Mental health first aid: when does a pastoral concern become a medical one?

Yesterday, the Children's Commissioner for England published its latest report, Over a million children referred to mental health services, with highest annual referrals as demand rises faster than systems can respond. The findings highlight the growing demand for children's mental health support across the country and the increasing pressure on schools to identify and respond to pupils who may be struggling.

❗ More than a million children in England had active referrals to mental health services in 2025 – nearly double the 2018-2019 figures. (Children's Commissioner)

❗ By the end of March 2025, more than 60,000 children had been waiting over two years to access mental health treatment – an increase of more than 15,000 compared with the previous year. Children waited an average of 224 days to receive support. (Children's Commissioner)

❗ In 2023 already, it was estimated that more than one in five children aged 8-16 had a probable mental health disorder, rising to over 23% among those aged 17-19. (NHS England)

These figures are not just numbers. They represent real children in real classrooms, many of whom are turning to the adults around them for support before they ever reach a specialist service. Schools play a vital role: it's often the first place where concerns are noticed and where children seek help.

Most of the time, concerns can be managed through pastoral care, wellbeing support, and early intervention. A pupil who is withdrawn, distressed, overwhelmed, or behaving differently may simply need pastoral support. However, some changes in behaviour can be a sign that a pupil is experiencing a mental health crisis and needs urgent help. Knowing the difference is important.

In this edition of The First-Aid Room, we explore how to distinguish between pastoral concerns and more serious mental health issues in pupils, including the key warning signs that may indicate a need for escalation. We also outline what staff should do when a concern becomes urgent, and how to follow safeguarding procedures and access external support to ensure pupils receive timely and appropriate help.

Understanding mental health in schools

Mental health exists on a spectrum. Just as physical health changes, emotional wellbeing fluctuates, and much like adults, children and young people can experience changes in their emotional wellbeing.

Supporting children's mental health is becoming an increasingly important part of school life. In fact, for many school staff, supporting pupils' emotional wellbeing has become an everyday part of the role, whether pupils' distress is due to exams, friendship difficulties, family challenges, anxiety about school, or simply a bad day. The government's latest white paper, Every Child Achieving and Thriving, reinforces the important role schools play in helping pupils feel safe, supported, and ready to learn.

Good mental health helps pupils attend school, engage with learning, build positive relationships, and reach their full potential. A whole-school approach to mental health and wellbeing can help create an environment where pupils feel able to ask for help when they need it.

Emotional ups and downs are a normal part of growing up. A pupil may feel anxious before an exam, upset after a falling-out with a friend, or withdrawn following something difficult at home, and while these experiences can feel overwhelming, they don't necessarily indicate a mental health condition. At the same time, some pupils experience more significant difficulties that affect their ability to learn, attend school, maintain relationships, or cope with day-to-day life. The real challenge for school staff lies in recognising the difference.

Importantly, schools are not expected to diagnose mental health conditions, provide counselling or therapy, or solve the problem. But discerning the signs of a mental health crisis, responding appropriately, and knowing when concerns should be escalated can make a real difference in helping struggling pupils access the right support.

What is "mental health first aid"?

The phrase "mental health first aid" can sound daunting, particularly for staff who have never supported a pupil experiencing emotional distress before, but in practice, it's simply about recognising when a pupil may be struggling, responding with empathy, and helping them access the right support. Often, the most important things school staff can do are to stay calm, listen without judgement, and make sure the right people are informed.

There is no expectation to have all the right answers. Just as school staff wouldn't be expected to diagnose the cause of chest pain before seeking medical help, they are not expected to diagnose mental health conditions. Their role is to recognise that something may be wrong, offer initial support, and follow the school's safeguarding and wellbeing procedures.

Understanding where professional responsibility begins and where it should be shared with others helps ensure pupils receive the right support while giving school staff the confidence to act when a child or teen indicates they need help.

What school staff can do if a pupil appears distressed

✅ Stay calm: Your response can help set the tone for the conversation. If a pupil sees that you are anxious or alarmed, it may heighten their own distress. Speaking calmly and moving at a measured pace can help create a sense of safety. Being a calm, reassuring presence is often the most important thing you can offer in that moment.

✅ Move to a quiet space: Where possible, move the pupil away from busy corridors, classrooms, or other pupils. A quiet room or pastoral space gives them the privacy to speak more freely and can help them feel more comfortable to discuss what is on their mind.

