Emotional and behavioural difficulties and mental (ill)health

The collaboration between health and education–based practitioners is essential to support children who struggle to cope with school, yet is often impeded by linguistic and conceptual misconceptions of each other’s worlds and pressures. We are delighted therefore, to edit this special issue of Emotional and Behaviour Difficulties, which we hope will bring these two groups closer together. The language used below reflects that in the literature quoted, and is not necessarily an endorsement of the application of such terminology in practice, but an accurate description of what was measured. Psychiatric disorder is used to describe studies that have applied structured diagnostic assessments that relate to the World Health Organisation’s International Classification of Disease and/or the American Psychiatric Association’s Diagnostic and Statistical Manual. The term psychological distress is applied when studies have used standardised questionnaires to measure the children’s difficulties and impairment refers to the impact on a child’s ability function and the distress/burden to the child and others related the child’s predicament.

Several overlapping populations of children could be conceptualised as having poor mental health: those in difficult circumstances that place them at risk of developing diagnosable psychiatric disorder, which includes special educational needs; those with diagnosable psychiatric disorder, and those whose poor mental health and/or difficult psychosocial circumstances impairs their ability to function (Wolpert 2009). Most of the papers in this special issue focus on children who meet diagnostic criteria for psychiatric disorder AND whose function is impaired, many of whom will have special educational needs in addition to and/or as a result of their psychological difficulties.

Childhood psychiatric disorders are increasingly common, persistent and associated with a range of adverse outcomes including exclusion from school, educational failure, adult psychiatric disorder, risk-taking behaviour and criminality.(Kim-Cohen et al. 2003; Collishaw et al. 2004; MacDiarmid et al., forthcoming; Whear et al. 2013) Epidemiological surveys that span many countries and over 50 years estimate the prevalence of psychiatric disorders among school-age children to lie between 3–22% (Canino et al. 1995; Offord 1995; Roberts, Attkisson, and Rosenblatt 1998; Costello, Egger, and Angold 2005). The British Child and Adolescent Mental Health Surveys in 1999 and 2004 (Meltzer et al. 2000; Green et al. 2005) both reported the prevalence of psychiatric disorder to be approximately 10% among school-age children and imply that two to three children in an average class of 20–30 will be significantly impaired as a result of their poor mental health. A new survey is planned that will report in 2018 and updated figures are eagerly awaited.

For each child who meets diagnostic criteria, there are probably three or four others with poor mental health, as when psychological distress is measured using a dimensional approach, there is a continuous spectrum of psychological functioning. That is to say that those who are struggling do not form a discrete group (Figure 1), although the proportion with disorder has a linear association with mean symptoms scores (Goodman and Goodman 2011). The level of impairment for any given constellation of difficulties will be influenced by the social and psychological predicament of the individual, something explored in relation to Attention Deficit Hyperactivity Disorder and school context in this issue (Gwernan-Jones et al). The substantial societal costs of antisocial behaviour in young people are not restricted to those with the highest level of problems, but are also evident among the more numerous children with lower levels of difficulty (Scott et al. 2001). While the long-term debate rages about the (ab)use of diagnostic categories and dimensional approaches (Rose and Day 1990; Doherty & Owen, 2014) the implication for those working with children in any capacity is clear; many children are struggling, and effective interventions could potentially improve functioning across the whole population as well as those currently experiencing difficulties (Huppert and So 2013). The latter is often stated, but remains to be empirically demonstrated, and relates to the complex issue of whether we should screen children for poor mental health in schools explored further by Humphries and Wigelsworth in this issue.

Figure 1. Frequency distribution of scores on the Strengths and Difficulties Questionnaire (SDQ) as reported by teachers, parents and young people from the British Child and Adolescent Mental Health Survey of 7998 children aged 5–16. Parents and teacher reports were sought from all children while young people completed the SDQ if aged 11 or over.

Children should not be expected to ‘grow out’ of psychiatric disorders. Half the children with a psychiatric disorder at baseline from both British Child and Adolescent Mental Health Surveys combined also had a psychiatric disorder three years later (MacDiarmid et al., forthcoming). Some factors that predicted persistence were potentially tractable, such as neurodevelopmental disorder, intellectual disability and parental psychopathology. In the Great Smoky Mountain Study, a population-based overlapping cohort study of children aged 9–13 years; those with childhood psychiatric disorder were three times as likely to have a disorder in subsequent waves in childhood as well as adulthood (Costello et al. 2003; Copeland et al. 2014). Similarly, half of the adults with psychiatric disorder at age 26 years in the prospectively studied Dunedin cohort had a psychiatric disorder before the age of 15 years, increasing to three quarters by age 18 years, and higher still among mental health service users in adulthood (Kim-Cohen et al. 2003). Similar findings emerged from retrospective enquiry in adults in the replication of the National Comorbidity Survey (Kessler et al. 2005). The implication is that effective prevention and/or intervention in childhood may reduce the burden of mental ill-health in adulthood as well as alleviating distress and improving functioning among children. The ethics of access to effective intervention notwithstanding, children who function better are likely to learn better.

