Professor Umar Toseeb Hello and welcome  to this ACAMH debate on “Where Next for   Universal School-based Mental Health  Interventions?” My name is Umar Toseeb,   I’m a Professor of Psychology and Education at  the University of York. I’ll be chairing the   debate. This debate follows a series of articles  that were published in the February issue of the   “Child and Adolescent Mental Health Journal” on  the same topic. Researchers who contributed to   the February issue are joining us today to share  their positions on the topic. I’ll start by going   around the room and asking the guests to introduce  themselves. Louise, should we start with you? Dr Louise Birrell Sure. Thank you so much for  having me. My name’s Louise Birrell. I’m a Senior   Research Fellow based at the Matilda Centre for  Research in Mental Health and Substance Use. Professor Umar Toseeb Bronwynè. Professor Bronwynè Coetzee Thanks very  much. Hi everyone. My name is Bronwynè   Coetzee and I’m an Associate  Professor of Psychology in the   Department of Psychology at Stellenbosch  University in South Africa. Thank you. Professor Umar Toseeb Emma. Dr Emma Carter Hi, sorry, my name is Emma  Carter and I work as a McKenzie Research   Fellow at the Assessment and Evaluation  Research Centre at the Faculty of Education,   University of Melbourne. It’s a pleasure to be  part of this panel discussion today. Thank you. Professor Umar Toseeb Jack. Dr Jack Andrews Hi, thanks,  Umar. Yeah, so I’m Jack Andrews,   I’m a Wellcome Trust Fellow  at the University of Oxford. Professor Umar Toseeb And finally, Lucy. Dr Lucy Foulkes Hi, I am Lucy Foulkes,  I’m a Prudence Trust Research Fellow at the   Department of Experimental Psychology in Oxford. Professor Umar Toseeb Thank you, everyone. So, in  terms of the context of this debate, there’s been   a rise in the reported mental health difficulties  in children and young people in recent years,   and Researchers have been working to find ways  to support children and young people with their   mental health. One approach, which is the focus  of this debate, is “universal school-based mental   health interventions.” Now, these interventions  are delivered to everyone in a class or a school,   irrespective of whether they’re experiencing  mental health difficulties or not. And   they’re usually based on the principles of  mindfulness or cognitive behavioural therapy. One aim of these interventions is to prevent  mental health difficulties before they arise. Now,   the Researchers on this call, there’s  a number of things that they agree on,   and then there’s some things that they don’t  necessarily agree on. So, in terms of what   they do agree on is that universal interventions  in their current form don’t work. So, at best,   they have very small effects, or at worse, they  do harm. And they also agree on the fact that   we need to pause and reflect and consider the  evidence before deciding on where to go next. So,   what I’ll now do is go around the room again and  ask each of the Researchers to briefly summarise   their position in terms of the suggestions to  move forward. Again, I’ll start with Louise. Dr Louise Birrell Thank you, Umar. So, it  is a real pleasure to be here today with   other colleagues who are equally passionate about  youth mental health, and I’d like to thank all of   the authors on the call today, as well as other  responses to the article and I’m really looking   forward to a constructive debate today. But I have  worked in school-based research for over ten years   now. I started as Project Co-ordinator of one  of the largest school-based trials in Australia.   We worked with over 71 schools and 6,000  students and since then, have worked with over   seven randomised controlled trials of school-based  interventions, both universal and selective. So,   I can talk to both of those approaches,  and alongside that, my partner is a School   Teacher and we actually lived in a school for  four years in a boarding house with students. So, I feel like I’ve got a lot of  different perspectives on this debate,   both from my research world and also hearing  on the ground from schools what’s happening.   But it is a really important topic to think about  where do we go next with universal school-based   mental health interventions? So, it’s a  topic that has sparked considerable debate,   not just from us. I think originally, Pim  Kuipers had a number of articles around the   crossroads for these universal approaches. And  some argue now the evidence base is too weak,   these programmes are ineffective, even harmful,  and I think we’ll hear that perspective today. But   we wanted to come to this debate with a slightly  more nuanced perspective, so one that acknowledges   the complexity of the issue, as well as the  importance of context, evidence and adaptation. So, the reality is schools are under increasing  pressure to address student mental health, and   in response, many programmes are being implemented  in schools. So, that’s the case here in Australia.   I’m sure it’s the case in other places too.  But there are a lot of programmes being   implemented in schools, many with no evidence  or evaluation, and some with weak evidence,   and this is deeply concerning. So, as  Prevention Scientists, practitioners,   I think we all agree we have a responsibility to  develop and evaluate interventions rigorously in   the school context and also ensure they’re  implemented thoughtfully and appropriately. And just without being too long-winded, a  brief history to this debate is that there   were systematic reviews, meta-analyses that  showed on balance, universal approaches for   anxiety and depression, and that’s what I’ll be  focusing on and I think most of us are focusing on   in this debate. So, I won’t be covering prevention  of other mental health concerns, like psychosis   or eating disorders, but we’re focusing in on  the evidence for internalising. These reviews   showed on balance, a small net positive benefit,  but they were small and short-term benefits,   and there were criticisms around the quality  of those included studies. But since then,   we’ve seen some large, well-powered, gold standard  randomised trials, most notably MYRIAD in the UK,   CSC in Australia, which I’ve been involved  in and we’ll draw on mostly in this debate,   which importantly, showed no significant  differences in their primary mental health   outcomes when delivered in this universal  way, but that’s not the full story. So, if I look at the CSC Trial and draw  on that trial that I was involved in,   when we looked at the combined intervention  running a universal mental health programme and   a substance use education programme, we did see  reduced growth in anxiety at 30 month follow-up,   and improved mental health knowledge. But we  also saw small short-term increases in the   analysis Jack led in internalising symptoms. And  this was a small effect that then disappeared,   but it gave us enough reason to pause  and look at the programme and think   really carefully about this approach, but it is  important that we contextualise these findings. So, both in MYRIAD and a lot of these other large  trials, and they’ve taken interventions to scale,   there has been significant implementation  challenges working with schools. Meaning   that sometimes students haven’t actually  received the large dose of the intervention   that they were meant to. There’s also  been a lack of engagement with youth,   as well as the realities of doing these  large-scale public health approaches in   schools which play a role. So, I think we  are urging – and our perspective urges us   to resist that temptation to draw these sweeping  conclusions from complex data. In fact, we argue   that abandoning universal approaches altogether  could be harmful. It risks creating a vacuum,   one which will be filled by untested and poorly  designed interventions and even misinformation. So, we think that rather than asking, should we be  doing universal mental health prevention? The real   question is, how can we do this better? How can  we tailor programmes to specific school climates?   