Investigating the links between mental health and behaviour in schools

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3 Promoting mental health and emotional well-being through the inclusive curriculum

Introduction

In this chapter we examine the second element said to be necessary in the creation of the health promoting school, namely a curriculum which serves all and aims to promote inclusion. Weare and Gray (2003) examine at some length the terminology surrounding concepts of 'emotional' and 'social' learning. While terms such as 'emotional intelligence' and 'emotional learning' are relatively new, though increasing in popularity, they exist alongside older established terms in school such as 'personal and social education' and 'personal and social development'. The authors discuss the advantages and disadvantages of the various terms. While accepting that a range of terms exists, will continue to exist, and should be freely drawn on, they also suggest that work towards some commonality of understanding across fields would be beneficial. They propose the use of two cluster terms that together cover environmental and pedagogic aspects: 'emotional and social well-being' and 'emotional and social competence'. The former focuses on the 'environment and underlying determinants that enable the competences to be developed', the latter is about 'the learning and teaching of knowledge, attitudes and skills.'

This section examines the curriculum considered both as process and product and focuses both on the literature and on examples from the findings from case studies and the interview survey.

Universal

Targeted

Processi.e. about pedagogy, ways of learning and teaching styles.

HOW

This is about how material is taught across all subject areas e.g. how you teach maths, geography etc., but also more specifically in the context of this project how children are taught en masse across all groups

A learning / teaching styles approach but only working with specific target group e.g. nurture groups

Producti.e. about things children can be taught i.e. subjects, information, frameworks.

WHAT

This is about teaching skills, knowledge and understanding etc. relating to social competence e.g.PATHS - but also about universal risks, so includes drug awareness, bereavement education etc.

This is about skills or content orientated teaching interventions aimed at selected high risk or vulnerable groups

Specifically, it examines pedagogic approaches which increase pupils' participation in their own learning and so enhance well-being and aim to increase pupil learning; ' PSD' and other aspects of the curriculum as discrete subject areas which aim to develop social competence; and targeted approaches which respond to the needs of specific groups. It thus conceptualises emotional and social learning in both holistic and individual terms. The chapter finishes with a short summary.

Section A: Evidence from literature

Curriculum as process: pedagogic approaches which enhance pupil well-being

There is considerable evidence to suggest that social/emotional competences can be taught (see, for example, Weare and Gray 2003; Weissberg and O'Brien 2004), but that this might be best achieved through a process approach rather than through the teaching of specific skills or bits of knowledge. An embedded whole school approach to emotional and social learning offers opportunities for students to both acquire and practice the skills, knowledge and affective aspects that underpin the notion of competence.

The notion that individuals construct their own knowledge is long established through the work of theorists such as Piaget (1896-1980) and Vygotsky (1896-1934). While Piaget emphasised the active nature of learning through exploration, Vygotsky's focus was on the social dimension. However, the implications of these widely accepted ideas have not been universally translated into practice. Much teaching still draws on a transmission metaphor which views knowledge as being transferred passively from the teacher to the learner. Piagetian principles pertain in the nursery but curriculum demands are often viewed as precluding a more exploratory approach as pupils progress through primary and into secondary school. Despite this, primary schools remain more likely to be prepared to undertake the wholesale review of teaching methods and approaches that is involved in moving towards a more health promoting approach, and this is partly because of the somewhat looser structural constraints on the curriculum, but also because of the widely accepted view that the early years are so critical in establishing the foundations of children's learning and wellbeing. Weare and Gray (2003:53) cite research which indicates that, 'programmes which start early, with the youngest children and which are developmentally sensitive to the age and stage of the pupils were best able to promote improvements in emotional and social behaviour, for all pupils.'

Desbiens and Royer (2003:123) cite work by Bowen et al (2000) which suggests that 'teaching methods that enable children to organise learning at their own pace, manage problem-solving processes and learn from interaction with other students generate encouraging results from social and educational standpoints'. Recognition of the social constructivist notion of learning is implicit in relatively long-established practices such as collaborative work and peer tutoring. Frey and George-Nichol's (2003) meta-analysis of interventions for children with emotional and behavioural difficulties suggests that peer tutoring and cross-age tutoring are effective in this regard. McKinstery and Topping (2003) report that peer tutoring in a paired reading scheme can produce gains in self-esteem for both tutors and tutees.

Recently, however, there has been growth of interest in 'brain compatible' learning which draws on research in the neurosciences. At the same time attention is being paid to factors such as learning style and to 'meta-learning' i.e. pupils learning about their learning. This is particularly evident in the widespread uptake of ideas emerging from the 'Assessment is for Learning Group' (Black and Wiliam 2002). Application of ideas associated with 'brain compatible' learning is seen in 'accelerated learning' (Smith 1998) and 'brain gym' (Brain gym website) an approach which is being enthusiastically taken up in some schools, though little formal evaluation appears to have been carried out. The recognition of a range of learning styles and the idea of a 'preferred learning style' together with Gardner's (1993) theory of multiple intelligences ( MI) is also gaining ground in schools. While there are critics of Gardner's MI theory and constructs surrounding learning styles (see, for example, Klein, 2003) this approach does challenge the bias in the curriculum against visual and kinaesthetic approaches. As Smith (2002:69) remarks, 'concern with equity and inclusion in the UK today gives teachers and curriculum planners the opportunity to use learning styles to make learning more accessible to a greater range and number of students.'

