Neil Humphrey – Addressing mental health difficulties among students with disabilities


(audience applauds) Morning, everyone.
– Morning. Right, I’m going to
start with a compliment. (audience laughs) So this is to all of
you, and it’s genuine. I’ve never been made to feel more welcome at a conference or an event
where I’ve been overseas than I have while I’ve been in Australia. It’s been absolutely fantastic,
so thank you to everybody. Everybody’s been so friendly,
been well looked after. You know, people have just wanted to chat. It’s absolutely fantastic,
so thank you to all of you for making me feel so welcome. (audience applauds) That’s just to get you
on my side for the rest of the presentation.
(audience laughs) So I’m going to talk to you about addressing mental health difficulties among students with disabilities. Just a note on terminology. I’ll almost certain end up referring to students with special
educational needs. That’s the terminology
that we use in the UK, but if say special education needs, it’s the equivalent of what you would refer to as disabilities. One thing I did want to mention, just to plug before I get into the talk, is our BEE Blog, Building
Evidence Into Education. So this is two of my doctoral students who clearly weren’t busy enough
with their doctoral studies, so they decided they were going to build a blog that was going to be useful for people like yourselves. So the BEE Blog, Building
Evidence Into Education, is a free resource. It will always be free, so you’ll never be asked for any money. It’s designed for educators,
busy education professionals. And the purpose of it is
to take education research that’s happening at
Manchester, but also elsewhere around the UK and
elsewhere about the world, and translate it into an accessible form. We know that teachers
don’t have a lot of time, and they don’t necessarily have the means through which to access the
latest research evidence. So the BEE Blog, which
you can sign up to online. You can also find them on Twitter. They have a Twitter account. Please do sign up for it. It’s taken a lot of work to get it going, and it relies on people subscribing. As I said, it’s completely free. It will always be free and it’s designed for
people like yourself. So the BEE Blog. And the BEE by the way,
for people that don’t know, the worker bee is the
symbol of Manchester. So you see, we’ve been very
clever with our acronym there. Okay, so sign up for the BEE Blog please. So the other way to think about what we mean when we
talk about mental health is to think about some of the archetypes of mental health that we
see around us every day. So who knows who this is here? (audience murmurs)
Joy. Hands up, who’s seen Inside Out? Right, those of you that
have got your hands down, shame on you.
(audience laughs) Inside Out should be, and I’m
not joking when I say this. Inside Out should be shown
in every developmental psychology course, every
introduction to mental health. It is absolutely brilliant
in terms of, kids love it. My kids love it as a movie. But it’s really fascinating
kind of mental health journey for the main character who is
on the cusp of adolescence, experiences a major life transition. So spoiler alert for those
of you that haven’t seen it, her family uproot her and they move from Minnesota to San Francisco. Sorry for the spoiler, but
it’s been out for years so tough luck.
(audience laughs) And as a result, her
emotions are in turmoil. And the Inside Out element of it, Joy is one of the
characters inside her head, are in turmoil with one another, and it’s about that journey
and those conflict of emotions, and her ultimate resolution
is a representation of the complete Stepped
Mental Health Model, because it takes joy,
but it also takes sadness to work together to get her out of that very difficult situation. So joy for me represents
that notion of well-being. The optimism, the positive affect. Who’s this?
– Eeyore. – Eeyore. So my second recommendation. If you haven’t seen Inside
Out, go and watch it. Not now, but later, maybe when one of the other keynotes is on.
(audience laughs) My second recommendation is if you Google psychopathology in the Hundred Acre Wood. (audience laughs) So this is a fantastic, I have to caveat, very tongue in cheek. It’s not intended to be taken seriously, but a fantastic paper that was written, it’s about 20 years ago now, where a team of psychologists, I think they’re from the States, essentially went through all the different characters in the Hundred Acre
Wood in A. A. Milne’s stories and applied the Dear Sam criteria to them. (audience laughs) And so Eeyore, they suggested, was some of the features
of low mood and depression. Eeyore can be quite negative. Eeyore struggles to see
the positive in things. They said low mood, depression. Eeyore, it also manifests physically. So when you see the cloud
that follows him around, that’s intended to be symbolic. Okay. Piglet. Classic generalised anxiety.
