Prevention of anxiety and depression
3.3 MODELS OF BEST PRACTICE
Process and Methods
The Projects collected by the national partners of the sector “Children, adolescents and young people up to 24 years in educational and other relevant settings” ranged from relatively small-scale practical interventions through local and regional initiatives
up to those at national and international levels. After carrying out a pre-selection in their country, the 14 countries involved submitted a total of 32 projects.
Responses to the Questionnaires varied greatly from country to country. Replies re-ceived from e.g. Austria, Italy and Germany were rather scant whereas Sweden, Norway, the Netherlands, Portugal and Iceland provided a number of very good proj-ects. The poor responses would appear to be the result of the absence of any mental health plan in these countries and in particular to the fact that mental health promo-tion and prevenpromo-tion strategies are still not deemed a priority for a number of EU Member States.
Mental Health Europe’s experts held a meeting to analyse and evaluate the projects that had been selected by the national partners. Since the aim of the project was to develop an evidence-based strategy for mental health promotion and prevention to cope with anxiety and depression in children, adolescents and young people, it was considered essential to identify and include as best practices only effective and evi-dence-based projects. The following criteria were used as inclusion or exclusion cri-teria for the selection of best practices:
1. Basis of the project
1.1 Is the project theory-based?
1.2 Is the project empirically based?
2. Scope of the project
2.1 Are the determinants linked to the goals?
2.2 Are the methods linked to the goals?
3. Implementation of the project 3.1 Training
3.2 Supervision 3.3 Manual
3.4 Involvement of end-users 4. Evaluation of the project
4.1 High quality research design: including controlled trials, with randomisation if possible or pre-post designs ideally with a control group
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4.2. In addition to the above, presence of process evaluation measures, for ex-ample participants’ satisfaction
Among the 32 projects collected, a total of 15 projects were identified as well evalu-ated projects but since six of them had not yet been completed, it was decided to select as Best Practices only the nine projects that had been completed at the time of collection. This did not mean that the other projects were not effective, but at the time of reporting, many good and promising projects had not been able to provide suffi-cient documented evidence of effectiveness and/or suffisuffi-cient information on the out-come of the project, or the project simply had not yet been completed, which made it impossible to assess the outcomes and their effectiveness.
Of the 32 projects in total, five focussed on the target group of children with psychiat-ric parents, five were about awareness-raising, ten projects were school tions, six dealt with depression, anxiety and suicide, two were community interven-tions and four projects dealing with care, treatment and rehabilitation fell outside the scope of this project and were therefore not taken into consideration.
It was interesting to notice that seventeen projects targeted depression and anxiety, seven were mental health promotion and prevention projects and eight were general health promotion and prevention projects.
A majority of the projects were school interventions, aiming to provide information about mental illness and to reduce stigma and prejudice. But there were also projects for babies of depressed mothers, group treatments in community mental health cen-tres, projects working with juvenile offenders, self-help groups, etc.
In the school setting, strategies which used a whole school approach and encourage young people to talk about their feelings, to get on better with peers, to manage an-ger, and reduce conflicts and bullying, to enhance resilience and educate teachers to support these initiatives, revealed themselves to be the most effective in reducing mental health problems, including anxiety and depression.
Analysis of the models of best practices
The nine projects in this category that were selected as Best Practices come from the Netherlands (2), Norway (1), Portugal (2), Sweden (2), and the United Kingdom (2).
These projects revealed that the settings, strategies and methods used to attain their aims were varied. Settings included community centres, primary health care settings, juvenile justice settings, but schools proved to be the preferred location for mental health promotion and prevention projects in the field of anxiety and depression for children and adolescents.
Projects in schools mostly aim to raise awareness, to stimulate discussions and to improve knowledge about mental illness among students and teachers. It is important that teachers are trained so that they recognise early symptoms of anxiety and de-pression. At the same time, schools should be linked with community services and school staff should be knowledgeable about the scope of services provided by com-munity agencies.
Target groups often included the general population of children, adolescents and young people but also more specifically children of psychiatric parents, foster chil-dren, juvenile offenders, teachers,parents, etc. These target groups were specifically defined in relation to those youngsters who are most at risk or most likely to suffer from depression.
One striking feature of the projects that were received was the fact that most of them target adolescents and young people between 14 and 24 years of age. There are however projects for pregnant mothers and their babies but children in the age range from 2 years to 7 years seem to be an age group in which projects in the field of is-sues related to depression, child abuse, prevention or promotion interventions, in early school settings have yet to be developed and improved.
The following projects have been selected as models of Best Practice.
A more detailed description can be found in the annex.
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§ Netherlands
Coping with Depression Course
Group treatment developed to reduce depressive symptoms and to prevent the onset of depressive disorder.
Dealing with Moods
A preventive intervention project in schools. Elevated levels of depressive symptoms in adolescence are associated with a host of behavioural problems and can be a pre-cursor of depressive disorders. This intervention was designed to reduce elevated levels of depressive symptoms and enhance cognitive, social & behavioural compe-tence as protective factors in the prevention of depressive disorder.
