Articles and Briefings

Mental Health Promotion for Children, Young People and their Families

BRIEFING PAPER
Dr Lois Lodge MB ChB, MSc, FFPHM, September 2006

Contents

0. Introduction
1. What is mental health?
2. What is mental health promotion?
3. Early interventions
4. Adolescence and health promotion interventions
5. Cultural issues
6. Conclusions
7. Annex A: Risk Factors
8. Annex B: Questions to Ask
9. References

Introduction

National attention was drawn to services for children and young people with mental health problems (CAMHS) by their inclusion in the Department of Health’s public service agreement (PSA) with the Treasury in 2002. This contained the objective of improving ‘life outcomes of adults and children with mental health problems through year on year improvements in access to crisis and CAMH services...’ and was subsequently reinforced in the Priorities and Planning Framework 2003-2006 (Department of Health 2002). All CAMHS were expected to provide comprehensive services including mental health promotion and early intervention by 2006. Underpinning these objectives was the ‘national capacity assumption’ that services will grow by at least 10% each year according to agreed local priorities, demonstrated by increased staffing, patient contact and/or investment.

The objective relating to mental health promotion and early intervention in CAMHS was subsequently reinforced within the Standard 9 of the National Service Framework (NSF) for Children, Young People and Maternity Services published in September 2004, and it remains a priority in the most recent guidance. The Report on the Implementation of Standard 9 published in December 2006 includes a section on early intervention and primary care and highlights the following NSF marker of good practice:

‘All staff working directly with children and young people have sufficient knowledge, training and support to promote the psychological well-being of children, young people and their families and to identify early indicators of difficulty.’

This Briefing Paper is designed to assist commissioners, managers and practitioners in understanding the importance of mental health promotion and how to evaluate the effectiveness of initiatives. It draws on Making it Possible: Improving Mental Health and Well-being in England¹ as a key reference document which is particularly useful for making the case for mental health promotion, providing an overview of relevant national policies, and identifying measures of success. It does not however concentrate on mental health promotion in children, young people and their families, whereas this paper will do so.

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1. What is mental health?

All too often mental health is defined by its absence, with the focus on an individual’s limitations and problems. However, in working with children and young people to develop their potential it is constructive to see mental health as a positive goal.

Mental health in children and young people can be defined as having the ability to:

• develop psychologically, emotionally, intellectually and spiritually
• initiate, develop, and sustain mutually satisfying personal relationships
• use and enjoy solitude
• become aware of others and empathise with them
• play and learn
• develop a sense of right and wrong
• resolve (face) problems and setbacks and learn from them²

It is apparent from this list that a large number of activities undertaken by the statutory sector and voluntary sector agencies are promoting the mental health of young people.

Good mental health is known to improve the outcomes in childhood, and as adults, in the following domains:

• physical health
• education
• employment
• parenting
• relationships
• crime
• health behaviours.

A number of risk factors have been identified that make it more likely that a child will develop a mental health problem, and equally a number of resilience factors that help them cope have been identified (Annex A). These factors are classified by whether they reside in the child, the family or the community. The greater the number and severity of risk factors, and the fewer the protective resilience factors, the more likely is the child to develop mental health problems.

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2. What is mental health promotion?

Health promotion is the process of enabling people to take control over, and to improve their (mental) health. It seeks to enable them to increase control over the determinants of health (risk and resilience factors), by action to strengthen skills and capabilities of individuals (families and communities), and by action to change social, environmental and economic conditions.

Mental health promotion concentrates on both positive mental health, and prevention of mental ill health, mirroring the World Health Organisation definition of health as being more than just the absence of disease. One criticism of national policy and its implementation is that it is focused on secondary or tertiary prevention (when problems have been noticed), rather than primary prevention (to stop problems occurring) or positive mental health.

Health promotion works on a lifecourse approach, recognising that childhood disadvantage (and advantage) impact on childhood and adult health, and also that the health and background of parents, and the milieu into which children are born and in which they grow up impacts on them. This suggests that coordinated interventions are needed at all ages, from the antenatal period to the transition to adulthood. Health promotion also works in ‘settings’ where it is closest to influencing the need, such as with individuals, in families, in schools, in the community, and at a broader policy development or advocacy level. It recognises that a balance of interventional approaches are needed, from those delivered ‘universally’ to the population, those delivered/tailored to ‘selected’ sub populations (such as asylum seekers and refugees), or those delivered to ‘indicated’ populations (such as young people with conduct disorders).

