Today the Education Policy Institute has published its official submission to the House of Commons Health Select Committee inquiry, ‘Children and young people’s mental health – the role of education‘. The inquiry examines what part educational settings can play in promoting emotional wellbeing in children and young people and preventing the development of mental health problems.
You can read the submission in full below, or download a PDF version here.
Where policy recommendations are made in this submission, they are the recommendations of the EPI’s Independent Commission on Children and Young People’s Mental Health.
Children and young people’s mental health – the role of education
- Schools can help to prevent mental health problems by raising awareness, reducing stigma and having good policies in place to prevent bullying.
- EPI research found that services turn away, on average, nearly a quarter (23 per cent) of the children and young people referred to them for treatment. We also uncovered a postcode lottery of waiting times.
- EPI analysis of local strategies to improve care found wide variation in the quality of these plans. We also uncovered serious barriers to the process of transforming services, such as funding and workforce. Of the £1.25bn extra funding announced in 2015, indications are that it is not reaching frontline services. 8 out of 10 providers who responded to an EPI freedom of information request cited that they had experienced recruitment difficulties.
- To address these concerns about young people accessing help, a national strategy on mental health and schools is required. This should include training for teachers and a consistent programme of evidence-based in-school support. It should also involve statutory, updated PSHE lessons and Ofsted taking wellbeing into consideration as part of any school or college inspection.
- A national strategy is also needed to empower young people to live safe digital lives.
- Over half of all mental ill health starts before the age of fourteen, and 75 per cent has developed by the age of eighteen. Around one in 10 children aged 5 to 16 have mental health problems, the equivalent of three in every classroom.
- Only 25-40 per cent of children and young people with mental health problems receive input from a mental health professional at all or at a sufficiently early age. The Education Policy Institute’s Independent Mental Health Commission (hereafter called the Commission) called for a Prime Minister’s Challenge on Children’s Mental Health, ensuring it is a high priority across government.
Promoting emotional wellbeing, building resilience, and establishing and protecting good mental health
Reduction of stigma
- Schools can help to prevent mental health problems getting worse by reducing stigma, and therefore increasing access to care. This is because one of the biggest barriers is young people and their parents asking for help. Teenagers experience significant embarrassment about mental health difficulties, becoming more secretive and reluctant to seek help.
- 24 per cent of students who spoke to Time to Change did not attend school, college or university because they were concerned what other students would say and 15 per cent of people experienced bullying as a result of mental health problems. 48 per cent chose not to disclose their mental health problems.
- The government should sustain efforts to reduce the stigma associated with mental health, targeting young people as well as their parents. It should include BME communities with awareness of cultural differences and language barriers. The Prime Minister’s Challenge should set clear goals to increase mental health literacy, including through the school curriculum. There should be statutory, up to date, PSHE in all schools and colleges with dedicated time.
Prevention of bullying
- The education system can help prevent mental health problems by tackling bullying. Being target of bullying in childhood has a lasting negative impact on children’s mental health, equivalent to being in local authority care.
Support for young people with mental health problems
- EPI research found that specialist children and young people’s mental health services turn away, on average, 23 per cent of the children referred to them for treatment by their GP or teachers. This was often connected to high eligibility thresholds, for example some people with eating disorders were told that their body mass index was too high to access treatment. Some services would not accept referrals where the problem was “entirely school-related”. This means that many young people need to wait until their problems get worse before they can get help.
- Those who do get accepted into services often face long waits. We found that the median waiting time for all providers was one month for a first appointment and two months until start of treatment. There was wide variation in average waiting times, from two weeks in Cheshire to 19 weeks in North Staffordshire.
- This average waiting time conceals longer ‘hidden waits’. The median of the maximum waiting times for all providers was 26 weeks (6 months) for a first appointment and nearly ten months (42 weeks) for the start of treatment.
- This is partly due to growing demand. There is evidence of a significant rise in those asking for help with mental health problems over the last five years. For example, the number of young people attending A&E because of a psychiatric condition has more than doubled since 2010.
- In 2015, every area was tasked with developing a Local Transformation Plan to improve support. The EPI analysis of these plans found wide variation in their quality, including some evidence of good practice. Croydon NHS plans to co-design a programme of support in schools with the education sector, including staff training, commissioning guidance and a whole-school approach to improving emotional wellbeing. In Oxfordshire, child and adolescent mental health workers now run weekly sessions within all secondary schools. In Liverpool, plans are in place for specialist support to be provided in all schools.
- The EPI also explored the barriers to improving care, including funding. Currently, children’s mental health receives only 7 per cent of the total NHS budget and it is heavily skewed towards specialist services.
