals for self‐harm at 5 year high’, December 2014, available from: http://www.youngminds.org.uk/news/blog/2364 7 M Suhrcke, D Pillas and C Selai, ‘Economic aspects of mental health in children and adolescents’. In Social cohesion for mental well‐being among adolescents. Copenhagen: WHO Regional Office for Europe, 2008.
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developed by the age of 24; yet many never receive any form of treatment.8 Many conduct disorders and eating disorders never get diagnosed and approximately 35 per cent of those with depression and 51 per cent of those with anxiety disorders are not in contact with any mental health services.9 In trying to close this treatment gap and improve the quality of life of CYP experiencing, or at risk of poor mental health, we need to strengthen the capacity of existing service provision. In some areas of the country, Child and Adolescent Mental Health Services (CAMHS) are overburdened and unable to provide timely and appropriate support. In moving towards a comprehensive CAMH system, we must ensure that all tiers of CAMHS are working effectively and the role of schools in promoting, protecting and providing early intervention for pupil mental health issues is fully utilised. This will not only improve mental and physical health outcomes but also to improve attainment, attendance and productivity in later life. In regards to practical implementation, the Department for Education (DfE) published a report in June 2014 with guidance on how schools can plan, commission and deliver interventions and services for young people with mental health and behavioural problems.10 This research takes this guidance into consideration and aims to ascertain the extent to which secondary schools in England are delivering a comprehensive mental health and wellbeing strategy, including the promotion of positive mental health, the identification of mental health mental problems, the delivery of interventions that promote positive mental health and interventions for complex problems, the referral of serious cases to CAMHS and the commissioning of services, in accordance with government guidance. Methods: This cross‐sectional study uses a 21‐item questionnaire at a single point in time. The participants were a randomly selected sample of 4961 head teachers (15 per cent response rate). Both quantitative and qualitative data was analysed. Data was disaggregated into four groups: (i) mainstream, maintained schools (academy converters, academy sponsors, community schools, foundation schools, free schools, voluntary aided schools, (ii) independent schools; (iii) special educational needs [SEN] schools and pupil referral units (PRUs). Key Findings: The key findings from our research are presented using the structure set out by the DfE in its departmental advice to schools. Incidence of behavioural and emotional problems: : Head teachers from English secondary schools report that a high number of pupils are presenting with behavioural and emotional problems: between one and ten per cent of pupils attending mainstream schools; and more than 40 per cent of pupils attending SEN schools and PRUs. However, head teachers in mainstream schools may be underestimating the extent of the problem. Existing evidence suggests that
8 RC Kessler, WT Chiu, O Demler, et al., ‘Prevalence, severity, and comorbidity of 12‐month DSM‐IV disorders in the National Comorbidity Survey Replication’, Arch Gen Psychiatry, 2005, 62(6): p.617‐27. 9 P McCrone, S Dhanasiri, A Patel, et al., ‘Paying the price’, King’s Fund, 2008. 10 DfE, ‘Mental health and behaviour in schools. Departmental advice for school staff’, June 2014.
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:
across the population the prevalence of behavioural problems in CYP is between 15 and 20 per cent.11 Whereas, the prevalence of emotional problems, including anxiety and depression in CYP is 4.4 per cent and 1.4 per cent respectively. This indicates that head teachers tend to underestimate behavioural problems but are accurate in estimating emotional problems. Qualitative analysis also revealed that head teachers think the incidence rate of behavioural and emotional problems is increasing each year and they cite environmental factors such as economic pressures, parental separation and the influence of social media as reasons for this.
Early identification: : Head teachers from mainstream schools may underestimate the significance of mental health problems in pupils presenting with behavioural and emotional problems: only 25 per cent of respondents from mainstream, maintained schools and 6 per cent of respondents from independent schools report that mental health problems were a significant factor in the presentation of behavioural and emotional problems. Whereas, over half of respondents from SEN schools (65 per cent) and PRU (63 per cent) reported that mental health problems were a significant factor in the presentation of behavioural problems and emotional problems. Head teachers from all types of schools reported that family life and relationships were the greatest attributing factors to behavioural and emotional problems in pupils. : The most crucial element for identifying mental health problems as early as possible is training school staff to be aware of the signs and symptoms of poor mental health and wellbeing. This research identifies the majority of schools have access to a training programme of this kind and in these cases, most importantly 75 per cent of head teachers think it is significant in helping them identify pupils with mental health problems. However, 9 per cent of schools report there is no mental health and wellbeing training available at all. : In addition to staff training, screening tools can be used to identify strengths and difficulties in young people. Less than half of schools (47 per cent) use screening tools, but where these tools are used, 86 per cent say they are effective and 64 per cent think they are important in the early identification of mental health symptoms. Screening tools are now routinely used in young people who enter the youth justice system in order to assess their physical, mental and substance use needs.12 : The vast majority of schools (93 per cent) also use an internal referral pathway when a mental health concern has been raised. Where they are used, head teachers report they are effective (90 per cent) and they have confidence in their staff’s ability to use them appropriately (96 per cent). Almost all of schools have pastoral care services available (98 per cent).
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M Parsonage, L Khan and A Saunders, ‘Building a better future: the lifetime costs of childhood behavioural problems and the benefits of early intervention’, Centre for Mental Health, January 2014. 12 National Child and Maternal Health Intelligence Network, ‘Assessment in the youth justice system’, 2014, available from: http://www.chimat.org.uk/yj/na/ayjs/assessment
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Promotion of positive mental health and interventions for complex needs: : The majority of schools surveyed report that they implement programmes to promote positive mental health universally across the student population: 93 per cent do this within the course of Personal, Social, Health and Economic (PSHE) education; 94 per cent do this in other lessons such as drama; and 75 per cent promote positive mental health in school assemblies. The promotion of mental health in PSHE lessons was reported to be the most effective activity across all types of schools (84 per cent). : Many schools surveyed report that pupils have access to psychological and physical health services: pupils in 86 per cent of schools have access to a trained/qualified counsellor(s); 86 per cent have access to a qualified psychologists (either educational or mental health); and 85 per cent have access to a school nurse. : Almost two thirds of schools (65 per cent) use peer mentoring. Referring serious cases: : 65 per cent of schools do not use screening tools to differentiate between severity of mental health need (mild, moderate or severe). Yet, in schools where these tools are used, 85 per cent of head teachers reported they were effective. Screening tools are most commonly used in PRUs (46 per cent) and least commonly used in independent schools (28 per cent). : Mainstream, maintained schools were most likely to have access to an external referral pathway to NHS or voluntary sector services for teachers to use when the mental health of a pupil is too severe or complex to be managed by the provision available within schools (94 per cent); independent schools were the least likely type of school to have access to this pathway (73 per cent). More than half (54 per cent) of all respondents said the referral pathway was ineffective. Schools commissioning services directly: : Three quarters of schools (77 per cent) commission mental health services directly: PRUs commission services in most cases (89 per cent); and independent schools commission services in the least number of cases (56 per cent). In moving forward with this agenda, there needs to be greater focus on promoting and protecting psychosocial resilience in CYP through a resilient workforce and in an organisation that is enabling. Building on our findings, we draw on four major conclusions. Resilient children and young people: Psychosocial resilience is about altering the circumstances in which people relate, live and work, in order to provide them with the opportunity to achieve satisfying social identities and derive support from membership of networks and groups.13 Many of the issues relating to adversity, risk and vulnerability are beyond the control of schools, but they do have a role in helping CYP develop protective factors, build psychosocial resilience as well as reconnect 13
S Bailey and R Williams, ‘Towards partnerships in mental healthcare’, Advances in Psychiatric Treatment, 2014, 20: p. 48‐51.
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with their social identity. This will help reduce the number of CYP who are at risk of developing mental health problems.14 Resilient workforce: An essential part of teacher training should include information relating to child development, mental health and psychological resilience in order to give teachers the knowledge and skills to identify CYP with emerging mental health problems. Teachers should also be able to promote positive mental health through the development of positive relationships with pupils. Teachers also need to be resilient themselves. According to the Health and Safety Executive, teaching is one of the most stressful professions, on par with nurses and managers. Approximately 41.5 per cent of teachers report they are ‘highly stressed’ compared to 20 per cent of the general working population.15 Schools as enabling environments: Enabling environments are places where a group of people come together for a specific purpose.16 If schools are to become enabling environments, they need excellent leadership that encourages new thinking and ideas. An enabling environment in schools means adopting a healthy, whole school approach. This means that the ethos and principles applicable to mental health and wellbeing are applied throughout the school, including staff. Our findings reinforce this as 81 per cent of schools are routinely raising awareness of mental health and wellbeing issues within the student body and 80 per cent of head teachers report these measures are effective. However, there are 19 per cent of schools that are not engaging in this activity. Overcoming the barriers to supporting pupils: In cases where staff are aware that a pupil has a mental health problem, our research identifies that the following factors are significant in affecting the current delivery of services to support these pupils. : Almost half (47 per cent) of respondents from mainstream, maintained schools and SEN schools say that increase in their general workload is impacting on their ability to identify mental health problems at the earliest possible point. : 87 per cent of head teachers report that concerns from the pupil about the attitude of their parents/ guardian/ family was a barrier to accessing support : 84 per cent said that a lack of parent/guardian involvement : The attitudes of friends was also cited as a significant barrier by 73 per cent of respondents. : Further qualitative analysis reveals that head teachers have significant concerns over the accessibility and quality of CAMHS. Issues reported include problems with access and the referral process, the Tier 4 CAMHS threshold is too high,
14
CentreForum Mental Health Commission, ‘The Pursuit of happiness: a new ambition for our mental health’, CentreForum, July 2014. 15 Centre for Occupational and Health Psychology School of Psychology, ‘The scale of occupational stress: A further analysis of the impact of demographic factors and type of job’, Cardiff University, for the Health and Safety Executive, 2000. 16 Royal College of Psychiatrists, ‘Enabling environment process document’, 2013, available from: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditation/enablingenvironments.aspx
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referrals will only be accepted by CAMHS if pupils attend appointments and it is difficult to access specialist support from CAMHS for pupils with SEN/Autistic Spectrum Disorder (ASD). Conclusion: This research provides a comprehensive analysis of head teachers’ perceptions of the mental health and wellbeing of pupils in schools as well as reviewing available provision in mainstream, maintained schools, independent schools, SEN schools and PRUs across England. The findings identify that many schools are implementing elements of a comprehensive mental health and wellbeing strategy, although gaps in provision exists. The key to this strategy is early intervention, achieved through identification, escalation and treatment. These findings clearly indicate that staff working in schools are able to identify pupils with behavioural and emotional problems to a certain extent but have a tendency to underestimate. Whilst respondents report that training opportunities, the use of screening tools and internal referral pathways are in place in schools, almost half (47 per cent) of respondents from mainstream, maintained schools and SEN schools say that increase in their general workload is impacting on their ability to identify mental health problems at the earliest possible point. This may explain why three quarters of vulnerable CYP are never identified.17 This research has also identified some of the complexities around delivering effective and timely support to CYP in both schools and CAMH services and has highlighted the important issues of commissioning and security of funding. Whilst many head teachers in this survey report that they implement a range of interventions on mental health, concerns were also raised by respondents that this is entirely dependent on funding and quite often, services are decommissioned. Government is right to be concerned about mental health and the recent publication of the Health Select Committee report places further emphasis on the serious and deeply ingrained problems with the commissioning and provision of children’s and adolescents’ mental health services.18 We welcome the Taskforce set up by Rt Hon Norman Lamb MP to look at child and adolescent mental health in detail. The DfE guidance for schools is also an important step forward. We call on government to implement the following areas of work. Recommendations: The national curriculum should include the requirement to teach CYP how to look after their mental health and build emotional resilience through approaches such as mindfulness. They should also include relationship skills education as standard, given the links between relationship distress and poor mental health. The exact nature of the wellbeing programme being offered should be at the discretion of individual schools but every school in England must be able to demonstrate they are providing something of benefit to their students. OFSTED would be charged with monitoring progress towards the goal of 100 per cent of primary and secondary schools incorporating wellbeing
17
Chief Medical Officer’s Annual Report 2012, ‘Our Children Deserve Better: Prevention pays’, Department of Health, 2012. House of Commons Health Committee, ‘Children's and adolescents' mental health and CAMHS: Third Report of Session 2014–15’, November 2014.
