Social, emotional and mental wellbeing in primary and secondary education

This guideline covers ways to support social, emotional and mental wellbeing in children and young people in primary and secondary education (key stages 1 to 5), and people 25 years and under with special educational needs or disability in further education colleges. It aims to promote good social, emotional and psychological health to protect children and young people against behavioural and health problems.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Recommendations relating to parents or carers might be less relevant to older young people, especially those in post-16 education settings and may need to be interpreted accordingly.
For the purposes of this guideline, the term 'school' covers schools, colleges, further education providers and other educational settings.

# Whole-school approach
Adopt a whole-school approach to support positive social, emotional and mental wellbeing of staff, children and young people (including people with a neurodiverse condition) in primary and secondary education.
Ensure that the school has a culture, ethos and practice that strengthens relational approaches and inclusion, and that recognises the importance of psychological safety.
Review the school's policies and procedures regularly to make sure that they promote social, emotional and mental wellbeing positively and consistently. This should include making them consistent with relational approaches to social, emotional and mental wellbeing.
Review regularly the school's accessibility plan, medical conditions policy and approach to understanding behaviour, taking into account neurodiversity and communication needs. Also take into account the value of trauma-informed approaches and parental co-production.
Consider monitoring and evaluating the impact and effectiveness of the whole-school approach as part of a school improvement strategy.

## Supporting the whole-school approach
Support the whole-school approach by:
having an outward-facing approach to the community and to engaging with local communities and groups
strengthening links to external agencies that can provide additional support, such as local children's health and care services and relevant voluntary and community sector organisations
having shared principles for engagement between education and mental health services, for example agreeing referral pathways
promoting the involvement of education providers in wider local strategic decision making about children and young people's mental health
having ways of feeding back to parents and carers.
Ensure that school governance structures support the whole-school approach and that school leadership is actively involved in supporting the whole-school approach. Make the responsibility for social, emotional and mental wellbeing curriculum content part of the remit of school leadership (including governance).

## Supporting staff
Ensure that staff have continuing professional development to support both their own wellbeing and the implementation of the school's approach. This could include training in emotional literacy, trauma, neurodiversity, communication needs and relational approaches.
Signpost staff to quality-assured local and national resources to support their wellbeing in line with the Department for Education's education staff wellbeing charter.
Support staff in their pastoral roles by providing protected time for supervision and continuing professional development.
Make peer supervision available for teachers and other school staff to enable them to have space and support to discuss issues and reflect on practice.
Ensure that all teachers can recognise children and young people's pastoral needs, and that they understand the wider context of the pupils' lived experiences and how they interact with their environment. Provide them with additional training or support if needed.
Ensure that all information held by the school related to the local early help offer is kept up to date.

## Involving families and pupils
Involve parents and carers in designing and implementing the wholeschool approach.
Involve children and young people in discussing and agreeing wholeschool approaches and communicate with them regularly about decisions, so they understand how their views inform practice. Take into account the opinions of all members of the school community. This may mean making adjustments to address neurodiversity and communication needs.

## Implementing the whole-school approach
Designate a lead person to determine what is needed to successfully implement universal curriculum interventions. The lead should also be the go-to person for advice on the most appropriate educational resources for any intervention. The lead person should be someone in a leadership post who has strategic responsibilities and oversight of social, emotional and mental wellbeing across the school.
When implementing whole-school approaches, take into account the core values that the school culture and practice are built on, and the psychological safety of pupils, staff members and leadership. For example, this could involve developing a school culture and ethos in which children, young people and staff feel safe to make and learn from mistakes.
Adopt a 'graduated response' (or 'step upstep down') approach to support (moving between universal and targeted support as relevant) as an integral part of the whole-school approach alongside broader universal approaches. Ensure that staff understand this approach and have the right support to implement it (see the recommendations on targeted support).

## Local support
Local public health departments, and children and young people's mental health services, should proactively gather and be responsive to the views and concerns of schools and colleges in their area about children and young people's social, emotional and mental wellbeing.
Local authorities should compile, and keep up to date, a directory of the local services that promote children and young people's social emotional and mental wellbeing and are available to support schools in their area. This should include:
what the services can offer
local mental health and special educational needs and disability (SEND) services, including services that might be less well known
details of how to access the services.
Take risk factors for poor social, emotional and mental wellbeing into account when developing the Joint Strategic Needs Assessment. This should include the contribution that schools can make to improving social, emotional and mental wellbeing and take into account schools' impact on learning and life chances (see the recommendations on identification and risk factors).
The local integrated care system and schools should work together to identify opportunities for joint practice to support the social, emotional and mental wellbeing of children and young people, for example agreeing principles for when and how to share information.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on whole-school approach .
Full details of the evidence and the committee's discussion are in evidence review A: whole-school approaches.
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# Universal curriculum content
Ensure that the curriculum for all pupils includes evidence-based, culturally appropriate information about social, emotional and mental wellbeing to develop children and young people's knowledge and skills as part of the whole-school approach.
Take account of the Department for Education's relationships education, relationships and sex education, and health education guidance when selecting or developing universal curriculum content.
Use an approach that builds on children and young people's previous learning (for example, a spiral curriculum) when planning and delivering a curriculum intervention for all pupils.
Integrate relevant activities into all aspects of education to reinforce the curriculum offer about social, emotional and mental wellbeing and skills.
Use non-judgemental 'strengths-based' approaches to support children and young people's social, emotional and mental wellbeing. These are approaches to improve or develop their:
self-worth (for example, self-esteem, empowerment, self-care)
skills (for example, problem solving skills, social skills, communication skills)
resilience (for example, coping skills and strategies, perseverance).
Use universal interventions that align with the whole-school approach, for example 'child- (or young person) to-trusted-adult' support.
Consider universal interventions informed by mindfulness or cognitive behavioural approaches (including trauma-focused cognitive behavioural approaches) for all children and young people. These should be delivered by trained staff who can teach children and young people how to use the approach and support them when they do.
Consider including regular rhythmic physical activity in the universal curriculum. If it is included, ensure that there is time and space available for this.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on universal curriculum content .
Full details of the evidence and the committee's discussion are in:
evidence review B: universal curriculum approaches
evidence review C: qualitative evidence synthesis for universal curriculum approaches.
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# Identifying children and young people at risk of poor social, emotional and mental wellbeing

