Summary: What Good looks like in Psychological services for Schools and Colleges. Primary prevention, early intervention and mental health provision .

The Child and Family Clinical Psychology Review No. 5 Autumn 2017

What Good looks like in Psychological services for Schools and Colleges. Primary prevention, early intervention and mental health provision .

Summary

Lucinda Powell

Chapter 1: Schools and Mental Health

The first chapter discusses what part schools can play in improving the mental health of children and young people (CYP), the rationale for moving some psychological services into schools and as well as the possible barriers to its success. The role of applied psychologists and psychological services is also considered.

Primary and early intervention

Schools are an obvious place to site mental health services.  School is the biggest influence on CYP and there is strong evidence that applied psychology is effective in schools.  There is a great opportunity to promote resilience and wellbeing and minimise adversity in school.  Teachers are also in a position to identify mental health concerns early and work with psychological staff to facilitate early interventions.

PSHE should be part of this early intervention with high quality, evidence based life skills being taught regularly as part of the curriculum.  As schools are places of learning it is logical to base wellbeing education within the context of school.  It also known that educational attainment and mental health are closely related.

Mental Health Provision

Schools are complex social places and CYP with psychological difficulties affect everyone around them in and out of lessons.  For many their school experience can make their difficulties worse. Schools vary in the amount and effectiveness of the provision to combat some of the issues such as anti-bullying campaigns, peer-mentoring scheme etc.  To develop schools into environments that can support the psychological wellbeing of children and young people; they need to be able to access and incorporate more specialist knowledge into their organisations.

• At the moment there are a number of barriers to provision such as this.  To overcome these, a number of recommendations are made:
• Schools need more funding;
• Schools need support in commission appropriate mental health support as they lack the expertise to do this well;
• The quality of Mental health support needs to be consistent (specialists need to have appropriate levels of training guaranteed);
• Ofsted Inspectors need to make schools accountable by routinely checking mental health provision.

Where there is counselling and school nurses it is often child focussed and does not involve the family of the environment of the CYP, and does not form part of the clinical pathways operating in the local area mental health provision.

CAMHS services should be more closely with schools will remove barriers to service access such as missing school, travel difficulties, work commitments etc.  This will increase choice for CYP about where they are seen.  It is important to recognise that this may not be appropriate for all and choice needs to be given to CYP and families about where they can gain psychological support.

Currently provision is provided by many different sectors (local authority, charities, NHS etc.) but it is fragmented and in equitable.  Pilots in 2015 linking services did seem to have some success in strengthening communication between schools and NHS CAMHS.

Applied psychologists and psychological services

Education and clinical psychologists have high levels of training and are able to make high quality assessments that are holisitic and systemic in approach.  By working with a CYP’s wider support network the CYPs often do not need specialist intervention.  This can be done by Applied and Educational Psychologists:

• ·        Training school staff and helping the school to develop a supportive environment alongside ongoing systems of consultations and advice with staff;
• ·        Some schools have developed multidisciplinary Psychological services which allows for greater scope and capacity to create change;
• ·         Developing systems to support and advise families and other carers through the school;
• ·         Harnessing the potential of young people themselves can make a real difference.

Models of mental health provision which ‘front-load’ specialist expertise early in the clinical pathways have a potential to make a significant impact on the well-being of children and young people and reduce pressure on CAMHS provision.

Chapter 2: Mental health, psychological wellbeing and resilience

Chapter 2 reviews the demographics and mental health conditions in children and young people and considers the importance of addressing risk factors and building resilience.

Mental Health issues amongst CYP are seemingly on the increase.  These are linked to poor life outcome and there is a need to reduce them at the earliest possible point.  However children in can have very different responses to same school environment.  The interplay between risk and protective factors across the different areas of a CYP’s life can shape outcomes for individual children.  Features of a school that can have positive outcomes for CYP are well managed classrooms and a strong attachment bond with a teacher. There are unique risk factors in schools as well such as bullying and exam pressure.

Resilience is an ongoing and interactive process between a child and the risk and protective factors in its environment.  The suggestion is that resilience should be promoted at the level of institutions or social systems.  It is often the case that problems at school go together with problems at home, and when there are multiple sources of adversity the effect can be cumulative.  The corollary is that if improvements can be made in one area of a CYPs life then the positive effect with felt in other areas of their life.

The aim should be to improve the wellbeing of families and young people through helping their communities function more effectively, therefore reducing the demand on specialist services.

