Schools have an important role to play in the promotion of children's mental health, as well as in the identification and treatment of children with mental health ...
A Framework for Promoting Mental Health in School GARRY HORNBY, University of Hull MARY ATKINSON, National Foundation for Educational Research
Schools have an important role to play in the promotion of children’s mental health, as well as in the identification and treatment of children with mental health problems. This article proposes a framework for a whole school approach to mental health. The framework focuses on four levels of involvement. The most general level is concerned with school ethos, which encompasses the values shared by all staff and pupils. The next level is whole-school organization, which comprises a range of school policies. Then there is pastoral provision, which concerns procedures in place throughout the school. The final level is classroom practice, which involves the practical strategies used by teachers. A model is presented in order to illustrate visually the four levels in the framework for the promotion of mental health in schools. It is intended that the model will provide schools with a useful framework with which to review their provisions for children with mental health problems and consider the issue of mental health promotion.
Why Focus On Mental Health?
Increasing numbers of children are experiencing mental health problems. A leading authority on mental health in children in the UK has estimated that, in the average secondary school of around a thousand pupils, at any one time, there will be fifty students who are clinically depressed, a further hundred with significant emotional difficulties, ten affected by eating disorders and up to ten who will attempt suicide in the next year (Mind, 1997). Despite these factors, children’s mental health has so far been paid insufficient attention in schools; yet teachers are uniquely placed to influence the mental health of children and young people (YoungMinds, 1996). As well as being in a position to ensure that mental health difficulties are quickly recognized and treated, they can enhance the social and emotional development of all children by creating a climate that promotes their mental well-being.
According to the Mental Health Foundation (1999), schools have ‘a critical role to play’ in these aspects of mental health. Although some teachers may consider that meeting the mental health needs of children does not fall within their remit, unmet emotional needs inevitably impact on children’s learning and, according to the DfES (2001a, p. 7), ‘promoting children’s mental health within schools has important educational payoffs’. Many mainstream teachers, however, lack the necessary knowledge, understanding and skills for fulfilling this role. It is with this in mind that the authors have written a Mental Health Handbook for Schools (Atkinson and Hornby, 2002). This handbook provides detailed accounts of the childhood and adolescent mental health problems which teachers are likely to encounter. For each disorder strategies are presented which teachers can employ by way of prevention and early identification, as well as intervention for pupils recognized as having mental health problems. This is set within a framework for a wholeschool approach to the promotion of mental health in schools, the delineation of which is the focus of this article. A Whole-School Approach to the Promotion of Mental Health
The DfES (2001a) has recently advocated that schools become mental health promoting organizations. Schools provide an ideal setting for the promotion of mental well-being, not only because children spend so much time there, but also because they are the primary setting for the development of relationships with peers and adults (Dickinson, 1999). Also, schools allow regular access to all children, which means that preventative strategies can be adopted that avoid stigmatizing those who are vulnerable to mental health problems (DfES, 2001a). The DfES and the Mental Health Foundation (1999) advocate that schools should promote children’s mental well-being by having the key characteristics of: ! a committed senior management team that focuses on creating a climate based on trust, integrity, democracy and equality of opportunity, within which each child is valued regardless of ability; ! a culture that values teachers, non-teaching staff and all those involved in the care and supervision of pupils;
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Figure 1. Framework for Promoting Mental Health in Schools (taken from Atkinson and Hornby (2002, p. 264), Routledge, with permission).
! whole-school policies for important issues, such as behaviour management and bullying, that are clearly set out and accepted and implemented throughout the school.
questions are provided to help schools audit their provision.
These three characteristics should be key components of a whole-school approach to the promotion of positive mental health, the various elements of which are outlined in the model presented in Figure 1. This sets out a framework which provides guidance on the development of procedures for identification, prevention and intervention for mental health issues in schools. At the same time, it is important to recognize the initiatives already being undertaken by some schools to promote pupils’ mental well-being and to realize that much of this work can be achieved through existing policies and practices (Dickinson, 1999). Many schools, for example, are implementing the National Healthy School Standard (DfES, 2001b) which offers schools an ideal opportunity to address health issues in a whole-school way and to focus on the emotional health and well-being of its pupils, as well as other aspects of health.
