Mental health difficulties and students with special ... Conference... · Mental health...

Mental health difficulties and students with special educational needs and disabilities: what

does the research tell us?

Professor Neil HumphreyManchester Institute of [email protected]

@neilhumphreyUoM

mailto:[email protected]

Manchester (the place, not your linen!)

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“Manchester is a city that thinks a table is for dancing on” (Mark Radcliffe)

Special educational and additional needs research at the University of Manchester

• Focus on developing, understanding, applying and evaluating approaches that aim to support vulnerable learners in schools and other contexts

• Local, national and international studies• Four distinct but related strands of research activity

– Applied Prevention in Education (APE)– Special Educational Needs and Disabilities (SEND)– Educational and Counselling Psychology (ECP)– Knowledge, Power and Identity (KPI)

• Some recent projects– A study of the experiences of students with SEND at post-primary school (Squires)– Achievement for All: national evaluation (Humphrey & Squires)– A study of the impact and experiences of primary-secondary school transition for children

with autism (Hebron)– Educating persons with autism: a systematic literature review with country case studies

(Bond et al)• More information available at

http://www.seed.manchester.ac.uk/subjects/education/research/sean/

http://www.seed.manchester.ac.uk/subjects/education/research/sean/

Overview• What do we mean by mental health

difficulties?• Is there evidence of increased prevalence

of mental health difficulties among students with special educational needs and disabilities? If so, why?

• How can we improve provision in schools to better support the mental health needs of students with SEND?

What do we mean by mental health difficulties?

SHEA et al (2000). Pathology in the Hundred Acre Wood. CMAJ, 163, 1557-1559


• Case vignettes (from Vostanis, Humphrey et al, 2013)• Child A – a ‘disruptive’ child

– Imagine a disruptive pupil who is abusive to teachers and other adults, who often fights with other children or bullies them, lies and is generally aggressive and difficult to manage. This has been going on for over half a term. Teachers have tried to talk to this pupil, but it doesn’t seem to have helped. The child’s parents have also been contacted but are unsure what to do.

• Child B – an ‘unhappy’ child– Imagine a pupil who is unhappy, appears to be quite isolated from other

children and often seems quite low in confidence and mood. They are very clingy and fearful in new situations, and can become tearful and appear worried. This has been going on for over half a term. Teachers have tried to talk to this pupil, but this does not seem to have helped. The child’s parents have also been contacted but are unsure what to do.


• Mental health difficulties may be defined as changes in thinking, mood and/or behaviourthat impair functioning (Murphey, Barry & Vaughn, 2013)

• Up to 20% of children and young people experience clinically significant mental health problems

– 50% of adult cases originate in childhood or adolescence (Belfer, 2008)• The individual and societal impact of mental health problems are huge, and include

reduced quality of life, lost economic productivity and higher rates of health, education and social care utilisation (Belfer, 2008)

• In financial terms the cost is around £105 billion annually in England (Centre for Mental Health, 2010)

– In Australia, $7.6 billion was spent on mental health-related services in 2012/13 (AIHW, 2014)

• By 2030, depression alone will yield the highest disease burden in high-income countries, accounting for nearly 10% of disability-adjusted-life-years (Mathers & Loncar, 2006)

• Distinction between ‘mental health difficulties’ and ‘wellbeing’– Complex relationship, different causal determinants and mediating factors (Kinderman

et al, 2015)• Dropping the language of disorder? (Kinderman, 2013)


• Mental health difficulties in childhood and adolescence are not distributed evenly. Anumber of key individual and social determinants (left) can operate as risk or protective factors (from Patel et al, 2007) that influence the likelihood and magnitude of difficulties experienced

Is there evidence of increased prevalence of mental health difficulties among students with SEND?

• In England, “A child or young person has SEN if they have a learning difficulty or disability which calls for special educational provision to be made for him or her. A child of compulsory school age or a young person has a learning difficulty or disability if he or she (i) has a significantly greater difficulty in learning than the majority of others of the same age, or has a disability which prevents or hinders him or her from making use of facilities of a kind generally provided for others of the same age in mainstream schools or mainstream post-16 institutions” (DFE/DOH, 2015, p.15-16)


• Broad areas of need: communication and interaction (e.g. autism), cognition and learning (e.g. dyslexia), social, emotional and mental health difficulties (e.g. ADHD), sensory and/or physical needs (e.g. hearing impairment)

– 15.4% of students in England; prevalence decreasing since 2010 (21.1%) (DFE, 2015)– 2.8% of students in England have a statement of SEND or an Education, Health and Care

Plan; stable over last decade (DFE, 2015)– Emphasis on service integration (education, health and care plan), parental choice and

control (e.g. personal budgets), and the ‘local offer’ in new code of practice• Conflation of behaviour, emotional and social difficulties (BESD) with mental health to

produce social, emotional and mental health (SEMH) in the new code of practice = mental health difficulties as a type of SEND?

