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1 Introducing the study

Introduction

This study was commissioned in April 2004 by the Pupil Support and Inclusion Division of the Scottish Executive Education Department. The work was undertaken by a group of researchers in the Rowan Group at the University of Aberdeen over a period of approximately 11 months. The research team were advised over this period by the group listed in appendix 1, to whom grateful thanks are due.

In this introductory chapter we sketch out briefly some of the policy background that lay behind the commissioning of this piece of work, before listing the research aims and examining the methods used to conduct the research. Finally we elaborate on the way in which the report is structured.

General background and policy context

Mental ill-health: the extent of the problem

Mental health problems affect us all to a greater or lesser extent. As we go through life it is inevitable that we will suffer stressful experiences that impact on our mental and emotional well-being and may cause us to behave in ways injurious to self or others, whether hitting the gin bottle or the cat. However, while recognising this fundamental aspect of what it means to be human (and thereby avoiding pathologising what are essentially normal experiences), we need to recognise the importance of support in enabling individuals to cope with adverse circumstances. Furthermore, we need to understand that emotional disturbances of childhood 'may not simply reflect a difficult developmental stage, but rather can signal persistent, recurring and ongoing distress' and are linked to adult mental health problems. Evidence suggests this is true even of 'sub-clinical emotional difficulties' (Bayer and Sanson 2003:8).

Recognition of the extent of children's needs in this area is beginning to emerge,

'It has only recently become clear that mental ill health among children and adolescents is not confined to only a small proportion of young people, but is surprisingly common. Although mental disorders may not constitute catastrophes that disrupt young people's lives and futures, they cause much suffering, worry and disturbance and they can be precursors of severe disorders in adults.' (World Health Organisation 2004a)

Worldwide, measures of child and adolescent mental health vary and are influenced by social and cultural factors. There is also a lack of consensus or shared understandings as to meanings (Rowling 2002). However, the World Health Organisation reported recently that 'in many countries 25% of adolescents show symptoms of mental disorder. Different indicators show that as stress increases this leads to depression, behavioural disturbance and suicide.' The Mental Health Foundation estimates that 20% of children and adolescents are experiencing psychological problems at any one time (Target and Fonagy 1996, cited by MHF website). Bayer and Sanson (2003) within the Australian context discuss the difficulties of estimating the prevalence of childhood emotional problems but suggest that 'up to one young person in five from the general population has an emotional disorder at some time in their childhood'. They suggest that this may be an underestimate and that evidence suggests that prevalence may be greater among those born more recently, so the problem may increase in the future.

In the UK research indicates a decline in the mental health of children and adolescents over the last 25 years ( MHF 1999). However, as West and Sweeting (2003) point out 'conclusive evidence on the issue is actually in very short supply.' One of the reasons for this lies in the methodological difficulties associated with researching this area. Recent research by Collishaw et al (2004) draws on data from three large scale national longitudinal surveys over a period of 25 years between 1974 and 1999. Findings indicated increases in conduct problems across all social groups and family types for both boys and girls, more especially for what they termed 'non-aggressive' (stealing, lying, disobedience) than for 'aggressive' conduct problems (fighting, bullying). Their findings indicate that emotional problems ('misery, worries, fearful of new situations') remained stable between 1974 and 1986 but have increased in the period 1986 to 1999, again for both boys and girls. The authors also suggested a link between conduct problems in adolescence and 'multiple poor outcomes' in adulthood. While the research has attempted to overcome some of the limitations of previous studies in this area, for example using comparable measures of mental health over the period of investigation, the findings should still be interpreted with caution.

One difficulty in comparing research findings lies in the way in which mental health constructs are operationalised. Thus, research by West and Sweeting (2003) which measured 'psychological distress' among adolescents in two longitudinal surveys indicated that while such distress has increased significantly for females between 1987 and 1999, and particularly for females from 'non-manual' and 'skilled manual' backgrounds, this has not been the case for males. The authors suggest that this increase is due to cumulative stressors associated with personal factors such as weight and looks combined with increased stress caused by school performance worries.

Suicide rates (for young men in particular) are also on the increase. Coleman (2000) cites figures that indicate a jump in UK rates from 4 young men aged 16-24 per 100,000 in the 1970s to 17 per 100,000 in the 1990s. Figures are worse for Scotland where in 1994 they reached a level of 31 young men per 100,000 of population. Coleman (2000) also reports that attempted suicides or cases of deliberate self harm appear to be increasing. Statistics are unreliable for a number of reasons but the Young People and Self Harm Inquiry (2004) reports that 'more than 24,000 teenagers are admitted to hospital in the UK each year after deliberately harming themselves. Most have taken overdoses or cut themselves.' While completed suicides are higher among young men, deliberate self-harm requiring hospital treatment is estimated to be three or four times higher among young women.

