In recent years much public discussion and significant sums of money have been directed towards supporting adults with mental health problems. Rather less public attention has been focused on the emotional well-being of children, although one child in ten aged 5-15 has experienced a mental disorder and, among 5-10 year olds, 10 per cent of boys and 6 per cent of girls have a mental disorder.
The government recognises there is a problem. In England, the DFES guidance Promoting Children's Mental Health within Early Years and School Settings has been backed up by the National Service Framework for Children, Young People and Maternity Services. This includes a standard on promoting health and wellbeing, and a section on positive mental health and emotional well-being for children.
In addition, there is the DFES/Department of Health Healthy Schools programme, with its National Healthy School Standard and Personal Social and Health Education (PSHE) curriculum, which include emotional well-being. The public health White Paper Choosing Health contains a strong endorsement for improving children's emotional well-being through better integrated working, improved CAMHS services, the Healthy Schools programme, and the planned development of children's centres.
While this guidance is welcome, it leaves open the question of what is actually happening on the ground.
The King's Fund review
To seek some answers to that question, in 2005 the King’s Fund decided to undertake a selective review of projects in London supporting the emotional well-being of children of primary school age (5-11). The review looked at the key factors that made the best projects successful to draw out lessons that could be disseminated more widely.
The review involved:
- a selected review of literature
- a postal and email questionnaire inviting submissions from projects
- 12 case studies involving visits to projects and interviews with staff
- five focus groups involving 48 children.
Sixty organisations responded to our questionnaire, providing core data on a range of projects across London. The vast majority of projects that responded were based in schools and further enquiries suggested that this is the case for the bulk of emotional well-being projects for children aged 5-11.
The review visited nine projects based in primary schools in Kingston, Greenford, Havering, West Ealing, Westbourne Green, Lambeth, Tower Hamlets, Catford and Queen's Park. Eight were mainstream schools and one was a specialist school for children with behavioural needs, geared towards returning them to mainstream school. The projects in some of these schools were run by the voluntary sector organisations theplace2be and the National Pyramid Trust.
The review also visited the Ebony People's Association in Edmonton (for children in African-Caribbean families), Chance UK (a project that mentors 5-11 year olds across London) and Jigsaw4U (for children experiencing loss and trauma).
The review found, not surprisingly, very great ethnic, cultural, social and economic diversity in the areas visited and the environments in which the projects operated. However, common to all projects was that they were responding to significant levels of assessed emotional and behavioural needs among children.
All 60 projects offered a wide range of interventions and activities, although some – such as 'circle time' – were common to many projects. They could involve groups of children, or one-to-one support. Most were targeted at children assessed as having an emotional or behavioural need, although some offered a whole-school facility. Activities included play and dance therapy, touch therapy (head and neck massage) and reflexology, sessions with learning mentors and on anger management and healthy eating, after school clubs, buddy schemes, peer mediation, the telling of folktales and the use of individual achievement profiles. There were also some parenting initiatives.
Despite their diversity, most projects faced similar challenges and cited common factors in their success. The review explored these factors through particular questions asked during visits to selected projects about the children who might benefit most from targeted work, funding, working relationships, engaging families, a space for activities and how to measure effectiveness.
With regard to which children, and what are their needs, the review heard many stories of children as young as 5 with serious emotional and behavioural problems. In some areas, a large proportion of children experienced unstable and sometimes chaotic home lives. Some children assessed as needing the targeted intervention would be boisterous and aggressive; others would be quiet and shy. Almost all the projects visited had significant numbers of children from different ethnic and cultural backgrounds, some of whom spoke little or no English.
There was universal agreement that it was never too early to look out for problems and seek to address them.
'We are forever saying catch them early. Why wait for them to become 13 and excluded permanently? If we can get some effective strategies in place for a child even in reception then hopefully that child will be better able to cope with this world.' (teacher)
'There are occasions when children come with extremely serious problems who burst upon schools like exploding shells.' (teacher)
A number of projects told us that they had waiting lists, and some specifically said they would like to undertake more work with parents and families but did not have the capacity to do so. Meetings often took place to prioritise needs among children, as only a certain number could be accommodated by the project.