(audience laughs) Okay? Again with Piglet, there is
a physical manifestation. So when you see the My Friends
Tigger and Pooh cartoons and the other versions
of A. A. Milne’s stories that have been shown on
TV, the stutter that comes, and that’s the anxiety
overwhelming Piglet. Piglet is a worrier, and those worries really get in the way of Piglet’s ability to kind of lead his or her everyday life. It’s controversial, apparently. Is Piglet a boy or a girl? I don’t know. Okay. Tigger. ADHD.
(audience laughs) And I’m going to give you
some evidence for that. So in one of A. A. Milne’s stories, Tigger wakes up and sees that there are fungi growing around
the Hundred Acre Wood. Tigger decides that he’s going to go and taste every single one of those. Now, doesn’t think about the consequences. Doesn’t think these might
not taste very nice. They might be harmful. They might be poisonous. They might even kill me. He jumps straight to the behaviour. Classic impulsive behaviour that we see among the children who sometimes
have that label applied. But additionally to that
impulsive behaviour, where you can see there in the picture. He’s psychically, he
bounces from place to place. He’s gregarious. He’s overactive. So Tigger is possibly a case
for ADHD, hyperactivity. Okay, final one.
(audience laughs) Who’s this? – Nelson.
– Nelson, okay. So Nelson Muntz in The Simpsons. Conduct disorder.
(audience laughs) Nelson is physically aggressive. He bullies. He steals. He’s defiant towards authority. But Nelson is also, when
we see the occasional insights into Nelson’s
home life in The Simpsons, you do get these fleeting glimpses. He’s massively affected by poverty. There is certainly kind
of neglect in the home, if not outright abuse. So Nelson’s home life is very difficult, and he doesn’t have good models
for appropriate behaviour. So Nelson also gives us a
little bit of an insight into some of the risk factors that underpin mental health difficulties. So this is the full range. The kind of classic distinction
is drawn about here. So these are difficulties where the distress is internalised, and these are difficulties where the distress is externalised. And it’s possible, of
course, to experience more than one mental health
difficulty simultaneously. And quite often, these
externalised problems are underpinned by internal distress. Okay. Some of the basic, I suppose, statistics. This one, actually, I
think is now out of date. So this is from a study that was done, a big national survey
that was done in England that’s about 13 years old now that suggested one in 10 children and young people experience
mental health difficulties. Our recent research that
I’m going to tell you a little bit about suggests that figure is actually quite a lot higher now. We’re awaiting, actually, the revised version of this survey. The results are going to be
published sometime this month, but my suspicion is that prevalence rate is going to be a lot higher. Our recent work with adolescents suggest you can probably
double that figure, if not go a little bit higher. In terms of the importance
of childhood and adolescence, we know from Kessler’s
work in The United States that 50% of all lifetime cases of mental health
difficulties begin by age 14. So if somebody’s ever going to experience mental ill health, they’re going to have their first onset by age 14. 75% by age 24. So by the time we reach young adulthood, three-quarters of people who will ever experience mental ill health will have had their first onset. So childhood and adolescence
and young adulthood are particularly crucial
development periods. And we also know that
mental health difficulties are not distributed randomly and evenly among the population. So just to give you an example, teenage girls are nearly three times more likely to experience
emotional problems, so things like anxiety and
depression, than teenage boys. And in terms of
deprivation and inequality, we know that kids who
live in the most deprived areas of our nations are
nearly five times more likely to experience mental health difficulties than those living in the
least deprived areas. So mental health is a
really powerful case example of how socioeconomic inequality can impact some peoples’ life
experiences and outcomes. In England, the estimated cost
of mental health difficulties is 105 billions pounds per year. That’s not how much we spend. That’s the economic
losses associated with, for example, if you’re an adult that experiences significant
mental health difficulties, then you’re much less likely
to be in gainful employment. So it’s the economics, the output losses, that the economists refer to, not just how much we spend. In England, we have socialised healthcare, so it’s free at the point of delivery. We spend a tiny proportion of our NHS budget on mental health, and of that tiny proportion, we only spend 6% on child and adolescence. So a tiny proportion of a tiny proportion we spend in terms of our health service. So a lot falls back on schools in terms of prevention
and early intervention. But then we also know
that if we get it right, and if we implement
evidence-based approaches to intervention, we get a
return on our investment. So this is the economic
estimate from every one pound, so every $2 roughly, that we spend on
evidence-based interventions. For adolescents who
