Children and young people spend a great deal of time at school, so it has an important role to play in their development. Time spent in school impacts not just on academic and cognitive progress, but also on social interactions, peer relationships, emotional regulation and behaviour. All these areas affect, and are affected by, mental health (Fazel et al, 2014).

The prevalence of psychiatric disorders in school-age children is around 12%, though many children outside of this group will also have some level of psychological distress (Costello, 2005).  However, around three quarters of these children and young people get no mental healthcare at all (Paulus et al, 2016), so the school environment can be a valuable mechanism of providing support.

Mental health problems in childhood are linked to educational failure, which in turn is associated with increased rates of psychiatric disorder (Trzesniewski et al, 2006). The most common mental health problems in school-age children are conduct and anxiety disorders (Fazel 2014), though attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders can also cause significant difficulties, because children find hard to manage in the school environment (Fazel 2014).

The school environment itself can also cause emotional and behavioural problems in children and young people. For example, the impact from bullying can be significant and lead to significant long-term anxiety, depression, panic disorders and self-harm (Copeland et al, 2013) that often continues into adulthood. A 2010 UK survey found that almost half of all school-aged children had been bullied at some time (DCSF, 2010).

Schools can offer a unique environment from which to support children and young people, in developing good mental health and resilience, in preventing mental health problems and in supporting the effective treatment of existing conditions. In recent years there has been an increasing recognition in the value of school-based interventions for mental health and with it, growth in the number and variety of interventions on offer.

There are three main types of approach in UK schools:

1. This type of intervention takes a whole school or class approach (Costello at al, 2005), which focuses on wellbeing amongst all students. These include anti-bullying interventions, the development of emotional literacy and conflict resolution, as well as helping children and young people to understand their own thoughts and feelings and develop resilience. They may involve peers, for example, as mediators in conflict and usually involve parents too.
2. Targeted/selective. These interventions are aimed at groups whose risk of developing a mental health problems are significantly higher than average (Costello et al, 2005).
3. Indicated or intensive interventions. These target young people with symptoms of mental health problems (Costello et al, 2005). Other agencies, such as CAMHS or counselling services are likely to be involved. A key member of staff might work alongside another professional, such as a counsellor or a psychologist, to implement strategies that may help support a vulnerable young person (Fazel et al, 2014).

A targeted approach is usually the focus in the UK, with most of the support that schools give centred on children with learning disabilities and children with already identified or developing mental health problems (Patalay et al, 2017). Around half of schools also have programmes and approaches that focus on preventing mental health problems and pro-actively promoting well-being amongst students (Patalay et al, 2017).

In the UK, interventions are most likely to be to be directed at students rather than at parents or staff, and are most often delivered by learning or SEN support staff and school psychologists (Patalay et al, 2017). The most widely used types of provision are physical and creative activities, behaviour support, social and emotional skills development and anti-bullying programmes (Patalay et al, 2017).

There is an emerging evidence-base supporting mental health interventions for in schools, focused on several conditions and encompassing mental health wellbeing, prevention, early intervention and treatment. These include:

• Skills development for social and emotional literacy, such as the PATHS (Promoting Alternative Thinking Strategies) programme aimed at primary-age children and the Incredible Years programmes for children, parents, and teachers under 12 (Evidence for Impact, 2017)
• LifeSkills Training, an educational programme aimed at preventing substance misuse and violence (Evidence for Impact, 2017)
• Cognitive Behavioural Therapy (CBT) for anxiety (Kavanagh et al, 2009; Stallard et al, 2013)
• Counselling services, such as for mild depression (Cooper, 2013)
• Bullying prevention, such as Steps to Respect, Olweus and Kiva (Clarke et al, 2015)

Implementation

Universal intervention programmes can be challenging to deliver. To keep them going in the long-term, school engagement and commitment is essential, and therefore programmes usually work better if offered by teachers (Fazel et al, 2014; Pearson et al, 2015).