How do we engage with students more meaningfully?  What do we learn from these large trials? As well   as looking to promising evidence and looking  at the low and middle-income country context,   which I know Bronwynè will speak to. So, it’s not  a call for blind optimism. It is a call to pause   for scientific humility, persistence, but we  think we should keep asking the hard questions,   refining our methods, listening to the voices  of young people, educators, and communities. So,   we think where to next? Not abandonment, but  adaptation, innovation and a deeper understanding. There’s much more we don’t understand  in terms of universal mental health   prevention than we do and we think these  could be really fruitful avenues for new   research and innovation. So, we have some  signposts from these large trials about   how to move forward, but we think in the  midst of the youth mental health crisis,   with rising prevalence across the globe,  we need to look at all possible avenues. Professor Umar Toseeb Thank you,  Louise. I’m going to move onto Bronwynè. Professor Bronwynè Coetzee Thank you, Umar, and  also, Louise, thank you for that introduction   to your piece. And our responses piggybacks  off of Louise’s piece in favour of, you know,   universal mental health interventions,  and specifically with the call to   focusing – or more – rather, on the potential that  it has for low and middle-income countries. So,   I was genuinely excited to be part of this  important debate. When we began this work in   2018, there was already a degree of  uncertainty about the value and the   future of universal school-based mental  health interventions. And a lot of this   uncertainty rising from high-income countries  where we know much of the work has been done. Louise, specifically now alluded  to all of the randomised controlled   trials that she has been involved in,  and with the many thousands of students   that they have enrolled in these trials. And in  South Africa, we have yet to conduct a randomised   controlled trial on universal school-based  interventions. So, we really are quite behind   in understanding these approaches and really,  in what their value holds. But that’s not to   say that there aren’t examples of randomised  controlled trials from other LMIC settings,   which really do show promise. So, it’s  really quite affirming and energising to see,   you know, leading Scholars talking about this and  still advocating for universal approaches, which,   you know, at least allows us to  engage in this opportunity more. But that said, I think it is important to  note that in South Africa in particular,   which is where I’m based and the lens through  which I speak to you today, has a considerable   mental health treatment gap, as many of you know,  and a schooling system that really currently   doesn’t include mental health in the curriculum.  What we do have is an integrated health strategy   which allows School Nurses to, as part of their  scope of work, do mental health assessment,   but as with most policies and implementation  frameworks and guides, this is not necessarily   done routinely. And so, there is quite –  there really is quite a large gap. But also,   just to say that my reflections are shaped by  our specific context, and I acknowledge that   other LMICs may have fewer resources. I mean,  South Africa is an upper middle-income country, so   the challenges or the solutions that we may offer  here might differ significantly in other places. So, in our piece, we really wanted to add  to what Louise and colleagues had said,   and they had really powerfully argued for the  current evidence base for universal interventions   and that what we know is largely  shaped by high-income context. So,   that we have very little – we have so much more  to understand in our context, where we haven’t   done a lot of this work, but also I think we  are acknowledging the importance of involving   young people quite early. And I know that we’ll  get to co-design, you know, at – or hopefully,   it’s something that’s actually going to come  out quite strongly from this conversation. We have a considerable amount to learn from what  has been done and it gives us a unique opportunity   to take what we have. And so, in terms of what  we have, and one of the programmes we allude to   in our piece is “4 Steps To My Future,” in  which we co-designed, although perhaps not   co-designed in the way that we would discuss  here, in which we had involved young people,   their parents, Teachers and School Counsellors  in the design and development of a programme   that we called “4 Steps To My Future,” which  we have only just piloted. And the pilot work   has shown to be quite acceptable and feasible. And  I’m hoping that through this conversation today,   that we also talk a little bit more about pilot  work and we talk more about, what is acceptability   and feasibility? What does it look like through  the various stages, and how are we making   decisions to progress from one step to the next?  How is it, for example, that young people can,   you know, in our work, specifically, identify  a great need for mental health support, but   then when we do large cale – scale trials here,  that these are not what they want or not what   they need or not in the current form in which they  are shared? So how are we including these voices? So, really our key arguments in favour of  universal school-based approaches is that young   people, especially in settings like ours in South  Africa - so just by means of the South African   schooling setting, while in South Africa we have  12 official languages, most schools do operate in,   sort of, an English primary language and then  a secondary language. So, we have language   and cultural and contextual factors which would  impact how we approach interventions like these   in different contexts. We have a public school  system, as well as an independent private school   system, and we have schools that are embedded in  settings that are very rural and remote and have   limited access to healthcare services, but also  set – schools in very urban settings, and really   with classes ranging from 15 to as many as 50  in a public school context. And that many public   schools in South Africa remain under-resourced,  largely as a part of the legacy of apartheids,   not only in terms of infrastructure, but also in  terms of healthcare provision. So, our context is   marked by deep inequality and so we really want to  urge for the contextual urgency of interventions   like these. Young people in our settings  are disproportionately affected by poverty,   violence, displacement, environmental degradation,  which most young people are as well. But a large   proportion of young people are in schools and  we can therefore provide them with this access. There’s the evidence gap that I alluded  to, that we know much more about these   interventions in those settings than we do  in ours. So, we do need to pause for critical   reflection and not just abandon things  altogether. And that there is promise from   LMICs in large-scale studies, like those  conducted in India and Vietnam, perhaps,   and that we have a lot to learn about  what it might look like in South Africa.   