Mental health provision in schools: approaches and interventions in 10 European countries

"We want it to be a culture": children and young people's perceptions of what underpins and undermines education-based wellbeing provision

BACKGROUND

Provision that aims to promote the social, emotional, and mental wellbeing of children and young people (including their mental health) is increasingly implemented in education settings. As researchers, policymakers, and practitioners explore the complexities of promotion and prevention provision in practice, it is critical that we include and amplify children and young people's perspectives. In the current study, we explore children and young people's perceptions of the values, conditions, and foundations that underpin effective social, emotional, and mental wellbeing provision.

METHODS

We engaged in remote focus groups with 49 children and young people aged 6-17 years across diverse settings and backgrounds, using a storybook in which participants constructed wellbeing provision for a fictional setting.

ANALYSIS

Using reflexive thematic analysis, we constructed six main themes presenting participants' perceptions: (1) recognising and facilitating the setting as a caring social community; (2) enabling wellbeing to be a central setting priority; (3) facilitating strong relationships with staff who understand and care about wellbeing; (4) engaging children and young people as active partners; (5) adapting to collective and individual needs; and (6) being discreet and sensitive to vulnerability.

CONCLUSIONS

Our analysis presents a vision from children and young people of an integrated systems approach to wellbeing provision, with a relational, participatory culture in which wellbeing and student needs are prioritised. However, our participants identified a range of tensions that risk undermining efforts to promote wellbeing. Achieving children and young people's vision for an integrated culture of wellbeing will require critical reflection and change to address the current challenges faced by education settings, systems, and staff.

The impact of universal, school based, interventions on help seeking in children and young people: a systematic literature review

Reviews into universal interventions to improve help seeking in young people focus on specific concepts, such as behaviour, do not differentiate between interpersonal and intrapersonal help seeking, and often report on statistical significance, rather than effect size. The aim of this review was to address the gaps highlighted above, to investigate the impact of universal, school-based interventions on help-seeking in children and young people, as well as to explore longer term impact. Four databases were searched. Data were extracted on country of origin, design, participant, school, and intervention characteristics, the help-seeking concept measured (e.g. knowledge, attitude/intention, behaviour), the duration between baseline and each follow-up (if applicable) and effect sizes at each follow-up. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Overall, 14 different interventions met inclusion criteria. The majority of the studies were rated low in the quality assessment. Three constructs were most frequently reported a) intrapersonal attitudes towards help-seeking, b) interpersonal attitudes towards help-seeking and c) intrapersonal intended help-seeking. Findings around intervention effect were mixed. There was tentative evidence that interventions impacting interpersonal attitudes produced small effect sizes when measured between 3 and 6 months post intervention and that when effect sizes were initially observed intrapersonal attitudes, this remained at 3-6 month follow-up. Further work should pay attention to implementation factors, understanding the core ingredients needed to deliver effective interventions and whether embedding mental health education could help sustain or top up effect sizes from help-seeking interventions.

Mainstreaming global mental health: Is there potential to embed psychosocial well-being impact in all global challenges research?

We explore if there is potential to embed psychosocial well-being impact in global challenges research where the primary aims are not mental health related. We are interested in the use of material practices to deliver impact through routine project activities of working with concrete things together. The UK Research and Innovation (UKRI) gateway to research was searched for information on Global Challenges Research Fund (GCRF) grants from 2015 to May 2020. Analysis shows that only 3 per cent of projects self-categorise as engaging with mental health. Thirty-six non-mental health GCRF grants were purposefully sampled for diversity, and each was coded independently by two researchers for relevant information. Findings suggest that 50-70 per cent of non-mental health GCRF projects already engage implicitly, but nonstrategically, with psychosocial well-being impact; opportunities for psychosocial well-being impact, from most to least frequent, are community mobilisation, community building, skills development, positive sense of self, positive emotions and sociocultural identity; the presence of material practice from most to least frequent is as follows: (i) interactions between or enactments upon people, (ii) written materials or images, and (iii) objects; when a material practice was present, it was usually considered usable as a focus to enhance psychosocial well-being. Our study provides evidence that there are low hanging fruit opportunities to impact psychosocial well-being across Sustainable Development Goals (SDGs) through routine project activities.

Long-term impact of a mental health literacy resource applied by regular classroom teachers in a Canadian school cohort

Application of evidence-based mental health literacy (MHL) curriculum resources by classroom teachers has been demonstrated to significantly improve knowledge and decrease stigma in the short term.

