ARTICLE: Knowledge dispels fear – children & young people’s mental health by Andrew Martin of Safeguarding Network
For the first time this month, NAPCE is delighted to team up with Safeguarding Network to publish the first in a series of articles concerned with keeping children and young people safe in the school environment.
Safeguarding Network was established in 2017 by John Woodhouse and Andrew Martin, two social workers with more than 40 years combined experience working with children and young people.
The organisation is concerned with the increasing requirement on schools to fill the void left by decreasing social care budgets and the sparse support available for schools when responding to a matter not deemed to meet the social care thresholds.
And to mark our collaboration, Safeguarding Network – which has a large number of valuable resources on subjects affecting the safeguarding of children – is offering a £20 discount off the first term of subscription (£79 instead of the normal £99).
For those joining in the half term, your membership will be extended until the Easter term for the one price.
To take advantage of this offer use the code ‘NAPCE’ when taking a subscription through their website here https://safeguarding.network
In this first article Andrew Martin offers insights and advice into dealing with mental health matters in schools from a safeguarding perspective.
Knowledge Dispels Fear – Children & Young People’s Mental Health
Why you need to know about children and young people’s mental health (in 60 seconds)
Mental ill health and specifically children and young people’s mental health is an emotive subject. Often staff will avoid talking about mental health with both peers and the young people they work with because of fear of the unknown. This stigma however serves to isolate the young person further at a time when they need help and support the most. On other occasions a young person may be seen as having behavioural issues and work is done with them to address this as opposed to recognising that the behaviour is linked to and an expression of mental ill health .
By reducing the stigma and helping children and young people to develop social and emotional resilience we can reduce the impact of mental ill health on individuals. By providing staff, children and young people with the knowledge to talk about mental ill health, we can reduce the fear response that is triggered when faced with unknown situations and instead focus on the needs of the individual.
Some groups of children and young people are more vulnerable than others, however the pressures of the school system (for example transitions and national examinations) can lead to the most emotionally resilient child developing mental ill health. Social media and modern technology are also cited as cause of mental ill health and so it is important that these areas are considered in the wider curriculum and as potentially affecting the many, not just the few.
Time to Change, a collation of charities working in the mental health arena, published a blog in July 2018. The author, aged 15, stated they had recently been told by one of their classmates that “they didn’t want to be involved with someone who self-harms”. The author goes on to set out that self-harm is addictive, and in a similar vein to smokers and drug users the author describes self-harm as a stress relief, anger release as well as serving other purposes. However, the issue is that the people who are potentially best placed to help are those who do not want to or feel unable to.
Mental health is a difficult subject for many people, young and old alike. Yet mental ill health is common, with it estimated that 25% of people will experience mental ill health at some point in their lives. In an average classroom of 30 children this means that on average between 7 and 8 children will have a period of mental ill health in the life that is ahead of them. NHS data (2016) builds on this suggesting that at least three children in every class (one in ten aged 5-16) has a diagnosable problem (e.g. conduct disorder, anxiety disorder, attention deficit hyperactivity disorder or depression), with half of these children having an established mental health problem by the time they are 14 years old. The same report reinforces that children experiencing these conditions are more likely to have poor outcomes upon leaving school.
The Royal College of Paediatrics and Child Health (2018) highlight that this is an increasing issue, particularly amongst girls. They summarise that:
“Although data are insufficient to estimate trends for diagnosed mental health disorders, reported mental health problems have increased five-fold over the past 20 years and will increase a further 63% by 2030 if current trends continue.” (p.4)
Stigma can be seen in different ways, for example “a mark of disgrace associated with a particular circumstance, quality or person” (Oxford Dictionaries), or “a negative set of beliefs that a group of people have about something” (YMCA, 2016). Essentially however it is negative thoughts attached by an individual or group of people to a certain situation / presentation. In this case the certain presentation is mental ill health.
Figures about the impact of stigma vary. Ditch the Label cite an oft-quoted statistic that 9 out of ten people with mental ill health report the negative effects of stigma and discrimination and consider this to be directly linked to their mental state. This statistic appears to have come from research undertaken in 2006 by the Mental Health Foundation which puts the issue of stigma in relation to mental ill health succinctly thus:
stigma projects the fear and anxiety felt by members of the general population onto the person with the diagnosis. People with a diagnosis do not really carry a mark that sets them aside. (p.2)
More recent research by the YMCA (ibid.) specifically looking at stigma faced by young people suggested that the figure was lower at around 1 in 3 (38%) of young people with mental health difficulties experiencing the negative impact of stigma. A third of those reporting difficulties stated that they experienced stigma at least once a week. This research highlighted that the majority of stigma was experienced in schools and around half of young people stated that the source was their own friends.
It is however clear that, regardless of the statistics, there is a significant stigma present in relation to people with mental ill health.
Behavioural issues or mental ill health?