## Identification and risk factors
When considering whether a child or young person has risk factors for poor social, emotional and mental wellbeing, take into account:
the number, duration and complexity of risk and protective factors, their cumulative effects and interactions between them
that the effects of risk and protective factors, or combinations of factors, might differ across life stages
that they may have unidentified or unmet educational needs, for example special educational needs or disabilities that impact on their ability to access education.For a list of risk and protective factors, see table 1 in the Department for Education's mental health and behaviour in schools guidance. Be aware that the list is not exhaustive.
Base the identification of children and young people at risk of poor social, emotional and mental wellbeing on information from a variety of sources, for example observation, self-report and consideration of their early life experiences. Be aware that some children and young people will internalise their distress and will therefore be more difficult to identify.
Assess children and young people identified as at risk and decide whether to monitor their social, emotional and mental wellbeing or to offer them targeted support (see the recommendations on tools and techniques). Take into account any existing assessments, for example from educational psychologists or child and adolescent mental health services.
When identifying risk in children and young people with disabilities or special educational needs, ensure that staff understand the graduated response to need as specified in the current Department of Health and Social Care and Department for Education's special educational needs and disability (SEND) code of practice, and that they can respond with relevant interventions. If necessary, they should seek input from specialised external agencies.

## Tools and techniques
If using a tool or technique to assess a child or young person who has been identified as at risk of poor social, emotional or mental wellbeing, consider using one that is validated (see Public Health England's guidance on measuring mental wellbeing in children and young people).
When selecting a tool or technique to assess social, emotional and mental wellbeing, take into account:
the child or young person's needs, wishes and feelings
the purpose of the assessment
how the tool or technique fits with the school culture and ethos
contextual factors, such as the child or young person's chronological or developmental age or ethnicity and any communication needs (being aware that assessment tools are context specific and vary in quality).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on identifying children and young people at risk of poor social, emotional and mental wellbeing .
Full details of the evidence and the committee's discussion are in:
evidence review D: risk factors for poor social, emotional and mental wellbeing
evidence review E: qualitative review for risk factors for poor social, emotional and mental wellbeing
evidence review F: risk factors for poor social, emotional and mental wellbeing.
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# Targeted support
Have clear guidance on how to identify individual children and young people and groups of people for targeted support based on their specific needs (see the section on identifying children and young people at risk of poor social, emotional and mental wellbeing).
Offer targeted individual or group support to children and young people who have been identified as needing additional social, emotional or mental health support. Use trained, experienced practitioners who are competent to provide the support. Any support should be culturally sensitive and take into account possible neurodiversity, communication needs and other needs of the child or young person.
Actively involve the parents or carers of the child or young person when deciding whether to offer targeted support (but think about whether the young person is competent to give their consent or there are reasons not to involve the parents or carers). Discuss with them any support that is being proposed and make sure that they understand it and agree with it.
Explain the targeted support to the child or young person and involve them in decisions about the support offered to them, including when and where it is offered. Where appropriate and possible, obtain their agreement before starting the support.
Take into account the range of individual needs and risks when putting together a group for targeted group support, including the developmental age and cultural background of the pupils it is being delivered to.
Promote a range of targeted support, including peer-to-peer support, that allows children and young people to express difficult feelings and talk about their experiences.
Aim to minimise the risk of any unintended adverse consequences and stigma and proactively normalise seeking support. Take care not to reinforce bullying by singling people out for support.
Ensure that all targeted support is delivered collaboratively with any other external agencies or services, the professional network around the child or young person and any support that the child or young person is already receiving.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on targeted support .
Full details of the evidence and the committee's discussion are in:
evidence review G: targeted social and emotional support
evidence review H: targeted mental health support.
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# Support with school-related transitions and other life changes

## All transitions and life changes
Train staff to recognise the wide-ranging impacts of transitions and life changes on children and young people's social, emotional and mental wellbeing, taking into account that they may differ between individuals, for example because of cultural background, age and gender. This includes recognising both planned (for example, moving between schools or classes) and unanticipated life changes, and the different ways that a child or young person typically expresses their mental health problems and responds to trauma.

