Mental Health and Behaviour in Schools – November 2018

The introduction to ‘Mental Health and behaviour in schools' says that it will help schools identify ‘whether a child or young person’s behaviour…may be related to a mental health problem, and how to support them in these circumstances'. Unfortunately it doesn't.

Whenever I talk to DSLs, the topic of poor mental health amongst the children and young people they work with always comes up. Services are dwindling, access seems almost impossible and the stresses of life continue to increase. These comments are true whether I am working with a school in an economically-challenged area or an affluent one.

School staff feel at a loss of how to help, other than by listening and being kind. They can feel overwhelmed by the child's situation and by their inability to ‘fix it'. The government has made the right noises with their green paper ‘Transforming Children and Young People's Mental Health provision, but weakly expects this transformation to happen in five years time in only a quarter of schools. Not very transformational.

When I saw that the government had published mental health guidance for schools, I was optimistic for a document that would support staff and young people. (Though not optimistic enough to think it might include funding.) Unfortunately ‘Mental Health and behaviour in schools' (DfE, 2018) is not that document.

Key messages in the document are conflicting: ‘schools should expect parents and pupils to seek and receive support elsewhere, including from their GP', but that schools, and especially MATs, should ‘consider collectively commissioning specialist support for identifying and supporting pupils with mental health needs'.

The document says that school nurses ‘can provide the opportunity for early identification of physical, emotional or mental health needs', so schools may wish to commission extra support. We all know how the school nursing service has fared in recent years.

I have a very personal take on mental health, from working with children who have social, emotional and mental health difficulties for most of my career, including a spell as head of a school in a child and adolescent psychiatric hospital, and as someone who has lived with episodes of mental ill-health myself. I think this gives me an interesting perspective as a carer and cared-for.

As a society we are still really struggling with how to describe mental illness. If the words aren't right, then somehow we're back in the asylums. We use lily-livered language like, well-being, or maybe mental health issues. Why can't we say it like it is? We all have mental health. All of the time. Sometimes it's good. Sometimes it's not, and when it's not, I prefer to say ‘mental ill-health'.

This ‘Mental Health and behaviour in schools' guidance curiously conflates these two issues and yet at the same time separates them. The behaviour language in this document is not congruent with the mental health language. Although it doesn't go as far as shortening this to the unhelpful ‘bad, mad or sad' shorthand of the past, the descriptions included here talk about poor and disruptive behaviour, bad or unusual behaviour. In the context of mental health this is not helpful. There is little consideration that behaviour is one manifestation of mental ill-health and even suggests that one useful strategy could be ‘behaviour modification'. Other outdated language includes saying that one risk factor is ‘low IQ'.

This guidance frequently refers to behaviour that needs to be managed, rather than understood, and this is unhelpful in the context. Useful strategies noted in this guidance includ

  • clear expectations of behaviour;
  • highly consistent consequence systems;
  • clear systems of rewards and sanctions;
  • positive classroom management;
  • support for the child to improve their behaviour; and
  • ultimately directing pupils off-site to improve their behaviour.

For a young person who is experiencing a period of mental ill-health, it is unlikely any of these strategies will be effective. When sending children on anger management courses, hardly anyone asks ‘what are you angry about', still less ‘what has happened to you'.

It isn't made explicit here, but when behaviour is discussed in this document, it is the ‘in your face' sort. The quiet, withdrawn, masking, ‘I'm fine' sort isn't mentioned.

In future, the green paper says the Designated Senior Leads for Mental Health will have free training on, amongst other things, ‘the design of behaviour policies'. A behaviour policy will not treat someone in mental distress.

The mental health part of the document is rich on the risk factors, and oddly silent on the what to do next. Except to list the seven top tips to get your referral accepted by CAMHS:

  • Have a clear process for identifying children by using the Strengths and Difficulties Questionnaire or Boxall Profile
  • document evidence of the symptoms or behaviour that are causing concern (and including this with the referral);
  • encouraging the pupil and their parents/carers to speak to their GP or school nurse, where appropriate;
  • working with local specialist CYPMHS to make the referral process as quick and efficient as possible
  • understanding the criteria that will be used by specialist CYPMHS in determining whether a particular pupil needs their services;
  • having a close working relationship with local specialist CYPMHS, including knowing who to call to discuss a possible referral and allowing pupils to access CYPMHS professionals at school; and
  • consulting CYPMHS about the most effective things the school can do to support children whose needs aren’t so severe that they require specialist CYPMHS.

So now you know. I especially like the one about ‘including' your evidence with the referral. Remember that bit, it's important.

Mental Health and behaviour in schools reminds staff that pupils at risk of mental ill-health include:

  • children and young people with SEN;
  • children who have been or are at risk of being, abused, exploited or neglected;
  • Children in Need;
  • children looked-after, or previously looked-after;
  • adopted children;
  • children living with socio-economic disadvantage; or
  • children who have lived through adverse circumstances.