Some groups appear to be particularly vulnerable to mental health problems and there is a clearly demonstrated link between social exclusion and mental ill-health which compounds associations between mental health and other factors such as gender and race. Thus while disorders such as schizophrenia affect more young men than women, the reverse is true for depression, and in each case prevalence is higher among disadvantaged groups (Sheppard 2002). Questions of race and mental health are sensitive issues. Figures indicating higher rates of mental health problems (particularly schizophrenia) among African Caribbean males, for example, are perhaps subject to cultural biases and again are likely to be exacerbated by disadvantage. A widely quoted report suggests that young Asian women may be particularly vulnerable to self-harm perhaps related to cultural factors including pressure from 'izzat' (honour) and 'sharam' (shame) (Newham Asian Women's Project 1998).

Agencies such as the Mental Health Foundation, Stonewall and LGBT (Lesbian, Gay, Bisexual and Transgender) Youth Scotland have found levels of suicide among young gay men to be higher than among the male population generally. Equally, homophobic bullying has been recognised as a major issue within schools but little systematic work has taken place on this. Levels of understanding about the experiences of young lesbians in schools remains poorly understood. Particular fears about disclosure are likely to influence the ways in which research with these groups takes place.

Socially excluded young people, such as looked-after children and those suffering neglect and abuse, are particularly vulnerable to mental health problems (Meltzer et al 2004; Scottish Executive 2002a) but many pupils experience adverse psychological events in their lives that have the potential to impact on their mental health. How this manifests itself in school will depend on a number of factors, including the way in which the school recognises and responds to these events. This in turn is dependent on the way in which pupils and their needs are conceptualised.

Responding to the issue: a new paradigm?

While the term 'mental health' and 'mental health problem' are terms used within health services, schools have, since the Warnock Report ( DES 1978), tended to use the term 'emotional and behavioural difficulties' ( EBD) or 'social emotional and behavioural difficulties' ( SEBD) to refer to a range of difficulties that can create barriers to children's learning.

The definition is, however, problematic. SEBD is a non-normative construct, and as a label can be arbitrarily bestowed (Daniels et al 1999). SEBD covers a continuum of behaviour and 'there is often considerable uncertainty about the boundaries between "normal" misbehaviour, emotional and behavioural difficulties, and mental illness.' (Atkinson and Hornby 2002: 4). Conflation of constructs such as SEBD, disaffection and disruption highlights the value laden-ness of terms used to describe difficulties that impact on behaviour.

Better Behaviour Better Learning ( SEED 2001a) recognises that there is no agreement on the meaning of the term ' SEBD' and adopts an inclusive definition:

2.13 'Whether a child 'acts out' (demonstrates bad behaviour openly) or 'acts in' (is withdrawn), they may have barriers to learning which require to be addressed. Children 'acting out' may be aggressive, threatening, disruptive and demanding of attention - they can also prevent other children learning. Children 'acting in' may have emotional difficulties which can result in unresponsive or even self-damaging behaviour. They can appear to be, depressed, withdrawn, passive or unmotivated; and their apparent irrational refusal to respond and co-operate may cause frustration for teachers and other children.

Atkinson and Hornby (2002) suggest that a distinction needs to be drawn between 'occasional withdrawn or disruptive behaviour on the one hand and a continuum comprising EBD, mental health problems and disorders on the other' otherwise the child's problems may be dealt with inappropriately.

Criteria for determining the distinction between 'occasional withdrawn or disruptive behaviour', EBD, mental health problems and mental health disorders depend on such factors as the severity and the persistence of the problem, its complexity, the child's developmental stage, and the presence or absence of protective/risk factors and presence or absence of stressful social and cultural factors.

However, in all these cases the mental and emotional well-being of the child is likely to be compromised. It is necessary to recognise that this may occur either as the result of some long-standing diagnosed mental health problem such as conduct disorder, ADHD, anxiety or depression or it may arise as the result of, or be complicated by, adverse psychological events. Events such as bereavement or divorce, or life situations that give rise to stress (for example, being homeless, subject to racial or sexual harassment, being bullied) may in themselves be part of the warp and weft of growing up but, coming on top of each other or of other life events, may trigger more deep seated difficulties.

