Introduction

The prevalence of mental disorders among children and young people (CYP) aged 8–25 years in England has increased since 2017 [1]. Mental health among CYP has worsened [2] and has increased the demands for mental health services which has been further highlighted by Lord Darzi’s report published in 2024 [3]. The latest data (2023) show that 1 in 5 CYP had a probable mental disorder, an increase from 1 in 8 in 2017 [1]. This is reported to be around 1 in 10 children in primary schools (aged 5–10 years) and 1 in 7 in secondary schools (aged 11–16 years) [4]. More than half of CYP diagnosed with a mental disorder report not having appropriate support at an early age [5]. Evidence shows that experiencing mental health problems prior to the age of 14 years increases the risk of mental disorder persisting into adulthood [6]. Additionally, disparities in mental health continue to widen; poorer mental health rates are higher among those living in poverty, some ethnic minority groups, and those with additional needs and disabilities [7,8] who may also experience inequitable access to mental health services [9,10]. Early intervention is crucial; mental health problems contribute to school absence, potentially impacting education outcomes and employment prospects in later life [1]. Efforts targeted at children in the early years may help reduce mental health need and contribute towards reducing mental health disparities over the life course [6].

Schools are recognised as playing a key role for promoting positive mental health [11,12]. They are included in the THRIVE Framework, an integrated (health, education, social care, and community settings), person-centered, and needs-led system change approach to deliver mental health services to CYP. As part of the framework, i-THRIVE is the implementation of THRIVE in practice to deliver a population health model for CYP mental health, and can refer children to specialist services such as CAMHS (Child and Adolescent Mental Health Services) [13]. In England, education is compulsory for all children from the ages of 5–16 years [14]. Schools are considered ideal public health settings for early interventions to promote positive mental health [15] as most children attend a formal educational establishment and mental health inequalities can be addressed.

In 2018, the Department for Education (DfE) published a review of the content of schools’ policies and practices for promoting mental health [11]. The review, based on 100 schools in England (45 secondary, 45 primary, and 10 special schools), relied on information published on school websites. The ‘desk-based approach’ highlights a research gap of promoting mental health in real-world settings. In 2021, Public Health England published a policy framework outlining eight principles of a whole school or college approach to promoting mental health [16]. These principles require effective leadership and management which supports efforts to promote mental health and wellbeing. DfE argue that the principles will help protect and promote CYP mental health and wellbeing when applied consistently and comprehensively [17,18]. In addition, since 2018/2019, NHS England (NHSE) regional teams have been implementing an initiative to provide Mental Health Support Teams (MHSTs) for schools [19]. MHSTs were initially focused in local areas where there are higher levels of need, inequality and disadvantage [18], led by Integrated Care Systems (ICSs) and Integrated Care Boards (ICBs). As of Spring 2023, MHSTs were reported to be reaching 6,800 schools and colleges and 35% of children in England [18]; the aim is for universal coverage to increase service accessibility and uptake. However, an early evaluation found gaps in MHST service provision in schools including some groups feeling underserved (e.g., those with Special Educational Needs and Disabilities (SEND), those from ethnic minority backgrounds, and children with challenging family or social circumstances) [20].

Despite indications of mental disorders being present as early as aged 5 years [21] and early interventions in school settings being widely recognised as important, qualitative evidence on the implementation of the promotion of mental health in primary schools is an under-researched area [22]. Previous studies report teachers’ perceptions using quantitative methods [23–25] or desk based research [11] which lack opportunities for an in-depth understanding around the complexities of implementing mental health promotion in schools. Furthermore, studies more often focus on adolescents (aged 11 + years) in secondary schools, which show that teachers’ are aware of the importance of supporting CYP mental health but lack the training and skills needed to provide adequate support [23,26–29]. Although views of secondary school teachers may corroborate with primary school teachers, their roles are fundamentally different; primary school teachers spend more time with children as they teach year-group cohorts and are potentially better placed to identify early developmental and behavioural characteristics of children’s mental well-being, whilst secondary school teachers teach subject-specific cohorts [30]. Additionally, few UK qualitative studies use in-depth qualitative methods with primary school teachers, and any relevant studies were published ≥5 years ago [31–33]. Mental health problems among CYP have worsened due to the Covid-19 pandemic (e.g., social isolation, anxiety), which may have increased challenges for teachers. Exploring in-depth views of primary school teachers is important to understand implementation of mental health policy in practice, which will inform intervention strategies to improve CYP mental health.

