The Mental Health Impact of COVID-19 School Closures

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In this podcast, we are joined by Dr. Karen Mansfield, a postdoctoral research scientist from the School Mental Health Project,  and Associate Professor Mina Fazel, Department of Psychiatry at the University of Oxford.

The focus is on the JCPP Advances paper ‘‘Covid-19 partial school closures and mental health problems: a cross sectional survey of 11,000 adolescents to determine those most at risk’’.

In this podcast, we hear Mina explain what the School Mental Health project is and what are its’ aims. Karen then provides us with a summary of their co-authored paper, its’ methodology and its’ key findings. Furthermore, we hear Mina and Karen discuss that the risk groups identified would benefit from a broad curriculum of support for education and wellbeing, plus their suggestions as to how this support might be delivered and in what form.

Mina and Karen also talk to us about how the findings from the paper tie in with other findings from the OxWell data, and what the implications of their findings are for professionals working with young people and their families.

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Dr. Karen Mansfield
Dr. Karen Mansfield

I am a postdoctoral research scientist interested in solving methodological challenges in the collection, analysis and safe-sharing of data to inform adolescent mental health and wellbeing research. Together with Mina Fazel, I work on a School Mental Health project, coordinating the OxWell online school survey. I also work with NIHR Professor Andrea Cipriani, coordinating and supporting projects adopted by the Informatics and Digital Health theme at Oxford Health’s NIHR Biomedical Research Centre. (Picture and bio from Department of Psychiatry, University of Oxford)

Associate Professor Mina Fazel
Associate Professor Mina Fazel

The main focus of my research is on how to improve access to mental health interventions for children and adolescents. I have a particular interest in school-based mental health interventions and each year since 2019 my team has been running the OxWell School Survey in order to better understand what school pupils need and also what they want. In 2021 we collected data on over 30,000 young people from 180 schools across 10 regional authorities. We work closely with young advisors to ensure that our findings are shared with school pupils. (Picture and bio from Department of Psychiatry, University of Oxford)


[00:00:27.930] – Jo Carlowe: Welcome to a different type of In Conversation podcast from the Association for Child and Adolescent Mental Health, ACAMH, where we will look at the paper ‘Covid-19 partial school closures and mental health problems: a cross sectional survey of 11,000 adolescents to determine those most at risk’, recently published in JCPP Advances. I’m Jo Carlowe, a freelance journalist with a specialism in psychology, and I have Dr. Karen Mansfield with me, a postdoctoral research scientist from the School Mental Health Project at the Department of Psychiatry at the University of Oxford and first author of the paper we’ll be discussing today, and Mina Fazel, associate professor in the Department of Psychiatry at the same institution, and senior author on this paper.

[00:01:15.090] If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with the rating or review and do share with friends and colleagues. Karen and Mina, welcome. Can you each begin with a brief introduction about yourselves?

[00:01:31.650] – Dr. Karen Mansfield: Thank you. I’m Karen Mansfield, so yes, as Jo said, I’m a postdoc at the Department of Psychiatry in Oxford, and my background actually is in experimental psychology, so I moved a little bit later in my career into mental health. I’m now particularly interested in the methodology around the collection, management and analysis of online data to understand mental health and wellbeing. My research goals are around understanding how to promote wellbeing and to prevent long term mental health difficulties. And this type of research benefits from access to a broad range of measures about the same individuals and to identify protective factors, such as lifestyle and healthy behaviour, for example.

[00:02:06.690] – Jo Carlowe: Great. And Mina, over to you.

[00:02:09.150] – Dr. Mina Fazel: Hi, I’m Mina Fazel. I’m a child and adolescent psychiatrist, and I work in the Department of Psychiatry at the University of Oxford as an associate professor. I have an interest in service provision for young people, especially for those that are deemed more vulnerable, how we can make our services more acceptable and accessible to these children. And so what’s quite exciting for us about this survey, which we call the OxWell School Survey, is that we asked young people quite a lot about what they’re going through and also what they might want to be able to access as well.

[00:02:44.430] – Jo Carlowe: Can you tell us about the School Mental health Project and its aims?