A widespread feature, certainly of primary schools, is 'circle time', popularised through the work of Jenny Mosley (1996). Despite claims for the benefits of circle time there has been rather little formal published evaluation of this approach. A recent report (Taylor 2003) suggests that many schools claim improvement in ethos, raised self-esteem of pupils and enhanced listening and group skills through use of circle time. Pupils too were largely enthusiastic, 'they liked talking, gaining attention, and learning about themselves and others and having fun.' However, Taylor notes that many classroom teachers have not received specific training for implementing circle time, a fact that she regards as potentially problematic, especially with respect to ethical issues such as disclosure and confidentiality. Taylor concludes that 'to reach its potential it requires preparation, planning and review and to mesh with other personal and social teaching and learning strategies and opportunities in the whole curriculum'. As a response to specific individual needs, however, circle time may have more limited application. In work by Wade and Smart (2002) children of divorce/separation spoke positively about circle time but indicated they would not use it as a forum to discuss personal issues.

Circle time is an example of a pedagogical approach which is likely to be used universally in the primary school setting for example. Some pedagogical approaches are designed, however, because of their very intensive nature, for use only with targeted groups. As an example of this we look at what has been written about 'nurture groups', an alternative curricular approach to meeting the needs of young children having difficulty coping with the demands of classroom life. Nurture groups aim to provide early and sustained intervention for children with emotional and behavioural difficulties.

Although nurture groups were first developed in the 1970s they are perhaps only now becoming widespread, finding a ready place in schools with the current emphasis on the development of inclusive practice. The theoretical underpinning of the nurture group is derived from Bowlby's attachment theory that proposes that, in order to thrive, infants need to be securely attached to a parent or other significant adult carer. When these needs are met, the child is able to engage in 'the exploratory behaviours that are so important to normal child development' (Cooper and Lovey 1999: 123). Without this early attachment to an adult who can nurture their development, providing a range of necessary experiences, children's emotional development is impaired, causing them to become 'stuck' at a particular developmental stage or to regress to an earlier stage. As a result of this, children arrive at school without the necessary maturity to cope with the exacting demands of school life.

The aim of the nurture group is to make good this perceived underlying nurturing deficit. Typically, a nurture group is a room in the mainstream school accommodating around 10-12 infant children and staffed by two adults, one of them a teacher. The room has a number of different areas reflecting home and school. Within this comfortable and secure environment the adults respond to the children's developmental needs.

Bennathan and Boxall (2000) emphasise that the nurture group should be seen as central to the functioning of the school - metaphorically and, preferably, literally. It is viewed as an inclusive intervention in that children remain within the mainstream setting and they start and finish each day in their mainstream classroom. In addition, parental involvement is considered to be a fundamental part of the nurture group.

A body of research evidence is developing about the effectiveness of nurture groups. Most of this evidence comes in the form of small-scale case studies. However, a larger project was undertaken by Cooper, Arnold and Boyd (2001). Teachers were almost unanimously positive, both with respect to children's educational progress within the nurture group and in terms of the impact of the nurture group on the life of the school as a whole. In particular, teachers highlighted:

  • The development of more nurturing attitudes and practices throughout the school
  • Changes in the ways in which teachers think and talk about children
  • Contribution of nurturing principles to whole school policies
  • Increased sense of empowerment with 'difficult' students
  • Evidence of increased awareness of developmental issues and the relationship between social-emotional factors and learning.
    (Cooper, Arnold and Boyd 2001:164).

Parental views about the value of the nurture group were less clear cut. The majority felt that behaviour, educational progress and enjoyment of school had all increased, but some parents expressed negative views.

Children's perceptions of the benefits centred on:

  • Quality of relationships with teachers
  • Opportunities for play
  • Quietness and calmness in the nurture group
  • Pleasant environment
  • Engaging activities (including preparation of snacks)
  • Predictability and structure

The authors conclude:

The evidence from this study suggests that such a holistic approach has the potential to produce positive outcomes across a wide range of variables, including social, emotional and behavioural and educational functioning of children; parents' attitudes towards their own children and the school; and the positive functioning of whole schools. (Cooper, Arnold and Boyd 2001:165).

O'Connor and Colwell (2002) assessed children entering and leaving a nurture group. The study showed that while the short term effects are quite clear, with children's emotional and behavioural difficulties reduced to a level enabling them to participate in the mainstream classroom, over the longer term this is not necessarily so:

It may be the case that some of these children still need a degree of nurturing in the normal classroom, if they are to maintain the changes and continue to flourish. (O'Connor and Colwell 2002:98).

Understandably, there has been considerable interest in 'transferring' nurture group principles into mainstream classrooms. Colwell and O'Connor (2003) undertook a small-scale study in four schools using quantitative observational techniques aimed at establishing the factors underpinning the success of nurture groups in comparison with mainstream classes. They found that within the nurture group teachers used more supportive language - conveying acceptance of pupil ideas and feelings, using fewer deprecatory remarks, less bland praise, calmer responses to inappropriate behaviour and encouraging more independence than did their mainstream colleagues. In addition, nurture group teachers used more 'positive non-verbal behaviour' which 'conveys feelings of acceptance and warmth.' The authors conclude that 'a climate in which a child feels safe and valued may allow for the rejuvenation of self-esteem.'

