Guidance

School-aged years high impact area 1: Supporting resilience and wellbeing

Updated 19 May 2021

Applies to England

Children and young people’s mental and emotional wellbeing is a significant public health priority. Young people’s own views on their feelings and emotions are valuable indicators of their overall mental health and wellbeing, and their ability to participate in school, to learn and socialise. Particular groups of children have significantly worse outcomes linked, for example, to gender, socioeconomic status, ethnicity, disability, sexual orientation, being a child in care or being in the youth justice system.

The latest prevalence survey for England highlights the number of children and young people with a diagnosable mental health condition. Rates of probable mental disorders have increased since 2017. In 2020, 1 in 6 children (16%) aged 5 to 16 years were identified as having a probable mental disorder, increasing from 1 in 9 (10.8%) in 2017. The increase was evident in both boys and girls.

Teenage mothers have higher rates of poor mental health for up to 3 years after the birth of their child.

In 2014, 18% of young people aged 11 to 15 reported they had experienced some form of cyberbullying in the past 2 months. Surveys of further education and the university sector report significant increases in the number of students with mental health difficulties.

A near to real time surveillance report about population mental health and wellbeing in England was developed during the COVID-19 pandemic. It includes updated indicators from multiple sources and summarises important findings from ongoing surveys and studies to inform policy, planning and commissioning in health and social care.

The government has set out its vision for a step-change in children and young people’s mental health. Future in Mind (2015) highlighted the need to build resilience, promote good mental health, promote prevention, and provide early identification and co-ordinated support. The 5-Year Forward View for Mental Health (2016) set out an ambition for transforming mental health services to achieve greater parity of esteem between mental and physical health for children, young people and adults. Department for Education (DfE) jointly published Transforming children and young people’s mental health: a green paper, setting out 3 proposals for designated mental health leads in all schools, new mental health support teams prioritised in working with children experiencing mild to moderate mental health problems and trialling reduced waiting times for specialist mental health services.

The NHS Long Term Plan reaffirms the commitment to achieve parity of esteem for mental health services and made a new commitment that funding for children and young people’s mental health services will grow faster than both overall NHS funding and total mental health spending. The Plan sets out a comprehensive offer for children and young people extending to those up to the age of 25 and aims to identify and treat mental ill health at the earliest possible point.

Article 12 of the United Nations Convention on the Rights of the Child says that children and young people should have a say in decisions that affect their lives. School councils can provide a meaningful way in which pupils can voice their opinions and have their views taken into account in decisions which impact upon them, giving young people a platform to express themselves.

Adverse Childhood Experiences increase the individual’s risk of health-harming behaviour. For every 100 adults in England, 48 have suffered at least one adverse childhood experience during their childhood and 9 have suffered 4 or more.

Children and young people with mental health problems are more likely to have parents with mental health problems and, conversely, parental mental illness is associated with increased rates of mental health problems in children. Rates of mental disorder tended to be highest in children living with a parent with poor mental health or in children living with a parent in receipt of disability related income.

Just over half of all UK children will have had a mother who has experienced mental illness by the age of 16. Of women living with a mental illness, 68% are parents, compared with 57% of men living with a mental illness. In addition, many children live with a parent who has long-term mental health problems, along with alcohol or drug problems and personality disorders.

Taking a preventative approach can yield both individual and wider system benefits, contributing to outcomes such as educational attainment, workplace productivity, reduced crime and a reduction in the demand for mental health services. Early intervention during childhood can prevent problems from escalating and continuing into adulthood.

School-based programmes to prevent bullying and school based social and emotional learning programmes delivered as part of personal, social, health and economic education (PSHEE) have been identified as cost-effective prevention activities focussed on promoting good mental health and reducing some of the impacts of poor mental health.

Promoting children’s and young people’s resilience is an important part of a public health approach to securing good outcomes for this age group. Resilience is the capacity to bounce back from adversity and children and young people may be exposed to a number of challenges as they are growing and developing. Protective factors increase resilience, whereas risk factors increase vulnerability. Resilient individuals, families and communities are more able to deal with difficulties and adversities than those with less resilience.