Teachers can sometimes help to identify mental health problems in their students and refer them to appropriate sources of external support.  There is some evidence however, to suggest that teachers are not always ideally placed to help pick up problems (e.g. detection of emotional disorders or gender bias in ADHD). Of course teachers are primarily there to teach and to generate academic success among their students, but given the right support, training and sufficient time they can work alongside mental health specialists to support mental health and well-being in their students (Fazel et al, 2014).

Prevention and mental health promotion programmes and activities can be effectively implemented by teachers and can have a significant impact on psychosocial and academic performance. The current pressure on schools and poor recruitment of teachers has resulted in many schools not having the dedicated time, training and ongoing support to carry out this work. It’s also worth noting that some preventative interventions may be less effective when delivered by teachers than when health-led (Stallard et al, 2014).

Interventions

School based interventions are well established and effective treatments for improving the mental health of children and young people (Paulus et al, 2016). However, it can be difficult to transfer interventions from the research clinic into the real world and the school environment, because following a programme manual may not meet the individual needs of either students or teachers (Paulus et al, 2016). In the clinic, deviating from the manual is associated with poorer outcomes, but this is often driven by the assumption that the manual is not quite right. Adaptation with fidelity is an important issue that needs further study.

School based interventions are most effective if they are completely and accurately implemented (Weare & Nind, 2011). In statistical terms, the effect of most interventions is small to moderate, but when applied in real world settings the effects are much larger (Weare & Nind, 2011). The characteristics of the most effective interventions include:

• focusing on positive mental health
• delivering a mix of universal and targeted approaches
• starting early with the youngest children
• long term interventions which embed within the whole school’s approach, including changes to the curriculum and teaching skills, and linking with academic learning,
• working with and educating parents
• community involvement and coordinated work with outside agencies
  (Weare and Nind, 2011).

There are academic benefits of mental health promotion in schools. Schools with social and emotional learning programmes show an increase in scores in standardised tests, compared with scores from non-intervention schools (Durlak et al, 2011).

Social and emotional development

Mastering social and emotional skills supports children to achieve positive life outcomes, including good health and social wellbeing, educational attainment and employment (Clarke et al, 2015). It also helps to reduce or avoid behavioural and social difficulties (Clarke et al, 2015).

There is good evidence for the potential benefits of school-based strategies that are designed to develop a child or young person’s social and emotional learning. This includes strategies to develop skills and positive personal attributes, as well as those that aim to reduce behavioural and emotional difficulties (Banerjee et al, 2016).

NICE recommends that for primary aged children, there should be a comprehensive programme in place in schools to help them develop social and emotional skills and wellbeing. This should include (NICE, 2008):

• A curriculum that integrates the development of social and emotional skills, (such as problem solving, coping and conflict resolution) within all subject areas.
• Training and development for teachers and practitioners, including how to manage behaviours and build successful relationships.
• Support to help parents or carers develop their parenting skills.
• Integrated activities to support the development of social and emotional skills and wellbeing and to prevent bullying and violence in all areas of school life.

NICE also recommends that children in primary education (aged 4–11 years), who are showing early signs of emotional and social difficulties, should be considered for the following interventions (NICE, 2008):

• problem-focused group sessions delivered by specialists, such as educational psychologists or those working in child and adolescent mental health services (at tiers one and two)
• group parenting sessions for the parents or carers of these children, run in parallel with the children’s sessions.

Anxiety and depression

Several studies have shown that anxiety prevention programmes, provided as universal or indicated interventions, can be effective in the short term, when compared to no intervention groups (Stallard et al, 2013).

School-based prevention programmes have a small beneficial effect on depressive symptoms, and with preventative work, even small effect sizes can be associated with meaningful improvements at a population level (Werner-Seidler et al, 2017). However, many school-based trials often do not include diagnostic outcomes, so understanding the full impact of these programmes can be challenging. Indeed, there is evidence that some young people at risk of common mental health disorders do worse as a result of prevention programmes (Stallard, 2013). Targeted programmes, such as cognitive behavioural therapy (CBT), undertaken with those students already showing signs of depression, may be most effective in reducing depressive symptoms (Kavanagh et al, 2009).