However, work by Doyle (2003, 2004) points to successful application of nurture group principles and practice to mainstream classes. In effect, she argues, the Nurturing School is the paradigm of the inclusive school. Doyle (2004) discusses the implementation of a curriculum for social development as a key element in ensuring that nurturing principles are grounded throughout the school. This curriculum describes clear learning outcomes focusing on:

  • Social skills
  • Self-awareness and confidence
  • Skills for learning
  • Self-control and management of behaviour

Doyle (2004) argues that this curriculum benefits all children, not just those with emotional and behavioural difficulties.

While most evaluations of the work of nurture groups are positive, Bishop and Swain (2000a, b) discuss some issues that question aspects of this. In particular, they question the philosophical underpinning of nurture groups which, in their view, seems to be based upon a 'pathological view' of children and their families. In a case study they suggest that the model of parental partnership held among staff was one of 'transplant' i.e. 'experts' (the teachers) pass on their skills and expertise to parents to be used at home. This, they argue, is a limited approach: 'the teacher retains control and thus this is not a full partnership.'

Although developed with young children in mind, some interest has been expressed in developing similar groups for older children and adolescents. However, there appears to be little published work on this aspect of nurture groups.

Pedagogical approaches are clearly linked to social and emotional learning and competence, and so the failure to pay attention to this at secondary level is the more obvious. Whitty and Campbell (2004:18) suggest that a disappointing feature emerging from the evaluation of New Community Schools is the extent to which curriculum reform (including approaches to learning and teaching) was minimal, 'integrated services will not achieve a significant impact if they do not involve an educational component, ideally linked to curriculum and classroom practice.'

Curriculum as product: approaches to promoting emotional competence

In the previous section we looked at claims that pedagogical approaches (the process of teaching and learning) could be used to create active learning and encourage emotional competencies. In this section we turn to what has been written about curriculum as product and focus inevitably on the ways in which much of the relevant curriculum is invested in that part of the school's weekly offering known as Personal and Social Development.

Programmes aimed at supporting pupils' personal and social development have the dual aims of enhancing pupils' social competence and teaching about specific topics such as resilience, bullying, bereavement, substance abuse etc. Anecdotal evidence suggests that PSD does not enjoy the high profile it arguably should, either in the eyes of school staff or of pupils, particularly in secondary schools. Its low status may be due, in part at least, to lack of ownership by teachers whose identity is bound up with loyalty to subject, and by the fact that it is not examined. HMIe (2004:14) reports that 'few mainstream schools had well-planned comprehensive programmes which took full account of pupils' prior learning and ensured challenge for them.'

One factor associated with effective implementation of published PSD programmes is fidelity to the curriculum. In a study of teacher implementation of a programme on substance abuse Ringwalt et al (2003) found that only 15% of teachers followed the guidance closely. Among the variables associated with programme fidelity were: how much teachers enjoyed teaching the programme; how effective they believed it to be; and how confident they felt teaching it. Recent training in programme delivery also enhanced fidelity. This suggests that ineffective PSD teaching may be bound up with lack of interest in teaching it, lack of appropriate training, and lack of belief that such programmes can make a difference. However, there is a tension between fidelity in implementation of published programmes and need to contextualise programmes for local circumstances. Greenberg (2004:9) suggests that 'the polarising debate regarding fidelity versus adaptation can be more effectively recast as focusing on the quality and nature of adaptations.'

However, while PSD is widely viewed as a Cinderella subject in schools, youth and community groups supporting excluded youth are more positive about its benefits. The Young Adult Learners Partnership ( YALP 2003) regard PSD as a means to develop social capital among disaffected youth, based on an understanding and development of resilience as a response to risk. In their research YALP consulted users of the Connexions service about PSD programmes they had participated in. Service users clearly valued opportunities to develop social skills within a group learning and sharing environment. In particular, they valued activities that included: performances; outdoor education; youth forums and councils; volunteering, mentoring and 'buddy' schemes; and planning and organising an event. Characteristics of effective programmes included:

  • Well-structured but flexible programmes responsive to young people's needs
  • Direct involvement of young people in planning, delivery and evaluating PSD programmes.
  • A holistic approach 'rather than a focus on a narrow set of specific skills'.
  • Well-trained and highly motivated staff.

An important aspect was the 'incremental transfer of power' from adults to young people within the programme.

Clearly there are lessons to be learned by schools from the experience of youth/community workers. Initiatives such as joint planning and delivery of programmes may be a means to provide more effective PSD in schools. Weissberg and O'Brien (2004:92) state that, 'one curious finding is that programs implemented by mental-health clinicians and peers have more positive effects than those provided by teachers.' Currently, opportunities for pupils in school to be engaged in the kinds of programmes outlined by YALP tend to be available only in the form of 'alternative curriculums' for disaffected pupils or those deemed to have emotional and behavioural difficulties. Head et al (2003:41) argue in their research on behaviour support that:

…the flexible approach to supporting some pupils did not necessarily result in a loosening of the tight structures within which most children received their education. There may be a contradiction in responding to some in highly responsive ways whilst maintaining the majority in rigid curricular systems.

