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Approximately 10% of children and young people experience clinically significant mental health difficulties that would require assessment and possible intervention (Green, McGinnity, Meltzer, Ford, & Goodman, 2005). This figure has risen in the last 30 years (Maughan, Iervolino, & Collishaw, 2005). The long-term consequences of child mental health difficulties can include an increased risk of a range of adverse psychosocial outcomes in later life (Farrington, Healey, & Knapp, 2004; Colman et al., 2009). These children and their families come into contact with a range of educational, mental health and social care agencies, although often in a noncoordinated way, and with high levels of unmet needs. The child mental health survey in England found that a third of parents worry about their child's mental health, of whom 90% have sought help (Green et al., 2005). Of those families and young people who had sought help, nearly three quarters had first approached a teacher, in contrast with a quarter who had visited their family doctor. It is in this context that schools are increasingly being seen as central sites for the promotion of emotional well-being. Indeed, there is an intuitive logic to the notion that schools can and should make a difference in this area (Weare & Markham, 2005). Greenberg (2010) suggests: “By virtue of their central role in lives of children and families and their broad reach, schools are the primary setting in which many initial concerns arise and can be effectively remediated” (p.28).
Governmental directives in England have thus increasingly emphasised the role for schools in preventing mental health problems and promoting well-being as part of the move away from the rationalist to a more holistic view of education. This has included ‘broad brush’ policies such as Every Child Matters (Department for Education & Skills, 2003); national strategies/initiatives such as the National Healthy Schools (Department of Health/Department for Education & Employment, 1999) and Social and Emotional Aspects of Learning (Department for Education and Skills, 2005, 2006; Department for Children, Schools & Families, 2007); and attempts to promote synergy between education and related services through the development of (for example) the Common Assessment Framework (Children's Workforce Development Council's, 2007). In parallel with the implementation of policy, some schools in England have imported evidence-based programmes and practices from the United States and elsewhere (Little & Hopkins, 2010). However, despite this progress, effective provision is still hindered by barriers between services, different priorities, poor understanding of individual roles and use of professional language. For example, a recent study of CAMHS and educational practitioners’ experiences of joint working indicated limitations in knowledge and competencies, and identified possible solutions such as establishing linking posts on the interface between CAMHS and schools, building local relationships and joint training (Vostanis et al., 2012).
There is increasing evidence of the impact of both universal (for all children, designed to prevent problems from occurring – the ‘inoculation’ metaphor) and targeted/indicated (for children at risk of or already experiencing difficulties) mental health interventions delivered in school settings (Wilson & Lipsey, 2007; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011; Dix, Slee, Lawson, & Keeves, 2012). However, almost all of the studies in this area originate outside England and are tightly controlled ‘efficacy’ trials in which schools access levels of support and technical assistance not normally available to them (Shucksmith et al., 2007). This is an important issue, because bringing interventions ‘to scale’ in real world settings can be problematic (Elias, Zins, Graczyk, & Weissberg, 2003), in that even well-validated programmes can produce null results in ‘effectiveness’ trials (Kam, Greenberg, & Walls, 2003). The reason is that such interventions do not occur in a vacuum, but rather form part of a complex set of approaches to developing effective provision in schools, which might include ‘one-stop shops’, that is concurrent input from different agencies (Tisdall, Wallace, McGregor, Millen, & Bell, 2005) or consultative models (Clarke, Coombs, & Walton, 2003). Many schools also develop their own sets of approaches ‘from the ground up’, and their work in this area often involves joint initiatives with other agencies, usually child mental health and educational psychology services. However, when joint initiatives are employed locally, they are often disjointed or lack generalisable outcomes with no evidence base. This may be due to response to short-term funding and other opportunities between agencies, which are not necessarily followed by partnerships, evidence to drive the opted intervention or service model and a sustainable strategy. What has been lacking thus far is a framework that brings such work together in a coordinated way, with rationalisation of the adopted interventions and service criteria; and in parallel to this, research to explore patterns and trends that emerge in terms of the kinds of strategies and approaches to promoting mental health in which schools subsequently engage.
