Professor Tamsin Ford Hello, my name is Tamsin  Ford. I am a Child and Adolescent Psychiatrist and   Epidemiologist, and I’m based at the University  of Cambridge. I’m going to talk to you today   about mental health interventions in school  and the prevention of mental health problems   that could also be based in schools, because  nearly every child spends an awful lot of time   in school. And there are an awful lot of children  and young people who need mental health support. The slide you’re looking at now relates  to last year’s National Survey and indeed,   has been superseded very recently with official  government statistics from this National Survey,   which demonstrate that the rapid deterioration  that we experienced between 2017 and 2020 has   been sustained, and that we particularly  need to worry about boys of primary school   age and girls of secondary school age.  And in fact, since almost ten years ago,   with the 2014 Adult Morbidity Survey for  mental health conditions, which goes down   to the age of 16, we very first got this signal  that hadn’t been detected in the three prior   adult surveys amongst 16 to 24-year-olds,  that young women were experiencing much   higher levels of depression, anxiety and  self-harm than they had in previous years. Another very consistent finding, which I first  studied in my PhD at the turn of the century,   is that schools are a major source of support.  It’s where children and young people and parents   turn, as you can see by this slide. Now, the  National Survey, we started off with two to   19-year-olds and they are now eight to 25,  but I think if you look at the orange bars,   it’s not surprising, you’ve only got 17 and  18-year-olds attending schools – excuse me   – you’ve only got 18 – 17 and 18-year-olds  attending schools, but there isn’t another   clear source of support for emerging adults.  And I think we need to think about where these   young people are and how we support them,  but today, I’m going to focus on schools. Now, the COVID-19 pandemic  was arguably a syndemic,   in that the infection revealed a lot of social  and health inequalities, and these intersect. So,   the graph that you’re looking at is from  the National Survey follow-up in 2020,   in terms of whether the index child in the survey  could access education. The grey bars are the   children who had a probable disorder, according  to the Strength and Difficulties Questionnaire,   where the blue bars are those who are unlikely  to have a disorder. And what you can see is those   in poorest mental health were also least  likely to be able to access their lessons,   and as well as widening health disparities between  the more privileged and the least privileged in   our society, we have a widened education disparity  which, no doubt, is feeding back on each other. There is a huge cost related to this. So what you  are seeing is the costs for mental health contacts   among five to 15-year-olds with a psychiatric  disorder, as measured in the 99 survey and some   follow-up interviews that I did as part of my PhD.  Only 25% of those with a mental health condition   got to a mental health service, but actually,  the most common service accessed and therefore,   the biggest costs, fell to frontline  education. And then, almost as many,   as were supported by mental health services,  were also supported in special educational   needs. There was some overlap between these two  populations, but rather less than you would think. These and other data, and sadly, we haven’t  made much of an improvement on that 25%   figure getting to mental health services  amongst those with an impairing disorder,   but these data helped argue for what  became the Transforming Child and   Adolescent Mental Health Services  policies introduced from 2018. It’s amazing – it really surprised me when I  went to check about how close the overlap between   special educational needs and mental health  conditions were; nobody really had done it. So,   we did, as you can see, this highly sophisticated  analysis called a Venn diagram, which most of you   will have done in your primary schools, between  those with a long-term physical health condition,   those with a DSM-5 diagnosis and those with  special educational needs in the 2017 sample.  On the left, you’re looking at special  educational needs as reported by parents. Now,   this may or may not equate to having school-level  support, and then, on the right-hand side, you’ve   got the smaller number of those who actually have  an Education Health and Care Plan or statement. And I’m sure it won’t surprise anybody who  works with either special educational needs or   mental health services that children with a DSM-5  disorder were nearly seven times more likely to   have a special educational need and six times more  likely to have an Education Care and – Health and   Care Plan, and this relationship is complex.  