Editorial Perspective: School exclusion is a mental health issue

School exclusion is associated with adverse consequences for both the individual and society more generally (Parsons, Hayden, Godfey, Howlett, & Martin, 2001). While exclusion rates in England have decreased over the last decade generally (Department for Education, 2012), in some groups the levels have remained stubbornly high. Groups of children overrepresented in those excluded from school tend to be male, be of black Caribbean ethnic origin, be eligible for free school meals, and have special educational needs (SEN). Although not surprising, these figures are worrying and remind us that the children who are most vulnerable to exclusion are also among some of the most disadvantaged within society. Furthermore, educational failure has been identified as one of the five pathways to poverty in a report carried out by the Centre for Social Justice (Centre for Social Justice, 2007). Recent media coverage has focused on illegal exclusions from UK schools, which may conceal the needs of many more children whose difficulties may have gone unrecognised (Children's Commissioner's, 2013). If asked, it is likely that education and mental health practitioners would agree that school exclusion would be more likely for children who have a psychiatric disorder or impairing psychopathology. The reality is that although this link is intuitively plausible, there is surprisingly little research that has tested this relationship. Two recent systematic reviews of the literature, one which examined exclusion among children and young people with clinically impairing psychopathology (Parker, C., Whear, R., Ukoumunne, O.C., Bethel, A., Thompson-Coon, J., & Stein, K., & Ford, T., unpublished data) and one which examined the prevalence of clinically impairing psychopathology among children who had been excluded from school (Whear, R., Marlow, R., Boddy, K., Ukoumunne, O.C, Parker, C., Ford, T., & Stein, K., unpublished data), demonstrated that no one has explored this relationship as a primary research question. Studies were included in these reviews if the population covered school-aged children (4–18 years), a validated diagnostic measure or questionnaires had been used to assess psychopathology and the child/young person had had an exclusion from school. Despite extensive searches, these reviews included only seven and five studies respectively. This lack of primary research in such an important area invites explanation, and also consideration of the implications that this may have on future research and policy implementation. There are a number of obvious methodological difficulties, although we would argue that they are not insurmountable. First, difficulties surrounding definitions and terminology make direct comparison between studies problematic, particularly when considering international comparisons. Although there is an assumed common language with regard to psychiatric disorders and diagnosis internationally, guided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Disorders (ICD-10), this is not true for the meaning of exclusion from school. Internationally, exclusion from school is accepted to be a disciplinary tool used in schools where a pupil is removed from the school environment; however the purpose, meaning and use of the exclusion from school varies country to country but also school to school. Contextualising the schools ethos, policies and their role in exclusion is not always feasible, but must be considered and acknowledged. The severity and impact of the child's behaviour in school will impact on the child's functional level in school but is also dependent on the aims and focus of the school and/or supporting services. One's school's severely disruptive behaviour is another's minor disruption. The lack of detail in the studies reviewed made it difficult to distinguish between the type, reason and duration of the exclusion and who the information had come from, which could have potential impact on the interpretation of the findings. Psychiatric disorders are heterogeneous and likely to have differing impacts on a pupil's ability to cope in school. Primary schools function in a very different way to secondary school, as do special to mainstream schools, so stratification by type of school is essential. In order to understand whether there is an impact of a psychiatric diagnosis on a child's ability to function in school, it is important to attempt to assess the duration and onset of psychopathology. It would seem unlikely that exclusion could precipitate disorders such as ADHD or ASD, given their neurodevelopmental basis. In contrast, for disorders such as depression which is recurrent and fluctuating, the disorder might easily be the result of the exclusion as well as the precipitant and consequently causation is unlikely to be linear. Mental health-related contacts are common in education; a three-year follow up of the 1999 British Child and Adolescent Mental Health Survey suggests that teachers were the mostly commonly consulted professional about mental health among those with psychiatric disorder at baseline, and that there were marginally more mental health-related contacts with specialist education professionals than with mental health professionals (Ford, Hamilton, Meltzer, & Goodman, 2007). The costs to the education system are enormous (Snell et al., 2013). There is already considerable qualitative literature that reveals the negative consequences and trajectories of children who have had exclusions from schools, but what is less frequently explored is any potential benefits, and who serves to gain from a child being excluded from school? In order to develop evidence-based interventions and services, rigorous quantitative studies are needed. We need to establish the prevalence of clinically impairing psychopathology among childhood that is associated with exclusion from school and characterise the types of disorder most likely to result in exclusion among different sociodemographic groups. We need to establish whether the mental health component is recognised or not; if not, recognition and referral may afford opportunities to prevent exclusion from school. The exclusion of so many children with SEN suggests that their needs may not be adequately met. Secondary analyses of existing large cohort studies might enable some of the questions surrounding the complex intertwined nature of the two processes to be more clearly elucidated. Exclusion, particularly among children at primary school, should arguably trigger systematic assessments to actively seek problems for remediation to prevent further exclusions/failure when the child returns to or moves school. However, anecdotally it is reported that some schools use the exclusion of a child as a gatekeeper to services due to the high threshold of need that children are required to reach before some services are able to work with the child and school. The decision made by a school to exclude a child does not necessarily mean the support will be available; parents are often left unsure of where the responsibility and ownership of the exclusion lie. The notion of assessments and giving children ‘labels’ is another contested area of considerable debate from not only the perspective of the educational and mental health professional but from the child/young persons and the parents view. The recent UK government published Green Paper, Support and Aspiration: A new approach to SEN and Disability (Department for Education, 2012) has brought about much needed discussion around the use of the SEN label and the wide variety of problems it applies to including psychiatric disorders. Government changes to identifying children with SEN could mean that vulnerable children are missed with undiagnosed disorders that could potentially lead to poorer outcomes at school including exclusion. The medicalisation of difficulties in children remains contentious, particularly in relation to mental health (British Psychological Society, 2013). However, the socialisation of medical problems is as much of a potential problem as overdiagnosis or medicalisation, particularly if it prevents children being referred for assessments and interventions that might improve their ability to function in school. A clear gap in the literature has been identified; further research to establish the inter-relationship of school exclusion and child psychopathology is required, and it is essential that it adopts several methodological approaches so that the complexities surrounding exclusion from school that extend much further than the child. This Editorial Perspective was invited by the Editors of JCPP and has undergone internal review. The authors have declared that they have no competing or potential conflicts of interest. The report presents independent research funded by the National Institute for Health Research (NIHR) and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health in England.