What can schools do to spot and avert mental health issues?

Schools across the UK are dealing with a mental health epidemic, with both primary and secondary school leaders reporting a rise in stress, anxiety and panic attacks in their pupils as well as depression, self-harm and eating disorders

Here, Dr Margot Sunderland, Director of The Centre for Child Mental Health and Co- Director of Trauma Informed Schools, discusses what schools can do to spot and avert mental health issues.

In 2017, 98% of teachers and school leaders came into contact with pupils they believed were experiencing mental health problems, according to a National Association of Schoolmasters Union of Women Teachers Teacher’s survey. And with children spending 190 days at school per year, teachers are in a prime position to provide much-needed support to pupils with mild to moderate mental health problems.

This is reinforced in the recent Government Green Paper (2017), Transforming Children and Young People’s Mental Health Provision which states, ‘There is evidence that appropriately-trained and supported staff such as teachers, school nurses, counsellors, and teaching assistants can achieve results comparable to those achieved by trained therapists in delivering a number of interventions addressing mild to moderate mental health problems such as anxiety, conduct disorder, substance use disorders and post-traumatic stress disorder’. Research also shows that, on average, it takes 10 years for a child to get help for a mental health condition (Centre for Mental Health, Missed Opportunities report, 2016) – and even then, only half who seek help get better so teachers play a crucial role in spotting, addressing and mitigating mental health issues early on.

But before schools can appropriately tackle poor mental health, it is essential that they take a step back and understand the causes behind mental ill health and the transition from emotional pain, which is experienced by us all, to mental health problems. Emotional pain for children and teenagers which may be caused, for example, by their parents separating, an illness or a death in the family, multiple house moves or bullying at school, and the impact this can have, needs to be understood and normalised by schools. Before discussing mental health conditions, schools should first focus on providing children with a space to talk about painful life experiences and offer appropriate support. The wealth of scientific research on ‘social buffering’ (having someone at the time of the painful life experience, to listen, empathise and understand) shows that this can prevent students’ emotional pain transitioning into a mental health issue.

Countless research suggests that painful childhood experiences, without ‘social buffering’ at the time, have a significant impact on children’s behaviour, attendance and learning outcomes. The Adverse Childhood Experience and Toxic stress: a Public Health Crisis study (Burke et al 2011) found that children with three or more adverse childhood experiences (ACEs), such as those mentioned above, were three times more likely to experience academic failure, five times more likely to have attendance problems and six times more likely to have behavioural problems. For those with four or more ACEs, more than 50% were likely to have learning problems and were 32 times more likely to have behaviour problems.

For teachers, early identification of the warning signs that a students’ painful life experience or emotional pain could, if not addressed, become a mental health problem, is critical. Some key signs to keep an eye out for include: marked changes in concentration, losing ability to focus on learning, staring out the window, tiredness and low self-esteem. More concerning signs and symptoms to watch for could include isolation and withdrawal from peers, parents also reporting marked deterioration in several areas of functioning, and indications of serious self-harm or suicidal ideation. In these cases, the pupil should be referred to Child and Adolescent Mental Health Services.

Our results-driven culture and focus on academic outcomes is also adding to widespread mental health problems in schools. Exams are frequently cited as one of the worst stressors facing pupils. In a recent National Education Union survey of teachers (April 2018), 82% said tests and exams had the biggest negative impact on mental health, with exams causing children acute stress, and many pupils breaking down in class due to the pressure or turning to self-harm or suicidal thoughts. Counselling service Childline receives a surge of calls from young people during the SATs and GCSE season, and reported receiving 3,135 calls from young people about tests and exams in 2016/17, an increase of 11% over the previous two years (National Society for the Prevention of Cruelty to Children). Problems sleeping and eating, school avoidance, panic attacks and self-harm and suicide are increasingly reported among young people during exam time.

Student wellbeing is just as important as academic outcomes, and needs to be treated as such. In fact studies show that paying attention to student wellbeing improves academic outcomes. Until Government education authorities, such as the Department for Education, Ofsted and the Regional Schools Commissioners, balance the scales between wellbeing and academic achievement, there will continue to be a mental health problem in schools.

The UK should look to other countries that are less testing-focused and follow their lead. Finland, for example, epitomises progressive education policy, with a later introduction to formal schooling (age seven) and no tests in primary schools (pupils are only tested at 18) and was ranked fourth in the world for reading in the last Programme for International Student Assessment (PISA), in 2016. The United Kingdom is way down the list at ranking 22. There needs to be national recognition of the importance of monitoring the wellbeing of schools. Governing bodies, trust boards and directors need to make pupil wellbeing, as well as staff wellbeing, a key performance indicator for schools across the UK. While test results continue to trump wellbeing, the education system will continue to add to mental health problems in students and staff, not heal them.

One approach schools can take to avert mental health issues is to provide pupils with ‘emotionally available’ adults. In effect this means that school staff should focus on building rapport with their students and strengthening their listening and empathy skills to help children regulate their emotions and reduce their levels of emotional stress.