## Transitions between schools and classes or leaving education
Plan and offer tailored interventions to prepare children and young people for educational transitions and for leaving education completely. This includes:
Establishing a relationship with the child or young person and their parent or carer.
Gathering the child or young person's views about their transition.
Supporting the child or young person to feel ready for the transition, for example understanding how they will get to and from the new school or job.
Sharing with the new class or school and staff information about the child or young person that will help them. The information should be positive and not set out to victimise or stigmatise them, and it should be shared in line with the National Data Guardian's Caldicott principles.
Identifying and communicating with the professional and personal network around the child or young person, if there is one, as part of good transition support.Also follow these principles for any managed moves (in which a child or young person is placed in a new school by the local authority or by school-to-school voluntary agreement).
Support the child or young person at the time of the educational transition to cope with the loss of important relationships caused by the transition.
Enhance children and young people's sense of belonging in the new school or class, for example by organising a peer mentor or buddy for them (see recommendation 1.4.6).

## After transitions between schools
Check on an ongoing basis to see whether the child or young person is settling in and thriving after moving to a new education setting. Offer them tailored support if necessary. Check more regularly if the child or young person is at a higher risk of poor social, emotional and mental wellbeing.
Promote peer mentoring between a child or young person entering a new education setting and a peer who has training in mentoring (see recommendation 1.4.6).

## Significant life changes
Address needs identified by children or young people (or their parents or carers) going through significant life changes, mental health problems or mental illness. This should involve the special educational needs and disabilities coordinator (SENCo) or designated safeguarding lead and other agencies if necessary.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on transitions .
Full details of the evidence and the committee's discussion are in evidence review I: interventions to support children and young people during periods of transition.
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# Terms used in this guideline
This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary and the Think Local Act Personal Care and Support Jargon Buster.

## Adverse childhood experiences
Highly stressful, and potentially traumatic, events or situations that occur during childhood or adolescence. They can be a single event, or prolonged threats to, and breaches of, the child or young person's safety, security, trust or bodily integrity.

## Early help
Providing support as soon as a problem emerges, at any point in a child's life. For example, see the Early Intervention Foundation.

## Psychological safety
The belief that one is in a safe place and will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes.

## Punitive behaviour management systems
An approach to classroom or school management that focuses on establishing clear expectations for appropriate behaviour, monitoring behaviour, and then reinforcing appropriate behaviour and redirecting or sanctioning inappropriate behaviour.

## Relational approaches
Approaches that emphasise connection, belonging and the teaching of effective conflict resolution skills. These approaches assume that behaviour is a means of communication and that behaviour that challenges can be a sign of unmet emotional needs. Relational approaches approach behaviour with curiosity rather than judgement. They are grounded in psychological theory and support children to build their self-regulation skills. They take account of context and the child or young person's lived experiences.

## Rhythmic physical activity
Any kind of activity that is based on a steady and prominent beat. During rhythmic activities individuals participate in rhythmic body movement, for example rebounding on a trampoline or moving to a beat.

## Spiral curriculum
A course of study in which pupils study the same topics in ever-increasing complexity throughout their time at school to reinforce previous lessons.

## Targeted support
Support aimed at individuals or groups who have been identified as being at greater risk of poor social, emotional and mental wellbeing.

## Trauma-informed approaches
Approaches to support children and young people who suffer with trauma or mental health problems and whose troubled behaviour is a barrier to learning.

## Trusted adults
Adults that children and young people can turn to in times of worry, stress or crisis.

## Universal curriculum content
Curriculum content that is for everyone.

## Whole-school approach
For the purposes of this guideline, 'whole-school' also covers colleges, further education providers and other educational settings.
A whole-school approach defines the entire school community as a single unit and involves coordinated action between 3 interrelated components:
curriculum, teaching and learning
school ethos and environment
family and community partnership.
The 8 principles to promoting a whole-school and college approach to mental health andwellbeing are set out in Department for Education and Public Health England's guidance on promoting children and young people's mental health and wellbeing.# Recommendations for research
The guideline committee has made the following recommendations for research.

