Judi L Kidger

The Effect of the School Environment on the Emotional Health of Adolescents: A Systematic Review

BACKGROUND AND OBJECTIVES: The evidence base for the importance of the school environment for adolescent emotional health has never been systematically reviewed. We aimed to synthesize the evidence for the effect on adolescent emotional health of (1) interventions targeting the school environment and (2) the school environment in cohort studies. METHODS: Searches of Medline, Embase, PsychINFO, CINAHL, ERIC, the Social Citation Index, and the gray literature were conducted. Criteria for inclusion were (1) cohort or controlled trial designs, (2) participants aged 11 to 18 years, (3) emotional health outcomes, and (4) school environment exposure or intervention. Relevant studies were retrieved and data extracted by 2 independent reviewers. RESULTS: Nine papers reporting 5 controlled trials were reviewed, along with 30 cohort papers reporting 23 studies. Two nonrandomized trials found some evidence that a supportive school environment improved student emotional health, but 3 randomized controlled trials did not. Six (20%) cohort papers examined school-level factors but found no effect. There was some evidence that individual perceptions of school connectedness and teacher support predict future emotional health. Multilevel studies showed school effects were smaller than individual-level effects. Methodological shortcomings were common. CONCLUSIONS: There is limited evidence that the school environment has a major influence on adolescent mental health, although student perceptions of teacher support and school connectedness are associated with better emotional health. More studies measuring school-level factors are needed. Randomized controlled trials evaluating 1 or 2 environmental components may have more success in establishing effective and feasible interventions compared with complex whole-school programs.

Part and parcel of teaching? Secondary school staff’s views on supporting student emotional health and well‐being

The need for schools to support children and young people’s mental and emotional health is increasingly emphasised in policy initiatives, yet the role of teachers in this has been under explored. This paper reports findings from qualitative, semi‐structured interviews with 14 school staff at eight secondary schools in England, examining emotional health and well‐being (EHWB) activities in which they were involved. Three emergent themes are discussed: (1) a strongly held belief that teaching and EHWB are inevitably linked; (2) a perception that many colleagues outside the study sample are reluctant to engage in EHWB work; and (3) a concern that teachers’ own emotional health needs are neglected, leaving them unable or unwilling to consider those of pupils. The findings endorse whole‐school approaches to emotional health, with a focus on teachers’ training and support needs and clearer aims, including consideration of how such work fits with the broader goals of schools.

Including young mothers: limitations to New Labour's strategy for supporting teenage parents

As part of its Teenage Pregnancy Strategy, New Labour has focused on ensuring more teenage mothers enter education, training or work, in order that they may avoid ‘long term social exclusion’. This paper argues that this conceptualization of the route to social inclusion is problematic for young mothers in that it ignores the structural and contextual barriers to them gaining inclusion, it discounts full-time mothering as a valid option, and it neglects the social and moral elements of their exclusion, while in fact contributing to this. A broader understanding of social inclusion is therefore advocated, which emphasizes the significance of social belongingness and community participation, along-side economic self-sufficiency. Data are drawn from interviews with 14 young mothers who act as volunteer ‘peer educators’ in school sex education, to illustrate the ways in which this wider conceptualization of social inclusion might be more useful in meeting the needs of this group.

Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: a self-report survey in England

BackgroundSubstantial numbers of adolescents self-harm, but the majority of cases do not reach the attention of medical services, making community studies essential. The prevalence of suicidal thoughts and plans at this age, and the inter-relationships between suicidal thoughts, plans and self-harm remain largely unexplored.MethodCross-sectional analysis of self-reported questionnaire data collected from members of the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort, England. Respondents (n = 4810) were aged 16–17 years old and have been followed up since birth.ResultsAltogether 905 (18.8%) respondents had ever self-harmed. The prevalence of lifetime self-harm was higher in females (25.6%) than males (9.1%). The most commonly used method was self-cutting: this was used alone or in combination in 73.5% of episodes, compared to 10.0% who took overdoses alone or in combination with other methods. Of those who reported self-harm, 25.3% wanted to die during the most recent episode. Concurrent depression was associated with a greatly increased risk of self-harm (OR 5.43). Only 12.4% of participants sought medical help following their most recent episode of self-harm, although this figure was higher (30.1%) where self-harm was carried out with desire to die. Of the whole sample, 15.8% had ever thought of killing themselves, and 4.3% had ever made plans to kill themselves. Compared to those who had never self-harmed, those who had self-harmed but not wanted to die during the most recent episode were at increased risk of ever having had suicidal thoughts (37.6% compared to 7.8% χ2 =102.3, p < 0.001) and ever making suicidal plans (8.7% compared to 0.7%, χ2 =166.9, p < 0.001). As the frequency of self-harm increased, so did the risk of suicidal thoughts and plans.ConclusionsSelf-harm and suicidal thoughts are common among 16/17 year olds. Although the majority of self-harm behaviour is not accompanied by a desire to die, all self-harm regardless of motivation is associated with increased risk of suicidal thoughts and plans, particularly when it is carried out repeatedly.

