70 Education and Health Vol.35 No.4, 2017 Dr Michelle Jayman is an Associate Researcher based at the School of Human and Social Sciences, University of West London. Dr Maddie Ohl and Dr Pauline Fox are Directors of Studies (Graduate School), University of West London and Bronach Hughes is the UK Pyramid Project Coordinator For communication, please email: michelle.jayman@uwl.ac.uk Michelle Jayman, Maddie Ohl, Pauline Fox and Bronach Hughes Beyond evidence-based interventions: implementing an integrated approach to promoting pupil mental wellbeing in schools with Pyramid club A rising tide of psychological distress among children and young people, coupled with extensive spending cuts to Child and Adolescent Mental Health Services (CAMHS), has created a treatment gap with increasing numbers of pupils presenting with mental health and behaviour difficulties in schools (Taggart et al., 2014). The crucial role of schools in providing early intervention to pupils with psychological difficulties is recognised, with some authors insisting that mental health should be part of the ‘core business’ of schools (e.g. Bonell et al., 2014). This sentiment is incorporated within a settingsbased approach to health (World Health Organisation, 1986), integrating sectors from the wider social system (e.g. schools, public health, local authorities and social care): it builds on the principles of community participation, partnership, empowerment and equity. A strategic framework for mental health that reduces risk and increases protective factors for children is imperative (Department of Health (DH), 2015) and couched within a settings-based model, places schools in a pivotal position to offer socio-emotional interventions. A political shift marked by decentralisation has given schools the capacity to influence the services that are commissioned by feeding information on the mental health needs of their pupils into local transformation plans. Moreover, they can contract services directly, working with local providers to support mental health promotion and deliver early interventions according to individual school needs. This article discusses school as an ‘ideal’ setting for promoting mental wellbeing, but goes on to argue that demonstrably effective interventions are not on their own sufficient to deliver positive health outcomes. Pyramid club is an established UK socioemotional intervention. The Pyramid model is introduced here and the challenge of reconciling process issues through an integrated approach to pupil mental wellbeing is explored. A unique setting Schools exist in almost all communities, providing a unique setting for optimising health outcomes due to their wide reach and the extended amount of time children are required to spend there. They offer an ‘enabling environment’, where individuals come together, experience a sense of belonging and collectively contribute to the growth and wellbeing of others (Royal College of Psychiatrists, 2013). School can be a source of supportive relationships outside the family, with the potential to exert a protective influence (Weare & Markham, 2005), and moreover, school staff are well-placed to identify pupils experiencing difficulties which may impact on their mental wellbeing. A body of literature (e.g. Durlak et al., 2011) demonstrating the association between mental wellbeing and academic performance suggests that socio-emotional interventions can provide a dual function: preventing the development or increasing severity of mental health problems whilst simultaneously improving educational outcomes. Nonetheless, the potential for schools to influence both domains is not fully harnessed and good practice is sporadic (Taggart et al., 2014). 71 Education and Health A scoping review of mental health provision in English schools (Vostanis et al., 2013) concluded that service delivery was predominantly reactive, not preventative, and largely not evidence led. These concerns were echoed by mental health professionals in a National Children’s Bureau (NCB) survey (2013) and, moreover, pupil respondents claimed that mental health issues were not given sufficient attention, with those experiencing difficulties reporting they received little or no support. While a welcome focus on promoting mental health has produced a growth in interventions designed to work with children in school, the dilemma for senior staff is selecting a quality programme from the extensive number available. Research suggests (e.g. Khan et al., 2014) schoolbased interventions are often poorly targeted, failing to reach those who would benefit the most. A thorough and robust commissioning process can be facilitated through organisations such as the Early Intervention Foundation (EIF) and Project Oracle which endeavour to strengthen the Vol.35 No.4, 2017 links between research and applied practice: programme evaluations are measured against rigorous standards