AIMS

To report results that extend these positive findings for a period of one year.

METHOD

In a naturalistic cohort study, 332 grade 9 students (ages 14-15) in a Canadian school district learned from an evidence-based curriculum resource (the Guide) applied by classroom teachers who trained in its use. Evaluations of knowledge and stigma were conducted before the Guide, immediately following the Guide delivery and at one-year follow-up.

RESULTS

Students showed significant (p < .001) and substantial (d = 0.68 and 0.67) short-term and significant (p < .001) and substantial (d = 0.44 and 0.58) long-term improvements in knowledge and reductions in stigma. Significant stigma reduction was found among female students than male students, but no gender differences on knowledge were found at long-term follow-up. Educators showed significant and substantial short-term improvements in knowledge (p < .001; d = 1.03) and reductions in stigma (p < .05; d = 0.35).

CONCLUSIONS

The Guide resource delivered by trained classroom teachers may have value in enhancing MHL outcomes for young people.

Feasibility, acceptability, and effectiveness of school-based dance movement psychotherapy for children with emotional and behavioral difficulties

Background

Schools have been increasingly employing dance movement psychotherapists to support children cope with daily worries and stress, express and understand their emotions, develop self-awareness and self-esteem. However, evidence on the impact of dance movement psychotherapy as a tool for prevention of mental health difficulties in childhood remains limited.

Methods

Sixteen children (aged 7–9) with mild emotional and behavioral difficulties from two primary schools were randomly assigned to a Dance Movement Psychotherapy (DMP) intervention or to a waiting list, within a larger pilot cross-over randomized controlled study which aimed to (a) test whether all elements of study design can work together and run smoothly in a full-scale RCT; and (b) investigate the effectiveness of arts therapies in improving children’s health related quality of life (HRQOL; EQ-5D-Y), wellbeing and life functioning (Child Outcome Rating Scale; CORS), emotional and behavioral difficulties (Strengths and Difficulties Questionnaire; SDQ), and duration of sleep (Fitbits). The therapeutic process was also evaluated through interviews with children, participant observations, the Children’s Session Rating Scale (CSRS), and ratings of adherence to the therapeutic protocol.

Results

The findings indicated that DMP led to improvements in children’s life functioning, wellbeing, duration of sleep, emotional and behavioral difficulties, but not in quality of life. The improvements were maintained at the follow-up stages, up to 6 months post-intervention. Interviews with children also suggested positive outcomes, such as self-expression; emotional regulation; mastery and acceptance of emotions; improved self-confidence and self-esteem; reduced stress; and development of positive relationships. However, children would have preferred smaller groups and longer sessions.

Conclusion

This study indicated that all outcome measures would be suitable for inclusion in a larger randomized controlled trial, though the EQ-5D-Y is not recommended as a stand-alone measure due to its lack of sensitivity and specificity for young participants. The adherence to the therapeutic protocol ratings differed between children and adults, highlighting the need to include children’s voice in future research. Strategies are also proposed of how to conduct randomization of participants in ways that do not hinder the therapeutic process.

Supporting children's mental health in primary schools: a qualitative exploration of educator perspectives

Schools are often seen as a key setting for the provision of mental health support for children. This study aimed to explore the professional perspectives of primary school educators in Victoria, Australia, regarding how schools can support the mental health of their students. Semi-structured interviews and focus groups were conducted with 17 primary school educators, from four schools. Thematic analysis was used to generate themes from the data. This study indicates that educators report significant concerns about the complexities of their role and their capacity to support children's mental health due to a lack of resources, overwhelming demands, and inadequate training. Educators highlighted the importance of partnership and communication with families and of a school culture that prioritises mental health. This study provides insights into external factors that can undermine effective support of children's mental health within primary schools and indicates a need for a more integrated approach to supporting children's mental health across education and healthcare.

The effectiveness of a school-based, universal mental health programme in six European countries

As children and young people today face ever increasing social, emotional and mental health challenges, schools, as one of the primary systems in children's lives, are called to broaden their agenda and help to address these challenges. This paper discusses the evaluation of a school-based, universal mental health promotion programme developed recently for the European context. The programme provides a universal curriculum from early years to high school, aiming to promote social and emotional learning and resilience and prevent social, emotional, and behavioural problems in children and adolescents. A total of 7,789 students (and their teachers and parents) from kindergarten to high school across 6 countries in Europe were recruited from 434 classrooms in 124 schools, making use of cluster sampling. A quasi-experimental longitudinal design was used to evaluate the effectiveness of the programme on students' outcomes by comparing the groups' outcomes within times (pre-test vs. post-test) and between groups (experimental vs. control group). A total of 779 classroom teachers completed pre-and-post scales measuring students' social and emotional learning, mental health and academic achievement. Results indicate that the experimental group had significantly larger increase in social and emotional competence and prosocial behaviour, and a decrease in mental health issues (externalising and internalising problems). No significant impact was found for academic outcomes. The findings are discussed in view of the limitations of the study and areas for further research.

