Promoting wellbeing in young people

MENTAL HEALTH

Promoting wellbeing in young people Willm Mistral

ABSTRACT Could you please provide an abstract?

Willm Mistral manager of the Mental Health Research and Development Unit (a joint unit of Avon and Wiltshire Mental Health Partnership Trust and the University of Bath) Email: W.Mistral@ bath.ac.uk Submitted for peer review 23 May 2011; accepted for publication 30 June 2011

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In recent years there have been efforts to avoid conflation of the terms ‘mental health’ and ‘mental illness’, and efforts have been made to promote ‘positive mental health’ or ‘mental wellbeing’. Both mental health and mental illness encompass a wide variety of states of being and promoting positive mental health and preventing mental health problems form part of the remit of a wide range of public services (Harden et al, 2001). Half of mental health disorders begin before the age of 14, and 10% of UK children have a diagnosable mental disorder. There is good evidence of the importance of the social environment, such as in families and at school, in mediating risks for psychological problems. It is necessary to strengthen the support mental health services provide to families, schools, and other services.

Mental problems Mental health problems vary by age. It is, however, particularly important to focus on young people, as half of all lifetime mental health disorders begin before the age of 14 years (WHO/HBSC, 2007). There is also evidence of intergenerational occurrence, so children of parents with mental disorders are particularly at risk (Kaakinen, 2007). Therefore, action to reduce mental disorders and promote wellbeing in young people, while praiseworthy in itself, may also serve to protect future generations and reduce the ever-increasing

demand for treatment of severe mental illness. This may be of particular importance in the UK—a report by UNICEF (2007) comparing a range of aspects of children’s wellbeing, including relationships, risky behaviours, education, and subjective reports of their own wellbeing, placed the UK at the bottom of a list of 21 of the world’s richest countries. A survey of 10 438 children aged 5–15 carried out by the Office for National Statistics found an overall rate of 10% with a mental disorder. Diagnoses included 5% with conduct disorders; 4% with emotional disorders such as anxiety and depression; and 1% with hyperactivity. Some children had more than one diagnosis (Meltzer et al, 2000). The association between mental health problems and substance misuse has been extensively catalogued, and UK adolescents have among the highest European levels of alcohol use, binge drinking and getting drunk (Hibell et al, 2009). Barnett et al (2007) in a UK study, reported 43% of people presenting with first episode psychosis met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 2000) criteria for alcohol misuse or dependence at some time during their life, 51% met criteria for cannabis abuse or dependence, and class A drug use was 58% compared with a national prevalence of 17%. The DSM-IV provides a common language and standard criteria for the classification of mental disorders, and is used across the world.

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A study of four inner-city community mental health teams (Weaver et al, 2003) found 44% of mental health clients reported problematic drug use and/or alcohol use, while 85% of alcohol service users and 75% of drug service users had a psychiatric disorder during the preceding year.

Protective factors There is good evidence of the importance of the social environment in mediating risks for psychological and psychopathological problems (Rutter, 2005). The World Health Organization (WHO) conducts a cross-national study of health behaviour in school-aged children (aged 11–15 years) every four years, involving 43 countries and regions. The study focuses on issues that affect and are affected by mental health and wellbeing. Protective factors for mental wellbeing were linked to family wellbeing, individual behaviours and skills, access to adolescent-friendly health and social services, cohesion at community level and integration of minorities. The 2007 study concluded that to promote child and adolescent mental wellbeing, psychosocial approaches are essential, and good relationships in the home, school and community play a part in ensuring that young people develop social competence and contribute to cohesive societies (WHO/HBSC, 2007).

Family factors In a comprehensive review of mental health among young people, Patel et al (2007) list inconsistent caregiving, family conflict, poor family discipline, poor family management, and death of a family member, as important risk factors for mental problems. These risk factors are very similar to those seen in excessive alcohol use among young people, and there is general consensus that combinations of supportive environments, family practices and family resources, are particularly significant in influencing resilience in young people (Templeton, 2009). The importance given


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to the potential role of parents in education and prevention can be seen in the guidance on alcohol consumption by young people published by the Chief Medical Officer for England (Department of Health, 2009). Overall, Patel et al (2007) argue: ‘The key to promoting youth mental health is through strengthening of the fundamental nurturing qualities of the family system and community networks while explicitly acknowledging the rights of young people.’

