Guidance
Rationale and impact
Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice or services.
Whole-school approach
Recommendations 1.1.1 to 1.1.22
Why the committee made the recommendations
The committee agreed that the inclusion health agenda (for example, see the Office for Health Improvement and Disparities [previously Public Health England] inclusion health: applying all our health) and tackling inequalities were central to this guideline. When implementing the guideline, schools and wider system partners would need to pay particular attention to marginalised or excluded groups, both in terms of their involvement and in terms of tailoring the recommendations to meet the needs of those groups. The committee made special consideration of the needs of children and young people with learning difficulties and special educational needs and disabilities (SEND). They agreed to place neurodiversity at the heart of their considerations and received expert testimony on the topic to inform their discussions. Professionals from special schools were represented on the committee, and the focus group work with children and young people that NICE commissioned included people from schools with high rates of SEND and from special schools and pupil referral units.
The committee discussed the benefits of implementing a whole-school approach for children and young people's social, emotional and mental wellbeing, including preventing the onset of poor outcomes and supporting those with identified needs. They agreed that this could have implications far beyond school environments, for example on employability and anti-social behaviours. The quantitative studies included various whole-school approaches with different combinations of components and various aims, although the strongest evidence was about bullying. They showed some benefit and no harms or adverse consequences. The qualitative evidence showed that pupils and teachers valued whole-school approaches and believed that they had a positive effect on school culture. Overall, the committee agreed that there was some evidence to support the effectiveness of whole-school approaches. There was evidence about the acceptability of whole-school approaches and what made them more or less likely to work, and the committee had more confidence in the findings from these studies than the quantitative ones. This evidence was supported by their expertise and experience and by the testimony of invited expert witnesses.
The committee heard expert testimony about relational approaches being more effective than using purely punitive behaviour management systems for managing social, emotional and mental wellbeing in children and young people. Together with this and their own experience and expertise, they agreed that embedding a relational approach in the overall culture and ethos of the school was the basis of a successful whole-school approach, and this would need to be reflected consistently in school policies and procedures. Reviewing policies regularly would help to ensure that this happens. Although the committee were not able to set a specific timeframe for review because there was no evidence, they agreed that annually would be reasonable. They also agreed that leadership was key to embedding this approach and that the leadership needed to come from a senior person. They discussed that this might fit well with the role of the designated school mental health lead. However, because this is a developing role, they agreed it would be premature to specify this. Additionally, having heard expert testimony about trauma-informed approaches in schools, the committee encouraged a shift towards these approaches to understand and therefore manage behaviour.
The committee regarded the whole-school approach as a framework that other interventions can slot into. They noted that interventions such as targeted support have a better chance of success if schools actively engage with local agencies. They also agreed that, to be effective, a whole-school approach needed monitoring and evaluating to make sure the approach was working.
The committee also noted that it would be more useful if future research focused on the effective components of interventions or approaches (see the recommendation for research on effectiveness of interventions).
Supporting the whole-school approach
The committee agreed that school leader support and governance was crucial for a whole-school approach to work and that the whole-school approach needed ongoing engagement with school staff, parents and carers, and the wider community. An effective whole-school approach would also lead to improved integration with external agencies, including mental health services and local public health departments. This is essential to ensure that schools can play an active role in decision making on the local transformation plan for children and young people's mental health.
The committee agreed on the importance of collaboration between schools and other services that were not school based but that had an impact on children and young people's social, emotional and mental wellbeing. They noted that, in their experience, schools did not always have mechanisms in place for working with key local services. They agreed that further research was needed to explore how agencies could work together (see the recommendation for research on system leadership and service delivery).
Supporting staff
The committee discussed the key role of staff in the whole-school approach. They agreed that staff needed to feel supported in their own wellbeing to be able to create an environment that fostered wellbeing in children and young people. Ways to do this include continuing professional development and formal and informal support.
Staff need to be able to recognise the pastoral needs of the children and young people they work with, and to understand how these are influenced by their wider life experiences. This can help them to relate better to the child or young person, and to other people who may be involved in their care. Understanding behaviour as a means of communication could help with this. They identified that staff need time and support for pastoral training.
The committee noted that there are national and local resources that staff can use to help them manage their own wellbeing. The resources can also help staff keep up to date with local agencies that could help with children and young people's mental health through the early help offer.
Involving families and pupils
The evidence supported the committee's view that the school's communication with parents, carers and families is important. The committee agreed that the whole‑school approach worked better if parents, carers and families were involved with the planning of it.
