This session focused on the CAMH paper by Aureliane Pierret, Dr. Joanna Anderson, Professor Tamsin Ford, and Dr. Anne‐Marie Burn. The session was recorded on Monday 26 April 2021.
Slides from the session
To get the most from the session we suggest reading the following resources;
- The full paper is available, for free, from the University of Cambridge
- Mental Elf blog
ACAMH members can now receive a CPD certificate for watching this recorded lecture. Simply email membership@acamh.org with the day and time you watch it, so we can check the analytics, and we’ll email you your certificate.
Other resources
- ACAMH Topic Guide
- ACAMH website search results
- The Centre for Suicide Research together with colleagues has produced a new resource on Self-harm for School Staff – Young People who self-harm – New Resource for School Staff Published
- Self-harm: What should school staff be aware of? via HeadTeacher magazine
- Self-harm: How teachers should respond via SecEd
- Coping with self-harm, guide for parents and carers via Charlie Waller
- No Harm Done – Explore our toolkits, videos and guides to getting through self harm and coming out the other side. via YoungMinds
- Five things you can do if someone tells you they are self-harming – via YoungMinds
- Self-Harm in Schools – Anna Freud National Centre for Children & Families
- Understanding Self-Injury/ Self-Harm – Mental Health Literacy
- Self-Harm: Sorting Fact from Fiction – Orygen
About #CAMHScampfire
ACAMH’s vision is to be ‘Sharing best evidence, improving practice’, to this end in December 2020 we launched ‘CAMHS around the Campfire’, a free monthly virtual journal club, run in conjunction with André Tomlin. We use #CAMHScampfire on Twitter to amplify the discussion.
Each 1-hour meeting features a new piece of research, which we discuss in an informal journal club session. The focus is on critical appraisal of the research and implications for practice. Primarily targeted at CAMHS practitioners, and researchers, ‘CAMHS around the Campfire’ will be publicly accessible, free to attend, and relevant to a wider audience.
About the panel
Aureliane Pierret is a final year medical student at the University of Cambridge with an interest in psychiatry. Whilst at medical school she has been involved in several research projects in the Department of Psychiatry, most recently working on a systemic review of interventions for school staff to respond more effectively to young people who self-harm. She will be starting an Academic Foundation Programme (AFP) at St Thomas’ Hospital in London this summer, with her research block in psychiatry at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) at KCL.
I am a Chartered Psychologist with background in clinical neuropsychology and health psychology. After completing my PhD in 2004 I shared my time between clinical and academic work. I am interested in development, evaluation and implementation of interventions to improve mental and physical health outcomes and wellbeing. My current research focus on early identification of mental health difficulties in children and young people and harnessing technology and AI to deliver mental health interventions. I am also interested in evidence synthesis methodology and I am involved in a number of systematic and scoping reviews. Bio and image via University of Cambridge
School-based mental health interventions is the current focus of my research. I am working with Oxford Health NHS Foundation Trust to develop better school-based mental health services for all children across Oxfordshire secondary schools. As part of this we are conducting an Online Pupil Survey for children in years 4 to 13. Schools can sign up here. I previously had an NIHR post-doctoral fellowship to develop a mental health toolbox for schools that any front-line worker, even if they do not have a mental health background, can utilise in the school setting. Refugee mental health needs have been a longstanding interest. I have conducted work on the epidemiology of and the risk and protective factors for mental health problems in refugee children, I am concerned about the psychological impacts of immigration detention and have an active interest in Narrative Exposure Therapy for PTSD. For Children’s Mental Health Week 2019 we have made a 6-part Podcast Series on Mental Health Interventions for Refugee Children aimed at anyone wanting to learn more about the needs of these children. Do listen! My clinical work is as a child and adolescent psychiatrist in the Department of Children’s Psychological Medicine at the Children’s Hospital, Oxford University Hospitals. Bio via Univerity of Oxford
André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He’s worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service. *The Mental Elf is a blogging platform that presents expert summaries of the latest reliable research and disseminates this evidence across social media. They have published thousands of blogs over the last 10 years, written by experts and discussed by patients, practitioners and researchers. This innovative digital platform helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland! Bio via The Mental Elf
I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it. This means you. I’ve been attempting this in the area of Evidence-Based Health Care since 1995. So far the results have been mixed. For some reason we expected busy clinicians to search databases and appraise papers instead of seeing patients. We also expected publishers to make the research freely available to the people who paid for it. Ha! Hence The National Elf service.
Transcript
Andre Tomlin – I’m the mental health and welcome to the CAMH campfire, pull up a toadstools, sit yourself down. It’s nice and warm around the campfire. We’re going to have a chat. We’re talking today about self-harm and schools and specifically a piece of research looking at support tools for staff in schools. Please do join in the conversation on the Zoom chat. So everybody here in the webinar who you can see on the screen is a panellist and I’ll introduce these lovely people in a second.
All you guys who are watching are attendees. We can’t see, we can’t hear you, but we can see the messages that you post in the chat. So if you haven’t already, please do introduce yourself in there and choose the panellists and attendees little blue button when you post so that everybody in the meeting can see who you are and what you’re saying. These meetings are very informal, but we always have loads of great conversations going on in the chat. So please do join in with that.