and assessed for quality1 and cost-effectiveness2. Projects of sufficient quality are added to an evidence hub for commissioners (including schools) and funders, providing guidance on programmes shown to improve outcomes for children and young people. Undoubtedly, school-based services should be selected on the strength of robust evidence, however, effective interventions need to be combined with effective implementation processes to be successful (Durlak et al., 2015). Even interventions with a solid evidence base are likely to fail if local needs and school culture are overlooked. The challenge for programme developers and service deliverers is, therefore, to provide practical models which can be smoothly integrated with existing school systems. The Pyramid model, nested within a health promoting schools framework (Figure 1), is presented in response to this challenge. Figure 1: A settings-based approach: Pyramid nested within the HPS framework EIF evidence quality ratings comprise: ‘no effect’; ‘2’ (preliminary evidence of improving a child outcome, but where an assumption of causal impact cannot be drawn); ‘3’ (evidence of short-term positive impact where a judgment about causality can be made); ‘4’ (programmes with evidence of long-term positive impact through multiple rigorous evaluations). Note: + ratings may be given to all numerical ratings, e.g. ‘2+’. 2 EIF cost ratings are on a scale from ‘1’ (the lowest cost) to ‘5’ (the highest cost). 1 72 Education and Health The national agenda and the Pyramid model Aligned with national policy to encourage schools to adopt whole school approaches to mental health, Public Health England (2015) identified eight key principles to promote wellbeing; with leadership and management to support and champion efforts at the core. Seven inter-connected components comprise: an ethos and environment that encourages respect and values diversity; a curriculum to promote resilience and socio-emotional learning; enabling students to influence decisions; identifying need and monitoring impact of interventions; targeted support and appropriate referral; staff development; and parent/carer collaboration. These principles are underpinned by NICE guidance (2008; 2009) and are linked to the 2015 Ofsted inspection framework. The Partnership for Wellbeing and Mental Health in Schools (a national network which supports schools and services to improve the mental health of children in education) has embodied these eight, best practice principles within a guidance framework (NCB, 2015) for school leaders and front-line staff. A dual strategy is recommended: a reactive strand, i.e. providing targeted responses for pupils already experiencing mental health problems; and a preventative strand, i.e. implementing targeted programmes to promote pupil wellbeing and reduce future risk of developing difficulties, for example, Pyramid after school clubs, which are now briefly introduced. Pyramid club supports social and emotional wellbeing, and targets socially withdrawn or anxious children (aged 7-14). It is a manualised programme, typically delivered as an after-school club (comprising ten, 90 minute, weekly sessions), and is designed to intercede early in life and in the course of difficulties. Pyramid clubs comprise small groups of selected pupils (usually around ten) and are run by three or four, trained club leaders: teams may comprise a mix of school support staff and volunteers from the community. There is strong empirical evidence of Pyramid’s effectiveness in improving socio-emotional wellbeing for vulnerable primary-aged pupils (e.g. Cassidy et al., 2015; Ohl et al., 2012). The robustness of this evidence has been assessed by the EIF (achieving a quality rating of 2+ and a cost Vol.35 No.4, 2017 rating of 1) and Pyramid is included in the latest guidebook for commissioners on interventions known to show improved outcomes for children. This accreditation by the EIF adds to Pyramid’s increasing recognition as a low-cost, demonstrably effective, school-based intervention. The most recent research (Jayman, 2017) examined the impact of Pyramid on secondary-aged pupils (aged 11-14), extending the evaluation literature to include the upper age range of children Pyramid supports. Moreover, an outcome of the research was to articulate the Pyramid model as a fivestage process, explicitly addressing crucial implementation considerations. Pyramid: a five-part model Adopting an ecological perspective, the Pyramid five-part model (Figure 2) takes into account the connections between different groups across the school and broader community (e.g. pupils, parents/carers, school staff, external agencies and Pyramid club leaders); thus factoring in local needs and resources, school culture and ethos, and support networks. Support and commitment from head teachers increases the likelihood of successful implementation by harnessing organisational