In recent years, there has been increased recognition of the important role schools can play in nurturing the mental wellbeing of pupils and identifying problems when they first arise.
Efforts to improve links between schools and local child and adolescent mental health services (CAMHS) have also attempted to improve children's access to formal assessment and treatment programmes.
These developments have been driven by growing concerns about the level of need among pupils. In May, the Institute for Public Policy Research found that 90 per cent of head teachers reported an increase in mental health problems among pupils over the past five years.
It called for all secondary schools to have access to a mental health professional on-site once a week.
Teacher training
Earlier this month, a "state of the nation" report from the Centre for Mental Health also found that a lack of proper mental health training for teachers means they often fail to spot psychological distress, and are instead mistaking it for bad behaviour.
Meanwhile, 2015 research by the National Children's Bureau identified how evidence-informed mental health interventions in schools can improve academic learning, wellbeing and behaviour.
"Schools need to have a clear awareness of the extent and nature of mental health problems in children and young people, and of their responsibility to be part of the response, not least because these problems do not go away," its report states.
The government has recognised this and funded a number of school-based mental health initiatives aimed at improving teachers, knowledge of the issue, expanding services and boosting school links with CAMHS (see box).
But health commissioners in Oxfordshire have taken things a step further by placing children's care and health professionals into schools as part of a programme called In-Reach, which has been developed as part of its CAMHS transformation plan.
In 2014, Oxford Health NHS Foundation Trust trained a group of professionals to provide mental health support in nine secondary schools in the county.
Andrea Shand, head of CAMHS in Oxfordshire and In-Reach lead, said the programme was developed as part of the wider recognition of the important role schools can play in improving mental health among children.
"Increasing mental health input via schools is to reach out to young people where they spend the majority of their time and to reduce time out of school for [CAMHS] appointments," she says.
The trust outlined in its local transformation plan that the pilot had been "very successful" and had improved access to treatment.
"It has reduced stigma and normalised getting support for mental health concerns. The schools involved in the pilot have been supported to build capabilities to support pupils within the school environment stopping unnecessary referrals coming to CAMHS," it stated.
Based on these positive early results, In-Reach was quickly extended to all the county's 34 secondary schools.
Each In-Reach worker is a qualified nurse, social worker or occupational therapist, and has experience in working with children and families. They perform their In-Reach role part-time alongside their other professional work.
The programme - commissioned and funded by Oxfordshire clinical commissioning group, and developed with Oxford University psychiatry department and NHS England - also sees school staff receive advice and training on mental health issues.
"All schools are offered various modules from psychological perspectives in education and primary care training. Dependent on their particular needs within the school, this training is offered to staff within schools," says Shand.
The programme offers staff the opportunity to discuss potential referrals of young people who are of concern, and supports them in offering early help.
It also offers guidance via a "consultation line" staffed by mental health specialists during the week who offer advice to teachers.
Counselling sessions between the In-Reach worker and young people are booked in advance rather than having drop-in sessions. At these, pupils are offered evidence-based interventions such as cognitive behavioural therapy.
"There are booked sessions for young people in schools and slots for staff for consultation, advice and support," says Shand.
The programme, according to Shand, aims to enhance and support existing services rather than replace them.
"In-Reach is not a replacement for existing services, it is enhancing our CAMHS offer in Oxfordshire," she says.
The trust plans to expand the programme to pilot it in a primary school in Oxford from September, with plans to evaluate it at the beginning of next year.
Shand says this decision was based on well-researched benefits of intervening early when mental health problems first arise.
"We know that early intervention is the preferred model and we know that primary school staff also have a role in supporting the mental health and emotional wellbeing of their pupils," she says.
However, she says the primary school programme may not offer exactly the same services as the offer in secondary schools.
"There are significantly more primary than secondary schools and this needs balancing with our resources and capacity," she explains. "So the model needs to differ from the secondary school model, in terms of a more consultative and training approach as opposed to actual interventions in the school. However, any children referred will be seen in the usual way."
Shand says the primary school pilot will still involve sharing information with schools and training staff.
"We hope to achieve improved support for school staff to feel more confident in identifying and managing early signs of potential mental health needs," she says.
"Increasing training, consultation and advice may lead to a reduction in referrals into CAMHS as we assist the wider system to build resilience."
However, Shand admits extending the programme to primary schools does not yet have the potential to reach the same scope as In-Reach in secondary schools. The trust is not directly commissioned to provide the programme to primary schools, so does not have the resources to provide it to the entire county.
Shand says the secondary schools offer is classified as a CAMHS Tier 2 service, as it is defined as early intervention, but it can refer to more specialist services.
"School staff can discuss any variety of mental health concerns, which may range from seemingly minor concerns to very concerning presentation requiring a direct referral to Tier 3 services for an assessment," she says.
"Some In-Reach workers have been a key part of physical education, and personal, social, health and economic education (PSHE) aspects of learning, they have offered talks in assemblies dealing with pre-exam anxiety, for example, and have been part of the support package after tragedies, such as the death of a fellow pupil."
Often, however, In-Reach workers are steered by the needs of the school, Shand says.
Less stigmatising
She believes one of the reasons the programme has worked well is because it is less stigmatising than other mental health services and routes to obtaining support.
"It is less stigmatising as it is school-based," she says. "We noticed that at first students may have been reluctant to engage in school, but now that the worker is getting to be a known face around the school many more are willing to be seen.
"There has been a reduction in stigma with regards to mental health and young people are becoming increasingly aware of their mental health needs and are feeling more confident in coming forward to ask for help."
She says the programme benefits from the trust's responsibility to provide school nurses and mental health services. "It makes the close working relationship between school nurses and In-Reach workers even more achievable," she adds.
In terms of evidencing impact, school staff are regularly consulted on.
"When there is a consultation with a staff member, we ask primary CAMHS workers to complete a log sheet to detail the nature of the consultation, further action and what value the consultation may have added.
"Where there is direct contact with the young person a similar form is completed to detail the nature of the session," Shand says.
"We will be formally evaluating transformation of our services as part of the transformation plans; school In-Reach will be part of this formal evaluation."
GOVERNMENT SCHOOL-BASED MENTAL HEALTH PROGRAMMES
- Single point of contact Childcare minister Sam Gyimah announced earlier this year that the Department for Education will be expanding a pilot where schools appoint a single point of contact to have a good relationship with child and adolescent mental health services (CAMHS). Each service works with 10 schools.
- Peer mentoring The government is currently collecting evidence on best practice of peer support - where one pupil helps support another - in schools across the country to help inform for national guidance for schools.
- Personal, Social and Health Education The DfE has funded the PSHE Association to produce guidance and lesson plans to support teachers to deliver age-appropriate lessons on mental health in personal, social and health education.
- Counselling DfE guidance on counselling in schools has been updated with a "counselling in practice" section, advising schools how to best work with CAMHS and to implement it as part of a whole-school approach to mental health.
Source: Department for Education
