Background: Education and support on emotional health are vital in helping adolescents to maintain good mental health and protect them from future ill health.
Aim: To investigate if mental health education is delivered in the school curriculum and explore teachers’ perceptions of the need for it.
Method: Unstructured interviews were carried out with a sample of seven teachers. A qualitative paradigm based on applied phenomenology was used.
Results: Teachers confirmed that provision for mental health education is made both in the curriculum and pastorally, although this is delivered with more of an emotional rather than mental health education focus. Support is also provided in several ways regarding pupils’ individual emotional and mental health needs. Teachers receive ongoing support in terms of having increased time to teach personal, social and health education; receiving support from outside agencies; and receiving ongoing training.
Conclusion: There is a strong need to further develop and raise standards of mental health education to address increasing evidence of depression and other mental health problems in schoolchildren.
Hunt, S. (2008) Raising awareness of mental health in schoolchildren. This is an extended version of the article published in Nursing Times; 104: 25, 32-33
In my work as a mental health nurse, I have become aware of adolescents’ need for emotional health knowledge and education on how to manage mental health. Education and support are paramount in helping them to maintain good mental health and well-being, and to protect them from mental ill health in the future.
The National Service Framework for Children, Young People and Maternity Services (Department of Health, 2004a) identified that poor mental health in children could result in more complex problems in later life, if not addressed during school years. It stated that many agencies, other than child and adolescent mental health services (CAMHS), could play a part in supporting children with mental health problems, and that much of the work required is related to early intervention and health promotion.
Education on making healthy choices is a key part of the government’s Choosing Health white paper (DH, 2004b). It clearly associated the UK’s healthier schools with greater provision of personal, social and health education (PSHE). Choosing Health (DH, 2004b) reinforced the World Health Organization’s (1997) Jakarta Declaration on leading health promotion – these documents identified education as one of the prerequisites for good health.
The Office for Standards in Education (2005) published a report on PSHE in secondary schools, stating that much of the education in this field was about knowledge and understanding. It identified a need to incorporate attitudes, values and personal development.
The Audit Commission (1999) highlighted the role teachers have in promoting mental health and identifying problems at an early stage, but did not provide an in-depth analysis. Child and adolescent mental health services stated that one in five children potentially suffer from a mental health problem (Audit Commission, 1999).
The DH (2003) indicated a growing gap between people who are prosperous and have good health and those who are poorer and more isolated with worse health. It identified the need for strategies to ensure that children in particular are given opportunities and support to improve their current health, and in preparation for later life. It can be argued that secondary school teachers are key in helping narrow inequality gaps in the UK.
Harrington (2001) described the difficulty in diagnosing mental health issues in young people. He attributed this to physical and cognitive changes, coupled with adolescents’ difficulties in explaining symptoms. The author concluded that many young people suffer symptoms of depression, but that few suffer depressive disorders. This research found the UK has some of the highest rates of deliberate self-harm in Europe, although it was pointed out that resolution may be found at an early stage. This suggests that health promotion and education can lead to change.
Weare (2000) recognised that health-service approaches were focused on illness rather than health. She went on to reinforce a coherent approach by schools to deliver mental, emotional and social health education that is both focused and holistic. Weare (2004) described the need for children to be able to make sense of their own lives, and both the society and world within which they live. She highlighted the need to address some of the chaos in children’s lives that could lead to mental health issues and identified that the ingredients of good mental health included empathy, problem solving, building healthy relationships with others, and communicating effectively. Ideally these skills are provided by effective parenting, but the education system also has its part to play. Dwivedi (2004) argued that several prevention initiatives were urgently needed.
Lee et al (2003) suggested the delivery of health promotion will fall largely to teachers, who will need increased health knowledge incorporated into teacher training. These authors commented that health promotion in the schools discussed was delivered by teachers who could apply a holistic approach, unlike more traditional teaching.
In summary, the literature suggests there is a need for teachers and health providers to work with children and young people to improve mental health outcomes, against a background of increasing prevalence of mental illness.
Standard 1 of the children’s NSF (DH, 2004a) promotes working in partnership. It advocated the need for a full-time nurse in each secondary school and recommended that all schools work towards the National Healthy Schools Programme (see www.healthyschools.gov.uk for details). This programme issued clear outlines on what was expected from secondary schools in pupils’ health education. It required secondary schools, PSHE teachers and headteachers to demonstrate they were implementing government guidelines. The Department for Education and Skills and DH (2005) outlined core guide requirements of a healthy school.