From: Childhood disadvantage and adult health: a lifecourse framework. HDA 2004

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3. Early interventions

No time is ‘too early’ to start mental health promotion. Babies grow within the mother, and her health impacts on theirs, most obviously by what passes across the placenta into the baby (eg nutrients, medicines). Mothers with alcohol and illegal substances addictions are known to give birth to babies with withdrawal syndromes. Mothers who are anxious during pregnancy will be exposing their babies to high levels of adrenaline at a time when their brains are completing 25% of their development. Therefore good antenatal care is part of mental health promotion, as is breast feeding because of its capacity to promote attachment. Antenatal care and breast feeding support are available universally, but additional support is needed for selected groups such as teenage mothers.

Seventy five per cent of the brain’s development occurs after birth, and it occurs in relation to the environment. Neurological pathways are established and reinforced in response to stimuli, and additionally there are ‘windows of opportunity’ in the development process, some in the key period 6-18 months. Negative experiences, or lack of positive stimuli, can have serious long term effects on the brain’s development. These long term effects can be seen later in, for instance, antisocial behaviour. The stimuli experienced by the baby will largely depend on their parents’ input, particularly that of the mother, and this is why it is important to manage postnatal depression if it occurs. The parental capacity to be alert to, recognise and respond to the baby from an emotional perspective, are key to the level and sort of stimuli that the baby receives. Cultural and socioeconomic factors in the life of the parents have an impact on their babies because of how it affects their emotional capacity (eg it is difficult to be emotionally responsive to your baby if you’re worried about housing, or can’t make ends meet). Parents often (unwittingly) reproduce what happened in their own early life, and so problems can become inter-generational.

Cognitive and non-cognitive abilities are important to success and they emerge early (before school). Cognitive ability (IQ and test assessed skills) is set by age 8, and differs between people. Non-cognitive abilities (eg social skills, motivation, dependability, self discipline, perseverance) substantially determine success in school and the labour market, and are malleable until a much later age. Access to higher quality resources early in life can contribute to the development of cognitive ability, and affect skills acquisition later in life. Gaps in cognitive and non-cognitive skills open up early, and are linked to family environment in the early years, rather than parental income in adolescent years. Children’s expectation of life and openness to schooling is moulded by those of their parents, and this accumulates into adolescence. Current national policy appears to concentrate overmuch on the development of cognitive skills (perhaps because they are more easily measured), and not enough on non-cognitive skills³. Furthermore, it is known that the younger a child the more vulnerable they are to risk factors for poor mental health, and the longer they are exposed to the risk factors the more likely is poor mental health.

Early interventions have been shown to be cost-effective in the longer term. They can lead to improved psychosocial outcomes in the long term, and benefit disadvantaged children most. However they must start early, be sustained, be flexible over time, and address multiple environmental risk factors rather than focusing on single issues. Working to improve one aspect of child and family functioning can be completely undermined by ignoring the environmental risk factors to which they are exposed⁴. A more thorough discussion of what works in promoting children’s mental health, particularly from a preventive perspective is provided by Zarrina Kurtz and Young Minds⁵.

Parenting education and support are particularly important early interventions. A growing number of scientific studies are demonstrating the importance of parenting practices on:

• early childhood development
• child social and emotional development
• child & adult mental health (including the risk of suicide)
• the adoption of longer term lifestyle choices⁶

Helpful parenting promotes mental health, protects children from mental health problems, and in poorer families protects against the impact of deprivation. There are other influences on mental health (including genes, temperament, and social deprivation) but parenting is one that is amenable to change. Poor parenting practice is seen where there is lack of sensitivity, lack of warmth, lack of clear, consistent, age-appropriate boundaries, lack of interest, intrusiveness, harsh and/or inconsistent discipline, and/or frank abuse and neglect. These aspects of poor parenting predict conduct disorder, antisocial behaviour, delinquency, violence, unpopularity with peers, and school failure. Many of these latter problems also impact on the family of the young person, and the community.

Poverty, and circumstances associated with it (poor housing, homelessness, poor facilities and environment, lack of play space etc) places huge strains on parents and make helpful parenting more difficult. So too do family break-up, domestic violence, and parental mental illness. The long hours culture of those in work, and single/both parents in work, can impact on the ability to parent well.

