‘The challenges of sharing information when a young person is experiencing severe emotional difficulties’: implications for schools and CAMHS

BACKGROUND
Supporting the education of children and young people with complex emotional mental health difficulties requires schools to have knowledge of their needs. Exchanging information about less visible mental health difficulties is, however, known to be complex. Exploring the perceptions of young people experiencing problems can explicate some of this complexity and identify solutions. Yet their views are rarely given credence in this context.


METHODS
The findings were derived from a broader qualitative study exploring the school experiences of young people, aged 14-16 years, identified by CAMHS as having severe emotional difficulties. Their parents' and teachers' perceptions were also explored. Data were collected via semistructured interviews and analysed using thematic analysis.


RESULTS
Findings demonstrated that young people experiencing emotional difficulties need to feel safe about exchanging private information pertaining to their mental health. Teachers having a basic knowledge of mental health promoted their safety as this ensured confidentiality. Participants reported that CAMHS practitioners needed to be more proactive regarding the practicalities of exchanging information.


CONCLUSIONS
Arguably, teachers need to have basic knowledge of mental health and schools need clearer mental health confidentiality guidance. CAMHS also have responsibility in identifying more information exchange mechanisms and young service users and parents can play a part in this.


Introduction
Young people experiencing emotional difficulties, such as depression or anxiety are at an increased risk of experiencing problems in school (Kramer, Vuppala, Lamps, Miller, & Thrush, 2006). Negative school experiences can exacerbate mental health difficulties, hinder recovery and impact negatively on learning and attainment (Herman, Reinke, Parkin, Traylor, & Agarwal, 2009;Morrison-Gutman & Vorhaus, 2012). However, evidence suggests that positive school experiences can promote recovery and improve academic achievements (Greig, MacKay, Roffey, & Williams, 2015;Kutash, Duchnowski, & Nancy, 2006;Weist & Murray, 2007). It is therefore of upmost importance, during turbulent periods of a young person's life, that mental health providers exchange key information with schools so that problems can be proactively addressed and the necessary pastoral and learning support provided.
Education providers require necessary information about a young person's needs. Possible difficulties experienced should be shared, so that their needs can be accounted for in the educational environment. Arguably, this is especially important when symptoms of a mental health difficulty are less immediately visible. Attention, concentration or memory problems associated with illnesses like depression and anxiety can be overlooked or misread by teaching staff as behavioural problems (Cooper, 2010;Ford, Hamilton, Meltzer, & Goodman, 2008;Kramer et al., 2006;Reddy & Newman, 2009) and has implications for the way in which young people are treated in school. Furthermore, because of a limited insight by teachers into the child's complex difficulties, they are less likely to proactively manage detrimental school-related problems such as bullying and exam stress.
Current policy and guidelines place a heavy emphasis on the importance of information sharing between mental health providers and schools. To date, however, much of the work conducted has focused on establishing firmer multiagency communication processes. For example, British schools use the multidisciplinary assessment and management protocol known as Common Assessment Framework (CAF), otherwise known as the Early Help Assessment. British health services sometimes, use the Care Programme Approach (CPA) when a child is experiencing more complex mental health difficulties (Department of Health [DH], 2015). The aim of these protocols being to ensure professionals exchange key information and work together to address the child's holistic needs, welfare, development and educational problems (Children's Development Workforce Council, 2009). Evaluations of these protocols suggest they can ensure better family support (Oliver, Mooney, & Statham, 2010). The CAF protocol does however rely heavily on families voluntarily participating. The CPA process can be complicated by ethical and legal issues, but in the main still relies on young people and their parents consenting to personal information exchange. An additional complexity hampering health information exchange is the fear of mental health stigma (Bowers, Manion, Papadopoulos, & Gauvreau, 2013;Zisman-Ilani et al., 2013), which may also hinder families from fully participating in protocols designed to help them.
Notably countries such as the United Kingdom are moving towards schools taking a more active role in supporting children with mental health difficulties on school premises i.e. via counselling or other school-based therapeutic interventions (DH, 2015). It is therefore timely that the complexities of information exchange between mental health providers and teaching staff are more thoroughly explored. This is because few studies focus on young people's or parent's preferences about the process of information exchange and the disclosure of mental health-related information to school staff (Kramer et al., 2006).