So, for some, their mental health condition,   such as ADHD or autism, may well be the special  educational need and you have a complete overlap   there. But if school is a place that you find  difficult to be because of anxiety, because   you’re being bullied or because of learning  difficulties or some other health condition,   sometimes all of the above, then that’s quite  a potent risk factor to your mental health. So, there is this complex and probably  bidirectional relationship between   special educational needs and mental  health conditions. And that means the   special educational needs system and how it  functions is actually really important to   the prevention of mental health conditions  and, also, their management and treatment. Another aspect of school, in the widest  sense of things, is the school climate,   how – whether young people feel they belong and  Teacher-pupil relationships. Now, I’m going to   present data today on Teacher-pupil relationships  because we found it both surprising and shocking   when we studied this rather nasty question that  was in the 2004 National Survey. So, I’m going to   read it out. It’s “Over the last year, has she  or he,” so it was asked to parents, “has she   or he been stressed because she or he feels that  they have been unfairly picked on by a Teacher?” Now, methodologically, that’s an awful question,  as well as this rather pejorative tone,   because does an answer “a lot” mean very  stressed or very picked on? However,   I hope I can convince you that a parent  answering “a lot” to that would suggest   that there is something problematic  in the Teacher-pupil relationship,   taking aside that Teachers are human beings and  some children and fam – you know, some children   are harder than others to get on with. But if  we think about Doctor-patient relationships,   the Doctor is very firmly the professional and  in this situation, the Teacher is very firmly the   professional. And it shocked us that nearly one in  20 parents reported “a lot” overall. You’ll see a   higher proportion in secondary school than primary  school, but it still really surprised us overall. We then looked at Teacher-pupil  relationship, as reported in 2004,   in relation to mental health in 2007. So, to  talk you through this rather difficult slide,   in the left-hand column, you have the outcome.  So, in secondary school, we ema – we examined   any psychiatric disorder in 2007, any conduct  disorder, because we suspected that children   whose behaviour challenged norms would be harder  to have a good relationship with, and exclusion   from school. We all looked – also looked at family  functioning, and I’ll pick that up in a minute. We   both controlled or adjusted for the presence of  psychiatric disorder in 2004 and then, because   adjusting doesn’t totally sort the problem, we  took those children out and did an analysis,   with everybody starting off in good mental  health, and we did the same for conduct disorder. The third thing we did is these data were  collected during the spring term. Now,   if we are looking for a signal of a Teacher-pupil  relationship three years down the line,   then we need to concede it may have had an  impact within the first half of the academic   year. We – so, we adjusted for the Strengths and  Difficulties Questionnaire at baseline. However,   that may be overadjustment, because  I said if the relationship is poor,   there may have been a impact on  the Teacher-pupil relationship. Equally, we know that the diagnosis disorder “no  disorder,” there are some who bubble just under,   and if their mental health is poor,  their behaviour might be poor, etc. So,   that’s why we adjusted for that.  The truth, if you want it in quotes,   probably lies somewhere between these two  columns, where we’ve just had “poor Teacher-pupil   relationship” as the exposure and then, when  we adjust for Strengths and Difficulties,   total difficulties score, which gives a  handle on mental health in the continuum. Now, these figures are odds ratios  with their 95% confidence intervals,   for those who like their statistics. For those  who that sounds like Chinese, where the figure   is in italics, and you’ll see it’s nearly every  response in this table, that means there was   a statistically significant prediction of  a poor Teacher-pupil relationship in 2004   to having a diagnosis of any disorder, new onset  conduct disorder and being excluded from school. Now, technically, an odds ratio of one means  that there’s no – excuse me – an odds ratio   of one means that there’s no effect,  and you’ll see this one for exclusion,   when you adjust for SDQ, just  dips over, but by .1 – it’s .01,   it’s so small, but that’s near as damn  it, statistically significant, as well. So, I think, you know, for secondary school  children, there is convincing evidence that   poor Teacher-pupil relationships have an impact  on child mental health and also, school career.   