Over the past two decades in the UK, the prevalence of mental health difficulties among school-aged children and young people (CYP) has steadily increased, with one in six aged 6–19 experiencing at least one disorder (Newlove-Delgado T, 2021; Sadler, 2018). Mental health difficulties in childhood and adolescence can cause a wide range of negative effects, including immediate disruptions to daily functioning and reduced academic performance, as well as long-term risks of poorer mental and physical health in adulthood (Costello & Maughan, 2015; Sellers et al., 2019; Thompson et al., 2023).
From a public health perspective, implementing interventions that prevent mental health disorders and promote wellbeing is key to reducing the associated health, social, and economic burdens (Arango et al., 2018). Schools have been championed as effective delivery systems for mental health interventions, since most CYP, including those from marginalised groups, spend a large proportion of their day at school, and school staff are often the first and preferred port of call for CYP experiencing mental health difficulties (Abdinasir, 2019; Hoover & Bostic, 2021). School-based services offer several benefits, including greater access to care (Rones & Hoagwood, 2000), improved treatment adherence, and better engagement from parents and teachers (Hoover & Mayworm, 2017).
A wide range of mental health interventions are being implemented in schools across the UK. The local offer is shaped by a combination of factors such as national policies, level of need, available resources, and input from key stakeholders. While these interventions show promise, ongoing evaluation is essential to ensure their effectiveness and suitability across diverse student populations.
Education for Wellbeing Programme
To generate robust evidence and ensure the effectiveness of universal mental health approaches in schools, the Department for Education (DfE) funded the Education for Wellbeing programme, one of England’s largest school-based mental health research initiatives. The programme included two randomised controlled trials (RCTs), conducted between 2018 and 2024: AWARE (Approaches for Wellbeing and Mental Health Literacy: Research in Education) and INSPIRE (Interventions in Schools for Promoting Wellbeing: Research in Education). Further research, including qualitative findings, can be found on their website.
A wide range of mental health interventions are being implemented in schools across the UK, yet robust evidence for their effectiveness remains limited.
Methods
The AWARE programme, delivered in secondary schools, evaluated two established curriculum interventions:
- Youth Aware of Mental Health (YAM), aimed at improving understanding of mental health and reducing suicide rates
- The Mental Health and High School Curriculum Guide (The Guide), focused on enhancing mental health literacy, reducing stigma, and increasing knowledge of available support (Deighton et al., 2025a, 2025b)
A total of 12,166 Year 9 (aged 13-14) pupils from 153 secondary schools participated. Schools were randomised to receive YAM, The Guide, or continue usual practice. Primary outcomes were emotional difficulties (measured by the Short Mood and Feelings Questionnaire; SMFQ (Messer et al., 1995)) for YAM, and intention to seek help (measured by the General Help Seeking Questionnaire; GHSQ (Wilson et al., 2005)) for The Guide.
The INSPIRE programme, delivered across both primary and secondary schools, tested three new interventions:
- Mindfulness-Based Exercises, delivered every school day for 5 minutes
- Relaxation Techniques, delivered every school day for 5 minutes
- Strategies for Safety and Wellbeing (SSW), a series of eight lessons designed to improve skills around personal safety, managing mental health and finding support (Deighton J et al., February 2025)
The trial involved 20,489 pupils from 213 schools, including Years 4–5 (aged 8-10) in primary schools and Years 7–8 (aged 11-13) in secondary schools. Schools were randomised to one of the three interventions or usual practice. For mindfulness and relaxation, emotional difficulties (SMFQ) were the primary outcome; for SSW, the intention to seek help (GHSQ) was the primary outcome.
Secondary outcomes in both trials included positive wellbeing, stigma (for AWARE only), and quality of life. Data collection points were consistent across both trials: baseline, 3 to 6 months (short-term follow-up), and 9 to 12 months post-intervention (long-term follow-up).
Two big school-based programmes — AWARE and INSPIRE — aimed to boost mental health literacy, reduce stigma, and improve help-seeking among young people. Over 30,000 pupils took part, testing approaches from mindfulness to classroom guides.
Results
AWARE
Analysis of the YAM intervention found:
- No significant impact on emotional difficulties at the short-term follow-up, potentially due to inconsistent implementation across schools, as several failed to deliver the intervention as planned.