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programmes into school curriculum by 2020. There also needs to be clear guidance, possible from NICE about what constitutes good curriculum content. Teachers should receive training in child development, mental health and psychological resilience to enable them to identify CYP who are vulnerable. We propose that mental health related training should be included on the Initial Teacher Training course by 2020 under a joint framework from the DfE and DH. That all CYP should be screened by teachers and other practitioners using tools such as the Strengths and Difficulties Questionnaire to identify CYP falling outside the normal range of healthy development. For young people experiencing mild to moderate mental health problems, there should be increased access to psychological as well as other therapies in schools or in the community. For CYP with moderate to severe mental health problems, all secondary schools should have routine access to a named CAMHS worker, either on site or through an effective referral pathway to CAMHS tier 3 or 4. All agencies who work with CYP need to work together to plan, commission and deliver a full range of CAMH services using current data and following departmental advice. NHS England, Clinical Commissioning Groups and local councils should prioritise funding for a comprehensive CAMHS, including the restoration of early intervention services in Tiers 2 and 3. As Tier 4 CAMHS is a specialist and finite resource, we need to ensure that universal and specialist community services are strengthened at a population level in order to meet the greatest need.
I have one student being sectioned under the MH [Mental Health] Act section 2 twice in the last term ‐ very limited help from health and the process on and off school site has taken between 12‐14 hours of my teaching staff time. On both releases NO action plan has been put into place to support this child and only by default have I and the police put a community plan in place. CAMHS have not helped in this process ‐ probably as they are over stretched with the referrals etc. External agencies don't restrain so it was left to us to do this. I also put in supervision for my staff as we work with highly vulnerable students who have many issues. It is difficult to differentiate between MH [mental health] and other syndromes/issues as we are only educators! We need more help to help our students. Head teacher, Pupil Referral Unit.
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Introduction
We have currently got a number of students who are exhibiting behaviours which we ae incredibly concerned about in terms of student's mental health but there is currently no service we can buy in or access to support these students. Inclusion Leader, Academy Converter.
The CentreForum Mental Health Commission made it clear that the primary focus of schools should be to cultivate a personal disposition to learn, work and relate, with the skills to live in society. It is vital that schools provide an environment that offers the opportunity for all children and young people (CYP) to learn and develop, regardless of need. 19 In order to achieve this, we must recognise that teachers are facing increasing challenges relating to a growing proportion of pupils presenting with mental health and behavioural problems. This chapter sets out the prevalence of poor mental wellbeing and mental health problems in CYP; the associated outcomes and costs; the adverse factors, risks and vulnerabilities; as well as protective factors and resilience. This is then considered in regards to available interventions and services, commissioning and funding structures and contemporary policy. Prevalence The majority of mental health problems, unlike many physical health problems, affect individuals in the early years of life. As many as ten per cent of CYP in England have low levels of mental wellbeing, at any one time. Compared to those with average to high wellbeing, these individuals are: : Eight times as likely to have conflict in their family; : Five times as likely to have been recently bullied; : Three times as likely to feel they do not have enough friends; : Three times as likely to feel they have a lot less money than their friends.20 Approximately ten per cent of CYP have a clinically diagnosed mental health problem at any one time, equivalent to three children in every classroom.21 The number of CYP admitted to hospital for self‐harm has been rising for the past five years. In fact, 43 per cent of 15‐year‐ olds say that they self‐harm at least once a month.22 Children and young people displaying severe behavioural problems can be indicative of an underlying mental health problem. It is estimated that 50 per cent of CYP in England do not have any behavioural problems, 30 per cent have mild behavioural problems, 15 per cent have moderate behavioural problems and 5 per cent have severe behavioural problems. The threshold for a mental health diagnosis is between moderate and severe. 23 19
CentreForum Mental Health Commission, ‘The Pursuit of happiness: a new ambition for our mental health’, CentreForum, July 2014. 20 G Rees, H Goswami, L Pople, et al., ‘The Good Childhood Report 2013’, The Children’s Society, 2013. 21 Mental Health Foundation, ‘Childhood and Adolescent Mental Health: Understanding. The Lifetime Impacts’, 2005. 22 YoungMinds, ‘Children’s admission to hospitals for self‐harm at 5 year high’, December 2014, available from: http://www.youngminds.org.uk/news/blog/2364 23 ER Brown, L Khan and M Parsonage, ‘A Chance to Change: Delivering effective parenting programmes to transform lives’, Centre for Mental Health, 2012.
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The most prevalent mental health problems in CYP are conduct disorders (5.8 per cent of population), emotional disorders (3.7 per cent) and hyperkinetic disorders (1.5 per cent). Less common disorders include eating disorders, tic disorders and autistic spectrum disorder, which affect 1.3 per cent of CYP.24 All of these problems can have a devastating effect on young people and their families.25 Mental health problems among children tend to increase as they reach adolescence with disorders in general affecting 10.4 per cent of boys aged five to ten, rising to 12.8 per cent in boys aged 11‐15. For girls, the prevalence of mental health problems is 5.9 per cent in children aged five to ten, rising to 9.65 per cent at age 11‐15.26 This can have a devastating effect on CYP and their families.27 Associated outcomes and costs Children and young people who develop a mental health problem are less likely to do well in school. This may because there learning or mental health needs have not been identified or their behaviour or mental health needs means that they are persistently absent from school or excluded. For instance, young people with severe behaviour problems or conduct disorder are twice as likely to leave school without any qualifications. Similarly, CYP with emotional problems are twice as likely as other CYP to have marked difficulties in reading, spelling and mathematics. This is also true of CYP with severe Attention Deficit Hyperactivity Disorder (ADHD) who may be four to five times more likely to struggle to attain literacy and numeracy skills.28 Pupils who are persistently absent from school are also at a disadvantage due to missed education. Across England the average proportion of persistent absenteeism from secondary schools is 7.4 per cent.29 These negative consequences can also continue into adulthood as not being in education, employment or training is a major predictor of later unemployment, low income, teenage pregnancy, depression, and poor physical health. 30 31 Currently, the average proportion of young people who are not in education, training or employment in England is 5.9 per cent. Furthermore, young people with a diagnosis of conduct disorders are more likely to engage in criminal activity and 20 times more likely to end up in prison, four times more likely to become dependent on drugs and six times more likely to die before the age of 30 when compared to the general population.32 Economically, mental health problems in CYP cost between £11,030 and £59,130 annually per individual.33 Conduct disorder is the most prevalent condition and the costs are accrued accordingly: education pays 31 per cent of the total costs; families pay 31 per cent; the NHS
24
H Green, A McGinnity, H Meltzer et al., ‘Mental health of children and young people in Great Britain’, Office of National Statistics, 2004. 25 Centre for Mental Health, ‘The Economic and Social Costs of Mental Health Problems in 2009/10’, 2010. 26 National Statistics Online, ‘Mental Health: Mental Disorder More Common In Boys’, 2004, available at: www.statistics.gov.uk 27 Centre for Mental Health, ‘The Economic and Social Costs of Mental Health Problems in 2009/10’, 2010. 28 Ibid. 29 H Taggart, ‘The CentreForum Atlas of Variation: identifying unwarranted variation across mental health and wellbeing indicators in England’, CentreForum, July 2014. 30 S Gibb, ‘Burden of Psychiatric Disorder in Young Adulthood and Life Outcomes at Age 30’, British Journal of Psychiatry, 2010, 197, pp. 122‐127. 31 B Coles, S Hutton, J Bradshaw, et al., ‘Literature Review of the Costs of Being “Not in Education, Employment or Training’ at Age 16‐18’, Social Policy Research Unit, University of York, 2002. 32 M Parsonage, L Khan and A Saunders, ‘Building a Better Future. The Lifetime Costs of Childhood Behavioural Problems and the Benefits of Early Interventions’, Centre for Mental Health, January 2014. 33 M Suhrcke, D Pillas, C Selai, ‘Economic aspects of mental health in children and adolescents’. In Social cohesion for mental well‐being among adolescents. Copenhagen: WHO Regional Office for Europe, 2008.
