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Education and Health Published by SHEU since 1983

Volume 32 Number 1, 2014

ISSN 2049-3665

Health-E-PALS: promoting Healthy Eating and Physical Activity in Lebanese school children - Intervention development Carla Habib-Mourad, Helen Moore, Maya Nabhani Zeidan, Nahla Hwalla and Carolyn Summerbell What’s the skinny? Evaluating the effects of instituting a ‘fat tax’ in America Kristin Cook Food and Healthy Eating in the Curriculum – a case of too many cooks spoiling the broth Frances Ryland Child and adolescent social gaming: What are the issues of concern? Mark D. Griffiths Finding Space to Mental Health - Promoting mental health in adolescents: Pilot study Luísa Campos, Pedro Dias and Filipa Palha Resilience and Results: How Promoting Children’s Emotional and Mental Wellbeing Helps Improve Attainment Paula Lavis “Drink doesn’t mess with your head … you only get a hangover”: Adolescents’ views on alcohol and drugs, and implications for Education, Prevention and Intervention Michael McKay and Séamus Harvey

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Vol.32 No.1, 2014

Education and Health

SHEU publications

David McGeorge

‘Education and Health’ is published by SHEU, an independent organisation, providing research, survey and publishing services to those concerned with the health and social development of young people. SHEU incorporates the Schools Health Education Unit, founded in 1977 by John Balding. The address for all correspondence is: SHEU, 3 Manaton Court, Manaton Close, Matford Park, Exeter EX2 8PF Many publications can be viewed online or purchased from SHEU e-mail:


(e-mail: Welcome to the first issue for 2014. The combination of issue and volume numbers enable us to proclaim 321! – a rare event that last occurred in 1994 with vol.12 issue 3. We continue with the proud tradition of independent publishing and offer an eclectic mix of articles. Contributions come from those working with young people and we welcome the interest from around the world. Developments in open access publications mean that our articles are available where there is Internet access. The journal, published since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readers, in the UK, come from a broad range of backgrounds and include: primary, secondary and further education teachers, university staff, and health-care professionals working in education and health settings. Readers outside of the UK share similar roles. The journal is also read by those who commission and carry out health education programmes in schools and colleges. Articles focus on recent health education initiatives, relevant research findings, materials and strategies for education and health-related behaviour data.

Contributors (see a recent list)

Do you have up to 3000 words about a relevant issue that you would like to see published?


The archive is also online. Please visit this weblink: I look forward to your company in the next issue.

Trends from 1983

A series of reports showing trends from 1983. Recent reports are ‘Young People’s Food Choices’, ‘Young People and Smoking’ and ‘Young People and Illegal Drugs’. Latest data come from a sample of over 629,000 young people mostly between the ages of 10-15 from across the UK. Reports are priced from £10-£15 including post and packaging (comb-bound or saddle-stitched stapled).

The Young People series Large numbers of young people, between the ages of 10 and 15 years, respond to over 100 questions about their health-related behaviour.

Free resources

Topics include:- Planning PSHE in your school; Research news about young people’s health and wellbeing; Literature search resource; Young People Reports into health and wellbeing; and more.


Schools and Students Health Education Unit

The specialist provider of reliable local survey data for schools and colleges and recognised nationally since 1977. "The survey reports have been used to inform commissioning at specific commissioning groups. They are also being used within our Extended Schools Clusters and to inform The Annual Public Health and the Joint Strategic Needs Assessment." Programme Manager - Young People For more details please visit TO SUPPORT YOUR WORK WITH YOUNG PEOPLE TRY SHEU’S FREE RESOURCES

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Dr Carla Habib-Mourad is a lecturer and project coordinator of the Healthy Kids School programme at the Department of Nutrition and Food Sciences, American University of Beirut, Lebanon. Dr Helen Moore is a Post-Doctoral Research Associate in the Obesity Related Behaviours (ORB) Research Group at Durham University, UK. Dr Maya Nabhani Zeidan is Accreditation and Program Review Officer at the Faculty of Agriculture and Food Sciences, American University of Beirut, Lebanon. Professor Nahla Hwalla is a professor of Human Nutrition at Department of Nutrition and Food Sciences, American University of Beirut, Lebanon. Professor Carolyn Summerbell is Professor of Human Nutrition in the Obesity Related Behaviours (ORB) Research Group School of Medicine, Pharmacy and Health, Durham University, UK For communication, please email:

Carla Habib-Mourad, Helen Moore, Maya Nabhani Zeidan, Nahla Hwalla and Carolyn Summerbell Health-E-PALS: promoting Healthy Eating and Physical Activity in Lebanese school children - Intervention development


ebanon is a small middle-income country in the Middle-East situated on the Mediterranean coast. Over the last three decades, Lebanon has experienced a nutrition transition resulting in a shift towards a diet high in energy-dense food and sedentary lifestyle. The results from a national population based study in Lebanon showed high prevalence rates of overweight and obesity similar with those observed in developed countries, both in adults and children (Sibai et al., 2003). Recently, a study on the secular trends in the prevalence of overweight and obesity in Lebanon over a 12 year period found an alarming increase in obesity prevalence in the Lebanese population, especially in children (Nasreddine et al., 2012a). Multicomponent interventions, policies and nutritional strategies to promote weight control and physical activity nation-wide were recommended to curb the childhood obesity crisis in Lebanon (Sibai et al., 2003; Hwalla et al., 2005; Nasreddine et al., 2012b). School-based interventions to promote healthy eating and encourage physical activity are lacking in Lebanon. A reassessment of the Lebanese Integrated Health Curriculum is warranted, as well as the need to adopt a comprehensive school health programme (WHO, 2005). In an attempt to address this gap, a theory and evidence-based multi-component school intervention was developed that focused on promoting healthy eating and physical activity to prevent weight gain in school-aged children. The intervention was pilot tested

using a mixed method study design involving both quantitative and qualitative research methodologies (Habib-Mourad, 2013). Eight schools were purposively selected from two different communities in Beirut (capital of Lebanon) and were randomly assigned to either the intervention or control group. Anthropometric measurements were taken, and questionnaires on determinants of behavioural change, eating and physical activity habits were completed by the students in both groups (N= 374) at baseline and post intervention. Focus group interviews were conducted in intervention schools at the end of the study. The study was granted ethical approval by the Institutional Review Board of the American University of Beirut. The present paper describes the development of the intervention and its components.

Intervention development The school-based multicomponent intervention was named in Arabic ‘Kanz al Soha’; which translates to health treasure. ‘Health-E-PALS’ was deduced as the acronym for: Intervention to promote Healthy Eating and Physical Activity in Lebanese School children. The intervention focused on the promotion of healthy food choices and active living rather than the achievement of an ideal body weight. By selecting this focus the intervention aimed to lessen the chance of stigmatization of overweight children and of contributing to eating disorders (Swinburn & Egger, 2002).

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Target behaviours When aiming at preventing unnecessary weight gain studies showed that strategies focusing on: changes in dietary behaviours; leading to decrease in energy intake; changes in physical activity and sedentary behaviours that would increase energy expenditure; were key factors in the onset of obesity (WHO, 2003). The specific behaviours that make up the energy balance equation have been referred to as the energy balance-related behaviours (Kremers et al., 2006). Diet and physical activity patterns that can be a factor in weight gain may differ among groups depending on age, culture, gender and socioeconomic status. The energy balance behaviours mostly related to excess weight gain in schoolchildren were: breakfast skipping; sweetened drinks consumption; energy dense snacks intake; sedentary and physical activities (Affenito et al., 2005; Bachman et al., 2006; Malik et al., 2006; Sallis et al., 2000). Based on the above evidence-based literature, the ‘Health-E-PALS’ intervention targeted the following obesity related behaviours in 9-11 year old children: 1. Increase consumption of fruits and vegetables 2. Favour healthy snacks over high energy dense snacks and drinks 3. Importance of having daily healthy breakfast 4. Increasing moderate physical activity 5. Decreasing sedentary behaviour Theoretical underpinning The theoretical underpinning of this programme is instruction with a behavioural focus; and goes beyond the acquisition of knowledge. The ‘Health-E-PALS’ intervention was based on the constructs of the Social Cognitive Theory (Bandura, 1986) which uses a multi-level approach involving individual behaviour change and environment modifications to support individual changes. Personal factors influencing individual behaviour include knowledge, skills and selfefficacy; environmental factors include reinforcement, modelling and availability. ‘Health-E-PALS’ had three coordinated intervention components that addressed specific behaviour determinants: nutrition knowledge; awareness; skills and self-efficacy; personal factors. Modelling and availability covered the

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environmental factors. The components were devised to work together to address behavioural and environmental factors related to students dietary and physical activity behaviours. Consistent with the Social Cognitive Theory, the components were based on the expectation that children will make healthier choices when introduced in a social setting that includes family and peers and uses active learning strategies. According to Bandura (Bandura, 1986, 2004), in order for an individual to perform a specific behaviour, he should know what to do and how it should be done; this is referred to as behavioural capability or knowledge; skills training helps in increasing mastery learning. Strategies that increase selfefficacy include self-monitoring and reinforcement, such as rewards and praise. Role modelling refers to observational learning, where one learns by observing others actions, especially credible others, in this case the parents and teachers. Availability and accessibility of healthy food choices were also considered. Consequently, the intervention had three components: 1 Culturally appropriate classroom sessions designed to promote healthy eating and physical activity. This component was designed to cover the personal and psychosocial determinants as outlined by the Social Cognitive Theory. 2 A family programme which introduces the intervention to families and assists them in creating a supportive environment at home for healthy lifestyle behaviours. This component covered the environmental factors at home: modelling and availability. 3 A food service intervention targeting the school shop and the lunch boxes sent by the family. This component covered availability of food in the students’ school environment. Through these three components, ‘Health-EPALS’ attempted to increase students’ knowledge and efficacy about food choices and physical activity, and modify the school and family environment in order to provide more opportunities for exercise and healthy eating. Figure 1 (see page 5) outlines the intervention components based on the Social Cognitive Theory constructs or determinants.

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Figure 1: Intervention components, behavioural, personal and environmental constructs

Intervention components The following section provides further details on the intervention components. Component 1: Classroom sessions Educational material Sessions’ topics and activities were developed based on the five energy related behaviours targeted in the intervention. The goal of the ‘Health-E-PALS’ intervention sessions was to provide appropriate nutrition education in a simple and fun layout. Delivery strategies reported to be effective in nutrition education include hands-on activities, and interactive learning that gives opportunities to participate in discussions and food activities (Birkett et al., 2004; Holston et al., 2004; Edward and Evers, 2001). Consequently, activities such as games, hands on activities and food preparation were used to make the learning fun and interactive and the themes easy to remember and relate to. The 45 minute sessions were delivered each week for 12 weeks. All materials were developed to suit Lebanese traditions and cultures, and featured traditional

foods in most games, visual aids and recipes. Languages used on educational items were Arabic and English. However, only Arabic materials were used with students, except for some posters and food cards that were bilingual. The educational component was designed to be integrative and interdisciplinary to facilitate implementation and minimize excess burden on existing school curriculum. Nutrition sessions were integrated into various classroom subjects during the regular school day. For example, students used the measuring centres session to practice fractions in Maths, and breakfast planning in writing topics in English or Arabic subjects. Table 1 (page 6) summarizes the topics, objectives, activities of the classroom sessions with the determinants targeted and the class in which they were integrated. Each session consisted of two sections; 10 to 15 minutes of discussion, information and interaction about the topic of the week followed by 30 minutes of activity: game and/or food preparation. In order to make the sessions

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Table 1: Educational sessions’ topics, objectives and tools with the matching theory determinant and class integration Title of the lesson Objectives of the lessons 1

Activity / Tool

Introduction to Food Classify one day food intake into food groups. Game : Food cards groups Classify foods according to different food groups.


Class session







Self-efficacy and skills


Self-efficacy and skills


Food counter: 2

Food Groups and Nutrients

3 What is a portion

Fruits and 4 vegetables: the

rainbow colours

5 & Physical activity 6


Importance of breakfast

8 Healthy snacks

Know the nutritional characteristics of each food group.

Know the serving size of foods in different food groups.

Where do fats and sugars hide


Clean teeth, good teeth

12 Value of food

Identify sedentary activities and try to minimize them.

Pedometer workshop

Increase regular Physical activities especially walking.

Activity booklet

The role and importance of breakfast

Plan and prepare a healthy breakfast (breakfast is yummy)

Self-efficacy and skills


Plan and prepare a healthy snack

Skills / Role modelling




Self-efficacy and skills


Find ways to facilitate breakfast intake Differentiate between healthy snacks and nonstop-nibbling.

Identify high fat, high sugar containing foods Identify caries causing foods Brush teeth the correct way Encourage water intake instead of other sweet drinks Compare foods according to their nutrients and energy content.

Table 2: ‘Health-E-PALS’ educational Kit • • • • • • • • •

Food diary booklet

Try new types of fruits and vegetables

To explain why water is the best fluid. 11 Water is the best

Measuring centres: Real experience with food Build a character with fruits and vegetables, tasting is a must

Eat more fruits and vegetables

Prepare healthy snacks at home 9

Visual tool that helps students see what they ate

Classroom posters (10) Take Home pamphlets (12 for each student) Food diary booklet (one for each student) Physical activity booklet (one for each student) Set of 60 food cards Board game: Treasure game Traffic lights signs Food counter box (one for each student) Pedometers (one for each student)

interesting and attractive to students, a set of visual aids have been developed. The teaching aids consisted of posters, pamphlets, activity booklets, card and board games (Table 2 above). One of the researchers (C.H.M) implemented the sessions with the help of a research assistant. Teachers were participating in all phases of the sessions each during his class

Game board: Treasure game Tooth brushing workshop Water tasting workshop

Game: The traffic lights

Knowledge and skills

Knowledge and skills

Social Studies Civic Education

hour. At the end of the intervention, the teachers received extensive two days training with the complete educational kit and teachers’ manual, to be able to implement the sessions later on. Material testing Educational material were pilot-tested on a group of seven to ten children aged 9-11 years who were related to the researcher and her colleagues. The children gathered few times during the summer vacation, prior to the beginning of the academic year. They were exposed to the educational material and tried all the activities included in the educational sessions. Following the piloting several food illustrations were changed as well as some nutrition terms that were modified to wordings

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more accessible to children. The board and card games were re-adjusted to fit within a 30 minutes time frame. Snacks and recipes ingredients were altered to suit children’s taste preferences. For more details on material content refer to

Lebanese children in primary schools also bring with them food from home to school, which consists of sandwiches and convenience foods. Students were encouraged to enhance the quality of their lunch box so as to include at least one fruit or vegetable portion and not more than one high energy dense snack.