Alexander (2002) groups mental health problems under the following headings, together with examples of how these might manifest in educational settings:

• Emotional (withdrawal, phobias, anxiety, depression, self-harm)
• Conduct (stealing, aggression, defiance etc)
• Hyper-kinetic (attentional problems)
• Developmental ( e.g. language disorder, autism)
• Eating (obesity, anorexia, bulimia)
• Self-care (soiling, wetting)
• Post-traumatic stress (following trauma such as rape, violent attack)
• Somatic difficulty (physical manifestation of psychological problem)
• Psychotic difficulty (eg schizophrenia indicated by cutting, over-dosing, hearing voices, extreme withdrawal).

While useful, a potential danger of such typologies is that they may focus the problem on the child and ignore the contexts in which the behaviour is occurring. In recent years there has been a drive in educational thinking to move from a 'child-deficit model' to a 'contextual model'. Concern has been expressed that the introduction of discourses originating within the health service may result in a resurgence of an individual oriented 'medical model'. For example Gott (2003:9) argues that

the concept of "depression"…[does] not sit easily, at the moment with contextual descriptions, leaving a feeling of powerlessness and inertia when faced with how to deal with the problem in school.

In these cases a reflexive understanding of how the school, through its organisation and structures, contributes to or ameliorates such feelings is crucial in order to avoid a focus on within-child factors. The educational policy context is relevant here. As the Mental Health Foundation says,

Schools have a critical role to play in aspects such as the early identification and referral of children with mental health problems. Pressures on schools, most particularly the demands of the National Curriculum, are contributing to the increase in mental health problems. ( MHF website)

This points perhaps to an inherent tension in policies surrounding social exclusion. Research indicates that educational test scores are one of the strongest predictors of future earnings (Hobcraft 2000). Already disadvantaged groups such as looked after children and young carers leave school with levels of qualification far lower than the national average with concomitant effects on outcomes in later life (Allard and McNamara 2004). Yet, too narrow a focus on attainment and testing may come at the expense of pupils' emotional well-being (Allan et al 2004). It is therefore incumbent on the educational system as a whole to encourage higher educational achievement among disadvantaged youth while at the same time fostering mental health. The importance of this balance in the aims of education is recognised in recent educational policy shifts in Scotland which have moved away from an emphasis on testing and target setting ( SEED 2004c).

Mental health has been defined as:

…self-confidence, assertiveness, empathy, the capacity to develop emotionally, creatively and spiritually, the capacity to initiate and sustain mutually satisfying personal relationships, and the capacity to face problems, resolve and learn from them, to use and enjoy solitude, to play and have fun, to laugh at oneself and at the world. (Mental Health Foundation 2001)

This affirming definition reminds us that mental health is not merely 'absence of mental illness' but encompasses 'emotional health and well-being and emotional competence' (Wells et al 2003). According to Weare (2004a) there has been a paradigmatic shift in thinking about mental health in recent years from a 'deficit to a strength perspective'. The emphasis is now on providing 'mental health promotion for all, family-centred care, early identification and intervention, moving care to natural settings such as schools, and interdisciplinary approaches based on evidence of effectiveness and permeated by a philosophy of continuous quality improvement.' (Weist 2003).

For schools to take on this role of promotion of mental health requires a change in the way schools understand and respond to issues surrounding 'mental health'. However, Weare (2004a) argues that concepts of 'mental health' are not well understood in school, having belonged until recently within a medical discourse. Moreover, she suggests that 'schools often find it hard to see the relevance of mental health to their central concern with learning.' This may in part be related to the unfamiliarity of the language and the tendency for the term 'mental health' to be conflated with 'mental illness' since schools are familiar with the language of social and personal development and the importance of self-esteem in learning - both important components of mental health and well-being.

Putting schools at the centre of the drive for promotion of mental health among children and young people forms part of the Health Promoting Schools Project of the European Region of the World Health Organisation which says that,

Every child and young person in Europe has the right, and should have the opportunity, to be educated in a health promoting school. ( ENHPS 1997).

The health promoting school is a holistic concept which focuses on the structure and organisation of the school as well as the individual. 'At the heart of the model is the young person, who is viewed as a whole individual within a dynamic environment.' (Bruun Jensen and Simovska 2002). In this model school organisation and structures are viewed as contributing to mental health and emotional wellbeing in three key areas: school ethos and environment, the curriculum and partnerships.

