Identifying mental health difficulties in children & young people: the role of schools

Emma Soneson and Professor Tamsin Ford CBE
Emma Soneson is a PhD student and Gates Scholar at the University of Cambridge. Her research focuses on public health approaches to identifying and responding to mental health difficulties in children and young people. She is particularly interested in the role of schools in improving mental health outcomes for their pupils. Professor Tamsin Ford CBE is Professor of Child and Adolescent Psychiatry at the University of Cambridge. She is an internationally renowned Child Psychiatric Epidemiologist who researches the organisation, delivery, and effectiveness of services and interventions for children and young people’s mental health.

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The problem

National survey data show that 1 in 8 children and young people (CYP) has a clinically diagnosable mental health disorder. Yet, only around a quarter of these CYP will access specialist mental health services. This means that there is a significant unmet need for care and support.

What contributes to this unmet need? Many factors, including low availability of care, lack of information about services, long waiting times, inflexible services, complex administrative procedures, treatment costs, and stigma can impede access to services for CYP with mental health difficulties.

The very first barrier, however, is under-identification of need. It’s estimated that key adults (such as parents, teachers, and GPs) identify fewer than one in five CYP with mental health difficulties. This means that the majority are struggling in silence. Accurate identification is the first step in any care pathway, so until we can improve detection of mental health difficulties in CYP, we’ll have little chance of reducing this unmet need for mental health care.

The role of schools in identifying mental health difficulties

Schools may be a particularly good place to pick up on the early signs of mental health difficulties. There are a number of reasons for this. First, we know that the majority of lifetime mental health disorders begin during the schooling years. Second, schools are where CYP spend the majority of their time outside of the home, which means that school staff are well-placed to notice changes in behaviour or demeanour that may signal a child or young person is struggling with their mental health. Third, nearly all UK children go to school (including those from groups that are at increased risk for developing mental health difficulties), meaning that working in schools is essentially a population-based approach. Fourth, schools are the most commonly-accessed form of mental health support for CYP, with moderate evidence showing the effectiveness of school-based mental health interventions.

Policymakers have recognised the role schools can play in improving CYP’s mental health. Both the 2017 Government Green Paper on CYP’s mental health and guidelines from the National Institute of Health and Care Excellence (NICE) set out expectations for schools to identify and respond to mental health difficulties in their pupils. Below, we discuss some of the types of programmes schools can use to meet these expectations.

Types of identification programmes

There are several types of programmes for school-based identification of mental health difficulties:

  1. Universal screening: all children in a school are assessed for signs of mental health difficulties using standardised questionnaires.
  2. Selective (or targeted) screening: only some children in a school are assessed. Children are chosen for selective screening due to being perceived as having an increased risk for mental health difficulties (e.g. those with SEN or free school meal eligibility).
  3. Curriculum-based (or mental health education for pupils): pupils learn about mental health in school, including how to recognise the signs of mental health difficulties in themselves and their peers and talk to an adult about their concerns.
  4. Staff training: school staff receive training on how to identify the signs of mental health difficulties and communicate their concerns appropriately.
  5. Staff nomination: school staff nominate pupils they’re worried about without any additional training.

Nearly all schools in the UK report efforts to identify mental health difficulties in their pupils. The single most common method of identification is staff nomination, although most schools report using more than one type of programme, including universal screening (15% of schools) and selective screening (24% of schools).

The evidence

Do school-based identification programmes work?

In a recent systematic review, we compiled the evidence on the effectiveness of school-based identification of mental health difficulties. We studied a number of outcomes, including accuracy of identification, referral rates, and service uptake.

We did not find strong evidence to support any one type of programme over another, though there were initial findings that more systematic programmes (such as universal screening) may be more accurate than more ad hoc ones (such as staff nomination). Further, a small amount of evidence suggested that using more than one model could improve accuracy. Still, there was wide variation in the number of false positive and false negative results within programme types.

It’s important to remember that accurate identification doesn’t exist in a vacuum, though – it’s not very helpful to identify CYP with mental health difficulties unless there is some support on offer. However, very few studies reported on referral rates and service uptake after school-based identification. The ones that did showed mediocre results, with up to half of CYP identified in these programmes not going on to receive further evaluation or support.

