Supporting children’s mental health and wellbeing in schools
The mental health of primary-aged children has received a great deal of media attention in recent months. Coverage included the revelation from 155 schools in England that 191 primary-aged pupils had self-harmed on school premises in the previous four years (Thomas & Titheradge, 2019). Other sources of evidence (NHS Digital, 2018) show that emotional problems e.g. anxiety and depression, in five to 15-year-olds have become more common for both boys and girls since 2004; whereas, other types of disorder, including behavioural difficulties have stayed broadly at the same level. Since the 2010 coalition, successive governments have pledged to tackle escalating mental health concerns and a Green Paper dedicated to children’s and young people’s mental health (Department of Health & Department for Education, 2017) set out measures to improve support by focussing particular attention on the pivotal role of schools.
Undoubtedly, mental health and wellbeing should be at the heart of children’s school experience. However, education staff feel ill-equipped to manage increasing demands and competing priorities, and research suggests this is having detrimental effects on their own wellbeing (Education Support, 2018). In the words of one teacher, ‘The government need to decide if they want us to be social workers, mental health workers or educators’ (Thomas & Titheradge, 2019). The implementation of school-based mental health interventions depends on good quality evidence and yet much work in this area is not sufficiently evidence-based (Vostanis, Humphrey, Fitzgerald-Yau & Wolpert, 2013). A recent systematic review of mental health initiatives in schools (O’Reilly, Svirydzenka, Adams & Dogra, 2018) concluded that statistically, the effect of the majority of interventions was small to moderate and there remained a need for a stronger and broader evidence base.
Interventions which facilitate children’s emotional expression; increase emotional literacy, and promote wellbeing are a crucial component of school-based strategies within which pupils can work to achieve their full potential – a priority set out in the Green Paper (DoH & DfE, 2017). During middle childhood, children experience an important period of change: their ability to recognise emotions in themselves and others increases; they have greater control over their emotions and are able to communicate more effectively about them, both expressively and with language. However, norms for the expression of emotion also change during this developmental stage and children are increasingly expected to modulate their emotions. The desire to support children to have greater control over their emotions is behind the evolution of ‘Book of Beasties’.
Developing Book of Beasties
‘Book of Beasties’ (BoB) is an intervention targeted at primary school children (aged 6-11 years), delivered in a small number of schools in the UK. At the time of writing, approximately 100 children had taken part in the programme since its launch in 2018. The BoB ethos is underpinned by the belief that every child should have the confidence to talk openly about their emotions and mental health. BoB aims to de-stigmatise mental health; promote wellbeing, and raise emotional literacy, ‘to inspire the conversation, normalise the subject [of mental health] and make it less daunting when experiencing difficulties’ (Book of Beasties, 2019, p.2).
The impetus for developing ‘Book of Beasties’ came from the creators’ personal experiences of mental health issues during their own childhood and adolescence, and the lack of support available at the time. Two clinical psychologists were consulted in the development of the specific features of each beastie – each of which aligns with symptoms associated with emotional disorders. The evolution of BoB has been practice-driven rather than led by a particular theoretical model or theory of change. Arguably, simply participating in pleasurable and fun activities increases wellbeing by providing an escape from daily stressors (Lyubomirsky & Layous, 2013). Nonetheless, a broad base of theoretical influences can be extrapolated including the therapeutic benefits of activity-based group encounters where children express emotional states through play and see that they share similar thoughts and feelings with their peers (a process known as universalisation). Links with positive psychology and competence enhancement models are also discernible. A meta-analysis of school-based interventions informed by positive psychology theories (Durlak, Weissberg, Dymnicki, Taylor & Schellinger, 2011) demonstrated that the availability of activities and opportunities for expressing feelings and thoughts, is an important component of successful programmes promoting mental health and wellbeing in children.
The game is delivered by trained school staff to groups of up to five children and can be implemented as a universal intervention or otherwise used with selected pupils referred by staff. Five, one-hour sessions are run consecutively with the same cohort on a weekly basis. BoB is accompanied by a manual which includes five comprehensive lesson plans. Core elements of the game are standard; however, there is in-built flexibility to pause and adapt play to suit the needs of each unique group. The game introduces 10 characters – the ‘beasties’ – each one embodies features (eg. self-consciousness or lack of energy) which may be associated with emotional difficulties (eg. anxiety or depression). The objective of the game is to help as many beasties as possible to overcome their worries by collecting special cards depicting ‘items’ that can be of assistance (for example, ‘Bellows’ help with calmer breathing); or a particular ‘comfort’, which can be a person, place or object (for example, ‘French rabbit’ is a cuddly toy, reminiscent of a favourite teddy a child would typically have).
At the start of the game, a story sets the scene and players are introduced to a team of characters who are also trying to help the beasties. Typically, two beasties per session are identified as the main ones in need of players’ help. So, for example, Populo is presented as sometimes getting ‘a foggy brain’ so she ‘loses her puff and can’t bring herself to do anything’ ( Book of Beasties , 2019, p.40). Children are encouraged to discuss how they might be feeling before play commences and at natural intervals during turn-taking. Time is allowed for discussing issues as they arise, such as: ‘What kind of things may cause you to get a foggy brain?’; and to do the linked wellbeing activities that can help (such as the deep breathing exercises practised in a fun way by making paper boats and blowing through straws to race them. Yoga, origami, arts and crafts, and mindfulness exercises are built into the game – they are sensory focussed and involve active (as opposed to passive) learning. This approach is supported by research (Durlak, Weissberg, Dymnicki, Taylor & Schellinger, 2011) which suggests that to achieve positive outcomes, interventions need to include participatory elements that concentrate on personal and socio-emotional skills.