Aims of the paper
The focus of this study was to explore the perspective of young CAMHS service users, along with the perspectives of their parents and teachers. Specifically, examining their views on how mental health information might be better exchanged and disclosed with the school. The findings reported are derived from a broader childcentred study. That broader study investigated how school pupils, aged 14-16 years who were identified by CAMHS as having serious emotional difficulties, perceived they could be better supported at school. The rationale for the research was to obtain a richer insight into the school needs of these young people because their perspective on their school experiences has rarely been explored (Cooper, 2010). Obtaining their viewpoints, alongside the perception of their parents and teachers, gave important insight into their school experiences, as well as exploring how services such as CAMHS and schools can better assist young people. A central issue discussed by all groups of participants was the sensitivity of information exchange.

Methodology
A qualitative thematic design was adopted, and to ensure consistency in its epistemological position, it was underpinned by macrosocial constructionism theoretical framework. Macrosocial constructionism is a theoretical position advocating that versions of reality are shaped by participants themselves, and linguistic and social structures shape the social world (Gubrium & Holstein, 2008). Macrosocial constructionism forms the basis of many studies exploring children's experiences (Fraser, Lewis, Ding, Kellett, & Robinson, 2004). This is because there is a widely held viewpoint that childhood, and indeed parenthood, are social constructed phenomena and are subject to change depending on the knowledge and discourse of the day (Greig, Taylor, & MacKay, 2007;Roy-Chowdhury, 2010).

Sampling and recruitment
A purposive sampling technique was used to ensure the inclusion of young people with identified emotional difficulties, their parents and teachers. CAMHS professionals identified fourteen young people aged 14-16 years. Seven children were receiving CAMHS support for depression and seven for anxiety-related problems. Many had comorbidities like eating problems or selfharming behaviours. The sample represented both genders and different socioeconomic backgrounds. All the children were domiciled with their parents and all, at the time of interview, were receiving outpatient treatment at CAMHS. Children with a primary diagnosis of ADHD were purposefully excluded from the study because their behaviour was likely to be more visible and easier to detect (Dupaul, Weyandt, & Janusis, 2011;Power et al., 2012). This was also the case for those diagnosed with autism as their problems are known to be complex and more difficult to evaluate (The National Autistic Society, 2010).
The young participants and parents when interviewed named a supportive teacher who was subsequently invited to participate. Nine teachers, from different mainstream schools in England participated. Sampling adequacy followed the saturation procedures of Francis et al. (2010) and was achieved within and across populations, which was appropriate for this approach (O'Reilly & Parker, 2013). Within the teacher sample, however, the checking recommendation (of +3) as recommended by Francis et al. could not be assured because not all young people provided a contact. Thus, while the stopping criterion did occur within the teacher sample, saturation could not be verified.

Data collection
Due to the sensitive nature of enquiry and the need to gain richer insight into participants' worlds, semistructured interviews were used (O'Reilly & Dogra, 2016). For practical and ethical reasons, these lasted approximately 40 min. Each participant was asked the same three broad questions: what they felt their school did well, what their school could do more of and what they felt hampered their needs from being addressed. Notably, participants were not asked specifically about CAMHSschool information exchange and yet many volunteered information about this.
Data collection for the young participants was facilitated by participatory techniques. To encourage them to freely express their views, short film vignettes were digitally developed. These vignettes depicted different children experiencing various emotional situations in school. For example, Vignette 1 depicted 'Darren', 15 years old, who had arrived late to class looking sad. Vignettes were sometimes shown to the young participants on an iPad when the researcher felt they were less confident in speaking about their own school experiences. In these cases, speaking about the character encouraged them to talk about their own school situation. The vignettes were also used to steer the young participant back to the matters needing further indepth exploration.

Ethical issues
Ethical approval was secured through the National Research Ethics Service (UK). Informed consent was given by all participants and transcripts were made anonymous and purposefully coded to prevent deductive disclosure.

Analysis
Data were analysed using thematic analysis due to its meaning-making focus (Braun & Clarke, 2013). The data were transcribed verbatim and NVivo facilitated coding frame development (Boyatzis, 1998). The broader project revealed 42 young persons, second order codes; 64 parent codes; and 50 teacher codes, which collapsed into 15 themes related broadly to perspectives of mental and emotional wellbeing and education. Intercoder reliability was achieved through multiple readings of the transcripts and repeated listening of the data, and assured through a team approach to the final coding frame and then agreement on the final themes. The focus of this paper is on the five themes that related to information exchange as sharing information was a central and important issue that arose from the broader project. This paper reflects 14 young persons, 22 parents and 15 teachers second order codes.