✅ Take pupils' concerns seriously: Even if a concern seems small, it may feel overwhelming for the pupil. Taking the time to listen, acknowledge how they are feeling, and respond with kindness can help them feel safe and supported. Avoid dismissing or minimising what they are sharing: every disclosure deserves to be taken seriously.

✅ Listen without judgement: A pupil who is struggling may already feel worried, frightened, or ashamed about how they will be perceived. Where possible, try to avoid evaluating, questioning, or challenging what they are telling you. Let the pupil lead. Avoid interrupting, offering immediate solutions, or steering the conversation towards what you think the problem is. While there is no perfect script, simple responses such as "Thank you for telling me", "Take your time", or "I understand" can help them feel heard and supported.

✔️ Helpful phrases include:

• • "I'm glad you told me."
  • "You don't have to go through this alone."
  • "I'm not going anywhere — take your time."

❌ Try to avoid phrases such as:

• • "I'm sure it's not as bad as it seems."

  • "You have so much to be grateful for."
    

  • "Other people have it worse."
    
    

These responses, however well-intentioned, can cause a pupil to shut down or feel like their experience is being dismissed. Staff's role in these moments is not to minimise or solve but to listen, stay present, and make sure the pupil knows help is available. In many situations, simply feeling heard and supported can help reduce a pupil's immediate distress.

✅ Allow the pupil to talk at their own pace: Rushing the conversation or finishing the pupil's sentences may cause them to withdraw. Give them the time and space they need, and allow them to decide how much they want to share.

✅ Let them know support is available: Pupils in distress may feel that no one will understand what they are going through or that things can't get better. A simple reassurance that you have listened, that you take what they have shared seriously, and that they are not alone can make a significant difference. Let them know there are people who care and that they will be supported to get the help they need.

✅ Record your concerns: If a pupil discloses a mental health issue or is involved in a mental health incident, make a clear record of what happened as soon as possible. Accurate records help ensure the pupil receives consistent support and allow relevant staff to build a clear picture if concerns continue over time. Keep your notes factual and objective. Record what the pupil said, using their own words where appropriate, what you observed, what action was taken, and who was informed.

✅ Share concerns and follow your school's safeguarding and wellbeing procedures: If you're worried about a pupil, follow your school's safeguarding and wellbeing policies and speak to your designated safeguarding lead (DSL) or another appropriate member of staff as soon as possible. Seeking advice is part of good safeguarding practice and helps ensure pupils receive the right support at the right time. Sometimes, a concern that seems small on its own forms part of a bigger picture that only becomes clear when information is shared.

🎯 If your school uses Medical Tracker, our integration with CPOMS means that mental health and wellbeing incidents can be logged and shared with your safeguarding team in one place. This helps ensure the right people have the right information at the right time, without duplicate data entry.

Involving parents and carers in mental‑health concerns

Schools work best when parents and carers are involved, but there may be occasions when deciding how and when to share information is not straightforward, particularly when a young person has asked for information not to be shared.

As a general principle, if there is any concern that a pupil may be at risk of harm to themselves or others, this information must be shared with the appropriate safeguarding leads and, where appropriate, parents or carers. Pupils should be told sensitively that while their privacy is respected, school staff have a duty of care that means some information cannot be kept confidential.

Where there is no immediate risk, decisions about involving parents or carers should be guided by professional judgement and your school's safeguarding procedures – this may include discussing concerns with your DSL – and should always be made with the pupil's best interests at the centre.

🎯 If your school uses Medical Tracker, you can manage which staff members can access pupils' information, including sensitive data related to mental health, by setting user permissions and role-based access controls.

If you do need to contact a parent or carer, framing it as "We've noticed your child has seemed a little unsettled recently, and we wanted to check in together" often feels less alarming than leading with clinical language and is more likely to result in a positive, supportive response from home. However, in some cases – for example, where there are concerns about the home environment – parental involvement may not be the most appropriate first step.

If you are ever unsure, follow your school's safeguarding procedures or speak to your DSL before contacting the pupil's family. They can help you decide what is in the pupil's best interests and how best to approach the conversation.

