Short Writing 2: Taking Notes On Related Studies

Identify in the article below studies that you believe are closely related to your own research That meansyou would like to build your study upon these studies in terms of research questions or methodology, or you hope the authors of these studies would read your study down the road.

Take detailed notes on their research questions, methods, and findings, and place your notes in a table like the one introduced in Becoming a Social Science Researcher, Chapter 4. In your notes, may quote from these studies and write down their page numbers. Toward the end of the table, in one or two new rows, jot down the patterns that you have noted about these studies' research questions, methods, and findings.

Topic:Embedding mental health support in schools: learning from the

Targeted Mental Health in Schools (TaMHS) national evaluation

Miranda Wolperta

*, Neil Humphreyb , Jay Belskyc,d,e and Jessica Deightona

aCAMHS EBPU, Anna Freud Centre, London,UK; bSchool of Education, University of Manchester,

Manchester, UK; c

Human and Community Development, University of California, Davis, USA; dDepartment of Special Education, King Abdulaziz University, Jeddah, Saudi Arabia; e

Department

of Psychological Sciences, Birkbeck, University of London, London, UK

The Targeted Mental Health in Schools (TaMHS) programme was a nationwide initiative that funded mental health provision in schools for pupils at risk of or already

experiencing mental health problems. The implementation, impact and experience of

this programme was evaluated using quantitative and qualitative methodology involving three main studies: (1) a 1-year RCT involving 8658 8-10 year olds and 6583

11-13 year olds, (2) a 3-year longitudinal study involving 3346 8-10 year olds and

2647 11-13 year olds and (3) qualitative interviews with 26 TaMHS workers, 31 school

staff, 15 parents and 60 pupils. The RCT demonstrated that TaMHS led to reductions

in behaviour problems but not emotional problems for 8-10 year olds. No impact was

found for 11-13 year olds. The effects on behaviour problems in primary school were

enhanced by the provision of evidence based self-help materials, but not by other area

level support. The longitudinal study found information giving and good inter-agency

working correlated with more positive outcomes for behavioural problems in secondary

schools. The qualitative findings indicated that TaMHS was well received by all groups,

though challenges to its implementation were noted. Overall, findings indicate the utility of targeted mental health provision in schools, particularly in primary settings. The

implications for implementation are discussed.

Keywords: CAMHS; children; mental health; intervention; multi-agency; booklets;

schools

The role of schools in meeting the mental health needs of children and young people

The possibility of embedding mental-health support efforts in schools has generated a great

deal of interest in recent years (e.g., Greenberg 2010). In this report we summarise the

implementation and evaluation results of one such national effort, called 'Targeted Mental

Health in Schools', hereafter referred to as TaMHS (Wolpert et al. 2011), while exploring

the implications of this programme for the broader field. Like reports by others included in

this issue (e.g., Humphrey, Lendrum, and Wigelsworth 2013), we begin by acknowledging

evidence (1) that a significant minority of children and young people experience clinically

recognisable mental health difficulties (Green et al. 2005), (2) that the proportion affected

has risen over the last several decades (Maughan, Iervolino, and Collishaw 2005), (3) that

schools are ideal settings for intervention (Greenberg 2010) and, finally, (4) that there may

be organisational issues that need to be addressed if mental health is to be successfullyEvidence of the effectiveness of school-based mental health provision

The array of approaches used in schools under the auspices of 'mental health promotion' is

vast and varied. As evidence of this, consider that schools in the USA report using a median

272 M. Wolpert et al.

of 14 different programmes to achieve this goal (Zins et al. 2004). In the research reported

herein, carried out across England, 13 distinct strategies were evident (Vostanis et al. 2012).

These can be conceptually organised, according to Humphrey (2013) and others, in terms

of reach (e.g., universal, targeted, indicated), components (e.g., focus on curriculum, school

climate and ethos, parents/community or some combination of these) and prescriptiveness

(e.g., the degree of manualisation or flexibility). To this we might also add variation in

the theoretical underpinnings and modalities of the different approaches (e.g., behavioural,

cognitive-behavioural, social skills training). These are not mutually exclusive, however.

