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Universal promotion of mental health programmes often focuses on constructs such as social and emotional skills, positive behaviours, social inclusion, effective problem solving, and good citizenry. An example is MindMatters, developed in the late s. Teachers participate in various professional development opportunities to support their learning in these curricular domains. Interventions to help behaviour management with whole-school or classroom-based programmes have increasing empirical support. Implementation of its primary prevention tier, which includes how to define, teach, and reward appropriate behaviour alongside a continuum of consequences for problem behaviour, was highly successful.

Schools are an ideal setting for capturing the entire population of children, and therefore a three-tiered approach has become an accepted model for conceptualising the range of interventions to prevent students from developing psychiatric problems. The three components are universal, selective, and indicated interventions. Because early intervention can positively change the mental health trajectories for youth at risk of mental illness, many high-income countries are turning to this three-tiered model.

Universal interventions target the whole school or classroom, selective interventions are targeted to population subgroups whose risk of developing a mental disorder is significantly higher than average, and indicated and treatment interventions target young people already exhibiting clinical symptoms. 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.

Universal approaches have particular appeal because they are the least intrusive, potentially incur the lowest cost, and therefore have the greatest chance of adoption in the school setting. Universal approaches have been studied for a broad range of presentations, including behavioural management, risky behaviours, and mood and anxiety disorders. A wide range of universal interventions have been tried in schools in children of various age ranges, and with various therapists and therapeutic modalities such as cognitive behavioural approaches CBT and stress reduction techniques.

Several systematic reviews of CBT-based interventions in schools have been done, 60 , 61 , 69 , 70 with a main focus on prevention of anxiety disorders 60 and depression. For example, in a systematic review of anxiety disorders, 60 investigators assessed 12 randomised controlled trials and recorded that the universal programmes had the largest effect sizes compared with selective and indicated programmes. For prevention of depression, 20 randomised controlled trials including more than 10 participants showed that universal interventions were less effective than selective and indicated programmes, 61 leading to debate as to whether these programmes should be widely disseminated before more evidence is collected.

One of the largest studies of universal interventions for prevention of depression was Beyondblue. This result might emphasise the difficulties faced in attempts to implement large-scale school-based universal interventions, with training of teachers in a new technique, and with engaging of adolescents in prevention programmes. Promoting Alternative Thinking Strategies is a widely used intervention in primary schools 73 and FRIENDS for Life is a ten-lesson programme, which has had variable success as a universal intervention for both anxiety and depression, although it was initially developed as a selective intervention.

In schools, several prevention efforts have been successful in addressing risk factors, including interventions to decrease substance misuse in adolescents who score highly on certain personality measures, suggesting an increased risk of problems with substance misuse. Prevention programmes are often delivered in classrooms or small groups—eg, the Coping Power Program 76 for students at high risk of aggressive behaviours, drug misuse, and delinquency. An evidence base is also emerging for provision of school-based services to specific populations, such as young people from low-income urban regions, 77 and refugees.

Evidence for selective school-based prevention and early intervention programmes is strong for specific behavioural difficulties, for students with risks such as parental divorce , and for students with anxiety or depressive disorders. Many studies have assessed indicated school-based programmes for anxiety or depression, deliberate self-harm, and post-traumatic stress disorder. Community-partnered school mental health services, delivered by staff employed in community-based agencies, often augment existing behavioural health supports for students.

Consultation in mainstream schools by mental health specialists can assist with case conceptualisation, differential diagnosis, or considerations for community care. Some schools employ or have links with community-based partners to provide onsite individual, family, and group treatment for students with identified problems such as anxiety, depression, disruptive behaviour disorders, and traumatic stress. Intensive treatment often takes place during the school day, which can be more time efficient for both students and parents. Increasingly, school-employed staff are enhancing their capacity to deliver specialised mental health treatment for students.