Results
The young participants and parents concurred that, if their schools had a better understanding of their mental health difficulties, it was possible they would be better supported educationally and this would facilitate recovery. The young people and their parents needed, however, to feel safe and secure at school before feeling confident to exchange 'need-to-know' information. Five themes were identified which were: (a) mental health knowledge, (b) confidentiality, (c) collaboratively deciding, (d) CAMHS practitioners being the conduit and (e) resistance to information sharing.

Theme 1: Mental health knowledge
Most young people (n = 12) did not feel secure in informing their teachers they attended CAMHS and generally, parents agreed. The main reason was they did not feel that teachers had a good understanding of mental health, which had implications for risks of being misunderstood and misjudged.
It just feels like they [teachers] don't understand me. . . what I am going through. (YP 1, Female 14 years) I just think they need to be educated more on the kind of problems that young people have like self-harm and that kind of thing because literally teachers . . .. . . will just kind of look in disgust at you. (YP 9, Female 15 years) Perspectives that teachers might hold negative attitudes were commonly expressed by young people. Their statements implied that if they revealed their difficulties this could lead to negative consequences. This included issues such as a 'look in disgust' or they felt that their teachers would fail to understand the nature of their problem 'they don't understand me'. They believed a consequence of this limited knowledge was teachers were powerless to help. The young people, therefore, proposed a solution; that teachers 'need to be educated'. Some young participants and parents gave further insight into the potential benefits of teachers becoming more educated about mental health. I think if they had more awareness or more knowledge; one of the problems when I have to talk to them is that I feel I have to explain myself which at times can be quite agonising. (YP 6, Male 16 years) I think they could do with going on courses about it, to realise how much it does affect people because I think schools, it's different now, they all have their targets to meet and stuff. (Mother A, of YP 16 years) Notable were the extreme phrases the young people employed when describing the daily emotional challenges faced. For instance, the term 'agonising' described how YP 6 felt when his teachers did not have the requisite knowledge to help him. Parents recognised these challenges because they spoke about teachers being inadequately trained to cope with their child's needs. Up-skilling teachers was, however, perceived to be challenging as 'they all have their targets to meet'. Many of the young participants (n = 7) and parents (n = 10) perceived teachers put attainment before wellbeing and were considered by many parents as detrimental.
Teachers acknowledged addressing attainment and wellbeing was a challenge because they were stretched in their role already. They perceived workload pressures meant additional training in mental health was more likely to be perceived as a burden. Despite this difficulty, they concurred that having some knowledge of mental health problems would help them (n = 6). Such knowledge they felt may enable them to better support children with complex mental health difficulties.
I only did one training course and that was on bereavement so I think that would have been better for me to have more training but . . . I think it's getting the right people for the job not everyone wants to deal with everyone's issues. (Male Teacher K) We are offered training from time to time which I would always take up, um but primarily my job really is being a maths teacher and the pastoral side almost comes second really. (Female Teacher J) These teachers voiced a fundamental challenge; the availability of training, as opposed to dispositional opposition on their part 'you just don't get offered things like that very often' or 'we are offered training from time to time'. Problematically, resources are an issue for joint working to be successful, particularly in an age of austerity and public spending cuts . Nonetheless, Teacher K pointed out that not all teachers are characteristically supportive and, therefore, were not likely to be interested in this type of training. Teacher J supported this and conveyed an opinion that the pastoral role is secondary to teaching. While this demonstrates the pressure faced by teachers to meet targets, it does contradict evidence suggesting the roles are mutually important when promoting learning (Charlton & David, 2012).
Theme 2: Mental health confidentiality A significant factor in the success of joint working between CAMHS and education is communication and it is essential to consider how this might happen effectively and privately (Sloper, 2004). Indeed, confidentiality was an issue raised by many young participants (n = 10) and parents (n = 8). All participants conveyed the importance of ensuring schools upheld safe working practices when it came to the exchange of private information pertaining to mental health. I think the school could be supportive if they knew about it. I have the feeling it will not always be totally confidential, I just don't know whether something will be written somewhere and that person will have access to that file. (Mother G, of child 15 years) Young people and their parents agreed there were serious concerns regarding the sharing of information, and what happens once it is available to the school. Young people expressed fear that teachers would engage in 'gossiping' 'in the staffroom all talking about me'. This concern was shared by parents who feared a breach 'it will not always be totally confidential'. The reasons for the fear were because they felt it would leave their child vulnerable to victimisation and stigmatisation, consequently exacerbating their emotional state. Of note is that all parents expressed (n = 16) fear their child's mental condition could worsen. Teachers also recognised the issue of confidentiality and expressed concern about their ability to safely handle mental health information (n = 8).
There are things that I have passed on then I have thought have I done the right thing because is it breaching that kind of trust? (Female Teacher Y) I had a child once . . . I was concerned because she had all these cuts and I didn't know whether her parents should be informed or you know what to do so you know I think training on that would be good. (Male Teacher K) The limits of confidentiality are a professional concern for teachers who by virtue of their profession must take the issue seriously. The complexities teachers experience when dealing with these issues were conveyed. For instance, information channels from schools to parents caused some tension, as teachers needed to tackle decisions about what they should or should not reveal to parents. Some teachers expressed that they would value some training 'I think training on that would be good'.
Many teachers spoke about relying on the school's safeguarding protocol when supporting children in distress. A tension was, however, expressed by teachers in distinguishing a safeguarding concern from the need for confidential support. This was also recognised by the young people.