Focus group research commissioned by NICE to explore children and young people's perspectives on the draft recommendations identified several important ways of successfully implementing whole-school approaches. Based on the findings of the focus groups, the committee recognised the importance of involving children and young people and capturing their views when agreeing on approaches, including views from minority and seldom-heard groups.
This focus group research also identified the importance of effective communication between school staff and children and young people. The committee recognised the need for excellent communication channels between these groups when implementing universal interventions. They also highlighted the importance of taking into account children and young people's views, how much time there was in the curriculum and resourcing, teacher understanding of the interventions and parental engagement for the successful implementation of universal interventions. These factors were identified from the evidence base and the committee's own experiences.
Implementing the whole-school approach
The committee discussed the challenges of implementing a whole-school approach. Based on the expert testimony they had heard and on their own expertise and experience in setting up, supporting and evaluating whole-school approaches, they agreed that there were key things they could recommend that would make the implementation smoother. This included the importance of creating a school environment that was a safe space for both teachers and children and young people and where they would not be punished or penalised for mistakes or for speaking up. Also, after hearing from experts, the committee highlighted the significance of core values and strong leadership when implementing a relational whole-school approach.
The committee agreed that if the universal curriculum was managed and planned by a specific person it would be better coordinated across the school and could be kept up to date more easily. This person would need to be a senior leader who was able to influence school policy. This coordination could also lead to a more streamlined approach to moving children and young people into and out of targeted interventions (a graduated or 'step up–step down' approach) when universal content was not meeting their social, emotional and mental wellbeing needs.
Local support
The committee discussed how the whole-school approach could be influenced by the wider local and national context. They agreed that local authorities, especially local public health teams and children and young people's mental health services, had a responsibility to respond to broader needs that schools identified and engage with schools and colleges. Local authorities and health partners also needed to consider the risk factors for poor social, emotional and mental wellbeing when gathering and analysing health data and planning the local response, for example through the Joint Strategic Needs Assessment.
The committee noted that schools often found it difficult to understand what was on offer locally that could support their children and young people, for example occupational therapy or speech and language therapy. Even if they knew about the services, they might not know how to refer children and young people into them. The committee agreed that local authorities and care systems would be best placed to address this.
How the recommendations might affect practice
The recommendations reinforce current best practice. They are based on existing processes that most, if not all, schools should be following. However, the committee recognised that adopting and maintaining a whole-school approach needs significant additional time, ongoing leadership and dedicated resourcing. For example, school staff may need more protected time to engage with pupils and local agencies and to undertake relevant training. This could partly be delivered as part of a school's ongoing continuing professional development, for example in inset days.
Universal curriculum content
Recommendations 1.2.1 to 1.2.8
Why the committee made the recommendations
The committee looked at a substantial amount of evidence about the effectiveness of universal curriculum-content interventions to improve social, emotional and mental wellbeing in primary and secondary education. Although they noted that much of the evidence was limited in terms of the confidence they could have in its findings, it supported their experience that universal curriculum-content interventions help promote the skills needed for good social, emotional and mental wellbeing. It also supported statutory guidance about what should be covered in the universal curriculum. They also considered a smaller amount of qualitative data of mixed quality. Because the qualitative evidence was from only a few studies and its findings were not useful for making recommendations, it was used only to contextualise the recommendations rather than to provide a basis for them.
The committee agreed that lessons from universal curriculum content should be cumulative and should be integrated into other school subjects and activities to consolidate children and young people's understanding.
The committee also agreed that using a 'strengths-based' approach to support children and young people's social, emotional and mental wellbeing would help to remove the fear of failure and would bring a focus on providing skills that children and young people would be able to use in the future.
Some evidence also showed that mindfulness interventions had benefits in developing social, emotional and mental skills in both primary and secondary school children and young people, and for academic outcomes in secondary school pupils. Cognitive behavioural approaches increased social and emotional skills and reduced anxiety in primary school children. However, the committee noted that trauma-focused cognitive behavioural approaches may be more appropriate for children and young people who have previously experienced trauma.
Evidence from expert testimony highlighted the value of regular rhythmic physical activity, such as running, bouncing or cross-training, in helping children and young people manage their social, emotional and mental wellbeing. They agreed that these interventions would be most useful in schools where there was a good fit with the whole-school approach.