'Do we have the capacity to provide adequate support? No. There are simply more children out there than we can help.' (voluntary sector worker)
For many of those we interviewed, the answer to building capacity was simple – more money.
The questionnaires revealed a wide range of sources of funding for projects – school budgets, the Children's Fund, the New Opportunities Fund/Big Lottery Fund, Excellence in Cities, local authorities, healthy living networks, neighbourhood renewal funds, charities and trusts, universities, the Arts Council, local businesses and ordinary tin-rattling: in short, a complex network of funding streams that involved many senior staff in time-consuming and often unprofitable applications.
Getting a project mainstreamed, as part of a school's annual budget, was the goal of many projects. We did find a number of projects where an initial limited amount of funding had been picked up and included in the mainstream budget once the value of the work had been realised. However this was by no means typical. A number of projects had no long-term security of funding and expected to close in 2007 or 2008.
'The Children's Fund money finishes in March 2008. I have been told provisionally that after 2008 the first year I will have Healthy Schools money, but I’m going to try and get external funding as well. Mainstream funding for this work in all schools would be the dream ticket.' (teacher)
'Six years ago the Education Action Zone paid for two years [for a dance and movement therapist]. Then that funding stopped so for three years we’ve managed to get a grant from three different places to continue it, but I can’t find anyone to apply to at the moment for next year.' (teacher)
The funding challenge faced by schools was also reported by voluntary sector providers based in the community, with one organisation saying that it had had to turn down approaches for help from schools through lack of funding.
Good working relationships were vital to the success of projects. Many individuals could be involved – teachers at all levels, SENCOs (special educational needs co-ordinators), school nurses, educational psychologists, speech therapists, play therapists, behaviour and education support teams (BEST), behaviour improvement co-ordinators, CAMHS staff, education link workers, learning mentors, family liaison workers, Sure Start staff, local community voluntary workers.
In the best projects there were clear and strong professional ties between different professionals. However, the review found little consistency across projects. Each has its own arrangements, some more effective than others, and some staff spoke of relationships that did not always work well. The review found little evidence that even the best projects had much contact with other similar projects in the area or learnt from each other, although there were isolated examples of networking among some professions.
In two cases school staff said parents had told them that all their hard work in supporting children with emotional and behavioural needs unravelled very quickly when the children moved on to secondary school, suggesting a greater need for liaison between primary and secondary schools about individual children.
The importance of leadership was repeatedly mentioned as a key factor in the success of a project – having a head teacher who fully supported the project, or particularly persuasive and committed staff who could take the lead.
'Within school, it’s always critical to have a link person with CAMHS, and this needs good working relationships. If the head teacher is not interested then it’s not going to work.' (teacher)
'They have to have total backing from the head in order for these things to happen, otherwise they don't happen. But also you need stability and if the head isn’t involved these things don't continue and so it has to have senior management totally committed to whatever you’re doing.' (voluntary sector worker)
The review demonstrated that it is not possible to separate a child's emotional well-being from his or her family circumstances. Many children’s problems were a result of family breakdown or difficulty. One interviewee suggested the single most important risk factor in a child's emotional wellbeing was a lack of parental involvement, interest or ability, and that parents also need structured support.
Interviewees suggested that many parents' own experience of school was often not a happy one, making them very reluctant to return to a school premises again. Teachers were therefore not always the best people to try to engage parents in conversations about their children's needs. It also often required considerable time – time that teachers did not have. As a result, a number of projects involved, or were looking to get funding to establish, a family liaison worker
'Some of the parents are really terrified about going into school. They might have had bad experiences themselves, a lot are pretty young. For quite a lot of our parents, to come and see me, for example, is still a huge step. You know they had very bad experiences in school and there is a fear of the head teacher's office.' (head teacher)
A number of interviewees referred to the stigma associated with mental health problems and the need to ensure that their work with both children and families was sensitively handled. The stigma was seldom reflected by children, who almost invariably found the project supportive and enjoyed their involvement. But it was felt strongly within families. Sometimes a significant amount of work was needed to persuade parents to allow their children to take part in projects, and to reassure them that their child did not have a 'mental health problem'.
