Mental Health

Bev Cockbill, Training Co-ordinator and structured teaching practitioner in complex learning needs , and Jo Egerton, Schools Research Consultant

‘School is a critical environment where young people should be able to flourish across all domains of their lives… [There is a] need to provide young people with the help, support and self-empowerment to develop and maintain resilience to stay mentally healthy in order to achieve and develop to their full potential.’

Professor Dame Sue Bailey

Chair of the Children and Young People’s Mental Health Coalition (Doward

2015)

In the UK children’s mental health is of deep concern. For adolescents worldwide, depression is the top cause of illness and disability, with self-harm and anxiety disorders both among the top 10 (World Health Organisation (WHO), 2014). In the UK, three-quarters of mental health problems emerge in children aged below 18 years (Frith, 2016), 10% of all children will have a mental health problem at any one time, and 20% in any given year (House of Commons Health Committee, 2014; Mental Health Foundation, 2007; Office of National Statistics, 2004). The outlook is more disturbing for pupils with special educational needs/disabilities – they are almost four times as likely to experience mental health problems as their typically developing peers (Dossetor et al., 2009; Emerson and Hatton, 2007), rising to seven times more likely for children with ASD (Dossetor et al., 2011). Unless identified and addressed early, mental health problems are likely to carry a lifelong impact (Bernard and Turk, 2009; National Institute of Mental Health, n.d.).

Schools have a critical but under-supported role in child and adolescent mental health (WHO, 2014). A 2016 Parent Zone schools survey found that 93% of teachers reported increased rates of mental illness among children and teenagers, and 62% supported a pupil with a mental-health problem at least monthly, while 20% did so at least weekly (Beedell, 2016). However, schools struggle with lack of appropriate funding, impoverished links with health services, training and resources (Values-Based CAMHS Commission, 2016; Frith, 2016). Although most schools have successfully embedded emotional literacy programmes (e.g. Social and Emotional Aspects of Learning (SEAL); Humphrey et al., 2010), many teachers are under-confident and under-resourced in providing focused support to pupils with mental health difficulties and problems (Byers et al., 2008; NASS, 2007).

There is a correlation between pupils’ learning engagement and their mental health. Pupils with early onset mental health disorders (e.g. anxiety, mood and substance use disorders) are twice as likely to drop out of secondary school (Leach and Butterworth, 2012; Lee et al., 2009). Wang and Peck (2013) observe that dropping out of school is a cumulative process of emotional and cognitive disengagement. They report that pupils with the lowest level of emotional engagement are at the highest risk for mental health problems and are most likely to disengage from schooling.

However, when engagement in learning is facilitated for pupils with mental health problems, it has been shown to strengthen their mental health (Brooks, 2014). Personalised, as-needed interventions by schools can enable pupils to engage in education, when their mental health difficulties might otherwise prevent this and have a detrimental long-term impact on their life chances (Carpenter, 2010; Carpenter et al., 2010; Carpenter and Egerton, 2013).

Schools need a systematic and deductive approach to mental health issues that enables them to identify problems, mobilise resources and provide an appropriate response (whether CAMHS-prescribed or an evidence-based interim response) to address pupils’ immediate mental health needs. The Engagement for Learning Framework and Guidance (Carpenter et al., 2011, 2015) can provide a structure in which schools can monitor the effectiveness of interventions to support children’s mental health through their subsequent engagement in learning. The following case study below show how it has been used for one young person.

 

Case study

Elspeth had just turned 9 years old during 2015, when she was first suicidal; CAMHS got involved and Elspeth had 12 counselling sessions, which did not appear to help. Elspeth is now 11 years old. Her parents divorced when she was very young; her grandmother died in 2012. Elspeth appears to struggle with understanding the emotions around grief and what happened in reality at the time of her grandmother’s death, as Elspeth has a different version of events in her mind.

Elspeth is an extremely bright child, and if given the correct personalised learning approach and opportunities, she could access the national curriculum and achieve at the same level expected as a neuro typical child.  She is highly motivated by a pop artist and various teen drama mystery-thrillers, which have become obsessional interests. She coped with her primary school but found her new middle school difficult. SATs were not an issue academically, but she needed to complete the tests in isolation to enable her to focus.