- In schools where YAM was delivered as intended, short-term improvements were noted, but emotional difficulties had significantly increased at the long-term follow-up (effect size = 0.08, 95% CI [0.02 to 0.14]), especially in schools without prior experience of universal mental health programmes.
Evaluation of The Guide intervention found:
- A statistically significant improvement in CYP’s intended help-seeking behaviour at short-term follow-up (effect size = 0.10, 95% CI [0.02 to 0.19]).
- Participants who received all sessions of The Guide experienced greater benefits compared to those who attended fewer sessions.
- Participants experienced short-term improvements in attitudes toward mental health (effect size = 0.11, 95% CI [0.03 to 0.17]), mental health knowledge (effect size = 0.26, 95% CI [0.18 to 0.33]), and related behaviours (effect size = 0.10, 95% CI [0.03 to 0.17]).
- At long-term follow-up, participants reported increased emotional difficulties (effect size = 0.09, 95% CI [0.03 to 0.15]) and reduced life satisfaction (effect size = -0.08, 95% CI [-0.13 to -0.02]).
INSPIRE
Analysis of Mindfulness-Based Exercises found:
- No statistically significant effect on reducing emotional difficulties CYP at either short-term or long-term follow-ups in both primary and secondary schools.
- Consistent delivery in secondary schools helped reduce emotional difficulties (high compliance resulted in 42 percentile point reduction in emotional difficulties), while in primary schools, high compliance was linked to increased emotional difficulties (19 percentile point increase).
- Some short-term benefits were observed for girls in primary schools and students with prior emotional difficulties in secondary schools.
- Pupils with Special Education Needs (SEN) or higher baseline symptoms in primary schools experienced increased emotional difficulties over time.
Evaluation of Relaxation Techniques found:
- No significant overall impact on emotional difficulties.
- In primary schools, consistent practice was associated with reductions in emotional difficulties (a 43 percentile point decrease in symptoms), but in secondary schools, high compliance correlated with increase in difficulties by 30 percentile point.
- At long-term follow-up, secondary school students showed an increase in their intention to seek help (effect size = 0.12 CI [0.05 to 0.19]).
- Benefits were seen for pupils from minority ethnic backgrounds (primary), and girls and those with prior difficulties (secondary).
Evaluation of the SSW (Strategies for Safety and Wellbeing) intervention found:
- SSW had a statistically significant positive impact on intended help-seeking behaviour in primary schools (effect size = 0.09, 95% CI [0.01 to 0.18]), but not in secondary schools.
- Pupils without SEN, those not eligible for Free School Meals (FSM), and those in urban schools showed greater improvements.
Despite big hopes, these large school-based mental health trials showed few lasting benefits and even some unexpected harms. Implementation challenges and mixed effects across groups underline just how complex school mental health work can be.
Conclusions
With increasing prevalence of mental health difficulties in CYP, schools have been consistently recognised as an ideal setting for prevention, early identification and treatment of mild to moderate mental health difficulties (Department of Health and Social Care and Department for Education, 2017; WHO, 2020). Universal interventions have gained particular popularity based on the belief that they build skills beneficial to all students, not just those currently experiencing difficulties (Cefai et al., 2021; Goldberg et al., 2019). However, the evidence on the effectiveness of such approaches is mixed (Hayes et al., 2024; O’Connor et al., 2018) with some studies, including these two RCTs, reporting adverse effects often impacting already vulnerable CYP (Foulkes et al., 2024; MacGregor et al., 2024; see Lucinda’s blog on the MYRIAD trial). Most interventions delivered through the AWARE and INSPIRE programmes resulted in either no improvements or only short-term benefits, typically limited to specific groups of students. Some interventions were associated with an increase in emotional difficulties over time, affecting students already at risk, including those with SEN and those experiencing symptoms of poor mental health.
While clinical trials typically report only minor harms, scaling an intervention to the population level can amplify and multiply these effects, making adverse outcomes significant. Foulkes at al. (2024) conducted a simulation to illustrate the potential impact of delivering a universal school-based mental health intervention with a small negative effect size (d = 0.1; comparable to outcomes reported in some recent studies) on a large scale. Their findings suggest that implementing this intervention across all pupils in an average-sized secondary school would lead to an additional 22 CYP exceeding the diagnostic threshold for emotional difficulties; if extended nationwide to all state-maintained schools in the UK, this would result in approximately 62,765 additional CYP meeting the criteria for emotional disorders.
