Mental Health and Emotional Wellbeing in Schools

Mental Health and Emotional Wellbeing in Schools
Hertfordshire 2017

About these slides These slides are provided for schools in Hertfordshire They are to support school professionals to feedback to colleagues within their schools after having attended training with the School CAMHS Link Managers These slides can be adapted to suit Please do not post these slides on the internet To access related training or for more information please contact the School CAMHS Link Managers (see last slide) Please also get in touch if you have comments or suggestions in relation to these slides

Mental health in schools – key messages
Part 1 Mental health in schools – key messages

Quiz time!

Myths and Facts Myth Mental health problems are very rare. Fact Mental health problems affect one in four people. Young people just go through ups and downs as part of puberty, it’s nothing. One in ten young people will experience a mental health problem. People with mental health problems don't experience discrimination Nine out of ten people with mental health problems experience stigma and discrimination.

Myths and Facts People with mental illness aren’t able to work. Fact
We probably all work with someone experiencing a mental health problem. People with mental health illnesses are usually violent and unpredictable. People with a mental illness are more likely to be a victim of violence. It’s easy for young people to talk to friends about their feelings. Nearly three in four young people fear the reactions of friends when they talk about their mental health problems

What is mental health? In pairs or small groups, list or brainstorm what comes to mind when we hear the phrase: mental health.

Defining mental health
Mental health has been defined as: “A state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” WHO 2004 Emotional wellbeing has been defined as: “A positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.” WHO 2007 For CYP: “Mental health, in effect refers to the capacity to live a full, productive life as well as the flexibility to deal with its ups and downs. In children and young people it is especially about the capacity to learn, enjoy friendships, to meet challenges, to develop talents and capabilities.” Young Minds

Find out what you're good at
A state of wellbeing Learn from setbacks Connect Friendship Have meaning Enjoy your life Play &Learn Deal with ups and downs Enjoy solitude Empathy Grow Relationships Belong Learn right from wrong MH foundation 2002 A bright future for all – promoting mental health in education Find out what you're good at Meet Challenges Feel safe Cope

Clinical terminology Neurodevelopmental Psychosis Bipolar disorder
Personality disorder Depression Hyperkinetic Schizophrenia Obsessive compulsive disorder (OCD) Post traumatic stress disorder

Bully Trouble maker Geek Anorexic Dyslexic Self harmer Artist Musician
Illustration by Fran Orford Artist Musician Lower expectations – limiting – individual / professional Self fulfilling / perpetuating – validation for behaviour – live up to expectation Too difficult to live up to – alienating, lowered self worth Athlete Bright ‘Would you go behind the blinds, take off your personality and put this label on …?’ Mathematician 11 11

Risk and resilience

The mental health of children and young people in England , PHE, Dec 16

Prevalence At least one in four people will experience a mental health problem at some point in their life and one in six adults has a mental health problem at any one time One in ten children aged between 5 and 16 years has a mental health problem, and approximately a further 15% are at risk Half of those with lifetime mental health problems first experience symptoms by the age of 14, and three-quarters before their mid-20s

Early Intervention Why so important?
Shorter and less specialised intervention can be effective (cheaper) Better chance of success Stopping unnecessary distress Improving educational and life outcomes

Awareness Children and young people will often let us know about their distress in one of the following ways: Direct disclosure of a practical problem, situation or life event, Direct disclosure of their feelings, Giving signals through their behaviour or presentation (can be observed).