The role of activities beyond the classroom in developing social competence may be particularly important. For example, breakfast clubs have been cited as one of the most successful initiatives in New/Integrated Community Schools (Sammons et al 2003). Watson and Marr (2003) discuss the setting up of a breakfast club in a special school for children with emotional and behavioural difficulties. A key finding from this study was that the club provided opportunities for pupils to develop and practice social skills in a real yet supported context. Whitty and Campbell (2004:18) also point to Breakfast Clubs as 'increasing engagement and improving social outcomes such as addressing issues of bullying'.

Beyond the PSD curriculum some efforts have been made to incorporate new curricula elements that will promote wellbeing. One such example is Aberdeen City's 'Chess Development Project' (Aberdeen City Council website), which has involved pupils in some primary schools in an area of deprivation being taught how to play chess within the curriculum. Findings from a study of the project suggest that pupils' social skills are developed, that active learning is encouraged and concentration in class is enhanced (Forrest et al, 2005). It is clear in talking to teachers that such initiatives are not uncommon, yet dissemination of practice appears to be limited. The 'Social Competence' initiative ( SOEID 1998) was an attempt to raise awareness of the importance of social/emotional learning in schools. While this initiative gave rise to a number of interesting projects and an extensive database little evaluation or follow-up of these appears to have been undertaken.

In addition to these rather generalised attempts to develop social and emotional competence within the PSD curriculum and beyond, there are a number of curricular offerings which set out very specifically to teach young people about mental health. If we accept that this is an appropriate component of the curriculum, how should it best be done? This question generates some debate over whether programmes should focus on prevention of mental ill-health or promotion of mental wellbeing. Weissberg et al (2003) present two views. In the first, prevention and promotion are seen as separate activities. The argument is that 'health promotion should not be driven from the standpoint of illness'. Others argue that prevention and promotion should be combined since prevention programmes are too narrowly based, focusing on a specific area of risk. This argument suggests that problem-prevention efforts should be linked explicitly to programmes to enhance competence. Programmes based on this notion therefore have a dual function 'as protective factors that decrease problem behaviours and as foundations that support healthy development and success in life'. This leads to another 'major issue' in the prevention field i.e. whether programmes should be 'universal' or 'targeted' at specific groups at risk.

Weissberg et al (2003) argue that universal programmes are 'generally not of sufficient dosage or targeted enough to have a discernible impact on higher-risk children'. For this reason they advocate the use of 'comprehensive' programmes 'combining universal, selective and indicated approaches in multi-component, multi-year projects.' Weare and Gray (2003:43) also present a strong rationale for whole school approaches: it is less stigmatising to work with everyone; it produces a kind of 'herd immunity'; it is inappropriate to target in cases where the distribution of cases is continuous (where do you set the cut-off point?); emotional, social and behavioural difficulties are within the population etc. However, they agree that these universal approaches should be combined with work with individuals. They suggest that a lack of understanding about the complementarity of the two approaches exists:

…we should indeed target carefully, but against a backdrop of overall provision where it is much more likely to be effective than targeting alone.

Whole-school approaches do not preclude the use of approaches that target individuals. Targeted interventions include programmes for anger management, counselling and alternative curricula. Nation et al (2003) conducted an extensive 'review of review' of prevention programmes in order to arrive at the principles underpinning effectiveness. Their research suggests the following characteristics for effective targeted interventions:

  • Comprehensiveness - providing 'an array of interventions to address the salient precursors or mediators of the target problem.' Comprehensiveness also includes the concept of having 'multiple settings' i.e. they should include two or more of, schools, family and community, peer group
  • Utilise varied teaching methods i.e. they should include active, skills-based components
  • Be delivered in sufficient dosage - measured in quantity and quality of contact hours
  • Theory driven i.e. have some 'scientific justification'
  • Provide opportunities for children to develop strong relationships with 'significant others'
  • Be appropriately timed
  • Be socio-culturally relevant
  • Be implemented by well-trained individuals.

In addition, Nation et al (2003) and other workers advocate the need for rigorous evaluation as part of 'evidence-based' practice. The notion of what constitutes appropriate 'evidence' is, however, contested. In the US this tends to mean quantitative research conducted within a positivist paradigm. On this basis a number of meta-analyses of programmes have been published in recent times ( e.g. Catalano et al 2002; Greenberg et al 2001; Wells et al 2003). Catalano et al (2002:4) looked at the efficacy of 77 programmes meeting the study's evaluation criteria ('research designs employing control or at least very strong comparison groups' and which 'attempted to measure behavioral outcomes') as part of the 'Positive Youth Development' project in the US. Of these 25 were deemed to be 'effective' by the criteria set. Weissberg and O'Brien (2004:94) emphasise that for these programmes to be translated into effective practice requires that they are embedded within broader systemic approaches, 'uncoordinated programs ignore the fact that problems such as youth drug use, violence, bullying, sexual promiscuity, and alienation are closely interrelated, complex and develop over time within the broader context of the school, family and community.'