The guidance reminds schools that ‘there is a complex interplay between the risk factors in children’s lives, and the protective factors which can promote their resilience'. A table within the document sets out the risks and protections that exist in the child, the family, the school and the community.

In order to be as protective and effective as possible, the school should promote good mental well-being for all pupils, and one way to achieve this is to ensure that the school is ‘a safe and affirming place for children where they can develop a sense of belonging and feel able to trust and talk openly with adults about their problems'.

A section in the guidance refers quite sensibly to Adverse Childhood Experiences, but misses the point that these adversities have a cumulative effect. The language of this section is in the present tense: ‘when difficult events happen' and schools should ‘provide support to pupils at such times'. Past adversities can leave some children with huge challenges to their mental well-being, even many years later, and to ignore this, misses out a potentially huge part of the root causes of mental ill-health. This is particularly important in secondary schools, where staff may be completely ignorant of what happened in the teenager's younger years, and cannot make sense of what may seem to be senseless behaviours.

Chapter 3 of the document defines mental health and then sets out the classifications of mental health problems or disorders:

  • emotional disorders, for example phobias, anxiety states and depression;
  • conduct disorders, for example stealing, defiance, fire-setting, aggression and anti-social behaviour;
  • hyperkinetic disorders, for example disturbance of activity and attention;
  • developmental disorders, for example delay in acquiring certain skills such as speech, social ability or bladder control, primarily affecting children with autism and those with pervasive developmental disorders;
  • attachment disorders, for example children who are markedly distressed or socially impaired as a result of an extremely abnormal pattern of attachment to parents or major care givers;
  • trauma disorders, such as post-traumatic stress disorder, as a result of traumatic experiences or persistent periods of abuse and neglect; and
  • other mental health problems including eating disorders, habit disorders, somatic disorders; and psychotic disorders such as schizophrenia and manic depressive disorder.

All of the above will often be manifest in behaviours, some of which may be regarded as ‘disruptive', others withdrawn. This chapter is where the Mental Health and behaviour in schools document appears to have been written separately by different people. A behaviour policy with ‘clear systems of rewards and sanctions', will not take the hyperkinetic out of a child, or disconnect the sensory overload panic from an autistic child.

And here's where the disparate elements of the guidance can be dragged together. Schools are told on the one hand to have a ‘highly consistent consequence system', but are elsewhere reminded that ‘behaviour policies…that [treat] all pupils the same may be unlawful where a disability affects behaviour'.

When excluding pupils ‘schools should consider any contributing factors…including where the pupil has mental health problems' and ‘where appropriate, schools should consider if action can be taken to address underlying causes of disruptive behaviour before issuing an exclusion'. Whilst the phrase ‘disruptive behaviour' may not be appropriate, as it may be a part of a mental health condition, the school should be have a view on the root cause of the behaviour. In the summer of 2018, a judge ruled that the exclusion of an autistic pupil was unlawful, since his ‘aggressive behaviour [was] not a choice for children with autism'. (See School exclusion of autistic boy unlawful, judge rules)

The document says that ‘where a pupil has a mental health condition that amounts to a disability and this adversely affects their behaviour, the school must make reasonable adjustments to its policies, the physical environment, the support it offers, and how it responds in particular situations'.

Mental Health and behaviour in schools says that staff will need to further develop their understanding of mental health and how it affects young people. School staff are not to diagnose mental health problems, but they are ‘well placed to observe children day-to-day and identify those…who may be experiencing a mental health problem or be at risk of developing one'.

Staff should be helped to develop their knowledge to include:

  • a clear understanding of the needs of pupils with mental health needs;
  • an awareness of some common symptoms of mental health problems: an understanding of what is, and isn’t, a cause for concern;
  • an understanding of what to do if they think they have spotted a developing problem;
  • strategies to ensure that stigma is reduced and pupils feel comfortable talking about mental health concerns.

Children struggling with mental health conditions often have difficulties with executive functioning and this will impact on learning, social situations and coping with emotions. Helping staff understand the role of executive function in daily life and in school may be useful.

The introduction to the guidance lists those who were involved in developing the advice. Disappointingly this does not seem to have included children and young people who have experienced mental ill-health, or their parents. Two groups that could have had a big impact on understanding how schools can help, and sometimes how they hinder mental wellness.

Resources for supporting pupils with mental ill-health are dwindling, but sometimes it's not about more availability, more counsellors or more money. Sometimes it's about changing a mindset. The Mental Health and behaviour in schools guidance could have helped change that mindset. It talks too much about ‘disruptive' behaviour, of ‘highly consistent consequence systems' and too little about relationships and understanding. It's a missed opportunity, and it's all the weaker for that.

Download the guidance here: Mental health and behaviour in schools

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