Bring in universal mental health checks in schoolsBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5478 (Published 24 September 2013) Cite this as: BMJ 2013;347:f5478
All rapid responses
I would like to thank Ford, Fazel and Goodman for their response to my article.1 I was encouraged that they found the arguments for early identification of potential mental health issues and for schools as the setting for screening compelling. Beyond this, they raise a few important points which require response.
Firstly, Ford et al suggest that there are many valid and reliable measures freely available. Whilst I disagree that the cost of the chosen measure – the Beck Youth Inventories (BYI) – would be unnecessarily burdensome, I agree that the BYI is not the only tool that could be used to undertake mental health screening in school-age children. In fact, it could be beneficial to use multiple tools to provide more thorough screening.
In my original article, I note that the BYI is just one example of a diagnostic tool which could be used for screening. It is true that the BYI, unlike some other tools, is not freely available. I thank Ford et al for their link to the summaries of free assessment measures. Going further, it will be useful for those interested in this debate to consult a good systematic review and recommendations for national policy for England for the use of mental health outcome measures with children and young people.2
As identified in the systematic review, the BYI has a number of strengths: It is quick and easy to use and is routinely used in clinical practice; it is good for monitoring children from baseline and is a good tool for pre- and post- measurement; it encompasses five scales in one measure and looks at a range of emotional difficulties rather than one; it is normed; and it is useful for formulation. Moreover, the appropriateness of any given tool depends on the intention behind its use. For instance, if we wish to look at behavioural functioning at a general level, then the BYI might be too clinically-focused and a tool like the SDQ (Strengths and Difficulties Questionnaire) might be more appropriate. However, if we are interested in assessing risk for clinical disorders, then the BYI is highly appropriate.
If cost does prove to be too prohibitive to policymakers, we might consider a two-tiered screening process, which begins with the universal distribution of a freely-available tool like the SDQ (Strengths and Difficulties Questionnaire), followed by a more in-depth tool (like one or all of the Beck Inventories)for only those children that have concerning scores on the SDQ.
Secondly, Ford et al’s point about needing appropriately-funded mental health services to meet the added demand of additional referrals resulting from screening is highly salient. It is a debate that needs to be had, but was beyond the scope of the original article. My view is that if we find, after adequate trialing, that screening is an effective way of identifying early mental health problems, then we need to find means through which the added demand can be met. I agree that “the most efficient and economical approach to tackling mental health problems detected in schools … may be to address these difficulties as far as possible in schools themselves”. There are already some interventions, such as those provided by the organization Place2Be, which explore novel interventions providing counseling support for vulnerable children and those showing the early signs of mental health issues.3 The goal should not be to adjust the demand to suit the resources, but instead to adjust the resources to suit the demand. We need to identify the need that we know is there and increase resources not just in schools, but also within the community and within the healthcare system. Whilst many social, behavioural and emotional problems can be addressed primarily within the school environment so long as resources are adequate, some mental health problems, particularly those which are potentially or already severe, require additional support from mental health professionals which is confidentially provided outside of the school.
Finally, I take Ford et al’s point that substituting “social, emotional and behavioural difficulties” for “mental health problems” might be effective in the short term as a means of encouraging more buy-in from those within the educational system, because it is, as they note, the preferred vocabulary of the educational system. However, I do not believe that, in the long run, this is likely to be the least stigmatising approach. Social, behavioral and emotional difficulties are related and similar to mental health problems, but they are not coterminous. Consciously choosing not to use a term because we are concerned about how it will be received only serves to perpetuate stigma. We need to encourage young people, parents and teachers alike that mental health problems amongst children are something that are real and not uncommon. In order to destigmatise mental ill health, we need to be able to talk about it explicitly and openly.
Simon Williams and Kimberly Dienes
1. Ford, T, Fazel, M, Goodman, R. Rapid Response: Re: Bring in universal mental health checks in schools. BMJ 2013 http://www.bmj.com/content/347/bmj.f5478/rr/669575
2. Wolpert et al. Review and recommendations for national policy for England for the use of mental health outcome measures with children and young people. Report for: Department of Children Schools and Families and Department of Health. 2008. Available at: http://www.ucl.ac.uk/ebpu/docs/publication_files/outcome_review_report31.