A study 83 of interpersonal therapy given in school-based health centres showed that the therapy effectively treated adolescent depression. Additional service developments in schools include treatment of serious emotional disturbances 84 and reduction of the duration of untreated psychosis.

Special educational schools or classrooms for children with severe emotional and behavioural difficulties are at one end of the range of mental health needs in schools and are found to variable extents in high-income countries. Such establishments might have a high proportion of children with both treated and untreated mental illness. Alignment of these schools or classrooms with community mental health services is often needed, but not universally available. Research about school-based interventions has restrictions and these could obscure important effects panel.

These restrictions include a reliance on small studies, use of non-random designs, wide variation in outcome measures that might not be validated or educationally relevant, and difficulty in generalisation to other contexts because of factors unique to specific school settings. Furthermore, although understanding about the effectiveness of treatments is increasing, research of fidelity to these treatments when delivered and implemented in schools is scarce.

However, the study methods varied, so the results did not allow practitioners to differentiate which aspects of what interventions were effective and therefore worth using. Additionally, no cost-effectiveness studies were done, thereby restricting the generalisability. School-based services are unlikely to be a panacea for identification and treatment of all childhood mental illnesses. Some children do not attend school, might feel estranged from their school, or prefer to receive mental health services outside the school context.

Some young people might fear labelling and medicalisation if teachers have a prominent role in the detection of psychological distress; these issues need careful attention in training for teachers about mental health. Which presentations of illness and treatments are better suited for the school or community services are important questions to clarify. Additionally, not all interventions done in schools have produced positive results and the potential for adverse effects from psychological interventions should be acknowledged and monitored.

Implementation of effective interventions in schools has many challenges, and these are beginning to be systematically catalogued. Understanding of the classroom factors that can increase social-emotional functioning and academic success is now clearer than it was previously. Training and feedback can improve implementation of universal and selective interventions.

This important dual approach is comprehensive, draws upon school staff, addresses educational and mental health issues, and improves implementation. An integrative study that combines universal and targeted interventions is BRIDGE bridging mental health and education in urban schools.

The strategies applied were empirically derived , — and tested in 36 urban secondary school classrooms—a challenging environment in view of the complex needs of the student population. This study showed improved relationships between teachers and students, student academic self-concept, and peer-reported victimisation. The hypothesised mechanisms of change targeted teacher—student interactions, with the aim to change the classroom norms and improve academic engagement.

A common barrier to the implementation of evidence-based interventions in schools is poor engagement of all levels of school staff—ie, teachers, counsellors, and support staff. Implementation science helps to advance the understanding of core organisation culture, climate, leadership , classroom, and teaching practices that can impede or aid uptake of evidence-based interventions. The models to improve implementation are complex and multitiered, but manageable when systematic approaches are taken.

A challenge for both research and practice will be to test strategies to implement and sustain integrated whole-school, classroom-level, and individual-level interventions. This strategy will require the development of interventions that are feasible, low burden, and can be easily integrated into routine school schedules. Consultation and training strategies that rely on resources already available within schools will be especially important. The EPIS model exploration, preparation, implementation, sustainability identifies different implementation phases and aspects of the outer and inner context that are salient at different phases.

This model can be especially useful for guiding of research because it explicitly acknowledges how different variables can play a crucial part at specific points in the implementation process. Similarly, lessons about implementation can be learnt from other successful public health programmes within schools.

The application to school systems of methods to improve health-care quality is a promising approach. For example, Nadeem and colleagues identified 14 cross-cutting components as common factors in improvement of health-care quality including in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in quality improvement methods. Similarly, cross-site learning, social networks, , and harnessing of the expertise of key opinion leaders seem crucial, as do the commitment of leadership and promotion of team effectiveness. Complex ethical considerations exist when working with children in schools.

Mental health services have clear pathways and requirements to gain consent and inform caregivers. A child might see a school nurse or counsellor without parental knowledge or consent. Clear protocols are important to allow information sharing, which might prove beneficial to both academic and health outcomes, but privacy and confidentiality are essential to maintain therapeutic relationships.