# Key recommendations for research

## Early signs of poor social, emotional and mental wellbeing
What are the early signs of social, emotional and mental wellbeing issues, including in children and young people who are internalising it?
a) What early factors predict poor social, emotional and mental wellbeing?
b) How do children and young people with poor social, emotional and mental wellbeing describe their thoughts and feelings at early onset stage?
c) What are the barriers and facilitators to identifying children and young people at risk of poor social, emotional and mental wellbeing at school?
For a short explanation of why the committee made the recommendation for research, see the rationale section on identifying children and young people at risk of poor social, emotional and mental wellbeing .
Full details of the evidence and the committee's discussion are in:
evidence review D: risk factors for poor social, emotional and mental wellbeing
evidence review E: qualitative review for risk factors for poor social, emotional and mental wellbeing
evidence review F: risk factors for poor social, emotional and mental wellbeing.
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## Intersecting social, cultural and personal factors
What is the role of intersecting social, cultural and personal factors in developing poor social, emotional and mental wellbeing?
For a short explanation of why the committee made the recommendation for research, see the rationale section on identifying children and young people at risk of poor social, emotional and mental wellbeing .
Full details of the evidence and the committee's discussion are in:
evidence review D: risk factors for poor social, emotional and mental wellbeing
evidence review E: qualitative review for risk factors for poor social, emotional and mental wellbeing
evidence review F: risk factors for poor social, emotional and mental wellbeing.
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## Targeted support
What is the effectiveness (including long-term effectiveness) and cost effectiveness of targeted group or individual interventions for children and young people who have been identified as needing additional mental health support, and does it vary by ethnicity, socioeconomic status or other cultural and personal factors?
For a short explanation of why the committee made the recommendation for research, see the rationale section on targeted support .
Full details of the evidence and the committee's discussion are in:
evidence review G: targeted social and emotional support
evidence review H: targeted mental health support.
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## Effectiveness of interventions
What components of interventions or approaches to promote social, emotional and mental wellbeing are effective and cost effective?
For a short explanation of why the committee made the recommendation for research, see the rationale section on whole-school approach .
Full details of the evidence and the committee's discussion are in:
evidence review G: targeted social and emotional support
evidence review H: targeted mental health support.
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## System leadership and service delivery
How can practitioners, institutions and organisations work together to improve systems leadership that impacts collectively on positive outcomes for children and young people's social, emotional and mental wellbeing?
For a short explanation of why the committee made the recommendation for research, see the rationale section on whole-school approach .
Full details of the evidence and the committee's discussion are in evidence review A: whole-school approaches.
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# Other recommendations for research

## Children and young people with special educational needs
Are children and young people with special educational needs at higher risk of poor social, emotional and mental wellbeing?
For a short explanation of why the committee made the recommendation for research, see the rationale section on identifying children and young people at risk of poor social, emotional and mental wellbeing .
Full details of the evidence and the committee's discussion are in:
evidence review D: risk factors for poor social, emotional and mental wellbeing
evidence review E: qualitative review for risk factors for poor social, emotional and mental wellbeing
evidence review F: risk factors for poor social, emotional and mental wellbeing.
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## Harms and unintended consequences
What are the possible harms and unintended consequences of targeted group or individual interventions for children and young people who have been identified as needing additional mental health support?
For a short explanation of why the committee made the recommendation for research, see the rationale section on targeted support .
Full details of the evidence and the committee's discussion are in:
evidence review G: targeted social and emotional support
evidence review H: targeted mental health support.
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## Targeted support
What are parents' and carers' views on targeted group or individual interventions for children and young people who have been identified as needing additional mental health support?
For a short explanation of why the committee made the recommendation for research, see the rationale section on targeted support .
Full details of the evidence and the committee's discussion are in:
evidence review G: targeted social and emotional support
evidence review H: targeted mental health support.
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## Views on transitions to secondary school
What are the views and experiences of children about moving to secondary school?
For a short explanation of why the committee made the recommendation for research, see the rationale section on support with school-related transitions and other life changes .
Full details of the evidence and the committee's discussion are in evidence review I: interventions to support children and young people during periods of transition.
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## Support for transitions
What do children and young people, including those from underserved populations, find useful to support life changes in the context of their education?
For a short explanation of why the committee made the recommendation for research, see the rationale section on support with school-related transitions and other life changes .
Full details of the evidence and the committee's discussion are in evidence review I: interventions to support children and young people during periods of transition.
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## Impact of COVID-19
What is the medium-to long-term impact of the COVID-19 pandemic on children and young people's social, emotional and mental wellbeing?
For a short explanation of why the committee made the recommendation for research, see the rationale section on identifying children and young people at risk of poor social, emotional and mental wellbeing .
Full details of the evidence and the committee's discussion are in:
evidence review D: risk factors for poor social, emotional and mental wellbeing
evidence review E: qualitative review for risk factors for poor social, emotional and mental wellbeing
evidence review F: risk factors for poor social, emotional and mental wellbeing.
Loading. Please wait.# Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice or services.