capacity. Moreover, a shared vision or ‘buy-in’ is more likely to be achieved if programmes have been shown to be effective, e.g. having EIF accreditation as Pyramid does. Figure 2: Pyramid five-part preventative model According to Durlak et al. (2015) there are five stages involved in effective implementation: Dissemination (communicating accurate and 73 Education and Health helpful programme information to stakeholders); Adoption (the programme is tried out); Implementation (high quality programme delivery to provide a fair test of ability to produce changes); Evaluation (examining how well targeted goals were achieved); and Sustainability (the programme, if successful, becomes routinely adopted and rolled out). These stages can be mapped to the Pyramid model which is now briefly described. Preparation and planning Head teachers are advised to nominate a ‘champion’ to promote mental wellbeing across their school (DH, 2015; Public Health England, 2015). Having a dedicated lead is pivotal for spreading wider awareness of socio-emotional interventions, establishing and maintaining support during implementation, and disseminating information about impact. The local Pyramid coordinator negotiates the set-up and delivery of clubs with the elected wellbeing lead, assessing the conditions and resources of individual schools, for example, pastoral staff or 6th form students may be recruited as club leaders. The use of paraprofessionals, including those from the school community, offers flexibility and is cost-effective compared to services requiring specialists to deliver them. Raising staff awareness about mental health issues, encouraging ‘student voice’ (input to school policies and practices), and working in partnership with parents/carers are recommended school strategies (NCB, 2015; Public Health England, 2015). Pyramid promotional activities aim to encourage attendance at clubs whilst simultaneously helping to reduce stigma and garner wider support from peers, school staff and parents/carers (prompting discussion on wellbeing issues). Informal, open events are offered in schools (led by the local Pyramid coordinator) and provide a forum to disseminate key information about clubs and answer questions from stakeholders. ‘Taster’ activities enable potential attendees to sample the programme, and, if a club has previously run in the school, Pyramid ‘graduates’ are invited to share their first-hand experiences. Screening Screening procedures help ensure Pyramid reaches children most likely to benefit: the Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997) is routinely used to identify suitable pupils. In line with schools’ responsibility to recognise pupils with mental health needs, the Vol.35 No.4, 2017 Department for Education (DfE) (2016) specifically recommends the SDQ: ‘a simple, evidence based tool’ (DfE, 2016:16). SDQ scores used to inform pupil selection for Pyramid clubs may also highlight others requiring alternative provision. NICE guidance (2009) advises schools to systematically measure and assess pupils’ socioemotional wellbeing as the basis for planning and evaluating interventions. All pupil level data collected for Pyramid can be fed back to schools, contributing to and complementing existing strategies for identifying pupils’ needs, commissioning services, and monitoring the impact of interventions. Inter-professional consultation/co-operation (selection) Inter-professional consultation/co-operation is an assumption of all stages of the Pyramid model but here refers specifically to pupil selection for clubs, providing cross-validation for the SDQ assessment and enabling greater conviction that the intervention is well targeted. The local Pyramid coordinator, school wellbeing lead and other professionals (e.g. head of year) discuss individual cases identified through screening. The combination of pupils in each group is fundamental to the therapeutic process; finalising the group requires input from professionals who know identified pupils well. This process of consultation/co-operation contributes to the professional development of school staff, helping them to develop the knowledge, understanding and skills to recognise pupils with mental health needs and recommend suitable pathways (NCB, 2015). Activity group therapy Pyramid activity clubs comprise physical, psychosocial, creative and reflective elements: circle time, arts and craft, games, and food preparation/snack time. The Pyramid ethos is underpinned by four key tenets of healthy child development (KelmerPringle, 1980) which reflect the Pyramid club experience for children: praise and recognition, love and security, new experiences, and responsibility. Clubs are a microcosm of the health promoting school model which embodies a pupil- focused, strengths-based approach to promoting mental wellbeing. The physical set-up of circle time symbolises connectivity, lending itself effectively