North West London (NWL), London, UK, has high levels of CYP unmet mental health need and is in the 20% most deprived areas of the national population [7]. NWL is diverse; it includes those from ethnic minority communities, people with SEND, and those with multi-morbidities. Improving mental health is one of five key priorities of the NWL ICB and Integrated Care Partnerships to improve access rates to CYP mental health services [34]. Whole school approaches for good mental health can play a crucial role in supporting CYP who may not yet meet thresholds for service support, and for those on waiting lists for mental health services. Therefore, understanding the implementation of mental health practices and policies in schools using qualitative approaches is important to complement quantitative methods. The aim of our study was to gain a better understanding of the implementation of mental health policies in real-world settings, by exploring teachers’ perspectives of mental health promotion in primary schools.

Materials and methods

Policy for promoting a whole school approach to mental health and wellbeing

Government policy for a whole school approach for promotion of mental health (Fig 1) centres around the principle of (1) ‘leadership and management’ which supports efforts to promote emotional health and wellbeing, and is surrounded by seven other principles: (2) to promote resilience and support social and emotional learning though curriculum teaching and learning; (3) enabling student voice to influence decisions; (4) staff development to support their own wellbeing and that of students; (5) identifying need and monitoring impact of interventions; (6) working with parents and carers; and (7) targeted support and appropriate referral; and (8) an ethos and environment that promotes and respects values and diversity [16].

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Fig 1. Eight principles for a whole-school approach to promoting mental health and wellbeing.

https://doi.org/10.1371/journal.pone.0336946.g001

Results

Discussion

The aim of our study was to understand teachers’ perspectives for promotion of mental health policy in primary schools that were located in a diverse region of London with high levels of unmet mental health need among CYP. The themes extracted highlighted the breadth of mental health needs, factors contributing to poor mental health, challenges teachers face in providing adequate support, and the need for collaborative working with families and health services to ensure children receive the right support at the right time. Lack of funding and resources placed immense responsibility on teachers to identify children with mental health needs, although that did not necessarily result in children being provided with adequate support. Concerns were raised about the lack of collaborative working with communities and health services to effectively promote mental health and wellbeing, and teachers not feeling fully equipped with the skills needed to support the range of mental health needs for children who did not always meet the thresholds for support from health services. Our findings highlight the challenges for teachers in the feasibility of implementing mental health policies in real-world settings to support CYP with mental health needs.

The themes extracted from our study demonstrate that the government’s recommended principles for a whole school approach for promoting mental health and wellbeing [16] may be difficult to implement where there are high levels of mental health need, inadequate resources, limited funding, and lack of collaboration. Three of the principles were highlighted throughout our themes which teachers identified as the most challenging to implement: ‘targeted support’, ‘working with parents and carers’, and ‘staff development’. ‘Targeted support’ would require the need for further training for teachers to support children who do not meet referral thresholds. However, further training adds to existing heavy workloads and an additional demand on teachers outside teaching the curriculum. Schools which had ELSAs and school counsellors found that having access to these support provisions were beneficial, but it was not available at all schools due to funding budgets. Increased funding may initiate the implementation of mental health wellness tools such as ELSA which has demonstrated to be effective to improving mental health and wellbeing within schools [43]. Despite there being a widely held view among teachers that counsellors provide expert support for children, there is limited evidence that counselling for this age group is effective. Nonetheless, teachers felt that counsellors take the main responsibility away from class teachers and work well in collaboration with allocated mental health staff (i.e., SENCO leads). Of particular interest was that none of the teachers reported that their school used the provision of MHSTs who are specifically trained to deliver mental health interventions and support teachers [20]. Whether this was because they were unaware of MHST support being available to their schools, or not taking advantage of this service provision needs to be explored further. However, an early evaluation of MHST service delivery reported mixed results; encouraging findings showed that schools reported MHSTs improved staff knowledge and confidence to deal with mental health needs, and CYP accessing MHSTs had positive experiences, but there were challenges with service delivery which was impacted by staff turnover limiting MHST availability, and unclear guidance around school needs and expectations vs the support provision provided by MHSTs [20].

