Mental wellbeing of children in primary education: Evidence from the NICE reviews on the role of families

1. Mental wellbeing of children in primary education: Evidence from the NICE reviews on the role of families

2. Producing the NICE guidance 2007 - National Institute for Health and Clinical Excellence (NICE) decides to produce public health guidance on promoting the mental wellbeing of children in primary education Two studies commissioned looking at universal interventions (University of Warwick) and at targeted interventions (University of Teesside Later addition of work on violence prevention/bullying

3. Whole school/universal approaches encompass school policies, systems and structures to create ethos and environment that promotes mental wellbeing includes physical environment, links with parents and community, management, development and support of teachers includes curriculum-based programmes and other activities aimed at developing social and emotional competence of all students

4. Indicated and targeted approaches focus on particular types of behaviour or particular groups of pupils address the factors likely to lead to poor mental health or mental disorders may include ways of identifying children at particular risk

5. Levels of need/parent involvement?

6. University of Teesside team Professor Janet Shucksmith Professor Carolyn Summerbell Susan Jones Vikki Whittaker

7. Aims of the systematic review To identify and synthesise primary research undertaken to evaluate the effectiveness of school-based targeted/indicated activities on the mental wellbeing of primary school children (aged 4-11 years) in the developed world.

8. Specific research questions What aspects of targeted/indicated activities effective in promoting mental health of CYP (4�11 years old) in primary schools? What content most effective? Frequency, length and duration of an effective intervention? Better if teachers, school support staff, or specialists (such as psychologists or school nurses) delivers intervention? Role of governors? Role of parents? Barriers to/facilitators of effective implementation? Any adverse or unintended effects?

9. Inclusion criteria Primary research studies Must be randomised and controlled Must focus on behaviours intended to produce outcomes related to improvements in mental wellbeing Written in English Published after 1990 Undertaken in developed countries Focus on primary age children between 4 and 11 years of age

10. Some further defining criteria Must use a targeted approach (on a group at risk) or an indicated approach (on a group already identified as having problems) Broad definition of �school involvement� taken import of other professional skills into classroom/school settings development by teachers and school personnel of skills used in mental health improvement interventions.

11. Exclusion criteria Primary studies excluded if did not cover any of the previous criteria and/or covered following exclusion criteria: interventions that lasted less than one month interventions that took place entirely in clinic settings out of school or at home interventions that focused on pharmacological treatment. Re Rob and tracy�s work evidence that strong bonding socila capiatl in disadvantaged communities and that this v necessary for survival, e.g. non monetary exchanges, childcare, loans, favours, but this almost inimical to operation outside this zoneRe Rob and tracy�s work evidence that strong bonding socila capiatl in disadvantaged communities and that this v necessary for survival, e.g. non monetary exchanges, childcare, loans, favours, but this almost inimical to operation outside this zone

12. Classification 32 primary research studies met the criteria for inclusion Decision made to use ONS classification of mental disorders to group studies, since most of targeted interventions designed to tackle specified mental conditions ONS groupings equate to DSM-IV and IDC 10 categories

13. Classification

14. Some examples: anxiety disorders Coping Koala (Australia) �developed from Kendall�s Coping Cat programme in US Brief (10 weeks and 9 weeks) targeted interventions with groups of children showing precursor symptoms

15. Some examples: anxiety disorders Coping Koala - CBT programme that teaches children strategies for coping with anxiety within a group format, using FEAR plan - each child develops and implements his/her own plan of graduated exposure to fear stimuli using physiological, cognitive and behavioural coping strategies Group processes used to help children learn positive strategies from each other and to reinforce individual efforts and change Parent training combined with child group CBT produced additional benefits for children over simply treating children

16. Some examples: ADHD Bloomquist et al (1991) - CBT interventions with ADHD children largely ineffective - short-term gains rarely sustained. Lack of success attributed to attention being focused solely on children (with supportive adults being only peripherally involved) Bloomquist et al�s programme interventions were multi component, targeting children, teachers and parents and also focusing on teaching children problem solving and self-instruction skills. Neither study reported significant effects May reflect the co-morbidity of ADHD with other conduct disorders

17. Some examples: ODD and CD Most prevalent disorder Parent behaviours and conduct disorder high punitive discipline lack of monitoring frequent reprimands Children with conduct disorders poorer social skills high rates cognitive distortion problem solving deficits

18. Some examples: ODD and CD Early interventions targeted solely at young people Later development of multicomponent programmes - involve complex mix of activities directed at young people, but also at parents and/or teachers Incredible Years Intervention developed by Webster-Stratton originally focused on parents and parent training and education Later intervention trials combined this with teacher training and child skills training - seem to demonstrate longer-term effects

