Will lessons in happiness solve the crisis in child mental health care?

bread and circussRome gave citizens bread and circuses. Is London giving citizens worthless randomized trials of inert interventions to solve the crisis of child mental health care without spending substantially more funds?

The UK  Department for Education (DfE) issued an Expression of Interest [ What’s that? ] for a large randomized trial comparing three preventive mental health interventions for promoting well-being among primary school children.

The three trialed interventions are:

Mindfulness

Mindfulness is the ability to direct attention to experience as it unfolds. It enables those who have learned it to be more able to be with their present experience, and respond more skilfully to whatever is happening. There is some evidence that it may be helpful in reducing anxiety, depressive symptoms and stress and improving wellbeing, attention, focus and cognitive skills.7 We know that mindfulness techniques are currently used by schools, with a range of existing programmes and approaches, but there is limited understanding of whether less intensive approaches work effectively in a school setting. The successful bidder will develop and trial a light touch (10-15 minute) intervention, comprising of simple exercises repeated at regular intervals (e.g. weekly or more than once a week) which provides teachers with materials to guide mindfulness practice e.g. audio tracks or guided exercises.

safety-net-PB-feeling-good-feeling-safe-resource-pack-a42Protective behaviours

Protective behaviours is a practical approach to personal safety, teaching children and young people to recognise early warning signs of not feeling safe and how to recognise where they can get help. It seeks to provide life skills, develop support structures and instil positive help seeking behaviours which can help keep children safe from a range of risks that may impact wellbeing and increase the risk of mental health problems. It is a well-established approach, with indications of ongoing use in schools, however evidence of effectiveness is limited. Some evidence suggests that it is beneficial for those at risk of mental health difficulties as well as the wider population, and it is relatively easy to integrate into the school environment. The successful bidder will develop and trial a light touch protective behaviours intervention which can easily be included in the school day, can be delivered by teachers/school staff to a whole class, with a small amount of training, and which builds on existing programmes and materials.

hands Relaxation and breathing-based techniques

Relaxation and breathing-based techniques and training for schools originated as targeted interventions to assist pupils with anxiety. However, there is emerging use of these approaches universally in primary schools, particularly in the form of short breathing exercises, with some reported increases in concentration, resilience, self-perception positivity and connection with others. There is currently limited evidence of wider use in schools or effectiveness, but there is a theoretical unpinning linking relaxation with improved wellbeing and engagement with learning. The successful bidder will develop and trial a light touch intervention that offers short regular exercises, delivered by teachers in the classroom with minimal training and materials, and which build on existing relation and breathing-based techniques.

Note that the requirement is that all three interventions be delivered in low intensity “light touch” versions, i.e, “easily be included in the school day, can be delivered by teachers/school staff to a whole class, with a small amount of training, and which builds on existing programmes and materials.”

The planned trial is ambitious and large-scale, involving:

  • Recruitment of 100 volunteer primary schools…representing a range of different school types, locations and demographics.
  • Even randomization of schools into one of three arms corresponding to the three interventions, with 33 schools in each arm.
  • Classes in each school evenly randomized to intervention or control group.
  • A small amount of funding would help cover costs of participation and to incentivise full engagement with the trial.:

Final selection of primary and secondary outcomes are left to applicants, but expected to include short measures of

  • Subjective Wellbeing
  • Mental health/psychological wellbeing
  • Engagement with education

The larger context

The expression of interest was a follow-up to “The Shared Society”, UK Prime Minister Theresa May’s recent speech at the Charity Commission. In that speech the Prime Minister identified “the burning injustice of mental illness” and stated:

“This is an historic opportunity to right a wrong, and give people deserving of compassion and support the attention and treatment they deserve. And for all of us to change the way we view mental illness so that striving to improve mental wellbeing is seen as just as natural, positive and good as striving to improve our physical wellbeing.”

However, the Independent noted:

The speech however barely announces any extra cash to improve underfunded services – with just an extra £15m expected to be pledged for creating “places of safety”. This amounts to about £23,000 per parliamentary constituency.

Research conducted by the Education Policy Institute Independent Commission on Children and Young People’s Mental Health in November found that a quarter of young people seeking mental health care are turned away by specialist services because of a lack of resources. Waiting times for treatment in many areas are also incredibly long.

The House of Commons Public Accounts Committee said in September that it was “sceptical” about the Government’s attempt to improve mental health services without a significant amount of extra cash.

Praise for the speech

Nonetheless, the Independent reported praise to the Prime Minister’s speech:

Paul Farmer, chief executive of Mind, the mental health charity, said it was good that the Prime Minister was talking about mental health.

“It’s important to see the Prime Minister talking about mental health and shows how far we have come in bringing the experiences of people with mental health problems up the political agenda,” he said.

“Mental health should be at the heart of government, and at the heart of society and communities – it’s been on the periphery for far too long.”

He said he welcomed the focus on prevention in schools and workplaces and support for people in crisis.

Sir Ian Cheshire, chairman of the Heads Together Campaign described the Prime Minister’s announcements as “extremely important and very welcome”.

“They show both a willingness to tackle the broad challenge of mental health support and a practical grasp of how to start making a real difference,” he said.

As I noted in another blog post, the Heads Together Campaign is an initiative of the Royals.

Paul Farmer, chief executive of Mind, the mental health charity, said it was good that the Prime Minister was talking about mental health.

“It’s important to see the Prime Minister talking about mental health and shows how far we have come in bringing the experiences of people with mental health problems up the political agenda,” he said.

“Mental health should be at the heart of government, and at the heart of society and communities – it’s been on the periphery for far too long.”

He said he welcomed the focus on prevention in schools and workplaces and support for people in crisis.

Sir Ian Cheshire, chairman of the Heads Together Campaign described the Prime Minister’s announcements as “extremely important and very welcome”.

