Sussex Psychosis Research interest Group (SPRiG)

Early Intervention for Stigma

Understanding and Promoting Positive Schema towards Severe Mental Health in Young Children Project


Lead: Dr Kathryn Greenwood

Principle Clinical Psychologist, Sussex Partnership NHS Foundation Trust & Clinical Research Fellow, School of Psychology, University of Sussex

Co-Researchers: Professor Rupert Brown (University of Sussex), Laura Ferrasi (Italy), Tracey Johnstone, Dr Mary John (University of Surrey DClinPsy), Helen Glossop, Janine King, Joanne Mueller (University of Canterbury (Salomons) DClinPsy), Kim Jamieson, Lucie Crowter, Christine Carroll (University of University of Sussex MSc)    

Brief Project Summary

Stigma towards mental ill health is a major factor influencing help seeking behaviour, uptake of interventions and social inclusion for people with mental health problems. Mental health problems are common and most start or have their early signs in adolescence. Young people are the least likely to access mental health services and show high levels of stigmatising attitudes to mental health. Current national anti-stigma campaigns are targeted at secondary schools yet recent research suggests that children develop concepts of mental health ill health and stereotyped attitudes at a much younger age.  

This project aims to develop a teaching resource and programme to enable schools and the NHS to work together to promote positive attitudes towards mental health and help seeking in young people. This project is novel in working with younger children at the developmental stage where understandings of mental health are emerging, rather than targeting older children with more fixed stereotypical views.


The project is operating in schools in Sussex and London and involves several stages:

Stage 1:

An investigation of children’s (aged 7-11) understanding of mental illness and their attitudes towards people with mental health problems. This will allow us to develop age appropriate materials and to target the correct age group so that we can intervene at the appropriate developmental stage (Dr Greenwood, Tracy Johnson and Lucie Crowter). This will include both qualitative information from focus groups of children who watch cartoons (project 1), and quantitative questionnaire based data (project 2) on knowledge, attitudes and behaviour in children aged 7-11 from different demographic backgrounds. Both of these projects are completed and are outlined below.

Stage 2:

A consultation with parents (project 3) and teachers (project 4) as key stakeholders in children’s education, to determine their views about mental health, their approaches to communicating and teaching children about mental health and the factors that impact on this communication process. This will enable us to develop appropriate tools and resources that are user-friendly and acceptable to schools and families. Two distinct qualitative projects with data being collected currently using grounded theory (Dr Greenwood, Janine King, Joanne Mueller), and these will be completed in July 2012.

Stage 3:

A consultation with young people with mental health problems, to determine the barriers and facilitators to help-seeking such as stigma and self-stigma (project 5) and to agree on key messages to be included in the programme. Messages might include the continuum of mental health and ill health, the importance of talking and the role of friends and family in mental health and recovery (Dr Greenwood and Helen Glossop). This project will be completed in July 2012.

Stage 4:

A pilot randomised controlled study of a brief intervention based on two specially written stories, (Lori and the Little Blue Bird (based on OCD) and The Mystery of the Necklace in the Tree (based on Psychosis)) aimed specifically at 7-8 year old children (project 6). In the stories, the children will encounter people with mental health problems, either other children their age or an older sibling of a story character. The idea is to portray mental illness in a realistic way, but also in a way that does not stigmatise the person with problems. We know from a lot of other work that conveying friendships across groups of children, even if only observed indirectly via stories, can be a powerful way to change young people’s attitudes. Each story will be followed by a brief discussion led by the researcher and focussed on scaffolding and errorless learning to create positive schema around mental health and help seeking. The same stories have been re-written without references to mental health in order to form two control stories would be read to a separate group of children (i.e., a Control group), so that we can compare their views with the children who heard the original stories. Children will be randomised to either experimental or control condition. In each condition, the children will hear both stories for that condition (plus discussions) on two different days. The following week, they will then be asked to complete some short questionnaire data about their knowledge, attitudes and behaviour about mental illness (Dr Kathryn Greenwood, Professor Rupert Brown, Laura Ferassi (author), Kim Jamieson & Christine Carroll. This project is now completed and the outcome is summarised below.


Project 1: Exploring understandings of mental ill health and the emergence of stigma in primary school aged children.

Tracy Johnstone, Mary John and Kathryn Greenwood, University of Sussex


Stigma and discrimination against people with mental health difficulties has not improved significantly over the past decade. This is despite numerous statutory national level strategies and interventions aimed at changing already held stigma in adults and adolescents. Investigation into the development of stigma at primary school age may provide information for more effective strategies and interventions to promote positive attitudes and reduce stigma as knowledge of mental illness develops. There is a lack of local, current and methodologically sound research in primary aged children. This study aimed to explore children’s attitudes towards and their understandings of mental health difficulties. Qualitative data was collected, using semi-structured interviews, from six focus groups with children who all viewed four cartoons depicting children with mental health diagnoses. These cartoon vignettes were used as part of the study to elicit discussion of children’s knowledge and attitudes towards mental health difficulties. The four vignettes were developed to depict experiences that were seen to be an indication of mental health problems and to represent a spectrum of mental health conditions; from a simple phobia (dog phobia) through to a depressive episode, Obsessive Compulsive Disorder (OCD) and psychosis, which is representative of a more severe and enduring mental health problem. Thirty-three children took part in the study from school years 3-6 and from two separate primary schools in an urban town on the south coast of England. Focus group transcripts were analysed using Thematic Analysis.