Everything will be saved afterwards and shared on the ACAMH web page and there’s a link to that already in the chat and we’ll post it again later on. So all the slides, the video, all that kind of stuff will be saved. So you don’t need to worry about losing any of that. So let me introduce everyone, first of all, we’ve got a really great group of people here today. We have Alicia. Give us a wave, Alicia. Hi. Alicia is as a member of the McPin Young People’s Network.
She has a diagnosis of Asperger’s, autism. Has used CAMH services in the past and has suffered with depression for many years as a teenager. She’s our lived experience representative this evening. Wonderful to have you here. Thanks very much for joining us. We have Lily, Lily Pierret who’s a final year medical student at the University of Cambridge. Hi, Lily, and with a big interest in psychiatry. She’s starting an academic junior doctor job in London this summer. Congratulations.
And Lily is the first author on the paper that we’re going to be talking about this evening. We have Jo. Hi, Jo. Dr. Joanna Anderson from the University of Cambridge. She’s a Senior Research Associate in the Department of Psychiatry and works in Child and Adolescent Mental Health. And we have Mina. Hi, Mina. Dr. Mina Fazel from Oxford, Associate Professor in Child Psychiatry at the university there with an interest in school mental health. Works a lot with vulnerable populations.
And then we also have my colleagues on the Campfire Team, Douglas. My colleague Douglas Badenoch, who is Co-founder and Director of the National Health Service and Information Scientist. He’s got a black belt in critical appraisal skills. He’s going to be doing all that kind of stuff this evening, and Celine, Dr Celine Ricart who is also here, one of the team organising the event, and she is a Clinical Lecturer. Hi, Celine, at King’s in London.
She’s going to be moderating the chat this evening. So you’ll see some messages from her as we go through. So I’m talking very quickly because we’ve got loads to cover in the next hour. We’re really hoping to get through as much as we can, and we’re going to start off just by kind of introducing this topic for you, talking a bit about self-harm in young people and what schools can do and how we can help staff improve their skills and their knowledge in this area.
So we’re going to do that for about 15 or 20 minutes. Just have a general conversation. Then we’re going to get into some critical appraisal and we’re going to look at the piece of research by Lily and Jo that we’re focussing on today, and Douglas is going to take us through that. So you’ll learn some stuff there about research methodologies and hopefully some stuff that you can take away and then we’re going to finish off by talking about, so what, what should we do now, now that we’ve got this research, now that we know this?
Are there any actions and, you know, I think we’re going to touch on some of the kind of practicalities of doing school based mental health research as part of that conversation because it’s not a straightforward topic to research and it’s not a straightforward place to do research in. So lots of issues there that I think is going to be interesting. So if you’ve got any questions do put them in the chat and we’ll try and put those to our panellists as we go along.
And I’m going to start by asking Mina, just broadly speaking, Mina what role do you think schools can play in identifying self-harm in young people and what support do you think that they can give them?
Dr. Mina Fazel – Good afternoon everyone and Andrew in particular and that’s a very big question. Before I start I am going to say I do have a naughty dog in the room that often barks at the wrong time. So apologies for that and occasional children as well that will wave behind us. So I think we should think about schools as playing a really, really important role. Probably they’re not playing quite the role they could play, and that’s where learning about it and the science is really, I think, going to help us over the next ten years or so.
So I think the first area that schools play a pivotal role is kind of the drivers of self-harm for young people. Now there is going to be many of those, but I think it’s useful to think about the main ones that should be around social connectedness and social relationship with young people, be around self-esteem issues and probably around bullying and they’re all interrelated. So schools, the first roles school could play is that they can actually do things in all of those areas, but it isn’t overtly saying we’re doing something for self-harm, but it’s actually about the school environment that can be dramatically important for a young person who might be at risk of self-harm or contemplating self-harm. If they can build systems in the school to make people feel more connected, possibly with non-academic, unstructured environments, as well as the structured environment, building ways to improve your feelings of self-esteem.
And then really, if there’s bullying in the school to think of ways, to consult with the young people and to really take that seriously and address it at school. So that’s first, thinking about the drivers of self-harm and then secondly, thinking about the young person who might be self-harming or considering self-harm, well schools provide a really important opportunity for young people to access adults outside of their family with whom they might be more comfortable talking to. So either that might be someone they recognise in the school and a teacher or it might be more formal support.
But schools are a place where young people can access those services. A term that we’ve used a lot is they democratise access to services. So you if you’re attending school you’re in a position where you can potentially access these services, which is very different to CAMHS for example, or formal mental health services where you might need referring. You might need a parent to take you. So I think those are the main areas and also for peers. So if you are a young person worried about your friend who might have self-harmed, then it also gives an opportunity and a place for that peer to express concern or ask for advice. So those are some of the, I think, key areas that I think schools can play for young people.
Andre Tomlin – Thank you. That’s great. I want to come to Alicia now. What’s your reflection on what Mina said there?
