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Views & Reviews Personal View

Bring in universal mental health checks in schools

BMJ 2013; 347 doi: (Published 24 September 2013) Cite this as: BMJ 2013;347:f5478

Rapid Response:

Re: Bring in universal mental health checks in schools

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.

31 October 2013
Tamsin Ford
Professor of Child and Adolescent Psychiatry
Mina Fazel & Robert Goodman
University of Exeter Medical Schooll
Institute of Health Research, Veysey Building, Salmon Pool Lane, Exeter Devon EX2 4SG