Despite these difficulties there was universal agreement that engaging families was crucial: that much of the good work done supporting children in school would be worthless unless there were changes in the child's home life as well.
A key factor for many projects was having a separate, designated space in which activities could take place and therapeutic relationships could be formed. Children liked the consistency of these arrangements.
'The Blue Room's philosophy is that it is a quiet space, a calming space where children can go. It's designed so that children who enter the environment immediately feel more relaxed and feel calmer. There’s pictures, there’s textures, there’s lighting, there’s messages of well-being. Children can listen to stories, they can talk about issues, they can do various relaxation and meditation activities. We were very lucky because we actually had this space.' (teacher)
However, many school-based projects had to make do with what space they could find. This could lead to interruptions from other children or teachers while therapists were trying to engage with children either individually or as a group.
'It's important to have this space. I don’t think the size has to be prescriptive but it has to be static. It's no good just coming in and we're working in this room this term and that room next term. That just doesn’t work.' (teacher)
One community organisation spoke of the benefits of having a safe and welcoming meeting space at their office for children and families outside school as well. This was not advertised as a ‘mental health’ service, as it was thought that would deter attendance.
The Goodman Strengths and Difficulties Questionnaire (SDQ) was widely used by schools to measure children's emotional progress. It involved teachers, parents and children, and allowed the measurement of positives, not simply negatives. In addition, many projects kept observation sheets and took formal notes of meetings about particular children, and had regular meetings with parents and other staff to talk about how a child was progressing.
Interviewees suggested there was no shortage of evidence that children participating in the projects had shown improvements in attendance, learning achievement and social networking. The children interviewed in focus groups indicated that participation in projects had brought about changes that were overwhelmingly positive.
Despite this, few projects felt able to prove that they were actually doing a good job, and the review found no evidence that the emotional well-being of children was being formally monitored once they had left the project and, in particular, once they had moved on to secondary school.
'It is extremely hard to measure if [we are] doing any good in any concrete specific way. It's because you feel it – for example, a group of girls last year had lots of quarrelling half-way through the year that just stopped and it hasn't started again.' (teacher)
'Changes are difficult to measure but by looking at how [children] are playing in the playground and things like that, and how they manage their day in school, you can see that there has been a difference, but it’s not something I have the tools to measure.' (teacher)
The review found that most projects supporting the emotional well-being of children aged 5-11 were based in primary schools. Despite the welcome Healthy Schools initiative, targeted projects clearly have a major role to play alongside whole-school approaches. Many primary school age children in London have significant emotional and behavioural problems that need addressing and there appears to be a level of unmet need.
Clearly much good and necessary work is being done across London. However, there is unmet need, funding can be insecure, networking between different professionals could be developed further, and more could be done to demonstrate the longer-term effectiveness of interventions. These areas need addressing if, as the government intends, the future mental health and well-being of the community as a whole is to be protected.
- Office of National Statistics (2000). Mental Health of Children and Adolescents. London: ONS
- Department for Education and Skills (2001). Promoting Children's Mental Health Within Early Years and School Settings. London: DFES
- Department of Health (2005). National Service Framework for Children, Young People and Maternity Services. London: Department of Health
- Department of Health (2004). Choosing Health: Making healthier choices easier. London: Department of Health
- Goodman R (1999). 'The extended version of the Strengths and Difficulties Questionnaire as a guide to child psychiatric caseness and consequent burden'. Journal of Child Psychology and Psychiatry, vol 40, pp 791-801