Behaviours Becoming withdrawn, isolated, quiet or very sad, tearful
Worry, stress, anxiety, panic attacks and fears Obsessive or repetitive behaviour or rituals Troubling dreams or memories sleep or eating problems Problems focusing or concentrating, over activity Aggressive or disruptive behaviour, getting into fights Self harm Talking about not wanting to be around anymore School refusing or producing disturbing work

Behaviours Problems with friendships or bullying
Risk taking behaviours including drug or alcohol use Wetting or soiling, unexplained physical problems Inappropriately sexualised behaviour Muddled thinking, racing thoughts, seeing or hearing things CHANGES Disengagement from their normal pattern Not enjoying things they used to enjoy

Understanding Behaviour
The triune brain, Paul D. MacLean. 2 3 2 processes information coming into our brain If it is tagged with an emotion it blocks access to the thinking brain (3) if overwhelmed, shuts down to the survival responses in 1 1 Survival Reaction Basic needs fight or flight Basic neuroscience Can you think straight when you panic, are frightened or angry?

Responding to behaviour
We see and respond to this Thoughts and feelings driving the behaviour: We don’t usually see or respond to this ??? Ironically, behaviour is often punished repeatedly but if the thoughts and feelings are resolved or eased, the behaviour will change. “When X happened, what were you thinking and what were you feeling?”

Behind the behaviour Nurture Portrait 2015/16 A snapshot of the social, emotional and behavioural difficulties in pupils throughout the UK, The Nurture Group Network

“Good mental health among
pupils is fundamental to their wellbeing and success. At the moment too many young people are unfairly labelled as trouble-makers when in fact they have unmet mental health problems. Teachers are not therapists but they play a vital role in the lives of their pupils. Teachers who know how and when to help can make all the difference for children with mental health problems.” (Education Minister Elizabeth Truss)

Resistance “But I’m a teacher – I shouldn’t have to do mental health…”
When we see mental ill health as an issue for specialist health services, we fail to support CYP at an early stage. If we fail to acknowledge distress as a normal part of life, we further stigmatise mental health problems, We fail to create opportunities for help to be sought It helps to know what the expectations are; teachers are not expected to deliver therapy or do more work. It helps to know that reducing emotional distress creates the best learning environment

‘The link between pupil health
and wellbeing and attainment – A briefing for head teachers, governors and staff in education settings’, Public Health England, November 2014 “Research evidence shows that education and health are closely linked. So promoting the health and wellbeing of pupils and students within schools and colleges has the potential to improve their educational outcomes and their health and wellbeing outcomes.”

Expectations Schools will: Understand the link between emotional wellbeing and good educational and wider outcomes Have a ‘whole school’ approach to supporting all pupils’ wellbeing and resilience Address bullying Ensure staff are aware of how mental health relates to their work Access the e-learning packages for non-health professionals, (search MindEd) Know what specialist mental health support is available Know when to intervene early to tackle mental health problems Challenge mental health stigma No Health Without Mental Health: Implementation Framework, DoH 2012

Natasha Devon, Ex Gov MH Champion
Focus on causes (bullying? Exam stress?) not symptoms Academic pressure and testing is detrimental to children’s mental health – how do we manage this? “If a child is being bullied and they have symptoms of depression because they are being bullied, what they need is for the bullying to stop. They need to feel safe again. They don’t necessarily need anti-depressants or therapy.” Drinking, smoking, teen pregnancy reducing but self harm, anxiety and depression increasing Calls to Childline about exam stress have tripled in four years

What else can we do? Ensure that our communication and behaviour in the classroom does not escalate emotional arousal Create safe learning spaces so children can connect with their problem solving brain Give permission and a language to talk about difficulties Promote holistic wellbeing, act early on concerns Understand what life is like for pupils, know the thoughts and feelings driving their behaviour Respond to the causes of emotional difficulties effectively Remember mental ill health is common and emotional arousal is normal Remember that we are already contributing massively to our pupils’ wellbeing, we don’t have to know all the answers Small thinks make the biggest difference – time to listen, daily check ins, code words for exit, developing strategies together etc Self review tool

What about me? Your sense of wellbeing has a significant impact on your pupils’ Don’t forget to look after yourself – 5 ways to wellbeing, Action for Happiness etc You can’t support pupils’ wellbeing if you are not supporting your own / being supported by your school Mental health difficulties are not weaknesses or deficiencies For support, search online for the Wellbeing Team Hertfordshire or visit 5 ways to wellbeing, action for happiness, MHF 101 tips to reduce stress

