Exclusions and mental health: a complex link

Last week the government opened a consultation on its proposals to “improve the consistency of school attendance support and management”. 

This is the latest step in the DfE’s drive to tackle low attendance.  It has also planned to deploy a team of “attendance advisers”, and has established an “attendance alliance”, made up of leading figures in education.

But while addressing low attendance rates is important, not all pupils who are currently out of school are absent because they are school refusers or isolating with Covid. There is another group physically absent from the classroom: those on fixed-term or permanent exclusions.

The impact of those exclusions on young people’s mental health can be significant, says Tamsin Ford, professor of child and adolescent psychiatry at the University of Cambridge. 

Here, she explains what research can tell us about the repercussions of exclusion.

Tes: What do we know about the relationship between exclusion and mental health?

Ford: We know that having a mental health condition, particularly a neurodevelopmental disorder such as ADHD, makes it far more likely that you will be excluded. However, we also know that being excluded makes you more likely to develop a mental health condition.

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I tracked a group of children for three years, and found that even when you take out those that initially had a mental health condition, being excluded predicted having a mental health condition three years down the line.

Other studies have found a similar link, such as the Avon Longitudinal Study of Parents and Children (ALSPAC). This is a birth cohort study that tracked over 14,000 children born in the early 1990s. There is very detailed data on these children, and one of the things it shows is that exclusion is linked to deteriorating mental health.

What types of problems did those children exhibit?

Firstly, the data showed that boys who are excluded by age 8 come into school with psychological distress that should be visible. Their scores in the Strengths and Difficulties Questionnaire [SDQ - a commonly used clinical measure of distress] are way higher than those of their peers. So, in other words, we should be able to see them coming. 

The scores are similar in girls, but very few of them are being excluded in early childhood. 

In older age groups, however, what we see is that being excluded in your teens actually predicts deteriorating mental health, particularly in young women. 

Is this deterioration of mental health a universal trend for every child who gets excluded?

It is likely to vary according to the child. When I was at Exeter University, together with colleagues, I edited a book that examines exclusion and attendance in relation to mental health, and one of the key messages was that, actually, school is a really hard place for some children to be. 

If you have special educational needs that aren’t being supported, or if you get very anxious and your anxiety problem isn’t being dealt with, then you might feel better off when not at school..

You won’t be better off in the long term, but the thing about anxiety is if you go away from what’s making you anxious, it gets better. And that’s why anxiety is really sneaky and pernicious, because it gets better immediately if you go away from the trigger. 

Does that mean that exclusion can be a positive thing for some children, at least in the short term?

They may feel better, but the issue is complicated - as the pandemic has shown. 

For instance, there was some very interesting research led by Emily Widnall and Judi Kidger at the University of Bristol. In October 2019, they went into 17 schools around the South West and gathered mental health data on Year 9 students. 

They then returned during the first lockdown in April 2020, and what they showed was that there was no change in mental health across the whole population. 

But if you split the data by established clinical cut points - so, in other words, if you looked specifically at those who were at risk of depression or risk of anxiety - those kids who were struggling in October were actually doing better in the first lockdown. 

And then for the whole population, in September 2020, when schools opened up fully again, there was an uptick in the levels of anxiety. 

So I think it is complex. 

Of course, living through national lockdowns is not the same as being excluded. Does exclusion affect mental health in different ways to other types of absenteeism? 

Yes, I think it does. But the research is plagued by sloppy terminology, and also the fact that sometimes we use the same words to describe totally different things. 

For example, at one point, when I first started training, there was felt to be a complete difference between school refusal - a child who wouldn’t go to school because they couldn’t, because they were so anxious or depressed, which was seen as primarily an emotional problem - and truancy, which was associated with being bad, essentially. But it’s much more difficult and nuanced than that, and, in fact, our research demonstrates a stronger association between depression and unauthorised absence.  

Teenagers who are really struggling in school, perhaps because they’re being bullied or because they’re very socially isolated and they simply can’t cope - if they come from a family where they can’t just go home, they will truant. 

But it’s kind of the same mechanism, so I don’t think we can think of there being an anxious group and a behaviour group. I think there are different kinds of vulnerabilities in individual children and their families and social networks. 

What does all of this mean for how schools use exclusions?

If a young person’s behaviour is partly driven by the fact that school is a very hard place for that child to be, and from my clinical experience I think it certainly is sometimes, then being excluded can be a blessed relief. In that case, exclusion is not going to stop the behaviour that you don’t want. In fact, in this situation, it may even reinforce it. 

Having said that, I totally appreciate that school staff have a responsibility for the safety of other children and the safety of their staff. And sometimes there is behaviour that is just beyond the pale and a message needs to be sent. 

But I think exclusion is a very blunt tool, and it needs to be used cautiously, if at all. And if we’re excluding a child repeatedly who has special educational needs, it would suggest to me a system failure to support that child. 

Can you explain what you mean by ‘system failure’?

I think sometimes children end up being excluded from school because the school can’t cope; the special needs provision isn’t good enough. And if, for the child and the family, it means leaving school feeling they have failed, when actually it’s the system that’s failed, then wouldn’t it be better to say, “This is not the right provision for you. Let’s find something that you can cope with”?

And then the transition to an alternative provision can be reframed as being not because of failure in mainstream but because it’s the right thing for that child.

What can schools do to improve the mental health of all students?

One suggestion comes from a study I was involved in of a mindfulness intervention in secondary schools across the whole of the UK, run by Willem Kuyken at the University of Oxford. 

At baseline, we had data from 26,000 children across 85 schools. 

We found that a big proportion of the average mental health across a school is determined by the catchment area that the school is in. In other words, there are a lot of factors that schools can’t control: the levels of deprivation, how many pupils have free school meals, special educational needs -  that kind of thing. 

But there is a small percentage of this variance that is related to other school factors, and there is one school factor, in particular, that’s tractable: school climate. 

The study demonstrated that school climate is one of the things that predicts levels of depression symptoms, overall wellbeing, as well as general behaviour problems, and emotional difficulties. 

It’s really important, therefore, that we work hard to have the best school climate that we can, because whilst many children will do fine wherever they are, there are a vulnerable few for whom that climate really will be make or break. 

So we really need schools that have a nurturing and positive school environment. 

What does that look like in practical terms?

It means a whole-school ethos that promotes connectedness and strong positive relationships, and that we need to take things like bullying very seriously. Bullying will happen in all schools at some point or other. It’s not so much whether it happens or not; it’s how it’s dealt with when it does happen that makes the difference. 

There are lots of evidence-based programmes or techniques that demonstrate an impact in reducing bullying and improving wellbeing. We’re just really lousy at implementing them, and we really need to up our game.

To be clear, I’m not blaming teachers here; it’s more about whole-school priorities. 

I think many educators realise that children are like adults: if you are really stressed or anxious, or if your mental health is not good, your performance at work or school suffers. 

So this is not a matter of, “Oh, we can’t do that because we’ve got to teach.” It’s a matter of, “We’ve got to get our school climate as good as possible, so we can teach and so our children can do better.”

Professor Tamsin Ford is one of the speakers at the upcoming E-ACT Ideas Conference in partnership with Tes