Component 2: Family programme The goal of the family involvement component was to introduce the programme to families and to assist them in creating a supportive environment at home for healthy lifestyle behaviours. The family intervention component consisted of the following activities: • Parents meetings: Parents were asked to attend meetings where the different components of the project where provided along with information and guidance on the importance of healthy diet and physical activity. A healthy breakfast followed the meeting • School events: These consisted of health fairs involving interactive forums using the educational sessions’ themes covered in class. The health fairs took place at schools at the end of the programme; parents were invited to participate in games prepared and presented by their children • Take home pamphlets: The intervention included sending a summary of the major points covered during the educational session home with the students as take home action packs after each session. Samples of food prepared in class were also sent home with the students. The goal of the take home pamphlets was to try to address non-compliance/ poor attendance of parents’ school meetings. Component 3: Food service Foods and drinks offered to students in the sampled Lebanese school shops include convenience foods such as chips, candy bars, sweetened drinks as well as ready prepared sandwiches, traditional Lebanese pastries, croissants and donuts. Fresh juices, fruits and vegetables are not available. Recommendations concerning the healthy list of snacks and drinks that should be available to children in the shop were provided to shop administrators. Posters encouraging healthy food choices were posted at the points of sales whenever possible.

Results and Conclusion This paper has concisely described the effective development of the ‘Health-E-PALS’ intervention and its components. Results from the cluster randomised controlled trial showed that knowledge and self-efficacy scores doubled for the intervention group but not for the control. Students in the intervention group also reported purchasing and consuming less chips and sweetened drinks compared with controls (86% & 88% less respectively p<0.001). Results from the focus group discussions conducted at the end of the intervention, showed that the programme was generally well accepted by students, teachers and their parents. It was viewed as novel due to its culturally sensitive and innovative components. The students learned to change their eating habits in a pleasurable way, and were successful in trying new healthy foods and preparing recipes. The programme was well integrated within the school curriculum and was well accepted by teachers and school principals. Finally, parents acknowledged the fact that the programme positively affected the family food environment. All agreed that longer duration interventions and sustainability of the programme will be required. More details about the pilot testing of the intervention, its research methodologies as well as results of its efficacy can be found elsewhere (Habib-Mourad, 2013). The ‘Health-E-PALS’ intervention is currently rolled out in Lebanon and other countries in the region as “Nestlé Healthy Kids –Ajyal Salima” programme in collaboration with health and education authorities in order to prevent the ramping childhood obesity epidemic in the area. Acknowledgment We thank the Ministry of Higher Education in Lebanon; the school children and their parents, and teachers, who participated in the study; Hiba Houri for data entry; Nancy Awada and Carla Maliha for referencing and proof reading. This research was funded by an Eastern Mediterranean Regional Office Special Grant for Research in Priority Areas of Public Health (EMRO/WHO).

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References Affenito, S. G., Thompson, D. R., Barton,B. A., Franko, D.L., Daniels, S. R., Obarzanek, E. Schreiber, G. B., & StriegelMoore, R. H. (2005). Breakfast consumption by AfricanAmerican and white adolescent girls correlates positively with calcium and fibre intake and negatively with body mass index, Journal of the American Dietetic Association, 105,(6), pp. 938-945. Bachman, C.M., Baranowski, T. & Nicklas, T.A. (2006). Is there an association between sweetened beverages and adiposity? Nutrition Reviews, 64, (4) , pp. 153-174. Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ, Prentice-Hall. Bandura, A. (2004). Health promotion by social cognitive means, Health Education and Behaviour, 31, (2), pp.143-164. Birkett, D., Johnson, D., Thompson, J. & Oberg, D. (2004). Reaching Low-Income Families: Focus Group Results Provide Direction for a Behavioural Approach to WIC Services. Journal of the American Dietetic Association, 104, (8), pp.1277-1280. Edward, H.G. & Evers, S.(2001). Benefits and barriers associated with participation in Food programs, Canadian Journal of Dietetic Practice and Research, 62, (2), pp.76-81. Holston, D., O'Neil, C., Guarino, A. & Keenan, M. (2004). Assessing perception of family nutrition program characteristics and nutrition education needs of low income families. Journal of the American Dietetic Association, 104, (8), pp.1-98. See also Accessed January 2014 Hwalla, N., Sibai, A.M. & Adra, N.(2005). Adolescent Obesity and Physical Activity, World Review of Nutrition and Dietetics, 94, pp. 42-50. Kremers, S.P.J., De Bruijn., G.J., Visscher, T.L., van Mechelen, W., de Vries, N.K. & Brug, J. (2006). Environmental influences on energy balance-related behaviors: A dual-process view, International Journal of Behavioral Nutrition and Physical Activity, 3, (9), pp. 1-10.

Malik, V.S., Schulze., M.B. & Hu., F.B. (2006). Intake of sugarsweetened beverages and weight gain: a systematic review. The American Journal of Clinical Nutrition, 84, (2), pp. 274-288. Mourad, C.H. (2013). An intervention to promote Healthy Eating and Physical Activity in Lebanese School children: Health-EPALS a pilot cluster randomised controlled trial, Doctoral thesis, Durham University. Accessed 27 January 2014 Nasreddine L., Naja, F., Chamieh, M.C., Adra, N., Sibai, A.M. & Hwalla, N. (2012a). Trends in overweight and obesity in Lebanon: evidence from two national cross-sectional surveys (1997 and 2009). BMC Public Health, 12, pp. 798-817. Nasreddine, L., Naja, F., Akl, C., Adra, N., Sibai, A. &Hwalla, N. (2012b).Prevalence and Determinants of Overweight and obesity in a National Sample of 5-12 Years Old Lebanese Children. The FASEB Journal, 26, 811.3. Sallis, J.F., Prochaska, J.J. & Taylor, W.C. (2000). A review of correlates of physical activity of children and adolescents. Medicine and Science in Sports and Exercise, 32,(5), pp.963-975. Sibai, A., Hwalla, N. & Adra, N. (2003). Prevalence and covariates of obesity in Lebanon: findings from the first epidemiological study. Obesity Research, 11, (11), pp.13531361. Swinburn, B.& Egger, G. (2002). Preventive strategies against weight gain and obesity. Obesity and Reviews, 34, pp. 289-301. World Health Organization. (2003). Diet, nutrition, and the prevention of chronic diseases (Report No. 797). Available from Accessed 27 January 2014. World Health Organization. (2005). Lebanon, 2005, Global School-based Student Health Survey (GSHS). Available from: Accessed 27 January 2014.


Schools and Students Health Education Unit

The specialist provider of reliable local survey data for schools and colleges and recognised nationally since 1977. For more details please visit

Education and Health The journal, published by SHEU since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readership is worldwide and in the UK include: primary; secondary and further education teachers; university staff and healthcare professionals working in education and health settings. The journal is online and open access, continues the proud tradition of independent publishing and offers an eclectic mix of articles.

Contributors (see a recent list) - Do you have up to 3000 words about a relevant issue that you would like to see published? Please contact the Editor

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Dr Kristin Cook is an Assistant Professor at Bellarmine University, Louisville, KY. For communication, please email:

Kristin Cook What’s the skinny? Evaluating the effects of instituting a ‘fat tax’ in America


arents, media, and peers inundate high school students with concerns about health and weight. Schools also make considerable efforts to offer healthier alternatives for lunch and advocate prevention methods, and parents enrol their kids in after school activities for the purpose of physical exercise; yet, despite these attempts, obesity rates among adolescents in America have more than tripled since the 1980s and 32% of children and teens are considered overweight or obese (Ogden et al., 2012). Countries around the world face similar dilemmas and have approached the growing problem in a variety of ways. In 2011, Denmark introduced the first ‘fat tax,’ a levy imposed on excessively fattening foods. The country’s fat tax added $2.70 per kilogram of saturated fats in a product and was levied on everything containing saturated fats (ie. butter, milk, and prepared foods like pizza). However, only a year later, Denmark pulled the plug on the fat tax, claiming that the administrative costs and loss of jobs were not worth the effort (Khazan, 2011). Despite the failed attempt of the fat tax in Denmark, other countries such as France and Hungary are considering similar approaches to combating obesity. In New York City, the transfat ban implemented in 2006, though recently ruled unconstitutional, did reduce trans-fat consumption significantly, according to a 2009 study that found that the percentage of restaurants using trans-fats had decreased from 50 percent to less than 2 percent (Angell et al., 2009). Do high school students, enrolled in a health course, think a fat tax would help US citizens

fight the battle of the bulge?

Student debate

In this argumentation-based inquiry, students debate the effects of instituting a nationwide fat tax in America and collectively explore and articulate varying viewpoints based on evidence while honing important 21st-century skills such as gathering and assessing information, thinking critically, and communicating among multiple perspectives. The following four-day project for high school students culminates in a classroom debate whereby students are assigned and must defend their position with regard to the effectiveness of a proposed fat tax using evidencebased argumentation. I have used this project many times at the end of the units on food energy, so students enter into the project with an understanding that caloric needs differ among individuals, that foods contain varying amounts of saturated and unsaturated fats which are stored and utilized differently by our bodies, and that metabolic rate can be affected by exercise and proper nutrition. Students can then apply their understanding of food for balanced health and nutrition to considering societal values and the governments’ role regarding consumption of fatty foods. As with other socio-scientific issues, allowing students to evaluate programmes targeting health through dialogue, discussion, and debate within a social and ethical context encourages both motivation and ownership of learning to the students. The intent is that such issues are personally meaningful and engaging to students, require the use of evidence-based reasoning, and provide a context for understanding and applying scientific

Table 1. Curricular Connections National Health Education Standards Health Education Standard 1 – Students will comprehend concepts related to health promotion and disease prevention to enhance health. 1.12.7. compare and contrast the benefits of and barriers to practicing a variety of healthy behaviors. Health Education Standard 2 – Students will analyze the influence of family, peers, culture, media, technology and other factors on health behaviors. 2.12.10. analyze how public health policies and government regulations can influence health promotion and disease prevention. Health Education Standard 5 – Students will demonstrate the ability to use decision-making skills to enhance health. 5.12.7. evaluate the effectiveness of health- related decisions.

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information (see Table 1 below for curricular connections).

Activities and Strategies To begin the classroom investigation on the feasibility of a fat tax in the United States, students are first introduced to the history of the fat tax in Denmark. While watching a short YouTube video “Denmark’s failed fat tax experiment” (Canadian Taxpayers Federation, 2013) about the failure of the fat tax, students should make a T-chart* that lists pros and cons of the fat tax. This beginning activity will help frame the sociopolitical and socioeconomic complexities of instituting such a tax. Informal class discussion about the points listed on their T-charts will help students summarize the issue and begin to pose questions and/or articulate viewpoints on the issue. Next, students read the article, ‘Denmark’s Failed Fat Tax,’ (Khazan, 2011) to help them consider what other countries, such as the United States, are proposing to help combat the increasingly alarming obesity rates. Teachers should prompt students to reflect by writing on the back of their T-charts their perspectives on whether a fat tax would be feasible in the United States. At the end of Day 1, this formative assessment prompt should be collected and reviewed by the teacher in an effort to begin a dialogue between the teacher and each student that probes their thinking (i.e. Have you considered…? What might be an alternative perception to this view? Who might hold an alternative perception and why?). Formative feedback should be returned to students at the start of Day 2. Note: As weight can be an extremely sensitive topic, teachers should pay close attention to verbiage used and claims made by students in formative assessment prompts and class discussions to address any concerns regarding lack of

sensitivity. Teachers should also be explicit with students that the ‘fat tax’ is a tax on foods, not on people. On Day 2, teachers should assign each student a role ‘for’ or ‘against’ the resolution #1 or #2 (see Figure 1 at end). Students are also assigned a role to assume within their argumentation (see Table 2 below). Homework for students is to read Would a Fat Tax Save Lives? (Silverman, 2013) so that prior to embarking on the debate students will have received the same background information on the fat tax. The article also contains several links to research the science of fat cells and metabolism should students should be encouraged to draw upon this information in their research. An additional resource that students should read to ensure their consideration of the differential economic impact on people is Big Brother declares war on consumption: How the move to mandate healthier foods inadvertently hurts the poor (Hoffer et al., 2013). This editorial will probe students’ thinking about the equity of such a tax on food, which should also be addressed in their debates. Preparation for the debate begins with background research, for which all students should have access to the Internet. Depending on their assigned role within the debate, they will be exploring different types of websites. For example, if they are assigned a citizen perspective within the debate, they could research recent student protests over exclusively healthier food options in their school cafeteria. Teachers should guide their students to a variety of resources and probe them to consider the agenda and credibility of the site. Some students may need additional time preparing arguments based on their

* A T-chart is used mostly to compare things like pros and cons. It is called a T-chart because to make it, a line is drawn across the page and another down the middle and looks like the letter T. Pros and cons are then listed in each column either side of the line. Table 2. The four debate roles Scientist “Scientist” is a broad term and may include a basic scientist (e.g., dietician), applied scientist (e.g., doctor or health consultant), or expert science teacher

Citizen Any person who is not formally trained in the natural sciences; Note: do not assume that just because this person is not a scientist that they are uneducated

Business Person

Government Official

A person from any sector of business who may have a vested interest in the outcome of the debate—what types of businesses might be affected by a fat tax?

Think more broadly than just mayor, state representative, or governor. A government official could also include a city/county officer, or someone who works for the Department of Health

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individual research, so teachers should allow time enough time for formative feedback after research is conducted in the classroom. To do this, teachers can request students submit a brief outline of their resources and conclusions prior to the debate. Day 3 and 4 are classroom debate days. With a group of 30 students, 15 will debate the first resolution and 15 will debate the second resolution. Those not debating will be conducting peer reviews and ultimately determining which of the opposing sides won the debate. The student instructions (see Figure 1 at end) outline helpful tips for preparing the debate that will yield maximum points on the teacher and peer rubrics (see Figure 2 at end). Teachers should review specific instructions and rubric with students prior to the debate days to resolve any questions. Assessment Technique: Students will be assessed in teams by both their instructor and peers. The instructor assessment will gauge all three performance indicators of NHES as well as assess the use of evidence in and organization of their argument. The peer assessment will gauge argumentation effectiveness.