Support and resources Reflective practice

Role of the school Mental Health Lead
Part 2 Role of the school Mental Health Lead

Model for schools All school staff: (Level 1)
Delivering health promotion and prevention to pupils who are thriving and early identification of pupils who are coping temporarily with setbacks or not thriving, Tier 1. Mental Health Leads in Schools: (Level 2) Designated senior members of staff with a responsibility for developing the whole school approach to mental health & emotional wellbeing. The Mental Health Lead, similar to a DSP, can respond to staff concerns, assess, arrange advice or help in partnership with the pupil and make referrals for more help where appropriate. Pastoral Workers: A range of Pupil or Family Support workers with training to support early intervention of mental health & emotional wellbeing. Helping pupils to get advice or help and facilitating access to more help when needed. Working at Tier 1 and 2.

UNDERSTANDING THE RELATIONSHIP BETWEEN MENTAL HEALTH & MENTAL ILLNESS
Module Two: the Guide Resource Dr. Stan Kutcher & Ms. Yifeng Wei March 2015

Key assessment questions
How severe are the difficulties? How long have they persisted? What impact are the difficulties having on the young person, school, family, peers? Is the young person a risk to themselves or others? Are the difficulties present at home, school and in the community? Are the difficulties proportionate to life events? What has been tried before? What helps / what does the young person / family think will help?

Toolkit to support assessment, recording and monitoring
Password protected area of Example resources: Information about the SDQ For all staff Level 2 – assessment of need Record of concern slip Level 1 - When to worry tool Matching need to intervention table Referral case studies For the Mental Health Lead Referral guidance Referral form Record of concern form

Tiers of service – current picture
0.075% 212 1.85% 5219 7% 19,747 256,922 All Children Estimated Hertfordshire Prevalence 0-18

Needs led approach – the future

Early Help Continuum of Need

The Families First Process
Families with emerging needs will be supported by a single agency. Request A request for support is made if a family needs more help than a single agency can provide and they do not meet the social care threshold. Families and professionals will make this request through the Customer Service Centre. Alternatively the case could be stepped down from the Multi-Agency Safeguarding Hub (MASH). FF Triage Families First Triage assesses the request for support and offers advice, guidance or signposting. Sends to Triage Panel as appropriate. Triage Panel Weekly multi-agency triage panel uses local knowledge to identify the most appropriate support for the family. Key Worker The family is allocated a Families First Keyworker (from any agency) The keyworker co-ordinates the support around the family. Action & Impact Cases showing no progress are brought to the relevant monthly Families First Action & Impact Meeting to discuss and progress.

Families First Contacts
East Herts & Broxbourne Senior Families First Coordinator: Tina Powell Families First Coordinator: Serena Yearwood St Albans & Dacorum Senior Families First Coordinator: George Gearing Families First Coordinator: Jackie Green Stevenage & North Herts Senior Families First Coordinator: Carol Jeffreys (Maternity Cover) Senior Families First Coordinator: Holly Turl (Maternity Leave) Families First Coordinator: Jenny Close (Job Share - Mon, Tue, Wed) Families First Coordinator: Anne Newby (Job Share - Thurs, Friday) Watford & Three Rivers Families First Coordinator: Carol Jeffreys (currently seconded to Snr. Coordinator Stevenage and North Herts) Welwyn Hatfield & Hertsmere Senior Families First Coordinator: Freya Rymer First Coordinator: Emma Delaperelle You can call to discuss most appropriate pathway…

