The EP Role in Supporting Social-Emotional Development: Targeted Support for Mental Health

What is mental health?

• Dogra et al (2002)

  • 'at one end of the continuum is normal human emotional experience and the other is extreme psychological distress and mental ill-health'

What is wellbeing?

•  Satham and Chase (2010)

  • Quality of people's lives. A dynamic state enhanced when people can fulfil personal and social goals

  • Understood in relation to objective (e.g. household income) and subjective (e.g. happiness) measures

What is the emerging consensus about childhood wellbeing?

multidimensional - includes dimensions of physical, emotional, and social wellbeing; on the immediate lives of children but also their future lives; incorporates some subjective as well as objective measures

Department for Education SEND Code of Practice (2015) on if mental health is a SEN

• Children and young people may experience wide range of social and emotional difficulties

• May include becoming withdrawn / isolated, and display challenging, disruptive, or disturbing behaviour

• Behaviours may reflect underlying mental health difficulties e.g. depression, anxiety, self harm, substance abuse

• Other children may have other disorders e.g. ADD, ADHD, attatchment disorder

• Schools and colleges should have clear processes to support children and young people, including how they will manage the effect of any disruptive behaviour so it does not adversely affect other pupils

Who provided a framework to consider risk and resilience?

Daniels et al (1999)

Places individuals on a set of axis

x axis = Adversity (vulnerable) to Protective (experiential dimension)

y axis = Resilience to Vulnerability (personal dimension)

How satisfied are children in the UK?

• In UK 2013-14, 8/10 YP 16-24 reported high or very high life satisfaction

• Around 1 in 5 YP aged 16-24 in UK reported some symptoms of anxiety / depression 2011-12

What did the 2009 Tellus4 survey reveal?

Clear decline in measures of emotional health and wellbeing largely due to fall in number of children who felt they could talk to an adult other than their parent if they were worried about something

What is some evidence that MH problems are increasing in CYP?

• Widespread perception that CYP are more troubled than previous generations (Murphy and Fonagy, 2013)

• Treatment and referral data indicate increased demand for specialist mental health interventions over past decade

• General surveys found increased levels of low wellbeing in children in England

• Data from ONS/NHS Digital (2018) survey reveals slight increase over time in prevalence of mental disorder in 5 to 15 y/os from 9.75 in 1999 to 10.1% in 2004 to 11.2% in 2017

• Increase in emotional disorder evident in boys and girls

What are there areas of stability in?

behavioural, hyperactivity, and other disorders

What did NHS England (2023) find?

• 1/5 CYP 8-25 y/o had probable mental disorder

• Rates of probable mental disorder 8-16 years similar for boys and girls, while for 17-25 year olds rates were twice as high for young women

What did ONS/NHS digital (2018) find?

• Over 1/3 of 5-19 year olds with a disorder were recognised as having special educational needs

• 1/2 of children with recognised SEN had an EHCP in place

• Contact with professional services and informal support was more likely where parents and young people recognised there were severe difficulties going on

How does learning link to children’s wellbeing?

• School environment plays important role in social, emotional, behavioural wellbeing

• Learning and enjoyment in primary found to predict later wellbeing in secondary

How does this differ between the genders?

• For boys, learning in primary school has the strongest influence on behavioural aspects of their later wellbeing

• For girls, more predictive of social wellbeing (Gutman and Feinstein, 2008; Gutman et al, 2010)

• In 2021/22 survey asked about their life, family, friends, appearance, school & schoolwork

• Children’s (aged 10 to 15) mean scores for happiness with their life as a whole, their friends, appearance, school, and schoolwork were all significantly lower than when the survey began in 2009/10.

• On average, children were most happy with their family, and least happy with their appearance. In terms of proportions, almost one in six children (15.6%) were unhappy with their appearance

• Girls were also significantly less happy on average than boys with their life as a whole, their family, their appearance, and their school.

• In 2022, the UK had the lowest average overall life satisfaction among 15-year-olds across 27 European countries.

• UK was also the country with the highest proportion of 15-year-olds (a quarter, or 25.2%)reporting low life satisfaction 

What did Meltzer et al (2000) find about MH support for CYP?

• 10,438 5-15y/os

• Just under half who had a mental health problem had not accessed a service 20 months later

• Of those that did, teachers were most commonly consulted, then CAMHS workers, then social services

What did a NHS Digital Survey (2020) find?

About 6/10 children 5-16 with a probable mental disorder had regular support from their school / college, compared with 76.4% of children unlikely to have a mental disorder

What are the 4 tiers of CAMHS?

• Tier 1 - frontline staff

• Tier 2 - network of professionals

• Tier 3 - specialist outpatient CAMH team

• Tier 4 - inpatient CAMH provision

What is a more recent argument for?

• developing a system without tiers (Future in Mind, DoH, 2015)

  • A single point of access / hub

  • Triaged and direct access to a service appropriate to your mental health need

What are EP’s contributions to MH support?