Theme 3: Collaborative decision-making
The possible tensions concerning confidentiality and safe information sharing from all three groups suggest a need for a more collaborative approach to decision-making. Indeed, the UN Convention on the Rights of the Child (1989) advocates the need to involve children in all decisions affecting them. This child-centred approach was reflected by the participants as all agreed there were benefits in exchanging information, provided teachers were accepting of emotional distress. Young people welcomed being involved in decision-making. The problem, however, was knowing what information should and should not be exchanged. All young participants and parents felt it was their CAMHS practitioners who should help. Thus, the collaboration was between families and CAMHS, rather than families and schools.
It was important because it gives somebody a quick understanding, of ah, that's why we have got to this point. If you don't have that explanation, it doesn't have to be that I have to talk about what has happened in his background, I don't particularly want to tell anybody, because it is none of their business but just the understanding of going to CAMHS for this. (Mother P, of child 16 years) Parents (n = 13) emphasised the need to withhold the complexities of the problem from the school, but argued there was a need to provide just enough 'need-to-know' information to ensure that their child's needs were met. This was considered essential to avoid unfair consequences, such as threats of exclusion, due to misunderstanding the child. Parents reported that it often took communication from them to ensure that exclusion was prevented. The young people (n = 9) concurred they needed help in determining what information should be exchanged.
I actually spoke to my counsellor at CAMHS and um she helped to set out the options, and then yeah, I said to the teacher I don't think I can do this paper and she said ok you can resit it. (YP 14, Female 15 years) Young participants and parents suggested CAMHS professionals could help in making decisions regarding what key 'need-to-know' information should be passed onto schools. This viewpoint was demonstrated by one father who described how his daughter initially kept her concerns secret and it was only following acute admission to hospital that her school became aware. At this point, the CAMHS in-reach schooling team helped improve his daughter's school experiences. When ((names child)) started back, there was a sort of you know it had to be mentioned by in-reach; . . .. . .The small bit of understanding that the teacher can take on board, they don't need to know what has happened to ((names child)), but they need to be aware that something has happened. (Father F, of child 16 years) This father's statement described how an important part of his daughter's reintegration back into school involved the CAMHS in-reach teacher discussing what personal information the teachers needed to know. Together, they made decisions regarding the young person's possible responses when asked questions. This father believed that these collaborative decisionmaking conversations helped his daughter better understand the importance of sharing information with the school and ascertained the nature of that information.

