25 years’ learning from practice and evaluation

Place2Be – 25 years learning from practice and learning

Place2Be – 25 years’ learning from practice and evaluation May 2021 Catherine Roche, Chief Executive Sarah Golden, Head of Evaluation Liz Greetham, Trustee & member of Research Advisory Group

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In the early 1990s, ‘mental health’ was a phrase shrouded in stigma and certainly in the mainstream media, and never used in association with children.

In 1994, Benita Refson founded Place2Be – bringing together the worlds of professional mental health support embedded in the everyday environment of school – designed to support children in a place where they spend a significant proportion of their daily lives, and without stigma.

A crucial and unwavering principle set out at the time was that Place2Be would collect data and evaluate what we delivered so that continual development and refinement of the service would be based on learning from our practice at the heart of schools alongside insights from wider research.

Over the following 10 to 15 years, Place2Be developed and enhanced the services offered in schools to build out into what is now more commonly understood today as ‘the whole school approach’. This comprises: • Promotion of positive mental health and wellbeing across the whole school, embedded in all aspects of school life (Psycho-educational whole class work) • A self-referral brief solution-focused service available and accessible to all children in the school (Place2Talk) • Targeted support via 1:1 counselling and structured group work for children with emotional or peer difficulties, attachment difficulties or experience of trauma • Support, input, consultation and advice for school staff (Place2Think) • Support, consultation and advice for parents (Parent Partnership) along with parenting skills • Engagement, connection and referral to specialist services, such as CAMHS (part of the joined-up continuum of care and support for children with mental health needs) • Having a mental health professional, who can bring an alternative professional insight and perspective, embedded in the school community.

In addition, back in 1997, we recognised that with a dearth of training for professionals providing mental health support for children (who often communicate in a very different way to adults, namely through play) that training would be required for the professionals to provide support for children in the schools. So, the format of providing a placement for clinicians was developed, with a safe supervisory structure along with specialist training in working therapeutically with children. Over time, Place2Be expanded and refined this to develop a range of accredited training programmes from Taster Day to Postgraduate

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Diploma and Masters, specialised in working with children. Key to this was training individuals in the community, local to schools, thus seeking to make both the training and placement accessible to a wide and diverse community and workforce.

“Place2Be helped me talk about my family member who died, and I don’t feel as sad as I poured my worries out. I can even sleep in the dark by myself now without a light. I used to get really scared but I don’t now.”

Eight-year-old girl

In 1999, the ONS carried out the first national study on the mental health of young people in the UK. The results highlighted the key public health significance of mental health problems for children and young people, showing that almost one in ten 5-15 year olds were assessed as having a clinically diagnosable mental disorder. A second national study was conducted in 2004 and confirmed the findings and prevalence.

Balancing the challenge of being a service provider in a very real, ‘messy’ and busy world in schools (as opposed to a research trial), over time the whole organisation - and crucially, frontline staff - began to understand the significance of data collection as an important tool and part of clinical work (rather than ‘paperwork’). In general, pre- and post- data collection in children’s mental health service delivery, at 25-30%, is poor.1 Place2Be now has between 63% and 86% pre- and postpaired collection from parents, teachers and young people2 and is aiming for 95% plus return. We know this is crucial for reliability of the data and findings.

The data we gather relate to the child, school and geographic area. They are analysed in-house with external scrutiny 1 Child Outcomes Research Consortium (2020) and Pla-

ce2Be 2019 Service Report: https://www.place2be.org. uk/media/8d89618b4b1a3c4/place2be-2019-service-report.pdf

2 Place2Be 18/19 Primary (paired results): 86% teacher SDQ, 63% parent SDQ. Place2Be 18/19 secondary (paired results) 66% teacher SDQ, 44% parent SDQ, 66% YP SDQ

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and validation by a Research Advisory Group made up of high-calibre independent experts, including our Research Chair, Professor Tamsin Ford from the University of Cambridge Department of Psychiatry. Over time, with an increasingly ‘clean’, consistent and growing data set, we began to delve into it and, with greater confidence, use it as a tool to better understand the different mental health problems that children present.

We began to try to link mental health and education data sets along with socioeconomic profiles using quasi comparator groups. We continue to seek to draw out a profile of children and their needs and the most effective intervention and means to meet those needs.