This all suggests that partner agencies (statutory sector, voluntary sector and business sector) should endeavour to create a child and family friendly environment, ensure their policies are child and family friendly, provide coordinated and consistent universal parenting education and support, with interventions suitably targeted to selected parents, or when specifically indicated. Coordinated and consistent parenting education and support is needed to avoid a mother of a 2, 8 and 13 year old (for instance) being given conflicting or confusing messages that do not reinforce one another. In addition partners should work together to minimise the effects of uneven distribution of the determinants of mental health on parents and children.

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4. Adolescence and health promotion interventions

Adolescence is a transition period, and a time of immense developmental change, both biological, psychological, and social^7,8. The biological development revolves around puberty, and the changes in body size, shape, and sex organs resulting from the flow of hormones. Body image and sexuality have to be accommodated. The psychological development includes moves from concrete thinking to abstract thinking, and the emergence of the young person’s own moral, religious and political ideals. The social developments include emotional separation from parents, and increasing identification with peers, as well as moving to work and financial independence. Young people want to be communicated with separately from their parents, and wish to be shown respect and not be judged. ‘Youth culture’ develops, which uses language and means of communication that are not familiar to the majority of adults and parents (nor service providers).

Adolescence is also a time when health behaviours become established that run into adulthood. There is a complex interplay between physical and mental health behaviours, and what decreases the undesirable behaviours. Whole school anti-bullying and emotional well-being programmes, for instance, succeed in reducing smoking and drug taking.

Young people themselves think that the following promote and maintain their mental health⁹:

• feeling safe – both physically and emotionally
• being able to talk to an adult of their choice in confidence
• having access to sports centres and youth clubs that can provide interesting and meaningful activities
• personal achievement
• being praised
• generally feeling positive about oneself

Effective mental health promotion for adolescents is similar to that for younger children. It depends on good parenting practice from early on, and on addressing the socioeconomic circumstances in which the young people were raised. Actions at a societal level ‘on behalf of’ the young person are more effective than directed messages, or single issue messages. Improving social abilities, self-esteem and self empowerment are most important, and it is here that schools play a major role, for example through the National Healthy School Standard and SEAL (social and emotional aspects of learning) curriculum. Children with special educational need, or disabilities, may need extra help to develop good mental health.

Mental health promotion may not be the best description of the work or interventions with young people. This is because of the use of ‘mental health’ when what is actually meant is mental illness, and the stigma that surrounds mental illness. Young people fear that mental illness will result in them being teased, stop them getting a job, isolate them from friends, reflect poorly on their families, and upset boyfriend/girlfriend relationships¹⁰.

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5. Cultural issues

There has not been as much research into mental illness, or mental health promotion in black & minority ethnic communities as in the White population in UK. What has taken place has largely been for adults, and been mental health service focused. This has called into question the appropriateness, responsiveness and equity of provision of services across the different racial groups. Recently a number of reports (including Minority Voices, and Celebrating our Cultures^11,12) have been produced that focus on children & young people, or on mental health promotion, in black & minority ethnic communities. In addition the ‘Quality in Mental Health Services for Children & Young People’ Conference in June 2005 had two presentations and workshops on the subject^13,14. The following discussion draws on these five references.

As Standard 9 of the National Service Framework (NSF) for Children, Young People and Maternity Services¹⁵ (2004) states, the concept of mental illness and the origin of emotional and behavioural difficulties vary across cultures. So too must the concept of mental health, and of parenting and child care, and of learning difficulty, or disability. The issues which children & young people from black and minority ethnic communities face are the same as for the indigenous population, but they are set in different cultural, historic, and religious, beliefs and backgrounds, and are subject to differing interpretation and significance by parents, the community and professionals. Additionally, children and young people from black and minority ethnic communities face racism, and if they are refugees or asylum seekers they will have more trauma, bereavement, loss and dislocation and language problems to deal with than their indigenous peers. Because so many black and minority ethnic people live in socio-economic deprivation their children & young people are more at risk of poor mental health.

None of the above implies that certain cultures or religions are detrimental to the mental health of children & young people from black and minority ethnic communities – they can be hugely positive and supportive. What it does imply is that mental health promotion and prevention work must be set in appropriate contexts, and provided in appropriate ways. Whole mind, whole body approaches may be more important to these young people, for example through the arts, spirituality, creativity, and physical activity. Using interventions that support white middle class norms are unlikely to be acceptable to the whole community. On the other hand, it may be equally unsafe to assume that excluded black and minority ethnic youth can be best reached through their family, community or religious elders, as it is in relation to their excluded white peers.