Conclusion In this inquiry, students are challenged to explore the controversy of a fat tax, which is informed by the science of food energy and integrates social aspects (moral, ethical, economic, etc…) to develop a position based upon their research (Klosterman et al., 2010; Tanner, 2009). I am always struck by the engagement with which students prepare their debates and excitedly work with their peers to formulate strong arguments. The challenge to win the debate brings forth (often from students from whom I would least expect) dynamic debate styles, with students assuming the roles of a variety of actors and creating background stories for their chosen personas. With this, however, some students get so excited about the preparation of their debate and developing their character that they neglect to connect the content and evidence they have researched in their arguments. We have seen in research on debates surrounding socio-scientific issues that students’ privilege faulty reasoning, hasty generalizations, and extreme examples to evoke

affective responses (Walker & Zeidler, 2007). For this reason, teachers should thoughtfully utilize the formative assessment opportunities as mentioned above to prompt students to ensure they are referencing appropriate databased evidence on which to base their arguments. At the end of the debate, a class discussion about which team won the debates can lead to a focus on what constitutes persuasive argumentation. Students can reflect on what aspects of the debate persuaded them most. Through this lesson, students must play close attention to the intersection of science and complex societal concerns, and teachers will find that this activity engages students in learning to make and articulate to others wellinformed decisions about socio-scientific issues. References Angell, S., Silver, L., Goldstein, G., Johnson, C., Deitcher, D., Frieden, T., & Bassett, M. (2009). Cholesterol control beyond the clinic: New York City's trans fat restriction. Annals of Internal Medicine, 151(2), 129-134. Canadian Taxpayers Federation. (2013). “Denmark’s failed fat tax experiment” [Video File]. Accessed 02/01/2014. Hoffer, A., Shughart, W., & Thomas, M. “Big Brother declares war on consumption: How the move to mandate healthier foods inadvertently hurts the poor.” USA Today, 4 Aug. 2013. Web. 8 Sept. 2013. Accessed 02/01/2014. Khazan, O. (2102, November 2011). What the world can learn from Denmark’s failed fat tax. The Washington Post. Accessed 02/01/2014. 1/what-the-world-can-learn-from-denmarks-failed-fat-tax/ Klosterman, M. & Sadler, T. (2010). Multi-level assessment of scientific content knowledge gains associated with socioscientific issues-based instruction. International Journal of Science Education, 32, 1017-1043. Ogden, C., Carroll, M., Kit, B., & Flegal, K. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA, 307(5), 483-490. Silverman, J. (2013, June 3). “Would a fat tax save lives?” Accessed 02/01/2014. Tanner, K. (2009). Talking to learn: Why biology students should be talking in classrooms and how to make it happen. Life Sciences Education, 8, 89 –94. Walker, K. & Zeidler, D. (2007). Promoting discourse about socioscientific issues through scaffolded inquiry. International Journal of Science Education, 29, 1387-1410.

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Figure 1. Class Debate Instructions Goals of the activity: • Conduct research to gain understanding about the impacts of obesity for those affected and in our society • Communicate, persuasively, the impacts of obesity both for individual and society • Evaluate the quality of evidence articulated in arguments What is a resolution? A resolution, when in context of law, is a written motion to be presented, debated, and adopted by a deliberative body. Half of the class will debate one resolution; while the other half will debate the other: 1. Be it resolved that the community will instigate extra fees for what is deemed to be excessively fatty foods. 2. Be it resolved that the community will offer tax incentives for consumers choosing what is deemed to be healthy food. Presenting the debate: Students should determine the order with which they wish to present in the debate, with the ‘for group presenting before the ‘against’ group. Each person will have 2 minutes to present an argument and 1 Minute to present their rebuttal. Be sure to practice speech/argument before presenting it to the class. This cannot be emphasized enough. Even the most compelling information may not come across effectively if pacing and tone are unpolished. Students may choose to bring a notecard of bulleted points to the podium, but should avoid reading from the card. Preparing for the debate: Rather than attempting to rattle of facts about the fat tax, select a specific thread to make an argument. For example, if the debate were about global warming and a student is in the role of scientist, that student may choose to focus on the related human health aspects rather than trying to cover everything about global warming. Visuals can be very helpful in persuasive arguments, but only if they are related to and enhance the argument. However, the most important aspect of the prepared argument is that it is grounded in scientific evidence. Utilize original research articles from peer-reviewed journals and information from government websites. Students may use other sources for background information or as springboards to identifying specific sub-topics, but using original scientific research is required. Students should be sure to listen to the opposing side and make notes of points that they could use in their rebuttals. Students will have 1 minute each for a rebuttal, and their teams will have 10 minutes to prepare rebuttals. Students should remember they are presenting as a “for” group and an “against” group. While it is not necessary to work together in preparing arguments, it does make sense to coordinate sub-topics and ensure no overlap of points. Students should submit: • A reference list of the sources used to prepare arguments • Notes, note cards, etc. used during your presentation • A peer-evaluation of other group’s presentation

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Figure 2. Debate Rubric & Peer Evaluation Team Rubric Criteria





All information presented was clear, accurate, & thorough

Most information presented was clear and accurate, but not always thorough

Information had some major inaccuracies or was not clear

All information presented was clear, accurate, & thorough

Most information presented was clear and accurate, but not always thorough

Information had some major inaccuracies or was not clear

All information presented was clear, accurate, & thorough

Most information presented was clear and accurate, but not always thorough

Information had some major inaccuracies or was not clear


All counter-arguments were accurate, relevant, and effective

Most counter-arguments were accurate and relevant, but several were weak

Counter-arguments were not accurate and/or relevant

Use of Data

Every major point was well supported with relevant data and examples

Every major point was supported by data, but the relevance or accuracy of some was questionable

Every major point was not supported by data


Team’s arguments were clearly organized to connect to central premise

All arguments were tied to a central premise, but the organization was sometimes unclear

Arguments were not tied to a central premise

Understanding of Issue

Team clearly understood the topic in-depth and information was conveyed persuasively

Team seemed to understand the main points of the topic, but were not thorough

Team did not show an adequate understanding of the issue

Presentation Style

Team consistently used gestures, eye contact, tone of voice, and a level of enthusiasm that kept the attention of the audience

Team sometimes used gestures, eye contact, tone of voice, and a level of enthusiasm that kept the attention of the audience

Team’s presentation style did not keep the attention of the audience

1.12.7. compare and contrast the benefits of and barriers to practicing a variety of healthy behaviors. Content 2.12.10. analyze how public health policies and government regulations can influence health promotion and disease prevention. Content 5.12.7. evaluate the effectiveness of health- related decisions.

TOTAL: Peer Evaluation Criteria Opening Statement: Clear, factual, relevant, & well organized st

1 Debater (Name:


Argument was stated clearly, relevant, & well informed st

1 Debater’s Rebuttal: Rebuttal was informed & effective 2


Debater (Name:


Argument was stated clearly, relevant, & well informed 2


Debater’s Rebuttal: Rebuttal was informed & effective



3 Debater (Name:

Argument was stated clearly, relevant, & well informed rd

3 Debater’s Rebuttal: Rebuttal was informed & effective th

4 Debater (Name:


Argument was stated clearly, relevant, & well informed th

4 Debater’s Rebuttal: Rebuttal was informed & effective Overall preparedness, effectiveness, & professionalism in the debate Which team won the debate and why?

Rating (1-10)


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This article is based on a doctoral research project “Food and healthy eating: progression in the curriculum”. For communication, please email:

Frances Ryland Food and Healthy Eating in the Curriculum – a case of too many cooks spoiling the broth


nowledge about food and healthy eating is so important that it has found its way into many areas of the National Curriculum in use in England today. Despite this, we are in the midst of an obesity crisis with The World Health Organisation (WHO, 2014) stating that ‘obesity is one of the greatest public health challenges of the 21st Century’. Paradoxically, anorexia cases requiring hospital treatment in England have also risen by 10% in the last 10 years (The Telegraph, 2009). Food and healthy eating forms part of the Science, Design and Technology (DT) and Personal, Social and Health Education (PSHE) remits so one might assume that pupils obtain a good understanding of the subject through their schooling. However, the figures appear to contradict this. I approached this area as part of a doctoral research project looking at progression in the Science curriculum (Ryland, 2009a). There had been reporting of pupils’ discontent due to poor progression and repetition (Lord and Jones, 2006). However, research was yet to confirm whether these claims were justified. The National Curriculum is based on the spiral curriculum proposed by Jerome Bruner (1960). Bruner (Ibid.) surmised: A curriculum as it develops should revisit the basic ideas repeatedly, building upon them until the student has grasped the full formal apparatus that goes with them. (p.13) This means that fundamental concepts are introduced in a basic form in key stage 1 (KS1) and are then revisited and developed in later key stages. Progression is paramount in the successful implementation of a spiral curriculum.

The Study My study centred on concepts connected to food and healthy eating for pupils in KS1 to

KS3. One primary and one secondary school located in Birmingham were involved in the study. The research was designed to assess progression through documentary analysis of the National Curriculum Science programme of study (PoS) (DfEE and QCA, 1999; QCA, 2007); the Qualifications and Curriculum Authority’s schemes of work (QCA, 1998); the schools’ schemes of work; and pupils’ exercise books. The views of pupils and teachers at the two schools were also sought.

Documentary analysis The National Curriculum Programme of Study (1999) Food and healthy eating was found to be taught at each KS of the National Curriculum. When the statutory content was analysed, it was found to show clear progression. The statutory content developed progression in both the use of language and the depth of knowledge. In KS1 the language focused on ‘types of food’. I interpreted this as meaning foodstuffs such as bread, meat, potatoes, fruit and etc. In KS2 the focus was on what food is used for, thus making the link between food and activity, growth and health, for example, meat/beans help us grow. Some more technical terms such as ‘adequate’ and ‘a varied diet’ were also introduced. In KS3 the key term ‘a balanced diet’ and the scientific terms for the main nutrients such as carbohydrates, proteins etc. were detailed. The sources of these nutrients were also covered. Digestion was not covered at all in KS1; in KS2 the very beginning of the digestive process was introduced by covering the function of teeth; in KS3 the digestive system was explored in addition to the function of enzymes. At each key stage there were aspects that were revisited and developed and further new aspects were also introduced.

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A new PoS for KS3 (QCA, 2007) was introduced in schools in 2008. The statutory content it proscribed was difficult to analyse for progression in relation to the previous two key stages as it was particularly vague when compared to the 1999 version. It seems relevant to note at this stage that despite the introduction of a new PoS in 2008 (during the field work stage of the research), both the school and QCA stated at the time that they had no plans to change their existing schemes of work based on the 1999 publication. Put simply, the new PoS was introduced to little effect. The reasons behind this will be discussed later, along with teachers’ views of the curriculum. The Schemes of Work The PoS is translated by schools into schemes of work. The QCA published schemes of work (QCA, 1998) as part of their non-statutory guidance and these could be adopted by schools. The primary school in the study used these schemes whereas the secondary school developed their own. The QCA schemes of work revisited the food and healthy eating twice per KS from KS1 to KS3; this was in years 1, 2, 3, 5, 6, 8, and 9. The secondary school’s schemes of work also revisited the topic twice in KS3 in years 8 and 9. When the content of the schemes of work were analysed for progression, there seemed to be little between the first and second revisit within KS1 and KS2 and some between the revisits in KS3 (Ryland, 2009b). For example, in the learning objectives, scheme 3A for year 3 states ‘an adequate and varied diet is needed to keep healthy’ (p.2) and in the year 5 scheme 5A ‘to stay healthy we need an adequate and varied diet’ (p.2). These objectives appear to be identical and it is difficult therefore to identify possible progression in their outcomes. Progression was much easier to observe in KS3, as the content covered was significantly different in theme, with year 8 concentrating on nutrients included in a balanced diet, digestion and enzymes and year 9 getting to grips with the intricacies of a balanced diet and focussing on deficiencies, disease, malnourishment and the adverse health effects of an excess of some minerals such as salt. The QCA schemes of work were also found to be confusing as to when certain concepts should be introduced. This was mainly because they

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contained terms within their guidance to teachers which were unsuitable for use with the pupils. For example, Unit 5A for year 5 states: ‘…children do not need to be able to classify foods formally into groups such as protein or carbohydrate’ and later ‘most children should be able to understand that energy foods are of two types - carbohydrates (starches and sugars) and fats.’ (p.2) To the casual reader it may appear that the term carbohydrate was to be covered with year 5 pupils. However this is not included in the National Curriculum until KS3. Another confusing example appears in the scheme 2A for year 2 (KS1), which outlines how some pupils will be able to ‘describe how their diet is balanced’ (p.1). So the words ‘diet’ and ‘balanced’ are being used in close connection, yet the National Curriculum does not introduce the term ‘diet’ until KS2 and ‘balanced’ until KS3. This suggests that some pupils may develop some understanding of the concept of ‘balance(d)’ two key stages earlier than planned. This may be an attempt to show potential for differentiation. However the mere mention in the scheme could indicate to teachers that they should be teaching the term to all pupils. I expect that some pupils could adopt and use the phrase relatively easily, but without grasping the true scientific interpretation as covered in KS3. Pupil exercise books The analysis of pupils’ exercise books was possibly the most informative aspect of the study. This revealed what had actually been included in classwork and homework. The analysis included books from each of years 2, 3, 5, 8 and 9. It showed that certain aspects were introduced much earlier than stated in the National Curriculum and then repeated at each revisit throughout the pupils’ education. For example key nutrient types, such as carbohydrates and proteins, were covered in year 2 (KS1) and then repeated at each revisit in years 3, 5, 8 and 9 although these concepts were not included in the National Curriculum until KS3. So pupils were being exposed to repetitive content throughout their education. Such scientific terms were observed in the exercise books in pupils’ own notes and also in externally produced worksheets for KS1 and photocopies of KS2 revision guides (Parsons,

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1999 reprinted 2005). Despite this repetition, some aspects did show progression. However, this was achieved by ‘borrowing’ content from the next key stage. For example, pupils in year 5 (KS2) gained progression by learning about the function of the digestive system which was only described in the PoS for KS3. As a result of this early introduction pupils were exposed to repetitive content in KS3. Comparative analysis of documentary sources When the documentary sources were compared, it was found that 42% of the concepts identified in the National Curriculum PoS were introduced early in the exercise books. It was also noted that more concepts and key words were observed in the exercise books than were observed in the corresponding schemes of work in KS1 and KS2. For example, in the QCA scheme of work for year 2 fifteen concepts and key words were included yet twenty-nine were observed in the books. Thus, more content was covered with the pupils than was required by the statutory content of the National Curriculum or the non-statutory guidance given in the QCA schemes of work and this was the case for all years in KS1 and KS2 in the study. Pupils’ voice Pupils in years 5, 8 and 9 participated in the pupils’ voice phase of the study, completing questionnaires on the food and healthy eating topic. A sub-set of pupils also took part in focus groups. The majority of pupils felt learning about food and healthy eating was important and should be taught in school because they recognised the health benefits arising from such knowledge. However, pupils also felt that it was covered too frequently and this lead to repetition and boredom. The pupils also reported learning about food and healthy eating from many sources both inside and outside of school and this compounded their negative feelings. They identified how the same content, such as food groups (fats, carbohydrates and proteins etc.) and a balanced diet was covered in Science, DT and PSHE lessons. Pupils were left feeling that they learnt about food ‘every year’ and this was too much. Teacher Voice Four teachers were interviewed as part of the study. These included a class teacher and a head

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of department from each school who were involved in teaching the pupils in the study. The teachers were largely unaware of what the pupils had learnt about food and healthy eating in the previous KS. For example, a KS2 teacher stated that he had ‘no idea’ what was taught about food and healthy eating in KS1 and a KS3 teacher stated ‘I think they vaguely cover healthy eating’ at KS2. As they were unaware of the detailed knowledge that the pupils had, they unwittingly included concepts in their lessons that were repetitive for the pupils. However they were much clearer about what had been taught earlier in the KS they were teaching as all the teachers in the study taught both years within a KS. This in-depth knowledge of the schemes of work and of pupils’ experiences led the KS2 teachers to introduce KS3 concepts early because they felt the QCA scheme did not offer enough progression for their pupils. The primary head of department, when speaking generally about the entire curriculum, stated: We are aware that we cover some material from secondary school…we like to extend the children…[I am aware] they then get bored in year 7 and 8. The KS3 teachers were aware that some KS3 content was covered in KS2. The head of department stated: In my view for primary schools to make their experience more pleasant they are nicking all the KS3 practicals [experiments]. So when the kids get here they find it dead boring… You see this is where prescription would be (pause) IS essential. He also outlined concerns that the 2008 PoS was too vague and described the content as appearing to be ‘top secret’ and felt that ‘absolutely anything’ could be included in exams. It was this feeling of vagueness that led the schools not to alter their schemes of work when the new PoS was introduced in 2008.