Mental health services when embedded within educational systems create a continuum of integrative care that can promote health, mental health, and educational attainment. Strategies to integrate the different tiers of interventions within a school, and use of resources from within the school, are probably the most sustainable.

Service systems that support educational and mental health promotion, prevention, and treatment are administratively, legislatively, and politically separate. These indicators include accountable care organisations, the meaningful use of data to improve quality, and pay-for-performance incentives to promote healthy behaviours.

Many countries eg, Australia, the UK, and the USA have also had an increase in local control, which affects school mental health services in relation to competing demands. Tensions between mental health and other school priorities have prevented some schools and education services from placing resources in mental health provision. Agreement about which entity or organisation owns or is responsible for mental health services schools vs the community is a debate that is being replaced by models of shared ownership.

These models include families, schools, and communities identifying evidence-based programmes and working together to establish a full continuum of services. Improved collaboration between education and health sectors would be enhanced by mutual contributions to basic professional training. At present, specific training for most mental health professionals to become familiar with the school context is scarce. These curricula include mental health screening and identification of common presentations of mental health issues.

Similarly, training teachers in mental health promotion skills might not only assist in identification and referral for children who need it, but also help teachers feel less overwhelmed by the emotional and behavioural challenges in their classrooms. Poor prioritisation of child and adolescent health and mental health restricts the positive possibilities of integrative services. Furthermore, economic analyses of British mental health-related service contacts show large costs to schools and special educational services that were greater than costs of mental health to other public sectors.

We searched the literature with Scopus to identify meta-analyses, systematic reviews, and narrative reviews about school-based mental health interventions published between Jan 1, , and May 31, , with no language restrictions. This search identified 37 articles; we added further landmark studies and sought additional expert opinion to ensure the most relevant information was included. We used the Institute of Medicine framework to help categorise the range of different interventions that are undertaken in school settings.

The interventions consist of a scale ranging from universal interventions that are mainly mental health promotion and prevention interventions, to more selective interventions for children at high risk of developing disorders. Interventions that are indicated target children with identified disabilities and include both prevention and treatment.

The knowledge base of effective classroom interventions to improve teacher—student interactions and classroom behaviour is expanding. Integrative strategies that combine classroom-level and student-level interventions have potential to sustain educational, health, and mental health improvements for children. Future research should focus on system-level implementation and maintenance of these integrative interventions over time. Both an ethical and a scientific argument exist for improving access for all children, irrespective of their income, to high quality mental health services.

Application of the evidence base can ensure quality, but public and political will are needed to ensure that the evidence base is successfully implemented universally. National Center for Biotechnology Information , U. Author manuscript; available in PMC Jun Author information Copyright and License information Disclaimer. Contributors All authors contributed to the first draft and subsequent revisions of the Review.


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The publisher's final edited version of this article is available at Lancet Psychiatry. See other articles in PMC that cite the published article. Abstract Mental health services embedded within school systems can create a continuum of integrative care that improves both mental health and educational attainment for children. Introduction Children spend more time in school than in any other formal institutional structure.

Needs assessment and screening Many professionals working with children advocate the use of a multiple-gated screening system to determine mental health need in schools. Mental health interventions in schools An empirically derived approach to map intensity and type of school strategies to the needs of students has been used in parts of the USA. Universal approaches Universal approaches have particular appeal because they are the least intrusive, potentially incur the lowest cost, and therefore have the greatest chance of adoption in the school setting.

Selective approaches In schools, several prevention efforts have been successful in addressing risk factors, including interventions to decrease substance misuse in adolescents who score highly on certain personality measures, suggesting an increased risk of problems with substance misuse. Indicated approaches Many studies have assessed indicated school-based programmes for anxiety or depression, deliberate self-harm, and post-traumatic stress disorder. Community-based mental health treatment Community-partnered school mental health services, delivered by staff employed in community-based agencies, often augment existing behavioural health supports for students.