• Typically work in a network of professionals whose role is expected to include

  • Promote positive MH, precent and provide for short term MH needs alongside other professionals

  • Supporting frontline professionals (teachers, GPs, social workers, health visitors) to meet the MH needs of CYP

  • To consult, involve, and seek supervision from specialist CAMHS as and when appropriate and needed

How is MH support and educational psychology accessed?

• A child psychologist may provide help and support to those experiencing difficulties

• CAMHS team will include a child psychologist, but may also be possible for schools to use the services of an LA educational psychologist or to commission one directly themselves, depending on local arrangements (DfE, 2015)

What is the purpose of Mental Health and Wellbeing Taskforce (DoH, 2014)

• Promoting resilience, prevention, early intervention

• Improving access to effective support - a system without tiers

• Care for the most vulnerable

• Accountability and transparency

• Developing the workforce

What are the UK government’s 3 pillars?

• To incentivise and support all schools and colleges to identify and train a Designated Senior Lead for Mental Health

• To fun new Mental Health Support Teams, which will be supervised by NHS CYP MH staff

• To pilot a four-week waiting time for access to specialist NHS CYP MH service

What was the professional response to the government's proposal on MH support teams?

• Strong message from respondents that teams should work with ride range of professionals and services, especially educational psychologists, school-based counsellors, and local authority services (DfE, 2017)

What role is there for EP in MH support teams?

• MHST …can be a valuable additional resource in and of itself, but can be even stronger when working closely with a range of other services.

• These other services include professionals who work closely with schools and colleges, such as educational psychologists, school nurses and counsellors, local authority troubled families teams, social services, peer networks, service user forums, and voluntary and community sector organisations.

• All of these roles play a crucial part in supporting young people with mental health problems and so we will test a range of models for putting the new teams at the heart of collaborative approaches with these professionals. (DFE/DoH, 2017)

What are some key support issues regarding MH and WB in schools?

• Patalay et al (2016) - schools increasingly being looked to for intervention and support

• Murphy and Fonagy (2013) - need for improved evidence-base of interventions, implementation, outcomes, in educational rather than clinical settings

• Future in mind, DoH (2015) - emphasis on integrated working and early intervention

• But ….Issues of collaboration between education and health and access remain (Independent CAMHS review, 2008; DfE/DoH, 2017)

• Challenges of increased diversity in education marketplace and commissioning of educational psychology services (BPS, 2024)

• EP role with Social, Emotional and Mental Health (SEMH) in state of flux linked to its statutory function and pressures in SEN and EHCP identification and assessment.

What is the medical model of MH?

• Useful way of understanding the complexity of the human condition, and to develop treatments suited to particular conditions (Scott, 2003)

• Systematic proliferation of disease names created independently of their anatomical, biochemical, microbiological, or physiological correlates (Szas, 1979)

Critique of the MH model

• Tew (2005) - biomedical perspectives remain dominant - and a concern with the overall complexity of a situation can become lost in an over-emphasis on diagnosing and treating individual 'pathology'

• We have no way of relating the outcomes of health service interventions to educational or often even social service interventions, yet where children present with mental health problems it is more likely to be the consequence of circumstance rather than the characteristics of their presenting problem (Murphy and Fonagy, 2012)

• Need to understand more about alternative settings in which treatments (interventions and support) may be implemented, especially for those CYP who are not currently reached by existing services. This should include not just physical locations such as schools and community centres, but also social contexts, for example involving community leaders, peers, and near-peers (Murphy and Fonagy, 2012)

How is the EP work linked to the medical model?

• Eps work with and alongside other professionals e.g. Community Paediatricians and may contribute to

  • Diagnostic processes

  • Supporting others to understand diagnostic processes and to consider the impact of labelling

  • Support the implementation of evidence-based interventions for particular conditions

  • Attempting to bridge the gap in understanding between health, social care, and educational settings

  • Evaluating impact and implementation of evidence-based / informed interventions in educational settings

What are considerations of the social model?

• Studies of attitudes to MH reveal younger people have very negative views and use pejorative terms in everyday language (Chandra et al, 2007)

• Young people with MH problems are more likely to experience higher levels of stigma than adults

• Stigma causes people to be secretive about their problems and discourages them from seeking appropriate help (Rose et al, 2007)

How is stigma tackled?

• Providing -  young people with info about MH issues has been shown to improve attitudes to MH and help seeking behaviour

• Training - teachers in MH issues has also been shown to improve understanding of MH (Gale, 2010)

Why do we need to consider young people’s voices?

• ‘Within many conventional medical, psychological and social approaches, there has been a tendency to impose frameworks upon people in ways that deny their own knowledge and expertise.’ (Tew, 2005, p17).

• ‘A holistic approach which helps to make links between what may seem bewildering thoughts, feelings and behaviours, and the realities of people’s social and personal experience may be more helpful…’ (Tew, 2005, p27)

What can schools do within the social model?

