Mentally healthy children and young people

  1. Page Contents:
  2. Introduction
  3. Desired outcomes
  4. Current evidence
  5. Recommendations
  6. Case studies

Introduction

A child’s mental wellbeing is often the result of healthy development within a nurturing environment. In the early years, infants make emotional attachments and form relationships that lay the foundations for future mental health.

Attachment relationships are particularly important, with consequences for developing emotional, social and cognitive skills. The quality of these attachments has far-reaching effects.

The period before birth is also important for mental heath – for example, evidence points to the negative impact of alcohol, drugs and poor nutrition during pregnancy on later child mental health.

Not all children and young people are born with the same opportunities in terms of mental health. The individual, the family, wider society and the environment all play a role.

On an individual level, risk factors include learning disabilities, specific developmental problems and communication difficulties, as well as low self-esteem and difficult temperament.

With respect to family, good parenting is fundamental for the development of a child’s mental health. All parents need to be supported and helped, but especially when they are parenting in difficult circumstances or facing uncertainty about the way they are bringing up their children.

Environmental risk factors include poor quality housing and deprivation, with limited access to safe places for play and constructive activities that are vital for mental wellbeing.

Without action to promote mental wellbeing and reduce the prevalence of mental health problems, our children and young people are unlikely to be able to fulfil their potential.

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Desired Outcomes

The desired outcomes for mentally healthy infants, children and young people are:

  • increased mental wellbeing among children and young people
  • reduced prevalence of mental health problems among children and young people
  • improved quality of life among children and young people experiencing mental health problems

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Current evidence

Pre-school:

Drawing on primary research, the World Health Organisation’s report Promoting Mental Health [PDF: 963kb] suggests that parenting programmes, home visiting and preschool education prevention programmes can contribute to improved mental, social and behavioural outcomes in children and improved mental health outcomes in parents.

A systematic review of reviews of interventions to promote mental health and prevent mental health problems in children and young people [external site] concluded that early interventions such as the Brazelton Neonatal Behavioural Assessment are effective in enhancing parents' sensitivity to their new baby.

Home visiting

Ante- and post-natal home-visiting programmes: a review of reviews [external site] undertaken for the Health Development Agency in 2004, concluded that there is evidence that home visiting programmes can have an impact on:

  • reducing rates of childhood injury
  • measures of intellectual development in children (particularly among children with identified problems associated with low birth weight or failure to thrive)
  • various dimensions of parenting or mother-child interaction (however, further work is needed to evaluate which types of programme, or which programme components, are likely to replicate these impacts and to develop measures which limit bias in results)
  • the detection and management of post-natal depression (though issues of measurement and report bias need careful consideration in future trials).

Insufficient evidence was found to determine the influence of home-visiting interventions on outcomes related to social support or to prove any long-term benefit of home visiting on maternal life course development.

There is evidence from randomised controlled trials that the Prenatal and Infancy Home Visitation Programmes, an intensive, nurse-led home visiting programme for vulnerable parents delivered in the USA, promotes improved maternal and child functioning and has positive impacts in the longer term.

The US model is being used in both Scotland and England in the Family Nurse Partnership programme [external site].

Parenting

A number of Cochrane systems reviews of parenting programmes with different populations have concluded that there is evidence that parenting programmes can have a positive impact on:

  • the short-term psychosocial health of mothers (see The Cochrane Library [external site] website for more information)
  • parental attitudes, parental knowledge, maternal self-confidence and maternal identity of teenage mothers (see The Cochrane Library [external site] for more information)
  • the emotional and behavioural adjustment of children under the age of three years, although there’s insufficient evidence to reach any firm conclusions about the role that the programmes might play in the primary prevention of such problems (see The Cochrane Library [external site] for more information)
  • mother-infant interaction and maternal mealtime communication language development among teenage mothers (see The Cochrane Library [external site] for more information)
  • the emotional and behavioural adjustment of children, with positive effects identified for group-based interventions and for programmes directed at black and mixed ethnic parents (see The Cochrane Library [external site] for more information).

There is limited evidence that parenting programmes are effective in improving outcomes associated with physically abusive parents. However, there is evidence that the programmes were cost-effective ways of improving parenting, and providing access to peer-based support.