Elspeth thrived in primary school, until year 3 when parents noticed a change in her mood. By February 2016, Elspeth was in middle school; areas of concern from the school were language and communication. She began to refuse school activities. It started with the odd day; she could not cope with the transition from home to school. Personal care became an issue, and she had become very violent at home. She would say to mum she did not feel safe at school. Although the school had a ‘pod’ for pupils to access when they felt the need, the environment was still too busy for Elspeth.  By June 2016, she had virtually stopped going to school, as she was terrified. To support her, the middle school referred her to a medical team within an education setting, but after visiting a few times, Elspeth also refused this option. She was referred to CAHMS, but she felt terrified at the thought of going to either her school or the CAMHS setting. In November 2016, she finally stopped going to school altogether. The middle school then approached a local special school, which offers school-to-school support, and asked them to become involved with supporting Elspeth. By this time, Elspeth had been out of school for over six weeks.

Elspeth is very rigid in her thinking, which impairs her functioning, and she has poor awareness of her own emotions. Her mental state can be very changeable. Her mood can be low or hyperactive and overly enthusiastic. When at home, she stays in her bedroom most of the time, and at times will barricade herself in. Sometimes, she will scream out randomly. She prefers to sleep during the day, as the environment is better suited to her at night. Her personal hygiene is extremely poor.

The special school started by visiting Elspeth at home. However, it was impossible to engage her in learning at home, as Elspeth would be delighted to see new visitors and would be happy to chat about high interest topics. However, when the topic of conversation was changed, Elspeth would disengage and return to her bedroom. The special school therefore offered Elspeth a vocational experience of school to re-engage her in a social and educational setting. This experience included enterprises such as beauty, upcycling and agricultural opportunities. Elspeth began visiting the centre once a week for an hour; over a period of eight weeks, this has built up to two full mornings.

To monitor the impact of the special school’s interventions on Elspeth’s ability to engage in school-based activities, they used the Engagement for Learning Framework. They completed an Engagement Profile for Elspeth, which noted the behaviours observed when she was highly engaged. This enabled staff at the school to develop high expectations of Elspeth as an engaged learner. Before putting any interventions in place, the school then completed baseline engagement scales in activities that Elspeth had a low level of engagement, together with input from Elspeth’s medical team and middle school. This gave a starting point from which the special school and Elspeth’s family could monitor progress from interventions put in place to support Elspeth.

Once the special school began the interventions, they realised they needed to look at two components – firstly her social and communication difficulties and secondly how to motivate her to participate in education. In view of this, they had two targets:

  • to re-engage Elspeth educationally
  • to re-engage Elspeth socially.

The special school developed a series of interventions that staff put in place one at a time, so it could be seen, from the varying scores on Elspeth’s Engagement Scales, which interventions worked for Elspeth and which did not. Examples of interventions included:

  • A schedule, informing Elspeth what to expect during her visit
  • Gradually extending Elspeth’s time visiting the centre
  • Staff avoiding asking certain questions (e.g. not asking Elspeth if she is happy or likes to visit the centre)
  • Starting the visit with Elspeth’s preferred activities related to topics (e.g. designing a poster for manicure treatment description/marketing etc.) before presenting unfamiliar or more challenging activities
  • Ending with a high interest activity (e.g. Demi Lovato or Pretty Little Liar’s quiz)
  • Establishing clear expectations and boundaries (e.g. attendance on a stated day; working with any staff member, not just one in particular; hygiene routines such as washing hands; etc.).
  • Introducing opportunities for social interactions (e.g. working with another student; making everyone a drink)

The progress graphs below show the progress that Elspeth has made over time, relating to the different interventions alongside other issues in Elspeth’s life. On the odd occasion, Elspeth refused to visit the school, but the most usual reason for this was extreme tiredness, not because she did not want to come. Elspeth has said she likes her visits to the centre

 

Using the Engagement for Learning Framework has helped guide staff on how to approach Elspeth sensitively and how best to work with her when her mood changes. Working with the information from the Engagement Profile enables them to hook Elspeth in by knowing what motivates her. This personalised style enables Elspeth to feel safe and re-engage in certain activities, which are ‘loosely’ connected with subjects such as maths and English. The activities have given her a purpose for part of her day.