There's an epidemic in your classroom that has every chance of going undiscovered. It is not the fact that one in five pupils is now known to have special educational needs (SEN) - they should be getting the correct support for their dyslexia, autism or learning difficulty. It is the fact that they are likely to have other problems, just as serious, which have not been diagnosed.
Almost half of the 1.7 million young people in the UK with SEN are likely to have mental-health issues, including depression, obsessive-compulsive disorder, attention-deficit disorders or behavioural problems. But their diagnosed SEN masks these other conditions, often meaning they go unidentified.
Now there are growing calls for teachers to be more aware of the link between SEN and mental-health problems.
Doctors have long known that children and young people with SEN are at greater risk of developing mental-health problems. Statistics prove their point. The 2001 Count Us In inquiry estimated that 40 per cent of young people with disabilities had mental-health problems. In 2004, the Office for National Statistics said a child is six times more likely to develop a psychiatric disorder if they have a learning disability.
The problem is that learning and physical difficulties make psychological and neurological problems extremely hard to identify. This means that mental-health issues can be overlooked. Triggers that should sound alarm bells for teachers - such as changes in behaviour - can be overshadowed and explained away by the fact that the child has SEN.
A lack of diagnosis and treatment makes these children even more vulnerable, and also prevents them from achieving their full potential: mental-health issues are linked with absenteeism and disengagement from learning.
Even if problems are spotted, traditional solutions such as talking therapies are often not an option for children with SEN because they are unsuitable for those who cannot speak or communicate well. Added to this, medication sometimes does not have the same effect for children with SEN.
Scant advice has been available for teachers on how to identify mental-health problems among children with SEN. And even when they spot an issue, convincing professionals to take on the case is often difficult. Many doctors and nurses in Child and Adolescent Mental Health Services (CAMHS) lack experience of working with children who have SEN.
Nowhere to turn
Panos Vostanis, professor of child psychiatry at Leicester University, believes teachers do not have the support they need. "Schools need good and direct links with child mental-health services for SEN teachers to access assessments and interventions for the more complex cases," he says. "The problem is that this context is usually missing from our systems, despite a promising recent Government initiative, Targeted Mental Health in Schools, which I have been involved in evaluating."
The good news is that many organisations are trying to make teachers aware of the multiple problems pupils with learning difficulties can face, and are producing guidance for them.
Academics from the Centre for Special Needs Education and Research at Northampton University are working with the National Association of Independent Schools and Non-Maintained Special Schools (NASS) to produce resources that will improve SEN teachers' understanding of mental health.
"The key issue we are facing is that these children are not being diagnosed with mental-health problems, solutions such as talking therapies are not suitable, and medication doesn't work for them in the same way," says Claire Dorer, chief executive of NASS. "Most teachers have a gut instinct when something is wrong. What we want to do is increase their confidence when it comes to recording and reporting problems.
"Mental-health concerns should be treated in the same way as you treat child-protection concerns. But many teachers find they have nowhere to take their worries. CAMHS are patchy and workers often don't want to take on the case. They need more training in how to work with children who have sensory and physical needs."
Spotting the warning signs
Of course, teachers know that a key part of their job is to help pupils overcome their diagnosed SEN. But psychiatrists and psychologists say there are warning signs that can help them identify mental-health problems, too.
Most noticeable are changes in behaviour - a child who becomes quieter is just as likely to have developed mental-health problems as one who becomes more unruly. Another important sign is any change in the child's daily activities, sleep patterns or eating habits.
Dinah Jayson, a child psychiatrist who works for CAMHS in Trafford, advises teachers to look out for children who becomes more "difficult" or moody. "Mental-health problems in boys tend to be shown through behavioural problems. Girls tend to give up and withdraw," she says. "A big sign of problems will be if the pupil is not achieving what they are capable of."
This means schools can be very good at picking things up, although their success with early intervention varies according to the quality of their pastoral support. It also depends on how well trained the school's SEN co-ordinator is, and how good the links are between nurses and the local primary care trust.
Rachel Allan, SEN and mental-health resource developer for NASS, points out that close attention should be paid to how the child interacts with others. "If children are distressed, communication is often the first thing to go, so any changes will help teachers identify that something isn't right," she says.
Teachers must be careful not to use children's learning disabilities to explain away unusual behaviour, according to Sarah Bernard, consultant psychiatrist for children and adolescents with learning disabilities at the Michael Rutter Centre, south London, and the Maudsley NHS Foundation Trust.
"Signs for teachers to look out for include the child becoming distressed, withdrawn, tearful or aggressive and not interacting with those around them. They should think about the reason for anything like this happening," she says.
A co-ordinated approach
Psychiatrists and psychologists agree that, once a teacher has established the pupil could have mental-health problems, they should talk to the parents before referring the case for medical evaluation. The pupil's family will need to be involved in their treatment and could also shed light on the causes of their changing behaviour.
If there is an obvious explanation, such as bereavement or divorce, teachers can introduce ways of making the child feel happier at school (see box, left).
Susan Lee-Kelland, an independent educational psychologist and SEN tribunal judge, explains that there is no need to call in a doctor unless the child's mental-health problems become "really difficult".
"The problem is children with SEN aren't always able to articulate their feelings. Teachers have to try to unscramble them, and that's why they must involve the pupil's family," she says. "The most important thing is to work with all the people who care for the child to get a consensus on the best way forward, and to sit down and talk with the child."