In our study, we found that engaging with families for mental health promotion was challenging for schools despite family and household factors contributing to poor mental health among children. Similar findings were shown in a study conducted in Australia [30]. Another study showed that reluctance of parental engagement could be due to reasons including not wanting to admit there is an issue with their child, fear of being blamed, stigma, and potential cultural barriers [31]. Teachers recognise that good quality school and parent relationships is needed to help the promotion of mental health of children, but it is not straightforward in practice. Furthermore, there was concern among teachers of the impact on staff; the burden on non-trained staff or those who feel they don’t have the required skills to support a range of children’s mental health needs which was affecting their own wellbeing. This finding supports that of other studies which have shown increased levels of stress among teachers based on the responsibility to support CYP with different mental health needs [44,45].

Anxiety was the most common reported mental health problem among children, with several contributing factors identified by teachers including household and family issues, and poverty. Anxiety is associated with children’s poor school attendance, which can impact learning and place them at higher risk of poor academic attainment, social isolation, and unemployment in later life [46]. However, there is a limited high-quality evidence base exploring the relationship between anxiety and school absence despite policy guidance on teachers roles and responsibilities around this issue [47]. Although an association between anxiety and school absence exists, research is needed to understand whether anxiety is on the causal pathway to school absence, or whether school absence increases anxiety preventing children from returning to school.

The whole-school framework promotes a supportive environment and culture which should address mental health needs of all students [16]. The findings from our study suggest some principles of the framework are not easily implemented, particularly around parental engagement and integration between schools and health services which are crucial to support a whole school approach of promoting positive mental health among CYP.

Most studies on promoting mental health in schools are commonly undertaken in secondary schools (CYP aged 11–16 years) which is perhaps due to mental disorders having a peak age of onset around 14 years [2]. However, early intervention which identifies children at risk and ensuring adequate support is provided at an earlier age may reduce worsening of mental health in adolescence. Nevertheless, our findings align with similar studies identifying views of mental health promotion in secondary schools which show that teachers do not feel fully equipped with interpreting signs of mental health problems among CYP [23,26–28], the need more resources to support CYP with their mental health [28,48,49], and the need for more clarity around the division of responsibilities between school staff and health services [48].

Whilst it is recognised that schools play a crucial role in identifying mental health needs, there are potentially greater benefits that could be gained from better promotion of positive mental health in schools [2], increased engagements with parents, better integration of health services with education systems [50] and preventative or early intervention which continues for as long as needed to reduce the risk of worsening mental health over time [2,19,51,52]. However, the pressures placed on teachers and the complexity of their evolving roles as educators requires further investment for policy effectiveness [53].

Conclusions

Primary schools in the UK are particularly well placed for identifying mental health needs among CYP for preventative and early interventions. However, the promotion of mental health in schools requires further investigation; collaborative approaches between schools, communities, and local health services are needed to reduce unmet mental health need among CYP in NWL.

Supporting information

Acknowledgments

We are grateful to all the teachers who participated in our interviews including but not limited to Celene Mannion, Tamsin Moore-Jaunaii, Bhavina Sachania, Manisha Devakumar, and to the schools including but not limited to Good Shepherd Primary School, Horsenden Primary School, Spring Grove Primary School, and Uxendon Manor Primary School.

This study was part of the research collaboration between the NHS North West London Integrated Care Board and the School of Public Health, Imperial College London, which aims to support evidence-based decision-making to address health inequalities. BR is supported by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) (Grant Reference Number NIHR 204000). This project is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Northwest London (ARC NWL). The Department of Primary Care and Public Health at Imperial College London is grateful for support from the NIHR Biomedical Research Centre funding scheme.

The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.