Schools are ever more in the front-line in handling the mental health crisis among our teenagers.
Society relies increasingly on teachers to notice when something is awry with the young and then to triage such problems – deciding whether this is just a blip or something serious enough to warrant expert intervention.
However, there are well-publicised problems with accessing Child and Adolescent Mental Health Services (CAMHS) in many parts of the country due to austerity measures and local funding cuts.
As such it certainly feels like society is increasingly relying on schools, and on individual teachers, to deliver some sort of on-going daily support for adolescents with mental health problems, even if experts from CAMHS are involved.
So, how fair is it to burden schools with these responsibilities? That is a question beyond the scope of this article. Suffice it to say that many experts would take the view that imposing these responsibilities is justifiable if teachers and school staff receive good training in these matters, and if the resources allocated to schools make it realistic for a teacher or other professionals in schools to devote the time and effort needed to support troubled individual teenagers. Those conditions are not met as often as they should be.
The statistics show that 10 per cent of our pupils are diagnosed with some sort of mental health problem – and given the constraints on CAMHS resources, this is almost certainly an underestimate.
Many adolescents with problems never get to the top of the waiting list for diagnosis, let alone treatment. Teenage problems vary from mild depression to severe post-traumatic stress, from substance abuse and other forms of self-harm to suicidal plans – and from problems that are reactive to circumstances, to problems that are exacerbated by genetic, chemical or neurological abnormalities – manic depression, schizophrenia, other forms of psychosis.
The vast majority of individuals who will ever suffer from any sort of mental health problem do so first in adolescence. For many, the problems continue through adult life. So asking schools to take a major role here is not a trivial issue. Addressing such problems is not a minor responsibility.
Official sources, the internet – even this article – are full of advice about how to recognise and address mental health problems in the young. Such advice is generally well-rooted in research (but common sense suggests picking your sources).
The trouble starts with three facts:
- Most suggestions for interventions require resources “over and above” the norm, which may not be available.
- Individual teachers (and psychologists and counsellors) differ in how adept they are in delivering the recommended interventions.
- There is seldom any real assessment as to how effective a given intervention has actually been: is the extra demand on resources justified by results in this case, or not?
Assessing the efficacy of interventions is important at many levels. It is important for the teenager struggling with a mental health problem; the mere fact that there is an intervention in place does not necessarily mean that it is working – and some interventions are actively counter-productive.
It is important too for the staff involved in delivering that intervention – is the extra work, the emotional demands, the burden of responsibility pointless or worthwhile?
And it is important for the school: diverting resources to address mental health problems inevitably reduces resources elsewhere. Is the benefit for the minority sufficient to justify the lesser input for the majority? Should the school-based intervention continue – or should one use evidence that it is not working to lobby vigorously for stronger expert input?
Assessing the impact of school-based interventions can sometimes be easy. If the goal was (for example) to reduce absenteeism or disciplinary problems and/or improve grades, then there are clear data, constantly collected, against which to judge whether a given intervention has worked or not. But the impact of interventions aiming to address socio-emotional problems or issues of mental health can be much harder to evaluate.
Take bullying, for example: how effective is a “zero tolerance” policy? Implementing such a policy may well reduce the number of complaints about bullying. But the number of complaints may fall for many reasons other than a reduction in actual bullying. Not all victims disclose bullying at the best of times. When penalties for the bully are high, the bully’s threats against disclosure rise too. So has the policy succeeded, or merely driven the problem underground?
Assessing the impact of interventions to address mental health problems is harder still. There are, of course, tools that allow us to assess how depressed, anxious, substance or self-abusive, suicidal, psychotic (and so forth) a teenager is “on presentation” (i.e. when the problem first comes to light), and tested again, how he or she is after X or Y intervention or time period.
However, few schools deploy these formal tools. This is partly a matter of poor access (the most reliable tools require a certificated training that few teachers have either to use or to interpret results) and partly a matter of the nature of the relationship between teenager and teacher: formal assessment measures change this relationship, not always in constructive ways.
Mostly, the efficacy (or otherwise) of a mental health intervention is assessed in schools primarily on a subjective basis – and this is of dubious reliability. Teachers heavily invested in the welfare of their students and in their own efforts to help may take an overly optimistic view of progress. Or conversely, being overly optimistic, they may have unrealistic expectations and so fail to notice small, but real progress.
Students may misrepresent their feelings for any number of reasons: from a desire to please the well-meaning helper to a determination to escape scrutiny, for example. Those with the more serious psychotic problems may simply have no reality-based view of the situation at all. So how to assess the impact of mental health-related interventions in schools? There is no easy solution.
CAMHS
Foster the gold standard, which would surely be to work ever more closely with experts from CAMHS, first in setting up such interventions and then in monitoring progress. Given the limited resources of CAMHS, this might imply a change in focus for experts: a change in role from directly providing interventions to a greater emphasis on designing, training and monitoring teacher-led inputs.
Research
Use the research in choosing interventions and assessments: there are many well-designed studies that report details of specific interventions – and data as to the efficacy of those interventions. Copying a process with a known efficacy obviously will not guarantee that that intervention is effectively implemented in your school, but it increases the odds. The criteria used in that research might also provide suggestions as to how to assess the impact in your situation.
Measurable signs
Look for objectively measurable signs of success As noted above, what teenagers say about their mental health problems is not always a good basis for assessing the success of an intervention. A child’s report of his or her emotional state may change for many reasons other than recovery.
A better evaluation of the efficacy of an intervention would assess whether observable behaviours associated with the mental health problem (such as the social withdrawal, apathy, and so forth of depression) had declined, and been replaced by healthier responses (social or academic engagement, for example). Best practice would be to have two teachers make such an assessment independently – in different contexts.
- Dr Stephanie Thornton is a chartered psychologist and former lecturer in psychology and child development. To read Dr Thornton’s previous articles in SecEd, go to http://bit.ly/2o1BVxK