The Scottish policy context for the promotion of mental health and well-being articulates with the international rights perspective that sees health as key in promoting equality and social justice. Within this, schools are viewed as playing a central role. In Scotland, all schools are to be health promoting schools by 2007 ( Being Well - Doing Well. A framework for health promoting schools in Scotland, Scottish Health Promoting Schools Unit, SEED, 2004a). Policy aimed at realising this encompasses a number of areas including education, health and social care. We look briefly at each of these in turn.

Education policy responses

The Standards in Scotland's Schools Act (2000) set out for the first time children's right to education and, following on from this, the five National Priorities for education were announced. The third of these priorities is Inclusion and Equality which arguably underpins the other four priorities.

Recent legislation on supporting children in schools broadens the previous definition of 'special needs' and shifts to a more inclusive focus of 'additional support needs' ( Education (Additional Support for Learning (Scotland) Act 2004). This comes into force on November 14th 2005 and will encompass any issue which could create a barrier to learning, whether long or short term, and arising from any cause.

The report of the Discipline Task Force ( Better Behaviour - Better Learning, SEED 2001a) and the recently published update ( Better behaviour better learning. Policy update, SEED 2004b) make a clear link between learning and behaviour and recognise that promoting better behaviour in schools requires the engagement of pupils and parents. The reports also acknowledge that both pupils and staff require adequate support in order to make schools safe and well-managed learning environments.

The report of the Curriculum Review Group ( A Curriculum for Excellence, SEED 2004c) continues this theme, recognising that the curriculum provided in schools must engage pupils and give them responsibility for their learning in order to meet their needs as children and young people and as a preparation for adulthood.

Recommendations for the development of support for pupils is contained within the National Review of Guidance 2004 ( Happy, safe and achieving their potential. A standard of support for children and young people in Scottish schools. SEED 2005a). This report emphasises the importance of partnerships in developing pupil support and is particularly relevant to the programme for all of Scotland's schools to be Integrated Community Schools by 2007.

The Review of Provision of Educational Psychology Services in Scotland (Scottish Executive 2002b) addressed concerns about the recruitment, training and role of Educational Psychologists. The report recommended that Educational Psychologists develop a greater role in the provision of integrated services for children and families; and in working in a consultative capacity with schools.

Ambitious, Excellent Schools ( SEED 2005b) sets out the government's broad vision for education 'built on our belief in the potential of all young people and our commitment to help each of them realise that'.

Health and social care policy responses

The report For Scotland's Children. Better Integrated Children's Services (Scottish Executive 2001) sets out the inequalities faced by Scotland's children and sets the agenda for the development of integrated service provision to ensure the best start in life for every child. 'If every child does matter, there is much to do and both the targeted and universal services that children and their families come into contact with must address better the picture presented here'.

The National Programme for Improving Mental Health and Well-being Action Plan 2003-2006 (Scottish Executive 2003) identifies the development of mental, emotional and social health and well-being in schools as a priority area and builds on the recommendations of the ' SNAP' report ( Needs Assessment Report on Child and Adolescent Mental Health, Public Health Institute of Scotland, 2003). This report emphasises the right of children and young people to be heard and their capacity to be engaged in the process of developing effective ways of promoting mental and emotional health; the importance of removing the stigma associated with mental ill-health; and the need to integrate promotion, prevention and care. As part of this programme, a draft consultation has been issued which will be completed by 25th March 2005 (Children and Young People's Mental Health. Scottish Executive 2004).

It's everyone's job to make sure I'm alright was produced as a report by the Child Protection Audit and Review (Scottish Executive 2002a). The review gives a comprehensive overview of services involved in child protection and emphasises the role of schools and other agencies and the need for 'joined up' responses to ensure children's protection. The report makes the link between child abuse/neglect and mental health problems which may manifest themselves as behavioural problems in school.

Taken together, these key reports and policy guidelines constitute a commitment on the part of government to develop 'joined up' responses to social injustice and exclusion. The role of the school within the community, providing a range of integrated services is central to this vision. However, it is apparent that different agencies and professionals have different perspectives about what 'joined-up' means. The development of integrated assessment frameworks is an essential step in developing 'joined-up' approaches (Gibson et al 2005).

Aims of the research

To the aims of the research as specified in the original tender document were added other aims that seemed to be implicit in initial tender details about the scope and design of the work. The list below gives the full set of aims, with key features of these aims highlighted.