Combining process and product

'Multi-component' programmes are defined by the World Health Organisation as those which 'focus simultaneously on different levels such as changing the school environment as well as improving individual skills.' ( WHO 2004). A particularly well-developed and evaluated 'multi-component' programme is the MindMatters, and latterly MindMatters+, initiative in Australia (Broomhall et al 2004; MindMatters website).

The MindMatters resource has been available to all schools in Australia since 2000. The resource provides: guidance for developing a whole school approach; curriculum materials focusing on resilience, bullying, loss and grief, and understanding mental illness; a professional development programme (supported by a two-day programme for school teams); and a web-site for ongoing support (Hazell et al 2002). In addition, it supports collaborative work with other agencies. MindMatters is not a prescriptive 'intervention'. It is described thus:

MindMatters is perhaps better viewed as a set of resources for schools rather than a defined program which has clear goals and objectives…[it offers] a menu of choices for schools in terms of both the health issues addressed…and the strategies to be used. (Hazell et al 2002:23).

The programme is aimed at achieving more than just the insertion of curriculum materials into schools but at promoting systemic and systematic change in schools in order to develop practices which foster inclusion. It is explicitly based on the model of the health-promoting school as an interaction of organisation, ethos and environment; curriculum, teaching and learning; and partnership and services (Wyn et al 2000).

The project has been extensively evaluated (Most recent evaluations are MindMatters Evaluation Consortium 2004a, b). A significant finding was that many teachers and students expressed the view that they felt more comfortable about discussing mental health issues, suggesting that, 'MindMatters had encouraged the development of a culture in which there was recognition of emotional needs and wellbeing.' ( MEC 2004a:27). In addition, some schools reported 'an increase in students' attachment to school'. Thus disaffection was reduced and with it came falls in truancy and exclusion rates. Students also welcomed greater opportunities to develop 'leadership skills' through peer support schemes and appreciated the opportunity to 'engage with real issues such as harassment, bullying and drug use'. A key outcome of the programme was in enabling change:

MindMatters contributed to a culture of innovation where people were open to school change, partnerships and other programs. ( MEC 2004a:32).

Factors which affected outcomes of the implementation included:

  • 'Readiness' of schools and teachers to change
  • Extent of senior management involvement
  • Resources allocated to implementation
  • The nature of MindMatters resources
  • Nature and amount of professional development training provided to staff
  • Value attached to health and wellbeing as a focus within the school
  • Value attached to health and personal development as a focus within the curriculum
  • Commitment to the adoption of MindMatters
  • Communication within the school.

Barriers to implementation included staff attitudes and reactions. In some schools staff resistance was evident. This arose from a number of factors including discomfort in discussing issues; concern about workload; questioning whether this is an appropriate remit for schools. Staff turnover was also found to be a barrier to effective implementation as was the effects of other change processes going on in schools at the same time. Overall, however, independent evaluations of the MindMatters programme are positive.

Section B: Evidence from empirical work

Introduction

The short timescale of this project did not seem appropriate for assessing fundamental curriculum innovation, so none of the case studies focus on interventions primarily delivered through the curriculum. Evidence presented in this section is, therefore, mainly gleaned from the telephone scoping surveys and from supporting documentation supplied by some agencies. As such, any information on effectiveness consists of self reports.

The scoping surveys reveal a bewildering range and number of approaches in this vein, many of which were imaginative and creative. However the depth of work on this varied considerably within and across areas with some intensive pieces of sustained activity in pockets of local authority areas and even within schools themselves and by contrast, other areas with very sporadic activity which was ad hoc and clearly dependent on the presence of individual champions.

Many of the initiatives took the form of pilot projects but frequently appeared to exist in a theoretical vacuum with little reference either to the previous work or ideas they might have been based on or to how the intervention would be sustained in the future. Many were staffed by highly dedicated, enthusiastic and skilled staff and volunteers who often worked hard to integrate their work and to give it credence with other professionals. This diversity is unsurprising given the variety of agendas, interests, lack of accountability, professional capacities and resources including expertise that exist. Many of those interviewed pointed out that work in their area was under review, in the early stages, or about to be reviewed.

Curriculum as process?

Survey findings indicate that the health promoting school and integrated schools model provided both a backdrop and a rationale for the development of work on emotional and mental wellbeing by health and voluntary sector staff. Importantly it also provided a gateway for health workers to extend their work in schools and to develop more coherent approaches with colleagues from school nursing and teaching. Key personnel such as health promotion staff were thus active in supporting schools to develop their work in this arena through the offer of training, materials in the form of packs and courses, working with other agencies and in making connections with related work in the area. Many of the small scale initiatives which were discussed in interviews demanded a high level of input of staff time in securing funding and were mainly short term or pilot initiatives.

However, almost by definition, innovations coming forward from other professional groups would have little chance of penetrating the educational ramparts in respect of pedagogical approaches. It was difficult to locate universal or non targeted examples where schools had really undertaken a fundamental shift in respect of teaching/learning methods.