Mental health-related service contact for childhood psychiatric disorder involves all public sector services (Ford et al. 2007); children’s mental health really is everybody’s business. In this issue, Paget and Emond explore the role of community paediatrics and other non-education-based agencies in the support of children are excluded from school, given that links between schools and community paediatrics have weakened considerably over recent decades, while Russell and colleagues report teachers’ views and experiences of teaching children who have ADHD. The parents of British school-age children reported more contacts with teachers about mental health related issues than any other professional group or service (14% of all children, 41% of those with psychiatric disorder at baseline over the next three years (Ford et al. 2007). Surprisingly, the same proportion of families were in contact with specialist education practitioners as with mental health services (5% of all and 25% with psychiatric disorder), with little overlap between access to the two services. The costs of these additional mental health related activities to schools (£799.2 million) and specialist educational services (£508.8 million) dwarfed those to other public sector services (£162.8 million for health and welfare combined; 2007–8 prices) (Snell et al. 2013). There were marked inter-individual variation in both levels of service utilisation and costs, which suggest inequalities in the way that public sector services are identifying and responding to the mental health needs of children and young people, and also to inefficiencies in the use of scarce resources (Knapp et al. 2015). Factors other than the severity of psychological distress that predicted service costs included some tractable issues, such as reading attainment and parental psychopathology. Effective reading remediation or the active treatment of parental depression might support the recovery of some children’s mental health and may reduce the burden of mental-health related demands on the education system. Reading remediation is clearly the remit of education, and parent support advisers are well placed to encourage parents to seek help if significantly depressed.

While several papers in this issue address the experience and/or attitudes of practitioners in relation to the support of children who struggle in school (Nye et al, Moore et al, Paget and Emond, Gwernan-Jones et al, Russell et al.), there are also some school-specific stressors that may adversely influence mental health. Bullying is probably the most tractable public mental health problem (Ford, Mitrofan, and Wolpert 2014; Scott et al. 2014). It is sadly a common experience that is frequently linked to school; a recent UK survey revealed that 43% young people had been bullied at some point, with nearly half of them reporting that victimisation occurred at least once per week (Ditch the Label 2015). Bullying may precipitate or aggravate depression, anxiety, psychosomatic symptoms, eating difficulties and self-harm; and is associated with suicide (Copeland et al. 2013; Lereya et al. 2013; Lösel and Bender 2011; Ttofi et al. 2011). A ‘dose-response’ exists so that children exposed to frequent, persistent bullying have higher rates of psychiatric disorder (Bond et al. 2001). People are often bullied because of some perceived difference, which includes poor mental health and/or special educational needs (Anti-bullying Alliance 2014) and childhood experiences of bullying can cast a shadow into adulthood mental health when it predicts an increased prevalence of anxiety, depression and self-harm (Meltzer et al. 2011). Classroom management and social structure are associated with substantial differences in the level of reported bullying (Roland and Galloway 2002) and whole-school interventions are more effective than curriculum-based interventions or behavioural and social skill training (Vreeman and Carroll 2007). We can and should do more to implement effective anti-bullying programmes, and the lack of a paper to include on bullying highlights the scope for more research in this area.

We should not forget that teaching can be a highly stressful occupation with poor retention and currently worsening recruitment, particularly at secondary school level (Official Statistics 2015). A recent study of secondary school teachers reported alarming rates of depression (Kidger et al. 2016). Teachers report that stress resulting from disruptive behaviour is central to burnout and exit from the profession (Kokkinos 2007). A recent review of school-based interventions for children with ADHD revealed a significant tension for teachers between tending to the additional needs of some pupils and those of the rest of the class as explored by Moore and colleagues in this issue. Austerity across high income countries is reducing access for children and teachers to external supports, which is likely to have a large impact on teachers and educational specialists, and therefore children with special educational needs. The ‘burnout cascade’ (Jennings et al. 2013) whereby difficulties with behavioural management lead to a decreased sense of self-efficacy and negative consequences for teacher-pupil relationships with a more reactive and negative classroom environment, may damage both teacher and child mental health. This is important because poor teacher-pupil relationships predict the onset of childhood psychiatric disorder, exclusions (Lang et al. 2013) and lower academic attainment (Cadima, Leal, and Burchinal 2010). Given these issues, we are delighted to include a paper by De Mauro and Jennings that explores professional self-efficacy among student teachers as well as the paper by Russell and colleagues that reports the experiences and views of teachers working with pupils who have ADHD.

Finally, conduct disorder, or challenging behaviour is the commonest childhood psychiatric disorder (Meltzer et al. 2000; Green et al. 2005). While we could have a lengthy and interesting philosophical discussion about whether challenging behaviour should receive a psychiatric diagnosis, childhood conduct disorder predicts all adult psychiatric disorders including anxiety, depression and psychosis, as well as substance misuse and personality disorder (Kim-Cohen et al. 2003). It also is strongly linked to exclusions from school, as are other psychiatric disorders (Parker 2014), so early and effective intervention is essential. Exclusion has profound impacts on all concerned, and sadly is commoner among those with special educational needs (Department for Education 2014, 2015). The experiences of parents related to the exclusion of their children are explored by Parker et al, while Paget and Emond explore the role of non-education services in supporting these children.

We have greatly enjoyed collating this special issue and hope that it stimulates interest and debate about the mental health of children who have special educational needs among the readership of this journal.

Disclosure statement

No potential conflict of interest was reported by the authors.