Indeed, most interventions typically embrace a blended approach. Furthermore, the evidence suggests that these blended approaches produce largely similar effects (Wilson and

Lipsey 2007).

Even if not entirely compelling, evidence for the efficacy of school-based mental health

services appears extremely promising. At the universal level, a series of systematic reviews

and meta-analyses indicate that high quality programmes can impact significantly on a

range of pertinent outcomes (e.g., Adi et al. 2007; Durlak et al. 2011; Sklad et al. 2012;

Wilson and Lipsey 2007). Effect sizes, it needs to be acknowledged, prove rather modest (Weare and Nind 2011), with larger ones emerging from efficacy trials with limited

external validity. Furthermore, measured effects vary greatly - and not surprisingly - as a

function of quality of implementation (Durlak and DuPre 2008). Finally, and perhaps most

importantly, we still know relatively little about whether, or the degree to which, different

universal interventions benefit students with the highest level of need (Humphrey 2013).

Thus, we still need to understand 'for whom, and under what conditions, interventions

work' (Weisz et al. 2005, 640; see also Roth and Fonagy 2004).

Beyond effects of universal services, a large body of work addresses the impact of

more targeted/indicated provision. Systematic reviews and meta-analyses indicate that

such interventions can be effective in promoting positive outcomes for children and young

people at-risk of (or already experiencing) mental health difficulties (e.g., Gansle 2005;

Horowitz and Garber 2006; Shucksmith et al. 2007; Wilson and Lipsey 2007). Effect sizes

here generally prove larger than for universal interventions, which is perhaps to be expected

given the greater intensity of targeted approaches and the contrasting levels of need in

universal and at-risk populations (which can often produce a ceiling effect in the former) (Humphrey 2013; Weare and Nind 2011). Despite such promising results, concerns

similar to those expressed in relation to universal approaches need to be acknowledged.

Specifically, the research focus on efficacy rather than effectiveness raises issues of external validity, replicability and sustainability when 'proven' interventions are brought to scale

(Shucksmith et al. 2007). Also, maintaining fidelity to treatment models is easier said than

done, though essential to achieving anticipated outcomes. Having said that, it should be

acknowledged that the 'manualised' tradition inherent in targeted/indicated interventions

often makes this easier than in the case of more diverse universal interventions.

In both universal and targeted/indicated school-based mental health provision, some

attention has been paid as to who are the most effective 'agents of transmission', such

as teachers or external specialist staff (Weare and Nind 2011). Although research is not

definitive, several high-profile analyses indicate that interventions led and implemented by

school staff are at least as effective as those involving external professionals (e.g., Durlak

et al. 2011). Given the likely cost-savings associated with in-house delivery of interventions

and the ability of teachers to 'get to the heart of the school process' (Weare and Nind 2011,

61), such work suggests that the most sustainable models of school-based mental health

provision will be those that centrally involve school staff in delivery. The emphasis in the

Emotional and Behavioural Difficulties 273

research literature on 'fidelity-at-all-costs', however, may create challenges in relation to

local ownership and the professional autonomy of teachers.

One final consideration is the balance to be struck between universal and

targeted/indicated provision. Educational policy in this area tends to support a model

whereby universal, preventive provision is supplemented by targeted programmes for students considered to be at-risk and intensive, indicated intervention for those already experiencing difficulties. This is the model recommended by the World Health Organisation

(2004), and variants of it can be found across the English speaking world (e.g.,

England [Department for Education and Skills 2005], Australia [Australian Government

Department of Health and Ageing 2009], USA [Sugai and Horner 2006]) and elsewhere.

The work just cited calls attention to the need to achieve balance between universal, targeted and indicated intervention (e.g., Adi et al. 2007; Weare and Nind 2011), though there

has been very little empirical investigation of this fundamental issue (Humphrey 2013).

To our knowledge, only one study has examined the outcomes of combinations of provision

at different levels (e.g., universal only, indicated only, combined) and it yielded equivocal

results (Sheffield et al. 2006). So, although it makes intuitive sense that a well integrated,

multi-level model of provision would be the most effective means of supporting vulnerable

and other pupils, confirmatory evidence is lacking.