Under the health promoting school banner Lothian Health had used a variety of methods with teachers, pupils and parents in 8 schools to explore their priorities for the health promoting school. There were 3 stages to the pilot which aimed to discover how 'happy, comfortable, safe you feel in school'. In the sense that this was encouraging active learning and participation by children it might be construed as an attempt at least to carrying out the scoping work necessary for any more fundamental review.

It was easier to find examples of work with targeted groups which examined pedagogical approaches. Examining ways of teaching, learning and working is perhaps easier when working with small groups, and /or dealing with children whose behaviour is so bizarre or whose circumstances so extreme that they will never be compliant within the normal classroom situation unless their needs are addressed in an intensive or different way first. Many of these programmes thus have at their root a desire to normalise 'abnormal' children into more acceptable patterns of behaviour.

An intensive targeted approach has been adopted by Glasgow City Council, through the introduction of nurture groups, run very closely according to the principles of the Boxall model described in the literature review. Pupils who have been identified by class teachers or educational psychologists are assessed using the "Boxall profile", a psychological tool which identifies "strands" to be addressed in the child's development, and from this a series of structured targets are defined before the child joins the group. The group is run by a qualified teacher who has been trained in the principles of nurture groups, and the progress of individual children is monitored in collaboration with the corresponding class teachers. Within the nurture group pupils follow the mainstream curriculum, where possible and appropriate, as well as undertaking activities which address their specific needs. Nurture groups are designed to be an integral part of the main body of the school with pupils maintaining contact with their peers and their class teachers, and being re-integrated as quickly as is possible.

The authority holds a very favourable view of the success of this intervention, reporting measurable success in improving children's social and emotional competence. Parental responses are held to be entirely positive. And benefits for schools are felt to go beyond the individual pupils to also improve and enhance the whole school awareness of mental health issues, leading to them becoming "nurturing schools". From an original pilot of four schools Glasgow has approved the roll out to 58 primary schools.

Another example of such a project was a joint piece of work between Interact and schools in Forth Valley focused on behaviour. Interact takes a whole person approach using the arts as a medium for exploring social and emotional issues. A pilot project is being run in two primary schools with high numbers of referrals to educational psychology. An advisory group of Education Development Officer, The Principal, Education Psychologist and two Head Teachers and a professional worker and some of the secondary school support work with the health promotion officer. The project works with six or seven young people in a class who appear to be unable to concentrate and who are very disruptive, helping them to develop better communication skills. At the end of the session the whole class meets up again. The worker was clear that no stigma was attached to involvement in the group and that in addition to offering additional support to the group, it provided respite for the teacher.

In Tayside a drama and dance initiative was developed by health promotion workers and staff and students at a drama college with 6 schools. This set out to engage with young people and to convey health advice and information in ways which could be followed up in schools or by young people using the contact details. Through the use of diaries and anonymous suggestion boxes, it allowed young people to voice their views and experiences. The programme was based on the findings from a questionnaire on health and wellbeing which had been completed by young people in Tayside and which had revealed anxieties about a range of mental and emotional issues. The initiative aimed to provide information about health services for young people in a useable form and to provide an opportunity to explore some of the issues. The dance performance focused on key themes and formed the basis for meetings between school staff and health workers. Workshops for parents and staff were also organised but were poorly taken up. Teachers were offered a day of training on promoting emotional wellbeing in schools and provided with a pack to follow up the work in lessons. Performances were undertaken in secondary schools across Angus and were also followed up by workshops with young people. Because the actors were drama students and close in age to some of the pupils, the initiative included elements of peer education which the health promotion worker felt were very useful in both airing issues and discussing the implications. This work built on several years of small scale collaborations and targeted both staff and young people with a view to embedding it in further work in schools. Importantly it enabled working relationships between different groups of staff, such as school nurses and teachers to be built up and sustained. It was very well received by staff and young people across the area. However this was a short term piece of work that was funded out of the Health Improvement Fund and it is unclear as to how this will be taken forward in future.

Video Interactive Guidance is a therapeutic intervention, used on an individual basis with young people to look at positive approaches to their difficulties and trying to generalise it to other aspects of their behaviour. While this is in the initial stages, it offers a means of using media in an imaginative way but it is highly demanding of staff in relation to dealing with sensitive issues and confidentiality. Originally developed in Holland as a an alternative to young people being drawn into the judicial system it targets and works with individual young people who are already involved with services. In West Lothian teachers, social workers and health professionals have been trained to use the technique with young people. It can also be adapted as a tool to work with teachers who are experiencing difficulties with their interactions with challenging young people, to examine their own responses to situations.

Greater Glasgow was piloting the SELF (Social and Emotional Learning Framework) for primary 6 pupils in 8 primary schools in Glasgow. The aim of this framework is to identify children who are likely to struggle in the transition from primary school to secondary school so the focus is on P7 to S1. This assessment tool was designed to ensure a more consistent approach and to provide an evidence base for the allocation of resources across schools. An Educational psychologist had been seconded to work over two years on how this could be developed, how it could respond flexibly, for example to take account of local situations and needs.