School Provision Early intervention and prevention – see self review
Provision to support mental distress (coping) – whole school approach and curriculum such as: Mindfulness, UK Penn Resilience Programme, Growth Mindsets, Circle Time, PSHE Association lesson plans, Forest Schools, Bright Stars, Action for happiness / Five ways to wellbeing, Philosophy for Children, worry box Provision to support mental health problems (coping and getting help) – targeted individual and group interventions such as: Protective Behaviours, SEAL, drawing and talking, nurture groups, parent support, mentoring, peer support / mediation, play / art / drama therapy, counselling

Referral to Tier 2 services
When school based interventions have not helped or MH problems escalate / a disorder is suspected Responding to practical problems and life issues de-escalates mental health problems (Early Help) STEP 2 via the Single Point of Access or direct for 6 week intervention EPS provide a quick query telephone service Tues and Weds pm 16+ can access the Wellbeing Service, HPFT AMH Kooth Online Counselling commissioned locally Community counselling & Safe Space Targeted service for CLA from HPFT

Referral to Tier 3 Persistent, complex and severe emotional or behavioural difficulties which are beyond a normal response range to life problems If Tier 1 and Tier 2 interventions have not been successful and needs escalate. Before referring to a mental health service consider the message this sends to a child, young person or family if what they are experiencing is a normal response to their circumstances As part of a CAF/ FFA (Early help assessment) SPA (password protected) Use the multi agency referral form cc GP

Eligibility Criteria for Specialist CAMHS
For children and young people up to their 18th birthday. Severe, complex and/or persistent difficulties which often present as emotional or behavioural symptoms An appropriate community (universal or targeted) intervention has not resolved the current difficulties Or the difficulties are of such a severity and are causing impairment to such a degree that a referral straight to specialist CAMHS is indicated e.g. Psychosis, risk of suicide or severe self – harm, severe depressive episode, eating disorders The young person or family consent to the referral

The SPA process All referrals received into SPA are screened by a shift leader to identify whether referrals are urgent or routine. Urgent referrals are dealt with by the SPA Urgent Pod (mini-team) for action on the same day. CAMHS are able to offer Priority appointments within 7 days of the receipt of referral. If a child or young person needs to be seen immediately or within 48 hours then the appropriate action is to send them to Accident and Emergency, in an emergency please dial 999. Routine referrals are processed the CAMHS Pod within 14 days from receipt of referral. A face to face assessment will be made within 28 days. The referrer should receive a letter confirming the course of action.

If problems deteriorate
Contact the local team on the telephone number on the appointment letter if this has been received and ask to speak with the duty worker (between 9am – 5pm,) alternatively contact the Single Point of Access (SPA) (between 8am – 7pm,) For advice and telephone support from a mental health professional out-of-hours (between 5pm –9am, 24 hours weekends and bank holidays) call the Mental Health Helpline on: Make an urgent appointment with their GP. Attend Accident & Emergency if a child or young person requires urgent mental health support or in an emergency dial 999.

Mental health Problems
Part 3 Mental health Problems

Anxiety is normal and natural
Anxiety is normal and natural. A little bit of anxiety can help us perform EG exams. Unpleasant physical response to make us take notice. Too much anxiety provokes flight, fight or freeze responses. Anxiety disorders more severe, last longer, interfere with school / work / relationships. Most extreme end can include panic attacks. Very common disorder (1 in 6 YP at some point), often with depression, higher prevalence for girls. Can be caused by environmental factors, medical factors, genetics, brain chemistry, substance misuse or a combination – stress most common trigger. CBT, self help most common treatment for mild to moderate disorder, interpersonal / family therapy and sometimes antidepressants for severe cases. CBT in effect helps people to identify patterns and change the way they think about / interpret certain things and their behaviour (EG avoidance) to change how they feel. In school, focus on goals, problem solving, breathing and distraction, relaxation, (careful) exposure, exercise, social, hobbies, challenge negative thinking. The mental health of children and young people in England , PHE, Dec 16

