Implementing mental health promotion in schools in the UK and learning from Dataprev in

Europe

Professor Katherine WeareProfessor Melanie Nind

University of SouthamptonSkw @soton.ac.ukIntecamhs meeting

Washington November 2010

Aims

To give an overview of what is happening with the promotion of mental health in schools in the UK

To communicate the key findings of the Dataprev project

My roleBackground in Health Promoting

Schools: Mental HealthWrote key document for UK Govt on

‘what works’ in promoting emotional health and wellbeing.

Helped create and monitor primary and secondary “SEAL” programmes

On working party for English “Targeted Mental Health” programme

Part of current “Early Intervention “reviews and policy

Reviewing evidence base for mental health in schools and uncovering programmes for EU: “DataPrev”.

Why schools in Europe are interested in mental health

Focus on positive mental health, wellbeing, prevention, early intervention, social and emotional learning, healthy schools

Long term concerns to reduce problems e.g. stress, anxiety, depression, bad behaviour, violence, disaffection

Changing focus of learning on skills rather than just content: preparing students for lifelong challenges

Improved evidence: knowledge of effective programmes and approaches

Current terminologies, paradigms, discourses

Paradigm shift in understanding of the role of mental health and wellbeing in schools in Europe Traditional view For young children Responsibility of the

home/ mental health services

For special needs/ those with problems

Trouble shooting/ prevention

Bolt on extra/low status activity

An art not a science

New view Everyone including adults Everywhere e.g. secondary

schools, workplaces All of us, including ‘without

problems’(?) Positives e.g. growth,

strengths, capacities Central to educational goals –

learning and behaviour Evidence based

Government interventions e.g.

Every child matters framework: wellbeing

4 reviews by National Institute for Clinical Excellence on wellbeing in schools – new one on early years underway

Early years review (ongoing with new govt)

Healthy schools framework – emotional wellbeing

Plus

Work in voluntary sector e.g. Place2Be, Pyramid Trust, Antidote,

Some imported programmes e.g. Paths, Second Step, EL in Middle Schools, Friends

Positive behaviour management

Mental health for

young people

in the UK

England: previous govt programmes e.g. Strong work on Personal, Social and Health

Education/ Enrichment/ Healthy schools SEAL: 2/3 of primary, 10% secondary and

growing Targeted approaches, some through SEAL,

recent DCSF £60mScotland: use frameworks and localised

approaches e.g. Overall “Curriculum for Excellence” Restorative practices, Being Cool in School,

Creating Confident KidsWales Local work on emotional Literacy and SEALNorthern Ireland Mainly through PSHE

Principles behind recent UK approaches to mental health in schools

Evidence based Emphasis on range of benefits including

links with learningTailored to local needsWhole school approach Supportive and balanced ethos and

environmentBalance universal, targeted, indicatedExplicit skill development: integrated into

teaching and learning and curriculumMonitoring and evaluationStaff development

Strong influence of international evidence that well designed programmes improve

Mental health problems - anxiety, depression, stress

BehaviourAttendanceExclusion – social and educationalCultural and racial understanding Teacher retention, performance

and moraleLearning

Summary of results of 207 SEL programmes in US:

11% improvement in achievement tests25% improvement in social and emotional skills10% decrease in classroom misbehaviour, anxiety

and depression (10% in each)

Social and emotional learning (SEL) and student benefitswww.casel.org/downloads/

EDC_CASELSELResearchBrief.pdf

Primary SEAL

Curriculum materials 7 themes, 5 levels Guidance, overview, curriculum

ideas, assembly, whole school opportunities

Evaluation by IoE of pilot very positive – measurable changes in behaviour, attendance, learning, test scores in numeracy and literacy

In 2/3 primary schools

Secondary SEAL Built on learning from SEAL

and others In 1/3 secondary schools Web based Strong whole school approach Guidance on evidence,

implementation, ethos, policy, leadership, links with parents and community, special needs

Learning materials for years 7- Positive evaluations of pilot and

by Ofsted (inspectors) Mixed results of RCT Positive results from schools

which followed guidance

National Institute for Clinical Exellence reviews concluded that universal base is vital

Less stigmatising Problems are widespread,

on a continuum, connected

Same processes which help everyone help those with problems – ‘more’ not ‘different’

Provides educated ‘critical mass’ of people to help those with problems

But also need targeted and early interventions

Targeting - start early and keep goingSome brief interventions

work with mild problems but most effective programmes take time

Involve parentsTarget the youngestAddress problems earlySpiral approachRevisit learningIntegrate with rest of school

Some demonstrably effective approaches

Long term programmes on social and emotional skills – reinforced in all interactions with children

Conflict resolution programmesPlay based approachesNurture groupsParenting skills Social skills and cognitive

behaviour therapy type mix

Targeted mental health in schoolsNational programme:

£60 million‘Pathfinders’Joined up workingMust link with SEALEvidence based approachNot yet evaluated

Key challenge – motivating staff What has this got to do with education? Overload“Too many initiatives” Cannot see the point (“our results are

good- why do we need it?) “Job of parents- not us” Too stressed Threatened, lack of skills, time, guilt Clarifying roles and expertise Need to involve all the SMT Lack of input into initial teacher education

Barriers to developing mental health in schools in the UK

Academic critics- ‘therapeutic education’ seen as harmful, creating dependency, threatening

Media scorn: silly, ‘nanny state’Target led nature of education,

especially secondaryNew government: focus on subjects,

back to basics, ‘peripheral issues’ will not be subject to inspection

Negative results of RCTs

Where next for the UK?