For targeted 1:1 counselling, results showed that: • The most common mental health problems in primary school children entering counselling are: generalised anxiety (73%), attention difficulties (71%) and low selfesteem (71%)3. There are differences in age and in gender. Girls were more likely to present issues with anxiety and family tensions. Boys had more ratings of severe mental health issues and were more likely to present issues with attention, mood swings, emotional behaviour, impulsivity, anger, callous behaviour and self-destructive thoughts or acts.

• Parents and teachers tend to see things differently and identify different types of need.

Parents are more likely to identify emotional issues while teachers are more likely to identify behaviour and hyperactivity. And while around a third of parents identify no difficulties for their child, and a similar proportion of children are recorded by teachers as having no identified difficulties, looked at together, only 10% of children had no identified difficulties according to both parents and teachers. Moreover, among this group, many had severe needs of one type such as emotional difficulties4.

• Year on year, we consistently find that around two-thirds of children have improved mental health after counselling according to teachers and a higher proportion of nearly three-quarters according to parents.

• 20-30% of children did not respond to counselling, and from the teacher perspective, the indicator of challenging behaviour changes the least5. Where we used a structured parenting intervention alongside 1:1 counselling, the average improvement was at least twice that of the parenting intervention group alone on both Conduct and Total Difficulties6.

3 Toth, K., Samad, L., Golden, S., Johnston, P., Hayes, R., & Ford, T. (2020). What issues bring primary school children to counselling? A service evaluation of presenting issues across 291 schools working with Place2Be. Counselling and Psychotherapy Research, 20(4), 571-579. https://onlinelibrary.wiley.com/doi/abs/10.1002/capr.12333 & https://www.nationalelfservice.net/populations-and-settings/schools/primary-school-counselling/ 4 White, J. (December 2018). Working with children and young people with ‘no difficulties’: Pathway pilot final report. Paper to Research Advisory Group.

5 Toth, K. (June 2017). Children with severe conduct issues. Paper to Research Advisory Group.

6 White, J. (October 2018). How can Place2Be best support parents with Parenting? An evaluation of Triple P Primary Care 1 year pilot. Paper to Research Advisory Group. Conduct: (2.8 average points improved compared to 1.0 for all 1:1 in 17/18), (8.4 average points improved compared to 4.3 for all 1:1 in 17/18)

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• Analysis of the duration of treatment showed that, typically, primary-aged pupils were provided with, on average, 22 sessions in the academic year. Further studies showed that children generally responded most within the first 10 sessions and, while they continued to progress in subsequent sessions, it was at a lower rate.

“Its absolute commitment to both gathering data, and analysing data is what sets Place2Be apart from most other organisations providing similar services.”

David Trickey, Consultant Clinical Psychologist, Anna Freud National Centre for Children and Families

A longitudinal follow-up study one year post treatment showed that improvement was generally maintained with 82% of children maintaining no or moderate difficulties one year on. When this was compared with a sample of children with similar characteristics who did not receive Place2Be’s input, there was more improvement in the children receiving Place2Be support than those who had not. A statistical model that predicted SDQ scores revealed that, for two years after the baseline measure, the scores for those who had received Place2Be support were lower, indicating better mental health, than those in the comparison group. This indicates that the outcomes from counselling are sustained, on average, and that the children who had counselling maintain better mental health than their similar peers who did not receive this support.7 We explored the impact on children’s engagement with learning and academic progress with findings indicating that Place2Be’s targeted mental health support is helping to stop the further widening of the education gap between those experiencing poor mental health and their peers: • Three-quarters of the children and young people who had been excluded from school for a fixed term before they had counselling, experienced fewer fixed term exclusions in the year they had counselling;

7 Finning, K., White, J., Toth, K., Golden, S., Melendez-Torres, G. J., & Ford, T. (2021). Longer-term effects of school-based counselling in UK primary schools. European child & adolescent psychiatry, 1-9 https://doi. org/10.1007/s00787-021-01802-w

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• Children’s engagement in learning improves, as indicated by improved outcomes across three measures reported by teachers: impact of children’s difficulties on their learning; attitude towards learning; and self-regulation/independent learning8 • Using a matched sample from DfE’s National Pupil Database demonstrated that children who had 1:1 counselling appeared to keep pace with their peers academically, showing that the possible negative impact of mental health difficulties on their academic progress was mitigated.