Black Dog video YouTube
Often referred to as low mood. Characterised as loss of enjoyment and interest. Affects ability to concentrate, get on with others – when severe can increase the risk of self harm, substance misuse, suicide. Again more common in girls (boys may feel emotional symptoms are not acceptable to present with and may manifest as behavioural difficulties) 10% recover spontaneously in first 3 months therefore watchful waiting is common if symptoms are mild, many more within a year, but can be persistent. A counsellor or other therapist may also be appropriate for those with mild depression and no suicidal thoughts or co-morbid problems. After 2-3 months, a referral to Step 2 / specialist CAMHS if no improvement. Number of YP aged with depression nearly doubled between the 80’s and 00’s. Broad range of risk factors – bullying, physical health problem, family breakup, bereavement, family history, medication, distressing event etc CBT also appropriate for depression – education about the illness, viewing symptoms as part of an illness that they can do something about, structure and routine, mood awareness, challenging negative thoughts, participating in enjoyable activity. EXERCISE. Self help website: get self help.co.uk The mental health of children and young people in England , PHE, Dec 16

Eating disorders affect a great number of people, predominantly female but on the rise for males
Up to 6.5% adults display symptoms, 35% of them male. Most common age for hospital admission males age 13, females age 15 Anorexia nervosa – distorted body image, self induced weight loss through food avoidance, appetite suppressants, excessive exercise, 15% below normal weight, loss of periods, high mortality rate (20% die), average onset is 16 to 17, nearly half recover fully, a third improve, 20% remain chronically ill, YP with low self esteem / perfectionists are more at risk. Bulimia nervosa – repeated episodes of uncontrolled over eating, extreme dieting, purging (induced vomiting), laxatives, could be overweight / under weight / normal weight, 5x more common than anorexia, average onset Binge eating disorder – episodes of uncontrolled over eating, no purging or compensatory behaviours, distress with over eating, at least two days a week for six months on average, equal numbers of males / females, associated with obesity, more common than anorexia or bulimia. EDNOS – eating disorder not otherwise specified, does not fit criteria, often early identified problems. Long term physical health problems, early intervention is key but difficult, often hidden.- we need to be curious. Like self harm, may be a coping mechanism / way to have control. Don’t comment on a person’s weight, body shape, looking healthy, this may validate their behaviour. Community Eating Disorder service exists in Hertfordshire. The mental health of children and young people in England , PHE, Dec 16

It’s a behaviour not an illness in itself, it’s a coping mechanism not a suicide attempt but there is a risk (11% go on to attempt suicide) because of ongoing and escalating distress / desensitisation to harm / accidental? It’s not attention seeking as it is often hidden. Asking about suicide if we are concerned won’t put the idea in a YPs head. Safeguarding issue. HSCB guidance – procedures. Purpose of self harm – to give relief from distress, feel in control, self punishment, cleansing, to feel something, to have a tangible wound as a physical manifestation of their distress etc Language – YP who self harm, not self harmers. Seriousness of injury isn’t representative of emotional distress. SH on a continuum, keep an open mind, not just cutting, boys and fights, under represented in data because not recorded as SH? SH warning signs? Suicide is not attention seeking or selfish – suicidal people don’t want to die, they don’t know how to live / don’t want death, want the pain to stop. Where there are existing issues in a family, a YP may not want to add to problems by speaking of their distress, suicidal people think that others would be better off without them. More females have felt suicidal but more males complete suicide, males more likely to use hanging / females OD (more likely to be found / saved). No longer a criminal act so to use committed suicide, successful suicide is not appropriate. Use attempted / completed suicide or died by suicide. Substance misuse can increase risk as well as exposure to suicide in family / community, untreated depression leading cause. What are warning signs? The mental health of children and young people in England , PHE, Dec 16

Assessing suicidal thoughts
Are you thinking about killing yourself? Have you thought about how? Have you thought about when and where? On a scale of one to ten, how unbearable is your distress / pain? Do you feel you have anyone that can help you? Have you ever thought about / attempted suicide before? Is anything different now? What stopped you before? Have you ever had any help from a mental health worker? Could you choose to stay safe for now? Could you put things on hold so we can try some things? Lack of a plan does not guarantee safety

