WHO Collaborating Centre for Health Promotion Research National University of Ireland Galway...

WHO Collaborating Centre for Health Promotion Research WHO Collaborating Centre for Health Promotion Research National University of Ireland Galway National University of Ireland Galway

Ollscoil na hÉireann, GaillimhOllscoil na hÉireann, Gaillimh

Why Mental Health Matters in Schools: Evidence and principles of effective implementation

Professor Margaret Barry

M. Barry, Dublin 2012

The importance of mental health‘there is no health without mental health’

• Mental health is fundamental to good health and quality of life» a resource for everyday life which enables us

to manage our lives successfully» contributes to the functioning of individuals,

families, communities and society» importance of promoting positive mental

health in its own right


Current definitions of mental health

‘more than the absence of mental illness’

Mental health may be defined as; “a state of emotional and social well-being in which the individual realises his or her own abilities, can manage the normal stresses of life, can work effectively, and is able to play a role in his or her community” (WHO, 1999)

“ Mental health is the emotional and spiritual resilience which enables us to enjoy life and to survive pain, suffering and disappointment. It is a positive sense of well-being and an underlying belief in our own and others’ dignity and worth”(HEA, 1997)


Mental Health and Young People

• Childhood – opportunity to lay the foundations for good mental health across the life cycle

• Around 25% of children and adolescents experience mental health problems, of which 10% are mental disorders warranting treatment

• Mental health problems co-occur with social problems such as school failure or delinquency as well as health problems like substance misuse

• Poor adjustment in childhood is linked with negative psychosocial outcomes in adulthood


Mental Health Promotion in Schools

• Schools are one of the most important settings for promoting the mental health of young people (WHO, 2001)

• Schools provide a socialising context that has a significant influence on:positive youth development sense of connectedness with family, community and

broader society• School as a setting – a systems approach



• Building academic success on social and emotional learning • promote academic, emotional and social competence• reducing school drop-out rates• reducing a range of negative health and social outcomes

• Teaching and learning of skills, attitudes and resources that are valuable for life - communicate effectively, work as a team member, resilience in

the face of difficulties, problem-solving, coping strategies, sense of control/efficacy

• Role of education in addressing social and health inequity


Social and Emotional Wellbeing

• Increasing focus on social and emotional wellbeing » Emotional intelligence (Salovey and Mayer, 1990;

Goleman, 2005) - skills of understanding our emotions» Emotional literacy (Steiner and Perry, 1990) - ability

to identify, manage and communicate how we feel; Weare (2004) “..and respond to the emotions of others in ways that are helpful”

» Focus on teaching and learning of personal and social skills for young people (Institute for Public Policy Research, Margo et al., 2006)

» Social and emotional learning (CASEL, 2004, 2010)


Collaborative for Academic, Social and Emotional Learning

(CASEL)

Essential skills for social and emotional learning:• Self-awareness - know yourself and others - identify

feelings, be responsible, recognize strengths• Self-management - manage emotions, understand

situations, set goals and plans, solve problems creatively• Social awareness - care for others - show empathy,

appreciate diversity• Relationships skills - communicate effectively, build

relationships, negotiate fairly, refuse provocations, seek help

• Responsible decision making - act ethically, appropriate social norms, respect others


Positive Mental Health

• Focus on promoting positive mental health• Conceptualisations of positive mental health

(Keyes, 2002; Huppert, 2005; Ryff et al., 2006)- Hedonic - subjective well-being and life satisfaction

- Eudaimonic - positive functioning, engagement, fulfilment and social well-being

• Keyes’ concept of optimal mental health or ‘flourishing’

• Abilities to develop psychologically, emotionally, intellectually, socially and spiritually


Promoting Mental Health

• Mental health promotion» focus on positive mental health and quality of

life across populations» building strengths, competencies and resources

• Prevention of mental disorders» concern with specific disorders - reducing

incidence, prevalence or seriousness of a targeted problem

» mortality, morbidity and risk behaviours

Universal

Selective

Indicated

Case identification St

anda

rd tr

eatm

ent

for

know

n di

sord

ers

Complia

nce with

long-term

trea

tmen

t

After-care

(including rehabilitation)

EmpowermentCompetenceSupportive

Environm

ents

Strategies for promoting

well-being & quality of life

Res

ilien

ce

Barry, M.M. (2001) International Journal of Mental Health Promotion, 3(1) 25-34.