The purpose of this study is to explore secondary school teachers’ experiences and perceptions of PSHE, and the need for mental health education in the curriculum.
A qualitative paradigm was used for this study. Part of the rationale for this was that teachers’ lived experiences and perceptions could be more appropriately obtained using unstructured interviewing. This allowed the interviewer greater participation and freedom to explore issues in more depth (Bowling, 2002). A phenomenological approach was used in this research.
A sample of seven teachers was chosen from seven secondary schools across East Sussex. The sample comprised both male and female teachers. The ages of pupils at the schools ranged from 11-18. Content analysis was used due to the size of the study and the need to find common themes for data analysis.
Adolescents’ individual needs
Several themes were identified. The first was pastoral work on an individual basis with schoolchildren. The research identified the dilemma facing teachers when pupils divulge sensitive information that may require further action. This can pose dilemmas around confidentiality. Within many of the schools a counselling service and/or a school nurse was available to help manage pupils’ difficulties. Gender issues were identified; boys particularly may have difficulties approaching staff if they are having problems.
Teachers identified the importance of creating and fostering a safe environment for pupils to talk about problems. They saw this as an important part of their role. In some cases, they recognised that schoolchildren often confide in friends and then, in some cases, friends may take responsibility for passing this information on. Several teachers commented that support was available in the form of formal teaching of PSHE, as well as access to school nurses, counsellors and informal one-to-one time with teachers.
Teachers described changes in behaviours of pupils and were concerned about having the skills to recognise and manage this. Some expressed concerns that schoolchildren’s emotional or mental health needs were increasing due to pressure on them. They suggested that pupils were experiencing more crises and problems at home, which included: witnessing domestic violence, marital disharmony and the consequences of parental mental ill health. They felt these areas affected pupils’ emotional health. They also observed that pupils are experiencing increasing levels of stress from academic pressures and tests. Some pupils were using cannabis heavily and binge drinking.
Despite the difficulties experienced relating to pupils’ behaviours, teachers also perceived that more schoolchildren were approaching staff for help. As such, they were fostering opportunities for pupils to approach them.
Teaching emotional health
Some teachers pointed out that staff foster and promote health for much of their time in schools. It became clear that it may be more appropriate to talk about emotional health rather than mental health. Several teachers mentioned that mental health was not covered as such within education, and was certainly not taught as a separate issue. They said two levels of mental health were being discussed and taught in schools: the first was the pastoral role and the second involved formal teaching of emotional health exploring pupils’ identity, coping with stress and pressures, and avoiding alcohol and drugs.
Staff limitations included ability and qualifications to teach PSHE. Resources, staff training and an understanding of emotional/mental health appeared important to participants, in their ability to deliver their specialist area of PSHE. Feedback from teachers suggested that time was precious in all parts of the school curriculum – incorporating PSHE time meant possibly putting substantial content into lessons that would only last a short time. There was a perception that PSHE was, to some degree, just tagged onto the curriculum.
Issues surrounding equality included: the needs of boys versus girls; young versus older children; and pupils with extra needs, depending on emotional or educational learning disabilities. However, this topic highlighted the limited time available in the curriculum for emotional/mental health education.
Government support and measuring success
Teachers felt the government had raised awareness regarding PSHE, but that a careful implementation strategy was required across the curriculum. Some felt that while government guidelines on PSHE teaching existed, they were too broad regarding what should be taught within PSHE. The ability to deliver PSHE lessons depended on the school, and whether they followed the guideline. The perception was that some schools would, or could, fail to deliver important aspects of the subject.
Teachers recognised that the national curriculum had brought uniformity, which was important in the delivery and focus of lessons, but formalising PSHE too much was deemed to be potentially difficult as some flexibility was required. Several teachers expressed concerns about the pressure to ‘tick boxes’ to meet government requirements. They pointed out that once PSHE requirements were met, the subject focus in the curriculum and within the school could fade. They felt this subject needed to be kept in focus.
In terms of the success of PSHE, some teachers felt it was too difficult to measure – this could only be measured longitudinally by how pupils lived their lives. Teachers expressed the view that they promoted health and appropriate behaviour all the time and that this was not measurable by tick boxes. Mental health teaching, along with modelling behaviour, is hard to measure.
Facilitating and coordinating teaching
Teachers highlighted the need for cultural awareness in a multicultural society, including preparing to meet the needs of children of asylum seekers. Some indicated there were specialist needs due to culture, a pupil’s history and their behaviours.