[00:02:48.750] – Dr, Mina Fazel: The OxWell School Survey, it’s a survey that Karen and I started working on in 2019, and then we’ve done it again in 2020. And now we’ve just completed 2021. And the numbers have increased with each year. So we had 5,000 students in 2019, around 19,000 in 2020, and around 30,000 in 2021. And what it is, it’s a big survey of mental health and wellbeing. We ask students from age nine to 18, so that’s equivalent to school years five to 13 in the English school system, a whole range of questions. Now, obviously, we ask slightly different questions depending on age, so we don’t ask the same questions in the 18 year olds we ask the nine year olds, but in general, we’re able to cover a whole range of really important factors around what young people are thinking, how they’re feeling, some of the risk factors associated with school, with healthy behaviours or not. And through this able to get a more detailed picture from the young people themselves because it’s all self-report in schools.

[00:03:58.290] The other important factor of this survey is that we try and get whole school populations. So there are a lot of problems with opt-in surveys where only those students whose parents get round to filling out the consent form… I’m definitely not one of those parents just because I’m disorganised… but so there are a whole range of factors why it’s difficult to get the full range of students at a school to complete the survey. But in this survey, the way we’re able to sample through schools, we’re trying to get as many young people as possible, especially trying to make sure we get the more vulnerable populations or those populations that don’t usually participate in surveys.

[00:04:37.410] – Jo Carlowe: How do you encourage them to take part? Do you have to incentivise them in some way?

[00:04:42.210] – Dr. Mina Fazel: Well, actually, we work through the local authorities, who have been incredible partners for us, so the local authorities, for example either the public health statutory bodies or the education bodies, and we speak to them. We get involved with schools. So we talk about how the measures we’re collecting are not only have being collected for us, but of great relevance to the services, to the concerns of everyone working to try and improve and enable young people to thrive. So what we first do is we make sure that our local partners are going to find this useful and they have access to all the data along with all the schools accessing the data. So because we work through a system where the data is gathered by us, but it’s also made available to the partners. Obviously, we protect the identity of the young people because we don’t collect many ways that these kids can be tracked. So the kids actually have to trust that from their perspective, they won’t be able to be identified.

[00:05:44.610] And because we have that we’re able to get whole schools involved because we go through the school, the schools write to the parents, they let the parents know a week in advance of the survey taking place, and the parents have the opportunity to ask questions and/or opt out their children from the survey. And then when the survey is conducted at school, obviously those whose parents have opted them out don’t participate, but then the children themselves can also decide if they want to participate or not. So we try and make sure that they’re all invited, but there is still a level of choice about participation, but there’s no direct incentive. The incentive is for the local authority and the school to be able to get access to data that we hope will enable them to decide what they want to do, what we call a data driven approach to any interventions they then might want to put in place.

[00:06:34.410] – Jo Carlowe: As mentioned in the intro, you co-authored the paper ‘Covid-19 partial school closures and mental health problems: a cross-sectional survey of 11,000 adolescents to determine those most at risk’, published in JCPP Advances. Can you give us a summary of the paper? What did you look at?

[00:06:52.110] – Dr. Karen Mansfield: We wanted to gather a picture of school pupils’ mental health during the first lockdown because then there was the time of the partial school closures. We also wanted to ask them how they perceived the lockdown to have impacted their wellbeing. So the main aim of the paper was to assess the extent to which those who were already at risk were more likely to experience depression and anxiety, as well as deterioration to their own perceived wellbeing. And we also wanted to know whether this differed for those at school versus those at home.

[00:07:19.170] – Jo Carlowe: What methodology did you use for the research?

[00:07:21.930] – Dr. Karen Mansfield: That’s a tricky one because it’s a cross-sectional survey. So like Mina mentioned, we don’t collect identifiers, so we can’t link the data to previous data collections. So what we do have, though, is a very broad range of measures on the same person from the same time. So it makes it quite difficult to think about things like causality. However, we did ask pupils, for example, how do you feel that lockdown has impacted on your wellbeing? And also the analysis focused on the role of demographics and contextual factors, which are unlikely to be influenced by the mental health outcomes. So, for example, gender, past mental health support, and indices of social deprivation, for example.