– 17.8% of all children receiving SEN support (without statement or EHC plan)– 12.7% of all children with SEN statement or EHC plan– Hackett et al (2010) – over 80% of students attending BESD schools show clinically

significant symptoms of mental health difficulties– Significant definitional challenges! (Armstrong, 2014)

• Conflation of mental health with SEND elsewhere in the literature, e.g. autism included in national survey of mental health difficulties among children and young people (Green et al, 2005)


• Green et al (2005). Mental health of children and young people in Great Britain. Newport, ONS.

– National survey of over 10,000 parents; mental health data sourced using ICD-10 criteria, focus on emotional symptoms (e.g. anxiety, depression), conduct problems and inattention/hyperactivity

– Children with emotional disorders twice as likely as other children to have SEND (35% vs16%)

– Over half (52%) of children with conduct disorders considered by their teacher to have SEND– Children with inattention/hyperactivity disorders more than four times as likely as other

children to have SEND (71% vs 16%)• Dix et al’s (2010, 2013) Kidsmatter data for South Australian cohort (N=3700+)


• Humphrey et al (in progress) PATHS to Success trial– c.5,000 children aged 7-9; mental health data sourced using teacher Strengths and

Difficulties Questionnaire (SDQ; Goodman, 1997), focus on emotional symptoms, conduct problems, inattention/hyperactivity and peer problems

– Data enables us to distinguish between different types of primary need; enables us to filter out BESD/SEMH

– Magnitude of difference considerable across all variables (e.g. effect size of 0.97 for SEND vs no SEND comparison for hyperactivity; greatly increased odds-ratio (x3.5) for scoring in the clinical range for conduct problems)


• Hebron & Humphrey (2014)– Comparison of 65 adolescent students

with autism, other SEND (dyslexia) and no identified SEND

– Mental health data sourced using Beck Youth Inventories (Beck et al, 2005), focus on self-concept, anxiety, depression, anger and disruptive behaviour

– Students with autism report significantly greater anxiety, depression, anger and lower self-concept than their peers with no SEND, and significantly greater anxiety and anger than their peers with dyslexia

– Magnitude of difference is considerable in some cases (e.g. effect size of 1.36 for ASD vs no SEND comparison for anxiety; greatly increased (x6) odds ratio for scoring in the clinical range for depression)


• Hebron & Humphrey (2014)– Interviews with five of the students from the autism group


• Problems in acquiring social and emotional competencies that promote resilience to onset of difficulties? (Dix et al, 2013)

• Students with SEND are more likely to be victims of bullying than their peers without SEND (Fink, Deighton, Humphrey & Wolpert, 2015)

• They are also more likely to experience lower peer acceptance, and have fewer friendships/friendship groups (Frostrad & Pijl, 2007; Pijl, Frostrad & Flem, 2008)

• Exclusion and SEND (DFE, 2013); x8 more likely overall, accounting for about two-thirds of all exclusions; pupils receiving SEN support (without statement or EHC plan) most likely to be excluded (x11)


• Inter-relationship between academic attainment and mental health over time (Wigelsworth, Qualter & Humphrey, in press) –instruction not tailored to learning needs?

• Teachers feel ill-prepared to address complex needs, misattribution of causes of behaviour(Rose et al, 2009)

• Educator perceptions of children with social, emotional and behavioural difficulties (Armstrong, 2014; Armstrong & Hallett, 2012), e.g. labelling and pathologising discourse?

• Family stress and wellbeing (Sen & Yurtsever, 2007)

• Education and health-related policy – e.g. major cuts to child and adolescent mental

health services in England since 2010

How can we improve provision in schools to better support the mental health needs of students with SEND?