Understanding ‘Book of Beasties’
The ‘Book of Beasties’ intervention runs for five consecutive weeks. Children complete a 6-item feedback questionnaire after their final BoB session, and school staff and parents/carers are invited to complete a 12-item questionnaire about the effectiveness of the programme. Qualitative data are also routinely collected from key stakeholders in the form of testimonials. However, no formal evaluation by an independent researcher was identified in either the published or ‘grey’ literature. In light of this and given that BoB does not align with an explicit theoretical model or theory of change (therefore lacking an evaluation framework), a single case study was set up to explore the intervention.
The right for children and young people to evaluate and inform practices and services targeted at them is increasing embedded in research designs and was a priority in this pilot study. The researchers’ main interest was to investigate the social validity of the programme: the acceptability, fitness of purpose, and satisfaction with the sessions perceived by the children, school staff and parents/carers. The aim was to gain an understanding of how beneficial (if at all) the sessions were in developing emotional literacy and promoting wellbeing for the children. A second aim of the pilot study was to test the suitability of selected, well-validated wellbeing and emotional literacy measures.
One West London school volunteered to participate in the research. Four pupils from Year 5 (aged 8-9 years) were allocated to the BoB group and four to the comparison group (two boys and two girls in each). Adult participants comprised two school staff who delivered the five BoB sessions and the parents/carers of the pupil participants (N=8). Quantitative measures were administered at baseline (before the first BoB session) and repeated after the final session. These comprised the Emotional Awareness Questionnaire (Rieffe, Oosterveld, Miers, Meerum Terwogt & Ly, 2008), Emotion Regulation Questionnaire (Gross & John, 2003), The Mood Questionnaire (Rieffe, Meerum Terwogt & Bosch, 2004), and the Parent-Rating Emotion Regulation Questionnaire ( Guzenhauser, von Suchodoletz & McClelland, 2017).
A focus group with the four children who participated in BoB was facilitated by one of the researchers . Focus groups can offer a less intimidating and a more supportive research encounter than one-to-one interviews, especially for children, as a group scenario can help mitigate perceived power differentials. A drawing activity was also incorporated so that the children were not limited to verbal responses. The study’s multi-method and multiple-informant approach included collecting observational data from the five BoB sessions and interview data from school staff and parents/carers, thus enhancing methodological trustworthiness.
Pilot study findings suggest that the selection of quantitative measures for pupils were suitable for examining the intervention effects with this age group and are therefore recommended for use in a full-scale evaluation of BoB. Thematic analyses of pupil and adult qualitative data revealed consistent findings. Overall, key stakeholders – parents, school staff (delivery agents) and children receiving the intervention – perceived BoB to be beneficial in terms of increasing emotional literacy and enhancing subjective wellbeing. Furthermore, integrating both quantitative and qualitative methods, and engaging multiple informants was deemed appropriate for the follow-up research on BoB.
‘Real world’ outcomes
The findings from this preliminary research will help inform the design of a full-scale evaluation of the ‘ Book of Beasties’ programme; one that will enable effectiveness outcomes to be robustly measured and underlying processes to be explored, thus enabling explicit links between theory and outcomes to be developed. Schools have not hitherto, always relied on the strength of research evidence to make implementation decisions regarding mental health and wellbeing initiatives. In part, this may have been due to the lack of evaluation literature. Nonetheless, the Department for Education’s unabated focus on school as the ideal setting to promote mental health and wellbeing commands a strong research agenda moving forward. This requires generating high-quality case studies to share with schools to promote best practice and evidence-informed commissioning. A cultural shift in schools is called for, whereby evidence-informed practice, derived from evidence-based research is embedded in whole school approaches to support and promote the mental health and wellbeing of all children and young people. The pilot research is a step in this direction and planned, further research on Book of Beasties will continue to blaze the trail towards this sea-change.
Book of Beasties (2019) The Beastie Guide . London: Book of Beasties Ltd
Department of Health & Department for Education (2017) Transforming children and young people’s mental health provision: A Green Paper. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf
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 , 82(1): 405-432
Education Support (2018) Teacher Wellbeing Index 2018. Retrieved from https://www.educationsupportpartnership.org.uk/resources/research-reports/teacher-wellbeing-index-2018
Gross, J.J. & John, O.P. (2003) Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology , 85: 348-362
Guzenhauser, C., von Suchodoletz, A. & McClelland, M.M. (2017) Measuring cognitive reappraisal and expressive symptoms in children: A parent-rating version of the emotion regulation questionnaire. European Journal of Developmental Psychology , 14(4): 489-497
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Rieffe, C., Meerum Terwogt, M. & Bosch, J. (2004) Emotional awareness and somatic complaints in children. European Journal of Developmental Psychology , 1: 37-47
Rieffe, C., Oosterveld, P., Miers, A.C., Meerum Terwogt, M. & Ly, V. (2008) Emotion awareness and internalising symptoms in children and adolescents: The Emotion Awareness Questionnaire revised. Personality and Individual Differences , 45: 756-761
Thomas, E. & Titheradge, N. (2019) Mental health: Primary school head teachers speak out about lack of support. Retrieved from https://www.bbc.co.uk/news/av/education-49018831/mental-health-primary-school-head-teachers-speak-out-about-lack-of-support
Vostanis, P., Humphrey, N., Fitzgerald-Yau N. & Wolpert, M. (2013) How do schools promote emotional well-being among their pupils? Findings from a national scoping survey of mental health provision in English schools. Child and Adolescent Mental Health, 18 (3): 151–157