[00:08:00.570] So we’re aware that the type of school provision might well depend on past mental health. So, for example, pupils who were already vulnerable were more likely to be offered access to onsite school, in-school provision. And so what we essentially did is we looked first at very descriptive statistics, and we looked at how this differed between these two groups, those who were in school versus those who were only receiving remote school provision. And then we did analysis, a mixed effects model, where we controlled for all of those background factors, including the school that they went to and the year group that they were in to assess whether there was still any remaining effect. And at that point, what we saw that the pupils who were, even though the ones who were at school, had generally poorer mental wellbeing, that this could actually be accounted for by those past contextual factors and demographics.

[00:08:49.410] – Jo Carlowe: Can you say more about the key findings from the paper?

[00:08:53.310] – Dr. Karen Mansfield: The key finding, I suppose, is that we wanted to know whether those who were already at risk were at increased risk of having depression or anxiety during the lockdown. And that is indeed what we saw. So those who had experienced past mental health difficulties, females more than males as well, which is very often seen, and also those, for example, who’d experienced food poverty. So those were the ones that stood out the most. However, what we also saw is that there were factors very specific to the lockdown. So, for example, those who had key worker parents were also at increased risk, and also students who, for example, were facing upcoming exams. So those who were in year ten or 12 also were at increased risk of depression and anxiety and experiencing deterioration to their wellbeing.

[00:09:39.930] – Jo Carlowe: Why do you think the children of key workers?

[00:09:42.450] – Dr. Karen Mansfield: Well, quite possibly there was a lot of stress at home, but unfortunately we didn’t analyse that in this particular study, but it’s something that we do want to look into more. But if you think about… In my situation, my husband was working in schools. It just makes it a little bit more difficult to go into a school in a setting where school is something completely different to what it was previously. So if you’re a key worker, to some extent that’s going to overlap with the fact that you’re more likely to be one of those pupils who is in school every day, but also your parents are going to be very busy. Your parents are going to be stressed having to go out to work. So this is something… Yes, this is more of a hypothesis at the moment, but something we do want to look into more.

[00:10:23.130] – Jo Carlowe: The other thing you noted, and you did mention it, that girls were more likely than boys to report deteriorations in wellbeing. Why do you think the impact of school closures has hit girls particularly hard?

[00:10:35.910] – Dr. Mina Fazel: It’s not surprising because they seem to be more vulnerable across the board in the whole range of mental health outcomes. So they’re more likely to experience depression, anxiety, suffer from sleep difficulties. And so it could well be that that, a sense too, that we really don’t know about other influences that are more commonly accessed by females, so, for example, social media use. So we’ve asked about that in the 2021 survey, but we know that more females go on social media and more males seem to be going on gaming. We’re looking at that in a bit more detail, but it might be that there are other influences as well that might have been impacted that we need to find out more about.

[00:11:20.490] – Jo Carlowe: Are there any other key findings that you would like to highlight from the paper?

[00:11:24.810] – Dr. Karen Mansfield: What was also very interesting to us was that we managed to gather a fairly diverse sample during a period where it’s actually quite difficult for many young people to have access to their school and to digital devices. And so it’s for us a confirmation that even in these very difficult circumstances, you can gather data from fairly diverse, and to some extent representative, and the exact representativeness we’re looking into further. But that was something else that we found very important from our data.

[00:11:53.670] – Jo Carlowe: You conclude that the risk groups identified would benefit from a broad curriculum of support for education and wellbeing. Any suggestions as to how this support might be delivered and in what form?

[00:12:07.290] – Dr. Karen Mansfield: So I’ll let Mina say more on this, but a lot of what our research is about the kind of support that students can be given in school, such as from education, mental health support workers, also from their peers. So we ask a lot of questions about the type of support that young people benefit from and the extent to which that support is helpful as well. So we’ve really got quite an in depth measure of which types of support are going to be most helpful to young people. And I think we can use that to work very closely with our partners and guide that. And Mina, maybe you want to add to that as well?