Theme 4: CAMHS Practitioners being the conduit
Young people (n = 9) and their parents (n = 8) felt information exchange was generally poor. This is consistent with research in the area which demonstrates that communication is a challenge for joint working . Young people were clear they wanted CAMHS professionals to pass on information, so their teachers could better assist them. They felt that the epistemic position of CAMHS professionals would be persuasive, which could assuage any negative attitudes or disbelief teachers may hold.
The thing is with teachers they don't really believe it if they hear it from a student. They have to hear it from a medical professional or at least a parent. (YP 4,Female,aged 16 years) From a young person's perspective, it is evident that they felt that their views were not taken seriously. Despite a contemporary emphasis on child-centredness, in practice it seems that children feel their views are less valuable than adults. Thus, there is still an adult-centric position being adopted, at least in the context of mental health. Given the disempowered position occupied by young people, parents felt placed in the difficult position of acting as the conduit between CAMHS and schools. They viewed, however, this role as central to protecting their child's welfare. They [school] are still waiting for a letter from the consultant, they won't do it just because parents say so. (Mother X of child 16 years) I mean, I had to write and say to the teacher that ((names child) needs a stress ball, but they took it off her. (Mother U of child 14 years) The epistemic authority of different parties was a negotiated difficulty for families as they tried to find an appropriate way of managing the challenges their child faced because of the emotional distress. While parents did have some power to communicate with schools about appropriate strategies, ultimately there was a need for professional interagency communication to ensure they were taken seriously. This is especially important because parent relations with the school, if not taken seriously, can be eroded.
Theme 5: Resistance to information sharing A challenge to information exchange was the negative feelings of the young people. Parents reported a helplessness and felt tension between respecting their child's wishes and the need for information sharing. From the young person's perspective, there were concerns about the involvement of parents in information sharing. For example, some believed their parents would unintentionally complicate school issues (n = 3), that parents' knowledge of school difficulties may cause additional problems at home (n = 3) or parents knowing about school worries might cause an ill parent additional stress (n = 4). Interestingly, young participants referenced the issue of parental school involvement approximately only eight times, whereas their parents referenced this approximately 362 and their teachers 57 times.
Information sharing is clearly complex and requires sensitive handling, particularly when there are issues about how information should be transmitted with disagreement between parents and teachers. Parents wanted more face-to-face meetings with interagency staff to ensure key information was not missed. Teachers voiced that a key disadvantage of meetings was that they were time-consuming and resource intensive.
Obviously I went in to see them and they sort of like said, you know, this is what we would like to do if you agree, and obviously I said, yes, and every, I don't know, sort of like every three months we'd go in and we'd both have an update. (Mother H of child 14 years) Illustrated here is an empowerment given to parents to be involved in their child's education through meetings. The school actively sought her opinion and regular updates in the form of meetings were viewed positively. Other parents did, however, highlight a disadvantage of formal meetings was that they often did not happen because they relied on teachers and healthcare professionals surrendering time from their busy schedules.
The school were meant to be setting up a meeting with us once a week, it happened once. They don't follow it through . . . they are busy. (Mother U of child 14 years) Importantly, the young people, in contrast, did not value interagency meetings, but instead sought more simplistic methods of information exchange such as letters or emails. I think ((names CAMHS clinician)) could maybe write a letter to the school and say how serious I have got. (YP 1, Female 14 years) Some participants did, however, highlight that even with written confirmation from CAMHS some school staff were sceptical and they were not always taken seriously. This reflects the issues raised in theme one, that of the need for mental health knowledge. Thus, mental health knowledge, confidentiality and CAMHS information exchange are interlinked as depicted in Figure 1 below.
To summarise, the young people felt that their schools could play a more important part in their recovery if they knew and understood more about their mental health difficulties. They did, however, feel when it came to information exchange they had a priority need, as illustrated in Figure 2.
First, for schools to better support them with their mental health difficulties, their school staff must have basic mental health knowledge; this would ensure information was handled confidentiality. When school staff understood the sensitivity of their mental health issues, they felt they were more likely to feel safer about sharing their mental health difficulties with their schools. They did, however, feel they needed help in identifying what information should and should not be exchanged and identified their key CAMHS professional to be best placed to help them with this.

Mental health Knowledge
Professional handling of confidentiality CAMHS exchanging information that matters