And that part of this is going to be – to include  young people, which we’ll talk about, but also in   some of the work that we’ve done. We’ve had a look  at the ripple effects of just our very small pilot   study in two schools in South Africa and just  the meaningful impacts that that had for parents,   who were not directly involved, but were involved  to some extent. So, parental involvement is also   an important discussion point at some  point, but it has wider benefits for   those who are involved. So, we don’t think these  interventions should be discarded, but rather,   reimagined and we're really looking forward to the  potential role of young people in this. Thank you. Professor Umar Toseeb Thank you, and that brings  us nicely to Emma. Off you go, Emma. Over to you. Dr Emma Carter Thank you, and thank you so  much for those contributions. That links very   well to what I’d like to focus on today. So, the  main argument of my contribution to the debate   series was to really highlight the importance  of listening to students’ voices and involving   them meaningfully in universal school-based mental  health programmes. So, this means throughout all   of its stages, from inception, from design  to delivery, right through to evaluation. What I also really try to point out in the paper  is that when student input is sought, not just at   a surface level, the impact of these programmes,  it – if it’s just done very superficially, it   tends to be quite short-lived and less effective  than what it could be. And I think a lot of the as   – evidence also speaks to this issue as well. But  when you’re able to treat students as co-creators   of these programmes, especially through using  qualitative methods which allow the students   the time and a feeling of comfort to express their  insights and experiences, I think the results can   be much more powerful and relevant, especially for  those students who are coming from marginalised   backgrounds. And it can also build a sense of  ownership amongst the students. It can boost their   engagement and also create interventions that  are actually meeting their mental health needs. And if I can just come back to  students from marginalised backgrounds,   given that we have a focus on  low and middle-income countries,   meaningful involvement is especially important  for these students, because often they’re the   ones whose experiences and needs are overlooked  in these one-size-fits-all approaches. But when   you can involve them in a way where they’re  co-designing these initiatives, you’re really   creating the space for their voices to be heard  and their unique challenges to be recognised,   as well. And this can lead to more inclusive,  more culturally relevant interventions that   reflect their realities and not the – just  the assumptions we have as adults and the   majority has of what these needs may be.  And this can also build trust, empowerment,   making them much more likely to engage and  benefit from the support that’s being offered. Professor Umar Toseeb Thank  you. Jack, what do you think? Dr Jack Andrews Hi, thanks. Yeah, and thanks  everyone for all of your really thoughtful   comments and this opportunity to reply to the  initial paper that Louise wrote. So, I guess,   Lucy and I’s paper comes at this – comes  to this at a slightly different angle. So,   we’re, in evaluating the evidence, arguing that  perhaps the best thing to be doing right now   is actually stopping and moving away from  universal interventions. And principally,   we think of this, and we have three main,  kind of, reasons why this might be. And the   first is that often when we’re designing these  interventions, we’re delivering to all people. Well, universal interventions by their premise  are delivered to all people, irrespective of   whether they’ve got a mental health problem or  not. But there seems to be an assumption that   we’re delivering preventative interventions  or primary preventative interventions to   stop the onset or growth of mental  health problems in young people.   Yet, we know that about a third of all young  people, 25% to 30% of young people in classes,   already have existing quite high  levels of mental health problems. And within a couple of or a few of these  trials now, large well-powered trials,   we see that actually this can be quite problematic  when we deliver a preventative intervention to   individuals that actually do need treatment,  where they need, you know, perhaps more one-on-one   intervention – more intervention type of work.  And we see this, for example, in the MYRIAD Trial,   where individuals that were high on depression at  the beginning ended up getting worse over time.   And this wasn’t seen for people that were starting  off at lower levels of mental health problems or   depression specifically. This also, sort of,  speaks to the point that actually there’s a bit   of an opportunity cost here. So, what’s happening  is we’re delivering interventions to young   people that whether they work or not, whether  they’re – sorry, iatrogenic or they, sort of,   don’t show any negative effects, their time  may well be better spent doing something else. So, even if we don’t see a negative outcome –  oh, sorry, if we – even if we do see a negative   outcome, they probably should be – that time  should be spent doing something else. And we also   know that even when these small effects are found,  these small positive effects that Louise touched   upon in these large systematic reviews, they seem  to be very unsustained. So, over time they don’t   last, which means that actually, you know, by  the end of the intervention trial, six months/12   months later, we’re not seeing any positive  effects. And again, that’s also an opportunity   cost. We also know that lots of qualitative  work has shown that young people don’t really   like these interventions and that they take some  autonomy away from them, so they don’t have choice   over what they’re doing. And I think that’s also  a really important thing to consider with these   types of interventions. And I’ll let Lucy touch  on some other points that I’ve probably missed. Professor Umar Toseeb Thank  you. Yes, over to you, Lucy. Dr Lucy Foulkes Thanks, yes, Jack summarised  some of my thinking there already. So, to go   back a little bit, I wanted to say that I worked  as a Postdoc on the MYRIAD Trial in – starting in   2015. And I remember back then, there was a lot  of enthusiasm. I was really enthusiastic about   this idea that we could teach whole classes of  people information that would help improve, either   improve their mental health or even possibly  reduce the risk of mental health problems starting   in the first place. So, I – ten years ago, I  was very enthusiastic about this possibility   and over the years, I’ve very gradually started  to shift my thinking. Even a year ago, I think I   might've said there’s still so – there still could  be something there with universal interventions. But now I’ve landed on the idea that even though  on paper, they sound like a good idea, I’m not   confident that the universal approach is ever the  right way to improve young people’s mental health.   