The TaMHS initiative in England

Launched in 2008, TaMHS was a large-scale initiative to embed targeted mental health

support in schools across England (Department for Children, Schools and Families 2008).

The overall aim was to develop innovative, locally crafted models to provide early intervention and targeted support for children (aged 5-13) at risk of developing (or already

experiencing) mental health problems, and their families. The TaMHS formed part of the

English government's wider programme of work developed to improve the psychological

well-being and mental health of children, young people and their families.

The aim of TaMHS was to build on existing whole-school interventions and focus on

need of pupils at risk of, or experiencing, mental health problems. The TaMHS was specifically developed to build on universal and small-group elements of a previous programme

rolled out nationally that was developed to support children's social and emotional learning (Social and Emotional Aspects of Learning [SEAL] [see Humphrey, Lendrum, and

Wigelsworth 2013, this issue]) and to provide more targeted and intensive support that was

complimentary (see Figure 1).

Selected schools in every local authority (LA) across England were involved and

total funding reached 60 million nationally across a period of three years. Funding from

TaMHS was available for LAs and schools and these could choose how best to use the funds

to meet their needs. Thus, LAs and schools had the freedom to invest in training, support

and consultancy for school staff and/or additional frontline practitioners to work with staff

and pupils and/or voluntary sector provision and/or associated management activity. With

a phased approach, 25 pathfinder local authorities began TaMHS in April 2008, 55 local

authorities joined in April 2009, and the remaining 71 in April 2010. By March 2011,

between 2500 and 3000 schools were involved in delivering TaMHS projects. To aid delivery of the project, the Department for Education1 commissioned the National CAMHS

Support Service (NCSS) to provide 'support and challenge' to all participating LAs.

The TaMHS drew on the aforementioned body of research and represents a good example of Domitrovich and associates' (2010) 'integrated prevention model'. This framework

is based on the view that a range of often inter-related individual and contextual factors

274 M. Wolpert et al.

Figure 1.The waves model of prevention and intervention for SEAL/TaMHS.

can place children at risk of problematic development (e.g., temperament, family climate,

neighbourhood cohesiveness). Thus, approaches to intervention focusing narrowly on a

single risk factor or outcome domain are presumed less likely to be successful in promoting

well-being by preventing and ameliorating problems than those that target multiple sources

of influence. Furthermore, the model stipulates that effective school-based prevention

should combine universal, school-wide approaches with targeted/indicated intervention

for specific groups of students. Finally, it is assumed that an integrated intervention model,

in which independent strategies or programmes are fused into a single, coherent framework in a co-ordinated manner, will exert synergistic effects. The TaMHS embraced these

core principles by, for example, ensuring that all participating schools had a strong track

record of universal provision and encouraging the integration of distinct strategies and

programmes.

Support and guidance materials developed by TaMHS for schools reflected two guiding principles: (1) that the selection of interventions be informed by the evidence regarding

'what works' in school-based mental health provision and (2) that the programme should

support strategic integration across agencies involved in the delivery of CAMHS. The

latter would be achieved by promoting joint leadership and ownership, interdisciplinary

teams and cross-site working (DCSF 2008). While these two elements were mandated at

a national level, the emphasis of TaMHS was very much on local implementation and

tailoring of support to local need. This was achieved by devolving responsibility of implementation to the participating LAs across England. Each LA developed their own bespoke

project in conjunction with colleagues based in primary care trusts and in the voluntary

sector to support a number of schools in their area through the provision of evidence-based

targeted mental health support.