Research in the YoungMinds and Cello Talking Self Harm report (2012) indicates that two out of three teachers are worried that if they have a conversation with a teenager about self-harm they might make it worse. If they listen empathetically, this is absolutely not the case. It is important for schools to focus on building teachers’ confidence in this area, and providing them with opportunities to gain skills around the type of language to use and how to approach a mental health conversation with a student.

If a teacher notices a child is expressing symptoms of poor mental health, for example, they should take the student aside and ask open-ended questions using empathetic language, for example: ‘I’m so sorry that you are going through a tough time at the moment, would you help me understand what is happening for you in your life at the moment?’, or ‘Would I be right in thinking that things at home are hard for you right now?’, ‘Is there anything we can do to help you with what’s going on for you in your life?’ and validating the child’s feelings with statements such as, ‘Of course you’re feeling upset because your mother is sick’, ‘It’s understandable that you’re feeling worried’. It is about building on the natural empathy that many teachers are likely to already possess.

A guide for teachers, which started with US third-grade teacher Kyle Schwartz asking her students to fill in the blank in the sentence: ‘I wish my teacher knew….’ has become increasingly popular in schools across the UK and is a great way to encourage children to discuss challenging feelings or experiences. Kyle was anticipating responses such as ‘I wish my teacher knew I wanted a pony’ but instead the vast majority of students (90%) responded to her question with answers relating to what was happening in their home life, such as, ‘I wish my teacher knew that my mother is ill and I’m frightened she might die’, ‘I wish my teacher knew that my parents have separated’ or ‘I wish my teacher knew that I’m very lonely’. There is an assumption that asking the question and starting a dialogue with a student about painful experiences will add to their distress, but it is actually the opposite.

Schools should also consider including activities that help children to calm high levels of stress that we know, if unresponded to, can trigger mental health problems. This means including activities that provide physiological regulation (calming the body down and improving thoughts and feelings) in their curriculum. Activities such as mindfulness, yoga or Tai Chi at the beginning of the school day have been proven to increase concentration levels, aid calmness and reduce stress levels in vulnerable students, thereby enabling them to learn.

A school in Bradford, West Yorkshire recently introduced a system which involved students choosing a feeling face when they signed the morning registrar. Children that choose a sad, angry or frightened face were consequently provided with one-on-one support by an empathetic member of staff. It didn’t take long, just a soothing voice or a hug was enough to calm the children. The school noted that the support significantly improved the pupils’ concentration levels for the rest of the day.

From a behaviour policy perspective, school leaders should look at revising sanction-based policies and implementing ‘relationship-based policies’ which underpin the importance of understanding the causes of pupils’ challenging behaviour and responding in a healing (empathetic and understanding), rather than a harming (angry and frustrated) manner. Relationship policies will ensure schools become nurturing environments for children and that teachers interact with children in a way that brings down stress, not exacerbates it.

Teaching school staff the science behind ‘toxic’ stress (chronic unrelieved stress) and its role in mental and physical health issues, including how to bring a child’s stress levels down from ‘toxic’ to ‘tolerable’, is also an important component in reducing or preventing mental health issues. Neurochemical reactions should be taught and understood throughout schools. For example, unmourned grief can trigger violent behaviour or withdrawal and because many senior leads do not know this, many children with blocked grief are excluded for aggressive behaviour. A child who is acting up as a response to grief should be helped to process their grief, not excluded. Neuroscience needs to be brought into teacher training and professional development otherwise schools may unwittingly do harm.

Schools should be catching students as they are falling, not after they have fallen. A dialogue needs to be started in schools that normalises emotional pain and discusses the causes of mental ill health. In dealing with painful life experiences, students need an empathetic and emotionally available adult – and with more than 1,000 hours spent at school per year, teachers are in an ideal position to provide this support.

For more information on child mental health and training call 020 7354 2913 or visit www.childmentalhealthcentre.org.

Dr Margot Sunderland

Director of Education and Training
at The Centre for Child Mental Health and Co- Director of Trauma Informed Schools UK

i. https://www.nasuwt.org.uk/article-listing/schools-need-support-mental-health-upsurge-pupils.html 

ii.Government Green Paper (2017), Transforming Children and Young People’s Mental Health Provision

iii. https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper

iv. Centre for Mental Health, Missed Opportunities report, 2016 https://www.centreformentalhealth.org.uk/missed-opportunities The Adverse Childhood Experience and Toxic stress: a Public Health Crisis study (Burke et al 2011)

v. National Education Union poll of 700 teachers (The Independent, April 2018, Eleanor Busby)

vi. Exam stress overwhelming for thousands of children, https://www.nspcc.org.uk/what-we-do/news-opinion/exam-stress-overwhelming-for-thousands-of-children/

vii. Talking Self-harm, Young Minds and Cello Report, 2012, https://cellohealthplc.com/pdfs/talking_self_harm.pdf