• Teach about good MH and emotional resilience

• Whole school approach which builds understanding about MH, tackle stigma, and develop emotional resilience

• Successful evidence-based models that increase access to MH support and services - see TAMHS (Targeted Mental Health in Schools (DfE, 2009))

What is EP’s role within the social model?

• Draw attention to the fact CYP's school experience can impact MH, distress, WB

• Promote systemic responses to MH, distress, WB

• Help address stigma, inclusion issues

• Help CYP to understand, cope with experiences of mental distress

What is the educational model of MH?

• Concerned with development of social, emotional competence

• Emphasis on teaching, learning of emotional awareness and social skills

• Draw on concepts e.g. emotional literacy, social and emotional aspects of learning

What are key social and emotional skills?

•  (DfES, 2007)

  • Self awareness

  • Self regulation

  • Motivation

  • Empathy

  • Social skills

Name some examples of work within the educational model

• National Healthy School Initiatives (DfES/DoH,1999)

• What works in promoting children’s emotional and social skills? (Weare and Gray, 2000)

• Social and Emotional Aspects of Learning (SEAL) Initiatives – in Primary (DCSF, 2006) and Secondary Schools (DCSF, 2007)

• Work on Developing Emotional Literacy in Schools (Weare, 2005)

• Supporting Emotional Literacy (Burton, 2008) via Support Assistants (ELSA) (Burton et al , 2010)

• Use of Peer Mentoring (National Mentoring Network and DfES (2004)

• Developmental Group Work ( Circle Time (Mosley, 1993: 1998) and R-time (Sampson, 2004).

What is the EP’s work within the educational model?

• Training on the Social and Emotional aspects of learning

• Support to help theory underpinning approaches

• Work with schools to develop whole school approaches

• Offer training to key staff in the knowledge and skills around how to support emotional literacy, peer mentoring, use of cooperative group work

• Provide training on Strengths Based Approaches e.g. Solution Focused and Orientated Practice (deShazer, 1990; O'Hanlon, 2000) and Positive Psychology (Selligman et al, 2009)

• Working with schools to provide targeted group work to children identified as at risk of social, emotional, behavioural problems

• Working with schools to support identification, assessment, provision of support to children with social, emotional, behavioural needs (DfE, 2015)

What does the psychological / eco-systemic model contain?

• Recognises

  • Importance of interaction between person and environment

• Considers

  • Impact of the individual on the system and vice versa

  • Impact of behaviour, cognition, emotion, interpersonal interactions

• Typically adopts

  • Eco-systemic approach and 'research-practitioner' mindset using a case formulation, hypothesis testing, problem solving

  • Different forms of consultation, assessment, evaluated intervention, and systems work

Who proposed the Interactive Factors Framework and what is it?

Monsen and Frederickson (2008)

Links between the environment, and biological, cognitive, and behavioural factors

Consider spheres - 

1. class and peer group - culture and environment

2. school culture - curriculum and behaviour policy

3. national and local policy and initiatives promoting MH in schools

How do EPs use eco-systemic theory?

• Draws on the principles of ecology and systems theory (Osborne & Dowling, 1994)

• Attempt to understand interactions within and between

• Microsystem

  • Exosystem

  • Macrosystem

  • Mesosystem

• Promote change using consultation (Wagner, 2000)

What role is there for the EP, to treat the child or the system?

• Educational psychologists are a key therapeutic resource for CYP especially in educational contexts (MacKay, 2007)

What is a current dilemma with EPs?

Harrison and MacDonald (1997)

Individualist (pipe-end, pathogenic, mandatory, dependency, inequitable, addictive, maintains status wuo) vs Whole system (systemic, salutogenic, participatory, sustainable, equitable, integrative, population health gain, builds social systems) approach

Evidence-informed practice

• Eps role advising on appropriate support and interventions

  • Consider: the case, the evidence, the context

• A range of meta-analytic studies and systematic reviews of interventions

  • e.g. Drawing on the Evidence (Wolpert et al, 2006) EBPU

  • Choosing what is best for you (2007) EBPU

  • Knowing where to look (2008) EBPU

  • Fonagy, P et al (2002) What Works for Whom?

• NICE Guidance for Health and Care Professionals

  • EPs are a statutorily regulated profession by HCPC

Limitations of treatment and therapy

• Murphy and Fonagy (2012)

  • Many CYP don't respond adequately to even the best-evidenced treatments

  • Need to find out more about sub-groups who don't respond to treatment, and to explore whether better results could be achieved by alternative means

  • The possibility of adverse outcomes of psychological therapies needs to be investigated and reported with the same diligence as pharmacological treatments

Future possibilities

• Unmet need is high - need innovative methods of service delivery e.g. through internet, media and social media, improving MH literacy in the wider community; in the contexts of prevention and intervention (Murphy & Fonagy, 2012)

• EP work developing Relational Approaches in Schools e.g. restorative practice, trauma-informed approaches