Children and Young People’s Mental Health: Promoting Integration and Early Intervention

1. DISCOVER Workshop Programme
Open-access CBT group
interventions for teeangers with
anxiety and stress
Dr Irene Sclare
Consultant Clinical Pyschologist

2. Outline of Presentation
• Why did we develop the DISCOVER Workshop Programme?
• What is DISCOVER?
• Does DISCOVER Work? The Evidence Base
• Reflections from students, school staff and clinicians
• Next steps

3. The DISCOVER Team
In schools since 2012
Supported over 500 sixth form students to
date
Innovation in practice awardwinner

4. Why develop the DISCOVER
Workshop Programme?

5. Very high rates of teenage anxiety, low
mood, self harm, especially in young
women. Multiple stresses are triggers

6. What is
Stress?
What
stresses
you out?

7. Prevalence of anxiety
and depression in UK 16-18’s
• 1 in 10 young people experience a mental health disorder
(Green et al., 2005)
• Increase in prevalence of mental health problems at 16-19
(Singleton et al., 2001)
• Over half of all mental ill health starts by age 14 and 75%
develops by age 18 (Murphy and Fonagy, 2012)
• Anxiety and depression are most common mental health
difficulties and these have high co-morbidity (Green et al., 2005)
• School learning, stress tolerance, confidence, motivation,
personal relationships will be adversely affected (Layard, 2008)
• Untreated anxiety or depression can have a significant impact
on employment, income and relationship stability in adult life
(Goodman, Joyce & Smith, 2011; Green et al. 2005)

8. Very few teenagers manage to get help at
an early stage

9. Barriers to 16-18’s help seeking
• Only 10% of teenagers in need in UK access CAMHS (Pugh et
al., 2006)
• CAMHS barriers are:
• Clinic-based
• Formal referral system (via GP)
• Waiting-times
• Prioritise high risk cases
• Limited specialist therapy
• Youth barriers are:
• Emotional problems are often ‘hidden’ from adults
• Stigma and confidentiality concerns
• May feel undeserving of help
• Anxiety with accessing services – motivation, trust, fear
• Unaware of nature of problems, or where to get help
• Real life – school, coursework and social pressures

10. Being in schools can make our skills and
help more accessible to busy sixth formers

11. Bringing mental health support to
schools provides...
• Interventions to build students’ wellbeing and
resilience (Future in Mind 2015; PSHE Association, 2015; Ofsted,
2015)
• Support teachers to identify and support young
people who are under stress, or having
emotional problems
• See young people at an early stage, to prevent
problems developing.
• Offer ‘democratic’ help and support
• Use interventions that are efficient and
effective, evidence based (Fazel et al, 2014)

12. No psychological therapy programmes
existed for anxious and depressed older
teenagers, for clinic or school settings.

13. So…… we designed and evaluated a new
approach…which we named
DISCOVER: How to Manage Stress and
Worry

14. What format would work best? Ideas from
developmental neuropsychology

15. Teenagers: brain and mind
 Developing an independent identity, and
start to separate from parents
 Form deeper peer group affiliations, and
influenced by peers’ actions
 Worry grows about others’ judgments and
the way things look
 Can start seeing new perspectives
 Enjoy experimentation and new experiences
 More responsible for themselves

16. What is the DISCOVER
Programme?

17. • An ‘lean’ approach for teenagers aged 16-18 with
anxiety, low mood and self esteem problems
• Award winner ‘Innovation in Practice 2016’.
• Good evidence base for DISCOVER
• Non-stigmatising workshop approach.

18. DISCOVER ‘How to Manage Stress and
Worry’
• Low intensity intervention, suitable for school or clinic
• For up to 15 teenagers aged 15-18
• Goal based, to personalise the intervention
• Built-in evaluation of mental health, including risk
assessments, and wellbeing outcomes
• Signposting as needed.