💡 Good to know: School staff do not have to promise confidentiality. Where you may need to involve parents or carers, let the pupil know that while you will treat what they tell you with care and respect, you may need to share it with the appropriate people if you are concerned about their safety or the safety of someone else. Being honest from the outset helps build trust and ensures pupils receive the support they need.

When does a pastoral concern become a medical concern?

Sometimes there is a single event or disclosure that makes it clear a pastoral concern has become a medical one. More often, however, it's a gradual change in a pupil's behaviour, mood, or presentation that signals they may need additional support. When assessing a pupil's emotional wellbeing, staff should consider the severity of symptoms and whether the pupil's safety is at risk.

Some warning signs that a pastoral concern may require escalation include:

• Significant changes in behaviour or personality

• Sudden deterioration in attendance, engagement, or academic performance

• Withdrawal from peers and school life

• Not wanting to engage in activities they used to enjoy

• Persistent distress that is not improving

• Extreme anxiety or panic that prevents the pupil from functioning
• Expressions of hopelessness or worthlessness

• Self-harm or disclosure of self-harm

• Suicidal thoughts or statements

• Refusal to eat or drink

• Concerns about eating disorders

• Hearing voices, seeing things that are not there, or appearing disconnected from reality

• Any indication or disclosure that the pupil may be at risk of harming themselves or others

While not every concern requires emergency medical treatment, these signs should be taken seriously and managed in line with your school's safeguarding and mental health procedures. 
If something feels significantly different or concerning, it is usually worth seeking advice and escalating concerns appropriately.

💡 Good to know: Many mental health conditions develop gradually: changes in a person's thoughts, feelings, or behaviour may be subtle at first and become more noticeable over time. However, changes can also occur rapidly. as sudden deterioration may be triggered by a traumatic event, overwhelming stress, or certain mental health conditions.

Recognising mental‑health emergencies in school

Most mental health concerns can be managed through planned support and referral pathways. However, some situations require urgent medical assistance.

When Immediate Emergency Action Is Required

Call 999 or seek emergency medical help immediately if a pupil:

• Has taken an overdose or is suspected of taking an overdose
• Has seriously injured themselves
• Has attempted suicide
• Is expressing an immediate intention to end their life
• Is experiencing severe confusion or psychosis
• Appears detached from reality and unable to keep themselves safe
• Is posing an immediate risk to themselves or others

In these situations, treat the incident as you would any other medical emergency: stay with the pupil, follow safeguarding procedures, and seek emergency assistance.

When a situation is urgent but not an emergency

Not every situation where a pupil is in distress requires emergency services, but it may still require urgent action and escalation.

If you are concerned about a pupil’s mental health or wellbeing, but they are not in immediate danger, there are several other routes for support.

Your first step should always be to follow your school’s safeguarding procedures and speak to your DSL or a senior colleague. They can help assess the level of risk and decide on the most appropriate next steps.

Depending on the situation, this may include:

• Contacting the local CAMHS crisis or urgent mental health line, where available, for same-day specialist advice and support

• Arranging an urgent GP appointment, which can help initiate faster access to mental health services or further assessment

• NHS 111, which can guide families towards local urgent mental health support where appropriate

These pathways can provide timely help when a situation feels concerning but does not meet the threshold for emergency services.

Knowing these options in advance means decisions don’t have to be made under pressure. Where possible, it is helpful for schools to agree clear internal processes with their safeguarding leads so staff feel confident about what to do and who to contact.

Supporting pupils after a mental health incident

Support does not end once the immediate crisis has passed. Pupils may feel embarrassed, anxious, or worried about returning to lessons after a mental health incident.

Schools can help by:

✅ Creating a supportive reintegration plan

✅ Working closely with parents and carers

✅ Liaising with external professionals where appropriate

✅ Identifying reasonable adjustments that may help the pupil

✅ Monitoring wellbeing over time

A supportive response can make a significant difference to a pupil's recovery and confidence.

Mental health concerns are becoming increasingly common in schools, but most pupils who are struggling simply need someone to notice, listen, and help them access the right support.

School staff are not expected to diagnose mental health conditions or have all the answers. By recognising when a pupil needs more than pastoral support, responding calmly, and knowing when to seek further help, they can play an important role in keeping children and young people safe.

Sometimes, the conversation that starts with "Are you okay?" can be the first step towards a pupil getting the help they need.

Supporting resources

👉 Responding to a distressed pupil - Quick Guide for School Staff