Discussion of the study The three phases of the study highlighted some key areas of concern regarding the repetition of concepts in Science lessons and identified some areas where future research could identify the extent of the overlap with DT

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and PSHE. Since the completion of the study, the new Coalition Government instigated a consultation on the National Curriculum. I submitted detailed data to that consultation, outlining my concerns regarding the teaching of food and healthy eating. This consultation culminated in the publishing of a new curriculum (Department for Eduation (2013b) for Science and DT (Department for Eduation (2013a) and I will now reflect on these documents. Curriculum 2013 My first observation is that the new PoS for Science details content on a yearly basis in KS1 & KS2 as opposed to the KS basis detailed in earlier documents. Looking at KS1 and KS2, food and healthy eating first appears in year 2. The 2013 statutory content is very similar to that included in the 1999 PoS, including types of food in the right amounts and the importance of exercise. Similar concepts are covered in year 3, including food types and amounts of ‘nutrition’. The non-statutory guidance for this year also mentions ‘food groups’, but does not specify terms such as carbohydrates etc. In year 4 pupils look at teeth. This again mirrors the content of the 1999 PoS, but differs in that the basic function of the digestive system is also included. This was previously KS3 content, although this study observed it being introduced in year 5. The topic is also revisited in year 6, when pupils consider the ways in which nutrients are transported within animals. This was previously included in KS3 in the 1999 PoS. So, in summary, the food topic is revisited in years 2, 3, 4 and 6 in the new 2013 curriculum, whereas those following the nonstatutory guidance of the QCA schemes based on the 1999 version revisited it in years 1, 2, 3 and 5. In KS3 the content is not described on a yearly basis and includes the key scientific terms carbohydrates, proteins etc., the consequences of imbalances, deficiency disease and the digestive system and enzymes. This reflects closely the 1999 PoS for KS3. The overall feel of the 2013 PoS is that is very similar to the 1999 version, all bar a small amount of tweaking to reflect what was being taught in schools anyway. My overriding

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concern however is that I do not believe it will solve the problem of repetition as it is not prescriptive enough. This is highlighted by the fact that the terms for the nutrient types only appear in the statutory content for KS3, yet evidence suggest their use in school from KS1. Indeed they were included in published revision guides for KS2 (Parsons, 1999 reprinted 2005). I shall now turn to the new DT PoS and identify a potential overlap with the Science curriculum. In the ‘cooking and nutrition’ section, content is detailed for each from KS1 to KS3. Content which has a clear identifiable overlap with Science includes the principles of a healthy and varied diet in KS1 and KS2 which would almost undoubtedly lead to the inclusion of food types. These concepts are revisited in KS3 when pupils should be taught to understand and apply the principles of nutrition and health. As an example of how such overlap or repetition is likely to occur, the Science PoS for year 3 ‘notes and guidance’ suggests that pupils (Department for Education, 2013b): Might research different food groups and how they keep us healthy and design meals based on what they find out (p.17) This also seems to be an entirely appropriate activity for the KS2 DT statutory content (Department for Education, 2013a): Understand and apply the principles of a healthy diet (p.5) In Science, pupils research how certain foods keep us healthy this is directly comparable to the pupils in DT understanding the principles of a healthy diet. Further, when the guidance in the Science PoS suggests pupils design meals, this could also be thought of as applying the principles of a healthy diet as outlined in the DT PoS. In summary, the 2013 National Curriculum continues to be vague, thus allowing a variety of different interpretations for a wide age group of pupils. Although this might appear to make it flexible, it is easy to see how repetition could continue to occur. References Bruner, J. (1960). The process of education. Cambridge, Massachusetts: Harvard University Press.

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Department for Education (2013a). National curriculum in England: design and technology programmes of study [online]. Available from: Accessed 13 January 2014 Department for Education (2013b). National curriculum in England: science programmes of study [online]. Available from: Accessed 13 January 2014 Department for Education and Employment (DfEE) and Qualifications and Curriculum Authority (QCA) (1999). Science: The National Curriculum for England. London, DfEE and QCA. Lord, P. and Jones, M. (2006). Pupils' experiences and perspectives of the National Curriculum and Assessment: Final report for the research review. Slough, NFER. Parsons, R. (1999; reprinted 2005 3rd ed.). Key stage two Science: the important bits. Coordination Group Publications Ltd. QCA (1998). Schemes of Work [online]. Available from: Accessed 13 January 2014 QCA (2007). Science Programme of Study for Key Stage 3. London, QCA.

Ryland. F. (2009a). “Food and healthy eating: document analysis to explore progression in the curriculum, Years 5-9.” Ph.D. thesis. School of Education, University of Birmingham. Available from: Accessed 13 January 2014 Ryland. F. (2009b). “Food and healthy eating: document analysis to explore progression in the curriculum, Years 5-9.” In Corcoran C. and Cooke S. (eds.) Papers from student conference. Education research, education researchers: diverse experiences and perspectives. Birmingham: University of Birmingham School of Education. pp135-144 The Telegraph (2009). Anorexic girls admitted to hospital rise by 80% in a decade [online]. Available from: rexic-girls-admitted-to-hospital-rise-by-80-per-cent-in-adecade.html Accessed 13 January 2014 WHO (2014). Obesity [online]. Available from: Accessed 13 January 2014

Education and Health The journal, published by SHEU since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readership is worldwide and in the UK include: primary; secondary and further education teachers; university staff and healthcare professionals working in education and health settings. The journal is online and open access, continues the proud tradition of independent publishing and offers an eclectic mix of articles.

Contributors (see a recent list) - Do you have up to 3000 words about a relevant issue that you would like to see published? Please contact the Editor


Schools and Students Health Education Unit

The specialist provider of reliable local survey data for schools and colleges and recognised nationally since 1977. "The (named) Children and Young People's Partnership has benefitted from the results of the SHEU survey locally for many years now, and we should like to continue to do so in future." Consultant in Public Health Medicine For more details please visit

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Dr Mark D. Griffiths is Professor of Gambling Studies and Director of the International Gaming Research Unit, Psychology Division, Nottingham Trent University. For communication, please email:

Mark D. Griffiths Child and adolescent social gaming: What are the issues of concern?


ver the last year, there have been an increasing number of media reports about the potentially exploitative and/or addictive nature of various types of social game that can either be played via social networking sites or be played after downloading apps from online commercial enterprises such as iTunes (Griffiths, 2013a). Most social games are easy to learn and communication between other players is often (but not always) a feature of the game, and they typically have highly accessible user interfaces that can be played on a wide variety of different devices (e.g., smartphones, tablets, PCs, laptops, etc.). According to Church-Sanders, (2011) there are eight different types of social gaming (see Table 1), most of which can (and are) played by children and adolescents.

In my own household, the two most popular games played by my family at the moment are the competitive casual games Candy Crush Saga and 4 Pics, 1 Word (both highly popular games across the UK more generally). In fact, at the time of writing this article, the most popular game being played worldwide on Facebook was Candy Crush Saga (CSS) with over 133 million people playing monthly. Most players of CSS appear to be adult but around 10% of players are thought to be adolescents. Clearly, most people that play social games find them fun and enjoyable to play with little or no problem. However, I have been receiving an increasing number of emails from parents, teachers, and the press about some of the more negative aspects of social gaming.

Table 1: Social networking games by genre (from Parke et al., 2013, adapted from Church-Sanders, 2011) Genre



Role playing games

Use the social graph (a playerâ&#x20AC;&#x2122;s social connections) as part of the game

Parking Wars, PackRat, Mobsters, Fashion Wars, Mafia Wars, Vampire Wars, Spymaster

Management/nurturing games

Main gameplay involves socializing or social activities like trading or growing

YoVille, Pet Society, FarmVille, Cupcake Corner, CityVille

Turn-based card, board and parlour games

Played within a social context or with friends

Farkel Pro, Monopoly

Virtual currency gambling

Games which would otherwise be played in a gambling context

Texas Holdâ&#x20AC;&#x2122;Em Poker, Bingo, Slots

Competitive casual games

Often word-based with friends only leaderboards

Words with Friends, Scramble, Scrabble

Dating and Flirting

Aim to meet (or dump) people

Friends for Sale, Human Pets, Chump Dump

Sports games

Based on real-life sporting activities

Premier Football, Tennis Mafia, FIFA Superstars

Virtual jokes

Gimmicky games that tend to be popular when initially launched then fade in popularity

Pillow Fight, Kickmania, Water Gun Fight

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There are arguably three main concerns relating to adolescent social gaming that have been aired in the national media. Firstly, there are concerns about the way games companies are making money from players by making them pay for in-game assets, in-game currency, and/or access to other levels within the game. Secondly, there are concerns about how engrossing the games can be that have led to various news reports claiming that a small minority of people appear to be “addicted” to them. Thirdly, there have been concerns that some types of social games are a gateway to other potentially problematic leisure activities – most notably gambling. This latter issue was covered in a previous issue of Education and Health (see Griffiths, 2013b). Therefore the rest of this article looks at these two remaining issues.

Exploitative practices in social gaming Almost anyone that has engaged in social gaming will have played 'freemium' products. Freemium social games give free access to the game being played, but players must pay for socalled 'premium' services. A recent review on social gaming and gambling by Parke, Rigbye, Parke and Wardle (2013) defined ‘freemium’ games as: “A business model in which users of the service (in this context, game) usually play for free but are encouraged to pay: for extended game play; to compete with others/status; to express themselves; to give virtual gifts; and to obtain virtual goods which are valuable due to their scarcity” (p.16). In games like CCS, players are not charged to advance through the first 35 levels but after that, it costs 69p for another 20 levels. Players can avoid paying money by asking their friends on Facebook friends to send them extra lives. Players on CCS are encouraged to buy 'boosters' such as virtual 'candy hammers' for around £1. Although this does not appear to be much money, the buying of in-game assets and items can soon mount up. In 2013, many news outlets covered the story of how two boys (aged just six and eight years of age) spent £3200 on their father’s iPhone buying virtual farm animals and virtual farm food with real money at £70 a time (Talbot, 2013). Another case involved a ten-year-old boy

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who ran up a £3,000 bill on the game Arcane Empire on iTunes (Gradwell, 2013). As a consequence of these and other high profile cases, the UK Office of Fair Trading is now investigating whether children and adolescents are being unduly pressured and/or encouraged to pay for in-game content (including the upgrading of their game membership and the buying of virtual currency) when they play free games. I have noted in a number of my more general writings about games played via social networking sites that ‘freemium’ games are psychological ‘foot-in-the-door’ techniques (see Griffiths, 2010a) that lead a small minority of people to pay for games and/or game accessories that they may never have originally planned to buy before playing the game (akin to ‘impulse buying’ in other commercial environments). I’ve also argued in a number of articles that many of the games played on social network sites share similarities with gambling especially as they both involve in-game spending of money (e.g., Griffiths, 2010b; 2013b). Although social gaming operators need to be more socially responsible in how they market their games and how they stimulate in-game purchasing, parents themselves also need to take responsibility when letting their children play social games or allowing them to download gaming apps. Simple measures that can help stopping children unwittingly buy ingame items for real money include: (i) not giving children access to online store passwords (ii) personally overseeing any app that they download (iii) using parental controls on phones and tablets (iv) unlinking debit/credit card cards from online store accounts (i.e., do not store payment details with online stores) (v) actually talking with children themselves about the buying of in-game extras

‘Addiction’ to social gaming In my interviews to the national press and online media (e.g., Foster, 2013; Hall, 2013; Pressmen, 2013; Rose, 2013) about what makes games like CCS attractive and potentially addictive, I have noted a number of different

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aspects. Games like CCS are gender-neutral games that have a ‘moreish’ quality (a bit like eating chocolate), and as such may appeal more to girls than boys (although I know boys among my own children’s peer group that play CCS). Social games like CCS and Farmville take up all the player’s cognitive ability because anyone playing on it has to totally concentrate on it. By being totally absorbed, players can forget about everything else while engaging in the activity. These are some of the psychological consequences of other more mainstream chemical addictions (e.g., alcoholism) and behavioural addictions (e.g., gambling addiction). At their heart, social games are deceptively simple and fun but can be highly rewarding on many different levels (e.g., psychological, social, physiological, and financial). As I argued in a previous article (Griffiths, 2013), social games like CCS and Farmville may not seem to have much connection to gambling, but the psychology used by the games developers is very similar. People cannot become addicted to something unless they are being constantly rewarded for engaging in the activity. Like gambling and video game playing more generally, the playing of social games provides constant rewards (i.e., behavioural and psychological reinforcement) that in a small number of instances could result in a person becoming ‘addicted’ to the game they are playing. Even when games do not involve money, most social games introduce players to the principles and excitement of gambling. Small unpredictable rewards lead to highly engaged, repetitive behaviour. In a minority, this may lead to addiction (Griffiths, 2013b). Basically, people keep responding in the absence of reinforcement hoping that another reward is just around the corner – a psychological principle rooted in operant conditioning and called the partial reinforcement extinction effect – something that is used to great effect in both slot machines and most video games (Griffiths, 2010b). At present there is little empirical evidence that social gaming is causing addiction-like problems on the scale of more traditional online games (e.g., World of Warcraft, League of Legends, etc.), although researchers are

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only just beginning to research into the social gaming area.