School Ethos
Within the model for mental health promotion there are four levels which are: ! school ethos: which encompasses the values shared by all staff and pupils; ! whole-school organization: which comprises a range of school policies; ! pastoral provision: which concerns procedures in place throughout the school; ! classroom practice: which involves the practical strategies used by teachers. The various aspects which comprise each of the four levels are discussed below and examples of 4
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To be effective the value of mental health promotion needs to be recognized and established as an integral component of the way that the school functions (Dickinson, 1999). The aim is to develop an ethos such that everyone involved with the school – pupils, teachers and parents – has a role and responsibility to promote mental health. Mental health promotion should be the business of all teachers, who need to be conscious of their own emotional needs as well as being supportive of those of others. With a positive, caring ethos in place the school can create a safer and more productive learning environment and one that is more facilitative and therapeutic for pupils, thereby preventing the development of mental health problems. This might encompass the following aspects:
Caring for all
It is important for their mental well-being that all children are valued (Young Minds, 1996) and that children with emotional problems are seen as ‘needy’, rather than ‘difficult’ (Parsons, 1999). ! To what extent does the school communicate to all its pupils that they are valuable? ! Are children encouraged to care for each other? ! Are children with emotional or behavioural difficulties perceived to be in need of help rather than problems to be got rid? PASTORAL CARE – JUNE 2003
Valuing diversity
Participation
A key aspect of the school ethos is the extent to which the diversity of pupils is valued (Weare, 2000). A history of victimization can lead to the development of mental health problems (Resnick, Harris and Blum, 1993).
Pupils need to be encouraged to participate fully in the life of the school to promote their social development and prevent isolation. This is facilitated when pupils and parents are consulted about issues concerning the school (Weare, 2000).
! Are all pupils valued and treated equally? ! Do teachers communicate positive attitudes about children with mental health problems?
! Does the school provide opportunities for meaningful participation and contribution? ! Does the school foster a sense of community and active involvement in school processes? ! Does the school openly challenge any form of social exclusion and exploitation?
Building self-esteem
A low sense of self-worth is a common risk factor for mental health problems so the development of a positive self-esteem is important for the health of all children (Rutter, Giller and Hagell, 1998). ! Does the school environment encourage a positive self-esteem and help build pupils’ confidence? ! To what extent do teachers enhance a sense of selfworth in their pupils? ! Do teachers focus on pupils’ strengths and assets rather than their weaknesses?
Fostering independence
Research shows that mental well-being is promoted and learning more effective when pupils are encouraged to think for themselves and allowed to be independent (Weare, 2000). ! Does the school provide opportunities for pupils to take responsibility and make decisions? ! Does the school encourage the development of selfmanagement skills?
Relationships
Children’s confidence and ability thrive, even in adverse circumstances, if they come into contact with adults who they can trust and who offer them a positive relationship (Dickinson, 1999). ! Do teachers convey caring, understanding and respect? ! Are they prepared to listen and able to establish safety and trust for pupils? ! Are cooperative relationships amongst pupils encouraged? Safety
It is important that children feel emotionally as well as physically safe in the school setting. Aggressive behaviour can make children feel threatened and cause them to withdraw (Peterson and Skiba, 2000). ! Do teachers convey high expectations of behaviour, along with firm guidance and structure? ! Does the school management recognize and actively work to reduce stress? Continuity
A sense of consistency is required for children to feel secure in the school setting. Having well thought out and well-established procedures for providing pastoral care can facilitate this (YoungMinds, 1996). ! Do Heads of Year move up through the school with their cohort of pupils? ! Do teachers employ sanctions fairly and consistently? PASTORAL CARE – JUNE 2003
Whole-School Organization
The second level of the framework, whole-school organization, involves getting mental health onto the agenda of the school so that it is taken into account when considering policies and the way that the school functions (Dickinson, 1999). It focuses on the need to develop clear policies in key areas of school functioning, including, for example, pastoral care, the curriculum, pupils with special educational needs (SEN), home–school liaison, behaviour management and bullying (DfES, 2001a). These aspects of school organization are particularly important in promoting mental well-being and dealing effectively with children’s mental health problems. Pastoral care
Effective pastoral care is essential for the prevention of mental health problems and for early intervention with children who develop such problems. Schools therefore need to have a comprehensive policy and wellestablished procedures for delivering it (Calvert and Henderson, 1998). ! Are staff aware of their responsibility for the promotion of mental health and prevention of problems? ! Are there policies and procedures for mental health promotion and for addressing mental health issues? Curriculum
Aspects of the school curriculum can be used to promote mental health (DFES, 2001a). It is important r NAPCE 2003.