Teachers spoke of individual pupils who approached them with various emotional issues. They indicated that they must have fostered an environment where schoolchildren could approach them when they needed help.
Although often not their main teaching subject, teachers displayed enthusiasm about coordinating and building dedicated teams to deliver PSHE subjects.
External support in teaching PSHE
Teachers discussed using drama to develop emotional literacy, or using external drama companies to produce a play at school to portray a message.
As discussed earlier, most teachers highlighted the fact that school counsellors and/or school nurses were available to refer pupils to, if they could not deal with children’s personal emotional or mental health needs in the classroom or on a pastoral level. CAMHS were also available for referrals of more complex mental health difficulties. Several teachers felt CAMHS was supportive locally and made positive comments about the times when CAMHS staff had visited schools to deliver teaching sessions to pupils on mental health. These lessons or health days were well received, and another teacher was going to book CAMHS staff to visit their school.
Some teachers felt the PSHE consortium for the local area was supportive and the feedback it gave was both positive and helpful. Some felt that implementing the consortium’s ideas could be difficult on occasions.
Curriculum areas outside PSHE
Teachers said emotional health was often covered within citizenship lessons. The subject area of bullying could fall outside PSHE and, although the emotions around being bullied were discussed with children, teachers did not specify in which lesson. Alcohol, its relationship with depression and its inadequacy as a coping strategy were sometimes covered in lessons.
Teachers felt that although it was not specifically labelled, mental health did feature in the curriculum but there was room to include more on the topic. Although subtly taught, one teacher felt that mental health also featured in lessons that tackled substance misuse – within this, attitudes and relationships were focused on. Some teachers felt my visit had acted as a ‘wake-up’ call, that perhaps a clearer lesson related to mental health should be created in PSHE and that mental health should be concentrated on.
Emotional or mental health was included in discussions around stress management in relation to exams, discussions on eating problems and within drama lessons.
Teachers perceived they were witnessing an increase in pressures on pupils from home and from academic issues. Although awareness of alcohol, smoking, sexual health and drugs was greater, teachers did not feel that pupils had a greater understanding of emotional health.
Stigma of mental health
The main research question to teachers revolved around mental health. However, during interviews it became unclear how mental health would be included in a more formalised manner, or if it needed to be. There was some discussion about the stigma surrounding mental health and teachers expressed the view that emotional health was an easier term to use and teach, as it encapsulated emotions and feelings.
Some teachers raised the issue of whether it was beneficial for pupils to be taught about mental health, asking whether this teaching would change outcomes for pupils.
This study demonstrated that teachers were aware of pupils’ individual needs. They observed that in some cases pupils were being more open and approaching staff for support for their emotional problems. Teachers also highlighted a difference in the way the genders dealt with their individual emotional issues. This was substantiated by Weare (2000), who discussed the difficulty men have in expressing emotion. She suggested that girls interpret their feelings differently to boys, and that girls respond to feedback from others, whereas boys interpret their feelings through their achievements. This research could not establish the specific needs within single-gender schools compared with mixed-sex schools. If the interviews had been structured, then the subject area of gender could have been a focal point for questions.
Teachers explained that their roles regarding health promotion go beyond that of PSHE and beyond sharing information with pupils. Ofsted (2005) outlined in detail how PSHE should be delivered but did not explain how schools and teachers should foster positive environments. In addition, Ofsted did not provide details on how PSHE lessons on emotional health should be delivered.
The difficulty of delivering lessons due to a lack of training and the pressure of work provoked strong feelings among some teachers. Their aspirations about developing PSHE teaching and creating a healthy school (DfES and DH, 2005) reflect the literature.
The study showed there was pressure on teachers to find time for PSHE lessons and that they felt teaching a subject that could be relegated or in competition for space on a timetable was not conducive to good morale. It also gave an indication of how other teachers, heads and professionals felt about the relevance of PSHE lessons.
The interviews indicated that PSHE teachers could potentially be under immense pressure and, therefore, close liaison between teachers, counsellors, school nurses and other professionals was of paramount importance. The small amount of feedback gave some indication of the desire to work more closely with colleagues in providing a more cohesive and supportive PSHE lesson.
Issues around facilitating, fostering and coordinating the teaching highlighted difficulties in education delivery. Staff who were not necessarily specialists in PSHE gave lessons in the subject. For those whose main subject was not PSHE, the difficulties of delivering sensitive subject matter to children at the right level and age and using appropriate content meant a great deal of work. Ofsted (2005) did not specifically highlight the difficulties of coordinating and facilitating PSHE.