Social connectedness was highlighted by the committee as a key factor for good social, emotional and mental wellbeing in children and young people in the context of the COVID-19 pandemic. The committee agreed that this encouraged the use of support by both peers and trusted adults.
How the recommendations might affect practice
The recommendations reinforce current best practice because they are based on existing processes that schools should generally be following, such as using a spiral curriculum and promoting the spiritual, moral, cultural, mental and physical development of pupils. There may be an impact on financial resources and day‑to‑day staffing for the training and peer support needed to deliver these interventions, but this may be partly covered as part of the staff's continuing professional development programme.
Additional time may be needed to establish good communication channels between staff and pupils, to help pupils and the trusted adult develop their relationship and to train teachers on the benefits of interventions.
Identifying children and young people at risk of poor social, emotional and mental wellbeing
Recommendations 1.3.1 to 1.3.6
Why the committee made the recommendations
Identification and risk factors
The committee looked at a substantial amount of quantitative evidence on several potential risk factors for poor social, emotional and mental wellbeing in primary and secondary education. They agreed that most of the evidence was of reasonable quality. They recognised that many of the individual risk factors could indicate other underlying causes such as unidentified or unmet educational needs. They also considered qualitative evidence from a single study. However, they did not believe that this evidence was strong enough to base recommendations on it.
The committee highlighted that the cumulative effect and interactions of multiple risk and protective factors were a much better indicator of poor social, emotional and mental wellbeing than single factors, and that the presence of a single risk factor did not in itself indicate poor social, emotional and mental wellbeing. They agreed that assessment needed to be based on both the number and the complexity of the risk factors, and that evidence needed to be gathered from a wide variety of sources. They agreed that it was unclear how interactions between various social and personal factors contributed to that cumulative effect (see the recommendation for research on intersecting social, cultural and personal factors).
Evidence also showed that adverse childhood experiences are a key factor associated with increased prevalence of poor social, emotional and mental wellbeing. The committee agreed that although the presence of 1 or 2 adverse childhood events should not be seen as a pre-determined risk for poor social, emotional and mental wellbeing, it was a sign that assessment was needed to decide whether to intervene or to monitor the child or young person's wellbeing. The committee recognised that children and young people with neurodiverse conditions (such as autism or attention deficit hyperactivity disorder) and those with special educational needs or disabilities were key populations. Therefore, it was important to take their individual needs into account and to engage with relevant agencies. They noted a lack of evidence about whether children and young people with special educational needs were at a higher risk of poor social, emotional and mental wellbeing and made a recommendation for research about this (see the section on other recommendations for research).
The committee agreed that an exhaustive list of risk and protective factors was not available, but that the Department for Education's guidance on mental health and behaviour in schools made a good start. They noted that it was last updated in 2018 and therefore did not include the effects of COVID-19 as a risk factor (at the time of publication of this guideline).
From their expertise and experience, the committee stated that lack of awareness and training for staff members was a key barrier to identifying children and young people at risk. They agreed that staff needed to be aware of how poor social, emotional and mental wellbeing may present so that they are able to identify issues. They also need to be aware that sometimes these issues can mask unrecognised special educational needs and it is important to understand how to respond to this. The committee noted that much of this is set out in statutory guidance.
They recognised that further research is needed into how poor social, emotional and mental wellbeing can be identified in children and young people, especially those who internalise their distress, and what the barriers are to school staff recognising it (see the recommendation for research on early signs of poor social, emotional and mental wellbeing). They discussed the impact of the COVID-19 pandemic on children and young people's social, emotional and mental wellbeing and agreed that the medium- to long-term effects of this are not yet clear, but need to be investigated (see the section on other recommendations for research).
Tools and techniques
The committee saw evidence from 1 study about tools for assessing social, emotional and mental wellbeing in children and young people, but it was not directly relevant to this guideline. However, they agreed that as a committee they had substantial expertise and experience in this area. On this basis, although they could not recommend specific tools because of a lack of evidence, they identified important factors that should be considered when selecting a tool. Staff need to be clear on what it is they are aiming to assess, because different tools measure different aspects of wellbeing. Tools are context specific and their appropriateness will be determined by situational factors, such as the chronological or developmental age of the child or young person. The committee also agreed that it was preferable to use validated tools, although they recognised that sometimes that may not be possible.