“They show both a willingness to tackle the broad challenge of mental health support and a practical grasp of how to start making a real difference,” he said.

Praise for the interventions that were selected for evaluation

 An article in The Guardian reported praise for the interventions that were selected for evaluation:

Laura Henry, an early years consultant and Ofsted inspector, said the trials could save the government billions in social care and housing costs down the line. “I think it’s an excellent idea,” she said. “Over the last decade there has been a massive push to academia, results and school league tables and children’s personal social development has been left behind.

“A holistic approach is needed and children should be able to self-regulate their own behaviour.”

Henry, a former teacher whose elder son is on the autistic spectrum, said specially trained teachers should help with grieving techniques and that any questions about bullying and pupils’ friends needed to be sensitive.

“It’s absolutely the best way to spend DfE money,” she said. “It will save x amount of money in social care when they are adults.”

And:

The mindfulness trial was welcomed by the educational pioneer Sir Anthony Seldon, who was pooh-poohed when he brought in such classes while master of the private school Wellington College. He said: “It was negligent of government [in the past] to have this unintelligent response to wellbeing, saying this was la-la land and psychobabble. We have a crisis in mental health which is reducible now that government is beginning to take seriously the right interventions to look after the wellbeing of young people.”

Professor Alan Smithers, of the University of Buckingham, where Seldon is vice-chancellor, was more sceptical. He said: “It is good the government is having a trial and not rushing in. There are so many demands on resources for schools that it is important we know that mindfulness lessons work. “There are many calls on school funding: the need for teachers, the squeeze on budgets and school buildings.”

Lord Layard, Britain’s “happiness guru”, and Lord O’Donnell, the former cabinet secretary, will meet the government this month to discuss how to enable schools to measure children’s wellbeing as a guide to performance. They want schools to give similar weight to children’s happiness as to their academic results. Under their proposals, schools would be measured on whether pupils’ happiness improved or declined. Children would fill in a questionnaire asking, among other things, whether “I have at least one good friend”; “other people generally like me”; “other people pick on me or bully me”; and “I would rather be alone than with others”.

Pupils’ scores would be confidential, but could be used to alert the school to serious difficulties. NHS workers would provide psychological treatment to children in schools at short notice before they became so ill that they qualified for admission to mental health services.

The interventions are unlikely to improve mental health comes, even self-reported well-being, and may prove harmful.

I dare you to be positive Tssk! The UK has some talented mental health services researchers. Why aren’t we hearing their collective voices of outrage about a useless trial squandering millions of pounds, potentially harming schools and students, and mainly serving to distract from the government’s lack of action to correct the underfunding of both mental health care for children and the school systems?

Instead, we have some self-proclaimed authorities waxing enthusiastically. As a group, they are lacking in mental health training and serve to benefit immensely from these initiatives. Journalists should get them out of the picture or at least better reveal the conflicts of interest and balance their commentary with comments that are more evidence driven.

Even when delivered with full intensity, the interventions lack evidence of effectiveness needed to justify a large-scale trial. Yet The Expression of Interest specifies that they be delivered in a lite form – only a few minutes a week . This is Unlikely to improve the measured outcomes or impact on effective use of already scarce child mental health services with an acceptably long wait times.

Funding the trial is a poor substitute for better funding for mental health services and schools. Yet politicians and policymakers can point to them and argue that the UK is conducting the research desperately needed to address these issues and so we need to be patient.

I’m not sure we should consider these trials as serious attempts to contribute to the mental health services literature. Selection of the particular interventions to be trialed seems to be political and tied to what is already being done in some schools. Their existing implementation likely reflects vested interests that undoubtedly influenced the selection for trialing and hope to benefit financially from the opportunities it will provide. I don’t think that the mere fact that interventions are already in use justifies an ambitious and expensive evaluation of them unless there is further evidence that they are likely to be effective.

The Expression of Interest cites one review of mindfulness studies. I looked it up and it is unusually candid in indicating the limitations in quality and quantity of relevant studies that mindfulness training can affect such outcomes. The review stands in sharp contrast to the unbalanced and prematurely enthusiastic Mindful Nation UK report.

We should have serious concerns about the lack of evidence that Protective Behaviours could have any effect on the outcomes selected to evaluate the programs. Conceivably, it could do some harm to at risk children. Getting children to disclose bullying and frank abuse at home and school can only aggravate these problem and invite retaliation if effective intervention is not available to address these problems. I would be curious to know the extent to which primary school teachers are already aware of such problems but lack the tools or time to address them.

Basically, Protective Behaviours is a kind of screening program facilitated by encouragement to disclosed. Such programs can prove ineffective if they do not occur in a system prepared to quickly offer affective interventions. Such screening programs can compete for scarce resources that would otherwise be used to deal with already known problems requiring more intensive and focused intervention.

There is the precedent of GPs screening women for domestic abuse. Routine screening seemed to address a documented ignoring of the problem. However, the World Health Organization (WHO) withdrew the recommendation because of lack of any evidence that improved health outcomes for women and summoned consistent evidence that at least some women were harmed by ineffectual interventions that heighten the abuse that they were receiving.

The breathing and relaxation exercises might conceivably be a nonspecific control condition, except that all of the inventions are untried, lacking in evidence, and delivered in such a low intensity that they themselves are best nonspecific control conditions. I think it’s inconceivable that meaningful differences will be demonstrated among the three interventions. At best, the trials can conclude that they are equally effective or not effective at all. The question whether these interventions are better than other active interventions or other deployments of scarce resources left unaddressed.

eBook_PositivePsychology_345x550I will soon be offering e-books providing skeptical looks at mindfulness and positive psychology, as well as scientific writing courses on the web as I have been doing face-to-face for almost a decade.

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