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pays 16 per cent; state benefits pay 15 per cent; social services pay 6 per cent and the voluntary sector pays 1 per cent. ADHD is another disorder diagnosed in childhood where schools pay the majority of the public sector costs (44 per cent). ADHD is estimated to cost £102,135 per individual. Centre for Mental Health predict this is because 71 per cent of CYP with ADHD have special educational needs, compared with only 16% of other CYP.34 As half of all lifetime cases of mental health problems develop by the age of 14 and three quarters develop by the age of 24, yet many young people never receive any form of treatment, there is a strong economic argument for early intervention during the early years. 35 Many conduct disorders and eating disorders are undiagnosed and untreated and approximately 35 per cent of those with depression and 51 per cent of those with anxiety disorders are not in contact with any services.36 Adversity, risk and vulnerability Adversity, risk and vulnerability all contribute to the development of mental health problems. Adversity can be defined as ‘an experience of life events and circumstances which may combine to threaten or challenge the healthy development of CYP’.37 There are many adverse factors that can affect CYP including incidents of physical or sexual abuse; traumatic incidents such as loss and bereavement; chronic situations – such as environments of neglect; experiences of bullying or racism; and family stressors and socio‐economic disadvantages, as well as many others.38 In an average classroom ten young people will have witnessed their parents separate; one young person will have experienced the death of a parent; 30 young people in an average secondary school will be caring for someone in their family; and of those CYP who are looked after by the local authority, approximately 60 per cent have a mental health disorder. 39 40 41 Young people living with a parent who has a mental health problem are also at an increased risk of developing a mental health problem.42 Furthermore, one in five CYP have been severely neglected, physically attacked or even sexually abused at some point in their lives.43 A further ten per cent of CYP say they have been bullied in school. 44 The London School of Economics found evidence to suggest that bullying can have a long‐term negative impact on employability meaning the lifetime earnings of a victim of bullying are reduced by around £50,000.45
34
M Parsonage, ‘The lifetime costs of attention deficit hyperactivity disorder (ADHD)’, Centre for Mental Health, November 2014. 35 RC Kessler, WT Chiu, O Demler, et al., ‘Prevalence, severity, and comorbidity of 12‐month DSM‐IV disorders in the National Comorbidity Survey Replication’, Arch Gen Psychiatry, 2005, 62(6): p. 617‐27. 36 P McCrone, S Dhanasiri, A Patel, et al., ‘Paying the price’, King’s Fund, 2008. 37 B Daniel, S Wassell and R Gilligan, ‘Child Development for Child Care and Protection Workers’, Jessica Kingsley Publishers, 1999. 38 B Daniel, ‘Concepts of Adversity, Risk, Vulnerability and Resilience: A Discussion in the Context of the ‘Child Protection System’’, Social Policy & Society, 2010, 9:2, p.231–241. 39 The Children’s Society, ‘Include project: information for teachers and school staff’, The Children’s Society, 2007. 40 National Institute for Health and Care Excellence, ‘Promoting the quality of life of looked‐after children and young people’, NICE, 2010. 41 Department for Children Schools and Families, ‘Children looked after in England (including adoption and care leavers) year ending 31 March 2007’, available from: http://www.dcsf.gov.uk/rsgateway/DB/SFR/s000741/SFR27‐2007rev.pdf 42 J Faulkner, ‘Class of 2011 yearbook: how happy are young people and does it matter’, Relate, 2011. 43 NSPCC, ‘Child cruelty in the UK 2011: The facts’, 2011. 44 GovUk, ‘Bullying at school’ June 2014, available from: https://www.gov.uk/bullying‐ at‐school 45 S Hummel, P Naylor, J Chilcott et al., ‘Cost‐effectiveness of Universal Interventions Which Aim to Promote Emotional and Social Well‐being in Secondary Schools’, School of Health and Related Research, University of Sheffield, 2009.
15
Risk factors, in addition to adversity, can make children, families and whole communities more likely to develop mental health problems. Risk is a term that ‘denotes the chances of adversity translating into negative outcomes’.46 Almost a third of children in the UK live in poverty and approximately six million of these children live in severe poverty. In these cases, 63 per cent of children living in poverty are in a family where someone works.47 Children living in large families or children of poorly educated parents or those living in social sector housing are at higher risk of developing a mental health problem. Similarly, those living in transient or unsecure communities such as refugee or asylum seekers and gypsy or travellers have increased risk of developing mental health problems.48 Young people with learning disabilities or special educational needs also have an increased risk of developing mental health and behavioural problems when faced with adversity; 36 per cent of young people with a learning disability also have a mental health problem, compared with 8 per cent of non‐disabled young people. More than two thirds of the young people who were involved in the August 2011 riots had special educational needs.49 Furthermore, of imprisoned young offenders, 95 per cent of have a mental health disorder and many of them are struggling with more than one disorder.50 There may be additional levels of vulnerability defined as ‘that which increases the probability (in terms of incidence, severity, duration) of an individual or group developing a mental health problem in the presence of a given risk. It is a factor or mechanism that interacts with the risk and in doing so accentuates the impact of that risk on the individual or group’.51 For instance, boys are more likely to develop conduct disorder compared to girls; and girls are more likely to develop eating disorders compared to boys. CYP from black and minority ethnic (BME) groups and those with LGBT orientation also have higher incidences of mental health problems.52 Communities can also be vulnerable to poor mental health and wellbeing. Social vulnerability refers to the inability communities to withstand adverse impacts due to characteristics inherent in social interactions, institutions and systems of cultural value and is linked to the level of wellbeing of individuals, communities and society. Protective factors and psychosocial resilience Despite the adversity, risk factors and vulnerabilities some CYP experience, not all go on to develop mental health problems. Protective factors can make CYP more resilient and can be defined as ‘that which decreases the probability (in terms of incidence, severity, duration) of an individual or group developing a specific problem in the presence of a given risk’. Similar
46
B Daniel, ‘Concepts of Adversity, Risk, Vulnerability and Resilience: A Discussion in the Context of the ‘Child Protection System’, Social Policy & Society, 2010, 9:2, p.231–241. 47 Barnardo’s, ‘Child poverty statistics and facts’, March 2014, available from: http://www.barnardos.org.uk/what_we_do/our_projects/child_poverty/child_poverty_what_is_poverty/child_poverty_statisti cs_facts.htm 48 Mental Health Foundation, ‘Lifetime Impacts: Childhood and Adolescent Mental Health’, 2005. 49 Child and Young People Mental Health Coalition, ‘Resilience and Results’, May 2014. 50 Office for National Statistics, ‘Psychiatric morbidity among young offenders in England and Wales’, 1997. 51 C Lacharité, ‘From risk to psychosocial resilience: conceptual models and avenues for family intervention’, 2005, available from: . ISSN 0104‐ 0707. 52 D Rees and Y Anderson, ‘BOND: Learning from practice based recovery’, YoundMinds, 2012.
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to vulnerability, it is a component that interacts with the risk, but instead of accentuating, it moderates the impact of the condition of risk on the individual or group.53 Protective factors are inherent within an individual and include personal characteristics, knowledge and skills; family factors such as family relationships and supportive peers; and community factors such as available resources, school characteristics, and community resources. The presence of protective factors can increase the resilience of CYP. Resilience is ‘that which increases the probability of a specific positive result in the presence of a given risk’.54 Psychosocial resilience is about altering the circumstances in which people relate, live and work, in order to provide them with the opportunity to achieve satisfying social identities and derive support from membership of networks and groups.55 This matters in the context of social identity, which refers to the extent to which CYP feel part of their local community and are able to engage with it. Haslam suggests that the cycle of social identity starts with a individuals having a sense of community and a feeling of belonging; this then provides a basis for support and coping; which leads to feelings of purpose, control and meaning, and finally to health and wellbeing.56 Therefore, in promoting health and wellbeing at a community level, we must ensure individuals have a social identity. This approach recognises that people live in groups, such as those associated with families, schools, workplace and faith. CYP are embedded in families; families are embedded in communities and embedded in communities are schools. Therefore schools have a role to play in promoting social identity. This is important as CYP can often become isolated from their social groups. Therefore, in helping CYP reconnect with their social identity and in turn, improve health and wellbeing, ‘sourcing’ should be used which focuses on how people with mental health problems can maintain connections, or reconnect with groups. ‘Scaffolding’ also refers to the process in which individuals with mental health problems are supported to build new social connections. All communities have assets and strength that value the capacity, skills, knowledge, connections and the potential of local people and resources. This is a place for promoting resilience and help in strengthening and improving the quality of social relationships within families and communities and building social support, social networks and social capital.57 Many of these issues relating to adversity, risk and vulnerability are beyond the control of schools, but they do have a role in helping CYP develop protective factors, build psychosocial resilience as well as social identity. In time, this will help reduce the number of CYP who are at risk of developing mental health problems through approaches incorporating psychosocial resilience, social identity, horizontal epidemiology and recovery.58
53
C Lacharité, ‘From risk to psychosocial resilience: conceptual models and avenues for family intervention’, 2005, vol.14. Available from: . ISSN 0104‐0707. 54 Ibid. 55 S Bailey and R Williams, ‘Towards partnerships in mental healthcare’, Advances in Psychiatric Treatment, 2014, 20: p.48‐51. 56 S A Haslam, ‘Psychology in organisations: The social identity approach’ (2nd ed.), Sage, 2004. 57 L Friedli, ‘Mental Health, Resilience and Inequalities’, World Health Organisation, 2009. 58 CentreForum Mental Health Commission, ‘The Pursuit of happiness: a new ambition for our mental health’, CentreForum, July 2014.