While evidence is inconclusive, there are few other interventions that have better established levels of empirical support regarding intervening with physically abuse parents. The authors conclude that use of parenting programmes that are based on models evaluated in the review may be justified.

See The Cochrane Library [external site] for more information.

Home learning environment and pre-school

A systematic review of reviews of interventions to promote mental health and prevent mental health problems in children and young people [external site] concluded that high-quality pre-school programmes such as the Perry Pre-School Programme and Head Start are effective in improving self-esteem and behaviour as well as non mental health outcomes.

Promoting Equality in the Early Years [PDF: 1.53mb], a report to the equalities review, provides insights into why some children and families succeed ‘beyond the odds’ and how understanding such resilience can inform policies and services.

Conduct disorder

Informed by reviews of effectiveness evidence, NICE technology appraisal guidance 102: Parent-training/education programmes in the management of children with conduct disorders [external site] recommended that:

  • groups-based parent-training and education programmes should be used in the management of children with conduct disorders
  • individual-based parent-training programmes are recommended only when there are particular difficulties in engaging with the parents; or a family’s needs are too complex to be met by group-based parent-training programmes.

No important differences were identified for this NICE appraisal, and NHS Quality Improvement Scotland advises that it is as valid for Scotland as for England and Wales.

Promoting maternal mental health

Informed by reviews of effectiveness evidence, Scottish Intercollegiate Guidelines Network (SIGN) 60: Guidance on post natal depression and puerperal psychosis [PDF: 636kb] recommended that:

  • Procedures should be in place to ensure that all women are routinely assessed during the antenatal period for a history of depression.
  • All women should be screened during pregnancy for previous history of puerperal psychosis, history of other psychopathology (especially affective psychosis) and a family history of affective psychosis.
  • The Edinburgh Post-natal Depression Scale (EPDS) should be offered to women in the post natal period as part of a screening programme for postnatal depression. The EPDS is not a diagnostic tool. Diagnosis of postnatal depression requires clinical evaluation.
  • Post natal depression and puerperal psychosis should be managed with due regard to the use of medication and breastfeeding or pregnancy and that due consideration should be given to psychosocial interventions.

SIGN 60 states that the research base for preventative interventions in low risk women is extremely limited. However, it provided good practice guidance that – in women who are at high risk of experiencing post natal depression – it may be effective to have post natal visits, interpersonal therapy and antenatal preparation.

Ante- and post-natal home-visiting programmes: a review of reviews [external link] was undertaken for the Health Development Agency in 2004. It concluded that there is some evidence of the positive effects of home visiting on the detection and management of post-natal depression.

Schools:

Informed by reviews of effectiveness evidence, NICE public health guidance have produced public health guidance on promoting social and emotional wellbeing in both primary and secondary education. NICE public health guidance 12: Promoting children’s social and emotional wellbeing in primary education [external site] made three action recommendations each with a number of action points. They recommended that all primary schools should:

  • adopt a comprehensive 'whole school' approach to children's social and emotional well-being
  • provide a comprehensive programme to help develop children’s social and emotional skills and wellbeing
  • ensure that teachers and practitioners are trained to identify the early signs of anxiety, emotional distress and behavioural problems amongst primary school children and that they discuss and agree options and an action plan with the child’s parents or carer.

NHS Health Scotland considered the recommendations in the Scottish context and the NHS Health Scotland Commentary [external site] on this guidance supported the action points, subject where appropriate, to adaptation to fit Scottish organisational arrangements. Details of, and links to, relevant Scottish policies, strategies, action plans and resources are also provided in the commentary.

NICE public health guidance 20: Promoting young people’s social and emotional wellbeing in secondary education [PDF: 270kb] has six recommendations each with a number of action points. These include:

  • a strategic framework to enable all secondary education establishments to adopt an organisation-wide approach to promoting the social and emotional wellbeing of young people
  • key principles and conditions concerned with, for example, demonstrating a commitment from head teachers and staff to promoting the social and emotional wellbeing of young people and providing an ethos that promotes learning, mutual respect and successful relationship
  • providing curriculum approaches that promote positive behaviours and successful relationships, and to help reduce disruptive behaviour and bullying
  • working with parents and families to promote the social and emotional wellbeing of young people and help parents and carers develop their parenting skills
  • working in partnership with young people to ensure that they can contribute to decisions that may impact on their social and emotional wellbeing
  • integrating social and emotional wellbeing within the training and continuing professional development of practitioners and relevant others involved in secondary education.