School factors As school attendance is potentially universal, the school environment has an important role in influencing the mental health and wellbeing of young people. Although a better understanding is needed of the interplay between the social environment and children’s individual characteristics, Weare (2010) reports that developing effective positive environments depends to a large extent on the skills of all who work and learn in schools, whose behaviours and attitudes shape the environment where most young people pass a large proportion of their time. Health services also have an important role in addressing socially determined risk factors for mental disorders and in fostering protective factors for mental wellbeing. Increasingly it is being recognised that to provide effective care to children and young people, it is necessary to strengthen the support that child and adolescent mental health services (CAMHS) provide to other services, such as schools, via multidisciplinary teams and inter-agency working. Health services can work to build coalitions to act on key determinants of adolescent mental health. They can improve service delivery by developing adolescent-friendly interventions for promoting mental health and preventing mental disorders, to be available in schools and communities, including through strengthened primary care services (WHO/ HBSC, 2007).

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Government initiatives Recent governmental policy has shown an increased recognition of the importance of developing positive emotional health in children. For example, the National Service Framework for children emphasised the need for positive mental health promotion and early intervention (Department of Health, 2004). Every child matters (HM Government, 2004) specifically identifies mental health and the need for preventive approaches. The Department for Education and Skills (2004) initiated a major initiative, the Social and Emotional Aspects of Learning (SEAL), to promote explicit and planned learning of social and emotional skills within the school curriculum while facilitating professional development for all school staff in this area. Complementing this is the Targeted Mental Health in Schools (TaMHS) initiative, which has two key objectives. One is to facilitate integrated, flexible and responsive early interventions by all agencies involved in delivery of child and adolescent mental health services including health services, schools, local authority services, and the voluntary sector. The other is to ensure that interventions are based on solid evidence (Weare, 2010). The Department for Education (2011) states a wide range of agencies both statutory and voluntary are becoming involved in developing and supporting work in this area. These include educational psychology, behaviour support services, attendance consultants, healthy schools coordinators, health services, school nursing services, speech and language therapy services, CAMHS and drug action teams.

Clinician initiatives Other mental health preventive interventions in schools can work alongside initiatives such as SEAL. A series of papers by Stallard et al (2005; 2008; 2010) provide examples of how NHS mental health clinicians can develop effective programs for use in

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schools, train teachers to deliver these programs, undertake evaluations, and demonstrate significant reductions in childhood anxiety symptoms. Childhood anxiety is a common condition which, if untreated, may become so severe that it increases the likelihood of mental health problems in adulthood. Surveys suggest that by the age of 18, 1 in 10 children will have suffered from an anxiety disorder (Costello et al, 2003). WHO (2004) identified a program called FRIENDS as being effective as a school-based intervention for anxiety (Barrett and Turner 2001; Lowry-Webster et al, 2001; 2003). FRIENDS, and the recent revision, FRIENDS for Life, is a 10-session program based on cognitive behavioural therapy (CBT) during which children are helped to become aware of their anxiety-increasing cognitions and to replace these with more helpful and balanced cognitions. They are taught a range of anxiety management techniques and problem-solving skills, while graded exposure is used to help them to systematically face and overcome their worries. Research in the UK has shown that school nurses (Stallard et al, 2005) and educational psychologists (Liddle and MacMillan, 2008) are effective in delivering FRIENDS.

Joint initiatives Joint health and education initiatives offer a number of advantages. Teachers do not necessarily have the knowledge required to deliver a mental health intervention based upon a therapeutic approach such as CBT, they may not feel comfortable or skilled in discussing some mental health problems, and input from a mental health professional ensures that difficult issues can be raised, discussed and, if necessary, referral for more specialist input can be facilitated. There are also issues of classroom management, discipline and student knowledge levels that are essential prerequisites for delivery of mental health programs, and teachers bring this information and expertise


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to the partnership. Finally, the joint health and education partnership helps to differentiate a program such as FRIENDS from other lessons, give it a clear identity, and ensure sessions are not postponed or omitted because of competing demands in the school (Stallard, 2010). Pettitt (2003), in research for the Department for Education and Skills, surveyed CAMHS across England and, of the 55% of services which responded, 81% reported working with secondary schools, 76% with primary, and 72% with special schools for children with emotional and behavioural disabilities. The most common form of work was consultation and support to school staff, often on a case-by-case basis with children referred to their service. 70% of CAMHS undertook direct work with children, including individual and group work in schools, assessment and observation. Clinical psychologists, community psychiatric nurses and social workers conducted the majority of the work, which represented a relatively small proportion of CAMHS resources. However, Pettitt (2003) points out that health services, especially CAMHS, are often historically determined, fragmented, and in many areas lacking in key personnel.