to practising skills such as speaking, listening and turn-taking. Children can express their feelings and thoughts in 74 Education and Health a non-judgemental, supportive environment; encouraging mutual trust. Art and craft activities are designed to be fun whilst simultaneously facilitating task-based and social skills practice with peers and adults. Similarly, club games allow children to engage in the type of activities they will encounter in the playground in a ‘safe and controlled manner’ (Pyramid, 2011:12). Snack time plays a significant part in Pyramid club, encouraging sharing, turn taking and prompting conversation. The normal school day offers limited opportunities for relaxed, uninterrupted conversations and Pyramid club is a space where unresolved issues can be brought up, perhaps for the first time. According to Lyubomirsky & Layous (2013), simply participating in pleasurable and fun activities increases mental wellbeing by providing an escape from daily stressors. Evaluation and impact Pyramid evaluation includes re-examining SDQ scores after clubs have finished. Pupil level data can be fed back to schools and contributes to existing procedures for monitoring wellbeing (identifying beneficiaries and flagging up any children in need of further support). At a club level, new findings can be added to the evidence base. As already highlighted, studies submitted to the EIF national hub and rated of sufficient quality comprise evidence available to funders and policy makers. This creates a diffusion loop whereby recent evidence of Pyramid’s effectiveness can be extrapolated and used to attract commissioning of future clubs. As the post-club phase is inextricably linked to the pre-club phase, the five-part Pyramid model is depicted as cyclical. Programme providers must monitor, and commissioners must consider, how interventions fit with the stated preferences of recipients so that provision can be shaped around what matters to them (DH, 2015). Capturing ‘the voice’ of Pyramid attendees is built into the evaluation process, supporting the social validity of the intervention and enabling the ongoing development of clubs. Collecting feedback from club members facilitates students having a voice in school; Pyramid ‘graduates’ contribute to the evidence under consideration with respect to future implementation choices. Harnessing the potential of schools A backdrop of economic austerity and reduced services, coupled with a mounting number of Vol.35 No.4, 2017 children experiencing socio-emotional difficulties, has brought increasing focus on schools to promote and support their pupils’ mental wellbeing. In line with the government’s settings-based policy for health (DH, 2015), models of demonstrably effective, school-based interventions as examples of good practice are in high demand. Short-term, socio-emotional programmes, like Pyramid, can improve children and young people’s mental wellbeing whilst simultaneously helping them acquire the skills they need to make good academic progress. Nonetheless, as it has been argued in this article, even demonstrably effective interventions run the risk of reduced impact, or even failure, if ‘real world’ implementation issues are not well considered. Service providers need to bear in mind the ‘fit’ between the intervention and the mission, priorities and values of the host organisation (Durlak et al., 2015). Pyramid works in partnership with schools and a comprehensible, five-part model provides a clear description of implementation processes that can be integrated with, and complement, existing school systems. Aligned with an ecological model, Pyramid clubs can operate as part of a multi-component Health Promoting School strategy. Abating the current tide of psychological distress requires a holistic approach to promote and support children’s and young people’s mental wellbeing, optimising the potential for both socio-emotional and educational outcomes to be successful. References Bonell, C., Humphrey, N., Fletcher, A., Moore, L., Anderson, R. & Campbell, R. (2014). Why schools should promote students’ health and wellbeing. British Medical Journal, 348(7958), p.3078. Available at: http://www.bmj.com/content/348/bmj.g3078 (Accessed 9th November 2017). Cassidy, T., McLaughlin, M., & Giles, M. (2015). Socio-emotional health in school children: An emotion-focused intervention. International Journal of School and Cognitive Psychology, 2(4), pp.1-7. Department for Education (2016). Mental health and behaviour in schools: Departmental advice for school staff. London: Department for Education. Department of Health (2015). Future in mind. London: Crown Publications. Durlak, J. A., Domitrovich, C. E., Weissberg, R. P. & Gullota, T. P. (Eds.). (2015). Handbook of social and emotional learning: Research and practice. New York: The Guilford Press. Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor, R. D. & Schellinger, K. B. (2011). The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development. Special Issue: Raising Healthy Children, 82(1), pp.405-432. 75 Education and Health Vol.35 No.4, 2017 Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38(5), pp.581-586. Jayman, M. (2017). Evaluating the impact of a school-based intervention on the socio-emotional well-being and school performance of pupils in early secondary education. Unpublished PhD thesis, University of West London. Kellmer-Pringle, M. (1980). The needs of children: a personal perspective. 2nd ed. London: Hutchinson. Khan, L., Parsonage, M. & Stubbs, J. (2015). Investing in children’s mental health: a review of evidence on the costs and benefits of increased service provision. London: Centre for Mental Health. Lyubomirsky, S. & Layous, K. (2013). How do simple positive activities increase well-being? Current Directions in Psychological Science, 22(1), pp.57-62. National Children’s Bureau (NCB) and National Health Service (NHS) Confederation (2013). Child health in the NHS: Results of a survey by the NCB and the NHS Confederation. Available at: https://www.ncb.org.uk/sites/default/files/field/attachment/news/19 0314_ncb_submission_to_health_select_committee_-_camhs.pdf (Accessed 9th November 2017). National Children’s Bureau (NCB) (2015). A whole school framework for emotional well-being and mental health. Available at: https://www.ncb.org.uk/sites/default/files/field/attachment/NCB%2 0School%20Well%20Being%20Framework%20Leaders%20Reso urces%20FINAL.pdf (Accessed 9th November 2017). Ohl, M., Fox, P. & Mitchell, K. (2012). Strengthening socioemotional competencies in a school setting: Data from the Pyramid project. British Journal of Educational Psychology, 83(3), pp.452-466. Public Health England (2015). Guidance for head teachers and college principals on the 8 principles for promoting emotional health and wellbeing in schools and colleges. Available at: https://www.gov.uk/government/publications/promoting-childrenand-young-peoples-emotional-health-and-wellbeing (Accessed 9th November 2017). Pyramid (2011). Pyramid club leader handbook. London: ContinYou. Royal College of Psychiatrists (2013). Enabling environments. Available at: http://www.rcpsych.ac.uk/pdf/ee%20standards%20%202013.pdf (Accessed 9th November 2017). Taggart, H., Lee, S. & McDonald, L. (2014). Perceptions of wellbeing and mental health in English secondary schools. Available at: http://www.centreforum.org/assets/pubs/headteacher-survey.pdf (Accessed 9th November 2017). Vostanis, P., Humphrey, N., Fitzgerald, N., Deighton, J. & Wolpert, M. (2013). How do schools promote emotional wellbeing among their pupils? Findings from a national coping survey of mental health provision in English schools. Child and Adolescent Mental Health, 18(3), pp.151-157. Weare, K. & Markham, W. (2005). What do we know about promoting mental health through schools? Promotion & Education, 12(3-4), pp.118-122. Education and Health Archive Each issue of the journal, published since 1983, is available via the archive. There are several simple indices that help to identify articles by keywords; year/issue number; author surname and article title. It can be seen that some contributors have had a number of articles published and there are a range of topics that have been covered over the years. Sometimes a contributor will update their article or develop points raised by another contributor. The pages on the website, that have been provided for the Education and Health journal, usually have the highest number of ‘reads’ across all pages on this Internet site. SHEU Schools and Students Health Education Unit The specialist provider of reliable local survey data for schools and colleges and recognised nationally since 1977 “The (SHEU survey) helped us to prioritise where we needed to be in terms of PSHE education. We delivered assemblies based on the evidence as well as curriculum development, and dealt with whole school issues – particularly in regard to pastoral care. The answers received to the question on the survey Who are you most likely to approach if you needed help worried staff as teacher was not a popular answer. Subsequently the staff asked themselves why this had happened and what needed to be done to address the issue. There was more emphasis on wider aspects of PSHE education delivery, which needed more attention. To summarise, the (SHEU survey) allows the PSHE department to assess the impact of teaching and learning and modify future lessons accordingly. It allows our school to look at whole school issues such as the extent to which the pastoral care system is meeting the needs of our pupils. It helps us to do need analysis of our pupils. It helps to provide important evidence for SEF / the extent to which we are meeting wellbeing indicators / National Healthy School standards.” Secondary School Head For more details please visit http://sheu.org.uk