Discussion
This study has exposed some of the complexities of children communicating mental health difficulties to their school staff, highlighting how difficult it is for teachers to identify children experiencing less visible distress (Cooper, 2010;DfE Guidance, 2015). The findings provide some insight into how CAMHS information exchange with schools could be improved. This is important because in exploring the perceptions of young participants with emotional difficulties, some insight is provided into why many children remain silent about their difficulties. This is consistent with previous research demonstrating the needs of young people with neurodevelopmental difficulties who are also reluctant to seek support from teachers because of stigma and a limited knowledge amongst school staff (Walker, Coleman, Lee, Squire, & Friesen, 2008;Wiener et al., 2012).
Ultimately, the first step in ensuring information can be exchanged is the need for schools to cultivate a firmer bedrock of emotional understanding for those experiencing mental health difficulties. The importance of the school milieu being caring and supportive has frequently been emphasised by literature focused on promoting universal pupil wellbeing (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011;Humphrey, 2013). Also well-known is how help-seeking behaviour is stifled when a nurturing caring school environment is not evident, consequently leading to young people suffering in silence (Kendal, Keeley, & Callery, 2014). Such lack of support subsequently impacts negatively on the child's learning and attainment. Teachers having a better knowledge of mental health issues could improve the school environment as emotional distress of pupils would be better detected and supported.
Debatable, however, is how to promote mental health knowledge in our schools. Many interventions have been trialled in schools, aiming to promote mental health knowledge and improve attitudes. For instance, universal antistigma programmes have shown positive results especially when a whole school approach is taken with staff as well as pupils participating (Weare, 2015). However, it is necessary to acknowledge that society's attitudes towards mental health are far-reaching and complex and, therefore, change is likely to be slow.
Globally, school programmes known as Social Emotional Learning (SEL) programmes have also been introduced into schools. These programmes aim to promote pupil and teacher wellbeing and resilience by improving the emotional literacy of all in the school. In some countries, these programmes have demonstrated positive impact on the emotional literacy of students (Zins, Bloodworth, Weissberg, & Walberg, 2007), but it is acknowledged there is no guarantee that these programmes lead to positive long-term impacts (Banerjee, McLaughlin, Cotney, Roberts, & Peereboom, 2016). For instance, the United Kingdom's programme known as SEAL had limited impact in secondary schools. This was mainly due to these larger schools finding it difficult to embed SEAL into their attainment driven school culture (Wigelsworth, Humphrey, & Lendrum, 2011).
More conventional mental health teaching workshops, aimed at teachers, like the Australian developed 'Mental Health First Aid' have shown promise with evaluations suggesting teacher confidence is elevated posttraining (Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010). A recurrent theme, however, amidst the various programme evaluations, is that secondary school teachers do not have time to take part in this type of activity. This suggests the UK's Carter review of initial teacher training (Carter, 2015) and Weare's (2015) recommendations that more student teachers should learn about mental health when undertaking initial training is a sensible way forward. Caution should be levered however, as implementing mental health on the training curriculum for preservice teachers cannot produce instant results.
An important issue highlighted by parental and young person's voices was that a key barrier to information exchange was confidentiality. Research has highlighted how confidentiality is a chief barrier to children seeking psychological assistance (Kendal et al., 2014). Yet, larger scale work has not been carried out investigating mental health confidentiality in schools. The ambiguity of confidentiality makes this particularly important (Moyer & Sullivan, 2008). Participants in our study suggested that confidentiality has been complicated by safeguarding protocols, which have confused teachers; therefore, arising from this is a potential to cause emotional harm. A more defined confidentiality code could, therefore, promote school security and encourage children to share information.
Enhanced mental health knowledge and confidentiality alone cannot facilitate safe information exchange. Child-friendly information exchange protocols need to also be developed. This is important because teachers are often not notified about the problems a child has or how to help them. Yet without information, tailored learning and pastoral support cannot happen. The findings indicated that CAMHS are best placed to play an active role in developing protocols in helping families decide what 'need-to-know' information may help educationally. Interestingly, it was also suggested CAMHS professionals may learn from their CAMHS in-reach  schooling colleagues. Their protocols are, however, not widely recorded or disseminated. Perhaps most importantly, even if mental health provision is expanded in our schools ultimately, the complexity of relying on children and their parents to exchange information will not go away. It is, therefore, more important than ever to ensure our schools feel safe enough for children and parents to feel they can exchange personal information and to ensure this happens their opinions must be sought more proactively. Multiagency professionals, therefore, need to address how young people and parents can be included in decision-making processes. This is because young people do not always share the same perspectives as adults and, despite the abundance of guidance advocating childcentredness, their opinions are still not being considered seriously enough. This may be because of complex barriers hindering their voices being heard, like adult-centric attitudes, which is positioned as a dangerous practice (Munro, 2011). Additionally, the lack of time to listen to young people makes involving them difficult. Protocols like CAF and CPA must, therefore, aim to ensure their involvement is not tokenistic and more processes must be developed to ensure their voices and opinions are considered.

Conclusion
Mental health and learning are intrinsically linked. To thrive and achieve at school, young people with complex mental health difficulties require additional school support. At present, however, many are choosing not to tell their teachers about their difficulties because they feel insecure about exchanging personal mental health information. Complex barriers of stigma, lack of mental health knowledge amongst school staff and formalised processes are hindering information exchange. Schools and CAMHS must, therefore, work together to strengthen information exchange. First, schools need an emotionally supportive environment, which requires school staff to have more mental health knowledge, so they are better equipped to handle confidentiality. CAMHS must also play a role in involving young people and parents in collaborative decision-making, deciding what information is exchanged and how. Most importantly young people must be involved in shaping new information protocols as they often do not share the same opinions as adults and their voices are presently not being given sufficient attention.