- £1.25bn of additional funding was announced in 2015. The Government’s decision not to ring-fence this, however, is putting the transformation process at risk. In the first year, of the expected £250m, only £75m was distributed to clinical commissioning groups (CCGs). While it is unclear how much of this has reached frontline services, mental health providers have indicated that they have not yet seen this increased investment. For 2016-17, £119m has been allocated to CCGs, but this has not been ring-fenced – with the risk that it will be spent on other priorities. Local authority cuts may also reduce the overall budget for children’s mental health.
- The Commission also recommended that local health leaders should not receive the additional funding each year unless they can demonstrate that they have robust plans to improve care and all the additional funding is being spent on children’s mental health and is not offsetting cuts elsewhere. Sustained investment needs to be focused on early intervention, including support within schools, to stem increasing demand for specialist support. This should include an annual audit of progress in delivery of their initial local transformation plan and expenditure including for 2015/16 and 2016/17.
- There should also be a fundamental reassessment of expenditure on child and adolescent mental health when new data on prevalence is available in 2018. This should include an analysis of where investment is currently being spent, and what savings can be released through redesigning current services.
- Another barrier to improving services is workforce, where 8 out of 10 providers who responded to our freedom of information request had experienced recruitment difficulties.
- Given the limited capacity of specialist services, the growing demand, and the limitations on expanding resources caused by recruitment difficulties, there is a need for a greater focus on early intervention. The Education Policy Institute Commission recommended that every area of the country should have an easy to access early intervention service, adhering to a national set of standards.
Impact of mental health on the education system
- The cost of young people’s mental health problems has been estimated as £1778 per person per year, with 90 per cent of the cost falling on the education system. Children with mental health problems are more likely to have time off school and to fall behind in their education. An ONS study found that 43 per cent had had more than 5 days absence and 17 per cent had had more than 15 days absence in the previous term. Among those with no disorder, these proportions were much lower (21 per cent and 4 per cent). The study found that 24 per cent of pupils with mental health problems were assessed as being behind in their schooling, with 9 per cent assessed as being two or more years behind.
- According to the Department for Education, children with higher levels of emotional, behavioural, social and school wellbeing, on average, have higher levels of academic achievement and are more engaged in school, both concurrently and in later years. A US meta-analysis suggested that schools with effective programmes showed an 11 per cent improvement in achievement tests, a 25 per cent improvement in social and emotional skills, and a 10 per cent decrease in classroom misbehaviour, anxiety and depression.
- Pupils with identified special educational needs (SEN) accounted for just over half of all permanent exclusions and fixed period exclusions in 2014/15. Pupils with SEN support (identified SEN but no EHC plan or statement) had the highest permanent exclusion rate and were over 7 times more likely to receive a permanent exclusion than pupils with no SEN. Those with social, emotional or mental health needs were the most likely of all children with SEN to face exclusion (16% of all those pupils compared to a rate of 6% for any SEN). Being excluded reduces the likelihood that children will access mental health support or specialist educational services.
Access to mental health support within the education system
- Children spend over 7,800 hours in school, which makes school an ideal environment to reach young people and to intervene early when mental health problems begin to emerge. When children do not reach the threshold for a specialist service, or if they are on a waiting list, early intervention support should be offered in schools.
- Schools and colleges are on the frontline of dealing with young people with mental health problems. They currently struggle to access specialist services for their pupils. According to one survey, 50 per cent of schools were dissatisfied with local referral systems.
- School and NHS boundaries do not easily overlap. One school may interact with several mental health services depending on where their students live. In addition, the distinct training and cultures of education, social care and healthcare workers, often interacting through written communications, can hinder communication between services. Professionals are naturally nervous about dealing with situations which are out of their sphere of experience. This can mean the young person is ‘referred on’ to another service where their needs could have been met in a more coordinated way. Integrated working can support teachers in having the confidence to know when a referral to specialist services is not necessary, and could help stem the increase in referrals.
- Teachers are often not aware of the services available to help, particularly early-intervention services in the community. The current performance framework for schools does not include recognition of the role of education as a first point of contact with the wider system of state support for young people in distress.
- The government has taken steps to improve the support and guidance offered to schools, such as the MindEd resource. Education staff, however, are not always aware of these materials.
- Mental health support within schools is currently patchy and there is little data on the level of provision. The Teacher Voice survey found 52 per cent of primary schools and 70 per cent of secondary schools offered some counselling support. A Place2Be and NAHT survey found 65 per cent of primary schools were not offering counselling. Of those that did, 59 per cent were on site for one day a week or less.
- School based counselling is often funded from schools’ own budgets, including from the Pupil Premium. EPI analysis found that, due to inflation and pension pressures, schools may be left with a funding gap of 10.7 per cent in 2020-21, or £4.8bn in 2015-16 prices, which could lead to cuts in mental health provision.