Alicia – Yeah, I thought it was really interesting because as a young person you spend so much time, you know, so many hours at school, and if staff are feeling more confident when situations arise, you know, they’ll make you feel less uncomfortable. When I’ve been in this situation myself and it really can show when staff aren’t confident and it can have a knock on effect. So you might not want to go again to chat to them about that situation, but if you’re both feeling confident, you might want to. You might want to next time, or like you said Mina, about a friend even.
Andre Tomlin – How well do you think schools do currently, Alicia, that in your experience? Speaking, you know, your own experience and speaking to friends, do you think that’s something that’s well dealt with in schools? Do you think teachers feel confident or do you think that’s something that we need to work hard on?
Alicia – I’ve had a good experience and a bad experience. So when I was at school I was in that situation and I’d often be sent home and, kind of, like have to wait for my parent to come and you’re kind of in a no man’s land then, but then when I was at college. So like a year at six form level, the staff there they had, like a college counsellor which was really helpful because then it was kind of like a named person that you could talk to.And you had her phone number on our phone, so we could… If you were in a lesson you could be excused for that, and for me it actually stopped me doing it. I actually was able to do more days in school. So it does make a big difference to outcomes for young people.
Andre Tomlin – It’s really hard, isn’t it? I want to bring in Jo to reflect a bit on this. My sense is that mental health is hard to talk about, you know, period, and self-harm is one of the hardest areas within mental health to talk about, and schools often fell or staff often feel, so we talk about schools. I mean people who work in schools often feel, oh, my God. I’m really worried about, you know, broaching this subject because I think I might cause more harm than good.
What do you think about that? What are schools’ view of having these conversations?
Dr. Mina Fazel – Hello, everyone. I’m really happy to be here. Thank you for having me. So, yes, as you said, I think schools are getting more and more comfortable to talk about mental health in general, but I think when it comes to self-harm that school stuff are still quite uncomfortable when it comes to those conversations, and probably one of the reasons for it is the fear of contagion or fear of putting ideas into young people’s heads. Well, we know that self-harm could have a social function.
So it could be a part of building a group identity or signalling belonging to a group or some way of connecting with peers. We also know that talking about self-harm not necessarily causes people to actually do it. So I think the very important thing is to talk about mental health in general and include self-harm as a part of that discussion, rather than treating it as a stand-alone topic and only approach it when there is actually a problem. Just building an awareness around self-harm and what are the reasons for it or how can we help? As Mina mentioned bullying before, actually we also know that young people who have a sense of belonging to a peer group or have a social support from their peers are much less likely to self-harm. So I think it’s also very important to foster those relationships and to prevent bullying.
Andre Tomlin – Thank you. So we’re going to focus on support tools, particularly because that was the subject of the review that you and Lily did. Do you want to give us a bit of an introduction to that Lily? Do you want to just tell us briefly what support tools are available for school staff? What you found with your review?
Lily Pierret – Yeah, so hi everybody. So in our review we included eight papers and two of them we’re looking at tools. So one was a website and one was a new policy, then the other six were looking at [loss of signal 11:37] kind of interventions in laptops and training courses and the aim of all of them was to improve school staff’s ability to understand, recognise and respond effectively to students who self-harming, and importantly it wasn’t just teachers. It was a broad range of school staff, so counsellors, nurses, admin staff, etc.
In terms of components of the workshops and training courses there were various different components, for example, presentations about an overview of self-harm, the epidemiology and the aetiology, but also teaching one how to respond to youth who have engaged in self-harm. How to do a formal risk assessment, and also some role play scenarios where the school staff could practice doing those things. So those were the main interventions that we were looking at.
Andre Tomlin – And I guess because this is a piece of research that you’ve done. It’s a review of other studies that you’re bringing together what you found is support tools that have been researched and published. So there may be support tools that are being researched and not being published that you may not have found, and then there may have been other support tools, maybe the majority of support tools for self-harm in schools that never get published or never get researched. So great literature, you know, unpublished stuff or things that are published in reports or school newsletters or whatever it might be.
That’s really important, isn’t it? I mean, Jo do you want to give us a bit of a sense of your view of the big picture here?
Dr. Joanna Anderson – Yes, we’ve actually had a look at what’s out there as a part of a different project actually, and there is actually probably more around of the ongoing guidelines or interventions that has never been published, but they’ve also have not been evaluated, but because some of them were developed by, say, charities and they’ve been delivered for quite a long period of time and they sort of change and being adjusted to respond to needs of the recipients, so different schools. They actually know quite well what is needed, what is well received and what are the barriers for implementing those interventions as well, how feasible they are for staff, how acceptable.
So it’s actually quite important to also look at those rather than just research, because the research ones we don’t actually know what happened with them after the study was finished. Whether they were sustained. Whether the staff are still benefiting from them. So I think it’s quite important to look at great literature as well.
