Improving mental health in schools – what works?

The need for improved mental health support in schools is greater than ever. 2023 figures from NHS England show that one in five young people in the UK has a probable mental health disorder and, since 2018, the number of children and young people in contact with mental health services has more than doubled in England.

The pandemic had a uniquely disruptive impact on young lives, with research indicating higher levels of depression and social, emotional and behavioural difficulties in secondary school children than before the pandemic hit. The long-term impact of Covid-19 is, in part, reflected by increasing rates of school non-attendance. Many other factors – including rising rates of poverty, social media use, racism, pressures at school, climate anxiety and global political upheaval – are also dramatically reshaping young lives. 

Back in 2018, way before any of us had heard of Covid-19, I set out with colleagues across Anna Freud and University College London (UCL) to find out how best to improve the mental health and wellbeing of children and young people in school. Seven years on, we can finally share these results. 

Our aim is to equip those who impact children and young people's lives the most, with the knowledge and skills to support their mental health, always guided by the latest science and lived experience. We knew that schools were committed to supporting the mental health and wellbeing of students but lacked clear guidance, particularly on curriculum-based approaches for supporting all students. Through the study, we set out to provide – for the first time – robust evidence on a range of universal interventions for schools, giving school staff more confidence in their approach to mental health. 

Funded by the Department of Education (DfE), the trial – Education for Wellbeing – was extensive and, out of my 22 years in research, is the most ambitious in terms of its scale and scope that I've worked on. It involved testing five different universal mental health interventions with over 30,000 students in more than 500 primary and secondary schools in England, making it one of the world's largest ever trials of its kind.

The study has also meant a lot to me personally over the years. My twins were six years old when it launched, and they are now 13. Watching them navigate this period of their life has been a vivid reminder that primary and secondary school are years of growth and change that can deal out both joys and challenges. Along with the achievements and celebrations, sometimes some extra help or guidance from home and school is important for children to navigate these times more smoothly.

The growing need for early support

When mental health issues go unsupported, they can become entrenched. Ensuring young people have access to the right support at the right time is vital so early intervention and prevention. Not only does this prevent problems escalating or developing in the first place, it eases pressure on specialist services and even boosts the economy.  Research consistently shows the economic benefits of investing in prevention through public health programmes, with a report recently revealing an extra year of good health through prevention costs an estimated £3,800, compared to £13,500 from treatment.

As a place children and young people spend a significant amount of time, schools have an incredibly important role to play in building their wellbeing. Through Education for Wellbeing, we were curious to see how universal mental health interventions could fit into this picture, including whether they could be used by schools as tools to protect students against mental ill health, and to what extent.  

The interventions

The study tested five approaches through two separate trials; AWARE and INSPIRE.

INSPIRE investigated three interventions in primary and secondary schools aimed at improving pupils' wellbeing:

• Strategies for Safety and Wellbeing, which was designed to help students normalise everyday emotions, like stress and sadness, better understand how to differentiate them from mental ill health and know where to access support if needed. The approach, which consists of eight 45-minute sessions, draws on techniques already used by schools but provides structured and comprehensive guidance to support staff in delivering these messages.
• Mindfulness Exercises, which involved training teachers to deliver daily five-minute mindfulness sessions in class. This consisted of activities that focus on the body, the mind and the environment to encourage pupils to be more present in the moment.
• Relaxation Techniques, which saw teachers trained to deliver daily five-minute relaxation-based sessions. This involved deep breathing and muscle relaxation exercises.

AWARE implemented and evaluate two mental health interventions with year 9 pupils:

• Youth Aware of Mental Health (YAM), which was delivered in schools by external mental health professionals. Originally developed in Sweden and the USA, YAM was adapted for English schools and involves a structured programme of five sessions involving group discussions and role plays.
• The Guide, which was delivered in schools by trained teachers. Developed in Canada and having been successfully implemented in other countries, it aims to increase mental health literacy in pupils and staff and consists of six sessions delivered by trained teachers.

The results of the interventions

At the start of the trial, we really hoped we'd be eventually able to recommend at least some of the interventions to schools and also offer valuable insights about how best to implement them using learnings from the study.

After analysing the results, we were pleased to see that the three interventions trialled through INSPIRE – when implemented consistently and frequently – showed promise for use in schools. However, it was also striking that Mindfulness Techniques and Relaxations Techniques, along with the interventions trialled through AWARE, had some negative impacts on certain groups of students. 

Here are some key takeaways from the results. 

1. The way we have conversations about mental health in schools is important

According to the findings, the most promising intervention is Strategies for Safety and Wellbeing.

The approach emphasises normalising everyday emotions and helping children understand when challenges might be considered mental health problems, along with where to find support. 

Along with how conversations about mental health are framed, it's crucial that wider support structures are in place. One of the mental health awareness interventions trialled, YAM, led to higher levels of emotional difficulties at schools where there were lower levels of similar pre-existing mental health support, compared to schools with more prior provision. This suggests students were more aware of mental health challenges but lacked anywhere to access help.   

2. Interventions need to be age-appropriate 

Some interventions only showed promise when delivered to certain age groups. The results suggest that five-minutes of relaxation a day can reduce emotional difficulties - when delivered frequently and consistently – in primary schools, but not in secondary schools, where there was evidence of emotional difficulties increasing.

The study had similar results for Mindfulness Exercises but in reverse, with the intervention – when delivered frequently – reducing emotional difficulties in secondary schools and increasing them in primary schools.

3. Some groups may be more likely to benefit or be harmed by approaches

Relaxation Techniques particularly benefitted children from minoritised ethnic groups compared with those from white groups. While the study doesn't tell us why this might be, it's important teachers and school leaders consider what intervention would work best for their setting and gather feedback from different groups of students, including those who might be particularly vulnerable

4. Implementation matters

Levels of implementation – or how frequently and consistently interventions were delivered – had a significant impact on whether students experienced any benefits.

In secondary schools, the overall impact of Strategies for Safety and Wellbeing on mental health literacy was not significant, but when  delivered in full, it led to significant increases in mental health literacy. In fact, extent of implementation impacted almost all of the results. 

School staff – who we know are stretched - should carefully consider whether there is capacity to fully implement these sorts of approaches before introducing them. Appreciating how much mental health challenges impact the school day, having resources to help staff cope with these problems are vital, so hopefully these findings will ultimately ease pressure on staff.

5. Universal interventions need to be part of a bigger picture

The results demonstrate that universal approaches to mental health and wellbeing can benefit students, but the impact of these interventions alone is small.

To create real change, universal approaches to mental health should be part of a wider, whole-school approach to mental health and wellbeing. This involves building supportive relationships and a sense of belonging across the whole school community, as well as ensuring more targeted support for those that need it.

Moving forward

Schools have a critical role to play in the wellbeing of children and young people and, with the right tools, can even help to prevent the emergence or escalation of mental health challenges. With results from this landmark study, staff now have much-needed guidance to support them in building the mental health and wellbeing of students.

While always well-intentioned, it's now clear that, while universal mental health interventions can bring benefits, they can also cause harm so choosing something evidence-based and age-appropriate is key, as is monitoring the impact. 

To find out more about our study, head to Education for Wellbeing to access the results.

• See also our 'Covid-19: Psychological perspectives' collection.