Key things that schools can do to improve wellbeing of students:

• ·         Poverty and Social inequality: schools should offer opportunity to enrich the lives of children growing up in poverty, enabling them to access opportunities and experiences.
• ·         Adverse Childhood Events (ACEs): people working with CYP need to be able to recognise the warning signs and ensure safeguarding is in place.
• ·         Social Isolation and bullying: identify and intervene with bullying; opportunities to develop CYP’s social world through youth and play schemes etc. outside of school hours; sporting opportunities need to be more inclusive.
• ·         Bereavement and Loss: need to train teachers to understand what normal distress is and what is likely to help and when more specialist help may be needed.
• ·         Neurodevelopmental and learning difficulties: schools need support in recognising where emerging difficulties indicate the need for specialist provision and work with parents and carers to achieve this.
• ·         Chronic and serious physical problems and physical disability: Schools need to have access to advice from the specialist working with the child both in hospital and the community to understand the physical and psychological nature of the problems and the steps which need to be taken to support them in school.

Chapter 3: Key elements of psychological approaches in schools

Chapter 3 considers the key elements in the provision of a good psychological service in school settings.

Evidence based practice is advocated in schools.  Applied psychologists should use their knowledge and experience to tailor any intervention for the CYP, parent or school. Locating applied psychological services for children, young people and families in schools offers a unique opportunity to offer specialist, interconnected interventions at a universal and a targeted level and both directly (to CYP and parents/ carers) and indirectly (to school staff). Staff training and support needs to be targeted at the whole school population enabling them to recognise possible problems and refer on.

Psychological assessment in school can be essential.  Assessment should use a variety of measures such as questionnaires, observations and clinical interviews.  It should also be multi-informant - gaining views of parents, teachers etc. as well as the CYP.

Formulation and intervention: any intervention needs to be shared across the CYP’s social contexts. Communication the formulation to CYP, parents, schools and networks can empower all the key people to effect change.  Evaluation and monitoring of progress can also be carried out by applied psychologists. They should use a variety of validated questionnaire measures as well as wider indicators such as school attendance.

All good psychological services should work to hear the voices of children, young people and parents/carers, to understand what works well and what works less well and change it. There are varying degrees of participation from being informed, through adults initiating but sharing decisions, to children and young people and adults initiating and sharing decisions together. Overall, authentic participation is participation that impacts every aspect of service delivery and supporting those it sees to go from passive recipients to active contributors to service design and delivery. Most schools already have arrangements like School Councils and these can be built upon in developing new psychological services.

Chapter 4: Models and examples of psychological approaches in schools

The final chapter considers the practical ways that psychological services can be organised in schools and the ways they can contribute at universal, selective and integrated levels of provision.

All schools should adopt a whole school approach to mental health.  Schools should work actively with parents and carers, this will improve identification of risk factors and enable resources to be allocated effectively (the right treatment/interventions are essential as psychological therapies can do harm to some people). 

As many as 70% of young people do not access help early enough so early intervention is key as it will reduce the need for expensive interventions later on.  However, there needs to be further research into school-based prevention programmes, especially long-term evaluation.  There are indications that, for depression, interventions delivered by external professionals outperform those by school staff.  The impact of such programmes on wider measures such as school attendance, behaviour and educational attainment also needs to be established.

Intervening at different levels: Universal Provision

Universal provision aims to maximise the social and emotional wellbeing of everyone in the school, it needs is less stigmatised, and usually does not require specialist skills or training, but may have small effects. 

Staff Training and consultation

This would involve staff support and training targeting the whole school population.  Teachers and school staff are well placed to promote preventative measures, early intervention and self-help skills for young people, and are often the first to be consulted regarding concerns about a CYP’s psychological functioning.

However, teacher’s knowledge of mental health is low and therefore they do not have the confidence to respond to mental health difficulties, they do not see it as part of their role and there are practical and organisational barriers that prevent them from engaging.  There is evidence that teacher training on mental health awareness can produce improvements in knowledge and confidence in responding to young people’s needs. However, it is unclear whether training of this type leads to sustained behaviour change in teachers or improved outcomes for young people themselves.

Three key factors determine whether training ‘works’:

• 1.       ‘Learner’ characteristics: is training relevant and accessible to the target audience?
• 2.       Training design: does the training content fit learners’ needs and is it delivered well?
• 3.       Workplace/organisational factors: is there opportunity, commitment and support within the workplace to implement the training and to change practice?