I absolutely agree that the problem is there,  that we need to figure out how to improve mental   health in young people, but I’ve landed on the  conclusion that this one-size-fits-all approach   is not the solution, even though we really want it  to be and even though in principle, it sounds like   a good idea. And we – the evidence backs that up  now. So, we’re all in agreement that we’ve done,   you know, meta-analyses that have shown  small temporary improvements. But then   when you look at the bi – the best quality big  trials, they show that either they don’t work,   i.e., we've have wasted young people’s time,  or that they actually make things worse. So, I think we’re at a point now where we –  one issue might be that we haven’t figured   out what to teach them in these lessons yet,  and that we should therefore keep going. And   I think that’s totally valid way of looking at  what we have, but I also think it’s possible   that the universal one-size-fits-all approach  will never be the solution, and that instead,   we should identify the people who need  help and focus on how we help them. So,   in a classroom full of people that you are  delivering this information to, as Jack said,   you’ll have some people who are already seriously  unwell, and we need to think about how did they   experience – if you have active mental health  problems and probably aren’t getting help for it,   how is the experience for you to sit in a class  and be taught about what anxiety is or be told   to do mindfulness exercise, for example? There’ll  also be the majority of young people who are not   unwell, potentially don’t need any mental health  intervention and when you ask them in qualitative   studies, young people say, some of them,  that "these classes aren’t relevant" to them,   and they’re right. So, we’re making them sit  through something that they do not implement,   they don’t go and do ‘cause they don’t like  it. So, we need to think about them as well. We have almost no understanding about how  neurodivergent young people - I get asked   about it all the time and I have to say,  “We don’t know.” We don’t know what it’s   like to be autistic and sit through  a class about mindfulness lessons.   We don’t know about people with language  difficulties, other learning difficulties,   people who’ve experienced trauma, etc. There’s a  huge variation of young people in any one class   that has led me to reach this conclusion that this  universal approach is not the right answer, even   though we really want it to be and even though  the need is absolutely there. And that instead,   I think we have enough information now that  we can possibly start to change tack a bit. The word abandon is interesting, and I remember  Jack and I talked about whether we would use   that word in the paper and decided against it,  because to abandon them suggests a, kind of,   dismissal or disinterest. And that’s absolutely –  I really want to clarify that my viewpoint here,   I’ve thought about an awful lot and I’m  very cautious about how we move forward. So,   it’s – I don’t think we, sort of,  dismiss in a disinterested way,   but I think it’s what can we – let’s listen  to what the data said and what young people   have said and think about how do we best support  people who want or need mental health support? Professor Umar Toseeb Thank you. Louise, do you  just want to come back in there, in the – so,   Lucy has been quite careful there to not use the  word "abandon," but I think in your piece though,   you did use that word, I think, potentially.  And so, what is – what are some of the risks of   moving away from universal interventions? And  you touch upon some of those in your piece. Dr Louise Birrell Yeah, so I guess let’s start  with two key risks. The first one is that there   will leave a gap for misinformation to fill.  And we know that the landscape of access to   information for young people is vastly  different today than it was, you know,   ten years, even a year ago. And there has been  a proliferation of mental health information,   especially on social media. There was, I think,  a piece out in The Guardian about the number of   #mental health posts on TikTok, and it has  just exploded with some helpful information,   but some things like "Go and stand in a  shower and eat an orange and that will help   your anxiety." And so, we have to acknowledge  that young people are accessing information   more than any other generation, and often  mental health information in these ways. So, I think if we were to step out of providing  even the basic level of just information and   knowledge gain, so let’s maybe think about  what’s the bar for these programmes, I mean,   reducing symptoms and onset of disorders is a  pretty high bar. What if we think is it more   realistic for us to be looking for mental health  literacy effects, increasing knowledge, improving   help-seeking? Maybe that’s the baseline that  these universal approaches should be aiming for,   and especially schools with their role to provide  knowledge. I mean, in every other subject students   take in school, the key outcome is whether their  knowledge has increased or not. Now, as Prevention   Scientists, we want to see behaviour change and  impact on symptoms, but increasing knowledge,   I think, is a really important goal. And if we’re  going to step away from this in the evidence-based   space, as Scientists and Researchers, I do think  it will be filled, in fact, I know it already is   being filled, with schools taking up all sorts  of programmes. So, I think there’s a role for us. And then the second point – I’ve just forgotten.  Oh yes, if we – a switch to selective and targeted   interventions only, and I think there’s a couple  of issues with that. And I agree that the evidence   is stronger for selective and targeted programmes  in terms of we’re looking at research outcomes   and symptom reductions, there are stronger  effects. But if you talk to schools and when   you’re working with schools, these are really  hard to do, and we’ve done it. We’ve tried to   do selective programmes with schools and it’s  possible, but it often takes a lot of extra   resources. And you have to screen the whole year  group, you need to know what you’re screening on,   there are potential for stigma. It can be  done and you can and put people into groups   and give them tailored interventions, but  it does require a lot of extra resourcing. And what I’m worried could happen is that you’ll  see schools that have access to resources,   and it sounds like Australia is similar  to in – to South Africa, that we have two   sets of schooling systems, the public government  schools and then our private independent schools,   and they have vastly different resources and  mental health supports