# Whole-school approach
Recommendations 1.1.1 to 1.1.22

## Why the committee made the recommendations
The committee agreed that the inclusion health agenda (for example, see the Office for Health Improvement and Disparities  inclusion health: applying all our health) and tackling inequalities were central to this guideline. When implementing the guideline, schools and wider system partners would need to pay particular attention to marginalised or excluded groups, both in terms of their involvement and in terms of tailoring the recommendations to meet the needs of those groups. The committee made special consideration of the needs of children and young people with learning difficulties and special educational needs and disabilities (SEND). They agreed to place neurodiversity at the heart of their considerations and received expert testimony on the topic to inform their discussions. Professionals from special schools were represented on the committee, and the focus group work with children and young people that NICE commissioned included people from schools with high rates of SEND and from special schools and pupil referral units.
The committee discussed the benefits of implementing a whole-school approach for children and young people's social, emotional and mental wellbeing, including preventing the onset of poor outcomes and supporting those with identified needs. They agreed that this could have implications far beyond school environments, for example on employability and anti-social behaviours. The quantitative studies included various whole-school approaches with different combinations of components and various aims, although the strongest evidence was about bullying. They showed some benefit and no harms or adverse consequences. The qualitative evidence showed that pupils and teachers valued whole-school approaches and believed that they had a positive effect on school culture. Overall, the committee agreed that there was some evidence to support the effectiveness of whole-school approaches. There was evidence about the acceptability of whole-school approaches and what made them more or less likely to work, and the committee had more confidence in the findings from these studies than the quantitative ones. This evidence was supported by their expertise and experience and by the testimony of invited expert witnesses.
The committee heard expert testimony about relational approaches being more effective than using purely punitive behaviour management systems for managing social, emotional and mental wellbeing in children and young people. Together with this and their own experience and expertise, they agreed that embedding a relational approach in the overall culture and ethos of the school was the basis of a successful whole-school approach, and this would need to be reflected consistently in school policies and procedures. Reviewing policies regularly would help to ensure that this happens. Although the committee were not able to set a specific timeframe for review because there was no evidence, they agreed that annually would be reasonable. They also agreed that leadership was key to embedding this approach and that the leadership needed to come from a senior person. They discussed that this might fit well with the role of the designated school mental health lead. However, because this is a developing role, they agreed it would be premature to specify this. Additionally, having heard expert testimony about trauma-informed approaches in schools, the committee encouraged a shift towards these approaches to understand and therefore manage behaviour.
The committee regarded the whole-school approach as a framework that other interventions can slot into. They noted that interventions such as targeted support have a better chance of success if schools actively engage with local agencies. They also agreed that, to be effective, a whole-school approach needed monitoring and evaluating to make sure the approach was working.
The committee also noted that it would be more useful if future research focused on the effective components of interventions or approaches (see the recommendation for research on effectiveness of interventions).
The committee agreed that school leader support and governance was crucial for a whole-school approach to work and that the whole-school approach needed ongoing engagement with school staff, parents and carers, and the wider community. An effective whole-school approach would also lead to improved integration with external agencies, including mental health services and local public health departments. This is essential to ensure that schools can play an active role in decision making on the local transformation plan for children and young people's mental health.
The committee agreed on the importance of collaboration between schools and other services that were not school based but that had an impact on children and young people's social, emotional and mental wellbeing. They noted that, in their experience, schools did not always have mechanisms in place for working with key local services. They agreed that further research was needed to explore how agencies could work together (see the recommendation for research on system leadership and service delivery).
The committee discussed the key role of staff in the whole-school approach. They agreed that staff needed to feel supported in their own wellbeing to be able to create an environment that fostered wellbeing in children and young people. Ways to do this include continuing professional development and formal and informal support.
Staff need to be able to recognise the pastoral needs of the children and young people they work with, and to understand how these are influenced by their wider life experiences. This can help them to relate better to the child or young person, and to other people who may be involved in their care. Understanding behaviour as a means of communication could help with this. They identified that staff need time and support for pastoral training.
The committee noted that there are national and local resources that staff can use to help them manage their own wellbeing. The resources can also help staff keep up to date with local agencies that could help with children and young people's mental health through the early help offer.
The evidence supported the committee's view that the school's communication with parents, carers and families is important. The committee agreed that the wholeschool approach worked better if parents, carers and families were involved with the planning of it.
Focus group research commissioned by NICE to explore children and young people's perspectives on the draft recommendations identified several important ways of successfully implementing whole-school approaches. Based on the findings of the focus groups, the committee recognised the importance of involving children and young people and capturing their views when agreeing on approaches, including views from minority and seldom-heard groups.
This focus group research also identified the importance of effective communication between school staff and children and young people. The committee recognised the need for excellent communication channels between these groups when implementing universal interventions. They also highlighted the importance of taking into account children and young people's views, how much time there was in the curriculum and resourcing, teacher understanding of the interventions and parental engagement for the successful implementation of universal interventions. These factors were identified from the evidence base and the committee's own experiences.
The committee discussed the challenges of implementing a whole-school approach. Based on the expert testimony they had heard and on their own expertise and experience in setting up, supporting and evaluating whole-school approaches, they agreed that there were key things they could recommend that would make the implementation smoother. This included the importance of creating a school environment that was a safe space for both teachers and children and young people and where they would not be punished or penalised for mistakes or for speaking up. Also, after hearing from experts, the committee highlighted the significance of core values and strong leadership when implementing a relational whole-school approach.
The committee agreed that if the universal curriculum was managed and planned by a specific person it would be better coordinated across the school and could be kept up to date more easily. This person would need to be a senior leader who was able to influence school policy. This coordination could also lead to a more streamlined approach to moving children and young people into and out of targeted interventions (a graduated or 'step upstep down' approach) when universal content was not meeting their social, emotional and mental wellbeing needs.
The committee discussed how the whole-school approach could be influenced by the wider local and national context. They agreed that local authorities, especially local public health teams and children and young people's mental health services, had a responsibility to respond to broader needs that schools identified and engage with schools and colleges. Local authorities and health partners also needed to consider the risk factors for poor social, emotional and mental wellbeing when gathering and analysing health data and planning the local response, for example through the Joint Strategic Needs Assessment.
The committee noted that schools often found it difficult to understand what was on offer locally that could support their children and young people, for example occupational therapy or speech and language therapy. Even if they knew about the services, they might not know how to refer children and young people into them. The committee agreed that local authorities and care systems would be best placed to address this.