The scale and scope of the TaMHS project also allowed for the exploration of three

additional approaches - at the level of the local authority or school - to supporting schoolbased mental health provision. At the LA level, booklets were delivered that were designed

to support project start-up based on learning from the first year of implementation in the

first 25 'pathfinder' LAs. These booklets included information for LAs about setting up

Emotional and Behavioural Difficulties 275

steering groups, engaging with schools and formulating plans, while providing examples of

good practice. Also at the LA level, Action Learning Sets (ALS) were implemented, which

involved group meetings provided regionally to LA Leads, TaMHS workers and school

staff in order for them to share learning and discuss challenges and solutions. Finally, at the

school level, the provision of evidence-based self-help booklets was trialled. The booklets

were developed to inform children of psychological, emotional and behavioural tactics to

use to improve their well-being. They included advice grounded in empirical evidence.

For example, the booklets provided instructions for some simple relaxation techniques to

help children feel calm when stressed. Different booklets were developed for primary and

secondary schools (primary: How to get up and go when you're feeling low; secondary: I

gotta feelin'2).

National evaluation of TaMHS

In early 2008 a large, multidisciplinary research group (including the authors of this article) were commissioned by the English Department for Education (DFE) to conduct the

national evaluation of the TaMHS initiative. This project - the largest of its kind to date -

utilised a mixed methods design, incorporating a longitudinal observational study, a randomised controlled trial (RCT), an interview study of TaMHS stakeholders and in-depth

case studies of a variety of implementation sites. The overall project was designed to

address the following research questions (RQs):

(1) What is the impact of TaMHS on mental health outcomes of pupils (when

compared to provision as usual)?

(2) Does the provision of additional support (e.g., ALS, LA booklets, pupil booklets)

enhance the effect of TaMHS provision on pupils' mental health?

(3) What different approaches and resources are used to provide targeted mental health

in schools?

(4) What school and individual factors are associated with changes in pupil mental

health outcomes in schools implementing TaMHS?

(5) How is TaMHS provision (and the support materials designed to enhance the

impact of such provision) experienced by project workers, school staff, parents

and pupils?

Ultimately, the goal of the research program was to inform future implementation, as well

as to enhance understanding of school-based mental health provision more generally.

The TaMHS research programme was comprised of two primary studies, one

naturalistic/observational and the second experimental (i.e., RCT). The first study involved

schools in the 25 LAs originally selected as TaMHS 'pathfinders', and was itself comprised

of two components. The first, quantitative aspect of this work involved the measurement

of child mental health and the factors affecting it in a sample of c. 20,000 pupils in over

350 schools. The second, qualitative component of the observational study involved interviews with TaMHS stakeholders (e.g. policy advisors, school staff, parents, pupils and LA

TaMHS staff) and in-depth case studies of select TaMHS sites.

The final major TaHMS study consisted of an RCT study, which involved schools

in LAs who came into the project from 2009 onwards. The sample included over

30,000 pupils attending over 550 schools. Random allocation to treatment conditions took

276 M. Wolpert et al.

Figure 2.Random allocation for the RCT component of the TaMHS evaluation.

place at both LA and school levels. The conditions that were randomised across the RCT

included:

(1) whether the area received TaMHS or not (TaMHS versus no TaMHS)

(2) whether LAs were invited to attend ALS or not (ALS versus no ALS)

(3) whether LAs received booklets designed to support project start-up or not (LA

booklets versus no LA booklets)

(4) whether schools received evidence-based self-help booklets for pupils or not (pupil

booklets versus no pupil booklets).

In the interests of clarity, the random allocation protocol is depicted in Figure 2.

Mental health in both the RCT and the naturalistic longitudinal study was assessed

primarily via pupil self-report, but supplemented with teacher and parent informant-report

surveys that included both well-established measures (e.g., the Strengths and Difficulties

Questionnaire [Goodman 1997]) and a bespoke measure developed and validated by the

TaMHS research group - the Me and My School measure (Deighton et al. 2012).

