Guest Editorial

Towards a comprehensive national early intervention program for children with mental health problems

Lyn Littlefield
Victorian Parenting Centre, Melbourne VIC

PP: 005 - 009

Keywords

early intervention, emotional problems, behavioural problems, children, adolescents, parents, parenting, program evaluation

Article Text

A high prevalence of mental health problems among Australian children and adolescents, estimated to be 14 percent, was found in the child and adolescent component of the National Survey of Mental Health and Wellbeing (Sawyer, Arney, Baghurst et al., 2001). Further, as many as one in five Australian children aged from four to 17 have significant mental health concerns (Zubrick, Silburn, Burton & Blair, 2000). These figures indicate an extremely concerning trend.

To reduce the prevalence and impact of mental disorders, it is essential to identify children at an early stage within the developmental pathway of the disorder and provide prompt and effective treatment. Early intervention can make a significant difference to reducing children's mental health difficulties and can result in dramatic, practical benefits that are sustained over time (Durlak, 1998). Effective intervention during the early stages of development of a mental health disorder can mean that children's behavioural problems are reduced, their social and emotional health is improved, and mental health issues are resolved before they become worse or entrenched, thus resulting in an increased quality of life for children and their families. To be effective, early intervention programs for children with behavioural, social and emotional problems must be multifaceted and use a coordinated approach involving the children, their parents, peers and teachers - that is, the significant people in children's lives.

Based on theoretical knowledge and research evidence of effective interventions, in 1986 the Exploring Together Program (ETP), an early intervention program for primary school-aged children with early signs of, or established, mental health problems, was developed (Littlefield, Story, Trinder et al., 2005). ETP was designed to treat both children with externalising problems and those with internalising problems. The program utilises a multifaceted approach involving the children, their parents, their teachers, schools and the local community. The multi-group program comprises: (1) a group for the children focusing on training in anger and anxiety management, prosocial skills and problem-solving, while also dealing with peer-related issues relevant to the age group; (2) a concurrent group for their parents focusing on child development, use of appropriate parenting practices, and assisting parents to deal with their own personal and family issues; and (3) a subsequent interactive group where the parents and children come together with a focus on enhancement of communication, problem-solving, negotiation and family relationships. In addition, the program involves meetings for partners or support persons, and liaison with schools and teachers to assist with management of children's behaviour and emotional problems in the classroom to ensure a consistent approach. Hence ETP is multifaceted, changing not only the children's problematic behaviour, but also dealing with the parents' difficulties and directly improving parent-child and teacher-child interactions.

Evaluations of ETP have shown it to be very successful (Littlefield, Burke, Trinder et al., 2000; Hemphill & Littlefield, 2001). The program has been shown to improve parenting practices, reduce parents' own problems, strengthen family relationships, significantly reduce the development of children's emotional and behavioural problems, and increase children's self-esteem and hence their resilience. It has won three national awards for excellence.

Evaluations of ETP demonstrating its effectiveness as an early intervention program have led to further evolution of the program and its adaptation for other target groups, such as preschool aged children, adolescents and Indigenous children. This issue of AeJAMH showcases ETP in a number of its iterations.

Dr Kate Reid and colleagues describe the development and evaluation of the Exploring Together Preschool Program (ETPP), an early intervention program designed for the very early identification of preschool children with behavioural, emotional or social problems and their families (Reid, Littlefield & Hammond, 2008). ETPP was found to be effective in reducing preschool children's behaviour problems, enhancing their relationships with peers and parents, and improving parenting practices and parents' satisfaction. The preschool version of ETP provides a comprehensive intervention that fills a gap in available programs for families with very young children who are at risk of developing mental health problems.

The Parents and Adults Communicating Together (PACT) program is based on a similar ETP model of training a group of young adolescents in communication, problem-solving and conflict resolution skills, separately training their parents in the same skills in a group, then bringing the parents and adolescents together in a combined group to practise these skills. Dr Michelle Soltys and I report on an evaluation of PACT which found the program was successful in increasing mothers' and adolescents' abilities to resolve conflict through using the model to find 'win-win' solutions to problems (Soltys & Littlefield, 2008).

Two preliminary studies of the effectiveness of separate components of the multi-group ETP for primary school-aged children are presented in this issue. Margot Trinder and colleagues report on an evaluation of the effectiveness of the stand alone Confident Kids program, which comprises the child group component of ETP (Trinder, Soltys & Burke, 2008). Results indicate improvements in parents' reports of children's internalising and externalising difficulties following completion of the program. Similarly, an analysis by Dr Susan Burke and collaborators of the effectiveness of the parent group component of ETP, Parenting Together, found significant reported improvements in children's emotional and behavioural difficulties, parents' style of parenting and level of parenting satisfaction (Burke, Soltys & Trinder, 2008).

Ngaripirliga'ajirri is an Indigenous version of ETP that was adapted for the Tiwi Islands based on the concept of Indigenous social and emotional wellbeing and taking into account the importance of the culture and the roles of the extended family and community in the rearing of Indigenous children. Associate Professor Gary Robinson and Dr Bill Tyler provide details of the ETP Tiwi adaptation in their paper (Robinson & Tyler, 2008). Although the research and development processes did not enable definitive research evidence of the efficacy of the program, case analysis suggested that the modified program produced many important outcomes for both parents and children.