Andre Tomlin – So, I mean, that raises all sorts of questions, doesn’t it, about academia and the third sector and how we can work together better to do more joined up real world science. There’s 100 questions I want to ask, but I’m not going to ask them because it’s going to derail the whole conversation. So, yes, thank you. That’s been helpful. So let’s move on. Let’s talk a bit about the research. Before I pass over to Douglas I just want to put a quick poll up, if I may, just too kind of get a sense who we’ve got in the audience. We’ve got over 200 people now. So just answer this question for us. Just tell us which of these best matches your current role. Just so we can get a sense of who we’ve got in the audience. Okay, thank you, Matt. So, oh, that’s great. So we’ve got 20% of the audience are educational professionals. We’ve got lots of CAMHs practitioners, lots of psychotherapists and students, a few academics and a range of other professionals.
So, yeah, that’s a very nice mixed audience. Thanks very much, everyone, for filling that in. So we’re going to talk a bit about the science now. So I’m going to pass over to Douglas and he’s going to talk through the blog that he wrote and some of his reflections and then we’re going to broaden it out again to a more general conversation in about 20 minutes or so. So, yeah, Douglas over to you.
Douglas Badenoch – Thank you, Andre. Thanks for having me on another campfire. I’m going to share my screen now, and hopefully that will do the business with the slides. There we go. So we’ve heard a little bit about how important schools are or schools can be, and we’re going to spend a little bit of time just looking at some of the details of the review, kicking the tires, looking the gift horse in the mouth, all that kind of thing, just to be sure that we’re getting the right messages from the study.
So when we started to plan for this campfire I was absolutely delighted because the paper is a systematic review, which the first one we’ve looked at in this series, but I thought I should just briefly give people a quick definition, because with an audience that’s very varied this may be a term that’s not familiar to people. So I’ve put the definition of what a systematic review is on the screen there, but sort of in layman’s terms, the way to understand it is [a] it’s a review.
So what the researchers have tried to do is find everything that’s been written about the subject and secondly, it’s systematic and what that means is they don’t just go looking for the stuff that they agree with. They look for everything, whether or not they agree with it, and then look at the totality of the picture. So you can imagine if you think that through that type of study is potentially very, very valuable because we’re all familiar with the situation of a study gets reported and well, it’s just one study.
More research is needed. A systematic review gives you the possibility of getting everything all onto one page and finding a definitive answer. The second really helpful thing about a systematic review is that you can clarify where there isn’t an answer. Where there are areas that we don’t know about, where we need more research. So I think from this particular review, we’ll see some examples of both of those benefits. The first thing that we always ask ourselves when we look at a paper is what is the question that the paper was actually addressing?
It’s important to do that because sometimes the message can get kind of lost in translation and can be remembered slightly differently. So what I did hear was look at the very useful table, table one I think it is in the paper, which gives you a list of all the studies that were included or rather how the studies were included. So the researchers went looking for studies which involved any school staff that were evaluating education training or support tools and which assessed outcomes relevant to people’s knowledge, confidence and response when working with children and young people who self-harm.
So that kind of gives us a composite question, if you like, but you know very much matches the topic that we’re dealing with today. It’s also worth pointing out that they were looking specifically for experimental studies or empirical studies. So studies that carried out an intervention and then followed it up over time to see what happened. Not studies that look backwards in time to look at the data. They were prospective studies. So we’ve done an intervention and then we’ve done an evaluation.
So what’s our conclusion when we look at the methods of the review? Well the traditional approach to assessing systematic reviews there’s, kind of, three broad questions that we need to ask ourselves. The first one is in their search for all the published evidence did they find everything, and is there likely to be stuff that’s out there that we didn’t find? One of the great things about this review, I was very impressed with your tables of search strategies.
You put an enormous amount of effort into defining ways of searching databases, looking for evidence about training and about education and things like that, which are quite difficult concepts to do a good search on. So it was a very impressive search strategy. Another thing that was good about it was that how you went across not just one domain of databases, you didn’t just look at mental health literature. You looked at education literature, social science, literature as well.
So that’s a strength of it, but something we might want to come back to later. As Andre mentioned when we discussed the paper earlier in the week, people are doing a lot of these types of interventions and maybe the reports don’t get published. So there’s probably a lot of expertise out there that’s not getting put into the literature, and I guess a venue such as this are a good way to discuss some of the details around that.
The second criterion that we usually apply to systematic reviews is the question of whether they only included good quality research in the review. If you include research that might contain bias, then that might skew your findings in a certain direction. So the reviewers have to take a, kind of, a rigorous approach to evaluating the studies that they included in the review to make sure it’s the best quality stuff, and in this case there’s a number of different ways of doing this using a standard instrument.
And they also check some of their findings to make sure that it wasn’t just one reviewer’s opinion. So that was an example of good practice as well. It’s important that that sort of second check is done, sort of blind to what the first reviewer decides. So if there’s two people looking at the data that they found, they want to make sure that they agree about which ones are relevant and what the quality of that data is. So that’s the methods of the review.
So we’ve gathered all the evidence. We’ve included the best quality stuff that all matches our criteria and we can skip on now to look at the findings. So we found, the review reported eight different studies, and as we’ve heard we’ve got a really wide range of interventions. We’ve got websites. There’s policies. There’s training sessions. There’s different modules of planned training sessions and something brilliant called a whole school initiative. So there’s a lot of different things were being assessed in the study.