Are school-based identification programmes feasible and acceptable?

We also completed a second review on the feasibility and acceptability of school-based identification in order to reflect the importance of these factors in successful programme implementation and long-term sustainability.

We found that screening, staff training, and curriculum-based programmes all generally aligned with schools’ and parents priorities (matching our own empirical findings amongst UK parents). However, there were significant barriers across all programmes in terms of cost, time, and resources – all very real concerns for schools that are already under-resourced and overburdened.

Where do we go from here?

Now more than ever, as we gather increasing evidence about the effects of COVID-19 on CYP’s mental health, we need to think carefully about how schools and mental health practitioners can partner together to promote and protect CYP’s mental health. Evidence from the Co-SPACE study shows that primary school pupils in particular are experiencing increasing rates of behavioural and emotional difficulties during this difficult time. Children who have experienced COVID-19 themselves or who have been bereaved by the disease may have particular mental health needs.

Schools will undoubtedly play a significant role in helping CYP adjust to the ‘new normal’. Part of this role can be through identifying mental health difficulties as pupils return to school after such a life-changing event. Although the evidence is patchy, there’s some indication that a blended approach to identification (e.g. a combination of staff training and curriculum-based programmes or staff training and screening) may be the best way forward. Ongoing evaluation of these programmes will be crucial in light of the remaining uncertainties about effectiveness and feasibility, especially in terms of referral rates and service uptake for those identified.

What’s clear is that identifying and responding to mental health difficulties in CYP must be a team effort. All of us – parents, teachers, mental health practitioners, and researchers – have a role to play in ensuring our CYP are supported to lead happy and healthy lives.

References

Anderson, J. K., Ford, T., Soneson, E., Thompson Coon, J., Humphrey, A., Rogers, M., … Howarth, E. (2018). A systematic review of effectiveness and cost-effectiveness of school-based identification of children and young people at risk of, or currently experiencing mental health difficulties. Psychological Medicine, 1–11.

Anderson, J. K., Howarth, E., Vainre, M., Jones, P. B., & Humphrey, A. (2017). A scoping literature review of service-level barriers for access and engagement with mental health services for children and young people. Children and Youth Services Review, 77(November 2016), 164–176. https://doi.org/10.1016/j.childyouth.2017.04.017

Department of Health, & Department for Education. (2017). Transforming Children and Young People’s Mental Health Provision: a Green Paper. APS Group.

Durbin, K., & Harmon, S. (2020). We Are on the Same Team: Child Psychiatry and the School System. JAACAP Connect, Winter 2020, 32–36.

Gee, B., Reynolds, S., Carroll, B., Orchard, F., Clarke, T., Martin, D., … Pass, L. (2020). Practitioner Review: Effectiveness of indicated school-based interventions for adolescent depression and anxiety – a meta-analytic review. Journal of Child Psychology and Psychiatry and Allied Disciplines. https://doi.org/10.1111/jcpp.13209

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of. Arch Gen Psychiatry. https://doi.org/10.1001/archpsyc.62.6.593

Levitt, J. M., Saka, N., Romanelli, L. H., & Hoagwood, K. (2007). Early identification of mental health problems in schools: The status of instrumentation. Journal of School Psychology, 45(2), 163–191.

NatCen Social Research, & The National Children’s Bureau Research and Policy Team. (2017). Supporting Mental Health in Schools and Colleges . (Department for Education, Ed.). London. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/634725/Supporting_Mental-Health_synthesis_report.pdf

National Institute for Health and Care Excellence. (2016). Social and emotional wellbeing in primary education. NICE Public Health Guidance. https://doi.org/10.4236/als.2014.24017

Pearcey, S., Shum, A., Waite, P., Patalay, P. & Creswell, C. (2020). Report 04: Changes in children and young people’s emotional and behavioural difficulties through lockdown. Retrieved from https://emergingminds.org.uk/wp-content/uploads/2020/06/CoSPACE-Report-4-June-2020.pdf

Sadler, K., Vizard, T., Ford, T., Marcheselli, F., Pearce, N., Mandalia, D., … McManus, S. (2018). Mental Health of Children and Young People in England, 2017. Retrieved from https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017

Soneson, E., Childs-Fegredo, J., Anderson, J. K., Stochl, J., Fazel, M., Ford, T., … Howarth, E. (2018). Acceptability of screening for mental health difficulties in primary schools: a survey of UK parents. BMC Public Health 2018 18:1, 18(1), 1404. https://doi.org/10.1186/s12889-018-6279-7

Soneson, E., Howarth, E., Ford, T., Humphrey, A., Jones, P. B., Thompson Coon, J., … Anderson, J. K. (2020). Feasibility of school-based identification of children and adolescents experiencing, or at risk of developing, mental health difficulties: A systematic review. Prevention Science.