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Interventions and services There are a number of evidence based interventions to meet the needs of CYP with mental health problems. These can be provided by schools, the NHS or the voluntary, community and private sectors. School based interventions In order to successfully support the increasing population of young people experiencing difficulties, there needs to be a whole school approach to mental health and wellbeing. This should include the promotion of positive mental wellbeing and mental capital to all pupils and then targeted support to those experiencing difficulties. School based programmes can include interventions through Personal, Social, Health and Economic (PSHE) education and the wider curriculum; anti‐bullying interventions; identification of CYP with emerging difficulties, a healthy schools programme; statutory exclusion guidelines and support for teachers.59 There are targeted programmes that can be implemented in schools with CYP who have specific mental health needs. For those with behavioural problems, school‐based Social and Emotional Learning programmes help pupils to recognise and manage their emotions, set and achieve positive goals, appreciate the perspectives of others, establish and maintain positive relationships, make responsible decisions and handle interpersonal situations constructively. If education services are to pay for this intervention (approximately £132 per individual), they are likely to recoup the full cost of the intervention in five years.60 Similarly, anti‐bullying programmes in schools can also demonstrate a 21–22 per cent reduction in the proportion of CYP victimised and offer good value for money, costing £15.50 to deliver but saving £1080 per pupil.61 Schools can also commission a number of Tier 1 – 3 CAMH services. Child and Adolescent Mental Health Services Children and adolescent mental health services are organised into a four tiered system. This system offers universal provision at Tier 1, through to specialist provision at Tier 4. The service model for Tier 1‐3 differs across the country but generally this includes the following services: mental health promotion; training to Tier 1 staff; CAMHS outpatient clinics and community services; family therapy and group work; out of hours on‐call services; provision to specialist schools; support to Youth Offending Teams; Looked After Children and Eating Disorders teams; and services that are delivered on an infrequent basis such as ante and post‐natal support, black and minority ethnic services, forensic CAMHS, sensory impairment teams, and crisis intervention services. Mental health promotion, prevention and early intervention is delivered in these services. Tier 4 services include: inpatient beds; eating disorders services; transition services; intensive outreach; and less frequently, day units, community based crisis support, family preservation schemes, and home treatment services. 62 As well as NHS provision, the private sector provides a large proportion of Tier 4 CAMHS.63 Children and Young People's Improving Access to Psychological Therapies Programme (CYP IAPT) works jointly with CAMHS and the voluntary sector to improve existing provision
59
Child and Young People Mental Health Coalition, ‘Resilience and Results’, May 2014. J Beecham, E Bonin, S Byford et al., ‘School‐based social and emotional learning programmes to prevent conduct problems in childhood’. In M Knapp, D McDaid and M Parsonage (Eds.) ‘Mental Health Promotion and Prevention: The Economic Case’, London School of Economics and Political Science, January 2011. 61 K E Evers, J O Prochaska, D F Van Marter et al, ‘Transtheoretical‐based bullying prevention effectiveness trials in middle schools and high schools’, Educational Research, 2007, 49: p.397–414. 62 CAMHS Tier 4 Report Steering Group, ‘Child and Adolescent Mental Health Services Tier 4’, NHS England, July 2014. 63 NHS England, ‘CAMHS benchmarking report: Raising standards and sharing through excellence’, December 2013. 60
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within the community. Where CAMHS and CYP IAPT have linked together, they form a Learning Collaborative. This Collaborative includes Higher Educational Institutions that provides training to existing CAMHS staff set out in the CYP IAPT National Curriculum. CYP IAPT has a target to work with CAMHS and cover 60 per cent of the 0‐19 population by March 2015 but evidence suggests that only 54 per cent of the under‐19 population is currently being covered.64 Commissioning and funding Four groups hold commissioning responsibility for CYP mental health services: local authorities, CCGs, schools and NHS England. The ‘commissioning footprint’ (i.e. the number of people a service can reach in a given area) increases from Tier 1 to Tier 4, meaning that services in the lower tiers are commissioned locally, whereas services commissioned in the highest tier is commissioned nationally. Since April 2013, NHS England has commissioning responsibility for Tier 4 CAMHS and CYP IAPT; whereas local authorities, schools and CCGs have responsibility for commissioning Tier 1‐3 services. Local authorities have control over the mental health services they commission and can allocate their budget accordingly.65 In terms of funding at a regional level, local authorities and CCGs have responsibility. CCGs fund all NHS and social care services whereas local authorities have responsibility to fund resilience and wellbeing services. Funding decisions should be based on a comprehensive Joint Health and Wellbeing Strategy (JHWS) that is tailored to the needs of the local population, dependent on the data acquired through a Joint Strategic Needs Assessment (JSNA). This is the responsibility of Health and Wellbeing Boards (HWBs). However, CAMHS have experienced severe funding cuts over the past few years. A freedom of information request by YoungMinds found that two‐thirds of local authorities have cut their CAMHS budgets, and the largest cuts have been to early intervention services (Tier 1 and Tier 2). 66 More recently, the mental health charity, Mind found that local authorities allocate a far greater proportion of their budget to preventing physical health problems, compared to mental health problems. In England, £671 million is spent on sexual health initiatives, £160 million is spent on smoking cessation, £108 million is spent on anti‐obesity interventions and £76 million is spent on increasing physical activity, in total. Less than £40 million is spent on mental health (1.36 per cent). This disparity of funding continues at a national level as NHS England only allocate 0.6 per cent of the total NHS budget to CAMHS.67 In trying to close this treatment gap and improve the quality of life of CYP experiencing, or at risk of poor mental health, we need to strengthen the capacity of existing service provision. In some areas of the country, CAMHS are overburdened and unable to provide timely and appropriate support. In moving towards a comprehensive CAMH system, we must ensure that all tiers of CAMHS are working effectively and the role of schools in promoting, protecting and providing early intervention for pupil mental health issues is fully utilised. This will not only improve mental and physical health outcomes but also to improve attainment, attendance and productivity in later life. 64
Children and Young People’s IAPT, ‘What is CYP IAPT’, October 2014, available from: http://www.cypiapt.org/children‐and‐ young‐peoples‐project.php?accesscheck=%2Findex.php 65 CAMHS Tier 4 Report Steering Group, ‘Child and Adolescent Mental Health Services Tier 4’, NHS England, July 2014. 66 YoungMinds, ‘Stop cutting CAMHS Services’, 2013, available from: http://www.youngminds.org.uk/about/our_campaigns/cuts_to_camhs_services 67 Mind, ‘Mind reveals ‘unacceptably low’ spending on public mental health’, October 2014, available from: http://www.mind.org.uk/news‐campaigns/news/mind‐reveals‐unacceptably‐low‐spending‐on‐public‐mental‐ health/#.VIh6izEQNfc
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Policy The DfE published a report in June 2014 with guidance on how schools can plan, commission and deliver interventions and services for young people with mental health and behavioural problems. There are seven key objectives: 1. Schools have a role to play in supporting pupils to be resilient and mentally healthy. 2. Where severe problems occur, schools should expect the child to get support elsewhere as well. 3. Schools should ensure that pupils and their families participate as fully as possible in decisions. 4. Schools can use the Strengths and Difficulties Questionnaire to help them judge whether individual pupils might be suffering from a diagnosable mental health problem. 5. There are things that schools can do – including for all their pupils, for those showing signs of problems and for families exposed to several risk factors – to intervene early and strengthen resilience, before serious mental health problems occur. 6. Schools can influence the health services that are commissioned locally through their local Health and Wellbeing Board. 7. There are national organisations offering materials, help and advice. Schools should look at what provision is available locally.68 Rationale
This research takes DfE guidance into account and aims to ascertain the extent to which secondary schools in England are delivering a comprehensive mental health and wellbeing strategy – including the promotion of positive mental health, the identification of mental health mental problems, the delivery of interventions that promote positive mental health and interventions for complex problems, the referral of serious cases to CAMHS and the commissioning of services, in accordance with government guidance. The objectives were to (i) identify the extent of mental health related demand and need in secondary school pupils in England; (ii) identify the specific components of the mental health and wellbeing strategy in place in schools regarding the promotion of positive mental health, the identification of mental health mental problems, the delivery of interventions that promote positive mental health and interventions for complex problems, the referral of serious cases to CAMHS and the commissioning of services; and in doing this, and (iii) consider the extent to which the mental health and wellbeing strategy of schools operates in accordance with the guidance set out by the Department for Education. This research may be of interest to head teachers, teachers, teaching assistants and other staff working in schools; health and allied professionals working in CAMHS; and national and regional departmental bodies such as the DfE, Department of Health, Public Health England, local authorities, HWBs and CCGs.
DfE, ‘Mental health and behaviour in schools. Departmental advice for school staff’, June 2014.
68
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Departmental Advice
Identification of mental health problems : Effective use of data so that patterns of attainment, attendance or behaviour are noticed. : Effective pastoral system : SEN : Working with local GPs Promoting positive mental health : Committed senior management team : Ethos : Strategic role for Special educational needs coordinator (SENCO) : Working with parent/carers as well as pupils : Continuous professional development for staff : Clear systems and processes to help staff who identify children and young people with possible mental health problems : Working with others to provide intervention for pupils with mental health problems that use a graduated approach to inform a clear cycle of support (assessment, plan, action, review). : Healthy school approach to promoting health and wellbeing. Intervention to promote positive mental health : PSHE education : Positive classroom management and small group work : Counselling : Child and adolescent psychologist : Developing social skills : Working with parents : Peer mentoring Interventions for children with complex problems : Support to the pupil’s teacher : Additional educational one to one support for the pupil : One to one therapeutic work : Medication : Family support and therapy Referring serious cases to CAMHS : Using a clear process for identifying children in need of further support (SDQ) : Documenting evidence of symptoms : Encouraging the pupil and their parents to speak to their GP : Working with local specialist CAMHS to make the referral process as quick and efficient as possible : Understanding the criteria that will be used by specialist CAMHS : Having a close working relationship with local specialist CAMHS : Consulting CAMHS about the most effective things the school can do to support children. Schools commissioning services directly.
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Methods
I anticipate the Time to Change programme to have a significant impact. Already staff have commented that they really appreciate the topic of mental health being discussed, and a number have told me about their own experiences of mental health problems. I am excited about the launch with our students and the impact it might have on them and their families. The key challenges for schools are: perceptions and misconceptions in all groups of stakeholders; and lack of resources to support young people and their families (i.e. more investment needed in CAMHS, more investment needed in quality in‐school services (i.e. trained psychotherapists). Head teacher, Academy Converter.
Research questions What are head teachers perceptions of the incidence of behavioural and emotional problems in pupils in English secondary schools? To what extent do head teachers think behavioural or emotional problems are compounded by an emerging or known mental health problem? What strategies do English secondary schools deliver in order to support the early identification of mental health problems in terms of ethos, staff training, use of data, the use of systems and processes, the influence of a pastoral system, the use of SEN teachers and local GPs? What interventions do English secondary schools deliver to promote positive mental health in their pupils? What interventions do English secondary schools deliver to support pupils with complex problems? What mechanisms do English secondary schools have in place to identify and refer pupils with severe mental health problems to CAMHS and what are the barriers, if any? Do schools commission mental health services directly, and if so, what are the barriers, if any? Design A cross‐sectional study design was used as this allows the health needs of a population, as well as other variables, to be examined at a single point in time. This is particularly useful in informing the planning and allocation of health resources. Participants The sampling unit was secondary schools in England and the target population was head teachers, or senior members of staff. A sampling frame of 4961 secondary school head teachers in England was obtained through a Freedom of Information request at the DfE. From the sampling frame, a randomised weighted sample was taken using simple randomising sampling method across 12 strata with a 95 per cent confidence level and a
22
confidence interval of one. This resulted in a sample of 3271 participants. There were 330 responses, equating to a 9.9 per cent response rate. Instrument Content A 29‐item questionnaire was developed by the CentreForum research team. Questions related to perceived demand, need and service provision in regards to the mental health of pupils in secondary schools. Responses were collected through a Likert scale or open ended questions. Audience This questionnaire specifically related to pupils aged between 11 and 18 years old. The survey was for completion by a head teacher or a suitable nominee. Data protection Participants were informed that all information collected in the study would be treated in confidence and that data would be stored in accordance with the Data Protection Act. Availability The questionnaire was available online and could be accessed at any time during the data collection period. Pilot study A small pilot study was conducted in December to ensure that the survey instrument was accessible to head teachers. Following this, minor amendments to the survey instrument were made. Data collection Participants were invited to take part in the survey by email. An attached letter gave details of the nature of the study with a hyperlink to the questionnaire through the online platform, Survey Monkey. Data was collected over a six week period. Analysis A descriptive analysis was used for quantitative data and all qualitative data were analysed using a thematic analysis. The sub‐groups for analysis were: Mainstream, maintained schools (i.e. academy converter, academy sponsor, community schools, foundation schools, free schools, voluntary aided schools); Independent schools; SEN schools; PRUs. Two respondents were from independent SEN schools and these were analysed with other respondents from SEN schools. All data has been rounded to one decimal place.
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Findings
Key personnel are trained to identify and refer pupils presenting with mental health issues. We work closely with outside agencies to provide a wide range of provision. There has been a marked increase in the number of pupils presenting with mental health issues over the last few years. The 'thresholds' for referral have also got higher as services have been cut back. This is a 'ticking bomb' as far as our future capacity to deal with these growing numbers (as a society) is concerned as these teenagers mature into adults and start to put pressure on adults mental health services. Deputy Head Teacher, Academy Converter.