We explored service accessibility in relation to ethnicity. Generally, based on our partner school community make-up, Place2Be is working with a much more diverse population in comparison to the wider population in England and Wales (2011 Census). Black/Black British children and young people and those of mixed ethnicity or from ‘other’ ethnic groupings access both targeted and universal services within Place2Be schools in line with their make-up in the school community - demonstrating the lack of stigma or barriers to engagement when a service is embedded as part of daily school life. White British children are over-represented while Asian and Asian British children are under-represented in both targeted and universal service access. White Irish and ‘other white’ children access the universal Place2Talk service in a representative way, but are under-represented in targeted support. There is more to learn about the drivers here.

We examined the role of the drop-in service available to all children in a school as part of a ‘whole school approach’. Such a service is well-used (on average by a third of a primary school population and circa 10% of a larger secondary school in any one year). Emotional issues such as sadness and worry are the predominant reasons children and young people access the brief solution-focused service. When the therapist is male, there tends to be a greater take-up from boys – highlighting the importance of positive male role-models and attracting more men into a traditionally female-dominated workforce.

We examined the relationship between the use of the drop-in service and a child or young person’s time in targeted 1:1 counselling. We found that attending Place2Talk was a significant predictor of the number of sessions attended in 1:1 counselling (notably fewer sessions than for those who did not access the drop-in first). This may suggest that the drop-in service and role it plays as part of a ‘talking’ school culture, has a role in preparing children for their subsequent therapy, so they require fewer sessions.

We looked at the cost effectiveness of Place2Be’s services. Pro Bono Economics’ findings, using conservative assumptions, demonstrated that every £1 spent on the 1:1 counselling 8 Toth, K. (December 2018). Place2Be engagement in learning 2015-2018. Paper to Research Advisory Group. Analysis across four academic years (14/15 to 17/18) of around 1500 primary-aged children annually.

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service delivered a societal return of £6.20 in the form of higher earnings for the individual and a lower cost to the taxpayer.

This is the clear ‘business case’ for early intervention.

We sought to understand the ‘whole school impact’ – challenging with the very great number of variables and moving parts. In 2011, we undertook a study of Contextual Value Added (CVA) data that was at the time publicly available for each school and demonstrated the academic progress of the school taking into account the factors that may influence this, such as the attainment for children when they joined the school and proportion receiving free school meals. We compared the CVA scores for Key Stage 1 to Key Stage 2, in primary schools three years before they had Place2Be and three years after. This showed that the schools had progressed by half a term on average in their academic attainment after introducing Place2Be.

“I think I’m more confident now and I like to stand up in front of everyone in class and read my answer. I didn’t like doing that before”.

Ten-year-old girl

We evolved our training to assist School Leaders to understand the ‘whole school approach’, to provide a framework based on our practice in Partner Schools, and provide a guide to plan and prioritise action in their schools. Crucially this also involved recognising support they might already have in place, allowing flexibility – not a ‘one size fits all’ approach. Programme results showed that 93% were satisfied with the programme and 91% had achieved the goals that they had set for themselves (completely or partially). There was also a notable increase in School Leaders’ confidence in leading the implementation of a mental health strategy in their school (from 59% to 95%)9.

We dipped our toes into digital delivery. With support from a range of partners but especially Hive Learning, we transformed our face-to-face training for class teachers and transitioned this online – growing reach from 1200 over two and a half years to 42,000 9 Naag, N. (October 2019). Mental Health Champions School Leader outcomes. Paper to Research Advisory Group.

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class teachers in six months (almost 10% of UK teachers). Importantly, 97% would recommend Place2Be to a colleague, over 90% believe the course has helped them lead a positive approach to wellbeing and mental health in their school community, and 73% learned something that resulted in a change in their action, behaviour or attitude in the workplace.

Working with Shout, Healios, Kooth plc and Parenting Matters Online has informed and is assisting our thinking around 24/7 coverage. These platforms bolster the support offer outside of school hours. We commissioned some research via The Participation People in 2019 looking at the role of digital and face-to-face support. Young people fed back that a choice of in-person and digital interventions is important.