Competing interests: No competing interests
Remember the Court Report 1976. "The rearing of the young is the fundamental issue in human society". Remember their recommendation that the preschool accessment of every child's physical, mental, developmental and social health was so important it should be a statutory examination. We carried out such a programme, shared between school doctors for children with known problems and school nurses for the rest and instituted programmes of support both in school and for the parents. This is no longer the practice.
Were we wasting resources? Over the 35 years that I undertook this work, it never felt like that. It felt like a responsible, demanding and challenging job. We needed to work co-operatively with social services, educational psychologists, child psychiatrists, speech therapists, special needs teachers and, of course, the head teachers of the receiving schools. Are children so well cared for and so mentally strong and healthy these days that such procedures are no longer required?
Competing interests: No competing interests
In his personal view, Simon Williams1 advocates repeated universal mental health checks in schools. We accept wholeheartedly his argument that a large proportion of adults with poor mental health first experience difficulties in childhood, which imposes huge costs on the children, their families and society. We would add that only a small minority of school-age children with clinically impairing levels of psychopathology access specialist mental health services2 and that the costs of these difficulties fall mainly on the educational system.3 The argument for early identification and schools as the setting for screening is compelling.
We were, however, surprised by the article’s focus on a single measure for screening, particularly as many valid and reliable measures are freely available (such as those accessible via the links below) while the cost of the chosen measure would be unnecessarily burdensome at a time when the NHS, schools and families are all under financial pressure.
A more important omission was the complete lack of any consideration of the capacity of current services to respond to those identified by such a screening programme. Furthermore, there was no discussion of the types of interventions that would best meet the needs of those identified. The referral of many children to mental health services via schools may raise concerns about inappropriate medicalization and labelling that may undermine good inter-agency working, as well as overwhelming services that are already struggling with long waiting lists for assessment and / or treatment. The most efficient and economical approach to tackling mental health problems detected in schools - which should perhaps better be called "social, emotional and behavioural difficulties" to reflect the preferred vocabulary of the educational system- may be to address these difficulties as far as possible in schools themselves. This is likely to be the least stigmatising approach, and for that reason alone may lead to greater buy-in from young people, parents and teachers. Schools are busy institutions, however, and may balk at taking on more work unless there is strong evidence that school based programmes can lead to better outcomes for the children. This is a realistic concern since many such initiatives are driven by good intentions rather than evidence of effectiveness. Without suitably trained personnel to deliver proven interventions, any screening programme is liable to do significant harm in terms of raising anxiety and expectations that cannot be met among young people, families and the practitioners working with them. In short, the realisation of the potential benefits of screening proposed by Williams requires a fully funded plan to deploy effective non-stigmatising programs for those identified as at risk or in need of assistance; without this screening would be unethical.
Tamsin Ford, Mina Fazel and Robert Goodman
Freely available measures for use in schools
1. Williams S. Bring in universal mental health checks in schools. BMJ 2013;347.f5478 doi: 10.1136/bmj.f.5478
2. Ford T, Hamilton H, Meltzer H, Goodman R. Child mental health is everybody’s business; the prevalence of contacts with public sectors services by the types of disorder among British school children in a three-year period. Child and Adolescent Mental Health 2007;12:13-20.
3. Snell T, Knapp M, Healy A, Guglani S, Evans-Lacko S, Meltzer H, Ford T. Economic impact of childhood psychiatric disorder on public sector services; estimates from National Data. Journal of Child Psychology and Psychiatry 203;54:997-985.
Competing interests: Youthinmind Ltd provides no-cost and low-cost websites related to child mental health. It has no commercial sponsors or advertisers. RG owns Youthinmind Ltd, which he runs with his family.
Correction: Please note that Simon Williams is currently a Visiting Scholar at the Feinberg School of Medicine at Northwestern University, Chicago. Simon was formerly a Research Associate at the Institute of Public Health in the University of Cambridge, and not an Academic Clinical Fellow as previously printed in the related article.
Competing interests: No competing interests