Changes in peer and sibling victimization in early adolescence: longitudinal associations with multiple indices of mental health in a prospective birth cohort study

Victimization by peers and siblings is associated with poorer mental health outcomes in adolescence. What is less clear is whether mental health outcomes improve if victimization experiences cease (e.g., being victimized in primary school but not secondary school). This study aims to explore how changes in victimization experiences are associated with changes in mental health outcomes in early adolescence. Data are from 13,912 participants in the Millennium Cohort Study (MCS), a nationally representative cohort of individuals born in the UK. Self-reported victimization by peers and siblings, as well as mental health outcomes (depressive symptoms, life satisfaction, self-esteem, and body image), were collected at age 11 and age 14. Victimization at either time point was associated with poorer mental health across the range of outcomes, with effects largest for those who were consistently victimized. Those who reported increasing victimization had greater deterioration in their mental health compared with their peers who were never victimized. Conversely, children whose victimization decreased showed similar mental health development over this period as those who were never victimized. There was a cumulative effect of victimization by peers and siblings, with effect sizes generally larger for experiences with peers. Victimization in adolescence is associated with enduring reductions in mental health. Nonetheless, the promising outcomes associated with reductions in victimization suggest the potential for bullying interventions in schools to limit the deterioration in mental health in victimized groups.

Mental Health Provision in UK Secondary Schools

Research reports high levels of mental health problems faced by young people in the UK. Schools provide a range of mental health support services, although these are often not robustly evaluated. This paper aims to explore the mental health provision of secondary schools across two large regions in the North of England and provide comparisons to the mental health questionnaire scores of their pupils. Results are part of a wider study providing an overview of the mental health of secondary school pupils. Measures include the Strengths and Difficulties Questionnaire, distributed to year 8, 9, and 11 pupils attending secondary schools and a bespoke mental health service provision questionnaire for school staff at the same schools. A total of 6328 pupil questionnaires and 36 staff questionnaires were returned from 21 schools. Results showed a non-significant correlation between provision and young people’s mental health scores and highlight a range of factors to take into consideration. There is a need to improve the evaluation and recording of school-based mental health provision. Mental health difficulties in young people are prevalent in schools. Future research is needed to elucidate which types of services are most helpful in preventing, supporting, and signposting those with mental health problems.

Teachers' views and experiences of student mental health and well-being programmes: A systematic review

Background: In schools, teachers are often tasked with implementing mental health and well-being programmes. However, little is known about teachers' views on and experiences with implementing these programmes.Aim: The aim of this systematic review was to explore teachers' views and experiences of mental health and well-being intervention programmes developed to promote and protect student mental health.Methods: A systematic review of the empirical literature was conducted using the following databases: Academic Search Complete, APA PsycArticles, APA PsycInfo, British Education Index, Education Full Text (H.W. Wilson), ERIC, Social Sciences Full Text (H.W. Wilson), and SocINDEX with Full Text.Findings: Seven papers met the inclusion criteria. Teachers reported several challenges to the successful implementation of mental health and well-being programmes, including a lack of time allotted in the curriculum, insufficient training, and inadequate interagency support. There was evidence of conflicting opinions regarding the role of teachers in supporting students.Conclusion: It is recommended that mental health and well-being are viewed as central to schools' ethos and that teachers are adequately prepared to implement programmes.

Strategies to Increase Uptake of Parent Education Programs in Preschool and School Settings to Improve Child Outcomes: A Delphi Study

Parent education programs, offered via family-school partnerships, offer an effective means for promoting the mental health and educational functioning of children and adolescents at a whole-school level. However, these programs often have a low uptake. This study aimed to identify strategies for increasing the uptake of parent education programs within preschool and school settings. A three-round Delphi procedure was employed to obtain expert consensus on strategies that are important and feasible in educational settings. First, thirty experts rated statements identified from the literature and a stakeholder forum. Next, experts re-appraised statements, including new statements generated from the first round. Ninety statements were endorsed by ≥80% of the experts. Primary themes include strategies for program selection; strategies for increasing the accessibility of programs and the understanding of educational staff on parent engagement and child mental health; strategies for program development, promotion and delivery; as well as strategies for increasing parent and community engagement. This study offers a set of consensus strategies for improving the uptake of parent education programs within family-school partnership.