Some highly imaginative work developed on a small scale in Fife and brought together work on classroom skills and attempts to raise self esteem. Creative writing was the main mechanism for this pilot which targeted young people in one primary school who were truanting, displaying challenging behaviour and difficulties in dealing with class work. Health promotion staff, a cultural co-ordinator and a local poet set the course up to work with a group of children referred by the head teacher using funding from the Quality of Life stream. The aims were, 'to help the kids to express their own emotions about what was going on for them as well as to raise self esteem and emotional health'. The group ran for 12 weeks and captured the enthusiasm and creative energy of the participants. Feedback from teachers suggested that some of the participants coped better in class, that reading and writing has improved overall and that generally participants have been calmer and less angry in class. As a result of this a year long project for 4 groups will be undertaken in a larger school and will work with mixed ages and backgrounds. In this roll out attention will be paid to the ripple out effect of the intervention on the wider class.

At one end of the spectrum Fairbridge and Right Track transported children out of the school for specific activities. Fairbridge is a national charity which sets out to work in partnership with schools by providing specifically tailored programmes to tackle disruptive behaviour and poor attendance and to re-engage disaffected young people in formal education. Programmes using informal education techniques are devised for work with young people defined as at risk of exclusion in areas of poverty. Activities include outdoor and sporting challenges alongside motivational work and participants are taken out of school for one or two days a week and for residential work. Similarly Right Track works with schools to develop personal and social development courses and takes a personal development approach, focusing on employability with school refusers. Young people remain on the school roll but are based at the Right Track premises not the school campus and agree not to sit standard grades. This is an 'exporting' model in which young people from school work with the agency in non school settings prior to moving back into the school at some stage. In some schools teachers were critical of this model for appearing to reward 'bad behaviour' through 'treats' and some difficulties were noted in reintegrating children into the unchanged situation which they had left:

..Because when they are out and they've missed all their work and they're out of rhythm of school and uniform - all those kinds of things - it's like children who go into hospital and come back. It's the same kind of problems. You're back to your mental health again. (Guidance teacher)

The provision of alternative educational opportunities for children who could not cope with or who were excluded from school was a feature of a number of authorities. This included a range of interventions ranging from home tutoring to more structured learning. In Moray this came at the end of a process whereby a voluntary sector agency, Moray Youth Action worked with schools and social workers to try to retain young people in mainstream education. Support staff undertook a mix of group work and individual work focusing on anger management and in some cases sitting alongside young people in class with the aim of retaining them within mainstream education. A person centred approach was adopted with training offered on this to all staff. A purpose built centre for senior pupils excluded from school was staffed by teachers and development workers with a flexible curriculum and a mix of one to one and group work. Young people were positive about the benefits of this but were very rarely reintegrated into mainstream school.

The Greater Glasgow Health Board offered a relatively long term level of support through their mental health promotion strategy. Ten projects were funded over three years to develop a range of work aiming to improve the mental wellbeing of young people with a strong emphasis on working with schools. Projects included youth mentoring, peer education, stress centre work, work with runaways, looked after children, counselling and drop in services. The employment of health development officers by the local education authority with funding from health promotion in Glasgow further aimed to promote the wellbeing of young people in a co-ordinated approach to whole school and targeted work within school clusters.

Curriculum as product

In this section we review what sort of curriculum products were on offer which might be said to be acting towards the improvement of mental health or the addressing of discipline issues through attending to mental wellbeing.

Inevitably much of this sort of provision, as pointed out in the literature review, was vested in the PSD element of the curriculum. The role of PSD was repeatedly referred to by interviewees as a means by which the emotional needs of children and young people could be addressed, but there was little optimism about the quality of existing provision. PSD was referred to by both educationalists and health professionals as a 'Cinderella' subject, particularly in secondary schools. It was thought to be undervalued by pupils who have been encouraged over the years to pay most attention to curriculum areas which involve assessment, and given low priority by some staff who often teach the subject with reluctance. However, there was innovative work being undertaken in some areas as part of the PSD programme.

For example, a curricular programme to promote resilience, PATHS (Promoting Alternative Thinking Strategies) was being used in West Lothian and in Orkney. Although it was still early days to comment on long term effectiveness this approach was described as having been well received by teachers and pupils. However, it was appreciated that such a programme was unlikely to reach the most vulnerable pupils who may either have poor attendance records at school, or who may not readily engage in classroom activities, and for whom such a generalised curriculum may be insufficient to meet their needs. It was felt that more targeted approaches would be needed to supplement the whole class work.

PSD time was used to explore the topic of mental health and well being by exploring feelings and language associated with those feelings in a particularly striking example of work undertaken in Renfrewshire. Here PSD lessons were delivered throughout the authority by workers from the voluntary organisation, Renfrewshire Association for Mental Health. Domestic abuse was also on the PSD curriculum in some areas, with West Dunbartonshire employing a domestic abuse worker with a specific remit to develop and deliver materials for this purpose. In South Ayrshire a domestic abuse worker from Womens Aid was involved in organizing and running training for staff.

The examples above indicate how common it was for external agencies to undertake work at a range of levels focusing on mental health and wellbeing and behaviour. Much of this took place in schools as part of PSD programmes and could be delivered both on-site and off-site. Some work that was based on drama or dance involved moving out of the school for a conference or day workshop to mix with others in the area. Some specialist work on behavioural issues was based on the exporting of young people to specialist settings for either workshops or longer periods of time.