It is important to highlight the inherent difficulties in conducting evaluations of early intervention programs in 'real world' settings, where many practical and ethical issues preclude the possibility of conducting randomised controlled trials. The practical difficulties inherent in evaluating the effectiveness of a program include obtaining a research population of adequate size and homogeneity, as well as commitment given the often chaotic lives of the families being targeted. In addition, there may be problems with participants completing questionnaires due to limitations in literacy skills and interest. There are also significant ethical issues in denying families immediate access to early intervention on the basis of research needs involved in wait-list controls and randomised controlled designs. Despite these issues, some very thorough evaluations of ETP have been undertaken and have consistently pointed to the effectiveness of the program. It is essential that as much research evidence as possible is gathered to enable refinement of the program and to ensure that families are receiving as effective assistance for their participation and commitment as is possible.

While there is considerable evidence to support the effectiveness of early intervention per se, very few children with mental health difficulties actually receive any professional support. Australian data indicate that only one quarter to one third of children with a mental health problem are likely to attend professional services (Sawyer et al., 2001). This means that the chances of receiving effective help are quite low, even for children who are identified, resulting in many children going on to develop serious mental health difficulties.

Concern for action to address children's mental health issues has been growing in Australia (and internationally) in response to the population trends indicating troubling rates of vulnerability to mental health problems. Given the prevalence of children experiencing mental health difficulties and the low level of access to mental health treatments and interventions, there is a need for population-based models for addressing mental health. In 2006, the pilot phase of a national mental health promotion, prevention and early intervention initiative specifically oriented to primary schools was established. KidsMatter (www.apapdc.edu.au/kidsmatter) has been developed in collaboration with the Australian Psychological Society, the Australian Principals Associations Professional Development Council, beyondblue: the national depression initiative and the Australian Government Department of Health and Ageing, and supported by the Australian Rotary Health Research Fund.

The knowledge and understandings from twenty years of implementing ETP provided much of the conceptual basis underpinning KidsMatter, particularly the importance of the multifaceted approach involving children, parents, schools and the community. The KidsMatter initiative has been specifically developed for implementation in primary schools, as schools are ideally placed to promote children's mental health and are in an effective position to identify and assist students who have early signs of mental problems. Further, almost all children attend school and teachers have a significant amount of regular contact and interaction with families and are able to link in vulnerable families who might not otherwise seek assistance.

The initiative emphasises a sense of shared responsibility for children's wellbeing and promotes partnerships with parents/carers, schools and a range of community services/agencies to improve children's mental health and family relationships. It seeks to enhance the capacity of school staff to recognise mental health risks and children showing signs of mental health problems and respond effectively. KidsMatter uses a risk and protective framework to focus on four areas where schools can strengthen the protective factors for students' mental health and minimise some risk factors as well as facilitate early intervention. These four areas make up the core content of KidsMatter and comprise the four KidsMatter components, as follows.

• Component 1: A positive school community, encourages schools to provide a sense of belonging and inclusion within the school community, a welcoming and friendly school environment, and a collaborative sense of involvement of students, staff, families and the local community.
• Component 2: Social and emotional learning for students, encourages the selection and inclusion of a social and emotional learning curriculum which is taught to all students and covers the five core social and emotional competencies as identified by the Collaborative for Academic, Social and Emotional Learning (2003): self-awareness, social awareness, self-management, relationship skills, and responsible decision making.
• Component 3: Parenting support and education, promotes school as an access point for families to learn about parenting, child development and children's mental health in order to assist parents with their child rearing and parenting skills.
• Component 4: Early intervention for students experiencing mental health difficulties, assists schools to support early intervention by identifying children showing early signs of mental health difficulties (as well as those children identified as having ongoing mental health problems). Teachers and schools can support these students by referring them for assistance, monitoring their function at school, and closely liaising with parents and support services.

Through the KidsMatter framework, schools are provided with the resources to systematically implement each of the four KidsMatter components, resulting in a comprehensive approach to addressing students' mental health tailored to the needs of each individual school's particular students and community. Implementing KidsMatter requires a planned and coordinated whole school approach. This involves the active commitment of school principals and the engagement of all staff in the implementation process. School leadership groups are assisted by State and Territory-based Project Officers in applying a systematic 7-step problem-solving model to plan and coordinate KidsMatter implementation. The 7-step model supports teachers' central role in the initiative and enables schools to systematically assess their strengths and needs in the four component areas. With the assistance of KidsMatter tools and resources, primary schools are supported to develop their capacity for promoting children's mental health and wellbeing and to respond effectively to mental health concerns affecting their students.

KidsMatter is being trialled in 101 schools across Australia with the view to making it available to all primary schools following an extensive and rigorous evaluation which is due for completion in 2009. The schools participating in the trial were selected from applications submitted in 2006 and represent a cross-section of public sector, Catholic and independent schools from across the States and Territories. Representatives from fifty-one of the selected schools were then involved in a two-day briefing in September 2006 and began their implementation of KidsMatter from that point on. The remaining fifty pilot schools attended an initial briefing in September 2007 before commencing their implementation.

A team based at Flinders University in South Australia has been engaged to undertake evaluation of the KidsMatter trial. The evaluation will provide information about the implementation process and whether the initiative leads to improved mental health for students. The findings will inform the subsequent national roll-out of KidsMatter initiatives.

The various iterations of the effective Exploring Together Program have helped to inform this exciting new mental health initiative which is facilitating access to early intervention for an even larger number of children with mental health difficulties. Feedback from schools that are participating in KidsMatter is extremely encouraging, and it is hoped that this will translate into positive outcomes in the formal evaluation to enable the national roll-out of KidsMatter to proceed. We will then have a truly comprehensive, nationwide prevention and early intervention program to address the risk and protective factors for children's mental health, contributing to a much brighter future for the next generation of Australians.

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