The recognition of youth culture and youth identity as different from that of parents and the parental community, is important to mental health promotion work. Youth culture may be a common denominator between young people from a wide range of backgrounds, but it is one their parents don’t share and often disapprove of. Black and minority ethnic youth are likely to have better English than their parents (depending on which generation they are from). They will also be aware of and using the language of youth culture that their parents are unfamiliar with. Youth culture may expect different things of young men and women than their parents experienced or think appropriate eg an equal voice for women. Black and minority ethnic young people will be struggling to develop not only their adult identity but also a cultural identity, that is likely to be a hybrid of all those that impact upon them and may therefore ‘fit’ nowhere.

In addition to ethnic/racial cultural issues and youth culture issues there are professional cultural issue to consider. Professionals may be worried and uncertain about their lack of cultural awareness or relevant skills in a multicultural environment. They may make unexplored assumptions, and apply bias in their observations and the meaning they attribute to them. They may apply narrow culturally biased views of child development, long term psychological goals, and ‘health’ and illness. This applies whether they come from a black or minority ethnic community or are from the white population. Indeed professionals from a black or minority ethnic background have to manage their aspirations, the (often) hierarchical relationship with seniors, the pressure to conform to British, or research, norms, and their own cultural identity. And if professionals are not good at relating and responding to differing cultural needs in the adult population, how much more difficult they will find it to be contextually child centred in their dealings with children & young people. Professional language can be another barrier to communication, to add to the potential barriers of differing first language and the language of youth culture.

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6. Conclusions

Consideration of the above factors leads to the following conclusions about the action required from the commissioners of CAMHS and managers of Tier 1 and 2 services.

• Identify children and young people in the most the vulnerable groups in your population, using available ONS data, which drills down to local level on population and determinants of health, to help you identify and plan appropriate mental health promotion initiatives.
• Adopt a lifecourse approach to mental health promotion that recognises the multiple inputs to child health over time, and eventually to adult health.
• Appoint a leader for mental health promotion for children & young people who is sufficiently senior and well connected to be able to influence other agendas at the highest level. This may depend on which forum(s) is responsible for action on mental health promotion.
• Move upstream in health promotion activities from the current secondary or tertiary level responses which attempt to stop situations getting worse or reaching crisis point, to one that attempts to promote positive mental health and prevent mental health problems.
• Adopt an approach that recognises the value of universal, selected group, and indicated group interventions, and seek to achieve a balanced portfolio of these three types of intervention.
• Accept that it is never too early in the child’s life (including the foetus) to reduce risk factors for mental ill health, and to improve resilience factors for mental health.
• Identify and map all strategies and initiatives contributing to mental health within your area (use questions set out in Annex B)
• Develop a coordinated Parenting Education and Support strategy that all partners are signed up to, and with agreed expectations of the outcomes.
• Work on the environment in which children grow up in the knowledge that this can affect their mental health. Work from their perspective, bottom up.
• Recognise that opportunities for physical activity, creativity, the arts and music, are not only healing but can contribute to positive mental health.
• Develop a universal educational programme for staff and carers that covers relevant cultural and religious beliefs and backgrounds, early neurobiology and adolescent development, youth culture, and professional cultures, so that staff and carers can relate to children, young people and families in the most mental health nurturing way.

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Annex A

Risk factors in the child

• Specific learning difficulty
• Communication difficulties
• Specific developmental delay
• Genetic influence
• Difficult temperament
• Physical illness especially if chronic &/or neurological
• Academic failure
• Low self-esteem

Risk factors in the family

• Overt parental conflict
• Family breakdown
• Inconsistent or unclear discipline
• Hostile or rejecting relationships
• Failure to adapt to a child’s changing needs
• Physical, sexual or emotional abuse
• Parental mental illness
• Parental criminality, alcoholism or personality disorder
• Death and loss – including loss of friendship

Risk factors in the community

• Socio-economic disadvantage
• Homelessness
• Disaster
• Discrimination
• Other significant life events

Resilience factors in the child

• Secure early relationships
• Being female
• Higher intelligence
• Easy temperament when an infant
• Positive attitude, problem-solving approach
• Good communications skills
• Planner, belief in control
• Humour
• Religious faith
• Capacity to reflect