- The Commission heard concerns from the NHS that schools are not bound by National Institute for Health and Care Excellence guidance on evidence-based treatment, and school counselling is under-regulated. School leaders often do not have the experience or the time to know how to commission high quality school-based counselling.
- The Commission recommended that support be provided in school, in partnership with the local NHS. This could include in-school counselling and peer mentoring. There needs to be clear guidance and national standards to ensure this support is evidence-based. Students need to be involved in the design of in-school support.
- The Commission proposed a national programme of support for mental health and wellbeing within schools. Schools, colleges and universities should be mentally healthy environments, and should adopt a Whole School Approach to mental health and wellbeing, not simply targeting support at those most at risk. This includes:
– Leadership that champions efforts to promote emotional wellbeing
– School ethos and environment that promotes respect and values diversity
– Curriculum and teaching to promote resilience and support social and emotional learning
– Enabling student voice to influence decisions
– Staff development to support their own wellbeing and that of their colleagues and students
– Identifying need and monitoring impact of interventions
– Working with parents/carers
– Targeted support and appropriate referral, with clear referral pathways for mental health as exist already for safeguarding.
- Schools should have a legal responsibility – in common with financial audit – to commission an independent annual safeguarding and well-being audit. In addition, within its existing framework categories, Ofsted should have regard to wellbeing in any inspection of a school or college. The Ofsted framework and the School Inspection Handbook should be revised to include more specific attention to mental health and wellbeing under the existing category of “personal development, behaviour and welfare”. The Independent Schools Standards should also be strengthened.
Building skills for professionals
- Teachers are not, and should not be, mental health specialists. Education staff do not always have the training to identify young people with mental health problems and to provide them with the right support. Yet teachers are often the first professionals that young people approach for help.
- School staff should know the basics of how to identify young people in need, provide the right early support and refer to specialist services where necessary. Teachers need to know what to do and what not to do in response to pupils’ mental health problems. Evidence-based mental health training needs to be part of Initial Teacher Training and continuous professional development, as recommended by the National Institute for Health and Care Excellence, along with child development, behaviour-management and SEND. Consideration should be given to amending the Teacher Standards on which ITT is based.
- Schools should have an obligation to provide the right levels of CPD training in mental health, including basic training for all school staff. There should be additional training for all teachers and TAs, and more detailed training for a mental health and wellbeing lead in every school. This should be a member of the school or college Senior Leadership Team. There should also be a named link for every school within specialist CAMHS, with joint training.
Social media and the internet
- According to the Understanding Society survey, 63 per cent of young people are using social networking sites for at least an hour every day. While 12 per cent of children who spend no time on social networking websites have symptoms of mental ill health, the figure rises to 27 per cent for those who are on the sites for three hours or more a day.
- A survey of eating disorder patients found that 35.5 per cent had visited pro-anorexia web sites; of those, 96 per cent learned new weight loss methods from such sites.
- Nevertheless, social media and the internet have also been shown to have a beneficial effect for young people experiencing mental health problems, who can connect with others going through the same experiences or access support online.
- The government should produce a strategy to empower young people to live safe digital lives. This should focus on developing young people’s resilience in the face of online threats, given the impossibility of eliminating all online risk. It should explore the potential for positive benefits from the internet and cover threats such as excessive internet use, child protection, websites promoting suicide and self-harm, and cyber-bullying. As part of this strategy, the PSHE curriculum needs to build resilience in young people in the face of online risks.
Comment – Emily Frith: ‘The Prime Minister’s Speech On Mental Health Is A Step In The Right Direction‘, The Huffington Post
Further information on the work of the EPI’s Independent Commission on Children and Young People’s Mental Health
 Kranke, et al., 2010.
 The Scottish Government, 2003. Australian Department of Health and Ageing, 2009. British Columbia Ministry of Health Services, 2003. Mental Health Literacy, Empowering the Community to Take Action for Better Mental Health, Anthony F. Jorm, University of Melbourne, American Psychologist, April 2012.
 Gowers, Thomas and Deeley 2015 survey of schools
 Education Policy Institute meeting with the Association of State Girls’ Schools 2016 and individual discussions with other teachers.
 Universal programmes in schools have resulted in moderately sized improvements to whole child population mental health, with particularly notable gains for higher risk children (Weare & Nind, 2011). Proven programmes must form part of a Whole School Approach to promoting mental health and wellbeing and should be reproduced faithfully (not adapted or dipped into). Programmes should be delivered by well trained and supervised staff (Durlak & DuPre, 2008);
 Ford et al., 2007.