available in schools. So,   you have the private schools that do have Clinical  Psychologists on staff and wellbeing staff, that   that’s their job and they could feasibly implement  these types of programmes. But in contrast,   we have government schools which may have a  School Counsellor split across three schools,   and there’s just no way they could implement these  kind of programmes with the resources they have. So, I guess my concern is there could  be an unintended inequity if we’re to go   down the route of tailored and selective  prevention programmes only. In reality,   what that will mean is with the  different resources schools have,   it won’t be an equitable way to reach students and  some students could be - risk being left behind. Professor Umar Toseeb And one of the  things, Louise, that you talked about   and other guests as well, is around the  acceptability and the implementation   of various whole school approaches. So,  I wonder if I can just come to Emma here,   what does meaningful co-production  look like in this space? Dr Emma Carter Yeah, that’s a really good  question, and I think this is coming back to   the concept of student voice, ‘cause I don’t  actually think student voice is always that   well understood. It could often just be gaining  students’ perspectives, but not really taking   it any further than that. So, what student  voice actually is, it’s definitely getting   their perspectives as part of it, but it’s also  making sure their voices inform action and that   the students also know that that’s happening so  that their voices are being valued. So, I think   when you’re involving students meaningfully in  co-producing these initiatives, you’d – you will   notice a real difference, and also the evidence  has attested to this as well, in the way that   they’re engaging with it. So, instead of just  giving their feedback or ability bias, I mean,   students can at end of an intervention, if you’re  using these sorts of approaches, then students   really become part of the process and that makes  it a lot more relevant and a lot more personal. And then this means that the information that  you are receiving in terms of what’s working,   what’s not working, is a lot more reliable, it’s  a lot richer and a lot less prone to some of these   issues like social-desirability bias, because  you’re engaging with them in a way which is   much more personable. So, when they can see  that their input is being taken seriously,   not tokenistically, especially from the outset  of implementation, then I think you're likely   to see a much stronger commitment level and follow  through. And that kind of connection has also been   seen to reduce dropout, boost satisfaction, and  make the whole intervention more impactful. And   there’s a toolkit that’s been put out by Origin,  which is a Australian-based organisation actually,   that has, kind of, collated the evidence on  this end and talks about strategies through   which you can use student voice in order  to elicit students’ perspective in a way   that goes beyond just getting their  views, but actually can use these to   inform change that is meeting their  needs in a much more effective way. Professor Umar Toseeb Thank you. Jack,  I’m just going to come to you. So,   based on what Louise and Emma have just described,  I think they’re addressing some of how we could   move forward without moving towards targeted  interventions. Do those things go far enough,   as in, could meaningful co-production address  some of the concerns that you have? Because I   think in your piece, you do talk about, you  know, students in other research saying that   they can’t relate to some of the content  in these universal interventions. So,   if they were meaningfully co-produced, might  that then address some of your concerns? Dr Jack Andrews I think – yeah, thank you  and thanks, Emma, for that point. I think   it’s a really important one and in principle,  it makes a lot of sense to me. But in my eyes,   each school context is so different that  to truly do it, we would need to do good   co-production in each and every school that  we’re delivering these universal interventions   into. And I think that makes it, sort of, quite  an unfeasible and not cost-effective approach to   actually do properly. You know, going and getting  a good representative group of people from London   and designing an intervention on that and then  delivering it out to the wider UK is not going   to then be representative and potentially, we  then, yeah, don’t know what the outcomes would be. I suppose if I could touch on the two comments  that Louise brought up, which is around, sort of,   increasing knowledge and help-seeking. I also  totally get that point and think obviously   increasing knowledge and help-seeking  can, on the face of it, be a good thing,   but we also need to make sure that if we are  increasing help-seeking among young people,   there is help available on the other end.  Otherwise, that can and possibly could lead   to even more distress among young people, that  are reaching out, but then there are no services   to actually support them. And those services  that they would need are probably targeted or   one-to-one specific interventions. So, in that  sense, actually asking young people to opt-in to   one-to-one or targeted interventions in the first  places – in first place, could get around that. I also think – I totally also get the issue  that, you know, there is a bit of - it's a bit   of the Wild West out there, with schools, sort of,  picking up information online and just delivering   interventions in the sch – in schools that aren’t  evidence-based. And I see that, but I’m not   convinced that the answer then is that we should  continue with universal interventions that we   know do carry some risk of causing harm, whether  that’s momentarily or not. We know at scale, when   we scale these harms up, they can have a genuine  impact on population-level clinical depression.   Lucy and I have published on simulations showing  that. So, I, kind of, am not quite convinced,   but I think the approach that I would take is  actually going to government and policy and   saying, "Until we have a strong evidence base that  minimises harm, we should be doing nothing, or you   should speak – you should be doing nothing, rather  than delivering the universal intervention." Dr Louise Birrell Can I jump in there? Professor Umar Toseeb Oh, please. Dr Louise Birrell I just want to pick up that  point around "doing nothing" and the potential for   "harm." I mean, firstly, we can have a debate over  whether the increases constitute harm. I would   probably argue that we’d – I would like to see  that translate into functional impairment in young   people’s lives, not just the symptom increase, but  to be using the word “harm.” I would be thinking   of that in a way that it means it’s having an  impact on their day-to-day life to be using words   like harm. But also, I think there’s harm in doing  nothing, ‘cause when we look at developmental   trajectories of internalising across adolescents,  the graph goes like this. And so, if we’re going   to step away and say, “Oh, we’re not going to do  anything that might cause harm,” I mean, I think   the harm has to be pretty big to justify that.  