If the issue is caused by family events, teachers can help pupils by making their time at school more sociable, according to Ms Lee-Kelland. "Look at how to improve children's social arrangements. If they are lonely, introduce a 'friends bench' - commonly used in schools now as an area where children who want to socialise can go, and older pupils are in charge of coming to help them," she says.
"Make sure children don't spend too much time alone and get those you are concerned about working in pairs.
"Many children with SEN and disabilities spend a lot more time indoors than other children and develop seasonal affective disorder. Teachers need to make sure they spend as much time outdoors as possible and consider using equipment such as a lightbox."
If school staff come to the conclusion that the mental-health condition is more serious or that the child might harm themselves, they should involve the local primary care trust. Dr Bernard says teachers who are concerned about a child should seek additional advice, "especially if they feel out of their depth".
"For this reason it's helpful for them to have good links with CAMHS, other professionals and school nurses," she adds.
When a teacher refers a child to medical professionals, they should have as much evidence as possible. Ms Allan says recording symptoms is crucial. "If you don't do this, it means there is no trace of what's going on and it makes it much more difficult to access CAMHS," she says.
"A lot of schools find this difficult anyway and it's not good to have an added disadvantage. Experienced teachers have a good gut instinct, which helps them know something is wrong, but they will have to justify that reasoning and pinpoint it."
Building emotional resilience
In future, it seems teachers will have more support to spot and cope with mental-health problems among their SEN pupils. As well as the NASS resources, there is also new guidance produced by the Schools Network (formerly known as the Specialist Schools and Academies Trust).
The network was commissioned by the Department for Education to investigate how to improve education for children with the most complex educational needs and disabilities. The result is the complex learning difficulties and disabilities research project, which has found young people with learning disabilities are six times more likely to have a mental-health problem than other children in the UK.
The project's final report argues that educators should have a "deeper understanding" of children's mental-health needs.
"As a profession, teachers don't really have a history of dealing with mental-health problems, but prevention is better than cure, which is why each school should have a 'well-being' team. This is a tangible way forward," says Professor Barry Carpenter, formerly of Oxford University, who led the research.
"Schools should be doing as much as they can to ensure children are emotionally resilient. Children need to learn how to understand their emotions and teachers need to give them as much opportunity as possible to express them.
"Somebody on every senior leadership team should have responsibility for well-being. Anxious children are not going to learn."
Professor Vostanis says teachers should familiarise themselves with conditions such as autism and attention-deficit hyperactivity disorder, and signs of emotional problems. Ms Allan also argues that frontline teachers should receive more training in mental-health issues.
"There is no golden ticket as to how to help children with SEN and mental-health problems. There is more awareness of mental-health problems in general now, but this is a branch we haven't explored yet," she says.
With increased awareness and greater knowledge of the undiagnosed problems faced by children with SEN, those children might not remain untreated for much longer - and teachers can help make sure that they do not stay hidden.
WHAT TO DO
The Schools Network has these tips for teachers:
Encourage children to talk about their problems through peer mentoring or even electronic communication aids.
Use services such as occupational therapy, art therapy, play therapy, music therapy, relaxation training and social skills training.
Seek help from the school nurse, educational psychologists, and Child and Adolescent Mental Health Services.
Increase the amount of exercise students receive to reduce anxiety and increase emotional well-being.
To engage children in schoolwork, try a topic-based approach that is likely to capture their interest. Also, try running activities relevant to them and involving them in discussions about the curriculum.
Make sure pupils complete some activities in groups, so they build relationships with other children and teachers.
Help children express themselves. For example, use picture cards so children who cannot communicate easily can "label" how they are feeling.
How schools can promote good mental health:
Do teachers listen to pupils?
Are there good links with other institutions and bodies to ensure effective multi-agency working?
Do schools have strategies in place to involve and support families in meeting the needs of vulnerable children?
Are schools effectively implementing the Healthy Schools programme and supporting the emotional well-being of their pupils?
Are young people at the centre of planning for their current and future needs?
Is there continuity in the personnel, particularly advisers or key workers, who work with students to plan for their future?
Do staff know where to refer pupils who experience mental-health problems?
Do staff have in-service training in the promotion of emotional well-being and the identification of emerging mental-health problems?
Rose, R. Howley, M. Fergusson, A. and Jament, J. "Mental Health and Special Educational Needs: exploring a complex relationship" (2009). British Journal of Special Education, 36 (1), 3-8
Carpenter, B. "The Mental Health Needs of Young People with Profound and Multiple Learning Disabilities" (2004). PMLD Link, 16 (1), 9-12
Child and Adolescent Mental Health: a guide for healthcare professionals (2006). British Medical Association. http:bit.lystQNOe
Emerson, E. and Hatton, C. The Mental Health of Children and Adolescents with Learning Disabilities in Britain (2007). Institute for Health Research, Lancaster University
Count Us In: the report of the committee of inquiry into meeting the mental-health needs of young people with learning disabilities (2001). Foundation for People with Learning Disabilities
Payne, H. and Butler, I. Promoting The Mental Health of Children in Need: Quality Protects research briefing no. 9. Available from Research in Practice: http:bit.lyuFign7
Reid-Galloway, C. and Darton, K. Learning Disabilities and Mental Health Problems Factsheet. Mind. http:bit.lytiHNRU
Making Sense of Mental Health: the emotional well-being of children and young people with complex needs. National Association of Independent Schools and Non-Maintained Special Schools. http:bit.lyuf1gEY.