Even before lockdown, children’s mental health was a growing concern. This email aims to support headteachers as they think through what implications there are for Primary’s.
Even before lockdown, children’s mental health was a growing concern. This email aims to support headteachers as they think through what implications there are for Primary’s. Pre-lockdown context Despite the very low base (from 0.6% in 1995 to 6% in 2014), there was a 10-fold increase in long-standing mental health conditions for 16-24-year-olds.
Pre-lockdown context
Despite the very low base (from 0.6% in 1995 to 6% in 2014), there was a 10-fold increase in long-standing mental health conditions for 16-24-year-olds. Reasons for this ranged from greater awareness and less stigma of mental health issues; greater school pressure; social media and cyberbullying, through to austerity-related cuts and increased numbers of children in poverty (1). While the study looked at children and young people aged 4 to 24, this 10-fold increase for 16-26-year-olds stole most of the attention.
A National Education Union poll of school and college staff in the same year, found a dramatic increase in self-harming, suicidal thoughts, and “mental health issues” as a result of “exam stress and pressure” (2). The NSPCC (3) reported a rise of a third in three years (2015 to 2018), of schools making referrals to CAMHS. 2018 also saw the NHS (4) publish data on mental health disorders in children and young people (replacing a similar data set of 2004). Fourteen-point-four-percent of 11-16-year-olds, and 16.9% of 17-19 years olds, were reported as having “a mental disorder”.
By the time the Children’s Commissioner was publishing her Annual Report ‘The State of Children’s Mental Health Services’ in January of this year (5), the mismatch between young people demand and CAMHS supply, was very loud, with long waiting times for assessment, and slow response for treatment, resulting in her warning of “a chasm between the current levels of NHS services and what children need”.
Compounded by lockdown
Then along came COVID-19, followed by lockdown, on top of a groundswell of concern and worry about young peoples mental health, so its no surprise that talk of a crisis and emergency are being bandied around (6).
Children under 11 were part of these reports and studies, but the headlines were, not surprisingly, with the bigger numbers, and older children.
The under-11’s picture
In 2017 (4) 9.5% of 5-10-year-olds were diagnosed with a disorder (from 8.7% in 1999), with the increase probably as a result of more assessments. A closer look at the mental health statistics tell us that more than half of the diagnosed disorders for 5-10-year-olds are behaviour-based, and boy-leaning (ADHD and ODD), and many of the others are emotionally–based conditions (mostly anxiety), and girl-leaning. These will be children who are known to your SENCO. With the highest estimates of “mental health” problems for 5-10-year-olds being 1 in 10, this translates to an average of 3 per class.
Of course, the larger numbers in older groups are still significant for Primary’s, especially in terms of what can be done to prevent them (more of that later).
Terms do not mean what some people want them to!
Unfortunately, too often terms such as depression, trauma, anxiety, mental health and mental illness are used interchangeably, and sometimes too loosely. All of these terms have definitions (although not always commonly agreed). So, for example, the DSM-5 definition of trauma (7) requires “actual or threatened death, serious injury, or sexual violence. Stressful events not involving an immediate threat to life or physical injury such as psychosocial stressors (e.g., divorce or job loss) are not considered trauma in this definition”. While this is seen as a narrow definition (8), the language/definition problems only start here. The terms trauma, traumatic and traumatised, are increasingly being used to describe children and their experience, and used as if they inevitably follow each other. Some people can experience trauma, but not find it traumatic, and not be traumatised. Some people can experience trauma, find it traumatic, but not be traumatised (see more below). Having an off day, is not depression, having a few off days does not make it chronic depression!!! Description is critical if we are to address the issues appropriately.
Headline tendencies
The headline tendency is driving a post-lockdown loud and exaggerated language. So, for example, the NSPCC website (9) headlines “depression, anxiety and mental health. If you are worried a child may be struggling with their mental health or has anxiety about coronavirus, we’ve got advice to help you support them”, but by the time you get to the advice it has toned down to suggestions such as “talk about feelings and worries”.
In contrast, the Maudsley (10) has a site where the language is of a different tone, that aims to advise "families under pressure" and the language used is much more measured, and asks, are you “worried about yourself or someone else” and has lots of practical suggestions about “difficult behaviour” “negative emotions” “keeping positive and motivated” and generally offers “tips”. They pitch the solutions, at the problem, without shouting. We might have a problem, but we don’t have a drama.
Language gear-change does not help
We seem to be suffering a generally loud and dramatic language gear-change. Before lockdown, there were two year 5 children talking (loudly) in the playground, one said to the other “I had a complete mental breakdown last night, in my room”, when I asked more, this translated to mean her mum said she had to do her homework before she could speak to her friends, and she sulked in her room. Even for many teachers awesome, fantastic and incredible have replaced good, satisfactory and adequate. Maybe those particular three needed replacing, but extremes mean that children, parents and some professional now talk about trauma, when they mean a bit anxious, a pandemic when they mean it is on the increase. Exaggeration has become the new normal, to enable it to stand out, and if we shout it, even more so.