Some recommendations As both educational and health services are undergoing substantial changes, a number of recommendations by Pettitt (2003) are still worth acting upon. At a national policy level, it is important to: Place greater emphasis is given across government departments to provision of preventive and early intervention mental health services within schools and other community settings Ensure that the Children’s National Service Framework, particularly the CAMHS component, contains clear targets for development of multiagency early intervention supports for children and families within schools Give schools are clear advice, guidance and support.


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Recommendations for action at a local level include: CAMHS, Local Education Authorities (LEAs), school governors, and head teachers to recognise joint working as part of the job description for some staff Consider basing Tier 2 CAMHS staff in small locality teams, in areas which match LEA, or school pyramid areas Create formal integrated linkages with LEA staff, including educational psychologists, behavioural support services and educational welfare officers to take advantage of multi-disciplinary, coordinated working Have named persons in CAMHS for schools to link with Allow time to build an understanding of the different cultures of education and health sectors (Pettitt, 2003). In line with these recommendations, Patel et al (2007) following a detailed exposition of young people’s mental health, conclude that the single most important recommendation is: ‘the need to integrate youth mental health interventions with all existing youth programmes, including those in the health sector (such as reproductive and sexual health) and outside this sector (such as education).’

Conclusions As Appleby and Butterworth (2009) recognise: ‘it will require courage and purpose to change existing mental health services so that they draw in and purposefully use other agencies and systems as a matter of course. Equally testing will be the challenge to the whole health and social care system to be sensitive to their role in supporting mental health and wellbeing.’

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KEY POINTS n 50% of mental health disorders begin before the age of 14 n 10% of UK children have a diagnosable mental disorder n The social environment mediates risks for psychological problems n It is necessary to strengthen mental health provision to families, schools and other children’s services

Sensitivity, courage and purpose are necessary but, unfortunately, probably not sufficient conditions for this task. In an era of budgetary constraints, if not swingeing cuts, it can seem fanciful to talk of diverting resources into long-term preventive activities in schools when caseloads are already overburdened with people with severe mental illness. Nonetheless, it is imperative that mental health services re-imagine and reinforce their role in the field of prevention. Otherwise service providers may find themselves suffering the same fate as Sisyphus who, the ancient myth tells us, was condemned to an eternally unsatisfying and unsatisfactory task of pushing a huge boulder up a mountain, only to see it to roll away just before the top, forcing him to begin all over again. BJHCM American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders. 4th edn, text revision. American Psychiatric Association, Arlington, VA Appleby L and Butterworth T (2009) Fifty years of endeavour, prevention and health in mental health policy. J Research in Nursing 14(6): 489–92 Barnett JH, Werners U, Secher SM et al (2007) Substance use in a population-based clinic sample of people with firstepisode psychosis. Br J Psychiatry 190: 515–20 Barrett P, Turner C (2001) Prevention of anxiety symptoms in primary school children: Preliminary results from a universal school-based trial. Br J Clin Psychol 40: 399–410 Costello EJ, Mustillo S, Erkanli A et al (2003) Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 60: 837–44 Department for Education (2011) What role can the wider community play in implementing SEAL? http://nationalstrategies.standards.dcsf.gov.uk/ node/66376?uc%20=%20force_uj (accessed 21 June 2011) (AQ: link does not work?) Department for Education and Skills (2004) Every Child Matters: Change for Children. Department for Education and Skills, London Department of Health (2004) The National Service Framework for Children, Young People and Maternity Services. The Stationery Office, London Department of Health (2009) Guidance on the Consumption of Alcohol by Children and Young People. http://tinyurl. com/3rdelzh(accessed 21/06/2011) Harden A, Rees R, Shepherd J, Brunton G, Oliver S, Oakley A (2001) Young People and Mental Health: a Systematic Review of Research on Barriers and Facilitators. EPPICentre, London Hibell B, Guttormsson U, Ahlstrom S, et al (2009) The 2007

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