The targeted mental health in schools (TaMHS) initiative
The latest government initiative aimed at fostering the role of schools in England in promoting mental health was rolled out from 2008 onwards (Department for Children, Schools & Families, 2008). It was developed not to test a particular hypothesis or model of practice, but rather to provide a framework through which local authorities and schools could develop their own context-and-situation-appropriate ways of working. Such an approach would theoretically increase the sense of ownership among staff and, ultimately, lead to more sustainable practices (Weare, 2010). In this article, we report on the service typologies present in participating schools during the baseline period of the TaMHS evaluation (Wolpert et al., 2010, 2011), that is before the government programme began, and representing typical provision in schools. This is the first large-scale study of its kind to be conducted in England. In a previous US survey (Teich, Robinson, & Weist, 2007), school-based mental health services were found to be widely available and to address a range of needs. However, their static or decreasing resources and funding did not often match children's increasing needs.
Our broad aim was to identify the mental-health-focused activities that schools in England were using, adopting and developing. Specifically, we sought to ascertain the general features of schools’ overall approaches to supporting the mental health of their pupils, that is whether interventions utilised were in the main preventative or reactive; their level of prescriptiveness; and the nature and extent of specific interventions put in place for pupils presenting with externalising/behavioural and internalising/emotional difficulties.
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The research reported in this article was the first large-scale survey of mental health provision in schools in England, and (to the best of our knowledge) only the second internationally (following Teich et al., 2007, in the US). A study of this kind was timely, given the increasing emphasis on emotional well-being in educational policy. The survey yielded several interesting findings which have implications for policy and practice, and raised some questions that future research might be able to address.
One key finding relates to the balance between preventative, universal provision; and reactive, targeted/indicated mental health provision. The literature in this area has increasingly moved towards an emphasis on prevention, following the idiom ‘an ounce of prevention is worth a pound of cure’. By putting in place mental health provision for all children and young people, it is argued that we can effectively ‘immunise’ them from later difficulties (Merrell & Gueldner, 2010). In theory, such a system is also more cost-effective to implement, as it avoids the costly screening procedures needed to identify those at risk (which, of course, may miss some children in need of targeted support) and the use of highly trained professionals that are often required to deliver targeted interventions (McLaughlin, 2011). As a result, universal preventive approaches are considered to be more sustainable.
Also, because universal approaches by definition include all children, their potential for stigmatising participants is reduced (Greenberg, 2010), they therefore align better with the principles of inclusive education (Booth & Ainscow, 2011). However, despite the fact that two thirds of schools reported focusing their efforts on all pupils, there was a clear trend towards reactive, rather than preventive approaches, particularly in secondary schools, where most reported focusing in the main on helping children who were starting to develop or already experiencing problems as opposed to preventing problems arising. Clearly, a balance has to be struck, as it cannot be an either/or choice for schools (Wells, Barlow, & Stewart-Brown, 2003); particularly given that there are always going to be some children who need to be exposed to universal, targeted and indicated interventions for their difficulties to be effectively remediated (Greenberg, 2010). The SEAL programme, which has been implemented in most English primary and secondary schools, provides a framework that incorporates intervention at each level, but evaluations of its constituent components have been inconclusive so far (Humphrey, Lendrum, & Wigelsworth, 2010).