Descriptive characteristics Participant and socio‐demographic data is provided in Tables 1 and 2. Please note, the sample comprised mainly of respondents from academy converters. Table 1. Summary of responses Group Type of school
Mainstream, maintained
Academy converter Academy sponsor Community schools Foundation schools Free schools Voluntary aided schools Total
Mainstream, not maintained Not mainstream
Independent schools SEN schools
Not mainstream, maintained
Pupil referral units Incomplete responses Total
Number of respondents (n) 114 29 22 7 3 6 181
Percentage of total sample (%) 34.6 8.8 6.7 2.1 0.9 1.8 54.9
28
9.1
50 22
14.6
49 330
14.9 100
6.7
Table 2. Socio‐demographic characteristics Indicator
Single sex or mixed school (%) Girls school Boys school Mixed school Boys school with mixed sixth form Girls school with mixed sixth form Total population of school (%) Fewer than 100 101 to 250 251 to 500 501 to 750 751 to 1000
Mainstream maintained schools (%)
10.7 3.4 81 3.4 1.7 3.9 8.3 16.6 29.3 32
Percentage of total population (%) 6.0 (3024) 2.4 (1135) 4.9 (1017)
5.1 (432) 5.4 (5176)
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
30 6.7 63.3 0
2.1 12.5 85.4 0
0 0 100 0
0
0
0
20 13.3 23.3 16.7 16.7
62.5 37.5 0 0 0
77.3 18.2 4.6 0 0
24
1001 to 1500 More than 1500 Pupils whose first language is not English (%) None 1 ‐ 5% 6‐10% 11‐20% 21‐30% 31‐40% 41‐50% More than 50% Pupils with special educational needs (%) None 1 ‐ 5% 6‐10% 11‐20% 21‐30% 31‐40% 41‐50% More than 50% Pupils from an ethnic minority (%) None 1 ‐ 5% 6‐10% 11‐20% 21‐30% 31‐40% 41‐50% More than 50% Pupils on free school meals (%) None 1 ‐ 5% 6‐10% 11‐20% 21‐30% 31‐40% 41‐50% More than 50% School location (%) Hamlet or rural area (1000 people or fewer) Village (1001 to 3000 people) Small town (3001 to 15 000) Town (15 001 to 100 000) City (100 001 to 1 million) Large city (more than 1 million people)
9.4 0.6
3.3 6.7
0 0
0 0
4.4 49.2 16 9.9 7.2 2.2 5 6.1
10 46.7 20 10 6.7 3.3 0 3.3
33.3 39.6 14.6 4.2 4.2 0 2.1 2.1
45.5 27.3 9.1 0 9.1 0 0 9.1
3.6 28.6 28.6 14.3 7.1 0 0 17.9
0 2.2 0 0 0 4.4 0 93.5
0 13.6 18.2 4.6 0 0 9.1 54.6
0.6 42.5 12.9 12.3 9.50 7.82 5.03 9.50
3.3 30 33.3 16.7 10 0 3.33 3.33
6.5 41.3 19.6 10.9 13 6.5 2.2 0
18.2 59.1 4.6 4.6 4.6 0 4.6 4.6
0.0 16.7 23.9 21.7 11.7 8.9 6.1 11.1
76.7 13.3 0 3.3 0 0 0 6.7
0 4.4 2.2 10.9 15.2 15.2 23.9 28.3
0 4.6 4.6 13.6 22.7 13.6 22.7 18.2
3.3
13.3
10.4
0
8.3
6.7
6.3
4.6
20.6
6.7
14.6
4.6
35.6
16.7
29.2
27.3
17.8
26.7
25
54.6
14.4
30
14.6
9.1
0.6 22.2 19.4 27.8 13.9 8.9 3.9 3.3
25
Mental health related demand and need in secondary school pupils In the last twelve months we have seen a dramatic increase in self‐harm in under 16's. The reasons cited are parental split, lack of attention of one parent, body image in comparison to peers, self‐loathing, excessive Internet use, Tumblr etc. Pressure to perform academically from parents and school. Student Welfare & Safeguarding coordinator, Academy Converter. Incidence of behavioural and emotional problems The majority of respondents estimated the incidence of behavioural and emotional problems in pupils attending mainstream schools to be between 1 and 10 per cent. The majority of respondents from SEN schools estimated the incidence of behavioural problems and emotional problems to be over 40 per cent. Table 3. Estimated incidence of behavioural and emotional problems Indicator
Incidence of behavioural problems (%) None 1 ‐ 5 6‐10 11‐20 21‐30 31‐40 Above 40 Incidence of emotional problems (%) None 1 ‐ 5 6‐10 11‐20 21‐30 31‐40 Above 40
Mainstream, maintained schools (%)
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
0 48 30 11 5 1 5
3 61 21 4 0 0 11
0 16 36 28 12 4 46
0 5 0 0 5 10 80
0.8 32.5 21.8 10.8 5.5 3.8 35.5
0 53 23 14 6 1 3
7 54 25 0 4 7 4
0 14 12 16 8 10 40
0 0 4 0 4 24 68
1.8 30.3 16.0 7.5 5.5 10.5 28.8
Extent to which respondents think behavioural or emotional problems are associated with an emerging or diagnosed mental health problem On average, 25 per cent of respondents from mainstream, maintained schools and 6 per cent of respondents from independent schools reported that mental health problems were a significant factor in the presentation of behavioural and emotional problems. Respondents from mainstream, maintained schools were 6.2 times more likely to attribute behavioural problems to an emerging mental health problem and 2.4 times more likely to attribute behavioural problems to a diagnosed mental health problem compared to independent schools. Similarly, respondents from mainstream, maintained schools are 5.6 times more likely to attribute emotional problems to an emerging mental health problem and 3.6 times more likely to attribute behavioural problems to a diagnosed mental health problem compared to independent schools. More than half of respondents from SEN schools (65 per cent) and PRUs (63 per cent) reported that mental health problems were a significant factor in the presentation of behavioural and emotional problems. SEN schools reported the incidence of behavioural
26
problems to be 1.3 times higher than emotional problems. Respondents from all types of schools reported that family life and relationships were the greatest attributing factors to behavioural and emotional problems in pupils. Table 4. Association between behavioural/ emotional problems with emerging/ diagnosed mental health problems Indicator 69 Mainstream,
Most likely cause of behavioural problems is a mental health problem Emerging mental health problem (%) Diagnosed mental health problem (%) Most likely cause of emotional problems is a mental health problem Emerging mental health problem (%) Diagnosed mental health problem (%)
maintained schools (%)
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
310
5
60
63
39.8
22
9
65
59
38.8
27
5
65
67
18
5
67
60
41.0 37.5
Further qualitative analysis revealed that respondents across all types of schools reported a rise in the presentation of behavioural and emotional problems and an increase in the incidence of self‐harm amongst pupils. Respondents also suggested that environmental factors such as economic pressures on families, parental separation and the influence of social media were reasons for this increase. Head teachers suggested this is having an impact on pupil attainment, performance and ability to cope with every day pressures.
69
Behavioral or emotional problems to be most likely caused from an emerging mental health problem from respondents who estimated the incidence to be 1‐10% for mainstream, maintained schools only and respondents who estimated the incidence to be more than 40% for SEN schools and PRUs.
27
Mental health and wellbeing strategies in English secondary schools Our school has a genius feature in its identity: we are a 'telling school' and this means that students feel no hesitation in speaking to staff if they are unhappy or feel bullied. Because this is the first thing they are told and it is emphasised every day by senior staff, it becomes a source of pride and a sense of identity. Head of year, Community School. Supporting the early identification of mental health problems In order to identify mental health problems in pupils at the earliest opportunity, teachers and staff working in schools need to be aware of the interrelationship between adversity, risk, vulnerability, protective factors, resilience and mental health problems. Teachers should in a position to identify the signs and symptoms of mental health problems, be able to signpost pupils to the appropriate support, either in schools or externally, and have knowledge of the services available in the local community. Ethos A schools’ ethos is fundamental to a mental health and wellbeing strategy. Respondents across all types of schools reported that a healthy, ‘whole school’ approach to mental health and wellbeing was essential. In particular, 81 per cent of respondents on average reported that their school delivered awareness raising activities around issues impacting on mental health. Respondents from mainstream, maintained schools also said there should be a strong and vigilent reporting culture in schools where pupils are able to talk to staff about any issues they are having. Respondents from PRUs also reported that an inclusive ethos where students can talk to staff at any time within an open and honest culture of working was the most beneficial. Some respondents also reported that their schools uses mindfulness approaches, social and emotional aspects of learning and they inform the entire curriculum with solution focused approaches. Two respondents also reported that their schools were piloting the Time to Change programme to good effect. One respondent from an independent schools also reported they were delivering initiatives such as ‘Blue Monday, Be Happy’ and creativity week which had been well received by pupils. One head teacher from a SEN schools reported that they participated in World Mental Health Awareness Day. Table 5. Mental health awareness raising activities in schools Indicator Activity delivered Reported to be effective
Mainstream, maintained schools (%) 83 60
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
72 83
80 78
90 100
81 80
Training Ensuring that teachers and other educational staff are adequately trained in identifying possible mental health problems is essential for early identification of mental health problems. The data indicates that the majority of schools have access to training and continuing professional development (CPD) opportunites on mental health issues (average 91 per cent). From this, three quarters of respondents think that specific mental health
28
related training is effective and a significant factor in supporting the early identification of mental health problems. However, it is not clear if all staff are able to access this training or feel competent in the issues discussed. One respondents from a mainstream, maintained school also reported that their staff were trained in mental health first aid as well as neuro‐ linguistic programming. One respondent from a SEN school also commented that CAMHS should be offering training and support to school staff. Table 6. Staff training and continuing professional development Indicator
Staff attend training and CPD on mental health issues Reported to be significant
Mainstream, maintained schools (%) 83
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
93
92
95
91
78
71
75
75
75
Use of data In supporting the early identification of mental health problems, teachers should make use of available data in order to detect patterns of attainment, attendance or behaviour. Our findings indicated that approximately half (47 per cent) of mainstream maintained schools and 37 per cent of independent schools use screening tools to identify mental health problems in pupils. In cases where this was used, the majority of respondents (85 per cent in mainstream schools and 91 per cent in independent schools) reported they had been effective. Screening tools were also used by respondents from SEN schools (54 per cent) and PRUs (64 per cent) to good effect. However, there was a mixed response in whether screening tools are a signigicant factor in the early identification of mental health problems amongst different schools types: PRUs are twice as likely to think screening tools are effective compared to independent schools. This is not surprising as screening tools are routinely used on young people entering the youth justice system. The tool, ‘Comprehensive Health Assessment Tool (CHAT)’, assesses physical, mental and substance use needs and was developed and agreed by partners across health. Evidence from youth justice suggests that this was especially useful in picking up neurodevelopmental problems and acquired brain injury which is often missed.70 Table 7. Use of screening tools Indicator
Mainstream, maintained schools (%) 47
Screening tools are used Reported to be 85 effective Reported to be 58 significant n in identifying mental health problems at an early stage
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
37
54
64
51
91
76
93
86
44
63
90
64
National Child and Maternal Health Intelligence Network, ‘Assessment in the youth justice system’, 2014, available from: http://www.chimat.org.uk/yj/na/ayjs/assessment
70
29
Clear systems and processes Mainstream, maintained schools were most likely to report an internal referral pathway for teachers to use when they have concerns about a pupil’s mental health (98 per cent), compared to 94 per cent of SEN schools, 91 per cent of PRUs and 87 per cent of independent schools. The majority of respondents from all types of schools reported that they had good levels of confidence in their staffs’ ability to use these pathways appropriately; although, there was varying levels of effectivess. Independent and SEN schools reported they had the most effective referral pathway in place (96 per cent) followed by PRUs (85 per cent) and mainstream maintained schools (82 per cent). Table 8. Use of internal referral pathways Indicators
Internal referral pathways are used Reported to be effective High confidence in the ability of staff to use pathways
Mainstream, maintained schools (%) 98
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
87
94
91
93
82
96
96
85
90
92
92
100
100
96
Effective pastoral system In this section of the report, issues around supporting the early identification of mental health problems have been discussed in terms of ethos, training, data and systems. Respondents across all types of schools reported that the most significant factor in supporting the early identification of pupils with mental health problems were the provision of pastoral care services (average 98 per cent). Table 9. Pastoral care services Indicator
Pastoral care services provided
Mainstream, maintained schools (%) 97
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
97
98
100
98
Special Educational Needs Discussion and engagement between classroom based support staff (i.e. teaching assistants) and pupils in class based activities was also reported to be signifcicant in the early identification of mental health problems. Table 10. Discussion and engagement with classroom support staff Indicator
Discussion and engagement between classroom based support staff
Mainstream, maintained schools (%) 75
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
64
92
95
82
30
Barriers The findings also indicate that staff workloads are having a negative impact on the ability of almost half of mainstream schools to identify mental health issues in pupils at an early stage. Table 11. Staff workloads impact negatively on the ability to identify mental health issues in pupils at an early stage Indicator
Agree/ strongly agree
Mainstream, maintained schools (%) 47
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
15
47
19
32
31
Interventions to promote positive mental health in pupils We are a specialist school which works with pupils with emotional and behavioural problems. For this reason, combined with their chromic inability to positively engage with our local CAMHS external mental health provider we have our own mental health specialist on site. Almost every pupil on site accesses her on a weekly basis and can also use her on an informal crisis basis, if needed. Staff also can access her support, if needed.