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  4. Gaps in school-based research and challenges in implementation Research about school-based interventions has restrictions and these could obscure important effects panel. Research gaps and service development priorities for mental health in schools. Identification of mechanisms and processes to use to maximise effectiveness of interventions in schools, including.

    Universal screening methods and processes that promote early identification and reduce duration of untreated mental health problems. Identification of screening thresholds by which to select children to participate in interventions. Development of specific implementation strategies to improve uptake, fidelity, and continuous learning for people delivering mental health interventions. Development of measures that integrate health, mental health, and educational outcomes to show individual, family, peer, classroom, and system-level improvements.

    Comparative tests of optimum modes of delivery for specific interventions such as individual, group, classroom, and whole-school, as well as unifying elements of successful interventions. Determination of best age range for specific interventions and studies that target secondary school settings and special educational settings. Research of interventions in schools for children with emerging or established mental health problems, including. Neurodevelopmental disorders such as attention deficit hyperactivity disorder or autism spectrum disorders. Development and assessment of young people and family peer models to promote engagement in schools.

    Interdisciplinary research that promotes collaborative scientific inquiry between education, mental health, and health researchers. Development of strategies, rather than programmes, which build on the naturally occurring ecologies within schools to strengthen skills and competencies around mental health identification and intervention.

    Clarification of consent and confidentiality procedures to aid and accelerate research and clinical practice in schools. Conclusion Mental health services when embedded within educational systems create a continuum of integrative care that can promote health, mental health, and educational attainment. Search strategy and selection criteria. Footnotes Declaration of interests We declare no other competing interests.

    Mental health interventions in schools in low-income and middle-income countries. The scientific base linking social and emotional learning to school success. Building academic success on social and emotional learning: Methods and public health burden. A longitudinal study of psychological functioning and academic attainment at the transition to secondary school. Low self-esteem during adolescence predicts poor health, criminal behavior, and limited economic prospects during adulthood.

    Prior juvenile diagnoses in adults with mental disorder: Time trends in adolescent mental health. J Child Psychol Psychiatry. Psychiatric disorder or impairing psychology in children who have been excluded from school: In defense of special education. Goodman A, Goodman R. Population mean scores predict child mental disorder rates: The prognosis of common mental disorders in adolescents: Longitudinal patterns of anxiety from childhood to adulthood: Prevalence and development of psychiatric disorders in childhood and adolescence.

    Working together to safeguard children: Relationship between peer victimization, cyberbullying, and suicide in children and adolescents: Victims of bullying in childhood and suicide attempts in adulthood. Influence of problematic child-teacher relationships on future psychiatric disorder: The quality of teacher-student interactions: Job stressors, personality and burnout in primary school teachers.

    Br J Educ Psychol. Multiple-gating approaches in universal screening within school and community settings. Universal screening in educational settings: American Psychological Association; Washington: Service use by at-risk youths after school-based suicide screening. Using the Strengths and Difficulties Questionnaire SDQ to screen for child psychiatric disorders in a community sample.

    Youth suicide risk and preventive interventions: Mental health screening in schools. Teacher involvement in school mental health interventions: Child Youth Serv Rev. Counselling in UK secondary schools: Center for Mental Health Services. School mental health services in the United States, — Expanding the toolkit or changing the paradigm: School-based social work interventions: Social Work United States ; Telepsychiatry and school mental health.

    Child Adolesc Psychiatr Clin. Severson H, Walker H. Proactive approaches for identifying children at-risk for socio-behavioral problems. Interventions for children with or at risk for emotional and behavioral disorders. The good behavior game and the future of prevention and treatment. Addict Sci Clin Pract. Factors facilitating and constraining the delivery of effective teacher training to promote health and well-being in schools: Preventing mental, emotional and behavioural disorders among young people: School-based mental health services: A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health.