The survey also found that, overall, schools did not report making use of evidence-based interventions, instead tending to focus on locally developed practices. This finding is, in a sense, not altogether surprising; there has not been much of an emphasis on the use of evidence-based approaches in English schools until relatively recently (part of the TaMHS guidance for schools included a practical guide to the evidence base for different types of difficulties; DCSF, 2008)., instead they have tended to rely on initiatives from central government (which usually have little or no evidence when they are launched – SEAL being one example); or their own ways of responding, which they have perceived to be effective (akin to ‘practice-based evidence’). This is a different picture to work in this field (and education more broadly) in the United States, where there has been a tendency to focus more closely on the evidence base for a given intervention – particularly in light of the No Child Left Behind Act – hence, the proliferation of databases that help schools to ‘separate the wheat from the chaff’ (e.g. What Works Clearinghouse, National Registry of Evidence Based Programs and Practices, Blueprints for Violence Prevention). As with universal and targeted/indicated approaches, the two should converge more. On the one hand, Merrell and Gueldner (2010) state, “It is usually a waste of time and resources, and is potentially risky, to implement a programme that has no or shaky evidence that it will produce the desired results” (p.29). However, focusing solely on ‘proven’ approaches risks stifling creativity and innovation at the local level, from which some effective, contextually appropriate work may emerge. It is also important to note that simply acquiring evidence-based interventions alone is not enough: these have to be implemented well to reproduce the effects demonstrated in published studies at the local level (Durlak & DuPre, 2008).
The role of school staff in supporting their pupils’ mental health also emerged as an important factor. There was an overwhelming trend towards work being conducted by members of staff, with less than 3% reporting using external, mental health specialists. In one sense, this is encouraging given what the literature base tells us – several reviews and meta-analyses have suggested that school staff are as effective as (and in some cases, more effective than) external specialists, at least when it comes to delivering universal interventions (Durlak et al., 2011; Wilson & Lipsey, 2007). Nevertheless, this survey also revealed that 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. Moreover, the largest proportion of staff involved in helping pupils were reported to have had no specialist mental health training. This is somewhat surprising, given that recent years have seen an expansion of training initiatives to improve mental health awareness and recognition of mental health problems in schools and other community frontline agencies (Madge, Foreman, & Baksh, 2008; Loades & Mastroyannopoulou, 2010). This research group has previously identified a similar gap of education-related training among child mental health practitioners, hence the importance of joint training arrangements (Vostanis et al., 2011).
In relation to the specific strategies and approaches used to help pupils experiencing difficulties, broadly similar patterns emerged between primary and secondary schools, and for both internalising/emotional and externalising/behavioural difficulties. A range of listening, communication and problem-solving skills appeared to be the first ‘in-house’ response for the vast majority of children. Some differences began to emerge when moving beyond the acquisition of social and emotional learning skills (Elias et al., 2003), for example in responses that overlapped with the role of external agencies such as exploring problems in more depth, and in relation to family issues and joint working with parents. It was not possible to establish from this data whether the schools that offered these interventions did so of their own accord or through input from agencies such as family support or CAMHS. As the vignettes were fairly broad and not diagnostic of specific types of problems, it was also difficult to establish whether responses that would consider the use of medication reflected attitudes towards specific conditions such as ADHD, or perceiving medication as an alternative to mental health problems that do not respond to other approaches. However, the rate of considering a pharmacological intervention for behavioural problems across secondary schools was, at nearly 20%, strikingly high, and it would be interesting for future research to explore the underpinning reasons.
A number of interventions implemented related to direct therapeutic work. This could be in the form of individual or group therapy, and including frameworks such as cognitive-behavioural therapy (CBT), solution focused, art and other creative therapies. This component requires clear definition of objectives, agency roles, allocation of resources and supervisory arrangements. It is important to determine what each modality aims to achieve; whether and why it should be provided within a school rather than an external specialist context; when external agencies provide direct input into the school; and whether therapists are adequately qualified and supervised. As counselling, including within school provision, is a broad and rapidly evolving field, these are important questions for future research, in addition to evidence on clinical and cost-effectiveness.
A number of limitations need to be acknowledged in this study. Although there was no shortage of reported school-based interventions for pupils, documenting these interventions can be a challenge due to the complex system in which they are embedded. Respondents may have differed in their perceptions and definitions of interventions, which were based on subjective ratings, without corroborative evidence of whether or how these were actually being provided. Despite the large number of schools involved and the socio-demographic data collected on their salient characteristics, it is plausible that more motivated schools took part, thus overestimating the rates and types of interventions provided.