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

1. Implementing mental health promotion in schools in the UK and learning from Dataprev in Europe Professor Katherine Weare Professor Melanie Nind University of Southampton Skw @soton.ac.uk Intecamhs meeting Washington November 2010

2. 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

3. My role Background in Health Promoting Schools: Mental Health Wrote 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”.

4. 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

5. Current terminologies, paradigms, discourses emotional intelligence resilience prevention mental health Early intervention wellbeing social and emotional learning happiness emotional literacy

6. 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 Paradigm shift in understanding of the role of mental health and wellbeing in schools in Europe

7. Mental health for young people in the UK 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

8. 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 £60m Scotland: use frameworks and localised approaches e.g. • Overall “Curriculum for Excellence” • Restorative practices, Being Cool in School, Creating Confident Kids Wales • Local work on emotional Literacy and SEAL Northern Ireland • Mainly through PSHE

9. Principles behind recent UK approaches to mental health in schools Evidence based Emphasis on range of benefits including links with learning Tailored to local needs Whole school approach Supportive and balanced ethos and environment Balance universal, targeted, indicated Explicit skill development: integrated into teaching and learning and curriculum Monitoring and evaluation Staff development

10. Strong influence of international evidence that well designed programmes improve Mental health problems - anxiety, depression, stress Behaviour Attendance Exclusion – social and educational Cultural and racial understanding Teacher retention, performance and morale Learning

11. Summary of results of 207 SEL programmes in US: • 11% improvement in achievement tests • 25% improvement in social and emotional skills • 10% decrease in classroom misbehaviour, anxiety and depression (10% in each) Social and emotional learning (SEL) and student benefits www.casel.org/downloads/EDC_CASELSELResearchBrief.pdf

12. 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

13. 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

14. 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

15. Targeting - start early and keep going • Some brief interventions work with mild problems but most effective programmes take time • Involve parents • Target the youngest • Address problems early • Spiral approach • Revisit learning • Integrate with rest of school

16. Some demonstrably effective approaches • Long term programmes on social and emotional skills – reinforced in all interactions with children • Conflict resolution programmes • Play based approaches • Nurture groups • Parenting skills • Social skills and cognitive behaviour therapy type mix

17. Targeted mental health in schools • National programme: £60 million • ‘Pathfinders’ • Joined up working • Must link with SEAL • Evidence based approach • Not yet evaluated

18. 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

19. 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 secondary • New government: focus on subjects, back to basics, ‘peripheral issues’ will not be subject to inspection • Negative results of RCTs

20. 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

21. Dataprev: mental health promotion in Europe

22. Role of the EU • EU - 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

23. Evidence in Europe • No strong tradition of evaluation- unlike US • Reviews 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)

24. The Dataprev project • Reviewing 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.

25. Schools workpackage: identifying and obtaining reviews • Systematic search of wide range of databases, websites • Direct contacts with known experts • Reference list from known reviews • Assessing for quality • Post 1990 Found 49 systematic reviews 10 evidence informed

26. Outcomes – 80+ terms under overarching terms positive states skills problems

27. 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

28. Programmes found in Europe- • 15 Large named US programmes that pass systematic review • 7 smaller European programmes • 3 European programmes that not yet in systematic review but which would be eligible • 2 larger national programmes that currently being evaluated

29. Quality of the evidence • Strong group of programmes/ approaches • Clear impact on anxiety, stress, • Some impact on depression, behaviour, crime • Some impact on +ve mental health and academic learning • Few adverse effects • Effects cannot be relied on even in country of origin • Most that are robustly evaluated originate in the US – few trials in Europe • A few programmes that are European in origin

30. Quality of the evidence: problems • Heterogeneity – comparison difficult • Not 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

31. What appears to make implementation more effective • Consistent implementation • Whole 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

32. 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

33. Age, stage, length • Early interventions seem more effective • Booster sessions useful • One offs never found to work • Short term can help with conduct disorders and anxiety • Conduct disorders seem to need longer interventions • Few programmes for 11+ age. Mostly conduct disorder. Evidence base weak. No clarity about length of intervention.

34. Targeting Balance/ mutual support: • Universal • Targeted • Indicated • More impact on boys that girls • More impact on high risk than low (ceiling effect?)

35. Whole school approach: using Skill development Curriculum and Methods Pupil support Pupil involvement Management Leadership Policies Staff School climate and ethos Community Parents Outside agencies Physical environment

36. 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

37. Whole school approach- features that seem influential Staff development Curriculum and Methods- CBT and social skills- integrated Climate, ethos, values, attitudes Parents Peers Involved and trained Appropriate targeting

38. 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

39. Specific mental health issues • Self 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

40. Specific mental health issues • Self esteem – tough to influence. Best if focused on • Depression – 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

41. Next steps for Dataprev • Finish final report (!) • Database of effective “approaches” • Conference in the Hague in February to share findings with policy makers