So for that reason we can’t kind of measure and come up with a one combined result because they’re looking at slightly different things. However, I think the key thing we find here is that the interventions there’s evidence here that the improved knowledge and confidence. That they were feasible and acceptable to the staff and they were all sort of in the same direction. So they were consistent, and that in a systematic review at least gives you some sort of confidence in the result, even though we don’t have a kind of overall meta-analysis.
The other really important thing I thought was from the qualitative data, which you’d planned to include, and I think that was quite a good approach to not just take the quantitative scores on how much people’s knowledge had improved, but also look for the feedback, a qualitative feedback that was reported in these studies and some quite interesting comments there around providing staff with the right support and processes to be able to respond to situations, to tailoring the educational interventions in the training to the particular setting and involving people from across different professional groups to make sure people are working together effectively.
So I just wanted to quickly put a little bit more detail, because I know that a lot of you will be educational, educationalists and will want to know well which interventions are being looked at here. So I’ve just highlighted the central column in that table just to show the wide variety of approaches that were taken, and it’s certainly worth if you want to pursue in a little bit more detail looking at the details of these, get into the supplementary data that comes with the full text of the paper, that would allow you to just have a look at what sort of things were done in each session.
But we’ve got that table in the blog, so you can explore that at your leisure as well. So my conclusions were we have some limitations of the evidence here, because it’s quite a difficult area to study, if you’re talking about taking a whole organisation or a whole team of staff and training them and then you’re measuring, sort of, a proxy outcome, you’re measuring their knowledge rather than… You know, those are quite difficult things to assess. So there’s some sort of inherent limitations in the evidence that we’ve spoken about, and there may be potential to expand or to rerun that search strategy, looking at unpublished reports to look at what’s done in other sectors. However, as I said before, it seems that we can affect these proxy outcomes, that people’s knowledge, people’s confidence in responding to young people, and as Alicia said, that’s an important feature for the young person to have confidence in or to feel that the person they’re talking to has confidence and is able to give them the support that they need.
But I think a kind of final underlying point, if you like, would be that one of the key things is about how we measure the outcomes from whatever we do when we try to change our practice, when we try to improve what we do. It can be difficult to know whether was it your training programme that made the difference or was it something else? It seems to me that the best way to approach this in the research would be to get young people involved in those evaluations and to work closely with young folks to see what outcomes matter to them and feed that into how we plan future research.
So that was my quick dash through the systematic review. I thought it was a very impressive piece of work and an extremely valuable point, I think, for folks who are committed to improving things in schools for young folk. I think there are some important issues that we’ve raised here. I wonder if the extent to which, well, what does the audience think about this and are there any questions that I haven’t picked up that you would like to ask the research team.
It’s not often you do critical appraisal when the actual researchers are sitting there. So hats off to you for undertaking trial by Zoo, but here’s your opportunity to ask. Matt, I was wondering if we could put up the poll around the audience’s opinion of whether they agree that this is a valid evidence about self-harm in schools. So just take your time to fill in and then we’ll come back at the end of the discussion to think about the interpretations of what we’re going to do differently as a result of this.
Okay, thanks for listening. I hope that was a helpful run through. I’ll pass back to Andre now and then we’ll reflect some of those questions to the research team and the other panellists.
Andre Tomlin – I want to give Lily… Thanks, Douglas. I want to give Lily and Jo [s.l. 29:07] a right to reply first of all. Just any comments on what Douglas has said, any things that he’s raised that you’d like to respond to.
Dr. Joanna Anderson – Thank you, Douglas. That was a really kind review. I think kinder than any reviewer ever probably, when we submitted it. I think the one thing that I would mention is also the descriptions of interventions were quite poor. I don’t know, Lily, if you would agree with me, but the two papers that we included were actually PhD dissertations. So they had no choice but to describe it in great detail and these were really, really detailed, good descriptions.
So we actually know what made the difference, what they implemented that led to change, but with other papers apart from one, we actually don’t know very well what was the content of the intervention because it was not included in the paper and we could not get the information from the authors. So that’s also probably something to keep in mind.
Lily Pierret – Yeah, and also lack of information about who was actually providing interventions as well. So in some cases they explained that it was counsellors or psychologists, but in some of them it didn’t even say who was providing the interventions. So there’s a lack of data on that.
Andre Tomlin – Thank you. I love the question from April in the chat. Thank you, April, for cutting through. A lot of the research it’s inevitable in these sorts of events but she says, I was wondering whether any of the interventions were found to be helpful at all? So what do you think? Which are the best interventions for improving staff knowledge and skills around self-harm in schools? Do we know?
Lily Pierret – I think based on the data we’ve got here it’s difficult to tell because they all use completely different outcome measures. So only one paper used kind of a standardised, validated measure. So used things like KSQ. These three different questionnaires, but all the others sort of made up their own questionnaires using like a five point scale. How much did this improve your confidence, but because they all used different questionnaires it’s very difficult to compare them, and all eight papers did show an improvement in school’s ability to respond and their personal confidence and their objective knowledge, but it’s difficult to compare between them. As I said, because we don’t have validated scoring systems to compare between the eight studies.
Andre Tomlin – Well, do you think Mina? Do you want to add anything to that, knowing some of these trials that are in the review?