In North Glasgow, the Youth Stress Centre ran courses in Springburn Academy which aimed to develop emotional intelligence. These courses ran for 12 and 15 weeks, were integrated into the broader PSD curriculum and were developed in collaboration with pastoral care staff. This integrated work offered the potential for progression as the courses originally ran in S1, S2 and S3. This work had been in operation for over seven years and was well supported by school staff who sought to increase the level of provision and to strengthen their links with the agency. However funding issues had threatened expansion in recent years.

This school overall worked with a variety of voluntary sector agencies and had a confident and well developed PSD strategy supported by an energetic and highly competent team of staff in pastoral care. The work with the North Glasgow Youth Stress Centre was also carried through into work with the learning support base which offered some continuity.

In addition to this universal provision, the YSC ran similar courses with targeted groups of young people in two other schools. In these settings, young people were selected by guidance staff and moved out of their class for the duration of the weekly session. Staff at the YSC were less satisfied with this approach since it did not allow for progression, was confined to a smaller group of pupils and those selected had to be withdrawn from their class. However staff in the school felt it offered an opportunity to bring together children from asylum seekers' families to work with indigenous children who were themselves facing difficulties in their lives and that this mix was valuable in building relationships. Specific courses on behavioural issues such as anger management were also developed and run within all these schools usually as a result of requests from school staff. Additionally, staff from the youth stress centre undertook one-to-one counselling sessions with pupils at all three schools in which they worked.

In addition to what went on under the guise of PSD there were also attempts at mounting single events to raise the profile of mental health issues. Thus we were told of conferences or whole school meetings with a focus on mental health, of drama work and the provision of packs and worksheets for use in the school on mental health. In Renfrew a booklet was produced under the community safety partnership banner and was distributed to all Primary Six children who were then brought to an annual event. At this, short bursts of information on the key topics which included confidence, self esteem, bullying etc. were imaginatively presented. A short drama presentation with an interactive question and answer session was based around related issues such as drugs and alcohol and the day was aimed to provide a catalyst for further work on the topic. However as with the packs it was unclear how this was translated into work in the classroom and how well equipped teachers felt about delivering the programme.

Summary

The curriculum is characterised here as consisting of both process features (related to pedagogy or ways of teaching and learning) and products (specific curricula designed to 'transmit' skills or knowledge).

With regard to process, primary schools have always been more prepared to accept the necessity for looking at the ways in which embedded pedagogical approaches can build competences and encourage active learning and good mental health. Teaching approaches like circle time may be used universally in a primary setting, but there is also evidence for the effectiveness of very targeted schemes for the most vulnerable, such as nurture groups. Secondary schools are notably resistant to reviewing the pedagogical process and even the advent of new community schools has not shifted the entrenched position of most, where transmission of knowledge and skills is the dominant mode of teaching and learning.

Curriculum products designed to produce better mental health tend to be invested in the Personal and Social Development silo of secondary teaching. Here, marginalised by its status as a non-examinable subject and not always commanding the loyalty of those drafted into teaching in this area, they often fail to impress. Properly managed and effectively run they can be seen to achieve more, but it is notable that young people, when asked, seem to value most those curricular offerings in this area that emphasise young people's own role in setting the agenda and which encourage active learning and a more holistic approach.

In relation to the transmission of explicit knowledge and skills about mental health, opinion divides around whether the appropriate focus is prevention (of ill-health) or promotion (of mental wellbeing). Experts also disagree about the virtues of universal versus targeted programmes. The former are non-stigmatising, inclusive and so on, but the 'dosage' is so low and so diffuse that it is relatively impossible to show 'effect' in research terms. Targeted programmes find it easier, if well engineered, to demonstrate gains for troubled young people, but at the cost of labelling and segmenting the youth cohort.

Some curriculum designers have attempted to produce materials that will combine process and product, thus focusing strongly not just on what is taught but how it is taught. The MindMatters programme is examined as a specific example of this approach. Early evaluation of the effectiveness of this programme is encouraging, but inevitably, the devil is in the detail. The level of commitment with which the programme is implemented clearly impacts on the level of success achieved. There is no simple 'magic bullet' set of curriculum materials that will improve mental wellbeing for all or even a few without the school having some real commitment to the task.

Empirical evidence is limited in this chapter to what emerged from the scoping surveys and from documentation provided by various agencies. None of the case studies explored curricular interventions. In practice little was heard of universalist curriculum interventions focused on changing ways of teaching and learning. There was however, a considerable array of interventions targeted at specific and vulnerable groups which sought to use different ways of teaching and learning. We speculate that smaller numbers make this possible, but also that the profound difficulties evident in some groups of children clearly demand a different approach of themselves. If traditional pedagogy is failing to engage young people then something else must be tried. In the cases cited in the report drama, storytelling and other forms of active learning were used to engage children and work actively towards the promotion of their mental health. Some of these were designed to explore with children how they might accept their inappropriate behaviour and 'normalise' it.

For the most part curriculum endeavours are focused on product, and most are carried within the school PSD curriculum. External agencies play a large part in delivering more innovative messages and materials on some of the difficult topics related to mental health issues, and interventions were offered both on and off school sites.