## How the recommendations might affect practice
The recommendations reinforce current best practice. They are based on existing processes that most, if not all, schools should be following. However, the committee recognised that adopting and maintaining a whole-school approach needs significant additional time, ongoing leadership and dedicated resourcing. For example, school staff may need more protected time to engage with pupils and local agencies and to undertake relevant training. This could partly be delivered as part of a school's ongoing continuing professional development, for example in inset days.
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# Universal curriculum content
Recommendations 1.2.1 to 1.2.8

## Why the committee made the recommendations
The committee looked at a substantial amount of evidence about the effectiveness of universal curriculum-content interventions to improve social, emotional and mental wellbeing in primary and secondary education. Although they noted that much of the evidence was limited in terms of the confidence they could have in its findings, it supported their experience that universal curriculum-content interventions help promote the skills needed for good social, emotional and mental wellbeing. It also supported statutory guidance about what should be covered in the universal curriculum. They also considered a smaller amount of qualitative data of mixed quality. Because the qualitative evidence was from only a few studies and its findings were not useful for making recommendations, it was used only to contextualise the recommendations rather than to provide a basis for them.
The committee agreed that lessons from universal curriculum content should be cumulative and should be integrated into other school subjects and activities to consolidate children and young people's understanding.
The committee also agreed that using a 'strengths-based' approach to support children and young people's social, emotional and mental wellbeing would help to remove the fear of failure and would bring a focus on providing skills that children and young people would be able to use in the future.
Some evidence also showed that mindfulness interventions had benefits in developing social, emotional and mental skills in both primary and secondary school children and young people, and for academic outcomes in secondary school pupils. Cognitive behavioural approaches increased social and emotional skills and reduced anxiety in primary school children. However, the committee noted that trauma-focused cognitive behavioural approaches may be more appropriate for children and young people who have previously experienced trauma.
Evidence from expert testimony highlighted the value of regular rhythmic physical activity, such as running, bouncing or cross-training, in helping children and young people manage their social, emotional and mental wellbeing. They agreed that these interventions would be most useful in schools where there was a good fit with the whole-school approach.
Social connectedness was highlighted by the committee as a key factor for good social, emotional and mental wellbeing in children and young people in the context of the COVID-19 pandemic. The committee agreed that this encouraged the use of support by both peers and trusted adults.

## How the recommendations might affect practice
The recommendations reinforce current best practice because they are based on existing processes that schools should generally be following, such as using a spiral curriculum and promoting the spiritual, moral, cultural, mental and physical development of pupils. There may be an impact on financial resources and daytoday staffing for the training and peer support needed to deliver these interventions, but this may be partly covered as part of the staff's continuing professional development programme.
Additional time may be needed to establish good communication channels between staff and pupils, to help pupils and the trusted adult develop their relationship and to train teachers on the benefits of interventions.
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# Identifying children and young people at risk of poor social, emotional and mental wellbeing
Recommendations 1.3.1 to 1.3.6

## Why the committee made the recommendations
The committee looked at a substantial amount of quantitative evidence on several potential risk factors for poor social, emotional and mental wellbeing in primary and secondary education. They agreed that most of the evidence was of reasonable quality. They recognised that many of the individual risk factors could indicate other underlying causes such as unidentified or unmet educational needs. They also considered qualitative evidence from a single study. However, they did not believe that this evidence was strong enough to base recommendations on it.
The committee highlighted that the cumulative effect and interactions of multiple risk and protective factors were a much better indicator of poor social, emotional and mental wellbeing than single factors, and that the presence of a single risk factor did not in itself indicate poor social, emotional and mental wellbeing. They agreed that assessment needed to be based on both the number and the complexity of the risk factors, and that evidence needed to be gathered from a wide variety of sources. They agreed that it was unclear how interactions between various social and personal factors contributed to that cumulative effect (see the recommendation for research on intersecting social, cultural and personal factors).
Evidence also showed that adverse childhood experiences are a key factor associated with increased prevalence of poor social, emotional and mental wellbeing. The committee agreed that although the presence of 1 or 2 adverse childhood events should not be seen as a pre-determined risk for poor social, emotional and mental wellbeing, it was a sign that assessment was needed to decide whether to intervene or to monitor the child or young person's wellbeing. The committee recognised that children and young people with neurodiverse conditions (such as autism or attention deficit hyperactivity disorder) and those with special educational needs or disabilities were key populations. Therefore, it was important to take their individual needs into account and to engage with relevant agencies. They noted a lack of evidence about whether children and young people with special educational needs were at a higher risk of poor social, emotional and mental wellbeing and made a recommendation for research about this (see the section on other recommendations for research).
The committee agreed that an exhaustive list of risk and protective factors was not available, but that the Department for Education's guidance on mental health and behaviour in schools made a good start. They noted that it was last updated in 2018 and therefore did not include the effects of COVID-19 as a risk factor (at the time of publication of this guideline).
From their expertise and experience, the committee stated that lack of awareness and training for staff members was a key barrier to identifying children and young people at risk. They agreed that staff needed to be aware of how poor social, emotional and mental wellbeing may present so that they are able to identify issues. They also need to be aware that sometimes these issues can mask unrecognised special educational needs and it is important to understand how to respond to this. The committee noted that much of this is set out in statutory guidance.
They recognised that further research is needed into how poor social, emotional and mental wellbeing can be identified in children and young people, especially those who internalise their distress, and what the barriers are to school staff recognising it (see the recommendation for research on early signs of poor social, emotional and mental wellbeing). They discussed the impact of the COVID-19 pandemic on children and young people's social, emotional and mental wellbeing and agreed that the medium- to long-term effects of this are not yet clear, but need to be investigated (see the section on other recommendations for research).
The committee saw evidence from 1 study about tools for assessing social, emotional and mental wellbeing in children and young people, but it was not directly relevant to this guideline. However, they agreed that as a committee they had substantial expertise and experience in this area. On this basis, although they could not recommend specific tools because of a lack of evidence, they identified important factors that should be considered when selecting a tool. Staff need to be clear on what it is they are aiming to assess, because different tools measure different aspects of wellbeing. Tools are context specific and their appropriateness will be determined by situational factors, such as the chronological or developmental age of the child or young person. The committee also agreed that it was preferable to use validated tools, although they recognised that sometimes that may not be possible.