[00:12:39.990] – Dr. Mina Fazel: I think actually what this is helping us understand a little bit more is if we step away from mental health support, and we need to bring mental health workers into schools. It’s about understanding what happens in schools and the whole range of activities, but as a picture in this totality provide a whole range of mental health supports to young people. So it’s thinking about what role school plays in structured and unstructured activities in, as the Children’s Commissioner has recently referred to, the enrichment activities of school, that actually we shouldn’t underestimate the value and importance of all of this, and that in the pandemic, there’s obviously been a lot of children and families worried about academic achievement and learning sufficiently in order for key examinations.

[00:13:28.350] But I think that that discussion is really taking away from the broader, far more important role, I think, that schools play, which is in the overall development of children and helping them understand their role amongst their peers, amongst their community, how they want to be. It gives you a place to build new skills, to get a whole range of feelings of self-esteem and achievement or learning what you like or dislike. So school offers an environment for a lot of children to be able to do this. And so when we removed that from children in the dramatic ways that happened during the pandemic… So even for those children, as Karen mentioned, who were going to school, school was dramatically different for the children that went to school during the pandemic compared to when they were going to school that was not during the pandemic.

[00:14:15.630] And then on returning to school after the most stringent lockdown measures were lifted, school was still a very, very different type of place. And there has been a lot of discussion about the learning needs, but I think we have to be much braver and say, actually, there’s so much more that schools… and schools know this. They know that kids need that whole range of activities in order to support their wellbeing in every way, and that we shouldn’t ignore that in part of the broader discussion about what’s needed for education and wellbeing.

[00:14:52.410] – Jo Carlowe: Well, as we’re talking about the broader picture, how do the findings from the paper we’ve discussed tie in with other findings from the OxWell data?

[00:15:01.170] – Dr. Mina Fazel: Well, we’re able to work with quite an amazing group of researchers who are looking at a number of different factors. So we’ve been able to look at the group of young people who said that they felt they were doing better in lockdown, so this was from the first lockdown. And there was about 30 percent said that they felt that they were doing better, so we want to look at that group, try and understand what the drivers are of that. We’ve looked at young people’s loneliness measures, looking at self-harm in relation to that. So there’s a lot of related learning that we’re able to try and glean from this incredibly rich data set. And so what we’re finding is that… I suppose it’s also biased by what we’re interested in. I’m very interested in the overall environmental context. So the questions that we’re posing to the survey are things around the importance of social networks. The way it’s tying in is just helping us build that full picture. We just don’t want to take a kid and their experience out of that full context of what’s happening.

[00:16:12.330] – Jo Carlowe: Is there any commonality between the 30 percent who were doing better during lockdown?

[00:16:17.430] – Dr. Mina Fazel: The findings… Well, they’re currently under peer review, so I’ll happily come back and tell you more about it. But I suppose what it came from was also my clinical experience. So I work as a consultant child and adolescent psychiatrist in a children’s hospital. And a lot of the young children who are struggling, they might have underlying health problems, they might have underlying communication difficulties, they might have just experienced that they’re finding it harder to fit in in school in certain ways, or they might just have concerns or anxieties, they might be bullied. So there are aspects of school that can be quite stressful and quite difficult.

[00:16:56.790] And not having that pressure in the first lockdown seems to have been quite interesting because in the hospital a lot of young people were saying how much happier they felt not having to go to school, not having to put school uniform on, not having to deal with the kids that they were scared of, not having to worry about being told off by their teachers, which is what a lot of young kids were saying. So we shouldn’t ignore some of the broader learnings from lockdown. That’s an interesting area. But we were only looking at the first lockdown, and I would imagine that picture would have changed as the lockdown extended and extended and extended.

[00:17:34.390] – Jo Carlowe: It’s interesting, isn’t it? Because it opens up the question as to whether education should be delivered differently to those children that you talked about?

[00:17:42.370] – Dr. Mina Fazel: Yes, well we can’t lose the opportunity to learn more about what helps children thrive. So if children, for example, are anxious and they’re finding it much better, as they were saying, to be at home learning, that might in the long term not be a great thing because part of the mainstay of treatment of anxiety sources is being able to find ways to expose individuals to what they’re finding difficult in a manner that enables them to cope with it. So just because a kid says it’s better for them doesn’t necessarily mean we should then abandon education in the traditional sense for that group. It’s just to try and understand what that’s about, how we can learn from it, how we can tailor it to better understand their overall needs. And there are a group of children for whom mainstream education is particularly complex to access. And that is a challenge and an important one to help us understand how best to think about them.