Clinical decision-making in a multidisciplinary gynaecological cancer team: a qualitative study.

Objective  To explore the factors that influence treatment decision‐making in a gynaecological cancer team (MDT).

Differences in risk factors for self-harm with and without suicidal intent: Findings from the ALSPAC cohort

Background There is a lack of consensus about whether self-harm with suicidal intent differs in aetiology and prognosis from non-suicidal self-harm, and whether they should be considered as different diagnostic categories. Method Participants were 4799 members of the Avon Longitudinal Study of Parents and Children (ALSPAC), a UK population-based birth cohort who completed a postal questionnaire on self-harm with and without suicidal intent at age 16 years. Multinomial logistic regression analyses were used to examine differences in the risk factor profiles of individuals who self-harmed with and without suicidal intent. Results Many risk factors were common to both behaviours, but associations were generally stronger in relation to suicidal self-harm. This was particularly true for mental health problems; compared to those with non-suicidal self-harm, those who had harmed with suicidal intent had an increased risk of depression (OR 3.50[95% CI 1.64, 7.43]) and anxiety disorder (OR 3.50[95% CI 1.72, 7.13]). Higher IQ and maternal education were risk factors for non-suicidal self-harm but not suicidal self-harm. Risk factors that appeared specific to suicidal self-harm included lower IQ and socioeconomic position, physical cruelty to children in the household and parental self-harm. Limitations i) There was some loss to follow-up, ii) difficulty in measuring suicidal intent, iii) we cannot rule out the possibility of reverse causation for some exposure variables, iv) we were unable to identify the subgroup that had only ever harmed with suicidal intent. Conclusion Self-harm with and without suicidal intent are overlapping behaviours but with some distinct characteristics, indicating the importance of fully exploring vulnerability factors, motivations, and intentions in adolescents who self harm.

Teachers' wellbeing and depressive symptoms, and associated risk factors: A large cross sectional study in English secondary schools

BACKGROUND Teachers have been shown to have high levels of stress and common mental disorder, but few studies have examined which factors within the school environment are associated with poor teacher mental health. METHODS Teachers (n=555) in 8 schools completed self-report questionnaires. Levels of teacher wellbeing (Warwick Edinburgh Mental Wellbeing Scale-WEMWBS) and depressive symptoms (Patient Health Questionnaire-PHQ-9) were measured and associations between these measures and school-related factors were examined using multilevel multivariable regression models. RESULTS The mean (SD) teacher wellbeing score (47.2 (8.8)) was lower than reported in working population samples, and 19.4% had evidence of moderate to severe depressive symptoms (PHQ-9 scores >10). Feeling unable to talk to a colleague when feeling stressed or down, dissatisfaction with work and high presenteeism were all strongly associated with both poor wellbeing (beta coefficients ranged from -4.65 [-6.04, -3.28] to -3.39 [-5.48, -1.31]) and depressive symptoms (ORs ranged from 2.44 [1.41, 4.19] to 3.31 [1.70, 6.45]). Stress at work and recent change in school governance were also associated with poor wellbeing (beta coefficients=-4.22 [-5.95, -2.48] and -2.17 [-3.58, -0.77] respectively), while sickness absence and low student attendance were associated with depressive symptoms (ORs=2.14 [1.24, 3.67] and 1.93 [1.06, 6.45] respectively). LIMITATIONS i) This was a cross-sectional study; causal associations cannot be identified ii) several of the measures were self-report iii) the small number of schools reduced study power for the school-level variables CONCLUSIONS Wellbeing is low and depressive symptoms high amongst teachers. Interventions aimed at improving their mental health might focus on reducing work related stress, and increasing the support available to them.

