Emotional literacy programme in special schools for children with a learning disability in England: the ZF-SEND feasibility RCT
Abstract Background Children with a learning disability experience a range of inequalities and adverse life events that put them at greater risk of mental health problems. The construct of emotional literacy has been shown to be a moderating factor of how life stress affects mental health. Teaching...
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| Main Authors: | , , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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NIHR Journals Library
2024-12-01
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| Series: | Public Health Research |
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| Online Access: | https://doi.org/10.3310/JTJY8001 |
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| Summary: | Abstract Background Children with a learning disability experience a range of inequalities and adverse life events that put them at greater risk of mental health problems. The construct of emotional literacy has been shown to be a moderating factor of how life stress affects mental health. Teaching emotional literacy in schools may therefore be an effective way to promote positive mental health. There is an identified need for adapted emotional literacy programmes in special schools. Objectives To evaluate whether it is feasible to conduct a large-scale randomised controlled trial of the effectiveness and cost-effectiveness of an emotional literacy programme (Zippy’s Friends special educational needs and disabilities) for children with a learning disability in special schools. The key aims were to assess the acceptability and feasibility of participating in the trial, data collection and the Zippy’s Friends special educational needs and disabilities intervention through quantitative and qualitative data collection. Design A feasibility, cluster randomised controlled trial that aimed to recruit and randomise 12 special schools to either deliver the intervention over 1 academic year or continue with practice as usual and to collect data from 96 pupils at baseline (pre randomisation) and 12 months post randomisation. Setting Special schools in England and Scotland. Participants Pupils with a learning disability, aged 9–11 years, attending special schools in England. Follow-up interviews were conducted with 8 pupils, 4 parents/carers and 11 school staff members. Intervention Zippy’s Friends for Special Educational Needs and Disabilities is a manual-based, classroom-based emotional literacy programme focused on a problem-solving approach to develop and improve children’s emotional literacy. The mainstream programme has been adapted for children with a learning disability by simplifying the activities, shortening the sessions and introducing more repetition. Main outcome measures Feasibility and acceptability of: (1) participation in the research trial; (2) the collection of the outcome measure data and (3) the Zippy’s Friends for Special Educational Needs and Disabilities intervention. Results A total of 8 schools and 53 pupils were recruited. Retention of schools after randomisation (100%) and retention of pupils (100%) met the prespecified progression criteria. For recruitment of schools (20.5% of those approached), pupil engagement with the intervention (50%) and collection of outcome and service use data (62.3%) the criteria were partially met. Fidelity of the intervention delivery (48%) fell just below the progression criteria. Thus, the feasibility and acceptability outcome progression criteria were largely met, suggesting that progression to a full trial is warranted with amendments to the study design. Limitations This feasibility trial was conducted during the COVID-19 pandemic, resulting in unusually high absences of pupils and teachers, different classroom arrangements (bubbles) and unprecedented stress and emotional challenges for pupils, parents and teaching staff. The findings are therefore specific to that period and all three main outcomes of this feasibility trial were adversely affected. Conclusions The findings of this study indicate that a large-scale randomised controlled trial is feasible provided that a number of amendments to the study design are made to improve: (1) the timing of the project to suit the demands of special schools’ yearly timetable; (2) recruitment and (3) outcome and service use data collection. Future work On the basis of the current findings, an application for a full trial will be prepared and submitted with a number of amendments. Trial registration This trial is registered as ISRCTN83610691. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR129064) and is published in full in Public Health Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information.
Plain language summary Why this research is important Emotional literacy (the ability to understand, express and manage your own feelings and be aware of other people’s emotional needs) is important for mental health. There are no programmes where research tells us that emotional literacy programmes for children in special schools ‘work’. The programme Zippy’s Friends is an emotional literacy programme widely used in mainstream schools. Zippy’s Friends for Special Educational Needs and Disabilities is adapted for use in special schools. How we did it Eight special schools were involved. Five used Zippy’s Friends for Special Educational Needs and Disabilities in at least one class over a school year. They were compared with three that used standard teaching programmes only. Teachers, parents and children completed questionnaires to measure changes in children’s emotional literacy, mental health and behaviour over the school year. We also interviewed teachers, parents and children to find out about their experiences of taking part in the study and Zippy’s Friends for Special Educational Needs and Disabilities. This study was designed to find out: How willing schools are to take part If Zippy’s Friends for Special Educational Needs and Disabilities can be delivered as planned If the questionnaires are suitable. The results Fifty-three pupils were recruited; none dropped out. Teachers returned questionnaires for 62% of children at the end of the school year. Feedback on Zippy’s Friends for Special Educational Needs and Disabilities from pupils, parents/carers and teachers was very positive. What this means This study took place during the COVID-19 pandemic. Although this made it more difficult, it was feasible. The results tell us that a larger-scale version of this study can be done, provided that we make changes to improve: (1) the timing of contacting schools; (2) how we collect information and (3) how we work with parents/carers. With these improvements, a larger study may be able to tell us whether Zippy’s Friends for Special Educational Needs and Disabilities can improve emotional literacy in children in special schools to help them cope with problems and have better mental health.
