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Child and adolescent mental healthMental health and society

New ways of thinking about the mental health and wellbeing of primary school-aged children

26 June 2018

Growing socio-political interest in child and adolescent mental health

A broad consensus among research suggests that 10 percent of children and young people in the UK have a clinical-level diagnosable mental health condition such as anxiety or depression.

There is a substantial research base which connects poor mental health in children with a range of negative educational, social and physical health trajectories in adulthood. Social and political interest in these interventions has grown exponentially over the past 20 years.

Increased importance has also been attributed to early intervention and prevention, catalysed by research into the prevalence of mental health conditions. Time-trend data shows that the median onset age of generalised anxiety disorders is 11, which makes primary schools a logical environment for mental health and wellbeing interventions.

The enhancement agenda

School-based interventions frequently combine the teaching of social and emotional learning (SEL), including skills such as relationship competence and self-awareness, with preventative approaches which seek to mitigate and ideally prevent symptoms of a range of different conditions such as anxiety and depression from developing in future years.

Recent US research using a 13-19 year longitudinal cohort has suggested a significant association between the teaching and monitoring of social and emotional skills and a number of positive outcomes relative to education, employment and mental health.

 The verdict on current interventions and provision

Alongside rapid increases in interventions, there is an expanding body of evaluation research into the effectiveness of these programmes.

Typical outcome measures include increased social and emotional competence, reduced mental health problems including internalisation symptoms, and improvements in academic attainment.

Systematic reviews and meta-analyses, which combine a range of interventions into one analysis, often conclude that although mental health and wellbeing programmes in the UK sometimes achieve their intended impacts in the short-term, these promising effects are all-too-often truncated or significantly reduced after six months.

Why don’t interventions always work as intended?

Poor implementation of interventions is an often-cited reason for ineffective outcomes. This was one of the problems found to be the case in a flagship UK-government sponsored SEL programme, the Social and Emotional Aspects of Learning intervention.

We can also hypothesise that programmes have endured a lack of cultural adaptability with the social environment in which they are based. This was the case with a popular US-based intervention (PATHS) which has been frequently delivered in the UK in primary schools.

The quality of this evidence-base is hindered by inconsistencies in evaluation methodologies. Evaluation studies frequently do not have longitudinal or controlled elements, which makes it difficult to appraise the effects of an intervention over a longer time period, or compare the effects with a population group who did not receive the same intervention.

The role of theory

Interventions are still often developed using theories of behaviour change, and centred on the individual rather than the social system in which they operate.  Purely individualistic approaches to these interventions can decontextualize social environments and subsequently neglect the influence of social structures on health outcomes.

Combining theories from disciplines including education, psychology and sociology is therefore a potentially more effective way of thinking about social interventions.

The role of social, cultural and environmental context

An emerging canon of work in public health suggests that focusing on the social, cultural and environmental contexts of social systems, rather than interventions in isolation, is a more effective way of developing sustainable settings for health promotion.

My research therefore looks to explore these contexts in relation to primary schools and their wider systems. It will do this by exploring a range of stakeholders’ perspectives on the determinants of child mental health, current intervention work in primary schools and what they believe makes their system more sustainable, and seeks to co-produce context-specific knowledge for future intervention development.

Methodological work with primary school pupils

I have also been running workshops with year five and six pupils in both inner-city and rural primary schools, and with different social demographics, and have designed two visual research methods designed to both engage pupils and schools in mental health research as well as answering study questions related to the progression of contextual knowledge for mental health programmes.

The first method, ‘brain mapping’, was developed based on the body mapping approaches in physical health research. This was used in conjunction with elicitation cards centred on previous interdisciplinary research, including epidemiological, psychological, sociological and educational studies into the child mental health, and was used for mapping pupils’ perceptions of their own biopsychosocial determinants.

The second method, circle ranking, was utilised to rank, compare and discuss a range of school-based mental health programmes. Elicitation cards this time were based on previous research with a range of school staff involved in programme delivery and organisation, where interventions and approaches used by both schools were discussed in semi-structured biographical interviews.

Initial conclusions

As a result of these workshops I am working with schools involved to produce reports which they can subsequently use for their mental health and wellbeing work and for future action plans and self-evaluations.

These methods have been evaluated for their suitability for engaging pupils and schools in interdisciplinary mental health research, and though the project is still ongoing, initial conclusions are positive based on verbal and written feedback, both in person and in anonymous reports from pupils and schools.

These suggest that this visual work is relevant and interesting for a range of pupils in different social, cultural and environmental settings, and is useful for progressing context-specific knowledge for developing mental health and wellbeing interventions across these different settings.

I have also used this feedback process to further improve the methods for future workshops and projects relative to the determinants of child mental health.

I will be presenting the full findings from this methodological work at the annual WISERD conference on the 18-19 July as well as the Interdisciplinary Social Sciences conference in Granada on 25-27 July.