How the recommendations might affect practice
School-based practitioners routinely undertake many of these tasks and monitor children and young people's risk factors as part of their pastoral role. However, there may be an increase in the number of children and young people being observed, assessed and offered interventions. This may have cost implications if the extra workload falls on school staff. The committee agreed that many of the tasks will be part of the already planned rollout of the mental health support team and educational mental health practitioners. However, it should be noted that currently there are only plans for mental health support teams to reach 25% of the country and no commitment or resourcing to extend this beyond 2023/2024.
Although school-based professionals are likely to have some awareness of poor social, emotional and mental wellbeing, there may be costs to train staff on identifying it, and on using trauma-informed approaches.
Targeted support
Recommendations 1.4.1 to 1.4.8
Why the committee made the recommendations
The committee discussed evidence on delivering targeted support for children and young people in secondary and further education who have been identified as needing mental health support (for example, because of symptoms of depression or anxiety). The committee had low confidence in the findings of the quantitative evidence, even though there were quite a lot of studies.
There was some better evidence from qualitative studies about the acceptability of targeted support, and the committee had more confidence in these findings. These studies included individual or group interventions that were delivered by school specialists (such as school counsellors) or external specialists (such as psychologists). Interventions lasted an average of 8 to 12 weeks. This evidence showed that targeted individual or group interventions were effective at reducing emotional distress and could also prevent a first diagnosis of depression. The committee therefore agreed that these were appropriate for pupils identified as needing social, emotional and mental health support. They agreed that although the evidence was from secondary schools, it was also likely to be relevant to primary settings. They were unable to assess from the evidence the comparative effectiveness of group and individual interventions on mental health. Nor were they able to assess the long-term impacts of these interventions or how they varied by population characteristics (see the recommendation for research on targeted support) or their potential harms and unintended consequences (see the other recommendation for research section on harms and unintended consequences).
The studies used varying criteria to determine whether a pupil would need targeted support, for example if they had symptoms of depression or anxiety based on clinical assessment or assessment tools. In practice, pupils are often identified by their externalising behaviours, and those with internalising behaviours can often be missed. The committee agreed that it is important to base referrals for targeted support on individual needs and to have clear guidance about this.
The evidence supported the committee's view that communication between schools and parents, carers and families is important for the success of targeted interventions. Families and parents or carers can influence their child's social, emotional and mental health behaviours, so the committee considered it was important that the school engages with parents and carers when considering targeted support. They agreed that further research could clarify what was important to parents in this regard (see other recommendations for research section on targeted support).
Specialists who provide targeted social, emotional or mental health support may be employed by the school or be external. The committee agreed that it is the school's responsibility to ensure that specialists have the relevant training and experience. They were also aware of existing advice on using counsellors in schools (see the Department for Education's guidance on counselling in schools: a blueprint for the future).
The committee were clear that for targeted support to be successful the pupil needs to be engaged and involved. They discussed the importance of getting their agreement (or that of their families and carers), not only because this is good practice, but also to help the pupil feel involved in the process.
The evidence suggested that when planning targeted support, it is important to consider any potential unintended consequences of the support. This supported the committee's view that care needs to be taken to avoid negative labelling or stigmatising pupils when selecting them for targeted support. For example, if a pupil is known to leave lessons for a counselling session, classmates or teachers might treat them differently and they could be at increased risk of bullying. They may become withdrawn or defiant as a result and increase the behaviour that the intervention is intended to address.
The evidence also highlighted that a group intervention may normalise undesirable behaviours. For example, groups that include pupils who are part of an existing friendship group known for behaviours that challenge may be difficult to work with. This is because of the potential for friendship status and 'membership rights' in the group to be a priority for the pupils rather than working to improve their social, emotional and mental health. The committee agreed that other factors such as developmental age and cultural background were also important to take into account when planning the membership of group interventions.
Focus group research commissioned by NICE to explore children and young people's perspectives on the draft recommendations identified the importance of peer-to-peer support. However, the committee recognised the need to offer a range of support (including peer-to-peer support). This was because evidence in the wider literature on peer-to-peer support indicates that there is a danger that it can perpetuate bullying. Furthermore, the committee highlighted the importance of environment when delivering targeted interventions, because children and young people need to feel safe and comfortable to talk through difficult feelings.
How the recommendations might affect practice
The recommendations reinforce current best practice. They are based on existing processes that all schools should be following, so they are unlikely to have a considerable resource impact.
Time and money may be needed to set up suitable environments for delivering interventions. Training and time may also be needed to ensure that school staff are able to monitor children and young people's wellbeing for signs of adverse reactions to receiving targeted support.