Dr. Mina Fazel – It’s very frustrating, isn’t it, because you’re like oh for God sake why is every study done something slightly different and measured it in a completely different way? Why in the world can’t we come up with some understanding as a result of all this hard work? So I think that the field is littered with these kind of problems across the board in whatever you look at. I think, you know, the reality is that there are many things that need to be done. So obviously, the young person’s voice, young people being involved in designing interventions, like this is obviously where we have to be going, but for now what we’re learning is that there seems to be a need and a desire from staff and schools to get more skill in this and that really will hopefully just, like Alicia is telling us, you know, really, as a young kid want to go to someone who looks a bit uncomfortable and really worried and then it doesn’t make you feel better, for having gone and told them something.
Firstly, you’re never going to go again. Secondly, all your friends will know that it’s been a crap experience as well. So that is one area that needs to be addressed, but I do think that, you know what we do, how we do it, how we develop it, how we measure it. I think what’s going to be happening more and thank God, is that young people are going to be involved in it.
So I’ll just tell you, one little finding we found from our survey of just kids at schools, it’s called the School Survey. We asked in 2019, so a while ago, you know, do you know who provides mental health support at your school and about 70% to 80% of young people at school said, yes, we do. And then we said if you had a mental health problem and emotional difficulties, I think we put, would you go to that person at school and only about 25% said yes. So one is kind of having what we think is a good idea as an adult to provide for young people, and then there’s that whole thing, well, is it acceptable to the young person in the first place? You know, once you’ve done all this training and you’ve created this wonderful network system with a great consulting room, you know, is that what the young people want? Is it acceptable?
We have to start learning about how to ask those questions? How to hear their answers? How to be adaptive in response to that as well. So I think it’s a really important questions that loads of loads more questions need to be asked and hopefully we’ll then be able to do something that’s more meaningful and useful for young people as well.
Andre Tomlin – And Alicia, you were nodding a lot when we were talking there about the responses from young people in that survey. Do you want to kind of say something here?
Alicia – Yes, I was listening closely and I was thinking, because you have to be honest, the teachers are there to teach a subject maybe. They’re not there to help with that. So some of them might be like, I don’t really want to do this. So I think, I don’t know in the future, I’d like to see maybe like a key person that maybe deals with that, even though every staff I feel needs to know how to deal with it when it arises, but having a key person that maybe volunteers them self and wants to actually be there that young people can go to, I think that would make a real difference, and also on the point of about the research and having young people at the forefront of it, about having lots of different young people because everybody’s experience is going to be different and it’s not going to be one size fits all. I think that’s important to note as well.
Andre Tomlin – Yeah, absolutely. There’s been lots of comments in the chat actually about young people with, you know, neuro-diverse young people, young people with different kind of backgrounds in terms of being bullied or being abused or having, you know, kind of all sorts of cultural differences and, yeah, I think that’s absolutely key. I mean, shout out to the McPin Young People’s Network, because I think the group that you’re a member of, I think they do that really well and they’re really tuned in to making sure that the young people that they have in their network are from a very diverse range of backgrounds. I think a lot of other groups could learn from their example. You make a point there about teachers, you know, being teachers and not being expected to be mental health professionals. That’s a really great point. I accidentally posted Darren’s comment and question into the chat earlier because I thought it was such a good question.
Do we expect teachers to be able to manage all situations, mental health, safeguarding, etc, etc., on top of teaching? Or are we expecting more from schools as places where children can receive this kind of multidisciplinary support? Jo, do you want to say something in response to that? What’s happened in school based mental health over the last couple of years? Things have changed quite a bit, haven’t they?
Dr. Joanna Anderson – Yeah, I think with the government’s expectation that school would take more responsibility for identification and also for addressing some mental health difficulties, but I think what is really, really important is to prepare school staff for taking on that role and also not expecting, as you said, that they’re going to become mental health professionals. So equipping them definitely with some level of skills, but also sort of showing them how to refer young people and they’re being more collaboration between schools and services as well.
So there is no, you know, people bouncing back and forth between the school and the mental health services because they don’t want to accept some referrals or not able to accept some referrals. So there are clear pathways to actually where to signpost those young people and they can actually receive help and I also think, as Alicia said, that any sort of programmes, interventions for the school staff, even though they are directed at the school staff, should start from the conversation with young people and actually finding out what are their expectations in terms of school response and what would be helpful for them and what they need, because we are actually finding out that staff and young people have very different ideas of what would be helpful and what they should be doing. So because the young people are ultimately the recipients, I think they should have the final say of what is important.
Andre Tomlin – So are examples of services in schools where that’s happened, where we have co-produced something and young people have driven it, where we’ve actually got something that works, or are we still in such early days that we don’t yet have an example of what works well?
Dr. Joanna Anderson – I think this is the approach that underpins our work. So our group at Cambridge, we are trying to involve young people with all the interventions that we are developing, including the one that we are looking to develop for school staff to better respond to self-harm, but I don’t know if there is a very common approach. I think Mina may know more about that. Sorry, Mina.