    Impact of school-based health promotion interventions aimed at different behavioral domains: A systematic review of effective interventions for reducing multiple health risk behaviors in adolescence. Am J Public Health. Lean D, Colucci V. A systematic review of universal approaches to mental health promotion in schools. Effectiveness of school-based universal social, emotional, and behavioral programs: Effects of school-based interventions on mental health stigmatization: Child Adolesc Psychiatry Ment Health.

    The positive impact of social and emotional learning for kindergarten to eighth-grade students: Findings from three scientific reviews. Visit Charlier Waller Trust's website to get free resources for staff and students link opens in new window. YoungMinds offers information and support for any parent who is worried about their child's mental health and wellbeing, link opens in new window or their own parenting skills.

    For some, Christmas time can be associated with loss of routine, loneliness, bordeom or unhappiness. This is particularly true for some children. Young Minds have out together some resources for schools to support children. The DfE has updated its guidance for schools on mental health and behaviour link opens in new window. The guidance gives advice on:. It also provides links to sources of further support and guidance. The films are based on young people's journeys through psychosis, including the symptoms and support they received.

    The aim of the films are to help young people identify symptoms of psychosis and also educate them on how they can obtain help from primary care and the early intervention in psychosis team if they or someone they know experiences a psychotic episode. Watch Fabi's film on Vimeo link opens in new window. Watch Josh's film on Vimeo link opens in new window. The DEAL Developing Emotional Awareness and Listening resources link opens in new window by the Samaritans offer teachers a comprehensive package of engaging teaching material focusing on emotional wellbeing and communication skills.

    The resources are aimed at students aged 14 and over and are free. The lesson plans and materials included in the DEAL resources are split into units which focus on the following key areas of the emotional wellbeing of young people;. The Marmot Review recognised the important role of schools in building resilience, and recommended as a policy objective that, 'schools, families and communities work in partnership to reduce the gradient in health, wellbeing and resilience of children and young people'. The Building children's and young people's resilience in schools review downloaded from GOV.

    UK link opens in new window and builds on that position and provides a summary of evidence about the effect of resilience on health, the unequal distribution of resilience and its contribution to levels of health inequalities.


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    Library staff can request the Shelf Help books free of charge for a young person. Visit the Reading Hack website link opens in new window to find out more. These books can provide information and advice to parents and carers supporting a young person.

    We should be talking about mental health at school

    Visit the Reading Well website link opens in new window for more information. We've teamed up with educational psychologists and youth services to produce a locally focused, user-friendly toolkit PDF 3. Mersey Care NHS Foundation Trust has produced a series of free films available to schools, colleges, teachers or anyone who wants to get young people talking about mental health. Anna Freud has produced a new animation and teacher toolkit: We all have mental health link opens in new window. The Charlie Waller Memorial Trust link opens in new window has released a new resource, developed by researchers at the University of Oxford, for school staff who may come into contact with students who have self-harmed or at risk of self-harm.

    The resource contains information about self-harm, its impact and practical ways school staff can help to support young people. CHUMS is delighted to deliver its early intervention training programe for schools across Central Bedfordshire for the next academic year. The training consists of half termly training and consultation sessions for an allocated member of school staff Emotional Wellbeing Lead.

    The training will be held at an external venue from 9am to 3: The day consists of training during the morning and an optional group consultation session in the afternoon.

    Introduction

    The consultation session provides an opportunity to seek advice and guidance on accessing appropriate support for young people within the school. Please avoid parking in the Child Development Centre's car park. Parking is available in the nearby street areas surrounding the site and on the lay-bys by Kempston Challenger Academy. We've collated additional local guidance, resources and presentations on mental health and wellbeing. The Anna Freud Centre has produced the third in the series of mental health in schools booklets: Supporting Staff Wellbeing in Schools link opens in new window.

    By devoting a lesson, assembly or short session plan to changing how your school community thinks and acts about mental health, you can make a huge difference. Time to Change is a growing social movement changing how we all think and act about mental health. It has developed five easy ways link opens in new window to start a conversation in your school and ensure no young person feels isolated or ashamed if they are struggling with emotional wellbeing or mental health issues.