Resilience factors in the family

• At least one good parent-child relationship
• Affection
• Clear, firm and consistent discipline
• Support for education
• Supportive long-term relationship/absence of severe discord

Resilience factors in the community

• Wider supportive network
• Good housing
• High standard of living
• High morale school with positive policies for behaviour, attitudes and anti-bullying
• School with strong academic and non-academic opportunities
• Range of positive sport/leisure activities

From: www.teachernet.gov.uk/_doc/4619/mentalhealth.pdf

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Annex B

Initial questions

• Is there a mental health promotion strategy?
• Is there a mental health promotion lead?
• Are there mental health promotion targets for children & young people, and families? Are there any other targets that may be relevant?
• Is there a steering group for mental health promotion?

Subsequent questions

Key area: Tackling violence & abuse

Is there a domestic violence strategy?

Is there Crime & Disorder Reduction Partnership strategy?

Is there an alcohol harm reduction strategy?

Is there a suicide (& self harm) prevention strategy?

Key area: Parents & early years

Is there a coordinated multi-agency Parenting Strategy across the PCT area?

If not, what parenting education and support initiatives exist, and who are they run by, and for which client groups?

What is the PCT response to Standards 2 & 9 of the Children’s NSF eg to the Child Health Promotion Programme through health visitor and school nurse services?

How is postnatal depression identified, and addressed?

Is there comprehensive, good quality, affordable, early years child care available, that is culturally sensitive?

Do adult mental health services alert Tier 1 & 2 services so that additional support may be provided for children of parents with mental health problems?

Key area: Schools

How many of the local primary schools are using the SEAL (social & emotional aspects of learning) curriculum resource?

How many of the local schools are taking part in the National Healthy Schools Programme and in particular, have achieved the Emotional Health & Well-being criteria?

What actions are underway to support children & young people making a positive contribution (ECM)?

Key Area: Employment & Workplace

Do members of the CAMHS Partnership all have family friendly policies in place?

Do adult mental health services have a ‘back to work’ strategy for their clients, in particular those who are parents?

Key Area: Communities

What are the LSP priorities for children & young people, and families, as recorded in the Community Plan/Local Development Plan?

What are the Local Area Agreement priorities?

What are the policies for homeless families?

Is there a Neighbourhood Renewal &/or community development strategy or plan?

Key Area: Other

Are there other initiatives that are thought to contribute to the social & emotional well-being, or the mental health & well-being of children & young people, and families?

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References

1. Making it Possible: Improving Mental Health and Well-being in England. October 2005. Care Services Improvement Partnership. National Institute of Mental Health in England.

2. Kay, H. (1999). Bright Futures: Promoting children & young people’s mental health. Mental Health Foundation.

3. IZA DP No.1444 Skills Policy for Scotland. James J. Heckman, Dimitriy V. Masterov. December 2004.

4. Policy Brief 1/2006. Early childhood and the life course. Centre for Community Child Health, Parkville, Australia.

5. Zarrina Kurtz. What works in promoting children’s mental health: the evidence and the implications for Surestart settings. Young Minds, 2004.

6. Parenting and public health: briefing statement. Faculty of Public Health, May 2005.

7. Deborah Christie, Russell Viner. ABC of adolescence: Adolescent development. BMJ, Vol 330:301-304.

8. Russell Viner, Aidan Macfarlane. ABC of adolescence: Health Promotion. BMJ, Vol 330:527-529.

9. Quoting from Healthy Care Briefing: Mental Health. National Children’s Bureau, March 2005.

10. Ben Sessa. I’ll have to lie about where I’ve been. Young Minds magazine 76, 2005.

11. Minority Voices: research report and good practice guide. Young Minds. www.youngminds.org.uk/minorityvoices

12. Celebrating our Cultures: Guidelines fir mental health promotion with black & minority ethnic communities. NIMHE, 2004.

13. Begum Maitra. Re-inventing Children: Communities, Culture and Mental Health Policy. Presentation & workshop at Quality Mental Health Services for Children & Young People conference, June 2005.

14. Frank Lowe. Enhancing Partnerships with Black & Minority Ethnic groups. Presentation & workshop at Quality Mental Health Services for Children & Young People conference, June 2005.

15. Department of Health. National Service Framework for Children, Young People and Maternity Services. 2004

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