Dr. Mina Fazel – I think a lot of the interventions that are being developed right now are incorporating young people’s voices much better. So I think that, you know, we have learnt and we are doing it. Do we have any good intentions? I think from North America there are some very interesting interventions that have been developed in that model, but we don’t really have great transfer from North America into the UK environment when it comes to interventions. So I think in the UK this is still an area that we’re going to be developing more but there are at this moment, Andre, interventions. [Inaudible 00:39:24]. What we do know is we need a whole school understanding and approach and thinking about drivers.
Dr. Joanna Anderson – They may not be very well reported also in publications that might be developed with the participation of young people. I think in Australia actually, where they developed the participatory design approach to developing interventions that would be directed at young people but the young people are very important.
They’re co-producing the intervention and develop it rather than just lend their views. So I think this is a really useful approach.
Andre Tomlin – We’ve had quite a few comments and questions about specific groups of young people, young people with autism, with neurodevelopmental conditions, young people who’ve got particular experience of abuse or domestic violence. I wonder, I mean, it feels like if we don’t even know what works for all young people, then it’s unlikely that we’re going to know what works for specific groups, but are we developing interventions in that way where we are thinking about everyone or are we really focussing on the middle ground here? You’re shaking your head, Mina.
Dr. Mina Fazel – My reading is I think I think in a way with these other important populations are globally ignored when it comes to intervention world. So I think that the learning right now is really taking place in the kind of mainstream context, because such massive numbers within that context are suffering from anxiety, depression and self-harm, but there is very important pockets that I think are being ignored and I don’t think what we’re learning and developing necessarily has relevance or kind of efficacy in these other groups. So I do think it’s important for us always to be aware of what we’re not looking at as well as what we are looking at.
Andre Tomlin – Yeah, absolutely, and if we’re still very early on in developing these interventions then now is the time to think of those populations, rather than in ten years’ time when people are banging on about, still banging on about it. Lots of comments as well about age of intervention. People are asking about intervening early in primary schools. What’s the kind of science showing us there? Are these all secondary school interventions or are they looking at earlier age groups as well?
Dr. Joanna Anderson – I think they are majorly secondary school interventions. I think I have not actually come across any intervention that would be for younger ages and the same looking at interventions developed for young people who are at risk of self-harm or self-harming. That is predominantly, well probably all of them in secondary schools. I have not seen anything for younger age groups because I think until recently it wasn’t very much talked about that the younger children may actually self-harm as well. So that could be one of the reasons why.
Andre Tomlin – Yeah, absolutely. So I’m going to go around all four of you now and just ask you to kind of give us some ideas about what you think schools should be doing. You’re kind of top tips for supporting young people who self-harm and I guess, you know, the preventing of it as well as the helping people who are doing it. Alicia, what would you say first of all? What do you think schools can do? You’re just muted at the moment.
Alicia – Sorry. So I think that obviously compassion like when they’re actually in the situation is vital but from the research, from young people’s perspective, young person’s perspective, I feel like there wasn’t any young people, whether they found the interventions. I know the staff said they found it helpful, but whether the young people actually found it helpful at all which is really important because they might not have found it helpful at all, even though staff said that they did and just involve young people more in, I guess, going forward with that.
Andre Tomlin – How do you think the school environment itself could change to be better for young people who are struggling with mental health issues who might then go on to self-harm?
Alicia – I guess it’s that thing about just making people more aware of it. That they have somewhere that they can go if they feel that they might do it or if they have already done it, and a non-judgemental space and maybe making it more known between peers as well is important. I guess in a PHE day, just breaking the taboo down and the stigma down generally I think is helpful.
Andre Tomlin – And Lily, you’re probably next closest to being at school. So I’m going in order of people that have got some experience of actually being first-hand in schools themselves. What do you think, because it’s been like 30 years since I’ve been in a school and I have no idea how they are now. What do you think needs to change? What do you think has changed? Do you think school environment has got worse over the last ten years? What’s your sense of how we can make the educational space better for young people with mental health issues?
Lily Pierret – I think it ties back to what Alicia was saying earlier in that I think it’s useful for all teachers and all schools to have an understanding of mental health difficulties and self-harm in young people, but I think ultimately if you have a point person who is the lead for mental health and you know that that’s someone you can approach and that’s someone who’s going to be more knowledgeable and hopefully more trustworthy and able to say the right services and resources, I think that would be particularly helpful, and I don’t know if that’s the case in all schools that they have a point person. That it’s part of a known [inaudible 00:45:36] point person with the student’s permission, if they’re struggling. So I think that will be really helpful.
Andre Tomlin – Yeah and Jo you said earlier that, you know, we know that talking about self-harm and talking about suicide doesn’t increase self-harm and suicide. So that’s one really clear, you know, bursting that kind of misinformation bubble. What else is there in that sense? What are the top tips would you give to schools?
Dr. Joanna Anderson – Yeah, I think, as you said, don’t be scared to talk about self-harm. Don’t be scared to talk about mental health, because the more we talk about it the more acceptable topic it becomes. So that would encourage young people to come forward and to hopefully that would reduce stigma. Also, I would say school staff get their hands on any training that is available because something is always better than nothing, and there are actually some resources available online that I think you’ve put in the resource list. The one developed by Oxford University together with Charlie Waller.