And when I look at the evidence on balance and,   you know, there’s a lot of emphasis on the MYRIAD  Trial, the CSC Trial I’m really familiar with,   and I’d argue there’s mixed findings across the  four groups, I don’t think that the evidence is   strong enough, to be making that call,  would be my rebuttal, to Jack’s point. Dr Jack Andrews If I could very briefly just  touch on that. I completely get that point around   function impairment and what we discussed as  harms, but then you could equally use that in the   counter and say, well, momentarily increasing or  sorry, reducing anxiety and depressive symptoms,   unless they translate to an improvement  in functioning, then the evidence base is   weaker. And we really don’t have enough evidence  on whether or not - you know, very few studies.   Susanne Schweizer and I published a paper that  showed that about 13% of school interventions   even study or report functional outcomes. So,  actually we have very limited knowledge of   that and until I think we, you know, we have  better understanding of this, there is some   concern that we could be potentially, you  know, making things worse for young people. Dr Louise Birrell Hmmm hmm. Dr Jack Andrews And parents need to be aware of  this, as well, I think. Ethically, like, when we   deliver these interventions, there is a risk of  increasing symptoms, irrespective of functioning.   And, you know, as a pare – as – if you’re a  parent, I would want to know whether there   are – what side effects or potential negative  consequences these interventions that are being   run in the school carry. And I’m not aware that  – of many Researchers that actually do, sort of,   in these information sheets, say that there is,  you know, a risk that we could make things worse. Dr Lucy Foulkes Could I also say, it’s also  the – so I agree, the word “harm” is quite   provocative and difficult to prove. And in my own  work, we’ve moved towards talking about “potential   harm” because, especially when – I mean, all the  effect sizes in any direction are pretty tiny. So,   I agree that “harm” is possibly an unnecessarily  strong word, but I think when the interventions   that don’t have negative effects, the best  quality ones just don’t do anything. So,   I think we also need to think about the principle  of an opportunity cost. So, if you – we are   wasting young people’s time if they have to, you  know, do eight or ten hours a term. So, actually,   even if they do – not causing harm or any negative  effects, the fact that they’re just not doing   anything at all is something that we should take  seriously and listen to them when they tell us   that, “We don’t like” – that they don’t like doing  this and they don’t find it relevant to them. I also just want to come back to what Louise said  about the mental health knowledge and literacy.   So, often, what I’ve landed on is that I think  it’s worth saying something about mental health   so that they know if they have some problems  that they could – where else they can access   support. But I think you can probably do that in  a – so this is - when we're having this debate,   my understanding is that we’re talking  about ones that have the goal of reducing   symptoms. But I think there’s possibly  something there to think about what   knowledge or literacy could we improve?  But to me that’s actually, kind of,   a separate question and it gets very murky about  how do you increase their knowledge without,   for example, inadvertently making them  interpret symptoms in an unhelpful way? So, I think it’s not about not talking about  mental health at all, but I think if the   goal is just to, sort of, explain what mental  health is, you can probably do that reasonably   briefly and you don’t necessarily need, like,  a multiple multi-week intervention. And yeah,   just to come back to what Jack said, I think I –  it’s a complete mess in the UK what’s happening in   schools. People are just making stuff up and  teaching it and I – like, I see all kinds of   utterly odd things being delivered and it’s a  real problem. But I agree with Jack that that   means - the vacuum being filled with junk,  which it is, that means we need to go high   up and tell the decisionmakers that universal  interventions don’t work. Rather than feeling   obligated to keep filling that slot when we  have reasonable evidence that it doesn’t work. Dr Jack Andrews I just want... Dr Louise Birrell Well, I think that’s a point  we’re going to disagree on, ‘cause I don’t think   that’s a good approach and I think what will  happen then is that we will go backwards,   you know, 20 years, when mental health was not  spoken about. If that was the advice to government   and they pull all universal programmes, it means  they would pull the knowledge programmes too,   because it’s hard for people to understand  the complexity of this evidence. And we need   to be specific when we’re talking about  programmes and findings. They’re saying   things like "Large-scale mindfulness lessons  delivered by Teachers doesn’t work." You know,   "The CBT intervention delivered online in  the CSC study didn’t work." Let’s not use   the word universal prevention doesn’t work  when we – we do need a bit of nuance in this   debate and that would be my fear if you were to  go to policymakers, it’s such a broad statement   that it would pull everything out of schools and  I just don’t think that would be a good thing. Dr Emma Carter If I could just come  in there, Louise. I think we do really   need to dig deeper into what’s causing –  how is this causing harm? ‘Cause I also,   in – when I was undertaking my literature search  and learning more about this area of research,   wasn’t really able to find these answers. I  saw these papers saying that it’s "exacerbating   symptoms," but there wasn’t - it didn’t really  into – go into depth into why this was happening.   Was it a question of the implementation? But I’d  like to just mention a study I did come across   that was conducted in Uganda with Coetzee,  which again drew on this student voice approach   to gain students' perspectives and suggestions for  improvement, found that there was an issue with   the implementation when Teachers were involved.  And that when you removed that power dynamic and   brought it in as a peer-led group opportunity,  then this was – students were much more open in   talking about their challenges and what was  working well with the intervention and not. So, again, this is coming back to this idea  of this meaningful engagement with students   in order to really understand perhaps what  is causing this harm. Is it a question of   implementation? Who’s implementing it? Is  it a question of the power dynamics? So,   I think this is something that also relates back  to that question of the method and the approaches   we’re using to understand these programmes  and why they’re working and why they’re not. Professor Bronwynè Coetzee Yeah, I’d love to add  to what Emma has said. All of us working in this   space know that schools are complex systems and  often when we’re coming in with these programmes,   as much as we – and, you know, Emma, you alluded  to, sort of, a tokenistic approach and I think   it very much can be. Especially in LMICs, where  we have a long history of Researchers from the   outside coming in to implement and develop  programmes and then leave