1) Review existing literature exploring the link between mental and emotional wellbeing and behaviour in schools

2) Identify (from literature review or empirical work) any particular circumstances or experiences associated with, or leading to, mental and emotional health problems, that can manifest as behaviour problems in schools

3) Examine the role of education authorities and their partners (other statutory and voluntary agencies) in developing structures, policies or resources which enable staff to identify links between mental and emotional problems and behaviour and develop appropriate responses

4) Examine whether any links between mental and emotional wellbeing and behaviour are mis-assessed or under-addressed in schools

5) Conduct research to identify how schools perceive links between behaviour and mental and emotional health difficulties

6) Identify what schools perceive as successful responses to behaviour they believe to be caused by mental and emotional health problems

7) Conduct research to identify how parents and children perceive links between behaviour and mental and emotional health difficulties

8) Identify what parents and children perceive as successful responses to behaviour they believe to be caused by mental and emotional health problems.

Aims 1 and 2 were accomplished largely (but not solely) through the literature review. Aims 3 and 4 were accomplished through a telephone survey and series of face-to-face interviews with key stakeholders at local authority, health board and national levels. Aims 5 to 8 were addressed through a set of six case studies.

Research methods

Three principal research methods were used in this study: literature review to establish what pre-existing work had to say about the issues highlighted above; telephone surveys undertaken as a scoping exercise with key informants in local authorities, health boards and voluntary agencies with an interest in work on mental wellbeing; and six intensive case studies of a number of interventions aiming to tackle issues of mental wellbeing and discipline.

Literature review

The literature review draws on key research in a number of areas. However, the field of potentially relevant literature is vast and this review is therefore necessarily selective. A number of databases ( e.g. British Education Index, Australian Education Index, ERIC, Educational Research Abstracts, PsychInfo) have been searched systematically with generic terms such as 'pupil mental health', 'emotional well-being', 'social and emotional literacy', 'emotional competence' etc. Other more specific terms such as PSD (personal and social development), SEBD (social, emotional and behavioural difficulties), guidance, pastoral care, divorce, bereavement, refugee etc have also been used. In addition to databases, sites such as DfES, Joseph Rowntree Foundation etc and the websites of charities working in related areas have been accessed. 'Thumb searching' has also been used where the bibliographies of relevant papers are examined for further promising literature. In addition to accessing relevant literature about UK contexts, writings in English that reflect on the experience of other countries on this topic ( e.g.USA/Canada, Australia/ NZ and a range of European countries) have been located.

Weare (2004b) argues that it is best not to be too 'precious' about the language used in speaking about mental health, emotional well-being and other related terms such as emotional literacy. She points out that different fields have different preferences for particular terms and that we need to 'speak to people in the range of contexts in which we find ourselves.' ( ibid: 7). In the literature review the terms 'mental health' and 'emotional well-being' are used in largely interchangeable ways though it is recognised that they have different antecedents and connotations. Used together, Weare (2004b) suggests, these terms help the notion of 'mental health' to lose some of its medicalised connotation and its association with mental ill-health. In addition, the literature review also draws on literature that refers to emotional and behavioural difficulties ( EBD). The rationale for this is that being deemed to have ' EBD' is taken to imply a compromise of mental health and emotional well-being. Using the terms mental health/emotional well-being and EBD together is a reminder that EBD is not just about 'acting out', though it is this aspect that most impinges on the teacher and the school.

Stakeholder telephone survey

A series of telephone interviews was undertaken with the following representatives in all local authority and health board areas in Scotland:

• local authority personnel, particularly educational psychologists and those with responsibility for pupil support. (respondents were identified by making initial approaches to local authority members of the Health Promoting School network, who referred us to appropriate colleagues)
• local health board personnel.

Interviews were structured, using a framework similar to that developed in the DfES report on CAMHS work in schools (Pettitt 2003). A total of 67 interviews were carried out.

Additional stakeholder interviews included representatives from:

• statutory organisations outwith the school system who work to promote mental health and well being in young people or would have this as part of a general social care remit, eg social work, community development and youth workers in specialist settings (for example, alternatives to school projects), community psychiatric nurses, school nurses, early years workers

• representatives of children's voluntary organisations and charities concerned specifically with mental health or who have expertise with key groups of 'vulnerable' children
• representatives of mental health support groups and parent organisations
• those working in national level agencies on mental health and/or behaviour issues, e.g.NHS Scotland, Health Promoting Schools unit.

These interviews, undertaken throughout Scotland, were semi-structured, recorded and transcribed. Most were undertaken over the telephone for reasons of economy and time, but where possible, face to face interviews were conducted.