Child and Adolescent Therapist, Special School.
Wellbeing on the curriculum The majority of secondary schools deliver interventions to promote positive mental health universally across the student population. The promotion of mental health in lessons such as drama and music was delivered in most cases (average 94.2 per cent), followed by promotion of mental health in PSHE lessons (average 92.9 per cent) and the promotion of mental wellbeing in school assemblies (average 75.4 per cent). The promotion of mental health in PSHE lessons was reported to be the most effective activity across all schools (average 84 per cent). Table 12. Wellbeing activities on the school curriculum Indicator
PSHE lessons dedicated to mental health are provided Reported to be effective Reported to be ineffective Not delivered Promotion of wellbeing and mental health in other lessons (e.g. Drama) is provided Reported to be effective Reported to be ineffective Not delivered Content of some school assemblies is dedicated to issues associated with mental health Reported to be effective Reported to be ineffective Not delivered
Mainstream, maintained schools (%) 88
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
90
93.6
100
92.9
69
77
80.6
86.4
78.3
19
13
13
13.6
14.7
12 88
10 93
6.5 95.7
0 100
7.1 94.2
62
62
80.5
86.4
72.7
26
31
15.2
13.6
21.5
12 84.3
7 80
4.3 66
0 71.4
5.8 75.4
57.3
63.3
42.6
47.6
52.7
27
16.7
23.4
23.8
22.7
15.7
20
34
28.6
24.6
32
Positive classroom management and small group work Teacher support in small groups was available in nearly all of schools surveyed (99 per cent). This was most frequently accessed through pupil self‐referral (74 per cent) and available on a daily basis (93 per cent). The qualitative analysis revealed that mainstream, maintained schools reported the use of self – esteem/ image groups, nurture groups, small group work with pupils at risk, Rite of Passage and a ‘Pets as Therapy’ dog in school once a week to support students. Mentoring Peer mentoring was available in the majority of mainstream and SEN schools. Just under half of PRUs offerred mentoring. The most frequent mode of access was through staff or pupil self‐referal. The majority of respondents across all types of schools said that information passed to staff relating to concerns about a pupil’s mental health was significant for early identification (average 83 per cent). Table 13. Peer mentoring Indicator
Peer mentoring is provided Mode of access: Staff referral Pupil self‐referral Drop in basis Availability: On a daily basis Once or twice a week Once or twice a month Reported to be effective
Mainstream, maintained schools (%) 83
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
73
59
43
65
64 68 45
67 44 30
44 56 22
60 59 37
59 11
48 4
29 14
47 14
3
7
9
0
5
86
97
62
86
83
63 67 50 53 27
Psychological services The majority of respondents (86 per cent) across all types of schools reported the use of trained/qualified counsellor(s) in schools. In the majority of cases, this service can be accessed through staff (97 per cent) and pupil self‐referral (58 per cent). This service is mostly frequently available once or twice a week. The majority of respondents from mainstream, maintained schools, SEN schools and PRUs reported employing a qualified psychologists (either educational psychologist or mental health psychologist) (86 per cent). Mainstream, maintained schools are 1.7 times more likely to have access to a qualified psychologists compared to independent schools. The mode of access to these services is most frequently through a staff referral and only available once or twice a month, in most cases.
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Table 14. Psychological services Indicator
Trained/qualified counsellor is provided Mode of access: Staff referral Pupil self‐referral Drop in basis Availability: On a daily basis Once or twice a week Once or twice a month Qualified psychologist is provided Mode of access: Staff referral Pupil self‐referral Drop in basis Availability: On a daily basis Once or twice a week Once or twice a month
Mainstream, maintained schools (%) 93
96 60 48 28 50 14 86 99 5 16 1 8 69
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
93
73
86
86
93 70 37
97 39 14
100 63 37
32 50 4 52
21 34 11 92
32 36 23 82
100 13 0
100 7 5
100 6 0
8 0 23
7 9 60
5 10 57
97 58 34 28 43 13 78 100 8 5 5 7 52
School nurse Access to a school nurse was available in the majority of schools (average 85 per cent). Mainstream schools were more likely to have access to a school nurse on a daily basis or once or twice a week; whereas, SEN schools and PRUs were more likely to have access to a school nurse only once or twice a month. Table 15. School nurse Indicator
School nurse is provided Mode of access: Staff referral Pupil self‐referral Drop in basis Availability: On a daily basis Once or twice a week Once or twice a month
Mainstream, maintained schools (%) 91
84 67 64 17 50 25
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
79
79
91
85
68 68 82
89 27 24
75 50 55
79 53 56
69 0
17 23
14 23
7
31
50
29 24 28
Factors that contribute to delivery of mental health services Across all types of schools, the most frequently reported factors that respondents said were significant in helping to facilitate the provision of services for pupils experiencing a mental health problem was the development of a positive relationship between staff and pupils (average 99 per cent), an accessible and welcoming environment (average 90 per cent), the availability of services (average 88 per cent) and the advertisement and promotion of services (average 49 per cent).
34
Table 16. Factors that facilitate the delivery of effective service provision Indicator
Mainstream, maintained schools (%) 57
Advertisement and promotion of the services Service(s) are available 88 regularly throughout the week Services provided in 93 accessible and welcoming environment Positive relationship 97 between staff and pupils
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
56
49
32
49
96
83
86
88
93
88
86
90
100
98
100
99
Where staff are aware that a pupil has a mental health problem, head teachers reported that the following top three factors are significant in affecting the current delivery of services to support these pupils: concerns from the pupil about the attitude of parents/ guardian/ family (average 87 per cent), lack of parent/guardian involvement (average 84 per cent), concerns from the pupil about the attitude of friends (average 72.7 per cent). Table 17. Factors that hinder the delivery of effective service provision Indicator
Teaching staff are absent from work Classroom support staff are absent from work Lack of parent/guardian involvement Concerns from the pupil about the attitude of parents/ guardian/ family Concerns from the pupil about the attitude of friends Pupils do not consider the services offered to be helpful to them
Mainstream, maintained schools (%) 33
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
25
48
43
34
25
52
33
37.3 36
85
69
89
91
84
87
93
76
91
87
69
83
49
90
72.8
49
43
47
81
55
35
Interventions to support pupils with complex needs External and specialist support is minimal and has not been effective as in my experience there is not been enough partnership working with school and other professionals. We therefore have trained our own counsellors and work with the students within the school setting, offering all the counselling that has been identified as their need on their Statement of Educational Need. Head Teacher, Special School. Children and young people with complex needs often require additional support in school in order to maximise their learning opportunities. Complex needs may include educational needs, mental health problems, neurological problems, physical health problems or disabilities. All of these problems can be further exacerbated by complex social circumstances. Support to the pupil’s teacher and additional educational one to one support for the pupil Respondents from SEN schools reported employing staff to support a pupil’s teachers when in class. Several respondents reported that they had employed an Emotional Literacy Support Assistants who plan and take group and one to one sessions. This can include social and therapeutic stories, circle time and ‘Philosophy for Children’. One to one therapeutic work One respondent from a SEN school reported that they offer personal therapeutic provision for pupils with complex needs. This includes individual care plans and relevant activities according to pupils understanding and person centred development sessions. Family support and therapy Respondents from mainstream, maintained schools reported the delivery of family based interventions, either through family support, workshops with parents or restorative approaches. However, they also added that service provision cannot address social factors such as home life. Respondents from SEN schools also reported that they discuss issues with parents/carers and incorporate appropriate "therapeutic" provision where possible. Respondents said family support and therapy was important because relationships can break down at school and families reach crisis point at home.