And this really surprised us because children  at secondary school are in contact with lots   of Teachers, not just one. We thought if we saw  an effect, we would see it in primary school. We   did see an effect in primary school, but it was  much less marked, and I think that was because   in primary school, there were fewer children  with a problematic Teacher-pupil relationship. Now, when things go really badly wrong at school,  exclusion, by which I mean being suspended or   expelled, is a really negative outcome, but  we’ve just shown that some school-based and   mental health-based variables may play into  that. So, Claire Parker, who’s in the picture,   was a PhD student of mine who studied this in  detail in the National Surveys and other datasets. So, some of you may be aware that the Strengths  and Difficulties Questionnaire has an “Impact”   supplement, and the first questions ask people,  “Does she or he have a problem with emotions,   behaviour, concentration or getting along with  people?” And we divided response to that into,   basically, “yes,” and “no,” as you can see in  the red and green, and then, we had the presence   of a mental health condition as assessed by  the Development and Well-Being Assessment,   the DAWBA. And that gave us four groups to study. Those with “no disorder or difficulty recognised,”   so reassuringly, that’s the largest group.  Then you have a “sub-clinical group” where   either a Teacher or a parent, sometimes both, were  worried about them, but they weren’t assessed to   have a diagnosis in the – on the DAWBA. Then you  have a group where nobody’s worried about them,   but they do have a disorder. We call them  “unrecognised,” and the final group was   where either a parent or Teacher, or both,  were worried about the child. They recognised   there was a problem, and they had a disorder.  And our theory was that maybe a proportion of   exclusions at school driven by mental health, it  was because nobody realised there was a mental   health condition. So, if we could only train  people to recognise these difficulties better,   then maybe we could prevent some exclusions  from school and get people into treatment. In fact, we found the opposite, and I think it’s  probably about severity. If you plot those four   groups and the proportion of exclusion, it looks  very much like a scale. But as you will see,   the presence or absence of psychiatric disorder  and whether or not it’s recognised, in 2004,   predicting forward to exclusion three years later,   adjusted for a whole load of background  characteristics. So, this is getting at   the independent impact of having a psychiatric  disorder. It was the children who were recognised   as having problems who were more likely to be  excluded, and we found that in various places. Again, perhaps it shouldn’t have  been as surprising, I did wonder   how many children with neurodevelopmental  conditions were not being recognised. Some,   as you can see from this graphs – graph, in the  purple there were some on the autism spectrum,   written there as “any PDD,” pervasive mental  disorder in the – in old language, or any with   hyperkinetic disorder. However, the bulk of  the children who had unrecognised conditions,   it was emotional disorders, and we know this. If  you have conduct disorder or neurodevelopmental   disorder, it often clashes with the demands of  the classroom or the playground and therefore,   brings you to the attention of adults around  you, whereas you can be quietly very anxious   or depressed and people may not notice. But it’s  an indication of where training needs to focus. Now, as I alluded to earlier, impairment related  to mental health is not just confined to those who   meet diagnostic criteria. What you’re looking  at there is the Strengths and Difficulties   Questionnaires from the 2004 survey, but I could  show you the same from all three of them. So,   on the left-hand, you have young people, and it’s  almost the perfect normal distribution. In the   middle you have parents, and on the right-hand  you have Teachers. As an Epidemiologist,   I’m absolutely fascinated by the difference in  the curves, because they are all asked the same   question. In fact, the only difference between  the parent and Teacher version is whether there   is a P or a T in the top left-hand corner  when it was printed out on paper. However,   it says to me that par – Teachers  are less likely than parents and   young people to report difficulties. We  should really listen to them when they   do. And these blue arrows show you where the  clinical cuts points are, and you could see,   it’s one distribution. It is not two separate  groups who have disorder and don’t have disorder. So, moving tack a bit. I talked about some general  things that schools can pay attention to. In fact,   lots of peo – there’s been lots of work over the  last decade, since I got interested in the school   mental health interface, and lots of really  fabulous work at policy level, in practice,   as well as research. So, this graph is from  Public Health England, who did a lot of work,   and it involved the Children and Young People’s  Mental Health Alliance, amongst other people,   to come up with the key to having a healthy  – a mentally healthy school. Excuse me. So   it starts with “leadership and management,” and  as most people would say, the focus, attention,   and attitude of the senior leadership team  is key here. So, the argument, very strongly,   is that the senior