Non-directive supportive therapy is a NICE-recommended intervention for mild depression. There is also emerging evidence to suggest that school-based humanistic counselling is effective at reducing psychological distress and helping young people achieve their personal goals (Cooper 2013). School-based counselling is seen by service users and school staff as having a positive impact and as an effective means of bringing about improvements in mental health and emotional wellbeing (Cooper 2013).

Overall it is imperative that those with clear mental health conditions are not delayed in reaching evidence-based interventions, which adds further weight to the argument that training and support is essential for frontline staff, so that young people can be referred as appropriate.

Other conditions

The evidence for whether school interventions improve ADHD symptoms or academic outcomes is mixed (Richardson et al, 2015). This includes approaches such as contingency management, cognitive-behavioural self-regulation, academic and study skills training, social and emotional skills training. Interventions should be tailored to individual children, classrooms and schools (Richardson et al, 2015).

Generally speaking, there are many positive effects of school based interventions. However, there is also a large variation in the efficacy and efficiency of different programmes, depending on the quality of the intervention and its implementation (Paulus et al, 2016). Therefore, we don’t know exactly what works best, in which groups and why.

We don’t know what interventions work best in the long term, and there is very little evidence to show how programmes compare with each other in term of the effectiveness (Stallard 2013). For example, we don’t know whether universal or targeted prevention programmes work better for conditions such as depression (Werner-Seidler et al, 2017).

It’s also unclear how much of the impact of school based interventions is down to the programmes themselves, and how much is influence from other factors such as the child’s age, gender or ethnicity (Stallard 2013). Prevention programmes need to fit well with each school’s culture too, and how they fit practically within a complex school timetable have been identified as a major obstacle that can affect delivery (Stallard et al, 2013).

Studies show that evidence-based treatments can be delivered in school settings, group models tend to be effective, and that engagement and participation rates tend to be high (Fazel et al, 2014). However, few rigorous assessments have been done of school-based interventions for students with disabilities or for specific disorders, including eating disorders or complex neurodevelopmental disorders (McMillan and Jarvis, 2013).

Children and young people may present to services such as counselling with a wide range of problems, including family difficulties. There is very little evidence about how these kinds of issues, which clearly impact on mental health and well-being, should be approached (Cooper 2013). Further research is needed in this area, alongside better outcomes data captured by practitioners. It’s not clear exactly how school-based counselling is helping young people, as well as whom it may be most suited to help (Cooper 2013). Evidence of the long-term impact of counselling is also sparse (Cooper 2013).

There are already many online mental health intervention programmes, some supported by and delivered in schools. The evidence base for these approaches is mixed. For example, computerised cognitive behavioural therapy for depression and anxiety in young people has been shown to be beneficial (Hollis et al, 2017). However, the evidence base for computer based interventions for other conditions, such as attention deficit/hyperactivity disorder (ADHD) and autism remains unclear (Hollis et al, 2017). However, what is certain is that with the rise in the popularity of the Internet and social media these kinds of programme will continue to grow and develop. The National Institute of Mental Health in the US predicts that in future, mobile technology will be used for managing a wider range of disorders, and will begin to incorporate face-to-face contact or remote counselling (NIMH, 2017).

There has been huge interest in the practice of mindfulness and how it might be adopted by schools to help improve psychological wellbeing and attention among children and young people. Currently evidence for its impact is limited. However, the first large randomised controlled trial of mindfulness training compared with ‘teaching as usual’ is underway (University of Oxford, 2015). It will take five years and involve 76 schools and nearly six thousand students aged 11 to 14.

As always, we must remember not to rush into implementing new approaches when we do not yet have sufficient evidence of their efficacy and safety. Doing something is not necessarily better than doing nothing, as many interventions that are effective for some young people, may actually be harmful to others.

Useful resources and websites

Evidence for Impact
A database of programmes available in the UK, including details on their effectiveness and cost, produced by The Institute for Effective Education.
www.evidence4impact.org.uk

MindEd
Free educational resource on children and young people’s mental health for all adults.
https://www.minded.org.uk/

Youthinmind
For stressed teenagers and those who care for them.
http://youthinmind.info/

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