The need for school-based mental health interventions
According to an NHS Digital survey, one in six (17.4%) children and young people age 6 to 19 years experienced a probable mental health disorder in 20211. While the Covid-19 pandemic likely contributed to this finding, the prevalence of mental health concerns in this age group was around 13%, even before the pandemic2.
To tackle this issue, interventions, ideally with a preventative approach, are vital to provide children and young people with the tools they need to handle challenges in their lives. In principle, schools are an ideal place to implement such interventions, allowing for all children and young people to be reached, independently of their socioeconomic background or their parents’ attitudes towards mental health.
In a 2019 survey, 79% of schools in England stated that they were taking a whole-school approach to promoting positive mental health and wellbeing3. This finding is promising but raises the question of whether, and if so which, school-based interventions are effective in preventing and/or treating mental health difficulties.
Anecdotal evidence for the effectiveness of school-based interventions
Anecdotal reports from students and teachers taking part in school-based mental health interventions highlight a number of benefits derived from such programmes:
“I have learnt many key skills so far this term. Many I think I will take further through my life. Resilience - I have learnt to become strong, and know when to say no... I have learnt to speak my thoughts a bit more, be more honest and take responsibility for my own actions. I also have learnt about risk taking. …[taking] the initiative to say ‘yes’ when [a] chance [comes] my way…What is also important is my understanding of myself, and what I can do. I am learning to prioritise my work, be more structured in my day, and keeping calm, when originally I would panic about work.” (Year 12 student taking part in a four-year school wellbeing programme focused on the habits of good living that will bring about flourishing4)
“[The] Paws b [mindfulness programme] has changed the children’s lives in such a positive way …[which is reflected in] our classroom climate... With the challenges of our children recovering from the pandemic, not only academically but physically and mentally too, Paws b has given them the strategies to cope with their everyday lives. The children had to learn to be together again in a classroom environment, they were struggling with relationships inside the classroom and how to deal with tricky situations on the playground, in class, and at home too.
The impact has been immense, with the survey the children took reflecting this. They are now able to recognise their different emotions and how to deal with them using mindfulness. Now the children understand the four areas of the brain that can be developed through mindfulness, they are able to use this knowledge and understanding to help them react positively in different situations. As we all know, knowledge is power and the children loved learning the Science aspect of Paws b too.” (Teacher taking part in Paws b, a programme teaching skills of mindfulness to 7-11 year olds5)
“If I get into an argument … I use some of the techniques that [the programme facilitator] taught us. … [I’d] either tell the person to just leave me alone or, if they didn’t do it and they carried on, I’d just walk away or I’d tell a teacher that they’re annoying me. Before, normally I’d probably just carry on arguing and end up in sort of like a big argument and would probably end up fighting”. (Year 7 student taking part in the UK Resilience Programme6)
These examples are encouraging. However, in order to provide strong evidence for the far-reaching effectiveness of school-based mental health interventions, controlled research studies are needed.
Research evidence for the effectiveness of school-based interventions
A wide range of mental health interventions have been trialled in schools as part of research studies. This includes interventions based on Cognitive Behavioural Therapy, interpersonal therapy, positive psychology, mindfulness, and mental health education7. However, many studies do not provide convincing evidence for the effectiveness of the interventions they examined. Some studies used flawed methods, such as not including a control group or testing only a small number of students8–10. Other studies were methodologically sound but did not demonstrate consistent improvements in mental health difficulties immediately and/or several months following the intervention11,12. Nevertheless, some favourable results have been obtained, mainly by interventions that are based on Cognitive Behavioural Therapy (CBT) techniques.
For instance, a CBT-based intervention (Stressbusters) implemented in three large secondary schools in South London yielded encouraging findings. As part of the intervention study 112 12- to 16-year-old students with mild to moderate depression symptoms either took part in an eight-week computerised CBT programme or were allocated to a waitlist control group. During each intervention session, students individually completed an online lesson including animations, videos and interactive exercises. Intervention components included: psycho-education about depression and its treatment, behavioural activation, recognising and changing negative automatic thoughts, improving problem solving and social skills, and relapse prevention. After the intervention, participating students demonstrated significantly lower depression and anxiety scores compared to the waitlist control group, with a clinically meaningful symptom reduction compared to their initial scores collected before the intervention13.