leadership needs to support  and champion efforts to promote mental health   and to prevent mental ill-health and to  support those who need it getting support. And then, there are these three other  – and these eight other key areas. So,   the “curriculum, teaching and learning” can be  tweaked and focused “to promote resilience and   support social and emotional learning,” and that  means, you know, learning about positive ways to   manage conflict. It means strong anti-bullying  policies. It means things like restorative   justice. There was an excellent trial from UCL  and the London School of Hygiene, led by Chris   Bonell and Russell Viner, which showed that a,  you know, a social justice focused programme   actually had a positive impact on mental health. The other thing is to listen to the students.   Enabling the student voice to influence  decisions is a very important factor.   Developing staff to support their own wellbeing,  as well as that of the students, again, crucial. Then, moving on to the more focused things about  who in your school population is struggling,   identifying need and monitoring  the impact of interventions,   so you don’t try – you don’t keep putting –  you know, doing the same thing if it’s not   working for your population. But you review  what you’re doing and if it doesn’t work,   you try something different and review it again,  until you find things that are working. And,   you know, there’s going to be no silver  bullet that works for every school. The other key thing, and I know Edu – loads  of Educationalists would agree with this,   is working with parents and carers, and  that is harder than it might seem because   of the pressures on families. You know, near  – you know, the vast majority of families want   their children to do well in school. However,  there are plenty of people working long hours,   working multiple jobs, not being able  to afford time or travel to come in. So,   it’s a challenge, but it’s one  that schools needs to rise to. Targeted support for those who are more at  risk. It’s quite likely that schools will   be very aware of some risks. So, children  with special educational needs, children   who are looked after by the local authority,  children who have English as a second language,   particularly if they’re refugees or asylum  seekers and have experienced traumatic events,   both coming up to migration and perhaps during and  shamefully, after migration. People on the pupil   premium. But there may be other forms of risk,  and it – schools need to think about how they   might monitor risk, get interventions to those who  need it and monitor how those interventions work. And finally, excuse me, if you do all of  this, you should end up with an ethos and   an environment that promotes respect and values  diversity, and you can end up in a virtuous cycle. So, I have been involved in several public  mental health trials based in schools,   and I’m going to tell you about some of them  and some of the others that have been done,   because actually, there are some things that  can be done that do make a difference. So,   there was a Campbell Colloquium [means  Collaboration] Systematic Review of interventions   that reduce exclusion from school, for example.  So, the trial I’m going to talk to you about   is of the Teacher Classroom Management part of  the Teach – of the Incredible Years Programme. So, we have – if you remember back when I talked  about the prevalence, one of the commonest   problems is conduct disorder. Affects about  one in 20, so at least one in every classroom,   and that’s on 2017 figures. It may well be higher  now, and there are hints that particularly,   those children who were toddlers or very early  in primary school, and particularly boys,   are more at risk currently. And certainly,  anecdotally, Teachers are talking about   children arriving in school, over the last  few years, very delayed in social skills,   very delayed in being able to access the  curriculum and be in school, sometimes with,   you know, gross delays in toileting, motor  skills, etc. Those may well play forward in   this group affected by COVID, so we really need  to be thinking about how we help these children. The Incredible Years Programme was main – was  originally a response to conduct disorder, severe   conduct disorder, and has a parent programme,  a child-focused programme, but then, later,   expanded to a, kind of, whole classroom programme,  and then, one for Teachers. And the idea was   that you trained everybody to work the same way  around the child and it managed their behaviour. Now, the parent programme went everywhere, all  over the world, and if you are going to tackle   conduct disorder, working with parents is probably  the best way to go. But the problem being that   if the school – if the problem is school-based  and perhaps not happening at home, well, then,   no amount of parent training is going to support  the problem. And when I’m feeling very brave,   I put to Teachers, you know, “How able do you  feel to be able to get your pupils to make their   beds and tidy their rooms? Because when you are  holding their parents responsible for the child’s   behaviour in the classroom, that’s, kind of,  parallel to what you’re doing.” Now, I’m being   flippant and, of course, that, you know, parenting  is hugely important, but it’s not the whole story. So, all three of the Incredible Years Programme  are based on operant conditioning, that all of   our behaviour, not just children’s, is influenced  by attention, rewards and incentives, but also,   Bandura’s work on modelling and self-efficacy.  