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that the curriculum strikes a balance between academic content and a strong focus on personal, social and moral development in order to facilitate the development of positive mental health in pupils (Best, 2000). ! Does the school curriculum focus sufficiently on personal and social development? ! Does it directly address the promotion of mental health, the prevention of mental health problems? ! Does it help pupils to learn of strategies for coping with such problems? Special educational needs
Children with SEN are at greater risk of developing mental health problems than other pupils and early intervention with learning difficulties can prevent associated mental health problems. Schools should have a comprehensive policy based on the requirements of the Code of Practice for SEN (DfES, 2001c). ! Does the policy include procedures for early identification and assessment of children with SEN? ! Does the policy include procedures for designing and reviewing individual education plans? ! Does the policy encourage collaboration with parents and outside specialists? Home–school liaison
Parental attitudes and good parent–child relations are key factors in children’s mental well-being, as well as their education, and are influential in the prevention of mental health problems (Resnick et al., 1993). Links with home are important in understanding children’s behaviour, as well as providing opportunities to establish mutual goals and to develop strategies that can be implemented both within the home and the school setting (Hornby, 2000). Many parents with children who have mental health problems feel that they are left to cope alone, so the school can often play a vital support role. ! Does the school have a policy that encourages and facilitates parental involvement? ! Do teachers convey messages to parents that support the mental health of young people, such as listening to children and setting clear boundaries? Behaviour management
Bullying
A history of victimization and the witnessing of violence are both risk factors for the development of mental health problems (Resnick et al., 1993) and bullying can lead to more serious mental health difficulties. In addressing the emotional health and well-being of its pupils, therefore, as the National Healthy School Standard (DfES, 2001b) and others (e.g. Jenner and Greetham, 1995 and Smith, 2000) indicate, schools should have a clear policy and code of practice for dealing with bullying and should focus on the development of positive relationships among pupils (Peterson and Skiba, 2000). ! Are all teachers and non-teaching staff aware of the policy and procedures in place for dealing with bullying incidents when they are encountered? ! Do the procedures ensure that incidents are dealt with quickly, consistently and effectively? ! Does the policy encourage all teachers to take responsibility for bullying? ! Are there clear rules and appropriate sanctions, as well as having systems in place to support victims? ! Do teachers focus on promoting cooperation and non-violent resolution of conflict amongst pupils? Pastoral Provision
The third level of the framework focuses on the need to develop effective provision of pastoral care within schools as a requirement for promoting mental health and supporting pupils with mental health problems. This involves having in place programmes for prevention of mental health problems, procedures for identification of disorders and strategies for intervention to remediate the various problems likely to be encountered in schools. This requires schools to have a clear policy and a comprehensive set of procedures for addressing mental health issues. Effective support can be an important means of reducing distress, isolation and helplessness for students who are attempting to cope with some form of problem. This involves having the following elements in place: Pastoral system
Mental health difficulties may manifest themselves in the form of challenging behaviour that is difficult to deal with in the school setting. Whilst children may require individual treatment, effort also needs to be put into improving behaviour management within the school (Cooper, Smith and Upton, 1994). ! Does the school have a behaviour policy that is known to all school staff, pupils and parents? ! Is the policy agreed to, and adopted, by all staff and understood by all pupils? 6
! Does it focus on encouraging positive behaviour, as well as sanctions, and setting clear boundaries?