Discussion

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That’s a really great post! When it is about mental health, people should be very careful. One must be able to get all the necessary information about the various health conditions and treatments you are dealing with. Children mental health care can be treated through proper care. Thanks for sharing! After reading this, a lot of people will get good ideas.

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Excellent post, informative and concise. The problem is more complex and acute in specialist education settings though, particularly in the COVID – 19 context.

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Hi,
I work for a company that assess all pupils in their schools so that we can track the emotional and social development of pupils. In this way staff are made aware of future potential risks to pupils over time. It doesn’t label pupils but says where they are at the moment. It is designed to help them steer the road ahead as well as just drive down it, avoiding the emotional car crashes that can occur by giving staff an extra piece of the jigsaw puzzle. https://steer.global/en

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Personally, I do not believe that under identification is the problem. For school staff such as teachers and TA’s who are in tune, children with mental health difficulties are evident and very visible. The question is what then? CAMHS only deals with the most afflicted and waiting lists are interminable.Many schools, especially the higher achieving ones , are bastions of inflexibility and do not want to make concessions for children with mental health difficulties because they fear it will open the floodgates and lead to a breakdown of carefully ordered structures, resulting in lower league table results.. What is advertised on the tin, such as differentiation, is difficult to implement in practice.. Please do conduct further research in the difference in approaches to addressing MH in needs improvement, good and outstanding schools. Once one scratches below the surface, one finds that the needs improvement schools try to do a lot more to address mental health issues as the need is more visible and urgent there.
Another issues is that staff or MH professions often say what is expected of them as they want to conform and appear professional and this may not necessarily be is in the best interest of the student. And then the students who cannot cope in the school environment, increasingly stay home, become school refusers and eventually become invisible in the system because nobody knows what to do about them. I feel that a culture of demonstrating flexibility, ongoing monitoring of student and engaging with parents to diffuse any precipitating factors are key and will serve as early intervention Schools demonstrating an understanding of the mental health presentation of the child to the child and an atmosphere of promoting awareness, mentalising, hope, empathy and safety will really go a long way to stem mental health in schools. and reassure anxious or depressed kids as they need to be reassured that they will get help when they need it and mental health is not a discipline issue. .As a supply teacher and intervention tutor, I visit loads of different schools and am happy to join the discussion. Thanks for your informative article.

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Great post and schools are great places hat can identify changes in behaviour and disposition. We need a workforce that is curious not simply reacting to a behaviour but reflecting on the cause.

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Very helpful. Ideally, what schools need is people who have both the skills to identify children who are struggling and knowledge about the types of intervention that might support them. Even better if there were staff in school who could deliver some of those interventions so they could be offered quickly and safely, and children referred on as more information becomes available or the cause of the difficulties becomes clearer or the child’s condition worsens. The government needs to fund schools to allow this to happen because otherwise those who might be able to deliver (e.g. Teaching Assistants) get pulled off to do academic catch-up instead. We can only keep campaigning for more recognition of the damage we do by not providing early intervention.

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I agree with much of what is said here and schools are ideally placed to help. However so many pupils are keeping their issues well hidden. In a recent survey over 50% of pupils said they would not mention an issue they had in school to anyone. Also rather than letting the situation get as far as CAMHS we need to be more proactive at putting extra scaffolding in place to help pupils before the emotional car crash takes place. If pupils are hiding their true selves on a private, back stage that we cannot see, either because they don’t want us to see it or they don’t know how to share it, then they are out of our reach.
Staff are brilliant at spotting changes to pupils’ responses and emotions and do an amazing job in helping. One of my greatest reflections as a teacher was that I was always acutely aware that I might have missed something and that perhaps I didn’t know a pupil as well as I thought I did.

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