Implementation and experience of TaMHS

Schools in both the first and second components of the overall evaluation completed annual

school co-ordinator questionnaires designed to examine the nature and range of approaches

to mental health provision they implemented through TaMHS. Insight regarding the initial

TaMHS provision based on the school co-ordinator surveys is reported in full in Vostanis

et al. (2012). In summary, schools reported providing a very diverse range of approaches,

from which 13 categories were identified:

Child-focused support:

(1) one-to-one psychological therapy (e.g., counselling, behavioural and cognitive

behavioural psychotherapy, interpersonal psychotherapy)

Emotional and Behavioural Difficulties 277

(2) small-group work, including group-based versions of the above interventions

(3) creative and physical activity to support well-being (e.g., drama, music, art,

yoga)

(4) information and advice-giving (e.g., advice lines, leaflets, texting services webbased information)

(5) peer support techniques

(6) behaviour for learning and structural support for pupils

(7) universal social and emotional learning approaches (e.g., SEAL)

Parent-focused support

(8) providing information about available services

(9) focused support to manage stress and other emotional reactions

(10) training to improve skills and confidence in relation to parenting

Staff-focused support

(11) supervision and consultation for staff

(12) staff training

(13) counselling and support for staff experiencing stress and other emotional

issues.

Schools reported implementing different combinations of these approaches to varying

degrees throughout the project. Across all schools, mental health support was generally

provided by teachers and other internal staff (e.g., teaching assistants), with a smaller

proportion relying on external professionals for this purpose. However, this varied as a

function of time, phase of education and difficulties. For example, there was an increase

from 2008 to 2010 in secondary schools in externally-led provision for pupils with externalising problems. In terms of training, there were decreases over time in the number of

schools reporting staff with no mental health training leading interventions, alongside an

increase in reported use of trained staff for this purpose.

Other data captured through our exploration of the implementation of TaMHS yielded

interesting insights into LAs and schools' adherence to the guiding principles outlined in

the guidance and support materials. Both primary and secondary schools initially used

approaches developed locally more often than nationally or internationally tested ones.

Hence, the norm was practice-based-evidence (PBE) as opposed to evidence-based practice

(EBP). In primary schools, however, there was an increase in the use of EBP approaches

over time, concurrent with a decrease in use of PBE strategies. Interestingly, the converse

was true in secondary schools. Perhaps unsurprisingly given the aforementioned challenges

to professional autonomy and local ownership of 'top down' interventions, no schools

reported using approaches that involved following a rigorous protocol or manual, which

remained true throughout the life of the project. The most frequently endorsed category

in this aspect of TaMHS implementation was work that was, 'based on a plan but open

to adaptation', perhaps indicating that the optimal delivery model for school-based mental

health provision is one which provides a balance between prescriptiveness and flexibility.

The link between schools and specialist health provision was also explored via school

co-ordinator report. Schools implementing TaMHS used more positive links with specialist

mental health services than those not implementing TaMHS.

In terms of stakeholders' experience, it was notable that staff, pupils and parents

were all positive about the experience of embedding mental health in schools. The different viewpoints captured from different perspectives each provided useful insights. Those

involved in the implementation of TaMHS noted that one fundamental challenge involved

278 M. Wolpert et al.

addressing differences in philosophy and working practice between agencies, and this challenge was itself exacerbated by the lack of and thus need for a common language between

schools and CAMHS. Factors that facilitated success included integration in schools, for

example: bringing all mental health support activities into the school setting, building on

previous initiatives and being sensitive to the existing context in terms of understanding

what has already worked, what issues need addressing and what current ways of working

look like. As one TaMHS worker noted:

I think one of the principles was around the idea of not replicating what was already there,

but finding out what was already there and building on that, and building capacity and starting

with interventions that people had already valued, rather than trying to find something totally

new and starting afresh. (TaMHS management team, interview)

School staff were generally enthusiastic about TaMHS and identified examples of positive change, which they ascribed to the project. Key facilitators identified included having

specialist mental health workers based in schools:

Putting staff into schools, it's as simple as that. That is the significant difference, having somebody that you can quickly speak to without a long rigmarole of referral and a long waiting

time with a perhaps you will, perhaps you won't get some support is actually people that you

can say, xx, I've got a problem with this child, can you help us out? (School staff member,

interview in TaMHS school)