36
Referring severe cases We feel that we are often let down by outside agencies. CAMHS is a real concern as they do not always feedback or the pupils report back that they did not see the value in the experience. Other agencies are over stretched and cannot give the time. Head teacher, Voluntary Aided School. Identifying children and young people who need additional support Schools have a role in ensuring pupils with severe and complex mental health problems receive appropriate assessment and intervention. In achieving this, there should be a clear process for identifying those CYP in need of specialist support, often through the use of screening tools. Just over a third of schools, on average, used screening tools to differentiate between severity of need (i.e whether a pupil is experiencing a mild, moderate or severe mental illness). The screening tools were most frequently used in PRUs (46 per cent), followed by mainstream maintained schools (34 per cent), special schools (31 per cent) and independent schools (28 per cent). In cases where these tools were used, head teachers reported high levels of confidence in their staffs’ ability to use them correctly. It is quite striking that only a third of mainstream schools use screening tools when this is where the majority of CYP are based. Table 18. Screening tools to differentiate between severity of need Indicator
Screening tools are used Reported confidence in the ability of staff to use these tools
Mainstream, maintained schools (%) 34
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
28
31
46
35
73
88
87
90
85
Referring to CAMHS Schools should have an effective referral pathway to specialist mental health services. Mainstream maintained schools (94 per cent) were most likely to have access to an external referral pathway for staff to use when the mental health of a pupil is too severe or complex to be managed by the provision available within schools. Independent schools were the least likely type of school to have access to this pathway (73 per cent). However, whilst this pathway was in place in the majority of schools included in this survey, the reported effectivness of this pathway was low, with less than half (46 per cent) of all respondents saying it is effective. Pupil referral units and SEN schools reported the lowest rates of effectiveness. Table 19. External referral pathway Indicator
External referral pathway delivered Reported to be effective
Mainstream, maintained schools (%) 94
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
73
88
86
85
46
59
43
37
46
37
Perceived confidence Mode of access: Staff referral Pupil self‐referral Drop in basis Availability: On a daily basis Once or twice a week Once or twice a month
88
91
95
95
92
100 10 2
95 27 5
100 5 2
50 0 50
86.3 10.5 14.8
7 16 62
21 4 38
11 9 51
18 32 36
14.3 15.3 46.8
Table 20. Significance of strong, positive collaboration between the school and external agencies in affecting the current delivery of services to support pupils with mental health problems Mainstream, maintained schools (%) Signficant 93 Insignificant 6 Not applicable 1 Indicator
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
89.3 7.1 3.6
87 6.5 6.5
91 4.5 4.5
90.1 6 3.9
The majority of respondents reported that having a strong, positive collaboration between the school and external agencies is significant in supporting pupils with mental health problems. However, further qualitative analysis revealed that many schools found the support of CAMHS to be inadequate. Qualitative comments from reponsdents at mainstream, maintained schools reported two main issues when referring to CAMHS: the referral process and the quality of the service. In terms of the referral process, respondents reported that referrals take too long to be accepted, the threshold is too high, it is difficult for teachers to refer unless the pupil is in crisis. Furthermore, CAMHS will only accept the referral if pupils and family are engaged (i.e. attending appointments regularly). In regards to the quality of the service, respondents reported that CAMHS is operating at capacity and it cannot provide intervention early on because of the time taken for pupils to be seen. Other comments included that CAMHS is underfunded, the quality is variable and there is a need to travel long distances to appointments. This was also reflected by independent schools who reported that CAMHS take too long to support students and provide the right intervention. Respondents from SEN schools also reported that access to CAMHS is poor: there is a long wait for referrals to be accepted and even when pupils reach crisis point, they are still not seen as a priority. Other respondents reported that CAMHS involvement seems to be harder to obtain for pupils with special needs, perhaps because there is a lack of SEN/ASD specialist skilled workers in CAMHS. Similarly, respondents from PRUs also reported that referral to CAMHS is extremely slow and as the thresholds for involvement is so high, most referrals are rejected. What’s more, in those pupils who have been assessed by CAMHS, they have been discharged without an action plan in place leaving teachers feeling unsupported in how best to support pupils. Respondents reported that this is most likely because CAMHS are overstretched with increasing referrals and less funds. Overall, the working relationship between teachers and local specialist CAMHS appear to be variable in quality.
38
Schools commissioning services directly Referral to external agencies is extremely slow (16 weeks for urgent CAMHS) and their thresholds for involvement are so high, most students are rejected. Bringing services in house to be offered via our own specialist staff has been instrumental in raising the effectiveness of these services.
Deputy Head Teacher, Pupil Referral Unit.
Across all local authorities, schools have sole commissioning responsibility for teachers and school counsellors. Schools have joint responsibility to commission CAMHS outreach workers (based in schools) alongside CCGs; and to commission educational psychologists alongside local authorities.71 Our research found that the majority of schools commission mental health services directly (average 77 per cent) in order to bridge the gap between school provision and the role of external agencies. PRUs most frequently reported commissioning mental health services directly (89 per cent) followed by SEN schools (87 per cent). This was reported the least in mainstream, maintained schools (75 per cent) and independent schools (56 per cent). Table 21. Commissioning mental health services directly Indicators
Mental health specialists are available on site
Mainstream, maintained schools (%) 75
Independent schools (%)
SEN schools (%)
Pupil referral units (%)
Average (%)
56
87
89
77
The qualitative responses from head teachers in mainstream, maintained schools indicated that they employ a number of mental health specialists including music and drama therapists as well as person centred counselling, a CAMHS mental health support worker and a CAMHs teacher. SEN schools reported that they source and fund their own counsellors to work with students in school, offering all the counselling that has been identified in their Statement of Educational Needs. One respondent also reported that their school shares resources, specialities and services with other schools in the Trust in order to help support pupils more effectively. Qualitative comments from head teachers in PRUs were generally quite positive about commissioning their own mental health services. One respondents said that they employ CAMHS support four days a week and find professionals to be a crucial element of their team. Other respondents said they provide mental health, anger management and other specialist services. Another respondent said that by bringing mental health services in house has been instrumental in raising the effectiveness of these CAMH services. In terms of the reported barriers to successfully commissioning mental health services, the main issue for mainstream, maintained schools was around adequate funding. Respondents reported that the cost of mental health provision is high and there is not enough funding to meet demand. Funding is also not secure year on year and in one case, a school had
71
CAMHS Tier 4 Report Steering Group, ‘Child and Adolescent Mental Health Services Tier 4’, NHS England, July 2014.
39
previously commissioned a counsellor and additional school nurses to good effect but due to budget cuts and pressures for more money to be spent on better maths and English teachers, the mental health provision was decommissioned. Similar issues were reported by respondents from SEN schools who said that there was a lack of school funding to provide these interventions but they felt they needed to do this because CAMHS is not able to provide appropriate interventions for SEN students. However, mental health services would be the first to go if their budget was to be cut. Access to qualified mental health practitioners, such as psychologists is also restricted due to the limited number available within the local authority. PRUs on the whole found commissioning services directly to be effective but they found even with this in place, they have no way of accessing any accelerated service provision and when pupils leave their unit and so they move on without the support they need.
40
Discussion
As a school we often feel that we do not have enough experience or training to deal with some of the often very complex mental needs of our students. Our CAMHS service is running full and referrals often take an incredibly long time. I have discussed concerns with our LA [local authority] and at our partnership meetings and [I] know other schools feel the same way […] we could really do with a layer of external support below CAMHS so that the children’s issues don’t escalate further. Assistant Head teacher Behaviour and Safety, Community School.
The purpose of this research was to ascertain the extent to which secondary schools in England are delivering a comprehensive mental health and wellbeing strategy, including the promotion of positive mental health, the identification of mental problems, the delivery of interventions that promote positive mental health and interventions for complex problems, the referral of serious cases to CAMHS and the commissioning of services, in accordance with government guidance. This research indicates that: Incidence of behavioural and emotional problems: : Head teachers from English secondary schools report that a high number of pupils are presenting with behavioural and emotional problems: between one and ten per cent of pupils attending mainstream schools; and more than 40 per cent of pupils attending SEN schools and PRUs. However, head teachers in mainstream schools may be underestimating the extent of the problem. Existing evidence suggests that across the population the prevalence of behavioural problems in CYP is between 15 and 20 per cent.72 Whereas, the prevalence of emotional problems, including anxiety and depression in CYP is 4.4 per cent and 1.4 per cent respectively. This indicates that head teachers tend to underestimate behavioural problems but are accurate in estimating emotional problems.
Early identification: : Head teachers from mainstream schools may underestimate the significance of mental health problems in pupils presenting with behavioural and emotional problems: only 25 per cent of respondents from mainstream, maintained schools and 6 per cent of respondents from independent schools report that mental health problems were a significant factor in the presentation of behavioural and emotional problems. Whereas, over half of respondents from SEN schools (65 per cent) and PRUs (63 per cent) reported that mental health problems were a significant factor in the presentation of behavioural problems and emotional problems. Head teachers from all types of schools reported that family life and relationships were the greatest attributing factors to behavioural and emotional problems in pupils. : The most crucial element for identifying mental health problems as early as possible is training school staff to be aware of the signs and symptoms of poor mental health 72
M Parsonage, L Khan and A Saunders, ‘Building a better future: the lifetime costs of childhood behavioural problems and the benefits of early intervention’, Centre for Mental Health, January 2014.
41
:
:
and wellbeing. This research identifies the majority of schools have access to a training programme of this kind and in these cases, most importantly 75 per cent of head teachers think it is significant in helping them identify pupils with mental health problems. However, 9 per cent of schools report there is no mental health and wellbeing training available at all. In addition to staff training, screening tools can be used to identify strengths and difficulties in young people. Less than half of schools (47 per cent) use screening tools, but where these tools are used, 86 per cent say they are effective and 64 per cent think they are important in the early identification of mental health symptoms. Screening tools are now routinely used in young people who enter the youth justice system in order to assess their physical, mental and substance use needs.73 The vast majority of schools (93 per cent) also use an internal referral pathway when a mental health concern has been raised. Where they are used, head teachers report they are effective (90 per cent) and they have confidence in their staff’s ability to use them appropriately (96 per cent). Almost all of schools have pastoral care services available (98 per cent).
Promotion of positive mental health and interventions for complex needs: : The majority of schools implement programmes to promote positive mental health universally across the student population: 93 per cent do this within the course of Personal, Social, Health and Economic (PSHE) education; 94 per cent do this in other lessons such as drama; and 75 per cent promote positive mental health in school assemblies. The promotion of mental health in PSHE lessons was reported to be the most effective activity across all types of schools (84 per cent). : The majority of schools offer psychological and physical health services: pupils in 86 per cent of schools have access to a trained/qualified counsellor(s); 86 per cent have access to a qualified psychologists (either educational or mental health); and 85 per cent have access to a school nurse. : Almost two thirds of schools (65 per cent) use peer mentoring. Referring serious cases: : 65 per cent of schools do not use screening tools to differentiate between severity of mental health need (mild, moderate or severe). Yet, in schools where these tools are used, 85 per cent of head teachers reported they were effective. Screening tools are most commonly used in PRUs (46 per cent) and least commonly used in independent schools (28 per cent). : Mainstream, maintained schools were most likely to have access to an external referral pathway to NHS or voluntary sector services for teachers to use when the
73
National Child and Maternal Health Intelligence Network, ‘Assessment in the youth justice system’, 2014, available from: http://www.chimat.org.uk/yj/na/ayjs/assessment
42
mental health of a pupil is too severe or complex to be managed by the provision available within schools (94 per cent); independent schools were the least likely type of school to have access to this pathway (73 per cent). More than half (54 per cent) of all respondents said the referral pathway was ineffective. Schools commissioning services directly: : Three quarters of schools (77 per cent) commission mental health services directly: PRUs commission services in most cases (89 per cent); and independent schools commission services in the least number of cases (56 per cent).
43
Conclusion and recommendations
Funding has now restricted all the good work we put in. [When] push comes to shove, sadly it’s the therapists that will go. Head Teacher, Special School.