Looking ahead In a previous article on social gaming I argued that the introduction of in-game virtual goods and accessories (that people pay real money for) was a psychological masterstroke (Griffiths, 2012). It becomes more akin to gambling, as social gamers know that they are spending money as they play with little or no financial return. The real difference between pure gambling games and some free-to-play games is the fact that gambling games allow you to win your money back, adding an extra dimension that can potentially drive revenues even further. The psychosocial impact of social gaming on adolescents is only just beginning to be investigated by people in the field of gaming studies. Empirically, we know almost nothing about the psychosocial impact of these games, although as I noted in my previous Education and Health article (Griffiths, 2013b), research suggests the playing of free games among children and adolescents is one of the risk factors for both the uptake of real gambling and problem gambling. Parke et al. (2013) recommended that stricter age verification measures should be adopted for social games particularly where children and adolescents are permitted to engage in gambling-related content, even where real money is not involved. I would add that age verification should be carried out in any game that requires the spending of money (even if it on virtual assets and items). Social media has enabled (and arguably encouraged) children and adolescents to spend money in-game and there is certainly some evidence that the techniques used to monetize social games have resulted in a minority of children and adolescents spending large amounts of money. To date, there is less evidence that youth are developing addictions to social games although this is more due to the fact that scientific research has yet to study such activity. Given the growing evidence on adolescent online video game addiction and adolescent social networking addiction more generally (e.g., Kuss & Griffiths, 2011; 2012; Griffiths, Kuss &

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Demetrovics, 2014), there is no reason to suppose that a small minority of children and adolescents would not develop an addiction to some types of social gaming.

References Foster, J. (2013). How women blow £400,000 a day playing Candy Crush, the most addictive online game ever. Daily Mail, October 17. Located at: Accessed 27 January 2014. Church-Sanders, R. (2011). Social Gaming: Opportunities for Gaming Operators. iGaming Business: London. Gradwell, H. (2013). How to stop your kids accidentally spending your money on apps and games. Think Money, April 12. Located at: Accessed 27 January 2014. Griffiths, M.D. (2010a). Online gambling, social responsibility and ‘foot-in-the-door techniques’. i-Gaming Business, 62, 100101. Griffiths, M.D. (2010b). Gaming in social networking sites: A growing concern? World Online Gambling Law Report, 9(5), 12-13. Griffiths, M.D. (2012). The psychology of social gaming. i-Gaming Business Affiliate, August/September, 26-27. Griffiths, M.D. (2013a). The psychosocial impact of gambling apps. Youth Gambling International, 13(1), 6-7. Griffiths, M.D. (2013b). Adolescent gambling via social networking sites: A brief overview. Education and Health, 31, 84-87. 1/eh314mg.pdf Accessed 27 January 2014.

Griffiths, M.D., Kuss, D.J. & Demetrovics, Z. (2014). Social networking addiction: An overview of preliminary findings. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment (pp.119-141). New York: Elsevier. Hall, C. (2013). Just how addictive are mobile games? Yahoo! News, October 18. Located at: Accessed 27 January 2014. Kuss, D.J. & Griffiths, M.D. (2011). Online social networking and addiction: A literature review of empirical research. International Journal of Environmental and Public Health, 8, 3528-3552. Kuss, D.J. & Griffiths, M.D. (2012). Online gaming addiction in adolescence: A literature review of empirical research. Journal of Behavioral Addictions, 1, 3-22. Parke, J., Wardle, H., Rigbye. J., & Parke, A. (2013). Exploring social gambling: Scoping, classification and evidence review. Report Commissioned by the UK Gambling Commission. The Gambling Lab: London. Pressman, A. (2013). Candy Crush: Insanely addictive today, but likely on borrowed time. The Exchange, July 11. Located at: Accessed 27 January 2014. Rose, M. (2013). Chasing the Whales: Examining the ethics of free-to-play games. Gamasutra, July 9. Located at: hale_examining_the_.php?page=7 Accessed 27 January 2014. Talbot, B. (2013). My 6yr-old spent £3,200 playing iPhone game – How to stop it. Money Saving Expert. February 19. Located at: Accessed 27 January 2014.


Schools and Students Health Education Unit

The specialist provider of reliable local survey data for schools and colleges and recognised nationally since 1977. "The survey reports have been used to inform commissioning at specific commissioning groups. They are also being used within our Extended Schools Clusters and to inform The Annual Public Health and the Joint Strategic Needs Assessment." Programme Manager - Young People TO SUPPORT YOUR WORK WITH YOUNG PEOPLE TRY SHEU’S FREE RESOURCES

Education and Health The journal, published by SHEU since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readership is worldwide and in the UK include: primary; secondary and further education teachers; university staff and healthcare professionals working in education and health settings. The journal is online and open access, continues the proud tradition of independent publishing and offers an eclectic mix of articles.

Contributors (see a recent list) - Do you have up to 3000 words about a relevant issue that you would like to see published? Please contact the Editor

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Luísa Campos, Pedro Dias and Filipa Palha are researchers at the Centre for Studies in Human Development, and Professors at the Faculty of Education and Psychology, Catholic University of Portugal. For communication, please email:

Luísa Campos, Pedro Dias and Filipa Palha Finding Space to Mental Health1 - Promoting mental health in adolescents: Pilot study


ental health is an essential component of social cohesion, productivity, peace and stability in the living environment, contributing to social capital and economic development in societies (World Health Organization, 2008). In 2005, the World Health Organization established the promotion of mental health as a public health priority, and recognized the importance of intervening primarily in young people (World Health Organization, 2005). Different reasons support the need to focus on this target group including: youngsters’ natural risk of developing a mental disorder (Patel et al., 2007); early stage of life is a period when attitudes are developing and can still be changed (Corrigan and Watson, 2002; Livingstone et al., 2013). Considering the current scenario of economic and social crisis in Europe, promotion of mental health has become even more urgent, since vulnerabilities associated with early development are being even more threatened by external factors, such as financial difficulties or unemployment of parents, which may lead adolescents to develop mental health problems [e.g., depression (European Parliament, 2012)]. Improving mental health literacy in young people, in order to increase their capacity to deal with expected and unexpected challenges, is an unquestionable priority. The concept of mental health literacy refers to the “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (Jorm et al., 1997, p. 182). Mental health literacy is not limited to having knowledge, since 1

knowledge is linked to beliefs that together determine attitudes (e.g. resistance to seek professional help). Early recognition of mental health problems and the appropriate helpseeking behaviours will only occur if young people are appropriately “literate” in this field (Jorm et al., 1997). The last decades have witnessed the development of effective programmes to promote mental health (WHO, 2005, 2010); school setting is considered the privileged context to develop such initiatives (Kelly et al., 2007). Based on the lack of systematic health education initiatives concerned with mental health in Portugal, the "Finding Space to Mental Health” project was carried out, in order to develop a school-based intervention to promote mental health literacy in young people (12-14 year olds). It comprises three major phases: pilot study, intervention and follow-up. The pilot study included two major steps: 1. A qualitative study, using focus groups, aimed at developing the “Mental Health Literacy questionnaire” and 2. The “mental health promotion intervention”2 The implementation of a pilot intervention in order to study its appropriateness and to study the psychometric properties of the questionnaire. This allowed to guarantee the adequacy of the intervention’s message to the specific target group (methodological accuracy - contents, format, and “wording”); to conduct a preliminary evaluation of the intervention; and to improve the programme’s contents and methods.

"Finding Space to Mental Health - Promoting mental health in adolescents (12 – 14 years old): development and evaluation of an intervention” (PTDC/PSI-PCL/112526/2009) - is developed by the Faculty of Education and Psychology of the Catholic University of Portugal (Oporto Regional Center), and funded by Science and Technology Foundation, in partnership with ENCONTRAR+SE – Association for the promotion of mental health. 2 For more detailed information regarding the methodology developed in the pilot study see: project website (; Campos, et al (in press)

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Considering the challenge of engaging young people in a subject not “appealing” and usually associated with stigmatised beliefs, the need to consider age-related issues (e.g., language, group dynamics, and age-related life events), and the importance to use attractive materials (e.g., music, videos) were considered when developing the intervention. This article presents the results concerning the impact of the mental health promotion intervention, developed and tested during the pilot study.

Method Participants Seventy students from three classes attending a private secondary school (38.6% in 7th grade, 41.8% in 8th grade and 20% in 9th grade) were included in this study. Students were aged between 12 to 14 year-olds (M=13.11; SD=0.81), and 41.8% were female. Concerning caregivers’ professional status, 91.4% were employed. Measure Mental Health Literacy questionnaire The version3 of the Mental Health Literacy questionnaire that was used in this study comprised 4 sections: 1) social-demographic information. 2) knowledge about mental health problems. 3) First Aid skills & help seeking. 4) self-help strategies. Sections 2 to 4 include 48 items organized in a 5-point Likert scale (1=strongly disagree; 5=strongly agree) and a multiple-choice item. The social-demographic form includes students’ age, gender, school year, and caregivers’ professional status. A preliminary analysis of the psychometric properties of the questionnaire – construct validity and internal consistency – was conducted with a sample of 239 students aged between 12 to 14 years old (M=12.95; SD=0.88), 46.4% female. An exploratory factor analysis (EFA) suggested a 3-factor structure: 1) knowledge, 2) First Aid skills & help seeking, and 3) self-help strategies. Internal consistency, assessed with Cronbach’s alpha, revealed good reliability scores for the three dimensions: knowledge = 0.76; First Aid skills & help seeking = 0.78; self-help strategies = 0.73 (Campos et al., 2012). 3

The Knowledge section comprised 32 items regarding prevalence and general characteristics of mental health problems, risk factors, symptoms of five mental disorders (Depression, Generalized anxiety disorder, Anorexia, Schizophrenia and Substance-related disorder), impact and stereotypes related to mental health problems. This section also includes one multiple-choice item, asking students to identify mental health problems from a list of eleven health problems. The First Aid skills & help seeking section comprised 10 items, including issues regarding informal help seeking, formal help seeking, and First Aid skills. The self-help strategies section included 6 items related to behaviours that can promote mental health. Based on the psychometric analysis of the questionnaire (EFA and Cronbach’s alpha), 11 items were removed from the following analyses. Mental health promotion intervention The intervention was developed based on a literature review on mental health literacy and promotion, school based interventions and stigma towards mental health problems; a discourse content from four focus group sessions held with 34 students; the material produced during an anti-stigma campaign (; and the UPA Makes the Difference (Campos et al., 2012) project’s material. The mental health promotion intervention is organized in two sessions (90 minutes each), implemented with one-week interval. The intervention was conducted by a graduate psychologist and one master’s level psychology student. The first session includes: • the presentation of the project and establishment of group rules • the exploration of students’ knowledge and beliefs about physical and mental health and illness • the exploration of mental health problems’ signs, their impact and risk factors • the identification of symptoms and signs of five mental disorders – Depression, Generalized anxiety disorder, Anorexia, Schizophrenia and Substance-related disorder

Further study of the questionnaire, based on the results of the pilot study, allowed the development of the final version of the MHLq (Campos and Dias, in prep).

25 Education and Health

the promotion of non-stigmatized behaviours towards mental disorders. The second session aims: • to explore beliefs related to mental disorders • to raise students’ awareness of mental health problems and their impact • to identify formal and informal help-seeking options • to promote First Aid skills towards people with mental health problems, and address self-help strategies (mental health promoting behaviours). Both sessions follow an interactive methodology (e.g. group dynamics, videos, and music), using materials, language, and strategies specifically developed taking into account this target-group. Procedures The Portuguese Ministry of Education and the Portuguese Data Protection Authority authorized data collection. Informed consent was given by students’ caregivers and by students prior to their inclusion in the project. Pre-intervention assessment was conducted one week prior to the implementation of the first session, and post-intervention assessment occurred one week after the second one. School teachers collaborated in this task. The sessions were scheduled to fit students’ timetable, and delivered in their classrooms. Data analysis Data was analyzed with IBM SPSS 21.0. Descriptive statistics were used for sociodemographic characterization, knowledge, First Aid skills and help seeking, and self-help strategies; Paired Samples t Tests and Wilcoxon Signed Rank Tests were performed in order to assess pre-post intervention differences. A mean score was obtained for each section of the questionnaire (total scores per section/number of items). The values obtained range from 1-5, and higher scores refer to higher mental health literacy. Seven knowledge items and one First Aid skills & help-seeking item were reverse-coded for calculating factor scores, since they are negatively phrased items. A McNemar test was used to test pre-post differences in mental health problems identified on the multiple-choice item. An alpha of 0.05 was used for statistical significance. •

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Results Knowledge There were significant differences between the mean value before (M=3.92; SD=0.30) and after (M=4.29; SD=0.23) the mental health promotion intervention (t(45)=-8.67; p<0.001). A detailed analysis shows significant differences in 12 items of the knowledge section (see Table 1). Concerning stereotypes, on post-intervention, significant differences were associated to those items with higher levels on pre-intervention, namely item 8 (M=2.17; SD=0.99 – pre-test; M=1.48; SD=0.80 – post-test; Z=-4.52; p<0.001), item 9 (M=2.23; SD=0.90 – pre-test; M=1.61; SD=0.95; Z=-3.89; p<0.001), and item 38 (M=2.67; SD=1.15 – pre-test; M=1.70; SD=1.03 – post-test; Z=-4.65; p<0.001). Table 2 presents the percentage of students that, from a list of 11 health conditions, considered them mental health problems. There was a significant decrease of physical problems and disabilities identified by participants, from pre to post-intervention, as mental health problems (Down’s syndrome, Parkinson’s disease and Cerebral palsy). On the other hand, there was a significant increase in mental disorders adequately recognized (Depressive disorder and Generalized anxiety). First Aid skills and help seeking There was a significant increase from pre (M=4.19; SD=0.58) to post-intervention (M=4.44; SD=0.49) students’ scores on First Aid skills & help seeking [t(61)=-3.26; p<0.001]. A detailed analysis shows significant differences in five items of the First Aid skills and help-seeking section, two of which were the lowest in the pretest [items 17 and 43 (see Table 3)]. Self-help strategies Results showed a significant increase of selfhelp strategies (M=4.19; SD=0.48 – pre-test; M=4.65; SD=0.41 – post-test; t(62)=-5.79; p<0.001). A detailed analysis shows significant differences in almost all items of the self-help strategies section except on item 25 (see Table 4).