Use different language e.g. ‘resilience’ and ‘grit’ not emotional literacy

Emphasise links with learning

Involve private enterprise e.g. in early intervention

New areas e.g. mindfulness

Dataprev: mental health promotion in Europe

Role of the EUEU - strong role in public health. Mental health key areas for action, and

children and youth are one of the five priority areas

Sequence of meetings, conferences, research projects, documents to guide practice and policy

Evidence in EuropeNo strong tradition of evaluation- unlike USReviews have found that projects not

robustly designed or evaluated – mostly process evaluation, before and after, or case study

No networks to pull it together unlike CASEL and SAMSHA in the US

Some databases established but not systematic, or not in English (e.g. Dutch)

The Dataprev projectReviewing evidence base systematically in 4

key areas: parenting, schools, workplace, the elderly

Identifying good practice: database of effective approaches

Aim: assist policy-makers with guidance and training on transferability of specific approaches and programmes to different countries and cultures

Improving lines of communication between researchers and policy-makers.

Schools workpackage: identifying and obtaining reviews Systematic search of wide

range of databases, websitesDirect contacts with known

experts Reference list from known

reviewsAssessing for qualityPost 1990

Found49 systematic reviews10 evidence informed

Outcomes – 80+ terms under

Some key sources of evidence

US – widespread broad frameworks e.g. ‘character’, ‘social and emotional learning’, ‘mental health’. 20 positively evaluated programmes- some heavily promoted in the UK

Australia – widespread frameworks e.g. Health Promoting Schools, ‘Resilience’ – ‘Kidsmatter’ and some positively evaluated programmes e.g. ‘Friends’

Europe – Health Promoting Schools – other key initiatives not so important e.g. EU, anti-bullying in Scandanavia

Programmes found in Europe-

15 Large named US programmes that pass systematic review

7 smaller European programmes3 European programmes that not yet in

systematic review but which would be eligible

2 larger national programmes that currently being evaluated

Quality of the evidenceStrong group of programmes/ approachesClear impact on anxiety, stress, Some impact on depression, behaviour, crimeSome impact on +ve mental health and academic

learningFew adverse effectsEffects cannot be relied on even in country of

originMost that are robustly evaluated originate in the US

– few trials in EuropeA few programmes that are European in origin

Quality of the evidence: problems

Heterogeneity – comparison difficultNot many programmes have long term

evaluation“Poor” design – e.g. randomisation and

blinding almost impossible Systematic review methods not well suited

to multi-modal long term school interventions- may be missing some features

But on the whole the results of the reviews support the qualitative work

What appears to make implementation more effective

Consistent implementationWhole school - multiple modalities,

positive school ethos, integration Skills development – CBT/ social

skills, developmentally appropriate, integrated with general curriculum

Inclusion of parents, teachers, and peers – supported by training

Longer time frame

Tailoring balance

UK and Europe generally suspicious of scripted programmes.

Too much prescription – lack of ownership, engagement, depowerment.

Too much tailoring – dilution, confusion, hard to evaluate

Age, stage, lengthEarly interventions seem more effectiveBooster sessions usefulOne offs never found to work Short term can help with conduct disorders

and anxietyConduct disorders seem to need longer

interventionsFew programmes for 11+ age. Mostly

conduct disorder. Evidence base weak. No clarity about length of intervention.

Targeting Balance/ mutual support:UniversalTargetedIndicated

More impact on boys that girls

More impact on high risk than low (ceiling effect?)

Physical environment

CommunityParentsOutside agencies

ManagementLeadershipPoliciesStaff

School climate and ethos

Skill developmentCurriculum andMethodsPupil supportPupil involvement

Whole school approach: using

Who should deliver?Hard to be definitive as few

direct comparisons, Psychologists effective,

especially for short term and complex interventions

Teachers often used, long term input, sustainable, integrated. Need training, can be effective, although unreliable judges of students

Essential to involve parents as part of the team – parenting education effective

Peer learning/ mediation effective

Best when agencies work together

Appropriate targeting

Whole school approach- features that seem influential

ParentsPeersInvolved and trained

Staff development

Climate, ethos, values, attitudes

Curriculum andMethods- CBT and social skills-integrated

Curriculum Usually a key part of effective interventions

Whatever the issue, CBT/ social skills mix seems to help

For long term impact, needs integrating with wider curriculum and processes

Specific mental health issuesSelf esteem and depression harder to

influence than anxiety and conduct disorder

Conduct disorder – reasonably good evidence, long term approach needed, training teachers to be less negative and work with parents more effectively helps

Bullying/ conflict resolution – peer training essential

Universal suicide prevention unwise

Specific mental health issuesSelf esteem – tough to influence. Best

if focused onDepression – also tough. Associated

problems make it complicated. Long term, CBT/Social Skills indicated.

Anxiety, stress, coping – easier to influence with medium term interventions using mixed methods e.g. relaxation, CBT, meditation, body work

ADHD – no effective interventions found so far

Next steps for Dataprev

Finish final report (!)Database of effective

“approaches”Conference in the

Hague in February to share findings with policy makers