Surveys of parents revealed that they regarded schools as the key point of contact for concerns about mental health issues and regarded teachers as the key group to turn to when

worried about their child's mental health. Parents also saw teachers as the persons most

helpful in these situations. Parents were generally positive about TaMHS and particularly

stressed the importance of good communication in working with schools on mental health

issues for their children:3

I mean every teacher that I've spoken to or associate. . . . They seem to have endless amounts

of time to talk to you. They never hurry you. It's lovely. (Parent of child in TaMHS school,

interview)

In the large annual survey of pupil experience, most pupils indicated they had access to

mental health support in schools, with those with more difficulties having accessed more

help. Pupils also showed an awareness of a range of approaches available in their schools

and an appreciation of the ways these could help:

Remember it isn't just for people who are getting bullied it is also for people who want to

improve their behaviour. (Male pupil, focus-group participant in TaMHS primary school)

TaMHS efficacy

Multi-level modelling of data from both the longitudinal, observational study and the RCT

provided data pertinent to the impact of TaMHS on pupil mental health. Although the

former is limited in terms of causal conclusions that can be drawn, it nonetheless provided useful indicators and trends that could be fed forward to the latter study. For primary

schools, the longitudinal work revealed decreases in both emotional and behavioural difficulties - as assessed by pupil and teacher surveys - over the three years of the evaluation.

Emotional and Behavioural Difficulties 279

The secondary school picture was more mixed, with pupil reports revealing a decrease in

emotional but not behavioural difficulties, but no change in either according to teacher

report.

In terms of factors associated with changes in pupils' mental health over time, school

reports of giving information to pupils in secondary schools proved to be positively related

to improvements in the mental health of children with behavioural difficulties. However, in

primary schools this same provision was associated with a smaller (rather than larger)

reduction in emotional problems. In terms of inter-agency working, school reports of

both the use of a shared interagency assessment framework, the Common Assessment

Framework and good links with specialist health-based CAMHS proved to be positively associated with improvements over time in secondary school children's behavioural

problems.

Findings from the RCT indicated that TaMHS provision benefited children with

behavioural difficulties in primary schools but no evidence of such emerged in the case

of older age groups or for emotional outcomes in primary school. An additional finding

from the RCT was that the evidence-based, self-help materials (i.e., pupil booklets) led to

more pronounced improvements in behavioural problems for primary school children when

coupled with TaMHS implementation, but not when they were provided in the control LAs.

Important to note, however, was that there was some evidence that these same pupil packs

were associated with reduced improvement in emotional difficulties for pupils in primary

school coupled with Action Learning Sets for staff.

Discussion

The TaMHS initiative represented a major effort by the previous English government

to improve the psychological well-being and mental health of children, young people

and their families. In many respects it was a unique - even innovative - approach to

school-based mental health provision, bucking as it did the trend towards heavily manualised, 'programme-for-every-problem' approaches to intervention that have dominated

the field (Jones and Bouffard 2012). The approach instead embraced an integrated model

(Domitrovich et al. 2010) and offered a robust framework for action that still respected

the requirement for implementation that could be tailored to local need. This seems to be

where the field is now headed - with examples of initiatives that embrace a similar philosophy and approach beginning to emerge in Australia (e.g., the KidsMatter programme

[Slee et al. 2009]), the USA (e.g., the School-Wide Positive Behavioural Interventions and

Supports framework [Horner et al. 2009]) and elsewhere, with equally positive findings in

regard to the potential to influence pupil well-being in a meaningful way.

Our national evaluation of the TaMHS project yielded a number of key findings that

have implications for both future implementation efforts and the broader field of schoolbased mental health provision. Given the finding from the RCT that targeted mental health

in primary schools reduced behaviour problems of children showing signs of behavioural

difficulties, we recommend that primary schools continue to focus on behavioural problems

to prevent later escalation and the huge societal costs that can come from these conditions

when not appropriately treated at an early stage (Scott et al. 2001).