As well as the stigma that comes with mental health issues, there is also the question as to whether we are correctly recognising issues as they develop in the classroom. As asked by a recent BBC article (2018), are these children with problems or problem children? It is well known that as children develop and grow, they develop awareness and understanding of not just the world around them, but also their changing emotional responses to what happens to them directly and indirectly.
How a child responds to challenging situations is individual to them and caught up in both sides of the nature / nurture argument. There is a growing body of research over the last two decades (e.g. Glaser, 2000) evidencing that brain development, even at the point where the child is still in the womb, can be negatively impacted on by stress and adverse childhood experiences (e.g. being abused, witnessing domestic abuse or parental drug and alcohol abuse). This can then lead to poor stress management in later life – nurture clearly influencing nature. This coupled with experiences in school, at home and amongst a young person’s peer group means that for some feelings around not being able to cope with stress and worry develop into something more enduring and persistent.
When faced with difficult or unknown situations a common and automatic response is the fight or flight response (explained in this video). For those who choose to fight, this can lead to labels of disruptive behaviour. Acting out can also be a way of avoiding stigma by hiding the true issue behind something else.
Research from the US (2018) suggests that difficulties in managing developing emotional may not solely be impacted on by negative stress inducing experiences as a child grows up, but also by what has been termed helicopter parenting. Such behaviour can include “parents constantly guiding their child by telling him or her what to play with, how to play with a toy, how to clean up after playtime and being too strict or demanding.” The research showed that the constant presence of the parent impacted the development of impulse control and consequently a child’s emotional regulation.
As set out in government issued guidance it is therefore important that schools fulfil the role that they have in enabling pupils to be resilient and develop good mental health. However, on the other side of this it is equally important that it is recognised when a child or young person is suffering from poor mental ill health and that they are supported.
Reducing the stigma
As well as considering how to support children and young people to develop social and emotional resilience, there is a need to reduce the stigma around mental ill-health. It is here where, as suggested by the title of this article, knowledge dispels fear. Many of the behaviours associated with mental ill-health are seen as taboo subjects, things that should only be addressed with the young person by people who have proper training, e.g. psychiatrists and psychologists. The fear is that if you have not had the proper training then you are going to make things worse.
Let us consider self-harm. Research by the Mental Health Foundation (2012) suggests that at least 1 in 15 young people self-harm, this translating into two children / young people in every classroom. The research paper argues that this is a high statistic that makes self-harm relatively common amongst school age children, before pointing out that there are many myths and misunderstandings in relation to self-harm. In a handout the Samaritans identify 5 of the more common myths about self-harm, including that it is attention seeking behaviour. As the handout identifies, people who self-harm are more likely to do it in private without attracting the attention of others.
Another misconception is that self-harm is primarily cutting, however it can also include burning, scalding, scratching, hair pulling and inducing illness amongst other things. Often however, self-harming behaviour is the exact opposite of attention seeking behaviour. If, for example, the mode of choice is cutting, then it is likely that the individual will cut themselves and clean themselves up in private and either wear clothing that covers their cuts or cut themselves in places that are not generally visible to others.
Another common myth in relation to self-harm is that people who do it want to kill themselves – often however self-harm is a way of coping with what is going on and preventing the person from spiralling out of control and ending up in a place where the only option is to take their own life. The fear of loosing this outlet is often what stops young people from talking about the fact that they are self-harming.
In the same vein as when disclosing abuse by another person, if a child or young person discloses that they have self-harmed the response they get will determine whether they open up or look to continue to hide it. Research shows that young people want “empathy, care and concern for their injuries, time and support, as well as encouragement to talk about the underlying feelings or situations that have led them to harm themselves.” (p. 30, Mental Health Foundation, 2012)
It is therefore important that these myths are debunked wherever possible, both with staff and pupils alike. Equally there is a need for staff to be clear about when to refer on for example if a child is expressing suicidal ideation.
Self-harm and thoughts of suicide can however be seen as the higher end of mental ill health issues. Action for Children identified that of the 5,000 15-18 year olds that they spoke to, 33% reported that they were struggling with some aspect of their mental health, with common problems including:
Inability to shake negative feelings
Struggling to ‘get going’
Feeling like everything is ‘an effort’
The challenge is therefore how to ensure that your staff are aware of children and young people who may be experiencing difficulties and ensuring that they feel empowered to have what they may see as a difficult conversation.
As with other areas where you may have concerns, conversations may be difficult for two reasons.
Not knowing how to start the conversation – it is not possible to have the answers to everything, or the knowledge to be able to solve every problem, however as the Samaritans set out, focusing on feelings may be what’s needed instead of trying to solve the problem instantly.
Personal impact – talking to someone about their mental health and associated feelings, reasons, etc. may be too close to home for some people and therefore it is better to avoid it than have to deal with it. As identified by this Anna Freud Centre resource, supporting the wellbeing of staff is just as important as supporting the mental health and wellbeing of the pupils.