Health Promotion action areas

Build healthy public policy

Create supportive environments

Reorient health services

Strengthen community action

Develop personal skill

combined into Health Promotion strategies

Systems

Policies

environment

organisation

community

person

Systems scale

Health Promotion Principles (participation, empowerment, equity, social justice)

Assessment

Pla

nn

ing

Implementation

Eva

luat

ion

micro - macro

Health Promotion Socio-ecological Model (Ottawa Charter, WHO, 1986)

The process of enabling people to increase control over their health and the determinants of health


Determinants of Mental Health(HEA, 1997; VicHealth, 1999)

Key determinants of mental health:• Societal level - healthy structures

» economic, social and cultural framework• Community level - citizenship

» social support, sense of connectedness and inclusion, social participation

• Individual level - emotional resilience» self-esteem, coping, life skills, sense of control


Settings Approach

• Where is mental health created ?- in the settings where people live their lives

• School ecology as a focus of intervention• Health Promoting Schools Initiative (WHO, 1997)“ a school constantly strengthening its capacity as a

healthy setting for living, learning and working”•curriculum approaches•improving the school ethos and environment•involving families and the local community

Teaching and learningHolistic Health Education

Group supportCommunication

mental health drug and sexuality education

Seeking help / safetyEmotions & feelings

Influences and decisionsPhysical health Ethos and environment

Individual differenceBelongingSupports

ConfidentialityAnti-bullying policy

Critical incident policyStudents at risk policy

Peer supportsEquity

CounsellingHPS

Partnerships School /parent links

Community health servicesAdolescent mental health services

PoliceLocal / national support groups

Local GovernmentLocal GPs

Learning support services

Whole School



• Classroom curriculum-based approach - generic life skills training

• Whole school approach - the school setting including the school ethos and environment, and involving the parents and the local community

• Targeted interventions - students at higher risk e.g. of depression and suicide



Sample Programmes

• Curriculum-based programmes- Botvin’s Life Skills Training programme- Cognitive skills training - problem-solving - Greenberg et al’s Promoting Alternative

Thinking Strategies (PATHS) - Kellam’s Good Behavior Game


Sample Programmes

• Whole School Approach- Australian MindMatters (Wynn et al., 2000) and Kidsmatter

programmes (Kidsmatter, 2009)- Olweus Bullying Prevention programme- UK Social and Emotional Aspects of Learning (SEAL)

• Targeted Programmes- Clarke’s Coping with Stress Course – depression- Gillham et al. Penn Resiliency programme- Resourceful Adolescent programme (Shochet et al, 2001)- Incredible Years Programme (Webster-Stratton et al., 2001)


Systematic Reviews of School-based Mental Health Promotion Programmes

• Lister-Sharp et al. (1999)• Wells, Barlow and Stewart-Brown (2001, 2003)

HSRU, University of Oxford• Harden et al. (2001) EPPI- Centre• Greenberg, Domitrovich & Bumbarger (2001)• CASEL (2003)• US Mental Health and Substance Abuse

(SAMHSA - www.samhsa.gov)• Implementing Mental Health Promotion Actions

Database (IMPHA & Dataprev)• Tennant et al. ( 2007); Adi et al. (2007), NICE

(2007); Payton et al. (2008); Durlak et al. (2011)


Conclusions from Effectiveness Studies (Barry et al., 2009)

• Mental health promotion in schools, when implemented effectively, can produce long-term benefits for young people, including emotional and social functioning and improved academic performance

• Traditional topic based health education approaches are of limited value (knowledge only programmes have minimal effects on behaviour)

• Programmes adopting a whole school approach are more successful and the most promising


IUHPE Special Issue, 2005“there is sufficient knowledge to move evidence into

practice”

Jané-Llopis, E., Barry, M.M., Hosman, C. and Patel, V. (Eds.) (2005) The Evidence of Mental Health Promotion Effectiveness

Comprehensive programmes that target multiple health outcomes in the context of a co-ordinated whole school approach are the most consistently effective strategy


Reviews of Evidence• Weare & Nind (2011) – review for the EU Dataprev project

Health Promotion International, Special Issue Vol 26 • Review of 52 systematic reviews and meta-analyses of

mental health interventions in schools (46 universal interventions)

• Positive effects on social, emotional and educational outcomes

• few examples of adverse effects

• higher risk children benefit more

• family and community involvement

• high quality implementation - clarity, intensity and fidelity


Effectiveness of programmes

• Weare (2004) “ programmes that teach social and emotional competence can result in gains that are absolutely central to the goals of all schools. Gains include improved school atmospheres, more effective learning, better behaviour, higher school attendance, higher motivation, higher morale of students and teachers, and better results for students and schools” (p13)


CASEL - evidence based support for social and emotional learning

(SEL)

• Improved attitudes toward school, better sense of community (Schaps et al., 2004) and higher academic motivation (Johnson and Johnson 2004)

• Positive school behaviours - more prosocial interactions (Johnson and Johnson, 2004), fewer absences and suspensions (Christenson and Havsy, 2004) and reductions in aggression, disruptions and interpersonal violence (Greenberg et al., 2004)

• Enhanced school performance in terms of improved maths, language, arts and social studies (Brown et al., 2004) and better problem solving and planning (Greenberg et al., 2004).


