Repairing children's mental health – through thick and thin

From all that UK research has been telling us lately, it seems that as a society we aren’t looking after our children’s emotional and mental health very well.

For three decades, we're told, children's mental well-being has been deteriorating; and more have disorders than was previously realised. [see also: Children's futures and the big screen]

Not surprisingly, much hand-wringing and soul-searching has followed these gloomy pronouncements, blaming everything from food additives to changes in family structure, usually without much evidence. According to some commentators, our society is plain ‘broken’ and requires radical political and cultural mending.

Could the answer be at once more complex and yet, in some essential respects, more straightforward? That is, aren’t there many interacting causes of mental health problems in childhood and adolescence, and couldn’t some of them be addressed, at least partially, through simple interventions?

A handful of new studies offer deeper insights into the nature of the problem and what can be done.

In Norway, a team led by Anette Christine Iversen at the University of Bergen compared the mental health of children in the general population with that of children receiving child welfare and protection services (CWS) – the majority of whom live at home with their biological families.

The study of over 4,000 children aged 10-13 years showed that just over half the 82 child welfare clients had worryingly high scores on the conduct problems and total difficulties sub-scales of the Strengths and Difficulties Questionnaire (SDQ). (This compares with a figure of about 40 per cent in two studies in England and Northern Ireland. )

They were were 13.5 times more likely than their peers to have a high score on ‘conduct problems’ and 14 times more likely to have a high score on ‘total difficulties’ (which include conduct problems, hyperactivity, peer problems and emotional symptoms).

The researchers also looked at how many problems children had, finding that 38 per cent of child welfare clients had high scores on three or more SDQ sub-scales (compared with 4% for other children). Such high levels of comorbidity leave no doubt that children’s problems are frequently complex.

Are front-line professionals equipped to deal with these difficulties? The sheer volume of cases involved indicates that they need to be. In England, for example, one in ten children aged 5-15 has a mental disorder. Put in plain terms, an average-sized primary school will have 30 such children, and there will be even higher numbers with some need. Further, in Norway, the majority of child welfare children living at home have mental health difficulties – in many cases complex ones, affecting several areas of their lives. One in ten receives CWS support.

The obvious implication is that social workers and teachers need extra training and support to identify and manage children with mental health problems.

The services provided for them may also need to change. The Iversen study found that the greater difficulties among child welfare clients could not be explained entirely by poor socio-economic conditions. This means that being in a lone parent, low income family with parents who have low educational levels and poor health makes a child much more likely to have a high level of ‘total difficulties’ – but it isn’t the whole story. Nevertheless, the most common support measure offered is economic, followed by respite care, childcare and a mentor or ‘support friend’.

Much of this provision is short-term and not likely to alter the developmental trajectories of children with complex difficulties. In making the case for additional training, Iversen and her colleagues say that any financial support offered by CWS should be accompanied by other interventions, such as strengthening parents’ parenting skills.

Other recent research supports the argument for simplified, research-informed interventions.

For example, an experimental study in England tested alternative approaches to dealing with ADHD-like behavior. It involved over 70,000 children in the first two years of schooling in 2,040 schools in 24 local education authorities.

The most effective strategy involved schools being sent a book with advice written in plain English about how to teach severely inattentive, hyperactive and impulsive children. It had a positive impact on children’s attention and behavior and, not surprisingly, on teachers’ quality of life: the children were nicer to be with. The effect was small but cost-effective.

Often it is assumed that a complex problem requires a complex solution, and in children’s services there has accordingly been a push for more so-called ‘thick’ services – intensive, highly structured and enduring interventions, characterized by proven models. At the other end of the spectrum, ‘thin’ services are increasingly likely to be dismissed.

The case for introducing more services that are thick enough to be able to alter children’s developmental trajectories is overwhelming. But if they are well thought-out and logical, brief, low intensity services have a place, too.

Two studies in related areas show what simple interventions can do. In an evaluation of the Triple P parenting programme, participants in the program group of a randomized controlled trial watched a 12-episode ‘infotainment’ TV series called Families on video and received tip sheets on parenting.

Unlike their counterparts in the control group, all parents who watched the videos reported a significant reduction in disruptive behaviors, an increase in parenting confidence and a decrease in dysfunctional parenting practices.

A second example comes from the field of managing depressed young people. The child and adolescent psychiatrist, the late Richard Harrington, found that following "a few sympathetic discussions with the child and parents, simple measures to reduce stress, and encouraging support" about a third of mild or moderately depressed adolescents remit.

As the evidence is beginning to show, as long as the are skilfully judged and well made, ‘thin’ services can work – even in addressing something as complex as mental ill-health.

references

Collishaw S, Maughan B, Goodman R & Pickles A (2004) Time trends in adolescent mental health. Journal of Child Psychology and Psychiatry 45 (8) 1350-1362.
Meltzer, H. (2007) "Childhood mental disorders in Great Britain: an epidemiological perspective", Child Care in Practice 13 (4), 313-326.
Iversen, A. C., Jakobsen, R., Havik, T., Hysing, M. and Stormark, K. M. (2007) "Mental health problems among child welfare clients living at home", Child Care in Practice 13 (4), 387-399.
Tymms, P. and Merrell, C. (2007) "The impact of screening and advice on inattentive, hyperactive and impulsive children", European Journal of Special Needs Education 21 (3), 321-337.
Sanders, M. R., Markie-Dadds, C. and Turner, K. M. T. (2003) Theoretical, Scientific and Clinical Foundations of the Triple P?Positive Parenting Program: A Population Approach to the Promotion of Parenting Competence, Parenting Research and Practice Monograph 1, Triple P.
Harrington. R. (2004) "Affective disorders", in Rutter, M. and Taylor, E. (Eds) Child and Adolescent Psychiatry, 4th Edition, Oxford, Blackwell Publishing.