Any approach therefore needs to be multi-faceted – empowering staff, debunking myths and providing staff and pupils with knowledge about mental health and mental ill health.
High risk groups
As with all areas in relation to safeguarding there are cohorts of children and young people who are more at risk of developing poor mental health.
In responding to data for England released by NHS Digital in November 2018, the Anna Freud Centre stated:
Everything we know from the evidence tells us that the increase in mental health problems and the detail behind today’s figures can’t be reduced to a single cause. What we do know is that these figures confirm that overwhelmingly and consistently poor mental health has been linked to social pressure and deprivation. It shows that children living in households with the lowest income are about twice as likely as those living in the highest to have a disorder.
The Care Quality Commission (2018) identify the following groups as being more vulnerable to poor mental health:
Children who experience multiple complex life events, such as parental mental illness, substance misuse, poverty, neglect, abuse, domestic violence and sexual exploitation;
Children and young people with disabilities, neurodevelopmental and long-term conditions
those in the criminal justice system (these include the children of parents who are prisoners);
refugee and asylum-seeking children;
lesbian, gay, bisexual and transgender (LGBT) children and young people;
looked after children, care leavers and adopted children and young people;
bereaved children and young people;
It is not however only these groups that can experience mental ill health – there are certain points in a child’s education that can impact on the most emotionally resilient child, for example transition to another school and national exams (SATS, GCSEs, A-Levels, etc) and therefore we need to ensure that all are mentally well, not just the high-risk groups. Nuffield Health go so far as to suggest that schools should have a Head of Wellbeing, citing the positive effects on the staff and student body of a pilot study in one secondary school.
Other factors can also impact on children and young people’s mental health. The Office for National Statistics (2018) shows that at least 1 in 10 children reported that they are “often” lonely, going up to around 1 in 5 of those living in a city. The data also shows that girls are often more likely to feel lonely than boys. One of the recommendations young people make to combat loneliness is to increase positive use of social media. The emphasis here needs to be on the word positive, as the Centre for Mental Health issued a briefing paper in September 2018 looking at the impact of social media on young people’s wellbeing, identifying how fear of missing out, jealousy and addiction to social media can all have a negative impact on a young person’s mental health. The Chief Medical Officer has also warned of the danger of social media on children’s mental health – citing evidence that shows that children who spend more than 3 hours using social networking websites on a school day are twice as likely to report high or very high scores for mental ill-health.
The multi-agency response to children living with mental health issues has been set as one of the key themes of a joint targeted area inspection (JTAI) in summer 2019. These see Ofsted along with other inspectorates looking at how well agencies work together to protect children.
Mental health and safeguarding
So when does child mental ill health become a safeguarding matter? Ofsted (2018), in their guidance for inspectors, are clear stating:
Safeguarding is not just about protecting children, learners and vulnerable adults from deliberate harm, neglect and failure to act. It relates to broader aspects of care and education, including:
children’s and learners’ health and safety and well-being, including their mental health (para 11, p.6)
The guidance is therefore clear that there is a responsibility on schools to protect the mental health of pupils – in this case the matter falling under the wider context of safeguarding.
The majority of Safeguarding Children Boards (or their replacements) have some form of a threshold document. Within this it is likely that the issues discussed in this article will feature and will indicate that some level of additional help or support is required. For individual pupils there will be a need to determine where they fall on any threshold matrix, factoring in what else you know about the child and their circumstances – the contextual information will be important in helping to understand what the underlying factors are.
As with other safeguarding matters:
Ensure that your staff are equipped to recognise mental ill health and know how to respond, with clear recording of all steps and decisions taken.
Act early where there are concerns – you may be able to support the young person in school without needing to refer on, but know your limitations.
Where there are concerns the impact of mental ill health, for example persistent self-harm or prolonged inability to cope, follow your safeguarding policy and refer on as appropriate.
Unless you consider there to be significant risk of further harm by doing so, you should involve parents / carers in your decision-making.
If other agencies are involved, hold them to account and be clear about your expectations of them.
If necessary, follow the safeguarding partnership escalation process in your area, advocating for your children and families. Record and track this as a school.
If there are gaps in service provision, work with colleagues in other schools to establish the extent of the issue locally and escalate it to your local partnerships.
Ultimately, if a child or young person is expressing suicidal ideation it is important that you get advice and support urgently – many young people who go on to take their own life have previously told a professional about their intention.
Against a backdrop of shrinking services and increasing needs there are still areas which remain difficult to talk about and essentially run the risk of becoming off limits. Mental health is one of these areas, however as we have seen, knowledge dispels fear. Debunking myths around mental health and ensuring that staff are equipped with the knowledge around approaching mental health issues and how to have difficult conversations are key. Contextual safeguarding is instrumental in helping to identify children and young people at risk of deteriorating mental health and, where possible early intervention to help children and young people develop appropriate social and emotional skills.