experience conduct problems, we get a 13 pound, or a $26 roughly, return on investment,
because those young people are less likely to be in contact with our criminal justice and mental health services as adults. So if we invest to save, then we can improve
peoples’ life outcomes. Okay, so what about mental
health among students with, like I said, the acronym we use SEND, Special Educational
Needs and Disabilities. Just to give you a little bit of the kind of context in England. So we had a revised code of practice that was published in early 2015 that looked at how we go about approaching identification and assessment for students who experienced special educational needs. There are four broad areas
of need that we refer to. So communication and interruption. So that would be things like
autism spectrum conditions, language difficulties and so on. Cognition and learning. So that would be things like dyslexia or kind of general or moderate
learning difficulties. Social, emotional, and
mental health difficulties, so things like ADHD. And then finally, sensory
or physical needs, so things like hearing impairments, visible impairments and so on. Now the immediate
complications that brings is you’ll that mental health is actually referred to explicitly in our special needs code of practice. So it can become quite circular when I start to say well,
what does the data show us about where the kids with
special educational needs experience mental health problems. We’ve got a little bit of a way around that with one of our data sets that I’m going to show you in a second, ’cause we can separate out the kids who have had that category applied and look at the kids who have special educational needs, but not SEMH. And in England, it’s about 14.6% of kids. And the big distinction that we make in terms of our provision is something called an Education Health and Care Plan. So one of the landmark things that this new code of
practice brought into place was that we would bring together the provision that we have in education, in health, and in social care, so that children aren’t having to go from service to service. Because families hate it. It draws things out. It makes it very difficult to get a kind of integrated support system. So we brought education, health, and care together under one banner. So it’s about 14.6% of kids. Only about 2.9% actually
have what’s called an Education Health and Care Plan. So this effectively is following
a period of assessment, and it’s a document that’s put together by specialists, educational
psychologists and so on, that outlines the nature
of the young person’s needs and what should be put
in place to support them. And crucially it brings additional financial resources for the school. The other bit of landmark kind of change that’s come through in this
new legislation in England is increased parental influence and increased parental choice. So we’ve been trialling
the idea, for example, of personalised budgets, so that parents actually have more of a say in how the money that’s there to
support their child is spent. And then finally, this
is the kind of the range. So these are kids who have a statement or an Education Health and Care Plan, and kids how have special
educational needs, but don’t yet have a plan. So not all kids who are identified as having special identification needs or disabilities in England will actually get to the point where
they require this EHC plan. What you can see is the big division. The overwhelming majority of kids who have an EHC plan in England have an autism spectrum condition. A relatively small proportion who have an autism spectrum condition
don’t have an EHC plan. Similarly, kids with kind
of cognitive difficulties, there’s a higher proportion for those that have got severe learning difficulty that have an EHS plan. And only a tiny proportion
don’t get to that point. And it’s reflective of the complexity and the magnitude of the
needs that you would expect. So what do we know about mental health for these young people? The big national survey that I mentioned. Over 10,000 people. This has been about 13 years ago. Children with internalising difficulties, so children with anxiety, depression, twice as likely as other children to have special education
needs in that survey. So they had background age on the kids. Over half of the kids who the survey suggested had conduct problems were considered by their teacher to have special educational needs. And children with inattention,
hyperactivity disorders, were more than four times more likely to have special educational needs. Much more recently, our
big Head Start survey. So this is a project
that I’m involved with that’s led by my colleague Jess Deighton at the Anna Freud Centre. We have data on nearly 30,000 adolescents. We published a prevalence paper. We’ve got another one. That’s actually in press
now, not under review in the British Journal of Psychiatry. And one of the things we
looked at was risk factors. So we had background age on the kids. Were they considered to have
special educational needs? And as you can see, there is significantly
increased odds ratio, so more likely to experience
emotional symptoms, conduct problems, et cetera,
et cetera, et cetera. So there’s a convergence of evidence that suggests kids who are considered to have special educational needs are more likely to experience
mental health difficulties. And that’s also true in Australia. So this is Catherine Dixon’s data from the South Australian
Cohort in the Kids Matter study. And again, the kids who have increasing range of disabilities are more likely to be in the elevated range in the strengths and
difficulties questionnaire, which is a commonly used
mental health measure. So I mentioned, though, that one of the problems is this is a bit of a circular argument, because mental health needs,
in England at least now, are considered to be part of the range of special educational needs. So to start to look at well, what about kids who have special needs, but don’t have that label applied? We took data from out PATHS trial, which I spoke about briefly yesterday because again, we have
background age on these kids. And what you can see here on the chart are these are kids with no identified special educational needs. These are kids who have
special educational needs, but not what we used to call BESD, Behaviour, Emotional, Social Difficulties, what we now call SEMH, Social, Emotional Mental
Health Difficulties. And then these are the kids
who have that label applied. And what you can see,
for every mental health difficulty that we’ve
look at is that increase. So even the kids who
special educational needs but don’t have that label of SEMH applied still experience, oops. Still experience a significant increase compared to their peers in
mental health difficulties. So even the kids who have other forms of special educational needs, the more kind of cognitive,
another form of special needs, are still at increased risk
for mental health problems. Okay, so some of the things
that then the research tells us. Well, let’s starts with bullying, because that’s the
theme of the conference. So we did a study about three years ago, and we found that kids with
special educational needs were much more likely to
be victims of bullying than their peers without
special educational needs. Catherine Dixon’s work
from the Kids Matter study suggested there might be an issue also in relation to social, emotional skills and social, emotional competence. So in that context, SEL,
which I spoke about yesterday, becomes all the more important. You all said isolation, or
many of you said isolation, and the research backs you up on that. So kids who are considered to
have special educational needs are more likely to experience
lower peer acceptance, have fear of friendships groups, and be more transient
in terms of friendships. So they’re more likely
to have those kind of, you know, one week it’s one friend. On week it’s another, rather those those really enduring bonds that kids build up. And in England, in terms of exclusion. So this is formal exclusion. This is what you would call suspension, when they’re kicked out of school. They account in England
for half of all exclusions. So of all children that
are excluded permanently from primary or secondary school, half have some form of
special educational needs. And the kids who have the
Education Health and Care Plan are five times more likely to be excluded than students with no
special educational need. We also know, though, from
my research at Manchester, we just published a developmental cascade study about a year ago. There is an interrelationship
between children’s learning and their academic attainment, and their mental health over time. So there’s a possible issue there, where instruction’s not necessarily being tailored to meet need, and as a result, children’s
mental health suffers because they’re suffering academically. So we know those things are related. We also know that teachers
may feel ill prepared to address complex needs. And again, that goes right
back to teacher training and pre-service time,
the amount of time spent focusing on how to support
those more vulnerable students. There might be family issues, and there are also policy issues. So I’ve written about the
state of play in England where there have been cuts to services that support our most
vulnerable young people, and that has a trick down effect that really impacts on
childrens’ life chances. So what can we do? My third, or however many
recommendations I’m going to make. One of my recommendations for you today is to visit the Mentally
Healthy Schools website. So this was set up. Again, it’s a free resource. It was set up by the Royal Foundation. So the Duchess of Cambridge has a very, very strong interest in
childrens’ mental health. And the Royal Foundation
that works with the Duchess has set up the Mentally
Healthy Schools website. It’s a work in progress. There’s content being added all the time. It’s quality assured. There’s an expert panel,
which I’m part of, that kind of looks at the resources that are being put on there to make sure that they are useful
and based in evidence. And it’s free to anybody
that has the internet. So you can go on even
if you’re in Australia. It doesn’t matter. You can go on and you can access that. And they have special pages
about particular issues, and one of them is around
supporting more vulnerable young people that have
special educational needs. They talk about the need for school ethos that emphasises inclusion and cooperation. Having really high
aspirations and expectations of all children, seeing past
the SEM or the disability label and having the same high expectations for those kids as we do for others. Implementing SEL, which
I spoke about yesterday to really help in the development of empathy, emotion regulation. Those are the key skills. And promoting the idea of difference and diversity has been
a really positive thing. So disability, just one other way in which children are
different from one another. And the best schools in the country, the ones that I visited in England, there were some fantastic,
really inclusive schools. That’s at the heart of
everything that they do. But diversity is something
that’s celebrated rather than something that’s seen as a way of dividing people. They also talk about the need to address bullying and discrimination, which of course we’ve been talking about yesterday and today. And also to be alert to increased risk and early warning signs, and mobilising protective
factors to mitigate risk. Most protective factors
that are well-established in the research literature are about relationships ultimately. And as educators, you’re in
a really powerful position to promote positive,
warm, caring relationships between children and other children, but also between the
adults in the building and the children in your
school, and with parents. It’s all about relationships. I wanted to end, ’cause
I’ve got three minutes and 16 seconds left, just to give you a worked example, as I
did in my talk yesterday, of what the research tell us about how effective some of
these approaches can be. So we were involved. We led an evaluation in something called Achievement For All, which was a Department For
Education initiative in England that was focused on
developing an integrated model to support children with special educational needs specifically. So it was in 10 local authorities, so 10 kind of schools
districts in England. We had about 450 plus schools, about 11,000 students across those schools with special educational needs. And the nature of this
approach to intervention was essentially three different things. The first thing was it didn’t
just focus on bullying, or it didn’t just focus on mental health. It focused on a whole range of issues. So it was trying to avoid that kind of programed for every problem phenomenon which we kind of get bogged down in. We need a new programme for bullying. We need a new programme for this. So this was about having
a comprehensive approach. So there’s an academic element too, which was about improving
assessment tracking and intervention for kids with
special educational needs. So monitoring their academic
progress more closely and changing what we
do if it isn’t working. Structured conversations with parents, so using the opportunity to engage parents and to find out more essentially. A lot of it was about finding
more about the young person, and using parents as
that incredible resource. They know so much about their children, and they’re an untapped
resource in that regard. And then finally, schools got to choose different wider outcomes
that they could focus on that were important to them locally. So it could either be
about improving attendance, improving behaviour, reducing bullying, improving positive relationships, improving wider
participation in the school. But ultimately, it was a combination of those different things. And all the schools did
something a little bit different, so the idea with this programme was that it wasn’t something
that was completely manualized and set, and
everybody does the same thing. It was designed to be flexible. So there were some guidance and resources, but ultimately it was about
local context and local need. And the schools were
supported by regional advisors and people working in local authorities. What we found in that, so this is just to give you a snapshot. This data was already
published about five years ago. We found, first of all, a decrease, relative to a control group, a decrease in behaviour
problems in AfA schools. manualised and set, and
everybody does the same thing. with special educational
needs in these schools. We also found a significant stabilisation in positive
relationships for children with special educational
needs in those schools. And then finally, a reduction in bullying of children with special
educational needs in those schools. Now I should hasten too, just ’cause I’m running out of time. This isn’t a randomised trial. So this is not the most
robust form of evidence, but we did have a control group. We did have a form of comparison. So compared to schools
not implementing AfA, children experiencing better outcomes. We’re actually in the midst at the moment of a randomised trial
of the AfA programme, the results of which we’ll
have in a year or two time. Okay, so in conclusion
with five seconds left. (audience laughs) So the research tells us
students with disabilities are at a significantly increased risk of experiencing mental health difficulty, and we all know just how
important mental health is in terms of life experiences and outcomes. But risk is about probability,
not about certainty, and schools have got an
incredibly central role to play in mobilising protective factors to support those students
who are at increased risk. And to do that, we can’t
just have, as I said, a programme for every problem. We need a school-wide,
multi-component, integrated model, where we bring things
together in a coherent way. are at a significantly increased risk Thank you. (audience applauds)