19. Key Features of DISCOVER in Schools
CBT principles
Easy ‘sign up’
Not NHS ‘patients’
Open access
Confidential
Familiar setting
Don’t have to get
parents’ consent
Focused on real
life problems
Designed with
young people
Adapted from evidence
based community adult
workshop model (Brown et
al., 2000)
Includes individual
assessment and
telephone support

20. Techniques to:
Improve concentration
Deal with work overload
Get a better night’s sleep
Handle fears and worries
Feel less tense and panicky
And an understanding of these problems and
how to get motivated to solve them
What DISCOVER offers to students

21. 1 • School planning meeting(s)
2
• Sixth Form assembly
3
• Information meeting
4
• Individual assessment
5 • The DISCOVER Workshop
6 • Goal reviews by phone
7
• 3 month follow-up
8
• Feedback and review session with teachers
The
DISCOVER
Programme
Overview
(4 Month
Programme)

23. The DISCOVER Workshop
Topics:
- Stress Psycho-education
- CBT cycle
- Thinking styles
- How to change:
• Your thoughts
• Your behaviour
• Your body sensations
Techniques:
- Thought challenging
- Mindfulness
- Problem solving
- Time management
- Relaxation
- Sleep ‘tips’
Goal setting:
- Setting own goal
Goal review by phone the
following week
Methods:
- Interactive
- Group activities
- Individual tasks
- Film vignettes
- Discussion
+ Workbook to take home

25. Laura

26. See Dsee DISCOVER Film
on
www.slam.nhs.uk/discover

27. Does DISCOVER work?
The Evidence Base

28. RCT Team 2014-15

29. Research Design
• 10 schools in Southwark
and Lambeth
• 5 randomised to
experimental group
• 5 randomised to
delayed treatment
control group
• Follow-up at 3 months of
155 students
• Research assessors blind
to experimental condition

30. Anxiety, depression and self
esteem measures
 Mood and Feelings Questionnaire (MFQ)
(Costello & Angold, 1988)
 Revised Child Anxiety and Depression Scale (RCADS)
(Chorpita et al., 2000)
 Warwick Edinburgh Mental Well Being Scale (WEMWBS)
(Tennant et al., 2007)
 Client Satisfaction Questionnaire (CSQ8)
(Larsen et al., 1979)
 Qualitative study interviewing attendees (n=15), school staff
(n=10), non-attenders (n=9)

31. Importance of Goal Based Approach
• 75% has a goal review
• 91% were already working on their goal
• 43% opted for a second review, (with 9% opting for a third review)

32. • More young women than young men
• Over 75% had not accessed psychological support despite their
needs
• 72% of teenagers who came forward were from BAME backgrounds
• Around a third met criteria for CAMHS
Who came forward to access
DISCOVER?

33. A. Age 16.
Time 1
• Depressed and anxious, risk assessment completed at Time 1.
• Quiet, did not express distressed feelings openly, teacher suggested she
attend DISCOVER, was apprehensive
• Poor school attendance due to high levels of stress. Not completing
coursework, distracted when studying. Procrastinating, napping.
• Not accessed psychological support, family opposed
Case Example. Goal-Based
Approach

34. A’s goals

35. Results showed:
• Significant reduction in anxiety
• Significant reduction in low mood
• Significant improvement in well-being
In the experimental group compared to the
delayed treatment control group
RCT results: Impact of DISCOVER
on
Mental Health and Well-Being

36. Waitlist Control vs. Experimental
20406080
100
Waitlist control Experimental
RCADS: Total t-score
Baseline 3 months
2030405060
Waitlist control Experimental
WEMWBST
Baseline 3 months
Figure 1: RCADS Results
Figure 3: WEMWBS Results
0
1020304050
Waitlist control Experimental
MFQ
Baseline 3 months
Figure 2: MFQ Results

37. Satisfaction with DISCOVER
• 96% of students were happy with DISCOVER and would recommend it

39. Reflections from our work so far….

40. Reflections: Students
• Overwhelmingly positive about the programme
• Felt more empowered to manage stress:
 “I think it’s made me think more about where the stress
came from and that there are ways to deal with it rather
than just freaking out.”
• Valued having both individual and group input
• Importance of learning practical techniques
• Pressure of taking time off school lessons near exams

41. Reflections: Clinicians Perspectives
• Pros and cons of a manualised approach
• Measuring resilience…...how and what does DISCOVER
impact?
• Mental health school- based delivery…it’s different!
• Teacher stress and overload
• Lack of pastoral support
• Social contagion effects, good and bad!