Developing resilience in children and young people is critical to enabling them to achieve the best possible outcomes regardless of the difficulties they may face. Many children and young people experience a wide range of challenges to their wellbeing. Some threats are very serious, such as maltreatment and neglect, but children and young people also must be resilient in the face of more ordinary everyday pressures such as family disruption and academic stress. The aim is to support successful coping or ‘bouncing back’, and adaptation to life tasks in the face of any kind of disadvantage or adversity.

Building resilience is important for all young people aged 10 to 24 years, because of the number of significant life events and challenges that occur in the transition from being a child at home, to becoming a self-supporting adult. Times of transition have been identified as critically important in developing and there are many transition points during this time, including the transition from primary to secondary school, to further and higher education or employment, from home to independent living, and for some the transition from the child services to adult services.

Poor mental health is both a contributor to, and a consequence of, wider health inequalities. School nurses support children and young people’s mental health issues on a daily basis. Working with partner agencies, they have a crucial role in positive mental health promotion and in providing therapeutic support for mild to moderate mental health problems within a family context. School nurses help to create confident communities and brighter futures for all, ensuring emotional health and wellbeing is promoted and seamless services are provided.

In addition, they are skilled in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating. School nurses work both in and out of school settings and delivery models will vary between local authorities. However, the commissioning guidance offers a robust framework.

The role of school nurses

School nurses and their teams are in a unique position to build trusting and enduring professional relationships with children and young people throughout their time in education to enable them to become confident and healthy adults. It is essential that young people in secondary education or college can have access to safe, confidential and accessible services when they need health support and advice.

Working with parents and families and partner agencies, school nurses identify the most appropriate level of support and intervention for individual and population needs. Although school nurses provide leadership, they will need to work with partners to deliver a comprehensive programme of evidence-based interventions.

School nurses and their teams provide a crucial interface between children, young people and families, communities and schools having defined skills to support holistic assessment of the health and wellbeing needs of children and young people. They provide health promotion, prevention and early intervention approaches to support individual, community and population health needs.

Using their skills with the wider health and care system and their trusted relationships with other partners helps to support and enable place based and whole school action to address health inequalities. Their involvement in delivering evidence-based interventions including HPV and other immunisation programmes in the teenage years, also provide opportunities for health promotion to support behaviour change.

School nurses deliver care in the most appropriate setting for the local community, using the principles of the You’re Welcome Quality Criteria. This includes using technology to improve access and support for children, young people and families.

Healthy Child Programme

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

Universal

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

Personalised

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ to improve outcomes.

Improving health and wellbeing

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

• individual and family
• community
• population

The place-based approach offers opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, and duplication of or gaps in service provision. School nurses, as leaders in public health, are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

School nurses have defined skills to support holistic assessment of children and young people’s mental health and wellbeing needs. They can provide mental health promotion, prevention and early intervention approaches.

Access to services needs to be timely and responsive to individual and family needs. School nursing teams work collaboratively with other health professionals, including GPs, Child and Adolescent Mental Health Services (CAMHS) and wider stakeholders – for example, education, youth services and social care – when supporting children to become more resilient and improve their emotional wellbeing.

It is important to ensure services are delivered in locations and at times that are appropriate to children’s needs. This may include home visits or community locations as well as schools.

Working together with education, school nursing services support children and families to socially integrate into the school community, promoting transition and school readiness. School nursing teams are well placed to identify children and young people who may require additional support such as children with disabilities, children in care, and young carers. They are also appropriately placed to identify children whose parent or parents suffer from mental health problems or who would benefit from signposting, co-working with, or referrals to, more specialist services such as CAMHS.

This can be achieved by:

• recognising that the importance of good relationships with family, friends and others is paramount in building resilience
• identifying and considering strengths versus risk when working with families
• recognising that parental wellbeing can affect the child’s emotional health and wellbeing and resilience
• ensuring early identification of need and provision of evidence based family centred support
• actively supporting children and young people, providing a joint and holistic approach to support the child and family

Community

School nurses are important local leaders, working collaboratively with local authorities, primary, secondary and specialist services. School nurses have specialist public health skills to identify and be responsive to needs. They are innovators in service development, assessing health needs and helping to influence changes where needed, ensuring that young people with mental health problems receive high quality care within school nursing services and beyond.