## How the recommendations might affect practice
School-based practitioners routinely undertake many of these tasks and monitor children and young people's risk factors as part of their pastoral role. However, there may be an increase in the number of children and young people being observed, assessed and offered interventions. This may have cost implications if the extra workload falls on school staff. The committee agreed that many of the tasks will be part of the already planned rollout of the mental health support team and educational mental health practitioners. However, it should be noted that currently there are only plans for mental health support teams to reach 25% of the country and no commitment or resourcing to extend this beyond 2023/2024.
Although school-based professionals are likely to have some awareness of poor social, emotional and mental wellbeing, there may be costs to train staff on identifying it, and on using trauma-informed approaches.
Return to recommendations

# Targeted support
Recommendations 1.4.1 to 1.4.8

## Why the committee made the recommendations
The committee discussed evidence on delivering targeted support for children and young people in secondary and further education who have been identified as needing mental health support (for example, because of symptoms of depression or anxiety). The committee had low confidence in the findings of the quantitative evidence, even though there were quite a lot of studies.
There was some better evidence from qualitative studies about the acceptability of targeted support, and the committee had more confidence in these findings. These studies included individual or group interventions that were delivered by school specialists (such as school counsellors) or external specialists (such as psychologists). Interventions lasted an average of 8 to 12 weeks. This evidence showed that targeted individual or group interventions were effective at reducing emotional distress and could also prevent a first diagnosis of depression. The committee therefore agreed that these were appropriate for pupils identified as needing social, emotional and mental health support. They agreed that although the evidence was from secondary schools, it was also likely to be relevant to primary settings. They were unable to assess from the evidence the comparative effectiveness of group and individual interventions on mental health. Nor were they able to assess the long-term impacts of these interventions or how they varied by population characteristics (see the recommendation for research on targeted support) or their potential harms and unintended consequences (see the other recommendation for research section on harms and unintended consequences).
The studies used varying criteria to determine whether a pupil would need targeted support, for example if they had symptoms of depression or anxiety based on clinical assessment or assessment tools. In practice, pupils are often identified by their externalising behaviours, and those with internalising behaviours can often be missed. The committee agreed that it is important to base referrals for targeted support on individual needs and to have clear guidance about this.
The evidence supported the committee's view that communication between schools and parents, carers and families is important for the success of targeted interventions. Families and parents or carers can influence their child's social, emotional and mental health behaviours, so the committee considered it was important that the school engages with parents and carers when considering targeted support. They agreed that further research could clarify what was important to parents in this regard (see other recommendations for research section on targeted support).
Specialists who provide targeted social, emotional or mental health support may be employed by the school or be external. The committee agreed that it is the school's responsibility to ensure that specialists have the relevant training and experience. They were also aware of existing advice on using counsellors in schools (see the Department for Education's guidance on counselling in schools: a blueprint for the future).
The committee were clear that for targeted support to be successful the pupil needs to be engaged and involved. They discussed the importance of getting their agreement (or that of their families and carers), not only because this is good practice, but also to help the pupil feel involved in the process.
The evidence suggested that when planning targeted support, it is important to consider any potential unintended consequences of the support. This supported the committee's view that care needs to be taken to avoid negative labelling or stigmatising pupils when selecting them for targeted support. For example, if a pupil is known to leave lessons for a counselling session, classmates or teachers might treat them differently and they could be at increased risk of bullying. They may become withdrawn or defiant as a result and increase the behaviour that the intervention is intended to address.
The evidence also highlighted that a group intervention may normalise undesirable behaviours. For example, groups that include pupils who are part of an existing friendship group known for behaviours that challenge may be difficult to work with. This is because of the potential for friendship status and 'membership rights' in the group to be a priority for the pupils rather than working to improve their social, emotional and mental health. The committee agreed that other factors such as developmental age and cultural background were also important to take into account when planning the membership of group interventions.
Focus group research commissioned by NICE to explore children and young people's perspectives on the draft recommendations identified the importance of peer-to-peer support. However, the committee recognised the need to offer a range of support (including peer-to-peer support). This was because evidence in the wider literature on peer-to-peer support indicates that there is a danger that it can perpetuate bullying. Furthermore, the committee highlighted the importance of environment when delivering targeted interventions, because children and young people need to feel safe and comfortable to talk through difficult feelings.