Scientific summary Background Children with a learning disability experience a range of inequalities that put them at risk of mental health problems in adulthood. Children and young people with a learning disability experience negative life events and adversity more frequently. The construct of emotional literacy has been shown to be a distinct and moderating factor of how life stress affects mental health and well-being. Teaching emotional literacy in primary schools has been shown to be an effective way to promote positive mental health and help children cope with negative life experiences, resulting in the long term in better mental health in later life. In mainstream schools, the Zippy’s Friends (ZF) programme has been shown to be an effective way in which to improve emotional literacy, coping skills and mental health outcomes. Emotional literacy is underemphasised in the special educational needs and disabilities (SEND) curriculum and mainstream emotional literacy programmes (except ZF-SEND) do not have SEND adaptations. The National Institute for Health and Care Excellence recommends that help should be given to those most at risk of mental health problems. Lack of investment in mental health promotion in special schools has significant costs for society. There is, therefore, an identified need for SEND-adapted emotional literacy programmes in special schools. Objectives The objectives for this study were to: Assess intervention delivery, fidelity and adherence, and factors influencing implementation, mechanisms of impact and context using data from multiple sources, including teacher-completed session records, qualitative interviews and observations of ZF-SEND lessons. Explore how children, parents/carers and teachers experience the intervention and research participation through qualitative interviews. Investigate the validity and reliability of the self-report measure of mental health (‘Me and my School’) and its relationship with other (proxy report) measures of mental health and behaviour. Establish by survey what constitutes education as practice as usual (PAU) for emotional literacy in special schools for children with a learning disability. Undertake a nested ‘study within a trial’ to explore the acceptability of two different study designs: one where PAU does not come with the offer of delayed access to ZF-SEND, and one where it does. Review the feasibility study against predetermined progression criteria and ascertain whether progression to a large-scale randomised controlled trial is feasible. Methods Design Two-arm cluster (school) randomised feasibility trial of an adapted ZF programme (ZF-SEND) delivered by teachers to children in special schools. Setting Special schools for children with SEND in England. Population/inclusion Children with a learning disability attending special schools in years 5–6 (aged 9–11 years), their teachers and parents/carers. Exclusions Child already receiving similar manual-based emotional literacy intervention(s). Parents/carers whose level of English language is insufficient for participation in informed consent and structured interview. Intervention Usual practice with ZF-SEND, delivered by teachers. ZF-SEND is a manualised classroom-based emotional literacy programme comprising six modules, each with four session plans. Sessions are adapted to different levels of comprehension. Sessions include at least two activities to explore issues relating to emotional awareness, emotional expression, problem solving and coping skills. Comparator Practice as usual (without ZF-SEND). Primary outcomes (1) Feasibility and acceptability of participation in the study (recruitment, retention and randomisation); (2) feasibility and acceptability of data collection (potential outcome measures for a large-scale trial, quality of life measurement and service use data collection) and (3) feasibility and acceptability of the intervention (fidelity, adherence, attendance, experience of delivering or receiving the intervention and intervention costs). Secondary outcomes (baseline and 8–12 months post randomisation) Strengths and Difficulties Questionnaire (teacher and parent/carer completed); Nisonger Child Behaviour Rating Form (teacher completed); Emotional Literacy: Assessment and Intervention (teacher and parent completed); Me and My School (pupil completed); quality of life measures (pupil and parent/carer completed); service use. Sample Quantitative data collection A total of 8 schools (5 intervention and 3 control), comprising 53 pupils. Qualitative data collection Eight pupils from four ZF-SEND schools, four parents/carers (two from PAU and two from ZF-SEND schools), seven class teachers (three from PAU and four from ZF-SEND schools), four members of senior leadership with management/oversight roles (two from PAU and two from ZF-SEND schools). Randomisation Schools were randomised following completion of pupil recruitment and baseline assessments. Schools were allocated to PAU or ZF-SEND arm using minimisation with 80% random component and balanced by size of school. Analyses Primary (feasibility) outcomes were estimated with their associated 95% confidence intervals (CIs). To inform a future trial, effect sizes and 95% CIs were estimated around the between-group comparisons of clinical measures (secondary outcomes) collected as part of the study. This analysis was based on the intention-to-treat principle and controlled for the clustered nature of children within schools using two-level mixed models. The qualitative process evaluation data were analysed with a framework analysis. Results The results of this study were impacted by the COVID-19 pandemic. It is likely that the pandemic resulted in reduced capacity and interest of schools to participate in research, higher staff and pupil absence in schools, increased pressure on school management, teachers, children and parents/carers, difficult family dynamics and poorer response rates of teachers and parents/carers. Despite this, eight schools were recruited and followed-up with acceptable rates of recruitment of pupils (N = 53) and 100% retention. Acceptable response rates at baseline and follow-up for teachers on the outcome measures were also achieved. Moreover, data collection from pupils was feasible and acceptable with high response rates. However, response rates for parents fell below the progression criterion. Owing to the difficulties in recruiting schools during the COVID-19 pandemic, baseline data collection occurred later than originally planned, resulting in delayed randomisation and ZF-SEND schools starting the programme, and a shorter follow-up period of 8–12 months post randomisation. Only one school completed the programme. Observational and interview data suggest that stakeholders found ZF-SEND feasible and acceptable, and teachers were positive and enthusiastic about the programme. However, there were problematic issues with collecting data about programme delivery on the session checklists, which means that quantitative measures of fidelity, adherence and engagement need to be interpreted with caution. Conclusions This study indicates that a large-scale randomised controlled trial of ZF-SEND is feasible and could provide important evidence about emotional literacy interventions for children with a learning disability provided that the study design is enhanced by: (1) approaching schools earlier in the preceding academic year, randomising schools in the summer term, providing training to teachers in the ZF-SEND arm before the summer break and again early in the autumn term; (2) refining and reducing the outcome measures; (3) embedding data collection on ZF-SEND delivery into the programme and (4) engaging more with parents/carers or, alternatively, omitting parent/carer data collection from the study design. Trial registration This trial is registered as ISRCTN83610691. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR129064) and is published in full in Public Health Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information. |
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| ISSN: | 2050-439X |