It is a pleasure to write the editorial for this issue of the journal, which also highlights the publication of a Virtual Issue (VI)1 which brings together some of the most influential articles published on child and adolescent mental health in schools over the last 10 years. The retrospective by David Galloway, written 2001, is an interesting starting point for commentary, looking back over what is now 30 years. Its themes about UK educational policies and their impacts resonate through the articles collected here from across the world and are in most cases are as relevant today as ever (Galloway, 2001*)2.
Galloway writes of the need to use the evidence base, which since he wrote has grown ever larger as the efforts of successive agencies result in programmes, interventions, guidance and occasionally prescription for schools. Across the world, small and large scale school-based programmes are becoming fairly common, (although, as Vostanis’ survey shows (Vostanis et al., 2013*), hardly yet routine) especially in places such as the US, UK and Australia, and we certainly need to encourage schools to use the best of them. Several contemporaneous articles describe typical programmes, including SEAL (Lendrum et al., 2013*), ‘Think, feel, do’ (Attwood et al., 2012*) and ‘Friends’ (Stallard et al., 2007*), all interventions based on good evidence, in their design at least.
We are also starting to identify the key and fundamental principles that need to inspire mental health work, an effort in which I have been myself for some time engaged, including a recent review of 52 existing reviews of interventions related to mental health (Weare & Nind, 2011). The principles that we identified echo the findings of all the articles in this issue and accompanying VI. We concluded that the characteristics of more effective interventions included: teaching mental health skills through the taught curriculum; focusing on positive mental health not problems; balancing universal and targeted approaches; starting early and continuing on in a spiral way; operating for a lengthy period of time; using a multimodal/whole-school approach with links with academic learning, school ethos, teacher education, and liaison with parents and outside agencies and the community. Furthermore, interventions were only effective if they were completely and accurately implemented: this applied particularly to whole-school interventions which could be ineffectively vague if not implemented with clarity, intensity and fidelity, a fate that has befallen the UK's SEAL programme in some schools according to one evaluation of it, reported in the Lendrum et al. article in this issue (Lendrum et al., 2013*)
Balaguru et al. (2013*) outline a similar review of principles in relation to suicide prevention and come to similar conclusions: “an ideal …prevention programme is one that is long-term, targets all possible risk factors … engages children, parents, staff and community, and has good accessibility, to …services.” However, getting the evidence-based principles out of the journal literature and into the classroom is problematic: as the survey of wellbeing in schools by Vostanis et al. shows, left to themselves schools rarely use the evidence base, and default to ineffective approaches such as, in the case of the UK, using targeted approaches alone rather than basing targeted work in a firm foundation of universal, preventive work. A targeted-only programme, especially in a mainstream school setting, gives rise to the problem of stigma, a bedevilling side-effect of well-intentioned mental health work. The article by Bowers et al. illustrates this vividly (Bowers et al., 2013*), with Canadian young people with mental health problems testifying movingly about the marginalisation that they experience. Similarly, the failure of the short term approach taken to bullying in some schools in Australia reported here by Hunt (2007*) was highly predictable from any review of the evidence. We need to do more to ensure knowledge transfer.
Using the evidence base relates not just to programme and principles but to what we know about implementation, as we realise that success or failure is more to do with delivery than design and the focus of mental health promotion in schools shifts to exploring what makes for quality in implementation. The articles by Lendrum et al. (2013*) and Dix et al. (2012*) both explore the implementation of large-scale whole-school approaches to mental health in schools, namely SEAL in the UK and Kidsmatter in Australia and their findings echo those of a seminal meta-analysis by Durlak, Weissberg, Dymnicki, Taylor and Schellinger (2011) in suggesting that for large, whole-school programmes to show measurable impacts rather than just be valuable enabling frameworks (which both most certainly are) we need to address the issues beloved of programme developers such as clarity, ‘programme fidelity’, ‘adherence’ and (the rather alarmingly termed) ‘dosage’.
There is, however, much more to effective implementation than just ensuring that teachers do as they are told by programme developers, however solid the prescription, and there is a key balance to be struck, as Dix et al. and Lendrum et al. both make clear. In getting mental health work to stick, the involvement and engagement of the stakeholders, such as staff, senior management, parents, and of course the young people themselves, is essential. Too much emphasis on top down approaches has already, in the UK at least, led to the law of unintended consequences. As Galloway notes, while the deprofessionalisation of teachers in the UK over the last 30 years may have had benefits for mental health by opening up the ‘secret garden’, leading to some improvements in consistency of approach and paving the way for valuable interventions, it has also resulted in a teaching force who have had their own mental health undermined by the lack of control and constant criticism, with low self-esteem, stress-related illness and significant attrition the inevitable result. Burnt-out teachers are not in a good place themselves to embody mental health skills and values or care deeply much about the mental health of their students, while changes imposed from without tend to be skin deep, with schools cynically and exhaustedly dropping the old initiative in favour of the next-when fashions and government policies change.
In promoting mental health in schools, we have to start with the mental health and wellbeing of teachers themselves, and not only with odd bits of training provided by discrete programmes but with a renewed respect for teachers' professionalism. This has to be based on substantial, principled, generic education and training provided by those in the forefront of evidence creation such as universities, as is the case in Finland where all teachers are educated to masters level. This contrasts with the teaching to a prewritten script and the ‘tips for teachers’ approach that has bedevilled teacher education in the UK in recent years, so that we now have a situation where, as Vostanis et al. note, “few schools considered training, consultation, supervision, counselling or support for their staff as a key part of their overall approach to supporting pupils' mental health… the largest proportion of staff involved in helping pupils were reported to have had no specialist mental health training.” Only when the basic education of school staff is strengthened will teachers feel professionalised and empowered enough to deliver specific interventions from a core of real understanding and engagement, be skilled enough to go off piste and develop their own approaches and/or select wisely from those available and adapt them appropriately to suit their circumstances.
Galloway also comments on an apparently intractable problem – the disengagement and alienation of many parts of the school community from the whole idea of school and indeed society, and most notably those from poorer backgrounds, a problem which is inextricably linked to mental health. Across the globe, children from disadvantaged homes continue to have an increased risk of suffering from mental health problems of all kinds as a direct result of the very real challenges their lives present in terms of lack of inadequate schools, lack of resources, environmental stress, risk, uncertainty and the kinds of violence that the article by Aviles et al. (2005*) shows is so detrimental to mental health and school functioning. The article by Ingul et al. (2012*)demonstrates that even in countries such Norway with a reputation for social equality the social risk factors remain – one of the most significant predictor of school absenteeism in their survey was having unemployed or undereducated parents. Since Galloway's piece in 2001, the social class divide in the UK has actually become greater and we still have what he summarises succinctly as “an under-class attending underprivileged and constantly criticised schools”. Central to mental health promotion (as Galloway, the article by Kendal et al. (2011*),and our own review (Weare & Nind,2011) suggest), is the creation of an appropriate school ethos and environment which supports and listens respectfully to students and parents of all types, cultures and classes, and provides a sound and relevant education for all. As Galloway says:
the school's contribution to children's mental health is determined by the quality of teaching and relationships in the classroom, with the government powerless to do more than facilitate or impede that process.
For the government, read everyone who would influence the school process.