Teachers felt that mental health was being taught indirectly through a mixture of lessons, as well as directly through PSHE. The study also highlighted the problem of knowing at what level and age to introduce mental health, and what should be taught. It was unclear whether teachers realised the extent to which they already taught mental health through the education delivered on emotional health.
There was a link between teachers’ experiences and perceptions and the literature both from the UK and other parts of the world. This study did not suggest there were particular issues that related specifically to PSHE education or mental health within East Sussex.
The literature review highlighted that, historically, the emphasis has often been on illness rather than health. During the interviews teachers appeared to emphasise health promotion far more than expected. It became apparent that teachers are key to creating the learning opportunities that will make a difference in relation to children’s personal, social and health education. This reinforced earlier discussion about health professionals working more closely with teachers to support and assist in the delivery of mental health education.
The transcripts identified that pressure on teachers was partly due to a large administrative element in their work. This competed against available time to deliver lessons to pupils.
It appeared that the delivery of education on emotional issues was carried out in a variety of ways, such as through drug and sexual health education. There was currently no separate discipline that specifically focused on mental or psychological health as a subject, in the way that, for example, physical education does. Teachers described the delivery of emotional health education through many subtle routes. Some described a lack of ongoing training due to cost, time and resources although they valued working with CAMHS and attending the PSHE consortium.
It could be argued there is a strong need to further develop and raise standards of mental health education in order to address increasing evidence of depression and mental health problems in children. This may lead to more positive personal, community and health outcomes in the future.
Implications for practice
- Increased promotion of the school nurse’s role and the important role they could play in health education in the classroom is needed.
- There is potential for school nurses, mental health nurses, school counsellors and teachers to build a stronger health promotion and education element in schools, working more closely and cohesively to form a centralised approach to health education. They should also continue to focus on reducing the stigma of mental and emotional ill health.
- Nurses and teachers should adopt a cohesive approach to achieving ‘healthy school status’.
- Child and adolescent mental health services (CAMHS) and local teachers should continue to build and develop working relationships. This would enable teachers to continue to focus their education and allow further research-based knowledge to be used in teaching and in pastoral work with pupils who may not be coping well.
- PCTs and mental health trusts should work alongside school consortiums and continue to support PSHE teachers in promoting their lessons in the school curriculum. These bodies should also meet with senior teachers to discuss how they can help with input and promote the importance of PSHE.
- Adult mental health workers should continue to be aware of the potential needs of their clients’ children, who are in stressful environments.
- Closer and more cohesive working relationships should be developed between adult mental health services and CAMHS, enabling the sharing of skills and knowledge to treat families with mental health problems. This should be followed by closer liaison with the school, who also may be involved with the family.
Audit Commission (1999) Children in Mind: Child and Adolescent Mental Health Services. www.audit-commission.gov.uk
Bowling, A. (2002) Research Methods in Health (2nd ed). Maidenhead: Open University Press.
Department of Health (2004a) National Service Frameworkfor Children, Young People and Maternity Services: The Mental Health and Psychological Wellbeing of Children and Young People. www.dh.gov.uk
Department of Health (2004b) Choosing Health: Making Healthy Choices Easier. www.dh.gov.uk
Department of Health (2003) Tackling Health Inequalities: A Programme for Action. www.dh.gov.uk
Dwivedi, K.N. (2004) Emotion regulation and mental health. In: Dwivedi, K.N., Harper, P.B. (eds) Promoting the Emotional Well-being of Children and Adolescents and Preventing Their Mental Ill Health. London: Jessica Kingsley Publishers.
Department for Education and Skills, Department of Health (2005) National Healthy Schools Status: A Guide for Schools.www.wiredforhealth.gov.uk
Harrington, R. (2001) Depression, suicide and deliberate self-harm in adolescence. British Medical Bulletin; 57: 47–60.
Lee, A. et al (2003) A comprehensive ‘Healthy Schools Programme’ to promote school health: the Hong Kong experience in joining the efforts of health and education sectors. Journal of Epidemiology and Community Health; 57: 3, 174–177.
Office for Standards in Education (2005) Personal, Social and Health Education in Secondary Schools. www.ofsted.gov.uk
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World Health Organization (1997) Jakarta Declaration on Leading Health Promotion into the 21st Century. Geneva: WHO.