School nurses can lead the implementation and delivery of group-based support and other preventive or early interventions to promote positive mental health, such as promoting physical activity. School nurses can provide direct support to children, young people and parents and carers, act as advocates, and link young people with specialist voluntary services to address health and wellbeing needs.

School nurses are key professionals in promoting positive mental health, working with individual young people and with schools, parents and other partners to enhance early support.

They have accessible information and resources on physical health and wellbeing and are aware of services to signpost young people to that promote healthier lifestyles.

School nurses and their teams make an important contribution to the safeguarding of children and young people through early identification, recognition and referral of children who are at risk of or suffering from harm through their knowledge and understanding of the health needs of children, young people, families and communities.

Population

All children have access to the universal Healthy Child Programme (5 to 19), which is led by school nurses as specialist public health nurses. Advocating for families with mental health difficulties, school nurses have a crucial role within multi-disciplinary pathways, providing effective and supportive mental health care to children and young people.

School nurses can help to develop local care pathways and provide training, consultation and support for school nursing teams and other professionals working with children and young people. Their role is crucial in the delivery of effective mental health and wellbeing care.

Working as local leaders, school nurses can influence wider opportunities to improve children and young people’s mental health, with the focus on joined up working. They understand a whole school approach is essential to the success of schools in tackling mental health and promoting resilience in children and young people.

Through a range of different opportunities, school nurses can help schools to support pupils with mental health needs, including mental health awareness training for staff.

School nurses can work with schools in the implementation of new relationships, sex and health education guidance which is statutory for all schools. Ensuring all pupils are aware of and know how to access local services is a requirement of the new guidance.

They can influence local transformation plans to focus on children and young people’s mental health as reflected in their local Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy.

School nurses can work with education to embed a whole school approach to mental health and whole systems approaches in colleges and universities. This includes working with NHS children’s mental health and education providers to support early intervention and support.

Using evidence to support delivery

A place-based, or community-centred, approach aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing.

The All Our Health framework brings together resources and evidence that will help to support evidence-based practice and service delivery, Making Every Contact Count and building on the specialist public health skills of school nurses.

Most health and care professionals focus on interventions which tend to be delivered on an individual basis, however health visitors and school nurses focus on individuals, families and communities. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches, enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. School nurses recognise that children and young people’s health is determined primarily by a range of social, economic and environmental factors; social prescribing seeks to address the needs of each individual in a holistic way, allowing people to take greater control of their own health.

Measures of success or outcome

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision-making process for the commissioning of services and plans to improve people’s health and reduce inequalities in their area. Outcome measures could include Public Health Outcomes Framework and NHS Outcomes Framework, child and maternal health profile indicators, measures of access and service experience.

School nurses and wider stakeholders need to demonstrate impact and evidence of improved outcomes. This can be achieved by using local measures.

Access

Measures include:

• number of children with emotional health and wellbeing issues who have access to the school nursing service
• number of children and young people accessing a school nurse
• number of children and young people who show improved mental health following interventions by school nurse
• number of referrals to specialist services

Effective delivery

Measures include:

• local CAMHS and multi-agency pathways in place
• measurable improvements in children and young people’s emotional wellbeing
• population needs met through provision of local services, including GP and counselling services

Measuring impact

Measures include:

• percentage of children achieving a good level of development at the end of reception year, published by DfE and available in Public Health Outcomes Framework and in the early years profiles
• patient Reported Outcome Measures, for example, children and young people report that they are more able to cope, are less anxious, have strategies to use and know how to access help
• pupil absence indicator
• number of first-time entrants to youth justice system
• number of 16 to 18 year olds not in education, employment or training
• under 18 and under 16 conception rates
• number of finished admission episodes in children aged between 10 and 24 years where the main cause is intentional self-harm, available in Child Health Profiles and in the Young People’s Profiles
• number of hospital admissions in children aged between 10 and 14 years where the main cause is intentional self-harm, available in Young People Profiles
• hospital admissions in children aged between 15 and 19 years where the main cause is intentional self-harm, available in Young People Profiles
• average difficulties scores for all children in care aged between 5 and 16 at the date of their latest assessment, who have been in care for at least 12 months as of 31 March, available in Public Health Outcomes Framework

User experience

Measures include:

• feedback from children, young people and families via the NHS Friends and Family Test, You’re Welcome accreditation and local service surveys

Other measures can be developed locally and could include local pathways and partnership approaches to supporting vulnerable children and young people, for example referrals to young carers groups, engagement of previously disengaged vulnerable children and young people with services for example school nursing led sexual health services

Connection with other areas

The high impact area documents have been developed to support delivery of the Healthy Child Programme and 5 to 19 agenda, and to highlight the link with a number of other interconnecting policy areas, for example childhood obesity, troubled families, mental health, drugs, immunisation, and social mobility. The importance of effective outcomes relies on strong partnership working between all partners in health (primary and secondary), local authority including education services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of Public Health England’s (PHE) 5-year Strategy which runs from 2020 to 2025. Best Start in Life is a priority for government and as such is included in the Prevention Green Paper (Advancing our health: prevention in the 2020s).

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy includes a range of work which underpins these plans including maternity and community data sets and implementation of the eRedbook (parent health child health record). A major contribution to achieving these ambitions and strategies is the modernisation of the Healthy Child Programme.

Collaborative working

Approaches to improving outcomes through collaborative working include:

• Public Health Outcomes Framework indicator reported and benchmarked by PHE and local authority
• revised commissioning guidance service specification 0 to 19
• information sharing agreements in place across all agencies
• integrated commissioning of services
• partnership working with schools to support integrated planning, delivery, monitoring and review
• information sharing from Joint Strategic Needs Assessment (including health data and information about families and communities) to identify and respond to joint priorities
• demonstrate value for money and return on investment

Improvements

These include:

• improved accessibility to mental health services for vulnerable groups
• improved engagement with children and young people and co-production of services to make them young people friendly
• integrated IT systems and information sharing across agencies
• development and use of integrated multi-agency pathways
• systematic collection of user experience NHS Friends and Family Test and You’re Welcome, local authority engagement and consultations with young people and families to inform action
• increased use of evidence-based interventions and links to other 5 to 19 performance indicators
• improved partnership working with schools, GPs, CAMHS, oral health services, sexual health services, alcohol and drug services, secondary care, children and young people and families
• consistent health and wellbeing messages and information for children, young people, parents and carers
• early identification of strengths and risks of the child or young person, young people not in education, employment or training

Professional or partnership mobilisation

These include:

• multi-agency training and supervision to identify strengths and risk factors and early signs of health and wellbeing issues
• multi-agency training, working in partnership with young people to identify strengths and needs to inform a holistic assessment
• multi-agency training in approaches for young-people-friendly services and interaction with children and young people
• multi-agency training in evidence-based early intervention and safeguarding practices
• effective delivery of universal prevention and early intervention programmes
• improved understanding of data within the Joint Strategic Needs Assessment and at the local Health and Wellbeing Board
• integrated working of school nursing services with existing local authority arrangements to provide holistic or joined-up and improved services for children, young people, parents and families. This includes effective joint working with specialist substance misuse services, CAMHS, sexual health services and Troubled Families teams
• identification of the necessary skills and competencies to inform integrated working, workforce development and skill mix
• increased integration and working with schools to ensure a whole school approach to provide a range of services or activities to promote health, emotional wellbeing and resilience

Associated tools and guidance

Policy

Children and Families Act 2014

Digital Child Health, NHS Digital, 2020

Friends and Family Test, NHS England, 2020

Improving young people’s health and wellbeing: a framework for public health, PHE, 2015

Improving social mobility through education, DfE, 2017

Local action on health inequalities: Building children and young people’s resilience in schools, PHE and UCL Institute of Health Equity, 2014

NHS Long Term Plan, NHS England, 2020

Working Together to Safeguard Children, DHSC, 2018

NHS England: Social Prescribing, NHS England, 2020

You’re Welcome quality criteria, Department of Health, NHS England, 2011

Transforming children and young people’s mental health provision: a green paper

PHE Strategy 2020-2025, PHE, 2019

Research

About the All Our Health programme, PHE, 2020

All Our Health: Early Adolescence, October 2019

A public health approach to promoting young people’s resilience, Association for Young People’s Health (AYPH), 2016

An RCN toolkit for school nurses: developing your practice to support children and young people in education settings, Royal College of Nursing, 2019