The fact that TaMHS was more effective in tackling behavioural than emotional difficulties in primary schools may reflect the greater awareness of and priority afforded to

externalising difficulties in schools. Teachers are typically more successful at appraising

children's behavioural difficulties than their emotional ones (Kolko and Kazdin 1993),

280 M. Wolpert et al.

likely due to the differential salience of these types of problems in relation to issues of

classroom management and climate (Atzaba-Poria, Pike, and Barrett 2004). Thus, they

may be better at identifying the group of children with behavioural difficulties requiring additional support than those with emotional problems. Furthermore, schools are

more accustomed to dealing with behavioural problems as part of general classroom

management so may also be more experienced in and thus able to give effective support to

children with these kinds of problems.

The finding that the impact was clearly more pronounced in children of primary school

age reinforces calls for earlier intervention to address mental health difficulties before they

become entrenched and less responsive to intervention (e.g., Allen 2011). However, the

contrasting systemic and relational contexts of primary and secondary schools may also

have influenced the effects detected. Secondary schools are typically much larger than primary schools, which in itself can present organisational and management challenges when

it comes to implementing a mental health program (Lendrum, Humphrey, and Wigelsworth

2012). Primary schools adopt a child-focused philosophy that is arguably more amenable

to mental health promotion than the subject-oriented approach that typically characterises

secondary schools. It should also be noted that research suggests that teachers in secondary

education can also be more resistant to non-academic interventions than their primary

school counterparts (Lendrum, Humphrey, and Wigelsworth 2012; Weare and Gray 2003).

Given this, a challenge for the future involves identifying effective means of increasing the

'buy in' in secondary schools. One way to do this might include placing greater emphasis

on the relation between children's mental health and academic attainment (e.g., Masten

et al. 2005).

Correlational findings from the longitudinal, observational study suggest a key focus

for work with secondary schools may involve fostering their links with specialist external resources, whether in health or elsewhere, and putting effort into signposting these

resources to young people rather than necessarily trying to provide the direct services

themselves. The fact that reports of good links with specialist mental health services

proved to be positively associated with improvements over time in behavioural difficulties

of secondary school pupils suggests the policy of seeking to establish closer links between

specialist CAMHS and schools should continue to be pursued. The finding under consideration also suggests that a focus on developing shared assessment frameworks and common

language should be encouraged.

Provision of self-help information booklets for pupils was found - in the RCT - to

enhance the well-being of children with behavioural problems in primary schools when

those schools provided targeted mental health. A note of caution emerged, however, given

the finding that giving booklets to pupils in primary schools was associated with deterioration in well-being for children with emotional problems in the context of staff having

received action learning sets. We have no explanation for how this finding should be

interpreted and, therefore, suggest it should be treated with caution.

Conclusion

The TaMHS project represented a major financial and political investment in school-based

mental health provision at the end of the previous English government's tenure. It was

arguably innovative in its approach, offering a framework for action based rather than a

prescriptive, 'one-size-fits-all' approach. This gave schools and LAs freedom - providing

certain guiding principles were evidenced (e.g., increased use of EBP approaches, links

with CAMHS) - to develop models of provision that were tailored to local need. Our

Emotional and Behavioural Difficulties 281

national evaluation of TaMHS provided a somewhat mixed picture of the relative success

of this model. One the one hand, some of the headline findings were very positive and spoke

to the impact of TaMHS on children's mental health outcomes. However, several analyses

yielded null results, suggesting areas for improvement and refinement. One possible issue

here is the EBP versus PBE conundrum in schools. Although our evaluation demonstrated

an increase in the use of EBP through the course of the project in certain contexts (e.g., primary schools), on the whole schools did not engage with this as fully as was hoped. There

are a whole range of reasons why this may be the case, but awareness (e.g., do schools

know which approaches are supported by strong empirical evidence?) and access (e.g., are

schools able to acquire the appropriate training, materials etc.?) are two immediate contenders. Given this, we might look to the Australian KidsMatter programme (see Slee et al.

2009) as an example of how more precise guidance can be helpful. In contrast to the documentation provided to schools in the TaMHS project, the Kidsmatter resources provide

participating schools with a guide to over 70 available interventions, with information covering the areas of focus, evidence base, theoretical framework, structure, points of contact

(e.g., organisations, training providers) and other factors to enable them to make informed

choices that suit their local context and needs (Humphrey 2013).