Part 4 Strategies to support

Strategies to support key issues
How to stay healthy How to know when things aren’t ok How to ask for help How to respond How to manage worry How to manage low mood Understanding feelings, behaviours, escalators and strategies

Don’t underestimate the value of…
Connect… Be active… Take notice… Keep learning… Give… Belonging Love Relation-ships Family Friends Connected to the environ-ment Physical wellness Exercise Healthy eating Good sleep hygiene Mindful-ness Interrup-ting autopilot Being outside Goals and personal achieve-ment Rewards, having fun and relaxation Nurtur-ing, pets, plants, garden-ing Helping others Giving to charity YP say teach us how to stay well, not just what ill health looks like… Action for happiness, MHF 101 tips to reduce stress

Resilience Resilience can be learnt
One key positive relationship with an adult (not necessarily a parent) Break overwhelming tasks into more manageable chunks (P4C?) Let them make mistakes and learn from failure (model, brain science, growth mindset?) Develop persistence through goal setting / personal meaning Don’t accommodate every need Avoid eliminating all risk Teach problem solving skills and don’t provide all the answers Teach concrete (practical) skills Avoid why questions Challenge catastrophic language, contextualise Help them manage their emotions Identify and develop personal strengths (Super Heroes?)

When things aren’t ok How long have I felt like this?
Does this problem stop me from doing normal things? How strong is the feeling / how big is the problem? Am I safe / are other people safe with me?

Permission We can talk with someone about anything, even if it is awful or small Barriers? How do we overcome these? Regular opportunity to ask about personal development as well as academic progress? Why is it good to talk? What are the qualities of someone you might talk with? How would you know? Who could it be? How could you approach them?

Network Hand

Responding to distress
Validate children and young people’s feelings: “I can see that you are very sad / angry” “How are you feeling right now?” Normalise the feeling and make a human connection: “I would feel very sad / angry if that had happened to me” “I can understand why you are feeling sad / angry” “I would think most people would feel sad / angry if that happened to them”

Give them time to reconnect their thinking brain:
“It’s hard to think things through when we are upset / angry so we need to figure this out when you are feeling less upset / angry” Give children as much choice and control as possible: “Would you like to do it now or later?” “Would you like to tell you mum or shall we do it together?” Create a sense of collaboration: “What do you think we should do next?” You don’t have to know the answers: “I’m not sure what to do about that. I need to have a think about it but I will try my best to help you.”

Respond - Reassure - De-escalate Empower – Pass on - Hold in mind
Thank children and young people when they tell you about feelings or other difficulties: “Thank you for telling me about this, I can imagine it wasn’t an easy thing to do.” Give hope for the future: “I know this is a really difficult feeling but I want you to remember that you won’t always feel like this, the feeling will go.” Respond - Reassure - De-escalate Empower – Pass on - Hold in mind

Reducing anxiety 1. Which of my worries belong to other people?
2. Which of my worries does everyone else have? 3. Which of my worries do I need an adult to help me with? 4. Which of my worries look smaller / disappear when I tell them to others? 1. Do I have any evidence to support my feelings? 2. What can I change? 3. What can’t I change and need to accept? 4. What needs my urgent attention? 5. Who can help me?

Bad day / good day Write down a commentary of your day
Go through what you have written and put a ring around any negative words Rewrite your commentary without any negative words I missed the bus and had to walk to school. I was late and had maths first which I hate. I didn’t have enough money for lunch. I walked to school. I was just in time. I had maths first then music. The office lent me some money for lunch. I had chocolate pudding.

East and North Herts CCG Breda O'Neill Breda. O'Neill@enhertsccg. nhs
East and North Herts CCG Breda O'Neill Mobile: Herts Valleys CCG Deborah Sheppard Mobile:

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