CASEL Technical Report on the impact of social and emotional learning (Payton et

al., 2008)

• Three scientific reviews - 317 studies involving 324,303 school children aged 5-13 years

• Strong and consistent support for sustained positive impact of SEL programmes

• Students scored 11 percentile points higher on standardized achievement tests relative to peers not receiving the programme

• Only when delivered by school staff did students’ academic performance improve significantly


CASEL 2008 Technical report on the impact of social and emotional

learning

• Improvement in multiple areas : • Social and emotional skills• Attitudes towards self, school and others• Positive social and classroom behaviours • Conduct problems - misbehaviour and

aggression• Emotional distress - stress and depression• Academic performance - test scores and school

grades


CASEL 2008 Technical report on the impact of social and emotional

learning

Interventions using four recommended evidence-based practices for skill training were more effective than those that did not;

• Sequenced - skills are developed sequentially in a step-by-step fashion

• Active - active learning -role plays and behavioural rehearsal with feedback

• Focused - time given exclusively to developing social and emotional skills

• Explicit - programme targets specific social and emotional skills


Characteristics of Effective Programmes (Green et al., 2005;

Weare & Nind, 2011)

• Aimed at the promotion of mental health rather than the prevention of mental health problems (Wells et al., 2001)

• Implemented continuously and long-term in nature i.e. more than one year (Wells et al., 2001)

• Include changes to the school climate rather than brief class-based prevention programmes (Wells et al., 2001)

• Extend beyond the classroom and provide opportunities for applying the learned skills (CASEL, 2003)



Weare & Nind, 2011)

• Adopt a health-promoting schools approach focusing on aspects of the social and physical environment of the school, family and community links with the school, the school curriculum and pupils’ knowledge (Lister-Sharp et al., 1999)

• Integrated with academic learning and the overall goals of the school (Weare & Nind, 2011)

• Balancing universal and targeted approaches(Weare & Nind, 2011)



Weare & Nind, 2011)

• Need for rigorous implementation• Focus on skills and enhancing generic social

competences - coping skills, good peer relationships, self-efficacy (Weare & Nind, 2011)

• Interactive teaching methodologies - active learning, activity-based, student participation (Weare & Nind, 2011)

Funded by: • HSE West • HSE Population Health, Health Promotion Directorate• National Office for Suicide Prevention• Irish Research Council for Humanities and Social Sciences

An evaluation of the Zippy’s Friends emotional wellbeing programme for

primary schools in Ireland

Aleisha M. Clarke & Margaret M. BarryHealth Promotion Research Centre

Department of Health Promotion

National University of Ireland, Galway

Evaluation of the Zippy’s Friends programme in Ireland (Clarke & Barry, 2010)

• Programme was introduced into designated disadvantaged Irish primary schools on a pilot basis in 2008

• Health Service Executive and Department of Education & Science

• 24 week programme – six modules, structured materials

• Teachers trained in its delivery

• Evaluation of process and outcomes

MethodologyStudy Design: Randomised Controlled Design

Data Collection

T1: Baseline (Feb ’08)

T2: Interim I (June ’08)

T3: Interim II (Oct ’08)

T4: End of Prog (Apr ’09)

T5: 1 Year Follow Up(Apr ’10)

DEIS Schools (n=42)

(n= 730)

Intervention(n= 523)

Control (n=207)

Intervention Type I(n=270)

Intervention Type II(n=253)

Evaluation of the Zippy’s Friends programme in Ireland (Clarke & Barry, 2010)

• Measures: structured scales, child participatory workshops, Draw-and-Write technique

• Teachers’ weekly reports on implementation, class observations, review sessions

• School Context – case studies

Summary of main findings• Successful programme adaptation to Irish designated disadvantaged

primary schools

• Significant positive effects on children’s emotional literacy, coping skills, hyperactivity and teachers’ relationships with the children

• 12 months post-intervention follow-up

Twelve months follow-up (Clarke, 2011 Doctoral thesis)

• Emotional Literacy (EL) improvements at 12 months follow up - total scores and empathy and social skills sub-scales