Adverse effects of universal school-based interventions are also an important ethical issue since they are delivered within compulsory school settings. Since many CYP have limited or no opportunity to opt out of interventions delivered during school hours, they effectively lose autonomy over decisions concerning their mental health and wellbeing. This situation raises critical ethical questions regarding consent, autonomy, and children’s rights. Schools have an ethical and legal responsibility to protect pupils from potential harms, and interventions that cannot demonstrate clear benefits – or, worse, that result in measurable harms – violate the ethical principles of beneficence and non-maleficence. Finally, as to an extent demonstrated in the described trials, adverse effects of universal interventions may disproportionately affect vulnerable pupils, potentially exacerbating inequalities and negatively impacting those already at higher risk.
Universal school-based mental health interventions must demonstrate clear benefit and avoid harm—particularly for vulnerable pupils—to ensure ethical and equitable practice.
Strengths and limitations
Strengths
- Large sample sizes, enhancing statistical power and the generalisability of the findings.
- Randomised controlled design, which helps to minimise selection bias and supports more robust causal inferences.
- Use of validated outcome measures, ensuring reliability and comparability with other research.
- Multiple data collection timepoints allowing for the assessment of both immediate and sustained intervention effects.
- Control for potential confounding individual and school-level variables, strengthening the internal validity of the findings.
Limitations
- Although some school-level characteristics were accounted for (e.g., school-level deprivation, setting and previous implementation of universal mental health programmes), school-level randomisation may introduce unmeasured school-level confounders.
- Despite conducting implementation analysis informed by teacher survey, implementation variability is likely, especially in the INSPIRE trial, where daily delivery of mindfulness or relaxation techniques could differ significantly between schools.
- Reliance on self-report measures for key outcomes may introduce social desirability bias and may be less reliable among younger participants.
While the analysis of both AWARE and INSPIRE accounted for some school-level characteristics, like previous implementation of universal mental health programmes, the school-level randomisation may have introduced additional confounders.
What’s next?
Ethically responsible practice must be based on rigorous assessment of both effectiveness and potential harms before widespread implementation of universal school-based mental health interventions.
Policymakers and schools must prioritise identifying potential risks and clearly communicating to all stakeholders, including CYP, parents/carers and school staff. Consent to participate in an intervention must be treated as a fundamental right of CYP and families. This means CYP and families must be receiving comprehensive and accessible information about the intervention’s aims, methods, potential benefits, and risks, including emotional distress or exacerbation of existing difficulties. Obtaining consent should not merely be procedural but genuinely informed, enabling parents/carers and CYP themselves to make choices regarding participation.
Continuous monitoring of interventions’ outcomes is essential to quickly identify and address adverse outcomes. If potential harms are identified, CYP and families should be immediately informed about new risks to facilitate ongoing informed decision-making.
Finally, legislation and international conventions such as Children and Families Act 2014, Gillick Competence, United Nations Convention on the Rights of the Child, 1989, uphold the autonomy and rights CYP. Therefore, schools should be providing explicit, practical, and clearly communicated options for opting out of universal mental health interventions. They must ensure these opt-out processes are accessible and free from stigma or negative consequences.
Ethically responsible practice requires ongoing, rigorous monitoring of both effectiveness and potential harms to ensure interventions remain beneficial and to promptly identify and address any adverse outcomes.
Statement of interests
None.
Links
Primary papers
Deighton, J., Thompson, A., Humphrey, N., Thornton, E., Knowles, C., Patalay, P., … & Rasmus Boehnke, J. (2025a). Effectiveness of school mental health awareness interventions: Universal approaches in English secondary schools. Department for Education.
Deighton, J., Thompson, A., Humphrey, N., Thornton, E., Knowles, C., Patalay, P., … & Rasmus Boehnke, J. (2025b). Effectiveness of school mental health and wellbeing promotion: Universal approaches in English primary and secondary schools. Department for Education.
Other references
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Cefai, C., Simões, C., & Caravita, S. (2021). A systemic, whole-school approach to mental health and well-being in schools in the EU. European Union.
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