[00:18:46.330] – Jo Carlowe: Mina, what are the implications of your findings for professionals working with young people and their families?

[00:18:53.050] – Dr. Mina Fazel: So we’re hoping that this will help us understand a little bit about how we tailor our services better. We can, as Karen mentioned, now look at the data and the results that the young people have given us and look at what they said they want with regards to services. So do they want to access services more in school or out of school? How do they engage with a whole range of other really important behaviours like exercise, like sleep? So there’s a whole range of things. So I think what we’re hoping the implications will be is it will help us really understand what is helpful and not helpful. And we’ve really, I suppose, got a wonderfully privileged insight into a very, very large number of children’s perceptions.

[00:19:41.650] So, for example, I was just looking the other day at the group that have accessed CAMHS and what they’re saying they found from CAMHS. So if you think about how CAMHS can evaluate what they’re doing, it’s quite difficult sometimes if a child has stopped coming to appointments to get their feedback on it. So we were able to get much larger numbers across the board of those that have engaged and not engaged and understand what drivers there might be. So we think that… We’re incredibly excited actually about the implications because there’s so many things that we can find.

[00:20:17.890] And a little example is, for example, this year, as well as last year, it was so clear how many young people are suffering, for example, with their sleep; it’s unbelievable. And so as a result of that, we’re thinking, well, maybe we need to develop a whole range of resources for parents, for teachers, for children across all the different age ranges, all about sleep. And maybe to encourage all of that for schools to think about having a sleep week in a few months’ time, so we can take the time, prepare it all and then really give a little bit more information in a whole range of ways to help young people with their sleep because sleep seems to be affected across the board, across a whole range of mental health problems, and might be quite a non-stigmatising route into helping young people. And so it’s from little things like that, which hopefully can have a big impact to really understanding more nuanced needs of particular groups.

[00:21:15.190] – Jo Carlowe: Is that something you’re planning to do?

[00:21:17.110] – Dr. Mina Fazel: Yes. We also open our arms to anyone who would like to come and work with us and think about it. We’re a small team, so we rely on collaborations with others who want to come and think with us about this and help us understand what to do.

[00:21:30.610] – Jo Carlowe: Mina, what message should policymakers take from your findings?

[00:21:35.230] – Dr. Mina Fazel: The message is that young people have a really important voice and we need to listen to it, and we need to create information and understanding for these young people that they can understand. So if we want young people to learn more about certain things, for example, like sleep, we actually have to make the information we prepare one that’s acceptable to them. I think policymakers… We’ve been working very closely with policymakers. We’ve been so supported by them because actually they find this data incredibly powerful because you get a snapshot into the vulnerable populations, which, from my experience, most policymakers are incredibly interested in, trying to work out what to do, how to make services more acceptable, how they can configure what they do. Should it be in the school? Which kind of kids might be best reached at school? Which might be best reached in other ways? Which groups are engaging more with a whole range of different activities? So what we’ve got is a snapshot into a large number of young people telling policymakers what they find helpful across a range of things that are being offered at school.

[00:22:45.010] – Jo Carlowe: You’ve mentioned sleep as an area for further exploration. What other follow up research can you reveal to us?

[00:22:52.810] – Dr. Mina Fazel: Oh, my gosh, I could talk for hours on this. There’s so much we want to learn about. So obviously, from what I said my interest in it is around services, around provision of services, around acceptability of services. But we ask a lot about, as I mentioned, social media and gaming. That’s something I don’t know much about, but we’re starting to learn about. We’ve got a big team working with Karen and I on self-harm. So there’s very, very detailed information gathered on those who say that they’ve self-harmed in the past. So if you answer yes, you have self-harmed, then you’re asked a whole load of questions related to that, so that we can learn more about all of that. So that’s just a snapshot of some of the areas that we’re looking at. Karen actually has a few other interesting ones that she’s looking at.