In 2019/20, just before the Covid-19 pandemic hit, we drew together our learning to shape our Clinical Delivery Model comprising a set of child-centric programmes, based on our data and experience over our first 25 years, seeking to further improve the life chances of children. This is set within a world where the latest studies (July 2020) show a growing deterioration of child mental health and wellbeing with one in six children and young people now having a diagnosable disorder.10 Supported by systematic training from King’s College London on Assessment and Formulation, the Clinical Delivery Model is based on a detailed analysis of the difficulties facing each child referred and appropriate clinical action. Following pilot studies, we have added new approaches to improve our effectiveness – initially Journey of Hope Groupwork and Personalised Individual Parenting Training (PIPT) for primary-aged 10 Sadler, K., Vizard, T., Ford, T., Marcheselli, F., Pearce, N., Mandalia, D., Davis, J., Brodie, E., Forbes, N., Goodman, A., Goodman, R., McManus, S. (2018). Mental health of children and young people in England, 2017: summary of key findings. Mental Health of Children and Young People in England, 2017. NHS Digital, London. https://files.digital.nhs.uk/A6/EA7D58/MHCYP%202017%20 Summary.pdf

Place2Be – 25 years' learning from practice and evaluation

“No other organisation I have worked with, or come across, in the mental health charity sector values and uses research quite like Place2Be. Research is a key component of all of Place2Be's work from strategic development, to training to policy and especially important to service delivery on the ground in schools. Supported by a dedicated research team and an external group of world-class advisers, they are not afraid to put all their practice under a research and evaluation microscope. It's not only impressive, it's crucial to being a learning organisation that cares about its impact - and I have seen first-hand the difference the research work makes to service provision on the ground. Place2Be also share its experiences and findings with the wider mental health community across the UK and internationally, to help influence policy and delivery. The number of peer reviewed journals and conference presentations made over recent years is truly impressive.

It is an honour and a privilege to be associated with Place2Be.”

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children, and a brief CBT-based model for 1:1 work with young people in secondary schools in development.

We have learned about the challenge of implementation of trials in a live service delivering on the front line in schools11 and the need for consistent focused execution in order to drive improvement and change in our practice.

There is always more to do and more to learn, and we have several issues under review: • Whole school impact evaluation • Design and execute a comparison trial • Continue to do long term follow-up • Improve data returns to 95% completion • Development of a fully seamless ‘blended’ offer of digital and in-person support to suit each school’s needs but always with child’s needs first • Refresh the design and accreditation of training curriculum to skill the child mental health workforce of the future delivered in a cost-effective blended learning format The prize is great, with the potential to double the effectiveness of our approach and make a difference for our future generations.

Gregor Henderson, Director of Mental Health, Public Health England

11 Cooper, M., Duncan, B., Golden, S., & Toth, K. (2021). Systematic client feedback in therapy for children with psychological difficulties: Pilot cluster randomised controlled trial. Counselling Psychology Quarterly, 34(1), 21-36. DOI: 10.1080/09515070.2019.1647142

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“Place2Be are impressive in the systematic way that they gather data about what they do - and reflect on it with critical friends to improve their practice and ultimately the outcomes for some of our most vulnerable children.”

Tamsin Ford, Professor of Child and Adolescent Psychiatry at the University of Cambridge

“Place2Be leads the nation in its continual drive to help children be happier and better adjusted. It evaluates its effectiveness, forever striving to include the whole population of children in need. One example is its evaluation of children with challenging behaviour. This work showed that counselling was not as effective as they would like, so Place2Be commissioned a new evidence-based parenting programme. Result: these children now do twice as well as before, and are set on a much more hopeful life path.”

Stephen Scott, Professor of Child Health and Behaviour at King’s College London’s Institute of Psychiatry, Psychology and Neuroscience.

Royal Patron HRH The Duchess Of Cambridge

place2be.org.uk

Place2Be is a charity registered in England and Wales (1040756) and Scotland (SC038649), a Company limited by guarantee registered in England and Wales (02876150), registered office: 175 St. John Street, London, England, EC1V 4LW.