Language gear-change does not help
This exaggeration does not end in the playground, but increasingly in surveys and “research”. Over the last two years there have been several studies looking at children’s/young people’s mental health, and what was asked, unsurprisingly reflects what came back. A current “study” from Sing Up (11) looking at “young people with mental health and wellbeing needs”, in an online questionnaire for those working in primary and secondary schools asks “from your daily experience, do you feel that there is a growing incidence of children and young people with mental health and wellbeing needs?” Anyone who has had a research methods module (even lecture), would pull this apart in terms of rigour, and even focus, and this loose language moves through each stage that follows. The Young Minds study mentioned above (6) had a sample of 1,854 parents or carers (745 had children who had received mental health support in the previous 3 months), and the first conclusion was that “Most respondents (in fact it was 67%, but we won’t stop there), we're concerned about the long-term impact of the coronavirus on their child's mental health". Wouldn’t you expect that to be the case? The surprise is that it wasn't more, but surely this is a “do you like ice cream on a hot summers day?” type of question. Aren’t we all concerned about the long-term impact of coronavirus, on pretty much everything? This might be one of those, where you decide on your answer, and then find a question to fit.
While I haven't been systematic in any way, if this is reflective of "research", headlines, and loose language, it will be hard to rely on any data emerging that is not hard numbers.
So, what do Primary Schools need to be addressing?
Deal with what we see and call what we see - let us make sure headlines and drama, do not drive what we do. If we have a spike of children who are anxious about returning to school, we have some anxious, but not traumatised children. If we have some anxious parents, we are more likely to have anxious children, who will not be “scarred for life" as a result of the lockdown.
Prevention and early intervention - the rising numbers in the older age groups raise important questions about how we might identify and prevent these conditions and issues, while children are still in Primary. Children are generally showing enough for us to know that small problems are likely to get bigger, rather than disappear through maturity. An over-physical boy at 4, maybe a much bigger physical boy at 14, best addressed when he is 4, than wait?
Acknowledge that no two people experienced the lockdown in the same way - garden, family, economics, and access significantly altered the way that the lockdown was experienced, but the way that this was then internalised by children, will not be the same. Even two children in the same family, will have internalised the lockdown experience in different ways.
Research in Northern Ireland and Palestine during the "troubles" and the "intifada’s" where children experienced low-level and on-going war (12), some were traumatised, others took it in their stride, suggesting it was an underlying ability to deal with traumatic environments, and not the environment itself.
How children deal with different types of stress – a model that helps us understand how children will react to different types of experiences (emotionally and academically), will help us support individual children.
The Centre on the Developing Child (13) illustrates this by suggesting there are three levels of stress, positive, tolerable, and toxic, that impact on children’s brains in different ways. “Positive stress (such as meeting new people, doing new things), helps children develop their stress response system. Tolerable stress (one-off, and not too serious accidents, illness of a family member, family arguments), coupled with "supportive relationship of an adult" will lead to their stress response system bringing their stress levels down again. Toxic stress “refers to strong, frequent, or prolonged activation of the body’s stress management system. Stressful events, that are chronic, uncontrollable, and/or experienced” without the support of a caring adult are more likely to lead to a toxic stress response. “In the extreme, such as severe, chronic abuse, especially during early, sensitive periods of brain development, the regions of the brain involved in fear, anxiety, and impulsive responses may overproduce neural connections while those regions dedicated to reasoning, planning, and behavioural control may produce fewer neural connections”. They go on to suggest “this wear and tear increases the risk of stress-related physical and mental illness later in life.”
So the development and maintenance of a "stress response system" will, to a large extent, determine how well children deal with lockdown and their return to school, and a whole host of emotional and academic challenges. Translated, this means that most of those that left school on the 20th March, are likely to return, and with some reminders of structure, routines and new rules should adapt quickly and easily.
In contrast, those that struggled before lockdown are much more at risk of going backwards and coming back to school less able to deal with the return and the new structure, routines and rules. Not unlike the Summer break, but more so (evidence that the six weeks break often leads to academic and social and emotional steps backwards (14)).
There will be behaviour challenges, but that there will be very few that are surprises to you and their teachers, and they are likely to be on your SENCOs radar. So we are not talking about a pandemic, or tsunami of behaviour problems, but more a ripple, or small wave.
Some additional issues - as outlined in my previous email (15), screen use; heightened emotions; restricted social contact, the loss of learning and school habits, and excess physical energy are all areas that may impact as a result of lockdown, and these will need to be contained, and managed, but trauma and mental illness are only likely to be an issue, if they were before the 20th March,
By Trefor Lloyd.