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The way that the pastoral system is set up is important in helping pupils to settle into the school environment, providing vulnerable pupils with a sense of security and in helping them to address any difficulties they may encounter. The National Healthy School Standard (DfES, 2001b) advocates that a healthy school needs to ensure that, when pupils are unhappy, anxious, disturbed or depressed, there are open channels for them to seek or be offered support, without stigma and with appropriate confidentiality. PASTORAL CARE – JUNE 2003
! Is there an effective pastoral system in place and are all teachers aware of their pastoral responsibilities? ! Are pastoral support plans (DfEE, 1999) used in a positive way to support pupils in school? ! Is the pastoral system seen as supportive rather than disciplinarian in nature? Early intervention
Schools need to be able to identify problems early so that more serious mental health problems can be averted. Raising the awareness of teachers to potential problem situations is therefore important (Atkinson and Hornby, 2002). The SEN Code of Practice (DfES, 2001c) provides a framework for identification, assessment and provision of support for pupils at different stages. ! Are children screened at an early age for social and emotional difficulties? ! Are learning difficulties picked up early so as to prevent secondary mental health problems? Support for vulnerable pupils
Personal counselling is a fundamental part of effective pastoral care that can help prevent more serious mental health problems from developing (Beynon and Wright, 1997). As part of the pastoral system, therefore, pastoral staff, such as heads of year and form tutors, need to be able to use counselling skills to help pupils with day-to-day problems (Hamblin, 1993). A trained specialist within the school, who can offer more in-depth counselling on an individual or small group basis when required is also helpful. In addition, it is important to recognize that children may be particularly vulnerable at certain periods of their life or particular stages in their education and may require extra support at this time. ! Does the pastoral team use counselling skills effectively to support pupils with personal problems? ! Are pupils supported through potentially difficult periods, such as the transition to secondary school? ! Is there a trained specialist in the school who can support pupils with more serious problems? Organization of PSE
By having a comprehensive personal and social education programme, which focuses on social and emotional development, schools can have a positive influence on their pupils’ mental well-being. This involves addressing the issue of mental health through the process, as well as the content, of PSE so as to enhance pupils’ social skills, coping strategies and emotional literacy. The National Healthy School Standard (DfES, 2001b) stresses that a healthy school programme recognizes that personal, social and health issues in all facets of school life are interlinked and this PASTORAL CARE – JUNE 2003
can provide a useful framework through which schools can focus on such issues. ! Are all teachers involved in delivering PSE? ! Do they all have the necessary skills for effective teaching of PSE, e.g. for group work? ! Do tutors use counselling skills effectively to facilitate group activities as part of the PSE programme? ! Is the issue of mental well-being infused into all subjects across the curriculum, as well as being included in the tutorial work programme? Support and training for teachers
It is unrealistic to expect teachers to be able to achieve their role in preventing mental health problems alone. It is important that they have some knowledge and understanding of the types of difficulties they may encounter (DfES, 2001a) and receive adequate training. Working with emotionally disturbed children can be particularly stressful and challenging as it can involve high levels of emotion. This can lead to debilitating levels of stress, so it is important that they are given supervision and support. ! Do pastoral staff have the relevant training to help them recognize mental health problems and enable them to offer support and counselling? ! Do teachers have a good understanding of mental health problems and know when to refer on? ! Are teachers supported in pastoral work through supervision, training, and links with external agencies? Liaison with external agencies
Teachers often have limited training, time and resources with which to deal with pupils’ mental health difficulties, or to provide effective counselling for distressed students or their parents (Branwhite, 1994). For this reason, in many cases, teachers may need to refer pupils and their parents to other agencies, such as the Educational Psychology Service or Child and Adolescent Mental Health Services (CAMHS). These services can also offer teachers support and training. ! Are students directed to other forms of appropriate help outside the school, such as CAMHS? ! Are pupils in need referred efficiently and effectively to external agencies for specialist help? ! Are there effective links with the local CAMHS team so that teachers can receive consultation, training and support with mental health issues? Classroom Practice
The fourth level of the framework focuses on the need to develop effective classroom practice for promoting the development of children’s mental health. This practice needs to be based on a thorough underr NAPCE 2003.