19. Some examples: ODD and CD Clinic - weekly 2-hour sessions over six months Treatments CBT based - offered by clinicians Groupwork - use of puppets, live and videotape modelling and role-playing, practice activities and fantasy play. Homework exercises also given Children in treatment programme showed more prosocial skills than controls All parent training conditions resulted in more positive parenting. Adding teacher training to both the parent training and child training regimes improved outcomes

20. Some examples: ODD and CD Fast Track - from PATHS (Promoting Alternative Thinking Strategies) programme PATHS whole-school programme but this is intensified form of intervention with targeted/�at risk� pupils. 9,000+ kindergarten children screened - 891 identified as high risk (living in areas of high crime and poverty plus teacher-parent ratings of disruptive behaviour at home and school, then randomly assigned to intervention/control groups

21. Some examples: ODD and CD Beginning in Grade 1, high risk children and parents asked to participate in combination of social skills and anger control training, academic tutoring, parent training and home visiting Universal classroom programme delivered to core schools attended by these high-risk children Intervention for Fast Track group involved attendance at a 2-hour enrichment programme held at school after school or at weekends once a week 22 sessions a year offered October to April Provision of childcare and transport included as inducement to attendance. Parents paid $15 for each session attended

22. Some examples: ODD and CD At enrichment session children attend �friendship group� where they learn/rehearse social skills using role modelling, discussions, stories and films During same hour parents meet in group led by family co-ordinators to discuss parenting strategies that would improve child behaviour After this, parent-child pairs spend 30 minutes together each session, participating in positive co-operation activities and practising positive parenting skills with staff support During last 30 minutes children work with paraprofessional support staff on reading skills while parents observe

23. Some examples: ODD and CD Overall conclusion at grades 4 and 5 follow up? Fast Track influenced key areas of children�s� adjustment throughout elementary school, children less likely to emerge as �cases�. Treated children less likely to be involved in deviant peer groups Hypothesis that Fast Track would improve academic and behavioural performance at school not met Project continues to track children through transition into high school Fast Track clearly �work in progress�, but intensive and costly and gains appear modest Extent to which results are diluted by the proportion of �false positives� - children identified as �at risk� in kindergarten on the basis of teacher and parent ratings, but who by grade 1 show no signs of serious behaviour problems?

24. Some examples: ODD and CD Early Risers - developed by August in US - aims to alter developmental trajectory of children with early onset aggressive behaviour Multicomponent intervention - features summer school programme, teacher consultation, student mentoring programme, parent skills training groups and child social skills groups Subjects recruited via screening programme based mainly on teacher rating carried out across ten matched kindergarten schools in semi rural area of Minnesota

25. Some examples: ODD and CD Children received main intervention at intensive 6-week summer school held at 4 elementary schools in the region Social skills training coupled with creative arts/sports training and recreational activities During rest of year Early Risers family advocates served as consultants to schools, making weekly visits to review student progress and give advice regarding potential interventions that might be useful for individual students Results at end of intervention? Gains for intervention children on academic achievement score compared to controls, but no significant differences on behavioural self-regulation, social competence or parent involvement

26. Some examples: ODD and CD Further analyses - effectiveness of intervention limited to certain subgroups on basis of behavioural severity and amount of attention received (intervention dosage). After further year�s intervention authors report significantly more success. programme After 3 years of intervention, intervention children showed greater gains in social skills, academic achievement and parent discipline Parents and teachers rated programme children as having more positive social skills than control children. Difference in social skills (not been evident at two year level) attests, in authors� opinion, to need for continuous intervention efforts or booster supplements when targeting at-risk children No programme versus control differences observed in children�s aggression, hyperactivity and impulsivity

27. Key findings: ODD and CD Multicomponent programmes: given intensive and lengthy nature of interventions, gains appear modest at intervention and follow up. Social problem solving and development of positive peer relations among outcomes with the strongest programme effects. Improved academic achievement as significant outcome of intervention (2 studies both 1++) Timing critical. Case for early intervention with aggressive disruptive children but improved benefits by giving booster intervention towards the end of primary education (1 study 1++)

28. Key findings: ODD and CD No magic bullets Parent involvement critical to success Interventions may need to be continuous and repeated Recruitment into parent programmes - major challenge. Given a choice, evidence from 1 study (quality rating 1++) indicates parents prefer targeted children to be treated at school rather than at home

29. Info gaps and caveats No UK studies � mostly US, some Australia Noticeable shifts in quality across period here - early proliferation of small-scale studies (mostly focused on YP alone) �Long game� of programme interventions - evidence lacking - fundamental aspect of programmes is �start early� and wait for �sleeper� effects Generalisability to the UK � may be high Few studies for targeted groups using school staff

30. Overall conclusion Current evidence inconclusive Results from multicomponent longitudinal programmes over next few years will be more revealing Real life interventions using school personnel raise new questions about school effects Level of resource involved in working with YP, parents and teachers is very large. Beneficial effect would have to be shown to be very large across multiple domains