NHS Health Scotland has considered the NICE recommendations in the Scottish context and the NHS Health Scotland Scottish Perspective on this guidance [external site] supported the action points, subject, where appropriate, to adaptation to fit Scottish organisational arrangements. Details of, and links to, relevant Scottish policies, strategies, action plans and resources are also provided in the Scottish Perspective.

Other NICE public health guidance, for example, NICE public health guidance 7: Interventions in schools to prevent and reduce alcohol use among children and young people [external site] recognises the role schools have in reducing health-damaging behaviour such as substance misuse, which can have a plausible impact on emotional and social wellbeing.

The NHS Health Scotland Commentary [external site] on this guidance supported the action points, subject where appropriate, to the cited amendments and adaptations to fit Scottish organisational arrangements.

The evidence statements and original recommendations made by NICE can be found on the NICE website [external site].

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Childhood Poverty

The Childhood Poverty Strategy sets out how we will focus on and give greater momentum to our efforts to takle child poverty.

Recommendations

Pre-school:

Local partnerships can help in:

  • developing and delivering universal parenting programmes, with a strong emphasis on mental health improvement
  • supporting all children and families, including targeted parent support
  • involving expectant parents, prospective adoptive parents, parents and children, and young people in developing information, resources and services to promote their mental wellbeing
  • providing awareness-raising training and consultation about children and young people’s mental health for midwives, public health nurses, allied health professionals, social workers, staff working in adult mental health services, nonmedical staff (such as those working in social services) and care and staff in preschool and childcare
  • ensuring links with education authorities, and with private and voluntary sectors’ childcare providers, to support the mental health of early-years staff
  • implementing the local authority parenting frameworks.

Schools:

‘Learning in health and wellbeing ensures that children and young people develop the knowledge and understanding, skills, capabilities and attributes which they need for mental, emotional, social and physical wellbeing now and in the future.

‘Each establishment, working with partners, should take a holistic approach to promoting health and wellbeing, one that takes account of the stage of growth, development and maturity of each individual, and the social and community context.’

Curriculum for Excellence [external site]

The following list of actions from the The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care [external site] requires implementation by 2015.

Local partnerships can help in:

  • increasing participation across all aspects of a school’s life to contribute improved wellbeing and a sense of belonging
  • involving children, young people, parents and carers in developing information, resources and services to support the improvement of mental health and the prevention of mental health problems
  • supporting the mental wellbeing of school staff to increase their capacity to support children and young people
  • awareness-raising training and consultation for teaching, non-teaching and out-of-school care staff about children and young people’s mental health
  • on-going training and support for teaching and non-teaching staff on specific issues relating to mental health, e.g. aggressive behaviour, self-harm, attention-deficit hyperactivity disorder and the mental health impacts of child protection issues
  • providing group support sessions on particular issues or at particular times of stress
  • supporting schools in developing and delivering activities to promote emotional literacy and peer support
  • providing confidential, accessible and non-stigmatising therapeutic input and support for staff and pupils
  • supporting parents in dealing with issues relating to adolescence
  • information provision about local support services and access, including internet resources
  • contributing to school policies particularly those to promote positive behaviour.

Resources

These resources aim to support strategic partners in the effective delivery of an evidence-informed approach to mental health improvement planning and delivery, within the context of Curriculum for Excellence.

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Case studies

Pre-school:

  • Play@home [external site]: The programme recognises that the first seven years of a child's life are the most influential in establishing good exercise habits. Establishing daily exercise routines early in childhood encourages children's enjoyment of physical activity and promotes the value of parents doing exercise as role models.

Schools:

  • Healthy Minds approach in Moray [external site]: Moray is one of four areas in Scotland testing out a programme called Health and Wellbeing in Schools, to help local youngsters become healthier, increase healthcare capacity in schools and reduce health inequalities.
  • Nurturing schools [external site]: part of a series of reports that are intended to promote improvements in Scottish education by illustrating effective practice, raising current issues, and stimulating reflection and debate.

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