Case studies

Case studies of the experience of individual schools/interventions form an integral part of the field work for this project. Undertaking such work involves an in-depth approach to data collection that gathered the views of all stakeholders in a setting, including teachers, managers, parents, pupils and extramural staff concerned with mental health or behaviour issues. Case study involves the compilation of data from a variety of sources and in a variety of formats, allowing - from the triangulation of perspectives - a view to emerge of the features of the setting, along with an analysis of those responses to problems which may hold promise for sustainable good practice in the field and which may be transferable to other practice situations.

Six case studies were undertaken. Case studies were selected from a total sampling frame derived from the stakeholder survey and interviews, and using theoretical parameters or typologies derived from the literature review. These were derived in discussion with SEED in order to ensure that the work was as focused as possible on the issue of interest.

The case studies selected were:

• ASSIST (Aberdeenshire Staged Intervention Supporting Teaching) - an initiative to support classroom teachers dealing with low-level disruption
• The Place2Be - a UK charity providing therapeutic and emotional support to children in primary schools in Edinburgh
• Newbattle Integrated Community School Team -This had developed from the New Community School pilot initiated in 1997 and was based in an area of Mid-Lothian which included areas of poverty and social exclusion. An integrated team headed up by a manager and including a range of professionals was based near a large secondary and worked closely in the school and feeder primaries.
• East Renfewshire Multi-disciplinary Support Team - a well established Integrated Community School team which included a youth counsellor and a social worker, and demonstrated a commitment to individual and community well being
• Clydebank High School Support Services Team -an extended team in which pastoral care, learning support and behaviour support staff had been amalgamated, together with a group of pupil and family support workers
• The North Glasgow Youth Stress Centre - a voluntary organisation working directly on mental and emotional wellbeing and behaviour with young people in three secondary schools and community settings.

Field work consisted of a concentrated site visit over a period of one week, with some follow up interviews by telephone to confirm detail. The following types of data were collected:

• documentary material relating to the intervention (funding plans, minutes of meetings, letters to parents etc)
• ethnographic observation data collected on site and recorded as field notes
• semi-structured interviews at individual and group level with those delivering and managing the intervention, collaborating partners in other services, children and young people in receipt of the intervention, parents and carers, ancillary staff (classroom auxiliaries, guidance staff)

Interviews with professionals were conducted as one to one or, where the school timetable allowed, as paired or group interviews. The format was semi-structured, allowing for freedom of response from the participants, and also enabling the interviewer to probe more deeply into areas of interest or concern to the participants.

Parents were offered the choice of group interviews or one to one, to enable those who felt the issue too sensitive for wider discussion to express their views in confidence. However, the inclusion of some group interviews allowed for collection of data from a larger number of participants.

Group interviews were conducted with children. The emphasis was on the use of child-friendly methods, which focussed discussion on vignettes which presented scenarios featuring fictional children. In this way pupils were invited to discuss issues relating to emotional and mental well being in the abstract, only disclosing personal information if and when they chose to do so. This avoids drawing children into any discussions which might cause distress.

Data from the case studies were synthesised to produce richly textured accounts of action in practice. These case studies are included as appendices at the end of this report.

Access and ethical issues

We recognise that such work imposes an onus on us as researchers to think carefully about the access and ethical issues involved. We worked closely with SEED to identify those personnel most likely to be of assistance in relation to the telephone survey. They and the stakeholders involved in the interview were assumed to be able to give permission for their own involvement. A letter outlining the aims and intentions of the project was sent to all those involved, giving assurances about the use of all material.

In relation to the case studies, permission was sought from local education authorities for work in schools, and from headteachers themselves. We tend to demur at HTs being automatic gatekeepers and surrogate consent-givers for all staff and pupils under their authority. Protocols for securing informed consent from all interested parties and at all stages of the work were therefore developed.

Using an experienced research team with a strong record of engagement with children and young people and of research with vulnerable young people, as well as a thorough understanding and familiarity with school context was seen as a major strength in ensuring appropriate ethical conduct. Rowan Group staff operate at all times within the ethical guidelines issued by the British Educational Research Association and the British Sociological Association.

Structure of the report

The framework for the report presented here is provided by the notion of the 'health promoting school' which contributes to mental health and emotional well-being in three key areas: school ethos and environment; the inclusive curriculum; and partnerships with the wider community. In structuring the report in this way it should be emphasised that these three areas should not be thought of as discrete entities but as synergistic elements.

The report concludes by drawing together the key themes emerging from the research and sets out the challenges underlying the changing nature of service delivery in schools, emphasising the importance of capacity building in this area.

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