It is quite comprehensive and I would say just look at anything that is available and also look at the broader mental health and school foster a culture where mental health is important to everyone, not just focus on the results assessment, but also on the wellbeing of students. I think this is very important.
Andre Tomlin – And you want to add, Mina, in terms of school leaders and people in more kind of senior educational positions, what do you think they can do?
Dr. Mina Fazel – Well, I think it’s just not to underestimate what Jo is ending up talking about. What you asked about school environment, like actually being a good school with lots of possible activities that can cater to the whole breadth of kids in your school. You know, you’ve got clubs where you can meet kids and other years, where you can build your friendships across different age groups, where you can learn, you know, you feel less lonely. You feel a sense of belonging to the school. You build your self-esteem, and all of these are going to have incredibly important impacts for the mental wellbeing of the children, as well as just their broader education. So, you know, it is an overwhelming need and overwhelming feeling for these educators to think, oh my God we’re now responsible for the mental health of all the kids as well as all their education, but I honestly think, like, you know, being a good teacher and encouraging your students is actually going to be phenomenally valuable in their mental health needs.
So I think that, you know, not to underestimate the role of all these other things that take place in school. So I often say to teachers that you have the most powerful mental health interventions at your fingertips. You just don’t know it and I have none of them at my fingertips. So I can’t take children and put them in a group with some other kids and, you know, not even pretend, well, why don’t you, you know, I’m going to split the class into these four groups.
You’ve got to do a project like that and you could take a vulnerable kid without them knowing, put them with the kids that you think will support them. Like these are interventions that I could never do in a clinic away from a school, but this could be… All that’s needed to facilitate young kids feeling less lonely, feeling it might be worth, giving them a bit of motivation and shifting the balance for them. So just to be aware that this is, I suppose, a really important mental health environmental, whether or not you like it, you know, that is the reality of what it is. So let’s find ways to enhance it and build it as well.
Andre Tomlin – That’s a really nice message. That’s such a positive message for teachers who I think really struggle with these kinds of conversations. You know, being a great teacher, being a lovely teacher and being great at circle time and all that kind of stuff is actually the thing that you can do most of all that’s going to help. What about Covid now? What about what’s affecting young people now having gone back to school, still working through what’s going on nationally? What impact is that having on education? Do you want to say something on that as well, Mina?
Dr. Mina Fazel – Well, I think it is, as we all know, a really complicated time and I think we just need to tread carefully. I loved, I read in the news about the school that just got rid of all lessons for a week and was just going outside. Actually I was like, oh, my God, that’s the right message. Like, I don’t care about academic attainment. I don’t care about these kind of things. So I think, you know, what we have to realise is that children have very mixed experiences out of school. Some have really thrived out of school. Some have found it very, very difficult. So we need to say, you know, step back. What does that tell us about our system? What does that tell us about different needs, but I think we have to be aware that especially for young people at a time where they’re learning about their independence, that it’s just been completely robbed from. Where they want to spend more time with their peers and ignore their families because their brains are suddenly telling them that’s what they need to do.
They’re not able to express that. So, you know, I suppose just be aware of how fragmented the world has become for a lot of these young people. That this is just a time where they need a bit of help. To learn how to interact better with one another. To not be so reliant on, you know, social media might have been a great thing for most of them but can we take a step back into the real world context as well.
So I think I’m very hopeful that things are getting much better now with regards to all these lockdowns, but for young people, I think, you know, messages around exams and academics it’s been quite difficult for them and we need to, you know, help everyone understand that the most important thing is just to be able to find a way to settle in again. To work out how to study again. To work out how to interact with your peers again and that’s all going to take time and don’t worry, if you’re young and it just doesn’t feel right or it’s really difficult, it should be. You know, you’ve been through quite an atypical time.
Andre Tomlin – It was really telling, wasn’t it, looking at the research findings during that first lockdown last year where they were looking at how it had impacted on young people and families and showing that primary school kids were struggling and secondary school kids were actually, many of them, much better off in terms of their mental wellbeing and their behaviour than they had been whilst they were at school, and there’s lots of researchers talking about that, saying, well, I’m not sure what this shows about our education system.
But it shows quite a lot, doesn’t that I think about how things need to change in order for mental health to be really promoted in schools with the education system more widely. So we’re kind of coming to a close now. I think we’re going to have a little poll just to kind of get a sense from the audience of what you thought of the meeting. Whether this was useful. If you’d recommend this kind of journal club to colleagues, let us know.
So one means you hated it and ten means you loved it. Tell us what you think and I want to let you know while you’re doing that, the next journal club that we’re going to have, the next CAMHS campfire session is on the 25th of May and it’s going to be looking at ADHD and medication for young people with autism with Steph Amos and Sam Cortese. So that’s a really interesting piece of research and it will be a great discussion as well, I’m sure.
And you can check out on the ACAMH website all the resources for this meeting today and the video will be available, I think, probably later on this week for you to watch again. So if you’ve got colleagues who you think might be interested do let them know.