again and then,   you know, these – they struggle to be taken  up. But to – in terms of the implementation,   when we’re thinking about the support  that young people need and in settings   where they’re based, like schools, we  need to spend a significant amount of   time understanding what that school is  like and what – and how it operates. And so, Jack, the point that you made  about it may potentially mean doing a   considerable amount of codes – development,  design work for each school in each context,   perhaps that’s something to consider building in,  as, like, an initial platform, but that the basis   of a programme, you know, is there that we can  work with. And many schools have various factors,   either at the level of the individual, so  Teacher factors, child factors, but also broader   structural and system factors, that impacts  on the way in which it functions and operates,   and that this takes better understanding. It takes  understanding in the UK context, it takes better   understanding in the Australian context, it takes  better understanding in the South African context. Emma alluded to, you know, the – and Louise  as well, about the "who" is delivering these   programmes and about Teachers. We know from  our work in South Africa that young people   and Teachers themselves explicitly told us that  they do not want to be involved in delivering   these interventions. Young people said – in  fact, our stakeholders were unanimous, that   this sort of support is needed and we know it’s  needed. In the absence of it, we will struggle to   identify young people who need support. Young  people also need the vocabulary to identify   when they are experiencing issues and they would  otherwise not have it without programmes like   these. But we need to understand school climate  more broadly before we are going from the outside   in. And that our engagement with young people, as  much as it is to better inform these programmes,   that it takes a lot of pre-engagement to really  build relationships, understand what is happening   when we are, essentially, also leveraging these  programmes to support a better school climate. So, many of the programmes that have  been delivered and through large RCTs,   have been through school staff, and understanding  what is the dynamic among school staff? We know   that in South Africa, especially in  the Western Cape, where I’m based,   there is a significant Teacher crisis in terms  of Teacher unmet mental health needs. And that   in many context and settings, this lack of  mental health support for Teachers first   means that there is essentially a somewhat  toxic school culture as a result. And so,   if Teachers are the ones who are delivering  the programmes and – to all – if there are any   Teachers on who are listening in or who may listen  to this in the future, I adore Teachers and the   work that they do, but we also acknowledge  that Teachers are expected to do a lot. You know, Lucy, spoke about  diversity in classrooms. Yes,   in South Africa we have the White Paper 6,  which calls for inclusive classrooms. So,   we not only have these overburdened classrooms,  but Teachers who are expected to cater to the   needs of learners with diverse learning needs  and then also behavioural and emotional problems,   which they don’t have many re resources to  address. So, a lot of our work has been in   collaboration with NGOs who try to fill the  gap in terms of mental health support in   our settings and incorporate – and including  them in these designs is important as well. So, a large part of this rethink, so not  abandoning, not, sort of, putting it away,   a large part of this rethink is to think about  what schools are as settings. Who are the people   involved? What are the relationships and dynamics  before? And try to see how best we can support,   promote, encourage, especially, you know,  in settings that are highly violent where   school safety is an issue, or learners are  afraid of their Teachers or vice versa,   that we understand what this looks like first  and put measures into place – and put measures   in place to support the school as  a whole. And to then go into our   – approaches where we can provide young  people with the access they need to   identify when they need support and help. And  then, as Jack alluded to, to make sure that we   really do that health system strengthening  where we can actually link them to support. Even in the NHS, even in South Africa in private  spheres, we have barriers to accessing healthcare,   for logistical and structural reasons  that are, sort of, socio-political,   big issues that need to be solved. We're  constantly in this fear of strengthening   healthcare systems for better support for  everyone. We need to do that in schools, too.   It’s systems strengthening and we need to think  about best practices that – for that together. Professor Umar Toseeb Thank you.  I have a final question for Louise,   before we have some similar – sorry, I have some  final question – I have a final question for Lucy,   not Louise, sorry, which is, in your piece  you talk about "opt-in interventions."   Can you tell us a bit about, very  briefly what those might look like? Dr Lucy Foulkes Yeah, so there’s a trial called  the BESST trial that was run by some researchers   at King’s College London, BESST as in, B-E-S-S-T.  And they – it was a group-based CBT intervention   for anxiety and I think it’s 16 to 18 year olds,  and they – it was, kind of, self-nominated. Like,   if you wanted to take part, you could go and do  it. And I think that resolves that issue about   having to screen everyone and then pick, you know,  the people who score above a certain threshold. I   feel like there’s no perfect option. They all have  issues, because obviously, with the self-selected   option, the opt-in option, the argument is, “Well,  what about the people who don’t realise they need   help or they don’t want to nominate themselves?”  So, I think it’s about weighing up a variety of   imperfect options, but yeah, I think to my mind  it’s more effective to offer interventions to   a smaller group of people who want or need  it, rather than delivering it to everyone. Professor Umar Toseeb Thank you. So, what  I will do is, I think just to go around the   room again. One of the things that I’ve picked  up in the various things that have been said   is that it seems that the indicator of  what success looks like differs, and it   could be at symptom level, it could be around  culture change, it could be about knowledge,   it could be about stigma or institutional  level change. I wonder if we could just   go around the room and each of you just to say  what success would look like in this space. So,   what does a successful intervention  look like? Should we start with Louise? Dr Louise Birrell Yeah, absolutely. So, I think  for me, success, I mean, sometimes I feel like   there’s a false dichotomy between approaches and  I think we can do both. We can have universal and   targeted and available treatment. I mean,  that would be success for me, is, like,   a life course developmental curriculum that is  delivered across settings, from early childhood to   primary school to secondary school to university  settings, which target the key risk factors and   risk periods that is across the spectrum. So,  