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:
- Universal screening: all children in a school are assessed for signs of mental health difficulties using standardised questionnaires.
- 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).
- 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.
- Staff training: school staff receive training on how to identify the signs of mental health difficulties and communicate their concerns appropriately.
- 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).
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.
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