Discussion This article presented results from the pilot study of a larger project aimed to promote mental health in adolescents. At pre-test, participants showed high-level scores in the

26 Education and Health

three sections of the Mental Health Literacy questionnaire. Participants of this study attended a private school and 91.4% of their caregivers were employed. School setting, combined with a very high rate of employment of caregivers, are indicative of a higher socioeconomic background. Both of these features may partially explain the results in the pre-test. Literature suggests a significant impact of socio economic background in knowledge related to mental health (von dem Knesebeck et al., 2012; Campos et al., 2013). Results from the pre-intervention assessment are also in line with international data suggesting that higher levels of knowledge related to mental disorders are associated with reduced stereotypes (Addington et al., 2012; Jorm, 2012). These levels of knowledge and stereotypes are related to: a) an increased capacity of young people to seek help and to know where to get this support (Jorm, 2012; WHO, 2010) b) the development of more appropriate mental health promoting behaviours c) an increased capacity to seek information about mental health (Jorm; 2012; Bourget Management Consulting, 2007) d) a greater motivation to help (Pinfold et al., 2005; Jorm, 2012; Loureiro et al., 2013; WHO, 2010). Furthermore, these results confirm that stereotypes in young people are still not completely consolidated and seem to be less negative when compared to adults (Corrigan and Watson, 2002; Farrer et al., 2008). Despite the fact that these students showed high overall scores in the mental health literacy questionnaire, the item analysis highlights relevant information gaps on the items related to the prevalence of mental health problems and the identification of Down’s Syndrome, Cerebral Palsy and Parkinson’s Disease as mental health problems. This difficulty in differentiating mental disorders from physical disabilities has also been referred in other studies (Jorm et al, 1997). Focusing on the impact of the intervention, results from the post-intervention assessment showed a significant increase on knowledge, First Aid skills and help seeking, and self-help strategies. A detailed analysis of the knowledge section

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showed increased results in items presenting lower levels at the pre-intervention assessment (in particular item 1 in 5 people will develop a mental disorder at some point in their lives – in which participants scored the lowest in the pre-test and the highest in the post-test assessment). Regarding the stereotypes, there was a significant decrease on items presenting the highest values in the pre-test. Concerning the multiple-choice items, there was a significant increase in the percentage of participants who identified depression and anxiety as mental disorders, and a significant decrease in the identification of Down’s syndrome, Cerebral Palsy and Parkinson’s disease as mental disorders. An unexpected result relates to the significant decrease in the identification of mental retardation as a mental disorder. This result shows the complexity related to this issue and highlights the need for a different approach when discussing this disorder during the intervention. Regarding First Aid skills and help-seeking, results showed a significant increase, from preto post- intervention, particularly in items presenting lower levels at pre-intervention. Finally, regarding self-help strategies, even though results at pre-intervention were already high, participants showed a significant increase in this dimension. Although the intervention showed itself to be adequate to reach the purposed goals, improvements will be made and contextual specificities will be taken into account, such as the socio-economic background of students. In conclusion, the present study showed the key importance of conducting a pilot study with the target groups when developing an intervention tailored to increase mental health literacy in young people (Campos, 2013). Acknowledgment The authors would like to thank the support from Ana Duarte (research assistant), Elisa Veiga (research team member) and the school where data collection took place – its board, teachers, and students. References Addington, D., Berzins, S. and Yeo, M. (2012). Psychosis literacy in a Canadian health region: results from a general population sample. Canadian Journal of Psychiatry, 57(6), pp.381-388. Bourget Management Consulting for the Canadian Alliance on Mental Illness and Mental Health (2007). Mental Health Literacy: A Review of the Literature. [Online] Available from: [Accessed 14 January 2014]

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Campos, L. (2013). Commentary on the paper, ‘Evaluation of a campaign to improve awareness and attitudes of young people towards mental health issues’ (Livingston et al., 2013). Education and Health, 31(1), pp.45-50. Available from: [Accessed 14 January 2014] Campos, L., Losada, A., Pinho, S., Duarte, A., Palha, F., Dias, P. and Veiga. (2013). Mental Health Literacy in students from public & private schools: Preliminary results from Finding Space to Mental Health. Atención Primaria, 45, p.164. Campos, L. and Dias, P. Development and psychometric properties of a new questionnaire for assessing Mental Health Literacy in adolescents (in prep). Campos, L., Palha, F., Dias, P., Lima, V. S., Veiga, E., Costa. N. and Duarte, A (2012). Mental health awareness intervention in schools. Journal of Human Growth and Development, 22(2), pp.259-266. Campos, L., Palha, F., Sousa Lima, V., Dias, P., Duarte, A. and Veiga, E. School-based interventions to promote mental health literacy in Portugal. In Innovative practices and interventions for children and adolescents with various disorders/disabilities (in press). Corrigan, P. and Watson, A. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), pp.16-20. European Parliament (2012). Mental health in times of economic crisis. Workshop conducted on European Parliament, Brussels, Belgium. [Online] Available from: [Accessed 14 January 2014] Farrer, L., Leach, L., Griffiths, K., Christensen, H. and Jorm, A. (2008). Age differences in Mental Health Literacy. BioMed Central Public Health, 8(125), pp.1-8. DOI: 10.1186/1471-24588-125 Jorm, A. (2012). Mental Health Literacy: empowering the community to take action for action for better mental health. American Psychologist, 67(3), pp.231-243. DOI:10.1037/a0025957 Jorm, A., Korten, A., Jacomb, P., Christensen, H., Rodgers, B. and Pollit, P. (1997). Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166(4), pp.182-186. Kelly, C., Jorm, A. and Wright, A. (2007). Improving mental health literacy as a strategy to facilitate early intervention for mental disorders. Medical Journal of Australia, 187(7), pp.S26S30. Livingstone, J., Tugwell, A., Kork-Uzan, K., Cianfrone, M. and Coniglo, C. (2013). Evaluation of a campaign to improve awareness and attitudes of young people towards mental health issues. Social Psychiatry and Psychiatric Epidemiology, 48(6), pp.965-973. DOI: 10.1007/s00127-012-0617-3 Loureiro, L, Jorm, A., Mendes, A., Santos, J., Ferreira, R. and Pedreiro, A. (2013). Mental health literacy about depression: a survey of Portuguese youth. BioMed Central Psychiatry, 13 (129), pp. 1-8. DOI: 10.1186/1471-244X-13-129 Patel, V., Flisher, A., Hetrick, S. and McGorry, P. (2007). Mental health of young people: a global public-health challenge. Lancet, 369, pp. 1302-1313. DOI:10.1016/S0140- 6736(07)60368-7 Pinfold, V., Stuart, H., Thornicroft, G. and Arboleda-Florez, J. (2005). Working with young people: the impact of mental health awareness programmes in schools in the UK and Canada. World Psychiatry, 4(1), pp. 48-52. von dem Knesebeck, O., Mnich, E., Daubmann, A., Wegscheider, K., Angermeyer, M., Lambert, M., Karow, A. and Kofahl, C. (2012). Socioeconomic status and beliefs about depression, schizophrenia and eating disorders. Social Psychiatry and Psychiatric Epidemiology, 48(5), pp. 775-782. DOI: 10.1007/s00127-012-0599-1 World Health Organization (2005). Mental health: facing the challenges, building solutions: report from the WHO European Ministerial Conference. [Online] Available from:

Vol.32 No.1, 2014 01.pdf [Accessed 14 January 2014] World Health Organization (2008). Social cohesion for mental well-being among adolescents. Copenhagen, WHO Regional Office for Europe, 2008. [Online] Available from: 21.pdf [Accessed 14 January 2014] World Health Organization (2010). Mental Health Promotion in Young People – an investment for the future. [Online] Available from: 270.pdf [Accessed 14 January 2014]

Tables 1-4 are on pages 28-29

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Table 1. Significant differences between pre-test and post-test on Knowledge’s items.

N 1. 1 in 5 people will develop a mental disorder at some point in their lives 6. A person with depression feels very sad 7. A person dependent on alcohol feels bad when not using 10. People with schizophrenia usually have delusions (i.e., may believe they are being persecuted and observed) 15. Mental disorders don’t affect people’s behavioursa 20. A person with anxiety disorder may panic in situations that she/he fears 23. Alcohol use may cause mental disorders 24. Mental disorders don’t affect people’s feelingsa 33. One of the symptoms of depression is the loss of interest or pleasure in normally enjoyable activities 34. A person with anxiety disorder avoids situations that may cause her/him distress 35. People dependent on drugs feel bad when they don´t use it 39. Drugs use may cause mental disorders 40. Mental disorders affect people’s thoughts 41. Anorexia involves great weight loss 45. A person with schizophrenia may see and/or hear things that nobody else sees/hears 48. Highly stressful situations may cause mental disorders Stereotypes1 8. People with mental disorders are less intelligentb 9. Only some people may be affected by mental disordersb 21. People with mental disorders come from families with little moneyb 26. Only adults have mental disordersb 38. Depression is not a true mental disorderb

Pre-test Mean (SD)


Post-test Mean (SD)


69 70 70 70

3.13 (0.68) 3.90(1.28) 3.95 (1.03) 3.63 (0.78)

64 64 64 64

4.78 (0.72) 4.17(1.03) 4.34 (0.78) 4.47 (0.78)

-6.45** -1.54 -2.27* -4.88**

70 70 70 70 70

4.16(0.81) 4.26(0.70) 4.06 (0.83) 4.03(1.05) 3.73 (0.99)

64 64 64 64 64

4.23(0.89) 4.38(0.75) 4.53 (0.62) 4.09(1.04) 4.30 (0.99)

-0.27 -0.88 -3.54** -0.78 -3.45**

70 70 70 70 70 70 70

3.72 (0.83) 4.29(0.76) 4.22 (0.75) 4.03(0.83) 4.61(0.73) 3.73 (1.16) 4.17 (0.68)

64 64 64 64 64 64 64

4.16 (0.74) 4.48(0.67) 4.45 (0.73) 4.08(0.97) 4.73(0.48) 4.45 (0.78) 4.42 (0.79)

-3.49** -1.57 -2.21* -0.12 0.87 -3.90** -2.40*

70 70 70 70 70

2.17(0.99) 2.23(0.90) 1.37(0.78) 1.47(0.61) 2.67(1.15)

64 64 64 64 64

1.48(0.80) 1.61(0.95) 1.33(0.59) 1.31(0.69) 1.70(1.03)

-4.52** -3.89** -0.21 -1.48 -4.65**

* p<.05 **p<.001 a reverse-coded item b item coded on its original form 1 Taking into account stereotypes as a result of misconceptions regarding to mental health issues, this analysis consider items on their original form (not recoded), whereupon higher mean values correspond to higher level of stereotypes.

Table 2. Differences between pre-test and post-test related to health problems considered, by participants, as mental health problems.

Depressive disorder Schizophrenia Anorexia Generalized anxiety Substance-related disorder Trauma Trisomy 21 (Down’s Syndrome) Mental retardation Parkinson’s disease Cerebrovascular accident Cerebral palsy *McNemar Test p≤.05

N 55 60 54 37 46 46 42 51 29 14 31

Pre % 78.6 85.7 77.1 52.9 65.7 65.7 60.0 72.9 41.4 20.0 44.3

Post N 61 55 55 53 44 35 24 21 13 10 9

% 87.1 78.6 78.6 75.7 62.9 50.0 34.3 30.0 18.6 14.4 12.9

P* <0.05 1.000 0.332 <0.001 0.839 0.286 <0.05 <0.001 <0.05 0.581 <0.001

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Table 3. Significant differences between pre-test and post-test on First Aid skills and help seeking section items.

4. If a friend of mine developed a mental disorder, I would offer her/him support 12. If I had a mental disorder I would seek for help from my family 14. If a friend of mine developed a mental disorder, I would encourage her/him to look for a psychologist 17. If a friend of mine developed a mental disorder, I would talk to her/his parents 19. If I had a mental disorder I would seek for professional help (psychologist and/or psychiatrist) 22. If a friend of mine developed a mental disorder, I would listen to her/him without judging or criticizing 29. If a friend of mine developed a mental disorder, I would encourage her/him to get medical support 31. If I had a mental disorder I would seek for help from my friends 36. If a friend of mine developed a mental disorder, I wouldnâ&#x20AC;&#x2122;t be able to help her/him a 43. If a friend of mine developed a mental disorder, I would talk to the form teacher or other teacher

Pre-test N Mean (SD) 63 4.52(0.69) 68 4.46(0.87) 70 4.29(0.85) 64 3.78(1.08) 70 4.30(0.81) 63 4.16(0.99) 70 4.24(0.77) 70 4.13(0.96) 64 4.08(1.10) 64 3.75(1.07)

Post-test N Mean (SD) 63 4.78(0.66) 64 4.44(0.94) 64 4.48(0.69) 64 4.17(1.08) 64 4.28(0.86) 63 4.56(0.67) 64 4.38(0.79) 64 4.30(0.85) 64 4.39(1.03) 64 4.33(0.86)

Z -2.81* -0.56 -1.47 -2.45* -0.17 -3.03* -1.38 -1.54 -2.10* -4.20**

* p<.05 **p<.001 a reverse-coded item

Table 4. Significant differences between pre-test and post-test on Self-help strategiesâ&#x20AC;&#x2122; items.

N 5. Physical exercise helps to improve mental health. 18. Good sleep helps to improve mental health. 25. The sooner mental disorders are identified and treated, the better. 32. Having a balanced diet helps to improve mental health. 44. Doing something one enjoys helps to improve mental health. 46. Talking over problems with someone helps to improve mental health.

70 70 70 70 70 69

Pre-test Mean (SD) 4.20 (0.94) 4.39 (0.64) 4.43 (0.79) 3.91 (1.00) 4.24 (0.73) 4.17 (0.77)

N 64 64 64 64 64 64

Post-test Mean (SD) 4.83 (0.52) 4.70 (0.53) 4.63(0.58) 4.61 (0.70) 4.66 (0.67) 4.52 (0.69)

Z -4.07** -3.47** -1.35 -4.69** -3.34** -2.84*

* p<.05 **p<.001

Education and Health The journal, published by SHEU since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readership is worldwide and in the UK include: primary; secondary and further education teachers; university staff and healthcare professionals working in education and health settings. The journal is online and open access, continues the proud tradition of independent publishing and offers an eclectic mix of articles.

Contributors (see a recent list) - Do you have up to 3000 words about a relevant issue that you would like to see published? Please contact the Editor

30 Education and Health

Vol.32 No.1, 2014

Paula Lavis is the Coalition Co-ordinator Policy and Campaigns, Children and Young People’s Mental Health Coalition. For communication, please email:

Paula Lavis Resilience and Results: How Promoting Children’s Emotional and Mental Wellbeing Helps Improve Attainment


his article looks at why children and young people’s1 mental health and emotional wellbeing is such an issue and why it is essential that they receive appropriate support when problems first emerge. In particular it will focus on the Children & Young People’s Mental Health Coalition’s work connected to schools. The Children & Young People’s Mental Health Coalition (Coalition2) brings together 14 leading children’s and mental health charities to campaign with and on behalf of young people in relation to their mental health and wellbeing. We have a shared vision of a nation where mental health is prioritised, positive mental health is promoted and early intervention practices are in place to secure mentally healthier futures for children and young people. Our priority areas include promoting early intervention and ensuring that support is easily accessible for young people when mental health problems first emerge; and ensuring that everyone working with young people receives appropriate training about mental health and child development. With this in mind, the Coalition has been working to help schools understand the importance of mental health and how to support their students.

What is Mental Health? People often confuse the term ‘mental’ with mental health problems. The World Health Organisation (WHO) defines mental health as being ‘a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (WHO.