• No significant effects for children in the “well below/below average” range -> additional support for children with specific emotional literacy needs

• Child participatory workshops - improved vocabulary for articulating feelings

• Emotional & Behavioural Wellbeing - Strengths & Difficulties Questionnaire – reduced hyperactivity scores for intervention group Control group – significant reduction in conduct problems sub-scale scores

• No significant effects for children in the “borderline’ and ‘abnormal’ score bands –> additional support for children with specific behavioural needs


• Children’s Coping Skills - Draw & Write Activity– increased use of active coping and support seeking strategies in dealing with conflict, rejection and loss

• All maintained at 12 months apart from conflict –> avoidance strategies

• Schoolagers Coping Strategies Inventory – few significant findings – intervention group more likely to ‘relax and try to stay calm’

Draw and Write Technique: Children’s Drawings

Draw and Write Technique: Children’s Drawings


• Programme Fidelity – high fidelity (over 90% implementation) positive impact on emotional literacy; low fidelity (less than 75%) no improvements in emotional literacy

greater fidelity and better quality implementation leads to better outcomes

• Positive impact on the Teachers – increased awareness of children’s emotional wellbeing

• Limited impact on the whole School - lack of whole school awareness

need for whole school training and parental involvement

A copy of the full report is available to download at:

http://www.nuigalway.ie/hprc

Or email:

[email protected]


Context Matters in Programme Implementation Clarke, Barry & O’Sullivan

(2010) Health Education, Vol 110, No. 4

• The specific contexts of schools participating in the study- contextual factors impacting on local implementation

• Two schools – large urban multi-cultural school in an area of multiple disadvantage; smaller mono-cultural rural school on the border region with Northern Ireland

• Case study - views of teachers, parents and key community informants•different levels of parental involvement•socio-economic and cultural factors in the local community•community histories and local politics•different stages of ‘readiness’

• Unique school culture within which programme implementation occurs


Context Matters in Programme Implementation Clarke, Barry & O’Sullivan

(2010) Health Education, Vol 110, No. 4

• Complex interaction of factors operating at the classroom, school and wider community level

• School culture, environment and whole school practices readiness for change (Bumbarger & Perkins, 2008) strategies for school organizational change

• Contextual factors in the local community (Wanders et al., 2007) teacher-parent relationship impact of economic and social factors on parental involvement

• Understanding the organisational and cultural contexts of schools is critical for implementation and sustainability (Rowling, 2008)


Importance of Implementation

• High quality programme delivery - supportive implementation system- engagement of school management, teachers, parents

and students

- teacher training, resources, organizational support • Finding the right mix of programme fidelity and

adaptation • The process of planning, implementation and

training systems


Importance of Implementation

• Sustained interventions over multiple years - once-off or short-term interventions are not likely to produce long-term effects

• Organizational and system-level practices and policies that will ensure the long-term impact of high quality programmes


Opportunities & Challenges

• Leadership - integrating efforts to promote social and emotional learning of young people with the school’s educational mission of academic learning

• Over-crowded curriculum• Adopting a whole school approach in practice

- wider school, parental and community engagement• Training and support - both pre- and in-service

- content and methodologies• Supportive policies and collaboration across the

education and health sectors


Useful Sources• Barry, M. and Jenkins, R. (2007) Implementing Mental

Health Promotion. Elsevier, Oxford• Jané-Llopis E, Barry M M, Hosman C, Patel V (2005)

Mental health promotion works: a review. Promotion and Education suppl 2:9-25

• Rowling, L., Martin, G., & Walker L (2002) Mental health promotion and young people: concepts and practice. McGraw Hill, Sydney

• Weare, K. (2000) Promoting mental, emotional and social health: a whole school approach. Routledge, London

• Payton et al. (2008) The positive impact of social and emotional learning for kindergarten to eight-grade students: Findings from three scientific reviews. CASEL www.casel.org or www.lpfch.org/sel


Useful Sources• Weare, K. and Gray, G. (2003) What Works in Developing

Children’s Emotional and Social Competence and Wellbeing? [online]. Available: http://www.dfes.gov.uk/research/data/uploadfiles/RR456.pdf

• Weare, K. (2004) Developing the Emotionally Literate School. London: Paul Chapman Publishing

• Weare, K. and Nind, M. (2011) Mental health promotion and problem prevention in schools: What does the evidence say? Health Promotion International, Special Issue Vol. 26.

• Zins, J. E. et al. (2004) Building Academic Success on Social and Emotional Learning. Teachers College Press, Columbia University.

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