Evidence on the transfer of training into practice also shows that using reflective practice models such as consultation and peer/ group supervision can greatly enhance the effectiveness and implementation of new learning.  Training must not be stand-alone but should involve follow up.  Effective training works best when based on assessment of need within the school and integrated into a whole school approach.  The role of teachers should be recognised as being part of the wider multidisciplinary care pathways not as a replacement for them.

Direct Universal Provision

This suggests screening whole cohorts then targeting universal themes on which to base group PSHE/mental health education.  May also identify CYP at risk of developing mental health difficulties and may need targeted intervention.  Interventions based on these screens could include:

• ·         Specific evidence based therapeutic approaches may be delivered to a whole group such as mindfulness-based approaches or specific topics such as anti-bullying.  May signpost where to get targeted help too.
• ·         Workshops and training may be offered to parents on a variety of topics such as managing exam stress, sleep difficulties.
• ·         Pre-referral ‘drop in’ session for parents to discuss worries about their children and help facilitate early identification.

Working with other agencies

Most efficient and effective provision will be in conjunction with networks of other local provision including:

• ·         School health or community child health services
• ·         CAMHS
• ·         Social Care
• ·         Youth and voluntary sector providers.

Intervening at different levels: Selective and indicated provision

Selective intervention target pupils at greater risk of developing a psychological problem because of known factors, they aim to prevent problems occurring. They differ by targeting resources more precisely at pupils who may need help, although this approach requires additional resources and expertise to identify pupils at risk, and can be more complex to deliver.  Indicated interventions are those offered to pupils who already show some signs of a psychological problem. They aim either to prevent the escalation of symptoms to a clinical level (prevention), or to ameliorate an existing clinical problem (treatment). This targeted support is often carried out by non-teaching professionals including applied psychologists, school nurses, community paediatricians, etc.

Indirect Provision

This aims to improve early identification of mental health difficulties and increases the ‘reach’ of psychological and mental health services, to benefit a greater number of pupils. It can include:

• ·         Attendance at school Pastoral Care or Team Around the School (TAS) meetings.
• ·          Sharing the formulation and understanding of a child’s difficulties and recommendations with those best placed to intervene in a positive way on a day to-day basis.
• ·         Signposting to CAMHS and other services for children and families with identified difficulties and acting as a ‘bridge’ between Health and Education services.
• ·         Regular consultation to, or supervision of, school staff focusing on students or groups of students who are of concern to staff.
• ·         Contributing to Education, Health and Care (EHC) plans. 

Direct Provision

Psychological assessments and interventions with children, young people, parents/carers and family work in schools can include:

• ·         Screening and assessment of developmental and neurodevelopmental conditions where observation of the child or young person within the school context forms a key part of the assessment.
• ·         Early assessment and treatment of school-based difficulties where there is a social, emotional and/ or behavioural component, where intervening in school is clinically relevant and evidence-based.
• ·         Assessment and ongoing therapy for an often complex population that has been or would be unable to access traditional clinic-based service. 
• ·         Preventative work for CYP likely to struggle with an educational transition.
• ·         Evidence-based group work for specific difficulties or diagnoses, such as CBT for anxiety.
• ·         Targeted parenting groups located in schools.

Working with schools as communities

Using an evidence base of Community Psychology, the aim would be to develop support systems within schools that help to build resilience at a wider social level (drawing in whole families).  The focus is on transforming social conditions and context will enable better mental health and wellbeing.  It is important to use a partnership approach, mapping and harnessing resources and strengths within a community and valuing others way of knowing.

The other significant issue that needs to be addressed is the wellbeing of school staff.  There is a large body of evidence to indicate significant problems with excessive workloads and high levels of concern that teachers have about the impacts of their job on their mental and physical health.

A community approach would consider the psychological wellbeing of staff, students, families and the local community together. All would be equal partners in developing a school strategy, supported by more specialist staff.

Harnessing the energy, creativity and ideas of the young people in particular can lead to very positive change that would not be achieved in more conventional models.

Thrive framework

Another relatively recent development in the conceptualisation of children’s mental health services is the THRIVE Framework.

The THRIVE framework below conceptualises five needs-based groupings for young people with mental health issues and their families. Each of the five groupings is distinct in terms of the:

• 1      needs and/or choices of the individuals within each group;
• 2.      skill mix required to meet these needs;
• 3.       dominant metaphor used to describe needs (wellbeing, ill health, support);
• 4.       resources required to meet the needs and/or choices of people in that group.

This approach is potentially attractive to policymakers, and may prove to be influential in the design of services in future because it describes services in a less rigid way, and might create new opportunities to overcome traditional barriers between service providers.