2011). This definition illustrates that mental health is a positive term and a key component of health and is similar to other terms, such as, emotional wellbeing and psychological wellbeing. Mental health problems refer to a wide range of difficulties, which vary in their persistence and severity. Mild problems are at one end of the spectrum and severe mental illness at the other.

Risk and Protective Factors for Mental Health It is well-established that children and young people who experience certain risk factors are at a greater risk of developing mental health problems. These risk factors can be within the child, within the family and within their environment (Department of Health, 2008). The more risk factors experienced, the greater the chance they will develop mental health problems. Research has found that 28% of young children are growing up in households with more than one risk factor, and with some experiencing five or more risk factors (Sabates and Dex, 2013). Outcomes for cognitive, emotional and conduct development and hyperactivity were all worse for children exposed to multiple risks by age five (Sabates and Dex, 2013). Conversely, there are well known protective factors, which help build resilience in the child and reduce the risk of mental health problems developing. These factors include: having higher levels of self-esteem, being securely attached to a main carer, having a good support network, having a good relationship with your

The term young people will be used throughout this article to refer to both children and young people. Coalition is used throughout this article to refer to the Children and Young People’s Mental Health Coalition, and doesn’t refer to the Coalition Government.

1 2

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parents, good housing and having access to schools with strong academic and non-academic opportunities (Department of Health, 2008). This is why early intervention is so crucial, both in terms of working to reduce the impact of risk factors and helping the child be more resilient and able to cope with the difficulties they may face.

Why Young People’s Mental Health is an Issue One in 10 young people are known to have a mental disorder (Green et al., 2004). Mental health problems often have their roots in childhood, so tackling problems when they first emerge is both morally right and cost effective (Department of Health, 2011). Mental health problems in childhood are associated with poor outcomes in adulthood. For instance, people who had severe conduct problems in childhood were more likely to: have no educational qualifications, be economically inactive and have been arrested (Richards et al., 2009).

How Mental Health Problems Impact on Educational Attainment Mental health problems have a profound effect on the educational attainment of some young people. ● Young people with persistent conduct or emotional disorders are: o more likely to be excluded from school o more likely to be assessed as having special educational needs, and o more likely to leave school without educational qualifications (Parry-Langdon, 2008) ● Young People with emotional problems are: o much more likely to do poorly at school o they are twice as likely as other children to have marked difficulties in reading, spelling and mathematics (Green et al., 2005) ● Young people with conduct disorders and hyperkinetic disorder may be four to five times more likely to struggle to attain literacy and numeracy skills (Green et al., 2005) ● Young people with higher levels of emotional wellbeing have higher levels of academic attainment and are more engaged in school (Morrison & Vorhaus, 2012).

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Training in Mental Health and Emotional Wellbeing The Coalition is concerned that most teachers have no or little training in mental health and emotional wellbeing, and child development. This is a big issue given the prevalence of mental health problems and the impact mental health difficulties have on the child and the rest of the school, including the teachers. While we know that many schools really do understand the importance of promoting children and young people’s mental health and emotional wellbeing, and see it as their business, others do not. Anecdotally, we have heard that schools are not always good at engaging with their pupils’ mental health. To support this finding, a recent study found that a problematic pupil-teacher relationship significantly increased the odds of a child having a psychiatric disorder or conduct disorder (Lang et al., 2013). While not causal, there is a clear association between developing a psychiatric condition and a poor pupil-teacher relationship. In another study concerning eating disorders, 16% of young people said that staff had little or no knowledge about eating disorders (Knightsmith et al., 2013). Worryingly only 1 in 10 young people thought that their school would provide a supportive environment for someone recovering from an eating disorder (Knightsmith et al., 2013). This lack of training is not just the responsibility of schools. It is something that the Government needs to address through teacher training. Hopefully the MindEd e-portal (2013), which the Government are funding, will help provide school staff with some knowledge about mental health. This portal will provide free online education to help adults to identify and understand children and young people with mental health issues. The National Association of Independent Schools and NonMaintained Special Schools (NASS) (2012) have also produced an eLearning training resource, which is called Making Sense of Mental Health. This training pack is aimed at staff working in schools with children and young people who have complex Special Educational Needs (SEN). Schools can help by encouraging their staff to complete this on-line training or to ensure that

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they develop their knowledge of mental health in other ways. Ensuring that school staff have training in mental health and emotional wellbeing is important in light of the SEN reforms. Government have proposed in the SEN Code of Practice that the Behaviour, Emotional and Social Difficulties (BESD) category be revised and renamed as Social, Mental and Emotional Health (Department for Education, 2013). Schools will need to be able to identify emerging mental health problems. So additional training in mental health will be essential if school staff are to be able to do this.

Helping Schools promote their Pupil’s Mental Health and Emotional Wellbeing Schools have a responsibility to look after and nurture their pupils. There is some research that shows that young people would rather speak to their teacher about their problems, than go to their GP or a mental health professional (Right Here Brighton and Hove, 2012; Green, et al., 2004). School staff are in a good position to help reduce the stigma around mental health, identify emerging mental health difficulties and work with local statutory and voluntary sector providers to help ensure that young people access specialist support when they need it. There are lots of things that schools can do to help support young people’s mental health, and for that reason the Coalition (2012) have produced a guidance document for schools called Resilience and Results. This document aims to encourage schools to think about how they can promote mental health within their school and provide additional support for those with mental health problems. It includes case studies, which illustrate what support is available, and quotes from young people, parents, and teachers. A whole school approach to promoting mental health within schools is a way of putting in place the right systems and developing the right culture for this to be implemented. It has been shown that to achieve this head teachers and senior staff need to be effective leaders and champion mental health (Durlak and DuPre, 2008). Research has found that a lack of leadership around emotional and mental wellbeing has a detrimental impact on the implementation of this vital work (Kendall,

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et al., 2013). The study by Kendall et al. (2013) found that staff often didn’t feel they were supported by managers to participate in the mental health promotion project being implemented within their school. A school culture that doesn’t support help-seeking may discourage pupils accessing emotional support. There are opportunities to use existing lessons and other systems that already exist within the school. A good pastoral system and staff such as learning mentors, teaching assistants, higher level teaching assistants and school nurses are all important resources to draw on to help children and young people who are experiencing difficulties. PSHE lessons could potentially be used to increase young people’s knowledge of mental health and wellbeing, increase their emotional literacy and reduce stigma. The young people that Coalition members work with have all experienced mental health problems; and they told us that they didn’t learn about mental health within their PSHE lessons. Most of these young people were very frightened and distressed when they started to experience mental health difficulties, and if they had learnt about this subject at school, they said they would have felt less frightened and more empowered to help themselves. OFSTED (2013) has reported that 40% of schools’ PSHE provision required improvement or was inadequate. OFSTED (2013) also asked a panel of young people what they would like to learn about in school, but currently didn’t. Young people told them that mental health issues were at the top of their list, with: • 38% wanting to learn how to deal with bereavement • 33% wanted to know how to cope with stress • nearly a third wanted to know more about eating disorders such as anorexia Embedding mental health and emotional wellbeing education within other subjects is one additional method of ensuring young people learn about this important topic. For example, English lessons could cover literature and poetry that deals with distress; students could learn about the mind, brain, emotions and medication through science lessons; the importance of exercise and nutrition in the context of mental health could be covered in

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physical education and food technology; and pupils could be encouraged to identify and express emotions through their music, art and drama classes.

Commissioning External Support These days head teachers have more control over their own budgets, so are in a position to develop or commission services that are tailored to the needs of their school. There are a number of different types of support that the school can commission. This might be commissioning an external organisation to provide mentors, or a mindfulness course. Some schools already employ their own counsellor, or commission an agency to provide counselling. The Coalition would advocate the latter, as there are a number of safeguarding issues that need to be addressed, such as whether they are suitably qualified, how their practice is supervised and so on. While this work isn’t free, there is good evidence to show that you get a good return on your money. A cost-effectiveness analysis conducted on behalf of the Department of Heath found that every £1 spent on the prevention of conduct disorders through social and emotional based interventions in school gave a total return of nearly £84 (Knapp, et al., 2011). So in the current economic climate, investing in school based services to support children and young people’s mental health makes both financial and clinical sense. Resilience and Results from the Coalition (2012) gives schools some guidance about commissioning external services and provides links to other resources which have more of a focus on commissioning, such as the BOND Consortium (2013). The focus in Resilience and Results is on how the voluntary sector can help and, with that in mind, it includes examples of how these organisations are working to support schools. However, there will also be statutory services such as educational psychology services and possibly private sector services that will also be able to help schools support the mental health of their pupils.

How Schools are Promoting Mental Health The Coalition held a competition in 2013 to find out how their guidance, Resilience and

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Results, was being implemented in schools and to identify good practice in supporting pupil’s emotional and social development. A panel of educational and health professionals, with input from young people, picked the winners. The competition was generously funded by the Zurich Community Trust The competition winner was the Kings Hedges Educational Federation, which is a Cambridgeshire primary school and nursery for 357 pupils aged 3-11. This school impressed the judges by really putting wellbeing at the centre of their work. They have used their Pupil Premium money and other funds to help all pupils by providing universal support, and they have commissioned targeted services aimed at those who are more vulnerable. For instance, they provide lessons to help all early years’ pupils to relax; they have commissioned a counseling service called Blue Smile; and they also have the Red Hen project, which works with parents. The runner ups were the Newall Green High School, which is a mixed sex secondary school and sixth form centre in Greater Manchester; and the Epsom Downs Primary School & Children’s Centre, which is based in Surrey. A highly commended award was given to The Harbour School, a special school in Portsmouth, which adopted a collaborative approach across the school to facilitate interagency working. Further information about the winners can be found on our website - http://www.cypmhc. References BOND Consortium (2013). training_services/bond_voluntary_sector Accessed 27 January 2014. Children and Young People’s Mental Health Coalition (2012). Resilience and results: how to improve the emotional and mental wellbeing of children and young people in your school, London: Children and Young People’s Mental Health Coalition. Accessed 27 January 2014. Department for Education (2013). Draft Special Educational Needs (SEN) Code of Practice: for 0 to 25 years, London: Department for Education. uploads/system/uploads/attachment_data/file/251839/Draft_SE N_Code_of_Practice_-_statutory_guidance.pdf Accessed 27 January 2014. Department of Health (2008). Children and young people in mind: the final report of the National CAMHS Review, London: Department of Health. Accessed 27 January 2014.

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Department of Health (2011). No health without mental health, London: Department of Health. publications/the-mental-health-strategy-for-england Accessed 27 January 2014. Durlak, J. A. and DuPre, E.P. (2008). ‘Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation’, American Journal of Community Psychology, 41, pp. 327-350. Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young people in Great Britain 2004, London: Palgrave. See downloads/theme_health/GB2004.pdf Accessed 27 January 2014. Kendal, S. et al. (2013). ‘Students help seeking from pastoral care in UK high schools: a qualitative study’, Child and Adolescent Mental Health, online early. Knapp, M. et al. (2011). Mental health promotion and mental illness prevention: the economic case, London: Department of Health. uploads/attachment_data/file/215626/dh_126386.pdf Accessed 27 January 2014. Knightsmith, P. et al. (2013). ‘My teacher saved my life’ versus ‘Teachers don’t have a clue: an online survey of pupils’ experiences of eating disorders’, Child and Adolescent Mental Health, online early. Lang, I.A. et al. (2013). ‘Influence of problematic child-teacher relationships on future psychiatric disorder: population survey with 3-year follow-up’, British Journal of Psychiatry, 202, pp. 336-341. Royal College of Paediatrics and Child Health (2013). MindEd eportal, Accessed 27 January 2014. Morrison, L.M. & Vorhaus, J. (2012). The impact of pupil behaviour and wellbeing on educational outcomes, London: Department for Education.

RR253.pdf Accessed 27 January 2014. The National Association of Independent Schools and NonMaintained Special Schools (NASS) (2012). Making sense of mental health, making_sense_of_mental_health.aspx Accessed 27 January 2014. OFSTED (2013). Not yet good enough: personal, social, health and economic education in schools, London: OFSTED. Accessed 27 January 2014. Parry-Langdon, N. (eds) (2008). Three years on: survey of the development and emotional well-being of children and young people, London: Office for National Statistics. Accessed 27 January 2014. Richards, M. et al. (2009). Childhood mental health and life chances in post-war Britain, London: Sainsbury Centre for Mental Health. publications/life_chances.aspx?ID=596 Accessed 27 January 2014. Right Here Brighton and Hove (2012). Young people’s views and experiences of GP services in relation to emotional and mental health, London: Right Here. Accessed 27 January 2014. Sabates, R. & Dex, S. (2013). 'The impact of multiple risk factors on young children’s cognitive and behavioural development', Children and Society, Online Early. World Health Organisation (2011). Mental health: a state of wellbeing, mental_health/en/ Accessed 27 January 2014.


Schools and Students Health Education Unit

The specialist provider of reliable local survey data for schools and colleges and recognised nationally since 1977. "The survey reports have been used to inform commissioning at specific commissioning groups. They are also being used within our Extended Schools Clusters and to inform The Annual Public Health and the Joint Strategic Needs Assessment." Programme Manager - Young People TO SUPPORT YOUR WORK WITH YOUNG PEOPLE TRY SHEU’S FREE RESOURCES

Education and Health The journal, published by SHEU since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readership is worldwide and in the UK include: primary; secondary and further education teachers; university staff and healthcare professionals working in education and health settings. The journal is online and open access, continues the proud tradition of independent publishing and offers an eclectic mix of articles.