Four main themes emerged from the data. These were: consideration of friendship, making sense of others, attitudes, and desire for certainty. A link between aspects of two of the main themes was identified as well as the influence of labelling and language. Additional sub-themes that related to the main themes included theory of mind, contact, search for meaning and availability of relevant schema. Children of primary school age had not yet fully developed their mental health schema and possessed both critical and sympathetic attitudes. A link was found between knowledge/understanding and more sympathetic attitudes. This was coupled with children actively searching for meaning and having a desire for certainty about social situations. Vignette type had an influence on children’s ability to make sense of the situation. The children generally struggled to use their already existing related schemata to make sense of the vignette that depicted a diagnosis of psychosis.

Stigma tended to emerge when children did not understand mental health behaviour and had no other language to describe it. This study suggests the development of an intervention program focussed on improving knowledge at this age might help to promote more positive attitudes relating to mental health.          

Diagram portraying relationships characterising the development of stigma in children


Project 2: Investigating the development of mental health stigma in children aged 7-11 years. 

Lucy Crowters and Kathryn Greenwood


One of the biggest barriers to the uptake of and adherence to mental health services is mental health stigma. The prevalence of mental health stigma has been widely researched in adults and adolescents, however less is known about mental health understanding in young children. This study aimed to examine attitudes as a function of age and gender and in relation to prior contact with and knowledge about people with mental health problems in children aged 7-11. Age-appropriate measures were developed from existing measures to assess children’s knowledge about and attitudes towards people with mental health problems, using vignettes describing OCD and Psychosis. Intergroup anxiety and contact (child’s self reported contact with someone like the vignette characters) was also recorded. Seventy-seven participants recruited from two primary schools completed the questionnaires. Multiple regression analyses were used to assess Age (Young (7-8) vs Old(9-11), Gender, and AgeXGender interaction as predictors of mental health knowledge, behavioural intentions and attitudes. Prior contact and knowledge were then added as predictors to investigate their independent effects and whether Knowledge acts as a mediator of Contact effects.

The results revealed that knowledge, attitudes and intended behaviour were all fairly positive (~4.0 on 5 point scale) and intercorrelated. Anxiety was generally low (<3.0).Boys show improvements in attitudes, behaviour and intergroup anxiety with age, while girls showed a slight deterioration in anxiety and behaviour.Prior knowledge was a reliable correlate of all measures; while prior contact was a weaker correlate, independent of knowledge.

The results suggest that providing knowledge and contact may influences attitudes and intended behaviours. These distinct interventions may be relevant for different ages and genders. Further work is required to understand the different age related responses of boys and girls, in order to tailor interventions to promote positive attitudes and behaviours and reduce anxiety.  


Project 6: Enhancing Young Children’s Views Towards Severe Mental Illness: The Development and Evaluation of an Intervention Combining Education and Extended Contact.

Christine Carroll, Kim Jamieson, Laura Ferassi, Rupert Brown and Kathryn Greenwood


The aim of this study was to design and evaluate the effectiveness of a short story-book intervention combining education and extended contact (contact with people with mental health problems through stories), which could be implemented with young children to improve mental illness schema (knowledge, attitudes and behaviour) and to reduce the likelihood of subsequent stigma development. A randomised between groups experimental design was used. Children (N = 42) aged 7-8 years were read short stories featuring characters with and without severe mental illness (Schizophrenia and OCD) in friendship situations, followed by a group discussion. A control condition heard similar stories but with all references to mental health omitted. Analysis of Variance was used to examine the effects of the intervention, controlling for gender. Regression analyses were then used to examine the potential mediators of those effects.

Finally, in light of the strong effect of knowledge in the earlier qualitative and quantitative studies, we also investigated the mediation of knowledge on the group effect. The intervention had a strong effect on all outcomes, leading to greater knowledge, more positive attitudes and intended behaviour towards people with mental illness and lower inter-group anxiety towards mental illness. Attitudes and behaviour were partly mediated by knowledge so that the more knowledge children had; the more positive were their attitudes and behaviour. These findings suggest that the combination of education and extended contact may be a successful strategy to promote positive attitudes regarding severe mental illness in young children.


An Excerpt from The Mystery of the Necklace in the Tree

Now it was time to talk about our mysterious case. Jack suggested going to the park in front of his house, because it was such a beautiful day. So Oliver, Hanna, Abbie, Jack and I headed for the park. Lori preferred to stay home to play with Jack’s cat. We all five sat under a big tree near a pond where ducks and swans swam.

"What do you all think about this?" Jack asked.
"About what?" Abbie said.
”About the necklace the caretaker has found on that branch," Jack said firmly.
"I reckon that the branch scraped along the bottom of the river and somehow caught the necklace, " Hanna said.

"It could be. Perhaps the necklace was thrown into the river by a thief, who was afraid of being caught with what he had stolen, so he threw it away, " Oliver said.
"Interesting idea,"  Jack said thoughtfully.

“Shut up!", suddenly we heard.
"What did you say Jack?" I asked.
"I didn’t say anything," he said.
"I said, YOU MUST BE QUIET! Why did you come to this spot when there are so many other trees in the park?", we heard again.
Suddenly, someone swung down from the tree above, right in front of us. Hanna and Abbie screamed with fright. None of us would ever have expected someone to swing upside down from above our heads like that!
"Oh Paul, give it a rest!", said Jack. "Guys, this is my brother Paul".

"I'm not your brother, I'm the brother of the trees. Only they understand me and only I understand them”, Paul said finally coming down from the tree to stand in front of them.