§ Norway Second Step
A universal prevention project designed to reduce aggression and promote social competence. The programme is designed to develop skills that are central to chil-dren’s healthy social and emotional development: a) empathy, b) impulse control and problem solving, and c) anger management. It is a practical tool to use for teachers to create a better environment in the classroom.
§ Portugal
Psychoprophylaxis and Pregnancy. A Psychosocial intervention among pregnant women with high anxiety
A clinical research project implemented in local primary care units. The key mes-sages of this project are that it is possible to say that there is a psychological risk during pregnancy with implications on the obstetrical outcome and in the mothers’
emotional state after birth (only women with a low biological risk were taken into con-sideration). The psycho-prophylactic intervention in pregnant women with high levels of anxiety (risk group) is able to bring restricted but significant changes, a lower fre-quency of dystocias and an increased number of women in the social-support net-work of the mothers near to the birth.
Working with juvenile offenders and adolescents at risk in the community
Probation officers working with adolescents with anti-social behaviour in the commu-nity. It is a joint project between a university and the Ministry of Justice and included an intervention with youngsters and training for probation officers. It was fully evalu-ated in 2002. The important aspect of this project is to have juvenile offenders par-ticipate and feel empowered changing their own lives and feeling good about it.
§ Sweden Life Skills
A time-effective method for schools to prevent mental and psychosocial ill-health, loneliness and bullying, and to give hope that personal problems can be solved, sup-ply help and information on how to seek help at an early stage. Preliminary results of an evaluation show that the number of self-reported suicide-attempts decreases in schools where the method is used compared with a control group.
Love is the best kick
This is a Video film aiming to increase the self-concept of young people about exis-tential problems, identity, relationships, love, etc. It is used –together with a teacher’s guide and an information booklet for young people -to enable classroom discussions about such difficult existential issues as suicidal ideas and acts among teenagers.
Looking at the film and discussing it has shown to enhance young people’s under-standing of themselves and their suicidal peers. One of the most important results of this project is that their suicidal thoughts decreased.
§ United Kingdom
The development of adolescent pupils’ knowledge about and attitudes towards men-tal health difficulties.
A project teaching pupils about stress, depression, suicide, eating disorders, bullying, and learning disorders.
The Foster Carers’ Training Project
A randomised controlled trial of a training project for foster carers, which aimed to improve the emotional and behavioural functioning of looked-after children. The three-day training was well received by foster carers and produced measurable,
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though non-significant reductions in symptoms of depression, anxiety, over-activity, conduct problems and attachment disorder in the children.
The need to take a whole school/ whole community approach
While it may be helpful to introduce specific projects which attempt to prevent anxiety and depression in children and young people, it is also important to work within an overall ‘settings’ approach to ‘health promotion’, which looks at environments rather than individuals as both the focus for concern and a focus for positive well being, not just on problems and deficits. This does not just involve schools: using a range of settings, including school, home and community rather than just one setting has been shown to be much more likely to make long term changes to students’ mental health (Catalano et al, 2002). In practice the arena in which the setting approach has been best developed is schools. The European Network of Health Promoting Schools, which now covers all countries of Europe, has been one of the most successful glob-ally in promoting a settings whole approach to health, including mental and emotional well being, and it is advisable that initiatives work within its principles, and where possible the networks it has set up.
There have been several recent large scale systematic reviews of the research evi-dence which have concluded unequivocally that controlled trials have shown that whole school approaches are more effective than targeting those at risk when at-tempting to tackle mental health in schools (Lister Sharpe et al, 2000; Wells et al, 2003; Catalano, 2002). The whole school approach does not just focus on individuals with problems but on the positive well being of all the people who work and learn there, staff as well as students, and on the totality of the school setting, which in-cludes its ethos, relationships, communication, management, physical environment, curriculum, special needs procedures and responses, relationships with parents and the surrounding community. (Weare, 2000). A whole school approach emphasises the need to develop a long term, sustainable, and co-ordinated approach across all parts of the school to all health issues, including mental health.
This does not mean that those with emotional difficulties should not be targeted, it means that any targeting will be more effective within a whole school approach.