42. Challenges of working in schools……

43. Next steps?
• Dissemination to more schools to buy in
DISCOVER
• Training others to run DISCOVER
• Delivering (and evaluating) DISCOVER to
waiting list teenagers in CAMHS
• Modifying DISCOVER for young care
leavers under stress.

44. References
 Department of Health & NHS England, (2015). Future in mind: promoting, protecting and improving our children and
young people’s mental health and wellbeing. Department of Health.
 Chorpita, B. F., Yim, L., Moffitt, C., Umemoto, L. A. & Francis, S. E. (2000). Assessment of symptoms of DSM-IV
anxiety and depression in children: a revised child anxiety and depression scale. Behav Res Ther, 38, 835-55.
 Costello, E. J., & Angold, (1988). A. Scales to assess child and adolescent depression: checklists, screens, and nets. J
Am Acad Child Adolesc Psychiatry, 27, 726-37.
 Fazel, M., Hoagwood, K., Stephan, S., & Ford, T. (2014). Mental health interventions in schools in high-income
countries. Lancet Psychiatry, 1, 377–87.
 Green H, McGinnity A, Meltzer H, Ford T, & Goodman R. (2005). Mental health of children and young people in Great
Britain, 2004. A survey carried out by the Office for National Statistics on behalf of the Department of Health and the
Scottish Executive. Basingstoke: Palgrave Macmillan
 Goodman A, Joyce R, & Smith JP. (2011). The long shadow cast by childhood physical and mental problems on adult
life. Proc Natl Acad Sci USA, 108, 6032–6037.
 Larsen, D. L., Attkisson, C. C., Hargreaves, W.A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction:
development of a general scale. Eval Program Plann, 2, 197-207.
 Layard, R., Mayraz, G. & Nickell, S. (2008). The marginal utility of income. Journal of Public Economics, 92 (8-9).
1846-1857.
 Murphy, M., & Fonagy, P. (2012). Mental health problems in children and young people. In: Annual Report of the Chief
Medical Officer 2012. London: Department of Health.
 Ofsted. (2015). Better inspection for all – a report on the responses to the consultation (No. 150006). Accessed at
https://www.gov.uk/government/consultations/better-inspection-for-all
 PSHE Association. (2015). Teacher Guidance: Preparing to teach about mental and emotional health. Public Health
England. Accessed at: https://pshe-association.org.uk/uploads/media/27/8115.pdf
 Pugh K, McHugh A, McKinstrie F. 2006. Two steps forward, one step back? 16-25 year-olds on their journey to
adulthood (SOS: stressed out and struggling). London: YoungMinds.
 Sclare, I., Michelson, D., Malpass, L., Coster, F., & Brown, J. (2015). Innovations in Practice: DISCOVER CBT
workshops for 16–18-year-olds: development of an open-access intervention for anxiety and depression in inner-city
youth. Child and Adolescent Mental Health, 20, (2),102–106.
 Singleton, N., Bumpstead, R., O’Brien ,M., et al. (2001). Psychiatric Morbidity Among Adults Living in Private
Households, 2000. London: Stationery Office.
 Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S, et al. (2007). The Warwick-Edinburgh mental well-being
scale (WEMWBS): development and UK validation. Health and Quality of life Outcomes, 5, 63.

45. Contact us…….
Dr Irene Sclare,
DISCOVER Workshop Programme
SLaM
Tel: 020 3228 7739
Irene.sclare@slam.nhs.uk
www.slam.nhs.uk/discover