Parental Suicide Attempt and Offspring Self-Harm and Suicidal Thoughts: Results From the Avon Longitudinal Study of Parents and Children (ALSPAC) Birth Cohort

OBJECTIVE Parental suicidal behavior is associated with offsprings risk of suicidal behavior. However, much of the available evidence is from population registers or clinical samples. We investigated the associations of self-reported parental suicide attempt (SA) with offspring self-harm and suicidal thoughts in the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective birth cohort. METHOD Parental SA was self-reported on 10 occasions from pregnancy until their child was 11 years of age. Offspring self-reported lifetime self-harm, with and without suicidal intent, suicidal thoughts, and suicide plans, at age 16 to 17 years. Multivariable regression models quantified the association between parental SA and offspring outcomes controlling for confounders. RESULTS Data were available for 4,396 mother-child and 2,541 father-child pairs. Adjusting for confounders including parental depression, maternal SA was associated with a 3-fold increased risk of self-harm with suicidal intent in their children (adjusted odds ratio [aOR] = 2.94, 95% confidence interval [CI] = 1.43-6.07) but not with self-harm without suicidal intent (aOR = 0.83, 95% CI = 0.35-1.99). Children whose mother attempted suicide were more likely to report suicidal thoughts and plans (aOR = 5.04, 95% CI = 2.24-11.36; aOR = 2.17, 95% CI = 1.07-4.38, respectively). Findings in relation to paternal SA were somewhat weaker and not significant. CONCLUSIONS Maternal SA increased their offsprings risk of self-harm with suicidal intent and of suicidal thoughts, but was unrelated to self-harm without intent; findings for paternal suicide attempt were weaker and not significant. Maternal SA, which may not come to the attention of health care professionals, represents a major risk for psychiatric morbidity in their offspring.

IQ and adolescent self-harm behaviours in the ALSPAC birth cohort

BACKGROUND Low IQ is associated with an increased risk of suicide and suicide attempt in adults, but less is known about the relationship between IQ and aspects of suicidal/self-harm behaviours in adolescence. METHODS We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based prospective UK cohort. Binomial and multinomial logistic regression models were used to examine the association of IQ measured at age 8 with suicide-related outcomes amongst 4810 adolescents aged 16-17 years. RESULTS There was some evidence that associations differed in boys and girls (p values for interaction ranged between 0.06 and 0.25). In boys higher IQ was associated with increased risk of suicidal thoughts (adjusted odds ratio per 10 point increase in IQ score=1.14, 95% Confidence Interval [CI] 1.01-1.28) and suicidal plans (1.15, 95% CI 0.93-1.43), although statistical evidence for the latter association was limited. There was also evidence for an association with non-suicidal self-harm (1.24, 95% CI 1.08-1.45) but not suicidal self-harm (1.04, 95% CI 0.86-1.25). In girls higher IQ was associated with increased risk of non-suicidal self-harm (1.11, 95% CI 1.02-1.22) but not suicidal thoughts, suicidal plans or suicidal self-harm. LIMITATIONS Loss to follow up and questionnaire non-response may have led to selection bias. CONCLUSION In contrast to previous studies of IQ-suicide associations in adults, we found that higher IQ was associated with an increased risk of non-suicidal self-harm in male and female adolescents and suicidal thoughts in males. Associations of IQ with self-harm differed for self-harm with and without suicidal intent, suggesting that the aetiology of these behaviours may differ.

Self-reported school experience as a predictor of self-harm during adolescence: a prospective cohort study in the South West of England (ALSPAC)

Background Several aspects of school life are thought to be associated with increased risk of self-harm in adolescence, but these have rarely been investigated in prospective studies. Methods Members of the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort completed postal surveys of school experiences aged 14, and self-harm behaviour aged 16 (n=3939). Associations between school experiences (feeling connected to school, enjoyment of school and perception of teachers as fair) and subsequent self-harm were examined using multivariable logistic regression models. Results Self-harm aged 16 was associated with earlier perceptions of school, specifically not getting on well with or feeling accepted by others (OR=2.43 [1.76, 3.35] and OR=2.69 [2.16, 3.35] respectively), not liking school or the work done in class (OR=1.40 [1.17, 1.69] and OR=1.36 [1.10, 1.67]), and feeling that teachers are not clear about behaviour or fail to address misbehaviour consistently (OR=1.59 [1.20, 2.12] OR=1.89 [1.51, 2.37]). These associations were partially attenuated in models controlling for mental health concurrent with the outcome. Poor school experiences were related to both suicidal and non-suicidal self-harm, with slightly stronger associations visible for the former. Limitations (i) There was some loss to follow up, (ii) experience of bullying was not measured, and (iii) exposure and outcome measures were self-report. Conclusions Students who feel unconnected to school, unhappy at school, or feel that teachers are unfair are more likely to self-harm in the future. Assessing students׳ perceptions of school may serve to identify those at risk of self-harm who would benefit from preventative interventions.