Another intervention demonstrating beneficial effects was carried out in 41 junior schools in Southwest England as part of a study that included 1262 9- to 10-year-old students. The intervention (FRIENDS) consisted of nine lessons delivered to all students in participating classes by trained health facilitators (health-led) or by members of the teaching staff (school-led). Following CBT principles, the lessons aimed to counter the cognitive, emotional, and behavioural aspects of anxiety, helping children to develop emotional awareness and regulation skills, to identify and replace thoughts that increase anxiety, and to improve their problem-solving skills. It was found that, after 12 months, students in the health-led intervention group showed a clinically significant decrease in anxiety, compared to the control group. However, it should be noted that this effect was not seen in the school-led intervention group14.
A further CBT-based intervention with favourable outcomes was implemented in nine primary schools in central Scotland as part of a study that included 317 9- to 10-year-old students. The intervention consisted of ten lessons delivered to the whole class by psychologists or teachers following a manual. It aimed to teach children new skills, giving them the opportunity to practice and reflect on how they might apply these skills to problems in their life. Specifically, lessons were designed to help children to recognise their own emotional symptoms, to decrease avoidance coping strategies, and to encourage proactive problem solving and support seeking. Breathing, muscle relaxation, and visualisation exercises were also included. Both the psychologist-led and teacher-led intervention groups showed significantly lower anxiety, lower avoidance coping, and higher problem-solving scores compared to the control group immediately and 6 months after the intervention15.
These studies are encouraging with regards to the effectiveness of CBT-based mental health interventions delivered in schools. However, other school-based interventions, including some that incorporate CBT techniques, have demonstrated no consistent improvements in students’ mental health difficulties16,17. This raises the question of what factors may prevent interventions from yielding beneficial outcomes.
Barriers to the effectiveness of school-based interventions
A number of challenges have been reported during the implementation of school-based mental health interventions which may negatively impact the interventions’ effectiveness.
Firstly, the limited training and lack of ongoing support received by teachers delivering the interventions may have a detrimental effect, leading to an incomplete understanding of the intervention methods and deviations from the delivery protocol12,14,16. For instance, one study reported that teachers did not give out the intended home assignments in 40% of sessions, thus limiting students’ opportunities to practice the skills they learned during lessons14. Recruiting specialists to run the intervention, or providing ongoing support for teachers rather than just initial training, may increase intervention effectiveness, in addition to ensuring that a clear protocol for intervention delivery is provided12,16. However, it should be noted that budgetary constraints form a barrier to this approach.
Secondly, intervention delivery may be hampered by a lack of commitment of teachers to the programme, due to prioritisation of academic targets and a perception, which has been voiced by some teachers, that supporting emotional wellbeing is ‘not real work’ because it is not tested and does not lead to a qualification17,18. Hence, it is crucial to convey the importance of mental health support to teachers, ideally through an authority figure such as the principal or a respected colleague, and to gain buy-in for the delivered intervention.
Moreover, it has been pointed out that some interventions may not be delivered across sufficiently long periods of time12,19 and/or may be too narrowly focused. Children’s developmental trajectories are influenced by a range of factors beyond the school environment, including their family circumstances, peer group, and community17,20. Thus, it may be beneficial to design more comprehensive interventions which, for example, incorporate parental involvement and/or are co-designed with students to better align content and structure to students’ needs, and increase their engagement. Additionally, it is important to ensure that students have the opportunity to build strong relationships with the teachers who are providing mental health support20.
Lastly, intervention effectiveness may vary depending on the type and severity of symptoms experienced by students, and preventative interventions delivered to whole classes of students may need to incorporate different components than approaches targeting students with current mental health difficulties16,17,20,21. In this context, it is especially important to consider whether a given intervention could have a harmful effect on certain subgroups of students. For instance, mindfulness-based cognitive therapy has been shown to increase depression symptoms in adolescents, especially in those at a high risk for depression, and in younger students 21,22. This also highlights the need to determine the effectiveness of an intervention for a given age group17. Further research into this area is needed.
Conclusion
Given the reported increase in mental health challenges in school-aged children and young people, school-based mental health interventions have the potential to have a substantial positive impact. While some CBT-based programmes have shown promising results, and therefore appear to be worth considering using more widely, a number of interventions have not demonstrated a consistent and sustained positive impact on students’ mental health, and some may even have harmful effects.
It may be possible to increase the effectiveness of interventions by providing ongoing support to teachers delivering the interventions, by recruiting specialists where resources permit, by broadening the approach to include parents, by co-designing programmes with students to increase engagement, and by finding ways to secure teachers’ buy-in. Further research is needed to determine which interventions are effective in maintaining the mental health and wellbeing of the majority of students who do not have a probable mental health disorder, which programmes are effective for which symptom types and severity for those students who do experience mental health challenges, and which age groups should be targeted, in what ways, to maximise intervention effectiveness.
Anna Frey and Barbara Baker, August 2022
References
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