National household survey of adverse childhood experiences and their relationship with health-harming behaviours in England, Bellis MA and others, 2014

Explore resources on Health Equity and the Social Determinants of Health, Institute of Health Equity, 2020

Place-based systems of care: A way forward for the NHS in England, Ham C and Alderwick H, 2015

Healthy Child Programme e-Learning for Healthcare

Future in Mind: promoting, protecting and improving our children and young people’s mental health and wellbeing, Department of Health, 2015

Incidence, clinical management and mortality risk following self-harm among children and adolescents: cohort study in primary care, Morgan C and others, 2017

Key Data on Young People 2019, AYPH, 2019

Chapter 12: Youth Justice, Lennox C and Khan L, 2012

Local Authority Health Profiles, PHE, 2020

Mental health promotion and mental illness prevention: The economic case, DHSC, 2011

NSPCC

Rise Above

Stability Index, Children’s Commissioner, 2019

Statistics on childhood and adolescent mental health, NHS Digital, 2017

Strengths and Difficulties Questionnaire

The Incredible Years

Parental mental illness: the impact on children and adolescents: for parents and carers, Royal College of Psychiatrists, 2020

The Prevention Green Paper: A Chance to turn talk into action, PHE, 2019

Understanding provision for students with mental health problems and intensive support needs, Lancaster University, 2015

Universal approaches to improving children and young people’s mental health and wellbeing, PHE, 2019

Report of the findings of a special interest group, PHE, 2019

Wave Trust

Young Minds

Guidance

Collection immunisation schedule: Immunisation for health professional and immunisation, PHE, 2019

Collection immunisation schedule: Immunisation for practitioners, PHE, 2019

Getting it right for children, young people and families: Maximising the contribution of the school nursing team: Vision and call to action, DHSC, 2012

Healthy child programme 0 to 19: health visitor and school nurse commissioning, PHE, 2018

Prevention concordat for better mental health, PHE, 2017

Alcohol, drugs and tobacco: commissioning support pack, PHE, 2018

Best start in life: Promoting good emotional wellbeing and mental health in children and young people, Local Government Association (LGA), 2016

Bright Futures: CAMHS, LGA

Local transformation plans, NHS England

Measuring and monitoring children and young people’s mental wellbeing: A toolkit for schools and colleges, PHE, 2016

Meeting the health and wellbeing needs of young carers, LGA, 2018

Mental health and behaviour in schools: Departmental advice for school staff, DfE, 2016

Mental health, resilience and inequalities, WHO, 2009

Mind-ed

No Health Without Mental Health,, HM Government, 2011

Ourtime

Parental mental illness: The impact on children and adolescents, Royal College of Psychiatrists

Preventing suicide in England: One Year on: First report on the cross-government outcomes strategy to save lives, DHSC, 2014

Prevention Concordat for Better Mental Health, PHE, 2017

Promoting children and young people’s emotional health and wellbeing: A whole school and college approach, PHE, 2015

Solihull approach

Subjective wellbeing in adolescence and teacher connectedness, Garcia-Moya and others, 2014

Suicide prevention strategy for England: Policy paper, DHSC, 2012

The Good Childhood Report 2020, The Children’s Society, 2020

The 5-Year Forward View for Mental Health, The Mental Health Taskforce, 2016

Time to Change

Working with schools to improve the health of school aged children, LGA, 2017

Working together to safeguard children, DfE, 2019

Young Minds

Youth MHFA courses, Mental Health First Aid

NICE guidance

Attention deficit hyperactivity disorder: diagnosis and management, NICE guideline [NG87], 2018

Depression in children and young people: identification and management, NICE guideline [NG134], 2019

Health and wellbeing of looked-after children and young people, NICE quality standard [QS31], 2013

Self-harm in over-8s: Short term management and prevention of recurrence, NICE clinical guideline [CG16], 2004

Social anxiety disorder: recognition, assessment and treatment of social anxiety disorder, NICE clinical guideline [CG159], 2013

Social and emotional wellbeing: early years, NICE public health guideline [PH40], 2012

Social and emotional wellbeing in primary education, NICE public health guideline [PH12], 2008

Social and emotional wellbeing in secondary education, NICE public health guideline [PH20], 2009