So, that the course is very experiential,   with lots of live roleplaying or video modelling,  that you rehearse what you’re going to do. It’s a   lot about the Teacher being able to step back from  their own emotions and to act, rather than react,   and taking the time to reflect. As well as  attachment theory. Teachers are important to   the children that they teach and having a good  – we’re back to Teacher-pupil relationships,   having that positive relationship is really  important, and not only to behaviour,   but to the child’s development. And so, the  onus is on building these relationships. Carolyn Webster-Stratton, who developed these  programmes, talks about in – putting money – you   know, “building up the savings in the relationship  piggybank” for when you do have to say, “That was   a mistake, you need to reflect.” So, you have  that positive relationship. So, you work through   praise, rewards or incentives when the child  does what you want them to do, and coaching. So, we ran a study where we took the  Teacher programme. We recruited 80 schools,   one Teacher from each school. These were primary  schools across Devon, and we went round at the   base – at baseline before randomisation,  so nobody could know who was getting what,   collecting Teacher mental health, par – child  mental health, and various other measures. We   also did observations in the classroom of the –  how the children behaved and how the Teacher was. Then schools were randomised either to get the  intervention, Teacher-classroom management,   or teach as usual. And then, the Incredible Years  course is six whole days spread a month apart, so   they started in November, they finished by March.  In the summer term, we went back to repeat our   measures, whilst the children were with the same  Teacher. But, of course, you can’t blind a Teacher   to the fact that they’re going on a course or not  going on a course. So, we insisted on single year   groups so that all the children separated from  their Teacher at the end of the year and went into   a different Teacher’s class, and we went back in  two subsequent years to get follow-up from them. I could talk for a whole hour on this trial,  but I won’t, but what we showed was a small,   but statistically significant, improvement on  Teacher reports of child mental health at nine   months, also, peer relationships and pro-social  behaviour, which is exactly what our theoretical   model said we should find. More exciting,  though, as a pre-registered sub-group analysis,   those in poor mental health at baseline showed a  sustained improvement on Teacher reported mental   health. And equally, for all children, classroom  behaviour and their concentration improved,   which may well transfer into academic work  later down the line. There was, similarly,   an interaction between baseline  mental health and academic progress,   although there was no impact overall,  and it did appear cost effective,   in the short to medium-term, depending  on how much you were willing to pay. The same group of us then went on and did  this practitioner review for schools via   the Education Endowment Foundation, which is still  available, which, basically, encouraged schools to   focus on the things that they can do directly. So,  relationships, teaching and learning environment,   the school organisations, and the kind of  attitudes that the school inculcates. That   it’s useful to be aware of various issues  that might impact on behaviour at a school,   but to realise that you can on – you might be able  to influence it, but not a huge amount. And then,   there’s some other things that you might need  to be aware of but should not expect to change. There was a second STARS trial, but sadly, it was  decimated by COVID, so the findings were – you   know, they found no effect, but they also lost  half their Teachers and half their children,   for various reasons, and couldn’t do very  many measures. It’s there for completeness. The next study I want to talk about is the MYRIAD  study. So, this was a research programme over   eight years, which explored whether a school-based  mindfulness training could improve the mental   health of young people in early adolescence.  