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standing of children’s development and the mental health problems to which they may be susceptible. Classroom practices for the promotion of mental health focus on the following areas: Facilitative teaching
A key factor in promoting children’s mental health in schools is the rapport which teachers develop with their pupils and the way that they use their skills to facilitate cooperative relationships amongst pupils. Strategies, such as peer tutoring (Topping, 1995) and cooperative learning (Johnson and Johnson, 1999), can be used to encourage pupils to help one another. ! Are teachers approachable and do they develop constructive relationships with their pupils? ! Do teachers motivate pupils through the use of encouragement and rewards? ! Are teachers fair and consistent in their enforcement of sanctions and in setting behavioural limits? ! Do teachers foster cooperation among their pupils? Personal and social education
Teachers have an important role to play in the personal and social education of their pupils, in teaching them to become emotionally literate (Goleman, 1998; Sharp, 2000), as well as preventing emotions being built up with the potential for later problems. The National Healthy School Standard (DfES, 2001b) states that pupils should be encouraged to express and understand their feelings and that issues of emotional health and well-being should be addressed openly. This can be achieved through the use of Circle Time (DfEE, 1999; Lang, 1998; Mosely, 1996) and other approaches, such as nurture groups (DfEE, 1999), peer support (Cowie and Wallace, 2000) and personal development programmes (Bell, 1998). ! Do teachers provide their pupils with opportunities to talk about their feelings? ! Are such opportunities structured into the school day? ! Are there strategies in place for developing pupils’ self-confidence and promoting their social skills? Guidance
Guidance involves helping students make personal, educational or vocational choices. At classroom level this involves the provision of information by classroom teachers as part of a wide range of subjects in the curriculum in order to provide pupils with the knowledge to make such choices (Hornby, Hall and Hall, 2002). ! Is this form of guidance infused throughout the curriculum? ! Do all teachers actively support pupils on a day-today basis with these types of decisions? 8
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Counselling
Whilst all teachers cannot be expected to be trained counsellors, they can be trained to use counselling skills (Lane, 1996; Lloyd, 1999). A key aspect of counselling for classroom teachers is the use of active listening (Hornby, 1994) which, it has been suggested, is the single best way to help those with emotional difficulties (Weare, 2000). ! Are teachers trained to use counselling skills to advantage both inside and outside of the classroom? ! Do teachers use counselling skills effectively within the classroom in order to provide a positive learning environment and promote high levels of pupil selfesteem?
Conclusion
Schools have a vital role to play in the promotion of children’s mental well-being and the prevention of mental health problems. Teachers need to be aware of the importance of fulfilling their roles in providing a whole-school approach to mental health. They also need to understand the influence of factors at each of the four levels involved: school ethos; whole-school organization; pastoral provision; and, classroom practice. Schools need to address the various aspects of the model at each of the four levels described in this article. It is also important for all teachers to be able to identify the different mental health problems and disorders they may encounter and to be able to implement effective strategies for dealing with them. Further information on children’s mental health problems and what teachers can do to help can be found in the Mental Health Handbook for Schools (Atkinson and Hornby, 2002).
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MIND (1997) The Bird and the Word: Materials for Mental Health Education in Secondary Schools. London: Mind. MOSELY, J. (1996) Quality Circle Time. Cambridge: LDA. PARSONS, C. (1999) Education, Exclusion and Citizenship. London: Routledge. PETERSON, R. L. and SKIBA, R. (2000) ‘Creating School Climates that Prevent School Violence’, Preventing School Failure, 44 (3), pp. 122–9. RESNICK, M., HARRIS, I. and BLUM, R. (1993) ‘The Impact of Caring and Connectedness on Adolescent Health and Wellbeing’, Journal of Paediatrics and Child Health, 29, pp. 823–32. RUTTER, M., GILLER, H. and HAGELL, A. (1998) Antisocial Behaviour by Young People. Cambridge: Cambridge University Press. SHARP, P. (2000) ‘Promoting Emotional Literacy: Emotional Literacy Improves and Increases your Life Chances’, Pastoral Care in Education, 18 (3), pp. 8–10. SMITH, P. K. (2000) ‘Bullying and harassment in schools and the rights of children, Children and Society, 14, pp. 294–303. TOPPING, K. (1995) Paired Reading, Spelling and Writing. London: Cassell. WEARE, K. (2000) Promoting Mental, Emotional and Social Health. London: Routledge. YOUNGMINDS (1996) Mental Health in Your School: A Guide for Teachers and Others Working in Schools. London: Jessica Kingsley. Correspondence Mary Atkinson NFER Northern Office Genesis 4, Science Park University Road, Heslington YORK YO10 5DG
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