    Mental health interventions in schools 1

    Choose from its range of free activities which include easy resources and activities that you can use throughout the school year. Talking about mental health is easier than you think. Some practical tips from Young Minds link opens in new window on talking to someone recovering from an eating disorder.

    Survey and case studies link opens in new window with schools on activities to support pupils' mental health and wellbeing. The Anna Freud Centre has relaunched the Youth Wellbeing Directory link opens in new window which provides details of over 1, free mental health services across the UK who offer support to children and young people up to the age of The site can be searched by location, topic or name of service. In addition, the site has links to useful information and support on a range of issues including, dealing with anxiety, bereavement or bullying.

    A guide link opens in new window which aims to: The PSHE Association has collaborated with RSPH and the Health Foundation to create free-to-download lesson plans, teacher guidance and a wealth of accompanying materials link opens in new window which focus on the factors that influence our health and wellbeing. A range of free resources link opens in new window from Boingboing to help schools to promote emotional resilience in pupils and students. Bedfordshire CAMHS has produced a video of a service user talking about her experience of combatting the effects of exam stress link opens in new window.

    The film tells the story of Joe, who finds it difficult to seek support due to the stigma associated with mental ill-health. Teaching children and young people coping strategies resources link opens in new window from the Samaritans. The programmes are aimed primarily at key stages 3 and 4 and are always practical and evidence based. The programme enables young people to develop skills that empower them to be more resilient in dealing with situations both in and out of school. Young people develop skills in emotion control and emotional awareness, problem solving, assertiveness, peer relationships, and decision making.

    Online training from Zero Suicide Alliance link opens in new window has been designed for practitioners working with young people and adults who may be experiencing suicidal thoughts. One of our local commissioned services has used the training and found it very helpful. The Youth Index link opens in new window is a national survey that gauges young people's happiness and confidence across a range of areas from working life to physical health.

    The latest report demonstrates that young people's wellbeing, which dropped last year to its lowest level since the Index was first commissioned, has fallen again to a new low this year, and that concerns about their job prospects are playing on their minds. The Local Government Association has produced an interesting summary of the position on children and young people's mental health and wellbeing and the associated services link opens in new window.

    These are as follows:. Training on a range of emotional wellbeing and mental health topics such as self-harm, early identification and behaviour. The PSHE Association has produced some guidance for teaching staff link opens in new window on the ground rules to follow when discussing emotional wellbeing and mental health issues.

    As school professionals, it is essential to ensure your own emotional health and wellbeing as well as that of your students. Everyone feels stressed or unhappy at some time. Generally, these difficult times pass, but sometimes there are problems that do not go away and it becomes harder to cope.

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    If you are 17 and over, the Bedfordshire Wellbeing Service link opens in new window can offer quick and easy access to help and support. The service is a free and confidential NHS service for local people. These resources from InnerWorld Work link opens in new window are a great insight into the inner world of a child or young person who has experienced trauma. It helps those around to understand the outward manifestations of this.

    The program uses content co-created with young people on topics such as smoking and exam stress. The PSHE Association has recommended this free lesson resource from Media Smart link opens in new window which is designed to get students aged 11 to 14 talking about body image and advertising, and exploring ways to develop positive body image through PSHE education. The Media Smart Body Image and Advertising resource includes teacher notes, presentation slides and printable worksheets, to help you plan and deliver a PSHE lesson that:.

    This free interactive short course provided by the Anna Freud Centre focuses on the effective use of outcome measurement. This course features engaging quizzes and activities to illustrate how staff can choose and use outcome measures to monitor wellbeing and how to analyse wellbeing information to demonstrate impact. Find out more about the free course link opens in new window. Watch the online tutorial on measuring wellbeing link opens in new window YouTube. The Education Policy Institute has published the following report:. Anna Freud has also developed a booklet: