1. Mental health promoting schools
Professor Jonathan Campion
Professor of Population Mental Health (University College
London) and Director of Population Mental Health (UCL
Partners)
Director of Public Mental Health (South London and
Maudsley NHS Foundation Trust)
13th
June 2013

2. Why is mental health important in schools?

3. Mental health/ wellbeing
• Broad range of health and other impacts relevant to
education as well as a range of other policy areas
• Large proportion of childhood and adolescence
spent in school
• Experience during childhood and adolescence
impacts across life course
• Variation of levels of child mental health and
wellbeing across Europe (Bradshaw & Richardson,
2009)

4. Health impacts of mental wellbeing
Associated with reductions in and prevention of
(Campion et al, 2012):
• Mental disorder in children and adolescents
including persistence
• Mental disorder and suicide in adults
• Physical illness
• Associated health care utilisation
• Mortality

5. Impacts outside health
• Improved educational outcomes
• Healthier lifestyle
• Reduced health risk behaviour - smoking, alcohol,
drug misuse, physical inactivity, diet
• Reduced anti-social behaviour, crime and violence
• Increased productivity at work, fewer missed days
off work
• Higher income
• Social relationships

6. Relationship between mental disorder and
wellbeing
• Improved mental wellbeing associated with reduced
risk of mental disorder
• Mental disorder associated with reduced mental
wellbeing
• Single largest group with poor wellbeing are those
with mental disorder – important group to target
promotion
• Promotion of wellbeing can prevent mental disorder
• Intervention for mental disorder addresses important
driver of poor wellbeing

7. Similar broad range of impacts of mental
disorder

8. During childhood and adolescence
• health outcomes
• self-harm and suicide
• educational outcomes
• antisocial behaviour and offending
• social skills outcomes
• health risk behaviour - smoking, alcohol and drug
misuse, sexual risk, nutrition, physical activity
• teenage parenthood

9. Impacts of emotional and conduct disorder in children
and young people in UK (Green et al, 2005)
Risk Behaviour Emotional
Disorder (6%)
Conduct
Disorder (4%)
No Disorder
Smoke Regularly
(age 11- 16)
19% 30% 5%
Drink at least twice
a week (age 11- 16)
5% 12% 3%
Ever Used Hard
Drugs (age 11- 16
6% 12% 1%
Have ever self
harmed (self report)
21% 19% 4%
Have no friends 6% 8% 1%
Have ever been
excluded from
school
12% 34% 4%

10. Increased risk of poor adult outcomes
Poor mental health in childhood and adolescence also
associated with poor adult health outcomes including
Higher rates of:
• adult mental disorder
• health risk behaviour
• physical illness
• suicide
• unemployment and lower earnings
• marital problems
• crime and violence

11. Impact of mental disorder
• 23% of burden of disease in UK compared to 16% for
cancer and 16% for cardiovascular disease
• Size of impact due to
 Mental disorder being common
 Arising early in the life course
 Broad range of impacts
 Only 10% receive notionally adequate treatment
(Wittchen et al, 2011)

12. Population level of mental disorder
• 10% of children and adolescents in UK have a
mental disorder (Green et al, 2005)
• 18% of children and adolescents have sub-threshold
conduct disorder
• 23% of adults in England have at least one mental
disorder (McManus et al, 2009)
• 38% of the European population experiences at least
one mental disorder each year (Wittchen et al, 2011)

13. Early onset of mental disorder
• Key reason for size of burden
• 50% of lifetime mental illness (excluding dementia)
starts by age 14 (Kim-Cohen et al. 2003; Kessler et
al, 2005)
• 75% by mid twenties (Kessler et al, 2007)

14. School offers important opportunities
• Place where children and adolescents spend large
proportion of time
• Opportunity to promote wellbeing at key time in the
life course with resulting range of impacts across
different sectors and policy areas
• Opportunity to prevent and detect mental disorder
early to enable early intervention preventing wide
range of impacts across different policy areas

15. Economics of mental health

16. Cost of mental disorder
• Europe cost of €798 in 2010 (Olesen et al, 2012) (37%
direct healthcare cost, 23% direct non-medical cost,
40% indirect cost)
• To UK economy: €123 billion annual cost of mental
illness in England (CMH, 2010)
• Crime: €70 billion annual cost of crime in England
and Wales by adults who had conduct disorder and
sub-threshold conduct disorder during childhood
and adolescence (SCMH, 2009)

17. Economic impact of wellbeing
Longitudinal studies indicate that subjective wellbeing
precedes (Lyubomirsky et al, 2005):
• productive work
• higher income
• better mental and physical health
• improved life expectancy

18. Certain groups at much higher risk of mental
disorder and low wellbeing
• Higher risk groups benefit proportionately more
from intervention to both promote wellbeing and
prevent mental disorder
• Need for information about numbers from higher risk
groups (Campion & Fitch, 2012)

19. Children and adolescents
• Looked after children (by the state) - 5 fold increased
risk of mental disorder (Meltzer et al, 2003)
• Children with learning disability - 6.5 fold increased
risk of mental illness (Emerson and Hatton, 2007)
• Special educational need (OR 3.7) (Parry-Langdon et
al, 2008)
• Young offenders: 18 fold increased risk of suicide
for men in custody age 15–17 (Fazel et al, 2005)

20. Mental health promoting schools

21. Preschool and early education programmes
Result in improved:
• cognitive skills
• school readiness
• improved academic achievement
• positive effect on family outcomes including for
siblings (Anderson et al, 2003; Sylva et al, 2007)
• prevention of emotional and conduct disorder
(Tennant et al, 2007)
Combined programmes for preschool children from
disadvantaged areas - improved parent and family
wellbeing (Nelson et al, 2003)

22. School based mental health promotion programmes
• Improved wellbeing, impacts on academic
performance, social and emotional skills, and
classroom misbehaviour (NICE, 2008; NICE, 2009)
• Reduced conduct problems and emotional distress
(Stewart-Brown, 2006; Adi et al, 2007)
• More effective approaches were long term, whole
school, including teacher training and parental
participation (Durlak et al, 2011; Weare & Nind, 2011)
• Interventions for children sub-threshold disorder
result in improved mental health, behaviour and
social skills (Reddy et al, 2009)

23. Social and emotional learning programmes
Meta-analysis of 270,000 students from US social and
emotional programme (Durlak et al, 2011)
• reduced conduct problems and emotional distress
• improved social and emotional skills, attitude about
self
• improved social behaviour
• 11% improved academic performance
• cost savings of reduced conduct disorder are £84 for
each £ invested (Knapp et al, 2011)

24. • Peer mediation effective in promoting pro-social and
behavioural skills in the long term (Blank et al, 2009)
• Secondary school curriculum approaches to
promote pro-social behaviours and skills can also
prevent development of anxiety and depression
(NICE, 2009)

25. School based prevention of mental disorder
during childhood
Prevention of conduct and emotional disorder
• Pre-school programmes (Tennant et al, 2007)
• Universal and targeted school programmes
(Horowitz and Garber, 2006; Merry et al, 2004)
• Penn Resiliency programme (Brunwasser and
Gilham, 2008)

26. School based prevention of violence and abuse
• Violence and abuse are important risk factors for
mental disorder and poor wellbeing
• Interventions to address violence and abuse can
promote wellbeing and prevent mental disorder
• School based violence prevention programmes
(Mytton et al, 2006)
• School based sexual abuse prevention programmes
(Zwi et al, 2009)
• School based bullying prevention programmes (Ttofi
et al, 2008)

27. Early recognition/ intervention for mental disorder
• Half of lifetime mental disorder has arisen by age 14
• Early recognition/ intervention of mental disorder
through improved mental health literacy in schools
• Results in improved wellbeing and outcomes
• Can prevent significant proportion of adult mental
disorder (Kim-Cohen et al, 2003)

28. Proportionate universal approach
• Certain groups at higher risk of mental disorder and
poor wellbeing
• To ensure groups receive proportionately greater
levels of public mental health intervention, need
information about (Campion & Fitch, 2012):
Local numbers from such groups
Levels of increased risk of different mental
disorder
Level of coverage of interventions

29. London Family School proposal
Targeted approach for pupils with mental and
behavioural disorder under negotiation with UK’s DfE:
• Addresses mental and behavioural disorder in both
individual and family context
• Promotes psychological and emotional well-being
To:
• Gain resilience
• Progress academically
• Remain in full-time education and return to
mainstream education

30. Improved range of health and other outcomes
Reflects broad impacts of mental disorder and
wellbeing
• Improved educational outcomes
• Reduced antisocial behaviour/ crime
• Improved employment outcomes
• Reduced range of health risk behaviours
• Reduced physical illness
• Improved quality of life
• Reduced burden and costs of mental ill-health
• Economic savings

31. Economic impacts of interventions

32. Impact of promotion, prevention and treatment
• Evidence from LSE highlights such interventions
also result in considerable economic savings even
in short term (Knapp/ DH, 2011)
• Significant proportion of savings accrue in areas
outside health reflecting broad impacts of mental
health
• Local economic savings from interventions and
costs of not providing interventions can be
calculated (Campion and Fitch, 2012)

33. Savings per £ invested (Knapp et al, 2011)
• Parenting interventions for families with conduct
disorder £8
• School-based interventions to reduce bullying £14
• Prevention of conduct disorder through social and
emotional learning programmes £84

34. Intervention gap
• In Europe, 10% of people with mental disorder
receive notionally adequate treatment (Wittchen et
al, 2011)
• In UK, minority of children/ adolescents with mental
disorder receive any intervention (Green et al, 2005)
• Lack of implementation of evidence based school
based mental health promotion and mental disorder
prevention programmes
• Lack of intervention has significant impact and cost
across broad range of sectors – local size, impact
and cost of unmet need can be estimated (Campion
& Fitch, 2012)

35. Summary
• Mental wellbeing and disorder have broad range of
impacts across different sectors and policy areas
• Majority of mental disorder and poor wellbeing
arises before adulthood
• School based interventions improve mental health
through wellbeing promotion, mental disorder
prevention and early intervention for mental disorder
• Result in broad range of short and long term impacts
across a range of sectors/ policies with associated
economic savings
• Lack of implementation of such interventions result
in long term impacts and costs in different sectors

36. Summary
• Mental health - key part of any policy
• Taking account of mental health improves outcomes
of every policy
• EU Joint Action on Mental Health includes work
package ‘Mental health in all policy’ and ‘Mental
health in schools’
• Effective promotion and prevention requires
interventions targeted in a universally
proportionate way
taking account of need
delivered through a sustained and coordinated
approach

37. References and contact
• Campion J, Bhui K, Bhugra D (2012). European
Psychiatric Association guidance on prevention of
mental disorder. European Psychiatry 27: 68-80.
• Campion J, Fitch C (2012) Guidance for the
commissioning of public mental health services.
Joint Commissioning Panel for Mental Health.
www.jcpmh.info
• Weare K, Nind M (2011). Promoting mental health of
children and adolescents through schools and
school based interventions: report of workpackage
three of the DataPrev Project. DataPrev.
• Email: jonathan_campion@yahoo.co.uk