## How the recommendations might affect practice
The recommendations reinforce current best practice. They are based on existing processes that all schools should be following, so they are unlikely to have a considerable resource impact.
Time and money may be needed to set up suitable environments for delivering interventions. Training and time may also be needed to ensure that school staff are able to monitor children and young people's wellbeing for signs of adverse reactions to receiving targeted support.
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# Support with school-related transitions and other life changes
Recommendations 1.5.1 to 1.5.7

## Why the committee made the recommendations
The committee discussed evidence on children and young people who are preparing for or undergoing a transition. Although there was a reasonable number of studies about the effectiveness of interventions to make transitions easier, the quality of the evidence was relatively low. However, the committee agreed with the evidence that transition interventions gave useful support. They also considered some higher quality evidence from qualitative studies about the acceptability of these interventions that helped them to make recommendations.
The studies included several types of transitions, including moving to a new school or going through a life event such as parental divorce, as well as support for children and young people from a refugee background. Because of the different types of transition identified, the committee agreed that there was a need for support based on individual needs. They discussed how to tailor interventions so that they meet the child or young person's needs and acknowledged that teachers might need additional training for this.
The evidence suggested that when planning for transitions it is important to consider any potential unintended consequences. This supported the committee's view that care needs to be taken to avoid negative labelling or stigmatising pupils, for example when sharing information with a new school. They discussed the lack of research about what children and young people themselves find useful during transitions, especially those from underserved populations (see the other recommendations for research section on support for transitions).
The committee discussed managed moves (in which a child or young person is placed in a new school by the local authority or by school-to-school voluntary agreement) and agreed that the principles for these were the same as for general transitions. The committee did not see any evidence about children's experiences of school transitions but agreed that future research was needed to fill this gap (see the other recommendations for research section on views on transitions to secondary school).
The evidence supported the committee's experience that communication and engagement between schools and parents, carers and families are important in managing transitions and life changes. This is also consistent with the committee's view that engaging with pupils and their parents or carers is an important part of a whole-school approach.
The qualitative evidence on practical supports, such as travel advice, buddy systems and orientation sessions, was also supported by the committee experience that these are useful practical steps.
Based on their expertise, the committee concluded that ongoing monitoring was beneficial in ensuring that the child or young person continues to progress and that the transition arrangements are effective over the whole of the child or young person's education. This is especially the case if they are at higher risk of poor social, emotional and mental wellbeing.
Focus group research commissioned by NICE to explore children and young people's perspectives on the draft recommendations identified the importance of peer mentoring during transition periods to promote good social, emotional and mental wellbeing. The committee agreed with the value of peer mentoring for children and young people entering a new school, particularly from older pupils who have been appropriately trained as mentors.
The committee discussed significant life changes in the context of the school environment and agreed that although these often could not be planned for (for example, a sudden bereavement), the school had a key role in supporting children and young people through these events and in arranging external support for the child or young person if it is needed. This included supporting children and young people through the loss of key relationships with school staff when they moved classes or schools. They agreed it was important to understand how children and young people could be supported through this (see the other recommendations for research section on support for transitions).

## How the recommendations might affect practice or services
The committee agreed that supporting children and young people through transitions to new classes, schools or out of education was part of the general responsibilities of the school. As part of their pastoral role, teachers and other school staff would be trained to engage with pupils and identify those who were not thriving. They noted that agencies outside the school could also provide important services that the school was unable to provide. The recommendations highlight the value of peer mentoring for pupils transitioning to a new school. Additional time may be needed to train older pupils on how to effectively mentor new students.
Return to recommendations# Context
Primary and secondary schools help children and young people learn social, emotional and mental skills through both the taught and the wider curriculum (such as activities outside the classroom). Schools can provide the supportive, caring and nurturing environment that supports positive social, emotional and mental wellbeing. They are also important settings in which to identify and provide early intervention for children and young people at increased risk of mental ill health.
Schools have statutory duties to establish environments where children and young people are supported and can fully engage. These duties encourage schools to support personal development, mental health and wellbeing. Many schools follow a whole-school approach to social, emotional and mental wellbeing (see the Department for Education's research and analysis on supporting mental health in schools and colleges). This approach goes beyond learning and teaching to include school culture, ethos and environment. It involves engaging with children and young people, their parents and carers, teacher and school leaders and outside agencies.
Social, emotional and mental wellbeing may be promoted in curriculum subjects such as personal, social, health and economic education and be embedded more broadly through a school's commitment to the spiritual, moral, social and cultural development of their pupils. Key challenges for schools include:
knowing what approaches improve student outcomes in a specific school setting
accommodating effective teaching of social, emotional and mental wellbeing in a crowded curriculum.
Schools use various methods to identify children and young people who may benefit from targeted interventions to support their approach to social, emotional and mental wellbeing. This may include information from other practitioners such as a speech and language therapist or special educational needs and disability coordinator.