This was eight weeks of a lesson a week,   so it was very comprehensive, and, in fact, many  schools had to drop other things to get it in. So,   I, you know, I did – I’m not sure how  practical it would be. Sadly, or not sadly,   we asked a question, and we can be very sure  of the answer, which is that curriculum in   that age group didn’t have an impact. That  meant we had this huge dataset that we can,   essentially, use as a cohort. It didn’t have  an impact on the children, I should say. So, we have studied school level variables in  mental health. You know, what, at school level,   influences the mental health of the  pupils? And the amount of variance,   depending on whether you’re looking for  – at a measure of depression, the CES-D,   the Strengths and Difficulties, which is  psychopathology overall, or wellbeing,   it’s only one to 3% of the variability  in schools that’s explained at a school   level. But I would argue that for some more  vulnerable children, that may well be important. Interestingly, cross-sectionally, at baseline, it  was the Teacher rated school climate was the only   tractable school level variable that predicted  student mental health. When we looked at – over   two years, over time, amongst those students who  were in the whole of the trial, so it’s a smaller   number, but still over 8,000, interestingly,  school climate came up as predicting pupil   mental health. So, really paying attention to the  climate of the school is – seemed very important. So, I said the school-based mindfulness  programme didn’t impact children,   but it did reduce Teacher burnout and it did  improve the school climate. There was a hint,   and this is important, that it might have  – might worsen depression amongst those   who were depressed at baseline. So, that’s  an important potential harm. We shouldn’t   just assume that because something is  preventive, that it won’t do any harm.   And I’ve put a picture of Judi Kidger, who’s  from Bristol, who run the – ran the WISE study,   which was about mental health first aid in  secondary schools, and she found the same thing. In fact, you know, whilst we were setting  up for the trial, Theresa May introduced a   policy where every school was going to  have at least one mental health first   aid trained person. In fact, it had no impact  on mental health in Teachers and pupils. So,   we really need to stick to the evidence  base. Even if it doesn’t do any harm,   the resources used could be better used  for things that are evidence-based. So, don’t try and take in the detail  of this rather busy slide, but we had   a natural experiment in this study, because one  cohort got all the way through before COVID hit,   and COVID hit between the third and fourth  datapoint in our follow-up of the second   cohort. Which meant we had this natural experiment  of children who’d got all the way through versus   those who were exposed to COVID, in terms of  whether it impacted their mental health or not. And what you see here is depression measures,  the Strengths and Difficulties Questionnaire   and the WEMWBS Wellbeing Questionnaire,  and cohort one is in blue and cohort two   is in red. So, high scores on the SDQ  and depression measure are – indicate   worse mental health. A high score on the  wellbeing measure indicates better. So,   the children who were exposed to COVID at the same  age, using the same schedule, were doing worse. So, what could we do about this? What you’re  looking at here is data from Place2Be on their   counselling course. So, they offer all  kinds of training and interventions in   school, but this is individual counselling,  unspecified as to what type of intervention,   with Strengths and Difficulties Questionnaire  completed by Teachers in the middle column and   parents in the right-hand column.  And you can see that there is a   big statistically significant drop between  the measure before or after intervention,   which is maintained, according to both  parents and children and young people. I should say, this work was conducted by Katie  Finning, whose photograph is there for you to   see. She now works at ONS. This is an indicator,  you know, the best that many services have that   what you’re doing is having an impact, but the  thing is, we don’t know what would’ve happened   if those children hadn’t had treatment. So, what  Katie did was use data from the National Survey,   so that’s the line in blue, of children matched  as closely as possible for age, gender, ethnicity,   parental mental health, all the background  variables that were available in the Place2Be   dataset, that we could replicate within the  National Survey data. And what you see here is   when you introduce a counterfactual, there’s very  strong evidence that for up to two years later,   these children’s mental health is improved. So,  counselling within schools or intervention within   schools could really make a difference. We should  be more optimistic about the treatments that we   have on offer for children and young people. We  just need to make them more available to people. Similarly, Jenny Saxton, in this photograph,  also on Place2Be data, analysed whether having   access to school-based counselling made a  difference to attendance. Now, at the moment,   this is a major issue because there are – has been  such a sudden jump in people who are persistently   absent, and that is described as missing at  least half a day a week or nine – less than   90% attendance. When you looked at attendance  just