Educators' perceived mental health literacy and capacity to support students' mental health: associations with school-level characteristics and provision in England

Conceptual frameworks for school-based, preventive interventions recognise that educators’ capacity is, in part, dependent on school-level characteristics. This study aimed to (i) examine the factor structure and internal consistency of the Mental Health Literacy and Capacity Survey for Educators (MHLCSE); (ii) assess responses in relation to supporting students’ mental health; (iii) describe schools’ mental health provision in terms of designated roles, training offered, and perceived barriers; (iv) investigate variance in MHLCSE outcomes explained by schools; and, (v) explore school-level predictors of educators’ perceived MHL and capacity after controlling for individual-level characteristics. A multi-level, cross-sectional design involving 710 educators across 248 schools in England was used, and secondary analyses of baseline data collected as part of the Education for Wellbeing Programme were conducted. Mental health provision data was available for 206 schools, of which 95% offered training to some staff, and 71% had a designated mental health lead. Secondary schools offered significantly more training than primary schools. Significant barriers included lack of capacity in Child and Adolescent Mental Health Services (CAMHS) and within school, and communication challenges between agencies. The amount of training offered by schools significantly predicted educators’ awareness and knowledge of mental health issues, treatments and services, legislation and processes for supporting students’ mental health and comfort providing active support, with increased training predicting higher scores. However, little variance was explained by schools (1.7–12.1%) and school-level variables (0.7–1.2%). Results are discussed in relation to current mental health and education policy in England.

Does Vigorous Physical Activity Contribute to Adolescent Life Satisfaction?

Background: Physical and mental health are the basis of life satisfaction (LS), even during adolescence. The aim of this study was to identify the associations between LS and types of physical activity (PA) in Czech and Polish boys and girls. Methods: The research involved 933 girls and 663 boys aged 15–19 years. LS was diagnosed using the Bern Subjective Well-Being Questionnaire and the WHO-5 Well-Being Index. The International Physical Activity Questionnaire-long form (IPAQ-LF) questionnaire was used to identify the types of weekly PA. Results: Adolescents with the highest LS had more recreational, moderate, vigorous, and total weekly PA. The strongest associations between LS and PA were in the Czech and Polish boys and girls who participated in vigorous PA (VPA). The recommendations for VPA were fulfilled by 45% of Czech and 46% of Polish boys and 40% of Czech and 50% of Polish girls, with the highest LS. The most significant positive moderator between LS and PA was participation in organized PA. Boys with the highest LS were 1.94 times more likely to meet the weekly recommendation of VPA than boys with the lowest LS. Similarly, girls with the highest LS were 1.77 times more likely to meet these recommendations. Conclusions: Promoting both current subjective well-being and organized PA, with an emphasis on achieving the VPA recommendations, may support general LS and a healthy lifestyle in adolescents.

Aplicación de un programa de educación socio-emocional para alumnado de Primaria

La escuela es un espacio privilegiado para la adquisición de conocimientos que van más allá de lo académico. Las habilidades y competencias socioemocionales deben convivir y compartir espacio con el aprendizaje cognitivo para lograr un desarrollo integral del alumnado. En este trabajo se presentan los resultados de la aplicación de un programa de seis sesiones grupales denominado CODIP-R que pretende promover, desde el contexto educativo, el desarrollo social y emocional. Se trata de un estudio cuasi-experimental sin grupo control. En el programa participaron 83 alumnos y alumnas de primer curso de Educación Primaria (media de edad = 6.18 años, DE = 0.42) de cuatro colegios de la ciudad de A Coruña. Se evaluó la conciencia emocional y la competencia social pre y post test con un instrumento ad-hoc. Los análisis indicaron que, tras la implementación de CODIP-R, los participantes incrementaron su conciencia emocional (mayor conocimiento de emociones positivas y negativas, mayor autoconciencia emocional y mayor capacidad para identificar los estados emocionales de los demás) y su competencia social (mayor capacidad para aportar soluciones a problemas interpersonales ajenos y propios). Estos datos muestran que un programa breve desarrollado en la escuela puede tener efectos beneficiosos en la conciencia emocional y la competencia social.