This research provides a comprehensive analysis of head teachers’ perceptions of the mental health and wellbeing of pupils in schools as well as reviewing available provision in mainstream, maintained schools, independent schools, SEN schools and PRUs across England. The findings identify that many schools are implementing elements of a comprehensive mental health and wellbeing strategy, although gaps in provision exists. The key to this strategy is early intervention, achieved through identification, escalation and treatment. These findings clearly indicate that staff working in schools are able to identify pupils with behavioural and emotional problems to a certain extent but have a tendency to underestimate. Whilst respondents report that training opportunities, the use of screening tools and internal referral pathways are in place in schools, almost half (47 per cent) of respondents from mainstream, maintained schools and SEN schools say that increase in their general workload is impacting on their ability to identify mental health problems at the earliest possible point. This may explain why three quarters of vulnerable CYP are never identified.74 This research has also identified some of the complexities around delivering effective and timely support to CYP in both schools and CAMH services and has highlighted the important issues of commissioning and security of funding. Whilst many head teachers in this survey report that they implement a range of interventions on mental health, concerns were also raised by respondents that this is entirely dependent on funding and quite often, services are decommissioned. In moving forward with this agenda, there needs to be greater focus on promoting and protecting psychosocial resilience in CYP through a resilient workforce and in an organisation that is enabling. Building on our findings, we draw on four major conclusions. Resilient children and young people Psychosocial resilience is about altering the circumstances in which people relate, live and work, in order to provide them with the opportunity to achieve satisfying social identities and derive support from membership of networks and groups.75 Many of the issues relating to adversity, risk and vulnerability are beyond the control of schools, but they do have a role in helping CYP develop protective factors, build psychosocial resilience as well as reconnect with their social identity. This will help reduce the number of CYP who are at risk of developing mental health problems.76
74
Chief Medical Officer’s Annual Report 2012, ‘Our Children Deserve Better: Prevention pays’, Department of Health, 2012. S Bailey and R Williams, ‘Towards partnerships in mental healthcare’, Advances in Psychiatric Treatment, 2014, 20: p.48‐51. 76 CentreForum Mental Health Commission, ‘The Pursuit of happiness: a new ambition for our mental health’, CentreForum, July 2014. 75
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Resilient workforce An essential part of teacher training should include information relating to child development, mental health and psychological resilience in order to give teachers the knowledge and skills to identify CYP with emerging mental health problems. Teachers should also be able to promote positive mental health through the development of positive relationships with pupils. The report, ‘Wellbeing and Policy’, demonstrates that much can be achieved in schools to promote wellbeing through the systematic and structured teaching of life‐skills and values throughout school life. Providing effective training to all teachers in mental health and the management of CYP behaviour is critical to success.77 A similar recommendation was made by the All Party Parliamentary Group on Social Mobility in that initial teacher training and CPD programmes should incorporate character and resilience. Character and resilience is a term used to describe ‘soft skills’ which include the ability to stick with tasks and see things through, the ability to see one’s life as under one’s control and to effectively shape its future course; the ability to understand one’s strengths and weaknesses accurately; the ability to recognise one’s responsibilities towards others, the ability to monitor and regulate one’s emotions appropriately and the ability to put oneself in other people’s shoes and be sensitive to their needs and views.78 Teachers also need to be resilient themselves. According to the Health and Safety Executive, teaching is one of the most stressful professions, along with nurses and managers. Approximately 41.5 per cent of teachers report they are ‘highly stressed’ compared to 20 per cent of the general working population.79 Schools that take a ‘whole school’ approach recognise that in order to promote psychosocial resilience in CYP, the workforce also needs to be resilient. Schools as enabling environments Enabling environments are places where a group of people come together for a specific purpose and are places where positive relationships promote wellbeing for all participants; where people experience a sense of belonging; where all people involved contribute to the growth and wellbeing of others; where people can learn new ways of relating; and that recognise and respect the contributions of all parties in helping relationships. Schools should act as an enabling environment for pupils and in achieving this, the environment must be ‘psychologically informed’. 80 The Royal College of Psychiatrists have developed a training package on this, which has already been implemented within secure or high risk areas using the similar ‘psychologically informed planned environment’.81 If schools are to become enabling environments, they need excellent leadership that encourages new thinking and ideas. An enabling environment in schools means adopting a health, whole school approach. This means that the ethos and principles applicable to mental health and wellbeing are applied throughout the schools, including school staff. Our findings reinforce this as 81 per cent of schools are routinely raising awareness of mental health and wellbeing issues within the student body and 80 per cent of head teachers report 77
Legatum Institute, ‘Wellbeing and Policy’, March 2014. C Paterson, C Tyler and J Lexmond, ‘Character and Resilience Manifesto’, CentreForum and Character Counts, January 2014. 79 Centre for Occupational and Health Psychology School of Psychology, ‘The scale of occupational stress: A further analysis of the impact of demographic factors and type of job’, Cardiff University for the Health and Safety Executive, 2000. 80 Royal College of Psychiatrists, ‘Enabling environment process document’, 2013, available from: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditation/enablingenvironments.aspx 81 C Turley, C Payne and S Webster, ‘Enabling features of Psychologically Informed Planned Environments’, NatCen Social Research and Ministry of Justice Analytical Series, 2013. 78
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these measures are effective. However, there are 19 per cent of schools that are not engaging in this activity. Overcoming the barriers to supporting pupils In cases where staff are aware that a pupil has a mental health problem, our research identifies that the following factors are significant in affecting the current delivery of services to support these pupils. : 87 per cent of head teachers report that concerns from the pupil about the attitude of their parents/ guardian/ family was a barrier to accessing support : 84 per cent said that a lack of parent/guardian involvement : The attitudes of friends was also cited as a significant barrier by 73 per cent of respondents. : Almost half (47 per cent) of respondents from mainstream, maintained schools and SEN schools say that increase in their general workload is impacting on their ability to identify mental health problems at the earliest possible point. Child and Adolescent Mental Health Services Schools cannot be expected to do it all, yet many head teachers are feeling unsupported by CAMHS. It appears the relationship betweeen schools and CAMHS is flawed in some areas or the country in terms of access, communication and follow up. We know there are major problems with access to inpatient mental health services and the data indicates that numerous ‘inappropriate’ referrals and admissions are made to Tier 4 CAMHS each year. The three main reasons for this is: poor risk assessment, the young person does not require inpatient service or the referral was an out of hours/ emergency admission. This is further evidenced as 70 per cent of Tier 4 CAMHS units report they have major issues with bed capacity and more than 40 per cent report major issues with community care provision. A reduced bed capacity is also the reason for many out of area admissions.82 However, not all referrals may be inappropriate but perhaps could have been avoided through earlier engagement with the lower tiers. In such cases admission is entirely appropriate because the problem has escalated to the level that they require inpatient care. Inevitably, some of the burden placed on Tier 4 CAMHS is avoidable. Another issues is the way CAMHS is commissioned and funded as this means regional variation exists in terms of access to provision and the quality of services provided.83 There must be greater focus placed on the way Tier 1‐4 CAMHS operates across the whole system so that CYP are able to access appropriate and timely support and not left vulnerable. We welcome the Taskforce set up by Rt Hon Norman Lamb MP, which will undertake a review of CAMHS and consider how to overhaul the commissioning process. Recommendations: In the main report of the Mental Health Commission, ‘the pursuit of happiness’, we argue that government should set a new ambition for our society’s mental health where the wellbeing and mental and social capital of the nation is promoted, there is a reduction in the
82
CAMHS Tier 4 Report Steering Group, ‘Child and Adolescent Mental Health Services Tier 4’, NHS England, July 2014. Health Committee, ‘the role of education and GP services’, 2014, available from: http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/342/34211.htm 83
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misery experienced, and there is delivery of effective interventions for people with existing mental health problems. One of the core principles underpinning this ambition is the need to invest in the prevention of mental health problems, and the promotion of mental wellbeing. We find these issues to be extremely resonant in our research. Our recommendations are based on the premise that a whole school approach needs to be led from the top but schools should actively consider the views of the student body. Survey evidence suggests that young people want more and better mental health education but feel they don’t currently receive this.84 Government is right to be concerned about mental health and give much needed attention to protecting and promoting the mental health of CYP. The recent publication of the Health Select Committee report places further emphasis on the serious and deeply ingrained problems with the commissioning and provision of children’s and adolescents’ mental health services.85 We welcome the DfE advice for schools on how staff can support pupils with mental health and behavioural needs but momentum should not be lost. This research indicates that a great deal is already happening in schools in terms of the promotion of positive mental health, early identification, delivery of interventions, referrals to CAMHS and the commissioning of services; yet it is clear there is great variability in the level of support offered to CYP across the country. We call on government to implement the following areas of work. : That the national curriculum should include the requirement to teach CYP how to look after their mental health and build emotional resilience through approaches such as mindfulness. This should also include relationship skills education as standard, given the links between relationship distress and poor mental health. The exact nature of the wellbeing programme being offered should be at the discretion of individual schools but every school in England must be able to demonstrate they are providing something of benefit to their students. OFSTED would be charged with monitoring progress towards the goal of 100 per cent of primary and secondary schools incorporating wellbeing programmes into school curriculum by 2020. There also needs to be clear guidance, possible from NICE about what constitutes good curriculum content. : That teachers and other educational staff should receive training in child development, mental health and psychological resilience to enable them to identify CYP who are vulnerable. It is also essential that teachers have the opportunity to learn more about the mental health of CYP and how to promote wellbeing in a school context through continuous professional development. For instance, MindEd is a free online training tool is now available to enable school staff to learn about specific mental health problems.86 However, we recognise that teachers are not substitutes for mental health professionals but they should have the understanding and skills to recognise problems and know how to refer them on for further help. This research has found that training and CPD has a significant impact on 75 per cent of schools. Therefore we propose that mental health related training should be
84
Health Committee, ‘The role of education and GP services’, 2014, available from: http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/342/34211.htm 85 House of Commons Health Committee, ‘Children's and adolescents' mental health and CAMHS: Third Report of Session 2014–15’, November 2014. 86 Minded, ‘Resources’, 2014 available from: https://www.minded.org.uk/
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included on the Initial Teacher Training course by 2020 under a joint framework from the DfE and DH. That all CYP should be screened by teachers and other practitioners using simple tools such as the Strengths and Difficulties Questionnaire to identify CYP falling outside the normal range of healthy development. This will help to identify those whose families may need support and allow schools and health and wellbeing boards to assess the overall levels of wellbeing in the local population. This data should be shared with schools as well as other local agencies such as public health departments. HWBs, CCGs, and local authority/public health commissioners should use this data to plan and commission relevant services, which may be schools based as well as clinic based. That for CYP experiencing a less severe or emerging mental health problem, there should be greater accessibility to psychological therapies in schools or in the community. For CYP with moderate to severe mental health problems, all secondary schools should have routine access to a named CAMHS worker, either on site or through an effective referral pathway to CAMHS tier 3 or 4. Schools should also be aware of the mental health and wellbeing resources available locally.87 All agencies who work with CYP need to work together to plan, commission and deliver a full range of CAMH services using current data and following departmental advice. Schools should be influencing the health services that are commissioned locally through their local Health and Wellbeing Board. NHS England, CCGs, schools and local councils should work together and prioritise funding for a comprehensive CAMH service. In recent years I do believe that the [CAMHS] service in this area has weakened. At a time when families are beset with so many other worries such as finance and pressures are greater than before therefore mental health issues likely to rise. I fear for the Education Health Care plan process due in September when Health is so much behind in its prioritising. Principal, Academy, Special School.
DfE, ‘Mental health and behaviour in schools. Departmental advice for school staff’, June 2014.
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