we have universal education, which might more   on – after all these trial results have come out,  might be more appropriately targeted at knowledge,   stigma reduction, help-seeking and then on top of  that, we would have opt-in or screened targeted   selective programmes, as well as available  treatment. For me, that would be success   and I know that’s a big goal and that’s not easy  to happen, but that would be what I dream of a,   kind of, ideal prevention model where we could  catch everyone and nobody would be left behind. Professor Umar Toseeb Thank you. Bronwynè,  what does success look like for you? Professor Bronwynè Coetzee Really, Louise,  couldn’t have said it any better, so I’m   quite brief. Absolute advocate for multi-tiered  systems in which we have all of these, sort of,   strategies and best practices together  and available for young people, and   as she beautifully ended off, to make sure that  nobody’s left behind. Thanks for that, Louise. Professor Umar Toseeb Thank you. Emma. Emma Carter So, mine perhaps is a bit more  fundamental. I think what success would   look like for me is really a paradigm shift.  It’s changing our perspective on students as   just the recipients of these interventions  to one that really acknowledges them as   co-designers and collaborators  to really strengthen engagement   in these programmes and  therefore, their effectiveness. Professor Umar Toseeb Thank you. Jack,  what does success look like for you? Dr Jack Andrews Yeah, I think – obviously,  I echo what the other three have just said,   but I think on a practical level, I think in  this specific space, I would also argue that   success would look like minimising any potential  negative effects, not just on primary outcomes,   but also in secondary outcomes. And also  developing interventions that young people   actually like, so there is, you know, a much  more of a – an impetus for them to actually   want to participate in them and not just  feeling like they’re being imposed on them. Professor Umar Toseeb Thank you, and Lucy? Dr Lucy Foulkes Yeah, so just to summarise  what everyone else has said, really. So,   interventions that meaningfully improve what – an  outcome that we wanted to improve. So, I thought   this discussion was more about symptom reduction,  but whether the outcome of it is symptom reduction   or general awareness, that that’s something  measured that does meaningfully improve. So,   it’s not just something that you would like  to happen, but is there, kind of, measurable   evidence that it does improve and that doesn’t  cause unintended negative effects. ‘Cause even   mental health awareness interventions, I've got  data from my own group showing that – and other   labs around the world, that by showing people  mental health awareness materials, you increase   the likelihood of self-diagnosis even though you  don’t increase symptom reporting, for example. So,   even mental health awareness, we can’t assume  that there’s no potential risk for problems there. So, I think something measurable that really  does improve what we want it to improve,   that doesn’t cause intended harms,  and that we listen to the enormous   variation of young people in  that classroom to make sure that   nothing unintended is happening and that it’s  performing in the way we want it to perform. Professor Umar Toseeb Thank you. So,  just, we have, like, a few more minutes   until we’ve finished at 12. I wonder whether -  so the conversation so far has been – to this   point has been about symptoms and things that  are delivered at an individual level, but my   understanding of whole school approaches is more  than the individual. It’s around the structures   around the children and young people. It could  be around classrooms, how teaching is done, how   assessment is done, school times, the knowledge  that Teachers have and all members of staff,   parents as well, involved in this. Is there more  – or do we know anything about factors that are   outside of what we’ve been talking about and what  the evidence base is around that? As in, does that   need to be integrated into the discussion  that we’ve had? That’s to anyone, really. Dr Louise Birrell Maybe I can start with  somewhere where I think we’re all going to   agree on and an area of promising research  is looking at targeting risk factors and   indirect prevention. So, this can be done in  a universal way and we’ve looked at this in   one of our school trials which targeted  key lifestyle risk factors around sleep,   diet, screentime, sedentary behaviour, and it did  see positive impacts on mental health outcomes,   which were secondary outcomes. So,  targeting those kind of factors could   be a really promising way for the field to  move forward, particularly around sleep. I know there’s a lot of emerging evidence around  the incredibly important influence of – on sleep   in adolescents. Again, let’s be specifics,  this is probably for the adolescent period,   if we were going to be targeting  primary school, early childhood,   although I have a five-year-old and sleep is  also very important. Then maybe we could do   that across the whole spectrum, but yeah,  maybe I’ll just end by bringing up that   indirect prevention approach and I think that’s  probably an area we’re all on – in agreeance on. Professor Umar Toseeb Thank you. Does anyone  else have anything to add on that point? the   other point I wanted to make was, so this  evaluation of intervention approach comes   from the medical model of, you know, when we  look for a new treatment for a given condition,   but the school environment is very different and  education is very different. And there’s some – I   had a conversation with a colleague the other day  who suggested that this approach to evaluation   where you try and single out one key ingredient  that you want to test the effectiveness of,   is not well suited to an education environment  and children and young people in general,   because we have lots of other things going  on. Could that be the issue here? Could   the issue be that we’re not going to be  able to find an effect for any, sort of,   intervention in a meaningful way because there are  too many other things that we can’t control for? Dr Jack Andrews I think that’s the whole  premise of having a really well-powered   randomised controlled trial. So, in theory, if  you do have enough participants or enough schools   to run an RCT, then we should be able to use  this medical approach – medical model approach,   to understand differences. Because by true  randomisation, you are then expecting that there   should be an effect observed in your intervention  or experimental group. But again, these trials   need to be well-powered and I think that speaks to  the point that many or much of the evidence that   we have on these interventions at the moment  come from underpowered trials where other   extraneous variables and confounding variables  do seep in and have a larger impact on outcomes. Professor Umar Toseeb Thank you. I think  we will call it a day there. So, it’s been   a fantastic conversation and I think some  varied views have been shared there and I   hope and expect that lots of you will be carrying  on this research. So, we look forward to seeing   your work coming out in the near future.  So, thank you all for taking the part.