Latent Class Analysis of Mental Health in Middle Childhood: Evidence for the Dual-Factor Model

Mental health is complex, comprising both mental distress and well-being. This study used latent class analysis to identify common combinations of mental distress and well-being (‘mental health classes’) among schoolchildren aged 8–9 years (N = 3340). Thirteen items, measuring a range of conduct problems, emotional symptoms, and subjective well-being, were included in the analysis. Four mental health classes were identified: (1) complete mental health (n = 1895, 57%), (2) vulnerable (n = 434, 13%), (3) emotional symptoms but content (n = 606, 18%), and (4) conduct problems but content (n = 404, 12%). The classes were reliably identified across different datasets, and for males and females. Differential relations with covariates indicated that mental health classes were distinct and externally valid. The results supported the dual-factor model of mental health, suggesting that mental distress and subjective well-being are separate continua. Three of the four possible combinations of high and low distress and subjective well-being posited by the dual-factor model were found using this inductive statistical method. Importantly, our analysis also revealed two ‘symptomatic but content’ groups, differentiated by symptom domain (internalising/externalising). The covariate analyses between mental health classes and sociodemographic factors, prior academic attainment, school connectedness, and peer support, indicated that there are nuanced relations between those variables and particular constellations of mental distress and well-being. As one of the few dual-factor studies to focus on middle childhood, the current study adds important new evidence that contributes to our understanding of the complexities of mental health among schoolchildren.

Academic Stress and Physical Activity in Adolescents

The issue of work-related mental health needs to be addressed at the school level. The aim of this study was to explore the associations between academic stress (AS) of adolescent boys and girls and their physical activity (PA) during recesses and after school and to propose measures to promote the adoption of lifelong healthy working habits. Adolescents from 16 schools in the Czech Republic and 6 schools in Poland participated in the study (187 boys and 339 girls). Monitoring of PA and cognitive stress was conducted during one school day. We used ActiTrainer accelerometers to monitor PA and physical inactivity. Data on time of PA and self-reported AS in school lessons were collected using recording sheets. We split the participants into two groups: those without a self-reported stressor and those who indicated one or more stressors. Differences in overall PA during recesses, as well as after-school PA, between boys with and without AS were not statistically significant for any PA characteristics. We observed similar results for girls. Repeated measures ANOVA confirmed that differences in PA (steps/hour) during recesses following particular lessons between participants with and without AS were not statistically significant in boys or girls (F (4,1612) = 1.83, p=0.121 , η p 2=0.005). It is noteworthy that girls with AS were statistically significantly more likely to meet the 6000 steps after school time recommendation (39%) than girls without AS (18%; p < 0.001). The study did not confirm the assumption that adolescents reporting AS have less PA during recesses or even after school than adolescents without AS. However, the overall low PA of adolescents during recesses and after school highlights the need to compensate for AS by adequate PA. This is especially true for adolescents with recurrent AS in several consecutive lessons.

Development and predictors of mental ill-health and wellbeing from childhood to adolescence

PURPOSE

The aim is to investigate the (1) longitudinal development in mental ill-health and wellbeing from ages 11 to 14, (2) predictors of changes in mental health outcomes, and (3) sex and reporter differences.

METHOD

Data are taken from 9553 participants in the Millennium Cohort Study, with both mental ill-health (parent- and self-report) and wellbeing outcomes of the cohort members measured at ages 11 and 14. A range of childhood socio-demographic, human capital, family and wider environment risk and protective factors are investigated.

RESULTS

Wellbeing has weak stability and mental ill-health has moderate stability between ages 11 and 14 and large sex differences emerge in all the mental health outcomes investigated, with girls experiencing lower wellbeing and greater symptoms of mental illness at age 14. Raw associations between outcomes, and differences in their predictors, indicate varying patterns emerging for parent- and self-reported mental ill-health, with parent-reported symptoms in childhood a poor predictor of both self-reported wellbeing and depressive symptoms in adolescence. Investigating the emergent sex differences in prevalences highlights childhood risk and protective factors at this age that are more salient in females, including family income, school connectedness, cognitive ability, whereas peer relationships and bullying were equally relevant for mental health development in both males and females.

CONCLUSION

Low-moderate stability of mental health outcomes stresses the importance of the transition period for mental health, highlighting an intervention window at these ages for prevention. Socio-economic status is associated with mental health development in females but not in males at this age, highlighting a sex-specific vulnerability of deprivation associated with poorer mental health in adolescent females.