[00:23:39.490] – Dr. Karen Mansfield: Yes. So we’re looking, for example, we’ve got a few measures of self-reported or self-reported changes to cognition, for example, which we’re looking at. I’m also very interested in looking at the demographics and the characteristics of our sample and comparing that to the census data. We’ve got so many different measures as well of mental health and wellbeing. It’s really fascinating to me to look at how those relate to one another, so the extent to which the measures of mental wellbeing can be seen as a reverse to the measures of depression and anxiety, and which other measures might you need to kind of tie in and make these more comparable.

[00:24:15.550] So there’s lots of things which are in the pipeline. And the first one, I guess, is the ones which are more related to Covid and informing rules and policymakers on which kind of impacts we’re seeing and which kind of aspects of mental and cognitive health have been impacted, and what might be protective factors for those that we can use to inform interventions and to inform support that’s given in schools, I guess, yes, that’s the key. There’s so much more. Again, just like Mina, I’ll be here all day I think if I carry on talking about it.

[00:24:47.410] – Jo Carlowe: Well, a final opportunity to talk about anything else in the pipeline for you both that feels really important to mention.

[00:24:54.610] – Dr. Mina Fazel: Quite funny, isn’t it, Karen? Neither of us have mentioned the things that each of us are most excited about looking at. I’m looking at the whole issue of consent. And so we’ve got very interesting data coming out around barriers to accessing care, and a lot of that relates to consent. And Karen’s looking at a whole range of factors around what we think are the bigger data collection and protection issues affecting young people and how they feel towards that. So I think, from my perspective, the next two things that I think are going to be most interesting and exciting for us are those two areas.

[00:25:32.050] – Dr. Karen Mansfield: Yes, and also, of course, the whole how to share the data in a way. So we’ve collected the data in a way where we’ve made it clear to the young people and their parents that we will only share data in anonymous form. And so there are huge challenges with… You’ve got people using machine learning and this kind of thing, which we’ve said we won’t use on our data, for example. So we’re looking at ways where we can create extracts of the data that would be extremely valuable for research, but that we can share them in a way where we’re 100 percent certain that this wouldn’t make it possible to ever identify someone. If you happen to know, for example, how many hours exercise they do per week or the fact that they take a bus to school, whereas everybody else in their class doesn’t; these kinds of things. These are challenges which we’re faced with in this age of wanting to maintain the privacy of young people at the same time as wanting to make the data accessible for research because it is so incredibly valuable. And so this is another challenge that we’re looking at and we’re trying to solve in a good way.

[00:26:38.230] – Jo Carlowe: And finally, Karen and Mina, what’s your takeaway message for those listening to our conversation?

[00:26:43.930] – Dr. Karen Mansfield: I think for me, the takeaway message is that our data set makes it clear how much you can get. And so we want to invite people to come and work with us. And if there are questions that they really want to ask a big audience and hope to get honest answers, accurate answers, from those young people, then to come and work with us and to try and do that. It gives us just a great opportunity to replicate research that’s going on in other people’s research groups, and to do that in this group, and then to test your hypothesis that’s been tested somewhere else in this data set as well, to confirm things and then to follow up and develop and just improve the questions that we have, to really use them to understand mental health of adolescents and how to protect it and how to promote wellbeing especially.

[00:27:30.010] – Jo Carlowe: And Mina?

[00:27:30.610] – Dr. Mina Fazel: I think what we are learning through this is the importance of the young person’s voice, how to hear it. And another area of what we’re trying to learn is then how to make the findings [inaudible] well, inform the young people who participated about the findings directly as well. So it’s about a movement of trying to put young people at the heart of what we do, their responses and what they’re telling us in some of the areas are so important and so rich, and seems that we’re missing a trick if we don’t really find more innovative ways to hear the young person’s voice. So this is just one way. It’s a survey done at school. There’ll be more ways as we learn and develop, and so it’s not just about hearing their voice with regards to the answers to our questions, but also to let them know our findings, get their feedback on it, learn together about what to do as a result of that. So that’s a process we’re committed to, but we’re still very early in understanding really how best to do that.

[00:28:29.530] – Jo Carlowe: Excellent. Thank you both so much. For more details on Dr. Karen Mansfield and Dr. Mina Fazel, please visit the ACAMH website, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

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