Contributors (see a recent list) - Do you have up to 3000 words about a relevant issue that you would like to see published? Please contact the Editor

35 Education and Health

Vol.32 No.1, 2014

Dr Michael McKay is the STAMPP Co-ordinator and Séamus Harvey is a Research Assistant with the Centre for Public Health, Liverpool John Moores University. For communication, please email:

Michael McKay and Séamus Harvey “Drink doesn’t mess with your head … you only get a hangover”: Adolescents’ views on alcohol and drugs, and implications for Education, Prevention and Intervention


ithin each of the four countries of the United Kingdom (UK) there exist different strategic approaches to the issue of alcohol and drugs. England (DH, 2007; H.M. Government, 2010) and Scotland (The Scottish Government, 2009) operate discrete alcohol and drug strategies, while Wales (The Welsh Assembly Government, 2008) and Northern Ireland (NI) (DHSSPSNI, 2006) strategically address “substances” collectively. Historically, NI operated discrete alcohol and drug strategies but, in May 2001, a Model for the Joint Implementation of the existing Drug and Alcohol Strategies (or Joint Implementation Model (JIM)), was adopted. Due to a failure to achieve core alcohol objectives (Parker, 2005), the JIM was replaced by the New Strategic Direction for Alcohol and Drugs (NSD) (DHSSPSNI, 2006) in 2006, which included among its long-term aims an aspiration to “increase awareness on all aspects of alcohol and drug-related harm in all settings and for all age groups” (p.17) and the promotion of opportunities “for those under the age of 18 years to develop appropriate skills, attitudes and behaviours to enable them to resist societal pressures to drink alcohol and/or use illicit drugs …” (p.17). A revised version of this strategy, the New Strategic Direction for Alcohol and Drugs Phase 2 (DHSSPSNI, 2011), retained these long-term aims. Prevalence surveys have consistently suggested that alcohol consumption among 1516 year olds in the UK is among the highest in the European Union (EU) (Hibell et al., 2009). Furthermore, while alcohol consumption may

be decreasing in some EU countries, the UK is an exception (Eisenberg-Stangl & Thom, 2009); and compared with the UK as a whole, alcohol consumption has increased since 1986 to a greater degree in NI (Smith & Foxcroft, 2009). This is largely due to an increase in consumption by 15-16 year olds through to people in their mid-20s. On the other hand, frequent and problematic drug consumption is less prevalent in the UK than in other EU countries (Hibell et al., 2009). Compared to other countries, cannabis use has fallen since 1995; with lifetime ecstasy use and the simultaneous use of alcohol and tranquilisers or sedative drugs also decreased (Hibell et al., 2009). Although the use of alcohol and controlled drugs by young people may share common antecedent risk factors (e.g. Donovan, 2004; Cleveland et al., 2008), findings suggest that use among 15-16 year olds in the UK follows different behavioural patterns. Whereas alcohol use is widespread, the use of controlled drugs remains relatively low. Given the co-existing realities of different prevalence rates and the joint strategic approach in NI, a series of focus groups were conducted in order to explore whether 15- and 16-year olds viewed the use of alcohol and drugs as similar or unrelated phenomena or behaviours. The data collected would help to inform the content of future alcohol interventions and education and facilitate an assessment of whether a joint strategy rather than a discrete strategy in terms of alcohol and drugs best serves the health interests of adolescent drinkers and/or drug users.

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Method Participants 24 focus groups were held in May and June 2008 in 24 post-primary schools in the greater Belfast area. A total of 216 young people from year 11 (age 15/16) participated, with a mean of 9 participants in each group (maximum 11, minimum 6). Procedure All participants gave informed consent to participate. The focus groups lasted between 50 and 75 minutes, depending on the length and depth of participant responses. All groups were asked the same set of prompt questions, although follow-up discussion was open ended. During the current set of focus groups, one young person, often the most experienced drinker, usually took the lead in responding. The facilitators were keen to avoid a situation where the most confident member would dictate the view of the group, particularly given the range of experience with alcohol among participants, so sought individual support for or challenge of this lead position from other members. The discussions were free-flowing, needed little facilitator intervention beyond the opening discussion or statement and involved a good degree of debate and at times differences of opinion. Detailed notes were taken by two researchers present at all focus groups.

Data Analysis The responses to individual questions were grouped and thematically analysed in order to identify and code recurring themes. The thematic approach to analysis advised by Braun and Clarke (2006) was used and the following phases were applied to data analysis: (1) familiarization with the notes, (2) generating initial codes, (3) search for themes, (4) review of themes, (5) definition and naming of themes and (6) manuscript preparation. The grouping and coding was undertaken by one of the authors and by two colleagues, one of whom was present at the focus groups and one of whom acted as a third party at the coding and whose role was to challenge any unwarranted interpretation of raw data. Within this part of the analysis, the facilitators who had been present at the groups were able to describe the

group interactions and dynamics to the third party so that while the coding identified the frequency of response types, the weight or importance of these response types were coloured by the passion or enthusiasm with which they were given in the initial group discussion.

Results Alcohol and Drugs… are they the same or different? Groups were asked to consider the differences between alcohol and drugs in general terms with subsequent specific prompts on whether or not both behaviours were “wrong” or involved “risk-taking”. The majority of groups rejected the idea that drugs and alcohol were the same for three main reasons. Firstly, discussion focussed on the “more damaging and dangerous” pharmacological effects of drugs compared to alcohol; for example, “Alcohol makes people more aggressive but drugs are more harmful” or “Drink doesn’t mess with your head … you only get a hangover”. One aspect of this was the onset of action of drugs compared with alcohol, and also the fact that participants believed that drugs can kill first-time users while alcohol is unlikely to. However, the more powerful and immediate effects of drugs were not always considered negative. Some argued that the more rapid effects of drugs could be positive (for example, with respect to anxiolysis) while the effects of alcohol could often be more negative (i.e. aggressive behaviour). The second issue centred on the cultural and social acceptability of alcohol compared to drugs. It was argued that because so many people drink alcohol and because it is so widely available that it is not really seen as a serious issue. On the other hand, fewer people in wider society would consider drugs to be acceptable or safe: “The effects are different … drugs are like taboo … alcohol is everywhere and is not as harmful … alcohol is more sociable, parents do it … people of all ages do it” (Boy). The legal status of drugs and alcohol was the third main issue. Participants believed that

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“alcohol is legal and drugs are not” and cited this as a reason for viewing and treating them differently. Additionally respondents argued that “there is a safe limit” for alcohol, you “get in more trouble” if you get caught with drugs, alcohol is “easier to access”, and you can “control yourself better” when consuming alcohol. In a small number of cases, respondents argued that alcohol may be as or more dangerous than drugs from a health point of view: “I don’t understand why drinking is legal and drugs are not … people don’t know what they are doing when they are drinking” (Boy). Consuming Drugs and Alcohol “safely” The majority of young people believed that it was acceptable for young people to drink as long as they did it ‘safely’. However, drugs were viewed as unsafe because they can damage the body even when taken in small quantities, first-time use can lead to death, different people react to the same drug in different ways, drugs are normally impure and contain unknown additives, and drug use can quickly lead to addiction. “There is no such thing as ‘safely’ when you are talking about drugs” (Boy). A small minority of participants argued that it was okay to take drugs if they were taken ‘safely’ and even among individuals who at first claimed that it could never be done safely, they suggested techniques or methods which, in their opinion, would serve to reduce harm. These included using drugs indoors, using drugs from a known dealer or supply route, using drugs supplied by a doctor, making sure that somebody knows what you are doing when using drugs, making sure that somebody else is not using and can help if necessary, not using drugs at parties where you do not know the people very well, not using dangerous drugs, not using a mix of different types of drugs, not using too much at any one time, and only using enough to make you “happy”. Drug and Alcohol Education in School Both drug and alcohol education in schools received negative appraisals. Drug education

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was described as “boring”, “stuff that we already know”, “not relevant to everyone” and it “makes some people feel uncomfortable”; while alcohol education was viewed as “repetitive” and “overly factual”. The majority of young people reported that they would like to learn more about alcohol and drugs in a “realistic” and non-patronising way which was “relevant to them”. They would like to learn about the effects and consequences of alcohol and drug use and the real-life experiences of people. Furthermore, they indicated a desire to learn how to recognise if someone has been using drugs, and what different drugs look like and the differences between them. Taught by teachers? A small minority of participants said that they would prefer to have drug education delivered by teachers with whom there is an existing “good relationship” and because there “could be continuity [of message with on-going contact]” or because “some outsiders use videos [and resources] that are really cheesy [old fashioned and simplistic]”. However, the majority of participants indicated that they would prefer to receive alcohol and drug education from external facilitators. It was believed that in comparison to teachers who have “little knowledge about the subject”, external facilitators would have greater expertise and would relate to the pupils in a more informed “on their level” way. Participants believed that some teachers would be “boring” and for some, if certain teachers were to teach alcohol and drug education, that in itself would be an obstacle to learning. Issues such as “not liking a particular teacher” and “teachers having a biased opinion” were cited as particular obstacles. Participants feared that teachers would breach confidentiality and discuss or pass on disclosed information to other teachers, year heads or parents. They also feared that if they disclosed the true extent of their alcohol use, they would be judged by their teachers. External facilitators were viewed with less distrust and as people with whom it would be possible to have an open discussion; anonymity would allow young people to be open and honest; and they would be less likely to judge

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students because of the short period of contact.

Discussion The focus group discussions demonstrated that the majority of participants view alcohol and drug use as distinct behaviours, with drug use considered more pharmacologically dangerous and less culturally and socially acceptable than alcohol use, with both considered very differently from a legal point of view. The majority of participants also believed that it is acceptable for young people to drink alcohol as long as they do it safely whereas any drug use was not considered safe. Despite stating reasons as to why drug-taking could never be considered safe, many participants were aware of harm reduction methods. In this sample of 15- to 16- year olds, there was informed discussion about the effects of alcohol, cannabis and sedative hypnotic medicines, but prejudiced speculation about the effects of other illicit drugs. There was a lack of consistency in the views presented and principally this would appear to result from a relative lack of experience of the effects of these drugs compared with alcohol. Equally worrying from a public health perspective was that participants’ discussion comparing drugs and alcohol was a simplistic one, generally lacking discrimination of types, quantities or drug purity and strengths of alcoholic drinks. The participants’ conversations suggested that it would be important for them to understand that all drugs have both acute and long-term effects, regardless of legal status or social and cultural acceptability. It is critical that those in health promotion try to engage young people honestly and meaningfully so that when faced with the decision about whether or not to use alcohol or drugs, their decisions are based on accurate information rather than speculation. Furthermore, because inaccurate knowledge and understanding of alcohol and drugs is apparent among students, educationalists should obtain an understanding of pupils’ views and attitudes toward alcohol and drugs even before the educational phase commences; this would also correspond with good practice recommendations that such education should be developmentally appropriate (AGDAE, 2008). Participants articulated concerns with drug

education in school, labelling what they currently receive as boring, patronising and lacking in real-world credibility. Of particular concern to educators might be the disparity between what young people are told by teachers and what they observe or hear from their friends. Teachers might want to consider the dangers inherent in risk amplification of abstinence-focussed education particularly if, as desired by the participants, alcohol and drug education is to be more credibly, maturely and honestly delivered. Participants indicated a desire to learn about alcohol and drugs in a way that was realistic, relevant and considered the consequences and real-life experiences of people. In relation to the participants wanting “real-life” educators (i.e. drug dependent individuals); schools might consider this carefully as there is likely to be a lack of concordance with the typical ex-user story and young people’s own experiences. The majority of students indicated a preference for alcohol and drug education to be delivered by outside facilitators rather than school teachers. While this is most likely unfeasible, school-based educators need to be aware of the need to present the issues in a mature and transparent fashion; otherwise young people cannot be expected to engage optimally.

Conclusion Young people in these groups did view alcohol and drugs differently. However, in an economic climate where services will be increasingly asked to do more for less money, a bilateral approach to universal prevention for alcohol and drugs seems difficult to justify. However, given the prevalence data suggesting that many 15- to 16-year olds drink to intoxication, yet fewer use drugs, and the data herein which suggest that drug awareness is often immature and illogical, public health might be better served by treating them as discrete issues. There are arguably two discrete target groups depending on whether or not one is discussing drugs or alcohol. For alcohol the ‘potentially vulnerable’ group are the majority of young people, who are exposed to harm resulting from their own or others’ drinking. Thus, specific harm reduction initiatives delivered on a population level appear

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warranted. For drugs, the vulnerable population are smaller in number, but the discussions in this paper suggest that a general naivety among the adolescent population regarding drugs and drug use, calls for a general review of drug education content and specific drug-harm education messages for the fewer who are at most risk. Above all there would appear to be the danger that strategically addressing alcohol and drugs jointly in an environment where their prevalence is so different, might lead the many drinkers to view it naively and simplistically (as they did generally with drugs) and/or to minimise the dangers of drugs as a result of the relative infrequency of adverse alcohol-related events. References Advisory Group on Drug and Alcohol Education (AGDAE), (2008). Drug Education: An entitlement for all, [Online], Available: s:// e11/DCSF-00876-2008 Accessed 12 February 2014. Braun, V. & Clarke, V. (2006). ‘Using thematic analysis in psychology’. Qualitative Research in Psychology, 3, 77–101. Cleveland, M.J., Feinberg, M.E., Bontempo, D.E. & Greenberg, M.T. (2008). ‘The Role of Risk and Protective Factors in Substance Use Across Adolescence’, Journal of Adolescent Health, vol. 43, no. 2, August, pp. 157-164. Department of Health/Home Office, (2007). Safe. Sensible. Social. The next steps in the National Alcohol Strategy, London: Home Office.

Department for Health, Social Services and Public Safety (Northern Ireland), (2006). New Strategic Direction for Alcohol and Drugs 2006 – 2011, Belfast: DHSSPSNI. Department for Health, Social Services and Public Safety (Northern Ireland), (2011). New Strategic Direction for Alcohol and Drugs Phase 2 (2011-2016) – A Framework for Reducing Alcohol and Drug Related Harm in Northern Ireland, Belfast: DHSSPSNI. Donovan, J. (2004). Adolescent Alcohol Initiation: A Review of Psychosocial Risk Factors. Journal of Adolescent Health, 35, 6, 529 e7-18. Eisenberg-Stengl, I. & Thom, B. (2009). Intoxication and intoxicated behaviour in contemporary European cultures: myths, realities and the implications for policy, (prevention) practice and research, Vienna: European Centre for Social Welfare Policy and Research. H.M. Government, (2010). Drug Strategy 2010, Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life, London: The Home Office. Hibell, B., Guttormsson, U., Ahlström, S., Balakireva, O., Bjarnason, T., Kokkevi, A. & Kraus, L. (2009). The 2007 ESPAD Report - Substance Use Among Students in 35 European Countries, Stockholm: The Swedish Council for Information on Alcohol and Other Drugs (CAN). Parker, H. (2005). Better Managing Northern Irelands’ Alcohol and Drug problems: A Review of the Northern Ireland Alcohol and Drug Strategies and the Efficiency and Effectiveness of their Implementation, [Online], Available: Accessed 12 February 2014. Smith, L., & Foxcroft, D. (2009). Drinking in the UK: An exploration of trends, York: Joseph Rowntree Foundation. [Online] Available: Accessed 12 February 2014. The Scottish Government, (2009). Changing Scotland’s Relationship with Alcohol: A Framework for Action, Edinburgh: Scottish Government. The Welsh Assembly Government. (2008). Working Together to Reduce Harm: The Substance Misuse Strategy for Wales 20082018. Cardiff: Welsh Assembly.

Education and Health The journal, published by SHEU since 1983, is aimed at those involved with education and health who are concerned with the health and wellbeing of young people. Readership is worldwide and in the UK include: primary; secondary and further education teachers; university staff and healthcare professionals working in education and health settings. The journal is online and open access, continues the proud tradition of independent publishing and offers an eclectic mix of articles.

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Education and Health Journal 32:1, 2014  
Education and Health Journal 32:1, 2014  

Open access journal for those concerned with the health and wellbeing of young people.