as, you know, the percentage attendance,   there wasn’t an association. However,  if you had been persistently absent at   the beginning of your counselling, you were much  less likely to be persistently absent later. So,   mental health services could perhaps help  those in schools who are struggling to attend,   showing how closely entwined mental  health and school services need to be. And in fact, this graph shows how people did  in terms of whether or not they were probably,   possibly or unlikely to have a disorder, either  before counselling or afterwards. And what you   can see, those who either remained unlikely to  have a disorder and their counselling was in   relation to maybe something traumatic happening  in their lives as a, kind of, preventive thing,   or those who improved, either from unlikely –  either from possible to unlikely, or from probable   to unlikely, they showed improved attendance.  Whereas the – those with probable disorder pre   and post showed poorer attendance. So, it links  – seems to link to how the counselling is going. I was involved, years ago, in – probably about  just under ten years ago now, in a systematic   review of non-drug interventions in schools to  support children with ADHD. There’s a link to   the report and papers in – at the bottom of the  slide. And when we’re working in schools that –   particularly those of us who come in health,  we’re used to thinking about the individual   child in their family. But when you’re thinking  about the school system, you need to think about   these other levels, as well, so the classroom, the  school, and also, the sociopolitical pressures.  This work showed that there was something  that happened that was helpful about non-drug   interventions in schools. Ironically,  shorter interventions seem to do better,   which I suspect is we shouldn’t expect Teachers  to be Therapists. They don’t actually want to   deliver a long intervention. What they want is  some strategies. And the dat – the literature   was so poor in describing what went into these  interventions, that actually, we can say something   works, but we don’t know what, which is not very  helpful to distilling down to the key ingredients. This work is now being taken forward  by my colleague, Abby Russell,   who’s at the University for Exeter, who has  a senior fellowship developing a, kind of,   toolbox for those who work with children in  schools who look like they might have ADHD,   but maybe they’re on a waiting list or they  haven’t been diagnosed yet. And the idea   is that it scaffolds Teachers and Teaching  Assistants to identify a particular problem   and in a structured way, try things to solve that  problem in their context. It’s going really well,   it’s in early stages, but watch this space, ‘cause  I think it could be a really exciting way to work. So, just to finish off, Claire Parker, who  did the work on exclusion, came up with this   wonderful idea of the “Coping Continuum,” and I  think you would – I’m sure you would all agree,   we’re all on a coping continuum. But if we  think about children in a school situation,   and her work was in relation to exclusion, but we  could think about a child with any mental health   condition that impacts their ability to access  school, they’re stuck between the school and the   family context. There may be issues around whether  to diagnose or not and whether they’re getting   support, which may ease or compound difficulties.  There are issues, often, around advocacy. So,   we really need to think about the children  who don’t have an advocate for them. Maybe   it’s because of English as a second language,  or maybe it’s because they are looked after,   but having someone who advocates for you is really  important, as is communication and relationships. But that, you know, often, people cope  well for a bit and something happens and,   you know, it’s a complex journey. It’s  not a, kind of, straight line, sadly,   and we need to make sure the scaffolding is  in there around these children to help them   to develop as well as possible,  and then, remember to, kind of,   slowly dismantle it when maybe they  don’t need so much, for various periods. So, the vast majority of children in  our school, even with the horrific   official statistics we have at the moment on  mental health in children and young people,   we can still say most of our population is  doing fine. What seems to have happened during   COVID is that this vulnerable group, more  of them have become a clinical population,   and what really good multi-level interventions  in school, which are aimed at prevention,   targeting intervention and indicated  intervention, if we could get health   and education and the third sector really  working together on this, maybe we might be   able to get more children into the general school  population thriving as well as they could be. I will stop there. These – all the studies I’ve  talked about, pretty much, apart from MYRIAD,   which was Wellcome funded, the  others were all funded by NIHR,   and references are in the slides,  which I will make available for you.