• Consideration of Patel’s (2007) protective factors (left)

• Causal and mediating factors for mental ill health and subjective wellbeing (e.g. social isolation feeds low subjective wellbeing) (Kinderman et al, 2015)

• Avoidance of zero-sum-game approach to academic attainment and wellbeing in education policy (Bonnell et al, 2014)

• Avoidance of the ‘programmefor very problem’ approach; need for an integrated model of provision (Domitrovich et al, 2010)

• Focus on systemic change as opposed to fixing a problem within the child


• A case study of an integrated model of provision• Achievement for All national pilot (DFE, 2009)

– £31m funding (2009-2011)– 10 Local Authorities across England– 450+ schools, c. 11,000 students with SEND

• 3 inter-related strands – Assessment, tracking and intervention– Structured conversations with parents– Provision for developing wider outcomes

• Support systems for schools– Regional advisors– LA AfA project leaders– LA AfA advisory teachers– Launch and update conferences– Training in key aspects of the pilot, e.g. structured

conversations with parents


• Strand 1: Assessment, Tracking and Intervention– Use of Assessing Pupil Progress (APP) system to track pupils’ progress– Setting of curriculum targets– Implementation of appropriate interventions to support children and young people to make

progress in their learning– Built upon previous pilot called Making good Progress; further training for schools and LAs

was provided in relation to use of Progression Guidance– Some LAs started to make use of (or built upon existing systems for) Information

Management Systems (such as Assessment Manager)

• Strand 2: Structured Conversations with Parents– Use of a clear framework for developing an open, ongoing dialogue with parents about their

children’s learning– Training provided for ‘key teachers’ (e.g. class teacher in primary school) in the appropriate

conduct of a structured conversation using a four stage model• Explore (e.g. active listening)• Focus (e.g. identifying priorities)• Plan (e.g. agreeing targets)• Review (e.g. clarify next steps)

– Up to 3 structured conversations per year with parents of children with SEND (one per school term)


• Strand 3: Provision for Developing Wider Outcomes– Development of whole school strategies and key actions to support children and young

people with SEND to make progress in any two of the following areas:• Attendance• Behaviour• Bullying• Positive relationships• Wider participation

– High degree of flexibility – although suggested activities were available, there was an emphasis on tailoring implementation to meet local needs

– Schools given the freedom to explore new and innovative approaches to improve wider outcomes

• National evaluation (Barlow et al, 2015; Humphrey et al, 2013; Humphrey & Squires, 2010, 2011a, 2011b; Lendrum, Barlow & Humphrey, 2015)

– Focus on impact of AfA on a range of student outcomes (RQ1), in addition to the processes and practices that were most effective in improving these outcomes (RQ2)

– Quantitative component (mainly RQ1): Teacher surveys, parent surveys, attendance and attainment data, school level surveys, contextual data

– Qualitative component (mainly RQ2): Interviews with local/regional lead staff, school case studies, student case profiles, ad-hoc qualitative data


• Significant impact of AfA on behaviour difficulties (d=0.26, 10% decrease), positive relationships (d=0.17, 7% increase) and bullying (d=0.28, 11% decrease) among students with SEND


• “In many ways what AfA has done is fitted in to best practice in the school” (Head Teacher, School 9, LA E)

• “To think outside the box and do things outside the norm because… it gives license and financial support to do it which is fantastic” (AfA Lead, School 16, LA H)

• “[We feel] more included in the whole picture” (Parent, School 18, LA I)• “We felt that if we developed the positive relationship side and children feeling

confident with each other... That might then help them with dealing with things in the playground and their perception of being bullied” (AfA Lead, School 18, LA I)

• “The heart of AfA is putting responsibility [for children with SEND] back with the class teacher” (AfA Lead, School 1, LA A)

• “Support from my friends [has helped me to improve my behaviour]” (Year 5 Pupil, School 1, LA A)

• “That [drawing and talking therapy] has had an impact on her academic work because, in herself she is so much happier and has worked through some things” (Key Teacher, School 15, LA H)

• “Back in Year 4 her attendance was really bad. She didnt want to come to school, sometimes she’d come to school crying... And this year, they seemed to be concentrating on her confidence, vuilding that and not forcing her to do anything, and its made a real difference” (Parent, School 15, LA H)

Conclusion• There is clear evidence of increased prevalence of

mental health difficulties among students with SEND• This increased prevalence is still evident even after

accounting for children and young people identified as having BESD/SEMH

• A range of factors are likely to contribute to this increased prevalence; children’s experience of school is the ‘common denominator’ that unites them

• Provision in school for children with SEND can be changed to better support their mental health needs– An integrated model of provision, such as AfA, is likely to be

more effective and sustainable than the traditional ‘programmefor every problem’ approach

Thanks for listening!

“It is easier to build strong children than to repair broken men”(Frederick Douglass)

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