There are a range of reasons why this would be the case. Emotional problems,
in-cluding anxiety and depression are extremely widespread, and if an arbitrary per-centage is targeted, the very many people who suffer from a problem to some extent will be ignored. The same basic processes that help those with emotional difficulties have been shown to promote the emotional well being of all –including teachers as well as students. The key processes include: beginning interventions early; promot-ing self-esteem; givpromot-ing personal support, guidance and counsellpromot-ing; buildpromot-ing warm relationships; setting clear rules and boundaries; involving people in the process; en-couraging anticipation and autonomy; involving peers and parents in the process, creating a positive school climate, and taking a long term, developmental approach (McMillan, 1992; Cohen, 1993; Rutter et al, 1998). If there is an overall social climate that supports emotional well being it is more likely that fewer children will have prob-lems in the first place, so a whole school approach has a preventive function. Those with problems will be spotted early and staff will be more confident of their assess-ment because they have a clearer yardstick of normality. It is less stigmatising to work with everyone, which means that those with problems are more likely to use the services offered and feel positive about them than if they feel they are being singled out. The principle of ‘herd immunity’ means that the more people in a community, such as a school, who are emotionally and socially competent, the easier it will be to help those with more acute problems. The critical mass of ordinary people has the capacity to help those with problems (Stewart-Brown 2000). Those who are given extra help will be able to return to mainstream school more easily, as the way they are dealt with in terms of special help is then congruent with the school to which they return.
Involving young people in the process
One of the criteria for inclusion of projects was that they involved end users, in this case mainly young people, in the process. The principles of empowerment and user involvement are generally recognised across the policies of the European Union as an important contribution to the creation of a democratic society, and are basic to current European models of health promotion (WHO, 1986), health promotion evaluation (WHO, 1999). Compared with adult groups, young people are not often consulted about mental health matters, often being seen as too immature or too un-reliable to know what is in their own best interests. However, there have been some
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interesting efforts to ascertain the views of young people about mental health and to build them into recommendations for action (Health Education Authority 1998;
Harden et al, 2001) , as well as to include a consideration of these views in develop-ing indicators and instruments to measure aspects of mental health (Harter, 1993;
Banks et al, 2001). These efforts have shown that young people are capable of making a well informed and considered contribution. It is therefore important to build on this work, and ensure that the voices and opinions of young people themselves shape significantly work that is intended to promote their mental health.
3.4 Outcomes
Recommendations
The analysis of the projects from the sector for children, adolescents and young peo-ple to promote mental health and prevent anxiety and depression has led to a num-ber of conclusions and recommendations for the Policy Report.
(1) Based on the results from Questionnaire I, it has become clear that many coun-tries in the European Union still lack clearly defined mental health policies or do not have a national mental health plan. Those countries which do have an approved and sound mental health plan have produced a notably higher number of projects on the topic of the promotion of mental health and the prevention of mental illness, including anxiety and depression, of children, adolescents and young people. It is therefore of utmost importance to develop mental health policies in all Member States, that fo-cus specifically on children, adolescents and young people and to address their needs. Governments should create strong and supportive mental well being infra-structures, collaborate internationally on enhanced anxiety and depression preven-tion research, disseminate the available knowledge of effective programmes widely, and create a properly resourced policy platform on mental health. There is a need to raise awareness of the importance of mental health issues at all levels.
(2) The end users need to be at the heart of the process. In order to meet these needs, the planning and the development and implementation of a mental health promotion project needs to include the genuine participation of children, and young people themselves from the concept stage through the implementation to the evalua-tion. Young people need to be not only consulted but have genuine power, influence
and decision making over policy and practice. Likewise parents need to be similarly involved.
(3) Disadvantaged groups have been shown to be at high risk for anxiety and de-pression. Countries should be encouraged to address social risk factors such as inequality, stigma, marginalisation, social exclusion and poverty and disadvantage with a special focus on children and adolescents.
(4) There is a need to take a positive overall focus, which starts from the strengths young people and their families have within themselves and to seek examples of positive mental health and of well being .
(5) Holistic approaches need to be used that focus on the whole context in which young people find themselves as both the seat of understanding the causes of prob-lems and as site for solutions, in a co-ordinated and planned way. This needs to in-clude the whole community with its health, leisure and educational resources, the full range of services available to help young people. A ‘whole-school approach’ is es-sential, which involves teachers, pupils and parents in co-ordinated efforts to promote mental, emotional and social health across the whole school setting and for the whole population of the school, including teachers and also in co-operation with the surrounding community.
(6) Within this overall holistic approach targets include individual young people, groups of young people, and families, at particular risk of anxiety and depression and related disorders. These might include, for example young people whose parents suffer from mental illness and or enduring physical illness, who have experienced particularly stressful life events, or are suffering from post traumatic stress.
7) It is also important not to treat this age group as a homogeneous group but to use a differentiated approach. Each stage in childhood and adolescence will require different methods and approaches towards promotion and prevention actions, and requires sensitivity to the differing needs of the genders, and to the different cultural and social groups.
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(8) At an early stage of childhood, it is essential to support good parenthood and facilitate strong parent/child relationship development. Any intervention that aims to improve effectively the mental health of children and prevent anxiety and depression will have to address the quality of parenting that the children receive and also the quality of their family relationships.
(9) Close attention needs to be paid to the needs of children who have parents who are suffering from mental health disorders and problems, including encouraging targeted prevention programmes for this group.
(9) Close attention needs to be paid to the needs of children who have parents who are suffering from mental health disorders and problems, including encouraging targeted prevention programmes for this group.